Ethics in Advertising
April 2, 2012
I was listening to the radio on the way home from work the other day and heard an advertisement for a dental office. The ad stated that they were specialists in cosmetic dentistry and implants and that they are the “premier” dental office in the area.
There is no recognized specialty in cosmetic dentistry or implants. Therefore, claiming that you are a specialist for either of these two areas is both illegal and unethical. While it is not illegal to say that you are the “premier” office, it too is unethical for advertising in dentistry.
While I have no problem with legal and ethical advertising in dentistry, what concerns me is over-advertising. The last thing the field of dentistry needs is the public looking at dentists in general as opportunists, and not as dedicated and concerned professionals. How this plays out in the long run will be decided by the ethical standards practiced in dental offices and the rules and regulations enforced by the governing within the profession.
Ethics is about doing good and the concept of right and wrong. Things that may be legal may not be ethical. On the same note, procedures that a dentist is not properly trained in or does not have the technical ability to perform, at least within the standard of care, may be legal for that dentist to do but not ethical. “”Do no harm”, should be the first item on the list of any dentist or any other healthcare provider.
Unfortunately there are healthcare providers, including dentists, who think they are doing people good but don’t realize they practice outside of their true ability. In 1952, the legendary (in the dental world) Dr. L.D. Pankey said, “It’s the moral obligation of the dentist to bring his ability up as close to his capability as possible in accord with his talent. Learning the technique is not enough. A dentist needs to learn how to take care of the whole person.” That is as relevant in 2012 as it was in 1952.
A healthcare professional’s core protocol should be prevention and the quest for determining an individual’s risk for future disease even before the patient has expressed concern. There is a push in dentistry to treat patients based on more objective data, which is commonly referred to as evidence based dentistry. Basically, information about a particular situation is fed into a database containing a multitude of clinical research and “the computer” spits out the best treatment options for that situation based on research. What this does is to minimize the emotionally and empirically based part of the clinical decision making process. My only issue with this is that the empirical, or practical experience of the provider, plays a key role in deciding what is best for a particular patient based on an individual’s unique circumstances.
Cosmetic dentistry poses a different challenge because it is highly discretionary. The dentist, or cosmetic surgeon if we are talking about medicine, must be the patient’s advocate and remain more concerned about the patient’s issues and wellbeing than their own. The benefits of treatment should always outweigh any possible negative consequences. Sometimes the best treatment is no treatment. Sometimes the best treatment for an individual patient is cosmetic enhancement because the benefits of this treatment will have a positive impact on their life.
Any general dentist does “cosmetic” dentistry and most at least do parts of implant procedures. As in any profession, there are varying degrees of talent. Your comfort level with the dentist and the office in general is most important. If you are interested in something that you hear advertised, ask your dentist. He or she probably offers those services.
Bridge vs. Implant
December 28, 2011
Over the past few weeks I have had numerous new and existing patients who have had the need to replace single and multiple teeth. Based on the conversations I have had with these patients, there seems to be some common misconceptions about replacing teeth. I would like to share my thought process that I communicate with patients when they are forced to decide between different treatment rationales.
Let me start by using an example of a new patient I had in yesterday. The patient presented with the chief complaint of pain. The diagnosis was an infection of a previously root canal treated tooth which was deemed non-restorable. The only treatment was extraction. The teeth adjacent to this tooth are in good condition. There are four treatment options: extract and leave the space, extract and replace missing tooth with a removable appliance (partial denture), extract and do a fixed, cemented bridge (non-removable), extract and replace missing tooth with a dental implant.
Extracting the bad tooth and leaving the space is always an option. There are, of course, esthetic concerns as well as concerns about other teeth moving and loss of function. Replacing the missing tooth with a removable partial denture is an option but is not one that most people choose due to the fact that they have to wear something in their mouth. That leaves the last two options that most people contemplate: a bridge vs. a dental implant.
Fifteen years ago, when I started practice, the standard of care was to replace the missing tooth with a bridge. A bridge is a laboratory fabricated restoration where the teeth on either side of the missing tooth (abutments) are prepared for crowns. An impression is taken of the prepared teeth and the final product, a one-piece “3-tooth” porcelain bridge, is cemented onto the two teeth that were prepared. The advantages of this are: typically can done quicker than an implant and if the abutment teeth need crowns anyway, all is accomplished with that one procedure. One major disadvantage is that if you get decay on one of the abutment teeth, the entire bridge is typically lost. So, if you are prone to decay (especially if you do not visit the dentist on a regular basis), a bridge is probably not the best solution. Another disadvantage is that if the abutment teeth do not “need” crowns, a bridge requires perfectly good teeth to be ground-down. Because the bridge is one piece, flossing requires a special tool to thread the floss under the bridge.
Today, I would consider a dental implant to be the standard of care. A dental implant is a titanium “post” that replaces the root of the missing tooth. A single crown is then placed on that “post”. The procedure is typically less invasive than removal of a tooth. You cannot get decay on a dental implant. If something goes wrong with one of the teeth on either side of the dental implant, you only have to deal with the one tooth and not three teeth as in the example of the bridge. The teeth are all separate so flossing is normal. The cost of a single dental implant vs. a 3-unit bridge is about the same.
Although there are other things to consider, I am out of space this week. I encourage your questions.
The Patching Theory
July 20, 2011
I would like to discuss some situations I have had over the past week with a few new patients. The common theme with these patients was the idea of “patching” things vs. treating for predictable long-term success.
