Ethical Dilemmas in Dentistry, Second Series
encompassing “I Want the Whitest Teeth”; “I Don’t Want to Lose My Tooth”; “Will You Stand Behind Your Work?” (1 credit hour)
After completing the course, participants will be able to:
- Understand the issues surrounding the ethical dilemma of a patient that has a ruddy complexion and is requesting dentures with the whitest shade of teeth possible
- Understand the issues surrounding the ethical dilemma of an emergency patient who needs endodontic and prosthetic treatment on an upper incisor, has no money to pay for care, and does not want to lose his tooth
- Understand the issues surrounding the ethical dilemma of patient that has a fixed partial denture that failed and asks if you will stand behind your work as she has no more money to pay for another bridge
- 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:
“I Want the Whitest Teeth!”
Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
What Would You Do?
Mr. Harold Davies is a patient who has come to your office eager to improve his appearance with a new set of complete dentures. He is a healthy, sixty-year-old male, who believes that these dentures will help him feel “younger and more vigorous.” You have completed the maxillomandibular relationship records appointment. As you begin tooth and shade selection, Mr. Davies states “just give me the whitest shade you have!” With his ruddy complexion you emphatically inform him that this would not look natural. Mr. Davies insists, “I want the whitest teeth!”
You are now faced with an ethical dilemma. Check the option(s) you would choose in this. case:
- show Mr. Davies the “whitest” shade;
- show Mr. Davies only those shades that you think are appropriate for him complexion and have him select one of these;
- insist that if Mr. Davies doesn’t trust your judgment that he should find another dentist;
- other: (describe)
Mr. Harold Davies is a patient who has come to your office eager to improve his appearance with a new set of complete dentures. He is a healthy. sixty-year-old male. who believes that these dentures will help him feel “younger and more vigorous.” You have completed the maxillomandibular relationship records appointment. As you begin tooth and shade selection, Mr. Davies states “just give me the whitest shade you have!” With his ruddy complexion you emphatically inform him that this would not look natural. Mr. Davies insists, “I want the whitest teeth!”
Mr. Davies’ desire to feel “younger and more vigorous is part of our culture to improve our health. our bodies and our overall appearance. Esthetic dentistry is a common feature in dental journals and dentists are inundated with advertisements in popular dental magazines for new materials pushed by dental materials companies vying for their share of this market. Yet, is the dentist simply the agent for patients like Mr. Davies in their quest for an enhanced self-image? Is the dentist responsible to inform patients of their esthetic “flaws,” just as they inform them of their periodontal condition? How does the dentist balance the patient’s demand for esthetic care against questions of function and his or her own professional judgment about esthetics?
Dentists who wrote about this case chose to have Mr. Davies select the shade but to also have him approve his selection at the wax trial-denture appointment. None of the respondents chose to show him only those shades that the dentist thought were appropriate for him (whitest shade not included) or to discontinue treating Mr. Davies since he did not trust the dentists judgment.
At first dance, this case seems somewhat mundane, unchallenging, and, perhaps easily “solved” by most dentists. However, understanding the ethics of our profession asks us to consider “the morality of ordinary practice”1 in order to make sense of competing obligations and responsibilities. The ability to restore function and esthetics is one of the distinctive qualities of dental practice. The interplay of these qualities may be clarified by viewing two standards for esthetics and by relating these standards to oral function and patient autonomy.
