By: Howard Farran, DDS, MBA, MAGD
Publisher, Dentaltown Magazine

Ronald and Nancy Reagan had a very popular and successful slogan for the war against drugs, “Just say no!” By simply teaching children what to say when the situation arises, children could learn ahead of time how to simply say, “No.” Substandard treatment could use the same Reagan-esque advice, “Just say no!” When your treatment plans are guided by insurance rather than science, or you avoid presenting treatments you do not perform, patients are getting substandard treatment. Sure, your patients may seem satisfied today, but their interest in “ideal” treatment will be greatest when your compromise fails.

The old saying is: Is the dog wagging the tail, or is the tail wagging the dog? Don’t let the patient talk you into treatment you do not feel good about. Why are you doing a five-unit bridge from a second molar to a canine, when you know the patient needs three implants with three crowns? A five-unit bridge is not the standard of care in 2006, implants are. You know it, I know it. Who cares if the patient doesn’t know it? Don’t offer alternatives you do not feel good about. When the patient walks in your door with the five-unit bridge in his/her hand, guess who has the problem now?

Your patient loses tooth #19, #18 has had a root canal and #20 has an MOD amalgam. Many dentists would list a bridge at the top of their treatment plan. Can these teeth really support a bridge? Are these teeth up to the task of supporting a molar? Can these teeth support a molar like a titanium root form implant can? I don’t think so. You know, the research clearly knows that the patient needs a root form implant and a crown. Yet for insurance purposes, or for low self-esteem purposes, you offer an alternative for a three-unit bridge. Why? You know there is a better alternative! You know your patient eats out two in every three meals. You know your patient wastes more money than the federal government. You know your patient could pay for an implant on his/her credit card alone. Yet, you offer a substandard treatment simply because it exists. Quit doing it! Just say no!

The last time I saw a good looking three-unit bridge people still wanted to see Ben Affleck in the movies. Asking your patient to floss under his/her bridge is like asking you to run three miles every morning; it ain’t going to happen. So, why does the sovereign profession of dentistry still do so many bridges instead of implants? Because you offer them! Quit doing it! Just say no! The easy way is not necessarily best for your patient.

When you see a child with a cross bite at age eight, you do the same thing. You tell the parents this child could use a Rapid Palater Expander (RPE) now to correct the problem, or as an adult the child might require more extensive treatment like orthognathic surgery. Orthognathic surgery is an alternative with paresthesia and complications and is for the truly hopeless, it is not a substitute for a RPE. You simply tell the parents the child MUST have treatment now or else there is no good alternative! Hand them a referral slip to your good orthodontist and send them on their way!

You have a patient with an MO amalgam and recurrent decay on #2 and #15. You know a white composite on #2 and #15 is going to last 10 years max. You know a full-arch impression for two MO gold inlays might outlast the patient; but you still offer composite. When the patients tell me they want white in this situation and I just say “No,” they go with the gold. I tell them no one will ever see it and it is the only thing that will work, so they go with optimum oral health. What is their alternative? To go find another dentist? Do you know how cumbersome that is for a patient to find a new dentist and go through a new patient exam? To start all over and still maybe hear the same advice? Do you know how much easier it is for the patient to just say, “Yes”? This will happen if you just say, “No!”

You need to restore a second molar with a five- or six-millimeter pocket with an impacted wisdom tooth. The patient wants the tooth restored now. You know, the research clearly knows this patient needs a periodontist and an oral and maxillofacial surgeon. Is the dog wagging the tail, or is the tail wagging the dog? Just say no! This is a trap. Your desire to provide the patient with “what they want” often leads to below average outcomes. The patient needs to fix the foundation first; end of story!

How many of your patients are on three-month recalls with 5 millimeter pockets on molars? How many patients need periodontal treatment and upon their insistence, you just give them a “cleaning”? This is supervised neglect! These patients need a periodontist! Watching deep pockets is like watching open margins, you are just waiting for trouble to blow up under your care. You need to be more aggressive. It is not your fault that patients need optimum oral healthcare. It is not your fault that patients eat 200 pounds of sugar each year and don’t brush and floss regularly. Don’t be afraid to tell the patients what you know is true, what you know they need.

By the time you read this far, you have probably said “but what if” to a number of the scenarios I have presented. Certainly there are many extenuating circumstances that must be considered, but the message is clear – maintain your convictions to convince your patients to choose optimum dental health. Our patients can be like children who do not yet know what is best for them.

These discussions inevitably lead to a debate about dental insurance. Some of these situations are directly influenced by dental insurance and you know that presenting something that is covered by insurance is an easier “sell.” Many dentists have excellent clinical skills, but they hate the treatment plan discussion and presentation. The first step to effective communication is to believe what you present. When you have strong conviction about a particular course of treatment, your patient will respond in kind.

Effective treatment planning requires a general dentist to be well versed in treatment alternatives. Start with visits to your local specialists and ask them to educate you about treatments they provide. If you haven’t restored an implant, get some training; you are already behind the rest of your profession. If you don’t provide orthodontics in your practice, seek CE to help you identify problems in their early stages. The ability to develop and deliver excellent treatment plans is the hallmark of a great dentist.