Ethical Dilemmas in Dentistry, Fourth Series

encompassing “Preventing Further Harm”; “The Painful Diagnostic Dilemma”; “Carole’s Unexpected Pulpitis.” (1 credit hour)

Learning Objectives

After completing the course, participants will be able to:

  • Understand the issues surrounding the ethical dilemma of an uninsured patient with limited funds who has had heck and neck radiation, including to his mandible, and who seeks treatment for multiple painful teeth
  • Understand the issues surrounding the ethical dilemma of a patient who wants you to extract symptomatic teeth, based on the opinion of another dentist given on an emergency basis, but you do not agree with that course of action
  • Understand the issues surrounding the ethical dilemma of patient who is in acute pain after placement of a class V restoration, and who wants to know why she should pay for a root canal—the course of action now indicated—when she was not told in advance about this possibility.
  • Understand the ethical reasoning behind the evaluation of these ethical dilemmas
  • Understand the decision making used to approach these ethical dilemmas
  • Understand options when confronted with an ethical dilemma

Please Review the Following Material:

“Preventing Further Harm”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #14)

What Would You Do?

Charles Finley is a 45-year-old construction worker whom you have seen on a sporadic basis over the last four years. You have practiced general dentistry in the same location now for ten years in a community of 2,000 and the nearest regional medical center is 150 miles away. Mr. Finley was recently diagnosed with a head and neck malignancy and received radiation treatment of 6000 cGy that included his mandible. His chief complaint is multiple painful teeth.

Visual examination reveals multiple decayed teeth, four that probably involve the pulp and one that may need to be extracted. Although he has not been a regular patient during the last three years, he has kept his appointments and paid his bills:

Mr. Finley is worried because he was told that because of his radiation treatment, he was at high risk for osteoradionecrosis from dental infection or extractions. He does not have dental insurance and admits that he has limited funds. He pleads with you — “Please help me. You are my only hope for treatment!”

You are now faced with an ethical dilemma. Check the course of action that the dentist should follow as indicated below.

  1. prescribe antibiotics and dismiss the patient,
  2. treat the infected teeth with root canal therapy,
  3. dismiss the patient,
  4. treat all the teeth comprehensively,
  5. treat symptomatic teeth with extractions, having Mr. Finley acknowledge the risks, or
  6. other alternative (please explain).
Response

Charles Finley is a 45-year-old construction worker who you have seen on a sporadic basis over the last four years. You have practiced general dentistry in the same location now for 10 years in a community of 2,000 and the nearest regional medical center is 150 miles away. Mr. Finley was recently diagnosed with a head and neck malignancy and received radiation treatment of 6000 cGy that included his mandible. His chief complaint is multiple painful teeth.

Visual examination reveals multiple decayed teeth, four that probably involve the pulp and one that may need to be extracted. Although he has not been a regular patient during the last three, years, he has kept his appoint merits and paid his bills.

Mr. Finley is worried because he was told that because of his radiation treatment, he was at high risk for osteoradionecrosis (ORN) from dental infection or extractions. He does not have dental insurance and admits that he has limited funds. He pleads with you—”Please help me, you are my only hope for treatment!”

The dentists responding to this case chose either to treat the infected teeth with root canal therapy (option #2) or treat all the teeth comprehensively (option #4). None chose to prescribe antibiotics and dismiss the patient (option # 1) dismiss the patient (option #3), or to treat all symptomatic teeth with extractions, having Mr. Finley acknowledge the risks (option #5). Alternatives were noted by letter and note and will be included in the response.

Proper treatment for a patient requiring head and neck radiation treatment (RT) includes a thorough dental exam and comprehensive case planning which should be coordinated with the radiation oncologist prior to RT. In this case, however, the dentist is not included by the radiation oncologist, and so must deal with the patient as presented.

There are three ethical issues involved: 1) the role of the dentist in preventing even further harm to the patient; 2) trust in the doctor-patient relationship: and 3) the responsibility of the profession to educate other health professionals about the complications associated with oral disease.

Preventing Further Harm

Preventing harm is a primary goal and attribute of our profession, but there are instances where harm has already occurred and the dentist’s concern is preventing further harm to the patient. Mr. Finley received head and neck RT without the benefit of prior consultation and coordination of dental care between the dentist and the radiation oncologist, although the patient was informed that he was at high risk for ORN from dental infection or extractions. Now Mr. Finley comes to you with multiple painful teeth, pulpal involvement and the possibility of one tooth needing extraction. These are conditions that should have been treated prior to RT.

