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Recommending the best treatment for patients
PERSPECTIVES
OBSERVATIONS
Recommending the best treatment for patients
T
he past few years have included some of the fastest product and technology changes in the history of dentistry, and the public’s opinions about oral treatment also have changed. In this column, I will discuss the numerous factors that have influenced those changes. The result of the economic changes has caused many patients to delay treatment because of lack of funds, accept provisional treatment because they can not afford or are not willing to spend the money to have defini tive treatment, and accept new, less expensive treatment that is relatively unproven just be cause it appears to satisfy their esthetic desires better. This column includes my observa tions about oral care related to ongoing economic changes and, in spite of economic conditions, a plea that practitioners sug gest to patients treatment that is best for them on the basis of both scientific research and long-term clinical observations. THE INFLUENCE OF THE GREAT RECESSION
The recession has brought a reduction in patients’ discre tionary money, as the U.S. unemployment rate has hov
ered for several years around 8 percent or more.1 Many in the population at large have been reluctant to spend reserve funds they have saved. While speaking to dentists both na tionally and internationally, I have been told by many of them about the recession-related re duction in patients’ acceptance of elective oral treatment such as crowns, veneers, orthodontic treatment, therapy for ongo ing but painless periodontal disease, implant placement or any type of expensive, estheti cally oriented treatment. In other words, in my opinion and my observation of thousands of dentists throughout the reces sion, the quantity and type of dentistry being accomplished in the United States has been markedly affected by the economic turndown, and the nature of the dentistry that is being accomplished is differ ent from what it was before the recession. What will be the eventual result of patients’ clearly ob servable reluctance to receive oral preventive care and treat ment and their acceptance of some of the newer, less proven and sometimes less expensive concepts? If the treatment was planned primarily for esthetic
Gordon J. Christensen, DDS, MSD, PhD 426 JADA 144(4)
http://jada.ada.org
purposes, there may be no sig nificant physiological problems caused by postponing the treat ment. However, if the denied prevention and treatment were really needed, or the acceptance of less proven clinical concepts caused failure, the result prob ably will be that more extensive mandatory treatment will be needed in the future. Are dentists educating patients adequately so that patients know that when they refuse suggested treatment of any type or accept new and less proven techniques, they may experience negative consequences in the future? And what can we do to better educate patients and influence acceptance of needed treatment plans? The American Dental Associ ation (ADA) has ethical stand ards on this subject that I sug gest readers review.2 The ADA also offers an easily understood website about evidence-based dentistry (http://ebd.ada.org/) that clinicians should use as a reference to assist in making clinical treatment-planning decisions. Any experienced ethi cal practitioner knows which treatment would be best for a given patient who has specific oral needs. Also, it is his or her professional responsibility to determine a patient’s apparent
April 2013
Copyright © 2013 American Dental Association. All Rights Reserved.
PERSPECTIVES
financial capabilities, thereby allowing adjustment of treat ment plans to best match the needs of each patient. In my opinion, treatment plans should include several alternatives for patients that range from simple to more complex. TREATMENT CATEGORIES
I suggest dividing treatment plans into two basic categories of treatment: mandatory and elective. dMandatory treatment is nec essary because of some obvious problem. Examples of such sit uations are pain or discomfort of any type, bleeding, broken teeth, suspicious oral softtissue lesions, temporoman dibular dysfunction and odonto genic and other infections. The need for this type of treatment is obvious to both the patient and the dentist. It must be accomplished to alleviate pain and to prevent further break down or serious complications. dElective therapy usually is esthetically oriented. Ex amples are crowns or veneers to improve the patient’s ap pearance, some types of orth odontic treatment, bleaching, removing metallic restorations for esthetic reasons, closure of diastemas and surgical correc tion of prognathism. Preven tive procedures such as sealant placement, application of fluo ride varnish, routine scaling and polishing, and radiography often are considered to be elec tive by patients, even though (if accomplished properly) these procedures can avert the need for subsequent expensive treatment. I suggest presenting manda tory procedures to patients with tactful but strong recommenda tions that they accept the treat ment. Most patients will accept the mandatory procedures because whatever condition is present is bothering them.
