The practice of outstanding dentistry has as its primary mission the preservation or restoration of the standard of health, comfort, function, and orofacial esthetics. Maximum attention to the anamnesis, clinical examination, diagnosis, and treatment planning processes is needed to achieve these noble goals [Figure 1-01].

[Figure 1-01] Synopsis of the overall context of the anamnesis, clinical examination, diagnosis, and treatment planning process. All the steps mentioned below are interconnected and contribute to developing a complete treatment plan capable of achieving consistent, high-quality results.

Welcoming and greeting the patient

The patient’s first contact with the clinic could be via phone, website, email, social media message, or in person. At this point, the trained receptionist should be kind and helpful, as the initial contact with the patient represents the first impression of the clinic. The receptionist should also ask the patient about the main reason for the appointment, whether there is pain or discomfort, and whether there is a need for urgent care for any other reason. This attitude demonstrates concern for the well-being of the “future” patient and allows the receptionist to gather helpful information for the dentist who will treat the patient. It is also advisable to ask the patient who the clinic should thank for the referral so as to reinforce the interpersonal bonds that facilitate communication.

The day before the appointment, the patient should receive a confirmation call or message (depending on the preference confirmed at the initial contact) as well as other information such as directions to the clinic and where to park a vehicle.

Upon arrival at the clinic, the patient should be warmly welcomed and greeted by the receptionist, who should introduce themselves and offer water, coffee, tea, or anything else in particular. For the comfort of the patient, a selection of varied and updated magazines should be available as well as the Wi-Fi password for internet access [Figure 1-02].

[Figure 1-02] Clinic overview: a warm and comfortable clinic décor has the potential to make the patient feel welcome and at ease.

As soon as the patient settles down, the receptionist should give them a Welcome Form and Medical-Dental Questionnaire [Figure 1-03], briefly explaining how to fill them out and remaining available to help in case of questions.

[Figure 1-03] The purpose of the Welcome Form is to succinctly present particular details of the clinic.

The Medical-Dental Questionnaire should be constantly updated, revised, and customized according to the clinic’s services. It should contain all the critical and significant patient data, avoiding redundant or unnecessary questions and information that is superfluous and irrelevant to treatment planning. Extensive forms are counterproductive and tiring for the patient to fill out. Additional data will be collected by the dentist and added to the back of the questionnaire following the initial conversation with the patient.

QR code linking to the Welcome Form and Medical-Dental Questionnaire templates that can be customized.

The first appointment in two acts: anamnesis and clinical examination

The first appointment is full of expectations, and the primary goals are to get to know the patient and develop a solid relationship of trust with them. The patient brings with them the anxiety of meeting a dentist with the supposed competence to solve their problems and – fundamentally – recognizing in the person of the dentist someone genuinely concerned with understanding their needs, wishes, priorities, and fears. Lindsey Pankey, one of the great references in the history of dentistry, explains that patients choose their dentists for their skills, care, and judgment. Skills are related to technical attributes, and care and judgment pertain to empathy and wisdom⁷. Thus, the only thing that is not a guarantee of harmony in this relationship is the professional’s academic credentials [Figure 1-04].

[Figure 1-04] The first appointment is full of expectations. The environment should be peaceful, and the communication process should occur without interruptions. The dentist should make it clear that the purpose is to answer the patient’s questions or help them understand the existing problems.

The anamnesis (from the Greek ana, to bring again, and mnesis, memory) is a structured interview to obtain relevant data from the history of complaints and the development of the disease (the problem) from the patient’s perspective. When performed effectively, the anamnesis is responsible for generating much of the information necessary for the diagnosis and should be complemented by the clinical examination and complementary tests.

The quality of the anamnesis has a direct influence on the treatment, and it is therefore recommended to set aside adequate time for the first appointment. Although it is difficult to determine a specific period because personal histories and clinical cases differ, a one-hour appointment seems to be a good average. The time allocation should be as follows: approximately 20 to 30 minutes (min) for the anamnesis, 20 to 30 min for the clinical examination, and 10 min for finalizing the appointment [Table 1-01].

