the examination.

Most important, the findings

should be in lay terms. We say ‘cavity’ not ‘caries’,
‘bruise’ not ‘hematoma’, ‘gumline’ not
‘marginal gingivae.’ When there is no simple
lay term for a finding, then the examiner must
stop and briefly explain the term that is used.
The purpose of verbalizing is to help the patient
understand the clinical findings better, not
to impress or confuse.
When a finding is noted that is unusual, significant,
or pathologic, the patient should hear
this, and be shown what the examiner is describing
(see below).
Verbalizing the findings gives patients an
appreciation of what the examination is covering,
and gets them involved in the diagnosis at
the very outset.
Show the findings
Show patients what you see in their mouths: a
good mirror works fairly well; a magnifying
mirror with a light source is better. An intraoral
video camera can be a very effective tool to
demonstrate intraoral findings. Color printouts
of captured video images can go home
with them.
Once diagnostic casts have been obtained
they can be used to show patients the problems
and conditions that are in need of attention. It
is sometimes useful to allow patients to take
their models home with them after you have
discussed the findings that they present. The
more opportunities given to patients to selfdiscover
problems in their own mouths, their
own dentition, the easier is the dentist’s job in
presenting diagnosis and treatment proposals.
SETTING GOALS
We can draw all kinds of roadmaps for dental
care and treatment, but we need to know where
the patient wants to go, and for that we need
to establish goals that have been agreed upon.
Formal training in dental school may produce
dentists who see the goal of 28 teeth in good
occlusion and alignment as the holy grail.
Esthetics, the appearance of the mouth, is often
considered as an accessory to that goal.
Patients, on the other hand, lacking the benefit
of years of dental education, may not know (or
much care) how many teeth they have, as long
as they are getting along ‘OK.’
Without an appreciation of the curves of occlusion,
canine protection, bone levels, or incipient
caries, they may simply seek a comfortable
mouth and attractive smile. Four very
simple questions might be posed, and goals
established on the basis of the patient’s answers.
These are in the order of most patients’
priorities.
How will they look?
Is the patient satisfied with the appearance of
the teeth: the alignment, the shape and the
color? Beauty is in the eye of the beholder, and
many patients seek the ‘whitest teeth money
can buy’ to the chagrin of the dentist striving
for a beautiful but ‘natural’ that is, ‘real,’ appearance.
On the other hand, many patients are
quite content with teeth that the dentist perceives
as disfigured, and in need of ‘improvement’
through bleaching, bonding, veneers, etc.
A large diastema may be a source of embarrassment
to one patient, a point of pride in a
family trait to another. Goals for esthetics can
vary greatly, then, from the desire for perfectly
straight and pearly white, to just ‘covering up
the black spots.’
How will they work?
Can the patient speak, chew, and swallow comfortably,
without undue difficulty? Can the
patient confidently take on tough foods without
fear of teeth cracking, or dental work coming
loose? Functional goals once again are individual.
Some partially edentulous patients
are perfectly content to go through life without
most of their posterior teeth, whereas other
patients are greatly perturbed by the loss of just
one posterior tooth, and demand prosthetic
replacement at the earliest opportunity!
BASIC PREMISES 17
Will they be healthy?
This question concerns patients’ ability and
willingness to care for their teeth, but it also
addresses the ease with which this may be
done. Severely crowded teeth, open contact
areas allowing food impaction, or rough poorly
contoured contacts that prevent floss from passing
through easily will inevitably lead to future
dental disease. Missing and tipped teeth,
deep bites, hypertrophic tissues, and complex
dental restorations that are inaccessible to reasonable
hygiene are all examples of health issues
that the dentist and patient need to consider
when setting treatment goals. Any existing
conditions that now compromise health, or
are likely to compromise health in the future,
need to be addressed.
How long will they last?
Dental care and treatment is, or can be, long
term. How long is obviously related to the type
of treatment selected, what materials are used,
and, most importantly how well the patient
maintains the work. We have all seen treatment
fail in the presence of uncontrolled disease or
excessive functional forces. We have also seen
what can happen when optimum dental treatment
meets rigorous daily home care and regular
professional maintenance. Esthetics, function,
and health can be maintained for decades.
