Putting the Patient First

"The patient-first concept means literally putting the patient first," says Tom Wiand, CDT, Owner and General Manager of Wiand Dental Laboratory in Scottsdale, Arizona. "How often does that actually happen? Many people place the patient first, but many do not. The patient-first concept requires slowing down, performing proper evaluations such as photographs and CBCT, asking patients what they want, and deciding what is achievable based on their finances and their oral situation."

Putting the patient first starts with looking in the mirror. Many of the solutions that successful dental professionals utilize do not involve extraordinary skills; rather, they require effort.

"The dentist and technician need to be as competent as possible, or else saying ‘patient-first' is inaccurate," says Joshua Polansky, MDC, Owner of Niche Dental Studio in Cherry Hill, New Jersey. "A laboratory needs to be able to provide a really good service."

Indeed, patients invest significant amounts of money, time, and emotion in the restorative process. A similar dedication on the part of the dental technicians handling their cases is necessary to achieve a worthy result.

"Everything we do as technicians should be patient-focused," says Phil Reddington, RDT, MDTA, Head Ceramist, Technical Director, and Managing Director of Beever Dental Technology Ltd. in Leeds, England. "If the patient is not happy and does not enjoy the experience and the journey, then we are not doing our jobs correctly."

A laboratory is still a business, so the restorative process must be profitable in order for technicians to continue serving patients. Reconciling laboratory fees with the costs of fabricating the best possible restorations can become complicated when patients have limited finances or insurance companies dictate prices.

"High-quality products cost more, and the time investment also needs to be considered when setting your fees," says Arian Deutsch, CDT, Owner of Deutsch Dental Arts in Surprise, Arizona. "You cannot be afraid to set those fees appropriately."

Appropriate fees, however, can be at odds with what the patient is willing to pay—especially if the dentist touts the merits of cheaper options.

"Some dentists advocate for a $69 full-contour zirconia crown for a patient, but if they needed their own No. 8 single central restored, they are willing to pay for a $2500 crown," says M. Reed Cone, DMD, CDT. "The lower-cost restorations will work, but it is a problem when you are not providing the same level of service and care to your patients that you would want for yourself. Whether that is being driven more by dentists seeking cheaper options or laboratories racing to the bottom is debatable, but there is a real dichotomy forming between high-end, customized dental offices and chain practices that care only about their bottom line. Both are for-profit businesses, but they are totally different models."

Part of the reason for that emphasis on price in many cases is insurance. Preferred Provider Organizations (PPOs), which direct patients to practices that offer discounted rates, account for 82% of today's dental insurance policies.¹

"Insurance obstructs the patient-first concept; it is patient-last," Wiand says. "To offer a service at the price the insurance company dictates, the laboratory must work backward from that price, telling the dentist and the patient what we can provide. The industry has created manufacturing practices with cheaper production costs to offer products at these lower prices."

When the insurance company dictates a certain fee and the patient is unwilling to pay out of pocket, the dentist and laboratory cannot provide optimal treatment without losing money.

"Like anything in the world, you get what you pay for, so a laboratory that is committed to quality cannot help these patients," Polansky says. "If you open yourself to every patient but also say the patient's best interests come first, you will probably go out of business."

Indeed, patients can be an obstacle themselves if their desires do not align with their best interests. Finances can lead patients to decline what they know to be the best treatment, but sometimes they do not even understand what is best.

"Patients' desires have evolved greatly," says Richard Greenlees, PGDipCDTech, Owner of Lovebite, a dental laboratory in Christchurch, New Zealand. "The internet allows them to be better informed, but sometimes they are not as well informed as they might think they are because they do not understand the whole process."

Wiand says patients sometimes request specific brands of materials. "That can be helpful, or it can be challenging," he says.

A red flag, Polansky says, is if patients use dental jargon such as mesial, distal, etc.

"We have even had patients who have attended dental trade shows," Polansky says. "I appreciate that they care, but they can be dangerous if they think they know more than they do."

Sometimes another dental professional has told the patient something that the next dentist or laboratory may not agree with in terms of providing the best treatment. Manufacturers advertising directly to patients also can have an impact.

"The biggest challenge is when a patient has been previously misinformed about treatment, or their desires are unrealistic," Deutsch says.

In some cases, patients actually may request more complex treatment than is necessary, so putting the patient first entails persuading them to actually spend less money on their treatment.

"When we talk about the patient first in my laboratory, it is about the patient before money," Polansky says. "Many times, patients have come to us for a consultation and I have talked them out of dentistry because it was not in their best interest. I am thinking about them and what is best for them instead of just making money. I believe if you stay honest and true to this philosophy then it comes back to you tenfold."

Patients typically want their restorations completed as quickly as possible, and efficiency is beneficial for dentists and technicians as well. New techniques and technologies can reduce the amount of patient visits and the final cost to the patient.

"Achieving a successful result can require such a long, long journey, so if we can make that journey quicker and easier in the process of also making it more predictable for the patient, that is helpful," Reddington says.

However, it is important to avoid sacrificing quality in the quest to be faster.