Esthetics — Two Standards
Esthetics has been described as having both an objective and subjective sense — the former concerned with the beauty of the object itself (e.g., proportion and harmony), and the latter with what is beautiful in the eyes of the beholder (e.g., the patient’s perspective).2
The objective element of esthetics and complete denture prosthodontics has been described as “an area of prosthodontics where art dominates science, where esthetics is the major concern and where knowledge must he applied to create a pleasing appearance while simultaneously maintaining oral function.”3 Creating objective esthetics requires that the dentist assess Mr. Davies oral anatomy, facial features, current dentures and photographs of the patient if possible. The dentist then makes an objective decision about tooth color, size, and morphology4; the arrangement of the teeth to create optimal lip support, tooth display, anatomic harmony, and phonetics; and the gingival color and tooth material.5 For example, one author suggests that selecting shades for complete dentures “is usually simple and problems uncommon,”6 while another states the “vast number of combinations in face form and size, arch form and size and the colors of hair. eyes, and complexion makes tooth selection anything but a menial task.“7
Prosthodontists have acknowledged the subjective esthetic preferences of patients and have, for example, identified three types of pleasing appearances: (1) the “natural look” selected by the dentist; (2) the “ideal look” characterized by a youthful appearance; and (3) the “preferred appearance” achieved by the orthodontist or represented by “small white teeth.”6 Mr. Davies is requesting the “ideal look,” but dentists who responded to Mr. Davies’ case wondered if his concern was tooth color or perhaps other objective esthetic flaws such as the “shape or alignment of the teeth” in his current dentures, or if he had “flattened out at the incisal edges” resulting in an “older look.”
The interplay of subjective and objective esthetics illustrates one of the subtleties of dental practice. Mr. Davies, who desires to look “younger and more vigorous,” is making a subjective judgment about esthetics when he asserts, “just give me the whitest shade you have.” The dentist. however, views this sixty-year-old man with the “ruddy complexion” and wonders if a dentist’s objective assessment of esthetics could realistically include, for example, a Bioform shade 100 or a Bioblend shade 59.
The elements of patient autonomy and oral function are also effected by the patient’s subjective and the dentist’s objective judgments about esthetics.
Appropriate Oral Function/Patient Autonomy
The dentist is permitting Mr. Davies to exercise his autonomy with his selection of the tooth color for his complete dentures. but is the dentist merely the agent who fulfills patient requests and is, therefore, free of responsible clinical decision-making?
Patients may have a diminished autonomy when they are in pain or have compromised oral function and esthetics. The edentulous patient has suffered a loss just as patients who suffer the loss of another body part and must adapt to a prosthesis, and some argue “no prosthetic restoration, even if mechanically and esthetically perfect, can restore a person’s image of himself as a whole person with no parts missing.”8 Most patients adapt to complete dentures and some even welcome the treatment. Even if they do adapt, they may feel, however, as one patient said: “the denture fits, l am not suffering any physical pain but part of me is gone. These are not mine, they are a dead part of myself.”8 When teeth are lost, “people lose more than function; they suffer a psychological shock that leaves them with a loss of self-esteem and other anxieties,” and some patients “may remain in a state of grief or depression indefinitely.”5,8 The edentulous patient may feel as physically and psychologically vulnerable during a dentist’s oral examination as during a physician’s physical examination. One patient expressed the pain of seeing herself without dentures by saying “it just ripped my whole self apart. l felt I was old…it was absolutely ghastly!”9 Psychologists describe the edentulous patient as potentially maladaptive (the patient that views tooth loss as a serious impairment of the quality of their lives). As a result, the patient may pretend to seek technical advice from dentists when he or she may be actually seeking emotional solutions.”10
Although Mr. Davies’ choice may seem misguided, even foolish, he has not asked for a treatment that is harmful or will compromise his appropriate oral function. Philosopher D.T. Ozar has ranked value categories in clinical dental ethics to establish a hierarchy that compares conflicting values in an ethics case.7 Ozar reasons, for example, that “accepting a trade-off which would leave a patient with significantly impaired oral function, even for the sake of autonomy…would be unethical practice.” If Mr. Davies’ brother requested. for example, full mouth extraction of his healthy, natural. objectively esthetic dentition so that he would feel “younger and more vigorous,” his request would not override the dentist’s responsibility for making a clinical judgment and determining if the treatment would significantly impair the patient’s appropriate function.
