Strive-The Student View
February, 2009 edition  

Looks Can Deceive
 By Amanda Nash

Summary

In dentistry, many procedures and tools are used in an attempt to make an accurate diagnosis. One of the most important tools in diagnosing dental disease is a dental radiograph. Without a dental radiograph, it is unknown what lies beneath the surface of a tooth or the gingiva. In the dental hygiene curriculum, we are taught not to perform any procedure within the oral cavity before proper diagnosis of recent dental radiographs. Although we must be careful of overexposing our patients to X-rays, radiographs are a necessary part of dental treatment.

Case Study

Suzy Lynn, a 12-year-old female, had chipped her left maxillary incisor on the side of a swimming pool while playing with her older brother. Upset, Suzy’s mother frantically rushed her to the dentist. At the appointment, X-rays were taken and the dentist reported there were no further problems, aside from the chip on her front tooth. Dr. McAllister decided that the best choice for Suzy would be to bond the tooth with an esthetic restorative material and to make it look as natural as possible. A year later, at the age of 13, the restoration broke, and Suzy’s mom took her to Dr. McAllister to replace the restoration. No complications occurred during this appointment.

When Suzy was about 17 years old, she saved enough money to have a veneer placed on the tooth (#9) she had chipped as a child. Her tooth still looked normal and seemed healthy, but Suzy was not satisfied with her smile cosmetically. Suzy eventually switched dentists, choosing the dentist in her area that had significant experience, interest and training in cosmetic dentistry. Dr. Jones agreed that a veneer was the best option for Suzy and worked very hard to make certain that its placement would look as natural as possible. For example, three veneers were rejected due to incorrect color, which resulted in Dr. Jones advising Suzy to go to a dental technician lab for a custom color match. Suzy was very happy with the outcome – the veneer really did look perfect!

About a year later, Suzy started to notice a gap forming between her two central incisors (#8 and #9). She ignored this for about a month until her mother encouraged her to make an appointment with Dr. Jones to determine what was wrong. The teeth tested vital. Suzy, being very concerned, asked Dr. Jones if he would take X-rays. A panoramic radiograph and later a periapical of the area were taken. The X-rays showed that there was 50 percent bone loss around #9, but no apparent bone loss around #8. Upon probing, there were 7 mm pockets on the mesial of #10 and distal of #9.

Dr. Jones explained to her that she would probably have to have #9 and #10 extracted, a bone graft surgery would be needed, and implants would replace the missing teeth. Meanwhile, she would probably have to wear a removable partial denture (flipper). Suzy was devastated and frightened. She had been nominated for prom queen and in three months was going to prom; this seemed to her like she was living her worst nightmare. Suzy’s mother supported her decision and felt that it would be best to continue with the surgical implant procedures as soon as possible—Suzy would simply have to wear a partial denture during prom. Dr. Jones promised Suzy that her partial denture would look better than her teeth now, so she agreed to it.

After prom, Suzy was referred to a maxillofacial surgeon for her bone grafting surgery. The graft was successful, but it took 10 months for her bone level to get up to 80 percent. Suzy received the implants three months later and the final crowns seven months after the implant surgery. Suzy was happy with the end result, but felt her dentist may not have always had her best interest in mind.

Commentary

As dental professionals, we are constantly striving to stay on schedule while completing our daily tasks and treating our patients, but are we always keeping their best interests in mind? Are we giving our patients all of the treatment options or just the ones that we prefer? Do we always treat our patients the best way we know how, or do we let time and money get the best of us? Our patients trust us as experts in our field of practice, and it is our duty to protect those who put so much trust in our hands. Putting yourself in the shoes of the dentist, what do you think was the reason for the bone loss? Did the bone loss come before or after the veneer was placed? Many factors play a role in Suzy’s case and how it went wrong. As for Suzy Lynn, how would you feel if you had been in her situation, no longer the dental professional but the patient? There are many different ways that this situation can be handled; some of them less ethical than others. If you were Suzy, how might you have handled this situation?

The first option is to do nothing. In this situation, Suzy will get through the prescribed treatment plan the dentist has laid out for her and complete it without sharing with the dentist how she feels about her treatment. If Suzy chooses this option, she avoids a potential conflict with the dentist, and will continue with the treatment she was prescribed. The disadvantage of choosing this option may not directly impact Suzy, but future patients that could possibly be misdiagnosed. While ultimately the choice is up to each individual patient, as consumers we must take under consideration how our choices may affect others, and ask our selves if we are making ethical decisions.

