Making an IMPACTT: A framework for developing a dentist's ability to provide comprehensive dental care

Abstract

This article highlights the benefits of comprehensive dental care for both practitioners and patients, and the ways in which dentists and their teams through upskilling, collaboration, and thoughtful patient communication can provide care across every stage of the treatment process. More specifically, it outlines a framework for the importance of clinical education that focuses on the mindset of patient-centred care and taking a comprehensive approach to treatment using evidence-based dentistry.

Key points .

• Define comprehensive dentistry and the relevant skills required to implement the clinical workflow for your patients

• Create a framework to help dentists and their teams identify their strengths and weaknesses in the patient care journey they currently provide

• Can these learnings be transferred to other disciplines in the context of clinical education?

• To give a short-term and long-term perspective on professional development related to clinical education and professional development programs to improve patient care.

Introduction

As a specialist orthodontist, having been involved in clinical education for general dentists on the subject of orthodontics, aesthetic dentistry and clear aligner therapy for over 15 years, this article shares my opinions and experiences on how the landscape has changed in delivering education in clear aligner therapy. There are many learnings I have had on what I consider to be important for delegate success in learning a new skill. This has helped me to create the framework of IMPACTT which may give insights that could be transferred to other disciplines within clinical education and courses.

Does a stand-alone one-day or two-day course prepare a clinician to start to implement a new skill in any discipline? The answer is yes and no. The course should be considered in the context of the clinician's current knowledge, experience and competency. However, the irony is that having a background in 'soft skills' such as communication, an evidence-based approach and treatment planning will prepare the clinician better for a course, whether it is in clear aligner therapy, composite bonding or functional occlusion. The post-certification availability of mentorship and clinical support is essential for developing the newly acquired skills. Also, the principal and the team need to fully support these changes entering the clinical environment.

Lastly, a well-designed course should nurture delegate motivation and create opportunities for more commitment towards learning. The course should be facilitating education, and this requires the student to invest time and effort into learning the new skills.

Comprehensive dental care: Then and now

Comprehensive dentistry could have a different meaning to different clinicians - essentially it is whole patient dental care. Comprehensive dentistry can be defined as utilising all disciplines of dentistry, such as prosthodontics, periodontics, orthodontics, oral surgery and endodontics to meet treatment goals related to aesthetics, function, structure and the biological needs of the patient. The concept of 'comprehensive dental care' seems to be a contemporary term for the provision of interdisciplinary dentistry. An interdisciplinary approach classically has a team consisting of the general dentist, with specialists at hand and all of them working in close communication.¹

However, through education and technological advances, today's modern-day general dentists have integrated many of these speciality fields into their clinical practice.² They may have upskilled themselves with multiple courses and training in the different disciplines, allowing them to provide many parts of the comprehensive treatment plan and essentially redefining how they practise general dentistry.

What are the motives for upskilling or post-qualification study?

The idealistic answer would be for the dentist and team to be up to date with current practice and provide better care for their patients. However, these intentions may indeed be driven by other factors:

1. The commercial presence of some of the big companies in the dental industry make it seem a good idea to have certain courses on your CV or for your practice profile

2. Demand for specific treatments in private dentistry is being led by consumer marketing and social media from dentists and influencers and companies

3. Pressure to gross a higher income as a practice owner or an associate

4. The need to get a ROI on the time and money invested into a course.

Whatever the intention may be, the plethora of courses available out there makes it difficult for dentists and their teams to choose the best training and education to expand their career pathways. Some dentists are able to learn and cherry pick the information they require from multiple courses to improve their practice whilst others unfortunately become 'course junkies' that struggle to implement the education they have been exposed to.

With the advent of dentists upskilling in many disciplines of dentistry, the need to refer, and knowing when to refer, has become somewhat of a grey area that varies from clinician to clinician. It is dependent on their clinical competence and expertise but this can be mapped with a structured training pathway. This will give the dentist and their dental team the skills and confidence to create and orchestrate effective treatment plans that build patient trust and make them feel comfortable.³

IMPACTT: How it works

IMPACTT is about connecting the dots and not looking at dental courses and clinical education as isolated events. It is about seeing your professional development plan as a continual journey that improves the level of comprehensive care you provide to your patients.

Whether it's for an emergency appointment or a standard six-month check-up, each visit is an opportunity for dental professionals to share their knowledge and help patients make informed decisions about their ongoing care. This requires seeing beyond the patient's immediate needs. A good analogy is the '-ING' effect we witness daily in our practice. At every appointment, as we periodically meet our patients over the years, their teeth could be mov-ING, wear-ING or chipp-ING, or the bone periodontium support could be reduc-ING. The '-ING' effect is happen-ING in the present tense and although we expect physiological wear and tear overtime. However, if this is accelerated, supervising this effect over the years without action may lead to extensive dental treatment in the future. A preventative solution with orthodontics, restorative intervention and a comprehensive treatment planning approach may avoid a potential full-mouth rehabilitation in a particular case.

