Treatment Planning: Making a Case for Its Ethical Importance

Gary Herman, DDS

ABSTRACT The treatment planning process is a continuing source of problems associated with current practices in dentistry; it is difficult to teach well and deals with a wide range of ethical principles and behaviors that are critical to the maintenance of the profession and to successful practice today.

When I was asked to contribute to this issue featuring ethics, I chose to focus on a topic that is both significant and timely. Treatment planning is an important procedure in dentistry for several reasons. The treatment planning process is a source of problems for many dentists currently practicing. It is difficult to teach well in school due to the complexity of options and the variability of faculty, [1] and it deals with a wide range of ethical principles and behaviors that are important to the profession and to a successful practice.

I will make a case that helps dental practitioners in different practice settings understand that spending the time and effort at the beginning of treatment is a good way to develop patient rapport, prevent misunderstandings and provide a basis for patient communication that will help achieve the goal of patient-centered, ethical quality care.

What Is Treatment Planning?

A treatment plan is defined by the American Dental Association (ADA) as “the sequential guide for the patient’s care as determined by the dentist’s diagnosis and is used by the dentist for the restoration to and/or maintenance of optimal oral health. [2] Although that sounds relatively simple and straightforward, the process of achieving that plan is complex, with many places for individual variations, personal practice values as well as many opportunities to skip steps and take shortcuts. Treatment planning has three primary and necessary components that are integral to the overall process: the patient examination, the development of the treatment plan and the treatment presentation.

The first component of treatment planning is the examination. All examinations should include a thorough evaluation of the patient’s past and present medical history, the patient’s medications and supplements, recent medical interventions including hospitalizations and, if necessary, consultations with the patient’s physician to clarify information and suggest modifications to treatment, if needed. It is appropriate to include the recording of vital signs, especially blood pressure. This may help find patients who have undiagnosed disease as well as those patients whose disease is not as well controlled as it should be.

The examination should continue with thorough intra- and extraoral examinations as all dentists are trained to perform. A detailed description of a complete patient examination goes beyond the scope of this article; however, it should include more than just teeth. Periodontal and endodontic considerations must be included. The patient’s oral hygiene and motivation must be evaluated.

Missing and hopeless teeth, evaluation of caries risk, prosthetic replacement options, temporomandibular joint issues and addressing a patient’s chief complaint, if any, are all integral to the process.

The next aspect of the treatment planning process is synthesizing the patient data and creating a problem list. The list includes procedures that should be addressed, regardless of whether treatment is delivered or deferred. Once the problem list is established, it is time for the dentist to compile a sequential treatment plan or several plans to address the options for comprehensively treating the patient’s needs and wants. It should be noted that the problem list should be developed after a general discussion with the patient regarding their specific concerns.

The activity discussed thus far leads to the treatment presentation. This final part of the process is, arguably, the most ethically relevant. The treatment presentation is critical to providing the patient with the information in a form the patient can understand regarding dental options, the risks and benefits of each option, the costs and time of treatment as well as the risks of not treating the problems. All of this information is vital to obtaining a free and fully informed consent from the patient, a primary ethical concern of all health care professions.

The Ethical Significance of Treatment Planning

Ethical principles have been developed by the profession, in this case dentists, to provide guidance to members of the profession on actions that strengthen the profession and protect the patient. The earliest guide to the ethics of dentistry in the United States, originally adopted in 1866, was the ADA Principles of Ethics and Code of Professional Conduct. The document was divided into four basic principles and has specific conduct attached to each principle. Those principles were autonomy, nonmaleficence, beneficence and justice. [3 ]Today, those four principles still remain and have been joined by an additional principle: veracity.

Dentistry 150 years ago presented a picture of a trade being transformed into a profession, with training predicated upon education rather than apprenticeship. At the time, the field of dentistry was full of charlatans, patent medicines and individuals with widely differing skills attempting to treat the public. The organization of the profession was built upon the responsibility to focus on the rights of and the benefits to the patients, above all else. The four principles adopted all speak to the protection of and benefit to the patient, not the dentist.

Treatment Planning Is the Heart of a Primary Ethical Principle

Treatment planning, as described above, is the primary concern of the first principle identified by the founders of organized dentistry, specifically: “Under the principle of patient autonomy, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s needs, desires and abilities …” [4]

Even the preamble of the ADA code “calls upon dentists to follow high ethical standards which have the benefit of the patient as their primary goal.” [4] It could be argued that once the founders of the ethical principles wrote the preamble, their goal would be likely to address their greatest concern first. By this reasoning, the concept of patient autonomy would have likely been one of the most important concerns that the profession chose to enumerate.

