Читать книгу Fundamentals of Treatment Planning - Lino Calvani - Страница 14
ОглавлениеWe often take our knowledge for granted, which in the medical field is a dangerous thing. While good sense and innate wisdom drive the profession, things are changing so quickly in our technological age that we need to constantly keep ourselves informed about new terms, concepts, rationales, procedures, and ideas in order to offer our patients the best treatments possible. The science is not static but must be constantly learned, understood, reviewed, and remembered. Only then are we in a position to formulate the best treatment plan.
So, what is the goal of a prosthodontic treatment plan? In most cases, patients come to us because they have an esthetic and/or functional problem in their oral cavity. It is understandable that they are not concerned about the physiology of the entire oral system and how all aspects of it are interrelated. What is not so understandable is how many dental medical professionals think it is sufficient to treat the teeth only, ignoring the overall context in which the masticatory system works. Considering the part as inseparable from the whole is the basis of the holistic approach to medical and dental practice.
Prosthodontists need to solve problems in the oral cavity, but that is not just a matter of teeth. Indeed, they need to find the best possible way of healing the oral cavity and its potential clinical problems, taking into account all the structural and biomechanical issues. They then need to rehabilitate the patient’s oral health in its entirety, focusing on the dentition and its compromised or lost functions, while also taking into account the patient’s needs, wishes, and expectations. Prosthodontists are called upon to improve the function of the dentition as well as the patient’s comfort and quality of life so that both physical and psychologic health are restored.
Prosthodontists should be equipped to manage treatment planing with understanding, expertise, and professionalism. This entails a sound knowledge of patient management, organization, and what is available in terms of clinical therapies that can be suggested to the patient.
Therefore, after the diagnosis, treatment planning is the moment where all the various aspects of education, knowledge, understanding, expertise, experience, observational capabilities, reasoning, dexterity, skills, ethical awareness, responsibility, communication, and critical thinking are distilled into one focus. From this focal point, treatment plans are conceived and presented to the patient. At this moment, professional values such as clarity, precision, and accuracy are key.
What follows are some basic concepts, definitions, and suggestions related to this aspect of the topic. Some may feel that their professional experience means they will not benefit from this level of basic analysis. But for those who humbly approach this subject with an open mind, these basic concepts will hopefully be useful to tune in, so to speak, to the matter of prosthodontic thought in order to enhance their knowledge and understanding. It should also be borne in mind that, unfortunately, the speciality of prosthodontics still does not exist institutionally in many parts of the world outside of the USA.
Some definitions and basic premises
The three cornerstone definitions are:
● Treatment: According to the Cambridge Dictionary, the word ‘treatment’ is defined as “the way in which somebody behaves towards or deals with somebody or something.” 1 In the sense of medical treatment, it refers to the care given to a patient in response to an illness or injury, and in the case of dental medical treatment, in response to an issue or issues concerning the oral cavity.
● Plan: A plan has been defined as “an individual or collaborative enterprise that is carefully planned to achieve a particular aim.” 2 Indeed, a plan is what results after:
● all the appropriate data have been acquired;
● the situation has been carefully studied;
● all the details are understood;
● appropriate conclusions have been drawn;
● one or more solutions necessary to solve the problem/s have been formulated.
● Purpose: The purpose of treatment planning in prosthodontic and restorative dental medicine has been analyzed by many authors.
According to Rosenstiel et al,3 the purpose is to formulate “a logical sequence of treatment designed to repair existing damage and restore the patient’s dentition to good and maintainable health, with optimal function and appearance.”
A treatment plan will only be successful and effective if it is:
● Organized: This important concept may seem obvious but often it is not, so it is emphasized here again that any treatment plan must be well organized and clear, first in the prosthodontist’s mind and then transferred as such to the patient. Only then can the plan be properly understood by the patient.
● Explicable: During treatment planning, we have the chance to understand the prosthodontic rehabilitative course in detail and foresee its possible final results. We then need to organize our conversation with the patient. Indeed, the treatment plan that is well understood and then accepted by the patient is the tipping point after which the clinical treatment may begin.
● Predictable: Predictability of the clinical results is the highest aim of treatment planning. Indeed, during the planning, prosthodontists need to consider all possible variables in order to reduce the likelihood of surprises or pitfalls during the clinical treatment and after the delivery of the prostheses.
