Patient management 1 /certified fixed orthodontic courses by Indian dental academy


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Patient management 1 /certified fixed orthodontic courses by Indian dental academy

  1. 1. PATIENT MANAGEMENT INDIAN DENTAL ACADEMY Leader in continuing dental education
  4. 4. Introduction Doctor patient relationships have a significant impact on successful treatment in dentistry.
  5. 5. Various other factors apart from the doctor patient relationship play a role to a successful patient management system.
  6. 6. • The office design of the clinic and a team approach play a role in the management of a patient. • Every individual in the clinic has a significant role to play in maintaining a very pleasant and cordial atmosphere.
  7. 7. Office design • Should be designed functionally to allow for maximum efficiency in both clinical and administrative tasks. • Should be categorized into a clinical area and administrative area.
  8. 8. Clinical area • Consists of entrance, waiting room, adolescent treatment room, adult treatment room, X- ray room, records room, wet lab, dry lab and consultation room.
  9. 9. Administrative area • Consists of business office, computer room, postage room, diagnosis room, doctors private offices.
  10. 10. Personnel • The members of the office staff are critical to the performance of the office. • Anything done by any staff member is a reflection on the doctor.
  11. 11. Office manager • Greets the new patients and give new card to fill. • Set up records for consultation in exam room • Help all the personnel regarding the day off, vacation time and any other problems. • Coordinate appointment book with office personnel & doctor.
  12. 12. Receptionist • Greets all the patients, attends the telephone. • Make all the appointments and keeps all the patient charts ready for each appointments. • Obtain the patients information and keeps a note on any changes
  13. 13. Chairside assistant • Maintain patient flow pattern. • Place separators. • Fit bands and prepare for bonding. • Scale cements and helps tie in arch wires. • Refill and clean sterilizers. • Check for loose appliances.
  14. 14. A sound Doctor-patient relationship in orthodontics can positively influence treatment outcomes by encouraging the patient to cooperate in the following prescribed instructions related to the particular appliance wear and maintenance of oral hygiene
  15. 15. • In the practice of orthodontics today, time should be invested in creating and maintaining the important “patient-doctor” bond. Orthodontist behaviors such as listening, empathy, and explanation are important in achieving that goal.
  16. 16. • The doctor's expression of concern about the well being of the patient is also found to be significant in predicting patient adherence. • Verbal communication, a calm and confident manner, and reassurance increases the patient compliance.
  17. 17. • With better communication, the patient can relate more information with greater accuracy, thus improving the quality of care. • Patient management can be greatly enhanced when the patients “understand” the nature of their conditions and the proposed treatment plan or procedure to be performed that will be used to improve their condition.
  18. 18. Self regulation approach to orthodontic patient compliance Recommended treatment regimen Motivation Monitor regimen relevant behaviour Adjust behaviour comparator Error signal Lyons &Ramsay (2000)
  19. 19. Patient centered care Vs Practitioner centered care The practitioner prescribes treatment plans based on individual patient expectations, priorities and capabilities. Under this concept would include patient education, patient empowerment and contracting procedures.
  20. 20. 1. Patient education This is very important to success in motivating the patient. Patients and parents are unclear about the treatment modalities. Various demonstration tools can be used to aid in the education process. Study casts and photographs can be used. Demonstration models and appliances help Patients to understand different appliances.
  21. 21. 2. Patient empowerment & contracting procedures Educating the patient regarding their condition gives them the tool to make informed decisions. Individual becomes more involved in the process of selecting what is most suited for him. Once decision reached- patient is empowered and selects a treatment option and the patient is obliged to comply with an agreement.
  22. 22. Rewarding complaint behaviour Behaviour modification by the way of a reward program can be effective in improving patient compliance to prescribed instructions. Rewards becomes a means of positive feedback for patients in the orthodontic treatment of malocclusions.
  23. 23. Patient satisfaction Parent satisfaction Doctor – patient rapport Superior treatment results Patient compliance
  24. 24. Patient Compliance: A Determinant of Patient Satisfaction? Bosa et al ( Angle Orthodontist July 2005) • The aim of this study was to investigate whether patient compliance, as noticed and recorded by the orthodontist during treatment, can be used as a determinant of patient’s satisfaction in the long run.
