Anatomy of a patient letter

Dr. Eddie Scher and Sarah Payne address some of the common warnings that a good treatment plan should include

Insight_Scher_600x300Every treatment letter that goes out must have warnings that are specific to each particular patient and treatment option. The template used by the authors in practice has grown in size, as more commonly used paragraphs and warnings have been added to it in order to ensure the patient fully understands the treatment and the risks involved.

Some of the warnings we give are used in every implant placement case, such as points about the condition of the bone, the patient’s oral hygiene, and the importance of good home care when you have teeth and implants together in the mouth.

It is also important to warn the patient that no treatment has a 100% success rate, but that you will do everything you can to make sure you get the best result possible. The majority of the letter will be case specific — and should always be double-checked to ensure absolutely every eventuality has been covered.

It is also important to warn the patient that no treatment
has a 100% success rate, but that you will do everything
you can to make sure you get the best result possible.

Below is the template used by the authors for some common warning paragraphs. These are not, and never will be “final” — they have been adapted and added to over time, and we are always looking at ways to improve upon them.

Medical history
Every patient’s medical history is likely to be unique and so will require different warnings. Diabetes is an increasingly common condition, and an example of what you might wish to raise with a patient is given here:

“We have discussed the fact that you are a controlled diabetic, and we have warned you that your expectation of success is only just a little lower than if you were a normal medical history. If you were an insulin-controlled diabetic then the prognosis would be much poorer.”

In the same way, a patient’s dental condition will be unique, which we mention in every letter as follows:

“Because each patient’s medical and dental condition and oral hygiene is unique, long-term success may not occur and cannot be guaranteed.”

Smoking
“As we discussed, recent research has shown that smoking reduces the healing capabilities of the tissues. It has now been shown that people smoking 20 cigarettes per day or more will reduce their predictability of success by approximately 11%.

“We have discussed the smoking cessation policy, and we have suggested to you that you should give up smoking at least 2 weeks before our implant procedure and refrain from smoking for 4 to 6 weeks after the procedure. Obviously, it would be very nice if you did not take up smoking in the future as this would be a tremendous advantage to your general health.”

Oral hygiene
“As you can imagine, it is important that your mouth is healthy and clean before surgery. Therefore, our policy is for you to see a hygienist a few days before the surgery.

Additional appointments may be required and are listed below:

  • Before implant placement to minimize the chances of infection
  • After implant exposure to familiarize you with the shape of the transitional restoration
  • After temporary crown/bridges are constructed
  • After completion of the treatment to guide you in the maintenance of the final crown/ bridgework.

“The number of appointments required will depend upon your needs. During the course of the treatment, you will need instruction to enable you to look after your mouth. This may be carried out at your practice with your own hygienist. Should you not have access to appropriately trained healthcare professionals, we are able to provide this aspect of care.

“As also discussed, it is totally essential that your oral hygiene and home-care procedures are maintained to the highest standards and that you attend all your prescribed hygiene and maintenance appointments. Recent research has shown that when implants are placed in the mouth where natural teeth are present, there is a greater risk of infection, and that the infection can be more acute. The essential lesson to be learned is that the oral hygiene and home-care procedures must be of the highest standard, in order to ensure no possible risk of infection. The remaining teeth will obviously benefit as well.”

Sinus grafts
Cases where the clinician needs to work in the sinus region carry a greater risk of complication, so as well as explaining the procedure, the patient letter must also add some warnings:

“If the sinus lining tears and cannot be repaired (and in some patients, it is very thin), we will abandon the procedure and close. We would then repeat the procedure approximately 3 months later.

“After a sinus lift procedure, it is very important that you do not blow your nose hard, and if it is necessary to blow your nose, then this must be done very gently. We will also ask you not to fly in an airplane, or swim for at least 2 weeks after the procedure.

“If you have the desire or need to sneeze, we will ask you to make your sneeze through your mouth and not through your nose. It is also very advisable that you stay out of an environment where you might pick up a respiratory tract infection. We will require you to attend our surgery approximately 10 days later to remove your stitches.”