Professionalism: four human factors
There are a number of positive characteristics that the prosthodontist (or any clinician) should ideally cultivate and develop in order to grow as a professional. These characteristics are further described in Chapter 7. What follows is a brief description of the main desirable qualities and skills necessary for us to succeed in clinical practice:
1. Proper communication and dialogue with the patient
The ability to communicate clearly is a primary skill. Clear, open communication leads to trust, which is not a given but is something that is earned. Trust is the key to successful patient management and treatment. However, it is not always possible to achieve trust during the first appointment, unless we are able to immediately tune into our patient’s state of mind. Trust often results when we successfully transfer to the patient through optimal communication skills a positive sense of our ability and professionalism from the outset. This entails the ability to clearly explain each step of the procedure and to motivate patients to trust us, to recognize our professionalism and capability, and to feel confident that we are able to solve their problems.
Often, patients must be motivated to be cured. Naturally, a patient’s personality, character, previous experiences, expectations, and other factors may influence this process (this important aspect is discussed later in the book). Clinical experience shows that a number of impediments to communication can be identified when approaching patients such as:
1. Lack of trust or agreement.
2. Stress due to patients’ personal problems.
3. Lack of communication and understanding.
4. Lack of constancy to care.
5. An exacting, fussy, and/or controlling patient.
6. Special physical issues or needs patients may have.
7. Demanding patients, and special psychologic attention they may require.
However, no matter what past experience or personal problems patients may have that could result in a negative attitude on their part, we need to know, understand, and remember to behave professionally at all times in order to inspire trust in our patients and communicate effectively with them.
This is one of the most important skills we need to develop for success in the clinic. Patient management depends mainly on us, and according to psychology is based on two personal qualities of the clinician that should be carefully nurtured and developed: the ability to take responsibility and our freedom of choice (free will).
Some patients have demanding personalities or suffer from complex psychologic problems. These factors could affect our ability to manage their cases.4 For this reason, when we are dealing with difficult patients, we need to pay even more careful attention to our interpersonal management skills because problems with these challenging patients may arise at any time.
Psychologic studies suggest that we should be professionally confident and capable and should take responsibility for everything we say and do. The more we transfer positive feelings to our patients, the more they will trust us and the easier it will be for them to accept the treatment we offer them. A number of psychologists have studied patient–clinician behavior and the kind of relations that should be established from the first visit. It has been noted that if we succeed in our intentions, our self-esteem increases, which in turn increases the positive attitude of our patients and the mutual ability to communicate and collaborate.4
Psychologic studies also highlight the importance of knowing how to evaluate patient feedback when we start to create a bond with our patients.4 According to the Oxford English Dictionary definition, feedback is “the information about the result of a process or action that can be used to modify or control a process or system.” It is therefore important to learn how to listen to our patients so that we are better able to help them. That is patient management in a nutshell.
4. Positive professional characteristics
Patient management is not an easy task to perform. To achieve success, we should always behave in an impeccable and appropriate professional manner – from the moment we first meet our patients, through the first dataset acquisition and case assessment, the explanation of the diagnosis and prognosis, the delivery and discussion of the proposed treatment plan, and finally throughout the entire clinical treatment and follow-up process. Professionalism in our appearance, our manner of speaking and listening, our body language (non-verbal communication), and our general attitude and demeanor is essential to the professional and respectful relationship we build with our patients. Every action has a reaction or consequence. Actions we take as professional caregivers are directly related to how our patients perceive us from the beginning and will have an impact on how much respect and trust they have in us – and ultimately in the success of the treatment. We need to listen carefully, be flexible in our approach, be adaptable to our patients’ needs, and respond with respect and empathy to their questions, requests, and concerns.
Simply put, when patients seek our help, they do so according to their own personal priorities. These priorities will differ for each patient. For some, the priority will be pain relief, which can be seen as an emergency. For others, it may be relief from discomfort, or perhaps unhappiness with the appearance of their smile or teeth. Our role is to assess these priorities and solve the case in such a way that the patient’s priorities are respected.
