Taking the risk out of treatment planning

Predictive risk management involves focusing not just on the problem at hand but the underlying reasons for it. If done correctly, your patients are likely to stay with you for a lifetime, according to John Kois, D.M.D., M.S.D., founder of the Kois Center, a dental training facility in Seattle.

His keynote presentation at the 2009 World Congress of Minimally Invasive Dentistry, to be held August 12-15 in San Francisco, will focus on the role he envisions interdisciplinary treatment planning playing in moving dentistry toward a model of precision medicine, he said in an interview with DrBicuspid.com.

"To help patients understand what they are at risk for before they present or express the problem is the future of dentistry," Dr. Kois said. "If you see a physician, they would ask you questions about your family history and put together data about your weight, cholesterol levels, blood pressure, etc. They could then develop some idea of your risk for cardiovascular disease down the road. But this is something we don't do in dentistry."

The key is to approach each patient from a system perspective, he emphasized.

"What I want to do is get people to switch to a wellness evaluation model rather than the traditional reparative model," Dr. Kois said. "You can treat a tooth and do root canals and periodontal surgery, but if that is done without looking at the context of the whole system, it may not work as well."

There is a big difference between doing comprehensive care involving one tooth at a time and comprehensive care that considers the whole system before treatment begins, he added.

"Interdisciplinary treatment planning is about making individual decisions that involve a lot of complex issues," Dr. Kois said. For example, to determine the type of restoration a patient might require, a dentist needs to know the health of the supporting structure, the status of the individual tooth, how much tooth structure remains, the bite force capability of the patient, the occlusal relationship of the tooth, and where it fits in the aesthetic needs of the patient, "but people make individual tooth decisions without looking at the shared risk factors that really may dictate outcome," he noted.

Be like Columbo

Dr. Kois thus urges all dentists to become crime scene investigators, focusing on what may have occurred that led to the problem at hand.

"We need to collect data that has true prognostic value," he said. "That way we can predict the health and wellness of the patient for a lifetime. What are the real health risks in the oral cavity that will help predict future disease? Many of the parameters we were taught in dental school, many of the parameters we use every day, do not have predictive value."

The goal is to be able to evaluate 25-year-old dentition and determine what would more likely than not happen to the oral health of that patient over the course of his or her life, he added.

"When we tell them they are fine, do we mean for a day, a month, or the rest of their lives?" What we should be focusing on is what it would take to minimize their risk so they can stay being fine," Dr. Kois said.

Many times, being able to treat patients to an ideal end point is easier than trying to understand what would be acceptable compromises, he added. For example, does everyone need a perfect class I occlusion to maintain occlusal health? What parameters can the dentist comfortably accept?

"In dental school we are all taught what is ideal, and then treatment is based on moving patients to some standardized ideal of perfection," Dr. Kois said. "But is that really necessary to maintain health and tooth mortality?"

These concepts are central to the practice of minimally invasive dentistry, he added.

"The idea is to increase tooth mortality in the most conservative way. So we need to determine what is the least treatment that could be provided that would still be adequate to minimize risk," Dr. Kois said. "Minimally invasive dentistry is geared toward minimizing risk to the tooth. But once the tooth requires restoration, how do we minimize risk to the restoration?"

In the long run, dentists want to know if they have helped their patients or made them worse, and to understand where the responsibility lies. Dr. Kois believes that interdisciplinary treatment planning and predictive risk management can help answer these critical questions.

For more information about the upcoming World Congress of Minimally Invasive Dentistry, visit the congress' Web site.

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