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The Interview


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Lesson #7: CORE Lesson #7 – The Risk Assessment Pyramid

About This Lesson

Instructions coming soon..


Action Items

  1. Either copy my Risk Pyramid or make some version of your own!
  2. Get patients thinking about risk assessment and goal setting!

Full Video Transcript / MP3

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What is up, everybody? Welcome back to module number four, which is all about the interview. We are going to cover a concept that is a conglomeration of all the different mentors that I've had put in a context to help patients get in a goal-setting mode. I introduced this concept in the interview, and it's a very simplistic way for me to help patients understand risk assessments. As you guys go, if you're moving towards a wellness-oriented mode, risk assessment is everything in this game. Because when patients understand that there's risks, there's pros and cons to everything that we do, and they know where they're at on their risk assessment pyramid in a way that they can easily identify. They move into a goal-setting mode. There's a couple things that I've talked about that helps patients move in a goal-setting mode. You have to get your patients in a goal-setting mode if they're moving towards something that they can't tangibly see.

When I first had a couple videos ago about dentistry, most of the disease in dentistry are chronic degenerative disease. Tooth decay and gum disease are chronic degenerative diseases, which means I always tell patients it's kind of like watching paint dry. Over time, from one six-month period to the next, you aren't going to be able to really tell a difference. It's the cumulative impact of years, of years of chronic degenerative diseases that cause problems. Periodontal disease is a classic example of this, and that's why I think there's so many links and associations between periodontal disease and heart attack, strokes, diabetes. All the bacteria cause the same level of disease, and it's the bacteria cause inflammation and inflammation is actually where the breakdown occurs and you have the problems.

Periodontal disease is no different than heart disease. With periodontal disease, you can go years, and years, and years and you never see a change, but it doesn't mean that the disease is not getting worse, and worse, and worse. Having patients understand risk assessments is everything in this game. So as we're going forward, that's what we're going to talk about. This is tenet number seven of the interview, is the risk assessment pyramid.

I'm going to show you this diagram. There's no text in this video, but this diagram is in the office manual. What I want you to do is really study this. This literally is the culmination of five, six, seven different mentors at different stages of my career broken down into a process that patients can understand. When I introduce the risk assessment pyramid, I actually have four photos for youth, early adult, late adult, and elder. That is a Pankey model. That is from the Pankey Institute, that youth, early adult, late adult, elder. Now if you consider, when I talk about youth, early adult, late adult, elder, I'm talking about tooth age. You have to remember, in my practice, I have a lot of older patients. What I tell patients is, "Listen, you can have a youthful mouth even if you're in your 70s or 80s. And that's what we want to shoot for because it has all the tenets of health. But you could also be 20 and have an elderly mouth. You're missing a lot of teeth. You might have dentures. That's an elderly mouth." I break in risks and terms of where they're at on the spectrum of youth to elder in those corresponding categories.

I keep it really simple to follow, though. I'm telling patients, "Listen, we're working our way up towards this pyramid of pinnacle health, and we have to start with the foundation with is the gum and bone." That's your periodontal risk. How likely are you to get periodontal disease that cause you to lose your teeth or cause you to have other problems? Are you very healthy in that capacity or you're at really high risk? Are you elderly in that capacity? And If you're at really high risk, we're going to have a different plan of attack than if you at really low risk. Does that make sense? Patients instinctively get that.

Then, once we figure out the foundation, that's like the foundation for a house, the gum and bone, then we're going to look at tooth decay. How likely are you to lose your teeth because of tooth decay. Or existing dentistry that's been done. Do you have a lot of large amalgams? Do you have a lot of the large fillings that have been done previously? Those are going to cause your teeth to more likely break or have problems in the future, more decay because of how much work has already been done. Again, I'm going to put you in a risk category level between youth and elder for tooth decay and biomechanical risk. How likely are your teeth to break?

Then, we're going to look briefly today ... I'm talking to you just like I would talk to a patient. Now we're going to look briefly today at your bite. Now, we probably won't get into your bite in too much detail. But if you remember those three diseases I talked about, tooth decay, gum disease, and bad bite, I'm looking at the corresponding parts of your mouth that would indicate whether or not you're at low or high risk for any of those three diseases. I'm going to look briefly at your bite. I'm going to look at signs of tooth wear and things of that nature to put you into a risk category of youth to elder there.

