The purposes of this article are to (1) offer a critical thinking skill set in decision-making and synthesis for caries diagnosis, and risk-adjusted and personalized management based on emulating the intended activity of the expert, (2) offer patient/case scenarios for application of the critical thinking skill set, (3) compare and contrast the results of applying an algorithm and expert thought process approach to patient analyses, (4) offer characteristics of the person making decisions and synthesizing information, and (5) for patients with complex health and social histories, include perspectives from other health care team members.
Key points
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Offer a critical thinking skill set in decision-making and synthesis for caries diagnosis, and risk-adjusted and personalized management based on emulating the intended activity of the expert.
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Offer patient/case scenarios for application of the critical thinking skill set.
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Compare and contrast the result of applying an algorithm and expert thought process approach to patient analyses.
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Offer characteristics of the person making decisions and synthesizing information.
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For patients with complex health and social histories, include perspectives from other health care team members.
Introduction
The science of cariology continues to build as the science of caries management continues to build. For the practitioner, 2 perspectives will determine success in managing caries: (1) an understanding of factors contributing to caries development and progression for the individual and (2) an understanding that these factors contribute to the presence and/or progression of the caries lesion as a manifestation of disease. For the educator, the challenge will be to translate the science into learning outcomes from which we can guide learning and assess performance at a level that will be accepted and implemented by peers. The challenge will be to translate the science and apply it to each patient to offer a comprehensive and personalized health-promoting and tooth-preserving strategy.
Decision-making synthesizes and analyzes the main information gathered from the first 2 elements at the patient level (patients’ caries risk assessment) and the lesion level (caries lesion classification and staging) resulting in a likelihood matrix that can guide the professional to assess whether new lesions will develop or existing lesions will progress over time ( Box 1 , Figs. 1–3 ), after which the practitioner can critically translate this information and produce a comprehensive and personalized caries management plan.
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Gather basic data
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Patient risk factors and history
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Caries lesion classification: stage and activity
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For patients with health and social complexities, incorporate interprofessional perspectives:
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Prioritize the health conditions
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Which of the patient’s problems are drug related?
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What is the patient’s capacity to subscribe to recommended treatments?
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Which of the patient’s problems are nutrition related?
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What are barriers to care?
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Which of the patient’s problems directly affect general health?
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Ask which data are important for the patient’s health and why. Use evidence and rationale
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Ask what happens if we do nothing (ie, whether caries disease will progress or not)
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Determine the risk status based on disease progression/stage and which factors were likely causative:
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Low-disease/low-risk factors: Low likelihood
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Low-disease/high-risk factors: Moderate likelihood
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High-disease/high-risk factors: High likelihood
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Ask what are alternatives with evidence and rationale to personalize a comprehensive caries risk-based management plan:
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The patient’s risk status (low, moderate, high) according to factors
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Tooth-preserving management of caries lesions according to stage, activity, and likelihood of progression
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What is the specific recommendation and why: patient preference, evidence, and rationale?
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Related to patient’s risk factors
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Related to caries lesion management (ie, prevention, nonrestorative care, tooth-preserving restorative care)
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What is the prognosis for the recommended treatment?
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What are your biases?
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Communications plan
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Self-assess: what was done well, what could be done better, and compare with peer assessment
The purposes of this article are to: (1) offer a critical thinking skill set for caries risk assessment based on emulating the intended activity of the expert —this approach follows an evolving critical thinking model in dentistry ; (2) offer patient/case scenarios for application of the critical thinking skill set; (3) compare and contrast the results of applying an algorithm and expert thought process approach to patient analyses; and (4) for patients with complex health and social histories, include perspectives from other health care team members. An assumption is made that persons with high caries levels have compounding health and social contributors.
