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Rule 3: 3 Reasons for Treatment

Posted By Stephanie Wilhelm, Tuesday, December 5, 2017

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.

 Three Main Reasons for Treatment:  Three Main Reasons for
Restorative/Prosthodontic Failure:
  • Appearance
  • Function
  • Comfort
  • Diet
  • Hygiene
  • Parafunction

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.


Tags:  Basic Rules  Racich  Treatment 

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Rule 2: Patient's Wants and Needs

Posted By Stephanie Wilhelm, Friday, August 11, 2017

The Basic Rules of …..

Basic Rule 2: Patient’s Wants and Needs


We all have wants and needs. Needs are necessities or obligations. Life rolls along a lot smoother if our needs are taken care of and we are not in “dire need” of the basics of life. Wants, on the other hand, are desires or wishes. What then do our patients want/need? It is critical that we identify their wants/needs before we embark on comprehensive care (Figure 1).

 Figure 1: We must understand our patient’s wants and needs


Sandy Roth in her book “Defining The Mission of Dentistry” explains that every patient is unique and every patient will always make a better decision for themselves.1 This holds true whether it is wants or needs based. Our job is to act as consultants and help our patients clarify their goals all within the confines of their reality, our core values, and accepted dental standards of care.2,3 We listen carefully to our patients in our initial interview and we define what the patient qualifies as a need and what is qualified as a want. We optimize the placebo effect (Basic Rule 1) by realizing that “everybody wants to be treated like a somebody”. Needs could be pain relief or cosmetic anterior tooth replacement. Wants could also be cosmetic anterior tooth replacement, for example a fixed partial denture, or replacement of non-tooth coloured restorations with tooth coloured. Although it is tempting to do what the patient wants as a priority, that approach might come back to haunt us later in the relationship. The patient has to be cognizant of the delicate wants/needs balance and make wise, customized decisions on the information provided.4,5 Clearly we need to address the patient’s chief concern (want or need) first, but it is essential that the patient’s needs are addressed as quickly as possible. The wants, after clarification and after realistic expectations have been set, are then addressed.


I don’t know about you, but we find that the more time we spend consulting with a new or existing patient, the fewer problems we have. We want to find out as much about our patients wants and needs to better facilitate their decision making. We consult as often as the patients’ requests. We keep the consultation visits to under an hour. Usually all that is required is just one consultation appointment. It’s probably because we have set in our minds that we are not in any hurry that it only takes one consultation. Having stated this, occasionally we might see the patient three or four times. Relationship building and clarification of patients’ wants and needs are too important to be rushed. Please do not forget that with each consultation we also thoroughly document what transpired.


In our practice our patients’ chief concerns are respected, be it needs or wants based. We are not foolish about this approach and it does have its limitations. For example, a patient presents with a chief concern of a cosmetic anterior tooth replacement, say a fixed partial denture, even though the patient in question has posterior edentulous areas with associated bite collapse. This is wants based. A needs based solution of posterior stabilization first with anterior fixed partial denture provisionalization or adhesive cosmetic bonding could readily satisfy the patient’s wants as well as provide the needed and necessary care. Whatever and wherever the chief concern leads us we definitely deal with needs issues in our practice as soon as possible before we tackle the wants knowing full well that it is the patient’s wants that motivate them to attend dental offices.6-9   Remember, we listen to our patients and respect their value system but work with our core values and accepted dental standards.10,11


There is another spin to this wants/needs equation that involves us, the team. As oral health care providers, we have needs such as seeing a certain number of patients and performing a number of procedures to provide our practices with a certain amount of cash flow. Qualifying the type of patients or procedures that we would preferably seek out to do, fits the wants department. This is all fine and dandy in a world where we could do whatever we want, provided we have the skill set. The need to pay the bills should not overcome our abilities to perform comprehensive dental care and the taking on of cases that are beyond our skill level.2 To improve our skill levels so that we can perform to a level that comprehensive care demands is noble and mandatory, and I encourage it before biting off more than we can chew. The dental team although faced with these practice considerations must look beyond their own plight to advance the cause of the star of the show, ie. the patients, and place their wants/needs first.


