Basics of Treatment Planning in Dentistry [B2B] – PDP088

Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati, and welcome to another episode of the Protrusive Dental podcast, back to basics series. Today we’re covering this mammoth topic of treatment planning, right? Where do you even begin with treatment planning? Well, you begin here, because I’m going to break it down with Dr. Paresh Shah from Canada, all about the fundamentals of the kind of conversations you have with your patients. What is the sort of mindset you have when you’re on treatment planning? What are the stages? How can you actually use your experience and use what the patient’s goals are to help inform the best treatment plan possible for your patient? So it’s something that I used to really puzzle me when I was a newly qualified dentist, I’d see a plan that was more complicated than just single tooth dentistry. And it will be like, how do I apply what I’ve learned from dental school to this patient in front of me. So it’s something that you sort of refine as you gain more experience. Now, I’m hoping that after this episode, it shouldn’t just give you that little bit more of an edge to allow you to think more rationally about your treatment planning. So like I said, hope you’re enjoying this back to basic series. And it’s been great fun to make it and the guests have been absolutely brilliant during this month. Thanks so much for watching. Now, if you have any more recommendations for topics, I’m always happy to hear them, you can DM me on Insta, you can comment below or you can email me jaz@protrusive.co.uk, I would love to hear your suggestions and I can get the right guests on as well as you want. The Protrusive Dental Pearl I have for this episode is very relevant to treatment planning. And it’s this. If you have a patient and you’re treating planning them, and it’s a it’s a bigger, more complicated problem. And I’m thinking like not just that it’s multiple teeth, but even something like missing teeth, like something that’s so common, right? The biggest problem I used to have is like if someone has missing teeth, then sometimes what dentists unfortunately trained to do or and do do is for every patient has a missing tooth, they say to the patient, okay, there are four or five things you can do, you can do nothing and accept the gap, you can have a bridge, you can have a resin bonded bridge, a conventional bridge, or you can have an implant, or we can do orthodontics or whatever, right? And you give the same bloody options all the time. This is really confusing to patients. Okay? So if you’re unsure which treatment plan to recommend, and that just means the following that you haven’t asked enough questions. So one way to help you to be able to give them the best plan for them. The best one for your patient, is to ask more question, how long do you expect this last? Do you want something removal or something fix something glued in? Do you want to be able to chew steak on it? Or is it merely just for looks? What’s your budget? These are kind of questions that should be asking to the patient to figure out exactly what treatment plan you should recommend. And then you can just let them know that Yeah, all these other things exist. But based on what you said, what you told me, this is the most appropriate treatment plan. And that is a much better way to go than to give everyone the same bloody five options a whole time It’s better just to give them a customized, tailored recommendation that’s going to meet their goal. So remember, if you’re not quite sure, you need to just step back and ask more questions so you can understand your patient better. So I hope you enjoy the series. We’re going to hit episode now with Dr. Paresh Shah. For a next episode we’ll go back to basics for occlusion. So I know it’s September which is going to be splintember, but we’re going to tie in with like a bridge episode, which can be back to basics for occlusion. So I’ll catch you in that one. Hope you enjoy this main episode with Dr. Paresh Shah and I’ll catch you in the outro.

Main Interview:

[Jaz]
Dr. Paresh Shah, Welcome to the Protrusive Dental podcast, it’s great to have you on, your work on social media that I’ve seen. We’ve never met in person but virtually You’re such a just a kind personnel I know very good, been very nice on social media to speak with you, DMing and comments, that kind of stuff and just inspirational to see the kind of work you do. And we started chatting and stuff and we thought it’d be really great to hear from you to pass on because all this has been like a back to basics month for the podcast. Has been to pass on knowledge to young dentists about treatment planning 101 and I’ve been really great to chat with you today. But for those people who don’t know where you are, you know who you are and what you do? Just give us a you know a minute or so on on this about you as a dentist.

[Paresh]
Thank you know, first of all, Jaz. It’s been really nice to connect with you. I appreciate it very much and you’re really nice sentiments about me. I appreciate that as well. I love what you’re doing as well because I like how you’ve kind of broken up themes And you’re giving people either practical tips to implement right away or food for thought. And I know for me that food for thought is a big thing. So I’ve been practicing 30 years. And it’s interesting, this, you didn’t know this, and not trying to do anything weird. But I’m right in the middle of almost finishing a textbook. And that textbook is partly about my story. But also, it’s not about teaching, treatment planning, because there are lots of different ways as you know, and different mentors in different systems. But the book is geared towards people who are, whether they’re early in their career or middle or late in the career to rethink how you’re approaching a patient. And that’s not always easy, because I think part of it has to come through taking courses with like, really good course. And we could go on for hours about that. And having great mentors and really good study clubs that actually collaborate well together. So quick thing with mine, I, after about eight years, I was just kind of doing drill and fill dentistry, didn’t really know anything different. And my circle of friends were similar, you know, we’ve just paid did this filling and did this kind of, Oh, I ended up doing six crowns one day, you know, it was kind of cool. And then all of a sudden, I got introduced to a program and a couple of mentors of mine now that from the University of Minnesota, and I went down there and started taking some courses. And it was a post grad aesthetic program. But it wasn’t all about aesthetics. All of a sudden, I’m getting introduced to occlusion and treatment planning and diagnostics. And, you know, having to put up casts and photos on a screen in front of a bunch of strangers. And it was like, Whoa, what is this and all of a sudden, it became a CSI type of thing, where all of a sudden, you’re looking at casts, and you see something there that shows up on an X ray, that shows up on a perio chart, and it’s like, oh, ding, ding, ding. And so I started looking at things differently. And all of a sudden, I’m coming back into my practice. And I’m like, okay, that cricket area, like, I know what I can do. And it started evolving that way. And then I started looking at things differently when I was doing my exams, because now I wasn’t looking to find a risk, always just a restorative solution. But I was seeing other possibilities. I was seeing implants, I was seeing oral surgery, I was seeing perio, I was seeing ortho, and but someone other people had to open my eyes to that. And I think part of the challenge is when you get out of school, there’s just not enough time to teach comprehensive dentistry. I think I feel and I don’t know what it’s like in the UK. But I’ll tell you in North America, I’ve seen a lot of it. It’s just hard. There’s just not enough time because you’re so focused on requirements in surfaces, and canals, and amount of teeth, you’re taken out rather than going ‘okay, let’s just take a step back. And let’s focus on comprehensive dentistry.’ And occasionally, you’ll get a part time instructor that pulls you aside and teaches you all the stuff. But you can’t talk about it in school. And so, anyway, I’m rambling. But that’s kind of that’s how my practice has evolved. And then, slowly as we went, I have a very close buddy of mine, Ken, and we kind of went on CE journey. And we did Kois and we’ve done Misch and, and we’ve just come back and because we’re buddies, we can help each other to reinforce what we’ve learned and go, okay, well, let’s slow down a little, let’s focus on learning the occlusion and implementing it in practice and then going on. So now I’m at the stage where I you know, I love what I do, and so much that I after 30 years, I bought a building and built a new practice rather than retiring like some of my friends.

