As discussed in Chapter 3, the treatment coordinator needs time to collect information from all the specialists in the interdisciplinary team and determine the treatment plan. In addition to the treatment options and sequences suggested in this treatment plan, the presentation should be understandable and meaningful. Communication should occur emotionally, with the patient realizing the meaningful benefits of treatments to achieve improved comfort, function, esthetics, and self-esteem. On the other hand, understanding the logical and scientific reasons for the suggested options is essential from a rational perspective.

Preparing the presentation of the treatment plan takes time and requires sophisticated communication strategies, considering the psychologic and behavioral aspects of the patient. According to this author, the dentist’s ability to emotionally connect with the patient and clearly express the result of the treatment in a positive – and ethical – way makes a big difference to the proposals being accepted. Moreover, in the long term, such behaviors will positively influence the succession of satisfied patients in the clinic.

This topic is approached superficially or is not openly discussed in universities, perhaps because it suggests a commercial bias within the realm of health in the academic world. In reality, these universities may even train some of the best dentists in the world. However, many will not be able to practice their skills or will never achieve recognition if they do not know how to communicate effectively with patients, helping them make informed decisions about recommended treatment.

Treatment plan presentation template

The case presentation strategy needs to be prepared according to the patient’s needs, expectations, and psychologic profile. Creating a multisensory experience with relevant data from the anamnesis, clinical examination, imaging examinations, intraoral scans, and esthetic smile project is recommended to facilitate understanding and increase patient interest. The better the patient understands their present esthetic, functional, structural, and biologic conditions, the greater their ability to make the right decisions and plan the future of their oral health^3,4,7–11.

The use of clinical images of the patient dramatically facilitates the understanding of the problems presented, while images of similar cases solved by the dentist increase their credibility. When possible and if indicated, the mock-up is a great help for the patient to feel and observe the results hoped to be obtained with the proposed treatment [Figure 5-02A–H].

[Figure 5-02A–H] The presentation of the patient’s photographs and videos should be prepared to facilitate the visualization and understanding of the problems diagnosed in a shorter period of time, avoiding the need for extensive and often ineffective explanations [A–D]. Whenever possible, also present images of the patient with the mock-up of the planned treatment, to generate additional motivation, as the patient participates in the decision making and can imagine the results of the treatment [E–H].

Discussion about the treatment plan should ideally not occur in the clinical room but in a quiet, private environment where you will not be disturbed. The primary objective of this meeting is to make the patient aware of their problems, and the dentist should remain attentive to the patient’s interest and motivation.

In a cordial and careful tone, the sequence of the presentation should be briefly explained to decrease the patient’s anxiety and increase their confidence and feeling of co-participation. Follow this proposed script: “First, I will start by showing you the main findings of your examinations and correlate them with your concerns and symptoms. Then, I will explain what can happen if no action is taken. Once this has been understood, I will present the most suitable options for solving these problems as completely as possible. Please feel free to interrupt, ask questions, or add information at any time. You need to know that all decisions will be made together for your well-being, aiming at the best possible results with minimal risks.”

Suggested treatment plan presentation script

1. In an empathic, didactic, and interactive way, make the patient aware of the current condition of their stomatognathic system^3,4,7–10. The main findings of the esthetic, functional, structural, and biologic examination should be shown, relating them to the concerns and symptoms. To be meaningful, the explanations should be carried out using vocabulary and a level of detail according to the patient’s interest and ability to understand. Thus, it is suggested not to overload the patient with excessive information or technical terminology, and not to omit information that may have negative short- or long-term consequences.

It is essential to encourage questions and ensure that the patient follows the explanations in an attempt to motivate them and identify possible barriers¹². Care is recommended not to anticipate the presentation of solutions, as the patient may not yet have emotionally and rationally processed the extent or severity of the identified problems.

2. Describe the likely consequences if no therapeutic action is taken. Psychologic studies show that most decisions are motivated by risk aversion, and there is an intense psychologic tendency to avoid losses rather than seek gains. Thus, the short- and long-term risks concerning the stomatognathic system’s oral and systemic health, integrity, and stability must be clarified. However, due to their uncertain and individual character, categorical statements about the course of the diseases or problems presented should be avoided. Helpful analogies and similar stories are compelling because they add to the patient’s emotional and rational understanding of the situation.

