The Fully Integrated Practice

Alex Touchstone, DDS

What a privilege it is to be a dental professional! We are blessed to be members of a profession that allows us to be of maximum service to others in the normal course of a day. We are currently in an era of accelerated innovation and increases in efficiency that dramatically improve our delivery of care. Through that care, we literally change the lives of our patients for the better. We enjoy a level of professional reputation, financial security, and personal freedom that is, especially now, virtually unparalleled in other professions. When high ethical standards, sensitivity to patients’ needs, and proper application of technological advances meet, success results.

We as dental professionals tend to measure success in a more technical, scientific sense than our patients. Facets of success from our perspective include desirable treatment outcomes, workflow efficiency, predictability, and profitability. Our focal points are thus:

1. Certainty of the diagnosis
2. Stress index of the proposed treatment
3. Time cost vs fee for the procedure
4. Longevity potential
5. Esthetic outcome

Our patients, however, operate by and large on another plane of thought—the emotional. The patient is typically asking these questions relative to proposed treatment:

1. Will the procedure hurt?
2. How long will it take?
3. Can I trust this provider to deliver a result I expect?
4. How long will the restoration(s) last?
5. What will I look like?
6. What will this treatment cost and is it a good value?

From the moment the patient first makes contact with our practice, the search for answers to these questions begins. The answers arrive through multiple channels of communication: verbal, visual, body cues, team cohesiveness, and other environmental factors. For instance, we all love a warm smile and a friendly greeting. When a patient is greeted in such a manner, a positive connection is made that sets the tone for the remainder of the encounter.

The term “fully integrated” defines a practice environment where our technical parameters of success harmonize well with our patients’ more sensate point of view. To be fully integrated, equal consideration must be given to the both the patient’s desires and our goals and objectives. With the concept of a fully integrated practice as a benchmark for success, we may evaluate the overall patient experience. Take, for example, one of the most common dental problems a typical patient presents with: a cracked, decayed molar and resultant irreversible pulpitis.

The Old Paradigm

For those of us who have been practicing for more than a couple of years, we remember a day where this patient’s initial visit probably progressed in the following manner: The patient would be seated, a medical/dental history taken and an initial clinical exam performed. The diagnostic process would also include film-based radiographs that require time-consuming processing that involves the use of toxic, environmentally hazardous chemicals. The exposure of film-based radiographs would necessitate a much higher radiation dose than that required for digital sensors. Moreover, because the tooth is cracked, two-dimensional radiographs alone may be insufficient to visualize the location and extent of the fracture, so we might have augmented that diagnostic tool with percussion tests and local anesthesia in an attempt to isolate the origin of the pain. Obviously, a thorough and comprehensive examination would also include a complete analysis of the sextant or quadrant, patient medical and dental history, chief complaint, percussion, palpation, cold tests, EPT, tooth mobility, probing depths, and evidence of occlusal disease, etc. About 30 to 45 minutes into the visit, we arrive at a diagnosis and treatment plan.  

At this point, we would seat the patient upright and begin to explain, with a bit of technical jargon, that he or she needs a root canal, possible post and core, and porcelain restoration. We further explain that the process will involve one to two visits for the root canal and two additional visits for the final restoration. We ask the patient if he or she understands or has questions, to which they simultaneously nod and shake their head in the subdued anxiety of the inevitable. We pat the patient on the shoulder as we leave, while giving the assistant the nod to route the patient to the treat-ment coordinator for dialogue over fees, insurance, and scheduling.    

To us, this scenario seems perfectly reasonable and on some level, it is. But as we revisit the questions a patient asks in relation to this example we begin to find chinks in the armor. First, we failed to show the patient anything visually meaningful that explains the diagnosis, falling back on the “trust me, I am a trained professional” position. The radiographs we used in the diagnostic process were less than ideal in that they may not have shown the fracture or the location and topography of all of the canals. Then, we presented a treatment scenario that involves multiple visits. All the while, the patient is scanning the room for visual cues as to our abilities and possibly looking for the nearest exit! The net effect is that the patient is understandably less than enthused about moving forward.

These gaps in communication and uncertainty in the diagnosis and treatment plan inevitably lead to less predictability in the treatment outcome. Complications along the way could include incomplete obturation, lack of patient compliance—especially once the patient is pain free, and problems with the temporary crown, to name a few.

The New Paradigm—Our Perspective

Today, we have the freedom to progress through such an event in a much more predictable, efficient, and comfortable manner. Going back to the beginning of the appointment, our first opportunity for improvement lies in the radiographic diagnosis. In the new paradigm of the fully integrated practice, we use a digital intraoral sensor to gain an instantaneous view of the tooth in question and this leads to a preliminary diagnosis within a couple of minutes (Figure 1). Let’s assume that this patient is one who has been in the practice for a while and at a previous comprehensive exam we took a cone beam CT scan and thus we have this on file. We simply call up the scan data and tour through the tooth in individual slices in a variety of planes to gain a clear understanding of the canal morphology (Figure 2 and Figure 3). The application of CBCT in endodontic diagnosis is well-documented in the literature.^1-3 With the additional understanding of the situation that CBCT provides, we are better able to determine exactly how to approach the instrumentation and whether a referral to a specialist is in order. Our patient sees us doing this and asks questions that imply a heightened interest in their condition. Next, we take a digital photograph of the tooth to give the patient a powerful visual of exactly which tooth is the source of the pain and the true extent of the decay (Figure 4). We present the treatment plan along with fees and insurance benefits chairside as an organic part of the conversation.