Is there an ideal treatment for all patients? First and foremost, the Latin phrase ‘primum non nocere’ (above all, do no harm) – included in the Hippocratic Oath – should be the medical principle that guides our minds and hands. In this respect, the ideal treatment plan is one that achieves the best possible long-term prognosis with the minimum of necessary intervention, and which addresses all the patient’s concerns and problems.5-7
Can this ideal treatment plan be achieved with every patient? There are many answers to this question, and this book explores them in some detail. A guiding principle could be the KISS rule. KISS is an acronym for ‘keep it simple, stupid’ or ‘keep it simple stupid,’ which was a design principle of the US Navy in 1960. The KISS principle states that most systems work best if they are kept simple rather than made complicated; therefore, simplicity should be a key goal in design, and unnecessary complexity should be avoided. Basing a treatment plan on this principle means that we seek out a simplified course of action and solution to avoid the complications that may arise when things become more complex, both during the treatment and in the long term. However, it is not as simple as this. Due to today’s digital technological environment and more sophisticated prosthetic rehabilitation options, simple may not always be the best option. Perhaps KISS should therefore be amended to ‘keep it simple, sometimes.’ Therefore, while the rule of simplicity when conceiving a treatment plan is a sound notion, it is not always entirely possible, nor is it always necessarily the best option. Again, flexibility is required in our thinking. We also need to bear in mind that with increasing complexity comes increasing compromise.8-19
Perfection should be the ultimate goal in treatment planning, although it is seldom possible to achieve. Despite our best intentions, we are usually forced to compromise. Experience tells us that even when the outcome is clear from the start, we need to propose more than one possible solution.
Furthermore, we should remember that there is no ideal treatment plan that fits all cases. Each patient is unique. We therefore need to be open-minded and knowledgeable enough to treat our patients using a range of possible treatments and prosthetic tools. Moreover, there is not one treatment plan for each patient, but possibly many. This depends on variables such as evidence, clinical factors, prosthetic limitations, and patient preference. It also depends on what is objectively possible and what we can imagine and plan within the context of the specific case.
Also, despite the number of treatment options that we devise and customize for each patient, there is usually one treatment plan that we particularly prefer for that patient. And then it sometimes happens that for a number of reasons the patient prefers a treatment other than the one we prefer.
Indeed, to restore and rehabilitate a patient’s mouth we usually have to agree to one or more compromises that we hopefully have foreseen. We then need to inform our patients of the final treatment plan in such a way that they properly understand it, agree to it as the best treatment for them, and willingly approve it.18-30
Therefore, we need to search for the best compromise that will achieve the ideal outcome for that particular patient, always taking into account the following four patient realities:
1. Chief complaint.
2. Health status.
3. Motivation/will.
4. Financial situation.
Prosthodontic treatments are never easy and are usually time consuming, both clinically and technically. Therefore, considering the high expectations of most patients, we would do well to heed Bolender’s advice: “Communication to avoid frustration!” 31,32 The right compromise can be reached only if both parties, the clinician and the patient, clearly communicate and agree. That is why it is so important for us to carefully pay attention and listen closely to our patients. It is also crucial to clearly and carefully explain to our patients what we can do for them (possibly in front of witnesses in cases where it is considered necessary) so that they clearly understand the limitations in terms of the clinical and technical realities. In this way, their expectations will not exceed what is feasible and possible in the circumstances and in terms of our professional capabilities.13,16,20-25,29,33,34-36
Prosthodontic economics and patient treatment costs
Prosthodontic treatments are usually expensive due to the:
● costly and ongoing dental office expenses;
● duration of the treatment;
● cost of dental materials;
● laboratory fees;
● services of other collaborating specialists, if any;
● clinical and prosthodontic complications that sometimes occur despite our professional experience and capability to foresee them;
● treatment follow-up;
● any relevant taxes that need to be paid.
