In Part One of this discussion,** I showed how assumptions, misconceptions, and commercialism cloud prosthodontic implant treatment decisions. Best practice evidence is incomplete, yet the more recent scientific literature indicates that simpler, less demanding implant treatments have good outcomes, and that in many cases, patients prefer the simple plan to the more involved. Being aware of the evidence is the first step in matching patients with appropriate treatment plans.
Dentists may be skilled at diagnosis and treatment planning for those requiring routine dentistry, but the patient facing the total loss of his or her teeth is different on many levels. A more disciplined strategy is needed to diagnose a full mouth disorder and develop a mutually satisfactory prosthodontic solution. In particular, seeing the process through the eyes of the patient while being that individual’s health care advocate fosters successful treatments.
Why an Advocacy Dialogue?
With the de-emphasis on Complete Prosthodontics in recent years, dental schools are not equipped to teach the management of the patient with a terminal dentition or a history of denture difficulties.1 Dr. Paul Homoly, dental communication coach and author of Making it Easy for Patients to Say Yes, points out the distinction that the average patient, one who is perhaps unaware he or she has a cavity or crack in a tooth, has little angst about that condition. Contrast those patients with the ones suffering with inadequate chewing or about to lose all their teeth. These patients are acutely aware they have a serious “disability” which carries an emotional component. The former merely needs information that leads to a straightforward treatment. The patient with severe quality of life issues needs a different level of guidance, both psychological and physiological, in what Dr. Homoly calls an “advocacy dialogue.”2
Dentists who fail to recognize each patient’s unique situation are inclined to miss the anxiety involved with extensive dental treatment as well. A health professional needs a special ability to communicate in order to engage a concerned patient, empathize with his or her situation, educate that patient to the issues, and then share responsibility to plan and implement useful treatments. Though underappreciated, there is a strong correlation between effective physician-patient communication and improved patient health outcomes.3
Understanding the Costs of Implant Treatment
The challenge we face as dentists is how to contain costs while meeting the needs of a variety of patients. The inventor of the osseointegrated root form implant, Dr. P. I. Branemark, recently advised, “Bring the cost of care down so that it is available to all… [First] focus on a minimum level of care that can improve the lives of patients.”4
Dentists whose focus remains at the procedural level may not fully appreciate the real costs that patients experience with extensive dental treatments.
I see the costs of major dental treatment to be:
1. Biologic cost: What vital structures need to be sacrificed or changed to accomplish the treatment?
2. Patient time, inconvenience, and discomfort: How much tolerance is available for treatment?
3. Future maintenance and liability: What risks does the patient need to accept?
4. Finally, the actual fee reflecting the expense of construction and dentist’s profit.
Overlooking any of these “costs” can adversely affect the patient’s experience and label an otherwise successful treatment as unsatisfactory. Underestimating the costs of full mouth treatment undermines trust and profitability. Careful consideration of the four costs must be part of the treatment planning process, and the patient is not fully informed without disclosure of all. Furthermore, it is important to remember that as the cost of treatment rises, patient expectation also rises even as he or she is being asked to endure more. The conflict inherent in that situation imposes a heightened stress level on the provider.
Patient Goals and Expectations
Many years ago I heard the iconic Dr. Peter Dawson say, “The ultimate goal for every patient should be maintainable health for the total masticatory system.”5 As dentists, we are faced with two distinct tasks to accomplish this: Help patients establish personal goals, and improve their oral health by finding the treatment that is best designed to meet these goals now and in the future.
That is why the latest call for a “restoratively driven implant treatment” puts the cart before the horse. When a provider attempts to promote a preconceived “ideal” treatment, it leaves out the essential process of reaching a mutual understanding with the patient about his or her personal treatment goals. Patients only become invested when they witness the careful process of determining their needs, including being asked for their input on how they envision the treatment will affect their lives. Patients appreciate the guidance as they help design the treatment best suited for their individual situations. Prioritizing their goals, whether they are comfort, function, appearance, or simply a feeling of well-being, is an essential part of a successful treatment.
The Psychology of Choice
There was a time when it was standard procedure for the restorative dentist to send a patient considering implants to the surgeon to determine how many implants could be placed simply based on the patient’s anatomy and finances. By default the surgeon felt obligated to present options of various prosthodontic solutions without much consideration of the specific outcomes of the various treatments. Inexplicably, little notice was taken of this unique situation in dentistry where one provider devised a treatment plan outside his or her area of expertise to be accomplished by another practitioner.
Dr. Carl Misch contends that implant discussions can only follow determination of the type of prosthesis, stating the obvious: “Patients want teeth, not implants.”6a Dentists err when they believe that an acceptable treatment plan merely consists of a list of procedures or CPT codes while overlooking that the actual outcome is of singular importance for the patient. Other missteps include the premature discussions of “options”, or their presentation by anyone other than the one responsible for ongoing care, the treating restorative dentist. Those options only attain credibility when the patient sees that they are principally derived from mutually agreed upon goals. I will explain how presenting too many options or options that are not useful, complicate an already difficult decision process for the patient.