[Jaz]
Amazing. What is it lovely to hear your journey? I didn’t know about the textbook that is amazing. I mean, the amount of work and effort I can only imagine how many I mean, it’s something you measured in years rather than how many months were I’m sure it’s been a project that’s spanning years. Right?

[Paresh]
Well, it came to fruition early in COVID. And but it’s been a lot of my journey so and what I’m trying to do is get people to just retrospectively I’m going back to cases that I did 10, 15, 20 years ago and go Okay, well what could I have done differently like it worked out but what did I learn? What do we know now like we’ve got CB CT, we’ve got so many different things that allow us to diagnose you know, at a higher level and knowing that hey, you know orthodontics plays a key role in getting teeth lined up better so maybe we could do minimally invasive dentistry. And so, just you know, when we’re in our day to day routine, we see simple thing lower anterior crowding and You know, people will, but you got crooked teeth on the top, persons only focused on just fixing those teeth. But you and I know that after 10, 15, 20 years, those teeth will keep shifting. And there’s a possibility that you’ll get either mobility on those teeth, were on those lower teeth, or mobility on the top teeth, or the veneers will chip like, our body compensates in some way, ignoring it, we could get lucky. But there’s also possibility we don’t and then what happens? So I, why not just get that fixed and lined up in the right spot, then yeah, if a person wants to just shave them down, we’ll find but at least discuss the ramifications. But and you see that every if not every day, every week in practice, why not at least approach it in a different manner than go? Oh, yeah, I can fix those 6th teeth or 8th teeth on the top. But why don’t we put this fixed? Like, let’s look at this first, get everything stable. And then you may not even have to cut down on these top teeth. Maybe we can do it with some bonding, as you call it in Europe, called edge bonding, right in North America, they call it bonding. But it is the same, like why not do that and, and approaching it in different ways. You know, if the tissue heights are off, well, why not discuss it ahead of time and maybe orthodontics or maybe crown lengthening might help not just making one crown look really long. And when it’s just little things that were sometimes we’re not taught to look for, or we don’t know how to address it or even a talk to the patient about and there’s a lot of dentistry in the general practice, you know that there’s tons of dentistry, but it’s just how we, how we clean it, and take it out and discuss it with the patients?

[Jaz]
Well, those little lightbulb moments, right? Our mind can only see what our brain knows, right is that kind of thing. So exactly like you said that, you know, going back to full circle to what you said at the beginning. Until you went on that residency program, you open your eyes. So unless you’ve treated someone with the upper anterior using that same example, they gave a lower incisor crowding, unless you’ve treated someone on the upper incisor only, and fold them up and seen a relative failure many years later, and then thought, Ah, that’s why this happened. Then the way to fast track that is to learn about it either from a mentor or from a course. And it’s about almost standing on the shoulder of giants and learning from others mistakes and you can then start implementing that. So sometimes it’s seeing and then learning that okay, this is a potential thing I need to have a conversation about. And it all goes back to that exam. I know this episode is a treatment planning 101 very much designed for young dentists and I’m keens as this episode progresses, to really pick your brain here, which will be amazing. And it’s such a vast topic, like we can go in any direction. But the first place I want to start with, if you don’t mind, Paresh is just to get some order and structure is the examination because I think your examination, the quality of your examination will dictate the what kind of treatment plan you can present. So just talk us through step by step. Even if it’s like something that starts before the patient actually lands in the chair, step by step, what is it that you’re doing to the patient? What are you saying to them? And then how do you come up with your diagnosis?

