A Patient-Centric Approach: Understanding the "big picture"

How should dentists approach treatment planning, especially for posterior dentistry?

Effective treatment planning in dentistry, even for posterior issues, should always begin with a "big picture" assessment, starting with the anterior teeth and overall aesthetics, then moving to occlusion, and finally, narrowing down to specific details like periodontal health, caries control, and root canal therapy. This holistic approach ensures that any planned treatment aligns with the patient's overall oral health and aesthetic goals, preventing complications or dissatisfaction later on. The actual treatment sequence, however, is the reverse: details (like prevention and caries control) are addressed first, leading up to the more extensive, aesthetic procedures.

What are the four primary concerns patients typically have, and why is it crucial to identify them?

Patients generally present with one of four main concerns:

1. Comfort: Addressing pain (e.g., toothache, denture discomfort) or issues like food impaction.

2. Cost: Financial considerations regarding dental procedures.

3. Function: The ability to chew effectively.

4. Embarrassment: Aesthetic concerns related to their smile or the appearance of their teeth.

Understanding the patient's primary desired outcome is paramount. If a dentist focuses on functional improvements when a patient desires aesthetic changes, or vice versa, the patient will likely be dissatisfied, potentially leading to additional costs for the dentist to rectify the work or the patient seeking care elsewhere. The treatment plan must directly address the patient's stated outcome, regardless of its clinical complexity.

Why is considering future dental work, like orthodontics or implants, important even when focusing on current restorative needs?

It's crucial to discuss potential future dental work, such as orthodontics or implants, with the patient even when the immediate focus is on restorative dentistry. For example, if extensive crowns are placed on posterior teeth, and the patient later decides to get orthodontics, the new crowns might need to be sandblasted or even replaced due to potential damage during brace application or subsequent recession. Similarly, if a space needs an implant in the future, planning restorative work on adjacent teeth without considering the implant can make the later implant placement more challenging or compromise the fit of the implant crown. Informing the patient about these potential future scenarios, and documenting their decisions, protects the dentist from "if I had known" complaints and ensures the patient can make informed choices about their long-term dental health.

How does tooth wear influence treatment decisions, particularly regarding indirect restorations and vertical dimension?

Significant tooth wear, especially if it's 2.5mm or more, reduces the available space for restorative material. Teeth often over-erupt to maintain contact, meaning that if a crown is placed on a worn tooth without addressing the wear, there might be insufficient space, potentially leading to pulp exposure during preparation or lack of retention for the crown. In such cases, the dentist must consider increasing the vertical dimension of occlusion or segmentally intruding affected teeth. Relying on large composite restorations for worn teeth is often discouraged because composite resins wear down over time, particularly in patients who clench or grind, leading to a continuous loss of vertical dimension. Ceramic materials are generally preferred for extensive restorations due to their superior resistance to wear.

When is it appropriate to "repair" existing dental work versus completely "removing" and redoing it?

While patching up existing dental work might seem like a minimally invasive approach, it is often more technically difficult, yields poorer long-term outcomes, and can leave the patient's mouth looking perpetually on "the brink of disaster." Unless the compromise is a temporary measure due to financial constraints or uncertainty about a tooth's prognosis, it is generally recommended to remove and redo compromised restorations properly. For example, if a large composite or amalgam restoration fails, rebuilding the tooth with a core and an indirect restoration (like a crown or onlay) offers a more durable and predictable outcome.

What are the key considerations when choosing between direct and indirect restorations, or between bonding and cementing?

The primary guiding principle for choosing between direct (e.g., composite filling) and indirect (e.g., crown, onlay) restorations, or between bonding and cementing, is ease and predictability of achieving a good result.

• Direct vs. Indirect: For small caries, direct composites are easier. However, if more than half of the occlusal surface is affected, or if cusps are compromised, indirect ceramic restorations are usually easier to execute effectively and provide a more durable solution, especially for patients with significant occlusal forces.

  
  

• Bonding vs. Cementing: Bonding is often easier for supragingival preparations with good isolation, as it allows for less precise retention and resistance form in the prep design. Cementing is more appropriate for subgingival preparations or when maintaining a dry field is challenging, as it relies more on mechanical retention rather than adhesive strength.

  
  

• Vertical vs. Chamfer Preps: Vertical preps, which lack a distinct margin, can be advantageous in areas with thick tissue or subgingival caries, offering more flexibility in crown placement. Chamfer preps, with a clear margin, are generally easier for most teeth that are not badly damaged and are supragingival, as they allow for better aesthetics and easier laboratory fabrication.

  
  

How does the balance between strength and aesthetics influence material selection for restorations?

