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Seed planting in dentistry
‘Seed planting’ in dentistry
James W. Thomas, D.D.S., Gallatin, Tenn.
Every dentist has within his practice pa tients whose ultimate treatment should be preceded by a program of “ seed plant ing” — education and suggestion as part of a treatment plan based on concern for the total oral health of the patient. Both basic and optimum dental health plans are presented. This low-pressure approach gradually leads to optimum dentistry for many patients.
Every dentist has within his practice many patients whose ultimate treatment should be preceded by a program of dental “ seed planting.” The term seed planting has been chosen because it ade quately expresses the approach suggested by this paper to treatment planning and presentation in many instances. It in volves more than casualness or subtle suggestions to the patient that he have certain treatment accomplished someday. It involves more than dental education in a general way. In other words, it goes far beyond throwing the seeds on the ground. This philosophy employs educa tion and suggestion as part of a definite treatment plan based completely on gen uine concern for the total mouth health of the patient. For this group of patients, a sound basic dental service combined with an adequate recall system would be sufficient to postpone for one to three
years the extensive restorative treatment required to meet the standards of opti mum dental health. It should be apparent at this point that it will be not only helpful but also necessary to differentiate between basic and optimum dental health as far as this paper is concerned. Basic dental health service may be defined as that dentist ry primarily concerned with individual tooth restoration. Patients who have re ceived only basic dentistry would nor mally exhibit: ( 1 ) large fillings instead o f inlays and crowns; ( 2 ) one or more missing posterior teeth; (3) replacement of anterior teeth, usually with a remov able appliance; (4) a tendency to have teeth with pulpal involvement removed rather than treated; and (5) a tendency to have badly broken-down teeth re moved rather than restored. Even a basic program should, of course, include root canal treatments and crowns, when necessary, to save in dividual teeth. Unfortunately, there are many patients who have been receiving far less than even basic dentistry as de fined here. Optimum dental health service may be defined as that dentistry which em ploys sound treatment procedures and technics in the prevention of dental dis ease as well as in repairing past dam age. Treatment is directed toward total mouth health.
76/514 • T H E JO U R N A L O F TH E A M E R IC A N D EN T A L A S S O C IA T IO N
O PTIM U M DEFERRED TREATM ENT It would be appropriate at this juncture to state categorically that the practice of presenting basic and optimum programs to patients has done more for the author as far as treatment planning and pres entation is concerned than would be possible to relate in this article. Patients understand this approach and this under standing is important. The value o f pre senting basic and optimum programs to patients goes far beyond terminology. This approach is a philosophy within it self. It affords the opportunity of show ing genuine concern for the total mouth health o f the patient without having him feel that his mouth is going to be neglected if it is desirable to proceed with only basic dentistry at this time. This treatment plan is accomplished many times by presenting portions of the treatment as “ optimum deferred.” For example, if a patient has had a missing posterior tooth for twenty years with very little or no damage as a result, why have him feel he must have that bridge next week or month? Plant the seeds first for greater patient reception later rather than “ selling” him now. This principle reduces to the ab solute minimum any discussion o f ma terials and is immeasurably better than offering the patient a choice of “ good—better— best,” or such terminology as “ recommended •— alternative — emer gency.” W hen using such relative de grees o f wording, emphasis on material and fees cannot be avoided. The patient is given three paths to follow and given the responsibility o f choice. If he chooses less than the best he feels he has chosen something inferior when the basis for decision has been primarily on cost and materials. In the approach suggested here, there is but one path, one goal and that is total mouth health. In certain instances the patient may influence the speed taken on the path; but, with proper diagnosis, treatment planning and
seed planting, the goal will remain the same. Patients who can benefit from a planned program o f education and seed planting will normally be adults from 25 to 60 years of age who have been see ing a dentist with reasonable regularity. They will normally be patients who have been receiving various degrees of basic dentistry and do not show complete neg lect o f their mouths. N o effort will be made to enumerate all the conditions that might properly be classified as basic dentistry but a few obvious conditions that lend themselves 1 most advantageously to seed planting and thus to optimum dentistry are: ( 1 ) an anterior tooth that has been weak ened with repeated silicate fillings and will need a jacket crown in the near fu ture; ( 2 ) a missing anterior tooth that has been replaced with a removable plas tic partial and should have a fixed re placement; (3) a malaligned tooth that should be extracted and replaced; (4) posterior teeth weakened with silver fill ings, or inlays, that should have the ex ternal support of a crown to prevent fracture; (5) replacement o f missing posterior teeth; ( 6 ) signs of abnormal wear and facets on teeth suggesting need o f occlusal equilibration; (7) early ob jective signs of a periodontal disturb ance; ( 8 ) early signs of third molar affecting periodontal health o f second molar; (9) wear on crowns caused by clasps of partial dentures: ( 10 ) any combination of these conditions where correction and treatment might properly be classified as complete mouth rehabili tation.
