letters published in dental journals
I'm writing in response to Dr. James Lynn Davis' letter on overtreatment in the April 17 ADA News. For many years, dentists were counted among the most honored and admired professionals. Our patients were treated with respect; we dealt with their needs, and we were available to them at a moment's notice. We placed a high value on the doctor-patient relationship and we were well compensated for treating and diagnosing disease. Often we had the privilege of treating multiple generations of a single family.
Unfortunately, the attitudes of some dentists towards their patients are changing radically, and rapidly. Sadly there are many excuses as to why things have changed. "The graduates are buried in debt, corporate dentistry is taking over, etc., etc." In my view, there is no valid excuse to justify any of the following situations.
One dreadful trend includes offices that have daily sales quotas in place for dentists and hygienists. Since when did selling and quotas become the new norm in dentistry? We are not selling used cars; we are ministering to the health needs of the public. We should be better than that. Our patients deserve the best care we can deliver based upon their needs; they are not ATMs.
When a 14-year-old comes to our office for a second opinion with a treatment plan for eight restorations, with only one carious lesion, I am disturbed. We should be better than that. Our patients deserve better.
How do we defend our profession when a patient is told she needs four quadrants of scaling and root planing, and she has no bleeding on probing and no pocketing? Tailoring treatment plans based upon insurance coverage, to increase reimbursement is becoming a pervasive trend. When did a routine, thorough prophylaxis become a "deep" or "periodontal" cleaning that you charge more for? We should be better than that. Our patients deserve better.
Clearly not every crown needs a core buildup. It is especially suspicious when the treatment plan is to replace crowns. No one can see the tooth structure underneath the crown to know that a buildup is needed. I am disturbed. We should be better than that. Our patients deserve better.
When patients with HMO insurance go to an office that had contracted to do resins at no or a very low fee and the dentist tells the patient that he needs to place a special liner under the resin for $195, which is not covered by insurance, this is just wrong. We should be better than that. Our patients deserve better. If you are not getting a fair fee for a procedure, stop taking that insurance, don't take it out on the patient by committing fraud.
When I mention going in on a Saturday to see a patient in pain, to a colleague and he asks, "Why did you go in, was it a close friend?" I answered, "No, it was a human being in pain who needed help." I am disturbed by the question, and I worry where the profession is heading.
When a former patient who has moved away calls to ask why her new dentist wants to replace all of her crowns for the sole reason that they are 5 years old, I am disturbed. We should be better than that. Our patients deserve better.
Yes, dentistry is not easy. There are difficult patients, cases that don't go well, even in the most skilled hands, and staff challenges and events that you cannot control. However, if you treat people fairly, you will love dentistry, you will be gratified, you will be appreciated by loyal patients, and dentistry will be good to you in return.
Lee M. Friedel, D.D.S.
April 2011Volume 142, Issue 4, Pages 447–448
How Do I Deal With What I Perceive to Be Overtreatment by Another Dentist When His or Her Patients Come to Me to Discuss Their Proposed Treatment Plans?
Q As the director of a postgraduate periodontics program, one of my responsibilities is to screen patients for treatment by our residents. To be accepted as a patient, the person must have therapeutic needs that will be challenging to the resident (for example, advanced periodontal disease, complex implant cases and esthetic surgical needs). Recently, I have seen several patients from one periodontal practice who have been told that they have generalized advanced periodontitis and require full-mouth periodontal surgery. The patients say that the periodontist told them that without surgical treatment, they likely would develop coronary artery disease in the future. These patients were scheduled for full-mouth surgery without having undergone any phase one therapy (root planing), but came to the dental school because of the cost at the private practice. My examination found that these patients had minimal pocket depth and could be treated successfully with conservative therapy consisting of plaque control and quadrant root planing, and their cases were not suitable for assignment to a periodontal resident. This is a real dilemma for me. We are in need of as many opportunities as possible for our residents, but I don't feel comfortable assigning these patients to them for plaque control and root planing only, nor do I wish to follow the periodontist's treatment plan and subject the patients to what I believe to be unnecessary surgery.
