At the interface of medicine and dentistry: shared decision-making using decision aids and clinical decision support tools

Abstract

Today's practice of dentistry at the interface with medicine is complex. With varying levels of evidence of effectiveness of many of our preventive, diagnostic, and therapeutic approaches to disease management and health maintenance, we must, together with our patients, weigh the risks of harm compared to the expected health benefits of all care options using the best medical evidence available. This practice environment places the onus on the provider to stay abreast of scientific discoveries and acknowledge that there may not always be one “best way” to prevent, diagnose, or treat a condition in order to improve the patient's health and well-being. Reports of clinical trials, systematic reviews, and meta-analyses in our journal contribute to our readers' knowledge of the changing landscape of patient management across the multiple specialties that support Oral Surgery Oral Medicine Oral Pathology and Oral Radiology. Engaging patients in the decision-making process allows their preferences to be integrated with health care providers' experience and evidence-based recommendations. A term for this practice is shared decision-making. This creates a paradigm shift, where the clinician relinquishes some control and collaborates with the patient as a partner. Shared decision-making improves the patient's understanding of available health choices, engagement, and adherence to the management plan, while respecting patient rights and reducing uncertainty and anxiety about alternative choices and the ultimate decision.1Makoul G. Clayman M.L. An integrative model of shared decision making in medical encounters.Patient Educ Couns. 2006; 60: 301-312Abstract Full Text Full Text PDF PubMed Scopus (1007) Google Scholar Shared decision-making is one strategy for improved patient engagement that is expected to improve health outcomes and patient satisfaction and to decrease the cost of care. Using shared decision-making, patients and health care providers discuss the condition or risk factors, preventive or treatment strategies and options, best available medical evidence to support each strategy, risks/harms and benefits of each strategy, and patient preferences to arrive at a personalized plan of care. For example, management of temporomandibular disorder (TMD), a preference-sensitive condition, often involves a combination of techniques for effective pain management. One patient with TMD pain might prefer any of a variety of conservative management techniques including nonsteroidal anti-inflammatory drugs, applied heat therapy, physical therapy and/or limiting opening, relaxation training, biofeedback, or electrotherapy. Another patient might prefer occlusal splint therapy or, if the severity of the situation calls for it, surgical modification of the joint apparatus. In many cases with multiple reasonable treatment approaches, from no treatment to conservative medical management to surgical correction, each with its own set of risks and benefits, the patient's unique circumstances and preferences should guide the treatment decisions. Shared decision-making is not as easy as it sounds. At the start, a patient's understanding of his or her health condition is informed by past personal experience and experiences shared by friends and family. A patient's health awareness will impact his or her ability to understand and access the medical evidence surrounding the condition. This is where the experienced clinician must discuss the evidence supporting alternative options in a manner appropriate for the patient to understand and use the information in informed decision-making. When evidence is poor or unclear, the clinician needs to forthrightly indicate that today we simply cannot accurately predict the outcome of such a treatment approach. In some cases, no active treatment (monitoring the condition for changes in symptoms and signs) might be the best course until medical advances help to define a clearer pathway to health. Patients must also be self-motivated and willing to accept responsibility for their health behaviors and not expect clinicians to provide 90% of the solution. This shifted dynamic of turning the locus of control back to the patient is also critical to the success of shared decision-making. Both the Patient Protection and Affordable Care Act of 2010 and the Centers for Medicare and Medicaid Services' criteria for meaningful use of certified electronic health record (EHR) technology have encouraged shared decision-making. This process has been facilitated through legislation and payment incentives for increasing patients' direct access to communication with their care providers as well as access to physician visit summaries, diagnostic test results, and self-management tools. Patients who actively use EHR patient portals for access to their personal health data, reports, labs, and patient education materials will likely have a more in-depth understanding of their specific health conditions than those who do not access this information. Many patients will also search the Internet for general unfiltered information on their health conditions and possible remedies before or after seeking professional advice and care. Various methods to assist with the patient and provider education components of the shared decision-making process have been proposed. These decision support tools or aids can include print and electronic materials, video presentations or discussions, and interactive sessions in person or with use of an electronic interface. Aids created for patients to facilitate screening and treatment decisions have been demonstrated in a systematic review to improve knowledge, lower decisional conflict, and create more active patient involvement in decision-making.2O'Conner A.M. Rostrom A. Fiset V. et al.Decision aids for patients facing health treatment or screening decisions: Systematic review.Br Med J. 1999; 319: 731-734Crossref PubMed Scopus (669) Google Scholar One of the first such decision-making support tools related to dentistry published in the literature was for the controversial topic of antibiotic prophylaxis for total joint replacement patients undergoing invasive dental procedures,3Jevsevar D.S. Shared decision making tool: Should I take antibiotics before my dental procedure?.J Am Acad Orthop Surg. 2013; 21: 190-192Crossref PubMed Scopus (8) Google Scholar which was paired with the 2012 American Dental Association (ADA)-American Academy of Orthopaedic Surgeons (AAOS) evidence review on the topic.4Watters 3rd, W. Rethman M.P. Hanson N.B. et al.Prevention of orthopaedic implant infection in patients undergoing dental procedures.J Am Acad Orthop Surg. 2013; 21: 180-189Crossref PubMed Scopus (83) Google Scholar To be maximally useful, patient decision aids need to be presented in a balanced manner and in plain language, be simple and rapid to use, and be rigorously validated and frequently updated to ensure that they help patients clarify their values regarding desired medical outcomes and quality of life. Lack of available decision support tools for oral health conditions is one barrier to progress in dentistry's full endorsement and application of shared decision-making. Federal government support through the Agency for Healthcare Research and Quality (AHRQ)'s Patient-Centered Outcomes Research Institute and international standards have been developed to assist professionals in developing decision support tools for health conditions within their purview. The AHRQ presents a number of medical condition–related patient decision aids on its website.5Agency for Healthcare Research and Quality. Patient Decision Aids. Available at: https://effectivehealthcare.ahrq.gov/index.cfm/tools-and-resources/patient-decision-aids/. Accessed October 19, 2016.Google Scholar To enhance the quality and effectiveness of these tools, International Patient Decision Aid Standards have been developed with content-specific decision aid developers, patients, practitioners, researchers, and policymakers engaging in a 2-stage Delphi consensus process.6International Patient Decision Aid Standards Collaboration. IPDAS 2005: Criteria for Judging the Quality of Patient Decision Aids. Available at: http://ipdas.ohri.ca/IPDAS_checklist.pdf; http://ipdas.ohri.ca. Accessed October 19, 2016.Google Scholar Critical to their usefulness is providing sufficient details regarding options to facilitate decision-making. With few existing clinical decision support aids that apply to dentistry, development of additional tools and implementation research is sorely needed. Merijohn et al. from the ADA Evidence Based Practice Center present an access-advise-decide approach to shared decision-making, using 1- to 2-page evidence summaries from the ADA.org website to facilitate chairside discussion of condition-relevant medical information.7Merijohn G.K. Bader J.D. Frantsve-Hawley J. Aravamudhan K. Clinical decision support chairside tools for evidence-based dental practice.J Evid Based Dent Pract. 2008; 8: 119-132Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar At the New York University College of Dentistry, Montini et al. developed and piloted a Web-based computer-mediated clinical decision support system for dentists to engage patients in the topic of tobacco use screening and referral that shows promise.8Montini T. Schenkel A.B. Shelley D.R. Feasibility of a computerized clinical decision support system for treating tobacco use in dental clinics.J Dent Educ. 2013; 77: 458-462PubMed Google Scholar Recently, a Web-based decision aid considering evidence but largely relying on professional experience and expert opinions of dentists and physicians, has been developed to help clinicians decide on appropriate courses of action for their total joint (orthopedic implant) patients regarding the use of antibiotic coverage to prevent joint prosthesis infection when undergoing dental procedures.9American Academy of Orthopaedic Surgeons. Appropriate Use Criteria for Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. Available at: www.aaos.org/poiudpauc. Published September 23, 2016. Accessed October 19, 2016.Google Scholar This AAOS Appropriate Use Criteria Web module helps to stratify theoretical risk of joint prosthesis infection using 64 hypothetical clinical patient scenarios into 3 management categories: rarely appropriate, may be appropriate, and appropriate for antibiotic coverage.10American Academy of Orthopaedic Surgeons. Appropriate Use Criteria for Management of Patients with Orthopaedic Implants Undergoing Dental Procedures Web Module. Available at: http://www.orthoguidelines.org/go/auc/auc.cfm?auc_id=224995. Published September 23, 2016. Accessed October 19, 2016.Google Scholar Considered in the theoretical risk stratification scenarios are invasiveness of the planned dental procedure, immunocompromised status, diabetic glycemic control, history of periprosthetic or deep prosthetic joint infection that required operative management, and timing of the joint replacement within the past year.10American Academy of Orthopaedic Surgeons. Appropriate Use Criteria for Management of Patients with Orthopaedic Implants Undergoing Dental Procedures Web Module. Available at: http://www.orthoguidelines.org/go/auc/auc.cfm?auc_id=224995. Published September 23, 2016. Accessed October 19, 2016.Google Scholar The most recent guideline from the ADA on this topic concluded, “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”11Sollecito T.P. Abt E. Lockhart P.B. et al.The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners – a report of the American Dental Association Council on Scientific Affairs.JADA. 2015; 146: 11-16.e8Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar The usefulness of this Web tool now needs to be investigated in clinical practice. I look forward to the development and validation of additional online tools to assist both patients and providers in shared decision-making as we move into the era of value-based health care.