There's an inherent trade-off between strength and aesthetics in dental materials: if it's beautiful, it's generally weaker, and if it's strong, it's often less aesthetic.

• Feldspathic porcelain (glass-based): Offers high aesthetics due to its amorphous structure but is more prone to chipping and fracture.

  
  

• Crystal-reinforced glasses (e.g., Empress, E.max): Provide a balance of improved strength while maintaining good aesthetics.

  
  

• Polycrystalline ceramics (e.g., zirconia): Are exceptionally strong due to their unique crystalline structure and transformation toughening mechanism (where cracks cause expansion, pushing the crack shut). However, they can be less aesthetic, particularly monolithic zirconia.

  
  

The choice depends on the specific clinical situation and the patient's priorities. For areas under high occlusal stress, strength might be prioritized, while for highly visible areas, aesthetics may take precedence.

What is the rationale behind recommending specific treatments to patients, and how should financial constraints be addressed?

Dentists should act as confident advisors, recommending what they believe is the "best option" for the patient, rather than presenting a multitude of choices that may confuse them. This involves clearly stating the recommended procedure (e.g., "I recommend you get a ceramic crown/onlay") and explaining why it's the optimal choice (e.g., better wear resistance, reduced crack propagation risk).

Financial constraints are a common factor. If the patient cannot afford the ideal treatment, a compromised, typically less expensive, alternative (like a large composite) can be offered as a temporary solution, explicitly stating that it is a compromise and may not offer the same long-term benefits. However, if a compromised treatment is unlikely to work effectively, it's sometimes better to delay treatment entirely until the patient is financially ready for the proper solution, rather than performing ineffective, cheap dentistry. Documenting these discussions and patient decisions is crucial for managing expectations and protecting the practitioner.

Notes from Dr. Lincoln Harris, RipeGlobal, Posterior Treatment Planning Lecture:

1. The Treatment Planning Philosophy: Big Picture First

The fundamental principle of treatment planning is to always start with the big picture and then narrow down to the details, which is the opposite of the actual treatment sequence.

• Planning Sequence: Begin with the smile, soft tissues (pink bit), and teeth (white bit, incisal edge), then consider details like periodontics, root canal therapy, and caries control.

  
  

• Treatment Sequence: The actual treatment is performed in reverse; start with details like prevention, perio, caries control, and stabilization, then move to the aesthetic "fancy bit".

  
  

• Analogy: This is likened to building a house; you design the house first, not plan the plumbing before the house design. This ensures a functional and aesthetic result, preventing issues like a pipe poking up in the middle of a lounge room.

  
  

2. Understanding Patient Issues and Desired Outcomes

Patients typically have only four core issues, and understanding which one is primary is crucial for successful treatment:

1. Comfort: Toothache, denture pain, food impaction.

   
   

2. Cost: Concerns about the financial aspect of dentistry.

   
   

3. Function: Desire to chew effectively.

   
   

4. Embarrassment: Self-consciousness about smiling, missing teeth, or dark crown margins.

   
   

5. Patient Goals Dictate Success: If you don't understand the patient's desired outcome, success is impossible. For example, if a patient wants to look good and you prioritize function, they will be unhappy if the aesthetics are poor, potentially leading to you redoing the dentistry. Conversely, if they want function and you talk only about aesthetics, they may leave for another dentist.

   
   

3. Initial Assessment: Looking at the Whole Mouth

Treatment planning for posterior dentistry always begins with an assessment of the anterior teeth and overall aesthetics.

• Anterior Teeth Concerns: Look for wear, chipping, crowding, and old crowns that are darkening.

  
  

• Orthodontics (Braces):

  
  

  • If a patient has crowded or worn anterior teeth, ask if they plan to get orthodontics, as placing braces on new crowns is difficult (requires sandblasting, acid etching, silane, which removes glaze and can lead to recession and exposed dark roots).

    
    

  • Provisional Crowns: If the tooth urgently needs a crown but the patient might get orthodontics, use a provisional crown. These can be sandblasted repeatedly without damaging a final restoration.

    
    

  • Documentation: Record the patient's decision regarding orthodontics in their notes to cover yourself if they change their mind later.

    
    

  • Veneers for Crowding: Avoid using veneers to straighten severely crowded teeth, as it results in poor aesthetics (wonky emergence profile, uneven gum heights) and can damage the pulp from excessive tooth reduction.

    
    

• Missing Teeth/Implants:

  
  

  • Ask the patient if they intend to replace missing teeth with implants.

    
    

  • If a space exists, adjacent crowns may lean into it, making future implant placement difficult without re-trimming new crowns or causing recession.