[Table 1-01] Average estimated time for the first appointment procedures.

Dentist-related aspects

Ideally, the anamnesis and clinical examination appointment should be carried out by the dentist responsible for planning and coordinating the treatment. With experience, the dentist will be able to detect the needs and expectations of each patient and, based on the degree of complexity of the findings, define whether the treatment will require other specialists.

The dentist should greet the patient in a friendly and welcoming way. The anamnesis should be performed without interruptions, in a calm environment – preferably non-clinical – where the patient feels less vulnerable. At this point, clear and focused communication is the dentist’s essential tool when facing the patient.

The anamnesis should have a predefined practical script but should also be flexible so that it accommodates the patient’s characteristics and facilitates communication. It should be started in a friendly way, aiming to open up and relax the conversation with, for example, a mention of thanks to the person who referred the patient or sincere affection for a mutual acquaintance.

Based on the Medical-Dental Questionnaire, some critical questions related to the main concern and the history of the problem(s) should be addressed, allowing the patient to explain the reasons that brought them to the clinic. The organized documentation of all the critical data from this questionnaire is recommended. The use of checklists proposed by this author practically eliminates the tendency of failing to analyze all potentially important data for treatment and has been considered essential in all areas of health, significantly reducing the incidence of medical errors¹³.

Before the patient starts their report, the dentist needs to mention that they will be taking notes of the most critical data while the patient speaks. This statement of intent shows consideration for the patient, who could feel undervalued if, at this sensitive moment, the dentist is taking notes with their head down instead of making eye contact. During the anamnesis, the dentist should speak as little as possible, preferably only if and when requested or questioned, and provide general and brief answers, as the patient will not yet have been objectively examined. Above all, the dentist needs to be interested in the patient’s message rather than try to be interesting.

The patient should be listened to effectively and with affection, without any personal filters or judgments that could increase their feeling of vulnerability¹⁴. This moment is potentially loaded with subjective information, feelings, and expectations. The dentist needs to expand the doors of their perception to capture the minimal and subtle nuances of verbal and non-verbal communication, such as tone of voice and body language¹⁵, as these can add significant psychologic aspects to the treatment.

It is essential to consider whether the reported problems are relevant and whether the patient has already done anything to treat them. In addition, what the patient expresses regarding previous treatments or dentists is of paramount importance. Individuals who transfer their frustrations or the blame for their problems onto previous dentists need to be evaluated with extra care, as they may represent the type of patient who does not take their responsibilities in the treatment seriously or is not adequately committed or motivated. After listening to the patient carefully, the dentist needs to reflect – with rationality and humility – whether they will be able to overcome such obstacles or expectations.

Emergency cases

Dental emergencies are frequent gateways for new or old patients to return to the clinic. They are usually related to pain, discomfort, infection, or inflammation relief (of endodontic, periodontal, periapical, or traumatic origin, or have to do with temporomandibular disorders [TMDs]), in addition to the immediate resolution of any esthetic problems.

In these cases, the anamnesis and the clinical examination should be short and specifically directed at the patient’s complaint, addressing it with prompt effectiveness. After the temporary or definitive resolution of the emergency, these patients should be educated about the need for an additional appointment for a complete anamnesis and clinical examination. In this context, many patients will comply with these recommendations and continue with treatment, while others will not continue once their urgent needs have been met.

The patient–dentist relationship

The interpersonal aspects of the patient–dentist relationship need to be discussed because they are essential in all phases of treatment. Knowledge of the patient’s emotional and psychosocial dimensions helps the dentist to develop a relationship of mutual trust and broaden the understanding of the treatment’s risks and limitations, in addition to establishing a partnership to achieve and maintain the best long-term results^16,17.

Although it is beyond the scope of this book to delve into topics related to psychology or behavioral therapies, since this would be an extensive matter and be subject to multiple interpretations, the dentist should have a basic understanding of the psychologic elements of their interaction with the patient.

