Stephen J. Stefanac Samuel Paul Nesbit
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T
he acute phase of care incorporates diagnostic and treatment procedures aimed at solving urgent oral problems. Acute care can involve a myriad of services from controlling pain and swelling to simply replacing a broken tooth on a denture. All types of patients may need acute care, including those under active treatment, on maintenance recall, new to a dental practice, or return- ing to a practice after being away for some length of time. Most people expect a dentist to be available to treat their immediate problems and are drawn to offices that provide such services. Good practice management and profes- sional responsibility require that every dentist effectively and efficiently manage patients who have immediate treatment needs without unnecessary disruption to the flow of the practice. The dentist is also responsible for managing his or her patients when they have acute prob- lems outside of normal office hours.The purpose of this chapter is to provide information about how to design, record, and execute the acute phase of a dental treatment plan. In the course of this discus- sion, the reader will become acquainted with the unique challenges of providing acute dental care. The profile of the acute patient’s typical problems is described. Guid- ance is provided for evaluating, diagnosing, treating, and providing follow-up care for this patient. In addition, suggestions for documenting all aspects of acute care are presented.
Two related terms are used throughout this chapter. An emergency problem incapacitates the patient and has the potential to become a life-threatening condition. In such a case, immediate attention is required for health reasons. Examples include severe dental pain, swelling, systemic infection, or trauma to the face or jaws. The dentist usually sees patients with emergency needs on the same day that contact is made. In contrast, an urgent
problem does not require immediate attention for health
reasons, but is a problem that the dentist—or, more commonly, the patient—thinks should be attended to “now” or “soon” (Figure 6-1). Examples include mild to
CHAPTER OUTLINE
Challenges Rewards
Profile of the Patient Requesting Immediate Treatment
Comprehensive Care Patient Limited Care Patient
Patient Evaluation
Patient History
Chief Concern and History of the Concern Health and Medication Histories
Past Dental History Psychosocial History Clinical Examination
Diagnostic Tests and Techniques Radiographic Examination
Common Acute Problems and Diagnoses
Complaint of Pain
Pain of Pulpal or Periapical Origin
Pain Associated With Periodontal Tissues Pain Associated With Tooth Eruption or
Pericoronitis
Pain Associated With Previous Dental Treatment
Other Sources of Oral Pain Complaint of Swelling Esthetic Complaints Traumatic Injury
Treatment Planning for Acute Needs
Defining the Range of Options
Factors Influencing the Treatment Decision Choosing a Plan That Takes Long-Term
Implications into Account
Acquiring Consent for Acute Care
Using Medications to Treat Acute Problems
Documenting Acute Care Treatment and Follow-Up
moderate pain without active infection, asymptomatic broken teeth, lost restorations, and other purely esthetic problems. Treatment of urgent problems can, theoreti- cally, be postponed without causing the patient unneces- sary pain or the risk of systemic illness. Often these problems can be managed with palliative care, for example, treating the pain, but not the underlying problem, until the patient can be conveniently worked into the office schedule.
Making the distinction between an emergency and an urgent problem is important to the dentist and to the patient to ensure that no true patient health problem goes unattended. On another level, the experienced dental practitioner recognizes that the distinction may become irrelevant in the mind of a distraught, anxious patient. From a practice management perspective, it is important that the office be able to accommodate patients with acute needs in a timely and attentive manner, regardless of whether a potentially serious health issue exists. Not infrequently, patients have questions about “new” find- ings in the oral cavity that they fear may be cancer, or they may develop esthetic problems that for reasons relat- ing to personal appearance and self-esteem need imme- diate attention. These concerns, although not true emergencies, do require the dentist’s recognition, if only to reassure the patient and to reschedule for definitive care.
CHALLENGES
Treating patients with acute care needs can be challeng- ing to the dentist in many ways. Initially the practitioner must determine whether the patient’s complaint is a true emergency requiring immediate attention or an urgent problem that can be treated at a more convenient time. Usually this discussion occurs over the telephone and may
be resolved by an office staff member without the dentist’s direct involvement. On the other hand, the dentist usually manages after-hours emergencies. Once the decision has been made to see the patient, enough time must be available in the dentist’s schedule to ade- quately diagnose and treat the patient’s problem. This can be difficult when the practitioner’s day is tightly scheduled. Some busy practices reserve time in the dentist’s schedule, or book the schedule lightly, to accom- modate occasional add-on appointments.
Arriving at a diagnosis and an acute care treatment plan can be time consuming. This problem is com- pounded significantly when the acute needs patient is new to the practice. In the absence of an existing health and dental history and an established relationship with the patient, the dentist must work without many of the usual clues or cues that would otherwise guide the process. The dentist needs to assess for the first time the patient’s health history, perform a limited oral exam- ination and diagnostic tests, obtain radiographs if neces- sary, decide on the appropriate treatment, and execute some level of care to alleviate symptoms. Difficult enough for a patient of record, this task can be extremely chal- lenging when it involves an anxious and emotionally labile patient whom the dentist has not met before.
During the initial appointment, the amount of time available to develop rapport is limited. If the patient is in significant pain or has been awake all night, he or she may not be thinking rationally. As a result, the dentist may have difficulty communicating the nature of the problem and the treatment options to the patient. The patient may have difficulty making a treatment decision or providing informed consent, especially for irreversible procedures, such as extractions or endodontic therapy.
Furthermore, it is common for some patients, espe- cially those who have never been seen in the practice before, to expect to have an acute need managed imme- diately and simply. These individuals may have experi- enced a lifetime of episodic dental care, may not understand the nature of the problem, and may be unre- alistic about the scope or complexity of the needed treat- ment. This can be frustrating for some practitioners, who see such patients as demanding and intrusive, and at the same time unappreciative of the value of comprehensive dental care. Nevertheless the dentist has the obligation, insofar as is possible, to educate the patient about his or her overall oral condition and to describe a vision for the way in which the emergency or urgent care treatment fits into the context of the person’s overall oral health. To help the patient understand and accept this vision, the dentist must be a good listener, take the time to explore all rea- sonable treatment options with the patient, and thor- oughly discuss any barriers to treatment that the patient Figure 6-1 Although not painful, the fracture of the right central
might perceive, especially with regard to time, finances, and pain. To accomplish this quickly, efficiently, and pro- fessionally—and to do so with a personalized and caring delivery—can be difficult for even the most experienced practitioner.
REWARDS
Efficiently managing the patient with acute problems is essential to attracting new patients and to serving the needs of patients already in the practice. Dentists who can treat emergency and urgent problems in a timely manner will retain patient loyalty and see their practices grow. Relieving pain or restoring a broken tooth can also provide great personal satisfaction to the dentist. Often, patients with such problems arrive fearful and unsure of what treat- ment will be required. A kind, empathetic approach to care and prompt resolution of the dental problem may per- suade some patients who present only for episodic treat- ment to become comprehensive care patients.