Surgical or Non-Surgical

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Surgical or Non-Surgical Periodontal
Treatment: Factors Affecting Patient
Decision Making
Amit M. Patel,* Philip S. Richards,† Hom-Lay Wang,† and Marita R. Inglehart†
Background: This study explored which factors affected pa-
tients’ decisions to pursue either surgical or non-surgical peri-
odontal treatment.
Methods: Data were collected from 74 patients at a regu-
larly scheduled periodontal appointment, at which each pa-
tient was told that periodontal treatment was needed, and
2 weeks following the actual treatment. The surveys assessed
the patients’ decisions and potential determinants of these de-
cisions. The dental anxiety scale-revised, the state-trait anxi-
ety inventory, and the Iowa dental control index were used to
measure psychosocial factors.
Results: Patients who decided to have surgery did not differ
from patients who decided against surgery in sociodemo-
graphic variables such as gender, age, education, and socio-
economic status, nor in their desire for control over the
treatment decision. However, they had less dental fear and
less general anxiety than the non-surgery patients. Although
the two patient groups did not differ in their responses con-
cerning how well the dentists had informed them about the
procedure, they differed in the degree of trust and rapport
with their dentists.
Conclusions: The less dentally fearful and anxious patients
were in general and the more they trusted their provider and
felt they had good rapport, the more likely they were to accept
surgical periodontal treatment. These results stress the impor-
tance of good patient-provider communication. J Periodontol
2006;77:678-683.
KEY WORDS
Communication; decision making; dental anxiety; surgery;
treatment.
S
tructural factors that shape fu-
ture dental health care services,1
challenges that dentistry faces
currently,2,3 and recommendations for
future dental education4,5 point to the
significance of providing truly patient-
centered care. One important aspect of
patient-centered care is the constructive
communication between a dentist and a
patient during the treatment decision-
making process. This study explored the
factors that affected patients’ decisions
to pursue surgical versus non-surgical
periodontal treatment, and the role that
the communication between periodon-
tists and their patients play in these
decisions.
Many well-designed clinical studies
established the effectiveness of peri-
odontal therapy.6,7 Most of these studies
focused on dental-treatment outcomes
such as the efficacy of the methods, gains
in periodontal attachment levels, and the
relationship between periodontal probing
depths and periodontal attachment when
considering whether periodontal disease
should be treated non-surgically or sur-
gically. However, even if clinicians and
researchers have a clear sense of the ef-
ficacy of various treatment approaches
and can make definitive treatment rec-
ommendations, they still need their
patients’ consent to actually perform a
specific treatment. Therefore, it is of
great importance to understand which
psychosocial factors shape patient deci-
sion making.
* School of Dentistry, University of Michigan, Ann Arbor, MI.
† Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan.
doi: 10.1902/jop.2006.050206
Volume 77 • Number 4
678
Research showed that certain sociodemographic
factors, such as gender, age, and educational back-
ground, affect patients’ responses to dental treat-
ment. For example, it was found that women tend to
report more dental fear than men8-10 and that younger
patients reported higher levels of dental fear than older
patients8,10 and were less likely to notice symptoms
thanolderpatients.11 Inaddition,patientswithhigher in-
comes and education levels reported less fear than pa-
tientswith lowerincomesandlowereducationlevels.9,10
Education levelmight also be correlated witha patient’s
knowledgeaboutdentistry.Researchshowedthat those
patients who lacked knowledge of the dental field pre-
ferred a more passive role in the decision-making pro-
cess.12 Given these findings, it may be worthwhile to
explorewhetherthesedemographic factorswouldaffect
periodontal patient decision making.
In addition to considering patient background fac-
tors, it may also be of interest to understand the role of
dental fear and general anxiety for patients’ treatment
decision making. Higher levels of general anxiety and
dental fear13 may affect patients’ responses to differ-
ent treatment options and may even prevent patients
from seeking dental treatment. In fact, ;15% of the
world’s adult population experience partial avoidance
of dental care (going for treatment only when symp-
toms appear) and another 6% show total avoidance
due to dental fear.13 In the context of periodontal
decision making, it may be worthwhile to explore
whether more generally anxious patients and patients
with higher dental fear may be less likely to accept
periodontal surgery treatment than patients with less
anxiety and fear.