Critical thinking concepts are applied when providing rationale and synthesizing to solve a problem, because health care calls for inquiry and finding alternative explanations. The current literature is scant on the effective use of critical thinking skill sets in patient assessment and treatment planning. One promising approach builds on critical thinking concepts from the Education literature to emulate the intended activity of the expert. These concepts have been used to design critical thinking skill sets in treatment planning, literature critique, and evidence-based dentistry, as well as caries risk assessment. The referenced caries risk assessment exercise successfully emulated the thought process of the expert in succinct enough fashion to be used by a novice in a clinical setting. One modification is to build in the dimension of time by including the state of disease progression. The risk assessment paradigm of “high,” “moderate,” and “low” alone does not offer the perspective of time. Because all patients are either progressing or reversing their health state, and none are static throughout their lifetime, this is an opportunity to include disease progression in the risk assessment, as has been done for the geriatric population.
A Critical Thinking Skill Set Synthesizing Caries Lesion Diagnosis, and Caries Risk Assessment as a Precursor to Developing a Comprehensive Personalized Plan
Designing a critical thinking thought process for risk-based caries management depends on: (1) basic knowledge of caries pathology; (2) combining the concepts of caries risk-based management plan with concepts in the Education literature on critical thinking; (3) direct emulation of the thought process of the expert; (4) viewing caries as a disease of the individual and viewing the caries lesion as a manifestation of the disease (tooth level), an approach that has been used for primary teeth ; and (5) for patients with complex health and social histories, inclusion of perspectives from other health care team members.
Although the act of conducting caries risk assessment by an experienced clinician can take place in a matter of seconds in a busy dental practice, novices learn this process by following specific steps practiced across the years of dental school that blend knowledge and critical thinking across disciplines. The final exercise demonstrating competence in performing individualized caries risk assessment is based on a solid foundation of knowledge, clinical exposure to patients, and case scenarios. First comes a basic understanding of the pathology of dental caries. Next comes an understanding of key risk factors, as well as classification of the activity and stage of each caries lesion. Although it is beyond the scope of this article to offer an in-depth presentation, a summary is offered here.
After understanding the pathology and risk factors for dental caries, the use of algorithms (see Figs. 1–3 ) offers a powerful approach in preparation for following a thought process approach to caries lesion management. This process stipulates the dentist as the responsible person deciding upon the patient’s condition and offering alternative intervention, with the patient making the final decision.
Because many patients have complexities in their health and social lives, a case is made for the dentist to incorporate the thought processes of fellow health team members in planning care. A compelling reason is that people with increased states of health risk and social risk are also at greater risk for caries.
The questions listed are derived from experts on the health care team but can be considered as “commonsense” questions. Identification of the health care provider is thus removed in Box 1 on caries risk.
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Primary care: prioritize the health conditions
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Pharmacy: which of the patient’s problems are drug related?
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Nursing: what is the patient’s capacity to subscribe to recommended treatments?
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Nutrition: which of the patient’s problems are nutrition related?
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Social work: what are barriers to care?
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Dentistry: which of the patient’s problems directly affect general health?
The expert may not be able to articulate the thought process they are going through as situations arise. A key for the novice or advanced beginner is to capture the thought process of the expert in succinct enough fashion for use in a clinical situation. A key concept in this progression is separation of learning the science of caries risk assessment from the critical thinking process of the accomplished clinician. Other critical thinking skill sets have been reported for dentistry.
The thought processes for assessing caries disease of the individual and its manifestation at a tooth level are complementary
The Algorithm-Based Thought Process in Assessing Caries Diagnosis and Treatment at a Tooth Level
Powerful algorithms are available in assessing caries for the tooth. Success in arriving at a decision on treatment rests on a sound understanding of the pathology of caries and the factors contributing to caries. The algorithm leads to a treatment more than a set of alternatives for each individualized patient. The responsibility of executing the treatment rests with the clinician. For situations with the tooth as the isolated variable, the approach holds great promise.
The Thought Process for Assessing Caries Disease at a Patient Level as a Disease of the Individual and as a Manifestation of the Disease at a Tooth Level
The thought process for assessing caries for the person involves compounding variables that may lead more to alternatives than a “correct” treatment plan and subsequent procedures. A basic difference is in the nature of the questions asked, with greater demand on the judgment of the clinician. For example, “Which data are important?” is a different kind of question than “How deep is the lesion?” The same is true for “What happens if we do nothing?” Assessing risk without time can depict caries as static. Risk plus time helps to depict caries as dynamic.
