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INFORMING PATIENTS ABOUT TREATMENT ALTERNATIVES
OBSERVATIONS
GORDON J. CHRISTENSEN, D.D.S., M.S.D., PH.D.
INFORMING PATIENTS ABOUT TREATMENT ALTERNATIVES Legal activity by dental pa-
tients has increased significantly in the past several years.1 There are numerous potential reasons for this challenging situation. Many more procedures are available in dentistry than in the past, and the alternatives—unless they are explained thoroughly—are confusing to patients. Some dentists do not offer all of the treatment alternatives, and they emphasize only those procedures provided in their own practices. Some clinicians attempt to judge patients’ treatment desires before offering all of the treatment options. In addition, treatment plans may be presented with unrealistic optimism for clinical success, helping give patients false expectations. One of the factors stimulating this legal activity may be that some dentists do not provide information to patients about all of the treatment options available for specific situations, and subsequently fail to obtain consent before beginning treatment. This article discusses six necessary aspects of informing patients adequately about treatment alternatives. 730
GIVING YOUR PATIENTS ADEQUATE INFORMATION
Alternatives for therapy. Almost every oral procedure has several alternatives. As an example, one missing maxillary lateral incisor may be treated with an implant and a single crown; a three-unit fixed prosthesis; a two-unit cantilever fixed prosthesis; a Maryland bridge; a fiber-reinforced, resinbased composite prosthesis; an all-ceramic prosthesis; a metalbased removable partial denture; a resin “flipper”; or nothing. Often, patients are not informed about the many available alternatives, and unless dentists or auxiliary staff members educate them, they may end up receiving treatment they did not want. Unless that therapy is excellent and the patient does not complain, delivering inadequate patient information about all of the treatment alternatives is asking for patient dissatisfaction or even a lawsuit. Advantages of each alternative. Each option has some advantages. As an example, analyze a few options from the missing maxillary lateral incisor alternatives. Use of an implant and crown does not re-
quire cutting adjacent teeth, which certainly is an advantage. A three-unit prosthesis is strong. A two-unit prosthesis does not require cutting the central incisor, and it can blend color characteristics well. You know the advantages as well as I, but do you take the time to explain them to each patient? Many dentists don’t. Disadvantages of each alternative. Often, patients arrive at the dental office with predetermined opinions about the various treatment options. These may or may not be correct. I have had many patients tell me they don’t want “caps” because they can always tell the teeth are false. I respond by using various analogies such as this: “Have you ever had a fender repainted on your car? If the repair person didn’t match the color well, you could differentiate the repair from the other paint. On the other hand, a well-matched paint repair is impossible to discern from the remainder of the paint on the car. Similarly, a well-constructed fixed prosthesis is not easily differentiated from natural teeth, but you can detect a poorly matched prosthesis.”
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
CHRISTENSEN Patients should be given realistic expectations about disadvantages of the various treatment alternatives. As examples, an implant requires several months to integrate into the bone, while installation of a fixed prosthesis usually is completed in two appointments. A three-unit fixed prosthesis extending from a maxillary canine to a central incisor requires the cutting of enamel from two teeth instead of one, and the natural central incisor and crowns may not match in color. Risks associated with each therapy. This aspect of patient education is often omitted, because patients tend to become discouraged from having the treatment if they hear the risks without proper explanation. An implant placement is associated with the normal surgical risks, which need to be explained. Each anatomical position in the mouth poses different surgical risks. A typical maxillary lateral incisor location with adequate bone presents few risks during implant placement, while a lower molar area with only 9 millimeters of bone from the occlusal crest of the bone to the superior aspect of the inferior alveolar canal presents significant postoperative risks of nerve damage and potential paresthesia. Risks of treatment should be discussed in a factual manner after patients have heard the advantages and disadvantages of each therapy and have made some tentative decisions. At that time, risks can be put in proper perspective and can be related to the patient’s specific situation. Even simple crowns carry risks, such as the potential need for later endodontic therapy. Omission of a discussion about
risks followed by the occurrence of an unexplained problem leaves the clinician vulnerable to legal action by patients. Cost of therapy. A common complaint among patients is that their dentists did not explain the cost of therapy before beginning. Consider the difference in cost between a resinbased removable partial denture (“flipper”) for replacement of a lateral incisor and an implant, abutment and crown. The removable prosthesis may cost 10 times less. If a patient is presented with only one expensive option and is influenced heavily toward that option, and then the treatment fails, there is al-
standings. Overemphasizing the necessity of treatment is asking for trouble; the overtreated patient would be justly upset to find out about the relative lack of need later. Overemphasizing treatment needs is one of the most frustrating aspects of diagnosis I see in my prosthodontic practice. Not everybody needs 16 veneers, a mouthful of crowns, orthognathic surgery or toothcolored posterior tooth restorations, although such treatments are promoted heavily by some dentists. Absolute honesty in treatment planning is still the best advice. EDUCATING PATIENTS
A common complaint among patients is that their dentists did not explain the cost of therapy before beginning. most a certainty of patient dissatisfaction. Costs must be discussed for all alternative therapies. Result of nontreatment. Some pathologic oral conditions require therapy to prevent serious consequences. An abscessed tooth can cause total debilitation because of the associated pain. Serious systemic conditions can occur. Conversely, a shallow carious lesion often can exist for months before any clinical situation of consequence occurs. Dentists can over- or underemphasize the need for any oral therapy. Instead, they should give patients realistic, honest approximations of the consequences of lack of treatment to prevent misunder-
Can a typical dentist provide all of this information to each patient? It is highly unlikely that most dentists can afford to provide this much patient education by themselves. In my own practice, the task of education has been delegated to dental assistants and dental hygienists.1-3 These people are assigned to provide information to patients about all of the areas described in this article and ensure that the educational requirements are fulDr. Christensen is filled. Only co-founder and senafter this eduior consultant of Clinical Research cation is comAssociates, 3707 N. pleted do I Canyon Road, Suite No. 7A, Provo, Utah want to enter 84604, and is a the treatment member of JADA’s editorial board. He planning/diaghas a master’s denostic room to gree in restorative answer quesdentistry and a doctorate in education tions and to and psychology. He provide my is board certified in prosthodontics. own profesAddress reprint resional opinions quests to Dr. about the most Christensen.