  25. 25. • It was expected that patients who were rated less compliant by the orthodontist during treatment would express more dissatisfaction with the treatment process and the treatment result.
  26. 26. • The results of the study indicated that although an orthodontist may judge a patient to be noncompliant, this judgment did not seem to affect the satisfaction of the patient with the treatment process and outcome in the long run. • The most important factor contributing to patient satisfaction was the patient’s satisfaction with the doctor-patient relationship.
  27. 27. • Sex was found to be a significant predictor of the patient’s satisfaction with the doctor- patient relationship and the situational aspects of the treatment. • Female subjects indicated dissatisfaction with their dentofacial improvement more often than male subjects
  28. 28. Child management Extreme care to be taken while managing a child. Compliance of the patient has to be gained by the doctor. Early treatment would always prove beneficial as a psychological advantage.
  29. 29. FEAR DEFINITION: Fear is the emotional response to a consciously recognized and usually external threat or danger. It is a primitive response developed to protect the individual from harm and self destruction.
  30. 30. Classification Fears can be classified into two types : 1. Objective fears 2. Subjective fears
  31. 31. Objective fears • Acquired objectively or are produced by direct physical stimulation of the sense organs • They are not of parental origin, which are unpleasant and disagreeable in nature. • Eg: Fear from unpleasant contact with dentisty. Repeated hospitalization leading to fear of uniforms worn by the dental team.
  32. 32. Subjective fears • Acquired based on the feelings and attitudes suggested to the child by others without the child personally experiencing them • Subjective fears are Imitative, Suggestive or Imaginative fears.
  33. 33. Suggestive fears • Acquired by imitation by observation of others. • They are generally recurrent, deep seated and are difficult to eradicate. • Displayed emotion in parents face creates more impression than verbal suggestions. • These fears also develop from friends, playmates and media and depend a lot on
  34. 34. Imaginative fears • Imaginative fears are formed as the child’s imaginative capabilities develop. • They become more intense with age
  35. 35. Value of fear • Fear – lowers pain threshold –hence pain produced is magnified. • Fear has a safety value when given a proper direction and control. • It is a protective mechanism for self protection. • If the child does not fear punishment or parental disfavour, his behaviour may become a
  36. 36. • The child should not be trained in the direction of eradicating the fear but rather should be channeled towards dangers that really exist and away from situations where no danger lies. • “Dentistry should not be employed as a threat or punishment”
  37. 37. Fears associated with age I. Birth to two years • This is the infancy stage – oral stage of freud and Erikson’s Trust Vs Mistrust. • First form of fear or anxiety are seen in this stage. • Fear of strangers and also fear developed from conflict of basic Trust Vs Mistrust
  38. 38. II. Two year old • Vocabulary is limited to 12 – 1000 words. • They lack cooperative ability. • Child will be too young to be reached with words alone and must touch and handle objects in order to grasp their meaning fully.
  39. 39. • Fear and anxiety of this age group is fear of falling, sudden jerky movements, bright lights, separation from parents and fear from strangers III. Three year old • Communication is easier. • Fear of this age group is fear of strangers
  40. 40. IV. Four year old • Usually listeners to explanation and are responsive to verbal directions. • Very lively and are great talkers • Increased ability to evaluate fear producing stimulations. • Intelligent children display more fear because of greater awareness of the danger and reluctance to accept verbal assurance without proof.
  41. 41. • Fear of this age group includes fear of falling. • Fear of bodily injury • Fear of noise and strangers are reduced. • Prick of needle and sight of blood can lead to increased response disproportionate to that of pain.
  42. 42. V. Five year old • Age to accept group activities and if trained properly by the parents there is little fear of separation. • Children are proud of their possessions. • They will combat on imaginative level, things they fear in reality. • This makes the child gain comfort as well as courage to meet the real situation.
  43. 43. VI. Six to twelve year old • Children of this age group learn from the outside world. • Become independent of their parents. • These are important years of learning and to abide by the rules of the society. • Children usually can resolve fears of dental procedures if the dentist explains and reasons well. • They also learn to tolerate unpleasant situations.