However, when presenting elective procedures, I suggest providing several treatment plans. These should range from sequential plans, spaced across years, to optimal plans, accomplished as soon as possible. Providing segmented plans that allow for spreading the elective procedures across several years makes acceptance of treatment far easier for typical patients who have an average income. The most important part of these suggestions is that dentists should educate patients about the importance of accepting the mandatory procedures as soon as possible. That means carefully planned, honest, nonfinancially oriented discussions with them about their needs. I often use the following statement: “If I were you and had your oral conditions needing treatment, and I had access to adequate financial support, I would do … .” Most reasonable patients will accept such treatment plans and, after the mandatory treatment is completed, usually will accept one of the described approaches for treatment of their elective oral care needs. PROVEN VERSUS UNPROVEN TREATMENT
When patients have accepted an overall treatment plan, dentists must suggest the best way to accomplish the approved plan. Patients see dentists because they trust them. You have some educated opinions about what treatment you yourself would choose to receive if you were in their situation. Express your opinions. During the past few years, numerous new concepts have arisen that still are in the proving stages. As you will remember, practicing evidencebased dentistry requires you to peruse the literature by going JADA 144(4)
OBSERVATIONS
to PubMed, Google Scholar, the Cochrane Library or other databases of published articles and reading and evaluating the conclusions regarding any subject in the literature. However, as Sackett and colleagues3 (initiators of the phrase “evidence-based medicine”) wrote, evidencebased medicine also requires clinical observation during a period of clinical use for whatever is being analyzed, be it a device, a technique, a medication or a material. Some of the oral concepts that are in the proving stages are clearly identifiable to practitioners but unknown to patients. I suggest that when presenting treatment plans to patients, the clinician should differentiate well-proven concepts from concepts that appear to be acceptable but still are being observed before being granted full clinical acceptance. What are some of the latter concepts? You may disagree with me, but, in my opinion, the following treatment options are among those that clinicians should discuss candidly with patients before patients accept them: dfull-zirconia crowns versus porcelain-fused-to-metal (PFM) crowns; dsmall-diameter implants (1.8 millimeter to 2.9 mm) versus conventional-diameter implants (3 mm or larger); dlaser therapy for periodontal disease versus conventional therapy; dconservative periodontal therapy versus periodontal surgical techniques; dtooth-colored pediatric crowns versus stainless steel crowns; dwhen either technique is possible, extensive bone grafting and implants versus conventional restorative techniques; http://jada.ada.org
Copyright © 2013 American Dental Association. All Rights Reserved.
April 2013 427
PERSPECTIVES
OBSERVATIONS
dleaving a questionable tooth in the mouth versus removing the tooth and placing an implant; dlong-span zirconia fixed partial dentures versus PFM bridges; din difficult access situations, amalgam versus resin-based composite restorations; dcast gold alloy crowns versus tooth-colored crowns. If patients accept any procedure that still is in the long-term observation period, they should know that is the case. As an example, the follow ing is a frequent experience I have when presenting continu ing education courses. I ask a group of attendees how many have gold alloy restorations in their own mouths; usually, about one-half of the dentists in attendance have such restora tions. When asked how many would have cast gold alloy restorations placed at this time instead of the in-vogue toothcolored full-ceramic crowns, the vast majority of practitioners report that they would do so. Patients deserve to have this type of information for
428 JADA 144(4)
http://jada.ada.org
any of the examples I have stated earlier. If they desire to undergo the less proven procedures, that decision is their prerogative. I feel strongly that as part of the informed consent process, clinicians should educate patients about whatever is the current level of evidence, both scientific and observational, regarding any technique they are considering. SUMMARY
The great recession has changed many aspects of dentistry, including acceptance of treatment plans. Dentists are advised to divide treatment plans into two categories: mandatory treatment and elective treatment. Patients should be well educated about the potential consequences related to refusing plans for mandatory treatment. When patients have accepted an overall treatment plan, they should be advised about which of the alternative treatments within the plan have wellproven components and which are the newer, less proven concepts. Of course, they have
the freedom to accept whatever procedures they deem most appropriate for themselves, but we dentists should make patients feel well advised about our best recommendations for their treatment on the basis of both scientific evidence and a reasonable amount of clinical observation. n Dr. Christensen is the director, Practi cal Clinical Courses, and a cofounder and the chief executive officer, CR Foundation, Provo, Utah. He also is an adjunct professor, Brigham Young University, Provo; and an adjunct professor, University of Utah, Salt Lake City. He is a diplomate of the American Board of Prosthodontics. Address reprint requests to Dr. Christensen at CR Founda tion, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Output, prices and jobs. The Economist 2012;405(8811):84. www.economist.com/news/ economic-and-financial-indicators/21566687output-prices-and-jobs. Accessed Feb. 28, 2013. 2. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. www. ada.org/sections/about/pdfs/code_of_ ethics_2012.pdf. Accessed Feb. 13, 2013. 3. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(7023):71-72.
April 2013
Copyright © 2013 American Dental Association. All Rights Reserved.