The first step in preventing further harm to the patient is to initiate a comprehensive review of his case with the radiation oncologist to identify the type of malignancy, and to locate the precise site including the point of entry, volume of tissue exposed, type of radiation used and the dosage, for determining the tissues at risk. Now you can begin a dialogue to coordinate dental care with a knowledge of his RT history that relates to the treatment plan of the radiation oncologist. There are a number of side effects following RT that may require the dentist’s expertise, including the difficulty in eating caused by xerostomia, mucositis, dysphagia, ageusia, nausea and vomiting, and loss of appetite along with the potential for radiation caries, trismus, pain and ORN. (1)

The next step is to establish a comprehensive dental treatment plan for Mr. Finley that includes root canal and restorative therapy for the painful teeth in conjunction with a meticulous periodontal evaluation, treatment, and maintenance program. Artificial saliva may be prescribed to manage xerostomia that maybe present along with analgesics for his pain, and antibiotics and/or antifungal medications. Removable, rather than fixed, prosthodontics is indicated if he has a high canes activity, and there may be an indication for endodontics, followed by crown amputation rather than extraction. Frequent dental recalls must be part of the comprehensive plan, along with the use of fluoride carriers to prevent radiation caries.

Invasive surgical procedures exposing bone at the RT site is contraindicated because the bone is hypoxic, hypocellular and hypovascular making it prone to ORN. (2,3) ORN is regarded as a condition of previously radiated bone which compromises its ability to remodel, repair and subsequently combat infection. An invasive surgical procedure may cause ORN because the bone is subject to tissue breakdown that may result in a non-healing wound. Osteoradionecrosis is a problem of wound healing rather than infection, (3) and if the extraction is necessary for Mr. Finley, precautions to minimize the risk includes: 1) prophylactic antibiotic therapy; 2) achieving primary closure of the surgical site and eliminating sharp ridges; and 3) the possible use of hyperbaric oxygen therapy (HBO) before and after the surgery.

Although proper preventive dental treatment will not eliminate the possibility of ORN, the failure to follow these recommendations may result in an adverse result for the patient and a lawsuit for the dentist. ORN may be a severely debilitating condition resulting in skeletal deformity. The ADA News this year reported a $2.96 million settlement made by a Florida jury to a dental patient who developed ORN after dental extractions. The lawsuit charged the defendants with “negligent failure to consult with or refer to an oral surgeon, negligent dental extraction, negligent supervision of surgical site and negligent failure to obtain informed consent for the extraction.” (6) To practice competently, dentists must continue to, improve the care they deliver through education, training and research, and to keep their knowledge and skill current. (7)

It is equally important that all health professionals, including radiation oncologists. keep their knowledge and skills current. What is the importance of the doctor-patient relationship in this case, especially when the dentist was not involved in proper preventive dental therapy before RT?

Trust in the Doctor-Patient Relationship

Trust is an essential part of the doctor-patient relationship. We have mentioned in earlier cases how trust, unlike other relationships that must be earned, is assumed when we become patients of a health care professional. In our case, this trust has been violated, and the patient and dentist must deal with the fear of uncertainty about risks that may have been avoided

In Mr. Finley’s case, we make an assumption that medicine has failed to address the oral conditions that may have prevented this fearful situation, although this can only be confirmed by contacting the radiation oncologist. If this assumption is correct, then the question is how to inform the patient that this preventable situation was not properly addressed without breaking the trust between the patient and his physician. Mr. Finley must deal with the diagnosis of a malignancy and the fear of ORN, and he trusts that his health professionals are the experts who have the knowledge and skills to “cure” him. The imbalance of this relationship has caused some to criticize doctors of being paternalistic, or treating the patient as you would a child, which has a long history in medicine and dentistry. The philosopher Edmund Pellegrino has described the “ethic of trust” as the cement of this imbalanced, doctor-patient relationship and that, “both are locked in a human relationship the acuteness of which is rarely encountered in day-to-day life.” (8) The TDA’s Principles of Ethics describes the relationship as “Trust by the public that serving their true dental needs with appropriate quality care is the heart of the patient-dentist relationship. This concept of trust, imbued with dedicated service, is the hallmark of professionalism…” (9)

A dentist who decides to treat Mr. Finley will be locked in a relationship that may require the full measure of that dentists, knowledge, skill and commitment throughout treatment. In this case, dentists chose to: 1) treat the infected teeth with root canal therapy; 2) treat him comprehensively: or to 3) try and refer him to a dental site that can treat him comprehensively. In response to the patient’s limited funds and no dental insurance, one respondent wrote: “I have practiced in a town of 2,000, and people will let you do as much free dentistry as you can stand. I will give him a discount if he does it all at once, but no free work. I’m sorry, but I can’t be charity to everyone.”

