There can be very few of us who have not benefited from the wisdom of hindsight in the course of our clinical career.
Spotting the 'problem' patient before it is too late or drawing back from the procedure which is doomed to fail, or resisting the temptation to provide treatment against our better judgement occasionally derives from inspired tuition or is gleaned from years of hard experience! More predictably, however, it is the result of a conscious decision to take every opportunity to 'test the water' before committing yourself to extensive or irreversible treatment.
One step at a time
After the treatment needs of the patient have been assessed and a treatment plan has been agreed with them then starting that plan, one stage at a time, gives the clinician an opportunity to assess the patient's ability to cope with those treatment procedures. Always try, however, to decide on a fall back position during those first appointments so that the situation can be recovered if the patient's co-operation or response does not prove to be as good as had been hoped for. This can be particularly useful for example when there are any concerns over the patient's ability to keep their mouth open for sufficient periods of time, to enable complex or intricate work to be carried out on one or more posterior teeth. A similar example could be where complex treatment can be deferred whilst checking a patient's ability to maintain adequate oral hygiene, or willingness to attend for treatment.
Making reversible decisions
Some complex treatments fortunately allow us to reverse the treatment process, or stop treatment altogether if necessary, at an interim stage with no clinical disadvantage to the patient.
For example in denture work there is the advantage that many decisions taken are also reversible as well. The try-in stage of a denture is a classic example of this, allowing both the clinician and the patient to assess the various aspects of the denture before jointly committing to the finished product.
At an earlier stage in the process of denture construction, 'training bases' are another triedand- tested approach to assessing, for example, how much palatal coverage or lingual pouch/tuberosity extension the patient can tolerate. A proposed change in occlusal height, or in tooth position relative to the edentulous ridge and soft tissues, can also be tested out in a way which still allows easy and inexpensive modification and adjustment if necessary.
For patients who have a severe 'gag' reflex or intolerance to palatal coverage, one is never quite sure how they might cope with a transition to full dentures, or partial dentures with extensive palatal coverage. A prudent exploratory stage - undertaken before any teeth are extracted - is to construct a 'mock' upper acrylic plate, and to adjust this in stages until acceptable to the patient.
The reline procedure is yet another proven means of establishing whether a denture can be made satisfactory by correcting any deficiencies in the fit surface. Often this can prolong the life of an existing, otherwise satisfactory denture.
Chairside, soft reline and 'tissue conditioning' materials are entirely reversible, but can still yield valuable information about problems with existing dentures, and potential problems that might arise when making new ones.
Listening to the patient
The clinician has full responsibility for the treatment. He or she must therefore only carry out treatment that they agree with. Patients may try to pressure us to provide treatment that they want, but with which we disagree.
This pressure must be politely but firmly resisted. However, if a patient requests modification that can be made, without compromising the treatment plan, then it can be agreed to.
A good example is the visible clasp of a chrome cobalt denture, which the patient discovers for the first time after the finished denture has been fitted. Usually the patient's dissatisfaction is based on aesthetic grounds; sometimes the clasp creates problems with comfort or function. If the denture fits and retention is unaffected then the clinician can accede to the patient's wish and remove the offending clasp. Another preventive measure that can help to head off some of these problems, is to use a black wax pencil (at the design stage) to show a patient exactly where the proposed clasp(s) would sit. This gives the patient the opportunity to raise any concerns before the denture is ever constructed.
The overriding general principle to remember, regardless of whether a potential problem can be anticipated or corrected later, is the importance of listening to the patients views, before during and after treatment. If they want something changing, and this is acceptable to us on clinical grounds, then this can be carried out.
Temporary or provisional stages
Temporary treatment stages can provide an ideal opportunity to preview, for example, a proposed tooth's length/ appearance/colour before proceeding with the final restoration. Despite the relative ease and simplicity of this treatment approach, it seems to be a surprisingly underused clinical tool when dealing with those patients who clearly have high aesthetic expectations and demands. Quite apart from its intrinsic value as a procedure, within the overall process of treatment, it can allay the concerns of the patient who lacks confidence in the outcome, reassuring them that you are doing everything that you possibly can to secure an optimal outcome for them. Another very useful 'check' procedure, during crown and bridge-work, is to try in crown and bridgework at the 'biscuit bake' stage of porcelain build-up, letting the patient see how things are progressing, and allowing any adjustments to be made before glazing and finishing the restoration.
Using provisional bridges to try out the shape, size, pontic width and colour of bridgework is a variation on this same effective technique. The temporary construction can also provide a timely indication if the proposed bridge abutments are undercut or divergent, and will not allow the insertion of fixed-fixed bridgework without further preparation.
Where anterior bridgework is replacing a denture, which has been worn over many years, problems can arise with speech because of the altered shapes and dynamics of the spacial relationships of the tongue, teeth and palate. The provisional restoration provides an ideal opportunity to resolve these potential problems, while adjustments remain easy to make.
The provisional restoration can also highlight potential problems with the occlusion and, on occasions, can point to previously unsuspected parafunctional activities which have the potential to compromise the success of the final restoration.
Another common cause of dento-legal problems is the under-prepared tooth, resulting in an over-built restoration which either has an excessively bulky appearance, or emergence profile (leading to periodontal problems), or height (leading to occlusal problems). The simple expedient of having a clear vacuum formed slip made before commencing any tooth preparation, allows the clinician to check that sufficient tooth reduction has been carried out, in all dimensions, to allow for the thickness of the restorative material. Unless teeth are adequately prepared, the subsequent restoration is often a compromise, either aesthetically or functionally - or both.
One further frequent pitfall is that the technician decides that the available occlusal clearance is only sufficient for a thickness of metal and not for bonded porcelain as well. The resulting metal visible on the occlusal surface or metal 'islands' often comes as a considerable disappointment to patients who are expecting a tooth coloured restoration. Here again, a relatively simple extra stage, introduced at the appropriate moment, can save a lot of patient dissatisfaction, and subsequent time and expense in remedying the situation.
Good records
Clear and comprehensive records are of paramount importance for all dental treatment, but particularly so in respect of the complex case. No matter how good our treatment or how well we explain and obtain consent, the records must be good otherwise we are vulnerable to allegations of poor treatment.
Risk management involves what we do and say and also what we write down.
For example in endodontic treatment a 'working length' or 'diagnostic' x-ray to provide reliable length control as a guide to subsequent instrumentation is clinically required, if an apex locator is not being used, but the details must be entered clearly in the records. If the records are inadequate then it becomes difficult to resist the argument that the failure to implement well-recognised and simple steps to establish the correct root length, has led directly to the problem with the RCT.
Summary
When things go wrong in dentistry, it is often tempting to wonder if the outcome might have been very different, if only an extra step or review had been considered along the way. Effective risk management need not be complex, costly or time consuming - indeed, quite the reverse when one considers the time and money that has to be invested in remedying a situation when things have been allowed to go wrong. A less obvious consideration is that of patient confidence. If the clinician takes deliberate steps throughout treatment to communicate to the patient all the things that are being done to ensure a successful outcome, the patient is much less likely to lose confidence in the dentist's ability. Once a crisis of confidence has arisen, it can be very difficult to recover from the situation.
On the other hand, if all available opportunities to maximise the treatment outcome have been seized by the clinician and communicated, and recorded effectively to the patient, not only is the treatment itself likely to be successful, but the patient will probably attach a higher value to the service provided and will be less questioning of the cost of their treatment.