    
    

  • Informed Consent: Inform the patient that delaying an implant can make future work more challenging, even if you don't care whether they get the implant or not.

    
    

• Tooth Wear:

  
  

  • Assess the amount of wear, particularly if it's significant (e.g., 2.5mm off a tooth).

    
    

  • Excessive wear means the tooth may have supra-erupted, leaving insufficient space for a crown without aggressive reduction, potentially exposing the pulp.

    
    

  • Pulp Location: Consider pulp height and distance from the occlusal surface. Large, "horny" pulps are more prone to exposure.

    
    

• Radiograph Analysis: Beyond caries and margins, also examine:

  
  

  • Pulp Height: Is there enough room for restoration without hitting the pulp?.

    
    

  • Contact Point to Bone Distance: This indicates the amount of soft tissue, predicting difficulty in placing matrix bands or rubber dams.

    
    

4. Repair vs. Remove/Replace

The speaker generally advocates for removing and replacing old dental work rather than patching it.

• Difficulty of Patching: Patching is technically about five times more difficult and often leads to compromised outcomes, paid less, and a mouth that looks "on the brink of disaster".

  
  

• Compromised Treatments: Doing compromised treatments is often technically more difficult, pays worse, and yields a lesser outcome than doing the job properly from the start.

  
  

• Crown Lengthening Example: Learning to do deep restorations without crown lengthening is harder than simply performing an easy crown lengthening procedure, especially posteriorly. Tissue regenerates quickly over exposed bone in healthy patients.

  
  

5. Vertical Dimension and Occlusion

• Increasing Vertical Dimension (VD): Ask if an increase in VD is necessary. This is typically needed if:

  
  

  • There is significant tooth wear at the front causing poor aesthetics.

    
    

  • You cannot reduce a tooth enough for a crown without hitting the pulp or leaving insufficient tooth structure (ferrule/resistance form).

    
    

• Alternatives to VD Increase: Segmentally intrude the worn tooth using temporary anchorage devices (TADs) or extract and place a deeper implant. You can also build up worn teeth with composite, then use orthodontics to intrude them and extrude other teeth.

  
  

• Assessing Occlusion: Look for signs of risk like wear, chipping, and cracks, which indicate high occlusal forces.

  
  

  • Risk Factors: Inform the patient if they are at high risk of damaging restorations due to occlusal forces, and document this (e.g., moderate, high, or low risk). Patients with high risk may need to expect to replace crowns periodically.

    
    

6. Material Choices: Composites vs. Ceramics

• Large Composites: Generally discouraged for large posterior restorations.

  
  

  • Wear: All composite resins wear, especially when replacing large tooth portions in patients who clench or grind (which is about 85% of the population).

    
    

  • Technical Difficulty: Massive composites are technically difficult, time-consuming, and often underpaid, leading to suboptimal outcomes.

    
    

• Glass Ionomer Cements (GIC): Described as a "terrible material" for permanent restorations.

  
  

  • Limitations: Highly moisture-sensitive (dissolves if too wet, cracks if too dry), and often appears like moth-eaten decay on X-rays, leading to unnecessary replacement. It's essentially a weak self-etching restorative material that dissolves and wears poorly, suitable for temporary restorations or implant screw holes.

    
    

• Resin-based CAD/Milled Materials: Despite marketing (e.g., "hybrid ceramics," "zirconia-infused resin"), these are still resins and will wear if the patient clenches or grinds. A simple test: if it burns in a furnace, it's a resin, not a ceramic.

  
  

• Ceramics:

  
  

  • Strength vs. Beauty: There's an inverse relationship.

    
    

    • Amorphous (Glassy): Feltpathic porcelain, more beautiful but weaker.

      
      

    • Crystal Reinforced Glass: Emacs (lithium disilicate), Empress (leucite) – stronger with added crystalline material.

      
      

    • Polycrystalline (Zirconia): Strongest but can be less aesthetic. Zirconia resists cracks by transforming from polycrystalline to monocrystalline, expanding and pushing the crack shut. This requires at least 1mm thickness.

      
      

  • Recommendation: For large restorations, especially those replacing cusps or more than half the tooth, consider indirect ceramic materials due to superior wear resistance and strength.

    
    

7. Managing Uncertainty and Interim Steps

• When Unsure: If you're uncertain about a tooth's prognosis (e.g., whether it needs a crown or will split), perform an interim step.

  
  

  • Five-surface composite as a Core: A large composite can serve as an excellent core for a future crown. If the tooth settles, you can proceed with a crown with more confidence.

    
    

  • Provisional Crowns: Use if you're not ready for "full commitment" to the tooth, or if you suspect a crack and want to see if it settles. They are also ideal for "exploratory surgery" under old crowns where decay or hopelessness is possible, allowing you to assess and then plan definitively without changing the treatment mid-appointment.