Patients assume that the doctor has the knowledge and skills to practice competently and that lifelong learning is a core commitment of that professional role. A dentist wrote that the physician treating Mr. Finley “should have anticipated the dental problems and had his dental problems and dental needs evaluated prior to radiation.” Does the dentist have an obligation to confer with Mr. Finley’s radiation oncologist about the need for proper oral therapeutics and RT?

Educating Health Professionals

Preventing complications due to RT is knowledge that is not restricted to our profession but an important component of the practice of medicine. This case illustrates the impact of proper dental therapy on the lives of our patients.

If the benefit of our patients is our primary goal, (7) it is the obligation of the dentist to contact the radiation oncologist and address these concerns for proper dental therapy before, during, and after RT to manage the numerous side effects and to minimize the risk of ORN.

Several steps could have been taken to coordinate Mr. Finley’s dental care prior to RT including: 1) coordinate therapy with radiation oncologist, regarding RT site, dosage and timing; 2) complete restorative and periodontal treatment; 3) extract teeth that would be compromised by RT (caries, severe periapical or periodontal disease (10), or abutting or invaded by neoplasm—remove bony ridges; 4) allow proper healing time of two to three weeks prior to RT: and 5) institute preventive measures including routine oral prophylaxis and fluoride treatments. (1,2)

Conclusion

Dentists are committed to preventing harm to their patients and, in some cases, preventing further harm by educating other health professionals about the consequences of dental disease. Patients who receive RT for head and neck malignancies must be seen for a comprehensive dental evaluation and coordination of dental care with the radiation oncologist to prevent complications and to prepare the patient properly for the many complications associated with RT. The dentist can lower risks of debilitating conditions like ORN by coordinating proper dental treatment before; during, and after RT with the radiation oncologist. Is Mr. Finley my patient? Most respondents said “yes.”

References
  1. Haveman CW. Radiation therapy for head and neck cancer: Oral complications. Oral disease update 1994; 1(1):2-6. (This is a publication of the TDA’s Dental Oncology Education Program and is available by contacting the TDA.)
  2. Sanger JR, Matloub HS, Yousif NJ, Larson DL. Management of osteoradionecrosis of the mandible. Clinics in Plastic Surgery 1993; 20(3):517-530.
  3. Marx RE. Osteoradionecrosis: A new concept of its pathophysiology. J Oral Maxillofac Surg 1983; 41:283-8.
  4. Marx RE. A new concept of its Osteoradionecrosis. J Oral Maxillofac Surg 1983; 41:351-7.
  5. Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: a randomized prospective clinical trial of hyperbaric oxygen versus penicillin. J Amer Dent Assoc 1985; 111:49-54.
  6. Spaeth D. Legal Affairs: Jury awards nearly $3 million in Florida malpractice lawsuit. ADA News 1994: 25(9):14-15.
  7. ADA Principles of Ethics and Code of Professional Conduct. Amer Dent Assoc 1994:2.
  8. A Philosophical Basis of Medical Practice. Toward a Philosophy and Ethic of the Healing Professions. Eds. Pellegrino ED, Thomasma DC. Oxford Univ Press, New York; 1981:66-7.
  9. Texas Dental Association. Principles of ethics and code of professional conduct. 1985:17.
  10. Gaper C, Epstein JB. Guze DA, Buckles D, Stevenson-Moore P. The development of osteoradionecrosis from sites of periodontal disease activity: Report of 3 cases. J of Periodon 1992; 63(4):310-6.

EDITOR’S COMMENT: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor Collegezof Dentistry. the National Center for Policy Analysis or the Texas Dental Association.


“The Painful Diagnostic Dilemma”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #15)

What Would You Do?

Carol Stallings is a healthy 45-year-old who has been in your general practice for 15 years and who has had regular dental care. She was a fearful dental patient who had poor experiences as a child and over the years you have managed to help Carol manage her fears. She trusts you implicitly.

You have seen her regularly over the last few months to try to identify the source of pain that started as diffuse occasional pain in the upper right quadrant. Her third molar was extracted 10 Years ago and she has small, clinically sound MOD amalgam restorations on all upper right posterior teeth. Although there was some wear on cusp inclines, she reports that she does not brux. You have studied radiographs. transilluminated all of her teeth, percussed the cusps at different angles, probed the occlusal fissures with a sharp explorer, and had the patient bite to try to identify the source of her pain. On the first appointment you adjusted the small interferences. When that wasn’t successful, you removed the small MOD restorations, checked for cracks and replaced them with IRM. Heat, cold, and electrical pulp tests again were inconclusive in the quadrant. Carol does not have allergies and her sinuses have a normal degree of radiolucency on both sides.