Treatment Planning Is Represented in All of the Ethical Principles

Besides being the highlight of the first principle providing patient autonomy, treatment planning and presentation can be found playing a role in the other principles. The next principle listed is nonmaleficence, commonly known as “do no harm.” Generally speaking, it relates to providing good care based upon training and practice. It also addresses issues related to referrals to specialists when indicated. In the discussion of referral for a second opinion, the dentist rendering the opinion should have the interest of the patient in mind and not a vested interest. Providing good care frequently comes down to an evaluation as to whether the standard of care has been met or not. This does not only refer to the end result of the product of dental treatment but would certainly also be considered when evaluating the process that results in the determination of a treatment plan.

As a principle, nonmaleficence seems to be appropriately included in the discussion of diagnosis, treatment planning and treatment presentation as areas where the standard of care can be applied and where practicing below that standard of care can cause harm to the patient.

A dentist who has a dissatisfied patient can certainly be evaluated as to the results of the treatment performed. It is fairly straightforward to establish if the dentistry provided meets the standard of care. Additionally, the dentist may find it necessary to show the process used to establish the particular treatment choice or choices given to the patient. It is likely that the standard of care would be applied to the overall process of determining necessary and appropriate treatment as well as the acceptability of the specific treatment rendered. A cursory review of disciplinary actions against dentists shows many instances where dental care options were not discussed or documented; treatment options were limited to a choice of one, when multiple options were available; and specific treatment options were being offered when the treatment was of questionable value or not necessary.

The principle of beneficence, that is “doing good,” specifically states that the most important action is the “competent and timely delivery of dental care within the bounds … presented by the patient, with due consideration being given to the needs, desires and values of the patient.” [5] The treatment planning process fits well into this principle.

The organization of the profession was built upon the responsibility to focus on the rights of and the benefits to the patients, above all else.

Providing the patient with the ideal as well as other acceptable treatment options meets the guidance above and is even more appropriate when viewed with the further requirement not to provide different treatment plans for people with different types of practice arrangements. Proper treatment planning should provide a plan that provides optimum care for the patient. If the patient has few resources, alternative plans that are less expensive are not only nice, they are necessary. The principle of beneficence admonishes dentists to make sure they are diagnosing for the patient within their circumstances, not based on a third-party contract and how that will affect the dentist.

Justice, or fairness, is probably the principle least obviously associated with treatment planning. That being said, the principle of justice includes the concept of justifiable criticism. If presented with the responsibility to provide a second opinion, it is likely that in order to provide that opinion, one must evaluate the original treatment plan to determine if it is within the standard of care. It would be necessary for the examining dentist to thoroughly look at both the original and next dentist’s treatment plan in order to determine if the treatment is not only sound, but also appropriate.

The final, more modern, ethical principle is veracity. To that end, the essence of an appropriate treatment plan is truthfulness. Dentists generally have an advantage over most patients in that they have a greater understanding of both the patient’s condition and the available treatment options. If the treatment plan is complete, thorough, well presented and fully factual, including risks, benefits and alternatives, its veracity will likely be recognized by the patient and, through truth, will lead to trust.

Consequences of Failures in Treatment Planning

Another way of looking at the importance of the treatment planning process is to examine failures of that process and evaluate the results of those failures. To that end, the Dental Board of California provides the public with information regarding disciplinary activity against dentists. The dental board receives complaints from patients and other sources, including other dentists, insurance carriers and law enforcement. After preliminary investigation, the dental board may choose to fully investigate and, when appropriate, place specific requirements on licensees as a condition of discipline. These actions often include required educational classes in specific areas that the board feels would address the deficiencies of the dentists being disciplined.

To evaluate the comparative frequency of topics requiring remediation, the monthly reports regarding dental board remediation, known as the Hot Sheets, were reviewed for October 2018 to December 2019. All dental board actions, which included probation of the dentist or a letter of public reproval for the dentist, were examined to determine if the disciplinary order contained a remedial education requirement. The specific educational topics needed were logged. It should be noted that some dentists had no requirements and others had several areas that required remediation. [6]

The results of this dental board evaluation revealed 25 remediations for treatment planning, 25 for recordkeeping, 16 for ethics, seven for practice management and 39 for didactic training (various disciplines; no single discipline had more than eight).

