Professional Documents
Culture Documents
PRACTICE
Underlines that it is important to allow
the patient time to explain the problem in
A good manageable treatment plan does not just happen, but comes about as the natural consequence of taking carefully
considered steps. History taking and clinical examination are two of the most important aspects of the patient assessment
process, and complement each other to such an extent that it is impossible to build a satisfactory treatment plan without
combining and collating information from the two procedures.
express themselves, and also cannot resist A problem and its diagnosis, though while taking a blood sample for
the temptation to interrupt. seemingly obvious, may in reality assessment is), and
It has been said that treatment cannot be masking a serious and extensive The examination using visual
be considered truly successful unless the disease which, again, will go untreated assessment, palpation and a probe
patient is satisfied. You will experience An assessment of the patients (probing to measure pocket depth is
situations where you feel that you have attitudes and the establishment of not a special investigation, taking a
done a really excellent job, but where, for good patient-clinician relationships periapical radiograph is).
whatever reason, you have failed to match are disregarded.
the patients expectations. Many patients Such tests have two functions. The first
do not really have expectations of the If previous records are available and you is as a screening tool to pick up unantici-
technical care we provide (for example, have not seen the patient before, then it is pated conditions, the second is as a means
how many patients would know if the your professional responsibility to exam- of confirming a provisional diagnosis. The
distal margin of a full gold crown had ine these records very carefully to note panoramic radiograph is a good example
an excellent adaptation?), but do hold any previous problems or patient concerns, of both functions. It can be used as a way
expectations regarding pain control (did and the need for any follow-up such as of screening the patient for unerupted
the dentist hurt me?), appearance (does medical conditions and treatments, pulp teeth, retained root fragments, unexpected
this filling look okay?) and function (can tests, radiographs and referrals. Have the bone cysts, tumours, etc., and as a way of
I chew comfortably and effectively after original dental problems been satisfacto- confirming the position and morphology
treatment? Has the filling or crown stayed rily treated? Update the medical and other of, for example, a partially erupted third
in place?). histories remember the adage never treat molar. Similarly, blood tests can be used
However, a small number of patients a stranger (Sir William Ostler). to confirm the diagnosis of a particular
hold what we might consider to be unreal- Collating the information gathered from condition such as anaemia, as well as a
istic expectations. Although we may wish the case history with that from the exami- general screening tool. Dental diagnostic
to fulfil all of our patients expectations, nation will enable the clinician to: casts can be mounted in a semi-adjustable
trying to do so for the patient with unre- Arrive at a tentative diagnosis articulator and used to assess modifica-
alistic demands usually courts disaster, as of the patients chief complaint(s) tions to the patients occlusion.
common sense and fundamental principles or problem(s)
may often end up being ignored. If you Determine any systemic factors that Final or definitive diagnosis
honestly feel that the treatment you pro- may influence this diagnosis The final diagnosis of a problem(s), how-
pose will not satisfy the patient, then it is Determine any systemic conditions ever simple or complex, only comes about
preferable to say so from the outset. It is that may require special precautions once the history, clinical examination
better to lose a new patient than to end up before and during dental procedures and various relevant special investiga-
being involved later in possible litigation. Compile a written record that tions have been conducted and the find-
will serve as legal evidence of ings collated. The next stage is to consider
History and examination professional competence. the various options available to treat the
The main purpose of the history and exam- patient and to choose the most appropriate
ination is to identify problems that may STEP 2: ESTABLISH DIAGNOSIS after careful explanation.
exist (such as dental, medical, psychologi- Initial diagnosis
cal, social and financial problems), and to STEP 3: CONSIDER
establish their relative importance to the An initial diagnosis of a problem can often
TREATMENT OPTIONS
patient and their effective management be formed on the basis of the information List and assess the various options
during subsequent treatments. History tak- gathered during the information collection
ing and clinical examination are two of phase, but it would be unusual to come to Enumerating the various alternative treat-
the most important aspects of the patient a definitive diagnosis without the use of ment options involves consideration of the
assessment process, and complement each one or more special tests. For example, a mouth as a whole, not just individual teeth
other to such an extent that it is impos- grossly carious tooth may seem the obvi- and, therefore, must also embrace struc-
sible to build a satisfactory treatment plan ous cause of a patients pain, but without tures such as the periodontium, soft tis-
without combining and collating informa- taking radiographs it would be difficult sues, and temporomandibular joints.