L O W -PR E SSU R E APPROACH Patients who need treatment will value the treatment more if their dental IQ is raised to the point where there is a complete understanding of the reason for the treatment. What a pleasure it is to have patients you have personally edu
THOMAS . . . VO LUM E 63, OCTOBER 1961 • 77/515
cated who now have explicit confidence in you and your ability. Compare these patients to the one who has reluctantly accepted a rehabilitation program from you after the first visit. The patient whose dental I Q has been raised will also follow through with home care more effectively and thus your treatment will be more of a service to the patient. How unfortunate it is to see a patient with extensive restorations who has neither been taught to care for his mouth at home nor been impressed with the need for home care. With proper selection, the aforemen tioned patients will respond to a “ lowpressure” approach gradually leading to optimum dentistry. Low pressure is nec essary because many of these patients could be expected to offer, some resist ance at first to suggestions for an exten sive rehabilitation program. This resistance would be fostered actu ally by a defense mechanism on the part of the patient, for this new dentist has told him, in effect, that his mouth has been neglected when all the time he has been receiving what he thought was good dental care. Mouths do not fall apart in a short time. Conversely, and consistent with the principle that no treatment is to be delayed that is needed now, fre quently there are dental conditions of the afore-mentioned type that can wait one, two or three years before extensive treatment is accomplished. It is during this period that the dentist begins to educate the patient and plant the seeds that may not be ready for harvesting until three years hence. The dental IQ of the patient is but one o f several reasons why some delay in treatment may be desirable, thus allow ing more time for seed planting and ed ucation, when necessary. Besides the den tal IQ , these factors may influence the treatment plan: ( 1 ) health of patient, ( 2 ) dental condition requiring further time for sound diagnosis and prognosis, (3) availability of patient for appoint
ments, (4) appointment schedule of the dentist and (5) economics. Recall again the type of patient being discussed and recognize that often the patient thinks he has been receiving op timum dentistry but he has not been. Even in diagnosis the low-pressure ap proach for patient management is useful in gaining the confidence and respect o f patients. For example, assume a pa tient has called for a routine examina tion. There is no discomfort or problem, as far as he is concerned. Visual exami nation reveals average home care, no cavities and slight calculus. The patient states that only an occasional single roentgenogram has been made. Appar ently the only treatment indicated is pro phylaxis. Bitewing roentgenograms and perhaps one or two single roentgeno grams to check a particular tooth are taken at the first appointment. Because of the absence of visual pathology, a complete mouth survey may not be taken. Then, at the time of the prophy laxis appointment when the bitewing roentgenograms are in view of the pa tient, the seed may be planted for a complete roentgenographic examination for the next appointment. Some refer ence may be given to what can be seen and the statement made that sooner or later it will be best to look at the roots o f all the teeth. Remember that the afore-mentioned patient is one who needs to be dentally educated with patience. He is one of a large group of patients who for one or more reasons change their dentist but nevertheless are of the opinion they have been receiving at least adequate dentist ry, until persuaded otherwise. It should be stated that no hesitation is used in taking complete mouth roentgenograms on a patient who presents the obvious need. There will be a high percentage of new patients in this group, patients who cannot wait for seed planting to satisfy the requirements for total mouth health. Many patients will need a different type
78/516 • T H E JO U R N A L O F T H E A M E R IC A N DENTAL A S S O C IA T IO N
of dentistry than they have been getting and they will need it now. The treat ment plan for such patients will still in volve basic and optimum dentistry, but the basic program is discussed only for the purpose o f having patients com pletely understand the difference be tween the basic program and the opti mum dental health service they need.
