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Decision making on the fly – communication is key

31 May 2019

Dr Nicole Stott looks at the importance of communication when educating patients on their condition and treatment

Working in a public clinic, I often see patients who have very complex medical conditions and large amounts of dental disease, but who lack an understanding of not only their basic health – such as what medications they are taking and for which conditions – but also have a lack of detail regarding their dental history.

Given that in the public sector some patients may be required to see multiple practitioners for various reasons, the messages about their condition and dental disease can be somewhat lost in the process. Communication is key to their required understanding in order to make the correct decision for their health.

Sometimes, when we are required to treat an acute condition, there can be limited time to discuss treatment decisions, which runs the risk of inadequate valid and informed consent. Several aspects are required to be discussed such as:

  • An explanation of the nature of the dental disease and how it is likely to have occurred (which involves a detailed history taking from the patient).
  • Reasonable solutions that can be taken to address the acute problem, as well as long term solutions to prevent such a condition from occurring again in future (if preventable).
  • The name of the procedure, the length of time required and number of appointments needed.
  • The prognosis of the procedure, individual to the tooth and the patient, given their own health and dental status. Remember to discuss the alternatives.
  • Possible outcomes if treatment is not under taken.
  • A demonstration of an understanding of all aspects discussed.

All too often when a patient is in acute pain, with limited treatment options, their reply to root canal or extraction will be “Just rip it out”. Perhaps if this patient was in less pain, or had not been kept awake the past several nights in pain, they may be able to better understand the gravity of the situation better.

One such occasion occurred when a stressed and anxious 32-year-old female patient presented to the clinic with a carious lesion in the mesial surface of the upper left lateral incisor. After clinical assessment, the diagnosis was found to be symptomatic irreversible pulpitis with healthy, apical tissues.

Radiographically and clinically, the tooth appeared restorable and endodontic therapy had a reasonably good long term prognosis. Upon examination, there were several other carious lesions in the posterior teeth, a missing lower right second premolar and some early enamel caries in other upper anterior teeth. History revealed that she had not visited the dentist for the previous ten years after a prolonged and difficult wisdom tooth extraction. She knew she had other work to be done but she did not like going to the dentist anymore, and suggested she should have all of her teeth removed so she “didn’t have to worry about them anymore”. Her previous quote for dental work had been in excess of $10,000.

Upon discussion of the options available to her, the two obvious choices involved endodontic therapy or extraction. She advised she had heard from members of her family that root canals were “very painful, very expensive and they didn’t work anyway”. She was certain that she just wanted the tooth out. Spending time educating the patient about her diagnosis with the use of diagrams and videos, the patient realised that she really wasn’t sure what decision to make, as she was now faced with the prospect of having a gap in her front teeth. This comment informed me that aesthetics were important to this patient. I advised that we could try giving some local anaesthetic to get her out of pain in order to help her make the decision when she was feeling better.

After the administration of local anaesthetic, the patient was out of acute pain and stated she felt immediately better. She subsequently decided she would like to keep the tooth and the procedure for an extirpation took place. The patient had completely changed her mind after her pain had been relieved. The root canal was routine and was completed over three appointments. Upon completion of the procedure, the patient stated that she was happy she had decided to keep the tooth.

This case highlighted to me not only the importance of education and communication, but how difficult decisions can be to make when a patient is experiencing acute pain. Distress and sleeplessness can detrimentally affect the patient’s psychological health, resulting in a reduced ability to make a decision. By performing a basic pain relief procedure, the psychological relief achieved can initiate a different thought process to that originally conceived.

It can be easy for us as the clinician to see that extracting a restorable anterior tooth with a good long term prognosis may end up in regret in future, but for that patient in pain, the only thought in their mind is to get rid of whatever is causing this agony. Taking the time to ensure the patient was informed resulted in a favourable outcome for her.

One issue identified in this scenario is that the patient had discussed her dental problem with her family and had created a belief system that the role of dentistry was only for pain relief and removal of teeth. Upon discussion about the various options for tooth replacement and the limitations of prostheses to replace natural tooth structure, it demonstrated to the patient the complexity of tooth loss for future consequences.

Open, clear and concise communication, with opportunities to ask questions, whilst creating a safe space to allow meaningful dialogue, helped this patient to understand her dental condition. So as busy as our schedules are, it is important that at the end of the day, informed consent has been gained through good quality communication channels.


Dr Nicole Stott is a general dentist, having graduating from James Cook University in 2016. She spent her first two years working in the public sector in Launceston, Tasmania. She currently works in full time private practice in regional Queensland. 

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