[Paresh]
Okay, that’s great. So I feel the medical and dental history is key. I know it sounds so like medical history just sounds so mood, but the thing is there. We know now compared to when I first got out of school that there are so many little clues that can lead towards just, you know, at least making sure we were not ruling out any gastric issues, sleep issues, things like that. So, and certain medications in terms of bleeding, and so forth. So it’s nice to have that. But the dental history is key. I’m not a mentor at the Kois Center or Johnson, it’s one of the courses that I’ve done. So I actually use his dental history. And the reason I use it is because it’s just broken up into subsets. And I don’t have to reinvent the wheel. That’s essentially what it is. But as long as you have a good dental history that asks specific, not general questions you can just buying off the internet, like really specific questions about the four main categories that no matter where you go, you know, I’m sure some of your mentors have taught, hey, you’ve got to look at biology, like at the look at the periodontal Foundation, you’ve got to look at the structure of the teeth, like how heavily restored are the teeth, you’ve got to look at your TMJ muscles. So ask a few questions about that. And asking a few questions about aesthetics, like what’s important to the patient. So if we have questions like that, it allows me before they come in, and if it’s an, if you’re an existing patient, and I’ve been seeing a bunch of things, and now you’re finally saying to me, “man, I wish I did this or I wish I did that years ago.” You know what? There’s still time we can do a few things. Let’s bring you back And we’ll we’re going to take between an hour and a half in two hours and do a comprehensive oral exam. And this is the same thing we would tell a new patient, but I would tell you that as an existing patient, and because it’s been a long time, there’s a lot of new procedures, technologies, materials that are available. And we might be able to address some of the concerns that you had. And some of it, it might be a little extensive. Some of it might be simple, but let’s just let’s reset

[Jaz]
Paresh, because I wanted to highlight something for those listening, cuz I think there’s a real gem in what you said there. Like, in our busy practices, sometimes, you know, I’ve taken over a list whereby the same dentist was there for 34 years. And now I’ve just taken over his list and his patients are in the 60s and stuff, right? And now sometimes the needs or the wants of the patient deserves more than a 15 minute check. And is having that courage to say to the patient, look, I can I’ve done my basic screening, Okay, a few issues, discuss fine, we can do that. But based on what you said, or based on what I found, you actually need something a full thorough assessment like you would have had, you know, many years ago, and it’s about having the courage and the conviction and the confidence out of the patient to bring them back and then carry out that full examination to then come up with the better suggestion, better plan. So it’s about remembering that just because you only have 15 minutes doesn’t mean you have to cram everything in. You totally need to as a young dentist, sometimes you feel shy or concerned or worried about inviting someone back.

[Paresh]
Absolutely. And listen, if you’re worried about I don’t like this phrase, I don’t want to step on toes because I think that’s a pile of crap. I mean, at some point in time, you’ve got to be bold, but not reckless. You know what I mean? And the bottom line is, you’ve got, you have a dentist that you respected or dentists that you respected whose practice you took over or you’re working with, or that did the previous exam. You know, for me, and I just had listened when I took over my practice, it was really heavily restorative driven, because that was back he graduated in the 60s, and I took over in the 90s. Perio wasn’t a big thing, so a lot of times he was just cleaning the lower six anteriors with a Cavitron. And that was it. And all of a sudden, I come out of dental school, Perio was a foundation and they’re going like what are you doing? Why are you spending so much time cleaning teeth? And Well listen, you know, back when John retired, when he came out of school, there were a lot of cavities, we have less cavities. So what they weren’t focusing on foundation we’re focusing on, so I wasn’t throwing him under the bus that was just reframing things. So it’s the same thing you go, listen, there are a lot of things that have changed right now, we have new materials, we have new composites, we have new ceramics, we have aligners which we weren’t using 20 years ago. So there are things that we might be able to do to help improve your smile in a conservative manner. And but I need more time. And one of the things that’s important, I don’t think we take enough. I’m not saying all the time, but every few years I think needs especially with people who have a lot of posterior restorative taking full mouth series, we have to. We got to be able to diagnose everything. We got to diagnose the margins, caries that we think. Now I’m rambling, so what i will suggest is that having a good dental history that will have some questions that can potentially lead to or like they’re more open ended questions, because they can put, if they put a yes there, you’ve got a lot of, you can have a lot of other things you can ask if they said “well, I have a fear of dentists” “Well tell me about that. What happened, how”, or “Hey, my bonding always chips I had that this week.” Someone came in at her consult, while the person did bonding eight months ago, and it’s all broken. But she has edge to edge occlusion and shear fractures. And she goes, “So I don’t want bonding. I just want veneers” and I go “Well, it’s not about veneers, it’s your bites not in the right spot. It’s not engineered properly.” So I would rather you consider seeing my orthodontist, and then I’ll do some bonding, but bonding doesn’t work. No, it’s not the and so but you can’t do that in a five minute exam. So a new patient, we asked them to come in and have a comprehensive oral exam. And part of that involves a periodontal assessment And that’s a full perio of assessment.

[Paresh]
That’s like I’m doing pocket depth chops on every single tooth right?

[Paresh]
The full, exactly what we’re doing with the periodontists that I choose to work with, which means not just pocketing, bleeding scores, clinical attachment loss, mobilities, recession, everything. That way, we and how do you do that? Bring in a periodontist, bring in one of the periodontist that you work with and say look, let’s work with the hygienist. Here’s what we need. Here’s the why. When we finish, okay, so that’s a perio and I’ll get back to that in a sec. But that the Perio assessment. Photographs, taken a full face photograph and a few digital SLR photographs at least a smile, occlusal shots. How do we get the assistance train? Well, now I had Sonny come in and do that. But before that, my orthodontist and most orthodontists do fantastic photos, and my best friend’s in orthodontist. So send the team, to your orthodontist, they spend an hour and a half of their cameras and retractors. Done. Now they know how to take pictures. Okay, so they come in and they take the pictures, we’ll take basic series of X rays. And if there’s a lot of restorative, then I’ll say, you know, we’ll talk about it and go, you know, what, we need a full mouth series. And then, in terms of the aesthetics, what I’m getting the hygenic, now they’re coming in, if it’s a new patient exam, there’s two ways to do it. But they’re coming in right now in the hygiene appointment. And I know there’s philosophically some dentists go, “No, I got to see first the other way,” you know, if you feel if you can train your hygienists well enough to at least gather the information appropriately, they can get started on some things and do the fact finding. That’s my feeling. And so they’re coming into, I have two entry points in the practice one is straight with me, which would be about an hour. And one would we with hygiene, it would be closer to about an hour and 45 minutes. Okay? And so when they come in there, they’ll gather the information. But the first thing I asked them to do is just to sit down and because that’s the same ways I would go through the dental medical history, sit, eye level with one another, and just go over the questions. And not get hung up on “Oh, I got to get the bib on, I got to start cleaning teeth.” No, this is about connecting, getting to know the patient’s why, their fears, what their expectations are, and build a relationship in that first little bit. And I tell the hygienists, if you don’t pick up the scaler, that first appointment, that’s okay. Because if that person had needs the time to talk, gather information, because it’s a complicated case, it’s okay. You can bring them back. But if you..