For the dental team a well choreographed balance between needs and wants has to be found for the patients’ best interests to be honoured. For the patients, they must be listened to.3,4,9-11  After the chief concern has been entertained their wants are addressed with respect for their needs. It’s a difficult balance to strike at times but with patience, perseverance, and proper planning we will get the job done to everyone’s satisfaction.


Further Suggested Reading and References:


  1. Roth SR. ProSpective volume two. Defining the mission of dentistry. Seattle: ProSynergy Press; 1995.
  2. Malament KA. Prosthodontics: achieving quality esthetic dentistry and integrated comprehensive care. J Am Dent Assoc 2000;131:1742-9.
  3. Schouten BC, Hoogstraten J, Eijkman MA. Patient participation during dental consultations: the influence of patients' characteristics and dentists' behavior.
    Community Dent Oral Epidemiol 2003;31:368-77.
  4. Liebler M, Devigus A, Randall RC, Burke FJ, Pallesen U, Cerutti A, Putignano A, Cauchie D, Kanzler R, Koskinen KP, Skjerven H, Strand GV, Vermaas RW. Ethics of esthetic dentistry. Quintessence Int 2004;35:456-65.
  5. Priest G, Priest J. Promoting esthetic procedures in the prosthodontic practice. J Prosthodont 2004;13:111-7.
  6. Smith RN, Smith ME. Marketing the cosmetic practice via television. Curr Opin Cosmet Dent 1995;:100-6.
  7. Demas PN, Braun TW. Esthetic facial surgery for women. Dent Clin North Am 2001;45:555-69.
  8. Alsarraf R, Alsarraf NW, Larrabee WF Jr, Johnson CM Jr. Cosmetic surgery procedures as luxury goods: measuring price and demand in facial plastic surgery. Arch Facial Plast Surg 2002;4:105-10.
  9. Schouten BC, Hoogstraten J, Eijkman MA. Patient participation during dental consultations: the influence of patients' characteristics and dentists' behavior.
    Community Dent Oral Epidemiol 2003;31:368-77.
  10. Klages U, Bruckner A, Guld Y, Zentner A. Dental esthetics, orthodontic treatment, and oral-health attitudes in young adults. Am Orthod Dentofacial Orthop 2005;128:442-9.
  11. Schouten BC, Eijkman MA, Hoogstraten J. Dentists' and patients' communicative behaviour and their satisfaction with the dental encounter. Community Dent Health 2003;20:11-5.

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Rule 1 The Patient

Posted By Stephanie Wilhelm, Friday, June 9, 2017
Updated: Tuesday, May 23, 2017

Section 1: The Patient

“When asked where most practitioners fail in their extreme makeover cases.”

Dr. Bill Dorfman (Discus Dental; Extreme Makeover TV series) answered: 

“They don’t listen to their patients …”

Dentaltown 2003

The Basic Rules of …..Basic Rule 1: Be Nice


Upon embarking on the journey for an oral rehabilitation the practitioner first and foremost must recognize that they will spending a considerable amount of time with their client, ie. the patient. It only makes practical sense therefore that everyone gets along with each other. It’s far easier to work with someone that we like and care for rather than in an adversarial relationship. In fact it’s imperative! One way we can build successful relationships is by being nice. Being nice means more than just smiling and telling jokes. Being nice involves developing a good relationship with our patients where mutual respect is fostered. Open communication and active listening are an integral part of this as well. The roadway of oral rehabilitation is fraught with many forks and pitfalls. A team approach which incorporates patient values as well as those of the dental personal will help smooth the ride when the road gets bumpy. Patients generally do not sue the practitioners they like.1-6


Over the years I have made my share of technical blunders. This I am not proud to state but it is a fact of my life. Nevertheless, the one smart thing that I always have done, though, is tell the truth. When it became apparent that a serious error had occurred, the patient was always informed immediately. Looking the patient in the eye and admitting that the treatment I have performed is less than ideal has always been, and still is, a humbling experience for me. Using simple words to express what has occurred and saying I’m sorry always goes miles in improving customer relations and satisfaction. Patients realize that I’m only human and their level of trust in our team skyrockets because of our honesty and the fact that we spent the time on developing a solid relationship before treatment commenced. In other words, we’re nice.