3. Propose solutions for the identified problems, avoiding detailed technical details. The patient should be involved in the objective and subjective benefits of the treatment such as the possibility of chewing the most diverse foods with comfort and safety or smiling confidently. It is recommended to discuss the short- and long-term advantages, disadvantages, risks, and limitations of the different options, seeking awareness and consensus to make a mutual decision. At this point, the financial aspect is a barrier to be considered and can be discussed if the patient wishes (see Author’s Note).

4. Once mutually agreed upon, the treatment planning should be completed in detail according to the patient’s priorities, preferences, expectations, and financial situation. At this time, further questioning and explanation regarding the treatment plan sequence can occur.

This detailed treatment plan should only be given to the patient after approval, and it will contain the main diagnostic findings and treatment goals. The total cost and payment method can be found at the end, together with observations considered necessary for the patient [Figure 5-03A–Q].

[Figure 5-03A–Q] The official treatment plan [A] containing information from the clinical and complementary examinations [B–I]. The esthetic smile project – Digital Smile Design (DSD) – [J] will guide the three-dimensional (3D) design of the restorations [K] that will be tested and validated in the mouth [L,M]. Orthodontic treatment to align and level [N] the teeth will be performed prior to restorative treatment with anterior ceramic veneers [O–Q]. →

[Table 5-01] Stages of presentation of the treatment plan8–10.

QR code linking to the Summary of the Diagnostic Evaluation and Preliminary Treatment Plan Form template that can be customized.

Objections to therapeutic action

The patient’s objections to treatment proposals should be considered normal and be welcomed, even after a detailed presentation with the abovementioned characteristics. Such objections should be faced calmly, and sincere and informed answers should be offered to consolidate the relationship of trust that has already been established.

One should seek to understand the objections expressed by the patient through their non-verbal communication, as they often do not feel comfortable expressing their fears openly. It is necessary to avoid confrontational situations that generate defensive attitudes and limit interpersonal communication. The patient should perceive the professional’s commitment to obtaining the planned results as a more critical factor than their professional “authority.”

The dentist needs to know that the patient’s decision will be based on several factors such as their values, priorities, attitudes, expectations, past experiences, and psychosocial and economic realities. A patient’s lack of interest in the proposed treatment plan may be related to their psychologic profile as well as a lack of understanding of the reasons presented and their tangible benefits. It can also be related to poor motivation. From a practical point of view, during this conversation, the dentist should try to answer the patient’s questions, for instance, whether there is an absolute need for treatment at that time. The dentist should also make it clear that they are the most suitable professional to perform such treatment.

Barriers to acceptance of the treatment plan

The dentist needs to recognize the main barriers to acceptance of the treatment plan before presenting it to any patient:

Fear: The patient may fear possible pain or discomfort. They may also be afraid that they will not adapt to the final result in some stages of the treatment. These barriers can be overcome by explaining the steps to be followed, the care that will be taken, and that possible unexpected issues can be corrected with a previously established alternative or contingency plans. The well-informed patient tends to feel more secure and willing to collaborate.

Economic constraints: In order to be accepted, the treatment plan must be within the patient’s financial limitations and priorities. Unfortunately, this is sometimes not the case due to the different socioeconomic levels of those who seek dental treatment. Three types of approaches are suggested to make the treatment financially viable: the first is to divide dental treatment into phases, starting with the preparatory phases and then progressing to the final phases, with the patient making payments as the treatment evolves. The division of the treatment into phases also provides security to the patient and professional by reinforcing the bond of trust. Depending on the financial policy of the clinic, the second approach would be to offer the possibility of the patient paying in installments, or suggest long-term financing, and carry out the treatment on an ongoing basis. A third option would be to propose an alternative treatment plan, solving only the most urgent problems.

Time: Some patients may justify the option of not having treatment due to a lack of time. Although time constraints due to a patient’s professional or personal commitments are common, this justification is often associated with a lack of prioritization of dental treatment over other activities. To overcome this barrier, the dentist should explain the possible problems of postponing treatment, creating a sense of urgency for the patient to prioritize their oral health. The experienced dentist knows that the evolution of any dental problem or disease does not necessarily follow a linear progression pattern. The patient needs to know that a lack of care or an unstable oral environment can make it more challenging and costly to solve the problems.

Lack of trust or affinity with the professional: This is associated with the behavior and communication skills of the professional. In addition to professional competence, the dentist must develop a personal relationship with the patient, making them feel that they are the right professional to do the job. The more the patient feels heard, cared for, and valued, the greater the chances of them accepting the proposed treatment.

