- Email: [email protected]
Quality of care: Compared perceptions of patient and prosthodontist
WALDMAN
15.
16. 17. 18.
Census. Washington, D.C., 1982, U.S. Government Printing Office. Hurd, M. D., and Shaven, J. B.: The economic status of the elderly. Working Paper No. 914. Cambridge, Mass., June 1982, National Bureau of Economic Research. Bridges, Jr., B., and Packard, M. D.: Price and income changes for the elderly. Sot Secur Bull 44~3, 1981. ‘81 poverty figure is a 15-year high. Newsday, April 7, 1983. U.S. aids third of households. Newsday, March 13, 1981,
19.
Porcine, J.: Overview of Aging in America. Greater Long Island Dental Meeting. April 7, 1983.
Reprint requeststo: DR. BARRY WALDMAN SUNY AT STONY BR~K SCHOOL OF DENTAL MEDICINE STONY BROOK, NY 11794-8706
P 8.
Quality of care: Compared perceptions of patient and prosthodontist Barbara B. Chamberlain, D.D.S., M.S.,* Michael E. Razzoog, D.D.S., M.P.H., M.S.,** and Emerson Robinson, D.D.S., M.P.H.*** University
of Michigan,
School of Dentistry,
Ann Arbor,
D
Mich.
ental patients envision themselves as consumers of dental products and services now more than ever. Patient satisfaction with the health care provider and treatment results is critical if today’s dentist is to survive successfully in an increasingly competitive marketplace. Although the patient may perceive dental care as elective, the dentist perceives regular examination and treatment as a necessity to allow early intervention into the disease process and thereby maintain optimum oral health. In addition to the apparent discrepancy in perceptions and expectations between patient and dentist, fears of the patient and dentist thwart interpersonal communication and lead to greater loss of understanding. The patient fears the uncertainty associated with the etiology of the disease, the required procedures, cost of treatment, and loss of control associated with dental disease. The dentist fears his or her ability to make the correct diagnosis and control the myriad of factors that will ensure successful treatment. The result is that both patient and dentist become frustrated and resentful.’ An often-expressed example of mutual frustration that leads to conflicts is found in the treatment of patients with complete dentures. The literature suggests that patient satisfaction with dentures depends on effective two-way communication and education between the dentist and patient. 2,3 Early clarification of differences between the perceptions of dentist and patient has been *Assistant Professor, Complete Denture Department. **Associate Professor, Complete Denture Department. ***Professor of Dentistry, Community Dentistry Department.
744
purported to be the key to successful treatment of the prosthodontic patient. 4,5 The importance and difficulty of satisfying the patient esthetically has also been stressed.6x7 The purposes of this study were to compare the perceptions of patient and prosthodontist regarding existing maxillary and mandibular dentures with standardized criteria and to develop a mechanism to enhance patient-dentist dialogue prior to initiation of therapy.
MATERIAL
AND METHODS
As a response to consumerism and from its desire to maintain high standards of treatment, dentistry has embraced quality assessment criteria to allow standardized objective evaluation of care provided to a patient. Standards for specific criteria have been developed for peer review committees and the dentist to assess the quality of care. Statements that reflect the quality of finalized complete denture therapy have been developed and tested for reliability at the University of Michigan, School of Dentistry.* The resulting composite instrument includes criteria statements for esthetics (tooth form, color, and position); comfort (outline form, vertical dimension, retention, and stability); and function (centric relation, lateroprotrusive occlusion, and plane of occlusion (Fig. 1). Patient perceptions can be assessedby rephrasing the criteria statements in terms of commonly occurring chief complaints made by patients in regard to their dentures (Fig. 2). To assessthe usefulness of criteria statements as an aid in establishing dentist-patient communication, 80 NOVEMBER
1984
VOLUME
52
NUMBER
5
COMPARED
PERCEPTIONS
OF QUALITY
OF CARE
QUALITY ASSESSMENTCRITERIA n -
Upon closing from physiologic rest position to the occlusal vertical dimension, an acceptable interocclusal distance is demonstrated.
cl
Excessive interocclusal distance is present by the signs and symptoms demonstrated.
0
No interocclusal distance can be demonstrated, or the interocclusal distance is not within the physiologic tolerances of the patient.
Fig. 1. Prosthodontist criteria for occlusal vertical dimension. Statement above double line defines clinically acceptable complete denture. Statements below double line indicate unacceptable denture.
