Wednesday, January 30, 2013

What's Best for the Patient?

Today, I would like to touch on a topic that every dentist deals with every day: patient autonomy and how we achieve it. I know there are a lot of sincere efforts by dentists all over the country to give the patient all of the information necessary to make a good decision based on the patient’s personal situation (finances, past experiences, personal preferences, etc.). However, nearly every practice in the country has patients that come to the realization that what their dentist secretly thinks is best, is in fact best.

Go into any community in America today and you can find a practice that only provides bridges and another that only does implants for single-tooth edentulous areas. You can find a practice that only provides posterior composites and another that only does posterior amalgams. How can we say we are giving the patient options when this is happening?

I am not saying it is the dentists’ fault at all. For one, go look at the research comparing those things. You will find that when dealing with long-term survival of anything in the mouth, the data is scarce and not definitive. Hence you can find whatever answer you are looking for. Another factor that must be considered when determining what is best for a patient is what the doctor is good at. A patient may feel that amalgams are just awful and leak mercury, but having a dentist who has never done a posterior IP composite is a recipe for disaster. Maybe the patient thinks composites leak too much BPA and want their children to only have amalgam. That might be tough job for a doc that hasn’t touched the stuff since dental school.

I want to share a case I ran across. I am stuck wondering what is best for this patient. There is irreversible pulpitis with normal PDL and normal probing on #3. We scheduled for RCT, opened it up and found a large distal crack.

At that point, I decided that since I had the time and she was numb, I would complete the endo and do a composite bonded buildup, prep, and permanently bond a temp crown and see how it felt. I explained ti the patient. “I have no idea if this will work for you in the short-term and I am very guarded about it in the long-term. I think we should leave the temp crown bonded on for six months to a year and monitor to see if there is any bone loss or symptoms. If there are ZERO symptoms and no signs of progression of fracture evidenced by probing depths, we’ll put a permanent crown on it. What do you want to do?”

Did I do the right thing? What would you do? What do you say to the patient to ensure patient autonomy in a situation like this?

Bryan Bauer, DDS, FAGD


Joseph Tagliarini said...

"Another factor that must be considered when determining what is best for a patient is what the doctor is good at."

That's why it's so important to establish a rapport with your patients. You don't want there to be any confusion between you and them.

Jon said...

Nice article
Jon Hardinger

gatordmd said...


Great post.
Talking about what a dentist is good at. I think it is up to us to go to enough CE to know what is out there. If I think amalgam is "the best" but I never go see a posterior composite lecture or I never go to a inlay/onlay lecture I am not educated enough to know what is "the best".
But on the other hand, you as a dentist can go crazy on this quest for "the best".

Now about this tooth. I think it might be a stretch to save this tooth. But you know what, you are doing what you think is best for this patient. Hey the alternative is taking it out. So if what you do fails, you are going to take it out anyway. You haven't done anything irreversible.
If you save this tooth another five did great.
But like you said...You inform the patient and move on.

Great job all around.

Unknown said...

These cases stink! Early in my career I would have went for what you did because "saving the tooth" was what we were taught. After watching these teeth over 10 years and seeing them fail over and over I have changed my mantra. Now it's "save the bone"
If my initial diagnosis is cracked tooth or I find a cracked tooth during treatment and the tooth needs endo it is now a EXT in my practice. A crack will ALWAYS leak and it will lead to failure, pain, bone loss and EXT. Why not save the patient the cost and eventual pain and do the treatment your going to need to do in 5 years today?

dentists lover said...

I agree with Kirk Poldek, very well said although I am just a reader. I am convinced easily with his statement "Why not save the patient the cost and eventual pain and do the treatment your going to need to do in 5 years today?" :)

Unknown said...

That was a really impressive root canal obturation-- one that I would have been proud to call my own. I'm going to take at face value that you really don't know whether you've done the right thing for this patient. That it isn't self-evident that a root fracture into the pulp is at least as damning to the fate of a tooth than if you had missed that second mesiobuccal canal you filled so nicely. But the fact that you're asking this question at all is sufficient to conclude that you were unsure whether you were doing your patient a favor. With due respect for a patient's autonomy, a patient can't make an informed decision if he's not informed, and he will not be informed if you don't inform him. Doing right by your patient is knowing when NOT to treat. Do you really think that just because the patient was numb and you had the time that root canal was the right thing to do? Do you really think your patient enjoys the experience, much less paying the fee, if he's not relatively sure that there's a benefit? This is not a matter of autonomy-- this is hubris on your part. There is no shame in closing up the tooth and referring to a specialist.

This is the sort of moment of truth that comes up more often than you might like. Do I start extracting that root tip if I'm not sure I can get it out without traumatizing myself and my patient? Can I put an implant fixture there, even if the mental foramen requires me to tip it at an angle that will be next to impossible to restore? These decisions are easier to make if you put aside your enthusiasm for dentistry for a minute, take a few deep breaths, and imagine yourself in your patient's place.

Mark Bornfeld DDS
Brooklyn, NY

Unknown said...

Tooth still doing great!

Refer to a specialist is honestly the worst advice on here. No one knows what is going to happen to the tooth. Refer to OS or Perio or anyone who does implants and they say take out. Refer to endo and they do endo. Just plain dumb not to handle it. Inform the patient NO ONE knows what will happen and there is a risk, that's patient autonomy. Plus these things are all covered in RCT consent.

"Why not save the patient the cost and eventual pain and do the treatment your going to need to do in 5 years today?" :) Main reason is the rct and crown are much cheaper than implant and there is no guarantee of failure on this. In my office the cost of rct and crown is about half implant and crown. Just heard Misch talk about how disappointed he is that so many dentists are unwilling to try to save teeth these days and are too quick to go to implants. He is running an implant complications office in Chicago now and seeing some of the fruits of the "take everything out and place an implant" has come to bare. I am sure this is why he now spends a decent percentage of his lecture on emphasizing teeth should be saved. He also talked about the benefits of proprioception.

Plus you say "place an implant" like there is no risk to failing immediately and if integrated it is a lifetime solution, both assumptions are foolish. I can think of three patients who have spent close to $10,000 to replace just one tooth, and not one of them was at all happy about it. Guess which tooth it was in all three cases? Upper first molars - failed bone grafts, failed implants, and sedation costs are something one must think about, especially in the upper posterior near the sinus.

Unknown said...

"Refer to a specialist is honestly the worst advice on here."

Really? I know this is the AGD, where general practitioners get to feel good about being generalists. But in the last analysis, it is the clinician's ability to reflect on his own limitations, coupled with a good faith informed discussion with his patient, that should guide the decision as to whether and when to refer. Your obligation to your patient's well-being should be the guiding principle here.

I also was a bit of a cowboy at the outset of my career. You'll come around.


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