Patient goals: The dentist needs to remember that all patients have their own goals; some only seek to solve urgent problems, while others are willing or have the financial capacity to accept and agree to the treatment recommended by the professional. The dentist needs to realize this divergence of goals and have a candid conversation with the patient to explain whether the treatment the patient wishes can or should be carried out, so as not to compromise the professional’s treatment principles and ethical values.

Patient–dentist relationship

The patient should not be judged or confronted by the professional with regard to the problems presented, as each individual has a life story and unique priorities. In order to establish a relationship of mutual collaboration – essential to therapeutic success – the dentist needs to introduce the patient’s predispositions and responsibilities empathically and carefully regarding the restorative treatment. According to this concept of ownership, the dentist should make it clear that the solution to the problem will be directly related to the patient’s collaboration during and after treatment. Predisposing factors must be identified, eliminated, or controlled so that the restorative cycle can be limited.

Thus, patients need to understand that restorative treatment can repair the damage, but only the patient–dentist partnership can eliminate or control the disease. Treating patients without promoting a change in attitude can be considered an omission that results in stress, failures, repetitions of treatment, and, consequently, a waste of time, energy, and financial resources as well as negatively impacting the professional’s reputation.

Resolution of therapeutic conflicts

A common aspect within the clinical reality is the possibility of the patient not accepting the dentist’s initial proposal for personal reasons and requesting an alternative, more straightforward or economical solution. Resolutions within a treatment plan refer to the conscious management of therapeutic conflicts between the theoretically ideal solution and the one that is realistic for the patient at that time. Such negotiations are part of the clinical routine, resulting from a thorough analysis of the diagnostic data by the interdisciplinary team, according to the limitations, risks, and benefits of each option.

It should be clear to the dentist that such therapeutic reconciliations or compromises usually result in incomplete or partial treatments, which can harm the quality and completeness of the results. Decisions regarding the control of active diseases and structural and biologic aspects are not negotiable, since the primary objective of any treatment is to preserve or restore health and provide stability to the stomatognathic system. On the other hand, issues related to esthetics and function can be negotiated to integrate them into the treatment in the most harmonious way possible.

The patient’s participation in this decision-making process considerably increases their commitment to the treatment plan, as they perceive that the dentist values their opinions. The meaning of these compromises regarding the risks and limitations in terms of the restoration’s final result or longevity should be made clear before the start of treatment. It is recommended that such decisions be documented and signed by the patient in an Informed Consent Form^2,12.

Modulation of expectations

One of the significant sources of failure in dental treatments is patients’ dissatisfaction with both the esthetic and functional results, when their expectations are not met and they have many subjective concerns.

During the anamnesis and initial interactions with the patient, the dentist must attempt to identify and differentiate patients with high expectations from those with unrealistic ones. Patients with high expectations will always be challenging, but they can help the dentist to achieve high-quality personalized work, which often involves extra time and dedication. The dentist responsible for the treatment should consider whether they have the technical and emotional capacity and additional time available to treat this type of patient.

Patients with unrealistic expectations need to be identified and managed carefully, as they can be a source of stress and dissatisfaction. These patients should be recognized and managed with great prudence, with the dentist explaining in detail the limitations of the case and how far it can be predicted^11,13–18. From this perspective, everything explained before the treatment can be interpreted as clarification, but everything explained later will sound like an excuse¹⁹.

“Problematic” patients

Every dentist should be modest enough to realize that it will not be possible to satisfy every patient. Therefore, it is recommended to be aware of signs or requests that can alert the dentist regarding the type of patient they are treating. The dentist must know the possible implications of treating certain types of patients, who will be more stressful to work with and require extra time, effort, and patience from the interdisciplinary team^4,11.

Examples of potentially problematic patients are those who do not objectively express their esthetic wishes or expectations or who constantly change their minds. Some patients complain about and blame the professionals who previously treated them, some have unrealistic expectations, and others have somatoform disorders^14–18. The latter are recognized as psychologic disorders characterized by the presence of symptoms that are not fully explained by the clinical signs present.

In case of doubt, it is suggested to propose a preliminary diagnostic phase that helps the interaction with the patient and allows the observation of their reactions and a recognition of the challenges that may be involved. The dentist should consider forgoing treatment if the patient has difficulty understanding, neglects their dental issues, has unrealistic expectations, or demonstrates difficulties objectively communicating their wishes.