A In deciding how to approach this ethical challenge, you will want to take into account the rights and responsibilities of all parties involved: the patients, the periodontist, the residents and you, the program director. Section 3 of the American Dental Association Principles of Ethics and Code of Professional Conduct1 (ADA Code), Beneficence (“do good”), reminds us that our “primary obligation” is to the patient and that we act for his or her benefit. Considering the patients first, you should determine whether the therapy planned by the periodontist is appropriate for their current conditions or whether the periodontist has overstated the need for and reasoning behind more aggressive treatment.
Although research supports various approaches to treating chronic periodontitis, there is general agreement in the literature indicating that conservative treatment can be successful for the type of early periodontitis you describe. Even if 4-millimeter pockets remain, the clinician can maintain the pocket depth successfully across time, while leaving open the option of more aggressive therapy if areas appear to progress. Performing surgery as the initial treatment when it is not indicated would be a violation of the ADA Code, Advisory Opinion 5.B.6, Unnecessary Services.
Another violation of the ADA Code has occurred if the patients have recounted accurately the periodontist's assertion that without surgery, they would be predisposed to developing coronary artery disease. Advisory Opinion 5.A.2, Unsubstantiated Representations, states that a dentist acts unethically if he or she represents that a particular dental treatment “has the capacity to … alleviate diseases … when such representations are not based upon accepted scientific knowledge or research.”1 To date, researchers have not proven scientifically that periodontitis causes coronary artery disease.
In accordance with Section 1, Principle of Patient Autonomy (“self-governance”), and Section 1.A, Patient Involvement, you should involve these patients, and indeed all of your patients, by discussing the examination findings and proposed treatment so that they can make informed treatment decisions. If the patients ask about the different treatment plan offered by the periodontist, explain truthfully that you have not found scientific research to substantiate the need for an aggressive approach to treat early-stage periodontitis or to prevent further periodontal problems.
If the patient presses you for further explanation, be sure that you know everything about this patient's situation and what the periodontist actually discussed with him or her. In this way, you will not breach your ethical obligation under ADA Code 4.C, Justifiable Criticism, and Advisory Opinion 4.C.1, Meaning of “Justifiable,” by making “unjustifiable disparaging statements against another dentist.”1 You can make sure your comments are “truthful, informed and justifiable” by consulting with the periodontist. In doing so, you may gain insight into his or her treatment philosophy and obtain information about what was discussed with the patient. You could relate your examination and research findings and perhaps the two of you can reach a consensus regarding the best possible approach to treatment. If you feel the need to do so, you can take this opportunity to explain how the periodontist's approach with these patients has placed you in a dilemma with regard to their treatment at the dental school.
You may be surprised to find that sometimes you can change other practitioners' practice habits for the better. A calm discussion of your examination findings in patients he or she has seen can educate even the most erudite specialist, as well as the less knowledgeable general practitioner or student.
However, if the periodontist refuses to talk with you about these cases or rejects any of your suggestions regarding the best course of therapy, you must discuss your findings and recommendations with patients in a straightforward manner, without undue criticism of the periodontist. The patient then must make the final decision regarding whether he or she wishes to be treated in the dental school or elsewhere in private practice.
If the patient accepts your recommended treatment, you may wish to assign the patient's case to a dental student rather than to a resident. Treating this patient would not serve the resident's educational objective of learning to manage challenging cases. Assigning the patient to a dental student, under the guidance of periodontal faculty members, could be beneficial for both the patient and the student.
Resolving your dilemma in this way will allow the patient to make an informed decision with regard to his or her needs, desires and abilities while benefiting your school by advancing the experience and skill of dental students and reserving the more complicated cases for residents. By contacting the periodontist, you also will have made an attempt to understand his or her interaction with the patient, as well as his or her philosophy of treatment.
As members of one of the most well-respected professions, we must base our treatment decisions, first and foremost, on the needs of the patient.
- American Dental Association. (Accessed Feb. 26, 2011)American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2011. American Dental Association, Chicago; 2010
Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the ADA Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail “firstname.lastname@example.org”.
The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA.
1Dr. Kent Palcanis is the former associate dean for academic affairs and a professor, Department of Periodontology, School of Dentistry, University of Alabama at Birmingham, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs.
© 2011 American Dental Association. Published by Elsevier Inc. All rights reserved.
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April 2011Volume 142, Issue 4, Pages 447–448
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How Do I Deal With What I Perceive to Be Overtreatment by Another Dentist When His or Her Patients Come to Me to Discuss Their Proposed Treatment Plans? - The Journal of the American Dental Association