Bone augmentation/grafting
“As we discussed, our object is to take a little piece of bone from your chin (inside your mouth) and use this piece of bone to fill in the gap where the root of your tooth was. At this procedure, we always use a bone augmentation material called mineralized freeze-dried bone to pack out the areas where the bone graft does not extend to, and also to fill in the chin area where the piece of bone
was removed.

“As we mentioned at your last appointment, it is possible when removing the piece of bone from the chin that your lower anterior teeth may be affected. This is a very rare occurrence, and what may result is a slight loss of feeling, rather like you having root canal treatment. It is possible that a lower anterior tooth might become devitalized and would need a root canal filling — however, as mentioned, this is a very rare occurrence.”

Platelet-rich plasma and platelet-rich fibrin
“In order to enhance our bone and soft tissue healing, our plan is to use a technique called platelet-rich plasma and platelet-rich fibrin (PRP/PRF), which enhances the healing of both the soft tissues and, to a lesser extent, the bone tissue as well.

“PRP/PRF is a procedure where we draw a little blood from your arm and use this blood in a special one-use-only sterile container. The blood is placed in a centrifuge and divides out your very best growth cells, which we can then add in to our operating site.”

Implant/surgery patients
There are a number of warnings that are appropriate to implant patients, which the clinician needs to choose appropriately for the case:

  • “As discussed, there is a gap of 3 to 6 months before we can load these implants. (This is to give the bone time to grow onto the surface of the titanium.)
  • If I am not happy with the quality or quantity of the bony ridge, I will discontinue the operation and only charge for you for my time and the disposables used.
  • It is requested that facial makeup not be worn on surgery days.
  • After implant surgery, your dentures will need to be left out for at least 2 weeks. However, as already discussed, it may be possible to insert it after 3 days/1 week with a soft lining for speech and appearance purposes only.
  • We have discussed the close proximity of the inferior dental nerve and the lingual nerve (the nerve that gives feeling to the lip, tongue, and surrounding areas), and the possible problems if either of these nerves is damaged. However, to put this into perspective, I have operated in this region many times and have never had a permanent numbness. If you have any sign of numbness or a change of sensation in this region after 6 hours, please inform me immediately.
  • As we mentioned at your last consultation, when operating in the posterior lower jaw, we have to be very careful of a nerve that runs through that jaw. From our special test we can see that this nerve is running very favorably — however, we will follow a special protocol in order to minimize any possibility of nerve damage in this region. The most important aspect of this protocol is that we give local anesthetic in the region of the operation only and not a full block. The reason for this is if we come too close to the nerve, then you will have some feeling in the region and can warn us of that. Also when we are approximately two-thirds of the length of the definitive implant, we will take an X-ray to check that we are in the correct position.
  • It may be necessary when placing the osseointegrated implant to augment the little nerve canal at the midline of your upper jaw. We would only do this if the nerve canal was extra-ordinarily large and crossed over the area where we want to place our implant. It is possible there might be a slight numbness on the palate if we did do this procedure. As we have explained, the augmentation material used in the surgery is mineralized freeze-dried bone of bovine origin.”

Postoperative warnings
Again, there may be a number of postoperative warnings that are appropriate to pass on to the patient. It is up to the clinician to decide what should be discussed, but an example of one very commonly used warning is given here:

“Gum recession will appear following your treatment. Gum recession is always present after treatment in patients with deeper periodontal pockets and bone loss, since this is part of the natural healing process.

“Gum recession can also appear around implants, which will result to exposure of the titanium threads and esthetic compromise, as well as the possibility of food impaction in the area.”

Dental prosthesis
The nature of your advice to your patients regarding their prostheses will depend on many factors, including the type of prosthesis fitted, the treatment modality, and their own personal circumstances. The following are common paragraphs included:

  • “As we discussed during your consultation appointment, all forms of dental prostheses require regular maintenance over the years. With any mechanical appliance, it is necessary that professional cleaning and the replacing of worn movable parts may be necessary from time to time.
  • We have discussed the problem of your relatively high smile line, and have explained to you that we will expose the implant in such a way that we will create a nice tissue cuff around your new tooth. It is still possible, however, that this tooth maybe slightly longer than the adjacent teeth.
  • Implant cement is used for the permanent restoration. This cement is different from traditional crown cement as we need to have access to the implant occasionally (in case the abutment should loosen, to treat any gum inflammation, and so on). Due to the nature of the implant cement, this does mean that the crown may occasionally debond. This is nothing to worry about and just requires a half-hour appointment to re-cement. This is not an emergency so can be booked at your convenience, depending on availability. If this happens on multiple occasions and becomes too inconvenient, then traditional permanent cement can be used instead. This does mean that, should access to the implant be needed, the crown would have to be drilled off and a new one made at our current prices.
  • We are very concerned about grinding and clenching forces on osseo-integrated implants. We have, therefore, recommended the construction of a night guard (occlusal splint) for you to wear when sleeping.
  • The provisional crown brings the implant into function, develops the contour of the gum, and helps us to decide on the shape of the final tooth. The provisional crown will allow you to criticize the shape, size, color, and position of the crown so that we can make any corrections before going to the final restoration in metal and porcelain.”

Dental legalities
Finally, it is extremely important that the letter refers to certain aspects of the patient consultation that explain why they have opted for a certain treatment, addresses the risk of failure, or explains who is carrying out certain parts of the treatment.

These warnings are a crucial part of documenting the patients’ consent and help show that you have had a clear, wide-ranging, and unbiased discussion with them about their treatment — and that their consent is supported by sufficient understanding of what they are agreeing to:

  • “This treatment, as we have discussed in detail, is not the ideal way to go forward, but other forms of treatment would be considerably more expensive; and we have designed the prosthesis so that in the future we can add in more implants and change the type of prosthesis when necessary.
  • My responsibility is only for the surgical phase. Dr X, who will be taking over the prosthetic phase, is giving you a formal estimate for this. I am more than happy to offer advice here should it be requested.
  • I also need to mention that no treatment can have a 100% success rate as any surgical treatment depends partly on the patient’s healing response. Although our success rate is extremely high, occasionally problems do occur; and if at any time I feel that a problem has arisen, I will discuss the possible outcomes with you.
  • If you have an emergency problem, regarding your dental treatment, Dr Scher’s telephone numbers are ___.
  • Please find enclosed an estimate of our fees, together with a copy of this letter for you to sign and return to me, signifying agreement to our treatment plan and estimate.
  • In order for us to document your smile transformation, clinical photography forms an integral part of our clinical records. These photographs are occasionally used for teaching, publications in scientific journals, and marketing. By signing below, you signify your agreement to this. Should you not wish this, please add a footnote with your signature specifying your wishes.
  • Please also note that this referral has been for a surgical assessment prior to possible treatment with dental implants. I have carried out a general dental assessment, but I have not carried out a detailed check of all of your remaining teeth and gums. As such, a check should be carried out by your normal dentist, who regularly cares for your teeth. You should confirm that your dentist is happy with the current condition of your mouth prior to the start of any implant treatment, and you should have regular dental check-ups to maintain the health of your mouth, any remaining teeth, and your finished implant.”

Conclusion
The authors believe that, by including the appropriate warnings from this article at the end of every treatment-planning letter, most eventualities should be covered — but every case is different, so the responsibility lies with the clinician to ensure that patients have been made aware of anything that could affect their outcome.

All the warnings written here should already have been discussed with the patient at the consultation stage of treatment and recorded in the clinical notes at that time. This letter and the clinical notes should support one another completely.

It is worth repeating that these common paragraphs and warnings should be adjusted where necessary to suit each patient, and that they are presented as a guide only.

This article is provided as guidance only; while every effort has been made to ensure its accuracy, the reader is recommended to seek professional guidance from his/her indemnifier or professional body about the suggestions made here.

Eddie Scher, BDS, LDS RCS, MFGDS RCS, is a specialist in prosthodontics and oral surgery. A founder and life member of the ADI, he is visiting clinical professor at Temple University, Philadelphia, and is the editor in chief of Implant Dentistry Today.

Sarah Payne, NEBDSA, is the senior surgical nurse and implant coordinator at the Walpole Street Dental Practice. She qualified in 1996 and has worked with Dr. Scher for 17 years.

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