Ethical Case Presentation?

As dental professionals we are expected to walk the line in helping people achieve whatever they desire that is within our realm. Laypersons expect us to mostly set aside our own desire for compensation; at least for the treatment planning and recommend what we feel is best.

Unfortunately dentists are graduating with limited treatment planning skills and their presentation skills are even worse. The good news is we can all get better at anything but the help we get from continuing education needs to be reviewed carefully. Being able to learn quickly is a pre-requisite for dental school, and yet we all seem to think ethics and this kind of intelligence comes hand in hand. They do not and this has led the profession onto shaky ground from which it seems to be retreating.

We get excited about new technologies and skills, and the training often includes sales skills that employ psychological tricks that are proven to increase the closing rates. While we don’t want to be looked at as super sales people by the public, we do value staff that are good at nailing down a patient to commit to paying for ‘ideal dentistry’. Informed consent includes breaking all the options down to the most simple forms, discussing pros/cons and long term costs. Why do we still use the word ‘permanent’ with crowns when we know they have a limited life…does Mercedes sell ‘permanent luxury vehicles’? Under cross examination a lawyer could use our staff to throw us under the bus with a few short questions.

With the advantage of greater understanding of all the alternatives the dental team needs to consider backing away from the intense focus on selling the most expensive choice. It is not always the best, and for example a mouth full of porcelain can be either the best dentistry has to offer or an example of ruthless greed. My personal breakthrough came from adding orthodontics to my general practice and while I may call myself an ‘UnCosmetic Dentist’ it is just a positioning statement that challenges those who feel they can un-sell one modality (orthodontics) simply because they are unable to provide it.


I find much inspiration from reading the American Journal of Orthodontics and Dentofacial Orthopedics journal (AJO-DO) and particularly enjoy the thoughts within the articles on ethics in orthodontics. As a generalist my perspective is a little different but the complex arguments are worth pondering.

The author discussed a situation where a patient previously had orthodontics and was interested in more improvements. She was absolutely refusing the ‘ideal’ choice of orthognathic surgery and didn’t even want to wear braces again. The discussion included the importance of fully explaining the choices and it was referenced that “Informed refusal can occur for various reasons. Previous experiences, prejudices, religious beliefs, cultural lore, financial limitations, phobias, or simply a whim might be sufficient grounds for a patient to reject the ideal option and choose a significantly compromised alternative.” (Weinstein BD. Informed consent and refusal. In: Cooke DB, editor. Dental Ethics. Philadelphia: Lea and Febiger; 1993. p. 76-7)

We use the term ‘ideal treatment’ all the time but the textbook results often come with greater risks, costs and time. If this is the case, we may be imposing our desires to be providing board certified results on patients who only discover the risks during the few minutes of time used to read over the fine print of a treatment consent form.

With specialists concern about ‘practice creep’ or overlapping generalist and specialist services, this discussion has become polarized. Generalists who are busy and ethical are more likely to suggest second opinions. Those that do not feel the love within the dental circle are less prone to give the patient a balanced presentation. I know there are ways we can all work together and it will be interesting to see how these adventures unfold.

Patients freak out over TV shows and media reports

Recently Dr. Oz did a story about dental amalgam and while I haven’t watched the episode many dental patients have. Like half the dentists in North America I still use mercury fillings in situations where conditions are harsh―poor oral hygiene, acid reflux, and with tight budgets. It would be irritating to have to replace some recent restorations if a patient freaked out over a TV show.

Then an oral surgeon somewhere in the U.S. gets caught with sloppy sterilization protocols. The media goes wild again. Dental assistants go into hiding and patients line up in the rain for free Hepatitis and AIDS testing. You do have to run a tight ship these days and the dental associations are trusting dentists and the staff to do what is right.

Even in the best situations there are going to be flaws in the system. Our staff use the word ‘dirty’ as in this room is ‘dirty’ or ‘wiped down’. While it irritates me, I’ve never suggested changing terms. An office that caters to groups of people with higher disease rates will become a carrier, for example hospitals kill as many people as they save.