PATIENT EVALUATION RATINGS cl
When I close my teeth together, the dentures keep my jaws apart at a comfortable distance.
cl
When my teeth are touching, are too close together.
my upper and lower jaws
Firr. 2. Patient criteria for evaluating: occlusal vertical dimension. Statement below do\ble line indicates unacceptable dekure.
patients were randomly selected from the screening clinic at the University of Michigan, School of Dentistry, and asked to respond to a questionnaire composed of patient-oriented criteria statements.* Some assumptions were made about the selection of this group of patients for questioning rather than a mixture of those wearing new and old dlentures. First, because treatment was being actively sought, it was assumed that the patient perceived a definite need for treatment of deficiencies that they expected to be corrected with new dentures. Second, the age range of the existing dentures was from 5 to 24 years, which was considered long enough to eliminate the two most common causes of disagreement between dentist and patient: money and personality conflicts. After the patients completed the questionnaire, they were examined by the prosthodontist who used the criteria to evaluate the existing prosthesis.8 The patients responded to the questionnaires prior to the initial screening appointment and without input from the examining pros thodontist. THE JOURNAL
OF PROSTHETIC
DENTISTRY
RESULTS AND DISCUSSION Direct comparisons of patient and prosthodontist evaluations illustrate that nearly 100% agreement was demonstrated for the denture esthetics criteria of tooth shade, lip support, and amount of upper and lower teeth displayed by the patient. While only 2% of the patients were satisfied with the general appearance of the denture when the prosthodontist was not, 14% of the patients expressed dissatisfaction with the general appearance of their dentures when the prosthodontist considered the total esthetic result to be acceptable. It may be asked whether this group of patients had expectations for esthetic appearance that were beyond the capabilities of treatment with dentures, or whether there was another variable responsible for thwarting patient satisfaction that could not be factored out, such as tooth form, shade, or position. With regard to comfort, greater than 90% agreement was demonstrated between the patient and dentist for outline form of the mandibular denture and nearly 100% agreement for that of the maxillary denture. Although 745
CHAMBERLAIN,
almost 60% of the patients agreed with the prosthodontist regarding the occlusal vertical dimension, 32% of the patients were satisfied with the interocclusal distance when the prosthodontist evaluated it as overclosed, and 4% were satisfied with dentures that the prosthodontist considered to be without adequate interocclusal distance. That the patient is less sensitive to more interocclusal distance than was deemed necessary by the prosthodontist is understandable, becausesomeexcessin the interocclusal distance is not usually a functional problem.9 However, the fact that 4% of this sample had been functioning for at least 5 years with dentures that the prosthodontist evaluated as being without adequate interocclusal distance is difficult to interpret. Either patient adaptability occasionally exceeds the dentist’s inadequacy, or the figure represents an error on the part of the prosthodontist in determining this elusive position. Almost 80% of the time, the patient and prosthodontist disagreed about the adequacy of maxillary and mandibular retention, although 80% agreement was found regarding denture stability. Approximately two thirds of the disagreement occurred when patients evaluated the dentures as nonretentive when the prosthodontist did not. Perhaps patients’ expectations about how much “hold” the denture should have may be greater than that which the prosthesis can provide. The sphere of greatest disagreement between patient and prosthodontist was that of function. Although nearly half the patients agreed with the prosthodontist that occlusion was inadequate, 44% were satisfied with occlusion which the prosthodontist found unstable or lacking in posterior contacts in centric occlusion and latero-protrusive contacts. Furthermore, 6% of the patients were dissatisfied with the occlusion when the prosthodontist found acceptable centric occlusion and bilateral balanced occlusion. This finding is also difficult to interpret. It is possible that patients who were well adapted to their old dentures with experienced muscle control could be satisfied with an “acquired” occlusal relationship. Perhaps the patients with poor muscle control who could not accommodate to any denture, regardless of the precision of the occlusion, comprise this 6% group.
