It's all part of the plan

March 21, 2012
Renee Knight
Issue 1

The take-aways Treatment planning should involve the entire team, including the patient, lab technicians and specialists. Today, there are plenty of high-tech options to help you get your patients to the smile they want. You have more control than ever before.

The take-aways

  • Treatment planning should involve the entire team, including the patient, lab technicians and specialists.

  • Today, there are plenty of high-tech options to help you get your patients to the smile they want.

You have more control than ever before.

The cases coming into your practice these days may be more complex, but the products and technologies behind the treatment plans you deliver have become more sophisticated. treatment planning today is more predictable and more personal, with plenty of products and technologies designed to get patients more involved in their care. 

From cone beam technology to patient education software to products like Invisalign that have changed the way you treat cases, everyone involved now has a better sense of what to expect from start to finish. Technology has made it possible for treatment planning to become a true collaboration among dentists, specialists, lab technicians and patients. Working this way not only takes out the guesswork, saving you and everyone else involved time and stress, it leads to happier patients who are more likely to accept treatment.

“To create the ideal smile we need interaction from the staff, the patient and the lab technician. If we get all those done and balanced out with my input, we’re going to come up with a smile that’s realistic and that will last a long time, versus something that’s out of balance because the lab, doctor or the patient drove the final result,” said Dr. Hugh Flax, President of the American Academy of Cosmetic Dentistry (aacd.com). “I don’t like to re-do things. I’d rather have a situation where we’re working together, and at the very end we’re actually exceeding the patient’s expectations.”

The right treatment planning tools can help you get there. Here, we break down some of the latest advancements powering advanced treatment planning in cosmetics, periodontics, implants, orthodontics and endodontics.

Cosmetics
The visual is a huge part of treatment planning, especially when it comes to cosmetics. If your patients see what you can do for them and understand what you have to do to get there, they’re more likely to be on board.

Advanced education
Interactive patient education is a huge part of today’s treatment plans, and there are now plenty of inexpensive and effective options designed to help your patients understand exactly what needs to be done and why, said Dr. Chris Ramsey. Programs such as Henry Schein’s Guru (howdoyouguru.com), which is what Dr. Ramsey and his team uses, are great adjuncts to help you explain procedures, but remember they don’t replace the still-important face-to-face time between doctor and patient.

If you want to add a little more of a wow factor to the patient experience, use an iPad to deliver your patient education. DDS GP (ddsgp.com) provides dental education software on the iPad that offers realistic animations and an easy way for you to upload and categorize photos from cases you’ve done.

“People like to feel comfortable. In a day and age where the iPod and iPad are items almost everybody touches on a daily basis, there’s now this software patients can hold in their own hands and it doesn’t feel foreign. It feels comfortable to them very quickly,” Dr. Ramsey said. “They can scroll through animations and touch pictures themselves. Once a patient is comfortable, there’s a level of trust and understanding. Once they’re comfortable, a lot of barriers that create the ‘no’ factor go away.”

These products help build relationships

Sitting next to a patient as he or she scrolls through images or looks at 3D animations on an iPad make the experience more personal, Dr. Flax said. They can see what the procedure you’ve proposed entails without actually going through it. You’re slowing down and taking the time to make a connection with them, something that has become an important part of patient care and treatment planning. These technologies are enabling you to build deeper relationships with your patients, which in turn creates a more satisfying experience for you and your staff.

“We’re not telling them this is what they’re going to get. They have some say, so it becomes their smile and not somebody else’s smile,” Dr. Flax said. “I want people to look in the mirror and look at their smile and say ‘wow I look great’ instead of ‘look at what Hugh Flax did to me.’ It should be their smile.”

Improved communication

When working on cosmetic cases, it’s important to communicate with your lab technicians and everyone else involved. Cases are becoming more and more complex, and you don’t have time to guess what another doctor involved did or didn’t do. Companies such as Sesame Communications (sesamecommunications.com) have developed software that make this communication easy, Dr. Ramsey said. Through Web-based software, everyone involved can go to one place to update what they’ve completed and see what other doctors have done. 

Moving to a digital workflow also helps, Dr. Flax said, making it easier for you to communicate with staff members who now don’t have to try to decipher your handwriting to figure out the next step in a patient’s treatment plan.