OBSERVATIONS
Recommending the best treatment for patients
T
he past few years have included some of the fastest product and technology changes in the history of dentistry, and the public’s opinions about oral treatment also have changed. In this column, I will discuss the numerous factors that have influenced those changes. The result of the economic changes has caused many patients to delay treatment because of lack of funds, accept provisional treatment because they can not afford or are not willing to spend the money to have defini tive treatment, and accept new, less expensive treatment that is relatively unproven just be cause it appears to satisfy their esthetic desires better. This column includes my observa tions about oral care related to ongoing economic changes and, in spite of economic conditions, a plea that practitioners sug gest to patients treatment that is best for them on the basis of both scientific research and long-term clinical observations. THE INFLUENCE OF THE GREAT RECESSION
The recession has brought a reduction in patients’ discre tionary money, as the U.S. unemployment rate has hov
ered for several years around 8 percent or more.1 Many in the population at large have been reluctant to spend reserve funds they have saved. While speaking to dentists both na tionally and internationally, I have been told by many of them about the recession-related re duction in patients’ acceptance of elective oral treatment such as crowns, veneers, orthodontic treatment, therapy for ongo ing but painless periodontal disease, implant placement or any type of expensive, estheti cally oriented treatment. In other words, in my opinion and my observation of thousands of dentists throughout the reces sion, the quantity and type of dentistry being accomplished in the United States has been markedly affected by the economic turndown, and the nature of the dentistry that is being accomplished is differ ent from what it was before the recession. What will be the eventual result of patients’ clearly ob servable reluctance to receive oral preventive care and treat ment and their acceptance of some of the newer, less proven and sometimes less expensive concepts? If the treatment was planned primarily for esthetic
Gordon J. Christensen, DDS, MSD, PhD 426 JADA 144(4)
http://jada.ada.org
purposes, there may be no sig nificant physiological problems caused by postponing the treat ment. However, if the denied prevention and treatment were really needed, or the acceptance of less proven clinical concepts caused failure, the result prob ably will be that more extensive mandatory treatment will be needed in the future. Are dentists educating patients adequately so that patients know that when they refuse suggested treatment of any type or accept new and less proven techniques, they may experience negative consequences in the future? And what can we do to better educate patients and influence acceptance of needed treatment plans? The American Dental Associ ation (ADA) has ethical stand ards on this subject that I sug gest readers review.2 The ADA also offers an easily understood website about evidence-based dentistry (http://ebd.ada.org/) that clinicians should use as a reference to assist in making clinical treatment-planning decisions. Any experienced ethi cal practitioner knows which treatment would be best for a given patient who has specific oral needs. Also, it is his or her professional responsibility to determine a patient’s apparent
April 2013
Copyright © 2013 American Dental Association. All Rights Reserved.
PERSPECTIVES
financial capabilities, thereby allowing adjustment of treat ment plans to best match the needs of each patient. In my opinion, treatment plans should include several alternatives for patients that range from simple to more complex. TREATMENT CATEGORIES
I suggest dividing treatment plans into two basic categories of treatment: mandatory and elective. dMandatory treatment is nec essary because of some obvious problem. Examples of such sit uations are pain or discomfort of any type, bleeding, broken teeth, suspicious oral softtissue lesions, temporoman dibular dysfunction and odonto genic and other infections. The need for this type of treatment is obvious to both the patient and the dentist. It must be accomplished to alleviate pain and to prevent further break down or serious complications. dElective therapy usually is esthetically oriented. Ex amples are crowns or veneers to improve the patient’s ap pearance, some types of orth odontic treatment, bleaching, removing metallic restorations for esthetic reasons, closure of diastemas and surgical correc tion of prognathism. Preven tive procedures such as sealant placement, application of fluo ride varnish, routine scaling and polishing, and radiography often are considered to be elec tive by patients, even though (if accomplished properly) these procedures can avert the need for subsequent expensive treatment. I suggest presenting manda tory procedures to patients with tactful but strong recommenda tions that they accept the treat ment. Most patients will accept the mandatory procedures because whatever condition is present is bothering them.