The video “Paradox of Choice – Why More is Not Always Better” by psychologist Barry Schwartz asks, if choice is such a good thing, why do people find difficult choices a burden? (http://www.youtube.com/results?search_query=schwartz+paradox&aq=f) Making high stakes choices without assistance often produces anxiety even in the well informed. Helping patients with dental decisions through an open dialogue in no way conflicts with the American Dental Association’s requirement for patient autonomy: “the dentist should inform the patient of the proper treatment, and any reasonable alternatives.”7 Note that it does not say that alternatives always have to be given, or that many options are encouraged. Hence, it is counterproductive to explain treatments that are not right for your patient. For example, if a dentist suspects a reduced tolerance evidenced by the patient taking antidepressant medication, it would be prudent to question the reasonableness of a two-year grafting, multiple extraction, and implant placement regimen.
Patients are allowed self determination when they willingly choose to accept a trusted clinician’s recommendations. It is no different from using a real estate agent to find a particular home per your wishes in your price range. Schwartz offers studies that show this approach greatly reduces patients’ anxiety in complicated decision making; they make better choices than on their own, and, most importantly, are more satisfied with the resulting outcome. This may explain the enigma of why a dentist with merely average clinical skills can be quite adept at making his or her patients happy.
A Patient Advocacy Presentation
In order to present the patient with an appropriate and satisfactory treatment plan, we must do our homework. As the baseball muse Yogi Berra is credited with saying, “If you don’t know where you are going, you are likely to end up somewhere else.” The patient draws the map in telling the dentist what is important to them. The dentist adds the proper landmarks and devises a route to get to the agreed upon endpoint. It is a mistake to turn the discussion toward solutions before goals are fully developed, just as it would be unwise to study airline schedules before you find out your destination is across town.
Exploring what the patient needs and desires requires good interviewing skills. I ask my patients, “If you could have anything you want, what would you see as the ideal result?” Most patients have a vision indicating reasonable expectations that direct us to an attainable outcome. Using the patient advocacy scenario, treatment ideas should be targeted at, but limited to, fulfilling expressed goals. Schwartz warns that people offered enhancements by a salesperson are susceptible to buy more than they need. Dissatisfaction with their decision and bad feelings toward the salesperson (i.e., buyer’s remorse) invariably result.
In our practice, treatment planning proceeds as follows. Taking into account the patient’s situation, the requirements that have been ascertained, and considering all costs except the fee, I present a rationale and then a treatment plan for what I feel will best meet patient expectations for a healthy and attractive mouth. Only when the general treatment direction is agreed upon do the financial aspects become relevant. Reversing the conventional logic, I seldom offer the most expensive plan first because that sends the message that I as the dental professional really want a high fee. Dr. Gordon Christensen agrees: “Patients see that their dentist is concerned about them rather than being promoters of the highest cost therapy.”8 When patients are consistently shown that their best interest is the provider’s overriding goal, the trust foundation for a successful treatment is laid.
To support my presentation, I make it known that I am using the best science available to come up with an effective and efficient individualized treatment. If a patient answers that he or she has been successful at some time with an upper complete denture (CD), I commonly consider a highly esthetic CD made with premium materials and an opposing snap-retained implant overdenture (IOD), hopefully fully supported by three or four implants. If some useable teeth with good prognoses are present, a tooth and implant supported removable partial denture can be offered, usually saving some time and expense. When treating either the fully or partially edentulous patient, a mandibular removable appliance with some implant support has unique practicality.
The simplicity of the IOD lies in the freedom to place the implant anywhere under the denture base, whereas fixed implant modalities need the implant in the far more precise positioning and angulations of the original tooth root. The surgeon’s ability to choose implant sites with the most favorable bone lessens the need for bone grafting and/or custom abutments. This allows the cost saving of fewer procedures and taking advantage of a smaller number of uncompromised implants.6b With little need to sacrifice boney ridge height, snap IODs’ minimal requirement for interarch space give them a nearly universal indication.
I reserve the use of connecting bars for greatly divergent implants or when the support of a cantilever is necessary to minimize further bone loss. There is extra expense if some type of reinforcement of the base is required. Differing from a snap IOD, both bars and implant fixed bridgework need considerable crown height space,9 and when the space is excessive, the implant hybrid bridgework (denture teeth processed to a metal framework) is the treatment of choice. I agree with Misch that when space permits, porcelain denture teeth are strongly recommended for their ability to maintain a good occlusion and provide a long lasting restoration.6c
I do not agree with the notion that if fixed implant bridgework is desired in both arches of a bruxer, you only need to increase the number of implants. My experience with these patients is the breakage of dental materials or even the implant body is at high risk with night stents only giving limited protection.10 I would prefer the stress relief of a maxillary CD or secondarily a maxillary IOD for a more dependable solution when the mandible has any implant enhancement.6d
All these relatively simple treatments, done well, have been shown to provide highly satisfactory results in the majority of patients.11 After the risks and rewards are disclosed, a full description is given of time, effort, and money required to permit a true informed consent (IC).