"In many situations, you can have it done right or you can have it done fast," Cone says. "As a specialist, I often see the results of dentistry that has been performed too quickly."

The impact of new technologies can vary from case to case and should be evaluated as such.

"It is important to ask yourself what is driving the case," says Michael T. Ricciardi, DDS, a private practitioner in Staten Island, New York. "Is it a functional case or an esthetic case? My choices might be slightly different with materials and technology. The technology cannot drive the cases; what's best for the patient should."

When a significant investment has been made in new technology, there can be the temptation to utilize it whenever possible.

"If you have a hammer, everything has a tendency to become a nail," Cone says. "However, you cannot apply the same recipe to every patient. CAD/CAM is just a tool. In some cases, it can help make the workflow more efficient. In other cases, analog processes are better. For example, if the margins are wavy or dip into the sulcus, then an analog impression may be best for that patient."

It can be a simple matter of patience. Reddington and Lee Mullins, RDT, envision a digital solution for their popular BDT (Burnout Denture Tooth) Technique in the future, but for now they use mostly analog processes.

"We are working very hard on a digital approach," Mullins says, "but we have not jumped into that because the software and hardware are not yet where we need them to be. Undoubtedly, we will get there."

As new solutions—not only digital ones—are developed to further the patient-first concept, it is important to maintain that primary focus.

"So many dental professionals look at treatment and treatment planning in terms of completing the most beautiful case, but they do not see the patient as a person," Ricciardi says. "I try to think about if it were myself or one of my parents in the chair."

The patient's long-term health is a priority to keep in mind throughout the entire case.

"What good are 20 veneers if they do not last or if the rest of the mouth is falling apart?" Ricciardi says. "You need to be able to stabilize and minimize the risk factors involved. My mind immediately goes to the patient's risk factors in certain areas—periodontal, biomechanical, functional, dentofacial, and medical history. I advise them and treat them in regard to the best way to lower their risk biomechanically, functionally, etc. By doing that, you are able to treat them long-term. That does not necessarily mean doing everything at once—it may be staging treatment over time, educating the patient, bringing different specialists on board, getting them more involved in their own physical health—but we need to look at the system as a whole, not just one individual tooth."

In many cases, the need for restorative work extends beyond functional necessity, and keeping that in mind can inform the members of the dental team.

"Patients who are missing partial or complete dentition are dealing with not only the physical absence of teeth, but also the psychological and emotional trauma of losing their permanent dentition, the daily challenges of not being able to smile freely from the soul, and impaired chewing ability," Deutsch says. "Many of these patients simply need to be listened to and provided with some restorative choices that fit their needs. When the patient comes first, the rewards are beyond any monetary figure; they are the patient's satisfaction in being made whole again, and the knowledge that the dental team gave its best effort."

That best effort usually needs to be within the parameters of a profitable process, but occasionally it becomes necessary to go the extra mile.

Wiand uses a fixed price for certain complex treatments, so that if unusual situations require additional costs, they are not passed on to the patient.

"We had one patient with a distinctive look to her teeth, and our normal high-quality denture teeth did not quite match her mold," Wiand says. "Esthetics were her highest concern, so we ordered a denture tooth that was significantly more expensive, but it was the perfect tooth for her, and we did not charge the dentist. You make that call; you just do it. The priority is to achieve the best outcome."

In order to go to extraordinary measures to serve the patient, the laboratory can benefit from direct interaction, in either the dental office or the laboratory.

"My philosophy requires working with the patient, with few exceptions," says Polansky, who recently opened a new facility with specific areas for patient visits. "It is a disservice to the patient if the person fabricating the teeth is not involved throughout the process. Some dentists do not embrace this idea, so it is important to associate with a clientele that is 100% open to the way you work."

The first step in planning esthetically is to determine what the patient wants. Sometimes the patient can verbalize this immediately, but other times it is necessary to talk it through.

"The patient must be clear on the desired outcome before you can be clear on how to help them," Ricciardi says. "Helping them to see their vision is extremely important. We do not want to project our own subjective opinions onto them; we want to clarify their thoughts and their vision."

As patients become more educated, it is important to have answers to their questions. Ricciardi cites a patient who asked why he recommended a crown vs an onlay. He needed to explain his rationale before she accepted the treatment.

Conversely, in some ways patients' esthetic desires have evolved in a positive way for the restorative team. Greenlees says he still spends time educating patients about what natural teeth look like, but that conversation has become easier.

"Patients are starting to realize that a 70-year-old man with a bright white, Hollywood smile lacks credibility as a person compared to someone whose teeth have some character," Greenlees says. "For those who do not initially understand that, it is important to take the time for patient education. I explain my rationale and show them pictures, and they usually accept my suggestions."

Using these conversations to get a sense for each patient's personality can be helpful as well. Greenlees says it is necessary to take an interest in the patient as a person.

"I do not just spend 5 minutes with them; I want to get to know them and what makes them tick," he says. "If I am not seeing eye to eye with the patient, then there is not much point in proceeding with the case."

If that happens, the laboratory should not be afraid to turn down a case, Deutsch says.

