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Episode #321: Lower Risk – Increase Prognosis, with Dr. Betsy Bakeman

the best practices show podcast Jul 23, 2021

Risk assessment is the most important tool for designing the best treatment. And to share the most effective way to lower risks and have a good prognosis for your patients’ teeth, Kirk Behrendt brings in Dr. Betsy Bakeman to talk about a new system of thinking, the four diagnostic parameters, for better outcomes in patients. Veneers are useless if you lose your teeth! To learn more about treating patients comprehensively for the long run, listen to Episode 321 of The Best Practices Show!

Main Takeaways:

  • It’s important to figure out why something is happening to patients’ teeth.
  • Always look to reduce risk in areas of perio, biomechanics, function, and esthetics.
  • You can reduce risk, but you can't always eliminate risk.
  • Risk is a moving target in patients — things change.
  • It’s important to help your patients understand their level of risk.
  • Treatment doesn’t need to be done all at once.
  • Continuing education is the best gift you can give yourself.


  • “The whole concept of lowering risk, of looking at a patient and making a complete diagnosis and looking at where their risk factors for breakdown are and really categorizing that in a very simple way: low, medium, high. Periodontally, biomechanically — which is the structural integrity of the teeth. So, that's the patient’s risk for caries, erosion. And then, functionally, load-based failure. And then, also looking at the patient for esthetics, do the teeth show, because that has an influence on where we put the teeth and everything. So, you categorize in those four areas, are they low risk, medium risk, high risk.” (04:40—05:24)
  • “You have to work to lower the risk. Now, that may be treating the decay. It may be saying the decay is too out of control, we need to remove the teeth and move toward implants. Load-based failures. Is this a parafunction patient? Is this just friction? Are the teeth rubbing together, and we can fix that, the way the teeth come together? So, we always are looking to lower risk. And the amazing thing that does when we really think about that and make a thorough diagnosis and we design our treatment plans to lower risk, we increase prognosis and predictability. And patients really get it.” (05:32—06:11)
  • “It’s just a different way of looking at things and looking at the whole patient and making some decisions about where to go with things. And people are so appreciative. You end up treating the patient for the long term and you create very happy, very pleased patients. And it doesn't mean you have to do it all at once. Sometimes, we stage treatment over time. But you're going in that direction to lower risk and increase prognosis. And it feels really good. It feels like you're serving the patient.” (07:32—08:06)
  • “You have to force yourself to think [in this way]. [John Kois], he has systems that go through that, that go through perio, biomechanics, structural integrity of the teeth, the function, and the esthetics. And you actually have to write down in those areas and think about it in that way. And in the beginning, you have to fill out the form. You have to start to get your brain to think that way. And you develop the risk assessment, and you say to yourself, ‘Okay. I know this patient wants veneers. But if I don't manage the function, the reason the teeth look this way, this whole thing is going to fail.’ Or if the patient doesn't treat the periodontal disease they have, I could do beautiful veneers, but they're going to lose their teeth. And so, you structure things that way.” (08:51—09:42)
  • “The patient that needs the most dentistry, they're coming with the highest level of risk. And sometimes, we can lower risk. But in some areas, we’re not able to. We just have to manage it, and to the best of our ability, but we’re not able to eliminate it. And so, that's where I find risk assessment is really important as well, because I actually talk to the patient about their presenting risk. But I also say, ‘If we do treatment, I can help you with the way the teeth come together and bite and chew. But you're also a nighttime bruxer, and so you need to wear a night guard.’ Or patients of high-risk decay, we can treat the decay. But unless the causative factors of the decay are eliminated, which probably aren’t going to completely happen, you're still at risk.” (13:25—14:21)
  • “What the patient has to understand is, oftentimes, the greater risk they are, there are going to be issues going forward. We want to minimize that. We’re designing things so things aren't falling apart, they're losing multiple teeth. But could they chip porcelain? Could they need a root canal going forward? I mean, yes. We aren't completely eliminating everything, and it’s important for patients to own their level of risk.” (14:27—14:57)
  • “Patients can be frustrated. Sometimes, the more money they spend, that would be a reason to think you're never going to have a problem again. Right?” (15:17—15:24)
  • “Risk is a big part that determines prognosis, but so does the age of the patient. So, an 18-year-old that's drinking a lot of soda and has a lot of erosion or maybe has gastric reflux, which is an intrinsic source of acid, which is much worse and harder on the teeth — so, you see, erosion on the teeth in an 18-year-old, that's a much different prognosis than it is in an 80-year-old. So, those pieces play into it. But things change.” (16:46—17:20)
  • “Patients, in my opinion, do not decide what they're going to do while they're in the office. They decide when they're back home and they're with significant others. And that's when they're making their big decisions. So, they may say, ‘You know what? I'm not worried about this tooth. It’s been kind of the same. You tell me it’s significant, but it’s not bothering me.’ And I say, ‘When it does, or if it does, you just let me know.’ And sometimes, they’ll be in hygiene, and they’ll say, ‘This is getting worse,’ or, ‘My teeth are becoming sensitive. What can we do?’ And I'd say, ‘Well, before we figure out what to do, we need to figure out why it’s happening and make a diagnosis.’” (21:54—22:35)


  • Dr. Bakeman’s background. (02:40—04:06)
  • Why risk assessment is an important topic. (04:39—08:06)
  • How this system of thinking changed how she does dentistry. (08:50—12:32)
  • You can't always eliminate risk. (13:22—15:24)
  • Risk is a moving target in patients. (16:28—18:12)
  • How to integrate these concepts with your team and specialists. (18:40—20:01)
  • When patients don't understand their level of risk. (21:04—23:00)
  • Pushbacks and misconceptions on risk assessment. (23:19—24:40)
  • CE is the best gift you can give yourself. (25:19—26:31)
  • Why the Kois experience is different than others. (26:46—28:51)
  • Beyond the education. (29:05—30:07)
  • The future of risk assessment in dentistry. (30:42—32:20)
  • Find out more about The Kois Center. (32:39—33:12)
  • Q&A for Dr. Bakeman and Kirk. (33:54—41:05)
  • Dr. Bakeman’s contact information. (41:15—41:44)
  • Reach Out to Dr. Bakeman:

Dr. Bakeman’s email: [email protected] 

Dr. Bakeman’s website: http://www.micosmeticdentist.com/

Dr. Bakeman’s Facebook: https://www.facebook.com/cosmeticdentistry.MI



The Kois Center: www.koiscenter.com

Dr. Betsy Bakeman Bio:

Dr. Bakeman teaches as an Adjunct Faculty member at the Kois Center in Seattle, Washington. She is a member of the American Academy of Restorative Dentistry and the American Academy of Esthetic Dentistry, and an Accredited Fellow of the American Academy of Cosmetic Dentistry (AACD). Dr. Bakeman is immediate Past-President for the AACD. She also serves as both Accreditation and Fellowship examiner for the AACD. She was the recipient of the AACD’s 2013 Award for Excellence in Cosmetic Dentistry Education. She maintains a full-time private practice in Grand Rapids, Michigan⁠⁠. 


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