SUMMARY AND CONCLUSIONS The results suggest that, with the exception of retention, differences between patients’ and prosthodontists’ perceptions of treatment with complete dentures display greater variability with regard to function than to either esthetics or comfort. Although the literature has suggested that satisfying the esthetic concerns of the patient is likely to be a major hurdle in denture treatment success,
746
RAZZOOG,
AND
ROBINSON
this study suggests that occlusion, retention, and vertical dimension may be of more importance to effective communication. Misconceptions and unreal expectations should be dealt with early in the treatment program to avoid patient dissatisfaction. During the 1972 International Prosthodontic Workshop held in Ann Arbor, Michigan, the statement was made that patients were generally an unreliable guide as to the adequacy of their dentures, especially after wearing them for a period of time, and that further research to document the patient’s reliability seemed unnecessary. ‘OThis study has demonstrated that patients are quite reliable judges of many criteria related to dentures, provided channels for two-way communication are opened. With the ever greater economic stresses that force dentists to consider patients’ concerns, perhaps it is increasingly the dentist’s responsibility to better educate patients to evaluate all aspects of the quality of care they receive and encourage extensive two-way communication early in the treatment process. The adjusted quality assessment criteria used in the present study may be a useful instrument to use with patients prior to the initial interview in an effort to establish a better dentist-patient relationship. REFERENCES 1. Boas, D. E.: Barriers to effective interpersonal communication: Causes and effects of health alienation. J Dent Educ 47: 110, 1983. 2. Koper, A.: Why dentures fail. Dent Clin North Am, 1964, p 721. 3. Bliss, C. H.: A philosophy of patient education. Dent Clin North Am, 1960, p 277. 4. Collett, H. A.: Motivation: A factor in denture treatment. J PROSTHET DENT 17:5, 1967. 5. Koper, A.: The initial interview with complete denture patients: Its structure and strategy. J PROSTHET DENT 23~590, 1970. 6. Beder, 0. E.: Esthetics-An enigma. J PROSTHET DENT 25:588, 1971. 7. Brewer, A. A.: Treating complete denture patients. J PROSTHET DENT 14~1015, 1964. 8. Barrett, G. D.: Evaluation of Proposed Quality Assessment Criteria for Complete Denture Treatment. Master’s thesis, University of Michigan, 1978. 9. Heartwell, C. M., and Rahn, A. 0.: Syllabus of Complete Dentures. Philadelphia, 1980, Lea & Febiger, p 214. 10. Lang, B. R., and Kelsey, C. C., editors: International Prosthodontic Workshop on Complete Denture Occlusion. Ann Arbor, 1973, University of Michigan, School of Dentistry, p 86. Reprint requests to: DR. BARBARA B. CHAMBERLAIN UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRY ANN ARBOR, MI 48109
NOVEMBER
1984
VOLUME
52
NUMBER
5
15.
16. 17. 18.
Census. Washington, D.C., 1982, U.S. Government Printing Office. Hurd, M. D., and Shaven, J. B.: The economic status of the elderly. Working Paper No. 914. Cambridge, Mass., June 1982, National Bureau of Economic Research. Bridges, Jr., B., and Packard, M. D.: Price and income changes for the elderly. Sot Secur Bull 44~3, 1981. ‘81 poverty figure is a 15-year high. Newsday, April 7, 1983. U.S. aids third of households. Newsday, March 13, 1981,
19.
Porcine, J.: Overview of Aging in America. Greater Long Island Dental Meeting. April 7, 1983.
Reprint requeststo: DR. BARRY WALDMAN SUNY AT STONY BR~K SCHOOL OF DENTAL MEDICINE STONY BROOK, NY 11794-8706
P 8.
Quality of care: Compared perceptions of patient and prosthodontist Barbara B. Chamberlain, D.D.S., M.S.,* Michael E. Razzoog, D.D.S., M.P.H., M.S.,** and Emerson Robinson, D.D.S., M.P.H.*** University
of Michigan,
School of Dentistry,
Ann Arbor,
D
Mich.
ental patients envision themselves as consumers of dental products and services now more than ever. Patient satisfaction with the health care provider and treatment results is critical if today’s dentist is to survive successfully in an increasingly competitive marketplace. Although the patient may perceive dental care as elective, the dentist perceives regular examination and treatment as a necessity to allow early intervention into the disease process and thereby maintain optimum oral health. In addition to the apparent discrepancy in perceptions and expectations between patient and dentist, fears of the patient and dentist thwart interpersonal communication and lead to greater loss of understanding. The patient fears the uncertainty associated with the etiology of the disease, the required procedures, cost of treatment, and loss of control associated with dental disease. The dentist fears his or her ability to make the correct diagnosis and control the myriad of factors that will ensure successful treatment. The result is that both patient and dentist become frustrated and resentful.’ An often-expressed example of mutual frustration that leads to conflicts is found in the treatment of patients with complete dentures. The literature suggests that patient satisfaction with dentures depends on effective two-way communication and education between the dentist and patient. 2,3 Early clarification of differences between the perceptions of dentist and patient has been *Assistant Professor, Complete Denture Department. **Associate Professor, Complete Denture Department. ***Professor of Dentistry, Community Dentistry Department.