Closely related to dental fear is the degree to which
a patient desires to have control in a clinical situa-
tion.14 Having a sense of control can decrease a pa-
tient’s level of stress in a dental situation.15,16 In
addition, negative experiences with dental treatment
contributed to patients’ lack of trust in their dentists
and led consequently to a desire to take a more active
role in the decision-making process.12 Therefore, it
might be worthwhile to explore whether the degree
to which a patient desires to have control is related
to the degree to which they would like to be involved
in the decision-making process.
In addition to patient factors, the actual cost of the
treatment17 might also affect the patient decision-
making process. Prior research indicated that having
dental treatment paid by a third-party payer (i.e., in-
surance company) had an effect on the patient deci-
sion-making process.17 In addition, patients may not
only consider monetary costs, but they may also take
other costs into consideration, such as the amount of
work missed due to the treatment.18 Patients’ percep-
tions of costs and benefits may thus affect the decision-
making process as well. Concretely, it could be pre-
dicted that the higher the financial costs, the more
time involved in recovery, and the more pain that is
expected to result, the less likely a patient will be to
choose a certain periodontal treatment.
Finally, the patient-provider relationship12 may
also influence a patient’s decision making. Research
showed the connection between the level of trust in
a dentist and the patient’s degree of passivity in the
decision-making process.12 Additionally, a patient’s
lack of knowledge about dental care appeared to be
closely related to the trust a patient placed in the den-
tist’s professional status.12 Therefore, it seems im-
portant to understand how the flow of information
from the provider to the patient and the quality of
the patient-provider relationship affects the patient’s
decision to pursue surgical versus non-surgical peri-
odontal treatment.
MATERIALS AND METHODS
This study was approved by the institutional review
board for the health sciences at the University of
Michigan.
Respondents
Data were collected from 74 adult dental patients
(32 males and 42 females; average age: 52.65 years;
SD: 13.08 years; range: 27 to 83 years) at a regularly
scheduled periodontal appointment at a graduate
periodontics clinic in a dental school setting between
June 24 and August 10, 2004. Some patients had
been referred by their private general dentists, by a
dentist/graduate student in another graduate clinic
(such as the graduate prosthodontics clinic or the pa-
tient admitting emergency services clinic), or by ju-
nior or senior undergraduate dental students to the
graduate periodontics clinic for consults. Some pa-
tients had received treatment in the graduate peri-
odontics clinic before. All patients were recruited to
participate in this study on the daywhen the graduate
student provider told them that surgical periodontal
treatment was recommended. In addition, these pa-
tients were also approached 2 weeks after the actual
treatment had been conducted. Fifty-five patients (22
males and 33 females; average age: 54.09 years; SD:
12.82 years; range: 29 to 83 years) responded to the
follow-up survey. Data were also collected from pro-
viders who treated 59 of these patients.
Patients were only included in this study if their pro-
vider had recommended surgery. However, the orig-
inally recommended type of surgery had not been
recorded. Data concerning the actually performed
treatment were collected from the 59 providers who
responded to the provider survey. They reported that
19 patients had non-surgical scaling and root plan-
ing treatment; 12 patients had extractions; eight pa-
tients had implants; six patients each had flap surgery,
J Periodontol • April 2006 Patel, Richards, Wang, Inglehart
679
connective tissue grafts, and socket preservation
therapy; and four patients each had frenectomy sur-
gery and osseous surgery. Some patients had more
than one of these surgeries.
