How ethical is your new patient exam?

As dentistry continues to favor an oral-systemic model, dentists are changing their approaches to the new patient exam. In this article, Dr. Shannon Johnson looks at the new ethics of diagnosing pathology, dentists' inherent biases in recommending treatment, and how the dental team can properly manage new patient expectations.

Aug 8th, 2017
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Every patient enters a dental practice with the goal of having a maintainable, healthy mouth. But what do “maintainable” and “healthy” mean? As a profession, it may be possible that our standards for “maintainable” and “healthy” fall short. Are we, as dentists, fully and consistently evaluating our patients’ overall health? Are we understanding our patients’ unique desires and needs? Are we recommending appropriate treatments? Are we delivering the high level of care we think we are?

Defining the components of a “complete exam” can help us understand why giving honest answers to these questions is difficult. Let’s challenge our mindsets regarding a complete examination. In the end, we may find ourselves asking, “Can a 15-minute new patient exam be ethical?”

Undoubtedly, everyone in our profession can agree that a new patient exam should determine the presence of oral pathology, periodontal disease, caries, missing teeth, and esthetic concerns. These are things all patients expect, and they are things we are meticulously taught in dental school. Patients and members of our profession readily accept that, without intervention, almost every dental problem is progressive. Therefore, a new patient exam must identify all active factors contributing to the breakdown of oral health or function.

Other systems in the body have proven to affect oral health, and vice versa. To be complete by today’s standards, our clinical assessments must evaluate the airway, temporomandibular joints, muscles of mastication, occlusion, function/parafunction, nutrition, and other areas. These components are not thoroughly taught in dental school, nor are they commonly understood by patients, but they are crucial to patients’ overall and long-term health. We must appreciate that these dynamic systems are functionally interrelated. Disorder or deterioration in any one of the aforementioned areas will eventually affect other parts of the masticatory system. Patients, therefore, cannot achieve and maintain healthy mouths if we fail to diagnose instability in these interconnected systems. It is impossible to offer appropriate treatment recommendations and develop predictable treatment plans if the total system is not fully evaluated.

The Concept of Complete Dentistry, as taught by the Dawson Academy, states that every patient deserves a complete exam, and every patient deserves to understand every problem that needs to be treated. An examination can be considered complete only when the provider has successfully

  • listened to the patient’s wants and desired outcomes;
  • developed a thorough understanding of the patient’s medical status and associated medications;
  • codiagnosed alongside the patient every sign and symptom of instability within the masticatory system that may negatively impact the patient’s oral and systemic health; and
  • educated the patient on the consequences of not treating those identified concerns in a timely manner (an implication mindset).

The added benefits of a complete examination are that it cultivates trust and that it communicates an authentic, genuine concern for the health of patients. We are not selling the patient a commodity; we educate and escort patients on their journeys to health.

The Concept of Complete Dentistry promotes an ethical dentist-patient relationship that adheres to the American Dental Association (ADA) principles of nonmaleficence, beneficence, patient autonomy, justice, and veracity, as well as to the Patient’s Bill of Rights. These principles guide our profession in providing the very highest patient care.

Nonmaleficence, or “do no harm,” is a natural expression of complete dentistry. The complete exam affords the opportunity to identify and communicate to patients every sign and symptom of instability within the masticatory system. By having a thorough understanding of all problems adversely affecting patients’ oral health, we can offer solutions that will be predictable, stable, and maintainable. The primary objective of any treatment plan is to provide the best, most conservative solution to patients’ problems.

Dentists have a deeply rooted desire to help people. Society expects no less. This squarely falls under the principle of beneficence, or “do good.” The complete exam is the best opportunity to demonstrate our role as patient advocates who listen, learn, and educate. We can use all of our available knowledge and skills to help each and every patient realize health. Adopting an implication mindset allows us to develop the best, most conservative treatment plan for patients. This is especially the case when evaluating patients with economic challenges.

Involving patients in their health-care journeys from the very beginning of the complete examination and continuing throughout the treatment planning process encourages patient autonomy, or “self-governance.” Showing patients in their own mouths the difference between healthy versus unhealthy is a powerful way to communicate dental problems and engage patients. This exercise often leads patients to begin asking for solutions on the spot. The codiagnosis and education that occur during the complete exam also allow patients to have meaningful participation in the treatment planning process. Patients become informed, which makes them capable of owning their problems. Dentists are the welcome experts to help resolve those concerns.

