Grey areas in restorative dentistry: part 1. What are the aims of treatment?

What is it that brings patients to our dental practices? After all, it is not a pleasant experience having someone probe around your mouth and the best we can do is to make it as less unpleasant as possible.

Broadly speaking there will be three drivers for our patients: a specific problem, a routine check-up to know if all is well and what problems, if any, may be developing (a dental MOT), and/or an aesthetic concern about the appearance of the teeth and face; that is, seeking an enhancement.

With each of these, once a diagnosis or assessment has been made, it is essential that the provider of care has a clear vision of what outcome is best suited to balance the expectations of the patient with what is realistically achievable– ‘disappointment lives in the gap between expectation and reality’. Having settled on an outcome that has been agreed with the patient a care plan can be drawn up to achieve the goal or goals.

While the traditional role of the dentist may have been the elimination of disease, the restoration of function, and the prevention of future disease, the current understanding of health, disease, oral health, and quality of life places a much broader responsibility on the practitioner and with it is poses clinical, moral and ethical dilemmas that need to be negotiated with those coming for care in order to achieve a successful provider-patient outcome and bridge that gap between expectation and reality.

The specific problem

Following on from its diagnosis, the aim of treatment will clearly be the management of the presenting complaint, examples of which are shown in Table 1.

The routine dental check up

Apart from the inherent difficulties in the routine examination in establishing the exact status of all the dental and oral tissues, the practitioner is required to make decisions about whether disease in the mouth should be managed or eliminated, what treatments should be offered, and, who decides?¹

Our aims of treatment will be predicated on how we envision the patient at the completion of treatment, and whether they will be able to undergo the treatment and to effect the necessary maintenance to ensure ongoing health. The weighting that the practitioner will give to these parameters will be determined by the practitioner's understanding of disease, health and oral health, and how these should be applied to each patient that comes for care.

These are the often-difficult decisions that must be made every day in dental practice to answer the ‘who, how, why, when and where’ questions about intervention that arise when looking inside a patient's mouth. There isn't a probe that we can put on a particular tooth that will tell us what to do. Fill this one. Watch this one. Repair this filling. Put a post in that tooth. These are all decisions that are ultimately subjective and are, therefore, the reason for the variations that we see in care plans between different dentists and even between the same dentist on different days and at different times. As human beings, we are not as consistent and reliable as we would like to think.

There are several factors that contribute to these variations. Undergraduate training; postgraduate training; time available; financial pressures; gender; age; and the environment that one is working in, be it general or private practice, hospital or academic. All of these will influence, to a greater or lesser degree, the choice or preference for the outcome for each patient that is seen.²

In drawing up a care plan, it is essential for the provider of care to understand what is meant by disease, health and oral health, and while there no universally accepted definitions for each of these, those presented below are a reasonable representation.

Health

According to Svalastog et al, ‘the holistic concept of health is contained in the expression of wholeness. Health is a relative state in which one is able to function well physically, mentally, socially and spiritually to express the full range of one's unique potentialities within the environment in which one lives. Both health and illness are dynamic processes, and each person is located on a graduated scale or continuous spectrum (continuum) ranging from wellness and optimal functioning in every aspect of one's life, at one end, to illness culminating in death, at the other.’³

Disease

Disease ‘is a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms.’⁴

Oral health

Oral health ‘is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the craniofacial complex. It is a fundamental component of health and physical and mental wellbeing. It exists along a continuum influenced by the values and attitudes of people and communities. It reflects the physiological, social, and psychological attributes that are essential to the quality of life. It is influenced by the person's changing experiences, perceptions, expectations, and ability to adapt to circumstances.’⁵

There has been a move away from the concept of dental and oral health as a diseasebased model that isolated the mouth from the person and, more recently, defines health and oral health, not as the absence of disease, but in terms of optimal functioning and social and psychological wellbeing. It would be reasonable to conclude, therefore, that disease can be present without necessarily impinging on function, and poor health may not only arise from pathological conditions.

In tandem with these definitions is the concept of the oral health-related quality of life (OHRQoL), which ‘characterizes a person's perception of how oral health influences their overall wellbeing and ability to perform the activities of daily life.’⁶ Quality of life embraces areas of our lives, such as:

• Physical functioning, e.g. eating, speaking;
• Self-care, e.g. cleaning teeth or dentures;
• Undertaking usual activities;
• Social functioning, e.g. going out, relaxing, sleeping, enjoying contact with other people;
• Perceived health;
• Cognition;
• Pain, presence or absence;
• Energy/fatigue;
• Self-esteem, e.g. emotional stability.

