Fundamentals of Treatment Planning. Lino Calvani
economics and patient treatment costs
Prosthodontic treatments are usually expensive due to the:
● costly and ongoing dental office expenses;
● duration of the treatment;
● cost of dental materials;
● laboratory fees;
● services of other collaborating specialists, if any;
● clinical and prosthodontic complications that sometimes occur despite our professional experience and capability to foresee them;
● treatment follow-up;
● any relevant taxes that need to be paid.
Affordability of the treatment plan
The financial resources available for treatment will differ for each patient, who will only be able to afford a certain type of treatment. This is potentially a serious limiting factor in treatment planning and selection. We therefore need to know the financial situation of our patients before we begin planning an appropriate course of treatment for them. In many cases, we need to propose multiple solutions for the same restorative problem in order to provide as many available options as possible for successful treatment and rehabilitation.37-39
From the start, it is wise to gently investigate to what extent patients are able to cope with the costs of the restorative care we may propose (including the follow-up maintenance costs) so that we completely understand their unique financial situation. This is a responsible course of action that would be acceptable to the majority of patients. To do this, we need to politely ask our patients what their profession, job or occupation entails. Indeed, this information should be recorded as part of the initial examination. This is not the same as asking outright about a patient’s income, which can be construed as rude even if we ask in a kind and confidential manner. Moreover, what we know about the occupation of our patients will throw light on their level of education, which has a bearing on how well they are able to understand the theoretical and practical information we need to transfer. However, we should always carefully explain why some treatment plans are more technical, time consuming, and/or expensive than others. It is our duty to help our patients to understand, and it ought to be a pleasure for us to take all the time necessary to do this in the best possible way. At the same time, we need to treat this issue with sensitivity because some patients may be embarrassed if certain prosthodontic solutions are too expensive for them to afford.37-39
If an infectious disease exists in the oral cavity, we have the duty as dental medical professionals to assess it and to find the best way to explain the gravity of the situation to the patient, together with the related treatment costs. Disease is a priority that needs to be resolved before any prosthodontic solution can be performed, especially if sensitivity, discomfort, and/or pain exist.37-39
It is crucial to plan the treatment costs as comprehensively as possible and to be honest about them with the patient in the interests of a good clinician–patient relationship. This will avoid surprises later on. If we anticipate additional service costs, we need to let the patient know about them from the outset. Treatment planning is not an easy task, and explaining a demanding prosthodontic plan is not like selling a product; we need to be truthful and transparent as we explain and advise about the solution/s that are in our patients’ best interests. At the heart of this aspect is having and showing respect for the patient.37-39
In the same vein, we need to be kind and polite and treat our patients with empathy and gentleness in order for them to view us as concerned professionals with integrity, as opposed to being only interested in the money we will make from treating them. We need to bear in mind that the decision regarding which treatment to choose lies with both the patient and the clinician, and not with the clinician alone. In some instances, patients are happy to allow us to make the decision, and may request us to do so on their behalf. The rule of thumb is to be polite and respectful at all times, an attitude that will reward us and our dental office with the trust and respect of our patients. This has a bearing on our business too, because every patient could potentially refer family and friends to our office.
The basic difference between the terms ‘consent’ and ‘informed consent’ is the degree of patient knowledge behind the consent decision. The amount of information required to make consent informed may vary depending on the complexity and risks of treatment as well as the patient’s wishes. In terms of our professional responsibilities and liabilities, it is important to understand the exact meaning of these terms.
Except in rare cases where we need to help patients immediately such as in an urgent clinical emergency or in the case of symptoms of severe pain, a patient’s consent to be treated is always required before the start of treatment.
Informed consent refers to a doctrine that was established in the 1950s and has been continually revised over the years. What is established with informed consent is that a clinician can only treat a patient if and when the clinician is sure that the patient is fully aware of and understands the type of treatment being proposed to solve the problem. Apart from the more ethical aspects outlined above, an informed consent is a necessary document for us to obtain to ensure control of our risk management and to try to avoid legal problems that may arise later on with some patients.
The House classification (see Chapter 5) was a practical, organized attempt to define the personality of the edentulous patient. It may also be helpful for other patients (ie, those who are not edentulous), and may indeed be useful to give us some idea of the complexity of patients and their idiosyncrasies. This allows us to be better equipped to avoid unpleasant surprises later on during the treatment.
Therefore, the treatment planning discussion or initial diagnostic phase is the first ‘filter’ that assists us to get to know a new patient, and it is the point from which all further decisions are taken. This sensitive phase is therefore very useful to our understanding of the personality and psychology of a patient. It colors the type of treatment plan we devise that is most likely to be accepted by the patient; in some rare cases, we may even see no chance to treat a particular patient at all.25,27,40,41