Shared decision making - A fundamental component of patient-centered care for dental patients

Abstract

When dental patients seek care to reduce—or preferably eliminate—existing oral health impact, or when such impact is anticipated in the future, to prevent it from occurring; ideally, they do this in partnership with the oral healthcare provider in a shared decision making (SDM) process. This process is essential to achieving an optimal oral health care experience for patients and providers alike and the best treatment outcomes, i.e., what dental patients want to accomplish when seeking care.

This report presents foundational knowledge about SDM and the characteristics that shape SDM for the dental patient. It presents SDM as a part of the dental encounter—the interaction between a patient and a dental provider in which dental services are provided.

This report also introduces a new concept, the four-dimensional dental encounter (4DE), in which the patient-clinician interaction centers around (i) the patient’s four-dimensional, i.e., functional, painful, aesthetical, and broader psycho-social oral health impact, (ii) the treatment options to address existing or prevent future impact from occurring, (iii) the patientś preferences for these options.

Given this new concept, dentistry as a field is well-positioned to reexamine how it engages patients, to meet patients where they are. Through the four-dimensional dental encounter (4DE), SDM for the dental patient can be more patient-centered by optimizing the patient’s care experience, improving treatment outcomes while not increasing costs.

This report proposes a new model of Shared Decision-Making (SDM) for dental patients. We argue that a contemporary understanding of oral health impact, i.e., the suffering of dental patients from oral disorders, needs to be incorporated into SDM for dental patients, as addressing existing and preventing future oral health impact is the primary reason patients seek dental care. Therefore, a new SDM model for dental patients is needed: one that adds a novel step to existing general SDM models and makes existing SDM components more specific and practical to dental care. We argue that this model is fundamental to oral health care, as without its incorporation, both the care experience and outcomes will not achieve their full potential.

This report is structured as follows: In Section 1, we provide an overview about general SDM principles. A description of the unique setting that typical patients and their providers encounter follows in Section 2. Consequently, a need for a new SDM model for dental patients arises, and we introduce this model in Section 3. Finally, in Section 4, we discuss the theoretical and practical implications of this new SDM model for dental patients as well as future research directions.

1. Shared decision making for patient care

The first of four sections describes the importance of SDM in general patient care, recognizing that dental patients are a part of this broader population. A brief historical context is also provided for SDM. The core elements of SDM are then presented, laying the foundation for understanding how this process can be enhanced by leveraging an improved focus on oral health impact—a central component of the patient-dental provider interaction.

1.1. The importance of SDM

Experts agree that including patients in their treatment decisions is paramount for high-quality care. The US Preventive Services Task Force (USPSTF) recognizes shared decision making (SDM) as a critical component for informing patients and ensuring their values and preferences are included in any treatment strategy. Review evidence concludes that while patients’ views are not monolithic, a majority prefer to be included in their care and treatment decisions.(1) Today, SDM is widely viewed as an ethical imperative and framed as a deliberate partnership between a patient and a clinician where communication centers on understanding care options, reviewing best evidence, and weighing options for what to do next. This model of care is not new and has emerged over time in response to care that has historically been driven by a doctor’s judgment with little attention to a patient’s values or preferences. These paternalistic systems of care were accepted practice for generations and assumed that the best clinical practice is determined solely as a product of clinical expertise.

The history of medicine has long been marked by tension between the authority of physicians and the lived experiences of patients. In Ivan Illich’s controversial book, Limits to Medicine, he writes, “A vast amount of contemporary clinical care is incidental to the curing of disease … Awe-inspiring medical technology has combined with egalitarian rhetoric to create the impression that contemporary medicine is highly effective.” (2) While contentious, the sentiment reminds us how clinical expertise has often eclipsed patient experience. As science improved over time, so did opportunities to diagnose and treat illness with unprecedented precision, yet the fundamental question remains: Does this progress reflect what truly matters to patients? Arguably, SDM emerged as an approach to address this very concern—bringing patient voices to the center of clinical encounters.

The origins of SDM lie in a gradual shift away from paternalistic models of care toward patient-centered frameworks. George Engel, who created the biopsychosocial model, did so by highlighting the limitations of applying a strictly biomedical model, suggesting that the relationship between patient and provider as well as psychosocial determinants were needed to provide better (more holistic) care to patients.(3) By the mid-twentieth century, new understandings of illness behavior (4) and the rise of medical sociology (5) underscored that patient experience and cultural context shape both perceptions of health and health outcomes.(6) These shifts laid the groundwork for SDM, an approach that acknowledges patients as active participants and experts in their own values, preferences, and life circumstances.(7)

