The patient perspective
A core component of patient-centred care is the discussion of a shared personalised plan of care. The ‘DECIDE’ stage focuses on identifying that plan and making it explicit. The co-creation of a care plan with the patient enhances the patient’s understanding and commitment to the plan.
What it is
Decide: the personalised care plan, at the patient and the tooth levels, is the third essential step in the 4D-cycle for effective and personalised care. The aim of this step is to synthesise all of the information gathered about the patient’s caries risk (1st D) and any caries lesions (severity and activity) (2nd D) to develop an informed, risk-based, tooth-preserving care plan. This step is very important because:
• It determines, at the tooth-level, what type of treatment to provide; preventive versus surgical
• It helps to maintain good oral health and avoid unnecessary removal of tooth tissue
• It helps allocate resources appropriately, based on risk
• It involves the patient’s active engagement on the importance of oral health, avoiding future caries and operative treatment
• It helps clinicians to determine the recall interval for the patient
How to develop the personalised care plan
This step involves discussion with the patient as well as synthesis and consolidation of all the information gathered about the patient’s history and clinical findings, as described in this guide. There are practical synthesis guides in relation to caries lesions’ stage and activity likelihood, as well as patients’ risk classification (for example, ICCMS guideline and webpage). Decision trees will help to determine the personalised care plan, both at the patient and tooth levels.
Arrive at a diagnosis for each caries lesion
Caries diagnosis is the result of combining the caries severity stage, as determined from visual and radiographic examination (initial, moderate or extensive), with an accompanying lesion activity assessment into the categories below:
• Initial active or inactive
• Moderate active or inactive
• Extensive active or inactive.
Note that, as with patient’s caries risk, lesion activity can change over time and therefore so can a lesion’s diagnosis. Taking into account the information gathered from the 2nd D (as described in Tables 1–4), Figure 3 shows a flowchart that outlines how the process flows from clinical assessment through radiographic assessment and lesion activity assessment to categorise coronal caries lesions as an example.
Arrive at a diagnosis of patient’s caries risk
A patient’s caries risk will have been determined after analysing history (1st D) and intraoral risk factors, including the presence of active caries lesions (2nd D) (Fig. 2). The influence of caries risk on deciding the appropriate care plan lies mostly at the two extremes of high and low risk. Correctly identifying patients who are particularly at lower risk and those who are at higher risk guides risk-informed appropriate care. Figure 4 shows the caries risk level classification flowchart, outlining the process flows to establish the level of caries risk.
Decide upon the personalised care plan: patient and tooth levels
Patient’s risk management plan: this is tailored to the individual patient and will involve actions to protect sound tooth surfaces from developing new caries lesions, arresting currently active lesions, and maintaining inactive lesions from progressing. In addition, it aims to lower the risk status of the patient, if not already low, and to maintain low risk status. A preventive plan should address both homecare and clinical interventions/approaches informed by the caries risk status of the patient.
Tooth-level management plan: information on each caries lesion will be synthesised in terms of whether or not they are likely active and if they are of initial, moderate or extensive severity:
• Initial likely active/initial likely inactive
• Moderate likely active/moderate likely inactive
• Extensive likely active/extensive likely inactive.
Figure 5 shows the patient’s care plan flowchart, outlining the logical flow of integrating the management of individual lesions assessed for activity and the management of risk at the patient level. The three management options for surfaces at the end of this flow are keeping sound surfaces sound, controlling lesions with non-operative care, and providing tooth-preserving operative care for only those lesions that need it. The management options to control caries risk at the patient level are also outlined.
Guidance references: 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,