Being nice also takes advantage of the placebo effect or the “complex social interaction” that occurs between humans.7 It’s sort of like “love at first sight”. Research has shown that up to 50% of treatment efficacy for chronic pain patients is placebo related.8 Furthermore, it is known that the endogenous opioid system is activated in this process. Not only are placebo effects (the vehicle) of merit but also is an understanding of patient expectations. Through open communication and relationship building, what the patient realistically expects and the practitioner can reasonably deliver can be ascertained and leads to a nice way to practice dentistry. On the other hand, the harmful effects of an adverse patient-clinician interaction (nocebo effect), whereby negative words and attitudes of the clinician may induce negative expectations, can occur as well.9 A good example of the power of words is the fascinating study by Pollo A et al.10 In this study three separate groups of patients were created. Each group was told that they were being given a complementary medication to supplement an analgesic. All were given the same placebo (saline solution), however, each group were told they were being given something different. The first group was told they were being given a rehydrating solution, the second group that it could be a potent analgesic or a placebo, and the third group was told they were being given a potent painkiller. Group three ended up having a significant decrease in the amount of the original analgesic that was required compared to the other two groups. Therefore, placebo and expectations are another way to look at practice management and the delivery of optimal services through developing good, open, caring relationships with our patients.

As dental professionals we are caring, trustworthy individuals. Aren’t you? So being nice is easy enough for us to do. And it will definitely make our journey as smooth as possible on the road ahead.

Mike Racich  

 For questions or comment: Contact me at  or (604)922-3465 or Skype at mikeracich1 

Further Suggested Reading and References:



  1. Dunne M, Brown JL. Risk management in dentistry.
    Curr Opin Dent. 1991;1:668-71.
  2. Irving AV. Twenty strategies to reduce the risk of a malpractice claim.
    J Med Pract Manage. 1998;14:130-3.
  3. Colon VF. 10 ways to reduce medical malpractice exposure.
    Physician Exec. 2002;28:16-8.
  4. Worthington K. Customer satisfaction in the emergency department.
    Emerg Med Clin North Am. 2004;22:87-102.
  5. Lal S. Consent in dentistry.
    Pac Health Dialog. 2003;10:102-5.
  6. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, Puopolo AL, Brennan TA. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354:2024-33.
  7.  Stockstill JW. The placebo effect in the management of chronic myofascial pain: a review. J Am Coll Dent 1989;56:14-8.
  8. Benedetti F. How the doctor’s words affect the patient’s brain. Eval Health Prof 2002;25:369-86.
  9. Benedetti F, Lanotte M, Lopiano L, Colloca L. When words are painful: Unraveling the mechanisms of the nocebo effect. Neuroscience 2007;147:260-71.
  10. Pollo A, Amanzio M, Arslanian A, Casadio C, Maggi G, Benedetti F. Response expectancies in placebo analgesia and their clinical relevance. Pain 2001;93:77-84.

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The Basic Rules of......

Posted By Michael J. Racich, Thursday, March 2, 2017

The Basic Rules of …..

The solution to complex puzzles is often quite simple. When something that has perplexed us for a long time is finally solved it can be very gratifying to put our minds at rest. Sometimes it can be exasperating too as we might wonder why we did not think of the simple solution first. This applies not only to all walks of life but also dentistry. When it comes to dentistry and performing any restorative or prosthodontic task we are often confronted with this conundrum. Such questions as: “Is it really this difficult?” or “Is there an easier way?” immediately come to mind. The simplification of the art and science of oral care, specifically oral rehabilitation, is what I wish to share with you over the ensuing months via a series of short essays. 