The broader movement toward patient-centered care—reflected in Emanuel and Emanuel’s deliberative model of the physician–patient relationship (8), and Charles et al.’s defining features of SDM—cemented the idea that patients and providers must share responsibility for health decisions, particularly when outcomes are uncertain or multiple reasonable options exist.(9) New impulses for SDM are expected from artificial intelligence (AI), as it can alleviate barriers SDM faces in clinical practice,(10) while also posing risks to the SDM process.(11)

Over time, SDM has been framed as both a clinical necessity and an ethical imperative. (12) Patient-centered communication models advanced in the 90s by McWhinney (13) and later refined by Makoul and Clayman (14) helped formalize SDM as a “meeting of experts” in which medical evidence and patient values converge. It not only strengthens patient-provider communication but also promotes partnership, ensuring that patients’ preferences and vulnerabilities are recognized in treatment planning.(13–15) In this time reviews have emerged, characterizing the impact and effects of SDM in clinical practice and demonstrating links between SDM and patient outcomes, with findings pointing to a positive effect in several clinical situations but not in all.(16) Despite this modest evidence for the SDM-outcome link, there is broad enthusiasm for SDM to improve care delivery because of its strong clinical plausibility.(17) Therefore, many experts agree that with more data and implementation studies, identifying additional aspects of the relationship between SDM and patient-reported outcomes is likely.(18)

1.2. The elements of SDM

The literature on shared decision making includes several definitions, but most experts in this field would agree that it centers on what happens when a patient and a clinician collaborate and deliberate (19) to determine what to do next. In fact, many experts agree that SDM describes the intentional interaction of patients and providers to address a patient concern. While definitions vary and subtleties exist, (20,21) we are borrowing from Stiggelbout and colleagues (22) a characterization of SDM in four steps. This approach is a compromise between models like Elwyn’s three-talk model (23) and the Agency for Healthcare Research and Quality (AHRQ)’s five-step Seek, Help, Assess, Reach, and Evaluate (SHARE) approach. (24) (Fig 5, left panel).

Figure 5:

Four-step SDM approach for patients in general and 5-step approach for dental patients

The four SDM steps can be briefly characterized as follows:

1. Inform the patient that a decision needs to be made. The patient and provider establish a relationship by laying the groundwork for addressing a problem or making a decision. Patient and provider introduce themselves and engage in a series of exchanges to determine what is on the patient’s mind or what potential problems may require assistance.

2. Explain the treatment options. Once the problem or concern is identified, the team deliberates potential options, if clear options are available. Based on the available evidence, the pros and cons of each option are discussed to ensure relevance and understanding. Tools such as decision aids are often used at this stage, (21) with evidence related to risks and outcomes methodically outlined.

3. Discuss the patient’s preferences. The team deliberates the options with respect to the patient’s preferences and values, with intention given to both evidence and uncertainties. This step involves intentional back-and-forth between the provider (content expert) and patient (lived experience expert) to elicit the patient’s preferences and values, while also working to increase the patient’s understanding of how the options align with their lived experience.

4. Reach a decision. The patient and provider, in partnership, develop a plan for next steps, which may include deferring a decision to a follow-up visit. The need for additional information and support is identified. This step also includes an acknowledgment of uncertainty.

Current theoretical controversies around shared decision making

Across medical practices, these four SDM steps have not translated into widespread application.(25) Some believe this has to do with continuous debates on definitions and best practices.(26) Others suggest that the term itself, shared decision making, lends itself to misinterpretation.(27)

The rise of the concept patient-centeredness has also added to potential misinterpretations and likely confusion among practicing clinicians across the care spectrum. As a consequence, many providers have chosen to adopt a version of SDM that strays from these core steps.(28) Researchers have noted these multiple uses of the term SDM over the past decade, calling attention to broad confusion around SDM’s application in various settings and across conditions.(19) This stagnant implementation of SDM is well documented and suggests that standardization may be helpful. (29) Here, AHRQ’s SHARE approach (24) has been cited as a way forward, yet some still believe that SDM remains too narrowly focused on the treatment decision itself.(30)

2. Shared decision making for dental patients

The second section describes the unique context of SDM encountered by dental patients. The SDM models discussed in the previous section, which are essential for explaining behaviors such as SDM, are also applicable to dental patients. However, because SDM is inherently context-specific, we explore whether general SDM principles require adaptation, a new model, for the dental care setting.

While dental patients in general are the target in this report, we focus on “typical” dental patients, meaning those suffering from tooth loss and the oral conditions that cause it. This includes conditions such as caries, periodontitis, non-carious processes (attrition, abrasion, erosion, and abfraction) leading to tooth substance loss, and trauma or injury. While our discussion is also relevant to disorders such as temporomandibular disorders (TMD) or oral cancer, these conditions share characteristics with other chronic pain disorders (e.g., headaches, back pain) or other cancer types, respectively. For these disorders, general SDM models remain highly pertinent when care is provided by a dentist.