 

Periodontics

Treatment planning perio cases goes hand in hand with successful cosmetic/restorative dentistry, said Dr. Don Clem, President of the American Academy of Periodontology (perio.org). He describes it as a partnership, with periodontics supporting restorative dentists to help them achieve their treatment goals.

“If I can generate tissue and esthetically manipulate the gingival margins, I can help restorative dentists do a better job placing veneers and achieve a better outcome,” Dr. Clem said. “If we create a healthy environment periodontically and achieve regeneration for optimal esthetics, patients benefit because they have a better looking, better functioning restoration, and the clinician benefits because the practice becomes more efficient and restorative goals are more predictable, given the dentist has a healthy, stable environment-provided by the periodontist-to work with.”

Making that treatment plan happen doesn’t just fall on a GP or a periodontist; it should come from a team approach that includes everyone involved with the case, Dr. Peter Cabrera said. And these days, there are plenty of product advancements to help that team give patients the best possible result.

Soft- and hard-tissue advancements

There are now more options available in soft-tissue grafting, and some of those options are even sterile, something that wasn’t available until recently, Dr. Cabrera said. Some of the new products are coming out with growth proteins already mixed in, which can enhance the body’s healing response. That can be a big factor when patients are deciding if they should go with the treatment you’ve recommended.

But that’s not all. With tissue engineering, clinicians can draw a patient’s blood, extract certain components from the blood and use those components as part of grafting, Dr. Cabrera said. This, along with the latest soft-tissue grafting products, is slowly developing and is fairly expensive, but does show potential and is an area that should continue to evolve. 

Bone and soft-tissue regeneration also are becoming more sophisticated, Dr. Clem said. Clinicians now have the ability to regenerate bone around teeth and to regenerate soft tissue around recession areas. They can be regenerated, and root coverage can be achieved with new soft tissue, tissue that doesn’t have to come from the patient. There are banked tissues from human tissue banks that clinicians can use in soft-tissue reconstruction.

There also have been advancements in terms of using collagen-based materials for root coverage, Dr. Clem said. For reconstructing bone around teeth, new bone grafting materials and growth factors and biologic modifiers are on the market that, at the local site, can help stimulate periodontal ligament cells and bone cells to help regenerate bone around teeth.

More good news for healing

While Dr. Cabrera said there’s still a lot to learn about lasers and what they can do, he sees a lot of potential. Although lasers will never replace a scalpel, they can access different types of tissue depending on the wavelength, produce a bloodless field, and there is some anecdotal evidence that lasers promote faster healing. It has promise to seal wounds or seal tissue to the root, which is something Dr. Cabrera described as fascinating.

Yes, there are advantages to lasers that might lead you to make them part of your treatment plan, but Dr. Cabrera cautions that at this point, the marketing is ahead of the research. All too often, lasers are overused to make up for the expense, he said. It’s important to only use this technology when the science calls for it, and that means doing your research and staying informed.

Knowing the risk

Risk assessment and other diagnostic tools are available that can calculate a patient’s risk for disease and identify a patient’s infection level and genetic risk, Dr. Clem said.

Calculating a person’s risk factors for developing periodontal disease can actually help predict disease progression.

This means it’s no longer enough to say a patient has moderate or severe periodontal disease, Dr. Clem said. Clinicians have to think about the patient’s age, if he or she is a diabetic or has cardiovascular disease. Treatment plans must factor in the oral-systemic link; you can’t ignore the other health issues the patient is facing and expect a successful outcome.

While these risk assessment products are available today, they are only the beginning, Dr. Clem said. He expects to see more products on the market soon and risk assessment becoming an important part of treatment planning for patients with periodontal disease. It will enable clinicians to become more targeted in their treatment planning, improving patient outcomes.

“In the future, clinicians will have the ability to take a look at their aging population and assess them and say these are the patients I can best manage in my practice and I have confidence based on these diagnostic tools that I should be able to manage these patients in a predictive manner,” Dr. Clem said. “As our population ages, we’ll see the dental community segment their patient population according to risk more, and therefore employ advanced care in other disciplines as well as with a larger knowledge base than ever before. As a result, general dentists will be able to more confidently identify those patients who can be treated in their office and those patients who may benefit by partnering with a periodontist in their diagnosis.”

