Patient Preferences Regarding 1-Visit versus 2-Visit Root Canal Therapy Kaci C. Vela, DDS,* Richard E. Walton, DMD, MS,† Martin Trope, DMD,‡ Paul Windschitl, PhD,§ and Daniel J. Caplan, DDS, PhDk Abstract Introduction: Patient preferences should be taken into account by clinicians when treatment planning. The purposes of this study were to describe the number of visits patients preferred when undergoing root canal therapy (RCT) and to assess whether their preferences were related to hypothetical treatment success rates. Methods: Self-administered questionnaires were mailed to 351 consecutive patients scheduled for initial RCT appointments in the University of Iowa College of Dentistry’s graduate or faculty endodontic clinic. The questionnaires ascertained demographic information; preferences for 1-visit versus 2-visit RCT given different hypothetical success rate scenarios for the 2 approaches, as well as patient dental history. Univariate frequency distributions were generated, and relationships between hypothetical success rates and patient preferences were evaluated. Results: Questionnaires were returned by 124 patients (35% response). Given equal success rates, 78% of respondents preferred 1visit RCT, compared with 7% who preferred 2-visit RCT and 16% who would follow their dentist’s recommendation. As success rates for 2-visit RCT went from equal to 5% better to 10% better to 20% better compared with 1-visit RCT, the proportion of respondents who preferred 2-visit RCT increased from 7% to 34% to 46% to 65%, respectively. Regardless of success rates, approximately 5% of respondents said they would prefer 2-visit RCT, and 20% would do whatever their dentist recommended. Conclusions: Although most respondents preferred 1-visit RCT regardless of success rates, many would prefer 2-visit RCT if its success rate were greater than that of 1-visit RCT. This finding confirms the importance of discussing success rates and considering patients’ wishes when treatment planning. (J Endod 2012;38:1322–1325)
Key Words Decision making, endodontics, patient preference, root canal therapy
s health care costs continue to rise in the United States, an increasing emphasis is being placed on quality of care. One important aspect of quality of care is proper communication between patients and providers. Providers’ treatment plans should reflect concerns expressed by patients. Although there are numerous articles in the dental literature about treatment decision-making, our knowledge with regard to patient preferences in endodontics is sparse. Clinical decision-making has been evaluated in endodontic retreatment studies (1), in review articles (2, 3), and in original research articles (4–8). These publications tend to report results from surveys of general dentists, endodontists, or undergraduate and graduate dental students and do not reflect opinions from endodontic patients. Studies have evaluated responses from endodontic patients directly (9–11), but to our knowledge there are no published reports that describe the number of visits patients prefer when undergoing root canal therapy (RCT). From some literature outside the field of endodontics, it is evident that patients have diverse needs and expectations that often differ from those of the treating provider. For example, Stewardson and McHugh (11) refuted the common belief among dentists that patients do not like the use of a rubber dam. Liedholm (12) demonstrated that patients prefer outcomes of third molar nonremoval as compared with outcomes of removal. Patients might value convenience factors more than structural factors such as board certification (13) and cite reasons such as dental fears and past dental experiences when choosing one treatment modality over another. Patients want to be actively engaged in the decision-making process (14) and consulted about the impact of treatment (15). One issue relating to patient preferences is whether patients prefer to have RCT completed in a single visit or in 2 visits. Although many patients undoubtedly would prefer the convenience of completing RCT in 1 visit, it also is possible that some would choose that treatment occur across multiple visits (eg, because of temporomandibular joint problems, inability to keep their mouth open, not being able to leave work for longer appointments, or transportation issues). Because little is known about the degree to which patients prefer 1-visit or 2-visit RCT, the purposes of this study were to describe the number of visits patients preferred when undergoing RCT and to assess whether their preferences were related to hypothetical treatment success rates. We hypothesized that given equal success rates, most patients would prefer 1-visit RCT, but that 2-visit RCT would be preferred if 2-visit RCT had greater success rates than 1-visit RCT.
Methods Before study initiation, the protocol and questionnaire were approved by the Institutional Review Board (IRB) at the University of Iowa. On receipt of IRB approval, the
From *Private Practice (Orthodontics), Iowa City, Iowa; †Department of Endodontics, University of Iowa, Iowa City, Iowa; ‡Private Practice (Endodontics), Philadelphia, Pennsylvania; §Department of Psychology and kDepartment of Preventive and Community Dentistry, University of Iowa, Iowa City, Iowa. Address requests for reprints to Dr Daniel J. Caplan, Department of Preventive and Community Dentistry, University of Iowa, Iowa City, IA 52242. E-mail address: [email protected]
0099-2399/$ - see front matter Copyright ª 2012 American Association of Endodontists. http://dx.doi.org/10.1016/j.joen.2012.06.038
Vela et al.