To complement our general considerations regarding SDM for dental patients, we review the current literature on SDM implementation in routine dental care settings.

2.1. Dental patients’ specific characteristics that influence SDM

Dentistry has some specific characteristics that can influence SDM:

1. Dental patients seek more preventive care than patients in general: Dental patients can be separated into those with a current oral health problem and those seeking to prevent a future one. Therefore, dental visits can be categorized as therapeutic or preventive. In dentistry, a large proportion of visits are preventive as many patients visit their providers at regular intervals to monitor their oral health. For example, in the US from 2001 to 2018 the proportion of preventive visits was consistently larger than the proportion of restorative visits.(33) While preventive and therapeutic interventions share many common characteristics, SDM for preventive interventions is typically less challenging because the patient is currently not (substantially) suffering, unlike SDM for therapeutic interventions, where the patient is typically distressed by their health condition.

2. Dental patients typically have lower disease severity and less complex treatment options: Disease severity in dental patients is generally lower, and the range of available treatment options is often narrower than for medical patients with systemic diseases. While medication is a frequent choice for many medical patients, dental treatment most often involves surgical approaches followed by restoration of the impaired structure, such as a filling for a decayed tooth.

3. Treatment outcome severity is typically less for dental patients: For dental patients, death, i.e., a patient’s survival or quantity of life, is rarely a disease outcome of concern. Instead, quality of life, specifically oral health-related quality of life, is the major outcome. Dental patient-reported outcomes (dPROs, (34)) thus become the primary targets for dental interventions. Because oral diseases are generally less severe, they typically require ambulatory care rather than hospitalization, long-term care, or similar intensive settings.

4. The time horizon for treatment outcomes to materialize is typically shorter for dental patients. The time horizon for treatment outcomes to materialize is related to the severity and complexity of oral diseases. Treatment length is shorter and treatment outcomes materialize relatively quickly. For example, tooth pain related to tooth decay is often immediately addressed with a dental filling.

5. Provider complexity is typically lower for dental patients: When disease severity and complexity are lower and treatment length is shorter, fewer providers are required for treatment. For most oral diseases, a general dentist is often able to provide the necessary care, whereas medical patients often require a team of physicians with multiple specialists.

2.2. SDM implementation status for dental patients

Despite frequent and intense patient-provider interactions in oral health care, the manner in which SDM is conducted remains largely unknown. (35) To explore SDM implementation for dental patients, we conducted a narrative review.

Aim:

We intend to address the following questions:

1. When SDM for regular dental patients is assessed, is a comprehensive assessment conducted using both expert-based and patient-reported evaluations?

2. What is the level of SDM in regular dental care settings when assessed by an independent expert?

3. What is the level of SDM as perceived by the patient, and how do they prefer it to be implemented?

Methods:

To study SDM for dental patients in regular care settings, we performed a systematized search for the following: shared decision making or patient participation and dentistry. A search (see appendix) was developed for Medline(R)ALL (via Ovid) utilizing controlled vocabulary and natural language keywords. The search syntax was translated to the following databases: Embase+Embase Classic (via Ovid), Scopus, and Web of Science (Core Collection). The search aimed to comprehensively capture literature about shared decision making in dentistry. Search results (3074 reports) were uploaded to Covidence for de-duplication, screening, and categorization. Two reviewers independently assessed articles for their relevance to SDM as it relates to dentistry. Only reports (N=13) were extracted that described regular dental care settings, i.e., new SDM approaches that authors introduced to patient care were not included. A hand search of the reference lists of the extracted articles was also performed. In total, 5 reports that met our criteria were included in our review.

To summarize the SDM rating results from individual studies, we used a random-effects model.

Results:

1. Comprehensive SDM assessment: No study was found that characterized SDM for dental patients using a comprehensive perspective that included both, (i) an expert-reported assessment of the SDM level and (ii) a patient-reported assessment of the SDM level as perceived by the patient.

   Conclusion: Currently, SDM for dental patients is not studied comprehensively using a contemporary approach that includes both an expert-based and a patient-reported perspective.

2. Expert-determined SDM level: One study examined expert-reported SDM. (36) Study subjects were a convenience sample of 32 orthodontic patients (response rate: 97%, resulting in 31 study participants), who attended a teaching hospital in the UK and all dentists (N=14) treating these patients.

   The SDM level was measured independently using OPTION-12 by two dentists who were colleagues of the treatment providers. OPTION-12’s total score was expressed as a percentage, with 0% indicating that none of the 12 SDM behaviors were observed and 100% indicating that all 12 behaviors were exhibited to a very high standard. A score of 50% indicated that the 12 behaviors were, on average, “observed and a minimum skill level [was] achieved.”