Carol was unable to reach you last weekend for an emergency and was seen by the dentist of a friend. The dentist diagnosed that she had fractured teeth and recommended the extraction of the upper right first and second molars. She refused this treatment and the dentist prescribed an analgesic and returned her to your office.

Carol is now insisting, “We need to do something, please extract the teeth, I trust you and I don’t want anyone else to extract them.” You explain that you do not agree with the treatment but she continues to insist “We need to do something!”

You are now faced with an ethical dilemma. Check the course of action that the dentist should follow as indicated below.

  1. extract the upper right first and second molars
  2. recommend and proceed with root canals on the upper right first and second molars
  3. refer her to a neurologist for further evaluation
  4. prepare the upper right first and second molars for crowns, cement temporary crowns, and wait to see if this improves her symptoms
  5. other alternative (please explain).
Response

Carol Stallings is a healthy 45-year-old who has been in your general practice for 15 years and who has had regular dental care. She was a fearful dental patient who had poor experiences as a child and over the years you have helped Carol manage her fears. She trusts you implicitly.

You have seen her regularly over the last few months to try to identify the source of pain that started as diffuse occasional pain in the upper right quadrant. Her third molar was extracted ten years ago and she has small, clinically sound MOD amalgam restorations on all upper-right posterior teeth. Although there was some wear on cusp inclines, she reports that she does not brux. You have studied radiographs, transilluminated all of her teeth, percussed the cusps at different angles, probed the occlusal fissures with a sharp explorer, and had the patient bite to try to identify the source of her pain. On the first appointment, you adjusted the small interferences. When that wasn’t successful, you removed the small MOD restorations, checked for cracks and replaced them with IRM. Heat, cold, and electrical pulp tests again were inconclusive in the quadrant. Carol does not have allergies and her sinuses have a normal degree of radiolucency on both sides.

Carol was unable to reach you last weekend for an emergency and was seen by the dentist of a friend. The dentist diagnosed that she had fractured teeth and recommended the extraction of the upper right first and second molars. She refused this treatment and the dentist prescribed an analgesic and returned her to your office.

Carol is now insisting, “We need to do something, please extract the teeth. I trust you and I don’t want anyone else to extract them.” You explain that you do not agree with the treatment but she continues to insist “We need to do something!”

The relief of pain is a core obligation of health professionals but occasionally the subjective nature of the patient’s symptoms makes the diagnosis perplexing. Carol’s case caused our respondents to abandon the four original options and write their own. The original options were: 1) extract the upper-right first and second molars; 2) recommend and proceed with root canals on the upper-right first and second molars; 3) refer her to a neurologist for further evaluation; and 4) prepare the upper-right first and second molars for crowns, cement temporary crowns, and wait to see if this improves her symptoms.

Carol’s case illustrates how the attempt to relieve pain, while not harming the patient, is a dilemma when the diagnosis is unclear. Respondents’ managed Carol’s painful diagnosis with varied diagnostic and treatment regimens.

Relief of Pain! Do No Harm

Patients seek the doctors’ skills to relieve pain while avoiding unnecessary harm. Since treatment choices have benefits and harms, the incorrect diagnosis of the etiology of the pain, whether it is dental pain as in Carol’s case, medical pain such as a back spasm, or the intractable pain of the terminally ill patient. A patient’s pain is often at the hub of the moral controversies about qualities of life issues, a patient’s right to die, passive and active euthanasia, and physician-assisted dying. Painful dental experiences were exploited in movies like the “Little Shop of Horrors” and “Marathon Man,” where the instruments used to heal the patient were used savagely and sadistically. The relief of dental pain is a skill that patients expect and our dental Code of Ethics defines. The TDA Code states, “Professional competence is the just expectation of each patient,” (1) and the ADA Code adds, “the overriding obligation of the dentist will always remain the duty to provide quality care in a competent and timely manner.” (2)

The desire not to harm Carol was clear in this case, as NONE of the respondents chose to follow Carol’s wishes and extract her molars. In an attempt to alleviate her pain, dentists chose to either treat her symptoms as a cracked tooth or as a temporomandibular disorder (TMD).