Affordability of the treatment plan
The financial resources available for treatment will differ for each patient, who will only be able to afford a certain type of treatment. This is potentially a serious limiting factor in treatment planning and selection. We therefore need to know the financial situation of our patients before we begin planning an appropriate course of treatment for them. In many cases, we need to propose multiple solutions for the same restorative problem in order to provide as many available options as possible for successful treatment and rehabilitation.37-39
From the start, it is wise to gently investigate to what extent patients are able to cope with the costs of the restorative care we may propose (including the follow-up maintenance costs) so that we completely understand their unique financial situation. This is a responsible course of action that would be acceptable to the majority of patients. To do this, we need to politely ask our patients what their profession, job or occupation entails. Indeed, this information should be recorded as part of the initial examination. This is not the same as asking outright about a patient’s income, which can be construed as rude even if we ask in a kind and confidential manner. Moreover, what we know about the occupation of our patients will throw light on their level of education, which has a bearing on how well they are able to understand the theoretical and practical information we need to transfer. However, we should always carefully explain why some treatment plans are more technical, time consuming, and/or expensive than others. It is our duty to help our patients to understand, and it ought to be a pleasure for us to take all the time necessary to do this in the best possible way. At the same time, we need to treat this issue with sensitivity because some patients may be embarrassed if certain prosthodontic solutions are too expensive for them to afford.37-39
If an infectious disease exists in the oral cavity, we have the duty as dental medical professionals to assess it and to find the best way to explain the gravity of the situation to the patient, together with the related treatment costs. Disease is a priority that needs to be resolved before any prosthodontic solution can be performed, especially if sensitivity, discomfort, and/or pain exist.37-39
It is crucial to plan the treatment costs as comprehensively as possible and to be honest about them with the patient in the interests of a good clinician–patient relationship. This will avoid surprises later on. If we anticipate additional service costs, we need to let the patient know about them from the outset. Treatment planning is not an easy task, and explaining a demanding prosthodontic plan is not like selling a product; we need to be truthful and transparent as we explain and advise about the solution/s that are in our patients’ best interests. At the heart of this aspect is having and showing respect for the patient.37-39
In the same vein, we need to be kind and polite and treat our patients with empathy and gentleness in order for them to view us as concerned professionals with integrity, as opposed to being only interested in the money we will make from treating them. We need to bear in mind that the decision regarding which treatment to choose lies with both the patient and the clinician, and not with the clinician alone. In some instances, patients are happy to allow us to make the decision, and may request us to do so on their behalf. The rule of thumb is to be polite and respectful at all times, an attitude that will reward us and our dental office with the trust and respect of our patients. This has a bearing on our business too, because every patient could potentially refer family and friends to our office.
The basic difference between the terms ‘consent’ and ‘informed consent’ is the degree of patient knowledge behind the consent decision. The amount of information required to make consent informed may vary depending on the complexity and risks of treatment as well as the patient’s wishes. In terms of our professional responsibilities and liabilities, it is important to understand the exact meaning of these terms.
Except in rare cases where we need to help patients immediately such as in an urgent clinical emergency or in the case of symptoms of severe pain, a patient’s consent to be treated is always required before the start of treatment.
Informed consent refers to a doctrine that was established in the 1950s and has been continually revised over the years. What is established with informed consent is that a clinician can only treat a patient if and when the clinician is sure that the patient is fully aware of and understands the type of treatment being proposed to solve the problem. Apart from the more ethical aspects outlined above, an informed consent is a necessary document for us to obtain to ensure control of our risk management and to try to avoid legal problems that may arise later on with some patients.
The House classification (see Chapter 5) was a practical, organized attempt to define the personality of the edentulous patient. It may also be helpful for other patients (ie, those who are not edentulous), and may indeed be useful to give us some idea of the complexity of patients and their idiosyncrasies. This allows us to be better equipped to avoid unpleasant surprises later on during the treatment.
Therefore, the treatment planning discussion or initial diagnostic phase is the first ‘filter’ that assists us to get to know a new patient, and it is the point from which all further decisions are taken. This sensitive phase is therefore very useful to our understanding of the personality and psychology of a patient. It colors the type of treatment plan we devise that is most likely to be accepted by the patient; in some rare cases, we may even see no chance to treat a particular patient at all.25,27,40,41
We are not obliged to treat all patients
There will be instances where, already at the first treatment plan discussion (initial diagnostic phase), we realize that we are not in a position to treat a given patient in a manner that is agreeable to us. In these cases, we may feel that, for a number of reasons, it is better not to start any treatment at all. Some of these reasons may be immediately evident, but unfortunately others may not. Obviously, it is always our duty to try to help, but if the situation does not feel right, or we are in serious doubt about whether we should commit to treating a particular patient for whatever reason, we need to heed that warning voice. If we conclude that we will not be able to help a patient properly, we have the right and the duty to suggest without prejudice from the outset – as kindly as possible and with the appropriate humility and politeness – that there may be more capable professionals who will be better able to help. It is therefore much better to spend more time initially with new patients, speaking clearly to them and carefully analyzing them and their situation.
Prosthodontics is often a matter of invasive and extremely complex treatments that go on for a long time, treatments that may dramatically change the esthetics and functionality of a patient’s mouth, teeth, and face. Therefore, we need to be sure that we will be able to work with the patient’s full compliance and understanding about the often difficult challenges that may lie ahead in the course of the treatment.15 The longer the treatment, the greater the need for clinician–patient understanding and trust. If during the first visit or during the treatment plan discussion we cannot communicate properly, or if patients are unable or unwilling to communicate properly with us, this may indicate the possibility that we will end up working under great stress or tension, with the possibility of misunderstandings. This, in turn, could result in the failure of the treatment, with further deep frustration as well as possible legal problems and consequences.16
If an emergency occurs and our diagnosis is clear and precise, we have a duty to explain to the patient what the emergency is, how and why it should be addressed, and what the costs of the procedure will be. In that case, always ask for written permission to treat the patient and request the patient’s full compliance and signed agreement before you proceed with the treatment. This applies even in a situation where we know the patient well. It is important to understand that even in the case of an emergency we require a patient’s full compliance via an informed consent document, if possible signed by themselves or, if not possible, by another responsible adult such as a parent or guardian.