I counsel my patients to look upon any treatment which goes beyond the demonstrated needs and their initial desires as being “elective.” Misch also makes the point: “When two or more approaches may obtain a similar result, use the least invasive and least complicated to achieve a predictable result.”6a Only after some positive patient response to questions like, “Would it be important to you to have your palate uncovered?” or “Is a locked-in lower bridge of great benefit to you?” do I explain the details of those enhanced treatments. In order to be the most helpful for decision making, the information should directly address a patient goal. Be mindful that emphasizing potential benefits while downplaying limitations of an alternate treatment can unwittingly raise the expectations where it becomes difficult to ultimately satisfy patient demands. A future upgrade of a modest treatment is usually more acceptable than the disappointment accompanying the necessity to downgrade a high-end treatment. At that point the uncomfortable question can linger about who absorbs unrecoverable costs.
If the patient accepts the single recommended treatment, I will reinforce his or her decision as one that is a good compromise of risk, reward, and cost. The patient knows he or she can elect to pursue a more expensive and involved treatment if it better meets the individual’s goals. This ladder-like approach gives the patient the opportunity to complement the recommended plan. The IC would carefully detail added liabilities and trade-offs when going beyond basic needs treatment.
If a patient finds any of the costs of the recommended treatment too great, only then do I suggest a secondary, less involved, evidence-based treatment using fewer implants. It comes with a possible compromise in preserving jawbone or the remaining dentition and perhaps a greater maintenance liability, carefully noted in the IC. Most of my patients accept the initial recommended treatment since they were included in the decision making process. A few go up or down as they re-evaluate their priorities. I am confident in offering one or perhaps two treatment plans because they were formulated with patient involvement. If presented with conviction, this will encourage patients’ acceptance and promotes their ultimate satisfaction.
Selling a “big case” is widely portrayed as an enviable accomplishment in dentistry, but it requires exceptional patient management, as well as greater professional responsibility. Patients exhibiting severe quality of life issues need a health care advocate to sort out issues and solutions. In order to be self determinative, treatment planning at this level has to be a cooperative effort seeking to solve specific problems. Take care to avoid a premature discussion of options, for the emotion brought by the patient is interrupted and attention is diverted from developing the individual’s all-important personal goals. Once determined, matching treatment goals with specific treatments is most reliably done with evidence-based outcomes. Additionally, be mindful that any major dental treatment comes with considerable costs, personal and financial, which must be fully disclosed and understood. Utilizing a patient advocacy dialogue, treatment presentations become both patient centered and outcome focused, thereby promoting a mutually satisfactory prosthodontic result.
1. Sadowsky SJ. The role of complete denture principles in implant prosthodontics. J Calif Dent Assoc 2003 Dec;31(12):905-9.
2. Di Toilia M. Twenty Questions with Dr. Paul Homoly. Chairside Winter2008;3,2:16-23.
3. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152;9:1,423-1,433.
4. Branemark P-I. Branemark Scientific Symposium. Oct 2009, Gothenberg, Sweden.
5. Dawson P. Complete Dentistry Course 1992; St. Petersburg, FL.
6. Misch, C E: Contemporary Implant Dentistry. Third Edition. St. Louis: Mosby, 2008: (a) pp. 85-7, (b) p. 296, (c) p. 383, (d) pp. 110-111.
7. American Dental Association Principles of Ethics and Code of Professional Conduct. Section 1- Patient Autonomy, Rev. 2010.
8. Christensen G J. The advantages of minimally invasive dentistry. JADA 2005 136,11;1,563-1,565.
9. Phillips K, Wong KM. Space requirements for implant retained bar and clip overdentures. Compend Contin Educ Dent 2001;22:516-518,520,522.
10. Pjetursson BE, Bragger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns. Clin Oral Implants Res 2007;18Suppl3:97-113.
11. Thomason, JM, Heydeche G, Feine JS, Ellis JS. How do patients perceive the benefit of reconstructive dentistry with regard to oral health related quality of life and patient satisfaction? Clin Oral Impl Res 2007;18(Suppl.3):168-188.
*Dr. Warpeha is a board certified prosthodontist in private practice in Minneapolis, Minnesota. He is a panel member of the Cleft Palate Clinics at the University of Minnesota School of Dentistry and Children’s Hospital/Minneapolis, and is a prosthodontic consultant to the Minnesota State Board of Dentistry. Email address is Rebecca@warpeha.us.
**“Pitfalls in Full Mouth Implant Dentistry. Part One: Perceptions versus Evidence in Prosthodontic Treatment Planning; A Limited Literature Review”, Northwest Dentistry, Volume 90, January-February 2011, pages 27-32.