There are many different ways to “successfully” practice dentistry. Success as defined by Webster’s is, “a favorable or satisfactory outcome or result.” Success can also be short-term or long-term. In dentistry, short-term success can be anything from a day to a few years. If you have a front tooth break and the dentist fixes it but it breaks a week later, it was successful for a week. The patient usually doesn’t look at it as being successful at all. The question is what problem caused it to break again? In this situation it usually has to do with bite related or structural issues and not with the fact that the dentist didn’t “bond” the tooth correctly.
I look at long-term success in dentistry as being anything over 10 years. However, there are many situations in dentistry where a short-term solution can lead to a longer-term success. But when it eventually fails (and everything fails at some point), the present fix of the current problem may involve more extensive treatment.
Let me use a specific example that we see every day in the dental office. I am sure many of you can relate to it. Let’s say you have a molar with a large filling and a piece of tooth breaks off while eating. The dentist tells you that he/she can patch the tooth with some bonding material at a cost of $200 or do a crown on the tooth for $1200. With that amount of information most people, understandably, would choose the patch if the outcome would be to “fix” the tooth. Five years go by and everything is great until another piece of tooth breaks off of the same tooth. The dentist now tells you that there is not enough tooth structure left to do a crown and the tooth needs to be extracted. The only problem is that it is a molar and you need it to chew, so you decide to replace it with a dental implant to the tune of $4000. Some may choose not to replace it, which is free, but you have just lost function. What happens if you have a bunch of teeth with big fillings that have been “patched” over the years?
Patients love dentists who patch teeth. They get a quick fix that costs a lot less….in the short-term. This is very understandable. When given the choice, I too would always like to spend less money to fix something than more. However, investing in a fix that gives you a long-term success is usually always a good investment.
I do believe that you should always be given a choice. They’re your teeth, not the dentist’s teeth. One of the problems is that there are those dentists who have very “successful” practices who don’t give the patients the choice. Their philosophy may be that patching is the way to go. That is fine. For the more progressive dentist, giving the choice to the patient means education….. and education takes a lot of time. Spending time talking with patients seems to be a lost art in the dental world.
I’ll say it again….. they are your teeth and you are the one who makes the decision on what is done with them. Just remember, investing in more predictable long-term care will usually mean having more teeth when you are older or spending much less over time. Studies show that the quality of life decreases with every tooth lost. Invest in your teeth; it’s better than any other investment out there right now. Your teeth don’t depreciate in value.
Facts You Should Know – Part 2
December 16, 2010
This week is a continuation from last week’s column on facts you should know if you are having any dental work done other than a simple filling.
STAINS and COLOR CHANGES: All dental restorative materials can stain. The amount of stain generally depends on oral hygiene as well as the consumption of coffee, tea, tobacco, and some types of foods or medicines. Dental porcelain usually stains less than natural tooth enamel, and the stain can be removed at dental hygiene cleaning appointments. Natural teeth tend to darken with time more-so than porcelain crowns. At the time a new dental porcelain crown or fixed bridge is placed, it may be an excellent color match with the adjacent natural teeth. Over time, however, this may change and bleaching or other appropriate treatment may be suggested.
BLEACHING: Bleaching provides a conservative method of lightening teeth. There is no way to predict to what extent a tooth will lighten. In a few instances, teeth may be resistant to the bleaching process, and other treatment alternatives may be advised. Infrequently, side effects such as tooth hypersensitivity and gum tissue irritation may be experienced. If these symptoms occur, technique modifications or products can usually alleviate the problem(s).
TOOTH DECAY: Some individuals are more prone to tooth decay than others. With a highly refined carbohydrate diet or inadequate home care, tooth decay may occur on areas of the tooth or root not covered by a dental crown. If the decay is discovered at an early stage, it can often be filled without remaking the crown or fixed bridge. Long delays in treatment, a loose temporary, or permanent crowns and bridges can result in additional decay, the “death” of a tooth nerve, which would require a root canal or even the loss of a tooth and/or teeth.
LOOSE CROWN or LOOSE FIXED BRIDGE: A dental crown or fixed bridge may separate from the tooth if the cement is lost or if the tooth fractures beneath it. Most loose crowns and fixed bridges can be re-cemented, but teeth that have extensive recurrent decay or fractures will usually require a new crown or new fixed bridge.
EXCESSIVE WEAR: Sometimes crowns and fixed bridges are used to restore badly worn teeth. If the natural teeth were worn from clenching and grinding the teeth (bruxism), the new crowns and fixed bridges may be subjected to the same wear. In general, dental porcelain and metal alloys wear at a slower rate than tooth enamel. However, excessive wear of the crowns or fixed bridges may necessitate an acrylic resin mouth guard (also called a protective occlusal splint or night guard.)
ADDITIONAL INFORMATION: Sometimes when teeth are prepared for crowns, due to the extent of wear, deep decay, large fillings or old crowns, the additional “trauma” to an already compromised tooth can possibly cause the nerve of the tooth to die. This usually requires root canal treatment. It does not normally require changes in your treatment plan.
MAINTENANCE: Even the most beautiful restorations can be compromised by gum problems, recurring cavities, and poor oral hygiene habits. Part of your dentist’s commitment to you is to provide you with the proper information to keep your gums and teeth (natural or restored) in good health. Professional cleaning by a dental hygienist at recommended intervals keeps your mouth healthy and can intercept potential problems early enough to avoid additional restorative work or unnecessary discomfort.