Scripts and ethical verbal alternatives to deal with common objections

Possibility of delaying treatment

Although it is impossible to precisely predict the evolution of the diagnosed problem, when asked about the possibility or consequences of postponing treatment, the dentist should present an honest, ethical, and motivating answer that encourages immediate action. For example: “Your treatment will never be as simple, conservative, and economical as it will be if it is carried out now”²⁰.

Treatment options

More than one treatment plan should be developed for the same diagnosed problems. The ideal would be to initially indicate to the patient the most complete and comprehensive treatment plan to treat or control all the problems presented^3,4,7,8,21.

If this option is not possible, a second alternative should be recommended, generally more limited in scope and cost. At this point, the patient should be made aware of the limitations and compromises involved in this choice. It should also be discussed with the patient whether this alternative will allow an upgrade in the future, i.e. whether it will be possible to carry out a necessary additional treatment without losing a part of the previous one or even having to change what has already been completed.

A third treatment option may also be proposed in complex cases, with many factors to be considered. It should be recognized, however, that offering a high number of treatment options can confuse patients and delay their decision.

The main objective will always be to define, together with the patient, a realistic treatment plan compatible with their life situation, needs, and wishes. The professional should not pre-judge the patient’s financial conditions or make decisions for them. The professional can often be surprised by the patient deciding to opt for the complete treatment. In this scenario, motivation and defining clear priorities are essential and are built from understanding the problems presented.

Treatment time

Both the dentist and patient should fully understand all the factors that influence treatment time, which will depend on the estimated number and duration of appointments and the required intervals between them. Conceptually, each stage of treatment represents an evolution from the previous one and should provide support for the subsequent phase. Effective treatment planning should consider different clinical scenarios and contain alternative routes. Although it is a common wish of both the patient and the professional to solve problems as quickly as possible, one should never “accelerate” the evolution of treatment when there is a risk of impairing its predictability, quality, and longevity.

A more extended evaluation period may be necessary when the patient has functional problems such as pain, joint disorders, or muscle dysfunction. In these cases, it is recommended to perform only noninvasive and reversible procedures such as stabilizing interocclusal splints, which should be adjusted and monitored until the remission of symptoms and clinical stabilization.

Factors influencing treatment time:

Personal preferences: Treatment time is linked to the personal preferences of both the patient and the dentist. It is recommended to ask the patient whether they prefer to carry out the treatment with longer appointments and fewer visits to the clinic. Extended appointments are more productive for the dentist but can become exhausting for the patient. Patients with health impairments or older patients generally cannot tolerate extensive appointments. As treatment progresses, the duration and number of appointments can be adjusted.

Biologic limits: The patient should be informed that treatments require a period of hard and soft tissue maturation. This period of time should be respected to optimize the results. Thus, orthodontic treatments will depend on the mechanics employed and the reactions of the patient’s dentoalveolar complex. Graft surgeries will require time for tissue healing, as will dental implants to allow for osseointegration. Rehabilitation cases will require a period in which the patient will use temporary restorations to ensure comfort, masticatory efficiency, and occlusal stability.

Economic constraints: Treatment should be adjusted to match the patient’s ability to make payments and the clinic’s financial policy, either phasing the treatment or performing only the non-elective parts, as discussed above.

Duration of treatments to be performed

It should be noted that there is no simple answer to this question and that it can constitute an objection to carrying out the treatment if it is not answered thoroughly and convincingly. Almost all patients do not have the technical or scientific knowledge to determine the durability of restorations, implants, or dental prostheses. In questioning the professional, the patient is trying to consider the cost–benefit relationship of the treatment from their point of view. If not convinced of the advantages of the proposed treatment, the decision to accept it may be postponed or the patient may lose interest in it.

Expectations of treatment longevity should be discussed from a realistic and individual perspective, seeking to determine the patient’s risk factors and anticipate the resolution of potential problems. The longevity of the procedures depends on several factors related to the professional and the patient, as explained below:

1. Complete diagnosis: The detailed analysis of the anamnesis, clinical examination, and complementary examinations allows the risk estimation of the global and individual treatment. The individual risk assessment is essential information to determine the patient’s susceptibilities and the risks of the treatment, incorporating information about the past and predicting the future of the treatment, including the time interval and duration of follow-up appointments.

