Dental Science & Practice 1 - Dentist-Patient Relationships

Dentist-Patient Relationships

Aim and Outcomes

  • The aim is to provide a framework for understanding how the dentist-patient relationship can enhance or impede person-centered care and communication.
  • To support reading about dentist-patient relationships.
  • To introduce 4 different models of the dentist-patient relationship:
    • Key characteristics of each model.
    • How they relate to healthcare.
    • How they relate to autonomy and control.
  • Outcomes:
    • Explain how each model can influence dentist-patient interactions, communication, and healthcare.
    • Apply understanding to patient-centered care by explaining different patient scenarios from different DP relationship perspectives.

Readings

  • Greenfield, J 2001. Medical decision-making: Models of the Doctor-Patient Relationship.
  • Roter D, Hall J 2006 The Nature of the Doctor-Patient Relationship.
  • Note: Substitute 'dentist' for 'doctor' as the same principles apply.
  • Consider:
    • Why is it important to understand the dentist-patient relationship?
    • How does theory help your practice?

Importance of Understanding the Dentist-Patient Relationship

Review of Student Thoughts

  • Refer to Discussion Board on MyUni.

Factors Influencing the Dentist-Patient Relationship

  • Roter & Hall 2006:
    • Dentists and patients shape the relationship, influencing each other, defining the process & outcome of care.
  • Process of care:
    • Ethics: Patient rights are an essential part of care.
    • Legal: Informed consent is essential.
    • Communication style influences all stages of care.
    • Person-centered care: shared decision making.
  • Factors:
    • Patient trust in the clinician.
    • Satisfaction with care.
    • Dental fear.
    • Therapeutic communication.
    • Involvement in clinical decision making - shared decision making.

Outcomes of Care

  • More accuracy and efficiency in diagnosis and treatment.
  • Improved patient adherence to professional advice and OH plans.
  • Better patient health outcomes – mental and physical.
  • Better patient and dentist satisfaction.
  • (Maguire & Pitcantely 2002)

Communication and Context

  • Communication and dental care happen in the context of a relationship.
  • The relationship is shaped by the cultures of the patient and dentist.
  • Dentist and patient may have different and possibly conflicting understandings, attitudes, values about oral health/dentistry (e.g., priorities, outcomes).
  • This influences the type of role adopted and the resulting relationship.
  • This influences communication and care; the ability to provide person-centered care depends on the type of dentist-patient relationship.

Key Models of the Dentist-Patient Relationship

  • Paternalism: Parent-child relationship, "Dentist knows best”.
  • Consumerism: Provider-Customer relationship, Patient demands services.
  • Mutuality – Collaborative: Dentist and Patient as Partners.

Models of the Dentist-Patient Relationship (Roter& Hall (2006))

  • Relative contributions of Patient and Dentist
  • Level of control
  • High Dentist control, Low Patient control: Paternalism
  • Low Dentist control, High Patient control: Consumerism
  • High Dentist control, High Patient control: Mutuality
  • Low Dentist control, Low Patient control: Default: unclear or incompatible

Model Characteristics (Roter& Hall (2006))

  • Paternalism:
    • Who sets agenda/goals? Dentist, based on dental science, clinical perspective.
    • Place of patient point of view? Not relevant, focus on disease.
    • Dentist role in decision-making? Dentist as ‘guardian’: wholly responsible.
  • Consumerist:
    • Who sets agenda/goals? Patient, based on own expectations, concerns, requests.
    • Place of patient point of view? Wholly drives agenda.
    • Dentist role in decision-making? Dentist as ‘consultant’: fulfill patient request (if professionally, ethically OK).
  • Mutuality:
    • Who sets agenda/goals? Dentist and Patient, Biopsychosocial perspective on health.
    • Place of patient point of view? Integral to care, Patient experience of illness important.
    • Dentist role in decision-making? Dentist as ‘advisor’: support patient by giving expert advice, aiding decision as much as necessary.
  • Default:
    • Dentist and Patient expectations re each of these may be different and not compatible  potential for conflict, dissatisfaction

Dentist-Patient relationships: Importance

  • Consider if the models presented are congruent/not congruent with providing person-centred care.
  • Two essential elements of person-centred care:
    1. Ethical protection of patients
      • Patient autonomy must be protected i.e. autonomy means that patients have the right to make their own health-care decisions - voluntarily and without any coercion
    2. Legal protection of patients
      • The dentist’s duty of care to the patient includes obtaining informed consent from the patient as the basis of any treatment decision

Autonomy vs. Control

  • Autonomy is not the same as control (having input to decisions).
  • Don’t confuse control and autonomy.