This data does not readily lend itself to complex statistical analysis, but an overview does help draw some useable inferences. Although treatment planning and record-keeping were equally represented as the most frequent remedial topic, it should be understood that complaints to the dental board are never for poor record-keeping. This is always an ancillary finding when the dental board investigates a complaint and tries to decipher the dentist’s records to evaluate the complaint. That is not to say that poor recordkeeping is not an ethical lapse. In such cases, it could be assumed that the principles of nonmaleficence and veracity are both potentially violated.

Another valuable insight occurs when one looks at those cases where treatment planning is required along with record-keeping. Of the cases requiring treatment planning remedial education, fully one-half of those also included an additional requirement for record-keeping. In general, it can be concluded that problems associated with treatment planning are a significant factor in patient complaints to the dental board, whether the patient realizes it or not. Failure to inform the patient of what will occur, failure to provide options of care and failure to receive informed consent may all result in a less than complete treatment plan.

The occurrence of both treatment planning issues and record-keeping problems is not likely coincidental. As described, the treatment planning process is detailed, comprehensive and may be quite time consuming. Most dentists find chart documentation to be time consuming as well. Do these dentists find crown preparations a timeconsuming process? The short answer is no because they are generating income when preparing a crown, but not when preparing a procedural note in the chart or gathering essential data to help deliver a thorough, well-documented and easy to explain treatment plan.

In dentistry, the common excuse regarding lack of time to do a thorough exam and treatment plan could be further expressed as “time is money.” Although anecdotal, many dentists complain that their patients will not allow them to charge for examination or discussions or at least will complain. The patients only want to pay for tangible dentistry. This seems to illustrate that in some way the profession has lost its way. In comparison, medicine charges principally for examinations and patients expect to pay for them. Conversely, in dentistry, whether due to a focus on product advertising or by not consistently explaining charges, many dentists seem to feel compelled to undercharge or undervalue their time related to examination and diagnosis.

It is human nature to expend time and energy when there is a probability of achieving a reward, whether this relates to managing a dental practice or playing golf. Without a reward, it is easier to extinguish a behavior. If a dentist chooses to do a cursory evaluation and delivers an immediate treatment plan to the patient, there is a danger of providing an incomplete and inappropriate plan. Additionally, there is a likelihood that the plan will not include all options and likely will not have achieved the patient’s full understanding. These factors all lead to the potential of a failure to provide a free and fully informed consent. Surprisingly, in that situation there is a significant possibility that the dentist may be actually decreasing the chances of obtaining the patient’s acceptance.

Dentists need to be reminded that the time needed to perform a thorough examination and develop a comprehensive treatment plan is necessary. It ensures that patients are well-informed, aware of all of the options, feel their questions and concerns have been addressed and carry the opinion that the dentist has their interests at heart. This is a scenario that will lead to the best outcomes both for the patient and the dentist.

Conclusions

The treatment planning process is the primary focus of the very important ethical requirement of autonomy of the patient in dentistry, historically and today. It is also represented and discussed in all of the remaining ethical principles of the profession. It is recommended that dentists should reflect on the fact that one of the most important things we do is provide patients with our time.

Taking shortcuts to decrease the time spent with patients examining, planning and obtaining consent can have a substantial effect on the dentist’s success and overall satisfaction of their profession. It can also significantly affect the satisfaction of the patient.

REFERENCES

1. Gordon SR, Kress GC. Treatment Planning in Dental Schools. J Dent Educ 1987 May;51(5):224–8.

2. American Dental Association. Glossary of dental clinical and administrative terms. www.ada.org/en/publications/cdt/ glossary-of-dental-clinical-and-administrative-terms.

3. Transactions of the American Dental Association at its Sixth Annual Session. Dental Cosmos 1866 Sept;8(2):88–90.

4. American Dental Association. Principles of Ethics and Code of Professional Conduct. 2018:4.

5. American Dental Association. Principles of Ethics and Code of Professional Conduct. 2018:6–7.

6. Dental Board of California. Hot sheets — summaries of administrative actions, October 2018 through December 2019. www.dbc.ca.gov/consumers/hotsheets.shtml.

THE AUTHOR, Gary Herman, DDS, can be reached at ghermandds73@gmail.com.

AUTHOR Gary Herman, DDS, teaches at the University of California, Los Angeles, School of Dentistry and lectures on ethics, dental law and patient management. He is past chair of the ADA Council on Ethics, Bylaws and Judicial Affairs and was a member of the CDA Judicial Council. Conflict of Interest Disclosure: None reported.