[Jaz]
It is good as a hygienist to hear that from your boss, right? So you don’t have the pressure, you can just do as be as thorough and as complete as you as you want to be

[Paresh]
Right. And it’s important for the patient to understand that. That’s why sometimes, a lot of times, we’ll start in the hygiene, because if it’s a simple condition, they can get some of the act of therapy started or even done and the patient’s happy. But if they don’t, as long as you have good verbal skills, and you feel confident enough, you can communicate that “Listen, you know, Jaz, you’ve had a complicated case, your teeth are, you know, not straight, you’ve got a lot of inflammation, we need to spend a little more time trying to figure out how to get you healthier. And so I don’t think we’re going to be able to get started today, I need these measurements. So when Dr. Shah comes in, we can have a really good conversation about how we can get started with you.” And if you build that value, it does work. I’ve seen it, it does work. So gathering the information on those forth.

[Jaz]
And the other thing that might do Don’t be shy is the other thing that might do is if you have that patient who’s just not playing ball with that, then that’s probably not the patient that you want in the practice anyway, right? So it gets rid of the weeds.

[Paresh]
Right. So I’m glad you said that. Because when I built the new practice, I really defined core values as strategic anchors. And one of the strategic anchors is we want our patients to partner in their care. And so I the entire team, including the admin, they know that so I sometimes when they started just newly started with me to go, “Oh, this person doesn’t want x rays. I go well, how does that get with our strategic anchors?” Well, it doesn’t. They go “Okay, so you know the answer, right?” So explain the value of him and just say, “Listen, in our practice, our patients are used to having that in partnering in their care. Here’s what we do,” and they have to sign off a form that they don’t want it but if they’re refusing everything, then we just say “Look, this is you know, this probably isn’t the practice for you.” And it’s hard when you’re young dentist and in during COVID, It hasn’t been busy but that’s what we’re doing. That’s what we’ve been doing. But I’ve got, those are the records that I’m trying to gather in a comprehensive exam is if they come to see me first, I will gather those records. I don’t usually do the periodontal measure. My hygienists are better at it. And I will tell them, I’ll get a rough idea of what it looks like. And I’ll say “Jaz, I’m going to schedule you with Aaron or Shane or Liz and I’m going to be there that day. And they’re going to take over the second part of it and we just, I just need a diagnosis.” Because one of the things that I want to do I want to give every patient [ ? ] patient, a periodontal diagnosis, AAP classification. The reason I want them to own their condition, I don’t want to own it. I don’t want to own it, I want them to own it. And the bleeding score for the last eight or nine years since we’ve been doing this is so powerful. Because my hygienists go “Look, your bleeding score is like 13%, I wanted at five, like you got to inflammation. And maybe you’re not going to get bone loss from it, but you’re going to.” Objective measurements, and they see that chart and they see the red spots. I will tell you, most of the patients own it. And they’re like, “oh, and so what do we do now?” When the inflammation is high, what did you learn in school? A Re-Eval. “You come in at six weeks, just like at the perio and you do a reevaluation, Jaz, you got to do your homework during those six weeks, because we’re going to take the measurement again. And if not, you’re going to see our periodontist.” And we do that, it takes extra time. But you know what our handoff also to our specialists or our Periodontist is smoother, because they know what we do. And they don’t sit and go through eight months of treatment again, they just go “Okay, we know what’s happening here, let’s just get started with our surgical intervention or whatever we need to do.” But the perio is a huge part of our practice. And that bleeding score and clinical attachment loss, that is powerful.

[Jaz]
Absolutely and you use reminded me of a couple of things where as some of the themes were hitting there. And one thing that you know the importance of asking the right questions as you do as part of the setlist you have. And one thing that I was always taught by a mentor was, if you’re not quite sure what the treatment plan should be for your patient, you haven’t asked enough questions. So that’s one thing I always keep in mind. That means ‘Okay, I need more, I’d ask more questions.’ And then I’ll feel more certain myself what to recommend. It just is a sign that haven’t obtained enough information. And the second thing is that you said about these set questions, and the importance of having a checklist of some sorts. And it reminds me a bit of a dentist came to shadow me one day, and she saw me do two new patient examinations. And then at the end of the examinations, he said, “Jaz, I noticed that you you did the exact same thing for those two patients.” Yes, they were individually, I treated them individually. And I came up with a different diagnosis and a plan. But the way I did things was exactly the same. And then she said, Yeah, I never thought I always just go with the flow with the patient, you seem to have a more structured way of doing it. So just tell us about the importance of having a structure, are you a checklist kind of guy?

