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ORIGINAL ARTICLE

ABSTRACT

Objective: The purpose of this study was to explore patient preferences in their dental treatment decision
making and establish their role as active, passive or collaborative.
Study Design: Questionnaire based cross-sectional.
Place and Duration of Study: Department of Prosthodontics and the Executive private clinics of the Islamic

st th
International Dental College, Hospital from the 1 of February till the 30 of March 2012.
Materials and Methods: A convenience sample of 80 patients, 40 recruited from the Department of
Prosthodontics and 40 from the executive clinics at the Islamic International Dental College were interviewed
and their preferences for participation in treatment decision making were established using a measurement tool
designed to elicit decision-making preferences. Patient preferences for participation in treatment decision
making were established using a simplistic modification of the Control Preference Scale (CPS) tool.
Results: This study found that 45% clinic patients perceived active/semi-active roles in treatment decision
making, 42.5% chose passive/semi-passive roles. 90% patients interviewed at the Department of
Prosthodontics preferred passive/semi-passive roles. Over all, out of 80 patients, 53 chose the passive/semi-
passive roles.
Conclusion: Patients presenting at the private clinics prefer being actively involved in their treatments, having
said that, majority of them choose to get treatment from private clinics because they expect better services and
have more trust in their doctors.

Key Words: Control Preference Scale (CPS), Treatment decision making, Patient preferences.

participation preferences of any Pakistani

population in their dental decision making. 

It is pertinent to explore the elements of

decision making in dental care, as patient

participation is a field which has both ethical

and legal implications in an increasingly

user-focused, 'consumerist' health service,

given that most dental care is paid for, in part

or whole, by the patient. More importantly,

b y i d e n t i f y i n g t h e p a t i e n t ' s d e n t a l

preferences as active, passive or somewhere

in-between, clinicians would obtain an

insight not only into the outcome the

patients have perceived but also in

deciphering between different patient

personalities.

Although, a number of methods have been

used to examine patients' decisional role

preferences, a modification of the Control

Preferences Scale would be used in this
5o b s e r v a t i o n a l s t u d y. T h i s s i m p l e

Introduction
The demise of “single best treatments”, rise 

in multi-faceted chronic illnesses, variations

in the provision of services, increasing costs

and increasing availability of newer and

easily accessible information are all cited as 

reasons contributing to patients getting

actively involved in the decision making of

their treatment plans. The shift in

paternalistic decision-making where

physicians play a more dominant role to one

that actively involves patient involvement
1has been documented to be on the rise.

Studies on patient-doctor relationship along

with elements addressing satisfaction have
2,3,4also been documented. No research so far

has been conducted on assessing the
-------------------------------------------------

A Study to Evaluate Patient Preferences in the Decision
Making of Dental Treatment
Faisal Moeen, Yawar Hayat Khan, Uzma Hasan

Correspondence:
Dr. Faisal Moeen
Asstt Prof of Dental Material
Islamic International Dental College, Islamabad
E.mail:faisal.moeen@riphah.edu.pk

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m e t h o d o l o g y i n v o l v e s p r e s e n t i n g

individuals with five options, each with a

written statement. These options describe

increasing levels of patient involvement in

treatment decision-making, from the patient

completely relinquishing control to

c l i n i c i a n s , t h r o u g h t o t h e p a t i e n t

maintaining complete control of treatment

decision-making. Patients are asked to

choose one most preferred and one least

preferred role from the five possible options

which would determine whether the patient

prefers a passive, collaborative or an active

role.

The aims of this study are to firstly evaluate

patient preferences in the decision making

of their dental treatments and secondly to

compare the dental decision making

preferences between patients presenting at

the Department of Prosthodontics and the

private, executive clinics both situated at the

Islamic International Dental College,

Islamabad.

Patients were eligible for inclusion if they

p r e s e n t e d a t t h e d e p a r t m e n t o f

Prosthodontics and the private clinics of the

teaching hospital for elective replacement of

missing teeth. They needed to be above the

age of 18. Patients were recruited

consecutively and studied prospectively

between February and March of 2012. The

protocol of the study was approved by the

ethics committee of the Islamic International

Dental College and all patients gave

informed consent.

A convenience sample of 80 patients was

r e c r u i t e d f o r t h i s s t u d y f ro m t h e

Prosthodontic Department (40) and the

executive clinics (40) of the Islamic

International Dental College. Each patient

Materials and Methods

was explained the objectives of the study

and assured confidentiality of their

responses. No patient declined to be a part of

this study and no patient was excluded.

Patient preferences for participation in

decision making were established using the
5Control Preference Scale (CPS). Although,

the CPS enables identification of a role

preference hierarchy for each respondent i.e.

an order of preference from most preferred

to least preferred role, our study for the sake

of simplicity would not formulate a

hierarchy of role preferences. Patients

would simply make choices as to the most

preferred and least preferred options. The

cards would however be presented to the

patients in a mixed, randomly arranged
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format. This would eliminate the possible

introduction of bias which exists if the fixed

order approach is used. Once an option was

selected, each patient was asked to give a

rationale as to why that option was selected.

