Ok – I know this isn’t an action packed clinical technique article. But hold on just a minute before you skip to the next post…
As a surgeon, this may very well be one of the most important articles you read on AOXSurgery.com.
Building the right referral relationships in your growing practice can have a huge impact on your AOX success or lack thereof. This is because All-On-X surgery is one of the most unique procedures that oral surgery provides.
This procedure relies heavily on two separate, but equally important aspects of dentistry. Achieving long term AOX success requires both a skilled surgical practitioner and a skilled prosthetic practitioner. A weak point in either area can and will lead to problems and/or complete AOX failures.
While many practitioners, especially new OMFS, are eager to jump into the AOX game with any referral they can muster up – in my opinion, one would be wise to slow down and consider the points listed below when building All-On-X referral relationships.
A little patience during the mutual selection of this “partnership” will lead to a happier, more fulfilling and more enjoyable AOX career for both parties involved.
A surgeon that lacks patience, may become quickly aware that having “the most” AOX referrals, is much less desirable than having “the best” AOX referrals. Working with well trained, focused, and involved restorative doctors will make your All-On-X life much less stressful, more enjoyable, and allow you to deliver a higher quality product.
None of us as surgeons should underestimate the importance of the prosthetic side of AOX surgery or the skill of the prosthetic colleagues that we work alongside.
In my career, I have had the opportunity to work with 13 different, full-time AOX prosthodontists. I have learned a great deal from each and every one of them.
Having worked with and learned from many different personality and clinical technique styles, I have come to appreciate 8 key traits that I feel go hand in hand with building a successful AOX referral relationship. Working with colleagues that exemplify these characteristics (and working to display them yourself) will produce an optimal surgeon – restorative provider relationship. This fine tuned surgical – prosthetic team is what provides the best long term AOX outcomes.
Before we begin, I would like to point out a couple of items.
First, the inspiration for this article came from a number of questions, phone calls, and long discussions with colleagues and friends in the OMFS private practice world inquiring about the best way to create All-On-X relationships with referring providers. These discussions also highlighted many frustrations and regrets amongst providers in “unhappy” AOX referral relationships.
While I am no longer in the private practice world – I have had the opportunity over many, many arches to see what has worked and what has not worked in the “Restorative/Surgeon Partnership” we all call… All-On-X.
When pondering a new AOX “partnership”, I would recommend considering the points listed below.
Second, please note that I am writing this article from my point of view as a practicing surgeon.
This article focuses on what I as the surgeon am looking for in a referring restorative colleague in order to optimize the AOX experience and outcome for both the patient and providers. While this is not discussed in this article, I should hope our restorative colleagues look for and value these traits in us as surgeons as well.
Furthermore, a future article will discuss how we as surgeons, can be more valuable and helpful to our referring restorative colleagues. This is absolutely a two-way street.
That being said – just as restorative providers discuss how to “find a great surgeon to work with” – This is my advice to surgeons looking to “find a great AOX referral to work with”.
8 Key Traits that Make or Break an AOX Referral Relationship
1. Chairside Manner
In my mind this is absolutely the #1 most important trait I look for in a referring colleague.
While chairside manner is of utmost importance to me as a surgeon – the reality in the AOX world is that full-arch patients will spend 90% of their time with the restorative provider over the course of their prosthetic experience.
The restorative provider is also often the first to encounter or be presented with any “problem” – whether it be prosthetic or surgical.
As the gate keeper and ultimate liaison for the patient, it is critical that the restorative provider have a great bedside manner. This includes being able to converse well with the patient, putting the patient at ease and instilling confidence in the patient.
Again, this is not to say that these traits should not be shared by the surgeon. They absolutely should.
The restorative provider, however, will have much more chair-time with the patient and the presence or absence of a great chairside manner will be readily apparent.
2. AOX Experience – Or an active approach to learning AOX.
Prosthetic experience in the AOX field absolutely makes a difference. An experienced restorative provider can help improve surgical outcomes with strategic prosthetic planning and post-op management of the prosthetic. This expertise will trickle over to the surgical side and lead to a smoother surgery and post-op course.
Furthermore, there will absolutely be “prosthetic complications” that need to be managed.
Assuming that the teeth are simply “screwed in” and the prosthetic work is then done – couldn’t be further from the truth.
Prosthetic experience and expertise are invaluable in managing AOX patients long term.
That being said, everyone has to start somewhere.
There is always a “first arch” for every provider – and there was for me as well. The key here, is a desire and willingness to learn and understand this procedure. That may include courses, advanced education, spending time with mentors etc.
The referrals that I would tread cautiously around are those that have no experience… and no desire to learn – and yet still want to bill for the prosthetic portion.
This type of referral often wants the surgeon to perform the prosthetic work-up, complete the surgery, create the prosthetic, deliver the prosthetic and then send the patient back so the referral can collect their check. This is suboptimal care.