One-half of the respondents attributed Carol’s pain to a cracked or fractured tooth, but were divided in treatment alternatives. Some chose selective local anesthesia techniques such as “PDL,” or “posterior or middle superior injections” to attempt to localize the offending tooth. Others chose to reduce the occlusion with or without placing orthodontic bands, or to refer the patient to an endodontist for a second opinion. Her symptoms did not fit the “classic” cracked tooth syndrome (3), as she was neither sensitive to thermal tests nor reported pain on mastication. However, cracked teeth may have a vital response to pulp tests, no pain on vertical percussion, and may be difficult to localize the pain to one tooth. (4) She did have MOD restorations which makes the teeth more prone to fracture, although the amalgams were small in size. (5) She did not have any signs of bruxism (4) or notable history from 15 years in the practice. All of these elements factored into the difficult nature of the case. One clinician, an endodontist, noted that some key information was missing, such as the nature of the pain, the patient’s response to palpation of “associated muscles and alveolar bone over the teeth,” or if there was any history of trauma in this area. Even after a full coverage restoration, some patients will still have symptoms and will need endodontic treatment. (4)

The remaining one-half of the dentists chose to perform a ‘”TMJ” or “myofascial pain” examination. This included palpating the muscles in the head, neck, and shoulders and feeling for “triggerpoints,” followed by the fabrication of a “TMJ” or “bite” splint. The complexity of this diagnosis is portrayed by the variety of names such as TMD (6), TMJ, MPDS (myofascial pain dysfunction syndrome) (7), and CMD (craniomandibular dysfunction) (8). Elliot Ramer, a private practitioner, wrote that, “many practitioners believe (TMJ disorder) has become a ‘wastebasket’ diagnosis of anyone presenting with a headache or pain of unknown origin.” (8) Somedentists wrote that if the “TMJ” or “myofascial” treatment failed in Carol’s case, they would chose either to treat the molars with root canals or prepare the molars for crowns and cement temporary crowns.

Patterns of Practice

The competent and effective clinician develops through education, training and experience, the expertise to deal with the myriad of cases, like Carol’s. Clinicians, as in Carol’s case, don’t always agree, however, and we can see in this case how a clinician’s philosophy or, what philosopher David Ozar calls, “pattern of practice,” (9) affects decision making.

The dentist makes a host of decisions in daily practice that range from the practical questions of what dental chair to buy to the complex diagnosis and treatment strategies for cases like Carol’s. Much of the knowledge and skill of the clinician is learned over time, and David Ozar describes the process this way: “No one can effectively apply complex expertise to concrete situations, such as the specific clinical needs of a particular patient, if every detail of that application must be self-consciously judged and chosen each time it arises. For this reason, becoming a competent and effective professional is, in significant measure, becoming capable of applying many aspects of one’s expertise habitually, without self-conscious attention.” (9) Just as the clinicians were split between a cracked tooth or TMD diagnosis, competent clinicians may disagree on the prosthetic replacement of missing teeth, or if healthy or restorable teeth should be extracted. The dentist’s pattern of practice may change with education, training and experience, as one dentist noted, “thirty-eight years in dentistry and ‘still learning’ and helping others.”

Conclusion

Carol’s painful dilemma reminded us that competent, compassionate clinicians may disagree on the diagnosis and treatment of painful conditions, and that dentists are occasionally faced with situations where a definitive diagnosis is not possible. Dentists that wrote about Carol’s case shared a common concern for the relief of pain. accurate diagnosis and conservative therapy, but responded differently when they were faced with her insistence that “We do something.”

References
  1. Texas Dental Association. Principles of Ethics and Code of Professional conduct. 1985: 16.
  2. ADA Principles of Ethics and Code of Professional Conduct. Am Dent Assoc 1994: 1.
  3. Gher ME, Dunlap RM, Anderson MH, Kuhl [L]. Clinical survey of fractured teeth. J Am Dent Assoc 1987: 114(2):174-7.
  4. Guthrie RC, Difiore, PM. Treating the cracked tooth with a full crown. J Am Dent Assoc 1991; 122(10):71-3.
  5. Lagouvardos P, Sourai P, Douvitsas G. Coronal fractures in posterior teeth. Oper Dent 1989; 14:28-32.
  6. Mohl ND, Ohrbach R. The dilemma of scientific knowledge versus clinical management of temporomandibular disorders. J Prosthet Dent 1992; 67(1):113-120.
  7. Nelson JF. Clinical evaluation of pain. In Coleman GC, Nelson J. Principles of Oral Diagnosis. St. Louis: Mosby Year Book; 1993:166.
  8. Ramer E. Controversies in temporomandibular joint disorder. Dent Clin North Am 1990; 34(1):125-133.
  9. Ozar DT, Sokol DJ. The questions of professional ethics. In Dental Ethics at Chairside: Professional Principles and Practical Applications. St. Louis: CV Mosby: 1994:6 1.

EDITOR’S COMMENT: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysis or the Texas Dental Association.


“Carole’s Unexpected Pulpitis”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #16)

What Would You Do?