Today, as the healthcare community moves toward delivering more patient-centred care, providers are increasingly obligated to treat oral health in its entirety and what is being done for the person, not just to them.^4,5 Ignoring the bigger picture is simply a form of supervised neglect. As the famed Dr Lindsey Pankey once said, 'I never saw a tooth walk into my office'.⁶

IMPACTT is a blueprint for building and expanding your resume, focusing on the holistic needs of the patient, positioning yourself and your practice to provide comprehensive care throughout the patient's journey. The IMPACTT model (Fig. 1) engages five pillars:

• to Improve Measures on:

  • Patient-centred care
  • Affirmation with evidence-based dentistry
  • Communication
  • Treatment planning
  • Treatment provision.

Fig. 1.

IMPACTT model

This model articulates a methodology that works for the entire dental team.

Patient-centred care

Our own customer service and clinical proficiencies and deficiencies can be a gauge for measuring how effectively we're delivering patient-centred care that is truly patient-centred. Do we see our patients as part of the decision-making journey? Are we encouraging them to take part in their own treatment plans? It's not unusual for clinicians to approach patients from a 'what's in it for me' perspective that reduces the exchange to a business transaction and supports an attitude that doesn't really consider the patient at all. In a study conducted in Quebec, Apelian⁷ describes an attitude of reluctance amongst dentists to share the decision-making process with their patients. Stemming from a belief that dentistry is a sacred 'art', these practitioners were open to shared decision-making when they involved low-value procedures, but much less inclined to engage the patient in discussions when the procedures were of higher value. Patients themselves identify 'patient experience' and relationships as key factors in characterising 'quality care,'⁸ essentially quashing dentists' long-established beliefs that they alone know what's best for the patient.

Whether they're visiting for the first time, a regular check-up or an emergency, every patient encounter is an opportunity to build on the relationship and discuss their individualised treatment plan. Over time, as communication between patient and practitioner and the team continues and the objectives of the treatment plan and care are being met, the patient's trust will grow.

Affirmation with an evidence-based approach

Evidence-based medicine is considered the gold standard by which practitioners make decisions about the care of individual patients. The main objective of evidence-based dentistry is to improve the quality of health care by balancing the best available evidence with the patient's needs and preferences.⁹ Publications such as Evidence-Based Dentistry are essential reading for the profession. Before a dental clinician can develop a proposed therapy that considers the patient's optimal care, they should answer these three questions: What knowledge and expertise do I offer? Do I have access to the best evidence available regarding the effectiveness and safety of the therapy? What are the patient's values, preferences and circumstances?

Having answered these questions, the dentist can then offer the right procedure along with the recommended best practice for the patient, the dentist and the entire dental team. Equally as important, they should be able to explain their clinical rationale to the patient.

With so much literature and published research available, there are many places to be educating ourselves. Social media, however, is not necessarily one of them, at least when one's learning goal is to access high-quality, long-term knowledge. Guckian et al¹⁰ concludes that while social media is enjoyable for students and may be a resource to improve short-term knowledge retention and enhance communication between learners and educators, higher-quality study is necessary for longer-term impact on knowledge and skills, providing clarification on professionalism standards and protecting against harms. If clinicians know the evidence, they can look a patient directly in the eyes and communicate with confidence.

Additionally, social media fails to provide two significant hands-on learning components: mentorship and experience. Skills should not be taught in isolation. When learning a new skillset, the GDC recommends mentoring which allows for a post-training support system to be considered.¹⁰

Broadening one's skillsets across disciplines can be a major decision, especially given that 'defensive dentistry' is said to be causing UK dentists to be become increasingly more conservative in their treatments. As Westgarth¹¹ outlines, a survey of 1,000 dentists performed by Dental Protection showed 89% were afraid of being sued and 74% said it affected how they practice. Quality continuing education coupled with an evidence-based approach can endow the practitioner with the expertise to offer streamlined care throughout the patient's dental journey and quell the fears of offering comprehensive services.

Therefore, the next pillar of 'communication' is as important as the training itself. This holds true for the entire dental team.