If you want to learn and perform the AOX procedure, that’s wonderful! But if you don’t want anything to do with it… don’t charge the patient for a service you didn’t provide. Send the patient to a provider or a group of providers that can give them a full surgical and prosthetic treatment experience.
3. Confidence
I have worked with many different providers and I have realized that confidence is contagious. When I work with a restorative colleague that is confident in their skillset, I notice that I in turn become more confident. I feel a greater sense of trust that the prosthetic work-up I am provided is accurate and that prosthetic will be delivered in a way that enhances the surgical outcome.
I have also noticed that a confident referring provider tends to refer patients who are more confident about me and the procedure at hand.
This confidence seems to flow through every aspect and everyone involved in the procedure.
4. Communication
Communication in AOX surgery is critical. Again, the restorative provider often has the first point of contact with the patient and their ability to effectively communicate the patient’s options, planned treatment, and what to expect throughout the process can make or break a case.
Additionally, a strong and clear form of communication between restorative provider and surgeon must exist to have consistently, well done AOX surgeries. I have done my best work with prosthodontists that were more involved, not less involved. This is a team sport.
5. Consistently creates a detailed treatment plan unique to each patient.
The best prosthodontists that I have worked with assess each and every patient in a detailed fashion and provide a personalized surgical plan unique to each patient.
If the referring restorative provider is unwilling to provide a prosthetic work-up or provides the same generic request every time – this is a red flag for me.
I appreciate providers that not only indicate accurate, patient specific reduction numbers, but that also assess and provide surgical guidance on things such as a patient cross-bite, class II or III jaw/dentate relationships, the presence or absence of bruxism/clenching, a TMJ history etc.
While these are all items I assess surgically – many of these require a joint plan from both the prosthetic and surgical side. Therefore having these things accounted for on the prosthetic side as well, gives me confidence moving forward and indicates attention to detail from the prosthetic provider.
6. Adaptable to intra-operative surgical complications.
The hallmark of a great All-On-X surgeon is adaptability. The same can be said for a great All-On-X restorative provider.
A restorative provider that can adapt on the fly to the plethora of AOX situations that arise will always have a line of surgeons that want to work with them. It makes the life of the surgeon much less stressful knowing that the restorative provider can adapt to and help offset an intra-operative surgical complication.
7. A care and understanding that their prosthetic work has just as much of an effect on the health and integration of the implants as the surgery itself does.
I know, I know… surgeons like to blame the restorative providers and restorative providers like to blame the surgeons. And round and round we go.
In my mind, both aspects are equally important. I know this because I can do a great surgery and have it completely fail due to a poorly made prosthetic. And just as easily, the restorative provider can create and deliver a perfect prosthetic – and have it fail if I perform a poor surgery. Both need to be done well for long term success.
I find, especially in the private practice world, that there is this permeating idea that the restorative aspect is simply “hooking on the teeth” and any/all problems are caused by the surgeon and therefore should be managed by the surgeon.
There are definitely surgical problems. But there are also prosthetic problems. These problems can be created by a poor prosthetic or an inexperienced clinician. On the flip side, these problems can be avoided and/or successfully managed by skilled restorative doctor that understands the importance of their skillset and how it relates to the long term health and success of the prosthetic.
This understanding of the very real value of the prosthetic side and the attention to detail that it demands, is incredibly important in an AOX restorative colleague.
8. A trust and confidence in me as the surgeon.
Finally, I look for prosthetic colleagues that have both trust and confidence in what I am able to do surgically – and what I am not able to do.
I realize that this takes time to build.
Ultimately though, I want to work with restorative providers that also want to work with me. This sounds obvious. But there are many practitioners out there who work with referrals for AOX procedures that they don’t really trust as a professional. This lack of trust and confidence will come across to patients at some point – whether you realize it or not.
I want to know that the prosthodontists I work with trust me and have my back when surgical or prosthetic issues arise. Complications will undoubtedly occur. And in the AOX world, it is a team effort to manage them.
This level of teamwork only occurs when there is a mutual trust and confidence from the restorative provider to the surgeon, and from the surgeon to the restorative provider.
All-On-X surgery brings a unique relationship to dentistry that we have not truly had before. Unlike other procedures, once you perform an AOX surgery on a referring restorative doctor’s patient – you are forever bound to that provider in mutual management of that patient.
Remember this when looking for “new referrals”.
We all have bills to pay – but more often than not – quality is better than quantity.
Here’s to building quality AOX referral relationships…
Matthew Krieger DMD
P.S.
A special thank you to all the amazing prosthodontists I have worked with and learned from over the years. You have all made me a better surgeon in one aspect or another – and I am always grateful for that.
P.P.S
If you do both the surgical and prosthetic sides yourself – I tip my hat to you. While this article may not be as valuable for you in your day-to-day – these are definitely traits to look for in associates as your practice grows.