Dear Readers:

Both patients and dentists desire to know the outcome before embarking on the treatment. For many of the procedures done in dentistry, the outcome (prognosis) is highly predictable. For example, the restoration of an incipient carious lesion on the distal of a maxillary premolar is highly predictable. Interdisciplinary therapy, however, has several challenges that make prognosticating difficult. The mere fact that the patient requires multiple disciplines often means that several variables exist that have outcomes difficult to predict. An example might be the treatment of a patient who requires the extraction of all the maxillary incisors that have significant periodontal disease. An initial phase of treatment might be orthodontics to erupt the teeth before extraction to coronally position the bone and soft tissue—but whether the bone follows the extruded teeth can be unpredictable. The treatment plan might then be to consider bone grafting to enhance the site before implant placement. Whereas the widening of the osseous crest may be very predictable, augmenting it coronally is very unpredictable. Then the implants might be placed and soft tissue augmentation performed only to obtain a result that is several millimeters short coronally of the desired free gingival margin and papilla levels. When the restorative dentist places the temporaries, the result looks significantly different than expected, and yet all the correct procedures were followed to resolve the original problems. Complex therapy often contains variables that are beyond the control of the dentists performing the procedures. Biologic response, patient compliance, the severity of the presenting situation—these are just some of the variables that can significantly alter the final treatment outcome.

The key to dealing with this dilemma is to be realistic about expectations. We may all want to see perfect tissue levels around four incisor implants after the removal of four periodontally involved teeth, but the reality is that it is not likely to happen. The dentist should assess what the most  likely outcome of treatment would be if he or she performed the procedure multiple times on several patients. Some could be exceptional; some could be disappointing; but what will the average result be?

In addition to predicting the outcome of each phase of treatment, it is important to consider how the scenario will be managed if the result falls below the average expected. For example, in the case of the four incisors being replaced with implants, if the soft tissue result is poor, consider splinting the final restoration and using pink porcelain to create the appearance of ideal gingival form, or perhaps using single units and a removable gingival mask to accommodate esthetics. While neither option is necessarily ideal, both are perfectly acceptable options. After considering the possible outcomes for each phase of treatment, it is important to decide if alternative modes of treatment, which in some ways may seem inferior, might be better choices. For example, a bridge or removable appliance can be used rather than the four implants to replace the incisors.

Ultimately the critical element of predicting outcomes is to predict realistically the results of each phase of treatment before performing any treatment. It is only after doing this assessment and considering what will be done if the outcome at any phase is less than expected that the team of dentists can confidently present the treatment plan and options to the patient. As long as the patient is given a prediction of what the range of outcomes might be as well as what can be done if any of the results are less than expected, including potential financial changes, most patients will be comfortable proceeding with treatment. In the end the challenge of predicting treatment outcomes may at times be difficult, but it does not need to be an obstacle.

Sincerely,

Frank M. Spear, DDS, MSD