Respondents to the case chose to involve Mr. Davies in the treatment decision11,12 by honoring the patient’s shade request at the wax trial denture appointment. One recommendation was to prepare a second wax trial denture based upon the dentist’s choice so the patient could compare the two. None of the respondents chose the paternalistic option to only show Mr. Davies a limited range of shades reflecting the dentist’s choice. Respondents also advised that persons whose opinion the patient respected have the opportunity to view the wax trial denture at the office, or some other convenient place. Involving Mr. Davies in decision-making prompted one dentist to write, “an educated, fully-informed patient is our best ally in determining the most satisfying smile makeover.”
When patients request esthetic dentistry, the subtle considerations of objective and subjective esthetics and the elements of respect for patient autonomy and preserving appropriate function must be considered in each case. Although Mr. Davies’ subjective request may not be congruent with the dentist’s more objective judgment. in cases where appropriate function is not compromised. the dentist should at tempt to educate the patient about these differences but is justified in deferring the final judgment to the patient.
- Kass, L. Practicing ethics: where’s the action? Hastings Center Report 1990: 20(1):5-12 at 7.
- Nash DA Professional ethics and esthetic dentistry. J Am Dent Assoc (Special Issue) 1988:7-E.
- Halperin AR. Graser GN, Rogoff GS, Plekavich EJ. Mastering the Art of Complete Dentures. Quintess. Chicago 1988.
- Williams JL. A new classification of tooth forms. with special reference to a new system of artificial teeth. Dent Cosmos 1914: 56; 627-628.
- Murrell GA. Esthetics and the edentulous patient. J Am Dent Assoc (Special Issue) 1988:57-E.
- Lamb DJ. Problems and Solutions in Complete Demure Prosthodontics. Quinces,. Chicago 1993:91.
- Clear DT. Schiedermayer DL. Siegler M. Value categories in clinical dental ethics. J Am Dent Assoc 1988; 188(3 ): 367.
- Friedman N Landesman HM. Wesley M. The influence of fear, anxiety, and depression on the patient’s adaptive responses to complete denture. Part 1, J Prosthet Dent 1988: 59:46.
- Friedman N. Landesman HM. Wesler M. The influence of fear, anxiety. and depression the patient’s adaptive responses to complete denture. Part II. J Prosthet Dent 1988; 59:46.
- Friedman N. Landesman HM. Wesler M. The influence of fear, anxiety, and depression the patient’s adaptive responses to complete denture. Part Ill. J Prosthet Dent 1988: 59:173.
- ADA Principles of ethics and code of professional conduct. Jan 1994.
- Kawabe S. Kawabe’s Complete Dentures. Ishiyaku EuroAmerica. inc. St. Louis. 1992:97.
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.
“I Don’t Want to Lose My Tooth”
Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
What Would You Do?
Mr. Howard Glover is an emergency patient who has come to your office because of a “bad front tooth.” He is a 30-year-old man who has an unremarkable health history and has had regular dental care until he lost his job one year ago. Mr. Glover is unemployed and admits to your receptionist that he will be unable to pay for expensive dental treatment.
Six months ago, Mr. Glover slipped on the ice and bumped his front teeth on the pavement. Mr. Glover explains that the teeth were loose initially but now seem to be firm, but one tooth, his maxillary right center incisor, has turned slightly darker than the other teeth and there is a slight swelling under his lip. He has had only mild pain for which had taken Advil for the few days after the injury. Your clinical and radiographic evaluation reveals that the clinical crown and root were not injured by the fall and the 2mm periapical radiolucency at the apex of #8 and the draining sinus tract confirm the diagnosis of pulpal necrosis. The tooth is restorable and a porcelain veneer crown is the treatment of choice because of existing mesial and distal composites. Overall, his oral health other than a generalized mild gingivitis seems stable—there are only a few posterior occlusal amalgams, no obvious caries, and his occlusion is stable.
As you explain your findings to Mr. Glover with the recommendation for nonsurgical root canal treatment and a porcelain veneer crown, he becomes distressed as you discuss the cost and exclaims, “I don’t want to lose my tooth, but I told your receptionist that I am unemployed and can’t afford expensive treatment. I have always taken care of my teeth and until I lost my job I have always had regular checkups. What can I do? I don’t want to lose the tooth but I can’t afford the root canal and crown!”