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
731
CHRISTENSEN adequate therapy for a specific patient. Auxiliary staff members need teaching aids to provide the information. Dental offices should be equipped with pamphlets, books (such as titles by Christensen4 and Goldstein5), videotapes, photographs and models to enable dental care workers to provide patients with information efficiently. CONCLUSIONS
We live in a time when dental therapy available to patients is more diverse and complex than that at any other time in history. Much of this therapy is elec-
732
tive, while some of it is necessary. Patients do not always know the difference. Dentists are responsible for providing sufficient information to patients. After being educated, patients should feel comfortable enough to sign an informed consent document stating that they have received the following information: alternative treatments for their condition; advantages of each treatment; disadvantages of each treatment; risks of each treatment; costs of each treatment; and the consequences of not treating the condition. ■
The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. Educational information on topics discussed by Dr. Christensen in this article is available through Practical Clinical Courses and can be obtained by calling 1-800-223-6569. 1. Christensen GJ. Educating patients: a new necessity. JADA 1993;124(8):86-7. 2. Christensen GJ. Educating patients about dental procedures. JADA 1995;126:371-2. 3. Christensen GJ. Increasing patient service by effective use of dental hygienists. JADA 1995;126:1291-4. 4. Christensen GJ. A consumer’s guide to dentistry. St. Louis: Mosby-Year Book; 1994. 5. Goldstein RE. Change your smile. Carol Stream, Ill.: Quintessence Publishing Co.; 1997.
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
GORDON J. CHRISTENSEN, D.D.S., M.S.D., PH.D.
INFORMING PATIENTS ABOUT TREATMENT ALTERNATIVES Legal activity by dental pa-
tients has increased significantly in the past several years.1 There are numerous potential reasons for this challenging situation. Many more procedures are available in dentistry than in the past, and the alternatives—unless they are explained thoroughly—are confusing to patients. Some dentists do not offer all of the treatment alternatives, and they emphasize only those procedures provided in their own practices. Some clinicians attempt to judge patients’ treatment desires before offering all of the treatment options. In addition, treatment plans may be presented with unrealistic optimism for clinical success, helping give patients false expectations. One of the factors stimulating this legal activity may be that some dentists do not provide information to patients about all of the treatment options available for specific situations, and subsequently fail to obtain consent before beginning treatment. This article discusses six necessary aspects of informing patients adequately about treatment alternatives. 730
GIVING YOUR PATIENTS ADEQUATE INFORMATION
Alternatives for therapy. Almost every oral procedure has several alternatives. As an example, one missing maxillary lateral incisor may be treated with an implant and a single crown; a three-unit fixed prosthesis; a two-unit cantilever fixed prosthesis; a Maryland bridge; a fiber-reinforced, resinbased composite prosthesis; an all-ceramic prosthesis; a metalbased removable partial denture; a resin “flipper”; or nothing. Often, patients are not informed about the many available alternatives, and unless dentists or auxiliary staff members educate them, they may end up receiving treatment they did not want. Unless that therapy is excellent and the patient does not complain, delivering inadequate patient information about all of the treatment alternatives is asking for patient dissatisfaction or even a lawsuit. Advantages of each alternative. Each option has some advantages. As an example, analyze a few options from the missing maxillary lateral incisor alternatives. Use of an implant and crown does not re-
quire cutting adjacent teeth, which certainly is an advantage. A three-unit prosthesis is strong. A two-unit prosthesis does not require cutting the central incisor, and it can blend color characteristics well. You know the advantages as well as I, but do you take the time to explain them to each patient? Many dentists don’t. Disadvantages of each alternative. Often, patients arrive at the dental office with predetermined opinions about the various treatment options. These may or may not be correct. I have had many patients tell me they don’t want “caps” because they can always tell the teeth are false. I respond by using various analogies such as this: “Have you ever had a fender repainted on your car? If the repair person didn’t match the color well, you could differentiate the repair from the other paint. On the other hand, a well-matched paint repair is impossible to discern from the remainder of the paint on the car. Similarly, a well-constructed fixed prosthesis is not easily differentiated from natural teeth, but you can detect a poorly matched prosthesis.”
