Various dental treatment plan choices may well serve you as the patient, but each may have advantages and disadvantages. You need to consider these before you can make an informed CHOICE!

Nine different issues will be considered here that may impact your choice dramatically.

You must realize that all dentists are interested in having you accept their plan – but it is up to you to decide if that plan is really in your best interest. You must distinguish between the dentist that simply wants to do complex procedures for the financial benefit to him/her from the dentist that has YOUR best interests at heart.

You may want to check out an article written FOR dentists to help them learn to be better salesmen. It is a reality that a dentist has to earn a living too – but DO they really believe in what they are selling you?

They may choose to educate you to help you make a decision, but this education may be selective. The purpose of this site is to educate you more completely, generally and above all independently, so you will have a much better idea about the truth of what you are being told.

Organization of this Chapter

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Basic Issues to Consider

1. Patient Finances

2. Patient’s Age

3. Patient’s Desires and Intentions

4. Esthetic Needs versus Wear

5. Home Care Performance

6. Dexterity

7. Professional Situations

8. Habits

9. Quality of Life

Bottom Line for Alternative Treatment Plans


Dental Treatment Plan Choices: Basics

The last chapter went over the basic sequence of pr ocedures that may constitute the entire treatment plan for a patient. Clearly not everything may need to be done for every patient, but the order of what DOES need to be done is critical.

We discussed procedures that were the most likely to be needed under various circumstances, but this was for the most ideal of situations. There are many things that determine whether a given treatment plan is really appropriate for a particular patient or not.

I’ve developed comprehensive treatment plans for some patients that could not get approved by the insurance company. I’ve developed comprehensive treatment plans for some patients that just couldn’t afford to do everything the “right way”. I’ve NOT developed treatment plans for patients that could have used some improvement in their function or appearance, but were at a time in their life where it didn’t matter that much to them.


1. Patient Finances

In this chapter we’ll discuss more about that some of the options are, and what are some of the patient factors that would suggest these options. Everything will be focused on the patient factors.

Clearly finances is a huge matter, maybe the biggest. When approximately half of the U.S. population would have to ask a friend to loan them $400 for an emergency need, in that they have no savings and have maxed out their credit cards, the cost of what is proposed must be carefully considered.

Depending on the demographics of the practice, most people could afford an expensive treatment plan, or nobody could! Where I live in Orange County, California – people in Newport Beach on the average can afford any treatment plan that is needed, and, for example no amalgam restorations have been done for years; whereas some 10 miles away there are towns where amalgam would be the most appropriate restoration for pretty much everyone, due to lower cost and longevity.

When a dentist chooses the town in which he will build his practice, he should be very much aware of the financial constraints of the typical person in that town. In California we have DentiCal, which for decades has provided dental care to those in need – and this still applies to adult patients, but the coverage is more limited than it once was.

Any dentist can decide whether he/she wants to be the dentist to the stars, or a dentist that will help someone that needs help and give them the best of what they can afford.


2. Age

The age of the patient, in and of itself, is not an important issue, but patients of certain ages tend to have common attitudes about the work that might need to be done. A patient in their 80s is less likely to be concerned about appearance than one in their 40s.

On the other hand, my 25-year-old students are often surprised when I tell them that there are many 70 year old men and women out there on dating sites looking for companionship – and they want to look as good as anyone else!


3. Desires and Intentions

It may be that a given patient is mostly just concerned about getting out of pain, and how you do it and what the restoration looks like at the end is not that important. They want to be comfortable and perhaps chew efficiently and bite evenly, and as long as those needs are met, whether there is a silver or gold restoration in the back of the mouth, or it is porcelain or composite makes little difference to them. Of course, when the dentist educates them about the pros and cons, they will elect to go with the most cost effective, short and long term.

If appearance is important as well, all of the compromises that must be made to preserve or improve appearance must be elaborated and explained to the patient.


4. Esthetic Needs versus wear

If the patient is coming in specifically to get help with their appearance, that is another issue entirely. But the dentist still has the responsibility to make sure that he/she does no harm!

