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VIEWPOINT: Assumption – Dentistry Today

by adminjay

Assumption can be one of the most dangerous words in the dictionary. It can even get you into trouble if you “assume” your next occlusal restoration will be like the last. Nevertheless, most of us do.  

In my early years, I learned the hard way. When I was 13, my parents took me to New York City and to a famous restaurant for steaks. It happened to be the best steak I had ever eaten, and from then on, I judged every steak by how good the one in New York was. It became my goal to go back to the same restaurant years later and order the “same” sirloin steak. I could not wait until I had my first bite and then the second and third. To my disappointment, it did not have the same wonderful taste I could still recall. Then I realized a different chef, sauce, and even the cow may have made the difference—so much for assumption in food.  

Throughout the day, most of us make decisions based on assumptions. For instance, while driving and approaching a green light that suddenly turns yellow-orange, do you stop or risk driving through?  

Two decades ago, I continuously used my favorite composite resin shade when I wanted to achieve a very natural-looking light color. However, several years later, ordering the same composite shade from the same manufacturer, the same shade was not the same and much different! Since I had an upcoming lecture in the manufacturer’s European city, I visited the factory and found, to my chagrin, they really had changed the formula, which was never as good as the previous one, despite the same identity number. 

I, unfortunately, recall a very costly assumption I made in changing the smile of a very attractive woman. I encouraged the woman to tell me what her vision was for her smile, but she insisted on having her husband come to the operatory. The husband vocally itemized exactly what we should do, and my assistant made detailed notes. My assumption was that she agreed with what her very demanding husband expressed.  

So, we created a trial smile that he really liked, leading us to complete the case. It was only after trying in the final ceramic crowns, then giving her a mirror while her husband was sitting in the waiting room that she finally vocalized her unhappiness, which finally led me to redo the case. As an aside note, they later got divorced. 

Now, when a new patient calls for a consultation, our treatment coordinator learns as much as possible about his or her desires to better get to know the potential patient. Next, after the patient is seated in the treatment room, my first assistant reviews the patient’s wishes and then communicates the outcome to me. In being the third person to listen to the patient’s desires, we have a good idea of what she or he expects.

Another example was an elderly lady with an aging full denture containing many artifacts of gold. I assumed she wanted me to make her look younger and prettier. When I tried in the final denture she looked in the mirror and started crying. I was pleasantly surprised at her happiness, which was short-lived. I said, “I’m so happy you like the final result.” Her response was “Like? I hate it! You left out all the gold?” I had assumed her desire to achieve a more youthful appearance would be to eliminate the gold. Well, it was back to inserting gold into her teeth!

For most of my career, I have been successful in treating difficult patients. In fact, one of my most popular lecturers was “How to Manage Difficult Patients…Before They Manage You!” My goal has always been to exceed my patients’ expectations. However, one patient I recall so well was a poorly dressed little old lady who arrived in tennis shoes with stains on her torn blouse. She told me she had lost considerable funds and did not think she could afford our prices. I felt sorry for her and brought in my partner, Dr. David Garber, to see how we could help her. As we asked her what she was looking for aesthetically, her answer was always, “You are the experts, and I know I will be happy with your treatment.” Finally, we agreed to do her case at a much lesser fee by each of us treating either the upper or lower arch. Our assumption was that she would be grateful and an easy case to treat. Unfortunately, she became one of the most demanding patients we had ever treated. We never realized there were so many things that patients could complain about, so we lost time, money, and our sanity treating her—so much for assumptions!

Years ago, a new patient complained that her face was ruined after her braces came off. I learned the orthodontist extracted 4 bicuspids and brought her anterior teeth back to fill in the gaps, but it collapsed her face. She happened to be the wife of a plastic surgeon, and she brought photos showing how beautiful her face was before the orthodontic treatment. However, when I called the orthodontist, he told me he extracted 4 bicuspids and completed orthodontic treatments with a perfect occlusion. He assumed that ideal tooth position could help create a patient’s ideal smile. Since he would not re-treat the patient to restore her attractive smile and face, it took another orthodontist to move her teeth labially and prosthodontics to restore her beautiful smile. 