You are now faced with an ethical dilemma. Check the course of action you would follow.
- Perform a pulpectomy, instrument the canal, and dismiss the patient.
- Extract #8
- Refer Mr. Glover to a local clinic that does low cost or charitable dental treatment.
- Complete the root canal treatment for Mr. Glover and have him pay what he can over time. Avoid doing the porcelain crown until he is able to pay.
- Complete the root canal and crown for Mr. Glover. Have him pay what he can over time.
- Dismiss Mr. Glover from your practice.
- Other alternative (please explain)
Mr. Howard Glover (complete case in April TDA Journal) is a healthy 30-year-old, who has come to your office as an emergency patient because of a “bad front tooth.” He had regular dental care until he lost his job one year ago and admits to your receptionist that he will be unable to pay for expensive dental treatment.
Six months ago he fell on the ice, which loosened his teeth initially. but now they seem to be firm. However, his maxillary right central incisor has turned slightly darker than the other teeth, and there is a slight swelling under his lip. He has had only mild pain for which he had taken Advil for a few days after the injury . Your clinical and radiographic evaluation reveals that the clinical crown and root were not injured by the fall and the 2mm periapical radiolucency at the apex of #8 and the draining sinus tract confirm the diagnosis of pulpal necrosis. The tooth is restorable and a porcelain veneer crown is the treatment of choice because of existing mesial and distal composites. Overall, other than a generalized mild gingivitis, he has only a few posterior occlusal amalgams, no caries, and a stable occlusion.
You explain your findings to Mr. Glover with the recommendation for nonsurgical root canal treatment and a porcelain veneer crown. He becomes distressed, however, as you discuss the cost and exclaims. “I don’t want to lose my tooth. but I told your receptionist that I am unemployed and can’t afford expensive treatment. I have always taken care of my teeth and until I lost my job, I have always had regular check-ups. What can I do? I don’t want to lose the tooth, but I can’t afford the root canal and crown!”
Mr. Glover’s case invoked a vigorous response, with most dentists choosing to complete the root canal and have him pay what he can over time (#4). A few chose to either perform a pulpectomy, instrument the canal, and dismiss the patient ( #1) or to refer the patient to a low-cost charitable clinic (#3). None of the respondents chose to extract the tooth (#2) or to provide the root canal and porcelain crown (#5).
What are the therapeutic options and the associated benefits and harms for Mr. Glover? Are dentists obligated to treat emergency patients without payment? Is this an ethical dilemma or is it, as one dentist wrote, mainly a question of whether a dentist is obligated to do “charity dentistry?”
There are three important ethical aspects to this case: 1) what are the issues of esthetics and function in this case?; 2) what do our professional codes say about our obligation to treat patients?; and 3) is dentistry a service or a profession?
Esthetics and Appropriate Function
Mr. Glover’s plight is that he is unable to afford the recommended treatment that would restore esthetics and maintain appropriate function. Unlike a previous ethical dilemma that featured the esthetic requests of a complete denture patient, Mr. Glover’s case intermixes esthetics and appropriate function as revealed in the assessment of risks and benefits of alternative treatments.
None of the respondents chose to extract #8, although the extraction would predictably remove the nidus of infection, resolve the chronic sinus tract, and prevent possible complications such as cellulitis. If the dentist extracts the tooth without prosthetic replacement, however, both esthetics and appropriate function are compromised, along with Mr. Glover’s hopes for future employment. His plight is intensified as the extraction contradicts the principle of nonmaleficence, or, “above all, or first, do no harm.”1 The extraction, although expedient, is an unattractive alternative.
Likewise, none of the respondents chose to extract #8 and restore prosthetically with treatment alternatives such as temporary acrylic denture, a fixed or removable partial denture, or an implant and crown. These alternatives have additional fees and laboratory costs that the patient may be unable to afford.