One of the satisfactions of a career in dentistry
is to see healthy patients, whose dental care and
restorations have provided them 10, 20, 30
years of esthetic, functional, and healthy service
and are still going strong.
These four simple questions can form the
basis for mutual goals between dentist and
patient. Some patients will come to us seeking
the utmost in esthetics, function, and health,
with time and money being no object. Most
patients in the real world, however, seek one
or more of these goals, but within a ‘budget.’
They put dental care in a hierarchy with all their
other needs and wants, and we need to reach a
compromise that will allow us to treat them
safely, with positive benefits, at a level that they
can accept. Some patients are more concerned
with esthetics, less with function or health. Our
responsibility is to show patients how those
issues are interrelated, and offer approaches
and alternatives that address them all. This is
where strategic dental treatment planning
starts.

19
The patient interview is usually the first and
often the most important step in effective diagnosis
and treatment planning. It is clear that
the impressions formed by the patient early in
the initial interview can have a huge impact
on the patient’s acceptance of the dentist, and
the dentist’s credibility with the patient. Lose
the patient now, and all the technology, all the
expertise, all the excellence in the world will
not salvage the relationship.
There are excellent texts and reference works
on patient interviewing, communication, and
behavior, some of which are cited at the end of
this chapter.1,2 Certain key issues are so critical
to the process, however, that they must be
briefly addressed here.
THE DOCTOR-PATIENT
RELATIONSHIP
To the extent that they are of legal age and
mentally competent, patients should be treated
as our partners in dental care and treatment.
Given the degree to which dental disease is
related to behavior, any other model is irrational.
If we accept that effective dental care
involves the control of dental and oral diseases,
as well as the long-term daily maintenance of
the oral cavity, including our restorations and
prostheses, then success of such care is primarily
in our patients’ hands. Furthermore, in a
traditional fee-for-service arrangement, patients
are not only in control of the outcome,
they are also ultimately responsible for paying
for it.
Given that, we must from the very outset
treat our patients as partners, communicating
with them on their level, rather than from
above. This does not mean that we relinquish
our position as trained and licensed professionals,
but it does demand that we treat patients
as we would wish to be treated, as fellow human
beings, deserving of all the respect and
dignity that we would wish for ourselves in
the same position. Here are some key issues to
consider in establishing that relationship.
• Meet and greet the patient at eye level, either
both standing or both seated in a comfortable,
non-threatening setting. Modern
dental operatories can (and should) conceal
dental handpieces and other instruments
that may be disturbing or distracting
to the new patient (Fig 2.1).

THE PATIENT INTERVIEW

Fig 2.1
Meeting the patient on an even playing field, at eye level,
in comfortable surroundings.

2
20 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
• Introduce yourself (or be introduced) and,
although you may be comfortable offering
your first name to the patient, you should
not, in most cases, address the patient by
their first name until invited, or until the
relationship has had time to develop. This
is especially true when addressing older
patients for the first time.
• Early in the initial interview, often at its
outset, you should pose an open-ended
question to the patient that frames the relationship
that you hope to establish. The
question goes something like this: ‘Mrs
Brown, how may I help you?’ or ‘Mr Green,
what can I do for you?’ or ‘Ms White, what
brings you to see me today?’
• Listen to your patients, really listen. Whatever
motivated them to seek care, or specifically
to select you as a dentist must be
understood and respected. They may be
dentally well informed and articulate, as
was one young man whose chief complaint
was a ‘chipped buccal cusp on number
three.’ Or they may have little or no understanding
of their various problems or
what might be done about them, in which
case education may have to precede and
accom-pany therapy. In either case, allowing
and encouraging our patients to tell us
why they came is a good way to find out
where they are at the outset of the doctorpatient
relationship. We must go to them,
appreciate our patient’s point of view, and
start the relationship there.