tion from the two procedures. For exam- to rule out the presence of other carious Practitioners should be conversant with
ple, a diagnosis might appear self-evident lesions, which also could be the source of the concept of evidence-based dentistry
by inspection alone. However, without an the pain. (EBD), which requires the judicious integra-
adequate case history the following may tion of systemic reviews of clinically relevant
easily be overlooked: Special investigations or tests scientific evidence with the practitioners
Coexistent diseases may go undetected These investigations provide information clinical judgement and the dental treatment
and, therefore, untreated unless that cannot be gathered by means of: needs and preferences of the patient.
the patient is allowed to express his The history (thus, taking a medical The following steps are required in the
or her complaints history is not a special investigation, EBD process:
Define a clinically relevant and assumptions about the reasons for their confidence of the patient. Fearful patients
focused question dental problems. Discussions in the area are much less likely to return for routine
Search for systematic reviews that may of relationships often focus on those situ- dental treatments. Fortunately, relatively
answer the question asked, such as the ations characterised by a lack of rapport few patients require further sedation and/
Cochrane Oral Health Group Reviews between the dentist and the patient, and or analgesic support methods once the
(www.ohg.cochrane.org/reviews) clashes of personalities. It is clear that such fear of needles and the fear of antici-
Evaluate the relevance of the evidence a lack of harmony can and often does lead pated painful dental treatment procedures
to the individual patients needs. to ill-considered treatment plans. Thus, are overcome. Both hypnosis and relative
a dentist may find treating a particular analgesia using nitrous oxide sedation
All possible treatment options should patient so unpleasant that he or she rec- have been shown to be successful support
be presented to the patient, who should ommends the least complex form of treat- methods in dentistry. Very apprehensive
be involved in deciding which of these ment, for example, extraction as opposed patients can benefit by writing down their
options will ultimately be chosen, and their to root canal treatment and a crown. At the earlier unpleasant dental experiences to
priorities. Some dentists favour present- other extreme, clinicians should be wary share with the dentist, and then for them
ing a single ideal option, the one they of treating friends and family since they to analyse the reality of what is pres-
see as providing the best possible result in may end up proposing treatment plans that ently happening with what they feared
terms of aesthetics and function, and then are too complex, for example, by advo- may happen.
drawing attention to particular weaknesses cating heroic measures to save a tooth
of other possible options as compared to which, in any other patient, they would The patients age
their favoured, supposedly ideal, course consider unrestorable. Clearly, the patients age will have a
of action. bearing on many treatment decisions. In
The problem with this normative need The patients beliefs about, and young patients the likelihood of further
approach is that it fails to take into
attitudes towards, dental care tooth eruption and large pulp chambers
account the patients dental healthcare One course of treatment that may make can impact on the decision whether or not
wishes, beliefs and attitudes or behav- complete sense for one patient may be to use a particular type of restoration to
iours, and it also fails to recognise that all unsuitable in another. For example, a restore a tooth. In older patients the greater
treatment options possess both advantages 25-year-old female patient presents with risks of periodontal disease and root caries
and disadvantages. It places the dentist in pain from a previously restored mandibu- can also play an important role in shap-
the position of being the only person who lar first permanent molar. The diagnosis is ing the treatment plan. In either case, any
knows what is good for the patient, and irreversible pulpitis and the patient is very advice given must be presented in a way
may result in significant unnecessary treat- keen to retain the tooth, so the decision that is appropriate to the patients age.