[Paresh]
So in my lecture, there’s even if it’s a clinical lecture, I throw it in the Checklist Manifesto made a huge impact on me years and years ago. And so read the book, checklists are part of the fabric of the practice. And what we do is we create a checklist. In fact, my assistants I’ve noticed in the last few weeks, I had a quick sidebar and a conversation with the team, I was noticing that the communication wasn’t great with the assistants, hygienists and admin and I said, “Listen, no one’s using the checklist regularly. We need to get back to it. There’s just too much information during the workflow to worry about stocking toilet paper and stuff. I mean, that’s a checklist thing. Don’t clutter your mind. Like we got to focus on patient care in our team and not go oh my god, I’m worrying about putting paper towels back. Are you kidding me? So get back to the checklist.” And the assistant said to me, “You know what, you’re starting to do things different with some of your restorative procedures.” And I go, “So what do we need to do? Because I need to update the checklist. I go, well, let’s do it. I’ll sit with you.” So what we do is we laminate the checklists, and we have a dry erase pen. And so yeah, there is a comprehensive exam, there is one for, you know, the near cementation or bonding, there is one for an annual periodontal maintenance. There’s one for a comprehensive oral exam in the hygiene room. And all I want

[Jaz]
it is clinical protocols and its clinical protocols as part of success.

[Paresh]
Right. And I want them to check it off. And the reason I want to even if it’s something that they don’t feel they need to do, I want them to check, physically check it off. I know it sounds mundane. But it’s the same thing. I said this yesterday, I said, “Team, here’s the thing, picture yourself on the operating room table. Because that happened to me last year, and I had my knee replacement and everyone in the operating room, introduce themselves to me and said what their role was, and there was someone in there with a checklist. I said, Do you want that? When you’re in the operating room or when you’re going on a plane? Do you want the pilot to glance over the list? Or do you want them to actually go No, I did look and see that switches there. That’s all I have to say. I don’t have to say anything else. And all I’m saying is it only takes you a second to check it that hey, okay. I didn’t need x rays today. But yeah, I considered it. But, and so yeah, the consistency, as you said is important. And so that’s what I do as well. And so we have a checklist in there and we’ll go, Okay, are we doing this? Are we doing that? Yeah, we grab it. And so sometimes your assistant, let’s say you’re doing an exam, they can actually get started before you come in, because maybe you’re finishing an exam, they’ve taken the patient and they go, look, I know, Paresh gonna want an intraoral scan. So let me just start it. I’ll just take it. So when Paresh comes in, it’s like, oh, you’re taking the scan. Okay. I’ll be back in a minute. Hi, Jaz. Nice to meet you. I’ll be back in two minutes. And we just were going, and you asked about records. Can I continue for a sec?

[Jaz]
Yes, please, please, I’m just absorbing this. Absolutely.

[Paresh]
One of the other records we take is an intraoral scan. So in our comprehensive exam, every patient gets an intraoral scan. So we don’t pull out the alginate and everything. And the hygienists do it if it’s in the hygiene room, the assistants do it if it’s in our room, and it honestly only takes them about five to seven minutes. That’s it. My assistants are faster, it takes two or three minutes, but I’m slower, it takes me more like five minutes. And but they do it. And you know the fear for them when I initially introduces ‘Oh, what are you going to do with it? What do you I go listen, it’s strictly diagnostics, we want to print a model if I want to send an STL file to one of the specialists, but I’m not making crowns on it, don’t worry.’ And so that’s part of the process that we do as well. So we’re gathering, periodontal charting, photographs, I also asked them to do all of the hard tissue charting on the chart as well, existing restorations and everything. So it does take time. But that allows me if it’s more complicated, I can sit now with the patient, introduce myself, talk about a few things and say, ‘Listen, I think you do realize now that it’s your conditions a lot more complicated, you’ve got a couple of areas of decay here, your your tooth is drifting over here, an implant might help. But I’m going to need a cone beam like a CT scan. So let’s gather this, I’ll bring you back and we can have a nice conversation over an hour rather than five minutes.’

[Jaz]
Let’s talk about that. So let’s talk about a situation whereby you’ve gathered all the information, the patient’s wants and desires. And now you’ve also found out the patient’s needs, you’ve got the perio staff, you know, your ortho classification, you’ve got your imaging that you want. Do you always invite them back for a second visit? To explain their findings? Do you do that virtually? Or do you do it in person? Do you sometimes not need to do it if it’s a quite a straightforward maintenance case, just give us a flavor to the young dentists about that.

[Paresh]
Okay, so if it’s a straightforward maintenance case, and they then I would probably I typically would just bring them in start the next you kno book them in for their next restorative appointment. And if there are a few things that you know how you you’re phasing treatment? In phase one, you want to treat caries and stabilize the perio. So, you know, in during that one, but there may be elective treatment, that in terms of crowns, and maybe a bridge or implant or things like that or ortho, so I will say look, and here’s our first phase, let’s get you scheduled because the decay on a couple of these teeth are pretty bad. And I want to get that started right away and maybe minimize the risk of a root canal. So let’s get you in there. And if I’ve got if I know there’s other treatment that is elective, but necessary, I will schedule extra time at the end of one of those appointments to go over it. If it’s strictly elective. I’ll say look, let’s get through and it’s just me, I’ll just let’s get through all of the initial cavities. And then I’m going to bring you back and we’re going to discuss elective treatment. And I’m going to give you because I know what that time it’s going to be things that I feel they can benefit from, but it might involve implants and might about ortho and I don’t want to do it in five minutes. I want to spend time showing them with their intraoral scan and their their x rays and everything ‘Look Why should you maybe consider upgrading these teeth and doing this and doing that?