Clearly, the digital workflow is beneficial throughout the diagnosis and treatment plan. Working in the digital realm becomes even more powerful during the restorative process. Instead of a three- to four-visit treatment sequence, we use rotary instrumentation and a chairside CAD/CAM restorative method to complete both the root canal and the final restoration in a single visit. Everything we need is literally within our reach in the operatory (Figure 5). The treatment workflow involves giving anesthesia, accessing the chamber, and beginning instrumentation to the point that hemostasis is achieved. Next, the tooth is prepared for the final restoration and a jacent tooth structure is acquired in seconds using an optical camera (Figure 6). Likewise, a bite registration is imaged as well with equally high efficiency and precision.⁴ The restoration is designed, a block of ceramic is selected, and the milling process is begun. During milling, the instrumentation and obturation of the canals are completed. The restoration is then finished and bonded using generally accepted bonding techniques. The precision of marginal fit, occlusal fit,⁴ and excellent longevity⁵ have been well-documented in peer-reviewed journals and symposia.^6-9

The digital workflow as presented here leads to both a more predictable outcome and efficient use of valuable chairtime. While these are important factors, in order for this to represent a fully integrated practice as defined earlier, we should also consider the patient’s response.

The New Paradigm—The Patient’s Perspective

First, we can assume that the patient is not happy to see us. They are in pain; they know that they will probably need a root canal and crown and that the treatment will be expensive and possibly painful. What a way to start an encounter with a patient! It has been said that within every problem there lies an opportunity in disguise. In this instance, the opportunity comes in the form of giving the patient a surprisingly easy, painless, and rapid resolution. As the diagnosis crystallizes during review of the intraoral and CBCT radiographs and digital photograph, the patient is able to see clearly the care with which we are proceeding and he or she gains a better understanding and acceptance of the treatment plan. In that moment, a patient may say something like, “Dentistry sure has come a long way!” These words are magic. The patient is expressing a sense of ease, trust, and confidence.  

We then give the patient anesthesia to alleviate the pain. Depending on scheduling circumstances, we may even initiate and complete treatment that day. During the treatment sequence, the second key moment for the patient comes with the realization that no physical impression is necessary. What a relief! Next, they see their tooth preparation on a screen and further understand the magnitude of the problem as the solution in the form of a new restoration is created before their eyes. As we finish and show them their new tooth with a second digital photograph, they marvel at the natural appearance and smooth feel of the ceramic restoration (Figure 7). They thank us for taking so little time while giving so much attention to solving their problem (Figure 8).

The leveraging of carefully selected technologies and communication methods allows for a much smoother process. Along the way, our patients appreciate the fact that we addressed the questions that matter most to them. The result is a happy patient, a successful result, and a fully integrated practice.

Author’s Note

The reader is invited to learn more about the fully integrated practice concept online by visiting Dr. Touchstone’s Web site at www.fullyintegratedpractice.com. There you will find videos demonstrating in detail the digital workflows described in this article as well a feedback section to facilitate dialogue with the author.

References

1. Tyndall DA, Rathore S. Cone-beam CT diagnostic applications: caries, periodontal bone assessment, and endodontic applications. Dent Clin North Am. 2008;52(4):825-841.

2. Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J. 2007; 40(10):818-830.

3. Winter AA. Why CT scans are already the standard of care. NY State Dent J. 2007; 73(6):28-30.

4. Fasbinder DJ. Controlling the occlusion of single restorations with CAD/CAM technology. Compend Contin Educ Dent. 2005; 26(6A Suppl):439-445.

5. Fasbinder DJ. Clinical performance of chairside CAD/CAM restorations. J Am Dent Assoc. 2006;137(Suppl):22S-31S.    

6. Kelly R. Mach Cer. In: Mörmann WH (ed). State of the Art of CAD/CAM Restorations, 20 Years of CEREC. Berlin: Quintessence, 2006:29-38.

7. Krejci I: Wear of CEREC and other restorative materials. In: First International Symposium on Computer Restorations. Berlin, Germany. Quintessence Publishing Co; 1991: 245-251.

8. al-Hiyasat AS, Saunders WP, Sharkey SW, et al. The abrasive effect of glazed, unglazed, and polished porcelain on the wear of human enamel, and the influence of carbonated soft drinks on the rate of wear. Int J Prosthodont. 1997;10(3): 269-282.

9. Strassler HE. Applications of total-etch adhesive bonding. Compend Contin Educ Dent. 2003;24(6):427-441.

About the Author

Alex Touchstone, DDS
Private Practice
Charlotte, North Carolina