    
    

8. Crack Propagation and Cusp Coverage

• Capping Cusps: The most significant factor in reducing crack propagation is lowering the height of the cusps. This reduces the leverage forces on the tooth, making it less prone to flex and crack.

  
  

• Material Indifference: Capping cusps stops teeth from splitting, regardless of the material used (amalgam, composite, onlay, crown). However, composite will wear significantly over time.

  
  

• Root Canal and Crowns: A common misconception is that all root-canaled teeth need crowns. The actual finding is that root-canaled molar teeth should have their cusps capped.

  
  

• Clinical Decision: For severe cracks, especially on second molars which are prone to catastrophic vertical root fractures, cuspal coverage with a stronger material (like ceramic) is preferred, even if it means removing more enamel initially.

  
  

9. Financial Considerations and Patient Communication

• Money Matters: Most patient unhappiness stems from financial issues.

  
  

• Delaying Major Dentistry: It is often better to delay major dentistry than to do a "compromise" treatment that won't work long-term.

  
  

  • "Rehab Shelf": Patients can be put on a "rehab shelf" until they are financially or personally ready for extensive treatment.

    
    

  • Pre-framing Costs: Give patients a rough outline of potential costs for ideal treatment early on.

    
    

• Patient Choices for Elective Work: Ask the patient how they prefer to approach elective work (all at once, wait until it breaks, or one tooth a year). This is not a clinical decision, but a patient preference.

  
  

• Making Recommendations: Dentists should confidently recommend the best treatment option.

  
  

  • Clear Options: Say, "This tooth is badly damaged. I recommend you get ceramic if you can afford to. If you can't afford to, we will do plastic." Then, shut up and let the patient decide. Avoid overwhelming patients with too much information.

    
    

• Documentation: Crucially, document all discussions with the patient, especially regarding their decisions about not pursuing recommended treatments (e.g., orthodontics, implants). This prevents the "If I had known" complaint.

  
  

10. Technical Aspects of Restoration Placement

• Core Build-up: When replacing old restorations, build the core material out to the ideal margins so the tooth is "like new again" before prepping for the final restoration.

  
  

• Vertical Crown Preps: These preps don't have a distinct margin, offering flexibility in margin placement (within ~0.5mm). They are aesthetically good in areas of dark teeth and thick tissue. However, they can cause slight gingival inflammation as they act like an overhang (though natural teeth also have overhangs).

  
  

• Managing Difficult Impressions/Bleeding: If getting a good impression is difficult due to bleeding or time constraints, put on provisionals and bring the patient back another day. Stress impairs decision-making.

  
  

• Crown Seating: For tight crowns, try wedging teeth apart or placing crowns in a specific order.

  
  

• Resealing Crowns: If a crown comes off without caries, it can be re-cemented successfully, but requires proper technique (sandblasting, anesthetizing, retraction cord) and should be charged appropriately.

  
  

11. Deciding on Restoration Type and Bonding Method

• Direct vs. Indirect: Guided by ease of the "good job".

  
  

  • Direct (Composite): Easier for small lesions (e.g., small DO caries) where extensive prepping for indirect is unnecessary.

    
    

  • Indirect (Ceramic Crown/Onlay): Easier for large restorations (e.g., MODL composite, replacing entire cusps) that would be difficult and compromised with composite.

    
    

• Bonding vs. Cementing: Again, guided by ease.

  
  

  • Bonding: Easier if the prep is largely supragingival and a dry field can be maintained easily. Allows for more flexible "Franken prep" shapes.

    
    

  • Cementing: Preferred if the prep is largely subgingival with bleeding or moisture control issues, as maintaining a dry field for bonding would be "super difficult". Isolation for cementing is often as important as for bonding.

    
    

• Chamfer vs. Vertical Margins: Guided by ease.

  
  

  • Chamfer: Easier for teeth not badly damaged, as it can be done supragingivally, providing sufficient thickness for aesthetics and strength.

    
    

  • Vertical Prep: Much easier for subgingival caries or deep distal carries, as it eliminates the distinct margin, offering flexibility in where the crown finishes.

    
    

In essence, successful treatment planning involves a structured, big-picture assessment that integrates aesthetics, function, and patient goals, followed by strategic decision-making regarding material, technique, and timing based on clinical ease, prognosis, and the patient's financial and personal circumstances.

Clear communication and meticulous documentation are paramount to managing patient expectations and ensuring long-term satisfaction.

Dr. Noor N. Ay Toghlo, BSc, DMD

drnoordmd.com/about