With esthetic or cosmetic cases it is likely that porcelain will be used as the restorative material, either in full crowns, onlays, porcelain veneers, or layered on top of metal. In any of these instances, we need to be concerned about the wear to the opposing teeth. It is up to the dentist to inform the patient about this possibility, and advise them appropriately, and perhaps even to design an altered plan, even a more expensive one, that will prevent this kind of damage. If the patient tends to grind their teeth anyway, a detailed study must be made to see if cosmetic restorations can be done that won’t cut the opposing teeth in half!

There was a guy I met some years ago and talked with for about a minute in an art gallery. He had had porcelain crowns done on all of his front upper teeth – and obviously so because they were way too white compared to the other teeth in the mouth, and had a pasty rather opaque look to them that was not natural for any age. He was probably in his late 70s. The LOWER incisors were ground WAY down, so far that the pulp had receded far below its natural position, by virtue of depositing secondary dentin in the pulp chamber. This secondary dentin was exposed on the visible surface of the tooth, and stained red because of its greater porosity. NOW THAT is a bad look, especially because he had a smile line that showed all of his lower teeth. An alteration in the treatment plan for him should have been done that would have cost somewhat more, but would have potentially eliminated the possibility of that ugly wear to the lower teeth!


5. Home Care

If a patient has not demonstrated that they can keep to a good and effective program of home care, there are certain kinds of dental restorations that should not be offered – because they are doomed. Implants and bridges to replace missing teeth should be passed by for the less expensive and less demanding partial denture. Yes – the need to take the denture out at night is unappealing for many people, but the expense of an implant and crown, or a bridge, which is lost later because of neglect is even more unappealing perhaps.

As the patient goes through cleaning, and potentially a root planing program in the office, and the hygienist evaluates periodically the pocketing and form of the gingival tissue and propensity for bleeding of these tissues, it becomes quite clear if the patient is doing at home what they have been advised. It should be made clear to them up front that any further work that needs to be done can easily be compromised by poor home care, and that their treatment plan will need to reflect the level of responsibility they are willing to take for their own teeth.

That being said – it is always a fact of life that if the patient finds another dentist who is not so careful, and who will just do the work irrespective of the patient’s home care, they may elect to have that dentist do the work. This will be sad because all that money is destined to be wasted.


6. Dexterity

Not everyone has the same level of manual dexterity, either through challenges in awareness of precisely where their fingers are in relation to their mouth, or because of issues with respect to movement of their fingers, or strength in their fingers.

I am reminded that the inability to SEE what you are doing will not hamper the ability to do needed home-care. This was amply proven to me by a blind patient that was in my practice.

Dexterity must be taken into account for certain types of treatment plans. If it is clear that the patient will have to not just brush well, but floss well also, and that the longevity of the chosen restoration may depend on their skills – their level of skill in this area determines the plan. The hygienist can help the patient learn how to floss, but if it does not come easily it probably won’t get done – and this needs to be considered.

Also, if the patient is going to wear a partial denture, the ability to position it in the mouth where it should be and then exert a force in a particular direction to get it to seat on the teeth is important. If a patient doesn’t have that kind of tactile or positional awareness, partial dentures could be challenging, or a design that is less dependent on manual dexterity may be planned instead.

Maybe the patient can get a partial denture IN, but cannot get it out! The dentist COULD have designed the denture to make this easier for them, even though the design would be different than most other people would need.


7. Professional Situations

If the patient has a professional life where their appearance is important, the plan needs to reflect this. It may be that dentistry that was done in the past is failing or not looking well managed, or makes it look like the patient can’t afford better work, and this casts negative impressions about the patient with his professional colleagues or clients. Such a patient with a partial denture could be fine, but if one of the clasps shows when the patient smiles, it generates an unconscious story in the mind of his/her clients – which may not be helpful.

Before I studied dentistry I remember a colleague that had a partial denture, but I did NOT know what it was. All I was aware of is that there was some king of metal piece wrapped around a tooth, that was visible conversationally. It generated the sense in me that something was wrong.

When a professional is working to improve something about the lives of their clients, the client wants to see that the care that they take of themselves would be consistent with the care they want to be offered. If the dental appearance suggests carelessness or a lack of resources, it strains the client relationship.

On the other hand, I know plenty of artists who sell their work for many thousands of dollars, where the appearance of the artist is not a factor at all. It may go the other way – if the professional artist is putting all of their care and creativity into a masterwork, that is to the benefit of the purchaser of the work!