SUM M ARY A philosophy has been presented that makes an appeal for patient education
and preparation for optimum dentistry. This preparation could vary to care for the needs of a patient who needs exten sive rehabilitation treatment involving numerous crowns and replacements to the patient who should be prepared for a single anterior jacket crown on a tooth weakened by repeated silicate fillings. This principle permits a presentation based completely on the requirements for total mouth health consistent with a gen uine concern for the health of the whole patient. 101 North Trigg Avenue
Science and Society • T h e relation o f science to society has changed and becom e more com plex during m odern times. Three hundred years ago Bacon and his followers were justified in claim ing that the im portant problem was to learn how to d o things. There was then so little that could be done. Soon it becam e apparent that the most effective m ethod o f progress was to try to understand natural phenom ena, their whys as m uch as their hows. N ow it can be said that it is possible to achieve almost anything we want— so great is the effectiveness o f technology based on the experimental m ethod. Thus, the main issue for scientists and for society as a whole is now to decide what to do am ong all the things that cou ld be done and should be done. Unless scientists are willing to give hard thought— indeed, their hearts— to this latter aspect o f their social responsibilities, they m ay find themselves someday in the position o f the Sorcerer’ s Appren tice, unable to control the forces they have unleashed. A n d they may have to confess, like Captain A hab in M o b y D ick , that all their methods are sane, their goal mad. R en é Dubos. The Dream o f Reason. H orizon 3 :4 July 1961.
James W. Thomas, D.D.S., Gallatin, Tenn.
Every dentist has within his practice pa tients whose ultimate treatment should be preceded by a program of “ seed plant ing” — education and suggestion as part of a treatment plan based on concern for the total oral health of the patient. Both basic and optimum dental health plans are presented. This low-pressure approach gradually leads to optimum dentistry for many patients.
Every dentist has within his practice many patients whose ultimate treatment should be preceded by a program of dental “ seed planting.” The term seed planting has been chosen because it ade quately expresses the approach suggested by this paper to treatment planning and presentation in many instances. It in volves more than casualness or subtle suggestions to the patient that he have certain treatment accomplished someday. It involves more than dental education in a general way. In other words, it goes far beyond throwing the seeds on the ground. This philosophy employs educa tion and suggestion as part of a definite treatment plan based completely on gen uine concern for the total mouth health of the patient. For this group of patients, a sound basic dental service combined with an adequate recall system would be sufficient to postpone for one to three
years the extensive restorative treatment required to meet the standards of opti mum dental health. It should be apparent at this point that it will be not only helpful but also necessary to differentiate between basic and optimum dental health as far as this paper is concerned. Basic dental health service may be defined as that dentist ry primarily concerned with individual tooth restoration. Patients who have re ceived only basic dentistry would nor mally exhibit: ( 1 ) large fillings instead o f inlays and crowns; ( 2 ) one or more missing posterior teeth; (3) replacement of anterior teeth, usually with a remov able appliance; (4) a tendency to have teeth with pulpal involvement removed rather than treated; and (5) a tendency to have badly broken-down teeth re moved rather than restored. Even a basic program should, of course, include root canal treatments and crowns, when necessary, to save in dividual teeth. Unfortunately, there are many patients who have been receiving far less than even basic dentistry as de fined here. Optimum dental health service may be defined as that dentistry which em ploys sound treatment procedures and technics in the prevention of dental dis ease as well as in repairing past dam age. Treatment is directed toward total mouth health.