Carole Walker is a 35 year-old high school English teacher and is a new patient in your general practice in a large metropolitan city in Texas. She is in good general and oral health and her previous care consisted of small amalgam and resin restorations. She has come to your office because another teacher has recommended you, even though she must drive 45 minutes to your office. You have been in practice now for four years and enjoy the location and the growth of your practice.

One of her concerns is sensitivity to cold when she brushes her teeth in the upper right canine area. She has a cervical abrasion into dentin on the facial surface of tooth #6. She has a clinically sound distolingual amalgam on #6 that was placed several years ago. The treatment plan is for a Class V resin and you isolate, prepare, etch, place, and polish the restoration. She is pleased with the appearance of the restoration and with the appointment.

That evening she calls you and she is in acute pain that started three hours after the appointment and has been “throbbing” for the last two hours. She is angry and disappointed and asks, “Why didn’t you tell me this could happen?” You prescribe analgesics and see her the next day and determine that she has an irreversible pulpitis that will require root canal therapy. You try to explain to her that this dramatic response to the placement of small resin restorations rarely happens, but she is now upset as she has heard “horror stories” about root canals. She asks, “Why should I pay the extra expense if l wasn’t informed about the possibility of this happening?”

You are now faced with an ethical dilemma. Check the course of action that the dentist should follow as indicated below.

  1. Refer her to an endodontist for evaluation and treatment at her expense.
  2. Refer her to an endodontist for evaluation and treatment at your expense.
  3. Proceed with the root canal at her expense.
  4. Proceed with the root canal at your expense.
  5. If she continues to be upset, discontinue her as a patient.
  6. Other (please explain)
Response

Carole Walker is a 35 year-old high school English teacher and is a new patient in your general practice in a large metropolitan city in Texas. She is in good general and oral health and her previous care consisted of small amalgam and resin restorations. She has come to your office because another teacher has recommended you, even though she must drive 45 minutes to your office. You have been in practice now for four years and enjoy the location and the growth of your practice.

One of her concerns is sensitivity to cold when she brushes her teeth in the upper right canine area. She has a cervical abrasion into dentin on the facial surface of tooth #6. She has a clinically sound distolingual amalgam on #6 that was placed several years ago. The treatment plan is for a Class V resin and you isolate, prepare, etch, place, and polish the restoration. She is pleased with the appearance of the restoration and with the appointment.

That evening she calls you and she is in acute pain that started three hours after the appointment and has been “throbbing” for the last two hours. She is angry and disappointed and asks, “Why didn’t you tell me this could happen?” You prescribe analgesics and see her the next day and determine that she has an irreversible pulpitis that will require root canal therapy. You try to explain to her that this dramatic response to the placement of small resin restorations rarely happens, but she is now upset as she has heard “horror stories” about root canals. She asks, “Why should I pay the extra expense if l wasn’t informed about the possibility of this happening?”

Dentists who responded to this ethical dilemma chose four of the options including: 1) refer her to an endodontist for evaluation and treatment at her expense (option #1); 2) proceed with the root canal at her expense (option #3): or 3) proceed with the root canal at your expense (option #4). Respondents also offered alternative actions for Carole’s case (option #6). None of the respondents chose to refer her to an endodontist at your expense (option #2), or to discontinue her as a patient if she continued to be upset (option #5). There was no consensus by the respondents as to who should complete the root canal and who should he responsible financially for this treatment.

Unlike other areas of medicine, most dental surgery is performed on conscious patients, who, in most cases, can immediately inspect completed care. Patients may even be asked for their input during a procedure, such as approving the esthetics of a fixed partial denture or the phonetics of a removable patient denture. Although most of the technical details of dental procedures are beyond the patients’ understanding, they can readily view and critique the form, function, and esthetics of dental care. Carole’s case requires us to review the possible sources of irreversible pulpitis following dental composite treatment and to discuss informed consent and whether she was adequately informed about the risks of dental treatment.

Dental Composite Controversies

Carole’s painful response following the placement of a dental composite restoration reinforced the need to consider potential complications due to existing clinical conditions and pulpal status, and the technique sensitivity of dental materials. While composites are increasing in importance, especially with the emphasis on esthetic or cosmetic dentistry, (1.2) the complexities of selecting materials and technique “have hindered their full success (3).”

Carole has had a history of hypersensitivity to cold and tooth brushing in an area of cervical abrasion on a maxillary canine that has been previously restored on the distal surface. Factors that may affect hypersensitivity following a composite restoration include: the preoperative pulpal status of the tooth, amount of sclerotic or “secondary,” and reparative, or “tertiary,” dentin, (4) the remaining dentin thickness (RDT), caries, and lack of enamel at the gingival margin (5). Regarding the pulpal status, an endodontist wrote, “preparing a Class V will, in all likelihood, irritate an already hyperemic pulp.”