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
CHRISTENSEN Patients should be given realistic expectations about disadvantages of the various treatment alternatives. As examples, an implant requires several months to integrate into the bone, while installation of a fixed prosthesis usually is completed in two appointments. A three-unit fixed prosthesis extending from a maxillary canine to a central incisor requires the cutting of enamel from two teeth instead of one, and the natural central incisor and crowns may not match in color. Risks associated with each therapy. This aspect of patient education is often omitted, because patients tend to become discouraged from having the treatment if they hear the risks without proper explanation. An implant placement is associated with the normal surgical risks, which need to be explained. Each anatomical position in the mouth poses different surgical risks. A typical maxillary lateral incisor location with adequate bone presents few risks during implant placement, while a lower molar area with only 9 millimeters of bone from the occlusal crest of the bone to the superior aspect of the inferior alveolar canal presents significant postoperative risks of nerve damage and potential paresthesia. Risks of treatment should be discussed in a factual manner after patients have heard the advantages and disadvantages of each therapy and have made some tentative decisions. At that time, risks can be put in proper perspective and can be related to the patient’s specific situation. Even simple crowns carry risks, such as the potential need for later endodontic therapy. Omission of a discussion about
risks followed by the occurrence of an unexplained problem leaves the clinician vulnerable to legal action by patients. Cost of therapy. A common complaint among patients is that their dentists did not explain the cost of therapy before beginning. Consider the difference in cost between a resinbased removable partial denture (“flipper”) for replacement of a lateral incisor and an implant, abutment and crown. The removable prosthesis may cost 10 times less. If a patient is presented with only one expensive option and is influenced heavily toward that option, and then the treatment fails, there is al-
standings. Overemphasizing the necessity of treatment is asking for trouble; the overtreated patient would be justly upset to find out about the relative lack of need later. Overemphasizing treatment needs is one of the most frustrating aspects of diagnosis I see in my prosthodontic practice. Not everybody needs 16 veneers, a mouthful of crowns, orthognathic surgery or toothcolored posterior tooth restorations, although such treatments are promoted heavily by some dentists. Absolute honesty in treatment planning is still the best advice. EDUCATING PATIENTS
A common complaint among patients is that their dentists did not explain the cost of therapy before beginning. most a certainty of patient dissatisfaction. Costs must be discussed for all alternative therapies. Result of nontreatment. Some pathologic oral conditions require therapy to prevent serious consequences. An abscessed tooth can cause total debilitation because of the associated pain. Serious systemic conditions can occur. Conversely, a shallow carious lesion often can exist for months before any clinical situation of consequence occurs. Dentists can over- or underemphasize the need for any oral therapy. Instead, they should give patients realistic, honest approximations of the consequences of lack of treatment to prevent misunder-
Can a typical dentist provide all of this information to each patient? It is highly unlikely that most dentists can afford to provide this much patient education by themselves. In my own practice, the task of education has been delegated to dental assistants and dental hygienists.1-3 These people are assigned to provide information to patients about all of the areas described in this article and ensure that the educational requirements are fulDr. Christensen is filled. Only co-founder and senafter this eduior consultant of Clinical Research cation is comAssociates, 3707 N. pleted do I Canyon Road, Suite No. 7A, Provo, Utah want to enter 84604, and is a the treatment member of JADA’s editorial board. He planning/diaghas a master’s denostic room to gree in restorative answer quesdentistry and a doctorate in education tions and to and psychology. He provide my is board certified in prosthodontics. own profesAddress reprint resional opinions quests to Dr. about the most Christensen.
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
731
CHRISTENSEN adequate therapy for a specific patient. Auxiliary staff members need teaching aids to provide the information. Dental offices should be equipped with pamphlets, books (such as titles by Christensen4 and Goldstein5), videotapes, photographs and models to enable dental care workers to provide patients with information efficiently. CONCLUSIONS
We live in a time when dental therapy available to patients is more diverse and complex than that at any other time in history. Much of this therapy is elec-
732
tive, while some of it is necessary. Patients do not always know the difference. Dentists are responsible for providing sufficient information to patients. After being educated, patients should feel comfortable enough to sign an informed consent document stating that they have received the following information: alternative treatments for their condition; advantages of each treatment; disadvantages of each treatment; risks of each treatment; costs of each treatment; and the consequences of not treating the condition. ■
The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. Educational information on topics discussed by Dr. Christensen in this article is available through Practical Clinical Courses and can be obtained by calling 1-800-223-6569. 1. Christensen GJ. Educating patients: a new necessity. JADA 1993;124(8):86-7. 2. Christensen GJ. Educating patients about dental procedures. JADA 1995;126:371-2. 3. Christensen GJ. Increasing patient service by effective use of dental hygienists. JADA 1995;126:1291-4. 4. Christensen GJ. A consumer’s guide to dentistry. St. Louis: Mosby-Year Book; 1994. 5. Goldstein RE. Change your smile. Carol Stream, Ill.: Quintessence Publishing Co.; 1997.
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.