The majority of the respondents chose the option to perform nonsurgical root canal therapy and to avoid starting a porcelain crown until he is able to pay. The root canal is the treatment of choice for his condition and has a good probability of success with less potential post-operative complications due to the draining sinus tract.2 Although delaying the porcelain crown may have possible deleterious effects, such as further discoloration of the tooth or possible fracture, Mr. Glover may prefer these risks over the certain disadvantage of extraction. A few respondents chose pulpectomy as an alternative, as an interim treatment for Mr. Glover.
One respondent, an endodontist, considered no treatment as an alternative as “we have all seen patients who have had fistulas that have drained on and off for years without any apparent problems.” Although the tooth may continue to discolor and his symptoms could exacerbate, Mr. Glover may prefer no treatment over extraction, as he is not in pain and his localized infection is currently palliated by the chronic sinus tract. A few dentists wrote that they would begin antibiotics for his infection. although a chronic sinus tract is not usually an indication for coverage.3
Professional Codes and the Obligation to Treat
Professional codes are an important source of understanding the values and norms of a profession. What do our professional codes say about the dentist’s obligation to accept patients. especially those that are unable to pay?
Both the ADA and the TDA, Codes agree that dentists “may exercise reasonable discretion in selecting patients for their practices” (ADA)4 and that they “may choose whom to serve.” (TDA)5 Both prohibit discrimination because of a “patient’s race, creed, color, sex, or national origin” (ADA) or because of “an individual’s particular class or group status.” (TDA)
For emergency patients, not of record, such as Mr. Glover, the ADA Code states that dentists are obligated to “make reasonable arrangements for emergency care,” while the TDA code is more specific in its statement: “a dentist should render appropriate care compatible with professional ability and existing circumstances.” Neither of these statements infers that “reasonable arrangements” or “existing circumstances” include providing emergency care for all patients regardless of their ability to pay.
A significant point of contention within the dental codes originates from the word “service” in the phrase “service to the public.” If the “primary obligation of dentists shall be service to the public4 does this infer that the dentist is obligated to provide care for all patients regardless of their ability to pay?
Service or Profession
The debate about what a profession is supposed to be, professional models for example, has been as perplexing for dentistry as it has been for medicine. Health care reform has prompted an intense introspection about professional norms and the values, particularly in regards to the interrelationship of the health professions with the larger community. Is dentistry a service that should be provided freely by its members, a commercial agreement as any business, an autonomous profession, etc.? Mr. Glover’s case allows us to briefly explore three professional models that delineate some of the Issues involved in the debate.
The first professional model is the Service Model in which dentists approach their profession with a “nearly selfless devotion, often sacrificing personal and familial needs in favor of serving their patient and the public at large.”6 Salvatore Durante, a dentist, has referred to the term “serve” in this context to literally mean “to be a slave.”7 None of the respondents chose to provide care without some expectation of payment by Mr. Glover.
A second model has been described as the Commercial Model where the dentist has “products and services to sell to patients” and the “doctor-patient relationship is a function of marketplace exchanges, with neither party having obligations to the other until a ‘contract’ is agreed upon.”6 In other words, “we offer a highly valued service, but we are still, in essence, traders — like anyone else in a free society.”7 Some respondents to Mr. Glover’s predicament wrote that “ours is a fee-for-service profession,” ” and that, “I do not believe that any dentist is under ANY ethical, moral, or professional obligation in any way to render treatment of any kind without expectation of full payment for his/her services.” In all responses, although the dentist expected some if not all payment for treatment, none of the respondents chose to dismiss Mr. Glover without providing some care, or at least a referral to a low-cost or charitable dental clinic.
The third model has been described as the Interactive Model, where “decisions made by the dentist and patient together involve a subtle meshing of the expertise of the professional with the choice of the patient, based on the patient’s own values, priorities, and purposes,” or simply described as a “partnership of equals.”8 The majority of respondents chose the option to complete the root canal treatment for Mr. Glover and have him pay what he can over time. Some dentists explained in notes and letters their office policy and how they would arrange for payment, including the number of months and the amount. Another respondent wrote that his office “always take the patients’ individual needs at hand,” and another wrote that patients like Mr. Glover are often appreciative and are “excellent patients and refer all their friends.” All of the respondents, again, expected some payment for their treatment, with some expecting full payment.
