Author: Jeremy Jacquot
Date: June 2005
Trust is the foundation of a successful patient-dentist relationship, as with all other relationships. By engendering feelings of ease and confidence in his or her abilities, a skilled dentist is capable of allaying a patient's fears, and of rendering the dental encounter a pleasant and painless one. A heightened sense of trust also facilitates a patient's interactions with the dentist, provides a greater feeling of satisfaction with provided dental services, and promotes therapeutic compliance. Although few studies have directly examined trust, factors that comprise the concept were reviewed in order to recommend ways to increase trust in patient care.
In the dentist-patient relationship, trust comes from the assurance that personal information will be kept confidential, that procedures are in the patient's best interest, and that patient autonomy is recognized. Furthermore, trust is a mutual understanding communicated in an egalitarian and ethical manner. Patients have more confidence in dentists who have the ability to communicate care and compassion (Epstein 2003). This confidence helps reduce patient anxiety and fear of dental procedures (Awad et al. 2000).
In 1996, professional dentistry enacted the Patient Bill of Rights to demonstrate dentistry's commitment to a patient's trust and autonomy, with respect to oral health and care delivery. The lack of trust in such a relationship may erode confidence in the dentist and in the dental profession, leading to limitations in meeting patient needs and expectations (Price et al. 2002). Although few studies directly examine trust, factors that comprise the concept are studied. These factors include the ethical standards of dentists, the communication between dentists and patients, and their shared responsibilities of decision-making. This article reviews such factors in order to recommend ways to increase trust when treating patients. The sources examined include articles from the medical and dental literature.
To obtain the necessary background information, a literature review was conducted using numerous online search engines including MEDLINE, Web of Science, and Ovid.
Specific search criteria were used to research articles on the search engines. These included articles written in English, articles from the case report/series, editorial, opinion, and clinical trial categories, and articles published after 1980. The keywords entered into the "PubMed" search engine of MEDLINE included "trust in dentistry," "ethics in dentistry," "dentist-patient relationship," and "dentist-patient communication." Similar keywords were used in Web of Science and Ovid to find relevant articles. Out of the 200 articles obtained from the keywords, 35 were further investigated. Of these, only 20 were used for this review. The chosen articles specifically addressed the topics I was investigating and were characterized by detailed explanations of methods used and the results obtained. The authors also supported their results with thorough discussions and postulations.
Various articles, scientific journals, and polls/surveys were obtained from these resources. Primary sources, including books and articles, were also taken from the UCLA Biomedical Library, but were later rejected in favor of more recent publications. Additional publications were acquired by researching articles from the sources' references. Books were also obtained through the UCLA Biomedical Library, but were later rejected in favor of more recent publications. Out of the 200 articles obtained, 35 were selected.
The factors most closely related to a discussion of trust include ethics, communication, and shared decision-making. Both patients and dentists view ethics as the integrity and honesty of care providers in conducting their practices. Efficiently communicating this integrity and honesty is another significant topic. Patients expect to be treated equally, and to not be discriminated against on the basis of their race or culture (Noonan et al. 2003). Ethics and effective communication have long been recognized as pivotal in the practice of dentistry (Schouten et al. 2003). Shared decision-making, on the other hand, has only recently been acknowledged in the literature, and its merits are now being reviewed in response to patients desiring a more active role in deciding treatment strategies (Chapple et al. 2003; McCann et al. 1996; Schouten et al. 2003).
Patient Expectations and Perceptions Ethics
As may be expected, patients value a strong sense of ethics and integrity. In November 2003, a Gallup poll showed 61% of respondents felt dentists were honest and trustworthy. This was up from the previous year where 56% responded as such (margins of error for this survey were not available). This indicates that less than a third of poll respondents consider dentists dishonest and opportunistic (Carr 1998). The specific question asked was, "How would you rate the honesty and ethical standards of people in these different fields?" Gerber et al. (1992) suggest that this is due to scandals and negative patient experiences that have shed unfavorable media coverage on dentistry over the past years. A patient's lack of trust in a dentist's ethics has serious implications. For example, patients confident in their dentists' integrity were more likely to assume a more passive role in deciding their treatment plans, while others' lack of trust compelled them to desire a more active role in the decision-making process (Chapple et al. 2003). More importantly, a patient's level of confidence in a dentist determines whether that patient will regularly seek healthcare (O'Malley et al. 2004).