76/514 • T H E JO U R N A L O F TH E A M E R IC A N D EN T A L A S S O C IA T IO N
O PTIM U M DEFERRED TREATM ENT It would be appropriate at this juncture to state categorically that the practice of presenting basic and optimum programs to patients has done more for the author as far as treatment planning and pres entation is concerned than would be possible to relate in this article. Patients understand this approach and this under standing is important. The value o f pre senting basic and optimum programs to patients goes far beyond terminology. This approach is a philosophy within it self. It affords the opportunity of show ing genuine concern for the total mouth health o f the patient without having him feel that his mouth is going to be neglected if it is desirable to proceed with only basic dentistry at this time. This treatment plan is accomplished many times by presenting portions of the treatment as “ optimum deferred.” For example, if a patient has had a missing posterior tooth for twenty years with very little or no damage as a result, why have him feel he must have that bridge next week or month? Plant the seeds first for greater patient reception later rather than “ selling” him now. This principle reduces to the ab solute minimum any discussion o f ma terials and is immeasurably better than offering the patient a choice of “ good—better— best,” or such terminology as “ recommended •— alternative — emer gency.” W hen using such relative de grees o f wording, emphasis on material and fees cannot be avoided. The patient is given three paths to follow and given the responsibility o f choice. If he chooses less than the best he feels he has chosen something inferior when the basis for decision has been primarily on cost and materials. In the approach suggested here, there is but one path, one goal and that is total mouth health. In certain instances the patient may influence the speed taken on the path; but, with proper diagnosis, treatment planning and
seed planting, the goal will remain the same. Patients who can benefit from a planned program o f education and seed planting will normally be adults from 25 to 60 years of age who have been see ing a dentist with reasonable regularity. They will normally be patients who have been receiving various degrees of basic dentistry and do not show complete neg lect o f their mouths. N o effort will be made to enumerate all the conditions that might properly be classified as basic dentistry but a few obvious conditions that lend themselves 1 most advantageously to seed planting and thus to optimum dentistry are: ( 1 ) an anterior tooth that has been weak ened with repeated silicate fillings and will need a jacket crown in the near fu ture; ( 2 ) a missing anterior tooth that has been replaced with a removable plas tic partial and should have a fixed re placement; (3) a malaligned tooth that should be extracted and replaced; (4) posterior teeth weakened with silver fill ings, or inlays, that should have the ex ternal support of a crown to prevent fracture; (5) replacement o f missing posterior teeth; ( 6 ) signs of abnormal wear and facets on teeth suggesting need o f occlusal equilibration; (7) early ob jective signs of a periodontal disturb ance; ( 8 ) early signs of third molar affecting periodontal health o f second molar; (9) wear on crowns caused by clasps of partial dentures: ( 10 ) any combination of these conditions where correction and treatment might properly be classified as complete mouth rehabili tation.
