Introduction and Provenance
Many General Dental Practitioners (GDPs) enter into providing a Dentistry-Community service with every noble intention gleaned from years of professional training. Attitudes knowledge and skills are honed into focus, to deliver all the services demanded. Ranging from public relations to major invasive oro-facial surgeries, other services called for include:- Office supervision, examination techniques, radiography, conservative and prophylactic therapies, restorative treatments, pain-control, osseointegrated implants, orthodontics, periodontics, dento-alveolar and maxillo-facial surgery. Essentially contemporary dentists run single handedly a mini-hospital. These services with practice administration, delivery of treatment and financial stewardship become all demanding, with consequent induction of unwelcome, unwanted, unavoidable, uncertainty and distress. Although one major influencing factor for non-compliance with treatment plans is the complexity of treatment, the real reasons for non-compliance remains obscure [1-4]. Some improvement of compliance manifests when patients are continually reminded about appointments, after they initiate therapy . Yet reports about providing dentists on how to avoid potential drop-outs and future non- compliance before initiating therapy are scant. The resultant waste of time effort diminished performance, loss of satisfaction and unwelcome depression and anxiety affects the GDP’s ability to successfully serve their communities. This advisory is targeted at general dental practitioners, oro-dental specialists and admissions officers for extensive dental therapy.
Aim: This contribution describes some simple approaches to ameliorate and positively moderate the stresses in general dental practice.
“Principles dictate policy” Touyz 1962. Stresses can be induced by factors external to Dental Practice. Distress deriving from stress and from various social activities encountered in living has been ranked in the Holmes-Rahestress inventory [also known as the Social Readjustment Rating Scale (SRRS)] on a scale of 0 to 100. An example of the first 10 events is summarized below (Table 1) .
Yet, major among the causes of stress to dentists, or to institutions delivering oro-dental therapy, is the poor, sometimes disastrous, selection of patients admitted into therapy at the practice. After over fifty years of teaching, supervision and practice, spread between two academic dental training schools (The Witwatersrand Oral and Dental Hospital Johannesburg South Africa, and the McGill Dental Faculty, Montreal Canada) among the major sources of anxiety arising for oral health care workers, was patient non-compliance and drop-out of planned therapy.
It remains a fact that:
Patients who don’t want to keep their teeth: These people are usually impeded by a meme that coerces them to remove their teeth and replace their chewing with full upper and lower dentures. They are not interested in retaining natural dentition. Frequently they are influenced by cultural norm that doesn’t teach oral hygiene, have a complete disinterest in adopting oral hygiene practices, and only want to have a complete dental clearance by extraction of all teeth, and as quickly as possible. This is their final panacea for dental problems. Patient education in this situation can induce anxiety and necessitates more chair side time to explain. These patients are not suitable nor are ready for any advanced restorative or gum therapy.
Of necessity dental treatment demands multiple attendances: A course of planned treatment will clearly indicate to the dentist, and accordingly also the patient, that attendances will need many appointments, extended over a period of time. It is not unusual for treatment plans to first stabilize soft tissues, and then embark on restoring decay, after which major reparative prosthetic work is necessitated. This also applies to orthodontics on children and adults. Consequently multiple attendances are required. Missed appointments waste time, money and effort from a running practice while blocking time slots for potential committed patients. Patients who are not willing to attend reliably, consistently and punctually are a huge source of irritation. Some people just never understand the discipline needed to run a practice, and even become resentful when told they will be charged for missing an appointment. Many think of dentistry as a personal service only to be used on demand when a toothache is felt. If a patient is unwilling to co-operate and attend regularly for optimizing therapy, these patients are not suitable nor are ready for general dentistry or any advanced restorative or gum therapy.
Clients don’t want to pay, or don’t have resources to pay: This situation is a major source of uneasiness, trouble, and stress. Spectacular dentistry demands and commands spectacular fees. Patients rarely can easily afford payments, and, unless they have made arrangements to pay, either by insurance, securing loans, or making arrangements with treating dentist, these people turn out to be unreliable, and often fee-dodgers. Those patients who do not want to know in advance what treatments are needed, proposed, or the costs incurred, can only be a source of future trouble, be delinquent in payment and try to maliciously exploit goodwill and gullibility of vulnerable dentists. These patients are not suitable nor are ready for any advanced restorative or gum therapy.
From the above, it is essential to recall some principles referral to:
The IARTI, PSR and CPITN: The Initial Assessment and Ranking of Periodontal Treatment Index is an Improved Rapid Classifying Index of Periodontal and Perio-Restorative Cases, which includes data derived from the PSR and CPITN. This IARTI asks three major questions: [7-9]
(i) Do you want to keep your teeth?
