Ten Steps to Creating the Interdisciplinary Team

John C. Cranham, DDS

With nearly 25 years of restorative dentistry experience, this author has arrived at one conclusion: cases with less-than-desired outcomes resulted from attempting to solve an arch-to-arch, tooth, or a gingival position problem with restorative dentistry alone. Because this author was not trained to appreciate some of the preoperative issues, an incomplete treatment plan made many of the outcomes less desirable, either cosmetically or functionally. Simply, ideal outcomes include:

1. The dentition should have properly aligned skeletal components when the temporomandibular joints (TMJ) are fully seated in centric relation (CR). The maxilla and mandible should be properly positioned sagittally and transversely to allow teeth to erupt into an ideal Class I relationship.

2. Every tooth should fit within each properly positioned arch and be aligned to have the forces over the long axis of the root, as well as have an ideal rotational position, to optimize patient self-care.

3. The periodontal structures should have no inflammation, no pocket depths greater than 3 mm, sufficient attached tissue on the buccal and lingual of each tooth, and a balanced and correctly positioned gingival frame in the esthetic zone.

4. Each tooth to be restored or replaced should provide an ideal biomechanical result, conserving tooth structure, and enabling maintenance of oral care (easily cleanable).

Essentially, problems in restorative dentistry arise when the necessary preprosthetic procedures that will ensure success are not treatment planned. Restorative dentists should become familiar with all procedures that their specialist colleagues offer: then these procedures will be incorporated into the patient's treatment plan and the necessary referrals made.

The key is to build a team of like-minded, dedicated professionals who share a common goal of providing optimum oral healthcare to patients. This article explores a step-by-step process for creating and developing the interdisciplinary team.

1. Shared esthetic goals

One of the best ways to improve the esthetic eye of each team member is to look at a variety of cases. (Step 5 includes the 16-step checklist that clearly identifies both the key esthetic and functional goals.) If an orthodontist, oral surgeon, periodontist, and restorative dentist each evaluate essential photographs (smile from three views, retracted three views, full-face, profile, rest, "e", and tipped-down smile), they will likely have different observations. A good exercise is to pass around the photographs and have all team members record their observations prior to any discussion. Once everyone is finished, each team member should describe what they saw. The goal is that the team arrive at similar views about the case and each member is aware of all treatment options for this patient.

At the Dawson academy, there are 12 specific criteria used to create ideal esthetics. If any component is missing, the goal is to find the most conservative way to fix the esthetic problem. The options for correction involve the "4 Rs":

1. Reshaping

2. Repositioning (orthodontics)

3. Restoring

4. Repositioning bone (orthognathic)

It is important to look at these options in order. Orthodontics should always be considered prior to restorative dentistry.

2. Shared functional/occlusal goals

There is little disagreement about the factors that create an optimum smile; however, arriving at a common occlusal philosophy among a team of dentists can be challenging. At the Dawson Academy, a high level of importance is placed on TMJ health. Developing a collective philosophy on the diagnosis and treatment of joint problems needs to be central to the team approach.

Dentists who train with the Dawson Academy often note that patients have poor occlusions following orthodontic treatment. To maintain certain standards, restorative dentists should cultivate and develop a relationship with an orthodontist who shares their vision. This requires time and some persistence; however, the rewards are considerable. An orthodontist who will work in CR and can consistently create anterior coupling with posterior disclusion is invaluable.

3. Shared biologic goals

Dental professionals agree that the dentition should have no gingival inflammation, periodontal disease, and dental caries. This requires all interdisciplinary team members to be focused on ensuring the patient has excellent oral self care and any biologic issue be addressed quickly. Special emphasis is placed on creating ideal tooth position and appropriate tooth contours to maximize the self-cleansing nature of natural tooth structure.

4. Common approach to record gathering

The interdisciplinary team should share as many records as possible, including photographs, computed tomography scans, x-rays, and mounted diagnostic models. A patient will be discouraged by being referred to multiple practitioners only to have diagnostic procedures repeated. Traditionally, this occurred in the multidisciplinary care approach with dentists working independently of each other. However, interdisciplinary care promises a cohesive approach among multiple oral care providers. The best way to impress a patient is to demonstrate a congruent, consistent diagnostic protocol that only happens once. Then the team meets and generates a treatment plan that encompasses the work of all dentists involved.