JOE — Volume 38, Number 10, October 2012
Clinical Research investigators mailed self-administered questionnaires to 351 consecutive adult patients (ie, $18 years old) who were scheduled for evaluation and/or initial nonsurgical RCT appointments in the University of Iowa College of Dentistry’s graduate or faculty endodontic clinic. Subjects were asked to return the questionnaires by mail; they could choose to return them anonymously or could identify themselves and receive a $10 gift card for completing the questionnaire (the IRB required that they identify themselves to receive payment). The questionnaires contained 26 questions that assessed demographic information, dental history, and patient preference for 1-visit versus 2-visit RCT. We assessed patient preference under the following 7 hypothetical scenarios: 1. If ‘‘2-visit treatment’’ and ‘‘1-visit treatment’’ had the same success rates 2. If ‘‘2-visit treatment’’ had a 5% better success rate than ‘‘1-visit treatment’’ 3. If ‘‘2-visit treatment’’ had a 10% better success rate than ‘‘1-visit treatment’’ 4. If ‘‘2-visit treatment’’ had a 20% better success rate than ‘‘1-visit treatment’’ 5. If ‘‘1-visit treatment’’ had a 5% better success rate than ‘‘2-visit treatment’’ 6. If ‘‘1-visit treatment’’ had a 10% better success rate than ‘‘2-visit treatment’’ 7. If ‘‘1-visit treatment’’ had a 20% better success rate than ‘‘2-visit treatment’’ The following text was used to orient the participants to the scenarios: Like any procedure, root canal therapy has ‘‘successes’’ and ‘‘failures’’. ‘‘Success’’ means that you have no symptoms in the tooth AND the x-ray shows proper healing. ‘‘Failure’’ means that you either have symptoms in the tooth OR the x-ray does not show proper healing. If your root canal fails, you will either need to: have the root canal therapy redone, undergo a surgical procedure to remove the end of the tooth, or have the tooth extracted (taken out). The rate of success of root canal therapy might depend on how many visits the treatment takes. For certain teeth, treatment completed over 2 visits might be better, while for other teeth, treatment completed in only 1 visit might be better. We want to find out what you would prefer given (these hypothetical situations). For the (seven scenarios), assume that: ‘‘1-visit treatment’’ means 1 appointment that takes about 2 hours. ‘‘2-visit treatment’’ means 2 separate appointments, each taking about 1 hour. The dentist charges the same amount for both types of treatment.
Subjects then were asked to choose from among 3 options for each of the 7 scenarios: 1. Prefer 1-visit treatment 2. Prefer 2-visit treatment 3. It does not matter, whatever the dentist thinks is best Univariate frequency distributions were generated, and the percent of participants who chose each option under each scenario were calculated. Data analyses were conducted by using SAS for Windows Version 9.1 (SAS Institute Inc, Cary, NC).
JOE — Volume 38, Number 10, October 2012
Results Surveys were returned by 124 patients (35% response), all of whom identified themselves and received the $10 incentive fee. Overall, most respondents preferred 1-visit RCT, but perceived success rate did appear to influence many patients’ preferences. Figure 1 shows the percent of subjects preferring 1-visit RCT, 2-visit RCT, or ‘‘whatever the dentist thinks is best’’ for each of the 7 success rate scenarios. If 1-visit and 2-visit RCT had equal success rates, 78% of respondents preferred 1-visit RCT, 7% preferred 2-visit RCT, and 16% would follow their dentist’s recommendation. However, if the success rate for 2-visit RCT were greater than that of 1-visit RCT (ie, as it went from 5% better to 10% better to 20% better than 1-visit RCT), the percent of respondents who preferred 2-visit RCT increased to 34%, 46%, and 65%, respectively, whereas the percent who preferred 1-visit RCT dropped from 40% to 31% to 13%, respectively. For the 3 scenarios where 1-visit RCT had better success than 2-visit RCT, the percent who preferred 1-visit RCT was relatively constant at around 75%, similar to the distribution for the scenario in which the success rates were equal. For each of the 7 scenarios, approximately 5% of respondents said they would prefer 2-visit RCT, and 20% would do whatever their dentist recommended.