 

Implants

Implants have changed the way Dr. Cabrera treatment plans. Today, Dr. Cabrera will recommend an extraction much earlier in the process than he would have in the past. Sometimes, you can anticipate problems that will arise by saving certain teeth. By being proactive, you can spare the patient extra procedures and difficulties. If an implant is inevitable the patient may be better off having it earlier rather than later.

“A patient I’ve had in my office for 25 years had problems with an upper molar. Twenty five years ago, I would have bent over backwards to save it,” Dr. Cabrera said. “Instead, I said let’s remove the tooth so we can preserve some bone, try to save the tooth next to it and place an implant.”

Oh, the possibilities

Not only can implants help you treat patients more predictably, they give you and your patients more options, Dr. Ramsey said. Instead of just giving a patient a lower denture, you can give them a denture that’s implant-supported-and that can be life changing.

And then there are the patients with single tooth problems. Once you show them their options, chances are they’re not going to want to go with a bridge when they find out they’re a candidate for implants.

“The best thing we can do for patients is to keep a single tooth problem a single tooth problem,” Dr. Ramsey said. “If there’s a problem with one tooth, with where we are with implant dentistry we don’t have to touch the other teeth. Many times, I show them what used to be done and explain that we don’t want to use that any more today. Then,

I show them why we should consider these other modalities of treatment where things like implants can help us do things more predictably.”

Managing implants

Developments in bone and soft-tissue regeneration have made it possible for more patients to receive implants, Dr. Clem said, and can help patients who have disease that’s developed around implants they already have.

“We’re understanding implants are not impervious to disease and we can have bone and tissue loss around implants,” Dr. Clem said. “That can be devastating to patients from a functional and an esthetics stand point. Many times, we will incorporate periodontal regeneration material and techniques that have been developed around teeth and apply them to implant treatment.”

Predictable planning

From a pure treatment planning perspective, three-dimensional imaging probably is the most significant development Dr. Cabrera has seen in recent years. Not only does he use it to help more predictably plan his implants cases, but he’s also finding the imaging can pick up other issues from an anatomical perspective, issues he once had to speculate about. From a surgical perspective, he doesn’t have to wait and see what he’ll find when he gets in. He can see it in the image. Three-dimensional imaging tells you how much bone loss the patient has and makes it possible to anticipate with much greater accuracy what you’re going to encounter.

While cone beam technology can mean great things for your treatment planning, Dr. Cabrera warns clinicians still need to know anatomy and biology, as well as have the necessary clinical experience to successfully execute the procedure. You simply can’t rely on three-dimensional imaging, something Dr. Cabrera fears too many clinicians are doing.

Once you have the proper training and knowledge base to use cone beam technology, Dr. Flax said it’s an “absolutely essential” tool for planning out where to place an implant and to determine what size implant you’ll need.

“The rule in business applies to implants as well: location, location, location,” Dr. Flax said. “I think you do your patients a disservice, whether you can afford the technology or you have it referred out, you have to have this technology to get the positive results you’re expecting in implant dentistry.”

 

Endodontics

When a patient comes to your practice with a tooth that you can’t decide if you should save or extract, you have to get the endodontist involved. He or she can tell you if the tooth should be saved or extracted, and should be part of treatment planning early on, said Dr. Louis Rossman, a past president of the American Association of Endodontists (aae.org) And today, there are many treatment planning tools available to help make these cases more predictable and outcomes more successful, yet another reason you can’t afford to not have an endodontist on your team. Remember, no matter the case, you always have to look at what’s best for the patient. 

It’s become so clear

The surgical operating microscope is a must to successfully treatment plan a case, Dr. Rossman said. It provides enhanced vision through magnification and illumination, and allows the endodontist to treat what he wouldn’t be able to see with loupes or lower-power magnification.  

“It has revolutionized surgery, increasing our ability to gain access to areas previously not attainable,” Dr. Rossman said. “We can reduce the amount of bone removal and, using ultrasonics, provide a retrograde access to the roots, canals and isthmus that was not possible years ago.”