The second option is to investigate and confront Dr. Jones in order to obtain a monetary refund for the failed veneer because due to its cost, Suzy had expected that it would last longer than a year. In choosing the second option, an investigation and confrontation may result in a refund for part or all of Suzy’s treatment and may demonstrate the importance and value of correctly diagnosing patients. The disadvantage with option two is that it may not be cost effective in terms of the time and money it could take for an investigation of her case.

The third option would be to investigate, confront Dr. Jones and report the incident to his professional association. A report could be filed against Dr. Jones for failing to provide the standard of care to Suzy Lynn. Dr. Jones treated only Suzy’s cosmetic wants instead of her periodontal needs, which should have come before esthetics. If Dr. Jones would have investigated, he might or might not have found bone loss. However, he would have provided a standard of care by ensuring periodontal health and absence of bone loss before placing a veneer. As a consequence of option three, Dr. Jones might receive a reprimand and encouragement for compliance with standard of care procedures and other ethical conduct. The problem with this option is that it may present too much red tape to be effective. The end result of option three may also be very costly in time and money.

The fourth option would be to investigate and confront Dr. Jones to ensure that a similar incident does not occur with another patient, without seeking financial gain and without the goal of punishing Dr. Jones. For Suzy, the best result would be that Dr. Jones would use this mistake as a learning experience and diagnose more carefully in the future. The argument against this option is that Suzy might not get the result that she would like; Dr. Jones may feel that he has done nothing wrong and may not change. From this experience, we would hope that Dr. Jones would commit to change and provide only the highest standard of care to his patients, always keeping their best interests in mind.

Discussion Questions

Is there an ethical dilemma?

Yes, because no matter the situation, as soon as the dentist knew he did something wrong, he should have been honest with his patient. It is not clear when Dr. Jones identified Suzy’s bone loss, whether it was prior to the placement of the veneer or after. The real problem is not that bone loss occurred; it is that even when Dr. Jones did address the bone loss, he did not accept any ownership of the result.

Did Dr. Jones do anything wrong?

Yes. Dr. Jones made a few mistakes; whether or not he meant to we do not know. Dr. Jones failed to take radiographs before performing a major procedure. There may be other things that can be found that Dr. Jones did wrong during Suzy’s treatment, but those will not be discussed further.

What critical steps if any did Dr. Jones leave out, and did he present all the treatment options?

Dr. Jones did not take radiographs as discussed above, nor did he review Suzy’s periodontal health. Since Suzy had never had a periodontal exam prior to the placement of the veneer at this office, he did not have a periodontal history on Suzy Lynn; therefore, probe scores should have been taken before a veneer was placed on tooth #9. Suzy’s age may provide a reasonable argument against providing the service, but there is still a standard of care that should be given when performing certain procedures. Was age a factor in not obtaining a complete periodontal and radiographic assessment?

Was Dr. Jones providing the best quality of care to his knowledge?

We do not know the answer to that question. Dr. Jones may have felt at the time he was giving the best treatment he knew how, and maybe he did not realize the crucial steps he was missing. Dr. Jones may have assumed Suzy was fine because of the visual appearance of periodontal health.

Did Dr. Jones address the patient’s rights?

Maybe or maybe not—we cannot really answer that question. Was there informed consent? Did Dr. Jones present all the treatment options or only the veneer as requested by Suzy and her mother? A veneer may have been the only treatment option he felt was available at that particular time. Dr. Jones, in a literal sense, did address Suzy’s chief complaint and may have provided the best treatment that was available. Did Dr. Jones consider the periodontal conditions either healthy or unhealthy? This may have occurred because Dr. Jones most likely did not imagine that Suzy, a 17-year-old female, could have periodontal issues based on a visual inspection. There is much to be speculated in Suzy Lynn’s case; we do not know exactly what her periodontal condition was prior to the decision to place the veneer.

Conclusion

This case scenario has attempted to address a potential ethical issue in a clinical setting. When making treatment decisions, it is important to consider all the contributing factors that may affect the treatment outcome and the role that outcome plays in the individual’s life.

Amanda Nash is a senior dental hygiene Student at Southern Illinois University Carbondale, and currently serves as the president of her program’s Student American Dental Hygienist’s Association.

The faculty mentor for this paper was Charla J. Lautar, RDH, PhD, associate professor and director, School of Allied Health, College of Applied Sciences and Arts, Southern Illinois University, Carbondale, Illinois.