Mr. Glover’s case asks us to consider our obligations to patients’ generally and specifically to those who are unable to pay. Although the professional codes do not articulate specific responsibilities in these regards, the responses to this case provide a glimpse of various professional models that are worthy of debate and scrutiny. As an overview. at least, none of the respondents abandoned Mr. Glover, but rather, in all instances, attempted to help him by providing some care or referring him to a charitable or low-cost dental clinic, with the majority providing root canal treatment and having him pay over time. In this regard it seems that the respondents were “caring and fair in their contact with patients.”4
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Second Edition. Oxford University Press 1983:107.
- Weine FS. Endodontic Therapy. CV Mosby 1989:217
- Gutmann JL, Dumsha TC, Lovdahl PE. Problem Solving in Endodontics: Prevention, identification, and Management. Year Book Medical Publishers, Chicago, 1988:137.
- ADA Principles of Ethics and Code of Professional Conduct, January 1994.
- Texas Dental Association Articles of Incorporation Constitution and Bylaws, and Principles of Ethics and Code of Professional Conduct, September 1985.
- Bebeau MI, Born DO, Ozar DT. The development of professional orientation inventory. Jour Am Coll Dent 1993; 60(2): 27-33.
- Durante SJ. The fallacy and danger of ” public service.” Texas Dent J 1990:107(9): 7-14.
- Ozar DT. Three models of professionalism and professional obligation in dentistry. Amer Dent Assoc 1985; 110(2): 173-177.
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.
“Will You Stand Behind Your Work”
Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
What Would You Do?
Ms. Stacey Allen is a forty-five-year-old patient who, along with her three children, has been in your practice for ten years. Ms. Allen is in excellent health, exercises regularly, and is conscientious about her yearly medical and dental examinations. Her chief dental complaint was the space caused by the loss of her mandibular first molar twenty years ago. She has excellent periodontal health, a stable Class 1 occlusion, no evidence of bruxism, good esthetics and only a few small anterior and posterior restorations. Since she did not have dental insurance, she saved her money until she could pay for an 18×20, three-unit porcelain fixed partial denture with all porcelain occlusion to replace the missing molar. Both abutments had small occlusal restorations, but overall the tooth size, crown-to-root ratio, alignment, and gingival attachment were favorable. The three-unit, fixed partial denture was cemented three years ago and she has been satisfied with the overall esthetics and function.
Last Friday, while Ms. Allen was eating a sandwich, Ms. Allen felt a hard object and, as she told your receptionist, “it’s the tooth-colored part of my bridge!” Your examination found that the buccal cusps of both molars had failed, leaving some bare metal and some porcelain on the buccal surface. Although she wasn’t in pain, the esthetic deficiency was obvious and she was angry. As she explained the situation, she wants to know if you “stand behind your work” because she cannot pay for another bridge. Although you explain to her that there are no guarantees for dental care, she still wants to know if you will “stand behind your work.”
You are now faced with an ethical dilemma. Check the course of action you would follow.
- Replace the three-unit fixed, partial denture at no fee.
- Ms. Allen should pay the laboratory fee only for the replacement.
- Ms. Allen should pay 50% of the full replacement fee.
- Ms. Allen should pay the full replacement fee.
- Other alternative (please explain).
Ms. Allen (April issue) is a forty-five-year-old patient who, along with her three children, has been in your practice for ten years.
Ms. Allen, who does not have dental insurance, saved for an 18×20 porcelain fixed-partial denture with porcelain occlusion that was cemented three years ago.
While eating a sandwich, she fractured the buccal cusps of both molars leaving some bare metal and some porcelain on the buccal surface. Although she wasn’t in pain, the esthetic deficiency was obvious and she was. angry. She wants to know if you “stand behind your work,” because she cannot pay for another bridge. You explain there are no guarantees for dental care but she still wants to know if you will “stand behind your work.”