Now, in the future, I'm going to give you some corresponding categories of restoring your teeth in a long-term fashion to achieve optimal health and then other health issues that you may have that we might be able to help you with to help you not just from a two standpoint but also from a face standpoint, a joint standpoint, an oral systemic standpoint. We're going to get you into a general health risk category. All we're doing when you're working in this practice is we're moving you up that pyramid and we're trying to lower your levels of risk if that's something that you're interested in doing.

What we're going to do today during the interview, or during the exam process, is we're going to first identify just where you're at. Where are you on this risk assessment pyramid? Are you at green at every level? Are you at red at every level? Or do you have a combination of red, yellow, orange, and green? Once we do that, we're going to have an opportunity after we do our exam today is to come back and actually talk about what we found so we can actually set a goal together at how healthy you want to be. We have some patients that are in orange on every category and they want to get to green. We have some that are in orange at every category and at the end of this process they just want to stay at orange. They don't want to go to red. Those two plans are going to be drastically different depending on your goals as a patient.

I want you to pay attention to that little small thing in the bottom, the cost of care to achieve wellness. This is the missing piece that a lot of dentists won't tell you about. Again, I'm talking just like I would talk to a patient. You see how as you go from green to yellow to orange to red those dollar signs get bigger and bigger and bigger? That's because if you ever went to red and you want to come back to green, you can imagine that's a lot more expensive than if you're at yellow and want to get to green. So the first thing that we need to make a decision on is if we're at certain levels on the risk assessment pyramid, we don't want those levels to actually get worse. The first decision we have to make is stopping the disease from getting worse, and then we can figure out at what level we want to get you back to in terms of health.

That is my goal as a dentist is to help you become aware of the conditions in your mouth and understand your risks and then give you the choice to improve those if that's something you're interested in doing. Would you like to move forward with that? That is my permission, and I'm going to talk a little bit more about that in the next video.

You see how I was able to do that? That's all you have to say. Don't get too far into it. But you have to master those things. You have to start to figure out how do I have a conversation with a patient that they can understand risk assessments, going further into risk is going to lead to more cost if you ever want to reverse that process, having them have a visual that they can actually see these things. And don't bombard them with information about technical dentistry, and periodontal disease, and things like that. Just say bleeding gums.

In my practice, I tell patients this. Listen, there's three things that we really want to accomplish in this practice. And if we can do these three things, I'm happy as a clam. I don't even know where that came from. But like I'm happy as a clam if we can do these three things. One, we want no bleeding gums. That's a sign of infection. If we can get rid of bleeding gums, we're in good shape from a gum and bone standpoint. Second is we want no tooth decay and we want no holes in your teeth. We don't want breakdown, and we don't want to decay. So if we see holes, we're going to be able to fill those holes so that everything is sealed. That's the second thing we want. And third is we want to protect your teeth at night with some type of appliance or device so that you can't wear your teeth out at night, which will protect your teeth, will protect your joints, will protect your muscles. Now, that's not everything that we can do here, but if we can get to that baseline of protection for all of our patients, we're really, really happy. There's other things that we can do and other things we can talk about, but I just want you to be aware of what's possible here.

These are things and discussions that I have with my patients all the time. I want them to understand that I don't care what level of health they ascribe to. I'm there to help them get as healthy as they want to be, but they do need to know what their risks are. In the interview in these new patients, this is the time to do it, guys. You cannot say, "Well, you know what? I don't want to throw too much at them at once. I want to take them through the process and then introduce this." You can't introduce this after the interview. You can't introduce this after the new patient process. You have one shot at this. Don't wait for six months, 12 months, one year, two years to have these conversations with the patients because they will not trust you. You have to have these conversations upfront.

Your action steps is either copy my risk assessment pyramid, which is, like I said, a conglomeration of [Coyson 00:10:05], Pankey, and Dr. Schuster, and all these different pieces and elements. I want you to copy the risk assessment pyramid or make some version of your own. The key is you have to be able to describe this to your patients with confidence and charisma.

Second is you got to get your patients thinking about risk assessment and goal setting. I use the risk assessment pyramid as, A, to let them know that there's different risks and different levels of health and, B, get them thinking about moving from one risk level to the next in a simple goal-setting fashion. If you do these things in your interview, I tell you, your patients will get onboard with wellness care. They absolutely will. Or even if you want to do cosmetic work, you can't do cosmetic work with perio issues, so you have to address the periodontal disease first. You have to address all disease that's bacterial in origin first or you're going to be fighting a no-win battle the entire time.