Patient Scenarios

  • Two patient scenarios will be considered to apply the concepts from the reading about the DP relationship:
    1. Gianni – this is a real story.
    2. Lizzie – this scenario is based on several real events.
  • First, Gianni’s case is given as a worked example of how the style of the DP relationship can affect oral health care and its outcomes.
  • Second, Lizzie’s case is to be analyzed the same way. Discuss it in groups to further develop the ability to understand and apply ideas about the nature of the DP relationship.

Gianni's Case

  • Gianni, 59 years of age
  • Reason for visit: a pre-surgery check-up with oral surgeon, referred by cardiac surgeon
  • MHx: Gianni has suspected heart valve damage due to previous rheumatic fever. He is due to have surgery for a heart valve replacement. The medical team has referred him to the oral surgeon (a specialist dental surgeon).
  • The referral is because Gianni has a heavily restored upper dentition; if any of the restorations are breached by bacteria and develop pulpitis (inflamed dental pulp due to the bacterial infection) during the first 3 months post-surgery (i.e. after the prosthetic valve insertion) this could cause a serious heart infection.
  • Tx plan: The oral surgeon decides that to remove this risk of post-operative infection, Gianni ought to have oral surgery prior to his cardiac surgery: Gianni requires a full upper clearance (i.e. removal of all upper teeth).

Oral Surgeon's Perspective

  • The oral surgeon is acting in Gianni’s best interest as he saw it i.e. he is well-intentioned:
    • Gianni requires the cardiac surgery and is possibly at high risk of post-operative infection from his heavily restored upper teeth
    • The oral surgeon has the scientific knowledge and skills (biomedical) to make the cardiac surgery safer i.e. he can perform oral surgery to remove all of Gianni’s upper teeth
    • Gianni accepts the oral surgeon’s expert advice and has the oral surgery
    • Gianni then has the cardiac surgery
Analysis of the Situation
  1. Who decides the agenda/goals of this situation?
    • The overall goal is Gianni’s health and safety
    • Both surgeons: the current priority is surgical management of Gianni’s oral and hence general health
  2. What place does Gianni’s point of view have in the process?
    • Gianni is not asked what he wished to happen, nor asked how he feels about the loss of his teeth
    • He is not actively involved in the decision-making
  3. What is the dentist’s role in decision-making?
    • The oral surgeon is completely responsible: he focuses on the scientific and biomedical aspects of Gianni’s situation i.e. the potential for disease in this case
    • He does not address Gianni’s perspective, i.e. his potential experience

Alternative Approach

  • An alternative approach is to work together to find out what is in the patient’s best interest and help the patient decide
  • This involves a mutual exchange of information, dentist’s expertise and patient’s point of view
  • After considering all the pros and cons, Gianni, his family, and his dentist arrive at a decision that he can accept
Analysis of Alternative Approach
  1. Who decides the agenda/goals of this situation?
    • The overall goal is Gianni’s health and safety
    • Gianni and his dentist/surgeon discuss his health and the decision
  2. What place does Gianni’s point of view have?
    • Gianni is invited to contribute his ideas from his own point of view: is encouraged to ask questions and seek family input/support if desired, he is asked what he thinks of the options and how he feels about the possible loss of his teeth
    • He can be actively involved in the decision to the extent he wishes
  3. What was the dentist’s role in decision-making?
    • The dentist/surgeon contributes his expertise about the procedure, its purpose, its pros, cons etc;
    • The dentist/surgeon helps Gianni to work through the complex process of coming to a decision – providing information & guidance