It is clear from the foregoing that, in addition to the physical management of disease, the psychological and emotional state of the patient must be considered when formulating a care plan, that is, deciding what the aims of treatment (outcome) are so that the interaction between the provider and the recipient of care can come to a mutually successful or win–win conclusion.

Our solutions for the patient's problems will depend on our clinical ability and our philosophy of dentistry. Is dentistry seen as restoring the patient to some perceived norm by the elimination of the disease processes and the correction of their sequelae? Or, as per some of the definitions above, do we look at the patient and their mental and physical wellbeing and accept levels of disease and deviations from the normal with which we feel comfortable.

It is important to put the ‘w’ into the hole.

W + HOLE = WHOLE

Practically, this means not just looking at the hole in a tooth, or the deficient margin of a restoration and deciding to replace it or repair it, but looking at the whole tooth, the whole mouth, and the whole patient. The aims of treatment, as contained in the care plan, should not be framed in terms of the localized problem alone. This is where the dilemmas arise. If we were able to take any tooth in question out of the mouth, out of context, we could look at it and say what the ideal way is to deal with the problems that this distressed tooth has. Put the tooth back into the mouth and now we must look at it in context, in relation to the sextant, the whole mouth and the whole person. It is this that should inform our aims of treatment.

Should we, as healthcare providers, be seeking, or indeed be able, to achieve a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, as laid down in the constitution of the World Health Organization?⁷ Huber and colleagues view the inclusion of ‘complete wellbeing’ in the WHO definition of health as no longer fit for purpose given the rise of chronic disease. They proposed changing the emphasis towards the ability to adapt and self-manage in the face of social, physical and emotional challenges.⁸ The problem with the concept of complete wellbeing is that it can set a practitioner on the path of intervention, either on clinical grounds or on demands by the patient: ‘I see therefore I do’ – the so-called ‘medicalization of society’. There is a view that ‘the requirement for complete health would leave most of us unhealthy most of the time because it lowers the threshold for intervention, inviting treatment for abnormalities at levels that might never cause illness’,⁹ while others are concerned that ‘the emphasis on preventing and treating individual diseases leads to overtreatment’,¹⁰ an issue shared in dentistry by Holden et al.¹¹

There are three sets of questions to which the answers should determine the outcome for treatment:

• In what ways are the complaints bothersome, i.e. what is the effect on the patient's physical, psychological and social functioning?
• What does the patient hope to achieve from medical (dental) treatment? What trade off is the patient willing to make? In the case of prevention, does the patient value ‘down the road’ benefits more, or does the patient have more immediate concerns.
• Are psychological or social factors further impeding health and functioning?

The responses to these questions should determine whether irreversible procedures are undertaken.

The challenge of disease management

With the current approach of prevention and minimal intervention for the management of dental disease, the dental practitioner must decide whether to monitor or treat diseased tissue and whether a cure is either possible or desirable, where cure means a complete restoration of health.¹² Treatment, on the other hand is ‘the action or way of treating a patient or a condition medically or surgically: management and care to prevent, cure, ameliorate, or slow progression of a medical condition’¹³ and refers to a process that leads to an improvement in health, but may not include the complete elimination of disease. There are, indeed, several measurable aspects of disease and their initiating factors, such as plaque and bleeding scores, tooth mobility, tooth surface loss and dietary intake. The acronym BRAN (Figure 1) can be useful in deciding with the patient just how much of this information should inform the clinical decision making regarding an acceptable or desirable outcome for treatment.

The two examples shown in Figures 2 and 3 show similar presenting clinical situations but may demand different management.

Would efforts for a young adult with a high plaque score, several bleeding sites and several new carious lesions be the same as for an elderly patient with a similar picture, but with multiple health problems and lack of manual dexterity? If not, why not? Who makes these decisions?

Although caries, periodontal disease, broken teeth, missing teeth, peri-apical lesions etc are deviations from the normal, the philosophy that it is essential to restore to what was ‘normal’ is questionable. It is essential to weigh the benefits of treatment against the risks, and to consider the long-term implications of any interventions. Figure 4 shows an asymptomatic peri-apical radiolucency seen on a routine long-cone peri-apical radiograph and demanding that a decision be made about its management. Caplin¹⁴ uses Figure 5 as an example of the range of options available to patients in any given clinical situation with a range from no intervention to the extensive tooth tissue loss of providing a crown for this distressed tooth.