   Expert-reported SDM level reached 46% (95% confidence interval: 33%−52%), indicating a “minimum [SDM provider] skill level.”

   Conclusion: Dental patients received only minimal SDM; however, the generalizability of the findings is extremely limited, as it is based on a single study with few patients and a narrow patient spectrum.

3. Patient-perceived and patient-preferred SDM level: Three studies investigated patient-reported SDM assessments, focusing on patients’ autonomy preferences (PAP). PAP was evaluated using the Control Preference Scale (CPS, (37)), which provided the following response options for patients’ perceived role and preferred role in decision making: 0 - only patient; 1 - mainly patient; 2 - dentist & patient; 3 - mainly dentist; and 4 - only dentist makes decisions.

   First study: In a convenience sample of 20 patients attending the University Dental Hospital of Manchester, UK (provider information was not specified) and a convenience sample of 20 patients from a general dental practice in Cheshire, UK (one provider), patients rated their preferences with a mean score of 3.2 at the hospital and 2.4 in the general dental practice setting. (38)

   Second study: In a consecutive sample of 101 patients from a specialized care setting (Department of Prosthetic Dentistry at the University Medical Center Hamburg-Eppendorf (UKE) in Hamburg, Germany) and all 15 dentists involved in treating these patients, 14 dental treatment decisions were averaged using the same CPS 0–4 response scale. A mean CPS score of 2.9 was observed. (39)

   Third study: In a convenience sample of 100 patients undergoing orthodontic treatment at the Eastman Dental Hospital, UK, and involving the dentists treating these patients, the patients rated their preferences with a mean score of 2.9. (40) Summarizing the three studies, the SDM estimates were relatively consistent across these diverse dental patient populations, with an overall mean estimate of 2.9 (Fig 1). This score suggests that treatment decisions were primarily made by the dentist. The results were precise, as indicated by a confidence interval of 2.6–3.1.

   Conclusion: Patients reported that their treatment decisions were predominantly made by the dentist. Although the findings were relatively consistent across the studies, the generalizability of these results is limited, as only four distinct dental patient populations were studied.

   The preferences regarding how patients preferred decisions to be made were also collected from the same four patient populations, using the same response options. The mean findings ranged from 2.1 in UK general dental practice and German prosthodontic patients to 2.2 in UK dental hospital patients, and 2.4 in UK orthodontic patients.

   Similar to patients’ perceived preferences, the study estimates for preferred decision-making did not vary substantially across these vastly different dental patient populations. The findings were summarized with a precise overall estimate of 2.2 (Fig 3). This result indicated that the typical dental patient preferred a collaborative SDM approach, but as shown in Fig 1, treatment decisions were mainly made by the dentist.

Fig 1:

Dental patients’ perceived preferences in decision making

Figure 3:

The elements of a care episode

Evidence synthesis:

When summarizing the current state of SDM implementation for dental patients, it becomes clear that this field is significantly understudied. This lack of research is notable, considering that approximately 50% of the global population suffers from oral disorders (41) and many of these individuals receive some form of treatment.

Consequently, there is limited understanding of the quality of SDM within this patient population. Existing data suggests that patients are not receiving the level of SDM they desire, as indicated by a discrepancy between dental patients’ perception of SDM and their preferred level of involvement. SDM research for dental patients also suffers from methodological shortcomings. The most significant limitation is that researchers have not consistently applied a contemporary dual-axial assessment, which includes two essential SDM components:

1. An Evidence/Science-Based Assessment: Measuring how SDM was performed by the dental provider, typically by utilizing one or more independent SDM experts.

2. A Patient Perception Assessment: Evaluating how SDM is perceived by the patient.

Furthermore, when SDM is measured, researchers typically rely on single-item instruments. Multi-item instruments, which offer a more comprehensive representation of SDM, should be employed instead. As a result of these issues, the current data on SDM for dental patients is not only scarce in quantity but also limited in quality.

3. A new SDM model for dental patients

As noted in the previous section, knowledge of SDM for dental patients is very limited, and no specific SDM model for dental patients exists, despite the unique characteristics of the dental setting that would favor such a model. As SDM for dental patients makes treatment decisions that need to be both evidence-based and aligned with the patient’s preferences, the question arises as to what dental treatments should accomplish for the patient. We argue that oral health impact, the suffering of the patients from oral disorders, is the target of dental intervention and, consequently, SDM needs to center around it in oral health care’s elemental unit, the care episode. What oral health impact is, how it can be measured, and how the standard SDM model can be modified into a new model that explicitly takes oral health impact into account is introduced.