8. Habits

There are a few habits that can alter a treatment plan – the most obvious is when someone persists in opening bottles of beer using their TEETH! OK – so a lot of bottles have twist off tops these days, but I think it was always the “macho” thing ….

But tongue thrusting is also a habit that can cause the upper front teeth to protrude, and if started at a young age can generate an open bite in the front of the mouth. This can be corrected in many instances, but it is the HABIT that needs to be corrected or things may relapse to the old positions.

Of course, grinding is a habit too, and we’ve talked a lot about that – but the fact that a person grinds their teeth can completely alter the plan, just because any porcelain that is placed in a person like this can destroy the opposing teeth.

But – also, the amount to which the grinding has already damaged the teeth needs to be taken into account. I had a patient once that had ground the front teeth so much against each other that the top ones, from canine to canine, had huge concavities on the lingual surfaces. These concavities were so big that there was practically NO tooth structure left on the facial side of the teeth. They LOOKED pretty normal conversationally, but at any moment the remaining enamel could just break off. These teeth could NOT be restored by simply doing a crown, because there was nothing to hold on to, and if these concavities were filled in there would be no place for the lower teeth to go, as they ground their way into the upper teeth in the first place! Even if root canals were done on each of these anterior teeth, crowns could be made, but still wouldn’t fit the lower teeth. In this type of case the only solution is to CROWN EVERY TOOTH IN THE MOUTH – opening the bite again so there is room to restore the teeth back to their original contours. Now THAT is an expensive treatment plan.


9. Quality of Life

Everyone has a different sense of what their quality of life should be like. Is the dentist going to design a treatment plan that will make their quality of life better, or not really change it at all?

I had a 93 year old patient once that had such a strange collection of teeth in her mouth, with so many really strange situations, that to design a rational treatment plan for her would be almost impossible without tremendous trauma and cost. She was missing a lot of teeth, but her smile had kind of adapted itself to the loss and talking to her was quite pleasant, even for someone aware of missing teeth professionally. She actually came to me because she had had a tooth extracted in the front and the gum was hurting her, because her previous dentist had left a sharp bony ridge near where the tooth was extracted. As soon as I opened the gum up and recontoured the ridge, she was comfortable and quite happy. She would eat, she could converse – she got along just fine, and I never suggested anything intrusive to her because it just was not appropriate for her.

That’s not to say there isn’t a healthy 93 year old out there that cares about their appearance because they spend all there time hanging out at the senior center with members of the other gender! For them the dentist might well be advised to explore certain procedures that would not be too traumatic that could improve appearance if not function.


Dental Treatment Plan Choices: The Bottom Line

Everyone is different, and viva la difference! As a dentist it has always been my greatest pleasure to experience life through so many other people’s eyes and needs and wishes and abilities – and to conform my service for them to their complex collection of limitations.

Every dentist should be WIDE OPEN to any alterations in plan that make sense for their patient. Some dentists seem not willing to avoid the destruction of their patient’s financial condition, whereas others are supremely cognizant of this responsibility and will customize the work to the patient’s totality of needs.

It is ironic that starting in the late 80s many dentists started billing themselves as “holistic” dentists, precisely so they could suggest to their health-minded patients that amalgams should be removed and replaced with composite. There was great money in doing this. The pitch was that the patient’s HEALTH would improve, which, of course, it would not. But their financial situation could have been impacted very adversely – especially as many of these dentists weren’t careful about the quality of their work, and the restorations they placed had to be replaced in just a few years. If a “holistic” dentist ever considered the WHOLE patient, I never saw one. I have seen the results of their work, however – and I simply urge caution.

That being said – there ARE oral conditions that can compromise overall health. Even the continued existence of an inflammatory response in the mouth can drive a systemic immune response which can produce physiologic and even emotional stress. I will elaborate more on this in another Chapter. And I’ve already discussed the stress that can arise from a bite that is disorganized.

The majority of dentists are quite responsible for presenting treatment plans that are designed with the patient’s life as well as their mouth in mind!

But, it is the presence of dentists with the diametrically opposed approach that makes this site necessary.