On an intellectual level, there are probably not too many dentists who would argue against doing comprehensive exams. But once you get past the intellectual discussion and into the "practical real world", the discussion changes its tone quickly. I just can't spend that much time on a comprehensive exam and plan - it's just impractical in my practice. I don't have the time and even if I did, I could not get paid for it. Besides that, most of my patients wouldn't want to do it any way and even if they did, they would accept the comprehensive treatment, so what's the point of doing that kind of exam? I make my money by doing the dentistry, not examining and talking so I need to get to doing the dentistry as quickly as possible. I could go on and on.

One of the saddest things I do in my practice is to remove and re-do significant amounts of failed restorative dentistry. Sad because the patient has already invested a significant amount of time, energy, effort and money on this dentistry. And it has failed for a number of reasons: technical such as open margins, recurrent decay, fractures; biologic such as periodontal breakdown; occlusal such as interferences as a cause of the breakdown, occlusal plane and anterior guidance issues, wear; TMJ/muscle issues that developed since the previous dentistry was done; esthetics; etc. Neglect on the part of the patient is rarely a factor. These are patients who have been conscientious at "recare" appointments and had followed their dentist's recommendations. The story is similar in pretty much every case. The dentistry was done a little at a time, piecemeal throughout the years, done as 'problems arose' until the cumulative effect becomes a major problem. As dentists, we are notorious for looking at our patients with tunnel vision. We see urgent little problems without seeing the big picture. We fix these little problems without seeing how the little problem might be a symptom of a bigger problem. Time goes on and we fix more little problems when they occur. And the effect becomes cumulative. Look at this patient who has been the recipient of "comprehensive dentistry" - crowns, bridges, root canals, periodontal treatment, implants, prosthetics. There are now broken teeth, furcas, recurrent decay, periapical infections, and dysfunction. When I did the complete exam, she said that this kind of exam was never done. No one had ever even done a full mouth radiograph series! She obviously spent a significant amount of money through the years. She obviously was an interested patient. Could we have helped her spend her money more wisely??

I recently had a conversation with a dentist who told the story of two veneers he did on two chipped lower incisors - a conservative solution to a relatively minor problem. Upon delivery, both he and the patient stepped back to admire this artistry in dentistry when he said that both he and the patient almost simultaneously noticed the worn edges and slanted plane of the other incisors! Talk about tunnel vision. And in retrospect, the dentist said that he did not do a complete exam because the patient really didn't have any problems and just needed a couple veneers on chipped incisors! Don't you think this situation would have been avoided if a complete exam with photos and articulated diagnostic casts was done? And the dentist taking some time to reflect on this information and have a heart to heart talk with the patient before being in such a hurry to get the two veneers done? What does it cost, not just in terms of money but also in hurt feelings, lost trust and confidence, possible damaged reputation when circumstances like this happen? How often do you think ANY failed dentistry might have been avoided if a complete exam, diagnosis, plan and sequence had been done first? How often do you think that any dentistry PERIOD may have been avoided if the patient at a young age had a complete exam with complete records and a diagnosis and lifetime master plan worked out? And a preventive plan to include proper occlusal management developed along with periodontal maintenance? And repeating this complete exam every 3-5 years and do a timeline comparison to pick up subtle signs of change and address them before they become bigger problems? Nothing is 100% but we need to slow down, be more careful, pay attention to the details and counsel our patients.

I sincerely believe that the answer is obvious. We have a big responsibility as the physicians of our patient's masticatory system. Our job is to honestly assess the status of their masticatory system and not just find problems. Prevention is more than fluoride, good self-care and periodic periodontal maintenance. That's why all my patients get complete exams with complete records. Not just the ones with 'problems' or the ones that 'need some dentistry'. No one gets dentistry done without an exam and a plan first. Unless of course it is an urgency in which case a simple non-definitive treatment approach is done. If this approach is offered and the patient simply is not interested in that approach, then they don't become patients in the practice. I am not talking about patients who ARE interested but just can't get it done right now because of their circumstances. We still have a master plan, we just figure a way to sequence in a way that fits their life. And we work hard at communicating the benefits in an understandable way. There are plenty of patients who need significant amounts of dentistry. The baby boomers will keep us busy for years to come especially with esthetics and implants. There are plenty of patients who don't have apparent problems, have no symptoms but have early signs that require our careful assessment. Don't our patients deserve our best and don't we deserve the peace of mind that comes with the time and reflection invested in a complete exam, records, master plan and sequence?