Team approach to interdisciplinary treatment planning

By Zackary T. Faber, DDS, MS

At its core, dentistry is a team sport. All of the specialties working in concert can produce a truly interdisciplinary, patient-centered experience. From the simplest crown to the most complex orthognathic-prosthetic reconstruction, every patient is a team effort. And every patient is part of the team. We need to teach our patients why the decisions we make may affect or limit treatment in the future. When a team works together and communicates well, patients are rewarded with the best possible dentistry we can deliver.

Now, I want you to think back to your last new-patient exam. What was the first thing you noticed? Was it the patient's nose, eyes, or teeth? As a dentist, I would hope that the teeth were at least in the top three. However, we need to visualize the entire picture of the dentition and its role in facial and smile esthetics. Each patient is entitled to a complete examination and an ideal treatment plan. It is only by knowing what the ideal is that we can make intelligent compromises.

When you go looking for a new house or office, the first rule in real estate is location, location, location. After that, you can scale down and concentrate on the physical structure. If it is reasonably close to your vision, then you might move inside and inspect its guts, correct?

This is how we should approach our patients — from the outside in, or from the external features to the internal ones. Unfortunately, too many of us fall prey to the "quick exam," which only focuses on the patient's chief complaint — things like "this tooth hurts," or "I don't like this." We are all victims of this at times; however, we should really take a few steps back even in our emergency patients. That is not to say that if the patient is in pain, we should ignore that chief complaint. Usually the general dentist, prosthodontist, or pediatric dentist is the first responder to these issues.

When we take time to explore the patient as a whole and use all of our skills, the patient will benefit maximally. Our patients will also realize the considerable time, effort, and energy we devote to their treatment by exploring all of the resources available to us.

I would like to further expand on a construction analogy. I like to think of myself and the orthodontic specialty as architects. I realize that most dentists don't truly understand or feel comfortable moving teeth, but that's only a part of the orthodontist's job. I believe that the orthodontist's job (and in turn, all of our jobs) is to make a diagnosis of the whole patient — not just the teeth. The quick, open-your-mouth exam just doesn't cut it.

Once a complete problem list is outlined, we can begin creating a plan. The architect's job is to plan ... plan where the teeth should be placed so that they will result in the best possible dentistry for that individual. The planner can be an orthodontist, a prosthodontist, or a general dentist. But just as the architect can plan the position of structures, the team members need to be consulted on feasibility, cost containment, and effort. Planning should go to creating an ideal treatment plan. We need to treat our patients as if they are family members. The patient is your mother, your brother, your child, and should be treatment-planned with the best possible dentistry. However, our patient gets the benefit of a subjective treatment plan without the emotional biases that we might give to our family members.

The general contractor in our group is the restorative dentist (GP, prosthodontist, or pediatric dentist). The restorative dentist is able to do the two most important parts of the patient's treatment. The first is to be able to recognize and prioritize the problems that are presented when the patient enters the operatory. The second is to take a thorough health history and allow the patient to explain his or her concerns. Any and all diagnostic records that can be obtained should be taken to allow a comprehensive plan to be developed. We all know how to do this, but we get busy and often look for the trees we can fix instead of considering the forest. By taking a set of diagnostic records, a thorough evaluation can be completed and a comprehensive treatment plan can be developed.

This is where an orthodontist has an advantage. As part of our specialty training, we are all taught that we should take a full set of diagnostic records at our first appointment, then review those records and develop a problem list, a diagnosis, and a treatment plan that includes the mechanical plan of how to move each tooth and/or skeletal unit.

With these records, the restorative dentist can develop a treatment plan and decide whether it falls within the scope of his or her practice. If it does, then the plan should be executed and discussed with the patient. If not, then the restorative dentist should get his or her team involved. This team can include other specialists (orthodontists, periodontists, oral surgeons, endodontists) and lab technicians.

Depending on the depth and complexities of the case, the team might discuss this on the phone by videoconference or face-to-face. A complete set of diagnostic records includes diagnostic models (mounted or not; again, this depends on the complexity of the case), radiographs (which might include a CBCT), and clinical photographs (intraoral and extraoral). This allows the team to review the case from all points of view, especially their own. It also serves as a reference for the team without the patient being present. Each team member can then evaluate the extent of the possibilities that he or she can contribute to the overall goals of treatment.

The team approach to treatment allows the patient to have the best possible outcome to resolve not only their problems, but also the cosmetics. It also allows the restorative dentist and the team to deliver a conservative and predictable result to the patient. By including the patient as part of the team and explaining the ideal treatment plan, it may awaken the patient to possibilities not previously considered. And maybe if the patient wants the "whole idea" treatment plan, a decision can be made about how to stage the treatment so that everyone contributes to the “best result.”

Author bio
Zackary T. Faber, DDS, MS, followed his father, Dr. Richard Faber, and grandfather, Dr. Albert Reitman, to the Baltimore College of Dental Surgery at the University of Maryland. He completed his orthodontic training at the University of Connecticut. Dr. Faber is an active member and founder of several study clubs across Long Island that collaborate across dental specialties. As an assistant clinical professor, he teaches orthodontic residents at SUNY Stony Brook School of Dental Medicine and volunteers at the Dentofacial Deformities Clinic and the Pediatric Residency Program at Cohen's Children's Hospital. Dr. Faber maintains a private practice in Melville, N.Y. You may contact him at [email protected] or at www.faberortho.com.