[Jaz]
Well. That’s all at the end of phase one, isn’t it? That’s all at the end of disease management. Right? You’re having that chat again, which makes so much sense

[Paresh]
Right. Now, having said that, if their focus has been, hey, my aesthetics, my aesthetics and I got to get the smile. No, I’m going to bring them back. Yes, we can schedule their restorative appointment, but I’m going to do I’m going to show them a smile design. I’m going to do a mock up on them. I’m going to do all of that and I’m going to schedule a separate appointment so when it comes to mock ups and smile design, I’m not doing, I’m going through a DS, digital smile design process with my lab. Or sometimes I’m doing it myself. And I’m designing the smile on exocad. And then I’m printing a model and creating a mock up. And if I don’t have time I get my lab to do that. And send me the model and a stamp, and then I’ll do a putty matrix in the mouth. And I’ll go through that whole digital smile design process.

[Jaz]
Do you build for that? Just because different doctors do it differently. Some will do it as a motivational thing to just cement the idea that ‘Hey, this is a good idea. And some doctors are afraid to charge because they don’t think they want the patient to see the mock up, right? whereas others like No, I don’t want any tire kickers, I want to be able to build for it to see if they’re committed to that. So where do you lie on that?

[Paresh]
I’m going through this process again, after this many years of my team’s like he got a bill for it. And I’m like, maybe not. And so it’s kind of a mixture. So part of it, if it’s a simple smile design that I’m comfortable doing quickly myself on my own software, because I have exocad, so I can use it, I it doesn’t take me long. So if I can do it in 10 to 15 minutes, and then send the model to our printer and print it out the next day and so forth. I’m not charging. But if I get involved with the lab, the labs charging a fee for that, and I’ll tell the patient Look, there’s going to be a lab fee for and I’ll just charge them the lab fee, which is a couple $100. And so it’s kind of a mixture. And I’m trying to get through that part right now. And I don’t think there’s a right or wrong answer. But it’s a fair question to ask. So I’m still wishy washy on it, I’m doing a little bit of both,

[Jaz]
No, it was just good to know how different doctors do it. So your way is valid as well. And then that’s great. Now, once you have, like you said all these different bits of information together, the funny thing is, you know, you’ll appreciate this is you and how you treatment plan now. And that same person who would have walked into you 15 years ago, they will get different treatment plans. and dare I even say it even last week, morning, afternoon, slightly different treatment plans. It’s just human nature, we know this, right? So how you treat and plan, how you diagnose it’s variable on time, experience, your mentorship that you have available to you. So I used to get very worked up about it. Like, there’s like so many different ways to treat this one individual and, you know, newly qualified as they are, should we go down this route, we should go down that route. And then sometimes what young dentists end up doing is that we end up confusing the patient, we say, Well, you could have this or you could have this. And then here’s the pros and cons and here’s the pros and cons, how do you A) come up with a plan that you think is the best for the patient? How do you convey that to the patient? And then how do you also then part of the you know, in the UK, certainly one of the sort of things that a regulator wants to do is we have to offer alternatives, and also the risk of no treatment. So you have to go through a lot of things. But how do you do it in a way that doesn’t confuse the patient?

[Paresh]
You know what? That’s a great question. Because, you know, sometimes I’ve been, I’ve found myself in the past, giving so much information that the patient goes through what we call analysis paralysis, they’re like, oh, man, so much information, I just don’t even want to talk about it. And then they just don’t do anything. So I think number one, like Simon Sinek says is finding out their why like, what is really, really the most important to them. And then from there, taking the information like I find for us there there was an interdisciplinary meeting that my two orthodontist buddies, and my restorative buddy, we went to that was headed by Vincent Kokich when he was alive years ago is about 20 years ago. And there was there are teams of oral surgery, perio, restorative, and up on stage and ortho up on stage, just showing a case. And there was an restorative doc that said some things because you don’t want we tend to look at things through restorative eyes, and the specialists looking at things through specialty eyes. And what we’re trying to do as a group is look through interdisciplinary eyes, we’re trying to look at things a little different. And I think as restorative Doc’s are, our lowest common denominator is just Hey, I can do restorative. And so what I try and do is I’ll try and look decipher, and it’s a little more complicated, I understand this, but I’ll try and decipher what your put together the problem list of the key things that are important to you. I’ll add the things that I note. Okay. And as I and Okay, sidebar there was a Jeff Morley and then to me ubank been teaching restorative and smile design like even 20 years ago, and I was taking a lot of their courses. And one of the things they taught me was to look at each of the records separately. So you take your x rays and you just quickly analyze all of them. Jot a few notes Put it away, pull up the clinical photos, jot a few notes, put it away, take the casts out, jot a few notes, pull the perio chart up, jot a few notes. And they say when you do that, all of a sudden, you’ll start seeing, hey, you’ve got to wear for set on a tooth. You look at the perio chart, and there a pocket and or mobility. And then you look at the X ray, and there’s a widened PDL, I’m making it simple. It’s all tied in. So I try and look at that quickly jot a few notes, come up with the list, and then I’ll say to you, okay, here, here are the things that you want to address. Now I can do this restoratively By doing this, this this, okay? However, if I do it, restoratively, can you see this picture? Can you see this too, I’m going to have to be pretty aggressive with my treatment on these to correct, what you want to have corrected. It’s maybe it’s a tooth that tipped, and let’s just keep it simple. We’ve got drifting here, someone wants an implant, or a bridge, and I’ve got a really aggressively treat all of these teeth. Whoa, what’s the risk of that? Well, I might need a root canal on these teeth. Well, I don’t want root canals. Okay. But that’s one. Well, what’s another way? Well, if you would consider seeing my orthodontist, or never, we could tip them up? Well, but I don’t want braces either. Okay, well, I get it. But are you willing to accept cutting those teeth down? If you are, that’s fine. And is there another risk? Yeah, I can cut these teeth down. But it’s tip so much that when I finished putting this crown, there’s going to be a gap over here, you will get food in there. And it may not be important to you now, but 20 years from now, you’re a little bit older, you’re on my age, and all of a sudden, now you’re getting all your food there. I mean, I don’t know about you, but I love eating food. I don’t like picking it out. But this is a possibility. And so I start bringing it that way. And when you say risks and complications, I want them to understand it in practical terms, in relatable terms of what it’s going to be, you know, they don’t need to, they’re not going to care about periodontal disease, they’re going to care about, I’m getting all my lunch stuck in that area. And when I’m sitting with my friends at the dinner table, I don’t want to be running to the washroom to clean it out. So give them something like that. So I try and break it up that way and give them a why as to what we can do. And now all of a sudden, it slowly opens up the conversation to other disciplines. Same thing with gummy smile, or uneven gingival heights, and they’ve got a gummy smile. Is it important to you? So I just did this with a patient yesterday. And I asked her, she came into nice young girl, she’s in her late 20s beautiful smile, but they’re just a little bit crooked and the gingival heights are great. And her lip dynamics are a little high. So what I and I, and I saw I mentioned I said, Look, there’s a couple there’s several different ways that we can do this, but we got to figure out why you have a gummy smile. Is it skeletally your jaw, the way it grew? Is it how much the teeth have erupted or not erupted with, even with the gum eruption? Or is it your lip is moving more than it should be? And how important is it? And so because that involves possibly orthognathic surgery, surgical crown lengthening, Botox, any of those, we know that right? So all these other disciplines because I can just throw veneers on there. But if she’s going to be unhappy with her smile, I’m dead in the water. She’s not gonna be happy with them after. So what do I do, I did a mock up, I just took some composite, dried off her lips, I put some composite over the gum tissue of one tooth that was shorter, I lengthen two other teeth. I now open up the conversation to three other disciplines. And you know what she says? This is exactly what I want. I don’t want to do anything else or you’re happy with the level in the way the reveal of the gum. Yeah, I’m happy. Perfect. Let’s do some bonding. We’ll turn this tissue on sound the bone. That was it. But I brought up in relatable ways. I hope I’m not confusing everything. It’s just something that they can relate to tangibly.