However, when presenting elective procedures, I suggest providing several treatment plans. These should range from sequential plans, spaced across years, to optimal plans, accomplished as soon as possible. Providing segmented plans that allow for spreading the elective procedures across several years makes acceptance of treatment far easier for typical patients who have an average income. The most important part of these suggestions is that dentists should educate patients about the importance of accepting the mandatory procedures as soon as possible. That means carefully planned, honest, nonfinancially oriented discussions with them about their needs. I often use the following statement: “If I were you and had your oral conditions needing treatment, and I had access to adequate financial support, I would do … .” Most reasonable patients will accept such treatment plans and, after the mandatory treatment is completed, usually will accept one of the described approaches for treatment of their elective oral care needs. PROVEN VERSUS UNPROVEN TREATMENT
When patients have accepted an overall treatment plan, dentists must suggest the best way to accomplish the approved plan. Patients see dentists because they trust them. You have some educated opinions about what treatment you yourself would choose to receive if you were in their situation. Express your opinions. During the past few years, numerous new concepts have arisen that still are in the proving stages. As you will remember, practicing evidencebased dentistry requires you to peruse the literature by going JADA 144(4)
OBSERVATIONS
to PubMed, Google Scholar, the Cochrane Library or other databases of published articles and reading and evaluating the conclusions regarding any subject in the literature. However, as Sackett and colleagues3 (initiators of the phrase “evidence-based medicine”) wrote, evidencebased medicine also requires clinical observation during a period of clinical use for whatever is being analyzed, be it a device, a technique, a medication or a material. Some of the oral concepts that are in the proving stages are clearly identifiable to practitioners but unknown to patients. I suggest that when presenting treatment plans to patients, the clinician should differentiate well-proven concepts from concepts that appear to be acceptable but still are being observed before being granted full clinical acceptance. What are some of the latter concepts? You may disagree with me, but, in my opinion, the following treatment options are among those that clinicians should discuss candidly with patients before patients accept them: dfull-zirconia crowns versus porcelain-fused-to-metal (PFM) crowns; dsmall-diameter implants (1.8 millimeter to 2.9 mm) versus conventional-diameter implants (3 mm or larger); dlaser therapy for periodontal disease versus conventional therapy; dconservative periodontal therapy versus periodontal surgical techniques; dtooth-colored pediatric crowns versus stainless steel crowns; dwhen either technique is possible, extensive bone grafting and implants versus conventional restorative techniques; http://jada.ada.org
Copyright © 2013 American Dental Association. All Rights Reserved.
April 2013 427
PERSPECTIVES
OBSERVATIONS
dleaving a questionable tooth in the mouth versus removing the tooth and placing an implant; dlong-span zirconia fixed partial dentures versus PFM bridges; din difficult access situations, amalgam versus resin-based composite restorations; dcast gold alloy crowns versus tooth-colored crowns. If patients accept any procedure that still is in the long-term observation period, they should know that is the case. As an example, the follow ing is a frequent experience I have when presenting continu ing education courses. I ask a group of attendees how many have gold alloy restorations in their own mouths; usually, about one-half of the dentists in attendance have such restora tions. When asked how many would have cast gold alloy restorations placed at this time instead of the in-vogue toothcolored full-ceramic crowns, the vast majority of practitioners report that they would do so. Patients deserve to have this type of information for
428 JADA 144(4)
http://jada.ada.org
any of the examples I have stated earlier. If they desire to undergo the less proven procedures, that decision is their prerogative. I feel strongly that as part of the informed consent process, clinicians should educate patients about whatever is the current level of evidence, both scientific and observational, regarding any technique they are considering. SUMMARY
The great recession has changed many aspects of dentistry, including acceptance of treatment plans. Dentists are advised to divide treatment plans into two categories: mandatory treatment and elective treatment. Patients should be well educated about the potential consequences related to refusing plans for mandatory treatment. When patients have accepted an overall treatment plan, they should be advised about which of the alternative treatments within the plan have wellproven components and which are the newer, less proven concepts. Of course, they have
the freedom to accept whatever procedures they deem most appropriate for themselves, but we dentists should make patients feel well advised about our best recommendations for their treatment on the basis of both scientific evidence and a reasonable amount of clinical observation. n Dr. Christensen is the director, Practi cal Clinical Courses, and a cofounder and the chief executive officer, CR Foundation, Provo, Utah. He also is an adjunct professor, Brigham Young University, Provo; and an adjunct professor, University of Utah, Salt Lake City. He is a diplomate of the American Board of Prosthodontics. Address reprint requests to Dr. Christensen at CR Founda tion, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Output, prices and jobs. The Economist 2012;405(8811):84. www.economist.com/news/ economic-and-financial-indicators/21566687output-prices-and-jobs. Accessed Feb. 28, 2013. 2. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. www. ada.org/sections/about/pdfs/code_of_ ethics_2012.pdf. Accessed Feb. 13, 2013. 3. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(7023):71-72.
April 2013
Copyright © 2013 American Dental Association. All Rights Reserved.