The individual risk assessment can be divided into five main aspects:

1.1. Aspects related to the patient: The psychosocial aspects of the patient should be considered. Their level of awareness and motivation are essential for the longevity of the treatment. Thus, sensible, understanding, and collaborative patients improve the treatment prognosis.

1.2. Biologic aspects: The patient’s predisposition to dental caries and periodontal disease should be considered. These require critical awareness and change in the patient’s behavior concerning daily care and treatment maintenance. Local aspects such as exposed root surfaces, intrasulcular restoration margins, or poor contours predispose to the recurrence of the problems mentioned above. Endodontic problems and those involving the hard and soft tissue should be treated and monitored periodically (more details in Chapter 6).

1.3. Structural aspects: It is necessary to carefully analyze the condition of the remaining teeth. Although it is difficult to determine the condition of the supporting teeth, the amount and location of enamel and dentin in the remaining tooth and the incidence of occlusal forces on this tooth should be considered (more details in Chapter 2). It is also recommended to pay attention to abrasion, attrition, biocorrosion, and noncarious cervical lesions due to their multifactorial nature and implications for treatment. In the case of dental implants, it should be evaluated whether their number, distribution, and position follow the functional demand of the patient’s stomatognathic system.

1.4. Functional aspects: The longevity of the treatment is directly linked to the forces applied to the restorations individually or to the stomatognathic system as a whole. Providing an adequate occlusal scheme and a wide distribution of forces is the dentist’s mission, but extra care should be taken for patients with parafunction. Excessive, poorly distributed, or misdirected loads should be considered risk factors. Many patients have worn down their teeth due to parafunctional activity. They should be very well educated on minimizing the risk of further wear or fractures in the teeth or restorations. The indication of a stabilizing interocclusal splint and the need for a follow-up program with reassessments and readjustments should be emphasized.

1.5 Esthetic aspects: Esthetic longevity should be explained straightforwardly to the patient from both the subjective and objective perspectives. Subjectively, minor imperfections may bother some patients, and major discrepancies may not be significant for others. Objectively, the stability of soft and hard tissue after surgical, prosthetic, or orthodontic treatments should be monitored, given their characteristics. Regarding the selected materials, some degrade faster than others, depending on intraoral conditions, diet, habits, hygiene, and regular maintenance. In general, restorative materials and clean, polished teeth have a greater longevity. It should be clarified that the exposure of the tooth–restoration interface by tissue recession can be a relevant problem when the color of the dental substrate is significantly darkened, especially in anterior teeth.

2. Comprehensive treatment planning: A preliminary diagnosis will lead to incorrect treatment planning, as only the identified problems can be planned for in the treatment. All diagnosed factors should be treated according to the appropriate schedule, following a logical sequence and with the preferred materials.

3. Precision in clinical and laboratory execution: All procedures will be performed by professionals with the necessary knowledge, experience, and skills, using state-of-the-art magnification, instruments, and equipment to optimize results.

4. Scientific literature: Numerous systematic review studies provide parameters regarding the longevity of restorative treatments that the clinician can use to inform and motivate the patient about the care to be taken. However, the interpretation of this literature deserves attention because the various methodologies are not fully applicable to all clinical situations.

It is also worth noting a distinction between success and survival rates. Success rates relate to treatment that remains in the mouth without requiring significant changes and that is free of any complications during the observation period. Survival rates refer to situations where the treatment remains in the mouth and may have undergone modifications or corrections within the observed period.

Analogies can also be used to increase the patient’s degree of understanding and motivation. As it is impossible to give the patient actual and individualized data regarding the longevity of the treatment, it is suggested to provide an estimate based on published survival rates. For example, explain to the patient that there is a more than 90% chance that ceramic veneers will remain in the mouth after 10 years^22–31 when their indication criteria are respected, the manufacturing techniques are meticulously executed, and the maintenance plan is strictly followed.

Following the same line of reasoning, for inlays and onlays, survival rates are also around 90% after 10 years, according to the most recent literature^{27,28,31–35}. Crowns of the IPS e.max type (Ivoclar Vivadent, Liechtenstein) present survival rates above 95% after 10 years^36–38. Tooth- and implant-supported fixed prostheses also present a survival rate of around 87% to 92% after 10 years, and from 69% to 85% after 15 years^39–41, with no significant differences between tooth-supported or implant-supported types.

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