(ii) Are you prepared to present at least 10 times?
(iii) Can you afford the costs?
In addition, the IARTI is performed using the WHO probe with tine-tip pressure of 15-25 grams. Probing depths are correlated to the pocket measurement to determine a code of the patient, to be able to locate appropriate treatment modalities, its’ clinical ranking and progression. The appropriate designated code and likely treatment according to measurement depths of the probe are indicated in Figure 1.
· Coping strategies: Three
initial fundamental principles evolve from this: 
(i) WAHUM TOMYO: What Arrangements Have You Made To Meet Your Obligations?
(ii) IPP: Immediate Payment Practice
(iii) BTP: Big Toe Philosophy
Successful perio-prosthetic therapy depends on patients returning many times, not only for direct therapy on the gums and teeth, but also for monitoring and maintenance for sustained oro-dental health [7, 10-13]. There are enough stressors which may affect any dentist in practice, which is why reducing the stressors in practice becomes essential. A complete trilogy of positive responses (yes, yes, yes to all questions) of the IARTI is essential before proceeding with treatment. Just using the PSR or CPITN alone, does not provide socio-economic or motivational insights from the patient. Sooner than later these indices (CPITN and PSR) precipitate a disaster, discontinuance, and failure of treatments, either due to lack of compliance, understanding disconnection, or finances. In multiple anecdotal reports from students, directors and clinical controllers and admissions officers, the IARTI has avoided problems, misadventures, and unpleasantness. Many a disaster was voided by rigidly applying this IARTI index in the initial admissions clinics and appointments. Punctuality is the mutual compliment and respect shown to Dentist and Patient.
After a successful IARTI has been established, it is essential for dentists to apply the next set of anxiety relieving principles. “WAHUM TOMYO. [What Arrangements Have You Made To Meet Your Obligations?]” is a direct extension from the IARTI (Figure 2).
Serious patients accept the full responsibility for payment of impending therapy. An open, honest discussion of payment arrangement clears the air, expectations are clarified and assumptions are assuaged. Assumption is the mother of all foul-ups, and it is mandatory to spell out in writing a Treatment Plan, treatment sequence, number of appointments, and the costs anticipated including how the payments will be made. Clear explanation of Immediate Payment Practice (IPP) and the BTP (Big Toe Philosophy) is essential for the patient to understand. IPP and BTP are direct applications of principles which ensure satisfactory liquidation of fees for work done. Some philosophical pundits insist that demand a “deposit” for proposed work is unethical or immoral, as this may affect the quality of delivery of clinically acceptable services. Accordingly applying IPP and BTP eliminates the stress of paying and restores the rectitude of any spurious implication about pre-payments of treatment.
Principles dictate policy, and this applies to the GDP’s Clinical practice. Dentists are not financial Institutions, Money lenders, or Credit Unions. Just keeping a clinic open, disinfected, staffed, and properly equipped, costs the professional a lot of capitol layout and incurs ongoing expenses for rent, staff, equipment power and insurances. GDP’s make their living by providing a professional community dental service for the collective health of their communities served. They deserve to be rewarded to sustain their practices and successfully take care of their patient’s oral health.
Stress and anxiety of practice management is improved by linking and applying newly established principles of practice, namely the Initial Assessment and Ranking of Treatment Index [IARTI] and What Arrangements Have You Made To Meet Your Obligations (WAHUM TOMYO), Immediate Payment Practice (IPP) and Big Toe Philosophy (BTP). [7-9]. BTP implies that as soon as a patient exits from the dental chair, and their BIG Toe touches the ground….BTP applies, which means, the fee for the completed procedure is payable immediately. Different approaches to ensure compliance have been tried . Successful treatment devolves on the communication between the patient and health-care-provider, and optimizing outcomes depends on the information the health-care-provider procures initially .
By assessing the patient and then asking leading questions, patients get involved with the process of treatment planning and subsequently most will ensure satisfactory compliance [11-13]. The advisory as laid out above reinforces the success of these insights.
By applying these fundamental principles into general dental practice, much anxiety is relieved, challenges and problems are avoided, and successful practice of dentistry is realized.
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Louis ZG Touyz, Faculty of Dentistry, McGill University, Canada, Tel: 514-398-7203, E-mail: firstname.lastname@example.org
Touyz LZG and Nassani LM. Application of IARTI and ameliorating principles to improve compliance and completion of treatment in general dental practice (2021) Dental Res Manag 5: 23-25.
Anxiety, Compliance, Distress, Finance, Management,
Practice, Administration, Community Periodontal Index Treatment Number (CPITN),
Initial assessment ranking of treatment index, Periodontal score recording.