3.1. SDM for typical dental patients in the context of the patient’s care episode

Dental care is typically performed in care episodes, i.e., complete sets of healthcare services to address a dental patient’s oral health concern over a defined period. The episode starts with a patient seeking care from an oral health care provider and ends with the patient’s discharge. (Fig 4) An example of a care episode for a dental patient is provided in Box 1.

Figure 4:

Four dimensions of oral health impact, also called oral health-related quality of life

Box 1. Example of a care episode for a dental patient.

An edentulous patient, experiencing oral health problems caused by ill-fitting dentures, seeks their replacement.

Following a comprehensive oral health assessment, starting with a four-dimensional assessment of the patient’s current oral health concerns, a thorough discussion of available treatment options comes next, in which patient and dentist collaborate to develop a detailed care plan. Together, patient and dentist reach a consensus on the optimal treatment, which may include, for example, a new set of conventional dentures. Once the decision is made, a clear plan for moving forward is established, and the treatment phase starts. Upon the successful completion of the treatment, which entails measuring the four-dimensional post-treatment oral health impact to quantify treatment performance, the patient is formally discharged from active care.

SDM is part of the Development of a Care Plan (Fig 3). As an ethical imperative to navigate the choices patients have to address their oral health impact, SDM is a necessary component of this element of the care episode. Once SDM concludes, the patient enters the third stage of the care episode, the Delivery of Interventions (Fig 3). After the interventions have been provided and the patient is discharged, the care episode ends with an assessment of the patient’s post-treatment oral health impact. As a foundation of evidence-based dentistry (42), this information is necessary not only for documenting treatment outcomes and evaluating provider performance but also for informing SDM for the next patient. As described above, an important component of the SDM process that informs the current patient about the expected benefits and harms of treatment is an understanding of how oral health impacts changed for previous patients. In a Learning Health System approach, current patients benefit from past patients’ treatment outcome results in a continuous cycle that generates steadily improved outcome predictions.

To better understand SDM for dental patients that occurs during the Assessment & Diagnosis and the Development of a Care Plan stages, it is helpful to visualize the care episode, in general, and SDM, specifically, through the lens of the four dimensions of oral health impact, also known as oral health-related quality of life (43). (Fig 4)

3.2. Four groups of oral health impacts need to be addressed in SDM in a care episode

SDM is helpful for addressing treatment options on why patients seek care generally, but is less capable of answering why do dental patients seek care from dentists. While some intuitive responses come quickly to mind, taking a closer look at the apparently complex and diverse (chief) complaints of dental patients will elucidate what the SDM process needs to accomplish for the patient. At the heart of health care in general, and specifically of the care episode, is the oral health impact, i.e., the patient’s suffering from oral disorders. Viewing the care episode through the lens of this impact, care-seeking patients can be differentiated into two broad categories:

• Patients with current oral health problems – these patients have a current oral health impact, and they seek to reduce—or preferably eliminate— this impact.

• Patients who do not have current oral health problems but want to prevent such problems in the future. Examples are follow-up, check-up, and maintenance appointments. These patients are likely to experience oral health impacts in the future and seek to prevent them.

A study conducted in 32 countries in all six World Health Organization regions assessed 15,800 dental patients’ reasons for visiting the dentist and found that Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the four core reasons dental patients seek care worldwide. (44) A subsequent analysis restricted to pediatric dental patients confirmed these results in children. (45) In other words, regardless of the patient’s age and whether oral health problems results from oral diseases or injury (Box 2), patients seek care when they have difficulty using the mouth and associated structures, when they experience discomfort or pain in the oral area, when the appearance of the oral structures is compromised, or when patients’ daily activities and their psychological well-being are affected by oral health problems (Fig 5).

Box 2. Four-dimensional oral health impact from oral diseases and injuries to mouth and teeth.

Oral disease and injury create the same broad types of oral health problems:

While most oral health impacts originate from oral diseases, injuries to the mouth and teeth, e.g., a bike accident, also create impacts. They are of a similar nature. A bike accident, resulting in a lost anterior tooth, would immediately cause a functional, pain-related, aesthetical, and psychosocial impact. The patient experiences problems with biting, suffers from pain, is aesthetically affected, and is limited in usual social activities such as being together with friends and co-workers.

The four dimensions of oral health impact are supported not only by clinical experience and plausibility, but also by consistent psychometric evidence derived from multiple methodological approaches. These approaches— including exploratory factor analysis, (46) confirmatory factor analysis, (47) validation analyses, (48) and correlation analyses (49)— have been conducted in large samples of both dental patients and the general population.