The use of the informed consent
The informed consent document needs to be very accurate and even customized in some cases. 6,27,41-50 There are various examples of informed consent forms and formats to be found on the internet. However, as every patient is an individual whose data will differ from the next patient, you will find in later chapters many suggestions about what to remember to include in the informed consent document. Please bear in mind that these suggestions are made from the vantage point of many years of experience.
Another thing to bear in mind is that dentistry and prosthodontics do not deal with an immediate threat to life. Therefore, patients can take all the time they need to listen to our proposals for solutions to their problems. They can then ask all the necessary questions in order to understand exactly what we are suggesting. They will then hopefully agree to a treatment plan and sign the informed consent form that we submit to them.17,30,34,51-55,57
Essential aspects of the informed consent document
All informed consent documents pertaining to a specific treatment plan should contain at least the following elements:
1. The patient is fully informed about all the characteristics of the entire treatment.24,29,30,42,45,47,58-61
2. The patient has a full understanding of the treatment plan in terms of its diagnosis, prognosis, anticipated benefits, therapy, timing, certainties, risks, consequences, and the need for future controls.17,30,34,51-53,56,57,59-61
3. The patient has been informed of alternative treatment courses and associated risks.42,62
4. The patient is fully aware of the risks associated with refusing the recommended procedures.17,30,34,51-56,59-61
5. The patient is fully aware of any possible temporary incapacitation that may occur during the course of treatment.17,30,34,51-56,59
6. The patient is fully aware of what information the patient is rewriting in front of witnesses (see later), freely accepts the treatment plan, and fully intends to be treated by the clinician in full respect of the professional rules of the dental office.17,30,34,51-56,59-61
7. The patient has read and discussed the informed consent document sufficiently to know and understand its entire contents and is fully aware of what it contains. If this is the case, the contents of the informed consent document should ideally be rewritten clearly in the patient’s own handwriting (see later).2,18,28
8. If the patient is unable to fulfill the above point (7) for any reason, another person should be appointed in the patient’s stead to do so in front of witnesses; this person should be able to take responsibility for the patient’s situation and health.3,7,11,29,39,49,50,58
9. Finally, the informed consent form should be signed, together with the signatures of one or more witnesses such as a relative of the patient, an office secretary or a chair assistant.2,6,30,39,41,52,56
If all these aspects of the informed consent document have been honored, the intellectual honesty, professional integrity and empathetic intentions of the clinician will be immediately clear to anyone who may consult the document later in the event that they may want to prove negligence in some way.2,6,14,15,19,30,36,39,41,52,55,56
It is important to note that any procedure performed in the absence of informed consent is liable to prosecution in a court of law and could be construed as intentionally inflicting physical harm on a patient.
Therefore, it is strongly advised that an informed consent for any prosthodontic treatment plan should be rewritten in the patient’s handwriting. In other words, the document should be copied out in full by the patient. The reason for this is that it has transpired on a few occasions that simply signing an informed consent without rewriting it is not sufficiently secure. Instead, asking patients to rewrite it in their own handwriting is a better guarantee for the dental office (or a court of law) that they have understood it, are completely conscious of the treatment details, and are willing to be treated without further doubt.
Finally, the patient should sign the informed consent document in front of one or more witnesses, who will countersign it afterwards. After the document has been signed by all the relevant parties, one copy must be given to the patient. The original document must remain in the safekeeping of the dental office where it is stored as a confirmation and a warranty for both the clinician and the patient.
Digital technology and informed consent documents
Although the advent of computerized technologies and the digitization of dental office documents has optimized the storage and management of patient documents and data, in the case of the treatment plan and informed consent it is still strongly advisable to retain hard copies of all original documents. This eliminates any possible questions that may arise later concerning possible alteration of these documents (ie, if they exist only as computer files), and eliminates any possible legal doubts about the honesty of the professionals and the dental office staff, which may create problems in a court of law.2,6,14,15,19,30,39,41,52,55,56 Therefore, when it comes to signed treatment plans and informed consent documents, it is still better to have the original hard copies on file in our dental offices.52,56
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