Drs. Donald J. Rinchuse, Sanjivan Kandasamy, Dara L. Rinchuse, and Mr. Donald N. Rinchuse discuss various ways to discover the patients’ perceptions of their orthodontic issues
An integral part of any orthodontic examination is the patient’s chief complaint, or “CC,” or “presenting complaint.” We typically start with general questions such as: “How are you today, Ms. Jones; what brings you to our office?” or, “What do you want us to look at today?” or, “What about your teeth troubles you?” The patient/parent may also make some comments about his/her bite, spacing or crowding, or about a particular position of a tooth or teeth.
There are a myriad of definitions and descriptions of what is meant by the patient’s chief complaint. These include:
• The main symptom, concern or reason the patient seeks treatment–i.e., the most troublesome ailment, problem, or symptom1• The most apparent clinical sign in a patient’s illness, called a cardinal sign1• The patient statement describing the symptoms, problem, condition, or other factors for the medical/dental/orthodontic encounter; this may also help form a differential diagnosis2• Used most often in the health history in medicine and is a subjective statement made by the patient describing the most significant or serious symptoms or signs of illness or dysfunction that caused the patient to seek health care3
The CC can be what the patient (parent) perceives as the problem or issue that needs to be addressed. It is more or less his/her “statement of the problem.”4 It must be mentioned that a patient’s CC, although a concern to him/her, does not necessarily mean that it is the fundamental problem. There may be other problems that are present, related or unrelated to the patient’s CC. The practitioner’s job, however, is to first define the patient’s problem(s) based on the chief complaint and then determine whether the concern is cosmetic, functional, and/or pain related.4
As it is commonly encountered, defining the patient’s problem or concern can at times be either simple or extremely difficult. Further, some patients are more adept at communicating their CC than others. A general guideline for the doctor/orthodontist in understanding the patient’s CC and planning treatment is to follow these steps4:
• listen• interpret• find additional or supplemental information• analyze the problem• plan therapy
As previously suggested, any guidelines must be approached from the perspective of whether the patient’s complaint is more medical, functional, and/or esthetic. A “disease-based” approach to interpreting the patient’s problem is to make use of the 6 major interrogatories in the English language: who, what, where, when, how, and why.4 An overview of this approach is described in Figure 1. In addition, there is an algorithm used in medicine for understanding the patient’s chief complaint, and it is understood as the History of Present Illness, HPI, and generally involves an 11-step action plan (Figure 2).5 It must be mentioned that this stepwise plan would work well for examining a patient’s CC involving many treatments in dentistry where there is disease or pathology (e.g., TMD) as opposed to the many elective aspects of orthodontics.
Never underestimate the importance of the patient’s chief complaint
The importance of the patient’s chief complaint cannot be understated. An orthodontist can achieve an exceptional orthodontic result, but if the chief complaint is not addressed in treatment, the patient/parent will be dissatisfied. This may sound simple, but it is often missed in the acquisition of all the so-called pertinent information and records deemed necessary to initiate orthodontic treatment. The patient may say at the end of treatment, “I realize you have corrected my bite or teeth, but I only came in because my right front tooth was slightly turned, and even though it is better now, it is not completely corrected.” Even the most extensive and ardent orthodontic diagnostics and treatment will not overcome or compensate for the lack of attention paid to the patient’s reason for coming into the orthodontic office. Often the patient’s CC is noted in the patient’s examination or treatment notes. The practitioner is usually satisfied that this step in the record gathering has been completed and then moves on to the next part of the exam. This can become a serious error in diagnostic judgment. In addition to asking the patient why he/she is here, there are several other considerations. Follow-up questions regarding the patient’s chief complaint is important to glean exactly what the patient may be concerned about. More specific or probing questions may need to be asked to properly characterize the patient’s condition and reason for seeking orthodontic services. Open-ended questions are often preferred over yes or no type questions.
One could ask:
• “What don’t you like about your smile?; or• “Could you point to the teeth or area of your mouth that you are concerned with?” ; or• This can be followed up with, “So let me understand Mrs. Jones, you are not concerned about the space between these teeth, but only about the way your ‘eye tooth’ looks?”; and then• “What exactly about the ‘eye tooth’ bothers you?”
Pinpointing the patient’s chief concern from the patient’s standpoint is critical especially in defining what the patient’s primary needs and concerns are. When it comes to treating children under the care of their parent(s) or guardian, it is often necessary to specifically ask the child (patient) what his/her concerns are in addition to what his/her parent may verbalize. At times, the child and parent may have antithetical views on what is “good” versus displeasing in relation to the primary complaint.