In patient populations that are affected by a wide spectrum of oral health impacts, i.e., TMD patients, psychometric properties of the four-dimensional impact framework are strong, as the framework allows for informative characterization of TMD patients’ well-being and daily functioning, (50) and improved comparability of these findings across patient populations. (51) Systematic reviews have found that the four dimensions represent the underlying attributes for dental patient-reported outcome measures (dPROMs) in general, regardless of whether the instruments are oral disease-generic (52) or oral disease-specific (53). They have been identified as the common factors underlying all multi-item dPROMs. (54)

The most practical tool for assessing the four OHRQoL dimensions is the 5-question version of the Oral Health Impact Profile (OHIP-5). (55,56) OHIP-5 measures Oral Function with 2 questions, Orofacial Pain with 1 question, Orofacial Appearance with 1 question, and Psychosocial Impact with 1 question. OHIP-5 is the recommended instrument for four-dimensional oral health impact assessment. (57,58)

3.3. SDM for dental patients focuses on oral health impact

The oral health impact is central to the entire care episode. In the Assessment and Diagnosis phase of the care episode, as illustrated in Figure 4, patients report on their oral and general health and undergo a clinical examination. A critical step in this phase is determining the extent of the patient’s oral health suffering. At the beginning of the dental encounter, it is essential to assess both the number of affected oral health-related quality of life (OHRQoL) dimensions and the degree of impairment in each dimension. Practically, this can be accomplished using instruments such as the Oral Health Impact Profile-5 (OHIP-5).

Consequently, before any dental interventions are applied, SDM engages patients by informing them about the available options and eliciting their preferences. The discussion centers around dimensional impact, characterized by scores, and the degree to which each treatment option is expected to reduce these scores, as changes in these scores represent the treatment’s therapeutic effect.

When patients and clinicians move into the second phase of the care episode—the Development of a Care Plan to address the oral health impact (Figure 4)—the patient’s current impact serves as the foundation for the provider-patient conversation. SDM is understood as helping “patients select the best evidence-based option given their preferences.” (19) Together, the patient and clinician develop a plan aimed at improving the oral health impact, as reflected in the dimension scores.

To achieve this effectively during the therapeutic dental treatment encounter, treatment options must be characterized not only by their expected benefits (i.e., a reduction in existing oral health impact) but also by their expected harms (i.e., a potential increase in oral health impact during the treatment). For instance, some prosthodontic treatments may substantially reduce problems reported before treatment, but simultaneously create new problems related to the treatment itself or the tooth replacements. (59) Therefore, describing treatment options requires characterizing both the positive and negative effects of each treatment and detailing the differences between alternative treatments.

Ideally, the description of these effects should be personalized. It should reflect the patient’s current level of oral health impact, their background characteristics, and the provider’s performance with previous patients. The incorporation of published research evidence is also warranted. A set of predicted four-dimensional scores that represent the most likely post-treatment oral health impact for the specific patient under different treatment scenarios would provide the most informative basis for SDM.

By offering patients this detailed picture of expected benefits and harms, providers create the necessary space for patients to fully engage in the conversation. In this manner, the discussion naturally progresses toward setting goals by eliciting what matters most to the patient. During this process, the inherent uncertainty of the information provided must be acknowledged, and the patient’s comprehension of the information must be verified.

This comprehensive presentation of the “best evidence,” using the four-dimensional oral health impact framework, is not only necessary to fully inform the patient but also serves as the prerequisite for the next SDM step, in which patients express their preferences regarding treatment options. SDM formally concludes for that patient once the patient and clinician reach a decision and proceed with a treatment plan.

We can summarize sections 3.1–3.3 as follows: Since patients’ complaints—functional, painful, aesthetical, and psychosocial impacts related to oral disorders—are the primary reason for seeking dental care, and because SDM aims for treatment decisions regarding these impacts, incorporating this four-dimensional impact concept into SDM provides an opportunity to tailor general SDM to the dental setting, making it more meaningful and practical for dental patients.

3.4. A new SDM model for dental patients – The Four-dimensional Dental Encounter (4DE)

SDM principles apply to dental patients as well, but the specific dental context needs to be taken into account to make this concept more meaningful and practical for this patient population. Because the four dimensions are central to dental patients, the general 4-step SDM process is adapted for dental patients, and the structure of the dental encounter is accordingly modified.

A dental encounter can be understood as any interaction between a patient and a dental provider in which dental services are provided. In a four-dimensional dental encounter (4DE), this interaction centers around:

1. the patient’s four-dimensional, i.e., functional, painful, aesthetical, and broader psycho-social oral health impact,

2. the treatment options to address existing or prevent future impact from occurring, and

3. the patientś preferences for these options.

In addition, before the regular SDM process begins, patients are educated about the four oral health impact dimensions, their relevance for patient care, and how these dimensions are used in the SDM process with the dental provider. This preparatory step is intended to make the 4DE process more effective and efficient.