[Jaz]
Exactly. And you showed her a visual aid to help come up which will then inform the best of the many ways to treat because all those ways could have had a role. But in terms of what would get her happy and what doesn’t involve perhapsorthognathic surgery if that wouldn’t be relevant or to correct. So a treatment for that individual. So so that’s very relevant.

[Paresh]
Right. And so part of the whole thing is I’ve got my list. I’ve got my problem list. I’ve got the why. And now

[Jaz]
That’s brilliant by the way, the problem, I just wanted to just before you just say, I just want to highlight, I’ve got to highlight the problem list is crucial. Something I was taught when I’m doing the orthodontics and orthodontists are really good at creating problem lists. But sometimes you forget that we can do in all disciplines. And I like that how when you were saying the problem is before you are relating it to them in patient terms. So it’s something that you I feel as though is a problem list that you feed back to the patient. So this is what I’ve understood. These are the problems. And these are the solutions to your problems. I feel as though that’s the very basis of the treatment planning.

[Paresh]
It is and I think, I tend to as I’m doing that, lead them first with lead them or start first with restorative solutions, because that’s what they can relate to. They’re coming to get a filling they’re going to get a crown, they’re coming to get a veneer and but the risks of some of that can be mitigated possibly by crown lengthening, periodontal intervention, ortho intervention, so it allows me to then go, Okay, well, if you don’t want to cut this down, then I think you should at least have a consultation with my orthodontist. Or you should at least have a conversation with my periodontist or my oral surgeon, and it opens up the interdisciplinary conversation rather than me just going in there. Well, you need to see ortho you need to see to perio, you need to see this. They’re like, whoa, wait a minute, I didn’t want that. I’m trying to relate it and let them make some of those choices to go. I really don’t want to cut these teeth down. Okay, that’s fine. But if we can put them in the right spot, well, how long would it take? Well, you don’t want some of that is just unraveling some of the teeth, I use simple terms, like let’s just, they’re all you know, they’re all closed, let’s just unravel them a little bit. And I don’t have to touch them. Because they’re beautiful teeth, we do some whitening, put the teeth in the right spot. And we’ll fix these three chips on the bottom that we’re down. Is that can be expensive? And I go Well, you’re going to spend the money on the orthodontics, but now you don’t have to spend them on the teeth and maybe 20 years from now you’re going to have if something breaks, you’re going to have the money and you’re going to have the teeth to be able to keep them. So it’s always taking it back to mitigating risk. And allowing them to relate to like make the decision on do they want to preserve tooth structure or not.

[Jaz]
You mentioned fees that and money which is so important because again, I it’s something that a lot of dentists are guilty of as young dentists in a few years out of dental school. The most, the worst thing to do is trying to diagnose someone’s wallet, right? Trying to say, Okay, well, I think this patient can afford this. Let me scale down my treatment plan to make it fit this imaginary budget that you come up with which was totally the wrong way to do it. But equally, there are patients who just can’t afford certain levels of care. So how do you present your treatment plan, and then also trying to make sure to, try and do it in a way that the patient can, is within the patient’s budget? Any any tips on that as my final question.