Patients expect dentists to listen and to understand their needs, as well as to objectively assess their social and cultural characteristics when explaining treatment options. As a recent study showed, dentists are the most important factor affecting dental outcomes. This is due in great part to dentists' ability to make the dental experience as enjoyable as possible, and to the dentists' display of effective communicative skills (Chambers 2001).
Not surprisingly, patients prefer dentists who exude a sense of humanity and compassion, as these traits facilitate the dental encounter and encourage better treatment adherence (Halpern 2003). Surveys and informal interviews carried out with the patients have shown that finding a dentist they can trust and who treats them with care and empathy is a significant consideration (Charles et al. 1999). Empathy has also been shown to facilitate trust and disclosure, and to directly enhance therapeutic efficacy (Halpern 2003). For instance, it has been directly linked to decreased patient anxiety, which, in turn, has led to a higher incidence of improved outcomes for a variety of illnesses (Halpern 2003). Especially for patients who experience dental fear and anxiety, exhibiting amiability and good interpersonal skills can greatly alleviate their worries and fears while making the experience more pleasurable.
An important aspect of the communication between dentists and patients is based upon an understanding and respect of different cultural backgrounds. Research has demonstrated that there exists a disparity in the perceptions of oral health status across distinct ethnic groups (Newton et al. 2003), and that people in general have a preference for health care providers that share their ethnicity (Noonan 2003). Distinct cultures tend to have very different values, with some placing more emphasis on their oral health than others, and some displaying a better understanding of the consequences of poor health. The "cultural deprivation" theory states that certain social groups will be less likely to seek healthcare as often as others due to poor health (Petersen 1990). For example, African-Americans tend to have less frequent visits to dentists and therefore often report more problems and higher levels of dissatisfaction with their oral health. On the other hand, Chinese and Indian groups are more concerned about their health, and habitually report higher levels of impact on their teeth than do other groups, including Caucasians. For example, Chinese patients have a much greater tendency to report limitations of or impact upon their ability to chew or speak that result from dental treatment (65% and 38%, respectively) than do Black Caribbean patients (19% and 17%, respectively) (Newton et al. 2003). There also exist interesting differences between how health and disease are viewed in Asian societies as opposed to Caucasian societies. While Asians learn about and practice healthcare at home, only seeking professional aid when home remedies fail, Caucasians, on average regularly seek out professional care and learn from their physicians. Furthermore, there are not any private dentists in several parts of Asia, including Japan and certain regions of China. Instead, polyclinics are found at or near the workplace or residences and provide services to the general populace (Kawamura et al. 2001). It is important that dentists comprehend and appreciate their patients' needs, and do their best to accommodate each patient's demands fairly, since people have different values and priorities. Doing so may engender feelings of trust in dentists whose patients might not necessarily possess the same cultural backgrounds. By appealing to each patient's individual beliefs and values, dentists may be more successful in encouraging continuity in pursuing treatments and in fostering better oral health.
Involvement in Decision-Making
Ever since the implementation of the Patient Bill of Rights, patients have been encouraged to participate more in their treatment plans in order to gain a better understanding of their therapy and to increase the satisfaction they experience upon its completion. While some research has shown that certain patients do not desire more involvement in the decision-making process, many others have demonstrated that they do. They want to learn more about their treatment plans and want an active role in the process (Chapple et al. 2003; Schouten et al. 2003). Also, even though some patients may want a more active role, their desires for information and participation is not reflected in their overt behavior. Amongst the factors that might dissuade patients from adopting a greater role include knowledge of dentistry and trust. Certain patients' lack of knowledge regarding their dental care causes them to relegate the decision-making process to their dentists. However, the patients who express more confidence and trust in their dentists' abilities are also less likely to assume an involved role in the decision-making process (Schouten et al. 2003). Indeed, the dentists' communicative behavior was negatively correlated with the number of questions the patients asked during emergency consultations (Schouten et al. 2003). This indicates that the more adept the dentist is at communicating with patients, the less information the patients tend to seek during consultations. On the other hand, those who felt less trustful of their dentists tend to take a more active role. This again shows the influence of trust on arguably the most important aspect of the dentist-patient relationship: both parties' participation in the decision-making process.