Procedure
When the patients arrived for a regularly scheduled
periodontal appointment at the periodontics graduate
clinic at the School of Dentistry, University of Michi-
gan, they were informed about their need to have
periodontal treatment, and they were asked to volun-
teer to participate in this study. If the patients agreed
to participate, they were asked to give written con-
sent to respond to a baseline and follow-up survey
and have their provider share information about
their treatment with the researcher. The patients re-
sponded to the baseline survey immediately after their
providers informed them that they needed surgical
periodontal treatment. Of the 74 patients who re-
sponded to this baseline survey, 55 patients had their
treatment conducted at the graduate periodontics
clinic. The providers were periodontal graduate stu-
dents who had been in their graduate program for at
least 1 complete year of training. After the actual per-
iodontal treatment had been performed, the providers
of these 55 patients were asked to volunteer to re-
spond to a provider questionnaire concerning each
patient’s treatment. Two weeks after the treatment
was conducted, the patients responded to a follow-
up survey either at their visit to the periodontics grad-
uate clinic or via a phone call. The purpose of this fol-
low-up questionnaire was to assess the patients’
evaluations of the treatment after it had been com-
pleted.
Materials
The data were collected in self-administered ques-
tionnaires. If the patients did not have a 2-week fol-
low-up appointment, the follow-up patient survey
was administered in phone interviews. The baseline
survey contained demographic questions and single
item measures and scales assessing psychosocial
variables. Dental fear was assessed with the dental
anxiety scale-revised (DAS-R).19 This scale is a re-
vised version of the original DAS20 that had been de-
veloped to assess the tendency to appraise dental
treatment situations as dangerous and threatening.
Ronis et al.19 revised and validated a gender-neutral
version of the DAS, the DAS-R. Both scales consist
of four multiple-choice questions, each with five alter-
native responses ranging in value from 1 being the
most calm choice to 5 being the most anxious choice.
DAS scores accordingly can range from 4 to 20. The
DAS-R has been shown to be reliable (Cronbach a =
0.81) and valid (convergent validity = 0.61).21 In re-
viewing the most commonly used dental-anxiety
measures, the DAS-R best suited the design in this
study, which focused on the dental anxiety in a treat-
ment situation.
General trait anxiety was measured with the state-
trait anxiety inventory (STAI).22 In reviewing state-
trait anxiety measures used in dental situations, the
STAI of Spielberger22 has been used almost unani-
mously. In the current study, the trait anxiety scale
that measures a patient’s tendency to become anx-
ious was used. This scale is reliable (test-retest relia-
bility = 0.73) and internally consistent (internal
consistency r = 0.93).22 The trait anxiety scale used
in this research consists of 20 items that determine
whether the patient is a generally anxious person. An-
swers are given on four-point answering scales with
1 indicating ‘‘almost never,’’ 2 being ‘‘sometimes,’’
3 indicating ‘‘often,’’ and 4 being ‘‘almost always.’’
Therefore, scores range from 20 to 80, with a higher
score indicating a higher level of trait anxiety.
To assess whether the patients wanted control in
the treatment situation, their desire for control was
measured with the Iowa dental control index (IDCI).14
This index was developed to specifically measure the
desire of control in a dental setting. The index is based
on the sum of the answers to two questions (reliability:
Cronbach a = 0.63). The responses to the two items
are given on five-point answer scales ranging from
1 being ‘‘no control’’ to 5 indicating ‘‘total control.’’
The two items have face validity.
Statistical Methods
The data were analyzed with statistical software.‡ The
responses of the patients who decided to be non-
surgically treated (with scaling and root planing) were
compared to the responses of the patients who chose
surgical periodontal treatment. If the dependent vari-
ables were categorical (such as gender), chi square
analyses were performed. If the dependent variables
were measured on an interval scale, t - tests for inde-
pendent samples were conducted.
RESULTS
Fifty-one of the 74 patients decided to have periodon-
tal surgery, 22 chose to have non-surgical treatment,
and one patient did not have any treatment at all. Pa-
tients who decided to have surgery did not differ from
the patients who made the decision to be treated non-
surgically in background variables such as gender,
age, educational background, and socioeconomic
status (Table 1). However, there was a tendency for
surgically treated patients to have more years of edu-
cation and to have a higher monthly income than non-
surgically treated patients.
As listed in Table 2, the surgery patients had sig-
nificantly less dental fear (five-point scale: 1.95 ver-
sus 2.39; P = 0.026), and less trait anxiety than the
‡ SPSS version 11.5, SPSS, Chicago, IL.