SDM addresses the fundamental ethical principle of patients’ autonomy, recognizing patients’ right to make informed decisions about their own medical care. Beyond fulfilling this ethical mandate, SDM for dental patients, when performed through the 4DE framework, provides the following benefits:

1. As a method of providing care, it can influence care outcomes. The 4DE approach can lead to more appropriate treatments, i.e., treatments that are better aligned with the reasons patients seek care. Treatment adherence improves when patients’ treatments are aligned with their preferences. Stronger patient-provider relationships can influence treatment satisfaction and reduce patients’ decisional regret about choices made.

2. Better patient–provider relationships contribute to a more positive care experience for patients.

3. Providers also benefit from improved relationships, which can make their care experience more satisfying and effective.

Care costs should not increase and may even decrease if the structured 4DE approach proves more efficient than traditional dental encounters; for example, if the standardized five-step SDM process can be conducted more quickly and effectively across diverse settings and oral health conditions than current SDM processes. We want to emphasize that a more structured SDM process does not necessarily mean it is longer or more time-consuming. While the assessment of oral health impact - step 0 in the SDM process (Fig 5) - is a mandatory component of a dental visit, how steps 1 through 4 are performed is context-specific. Scope and duration of the SDM process correspond to the oral health impact magnitude, characterized by the extent of the impact, i.e., how many dimensions need to be addressed by the treatment, and the severity of the impact, i.e., how much each dimension is impaired. Low oral health impact in one dimension, e.g., a minor appearance problem with a tooth, requires less SDM than major impacts in all dimensions, e.g., oral rehabilitation of impaired function and appearance, and the presence of pain and psychosocial impact due to mandibular resection following cancer treatment. The patient’s familiarity with the oral condition also influences SDM’s extent. A patient with a new carious lesion, who had several lesions treated before, can be approached with an abbreviated SDM compared to a patient who presents for the first time with an oral condition and is not well-informed about it. Casting a complex oral health situation in a four-dimensional framework will help to focus on the essence of the patient’s oral health problem, and, consequently, may save time. For example, chewing problems and impaired biting may appear to the patient as distinct, but they are correlated in their occurrence because of the underlying tooth loss. Consequently, in a four-dimensional oral health perspective, they are both functional oral health problems, and they can be discussed together as interventions restoring oral function will address both.

While it is challenging to estimate the magnitude of these benefits, they may be modest for individual patients. Nevertheless, based on the current state of evidence in the field, we can predict that SDM performed with dental patients is worthwhile to the patient, given that no additional burden from 4DE arises for the patient as compared to a traditional dental encounter. At the population level, the cumulative effect of individual SDM benefits may be substantial as all dental patients worldwide could be targeted. The new SDM approach could be readily incorporated into the dental curriculum or continuing education efforts, allowing the dental community to adopt it without significant barriers.

4. Theoretical and practical implications of this new SDM model for dental patients as well as future research

A new approach to SDM for dental patients comes with implications of how our existing SDM knowledge for dental patients is challenged, with recommended practical steps in patient care, and with research directions.

4.1. Theoretical implications

This report highlights the need for dentistry to move from a largely intuitive approach to SDM—patient-provider interactions that feel appropriate for the specific situation without conscious reasoning—to a structured model that breaks SDM into distinct steps, making the process more transparent and accountable. Implementing this model can bridge the gap between the high frequency of these interactions (e.g., two-thirds of US adults had a dental visit in the last 12 months (60)) and the very limited knowledge of how these interactions actually happen. Asa’ad noted in 2019 these limitations by stating “Despite the fact that SDM is an established concept in clinical medicine, there is a very limited number of publications that have investigated SDM in dentistry” (61) and by 2025, not much had changed when Chamber and Iyer pointed out that SDM “is widely studied in medicine but not dentistry.” (35)

Specifically, patients’ preferences, a core element of evidence-based dentistry, are neglected - Faggion et al. noted that dental patients’ values are an “important—but usually forgotten—aspect in decision-making.”(62) Confusion even seems to exist about what SDM represents at all in dentistry when Hayer and Wassif stated: “Overall, there was a misunderstanding of what constitutes shared decision making among dental practitioners, with communication focused more on information provision rather than collaborative discussion.” (63)

While the literature characterizes SDM for dental patients as poorly understood and understudied, dentistry as a field is well-positioned to reexamine how it engages patients. Decades of editorials and position papers have highlighted gaps in oral health care, the need to meet patients where they are, and the potential of patient-centered care to transform care outcomes. This decades-long interest in patient-centeredness in dentistry irrefutably signals a high level of interest. A sharpened focus on oral health impact—the reason why dental patients seek care—paired with a practical approach to implement SDM, can increase the value of oral health care for patients and providers alike. 4DE is integral to evidence-based dentistry by focusing on oral health impact when presenting evidence to the patients and eliciting their treatment preferences, and to value-based oral health care by enhancing care outcomes and experiences.