744
purported to be the key to successful treatment of the prosthodontic patient. 4,5 The importance and difficulty of satisfying the patient esthetically has also been stressed.6x7 The purposes of this study were to compare the perceptions of patient and prosthodontist regarding existing maxillary and mandibular dentures with standardized criteria and to develop a mechanism to enhance patient-dentist dialogue prior to initiation of therapy.
MATERIAL
AND METHODS
As a response to consumerism and from its desire to maintain high standards of treatment, dentistry has embraced quality assessment criteria to allow standardized objective evaluation of care provided to a patient. Standards for specific criteria have been developed for peer review committees and the dentist to assess the quality of care. Statements that reflect the quality of finalized complete denture therapy have been developed and tested for reliability at the University of Michigan, School of Dentistry.* The resulting composite instrument includes criteria statements for esthetics (tooth form, color, and position); comfort (outline form, vertical dimension, retention, and stability); and function (centric relation, lateroprotrusive occlusion, and plane of occlusion (Fig. 1). Patient perceptions can be assessedby rephrasing the criteria statements in terms of commonly occurring chief complaints made by patients in regard to their dentures (Fig. 2). To assessthe usefulness of criteria statements as an aid in establishing dentist-patient communication, 80 NOVEMBER
1984
VOLUME
52
NUMBER
5
COMPARED
PERCEPTIONS
OF QUALITY
OF CARE
QUALITY ASSESSMENTCRITERIA n -
Upon closing from physiologic rest position to the occlusal vertical dimension, an acceptable interocclusal distance is demonstrated.
cl
Excessive interocclusal distance is present by the signs and symptoms demonstrated.
0
No interocclusal distance can be demonstrated, or the interocclusal distance is not within the physiologic tolerances of the patient.
Fig. 1. Prosthodontist criteria for occlusal vertical dimension. Statement above double line defines clinically acceptable complete denture. Statements below double line indicate unacceptable denture.
PATIENT EVALUATION RATINGS cl
When I close my teeth together, the dentures keep my jaws apart at a comfortable distance.
cl
When my teeth are touching, are too close together.
my upper and lower jaws
Firr. 2. Patient criteria for evaluating: occlusal vertical dimension. Statement below do\ble line indicates unacceptable dekure.
patients were randomly selected from the screening clinic at the University of Michigan, School of Dentistry, and asked to respond to a questionnaire composed of patient-oriented criteria statements.* Some assumptions were made about the selection of this group of patients for questioning rather than a mixture of those wearing new and old dlentures. First, because treatment was being actively sought, it was assumed that the patient perceived a definite need for treatment of deficiencies that they expected to be corrected with new dentures. Second, the age range of the existing dentures was from 5 to 24 years, which was considered long enough to eliminate the two most common causes of disagreement between dentist and patient: money and personality conflicts. After the patients completed the questionnaire, they were examined by the prosthodontist who used the criteria to evaluate the existing prosthesis.8 The patients responded to the questionnaires prior to the initial screening appointment and without input from the examining pros thodontist. THE JOURNAL
OF PROSTHETIC
DENTISTRY
RESULTS AND DISCUSSION Direct comparisons of patient and prosthodontist evaluations illustrate that nearly 100% agreement was demonstrated for the denture esthetics criteria of tooth shade, lip support, and amount of upper and lower teeth displayed by the patient. While only 2% of the patients were satisfied with the general appearance of the denture when the prosthodontist was not, 14% of the patients expressed dissatisfaction with the general appearance of their dentures when the prosthodontist considered the total esthetic result to be acceptable. It may be asked whether this group of patients had expectations for esthetic appearance that were beyond the capabilities of treatment with dentures, or whether there was another variable responsible for thwarting patient satisfaction that could not be factored out, such as tooth form, shade, or position. With regard to comfort, greater than 90% agreement was demonstrated between the patient and dentist for outline form of the mandibular denture and nearly 100% agreement for that of the maxillary denture. Although 745
CHAMBERLAIN,