Are dentists obliged to redo at no charge treatment that fails? What do our professional codes say about this? Should dentists guarantee their work and, if so, for what length of time?
The majority of the respondents chose to replace Ms. Allen’s fixed partial denture at no charge. A few chose to either have Ms. Allen pay only for the laboratory fee, or 50% of the full replacement fee. None of the respondents would have Ms. Allen pay the full replacement fee.
Are dentists obligated to “stand behind their work?” The following three ethical issues provide a context for analyzing this complex case: (1) appropriate function; (2) guarantee or informal consent; and (3) promise-keeping.
Appropriate Function/Technical Considerations
One of the predicaments dentists face is satisfying both the functional and esthetic demands of the patient. Some patients have extremely high esthetic expectations without an appreciation for the limitation of the materials and technique. A few of the respondents challenged the selection of porcelain occlusion in this case and discussed the possibility of dental laboratory error as a source of failure of this prosthesis.
Porcelain occlusion is contradicted in some circumstances. (1) One respondent wrote that the dentist “should not have made that type of bridge in that part of the mouth in the first place.” Porcelain occlusion has the inherent characteristics of high-compressive but low-shear strength. It is more difficult than metal to establish occlusion and is contraindicated in cases where the patient bruxes, has short clinical crowns, or large pulp chambers. (2,3) Although Ms. Allen has “excellent periodontal health, a stable Class 1 occlusion, and no evidence of bruxism,” the risk of brittle fracture exists and may be attributed to the dental laboratory technique.
“Bare metal is a laboratory error,” one respondent wrote and his lab would not charge to redo this case. A failure at the metal-oxide/opaque interface, characteristically the strongest interface, indicates the possibility of a dental laboratory error that could include: (1) excessive or inadequate metal oxide formation; (2) contamination of the metal surface; (3) porcelain/metal coefficient of thermal expansion mismatch; and/or (4) improper framework design that leaves the porcelain over 1.0 mm thick. (1,2,3)
However, both the dentist and the dental laboratory technician are restricted by the clinical parameters of the patient and the physical requirements/limitations of the dental materials and techniques. Ms. Allen’s case highlights the importance of communication and teamwork between the dentist and dental laboratory technician as they both strive to accomplish the rehabilitation of form, function, and esthetics in complex clinical situations.
A few dentists wrote that their laboratory would redo at no charge, in one case up to five years after cementation. One dentist wrote that after one year, redoing the case would be at full charge to the patient, although they would make an exception in Ms. Allen’s case.
Should the dentist also guarantee his or her treatment and for what period of time?
Guarantee or Informed Consent
The ADA Council on Insurance advises dentists not to guarantee treatment but rather to involve patients in treatment decisions as recommended by the ADA Principles of Ethics.(5)
Guarantees infer that dentists provide a product or commodity as in any business, rather than a valued professional service. The dental educator Nash (6) described the business of proprietary culture in dentistry as “selling cures” in contrast with the professional culture rooted in a tradition of “curing.”(6) Along this theme, the philosopher Pellegrino (7) observed that one of the emerging sociocultural forces in medicine is, “the partial reconceptualization of medicine as a business, replete with providers and consumers and increasingly controlled by market forces or governmental regulations.” Moreover, making claims that a health professional can “guarantee” a successful treatment does not acknowledge the inseparable role of the patient’s attitude and aptitude in the successful maintenance of his or her own health.
Training may help to explain why dentists often focus on the procedure rather than the person. Traditionally, the clinical training of dentists is technically-oriented, with success or failure measured more by the fit of the margin in microns and the completion of required numbers of clinical procedures than restoration of health itself. If the crown doesn’t fit, the dental student will redo the crown until it is acceptable. If we perceive dentistry as simply the selling of services and procedures, rather than the restoration of health, we could move dentistry into a marketplace where guarantees and warranties are expected by the patient.