Patient Decision Making Concerning Periodontal Treatment Volume 77 • Number 4
680
non-surgery patients (four-point scale: 1.58 versus
1.77; P = 0.09). However, the two patient groups did
not differ in the degree to which they wanted to have
control over the treatment decision.
In addition, although patients in both groups had
similar responses to the items concerning treatment
cost (Table 3) and how much the treatment would in-
terfere with their lives, there was a tendency for the
surgery patients to evaluate the effectiveness of their
treatment as higher than the non-surgery patients
(five-point scale: 4.27 versus 3.82; P = 0.072).
Table 4 provides an overview of the average re-
sponses to the three questions concerned with the
flow of information from the periodontist to the patient
and the five questions concerned with the affective
side of the patient-provider relationship. The surgi-
cally treated patients did not differ from the non-
surgically treated patients in their responses concern-
ing the expertise of the periodontist and the amount of
received information they had wanted and needed.
However, the two groups differed significantly in their
perceptions of the affective side of the provider-pa-
tient relationship. Compared to non-surgically treated
patients, the surgically treated patients liked their pro-
vider more (five-point scale: 4.78 versus 4.41; P =
0.014); trusted their providers more (4.63 versus 4.23;
P= 0.014);andweremore likely tobelieve that theirden-
tist was concerned about their oral health (4.84 versus
4.49; p.041) and was concerned about not inflicting
pain (4.74 versus 4.41; P = 0.041), and that theirpro-
vider listened to them (4.80 versus 4.27; P = 0.001).
In summary, the patients who decided to have per-
iodontal surgery had a lower level of dental fear, less
trait anxiety, and a more positive and trusting relation-
ship with their periodontist than the patients who
chose not to have periodontal surgery.
DISCUSSION
All patients included in this study had been informed
by their provider that they needed periodontal sur-
gery. However, 23 of the 74 patients did not follow
their periodontist’s recommendation. A comparison
of the responses of the 51 patients who chose to have
the periodontal surgery and the 22 patients who chose
non-surgical treatment was conducted to gain a better
understanding of how these two patient groups dif-
fered. The results showed that the two groups did
not differ in general background characteristics. Con-
tradictory to the expectation that there might be a
Table 1.
Comparisons of Background
Characteristics of Surgically and
Non-Surgically Treated Patients
Background
Characteristics
Surgical
Treatment
Non-Surgical
Treatment P Value
Gender 19 males;
32 females
12 males;
10 females
NS
Age (years) 52.16 53.77 NS
Education (years of
schooling received)
14.67 13.30 0.088
Monthly income* 4.85* 4.77 0.08
NS = not statistically significant.
* Measured with the following categories: 1= <$500; 2 = $500 to <$1,000;
3 = $1,000 to <$1,500; 4 = $1,500 to <$2,000; and 5 = >$2,000.
Table 2.
Average Dental Fear, General Anxiety,
and Desire for Control of Surgically and
Non-Surgically Treated Patients
Surgical
Treatment
Non-Surgical
Treatment P Value
Dental fear* 1.95 2.39 0.026
Trait anxiety† 1.58 1.77 0.09
Desire for control‡ 2.48 3.11 0.311
* Answers to questions on the DAS-R1 were given on a five-point scale, with
1 = ‘‘no dental fear’’ and 5 = ‘‘extreme dental fear.’’
† Answers to questions on the STAI2 were given on a four-point scale, with
1 = ‘‘no trait anxiety’’ and 4 = ‘‘extreme trait anxiety.’’
‡ Answers to the questions of the IDCI3 were measured on a five-point
scale, with 1 = ‘‘no control desired’’ and 5 = ‘‘total control desired.’’
Table 3.
Treatment and Cost Considerations
of Surgically and Non-Surgically
Treated Patients
Surgical
Treatment
Non-Surgical
Treatment P Value
How much of a
financial burden will
the treatment be?
3.06 2.64 NS
How much will the
treatment interfere
with your life?
2.54 2.36 NS
How effective will
the treatment be?
4.27 3.82 0.072
At 2-week follow-up:
How much of a
financial burden
was the treatment?