Not only that, the microscope makes endodontics cleaner for the patient and the operator, Dr. Rossman said. For instance, when gaining access through a crown, it makes it possible to see canals, find additional canals and reduce the amount of tooth structure removed to gain access to these areas. His Zeiss microscope (zeiss.com) even has a camera attachment for documentation and education.

Using ultrasonics in concert with a surgical operating microscope will only improve your results and allows clinicians to do procedures that never could be done before without removing tooth structure.

High-tech education

Digital radiography is a great tool for patient education, Dr. Rossman said. You can show your patients right on the monitor why they should consider treatment. The clarity the latest sensors provide is outstanding, which is key for predictable treatment planning and educating patients about what’s going on in their mouth and what you plan to do about it. Beyond that, digital radiography allows clinicians to evaluate patients using much less radiation, which Dr. Rossman said is the biggest benefit.

“The new Schick sensors are built to last,” Dr. Rossman said. “The ability to replace the weak link of a broken wire has been solved, and the image is superb.”

It’s all about predictability

There are plenty of advancements in endodontics that simply make treatment planning more predictable, Dr. Rossman said. From titanium rotary files that allow clinicians to completely clean and shape the root canal system better, to the M-wire NiTi from DENTSPLY Tulsa Dental Specialties (mwireniti.com) that reduces the chance of separation of the instruments, to new materials that seal off perforations and the apex of the tooth surgically, endo cases are more predictable than ever before.

Apex locators also are great treatment planning tools that allow for a more accurate determination of working length of the root, which in turn allows for a better, more predictable outcome.

Another technology that can help with predictability? Cone beam. This technology can help when you know certain fractures exist, but you can’t identify them. It also can help you identify anatomic anomalies that may have contributed to disease in re-treatment cases. Finding these problems before you’re in the middle of a procedure will only help you achieve the results you told the patient you were after.

“It’s a new world of endodontics,” Dr. Rossman said. “We can now achieve a success rate we could only dream about years ago.” 

 

Orthodontics

 

Advanced technology has given orthodontists a variety of enhanced techniques to choose from when treatment planning their patients, allowing for a decrease in chair time, treatment time and an increase in overall comfort and the final outcome, Dr. Jacqueline Fulop-Goodling said. Today’s technology enables clinicians to show their patients their final smile before initiating their patient’s orthodontic treatment. Software programs also aid in taking the guesswork out of a patient’s treatment time and can motivate patients to stay on track and return to the office, although their visits are less frequent now.

Choices, choices

Depending on what’s most important to you and your patient, there are plenty of directions to take when it comes to orthodontics.

Align Technology’s Invisalign (invisalign.com), one of the clear aligner options, consists of a series of aligners that patients switch out every two weeks. Each aligner is individually manufactured with calculations to gradually shift a patient’s teeth into place. It takes out the discomfort associated with braces, and saves you and your patient time. Rather than the patient coming in for multiple visits, you take one impression and from that a software program creates the patient’s custom-fit aligner.

There are other products designed to shorten treatment time, such as SureSmile. SureSmile, in Dr. Fulop-Goodling’s opinion, can cut an average orthodontic treatment time of 18 months in half. How does it work? It uses advanced 3D imaging, virtual simulations and robotically bent archwires customized for each patient’s treatment plan. With this system, you don’t have to bend an archwire by hand. When the SureSmile wire is inserted into the brackets, each tooth moves directly to the prescribed position and with greater accuracy because of the different anatomy of each tooth. Even the same tooth, like a mandibular first molar on the right and left side of the same patient, varies naturally in anatomy.

Even though products like Invisalign and Clear Correct (clearcorrect.com) offer a more subtle option, some patients don’t want a removable orthodontic appliance to straighten their teeth. 3M ESPE’s Incognito™ Orthodontic Braces (hiddenbraces.com) may be the right option for these patients. These are placed on the lingual side of the teeth, Dr. Fulop-Goodling said, and are hidden from view.

Regardless of what you and your patients are thinking for the final result, you have plenty of options to get them there.