The decision-making process and informed consent
It is important to mention that in the contemporary “Evidence-Based Dentistry” (EBD) paradigm, the patient has autonomy in the decision-making process with regard to his/her treatment when presented with all the salient information and options. That is, EBD is defined as “an approach to oral health care that requires the judicious integration of systemic assessments of clinically relevant scientific evidence, relating to patients’ oral and medical conditions and history, with the dentists clinical expertise and the patient’s treatment needs and preferences.”6 The goal of the EBD approach is to narrow the gap between what is known and what is practiced, and to improve patient care based upon informed decision-making.6 Hence, the patient’s chief complaint bears relevance in the practitioner’s overall considerations and choice on a particular course of treatment. Certainly, that choice should not be autocratically dictated from either the side of the orthodontist or the side of the patient, but from a two-way dialogue.
In addition, the patient’s chief complaint interfaces with the doctor’s legal and ethical obligation of providing the patient/parents with all the required information in order to attain adequate “informed consent.” This, however, needs to be provided in a language for laypersons to comprehend. The patient/family must be advised on how the patient’s CC may fit into the orthodontist’s recommendation for the ideal treatment. At times, what the patient is concerned with is out of the realm of orthodontics and is more a restorative dentistry problem and/or an orthognathic surgical issue. Furthermore, what the patient may desire in regard to treatment may be beyond the scope of the appliances the patient may be requesting. If the patient chooses a treatment that is less and/or different from the orthodontist’s recommended treatment, the patient/family must be clearly advised of the limitations of such treatment. Sometimes patients/parents may have a misconception of what constitutes a proper smile, bite, and/or tooth position. It is important for the orthodontist to illustrate (visually) and educate the patient and/or parent(s) on what constitutes an ideal occlusion and facial balance, and how their chosen alternative or compromised treatment plan deviates from this.
Further, it is important to communicate back to the patient’s family dentist the treatment the patient will be having. The family dentist needs to know that the patient/family has decided on a compromised treatment plan versus the recommended ideal treatment. The family dentist (as well as the patient/parents) needs to be advised as to what specifically will be done, including an outline of all the aspects of the patient’s orthodontic problem(s) that will not be corrected (e.g., 2 mm midline deviation) as well as the relevant risks/limitations/benefits of the treatment selected and in relationship to all the other possible options of treatment.
As previously mentioned, interrogatory questions regarding the patient’s CC not only serve to isolate the concern(s) of the patient/parents but at times help the parent/parents understand some of the more important aspects of orthodontic treatment such as the occlusion. This is also helpful in certain instances to highlight for the patient/family the point that orthodontics is most often not a simple matter of correcting one or two teeth. The orthodontist may demonstrate (maybe with the use of a contemporary patient education software program) how resolving a one tooth/two tooth problem(s) involve(s) resolving the bigger problem (overall bite) and how the dental and skeletal elements are interrelated.
Practice management considerations
In the contemporary climate of private clinical practice, clinicians are coached to incorporate systems that optimize patient flow, clinical management, and delegation to auxiliaries within day-to-day time constraints. Contemporary practices are geared more toward seeing more patients and treating them in shorter periods with less visits. Given today’s pressures of increasing overheads, patient demands, and staff management, there is no doubt that this makes sense–i.e., having obvious benefits for both the clinician and patient. The problem, however, is that as clinicians gear themselves toward being super-efficient, they may fail to spend the necessary time to take into consideration the patient’s chief complaint, family concerns, as well as, spend the time to educate the patient of all the possible options of treatment that would then allow the patient/parent to make a proper informed decision. Certain cases demand more time to establish a well-structured treatment plan and associated treatment options. This extra time allows the clinician to also identify and clarify unreal patient and parent expectations. Spending the appropriate time as well as establishing a rapport with the patient/parents not only minimizes any confusion or anxiety during treatment but will also tend to improve patient compliance and increase the chance of having a satisfied patient at the end of treatment.7 This also provides the patient with the feeling that his/her needs are at least being considered. The cost in time to truly understand the patient’s concerns/needs is worth the effort when considering the stress that would be involved with any legal actions associated with not spending enough time with the patient/parents. The practice management bottom line is happy patients are good for business!
To further illustrate the points we have made so far, we offer several patient examples. A patient may say that “I only don’t like the gap between my two front teeth” and points to the maxillary midline diastema (Figure 3A). At first glance, the presenting complaint of the patient might appear to be simple; however, when one looks at the big picture, there is a significant overjet, crowding, and an underlying skeletal Class II malocclusion (Figure 3B). Another example is the patient who states that his/her CC is: “I don’t like this tooth sticking out” referring to the proclined maxillary right lateral incisor tooth (Figures 4A, 4B and 4C). Looking at this case carefully, there is not only the proclined upper-right lateral incisor, but crowding in both arches, a deep bite, asymmetric wear of the maxillary central incisors, and asymmetric gingival margins (Figure 4D). Here the patient has to be educated of all the problems regarding his/her malocclusion, including the need for the prosthodontic management of the worn incisor teeth should he/she want to achieve the best esthetic and occlusal outcome (Figures 4E and 4F). The limitations associated with only addressing the proclined tooth needs to be discussed with the patient as well. Follow-up questions directed at the patient’s bite (and more) are necessary. The orthodontist may ask:
• “Do you have trouble chewing?” • “Do you have trouble biting into any foods such as pizza or sandwiches?” • “What do you think about your bite?” • “What do you think about the color, size, and shape of your teeth?”