Dentist Expectations and Perceptions Ethics
A recent study reported that dentists hold firm beliefs in complete disclosure and in the value of kindness. This indicates that they cherish the notion of presenting honest and ethical opinions to their patients (Chambers 2001). Recent findings have shown a small deterioration in the level of confidence displayed by people in the field of dentistry over the past few years. A study that conducted extensive polling of dentists showed that a great majority (92% of respondents) believe that the decline in public image of the dental profession was due to sensationalism in the media (Gerber et al. 1992). Indeed, most dentists are united in their consternation over this problem, although they differ in the solutions they offer to help remedy it. Dentists as a whole view most of their colleagues as honest and competent, with only a few expressing misgivings about those that fail to abide by dentistry's basic tenets. The fact that only about 2% of respondents would allow their colleagues to do all their dental work does not indicate wide distrust (Gerber et al. 1992). Instead, it more likely demonstrates that dentists simply believe that their own individual skills are better (Gerber et al. 1992).
The dentist's ability to communicate clearly and effectively is one of the underlying factors assuring a successful dentist-patient relationship and the key to all outcomes of the dental practice. Personality and a deep understanding of different cultural and ethnic backgrounds are the most important components of this communication.
Chambers investigated exactly what constituted the typical dentist personality and value structure (2001). One pattern discovered is that dentists tend to show a preference for the concrete over the theoretical, favoring the practical, objective, and definite. In other words, dentists place emphasis on the practical. The Allport-Vernon-Lindsey survey was also used (Chambers 2001). It provides scores in six areas which include economic, theoretical, esthetics, social, political, and religious. The results show that dentists and students are high in the economic (they tend to orient towards the practical and useful), theoretical (they value truth), and political areas (they like having power), but were low in the esthetics area (emphasizing form and harmony). According to the Gordon Survey of Values, dentists also value social good (Chambers 2001). Thus, the data suggests that dentists orient themselves toward what is true and practical, disdaining what is theoretical and abstract. Dentists believe in the importance of giving back and alternatively tend to value power. Displaying a strong sense of benevolence through a kind and compassionate personality, and a value for truth through an ethical persona, go a long way toward facilitating the communicative process and allowing it to be more egalitarian and enjoyable.
Once a profession dominated by white males, the dental field has witnessed a growth in the numbers of dentists from different ethnic/cultural backgrounds, with Asians accounting for an overwhelming majority of these new arrivals (Brown et al. 2000). However, due to the great disparities in oral health that still exist between different ethnicities, there is still a strong need for greater diversity in the dental profession. In general, past studies illustrate that people seek, and have a preference for, healthcare providers with whom they share a similar ethnic background (Noonan et al. 2003). This generally seems to be the case, as surveys portray whites as being the overwhelming majority of patients treated by white dentists, with the same results applying to African-Americans. Brown, et al., concluded from their results that the race/ethnicity of dentists seemed to influence the race/ethnicity of patients who visited them for treatment (2000). Therefore, some dentists believe that besides helping to promote and provide oral care for all people, increasing the diversity of dentists will be useful in targeting diseases and other problems that are linked to certain populations. For example, if African-Americans on the average were more likely to develop periodontal disease due to genetics or cultural values and practices, an African-American would be most effective in providing services to this group due to a more fundamental understanding of population dynamics (Noonan et al. 2003).
Involvement in Decision-Making
Traditionally, dentists have presented evidence and treatment options in a paternalistic approach (Chambers 2001; Schouten et al. 2003; Chapple et al. 2003). According to this approach, the dentist knows how best to treat the patient so he/she should be given full responsibility in the decision-making process. Many dentists prefer not to get their patients involved out of a sense of benevolence, because they believe that they know what is best for them and therefore do not see the need for patient input (McCann et al. 1996). They also prefer to take control so that their behavior remains unopposed, and their risk through interface drastically lessened (Chambers 2001). On the other hand, there are also many dentists who have relegated more responsibility to the patients and who make it a point to explain oral care problems and potential treatment plans to them in order to let them make the final decision. The problem is that in order to engender trust, dentists need to maintain an egalitarian relationship with their patients, which basically means that they have to convey all the information relating to the dental case and potential treatment plans to them. This relates to informed consent, or the idea that a patient agrees to an operation after the dentist explains the risks, consequences, and alternatives involved. As many of the articles indicate, this is an area in which dentists should improve in order to better accommodate their patients' needs (Chapple et al. 2003; McCann et al. 1996; Schouten et al. 2003). Not doing so may promote errors in treatment, lead to unmet needs, and cause patients not to listen or follow suggested treatment or compliance.
Discussion and Recommendations
To build upon the foundation of trust in the dentist-patient relationship, it is imperative that dentists follow certain guidelines during their consultations. While they have the right to offer an honest opinion or second opinion, dentists always should act within the jurisdiction of fairness and truthfulness, and in the patient's best interests (Jeffcoat 2002).