The practitioner is, in effect, being asked to predict the future and to decide what would be the most acceptable way to deal with the tooth so that it lasts as long as possible. Restoring it is not necessarily the fall-back position because treatment can inflict more distress on the tooth and its supporting structures.

Aesthetic/cosmetic enhancements

Should the practitioner refuse the patient's requests, assuming them to be legal and ethical, if the desired outcome, as visualized by the patient, is enhancing whereas the practitioner has a different perspective on the situation? Furthermore, in the absence for clinical need, should we be informing those who come to us for care for treatments that could potentially change (improve or enhance) the patient's smile and facial appearance?¹⁵

When a healthcare provider considers the emotional and psychological wellbeing of their patients it places an additional layer of responsibility on the route to successful dentist-patient outcomes. Are we healing and/or enhancing those who come to us for care?

If in clinical practice the dental professional embraces the quality-of-life concept it can be argued that the practitioner is thereby challenged to undertake any treatment that the patient feels will improve their life. Nevertheless, it should be remembered that the practitioner has a choice, and even though a patient has autonomy, their wishes are not absolute and binding on a practitioner. The dentist has the legal right not to provide a certain procedure if it is considered that it will not benefit the patient or even harm the patient (non-maleficence).

The ‘daughter test’ can be a very powerful influence in planning outcomes. At its simplest, in relation to elective aesthetic dentistry, the question, ‘knowing what I know about what this procedure would involve to the teeth in the long term, would I carry out this procedure on my own daughter (or any other close relative)’?¹⁶ Morals, values, culture and philosophy will influence each individual practitioner. But in reality, we are not as consistent as we would like to think.

There may be general agreement about the need for surgery for the child in Figure 6 to correct the obvious defect, even if the individual was functioning in an acceptable way. Life chances would be improved, no doubt. In the situation in Figure 7, cosmetic changes requested by the patient may well be undertaken without a second thought.

However, if the owner of the smile in Figure 8 requested a gold crown to a front tooth, and was considered to be in control of her faculties, and was prepared to pay whatever the price, how much agreement would there be to undertake this procedure, even if it were considered by the patient to be a life-enhancing opportunity? If, as the practitioner, you would not be prepared to undertake this patient's request, why not? What if the patient was prepared to pay £700, £1000, £5000, £10,000, £20,000, £50,000 £100,000…? Is it possible to be persuaded to a change of mind and justify an intervention when the financial stakes are raised? After all, the case could be made that the patient's psychological and emotional welfare were being considered and responded to (Figure 9).

What is it that is influencing the choice of outcomes in these scenarios? Whose interests are being served – the patient's or the practitioner's?

Conclusion

Whatever it is that motivates a patient to seek the help of a dental practitioner, it is essential that the clinical and emotional needs and desires of that patient are considered in equal measure.

There are practical challenges in accurately assessing the state of the hard and soft tissues, the care planning challenges in the management of deviations from the normal, and the ethical and moral challenges of meeting the desires and expectations of patients. There is the ever-present risk that the aims of treatment by the practitioner, especially in cosmetic enhancements, will be susceptible to financial consideration. ‘Money corrupts the process of reasoning’. The practitioner must be alert to this and be aware of whose interests are being served when undertaking any procedure, but especially so when aesthetics/cosmetics are the driving force.

Where the elimination of existing disease may not be possible or desirable, the practitioner must decide at what point intervention should take place. Since we are dealing with an area of the body that is loaded with bacteria, and since it is rare to find a patient who does not have some degree of gingivitis or periodontitis somewhere in their mouth (assuming, of course, that they are dentate), then it follows that we must accept some degree of disease in the mouth. The question is, how much treatment do we offer to eliminate this disease? Can we eliminate this disease without the co-operation of the patient?

How much disease to accept should be based on a thorough understanding of the person who has come for care and their attitude to their mouth, as well as the desire or the ability of such a person to attend on a regular or frequent basis in the future to maintain health. Fundamentally, dentists should enhance the lives of those who come for care. We want our patients to be free from pain, to be able to chew and speak well, to be comfortable with their appearance, to feel good about their mouths, and to have the knowledge and understanding to maintain their mouths in as healthy a condition as personal circumstances allows. The best dentistry is no dentistry. To plan or not to plan, to intervene or not to intervene, these are the challenges, and a clear vision as to the aims of treatment is the best way to achieve these.