Obviously, many of the recommendations in this article are not novel and profound. Nonetheless, they support the view that communication between the doctor and patient is paramount in the contemporary environment of patient-centered care vis-à-vis doctor-centered care. The orthodontist must talk with the patient, not to, or at, the patient.8 A teaching lesson that dates back many years advises: “Listen to the patient; he/she will tell you the diagnosis.” At times, this adage is overlooked, and health care providers rush to complete the so-called necessary and required parts of an examination, and unfortunately, do not find the time to listen to what the patient is really saying. In this regard, Dr. Lawrence Jerrold advises, “Never treat a stranger.”9 Dr. Jerrold also wrote: “We don’t treat malocclusions; we treat patients who happen to have malocclusions. We must never forget that we are in a personal-service business. Yes, it happens to be an arm of the health care delivery system. It happens to be a specialty, but we provide a personal service.”10
Many professionals forget to realize that communication is two-pronged, and this involves both speaking and listening. Further, a patient’s non-verbal actions are also a form of communication, and this needs to be considered. Be reminded, most malpractice claims commonly stem from breakdowns in communication rather than poor treatment results.
In the modern era of patient autonomy rather than the older view of paternalism, it is important to precisely discern the patient’s concerns and desires in regard to diagnosis and treatment. Paying attention to the patient’s chief complaint is of paramount importance throughout the diagnostic, treatment planning, and patient-education process. We believe all practitioners understand what we have said in this article, but just every so often we all need to be reminded of this very critical step in any health-related examination that can frequently and easily be missed or glossed over in a busy clinical setting. Focusing on a patient’s chief complaint is not only essential to having a happy patient but also important in keeping the health care provider out of the court room.
Donald J. Rinchuse, DMD, MS, MDS, PhD, is a professor and Graduate Orthodontic Program Director, Seton Hill University, Greensburg, Pennsylvania. Sanjivan Kandasamy, BDSc, BScDent, DocClinDent, MOrthoRCS, MRACDS, is clinical senior lecturer in Orthodontics, Dental School, The University of Western Australia, Nedlands, WA, Australia. He is an adjunct assistant professor in Orthodontics, Center for Advanced Dental Education, St. Louis University, St. Louis, Missouri, and is in private practice in Midland, WA, Australia.Dara L. Rinchuse, DMD, is adjunct faculty, Graduate Orthodontic Program, Seton Hill University, Greensburg, Pennsylvania, and is in private orthodontic practice in Pittsburgh, Pennsylvania.Donald N. Rinchuse, MS, PA-C, is a physician assistant, Seton Hill University, Greensburg, Pennsylvania.
1. Saunders Comprehensive Veterinary Dictionary (2007) 3rd ed, Elsevier, www.google-“chief complaint”-TheFreeDictionary.2. Dorland’s Medical Dictionary for Health Consumers (2007) Saunders, www.google-“chief complaint”-TheFreeDictionary.3. Mosby’s Medical Dictionary (2009) 8th ed, Elsevier, www.google-“chief complaint”-TheFreeDictionary.4. Burns J, Svirsky JA, Carter LC. (Oct 7, 2010) Virginia Commonwealth University School of Dentistry-Oral and Maxillofacial Pathology Diagnostic Service: Basic Diagnostic Skills, Module 3, Part 1-http://www.dentistry.vcu.edu/about/departments/opath/lascasex/textfiles/clindxmodules/m... 5. Bickley LS, Szilagyi PG (2007) Chapter 1- Overview of physical examination and history taking. In: LS Bickley. Bates’ Guide to Physical Examination and History Taking. 9th ed. Lippincott, Williams & Wilkins: Philadelphia p. 6-7.6. Ismail AI, Bader JD (2004) Evidence-based dentistry in clinical practice. J Am Dent Assoc 135:78-83.7. Kandasamy S, Bokas J (2008) The one-visit consultation--a step in the right direction? Orthodontic Products 15(1):152-155.8. Ackerman JL, Profitt WR (1995) Communication in orthodontic treatment planning: bioethical and informed consent issues. Angle Orthod 65:253-262.9. Jerrold L. (2011) When patients lie to their doctors. Litigation, legislation, and ethics. Am J Orthod Dentofacial Orthop 139:4157-4158.10. Jerrold L. (2011) Bringing skeletons out of the closet. Am J Orthod Dentofacial Orthop August 140:277-279.
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