Discussion This study had several important findings. 1. Given equal success rates, 78% of subjects preferred 1-visit RCT, and 7% preferred 2-visit RCT. 2. If success rates for 2-visit RCT were at least 10% greater than those of 1-visit RCT, more patients would prefer 2-visit RCT than 1-visit RCT. 3. Even when success rates for 1-visit RCT were greater than those for 2-visit RCT, approximately 5% of respondents said they would prefer 2-visit RCT, and 20% said they would do whatever their dentist recommended. It is likely that for patients who consistently preferred 2-visit RCT or who consistently would do whatever their dentist recommended, reasons other than perceived treatment success drove those preferences. Still, the substantial number of patients whose preference was influenced by perceived success rates underscores the importance of practitioners being knowledgeable about the most current scientific evidence regarding treatment success rates and sharing this knowledge with their patients. The patient can then share in decision-making as to treatment options. Recently, several articles have shown no difference in healing between 1-visit RCT and 2-visit RCT (16–18). In addition, the literature on success of 1-visit versus 2-visit RCT primarily relates to teeth with necrotic pulps and apical periodontitis. Although overall there might be no differences observed between comparison groups in recently published studies, it is possible that certain subgroups of patients could benefit from multiple-visit or even single-visit treatment. We selected the topic of 1-visit versus 2-visit RCT not to add to the extensive literature in that area, but rather as a starting point to evaluate patient preferences in endodontics. Specifically, we evaluated whether hypothetical success rates for 2-visit RCT could be considered important enough by patients to overcome the convenience of 1-visit RCT. We designed our study in this manner because patient values should always be a component of the decision-making process, regardless of diagnosis. Although our findings were consistent with the notion that success rates are important to many patients (and potentially can outweigh the
Patient Preferences Regarding 1-Visit versus 2-Visit RCT
Figure 1. Patient preferences for 1-visit versus 2-visit RCT across various success rate scenarios. Black = It does not matter, whatever the dentist thinks is best; Hatched = Preferred 2-visit RCT; Gray = Preferred 1-Visit RCT. Shown are the percent of subjects who selected 1-visit RCT, 2-visit RCT, or ‘‘whatever the dentist thinks is best’’ for each success rate scenario. Far left column represents the scenario in which 1-visit and 2-visit RCT had equal success. Next 3 columns represent the scenarios in which 2-visit RCT had better success than 1-visit RCT. Three columns on the far right represent the scenarios in which 1-visit RCT had better success than 2-visit RCT.
convenience of having RCT completed in a single visit), our study was not without limitations: 1. The response rate (35%) was relatively low but was comparable to or better than response rates of other surveys published in the endodontic literature (19–21). 2. Treatment times and success rates provided as examples in this questionnaire will not necessarily reflect those characteristics for all providers, because every practitioner provides treatment commensurate with their levels of skill and desired quality. The questionnaire’s presentation of 1-visit RCT taking twice as long as each appointment of 2-visit RCT oversimplifies things considerably, because the clinical time required to anesthetize, temporize, place intra-appointment medicament, and re-access and remove said medicament always will be added to the total treatment time in a multiple-visit scenario. Success rates also might be expected to differ by factors such as tooth type and quality of subsequent coronal restoration (22). 3. Patient preferences might be different if the scenarios were framed in terms of failure rather than success. Patients might view comparisons between 90% versus 80% success differently than comparisons between 10% versus 20% failure, even though these 2 phrases describe identical outcomes, because a perceived doubling of the failure rate could have more influence on patients’ decisions 1324
Vela et al.
than a perceived 10% improvement in success (23). Similarly, reported preferences also might differ if success rates of the 2 approaches were simply presented side by side, and respondents were asked to evaluate the difference (24). Despite the above limitations, this study serves as a good first step in this arena of research and could help practitioners provide better care by taking patients’ preferences into account with regard to their number of endodontic appointments. Further studies evaluating patient preferences (and factors related to those preferences) are needed to enhance our knowledge base so that practitioners could be provided additional patient-centered evidence when planning treatment.
Conclusion Practitioners often make assumptions about patient preferences, such as presuming that patients prefer treatment to occur in fewer visits. Our findings showed that this was not always the case. Although many patients preferred 1-visit RCT regardless of success rates, many others would prefer 2-visit RCT if the latter were shown to offer a substantially higher likelihood of success. These findings confirm the importance of discussing success rates of endodontic procedures with patients when planning treatment. JOE — Volume 38, Number 10, October 2012
Clinical Research Acknowledgments The authors thank Ms Katie Lee for her contributions to the data analysis and the University of Iowa’s Departments of Endodontics and Preventive and Community Dentistry for funding the study. The authors deny any conflicts of interest related to this study.
