Basic Rule 3: 3 Reasons for Treatment
People seek dental treatment for three main reasons: appearance, comfort, and function. Dr. Earl Pound spoke and wrote about this concept decades ago and in today’s supercharged world of cosmetic dentistry these words still hold as true now as they did back then.1 Dr. Pound was a removable prosthodontist who realized that the main reason that people sought out his services was for appearance, however, he also realized that the patients would never be happy with their appearance unless they were comfortable and functioning satisfactorily. We see this often in our practices. A good example is a procedure such as anterior veneers. Let’s say for example that a patient has some cervical temperature sensitivity after cementation of some freshly placed maxillary central incisor conservative laminates. Chances are that the patient will inspect their new restorations to possibly find a minuscule amount of root exposed on one of the teeth. A minor discomfort issue might then escalate to an appearance concern. On the other hand, let’s imagine that one of the new veneers is contoured incorrectly in the incisal one-third such that phonetics (ie. function) is altered. They are unable to say “F” as they did before. The patient might once again inspect their new restoration closely and once again an appearance concern might ensue. It is of critical importance therefore to listen to patients’ chief concerns and although cosmetic or esthetic priorities quite frequently top the list, the prudent practitioner must identify discomfort and dysfunction considerations first.
Discomfort concerns are either of an acute or chronic nature. The dental profession has become very proficient over the last century in handling patient acute pain situations. Prompt, efficient care is important and we can thereby move forward with our treatment in a timely and sequential manner after we address the acute concern. Chronic pain is another matter. It’s as if the average practitioner runs for the hills when confronted with a patient or patients with conditions such as long term TMD (temporomandibular disorders). Interdisciplinary care is widely preached and encouraged by academics and leading clinicians but sadly this aspect of it is commonly ignored. More frequently the sexier and more lucrative cosmetic dental disciplines get the limelight unfortunately.2 There are many fine, contemporary textbooks available that cover the topic of patient discomfort, that are easy to read and allow immediate clinical application.3,4 Please avail yourself of this literature or refer your patient to other health care providers in a timely fashion in order to provide optimal care and service for your patients in an evidence-based manner.
Dysfunction is multifaceted and it also needs to be definitively addressed as well before moving forward with oral rehabilitative treatment, comprehensive or not. Dysfunction can be psychologic, physiologic, anatomic, behavioral, or pathologic. We have to identify which one it is and either structure a program to deal with it or refer to another medical or dental health care provider. If the dysfunction is related say, to bruxism, then patient education and appropriate follow-up (ie. evaluation, differential diagnosis, and preliminary treatment plan) is indicated. For bruxism as an example, the patient would be educated on diurnal bruxism (ie. “keep your teeth apart”) and for sleep-time they would be advised that bruxism is now considered a sleep movement disorder.5 The later would be managed with a sleep-time only orthotic use and referral to a sleep clinic for assessment would be offered.6 Oral rehabilitation could then proceed following The Basic Rules of ...
Appearance dentistry is driving the dental industry today with unprecedented demand for cosmetic services. I hope that I don’t have to remind you that esthetic and cosmetic dentistry are not one and the same. Cosmetic dentistry can’t always be made esthetic but esthetic dentistry can always be made cosmetic. Cosmetic is defined as “superficial measures to make something appear better”, whereas esthetic is defined as “pertaining to a sense of the beautiful”.7 It’s esthetic dentistry then that will make our patients happy with their appearance more times than not. There are many books available to help clinicians understand and practice smile design and facially generated treatment planning that is highly esthetic (and cosmetic if the patient so chooses). 8-14 This essay series will address esthetic dentistry in detail as we go through The Basic Rules.
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Knowing the three main reasons why patients come to our office is an essential overall concept to understand, but defining what could go wrong with our oral rehabilitations and why, is mandatory. The answer I break down into three main areas: diet, hygiene, and parafunction. All three of these etiologies can be prevented only by the patient. Poor dietary choices, bad hygiene, and relentless bruxism are three vices to make our patients aware of and if we can, then we are well on our way to a successful post-treatment scenario. We act as the facilitators of dental education and patient oral care. Failure to properly educate and monitor these three etiologies will be our undoing. That is why excellent communication and rapport are essential before embarking on a major undertaking such as an oral rehabilitation.
Dr. Pound was right about appearance, function, and comfort. Dr. Pound also developed and enhanced a total body approach, not just the teeth and smile, to his patient care experience by discussing with patients general health guidelines many of which are standard today. He discussed with his patients the importance of exercise, diet, vitamin and antioxidant protocols. When his patients came to him with one of the reasons for treatment, he dealt not only with their chief concern, but he also gave them a whole lot more and never forgot that the patient would never be happy with their appearance unless they were comfortable and functioning satisfactorily.
Further Suggested Reading and References:
1. Pound E. Lost – fine arts in the fallacy of the ridges. J Prosthet Dent 1954;4:6-16.
2. Roblee RD. Interdisciplinary dentofacial therapy: a comprehensive approach to optimal patient care. Chicago: Quintessence; 1994.
3. McNeill C. Science and practice of occlusion. Chicago: Quintessence; 1997.
4. Okeson JP. Orofacial pain: guidelines for assessment, diagnosis, and management. Chicago: Quintessence; 1996.
5. Blanchet P, Rompre P, Lavigne GJ, Lamarche C. Oral dyskinesia: a clinical overview. Int J Prosthodont 2005;18:10-9.
6. Racich MJ. Predictable fabrication and delivery technique for full-coverage hard acrylic non-sleep-apnea dental orthotics. J Can Dent Assoc 2006;72:233-6.
7. Flexner SB, ed. The Random House dictionary of the English language. 2nd ed. New York: Random House; 1987.
8. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition. A biomimetic approach. Chicago: Quintessence; 2002.
9. Chiche GJ, Aoshima H. Smile design: a guide for clinician, ceramist and patient. Chicago: Quintessence; 2004.
10. Fradeani M. Esthetic rehabilitation in fixed prosthodontics. Vol. 1 & 2. Esthetic analysis; Prosthetic treatment. Chicago: Quintessence; 2004, 2008.
11. Racich MJ. The basic rules of oral rehabilitation. Markham: Palmeri Publishing; 2010.
12. Racich MJ. The basic rules of occlusion. Markham: Palmeri Publishing; 2012.
13. Racich MJ. The basic rules of facially generated treatment planning. Markham: Palmeri Publishing; 2013.
14. Racich MJ. The basic rules of being a dental patient. Markham: Palmeri Publishing; 2016.