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FOCUS ON: Patient-Centered Outcomes
David J. Clark, DDS, defines patient-centered outcomes vs process outcomes
and promotes a more minimally invasive mindset in the profession that favors
preservation and restoration of the natural tooth.
Q: What are patient-centered outcomes?
A: Patient-centered outcomes are the treatment
results that are important to patients. We may
contrast this with process outcomes, which are the
things clinicians do in an effort to affect the desired
patient-centered outcome. An example of targeting
process outcomes is when an endodontic retreat-
ment is recommended because the obturation does
not meet the standards of contemporary endodon-
tic practice. For instance, there was a newsletter sent
out by the American Association of Endodontists
essentially advocating for the retreatment of root
canal treatments simply because the canals looked
underfilled in the radiographs. In the absence of
pain, clear signs of infection, or functional impair-
ment of the tooth, such treatment is unjustified and
certainly not evidence-based. We extract a physio-
logic cost every time we “treat” a tooth. We may have
improved the radiographic aesthetics of the treat-
ment result; however, the questions that we should
be asking are: Has the patient received improvement
in his or her quality of life as a result of the treatment
rendered? Will the tooth be further weakened with
additional treatment? I think we would all agree
that such a scenario is not patient-centered.
Q: You have said that in other countries, when
discussing dentistry, some call the United States
“the Amputation Nation.” Is that fair?
A: Dental care, in many nations, does not have
the robust recall tradition that has been pro-
moted in North America. Unless there is a system
of socialized health care, patients have little or no
insurance and must self-pay, thus decreasing the
financial incentive for using indirect restorations.
Without a regular recall system, clinicians are less
aware of long-term functional or aesthetic failures.
In contrast, in North America, insurance reimburse-
ments for indirect restorations are exponentially
higher than for direct restorations. We also have a
tradition for regular and ongoing care that impacts
our patient and professional expectations for long-
lasting treatment. As a profession, we have been
skeptical that traditional bonding can have similar
longevity and aesthetics vs a crown. Thus, our bias
is to treat more teeth with crowns, often without
solid evidence supporting these treatment choices.
We should accept a reasonable, but limited, life
expectancy for any treatment and weigh such expec-
tancy relative to the invasiveness of the treatment
and remaining options for future revision. Thus,
our treatment planning should have context. For
instance, how confident are we that an implant
DENTISTRYTODAY.COM • AUGUST 2018
David J. Clark, DDS
restoration can last a lifetime in a 30-year-old vs a
60-year-old? Astute clinicians are becoming increas-
ingly aware of implant longevity and complications.
The pendulum is swinging back toward preserva-
tion and restoration of the natural tooth. We need
a shift in our professional expectations and modus
operandi. Our patients’ life expectancies are much
longer, and our professional care for them will be
a marathon. We believe that this entails a focus on
preservation of tooth structure rather than acceler-
ating toward terminal treatment options.
Q: How can clinicians serve their patients better in
the long-term without resorting to so many crowns?
A: The first intervention is critical. Pediatric den-
tists and restorative dentists need to be given
the tools to potentially provide 20-year, not 2-year,
outcomes when they place the first direct restora-
tion. That is the mission of the Bioclear Learning
Centers, now located in 3 countries. We are also
working with a dozen dental schools to discuss mod-
ernizing the restorative curriculum. We don’t need a
better filling material. We need a better procedure!
Q: What if a restoration fails or a tooth is broken?
A: Patients are willing to go to extreme lengths
once they realize that crowns require us to
remove potentially 74% of the tooth’s coronal vol-
ume. When quizzed, many dentists think that
number is closer to 30%. Think about it: How many
dentists avoid crowns on their own teeth? Recently, I
treated the wife of a dentist who had failed bonding,
replacing almost half the incisal length of her max-
illary central incisors. She was specifically referred
to me for injection overmolding with the Bioclear
Method. This was not an easy case at all, and, techni-
cally, crowns are much easier to do. After seeing the
final result, the patient looked me in the eye and said,
“Dr. Clark, I’m so glad you didn’t have to do crowns
on my 2 front teeth! Thanks!” Wow! Not quite what
we would expect to hear. Patients intuitively and
understandably fear having their teeth ground
down. Injection overmolding of teeth, which avoids
sacrificing tooth structure, is a patient-centered
procedure that is rapidly growing as a treatment
alternative. After placing thousands of these resto-
rations, my partner, Dr. Jihyon Kim, and I have the
confidence to provide 10-year warranties on them.
Monolithic injection-overmolded restorations
are built upon a foundation of complete biofilm
removal; the injection of heated flowable and regu-
lar composite; the placement of ultra-thin anatomic
tooth forms that allow monolithic composite to
shrink-wrap the tooth; and achieving a rock-star
polish. This method provides a third option of treat-
ment. Unlike direct bonding, it can be as permanent
as crowns when done properly. Unlike crowns, it
does not require sacrificing a significant volume of
healthy tooth structure to accommodate a path of
insertion or other mechanical properties of mod-
ern ceramics. With indirect options, the tooth must
be shaped to accommodate ceramic needs. With
direct injection overmolding, the composite adapts
around the existing tooth structure.
Q: Any additional thoughts on the topic?
A: Similar to how we amputate healthy tooth
structure for indirect restorations, in end-
odontics, we remove a hefty volume of peri-cervical
and radicular dentin to target the process outcome
of the tapering shape of obturation materials and
technique. Canals are typically not round in cross-
section or tapering from the coronal to apical
dimension. Thus far, these traditional shaping pro-
tocols have not been linked to any improvement in
outcomes and may even have reduced positive long-
term outcomes. In fact, crown and root fractures
are now epidemic. We need to adapt the obturation
material to fit the canal.
Dr. Clark maintains a private practice in Tacoma, Wash. He
founded the Academy of Microscope Enhanced Dentistry and
is a course director at the Newport Coast Oral Facial Institute
in Newport Beach, Calif. Dr. Clark is a co-director, along with Dr.
Jihyon Kim, of the Bioclear Learning Center in Tacoma. He can
be reached at bioclearmatrix.com.