Consequences and Trust

  • When Gianni is told he required a full upper clearance, he is devastated at the thought of losing all of his upper teeth
  • He goes ahead and has the oral surgery followed by the cardiac surgery
  • Following the cardiac surgery, he is told that he did not need a prosthetic heart valve, because his own heart valve was intact and healthy…. This means he did not need to lose his teeth!
  • Consider:
    • The paternalistic approach: what happened and what is the likely consequence for Gianni’s trust in the medical/dental profession?
    • The collaborative (mutuality) approach: what could have happened and what would be the likely consequence for Gianni’s trust in the medical/dental profession?
Analysis of Approaches
  • The paternalistic approach:
    • Gianni is very unhappy but submits to the health professional because he believes that he has no choice
    • Gianni’s trust in the oral surgeon (and possibly dentists in general) is weakened, he is unlikely to want further contact with dentists
  • The collaborative approach:
    • Gianni may decide on the oral surgery, even though he may not be completely happy with this option, on balance it is his own decision; it has not been made for him by well-meaning but paternalistic health professionals
    • Gianni may decide not to have the oral surgery and accept the risks; this would also be his own decision
    • His trust and confidence in dentists would remain

Models and Patient-Centered Care

  • Consider if any of the models presented in Greenfield (2001)/Roter and Hall (2006) are congruent/not congruent with providing patient-centered care.
  • Reasons?

Lizzie's Case

  • Lizzie, aged 23, has attended your clinic for the first time.
  • When asked about her reason for visiting, she says she wants her teeth whitened and a gap (‘diastema’) put between her teeth – she shows you a magazine article.
  • (Refer to the magazine article “The smile everyone wants”).

Clinical Examination

  • Lizzie, aged 23. You examine Lizzie.
  • Note: It would be possible to create a diastema, as Lizzie’s centrals are quite wide, it could be achieved by reshaping the mesial surfaces of the central incisors. The teeth would remain intact, but the enamel is made thinner. If Lizzie decided later, the diastema could be filled in by building up the enamel with composite resin

Course of Action

  • View the image of Lizzie’s teeth: briefly, what could you say about her oral health, particularly her teeth?
  • You are Lizzie’s dentist, decide what your preferred course of action is
  • The options regarding Lizzie’s request are:
    • to agree and do the procedure, or
    • to disagree and not do the procedure
  • The next step is to communicate with Lizzie about her request
    • What you say and how depend on what style of D-P relationship you establish

Interaction Scenarios

  • How might the interaction proceed if:
    • you are a paternalistic dentist?
    • you and Lizzie enter into a consumerist transaction?
    • you and Lizzie engage in a collaborative manner?
  1. Who decides the agenda/goals of this situation?
  2. What place does Lizzie’s point of view have?
  3. What is your (dentist’s) role in decision-making?
  • Suggest how the conversation between you and Lizzie might proceed

Additional Questions

  • Some additional questions:
    • How much control do patients need or want?
    • What if patients ask you what you would recommend?
    • What if patients want to have a paternalistic relationship? (“You decide, Doctor”)

References

  • ADC (2022) The ADC Professional attributes and competencies of the newly qualified dentist, Australian Dental Council
  • Emanuel EJ & Emanuel LL 1992. Four models of the physician patient-relationship.
  • *Greenfield J 2001. Medical decision-making: Models of the doctor-patient relationship. In Healthcare Communication Review V1(1).
  • Humphris G & Ling M 2000. Expectations of the consultation, in Behavioural Sciences for Dentistry.
  • Kay E, Tinsley S, 2004. Relationships with patients: why bother?, in Kay E & Tinsley S, Communication and the Dental Team.
  • *Roter D, Hall J 2006. The Nature of the Doctor-Patient Relationship, in Roter D, Hall J, Doctors Talking with Patients, Patients Talking with Doctors: Improving Communication in Medical Visits 2nd edn.
  • Szasz TS & Hollender MH 1956. A contribution to the philosophy of medicine: The basic models of the Doctor-Patient relationship
  • Silverman J, Kurtz S, Draper J 2005. Building the relationship, in Silverman J, Kurtz S, Draper J, Skills for Communicating with Patients 2nd edn.
  • *Essential readings: Available on MyUni

Additional Reading

  • Impact of the dentist-patient relationship on oral health Song Y , Luzzi L, Chrisopoulos S,; Brennan D. (2020)
  • Trust and the dentist-patient relationship Song, YoungHa ; Luzzi, Liana ; Brennan, David S (2020)