There are a number of technical considerations that could affect the management of Carole’s canine. First. the extent of the preparation could range from: 1 ) conventional Class V preparation typically used for cariously involved teeth that includes retention grooves in dentin; 2) convention Class V cavity preparation with cementum involvement where the gingival margin is a butt joint with a dentinal retention groove with no bevel gingivally; to 3) a modified Class V preparation for abraded teeth that includes roughening the internal cavity walls, beveling all enamel margins, and a retention groove in the non-enamel margin(s) (5.6). If the RDT is less than 0.5-mm, a calcium hydroxide liner should be used, although it is recommended that the use of liners and bases should be limited to allow the bonding systems to attach to more dentin (3). Total etching of enamel and dentin with phosphoric acid has been recommended; however, there is a concern for over-etching dentin either by too high a concentration of the etchant or too long a period of exposure (7). Dentin etching or conditioning removes or modifies the smear layer on the dentin surface while also demineralizing the outer layers of dentin between the tubules (3), and requires a weaker acid, such as 10% phosphoric rather than the 37 to 40% used for enamel etching (7). The acid should be applied for 15 seconds and placed passively without rubbing or scrubbing of the surface (5). A dentin bonding system should be used in this case, as the bond strength of surrounding enamel is stronger than the bond to dentin and the etched enamel may pull the composite away from the dentinal wall, causing a gap at the cavity wall (5). Research has demonstrated that dentin without a dentin bonding agent has increased bacterial invasion (8), disappearance of the odontoblastic layer, increased inflammatory cell infiltration, and increased irritation dentin formation. Using a dentin bonding system requires conditioning the dentin (etching), priming (impregnating the surface to form a hybrid layer), and bonding (3). Although some dentin moisture is needed for a strong bond, excessive moisture or desiccation may affect bond strength (3). There is also evidence that there is a significant variability in the bond potential and stability of various dentin bonding systems that may affect marginal leakage and gap formation (3). The research on dentin bonding typically invokes primary dentin, rather than abrasion lesions, that may be more sclerotic and less successful to dentinal bonding (4). Overall, dentin bonding systems require meticulous technique with no surface contamination (9). The composite material itself may affect gap formation if there is excessive shrinkage that may debond the restoration. Fillers in the composite have a variety of particle sizes, different ratios of particle sizes, and variability of filler rates between 35 to 71 percent by volume (3). The management of the light source may accentuate composite shrinkage if the material is placed too thick, over 0.5-mm, if the light intensity of the curing unit isn’t greater than 300 milliwatts/cm2, if the light is held too far away from the surface, or if there is excessive internal scattering of the light within the composite (3).

Overall, there are numerous factors that may have contributed to Carole’s acute response, including the preoperative pulpal status, RDT, preparation design, acid etch concentration and exposure time, dentinal bonding system efficacy, composite materials properties, and overall quality of isolating, preparing and restoring her tooth. Should patients be informed about all the risks of dental treatment? Where should we “draw the line” when seeking their consent?

Informed Consent

One of the major challenges to practicing dentists is understanding and seeking patients’ informed consent. Informed consent in dentistry is complicated by the intertwining elements of law and ethics, and the technical nature of dental treatment.

Canterbury v. Spence (1972) (10) was a landmark informed consent decision in which Judge Robinson stated: “The root premise is the concept, fundamental in American jurisprudence, that every human being of adult years and sound mind has a right to determine what shall be done with his own body,” and “true consent to what happens to one’s self is the informed exercise of a choice, and that entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each (11).” The Canterbury Case, along with earlier cases, was a turning point in medicine because it recognized the patients’ right to self-determination. Philosophers like Bruce Weinstein base the ethical principle for informed consent on the respect for patient autonomy (the patient’s personal liberty) (12). The courts have said that patients have a right to information and our ethics codes have stated: “The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions” (ADA Code) (13) and, “Dentists should merit the confidence of their patients by rendering appropriate service and attention, competently and timely, based upon the patient’s right of informed self-determination” (TDA Code) (14).