• Understand the level of trust that our patients
need to have in us. For most people,
the dental environment is at best somewhat
uncomfortable and, at worst, terrifying. We
used to think that that would change, with
fluoride and preventive dentistry reducing
or eliminating entirely the need for many
dental procedures in childhood, and with
the actual realization of ‘painless’ dentistry.
We supposed that most patients, particularly
young adults, would have less anxiety,
never having experienced painful or
fright-ening dental treatment in the past.
For some, this is indeed the case. But current
research is suggesting, much to our
chagrin, that there remains a broad, culturally
based level of dental fear and anxiety
even among people who have had no unpleasant
dental experiences; this has to be
dealt with one patient at a time.
Perhaps other concerns about cost, appearance,
and so forth are also involved
here. More likely, the fact that dentists invade
patients’ personal space, working
right in the head, so close to where we ‘live,’
is what makes apprehension unavoidable.
Given that, we have to appreciate the tremendous
trust that our patients place in us,
to use needles, drills, and all types of sharp
and blunt instruments in their tender and
vulnerable oral cavities.
• Allow the patient to feel ‘in control.’ To
accept the invasion of personal space, our
patients must feel in control at all times, so
that if they feel pain or need to close or clear
their mouth, they know that you will stop.
Look them in the eye and tell them so. ‘If
this is uncomfortable, or you need me to
stop, just raise your hand.’ ‘Please tell me
if this bothers you and I will stop.’ ‘Let me
know if you feel any of this and we’ll stop
and give you more anesthetic.’
A gentle touch on the forearm or a pat on the
shoulder, accompanying these reassur-ances,
helps to secure ‘permission’ from the patient
to proceed. The dentist must then be trustworthy,
and allow the patient to call ‘time out.’ In
some situations, this will undoubtedly make
for prolonged treatment time. It also cements
the doctor-patient relationship with a strong
bond of trust, and can pay great dividends in
the long run. As trust builds, the need for ‘time
outs’ often decreases. For some patients, however,
checking out their ‘parachute’ is a ritual
at every appointment and we need to permit
and even encourage patients to test their control
of the situation.
When patients praise their dentists, it’s seldom
related to the integrity of their margins,
although over time patients do come to value
long-lasting and trouble-free dental work. More
often, however, the statement that ‘my dentist
doesn’t hurt me,’ relating to a painless
anesthetic technique, good anxiety and pain
management, and continual monitoring of patient
comfort, for example ‘How are we doing
Ms White?’, attests to a bond of trust which
comes from putting the patient in control.
THE PATIENT INTERVIEW 21
THE INTERVIEW PROCESS —
TOOLS OF THE TRADE
Most dentists employ some kind of pre-printed
form or questionnaire to assist in information
gathering. These forms can be useful tools, and
save time by allowing patients to complete
them before the appointment or before the interview
(Fig 2.2).
Avoid questionnaires that are unnecessarily
intrusive or lengthy, or you may alienate or
antagonize patients before you ever meet them.
Labelling the form ‘CONFIDENTIAL’ and including
some explanation of why the information
is being requested may help, along with a
courteous and apologetic presentation when
the form is given to the patient such as ‘we
know it’s a bother to fill out forms, but we want
to be sure we get your information right, and
treat you safely.’
Just as important as careful selection and
presentation of questionnaires is their sensitive
use to frame the interview. If the doctor appears
to ignore the information that the patient has
just spent time and effort writing down, it can
compromise the interview.
Thank patients for completing any forms
and questionnaires, and take time to peruse
them. Refer to them again in the interview process,
to probe, to clarify, and to document additional
information.
Finally, be aware that the information provided
by patients on questionnaires is not always
accurate, or complete. Nothing takes the
place of a careful one-on-one interview to elicit
critical information from patients, especially
when it is sensitive or potentially embarrassing
in nature (Fig 2.3).
Given these premises, let’s consider the baseline
data necessary to diagnose and plan quality
comprehensive dental treatment.
BASIC DEMOGRAPHIC
INFORMATION
The dentist needs to know the patient, for both
business and legal reasons. In addition to name,
address, and telephone number, etc, a personal
profile of the new patient is useful to find the
common ground necessary to establish communication
and to initiate the relationship. At
the least, the following demographic information
should be obtained and recorded:
• Patient’s full name, and how he or she prefers
to be addressed, for example, Mrs, Ms,
first name, etc. If the name is unusual, a
phonetic spelling to assist in correct pronunciation
at the initial interview can be
very helpful.
