The Missing Tooth on the Treatment Plan
A 62-year-old man attends for a comprehensive examination. He has generalized moderate chronic periodontitis with probing depths of 5-6 mm in the posterior sextants and 4-5 mm anteriorly, bleeding on probing at 40% of sites, and radiographic bone loss of 30-50%. He is a former smoker (quit 8 years ago) with well-controlled type 2 diabetes (HbA1c 6.8%). He has a failing 3-unit bridge on teeth 14-16 supported by 14 and 16, with recurrent caries under the retainer on 14 and a questionable prognosis for 16. He also has a missing 36 that he would like replaced. He asks for a "full mouth makeover" and says he has budgeted $30,000. He is scheduled for a 60-minute appointment and expects a definitive plan today.
1. What is your phased treatment plan, and why is sequencing important here?
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Phased plan:
Phase 1 - Disease control and stabilization (the foundation):
- Full-mouth periodontal therapy (scaling and root planing) with re-evaluation at 6-8 weeks, including full probing depths, bleeding scores, and plaque control assessment.
- Caries control: excavate and restore the recurrent caries on 14, or place a provisional restoration if the extent is unclear.
- Extraction of 16 if it is deemed non-restorable after assessment, with socket preservation considered if an implant is planned.
- Medical liaison: confirm glycemic control with the patient's physician if there is any question, and reinforce smoking cessation maintenance.
- Oral hygiene instruction and risk-factor modification.
Phase 2 - Re-evaluation: Reassess periodontal response, caries risk, and the prognosis of 14. Only now can restorative and replacement decisions be made on a stable foundation.
Phase 3 - Reconstructive and replacement care: Decide between a new bridge, an implant-supported restoration, or a removable option for the 14-16 region depending on the periodontal response and the patient's preferences. Address the missing 36 with an implant, a fixed partial denture, or a removable partial denture after discussing the merits of each.
Phase 4 - Maintenance: A tailored periodontal maintenance schedule (likely 3-month intervals initially) with radiographic review.
Why sequencing matters: Placing expensive definitive restorations or implants before periodontal stabilization risks failure, and the patient's $30,000 budget could be consumed by replacing work that failed because the underlying disease was never controlled. Sequencing also lets the clinician and patient make decisions with real prognostic information rather than guesses.
2. How do you manage his expectation of a definitive plan today within a 60-minute appointment, and what informed consent issues arise?
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Managing expectations:
- Be transparent about the process. Explain that a definitive plan cannot responsibly be finalized until the response to initial therapy is known, because the prognosis of teeth like 14 and 16 depends on that response. Frame this as protecting his investment, not delaying care.
- Give him a provisional roadmap today. Provide a written phased outline with estimated costs and timeframes, clearly labelled as provisional, and schedule a re-evaluation appointment with a specific date.
- Address the 'makeover' request directly. Acknowledge the desire for a comprehensive result and explain that the fastest route to a durable outcome is to treat the disease first. Avoid overpromising aesthetics or longevity.
- Use the appointment time efficiently. Prioritize the diagnosis, the phase 1 plan, and the re-evaluation booking; defer detailed discussion of implant options to a dedicated consultation.
Informed consent issues:
- Material risks and alternatives must be presented for each option, including the option of no treatment and the option of extraction rather than restoration.
- Costs and sequencing must be explained so the patient understands that the $30,000 estimate may change depending on the periodontal response.
- Prognosis uncertainty should be explicit - the patient should understand that a tooth may be lost despite treatment.
- Consent is a process, not a signature. Document the discussion, provide written estimates, and confirm the patient's understanding before any treatment begins.
- If the patient insists on proceeding with definitive work before stabilization, document the advice given against it and consider whether the requested treatment is in his best interest; a clinician is not obligated to provide care that is likely to fail.