Treatment Planning in Restorative Dentistry and Implant Prosthodontics

The gathering and organization of clinical data can be divided into two parts: (1) information gathering about the patient as an individual and (2) clinical examination. This chapter focuses on the patient as an individual and his or her general state of health upon presentation to the office, while chapter 3 details the clinical examination and the examination of diagnostic aids. The sum and value of information obtained during the data-gathering process are influenced by the level of education, skills, and experience of the clinician as well as the methodology used to assess the patient's condition and the severity of the patient's problems.

The initial consultation begins the moment the patient steps into the office. The dental professional should make sure the patient feels welcomed, and every effort should be given to making a good first impression. Patients usually seek professional care because of some perception of abnormality that requires correction or simply for a checkup to maintain oral health. For either situation, it is imperative to recognize what motivated the patient to seek examination (ie, his or her complaints and expectations) as well as the source of referral. This information may help the clinician better understand the patient's personal characteristics and expectations. Furthermore, the clinician should become acquainted with the patient as a person in hopes of building confidence in the relationship.

Becoming Acquainted with the Patient as a Person

One of the most important objectives to achieve when the patient first presents for treatment is to become acquaint-ed with the patient as a person. The dentist should try to demonstrate competence and organization and, above all, make it clear that he or she will act in the patient's best interests. These are major prerequisites for gaining the patient's confidence. Patients often start trusting the dentist only when problems begin to be solved, so it might take a while before the doctor-patient relationship reaches a comfortable level of trust. Once a comfortable level of trust has been reached, patient management and all other treatment procedures tend to proceed smoothly and in a satisfactory manner.

In general, when there is a need for treatment, patients wish to know what their problems are, the possible solutions to correct them, as well as the time and cost involved in the treatment. While meeting patients' expectations can be extremely helpful in maintaining a friendly doctor-patient relationship, patients should be made to understand that solutions and specific information about treatment can only be offered after the dentist becomes familiar with the patient's oral condition.1 Once this has been accomplished, accurate information concerning existing problems, treatment modalities, and costs can be given to the patient. With this in mind, during the initial consultation the patient should be informed of the different phases involved in a complete treatment (ie, diagnosis and treatment planning, treatment plan delivery, and control and maintenance) and what these phases consist of. Moreover, it should be explained that oftentimes other special-ists may be required to solve problems related to areas other than restorative dentistry.

Patients should realize that diagnosis and treatment planning is the phase in which the clinician learns about the patient's needs, expectations, and limitations1,2 and that multiple visits involving diagnostic procedures may be necessary, particularly in complex cases. It is advisable to give the patient an estimate of the number of visits and fees involved in this initial part. Patients should understand that before this phase is completed, the dentist will not be able to provide accurate information about their condition, and as a result no treatment recommendations can be made. They should also be informed that no set amount of information is required for each patient. The volume of information collected and the complexity of the data collection process naturally depend on the severity of the patient's problems. As more information comes to light, additional diagnostic techniques may need to be employed.

It is also extremely important for patients to realize that actual treatment is not initiated until after the diagnosis and treatment planning phase. Once all data has been collected and properly assessed, a plan of care addressing the patient's specific needs will be devised, and only after this plan is presented and discussed in detail can treatment truly begin. In addition, patients should understand that before any therapeutic measures are delivered, an informed consent document must be read and signed, acknowledging that they have received thorough information about their treatment and that they accept it. Therapeutic measures during the initial phase should only be delivered in an emergency situation. The desired outcome of the initial consultation is to establish a cooperative and harmonious interaction between the clinician and the patient.

Patient Interview

For new patients, this phase may begin with registration procedures. Most dental practices have the patient fill out a preprinted form in which the patient's personal information is recorded, and this can be done either before or during the initial consultation. This information commonly includes the patient's name, address, phone number, email address, third party (insurance) information, social security number, age, birth place, marital status, occupation, and so on. The office staff may also interview the patient if additional information is required or if information requires updating.

During the initial interview, the dentist has the opportunity to study and evaluate the patient as a person, gaining insight into the patient's thoughts and motivations. Information gathered in this phase not only helps to establish the doctor-patient relationship but also helps to reveal the patient's desires, expectations, and limitations. The patient interview may be more important than any other treatment phase. Despite its importance, it is frequently overlooked, and oftentimes not enough time is devoted to it, keeping the dentist and the patient from assessing each other properly.

In order to obtain accurate information without influencing the responses, the dentist must be a systematic and unbiased information gatherer.2 Being a good listener is vital to this process of information flow. The patient should be encour-aged to talk about his or her problem(s) or complaint(s). Any complaints are best obtained by asking the patient open-ended questions. These usually begin with "how" or "what" and avoid leading the patient to a specific answer. In general, open-ended questions should be used when beginning to inquire about a problem. They cannot be answered with a simple response, such as yes or no. Closed questions, on the other hand, are usually simpler to answer with yes or no. They permit specific factors to be obtained or clarified but do not give insight into the patient's beliefs, attitudes, or feelings.

The dentist should take note whether the patient can explain himself or herself easily and clearly and if what is reported by the patient is logical and coherent. It should also be recognized whether the story is told with exaggeration or in a balanced mood. It is important to identify what the patient likes, dislikes, and can or cannot tolerate. It is also essential to assess the level of dental awareness of the patient, particularly with regard to esthetics. The patient with zero dental awareness requires maximum education and motivation. On the other hand, patients exhibiting a high dental awareness tend to be more demanding and oftentimes may have unrealistic expectations about their treatment results.

During the patient interview, the dentist should learn as much as possible about the patient's complaints, expectations, and personal as well as emotional characteristics. These topics are discussed in more detail in the sections that follow.

Chief Complaint

The chief complaint or chief concern can be described as the motivating factor for a patient to seek dental care. It is the primary reason why the patient first presented for treatment and expresses what most concerns the patient about his or her oral health. It is advisable to record all patient concerns in quotes, indicating that the patient's own words were used. For most patients, a chief complaint can be either a symptom or a request, sometimes both. In some cases, complaints may involve one or more topics, and they may be specific or gener-ic. The desire for an esthetic appearance is frequently a major driving factor for patients seeking professional dental help; function and comfort are also common patient concerns.

When recording the patient's dental history, the dentist should check whether the complaint reported by the patient is a continuation of past symptoms or a new development. If the complaint is a continuation of past symptoms, the dentist should try to learn about previous treatments (eg, treatments rendered by a previous dentist), because they may not have been adequate to solve the patient's problem. It is important to understand what went wrong or why previous treatments may not have worked. This information may be helpful for planning new treatment. Regardless of its nature, the patient's chief complaint should be resolved as soon as reasonably possible, and emergency needs should always be addressed as first priority.

Before initiating treatment, the dentist should have a clear understanding of all patient...