Fig 2.2
Most patients understand the need to complete ‘paperwork’.
A courteous request, with an explanation of why
the information is needed, makes the task less onerous.
Fig 2.3
Reviewing the written history with the patient is critical.
22 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
• Address and telephone number(s).
• Age, sex, and race. Although this information
is routinely included in patient questionnaires,
it may be more prudent to house
it in the medical history instead of the demographic
form, emphasizing its need for
legitimate patient care purposes.
• Occupation.
• Marital status.
• Party to contact in case of emergency.
• Third party involvement, if any, such as private
insurance, Government benefit programs,
and the like.
• Responsible party: when dealing with a
minor child, or legally disabled adult, it is
critical to ascertain who can give consent
for treatment, and who will be responsible
for payment of fees. Divorce, remarriage,
and all the complications of modern family
life can make this question at once both
difficult and absolutely essential to answer
before proceeding very far.
In addition, a personal profile is useful, and can
help structure the new patient interview. Areas
to be explored may include the following:
• Referral source: how did the patient happen
to choose you or your practice for dental
care? Referrals from close friends or relatives
obviously imply a higher level of trust
than, say, simply finding your name in the
telephone book.
• Attitude: how does the patient react to you
and the dental setting? Is the patient apprehensive,
hostile, and noncommunicative,
or relaxed, friendly, and outgoing?
• Desires for treatment: what is the patient
interested in doing or having done about
his or her mouth and teeth? Has the patient
considered comprehensive dental
treatment that might prevent so-called
‘emergency’ situations?
• Family history: do the patient’s parents
have their own teeth? What dental problems
seem to be common among the patient’s
family members?
• Oral habits: does the patient smoke? What
other potentially harmful oral habits does
the patient admit?
• Socioeconomic status: what is the patient’s
present lifestyle and how will it influence
dental treatment planning? Do not prejudge
any patient’s willingness and/or
ability to afford good dental care. Socioeconomic
status and lifestyle may affect the
dental ‘IQ’ of the patient, however, and
consequently the level of communication
at which we must start the interview.
DENTAL HISTORY, INCLUDING
CHIEF COMPLAINT
Our patients’ past experiences with dental
problems and dental treatment will have a
strong influence on the developing doctor-patient
relationship. At the least, the following
information should be obtained and recorded:
• Chief dental complaint: what prompted the
patient to seek care at this time? This may
be as general as ‘I think I’m due for a checkup’
or as specific as ‘I lost a filling on my
upper front tooth.’ Whatever it is, the chief
complaint needs to be addressed, even if it
is a minor issue in the overall course of
events.
• Present dental illness, that is, history of the
chief complaint: when did it first arise and
how has it progressed up to the present?
• Past dental problems: what dental conditions,
diseases, pain, or dysfunction has the
patient experienced in the past?
• Past dental treatment: what types of treatment
has the patient received in the past?
How does the patient feel (subjectively)
about the dental care and treatment encountered
up to now?
Exploring the issue of past dental treatment
may trigger lengthy recitations of unhappy
experiences, dissatisfaction with previous dentists,
and past dental care. There is no point in
arguing with what may sound like unfair criticisms,
nor is there a need to agree with even
the most plausible complaints when we are not
privy to all sides of the story.
Simply acknowledging the patient’s feelings
and empathizing (without necessarily agreeing)
are sufficient. ‘I can understand how you
THE PATIENT INTERVIEW 23
feel’ is preferable to ‘you must have had a terrible
dentist!’ for obvious reasons.
Implicit in this history is the need to assess
the patient’s level of dental anxiety or fear, so
those issues can be effectively confronted and
dealt with by the dentist and the dental team.
A standardized instrument, such as the Corah
Dental Anxiety Scale3,4 may be employed, or
the dentist may explore these issues during the
course of the initial interview (Fig 2.4).
Fig