Early in the process, the team should decide what each member requires to make a diagnosis. Who will take the film if cone-beam computed tomography is needed for evaluating a TMJ or bone quantity/quality prior to implant placement? Which articulator system will be used? Who should duplicate models or provide multiple pours of a polyvinyl siloxane impression to prevent retakes? If this is decided in advance, the patient experiences a seamless, congruent course of treatment.

5. Systematic approach to treatment planning

In school, dentists are trained to fix teeth in the position in space that they are in. Generally, in patients who need an interdisciplinary team, the teeth or dental arches are not in the correct position. These cases require thorough records and a careful analysis.

While examining the step-by-step approach to treatment planning is beyond the scope of this article, the use of checklists is extremely beneficial, providing a framework for each team member to analyze the pretreatment records. The 16-step functional esthetic checklist (available at https://www.thedawsonacademy.com/Websites/dawsoncenter/Images/16Steps_to_FE.pdf) is the starting point of analysis. Using a checklist will help the team identify all esthetic and functional problems prior to treatment planning.

6. Learn the treatment options of each member

One of the important responsibilities of the restorative dentist is to be aware of all the treatment modalities that the specialists offer. Knowing how they do it or what materials they will use is not necessary. However, the practitioner must recognize when it is needed. This author's favorite part of every monthly meeting is to identify a specific problem, then listen how the team can creatively tackle the problem using conservative means; this is an amazing opportunity to learn about the specialty disciplines. The more each team member understands each other's capabilities, the more the team starts functioning as a unit. This leads to the appropriate cross referrals at the proper time without compromising care.

7. Meet regularly

Although challenging because of busy schedules, regular meetings of the interdisciplinary team are essential. This author's team meets once a month immediately after work, typically for 2 hours. The key is to maintain a regular schedule, have office staff help coordinate-and commit to meeting.

While it may be tempting to turn this monthly meeting into a "study club" to which other dentists are invited, this author strongly recommends maintaining focus only on the patient cases that the team is evaluating, which will strengthen the relationship between the professionals.

8. Make it fun

Working with like-minded colleagues is more rewarding and engaging than functioning alone. When interdisciplinary care is indicated, the outcomes are often improved. Along with the team's regular monthly meetings, taking continuing education courses together and meeting socially will create camaraderie. The most successful teams have mutual respect and concern for each other-and patients can sense this. Congruency and respect will naturally lead to increased case acceptance, better patient care, and healthier practices for each member.

The Dawson Academy's Interdisciplinary Treatment Planning class for 2011 is designed for students to invite their orthodontist, surgeon, and periodontist to solidify these relationships. The 3-day program will include hard work pursuing a common path of excellence, while providing an enjoyable environment to create lifelong relationships.

9. Celebrate success

One of the more difficult aspects of interdisciplinary treatment plans is the time required to complete these cases. Often, the process may require 2 to 3 years for a patient who receives orthodontics, orthognathic surgery, dental implants, and restorative dentistry. Because the restorative dentist often takes both the initial and postoperative photographs and records, a system must be created to share this information with the specialists involved.

If it is following the protocol recommended in this article, the team should meet regularly, and the scrutiny of cases that are being completed will be a standard item on the monthly agenda. For any specialist who does not have a long-term relationship with these patients, this step is extremely important. Frequently, these professionals will only see the result in the middle of an interdisciplinary plan. Seeing the philosophy in action becomes a great motivator for each dentist. Celebrating a job well done creates the energy that will take the team to the next level.

10. Learn objectively from the cases that fall short

While failures or cases that fall short may be discouraging, they are also invaluable learning experiences. Each team member must be completely objective when analyzing the post-treatment records. Only then will improvements to protocol and creative solutions for patients be developed.

Conclusion

As dental professionals, we are practicing in very interesting times. The aging baby boomer population is predicted to live longer than previous generations, while also retaining a greater number of natural teeth. In addition, this group is spending billions of dollars on appearance-related issues. These factors are resulting in more complex dental cases. No longer can the restorative dentist work in isolation in the pursuit of optimum care. Establishing relationships with like-minded specialists is imperative for success in today's competitive marketplace.

Patients are well educated and have high expectations in regard to their care. With the economic downturn, these same patients are looking for ways to segment their dentistry, sacrificing time but not quality. Interdisciplinary planning often results in less dentistry and a superior result. Because treatment is phased, patients can spread out the costs. While this may initially appear to lower the restorative dentist's income, successful outcomes lead to satisfied patients, which results in increased referrals. This win-win approach to patient care requires time and commitment, but this author believes it is the only way to practice.

About the Author

John C. Cranham, DDS Clinical Director, The Dawson Academy Chesapeake, Virginia