Another patient who had maxillary porcelain crowns developed periodontal disease around 4 of the crowns. So, I referred her to a periodontist and warned him not to cut away her labial papilla but to use a lingual approach.

Weeks later, after her appointment, she came back to me crying that her smile was ruined because of black triangles between her front teeth. When I again called the periodontist, he told me he assumed he could get a better surgical result if he did surgery on both labial and lingual areas despite my warnings. Unfortunately, the patient had to pay for new crowns to close the black triangles. It was the last time I used that periodontist for aesthetic referrals!

By now, you may agree that I may be the right dentist to write this article. It brought back a lot of aesthetic and functional failures during my career wherein I learned to take more time to listen and not only do what patients say but also find what they aren’t saying to make them truly happy, especially if I wanted to exceed their expectations. I advise that one of the best ways to reduce your risk of failure is to not assume but make a careful analysis on your communication to and from your patients in your treatment planning. 


1. Never assume your patients fully understand your verbal postoperative instructions. Always document verbal consent with a staff member present and follow up with written instructions. However, never assume your patients will actually follow all your instructions.

2. Clear warranties are essential, so be specific with what is warrantied and what is not. For instance, “Wear from bruxism or grinding can shorten the life of restorations.”

3. Never assume that your patient who loved the veneer or crown you inserted at the “seating” appointment will be just as happy at the post-treatment appointment. Be ready to make minor changes to help exceed his or her expectations. I have had several patients leave our office completely satisfied, only to return after getting in their cars and finding concerns after looking in their car mirrors. I learned not to change out of my office clothes until the cars had left the parking lot!

4. Most dental offices make timed appointments based on previous experiences. So make sure your scheduler ensures additional time and a possible higher fee if the patient warrants it.

5. Never assume your bite-opening case will work fine without having your patient in temporaries for several months to ascertain the patient’s tolerance to reduced freeway space. 

6. Never assume you can satisfy your body dysmorphic patient. Unfortunately, I did and found out there is almost no fee to warrant the stress of treating a patient with this disorder. Also, never assume you can perfectly match a single central incisor for this type of patient. Allow more visits and consider an extra fee. Or consider Dr. Lloyd Miller’s advice and treat both central incisors instead of just one. 

7. Never assume veneers will work for a patient with a bruxism habit.

8. It is a mistake to assume the patient who wants a quick fix (refused orthodontics) will be happy with your prosthetic approach.  

9. Spend extra time and don’t assume you know exactly what the patient really wants. I usually confer with my assistants and our laboratory ceramists first before deciding if we will be able to satisfy the patient.

 10. One of my dearly departed Atlanta dentist friends, Dr. J.O. Wilson, had each new potential patient fill out a one-page questionnaire. After reviewing the answers, he would decide if he would actually treat that patient. His success rate was extremely high. I’m not suggesting that you should follow Dr. Wilson’s advice, but there are psychological studies that proved his technique was worthwhile. It would be a wonderful dental world if we could only treat undifficult patients. However, if you assume you might be able to satisfy your difficult patients, consider itemizing the fee for one or several extra mockups.


Dr. Goldstein is a professor at the Dental College of Georgia at Augusta University, an adjunct clinical professor at the Boston University School of Dental Medicine, and an adjunct professor at the University of Texas Health Science Center in San Antonio. He recently published a coffee table book, About Life: A Photographer’s Story. All proceeds go to Tomorrow’s Smiles (tomorrowssmiles.org) to fund dental care for disadvantaged teens. Dr. Goldstein maintains a private practice in Atlanta. He can be reached at esthetics@mindspring.com.

Disclosure: Dr. Goldstein reports no disclosures. 

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