  44. 44. VII. Teenage • Children especially girls tend to become concerned bout their appearance. • They like to be as attractive as possible. • This can lead as a motivational factor for seeking dental attention. • To satisfy their ego they will be willing to cooperate.
  46. 46. Behaviour management • Defined as a means by which the dental health team effectively and efficiently performs dental treatment and thereby instills the dental attitude. ( Wright 1975 )
  47. 47. Methods of behaviour management Mainly includes two methods: 1. Non pharmacological methods. 2. pharmacological methods.
  48. 48. Non pharmacological methods 1. Communication 2. Behaviour shaping( modification ) ( a ) Desensitization. ( b ) Modeling. ( c ) Contingency management. 3. Behaviour management. ( a ) Audio analgesic. ( b ) Bio feedback. ( c )
  49. 49. ( d ) Voice control. ( e ) Humor ( f ) Coping. ( g ) Relaxation. ( h ) Implosion therapy. ( i ) Aversive conditioning
  50. 50. Pharmacological methods 1. Premedication ( a ) Sedative – Hypnosis. ( b ) Anti anxiety. ( c ) Anti histamines. 2. Conscious sedation. 3. General anesthesia.
  51. 51. Intra venous sedation – an alternative Gozal & Becker ( EJO2002) • Excellent alternative to GA. • Need for hospitalization & use of theatre are eliminated. • Rx can be carried out in a fully equipped orthodontic operatory. • Induction and recovery is rapid. • Safe level of sedation with minimal side effects. • Reduced cost.
  52. 52. Communicative management •It forms the basis for re establishing a relationship with the child which may allow a successful completion of dental procedure or help the child to develop positive attitudes towards dental care.
  53. 53. Types of communication: • Verbal communication is by speech. • Non verbal communication is by : ( a ) Body language ( b ) Smiling ( c ) Eye contact ( d ) Showing concern ( e ) Touching the child ( f ) Expression of feelings without speaking
  54. 54. • Communication should be relaxed and comfortable. • Language should express concern and friendliness. • Verbal communication is best for child more than 3 yrs. Voice should be constant and gentle. • Tone of voice can express empathy and support.
  55. 55. • Content of the conversation with the child should make the child feel that the dentist is his well wisher. • Communication should be from a single source – B/w dentist and the child or child and the dental assistant to avoid confusion. • Sitting and speaking at the eye level brings bout a more friendlier atmosphere.
  56. 56. Euphemisms • Substitute words which can be used in the presence of children. • Effective in communicating with the child. • Employing certain words that are meaningful to the child would exhibit a more cooperative behaviour. • Word substitutes are more efficiently used with the preschool children. • Egs : air – wind , anesthetic – sleepy water, X ray equipment -
  57. 57. Behaviour shaping • Involves the use of selected reinforces that being learned will change a child’s behaviour from an inappropriate to an appropriate one. • This is based on the stimulus – response theory.
  58. 58. • This is a step by step procedure to make the child involve in the dental therapy. • These children should be cooperative and communicative to absorb the information which may be complex to them. • The overall procedure should not be explained with a single explanation • Childs level of understanding – euphemism .
  59. 59. Various methods – behaviour shaping 1. Desensitization • One of the most effective methods for reducing maladaptive anxiety. • Teaching a patient to induce a state of deep muscle relaxation - describing while in the relaxed state- imaginary situations relevant to the patient
  60. 60. • Effective in managing a broad spectrum of phobias including fear of rejection, physical injury and injections. • Systemic desensitization requires 15-25 therapy sessions in order to train the patient properly and reduce anxiety. • Reciprocal inhibition – inappropriate response is changed to appropriate response
  61. 61. Tell show do technique • Introduced by Addleson in the year 1959. • Dentist uses the language understandable to the child and tells the patient what is to be done.
  62. 62. • Dentist demonstrates the procedures to child using a model or himself and is done slowly • The dentist proceeds to do the treatment exactly as described. • This procedure should be continuous from the child’s entry into the clinic through all procedures involved in the treatment.
  63. 63. 2. Modeling • Introduced by Bandura ( 1969 ). • Involves allowing patient to observe one or more individuals who demonstrate a positive behaviour in a particular situation. • Patient will frequently initiate the models behaviour when placed in a similar situation.