The responses were recorded verbatim. By

the end of the procedure, each patient would

have chosen one option of the five and

would be classed as either having an active,

collaborative or passive decisional role

preference.

Data from the Control Preferences Scale can
5be analyzed in a number of ways. The

simplest approach which is adopted here

Active role
options

Collaborative role
options

Passive role
options

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will be to extract the most and least

preferred roles from each patient's response

followed by a frequency count for each role.

Non-numerical data relating to patients'

rationales for choice of role preference were

content analyzed to enable identification of
7themes.

All 80 patients appeared to understand the

options presented in each of the five cards

and their applicability to dental situations

was confirmed. No further revision of the

cards was necessary. Each participant

understood the concept of choosing the

most and the least preferred options

applicable to their treatments however some

degree of explanation was required in a few

situations.

At the hospital setting, 21 patients out of the

40 (52.5%) chose card 'E' as the most

preferred choice, leaving all decisions

regarding their treatment planning and

execution to the dentists. 15 patients (37.5%)

chose card 'D' as their most preferred choice

which is again following a similar trend as

card 'E' i.e. the doctor deciding what is in the

best interest of the patient although in

consult with the patient. Patients who were

questioned at the executive clinics/private

setting showed varied and mixed responses

with choices leaning slightly more towards

an active or a semi-active role. 6 patients

(15%) chose option 'A', 12 (30%) chose

o p t i o n ' B ' , h e n c e 4 5 % p a t i e n t s

accumulatively chose between options 'A'

and 'B'.

Five patients (12.5%) chose option 'C', 15

(37.5%) chose option 'D' and finally only 2

patients (5%) chose option 'E' as their most

preferred choices. 42.5% patients hence

choose between options 'D' and 'E'.

Results

The two extreme choices 'A' and 'E' were

overwhelmingly the least preferred at both

sites, with the fully active role (card A) being

particular unpopular. From the 40 patients

questioned at the dental college, 30 patients

(75%) chose option 'A' and 10 (25%) chose

option 'E' as their least preferred choices. 22

patients (73.3%) and 18 (45%) chose options

'A' and 'E' respectively from the clinics.

Figure 1: Distribution of the most preferred roles
in treatment decision making.

Figure 2: Distribution of the least preferred roles
in treatment of decision making.

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Discussion
Previous studies using the Control

Preferences Scale have mainly been with

patients suffering from cancer or other
8 - 1 0s e r i o u s i l l n e s s . H o w e v e r, t h e

methodology has worked well in the dental

context giving rise to interesting insights

which are of great relevance to dental
11, 12practitioners. This would suggest that

this extremely useful methodology is

transferable to dental settings.

Although this study focuses on a select

group of patients and the results obtained

from such a small sample size does not

represent the preferences in dental decision

making of the general population, it does

provide valuable information regarding the

attitudes patients can have towards

involvement in their treatments. Dentists

need to help patient participation in the

decision making by explaining the nature of

the disease, treatment options, benefits of

the options, time required in completing the

treatment and most importantly the cost

incurred in achieving the desired treatment.

Analysis of the verbatim data regarding

patients' rationales for their role preference

revealed that 52 of the 80 patients

interviewed mentioned lack of knowledge

of the subject as influencing their ability to

participate in treatment decisions, and

several comments were: “I don't know the

science behind medicine, so I'll leave the

decision to someone who does”.

Patients presenting at the private clinics in

particular mentioned that they were paying

extra to get treated by a specialist and hence

they would seriously consider the decisions

of their doctor. Trust was specifically

referred to by 68 of the 80 patients, with

comments like: “the doctor is a professional,

therefore you should trust him/her”, “if you

can't trust the doctor, there's something

wrong”. Therefore, either the patients

lacked knowledge about health care and

hence had no choice but to trust the

healthcare provider or they knew the doctor

before hand having genuine trust in his/her

abilities and decision making skills.

A further common theme amongst patients

was lack of time for discussion. Twenty nine

of the 80 patients cited lack of time as a

reason, and comments were: “there isn't

enough time for the doctor to really consider

my opinions”, “there's never enough time to

sit and discuss everything”.

In the part of preferences for patient

participation in treatment decision making,

the most preferred role in the private clinic is

semi-active compared to a collaborative role

in the hospital setting. It is interesting to see

that 15% of patients at the private clinic

choose option 'A' as their most preferred role

with the rationale that they know

beforehand the expenses involved in getting

treatment from a private clinic and they

would solely decide if or when is the correct

time to proceed with the treatments.

In this study an active role was more

commonly perceived in clinics than in the

teaching hospital. Over-all lesser number of

patients preferred an active rather than the

passive role, however, there is no clear

evidence that Pakistani patients prefer more

active roles than do their counterparts in

advanced countries. Finally, this finding

suggests that a majority patients presenting

at the Islamic International Dental College

h a v e p o s i t i v e a t t i t u d e s t o w a r d s

participation in dental decision making if

they are fully informed.

Conclusion

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