2.84 2.44 NS
Responses were given on a five-point rating scale from 1 = ‘‘not at all’’ to
5 = ‘‘very much.’’
J Periodontol • April 2006 Patel, Richards, Wang, Inglehart
681
gender and age difference,8-10 men and women were
equally likely to choose surgery. In addition, patient
age was not a significant predictor of the treatment de-
cision. However, there was a tendency for surgically
treated patients to have more years of education
and a higher monthly income than the non-surgically
treated patients. Although the cost of surgical and
non-surgical treatment in a dental school setting is re-
duced compared to the cost for these procedures in a
private dental office, there still is a considerable differ-
ential between the costs for surgical and non-surgical
periodontal treatments. Given this fact and the finding
that surgically treated patients had a higher monthly
income, it cannot be ruled out that cost was a factor
affecting the treatment decision making, and that it
might be even more significant in private dental prac-
tices. It would be interesting to explore the role of cost
in more detail in future research, and especially to ex-
plore how cost considerations would be affected by
provider-patient communication.
Prior research indicated that patients from lower
socioeconomic backgrounds had higher levels of den-
tal fear than patients from higher socioeconomic
backgrounds on average.9,10 The findings from this
study demonstrated that monthly income correlated
with trait anxiety, whereas years of education and
monthly income were not significantly correlated with
dental fear. The higher the patient monthly income
was, the less general trait anxiety the patient had (r =
-0.313; P = 0.013). This finding may indicate that
there is a potentially confounding ef-
fect of socioeconomic background
and general anxiety and their effect
on patients’ treatment decisions.
However, it was interesting to find
that the two patient groups did not dif-
fer in the value they placed on finan-
cial cost for their treatment decision
making. In addition, the two groups
did not differ in the degree to which
they thought that the treatment would
interfere with their lives. Considering
the actual recovery process after sur-
gical versus non-surgical treatment,
this finding is quite surprising and
could be an indicator of a lack of in-
formation concerning the immediate
consequences of surgical and non-
surgical periodontal treatment. In this
context, it is also interesting to con-
sider that the two groups did not differ
in their responses concerning the de-
gree to which they perceived to have
received information they 1) had
wanted and 2) had needed about
the treatment options.
The factors that most affected treatment decision
making were affective factors, namely the degree of
dental fear and general trait anxiety and the level of
trust and rapport with the periodontist. The data
clearly illustrated that surgically treated patients
had less dental fear, lower trait anxiety, and a more
positive patient-provider relationship than the non-
surgically treated patients.
CONCLUSIONS
Although periodontists have the expertise to provide
patients with the best treatment plans, they may not
be able to actually perform the treatment because pa-
tients may not pursue the recommendation made by
the periodontist. Therefore, it is crucial for providers to
be aware that the quality of the patient-provider rela-
tionship is a determining factor in the patient decision-
making process.
These findings clearly support the recommenda-
tions of the Institute of Medicine’s report on the future
of dental education4 to educate future dental health
care providers to be more patient centered. Ulti-
mately, positive patient-provider communication will
allow dentists to provide optimal treatment for their
patients and, thus, increase their patients’ periodontal
health.
ACKNOWLEDGMENTS
The authors want to thank Dr. Laurie K. McCauley,
chair of the Department of Periodontics and Oral
Table 4.
Evaluations of the Provider-Patient Relationship of
Surgically and Non-Surgically Treated Patients
Surgical
Treatment
Non-Surgical
Treatment
P
Value
Informational aspects
My dentist is knowledgeable. 4.78 4.59 0.136
My dentist gave me all information I wanted. 4.78 4.55 0.127
My dentist gave me all information I needed. 4.75 4.62 0.374
Rapport/trust
I like my dentist. 4.78 4.41 0.014
I trust my dentist. 4.63 4.23 0.014
My dentist is concerned about my oral health. 4.84 4.59 0.041
My dentist listens to me. 4.80 4.27 0.001
My dentist is concerned about not inflicting any pain. 4.74 4.41 0.041
Responses were given on a five-point rating scale from 1 = ‘‘disagree strongly’’ to 5 = ‘‘agree strongly.’’