More than 80 years ago, the American Dental Educators Association emphasized the need to understand aspects related to patient behavior. Since then, psychiatrists, psychologists, and dentists have been studying how individuals react to the experience of being patients¹⁷.

Some classifications of psychologic profiles have been described in the literature^17–22. One of the first citations regarding personality types or “moods” of individuals was proposed by Hippocrates (460 to 370 BC)¹⁸. In his work, he described four basic temperaments: choleric, sanguine, melancholic, and phlegmatic. This description has been a source of reference for countless other authors throughout history.

A classification of patients’ behavior patterns according to tooth loss and their adaptation to complete dentures is accredited to House^17,20,21. According to that author, patients belong to one of four groups – philosophical, exacting, hysterical, and indifferent – according to their psychologic make-up, experiences, difficulties, and expectations. The philosophical patient is rational, sensible, balanced, calm, and accepts the dentist’s diagnosis, treatment, and prognosis recommendations. The exacting patient is methodical, precise, impatient, and may require additional attention and care from the dentist. These patients are concerned about the appearance and efficiency of complete dentures. They are usually dissatisfied with the treatment and reluctant to accept the dentist’s advice, and they request written guarantees. The hysterical patient is erratic, anxious, presents negative behavior about their current condition, and often has unrealistic expectations such as the notion that the denture will function similarly to their teeth. On the other hand, the indifferent patient is apathetic, has low motivation, and is unconcerned about appearance or chewing ability. These patients usually have low adherence to the treatment.

This author has been using a recent classification that, like the one by Hippocrates (to which it may be related), defines four distinct types of personality profiles: director, thinker, socializer, and relater. It offers a pragmatic point of view to understand patients’ psychologic profiles and values and to enhance the communication and collaboration process between the patient and dentist²³ [Table 1-02].

Director: These patients are direct, competitive, often impatient, demanding, and focused on results. They are not there to establish new relationships but instead to effectively solve their problems. They are usually outgoing, assertive, and take risks.

When dealing with these patients, it is essential to demonstrate knowledge and competence and to be punctual, specific, and direct in communication. It is recommended to share critical information so that they actively participate in the decision-making process to reach the most appropriate solutions.

Thinker: These patients are methodical, centering, critical, and generally serious; they are detail-oriented and focused on facts, not on building interpersonal relationships. Unlike directors, they are not impulsive and are averse to taking risks.

These patients need to trust the dentist and recognize the purposes of the treatment. They require detail and time to evaluate treatment options and make decisions based on reason and caution.

Socializer: These patients are outgoing, spontaneous, dynamic, and persuasive. The main difference between them and the directors and thinkers is that they focus on interpersonal relationships and on obtaining social recognition, not on solving tasks.

With these patients, one should maintain a relaxed and friendly atmosphere, ensuring that every detail of the conversation is understood without losing its primary purpose.

Relater: These patients are the friendliest of all the personality types. They are generally tolerant and apathetic. They value their sense of belonging to a group and dislike changes to their routine or interpersonal conflicts. They are indecisive or slow to make decisions because they do not trust easily, but when they do, they are loyal. They are balanced and calm people.

The relater needs a calm and attentive communication process and appreciates safe and conservative alternatives that guarantee comfort and stability.

According to Alessandra and O’Connor²³, 80% of people present one or two dominant personality types. Therefore, recognizing the patient’s profile is essential to treating them according to the “Platinum Rule”²³, in other words, the way they would like to be treated.

[Table 1-02] Behavioral characteristics associated with different personality profiles23. The dentist should understand the communication process from the patient’s point of view.

Needs versus WISHES

The patient comes to us with their unique needs, wishes, priorities, and expectations. Needs basically refer to discomfort or pain related to functional, structural, or biologic problems. They may also be due to some esthetic concern such as a fractured tooth or restoration. Wishes are generally related to an improvement in the general condition of the teeth or the appearance of the smile, although in today’s highly competitive world it is not clear whether esthetics is a necessity or a wish due to the preponderant role of self-confidence and self-esteem in the individual’s daily activities.