“Every orthodontist has their own signature smile. Some like a broader smile and like to expand their cases while others like a more natural-looking narrower arch form,” Dr. Fulop-Goodling said. “Today, there is a larger menu to create a nicer smile. Removable braces like Invisalign, fixed braces on the facial surface like SureSmile or on the lingual surface like 3M’s Incognito braces aren’t the be-all and end-all of orthodontics today. There is an array of treatment options and so much more to learn and know, including using these techniques in conjunction with other ones, such as surgically facilitated orthodontic treatment, or accelerated osteogenic orthodontics. Previously, it was perfecting smiles with perfecting bracket placement and wire bending techniques.

Today, it’s perfecting the most ideal smile with the least amount of discomfort, least amount of time and in the most technologically savvy way.”

Fewer extractions

When Dr. David Sarver, spokesperson for the American Association of Orthodontists (braces.org) was growing up, children who needed braces ended up with a metal band put around every tooth. That not only led to problems with oral hygiene, it meant an extra quarter of a millimeter of space between each tooth. That added up to space that all too often would lead to extractions. Bonding adhesive technology has changed all that because that extra space once needed just to put the braces on is no longer part of the plan. Losing the metal bands has enabled more patients with crowding to keep all their teeth.

Looking into the future

Using computer imaging technology, clinicians can show their patients what their smile will look like once the recommended treatment plan is completed, Dr. Sarver said. You can take a picture of your patients, put it into the software and show them what will happen to their smile if you lengthen or straighten their teeth. You can compare a patient’s current smile with the smile you’ve created, side by side on the screen, and you can explain different aspects of the treatment. This is much more effective than just words. The patient can see what is possible and what needs to be done, which leads to a greater understanding of the options and higher case acceptance.

“We can, with some degree of assuredness, feel that this plan we just showed her is what we’re going to get,” Dr. Sarver said. “What the visual imaging allows us to do is have an actual template by which we can have a discussion in a common language. We can both see that. Then I can measure what we are trying to offer her so I can have a plan to go by rather than saying ‘let’s try this’ or ‘let’s try that.’

”Treatment planning this way gets your patients more involved, and not only helps them understand their options, but understand why cooperation and compliance are so important for a successful outcome. They know what they have to do to expedite treatment so a two-year treatment plan doesn’t become a four-year treatment plan.

“They can see that you’re visualizing an outcome, and the more interaction patients have with the doctor, the more satisfied they are going to be with the outcome,” Dr. Sarver said. “If your doctor has a discussion with you, you’re more likely to be happy with that doctor. This is a way we can talk with the patient. Here’s what I see, what do you see? Here’s what I recommend, here are your options. Patients buy that, but for the right reasons. It’s not because you are selling them something but because you are helping them understand their choices.”

Let them see the now

Want something even more effective than a photograph to show your patients’ what their smile looks like today? Video technology does that, and is something Dr. Sarver expects to become a standard for treatment planning esthetic cases. How does it work? Use video cameras to record the motion of your patients’ smile. This engages your patients, getting them to smile in a natural way that allows you to truly evaluate their smile.

The cone beam advantage

As with implant cases, cone beam technology can be a huge help when treatment planning orthodontic cases. But often a 3D image of the entire head may not be indicated. Limited-field cone beam is a great option, Dr. Sarver said, because it limits the size of the area you’re looking at, and that limits radiation exposure. This technology can show you things you wouldn’t see on a conventional panoramic field, which will lead to more predictable, precise results.

 

It’s up to you

Regardless of what area of dentistry you’re talking about, treatment planning continues to grow more complex, yet more predictable if you’re using the right tools. There have been plenty of advancements that can help make your patients more comfortable with the thought of treatment and prepare them for the procedure, post-op and the final outcome. But to know which products are best for your patients and your practice, you have to keep up-to-date on what’s going on in the industry. Read journals, do research online, talk with your colleagues, attend CE courses. Don’t think you can take the manufacturer training and that’s it, you’re ready to apply the technology in your practice. To use these products to help you create treatment plans that lead to successful results, you have to put the effort in. You have to keep your skills sharp and your knowledge base growing.

“More than anything we have to have comprehensive knowledge and pay attention to what’s happening in dentistry,” Dr. Cabrera said. “You have to be a constant student. From the standpoint of adopting new technology, manufacturer training is just the surface. To be a clinician you really have to be involved.”