L O W -PR E SSU R E APPROACH Patients who need treatment will value the treatment more if their dental IQ is raised to the point where there is a complete understanding of the reason for the treatment. What a pleasure it is to have patients you have personally edu
THOMAS . . . VO LUM E 63, OCTOBER 1961 • 77/515
cated who now have explicit confidence in you and your ability. Compare these patients to the one who has reluctantly accepted a rehabilitation program from you after the first visit. The patient whose dental I Q has been raised will also follow through with home care more effectively and thus your treatment will be more of a service to the patient. How unfortunate it is to see a patient with extensive restorations who has neither been taught to care for his mouth at home nor been impressed with the need for home care. With proper selection, the aforemen tioned patients will respond to a “ lowpressure” approach gradually leading to optimum dentistry. Low pressure is nec essary because many of these patients could be expected to offer, some resist ance at first to suggestions for an exten sive rehabilitation program. This resistance would be fostered actu ally by a defense mechanism on the part of the patient, for this new dentist has told him, in effect, that his mouth has been neglected when all the time he has been receiving what he thought was good dental care. Mouths do not fall apart in a short time. Conversely, and consistent with the principle that no treatment is to be delayed that is needed now, fre quently there are dental conditions of the afore-mentioned type that can wait one, two or three years before extensive treatment is accomplished. It is during this period that the dentist begins to educate the patient and plant the seeds that may not be ready for harvesting until three years hence. The dental IQ of the patient is but one o f several reasons why some delay in treatment may be desirable, thus allow ing more time for seed planting and ed ucation, when necessary. Besides the den tal IQ , these factors may influence the treatment plan: ( 1 ) health of patient, ( 2 ) dental condition requiring further time for sound diagnosis and prognosis, (3) availability of patient for appoint
ments, (4) appointment schedule of the dentist and (5) economics. Recall again the type of patient being discussed and recognize that often the patient thinks he has been receiving op timum dentistry but he has not been. Even in diagnosis the low-pressure ap proach for patient management is useful in gaining the confidence and respect o f patients. For example, assume a pa tient has called for a routine examina tion. There is no discomfort or problem, as far as he is concerned. Visual exami nation reveals average home care, no cavities and slight calculus. The patient states that only an occasional single roentgenogram has been made. Appar ently the only treatment indicated is pro phylaxis. Bitewing roentgenograms and perhaps one or two single roentgeno grams to check a particular tooth are taken at the first appointment. Because of the absence of visual pathology, a complete mouth survey may not be taken. Then, at the time of the prophy laxis appointment when the bitewing roentgenograms are in view of the pa tient, the seed may be planted for a complete roentgenographic examination for the next appointment. Some refer ence may be given to what can be seen and the statement made that sooner or later it will be best to look at the roots o f all the teeth. Remember that the afore-mentioned patient is one who needs to be dentally educated with patience. He is one of a large group of patients who for one or more reasons change their dentist but nevertheless are of the opinion they have been receiving at least adequate dentist ry, until persuaded otherwise. It should be stated that no hesitation is used in taking complete mouth roentgenograms on a patient who presents the obvious need. There will be a high percentage of new patients in this group, patients who cannot wait for seed planting to satisfy the requirements for total mouth health. Many patients will need a different type
78/516 • T H E JO U R N A L O F T H E A M E R IC A N DENTAL A S S O C IA T IO N
of dentistry than they have been getting and they will need it now. The treat ment plan for such patients will still in volve basic and optimum dentistry, but the basic program is discussed only for the purpose o f having patients com pletely understand the difference be tween the basic program and the opti mum dental health service they need.
SUM M ARY A philosophy has been presented that makes an appeal for patient education
and preparation for optimum dentistry. This preparation could vary to care for the needs of a patient who needs exten sive rehabilitation treatment involving numerous crowns and replacements to the patient who should be prepared for a single anterior jacket crown on a tooth weakened by repeated silicate fillings. This principle permits a presentation based completely on the requirements for total mouth health consistent with a gen uine concern for the health of the whole patient. 101 North Trigg Avenue
Science and Society • T h e relation o f science to society has changed and becom e more com plex during m odern times. Three hundred years ago Bacon and his followers were justified in claim ing that the im portant problem was to learn how to d o things. There was then so little that could be done. Soon it becam e apparent that the most effective m ethod o f progress was to try to understand natural phenom ena, their whys as m uch as their hows. N ow it can be said that it is possible to achieve almost anything we want— so great is the effectiveness o f technology based on the experimental m ethod. Thus, the main issue for scientists and for society as a whole is now to decide what to do am ong all the things that cou ld be done and should be done. Unless scientists are willing to give hard thought— indeed, their hearts— to this latter aspect o f their social responsibilities, they m ay find themselves someday in the position o f the Sorcerer’ s Appren tice, unable to control the forces they have unleashed. A n d they may have to confess, like Captain A hab in M o b y D ick , that all their methods are sane, their goal mad. R en é Dubos. The Dream o f Reason. H orizon 3 :4 July 1961.