It is recommended to determine the extent of the patient’s expectations regarding the treatment so that they can be contextualized in relation to the limitations of the different treatment options. In this author’s opinion, the failure to determine and modulate patient expectations is one of the greatest sources of failure and frustration in clinical practice. Patients with high expectations are challenging, but generally ensure that the dentist’s dedication produces personalized work. On the other hand, litigation can result from patients with unrealistic expectations or those with psychosomatic disorders²⁴ due to the difficulty or impossibility on the part of the dentist to meet their expectations.

Conclusion of the initial appointment

At the end of the initial appointment, after the clinical examination, the dentist should make a didactic summary of the most significant findings, making it clear to the patient that the analysis of the information is still incomplete and that it will be reviewed after the evaluation of the complementary examinations and discussions with the interdisciplinary team during treatment planning. This summary has the primary objective of guiding the patient about their current conditions and presenting a safe path to be followed with the personalized and detailed work of a trained and committed team. At the end, a brief presentation of images of similar cases performed by the dentist and their team allows an opportunity to show the level of professionalism involved and encourages patient motivation [Figure 1-05].

[Figure 1-05] The succinct presentation of clinical cases showing treatments similar to those probably required by the patient increases the patient’s motivation because it allows them to see the quality of the work performed by the dental team.

Before saying goodbye, it is suggested to ask the patient whether there are any questions or special considerations regarding everything that has been discussed up to that point. The second appointment should be scheduled as soon as possible but with sufficient time in between to allow the dentist coordinating the treatment to gather all the data and expert reports and to prepare the preliminary treatment plan(s).

Fees

It is recommended to avoid any mention of the financial aspect of treatment during the first appointment, as all the data from the anamnesis, clinical and radiographic examinations, and models mounted on the articulator have not yet been assessed by the dental team. In addition, the patient is not yet aware of the extent of the problems and possible consequences. If, however, the patient insists, the experienced dentist can provide a rough estimate of the expected financial commitment, using costs from similar cases of patients treated in the past year. At this point, it is important to make it clear that treatment planning is essential to define the exact stages and treatment costs more precisely.

Importance of the Medical-Dental Questionnaire

Marcelo Calamita

Eduardo Rodrigues Fregnani and Wanessa Miranda-Silva

As explained above, the Medical-Dental Questionnaire should cover the most frequent medical and dental conditions and be accompanied by a candid conversation about the relevant facts that may emerge during the appointment and that are essential for the proper management of the patient.

It is estimated that 25% to 30% of patients seeking dental treatment²⁵ have at least one potentially relevant systemic issue. For the safety of all involved, the dentist should be prepared to assess and identify situations that require modifications to their conventional conduct. They may be faced, for example, with the need to perform a surgical procedure on a patient with heart disease using anticoagulant medication. Alternatively, they might have a diabetic patient, who, when the diabetes is not controlled, may have altered wound healing capacity in the face of some clinical procedures. Thus, a number of systemic conditions need to be understood in order to take safe and effective preventive measures before, during, and after treatment.

Medical-Dental Questionnaire

The primary purpose of this questionnaire is not to carry out an extensive, complete, or definitive review of all possible health issues, the medication used, and the patient’s dental treatment history. Rather, its central objective is to identify the main risk factors that could involve changes to the treatment plan and effective patient care [Figure 1–06; Table 1-03].

[Figure 1-06] The Medical-Dental Questionnaire should contain all the critical issues that have the potential to interfere with the patient’s diagnosis and treatment plan. The receptionist should provide a brief explanation to the patient of how to fill it out and be available in case of questions. This document will be a roadmap for all significant data related to the patient’s medical and dental history. Its understanding and effective use will be the foundation for a successful treatment plan. The patient will fill out the first page, and the dentist the second page.

[Table 1-03]

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