While a full discussion of consent is not possible in this brief overview, there are two points relevant to Carole’s case. First, most dentists probably perceive informed consent as a legal rather than ethical concept (15). This is not surprising, as doctors must deal with how they will manage the practical problems of consent, including: 1) how much information should be included?; 2) does my patient understand the information?; 3) is my patient capable of understanding the information?; 4) are there others who need to be involved in the decision?; and 5) should consent be in writing? Doctors sometimes view consent as primarily a one-way communication, where treatments, risks and benefits are listed, and patients sign a form acknowledging their understanding. Philosopher David Ozar challenges this view when he says, “The ideal relationship requires choosing on both sides and mutual respect for autonomy on both sides as well (16).” The second point that affects this ethical and legal discussion is the technical nature of dental practice. There are no guarantees in health care precisely because our knowledge and skills are imperfect and our patients are unique. Although we may review the research and use the most contemporary materials and technique, we understand that our success or failure regarding the benefits and risks of treatment are patient-dependent, and we must acknowledge that we have no perfect materials and techniques. Even seasoned clinicians face situations where the patient’s response to treatment is the exception, rather than the expected norm. One respondent wrote in this regard, “the probability of this event is outside the range of routine informing, which would tend to alarm patients more than help them.” An endodontist wrote: “A certain percentage of Class V restorations, no matter how carefully done, will result in the pulp developing an irreversible pulpitis. That is dentistry. They cannot be predicted.” Other dentists wrote that desensitizing should have been attempted first before restoring Carole’s tooth, while another added that after the painful episode the dentist should first attempt palliative treatment with ZOE to “let the tooth calm down.” Another respondent concluded: “This dilemma seems to be more about pride than ethics. If you don’t bend a little now, you are going to have to do some major sucking up later — get it over with and possibly make a friend.”

Conclusion

Doctors are legally and ethically obligated to discuss proposed treatment, reasonable alternatives and risks and benefits of treatment. While it may be prudent to inform patients that any restorative technique may cause an irreversible pulpitis, dentists should understand the risks of dental materials and techniques and convey relevant information. In Carole’s case, this means the possibility of postoperative hypersensitivity and even irreversible pulpitis, depending on the preoperative tests. If Carole’s dentist was practicing competently using the dental composite technique, and if the lesion offered no observable complications (i.e.. pulp tests and RDT), the dentist is not ethically obligated to perform, or refer, root canal treatment at no fee.

References
  1. Gilbert, JA. Ethics and estetics. J Am Dent Assoc 1988; 117(3):490.
  2. Nash, DA. Professional ethics and esthetic dentistry. J Am Dent Assoc 1988; 19(10):7E-9E.
  3. Bayne SC, Heymann HO, Swift EJ. Update of dental composite restorations. J Am Dent Assoc  1994 125(6):687-701.
  4. Duke SE, Lindemuth J. Variability of clinical dentin substrates. Am J Dent 1991; 4(5):241-246.
  5. Stanley HR. Pulpal consideration of adhesive materials. Oper Dent 1992: Suppl 5:151-164.
  6. Studevant CM, Barton RE, Sockwell CL, and Strickland WD. eds. The art and science of operative dentistry. 3rd edition. St. Louis: CV Mosby Co. 1995:565-570.
  7. Benolotti RL. Conditioning of the dentin substrate. Oper Dent 1992: Suppl 5:133.
  8. Harnirautsat C. Hosoda H. Pulpal responses to various dentin bonding systems in dentin cavities. Dent Mater J 1991; 10(2):149-164.
  9. Christensen GJ. Should we be bonding all tooth restorations? J Am Dent Assoc 1994; 125(2):193-194.
  10. Canterbury v. Spence. 464F 2d 772 (D.C. Cir. 1972).
  11. Katz J. ed. The silent world of doctor and patient. New York: Free Press, 1984:71-80.
  12. Odom JG, Bowers DF. Informed consent and refusal. In: Weinstein BD. ed. Dental ethics. Philadelphia: Lea & Febiger. 1993:65.
  13. ADA Principles of Ethics and Code of Professional Conduct. American Dental Association, May, 1994:7.
  14. Texas Dental Association. Principles of ethics and code of professional conduct. 1985:16.
  15. Hasegawa TK, Lange B, Bower CF, Purtilo RB. Ethical or legal perceptions by dental practitioners. J Am Dent Assoc 1988; 116(3):354-360.
  16. The relationship between patient and professional. In: Ozar DT, Sokol DJ. eds. Dental ethics at chairside: Professional principles and practical applications. St. Louis: CV Mosby Co., 1994: 49-50.

EDITOR’S COMMENT: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysis or the Texas Dental Association.

Reference

The ethical dilemmas presented in Course 5 were originally published in the Texas Dental Journal in 1994 and 1995, various pp., and are reprinted with the permission of the Texas Dental Journal. The dilemmas were originally edited by Thomas K. Hasegawa, Jr., DDS, MA, Associate Dean for Clinical Services, Baylor College of Dentistry. Sincere appreciation is extended to both the Texas Dental Journal and Dr. Thomas K. Hasegawa, Jr.

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