ment. Unfortunately also, the literature is is made to treat the tooth endodontically
replete with studies that have highlighted and place a ceramometal crown. A sec- The patients ability to tolerate
marked differences between practitoners ond female patient of a similar age and
dental treatment and to maintain
any treatment provided
in their diagnoses and preferred treatment an identical clinical condition is not both-
plans for the same patient. What is relevant ered if she loses the tooth and so requests A perfectly logical treatment plan may
or significant to one practitioner may not extraction. Two almost identical patients, falter as a result of the patients inabil-
be to another practitioner. Of course, the but two very different treatment plans. ity to tolerate treatment, especially where
patient is more than likely to ask which Often, a patients negative beliefs and long treatment sessions are involved. The
option do you think is best?. Your rec- attitudes have been conditioned by previ- patient may simply not be able to open his
ommendation will draw on the following ous unfortunate dental experiences. The or her mouth wide enough for you to gain
information gathered during the history patient may be very apprehensive follow- sufficient access. Similarly, the patient
and examination process. ing previous unpleasant or painful per- may present with a neuromuscular con-
sonal dental treatments, or by seeing such dition that makes fine tooth preparation
General considerations treatments experienced by others. In most impossible. Such conditions also make the
The patient-dentist relationship instances, a caring attitude, a full expla- maintenance of oral hygiene that much
nation of the proposed dental procedure, more problematic, and it is unreasonable
Without due care and attention the likeli- and careful pain control techniques by the to expect all patients to be capable of
hood of the dentist and the patient envis- dentist are usually all that is required to effectively cleaning complex bridgework
aging the same treatment expectations encourage the patient to accept appropri- (fixed partial dentures).
may not be high. There may be a dichot- ate treatment. The patient should be placed
omy between what the patient wants and semisupine in the dental chair (when this The patients willingness to attend
what the patient actually needs. Patients is possible) and reminded to relax tense
and their past attendance record
may be confused by dental terminology or shoulder and arm muscles while the Decisions on whether to leave alone, stabi-
jargon and fail to understand what is being warm local anaesthetic solution is being lise (and keep under review in either case) or
proposed and why it is being proposed. slowly administered. A simple procedure to restore a tooth are often influenced by the
They may have strong, but incorrect, should first be chosen to gain the trust and degree of certainty as to whether the patient
will attend in the future. The dentist who patient from this type of treatment, but treatment planning is to identify problems
is confident that a particular patient will will necessitate referring the patient to of varying importance and urgency, to
comply with requests to attend at certain someone who does possess the required arrive at possible diagnoses, and to provide
time intervals will be more likely to defer skills. Equally, you might be able to per- appropriate feasible solutions.
restoring a tooth, prefering to keep it under form the treatment, but lack the necessary The most appropriate treatment option
review and ascertain the response to pre- equipment and facilities to do so. Extend is the one which allows you to meet your
ventive measures rather than immediately the services that you can offer by attend- professional ethical commitments, while at
place a permanent restoration. Work and ing practical continuing education courses the same time satisfying the patients needs
family pressures, ill health, unemployment, for proper training, and by investing in and demands. In the majority of instances
and having to commute a long distance may newer equipment and technology. this happy balance will be easily achieva-
cause problems in attending for treatment. ble. As was described earlier though, prob-
Specific dental considerations lems arise when these two requirements
The patients financial considerations These relate to the specific dental treat- are competing and cannot be reconciled.
The cost of dental treatment cannot be left ment being contemplated and include such When in doubt, do not go ahead with pro-
out of the treatment planning process, espe- factors as: viding treatment that you feel uncomfort-
cially when the patient is expected to pay Oral hygiene status, and motivation or able with, however much pressure you are
for all, or even part, of the treatment. Studies cooperation of the patient subjected to by the patient.