almost 60% of the patients agreed with the prosthodontist regarding the occlusal vertical dimension, 32% of the patients were satisfied with the interocclusal distance when the prosthodontist evaluated it as overclosed, and 4% were satisfied with dentures that the prosthodontist considered to be without adequate interocclusal distance. That the patient is less sensitive to more interocclusal distance than was deemed necessary by the prosthodontist is understandable, becausesomeexcessin the interocclusal distance is not usually a functional problem.9 However, the fact that 4% of this sample had been functioning for at least 5 years with dentures that the prosthodontist evaluated as being without adequate interocclusal distance is difficult to interpret. Either patient adaptability occasionally exceeds the dentist’s inadequacy, or the figure represents an error on the part of the prosthodontist in determining this elusive position. Almost 80% of the time, the patient and prosthodontist disagreed about the adequacy of maxillary and mandibular retention, although 80% agreement was found regarding denture stability. Approximately two thirds of the disagreement occurred when patients evaluated the dentures as nonretentive when the prosthodontist did not. Perhaps patients’ expectations about how much “hold” the denture should have may be greater than that which the prosthesis can provide. The sphere of greatest disagreement between patient and prosthodontist was that of function. Although nearly half the patients agreed with the prosthodontist that occlusion was inadequate, 44% were satisfied with occlusion which the prosthodontist found unstable or lacking in posterior contacts in centric occlusion and latero-protrusive contacts. Furthermore, 6% of the patients were dissatisfied with the occlusion when the prosthodontist found acceptable centric occlusion and bilateral balanced occlusion. This finding is also difficult to interpret. It is possible that patients who were well adapted to their old dentures with experienced muscle control could be satisfied with an “acquired” occlusal relationship. Perhaps the patients with poor muscle control who could not accommodate to any denture, regardless of the precision of the occlusion, comprise this 6% group.
SUMMARY AND CONCLUSIONS The results suggest that, with the exception of retention, differences between patients’ and prosthodontists’ perceptions of treatment with complete dentures display greater variability with regard to function than to either esthetics or comfort. Although the literature has suggested that satisfying the esthetic concerns of the patient is likely to be a major hurdle in denture treatment success,
746
RAZZOOG,
AND
ROBINSON
this study suggests that occlusion, retention, and vertical dimension may be of more importance to effective communication. Misconceptions and unreal expectations should be dealt with early in the treatment program to avoid patient dissatisfaction. During the 1972 International Prosthodontic Workshop held in Ann Arbor, Michigan, the statement was made that patients were generally an unreliable guide as to the adequacy of their dentures, especially after wearing them for a period of time, and that further research to document the patient’s reliability seemed unnecessary. ‘OThis study has demonstrated that patients are quite reliable judges of many criteria related to dentures, provided channels for two-way communication are opened. With the ever greater economic stresses that force dentists to consider patients’ concerns, perhaps it is increasingly the dentist’s responsibility to better educate patients to evaluate all aspects of the quality of care they receive and encourage extensive two-way communication early in the treatment process. The adjusted quality assessment criteria used in the present study may be a useful instrument to use with patients prior to the initial interview in an effort to establish a better dentist-patient relationship. REFERENCES 1. Boas, D. E.: Barriers to effective interpersonal communication: Causes and effects of health alienation. J Dent Educ 47: 110, 1983. 2. Koper, A.: Why dentures fail. Dent Clin North Am, 1964, p 721. 3. Bliss, C. H.: A philosophy of patient education. Dent Clin North Am, 1960, p 277. 4. Collett, H. A.: Motivation: A factor in denture treatment. J PROSTHET DENT 17:5, 1967. 5. Koper, A.: The initial interview with complete denture patients: Its structure and strategy. J PROSTHET DENT 23~590, 1970. 6. Beder, 0. E.: Esthetics-An enigma. J PROSTHET DENT 25:588, 1971. 7. Brewer, A. A.: Treating complete denture patients. J PROSTHET DENT 14~1015, 1964. 8. Barrett, G. D.: Evaluation of Proposed Quality Assessment Criteria for Complete Denture Treatment. Master’s thesis, University of Michigan, 1978. 9. Heartwell, C. M., and Rahn, A. 0.: Syllabus of Complete Dentures. Philadelphia, 1980, Lea & Febiger, p 214. 10. Lang, B. R., and Kelsey, C. C., editors: International Prosthodontic Workshop on Complete Denture Occlusion. Ann Arbor, 1973, University of Michigan, School of Dentistry, p 86. Reprint requests to: DR. BARBARA B. CHAMBERLAIN UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRY ANN ARBOR, MI 48109
NOVEMBER
1984
VOLUME
52
NUMBER
5