Like most of my colleagues I attend numerous programs and congresses throughout the year. As I attend these meetings a common thread appears to run through them as I tend to hear the same messages over and over. Instinctively, I want to distill down what was really important from these messages for our profession and what is on the periphery so to speak. I have spent a considerable amount of time reflecting on and reviewing what is essential for an oral rehabilitation and what our profession has recommended over the last six decades and it appears to me that there are some basic fundamentals that optimize success; basic rules if you like. Yes, being a meticulous single tooth dentist and paying attention to all the details for an oral rehabilitation is important but it is essential to know the overall basic rules and what the end points are. This series of essays will be a tribute to this concept.

As such, I plan to be as transparent in my writing as possible. These essays will be written as an overview of the complex topic of oral rehabilitation. They will be also written to be concise and entertaining, food-for-thought if you like, that can be easily read on an overseas flight or poolside. In no way will these essays be assembled as a definitive source or to minimize the heroic efforts of the countless published academics and master clinicians that have made dentistry the wonderful profession that it is today. We all owe an immense amount of gratitude to these individuals. My intention, therefore, is to be synergistic and complimentary to the works of others. Evidence-based dentistry affords the practitioner the tools to rate the information that is presented to them and blend this information with patient values and professional beliefs and experiences; this is the key thought behind the motivation for these essays.

The Basic Rules of Oral Rehabilitation essay series will create and simplify for the reader a practical approach for the diagnostic, treatment, and maintenance phases of patient care by providing Basic Rules which are memorable, sequential, and gratifying. Appropriate references are included with each Basic Rule for further study by the reader. The Basic Rules will be divided into 4 major sections: The Patient, The Plan, The Process, The Payoff. Each major section of the Basic Rules essay will sequentially lead the reader through the steps necessary for an oral rehabilitation. 

I hope you enjoy these informative essays as much as I will enjoy putting my thoughts into words.  Depending on the feedback from this first essay series foray, a second Basic Rules essay series (The Basic Rules of Occlusion) will follow. I enjoy the art, science, and practice of dentistry and I particularly enjoy sharing it with my colleagues. Please feel free to contact me at your convenience, preferably via media such as Skype (mikeracich1). I wish you good health and continued success in your dental journey, no matter how lofty or humble you choose it to be.


Tags:  Basic Rules  Racich  Rehabilitation 

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Dr. Michael Racich introduction

Posted By Stephanie Wilhelm, Wednesday, March 1, 2017
Updated: Thursday, March 9, 2017

ADI is proud to have one of our Fellows offer his writings to ADI Fellows.  Dr. Michael Racich of West Vancouver, British Columbia will share his series. ADI is extremely grateful Dr. Racich ~ Thank you!


Dr. Racich, a 1982 graduate ofthe University of British Columbia, has a general dental practice emphasizing comprehensive restorative dentistry, prosthodontics and TMD/ orofacial pain. Dr. Racich is a member of many professional organizations and has lectured nationally and internationally on subjects relating to patient comfort, function and appearance. He is a Fellow of the Academy of General Dentistry and the American College of Dentists as well as a Diplomate of the American Board of Orofacial Pain and the International Congress of Oral Implantologists. Dr. Racich has published in peer-reviewed scientific journals such as the Journal of Prosthetic Dentistry and the International Journal of Periodontics and Restorative Dentistry and has authored the books: The Basic Rules of Oral Rehabilitation (2010), The Basic Rules of Occlusion (2012), The Basic Rules of Facially Generated Treatment Planning (2013), and The Basic Rules of Being a Dental Patient (2016). Currently he mentors the didactic/clinical FOCUS Dental Education Continuum (study clubs, proprietary programs, coaching, 2nd opinions only).

Tags:  Basic Rules  Racich  Rehabilitation 

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