Improving upon their communication skills should be another important priority for dentists as they strive to make the dental encounter pleasurable and worthwhile for the patients. Accomplishing this will likely have dual benefits. The first one being that by displaying genuine sympathy and interest in the patient as an individual, the dentist may make the patient feel more at ease and assuage those patients that exhibit dental fear and anxiety. The second, and potentially most significant benefit, may be to foster continuity in regularly seeking dental care, and encouraging the patient to adopt a more active role in maintaining proper oral health. Besides being more personable, dentists also need to better understand their patients' various ethnic/cultural backgrounds in order to better accommodate their individual needs and concerns while still showing respect for their values and beliefs.
The most pressing issue that dentists should attend to, however, is the issue of patient involvement in the decision-making process. First of all, offering longer and more thorough consultations will likely lead to a greater willingness to participate, while informing patients of their rights and of the circumstances surrounding their case may encourage more active debate (Chapple et al. 2003). The "paternalistic" model should be discarded in favor of creating an egalitarian relationship in which both parties can contribute to the decision-making process and in which the patient retains the final say.
Although dentists are still highly regarded and widely trusted by the majority of the populace, there is still much work that can be done in order to instill a greater sense of trust into their patients and to improve the dynamics of the patient-dentist relationship. For a consultation based upon mutual trust and communication, both parties must accommodate each other's needs and demands for equal roles in the entire process. Dentists should be the ones to relinquish more control and take an active role in understanding and valuing their patients as individuals. Moreover, to ensure a successful relationship and continuity in the treatment process, dentists need to focus on building a strong sense of trust that pervades all aspects of dentist-patient interactions.
Awad M.A. et al. (2000). Determinants of patients' treatment preferences in a clinical trial. Community Dent Oral Epidemiol. 28:119-25.
Brown LJ et al. (2000). Racial/Ethnic Variations of Practicing Dentists. JADA 131:1750-4.
Carr CJ. (1998). Gallup Poll Rates Honesty and Ethical Standards. Regulatory Toxicology and Pharmacology 29:96.
Chambers DW. (2001). The Role of Dentists in Dentistry. Journal of Dental Education 65:1430-40.
Chapple H, et al. (2003). Exploring dental patients' preferred roles in treatment decision-making - a novel approach. Br Dent J. 194:321-7.
Charles C, et al. (1999). Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Social Science & Medicine 49:651-61.
Epstein RM. (2003). Virtual physicians, health systems, and the healing relationship. J Gen Intern Med. 18:404-6.
Gerber B, et al. (1992). How dentists see themselves, their profession, and the Public. J Am Dent Assoc. 123:72-8.
Grace M. (1999). Opinion. Facts and myths. British Dental Journal. 186:595.
Grace M. (2003). Opinion. Trust. British Dental Journal. 194:289.
Halpern J. (2003). What is clinical empathy? J Gen Intern Med. 18:670-4.
Holt RD. (2004). Editorial. International Journal of Paediatric Dentistry. 14:153-4.
Jeffcoat MK. (2002). Editorial. A dentist's bill of rights. What are the fundamental principles? J Am Dent Assoc. 133:540-1.
Kawamura M et al. (2001). A cross-cultural comparison of dental health attitudes and behaviour among freshman dental students in Japan, Hong Kong and West China. Int Dent J. 51:159-63.
Lange AL et al. (1982). Professional satisfaction in dentistry. J Am Dent Assoc. 104:6219-24.
Matthews R. (2001). Trust me, I'm a dentist. British Dental Journal. 190:276.
McCann S and J Weinman. (1996). Empowering the patient in the consultation: a pilot study. Patient Educ Couns. 27:227-34.
Newton JT, et al. (2003). The self-assessed oral health status of individuals from White, Indian, Chinese and Black Caribbean communities in South-east England. Community Dent Oral Epidemiol. 31:192-99.
Noonan AS and CA Evans. (2003). The Need for Diversity in the Health Professions. Journal of Dental Education. 67:1030-3.
O'Malley AS, et al. (2004). The role of trust in use of preventive services among low-income African-American women. Prev Med. 38:777-85.
Petersen PE. (1990). Social inequalities in dental health. Towards a theoretical explanation. Community Dent Oral Epidemiol. 18:153-8.
Price J and L Leaver. (2002). ABC of psychological medicine: Beginning treatment. BMJ. 325:33-5.
Schouten BC, et al. (2003). Patient participation during dental consultations: the influence of patients' characteristics and dentists' behavior. Community Dent Oral Epidemiol. 31:368-77.