have shown that the cost of dental treatment Control of dental caries, tooth wear,
may be less of a factor for patients than and periodontal disease Formulate the treatment plan
when and how the subject, and the mak- Pulpal and endodontic status of A well thought-out and documented treat-
ing of payments, are discussed. However, individual teeth ment plan, tailored to the patients needs
costs become more significant with more Functional occlusal relationships and and expectations, provides the following
complex treatment alternatives such as occlusal forces or stresses advantages:
endodontic therapy versus tooth extrac- Appearance of the dentition A smooth and logical progression
tion, all-ceramic crown versus resin com- Restoration retention (crown height, through the various treatment phases
posite build-up, and acrylic resin removable enamel available for bonding, etc). Reduced stress for the patient, dentist
partial denture versus ceramo-metal fixed and staff
partial denture or dental implant. Costs Risk assessment A more effective use of clinical time
also may be incurred from taking time off This stage of the treatment planning pro- Less inconvenience for the patient
from work. In private dental practice, costs cess is important and often done almost A greater likelihood of achieving the
are often closely linked to patient prefer- subconsciously. It requires the dentist to patients expectations
ences and affordability, which then often consider the likelihood of success or failure The provision of essential information
determine the final treatment plan selected of the various treatment options as shown for the patient such as the time
from several options. Affordability may also preferably by evidence-based studies, and involved, costs, expected treatment
relate to the type of dental health insurance to ensure that the patient fully understands outcomes and anticipated prognosis
benefits or other third party reimbursement the probable long-term prognosis for each A reduced risk of non-payment of fees
schemes that a patient may have for par- option. Unfortunately, only limited informa- and of dento-legal problems
ticular dental treatment costs. tion is available on the cost-effectiveness of The anticipation of any complications
Many dentists list the prices for indi- restorative treatment options, which takes and the provision of contingency plans
vidual items of treatment. Other dentists into account the long-term survival esti- The ability of a colleague to continue,
believe that the prices for individual mates of different treatments that have been without difficulty, the treatment in
items of treatment should not be shown discounted for their initial treatment costs. your stead if required.
to patients even if they are the basis upon In addition, the survival of such treatments
which the fees have been set. Instead, the is influenced by the current oral disease risks By the time the practitioner is able to
patient is quoted a global sum with the present, such as those for dental caries, tooth present several possible treatment options
actual price list used merely as a refer- surface loss and periodontal disease. having different advantages or benefits
ence by the dentist. Whichever approach is for the patient, a certain degree of trust
adopted, one common fundamental princi- STEP 4: FORMULATE and rapport should have been established.
ple is that patients must be fully informed
TREATMENT PLAN Communication should avoid the use of
in writing of the probable costs of expen- Select the most appropriate technical terms and overwhelming the
sive procedures in particular before treat- treatment option patient with minute details. The dentist
ment is started. should first spend time in educating the
The aim of treatment is to provide a patient about the causes, and the future
Your ability to perform masticatory system that is functionally prevention if relevant, of the dental prob-
a particular treatment adequate, free from active disease and lems diagnosed. Photographs, drawings,
A lack of experience in, for example, plac- discomfort, and which is aesthetically radiographs and diagnostic casts can
ing dental implants does not preclude the pleasing to the patient. The objective of assist in this education and explanation.
Table 1 Overview of the treatment management process treatment apart from usually the relief of
discomfort or pain. These patients often
Treatment Phase Treatment Items have their own dentists from whom they
Emergency, and stabilisation Control of acute pain, infection, tooth fracture, gingival bleeding, will seek follow-up treatment. A medical
etc. Medical consultations if required. Extraction of non-strategic history should be obtained to ensure that
hopeless teeth and retained roots, and caries and erosion control
there are no systemic conditions present
Preventive, and disease control Oral hygiene instruction (OHI), scaling and prophylaxis, fluorides,
that would cause any problems from your
chlorhexidine mouthrinses, casein-derived pastes, dietary analysis,
splint construction dental treatment. Where appropriate, a
Initial restorative, and consultations Simple restorative work, placement of cores (foundations). brief note addressed to the patients dentist
Endodontic, periodontic, prosthodontic, orthodontic, etc, and outlining what has been done may be
consultations
given to the patient.
Review, and occlusal analysis Assess responses to previous preventive and operative treatments.
Regular patients will only require the
Evaluate mounted casts and diagnostic wax-ups
updating of their medical and dental his-
Definitive complex restorative Conformative or re-organised occlusal scheme? Need to increase the
occlusal vertical dimension and the clinical crown lengths? tories when they attend for recall. It is
Maintenance, and monitoring Recalls: review oral hygiene and home care, periodontal health, usually sufficient to enquire whether their
caries activity, occlusion, fixed and removable prostheses, implants. medical status and any medications have
Further radiographs and tests as required
changed since the last visit, and whether
they have any dental problems that require
Emphasise the benefits of the treatment emergency and initial restorative treat- attention. Patients can also check their
proposed, and how it will help the patient. ments also required. previous documented medical and dental
Confirm that the patient understands what Often, restorative and initial subgingi- history questionnaire responses.
you are saying, and is aware of the conse- val scaling and root planing treatments
quences of not having treatment or failing are performed under local analgesia in the READING
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