"Ultimately, it is the patient's choice as to what treatment they decide on," Deutsch says. "The dental team can only inform, and at times may need to turn away a case if the patient's desires and expectations are outside the realm of possibility. I would say to laboratories and clinicians alike: Do not be afraid to turn down a case. Do not be afraid to say ‘no' to a patient who is determined to seek a treatment that you know will be unsuccessful or possibly even detrimental to their dental health."

Cone says he spends 60% to 70% of his time in the office talking to patients about treatment planning. He explains where the laboratory work will be done, how he interacts with the laboratory and the surgeon, etc. He avoids comparisons to lesser options and instead shows a "look book" with before-and-after shots of various options.

"I create a story, putting a human behind those white things," Cone says. "I hope patients will know quality when they see it. I do not sell dentistry; I just show them the options. Stepping off the gas a bit helps develop trust, and the patient really develops a rapport with me."

For technicians used to working at the bench, developing that rapport may be challenging.

"When you start dealing with people, it is a whole new ballgame," Polansky says. "You absolutely must have soft skills, not just hard technical skills, because people are tough. Models do not talk back to you, but people do."

Polansky suggests using softer language, such as the word "warm" instead of "yellow" in discussing tooth shades. He utilizes digital design features to educate patients, but he also keeps non-dental books in the laboratory to show patients photos to which they can relate.

"We can hone in on teeth they like and go from there to wherever they want to go," Polansky says. "We have a lot more latitude to allow patients to dream and feel good than in a dental office. We want patients to escape the dental world into a fantasy world. The dental world is harsh."

Beyond face-to-face interaction, it is important to utilize photographs of the patient throughout the case (see related article).

"Even if you never meet the patient, you can see them two-dimensionally," Polansky says.

Greenlees recommends also using older photos from when the patient had healthy dentition.

"I look closely at rebuilding the face and rebuilding facial features," Greenlees says. "That takes time, and it takes an understanding of what has been lost in the first place. Often, the process can move too quickly, and people do not think about what is gone and what needs to be put back. Photos really help to trigger the emotional side of our work."

A number of new techniques have been developed to make the patient experience easier and the final product better. For example, Reddington and Mullins use the BDT Technique to more accurately record, transfer, and retain patient information through the final bridge, reducing the number of patient visits and creating a more precise restoration. Deutsch uses telescopic and mild conical tooth-borne connections to preserve the patient's periodontal ligament and close off the interdental space while providing a removable prosthetic conducive to hygiene.

"A lot of practices try to simplify the restorative process by offering only one or two solutions," Deutsch says, "but I find that patients are so varied in their personalities and desires that the only way to effectively treat them is to have a good variety of solutions, and know the limitations and benefits of each solution well."

Existing techniques and practices continue to evolve, as well. Greenlees cites the theory of the neutral zone in prosthodontics as a commonly accepted notion that should be revisited.

"Focusing on the active zone and giving the face something to work on is better for the patient," Greenlees says. "Edentulous patients' facial muscles get less and less exercise as their dentures get smaller and they get older. With the neutral zone theory, the muscles atrophy, which is when you see a patient's face really collapsing in. However, when that oral architecture is built up properly, rather than trying to work inside a neutral zone, you provide the facial muscles with a sort of gymnasium to stay in shape."

The best tools and techniques are often only effective, of course, if the entire restorative team buys into the patient-first concept and works collaboratively to achieve the best results.

"When considering working with a new client," Deutsch says, "I prefer to have a video chat or phone conversation with them prior to sending our fee schedule or new client form in order to assess what their priorities and goals are. Not all potential clients will invest in a patient-first approach. I would rather be able to determine whether we will be a good fit at the outset."

In addition to actively contributing to treatment planning, Wiand hosts CE and lunch-and-learns for dentists to emphasize the importance of collaboration with the end result in mind.

"The ultimate goal is to make sure the patient is satisfied," Wiand says, "so after learning their desires, it is important to ensure that the treatment plan is followed through and everyone is accountable. We do this by starting with the end in mind. The surgeon and the laboratory both need to do our due diligence to make sure everything the patient wants can be done. Then we all work together throughout the case."

When the entire dental team puts the patient first and successfully completes a case, all parties can benefit. For the laboratory, it leads to loyal clients. Wiand says going above and beyond for a particular patient often prompts dentists to say they would never use any other laboratory again.

"There will always be a demand for patient-focused care," Deutsch says.

Committing to the concept is a significant undertaking, though, and can take time.

"If you start slowly doing it," Polansky says, "suddenly you blink your eyes and it's 15 years later and all your dentists are sending patients to you."

Much of what goes into embracing the patient-first concept involves effort and commitment, rather than natural skills. Anyone can do it.

"Someone once told me that there is always room at the top," Greenlees says. "All day long, we are treated to views of our canvases through people's faces and smiles. Doing homework by paying attention to how patients look, how they smile, and how teeth work will really help even the most average laboratory move forward with its work. That is a massive opportunity."

1. Understanding Dental Insurance. ASDA website. https://www.asdanet.org/utility-navigation/career-compass-home/financial-and-practice-management/understanding-dental-insurance. Accessed April 4, 2018.