Proper execution of complete examinations on patients requires dedicated doctor time and the support of a well-trained team. It requires a commitment to further one’s knowledge base and skill set. Various practice and personal circumstances may divert our professional attention from time to time. However, it should be understood that our chosen profession carries a calling from the ADA to “follow high ethical standards, which have the benefit of the patient as their primary goal.” (1) To fulfill this calling, the complete examination is key for more than the obvious reason of incomplete diagnosis and missed patient education.

This leads me to the question, “Which patient does not deserve an ideal treatment plan detailing the pathway to a maintainable healthy mouth?”

With the spirit of justice, or “fairness,” let’s look at the obvious answer: Every patient deserves a complete examination. Every patient deserves to know all the problems that affect his or her oral health. Every patient deserves to know the most ideal plan to achieve health. Patients from every walk of life deserve to be treated fairly and without prejudice—without exception. The ADA states every patient has the right to know the optimal treatment plan, as well as the right to request alternative treatment options. (2)

Poor economic climates paired with the overwhelming presence of dental insurance may motivate patients to seek out alternatives to ideal treatments, but ethically the provider must always offer and discuss the best option. Dentists too often stumble into the trap of examining, diagnosing, and treatment planning based on assumptions, thinking patients only want treatment that insurance will cover, or thinking that patients cannot afford treatment because of the way they are dressed, the car they drive, or the zip code in which they live. Neither the patient, nor the dentist, nor the profession benefit from such an outlook.

Instead, the practitioner can embrace the idea of providing truly complete examinations. Listening, engaging, and educating throughout exams culminates in trustful, informed patients. The payoff is that trusting patients are the ones who desire and accept treatment.

Within the implication mindset, treatment needs are categorized into three categories: immediate, deferrable, or elective/optional. Immediate needs that are left untreated will only progress into more complicated problems, which may require additional treatments, cost more, and cause undesirable outcomes. For example, caries into dentin will only worsen with time. Caught early enough, a simple direct restoration will restore a patient to health. But left untreated, the decay will progress. In the future, a patient may require a root canal and crown, or worse yet—the tooth may not be restorable and need extraction. Earlier treatment would have resulted in a better outcome.

Deferrable needs can be just that—deferred—for a reasonable time without resulting in more complex problems for patients. Let’s imagine a patient presents with significant decay on numerous teeth that, ideally, require full-coverage crowns, yet financial constraints do not allow the patient to restore all the teeth this way in a short period of time. By restoring all the teeth with direct restorations, though larger than ideal, the decay process is halted. Occlusion and function are treated to maintain harmony and minimize the risk to the large restorations. Now stabilized, the patient can have teeth restored with crowns as finances allow, and the risk of further harm has been reduced. Immediate needs have become deferrable.

Elective/optional needs are ones that do not lead to the further breakdown of the system. After a complete exam, for example, it is determined that a patient needs Nos. 7–10 restored with indirect restorations due to wear and recurrent decay. The gingival levels are uneven, and it would result in a more ideal esthetic outcome if the patient were to have crown lengthening on the central incisors. The patient must be informed that periodontal treatment to solely improve the cosmetic outcome of the case is elective. The patient could confidently elect to proceed with the indirect restorations without periodontal treatment, knowing the system itself will not progressively worsen.

The principle of veracity, or “truthfulness,” in tandem with an implication-focused complete examination, frees the dentist to always offer the patient the ideal treatment plan, sometimes with a creative twist. Dedication to the complete exam process boosts the provider’s confidence when proposing appropriate, necessary treatment and discussing acceptable modifications. Patients who trust their dentists proceed with treatment. Even patients with financial constraints more readily accept ideal treatment plans when they can be phased over a period of time without sacrificing the clinical outcome. It’s a win-win.

So, let me ask you now, are you providing the complete care your patients deserve?


References

1. Preamble. American Dental Association website. http://www.ada.org/en/about-the-ada/principles-of-ethics-code-of-professional-conduct/preamble. Accessed June 29, 2017.

2. ADA statement on dental patient rights and responsibilities. American Dental Association website. http://www.ada.org/~/media/ADA/About%20the%20ADA/Files/statements_ethics_patient_rights.pdf. Published August 2009. Accessed June 29, 2017.


Shannon Johnson, DMD, attended the University of Louisville, where she received her undergraduate degree as well as her doctor of dental medicine degree. Dr. Johnson is a former instructor at the University of Louisville Dental School and the University of Florida College of Dentistry. She now practices in Elizabethtown, Kentucky, and is an associate faculty member at The Dawson Academy.

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