The young associate dentist evaluates a new patient. The patient is a 50-year-old woman, who is a type II diabetic, and taking medications for both diabetes and high blood pressure. She is missing her lower right first molar (#30) and has several old amalgam fillings that are breaking down plus, they all have recurrent decay. The woman has periodontal probing’s measuring 4-6 mm’s in depths. The periodontal infection is localized to the posterior quadrants and includes a 6 mm distal pocket depth on #31. All of the periodontal pockets have BOP. Excited, the young doctor immediately discusses and schedules a three-unit bridge to replace the missing #30, with abutments on #29 and #31.
To use the analogy of building a house, this young doctor placed the roof before he poured the foundation. I can still remember from many years ago, when I was in dental school, they gave us a sequence that we were told to never violate. Oral surgery, endo, perio, restorative, and finally; prosthetics.
When we presented our dental treatment plans to our instructors, we always had to follow this same sequence.
The Foundation refers to removal of infection and any non-restorable teeth. If there are teeth that cannot be saved, get them out of the mouth first! Stop pain and take care of any abscesses. Either treat teeth with endodontics or extract them. This is important to eliminate systemic infection because we know that infection in the mouth causes infection in the does body.
There is one exception to this rule: you must address the patient’s primary need first, IF, it does not seriously violate the rest of the sequence. An example could be, a missing filling in a front tooth, and the patient was self-conscious about the esthetic problem.
The Floor can be built. The floor is built on the foundation and is similar in function. Our next step is to control or eliminate any periodontal infection so the patient will have a strong foundation that will not become progressively worse after we build our fine restorations.
This is the rule that the young dentist in the above story broke. He constructed a bridge before he had cured the periodontal problems his patient had. I can’t imagine trying to locate where the margin on the abutments will be with the pocketing present, the over extension into a sick periodontal pocket, and trying to have a dry field when trying to cement the bridge. This treatment can include debridement, scaling and root planning, any grafts and surgery that may be needed, and maintenance to be sure our house will be strong and healthy.
The Walls can now be placed on a healthy, strong foundation and the floor. The Walls can be compared to doing the necessary removal of decay and broken fillings present in the patients mouth. This will make smoother margins and will often uncover decay that may be present. Now we must go back to our foundation. If there is a pulp exposure this requires treating the nerve before going any further. When a tooth needs a crown later in the process, sometimes a core filling will be needed to make sure the tooth is strong and will retain the crown.
The Roof comes next. This can include a number of procedures, including the bridge our young doctor immediately decided was the most important project; the shiny thing, the high priced project he wanted to get completed in the first sequence of the treatment plan. Unfortunately, this sequence of treatment is the case too often. We hear of all the total restorative make-overs, the implant retained prosthesis that are done in one day, and also the twelve veneer cases that are done on the second visit in some offices. My prayer is that when you place the roof on your cases, you have made sure the foundation, the floor and the walls are all solid, so that the roof won’t collapse, a few years after you have placed that last nail to hold the shingles in place.
FOUNDATION, FLOOR, WALLS, ROOF. Make sure you follow the correct treatment sequence and work through each needed step to insure your patient’s dental house will be strong and last for many years to come.
Dr. Black is currently an associate coach and consultant, for Dental Practice Solutions, one of the leading consulting firms for nearly twenty years. As a seasoned practitioner, Dr. Black adds to the proven hygiene profitability coaching that Dental Practice Solutions is well-known for providing, to dental practices around the world.
Dr. Black’s expertise as an EQ and DISC trainer, makes him the best person to help more patients to say “YES!” to your patient care, as well as to enjoy working together as a team and loving what you do for your patients!
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