Because all activity starts with articulating the thought process/skill set, the following are steps in the thought process of the expert in synthesizing an individual-based (rather than a tooth-based) personalized caries risk-based management plan (see Box 1 ). This is based on literature regarding characteristics of learning effectiveness or improvement. The process is designed to lead to alternatives before reaching a final recommendation for intervention.
Key questions can quickly identify whether the practitioner understands the scope of the patient’s condition. After gathering basic data, the first question of the expert should be, “Which data are important for the patient’s health and why?” This question quickly focuses in on the practitioner’s grasp of the larger context of the patient/case. In a similar vein, a next question may be, “What happens if I/we do nothing for some period of time (6 months or 5 years)?” This question also quickly focuses on the practitioner’s grasp of the dynamic of the patient/case. The question leads to a prognosis with no treatment.
A next step is to determine the risk level and likelihood of new caries lesions and/or progression. Referencing risk to disease progression depicts the patient’s situation and caries lesion itself as dynamic rather than static. For example, use of “high,” “moderate,” or “low” can depict a static situation. The risk orientation toward disease progression adds a time dynamic: low risk/low disease (low likelihood), high risk/low disease (moderate likelihood), high risk/rapidly progressing disease (high likelihood), extensive destruction/which factors contributed?
Once the risk is established, a next question is what are the alternatives, and what is the evidence and rationale for each? This focuses the clinician on synthesizing alternatives that target the patient’s most relevant risk factors, the alternative tooth-preserving treatment options according the stage and activity of each lesion, the likelihood of progression, and creativity in developing alternatives. The habit of looking for alternatives rather than a “right” answer is consistent with the general occurrence in health care of alternatives more than “right” answers. Thus, different kinds of thinking are brought to bear in the process. Although algorithms are valuable, the dentist remains responsible for decisions.
Next is the decision to choose one alternative, calling on the patient’s preference as well as the evidence and rationale. A next step is to assess one’s biases. We all have them and many are healthy, yet it is essential to consider our biases. Next is the communications plan with the patient, based on evidence and rationale. It is beyond the scope of this article to offer fundamentals of communication. Finally, self-assessment closes the loop on the process. Since self-assessment will be a key activity for success in practice, it is included in this and other thought processes.
Concepts in Critical Thinking Used to Design the Skill Set
Concepts underlie previously reported critical thinking skill sets for treatment planning, search and critique of the literature, and evidence-based dentistry, in addition to caries risk. The following is a summary of the concepts underlying the aforementioned caries risk-based management skill set.
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Provide multiple (not endless) situations calling for critical thinking—the more situations, the more likely one is to adapt to new ones.
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Emulate the intended thinking as directly as possible.
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Gain agreement of experts on content, application, and assessment.
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Use the same instrument to guide learning and assess (or self-assess) performance.
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Consider alternatives, biases (toward own abilities, patient conditions, and so forth), and self-assessment.
Patient/case scenarios
The use of patient/case scenarios can help to demonstrate the difference and complementary roles in assessing stage and progression for the tooth as well as assessing caries risk factors for the individual. A side-by-side comparison of the algorithm shown previously and the thought process/skill set of the expert show the key differences. The following 3 patients/cases demonstrate the application of the caries management thought process at a patient level and at a tooth level.
Patient/Case 1
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A 25-year-old who works night shifts in a convenience store selling gasoline, snack foods, and sweetened pop. Free beverage consumption is available for workers.
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The patient’s medical history includes depression and anxiety. Antidepressant and antianxiety medications have been used for several years.
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The patient fails on the first appointment for an examination, keeps the second appointment, and fails the third appointment.
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The patient is slightly overweight but otherwise healthy. The patient has extensive tooth destruction from the caries process.