References 1. Rawski AA, Brehmer B, Knutsson K, et al. The major factors that influence endodontic retreatment decisions. Swed Dent J 2003;27:23–9. 2. Derhalli M, Mounce RE. Clinical decision making regarding endodontics versus implants. Compend Contin Educ Dent 2011;32:24–35. 3. Zitzmann NU, Krastl G, Hecker H, Walter C, Waltimo T, Weiger R. Strategic considerations in treatment planning: deciding when to treat, extract, or replace a questionable tooth. J Prosthet Dent 2010;104:80–91. 4. Alani A, Bishop K, Djemal S. The influence of specialty training, experience, discussion and reflection on decision making in modern restorative treatment planning. Br Dent J 2011;210:1–9. 5. Stockhausen R, Aseltine R Jr, Matthews JG, Kaufman B. The perceived prognosis of endodontic treatment and implant therapy among general practitioners. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e42–7. 6. Sathorn C, Parashos P, Messer H. Australian endodontists’ perceptions of single and multiple visit root canal treatment. Int Endod J 2009;42:811–8. 7. Dechouniotis G, Petridis XM, Georgopoulou MK. Influence of specialty training and experience on endodontic decision making. J Endod 2010;36:1130–4. 8. Davies BJ, Macfarlane F. Clinical decision making by dentists working in the NHS General Dental Services since April 2006. Br Dent J 2010;209:1–4. 9. Dugas NN, Lawrence HP, Teplitsky P, Friedman S. Quality of life and satisfaction outcomes of endodontic treatment. J Endod 2002;12:819–27. 10. Gatten DL, Riedy CA, Hong SK, Johnson JD, Cohenca N. Quality of life of endodontically treated versus implant treated patients: a university-based qualitative research study. J Endod 2011;37:903–9.
JOE — Volume 38, Number 10, October 2012
11. Stewardson DA, McHugh ES. Patients’ attitudes to rubber dam. Int Endod J 2002;35: 812–9. 12. Liedholm R. Mandibular third molar removal: patient preferences, assessments of oral surgeons and patient flows. Swed Dent J Suppl 2005;175:1–61. 13. Bornstein BH, Marcus D, Cassidy W. Choosing a doctor: an exploratory study of factors influencing patients’ choice of a primary care doctor. J Eval Clin Pract 2000;6:255–62. 14. Coulter A, Jenkinson C. European patients’ views on the responsiveness of health systems and healthcare providers. Eur J Public Health 2005;15:355–60. 15. Frosch DL, Kaplan RM. Shared decision making in clinical medicine: past research and future directions. Am J Prev Med 1999;17:285–94. 16. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth. J Endod 2008;34:1041–7. 17. Penesis VA, Fitzgerald PI, Fayad MI, et al. Outcome of one-visit and two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod 2008;34:251–7. 18. Sathorn C, Parashos P, Messer HH. Effectiveness of single- versus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and meta-analysis. Int Endod J 2005;38:347–55. 19. Dutner J, Mines P, Anderson A. Irrigation trends among American Association of Endodontists members: a web-based survey. J Endod 2012;38:37–40. 20. Naylor J, Mines P, Anderson A, Kwon D. The use of guided tissue regeneration techniques among endodontists: a web-based survey. J Endod 2011;37:1495–8. 21. Crawford JF, McQuistan MR, Williamson AE, Qian F, Potter KS. Should endodontists place implants? A national survey of general dentists. J Endod 2011;37:1365–9. 22. Tavares PB, Bonte E, Boukpessi T, Siqueira JF Jr, Lasfarques JJ. Prevalence of apical periodontitis in root canal-treated teeth from an urban French population: influence of the quality of root canal fillings and coronal restorations. J Endod 2009;35:810–3. 23. Levin IP, Schneider SL, Gaeth GJ. All frames are not created equal: a typology and critical analysis of framing effects. Organ Behav Hum Decis Process 1998;76:149–88. 24. Zikmund-Fisher BJ, Fagerlin A, Roberts TR, et al. Alternate methods of framing information about medication side effects: incremental risk versus total risk occurrence. J Health Commun 2008;13:107–24.
Patient Preferences Regarding 1-Visit versus 2-Visit RCT