By contrast, informed consent establishes a professional relationship which acknowledges both the patient’s awareness of his or her own goals or values and the dentist’s expert knowledge of the risks and benefits of dental treatment. The dentist seeks to involve the patient in treatment decisions by making the patient aware of the risks and benefits of the recommended treatment, reasonable alternatives, and the risk of no treatment.(4,8,9) In Ms. Allen’s case, we do not know if she insisted on porcelain occlusion over the dentist’s objection, if she was informed that the risk of failure due to fracture was higher for porcelain over metal occlusion (10), or if she was informed about any replacement policy in the office before treatment was started. These three factors define some of the risks of treatment and may have prevented Ms. Allen’s angry response. As for the longevity of restorations, patients should be informed that there are no absolute standards as reflected by the varied responses to this case. There may be individual standards, however, established by dental insurance companies or dentists practicing in a community.
By involving patients in treatment decisions, dentists fulfill their promise to the patient to work in his or her best interest.
Although the ADA Principles of Ethics do not explicitly describe the dentist’s responsibility in Ms. Allen’s case, they do challenge dentists to be “caring and fair in the contact with patients.”(5)
The moral obligation to keep promises is an “important part of the dentist-patient relationship, just as it is in any other interpersonal relationship.“(11) Ms. Allen’s question, “Do you stand behind your work?” focuses on whether the dentist is working in her best interest and questions the very trust that is essential for a healthy dentist-patient relationship. As one dentist said, “She trusts you would do the right thing.” Another dentist wrote that he tries to base his decision on “looking from the patient’s perspective.” Considering the amount of therapy he does during the year, redoing the case, even if he had to pay the laboratory, the cost would be “minuscule” in relation to his total practice.
Dentists also realized if they were not sensitive to her plight it could result in damaging the dentist’s image in the community as the patient expressed her dilemma with others.
Ms. Allen’s dilemma causes us to consider our obligations to patients when treatment fails, and that others, such as dental laboratory technicians, may share in this responsibility. The case also asks us to reflect on, and acknowledge, the reality that our treatment may fail and there are no absolute standards for longevity. Preparing the patient includes educating the patient about these risks. Finally, although to ADA Principles of Ethics offers no explicit advice for this situation, the fact that dentists responding to this case considered Ms. Allen’s loyalty as a factor in replacing the prosthesis at a reduced or no fee, provided evidence that they were concerned about being “caring and fair” with Ms. Allen.
- Shillingburg HT, Hobo S, Whitsett LD. Fundamentals of Fixed Prosthodontics. Quintessence Pub, Chicago 1978: 319, 323.
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- McLean JW. The Science and Art of Dental Ceramics. Vol 1 Quintessence Pub, Chicago 1979:83-85, 197-200.
- Council on Insurance. Informed consent; a risk management view. J Amer Dent Assoc 1987; 115(10):630-635.
- ADA Principles of ethics and code of professional conduct. Revised January, 1994.
- Nash DA. A tension between two cultures…dentistry as a profession and dentistry as proprietary. J Dent Ed 1994; 58(4):303.
- Pellegrino ED, Siegler M, Singer PA. Future directions in clinical ethics. J Clin Ethics 1991; 2(1):5-9.
- Pollack BR, Marinelli RD. Ethical, moral, and legal dilemmas in dentistry: The process of informed decision making. Law and Ethics Dent 1988; 1(1):27-36.
- Smith TJ. Informed consent doctrine in dental in dental practice: A current case review. J Law and Ethics Dent 1988; 1(3):159-169.
- Cheung GS. A preliminary investigation into the longevity and cause of failure of single unit extracoronal restorations. Abstract J Dent 1991; 19(3):160-3.
- Kahn JP, Hasegawa TK. The dentist-patient relationship. In Dental Ethics. Edited by BD Weinstein, Philadelphia, Lea & Febiger 1993:61-62.
Editor’s Comment: Fredrick Alexander Shaw III, D.D.S., Assistant Professor in Restorative Sciences, Baylor College of Dentistry is a consultant for this ethical dilemma. Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysts or the Texas Dental Association.
The ethical dilemmas presented in Course 3 were originally published in the Texas Dental Journal in 1994, 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.