Grey areas in restorative dentistry: Part 3. clinical decision making and care planning

When a patient attends either for a routine examination or as an emergency, it is essential to have a standard protocol so that an effective and appropriate care plan can be drawn up. This will involve listening, observing, questioning, examining, making a provisional diagnosis, testing, reviewing the test results, revisiting the provisional diagnosis and then, with all of the gathered information, producing a care plan that meets the needs and wants of the person that has come for care.

The care plan will be based on what outcome is agreed between the patient and the practitioner. Sometimes it will be just the management of a single issue, whereas at other times, it may be bringing the mouth to a state of good oral health. It is time well spent in discussing with the patient their hopes and aspirations for their dental care because it can avoid misunderstandings, disappointment, and perhaps legal redress, later on in the treatment and post-treatment phase: ‘disappointment lives in the gap between expectation and reality’.

A written plan will certainly aid this process. At the time of the examination, it should be realized that the clinical situation presented is part of an ongoing, vital process and it is essential to understand what has gone before to bring the patient to this state and in the light of this knowledge to plan for the future (Figure 1).

Clinical decision making

It is important to remember that dentistry is ‘the art or profession of a dentist’¹ and that much of clinical dentistry is subjective rather than objective. Indeed, Fish and Coles² consider clinical decision making as professional artistry. There isn't a probe that we can put onto a tooth that will tell us what to do. Fill this one. Watch this one. Repair this filling. Replace this filling. Put a post in this tooth. Extract this tooth. These clinical decisions are ultimately subjective and, therefore, are the reason that there can be wide variation between dentists as to how they would manage a particular situation, and even a wide variation by the same dentist on different days and at different times. As Kahneman³ pointed out, ‘the extent of the inconsistency is often a matter of real concern. Experienced radiologists who evaluate chest x-rays as “normal” or “abnormal” contradict themselves 20% of the time when they see the same picture on separate occasions. A study of 101 independent auditors who were asked to evaluate the reliability of internal corporate audits revealed a similar degree of inconsistency. A review of 41 separate studies of the reliability of judgments made by auditors, pathologists, psychologists, organizational managers, and other professionals suggests that this level of inconsistency is typical, even when a case is re-evaluated within a few minutes. Unreliable judgments cannot be valid predictors’.

Dentists are not immune to this lack of consistency. Like it or not, our decisions are going to vary.⁴ From a professional development point of view, we should think about them, reflect on them, and learn from the outcomes of the treatments.

The stages in the production of decisions are:

• Framing of the problem that is to be solved.
• The collection of relevant information leading to a decision.
• Reflection and review.

For any given tooth, there will be several aspects that should be considered when deciding on a care plan (Figure 2, Table 1). These patient factors can be the cause of much stress often based on incorrect assumptions by the practitioner, as indicated in Figure 3.

Bearing in mind these various factors, decisions have to be made, ranging from individual teeth to the whole mouth, and a chart such as shown in Figure 4 is very useful for recording the status of all teeth present in the mouth

Context is an essential part of the care plan for either an individual tooth or the whole mouth. If it was possible to take the distressed tooth out of the mouth and the question asked ‘what would have to be done to restore this tooth to health and function’, the answer may be very different to the same question if that distressed tooth was placed back in the mouth because the factors mentioned above are critical components in the decision-making process. The care plan should enshrine the concept of ‘best guessing’ what treatment would be the most appropriate for ensuring longevity. We cannot know what will work best as there as so many factors that contribute to the success or failure of treatments, some of which can be predicted but many of which cannot be known.⁶ This needs to be discussed with the patient. There have been attempts to reduce the subjectivity in dental clinical decision making,^7,8,9,10 but each situation and each practitioner is unique and so will give rise to the variations that are seen (Figure 5).

The shortened dental arch

There also needs to be consideration as to the replacement of missing teeth. In the absence of aesthetic considerations, the concept of the shortened dental arch should be considered because patients can function well without the full complement of teeth and where attempts to replace them exposes the patient to greater risks than benefits.^11,12,13 In 1992, the World Health Organization stated that a functional and aesthetic dentition requires no less than 20 well-distributed teeth.¹⁴

Varying the care plan

Where there is extensive dental and periodontal disease and/or occlusal disharmony, the care plan may have to be broken down into phases, each subsequent phase dependent on the success or not of the previous treatment and advice.

Immediate phase

This is to relieve pain, restore aesthetics, and comfort and is generally completed over a relatively short space of time.¹⁵

Intermediate phase

This is to deal with the factors that have led to the current state of poor oral health:

• Diet analysis;
• Temporary improvement of any restorations preventing good periodontal health;
• Oral health advice alongside periodontal treatment;
• Occlusal adjustment.

Definitive treatment should not be undertaken until the practitioner is satisfied that the patient can maintain a good level of oral health, otherwise there will be the continuing cycle of drill, fill and bill!

The aim should be to have the patient reduce their plaque score to 10%, the reduction of pockets, and to eliminate any sites of periodontal bleeding. This phase can last several months, even a year or more, working with the patient to eliminate those factors that have brought them to their current state of poor oral health. That is why it is prudent not to provide definitive restorations, such as indirect restorations, if they are going to be inserted into a disease-producing environment (Figure 6).

No plaque = No caries or periodontal disease

Final phase

The care plan will now be dependent on how well the toxic environment has changed. With good oral health and hygiene practices, the patient can be offered all the options in Figure 5 with a degree of confidence that there will be longevity for any restorative treatment undertaken. Should there be anything less than this, the practitioner should think carefully about prescribing indirect restorations that are expensive in terms of both tooth tissue loss and cost, because if nothing changes, nothing will change. That is, it is necessary to break the cycle that has brought the patient to their current state (Figure 7).

Conclusion

Each clinical situation is unique. Each dental practitioner is unique. Using knowledge, judgement, and experience in the clinical decision-making process a care plan can be drawn up that meets the needs and wants of the patient and at the same time does not conflict with the ethical, moral, and professional responsibility of the practitioner (Figure 8). The various options should be weighed carefully for their risks and benefits and a full discussion held with the patient. Full notes should be made. Although this takes time, there is no substitute for good contemporaneous records. The final agreed course of action should be based on rational thinking and not what seems like a good idea at the time. It should be justifiable to a third party should the need arise.