[Paresh]
I use the phrase, ortho is my best friend. And even though I don’t do a lot, maybe like 5%, it’s ortho, if you can put the teeth in the system. And now I’m using the word system not for patient. I can say with system like you’re the engineering of your bite is not ideal. It’s wonky. Okay, it’s just no different than when you’ve got shifting of piles under your house and the house is settling. And you’re wondering what the heck is going on? Or the cars imbalanced. And I could in very relatable terms. Like do you want me to rebuild the house on those wonky piles? Or would you rather us Let’s take the piles out, get it nice and level. So your system is an ideal if we can put the system in the right spot. And yes, you’re gonna have to spend some money doing orthodontics, I can do single tooth dentistry for the rest of your life. If the teeth are all lined up properly and you can only afford one crown or one filling a year, Fine. I’ll do that. If you can afford three of them. I’ll do three of them. But if they’re crooked and everything and the bites not good, I’m going to put it in a failing system it’s going to steal, your risk wearing them down the road or chipping or breaking them. Go through orthodontics, line them up, keep your aligners I and what some dentists will go well but then you know I missed out on this. You don’t want you still gonna make the money. You’ve got a periodontal patient that’s compliant. They come in regularly. So you don’t make the $10,000 in one night you make it, you make $15,000 over five years, it’s an annuity, like you’re still making it financially. But now you’ve got that

[Jaz]
We need to hear that because that’s very good.

[Paresh]
Right? And so

[Jaz]
and then now you have the satisfaction of knowing that you’ve done the best for the patient.

[Paresh]
Right? And so, if they choose not the ortho then how do you do that? You transition them with transitional bonding whether it’s direct or Whether it’s with milled pmma, or something like that, you can do that. But when you do it that way, they are committing to some sort of treatment on some of the teeth because you might be reshaping on while with the ortho, you can just kind of stick them there. So you can still give them both options to stage treatment. And then they’re going to have to deal with the maintenance of chipping some of the fillings or transitional bonding. And so you just say, Listen, if they do chip or break, here’s the fee for fixing it. But at least I can transition you over four or five years, if you can only afford a few $1,000 a year, your insurance maybe covers 1000. And you say that you can probably put in a couple 1000, but you got a $10,000 treatment, I’ll get you there in three years. But we’re gonna the first year we’re going to do is stabilize your decay, and we’re going to just get your bite stable. And it’s gonna be one or two ways orthodontics or transitional bonding.

[Jaz]
Well, the main thing that I think to take away is that the foundation, the disease management is there. And that’s part of the thing that you know, you can’t really compromise on. So you present that. And then what you what you also pretty much said there was that you haven’t given them a plan and you try and diagnose their wallet or anything, you’re giving them the ideal solution, and you’re giving them the why related to them as why that is ideal. But it just you just might know that okay, instead of doing it all now, you spreading over time. So they still get the best care. I think that’s the best way to summarize them.

[Paresh]
Yeah, no, absolutely. And that’s what I feel. So, I mean, I’m sure you have cases right now, where it’s taking three, four years, because they’re going through a lot of work and, and sometimes you forget about you go Damn, I’m not doing it. And then all of a sudden, it’s like, oh, they just finished orthognathic surgery, or they just finished this. And let’s start going. And it’s kind of fun, because it’s almost like, Oh, I forgot about you. It’s great. And but the thing is it does it I don’t know, it’s I just find it more rewarding. And I’m sure you do too, at your stage now. I do feel it can be a little scary and daunting for a young clinician to look at all of this and go, Oh my god, that’s so much. But it really isn’t. Because if you really think about it, most dental schools you went through and had to do at least one or two comprehensive care cases, I would assume where you had a series of clinicians that you worked with, and that was probably the most intimidating because there was one doctor that you knew was going to tear you apart with questions and literature, but you did it. And it’s a matter of just okay, going back to that foundation and just almost doing an overkill of you what you feel might be an overkill of your exam, because that’s what you really want to do. So just do that, like go back to that fundamental. And the other thing that I would say is, find a mentor, find an experienced mentor, that will walk you through gathering the information, showing you if you’re doing analog, why it’s important to mount the cast rather than just holding it in your hand. And how to interpret this stuff. But actually sitting and listening like you said that young dentist, she watched you do exams and watch and observe because a big part of it is interpersonal communication when you have that information, and presenting it and communicating. So that it makes sense, and it’s not jumbled up and it is relatable takes time. It’s you can’t be technical with the patient.

[Jaz]
Amazing. That’s been really good. I mean, it’s a big topic to cover, treatment planning. But I feel like the themes that we’ve gone into is going to be quite helpful for young dentists as part of the back to basics series. Please you must let me know when your textbook is out I’d love to share it with the Protruserati and again if you’re not already following Paresh on Instagram, please do check it out. His sensational work are amazing. Aesthetic work, Veneers, Ortho-Restorative complex plans. Sometimes these just by seeing the work as possible inspires you as a young dentist, sometimes you know, you look ahead anything I you know, how am I going to complete that, but just by hearing Paresh’s story today and seeing his development, and he did Kois and he did that residency, it’s not something that happened overnight success, something that took time for you to build into. So as inspiration, I would encourage you to look at those cases.

[Paresh]
Thank you so much, Jaz. I really enjoyed the conversation. And like you said, it’s a very complex topic. And you know, I hope it wasn’t overly confusing or daunting, but hopefully just took a few the, you know, some of the audience took a few pearls out of there.

[Jaz]
It’s those pearls that you know, the way we communicate to patients or the way you present certain things. And so it’s about the conversations that we have on a day to day basis. And I thought this episode was full of those kinds of conversations and the importance of a checklist, a lot of very foundational things which we don’t talk about enough, I think so again, thank you so much. And I hope you have an awesome weekend in Winnipeg, Canada where you’re based.

[Paresh]
Alright. Thanks very much. I hope you have a great weekend as well.

Jaz’s Outro: Well, there we have it. Thanks so much for listening or watching all the way to the end. If you’re listening on your podcast player please do hit that subscribe button so you don’t miss a single episode. If you’re watching on YouTube or on Dentinal Tubules hit that subscribe button. I’d really appreciate it as well catch you in the next episode of the series.