Patient Decision Making Concerning Periodontal Treatment Volume 77 • Number 4
682
Medicine, School of Dentistry, University of Michigan,
for her support; Ms. Bonnie J. Loepke, administrator
of the graduate periodontics clinic, School of Dentis-
try, University of Michigan; and the graduate students
in the Department of Periodontics and Oral Medicine,
School of Dentistry, University of Michigan, for their
assistance with the recruitment of study participants
and the collection of clinical data. This research was
supported by funding from the Department of Peri-
odontics and Oral Medicine, School of Dentistry, Uni-
versity of Michigan, for AMP.
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Correspondence: Dr. Marita R. Inglehart, Department of
Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI 48109-1078. Fax:
734/763-5503; e-mail: mri@umich.edu.
Accepted for publication October 18, 2005.
J Periodontol • April 2006 Patel, Richards, Wang, Inglehart
683
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 /GrayImageMinDownsampleDepth 2
 /GrayImageDownsampleThreshold 1.50000
 /EncodeGrayImages true
 /GrayImageFilter /FlateEncode
 /AutoFilterGrayImages false
 /GrayImageAutoFilterStrategy /JPEG
 /GrayACSImageDict <<
 /QFactor 0.15
 /HSamples [1 1 1 1] /VSamples [1 1 1 1]
 >>
 /GrayImageDict <<
 /QFactor 0.15
 /HSamples [1 1 1 1] /VSamples [1 1 1 1]
 >>
 /JPEG2000GrayACSImageDict <<
 /TileWidth 256
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 /Quality 30
 >>
 /JPEG2000GrayImageDict <<
 /TileWidth 256
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 >>
 /AntiAliasMonoImages false
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 /MonoImageDownsampleType /Average
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 /MonoImageDepth -1
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 /EncodeMonoImages true
 /MonoImageFilter /CCITTFaxEncode
 /MonoImageDict <<
 /K -1
 >>
 /AllowPSXObjects false
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 /PDFX1aCheck false
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 /PDFXOutputIntentProfile (None)
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 /NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken die zijn geoptimaliseerd voor prepress-afdrukken van hoge kwaliteit. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.)
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 /ENU (Use these settings to create Adobe PDF documents best suited for high-quality prepress printing. Created PDF documents canbe opened with Acrobat and Adobe Reader 5.0 and later.)
 >>
 /Namespace [
 (Adobe)
 (Common)
 (1.0)
 ]
 /OtherNamespaces [
 <<
 /AsReaderSpreads false
 /CropImagesToFrames true
 /ErrorControl /WarnAndContinue
 /FlattenerIgnoreSpreadOverrides false
 /IncludeGuidesGrids false
 /IncludeNonPrinting false
 /IncludeSlug false
 /Namespace [
 (Adobe)
 (InDesign)
 (4.0)
 ]
 /OmitPlacedBitmaps false
 /OmitPlacedEPS false
 /OmitPlacedPDF false
 /SimulateOverprint /Legacy
 >>
 <<
 /AddBleedMarks false
 /AddColorBars false
 /AddCropMarks false
 /AddPageInfo false
 /AddRegMarks false
 /ConvertColors /ConvertToCMYK
 /DestinationProfileName ()
 /DestinationProfileSelector /DocumentCMYK
 /Downsample16BitImages true
 /FlattenerPreset <<
 /PresetSelector /MediumResolution
 >>
 /FormElements false
 /GenerateStructure false
 /IncludeBookmarks false
 /IncludeHyperlinks false
 /IncludeInteractive false
 /IncludeLayers false
 /IncludeProfiles false
 /MultimediaHandling /UseObjectSettings
 /Namespace [
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 /PDFXOutputIntentProfileSelector /DocumentCMYK
 /PreserveEditing true
 /UntaggedCMYKHandling /LeaveUntagged
 /UntaggedRGBHandling /UseDocumentProfile
 /UseDocumentBleed false
 >>
 ]
>> setdistillerparams
<<
 /HWResolution [2400 2400]
 /PageSize [792.000 1224.000]
>> setpagedevice