  64. 64. Advantages Patients attention is obtained. Desired behaviour is modeled. Reinforcement of the guided behaviour may be provided. Fear is eliminated.
  65. 65. Contingency management • Method of modifying behaviour by presentation or withdrawal of reinforcers. • Reinforces increases the frequency of behaviour. • Two types – 1.positive 2.Negative. • Negative reinforcer is usually the termination of an aversive stimulus.
  66. 66. • Types of reinforcements may be : Social reinforcements Material reinforcements Activity reinforcements
  67. 67. Aversive conditioning • One mode of behaviour management. • Two common methods used are the HOME and PHYSICAL RESTRAINT. HOME • Termed Hand over mouth technique. • Introduced by Evangeline Jordan in the year 1920. • Purpose is to gain the attention of the child.
  68. 68. Technique • Technique • Once the child cooperates ,he should be complimented. • Childs airway should not be restricted • Procedure should not last more than 20 to 30 sec
  69. 69. Indications • Healthy child who can understand but exhibit defiance and hysterical behaviour during treatment. • 3- 6 yrs • Child who understands simple verbal words.
  70. 70. Contra indications • Child below 3 yrs old. • Handicapped child/ immature child.
  71. 71. Physical restraints • Last effort for handling stubborn or defiant children. Types of restraint : • Body : Pedi wrap Bean bag with straps Towel and tapes. Papoose board
  72. 72. • Extremities : Velcro straps Posey Straps. • Head : Head Positioner. Extra assistant. • Mouth : Mouth Props Bite blocks
  73. 73. Papoose board
  74. 74. Orthodontic management of an autistic child ( JCO FEB 2005 ) • Autism is an organic disorder characterized by abnormalities in the brain especially the limbic function and cerebellum, it is manifested in an impaired capacity for communication and social interaction and in repetition of actions and behaviour.
  75. 75. Characteristics of autistic child • No imaginative capacity. • Speak a fluent unintelligible jargon called “delayed echolalia”-bits and pieces of memorized dialogue. • They echo the speech of others or produce meaningless words. • Repetition of stereotyped movements. • Unusual tolerance for monotony.
  76. 76. • Management of an autistic child is a challenge to the orthodontist. • Thorough understanding is required of these special need patients. • They have better non verbal (visual – spatial ) than auditory- verbal skills. • Dental care for autistic children are provided generally under General anesthesia.
  77. 77. • Autistic children responds well to visual pedagogy. • Rehearsals employed by the parent at home to help condition the child prior to his clinic visit. • Repetitions should be used to help child learn bout each procedure. • Exposure to the dental environment should be a gradual and slow process with non threatening contacts.
  78. 78. • Autistic children follow routines strictly and resist changes in their daily life. • Cooperative behavior by the child should always be rewarded. • “show-tell-do technique” is employed rather than the traditional tell-show-do technique as they lack imagination. • Brackets should be told as “silver earrings” that would be stuck to the teeth..
  79. 79. • Attention span of an autistic child is short and hence the duration of a particular treatment is very crucial. • Amount of work to be performed at each appointment must be carefully considered.
  80. 80. Adult management • Management techniques vary from that of the child. • Major motivation for child- parents. • Adults seeks treatment because of the need for that “something” which is not clearly expressed. • Important to identify why the patients seeks treatment.
  81. 81. • Most adult patient understand why they need treatment and have a better positive self image. • Two types of motivation : 1.External motivation 2.Internal motivation ( Edgerton and Knorr AJO 1982)
  82. 82. • Internal motivation better cooperative. • Should be asked the question “ why now?”. • Adult patients always require a considerable degree of explanation so that they will be compliant. • They can be less tolerant to discomfort and pain and hence additional chair side time should be anticipated.
  83. 83. • Open area of room is better than a separate adult room –gives them a positive influence in patient adaptation to treatment. • If expectations of both the doc and the patient are realistic then comprehensive Rx for adults can be a rewarding experience for both.
  84. 84. Conclusion • Patient management is an important criteria in achieving clinical results • Efficient patient management helps to cultivate a good patient doctor rapport which is an incentive for the patient always to get back to the doctor ~ practice management
  85. 85. For more details please visit