4.2. Practical implications

Given the current state of the field relative to other areas of medicine, dentistry must develop a sense of urgency in adopting effective patient-centered strategies that promote better, preference-based outcomes for patients. Shared decision making, implemented through the Four-Dimensional Dental Encounter (4DE), provides a clear pathway to patient-centeredness by offering a stepwise framework for engaging patients in everyday practice. What is now needed are dentists willing to test these approaches in their own practices, assess their current performance using patient-reported measures of SDM, and evaluate how this well-founded framework will affect care outcomes.

4.3. Research directions

A research strategy needs to accompany these practical efforts outlined in the previous section. As demonstrated, the 4DE model offers a valuable set of parameters that enable dentists to apply their expertise and knowledge more effectively to enhance their experience treating patients and find the right care for the right patient. Such a platform may produce better treatment outcomes, economic benefits through shorter and more efficient visits, and improved care experiences for patients and dental providers alike. A general research strategy would encompass implementation projects—including qualitative studies, where researchers can engage meaningfully with patients and clinicians on process and experience —designed to assess how patients and providers value care under this new model. Observational studies comparing 4DE with traditional encounters can provide preliminary evidence regarding efficacy and effectiveness, by investigating (i) care outcomes, (ii) patient and provider care experience, and (iii) costs across various settings ranging from primary to tertiary oral health care. Finally, randomized trials would be required to substantiate any benefits identified in observational studies. Subsequently, systematic reviews would synthesize these primary studies to reach the highest levels of evidence, allowing for actionable recommendations to be generated by practice guidelines.

5. Conclusion

We made the argument that the extent to which shared decision making is performed with dental patients in regular care settings is largely unknown. In addition, SDM for the dental patient also has methodological shortcomings, specifically that no assessments exist that use both an independent, expert-based and a patient-based assessment of SDM. Despite this uncertainty around SDM evidence for the dental patient; however, one finding appears to be consistent and strong. Published findings indicate that dental patients prefer collaborative decision making. They show this desire despite recognizing that decision making is often dominated by the provider.

As described, the Four-Dimensional Dental Encounter (4DE), i.e., the interaction between patient and dental provider before treatment, is firmly grounded in SDM principles. By intentionally integrating SDM with the 4DE framework, dentists have a greater opportunity to elicit what matters most to patients by providing a structured, meaningful way for patients to understand what dental treatments should achieve for them.

Fig 2:

Dental patients’ preferred preferences in decision making

Box 3. Five SDM steps for the dental patient.

FIVE SDM STEPS FOR THE DENTAL PATIENT

Step 0: Prepare the patient for the upcoming 4DE.

Explain to the patient that four major oral health problem areas (Oral Function, Orofacial Pain, Orofacial Appearance, Psychosocial Impact) exist for dental patients. Explain that the clinician will assess these problem areas with them, engage them in a conversation about treatment options for these four problem areas, elicit their treatment preferences, and support the patient’s treatment decision addressing the four problem areas.

Step 1: Inform the patient that a decision needs to be made.

Communicate that treatment choices exist and encourage the patient to become involved in the conversation. Depending on the patient’s oral condition and its treatment options as well as the patient, the length of the four-dimensional dental encounter will vary.

Step 2: Explain the treatment options.

Introduce the treatment options and explain their four-dimensional effects (and side effects), i.e., the positive and negative changes in the patient’s oral health impact, including the differences among options. Ideally, these changes are quantified numerically and personalized for the patient, and they take the patient’s current four-dimensional impact situation into account. This information can be derived from previous patients and literature evidence.

Step 3: Discuss the patient’s preferences.

The patient expresses their assessment of each treatment option, including their four-dimensional effects. The clinician assesses the patient’s understanding and supports their process.

Step 4: Reach a decision.

The clinician listens to the patient, and the patient listens to the clinician. From this collaborative process a decision arises, with the clinician evaluating the treatment plan from a professional standpoint.

Appendix: Search to identify studies implementing SDM in regular dental care settings

Ovid MEDLINE(R) ALL Search Strategy

exp Decision Making, Shared/ exp Patient Participation/ ((shared or participant* or patient*) adj decision*).tw,kf. (patient* adj centered).tw,kf. (patient* adj engage*).tw,kf. (patient reported outcome* or PROM or PROMS or dPRO or dPROs or dPROM*).tw. exp Decision Support Techniques/ patient*.ti,ab. 7 and 8 1 or 2 or 3 or 4 or 5 or 6 or 9 exp Dentist-Patient Relations/ or Dentistry/ (dentistry or dental or dentist* or chairside).tw. 11 or 12 10 and 13 exp animals/ not exp humans/ 14 not 15 limit 16 to English language