Communicate with the patient

As Santana et al.¹² explains, communication is a complex clinical skill whose importance is not always accepted or valued by professionals in the dental community. Thus, it's no surprise that one of the biggest problems in dentistry is communication. However, if you want your patients to feel secure in their treatment, open communication must exist at every level of the team. Long gone are the days when the doctor tells the patient what to do and the patient acquiesces without comment or questions. Today's treatment planning is one of co-ownership and co-diagnosis, whereby the doctor explains the options and benefits and then works in tandem with the patient to determine the best course of treatment. Clinicians who are resistant to change may initially balk at this the notion of co-ownership, but Santana's research pointed to more efficient consultations, improved patient outcomes, more satisfying work and better interpersonal relationships with patients and colleagues when dentists take the time to communicate effectively.¹⁰

The IMPACTT model spells out three distinct approaches for communicating effectively with the patient: ensure they are given enough information on the procedure(s), explain all the options, and offer a risk/benefit perspective on each option that allows the patient to make an informed decision. The goal here is to educate rather than sell. Have you explained every option and given the patient enough information regarding the benefits and risks of each procedure? Do they understand the biological benefits to them? Have you offered the patient a thorough risk/benefit perspective which gives them the information they need to give consent that is truly informed?

This is the time to share your upskilling and continuing education knowledge to help build your patient's confidence in you. If you don't have the expertise for a particular treatment, advise them on a specialist who does. As Waylen concludes, clear communication between the dentist and the patient is associated with increased efficiency, more accurate diagnoses, improved patient outcomes and less likelihood of complaints or litigation.¹³

A treatment planning mindset

How do you approach your clinical practice? Effective treatment planning involves a systematic, comprehensive approach that considers the patient's values and goals and gives them and the clinician more control in managing their care. So much vast data from the assessment and diagnostics must be put into a funnel and then narrowed to a problem list, treatment options and goals, which is then finalised to create the treatment plan.^14,15 A systematic approach to treatment planning should be ethically based and consider the clinician's specific expertise, the values of the patient and cost considerations.

Much of today's treatment planning relies on modern technology. Digitisation is quickly evolving as a way for dentists to move beyond the boundaries of traditional dentistry and improve workflow and the ways in which they deliver services. The benefits of digital dentistry are numerous: integrated internal workflow, seamless integration with other digital solutions, seamless interaction between multiple entities, increased training capabilities, minimised outsourcing costs, better patient outcomes and the ability to perform treatments that were previously too complex to execute.

Early adopters such as the United States and Germany are increasingly incorporating digital imaging, computer-aided design and other modern technologies into their practices to provide patients with more accurate and time-efficient results. The UK, however, lags in its use of digital technologies. In Tran et al,¹⁶ we learn that just 15 percent of UK dentists were using digital technologies in 2016, citing cost, particularly with NHS dentistry, and quality concerns of chairside restorations. However, just a few years later, traditional practice took a back seat as COVID-19 advanced the need for virtual clinical practices and teledentistry.¹⁷ This move toward real-time intelligence can be adopted further to advance a digital mindset and provide patients with a more personalised patient journey experience.

Treatment provision - performing the actual work

Treatment, which is the fifth pillar in the IMPACTT model, can only move forward when the first four pillars are accomplished. Before delivering treatment, the four earlier pillars give the clinician insight to make an honest assessment of their knowledge and experience and determine whether they're competent enough to do the job or a specialist is necessary. Practitioners who are truly committed to self-improvement are asking tough questions and looking for honest answers. They want to explore their strengths and their weaknesses. They're interested in knowing where their further training would be best spent. These professionals work within their scope of practice, but they are continually upskilling to broaden their expertise with an eye on expanding their practices. If they can't treat it, they are able to understand the problem and leverage the help of a wider team of specialists.

Technical competency comes with practice and reflection, for most of us, experience equates to technical competency. Having a hands-on component using typodonts in courses seem to be a good start point. How, then, can we gain technical competency after learning about a new clinical skill? Moore et al¹⁸ reports that a hands-on mentor/mentee program between the junior and senior dental students in Aarhus, Denmark counteracted the junior students' emotional trauma and stress levels of moving from preclinical education to clinic, inspired professionalism and confidence, and helped them reflect on and better understand their competencies. This is exactly why, regardless of one's stage in their career, finding the right mentor and engaging in like-communities whether face to face or digital is such an important part of this journey.

Conclusion

Practitioners that continually upskill themselves, self-assess, cultivate relationships with their patients and commit to practicing comprehensive dental care can become dentists who travel with their patients throughout their entire journey. The journey is constant as our patients need continual care with maintenance and reviews over their lifetime. Furthermore, technology will continue to substantially change the way the dental profession delivers health care. Digitisation is making workflow more efficient, generating models faster, improving outcomes and enhancing the patient experience.

Clinical education and course providers should consider a standardised approach to help service the comprehensive needs for our patients and to facilitate learning and competency for its delegates.

Moreover, principals have an obligation to make it easier for their entire dental team to upskill and support professional development. Just as importantly, young dentists themselves have a duty to advance their own skills by investing the time and dedication required. When experienced, reflective physicians engage in a mentoring, peer to peer educational environment that supports willing learners, we endorse a culture that delivers a powerful message about how we want to educate the profession. ◆

Conflict of interest statement

The author declares no conflict of interest.