Ask your staff if they see anything that needs to be improved. ‘Looking clean’ can be almost important as sterilization protocols.

Leann Rimes drives a cosmetic dentist into bankruptcy?

There were mixed emotions as I researched the lawsuit launched by singer Leann Rimes after an extreme smile makeover gone wrong. She was a high risk client with high expectations, a pre-existing TMJ problem and emotional issues…but what patient these days doesn’t have a few issues? By promising a perfect smile dentists are setting themselves up for the occasional mega lawsuit, and some simply feel this goes along with the job.

When discussing this case with other dentists, some were defensive and blamed Rimes while others said the dentist obviously is in hot water for a reason. Simply knowing she went from veneers to crowns, to root canals to an extraction and gum infection puts me in the celebrity corner. OK, so I do enjoy finding potential examples of abusive cosmetic dentistry…but brought down to the basics you have an unhappy patient in pain and a dentist under the microscope.

There is a possibility that this could turn into the largest cosmetic dentistry malpractice suit in U.S. history. The expert witnesses will easily show how the dentist slipped up somewhere (like we all do) or at least could have chosen a different route. The celebrity seems to growing irritable from personal attacks from the press, a husband’s former wife and the public so striking out at the dentist that she feels hurt her would be coming from a place that is less than ideal. Many dentists work on patients who are either financially or emotionally stressed.

Recently one of our hygienists was accused of being too rough and knocking off an eight year old bridge fabricated at another clinic (she’d never had a similar complaint before this). The preparations were extremely short, the patient was a bruxer and she did not wear a splint. Explaining that a healthy bridge could not come off from a routine cleaning did not cut it, and I simply agreed to pay for the lab bill for repairing the chipped porcelain and re-cemented it at no cost. Certainly I am referring her to the prosthodontist because alarm bells are ringing.

As the celebrity lawsuit progresses we can all learn how to reduce our exposure to the same fate. Doing fewer porcelain veneers may be the first step. If the lawsuit settles for millions, the dentist may have a tough time finding malpractice insurance. Then what? To read what I would have suggested as a different solution for Rimes visit and click on the Leann Rimes webpage.

Calling the Police on a Dentist?

This doesn’t happen very often…I hope. A colleague informed me that a patient had been acting extremely nervous and actually would not let him look at the teeth without keeping the lead apron on. The person finally mentioned to the dental assistant that there was previous sexual abuse within a dental office when the person was a child. The person stated it had occurred on multiple occasions.

Without much thought I reached for the phone and called the police. The authorities came to the office and took a statement from the staff member and stated there would be follow-up with the victim. I then called the dental association and asked for their official policy. They didn’t have one.

If I would have hesitated and asked who it was, I could have found a reason not to report it. It’s easier not to get involved and leave it to the patient to decide if they want to call the police. It was only a week prior that I had been reading about the prolific celebrity child-pervert in the UK that had gone to his grave without prosecution. Last week, I lectured in the actual hotel where the dead celebrity had his funeral service. He got away with it.

I soon discovered that another dentist had known of a similar event and did not know what to do. It went unreported. Are you covering up for a fellow dentist who you suspect could be abusing patients -sexually, ethically, dentally or emotionally? We all do.

Snooki DDS – How Celebrities Can Help Dentists Destroy Teeth

You may resent the fact that a person without a dental degree is able to instantly modify the thinking of your patients with a simple press release. U.S. reality television star Snooki sharing her new veneer smile on Twitter and Facebook could easily lead many young impressionable girls to consider asking for porcelain teeth to replace their natural smiles. Who should be held responsible?

We know dentists use celebrities to help promote their practices and this actually can lead to ‘celebrity abuse.’ My own exploitation of John Lennon’s rotten molar into all kinds of publicity stunts and even an upgraded seat on Anderson Cooper LIVE and a better price on an expensive coat are harmless when compared to how a cosmetic dentist could cross the line. You can imagine the racing heart of a dentist who is setting a celebrity up for a smile makeover…it’’s their BIG BREAK.

The issue is certain celebrities can send shock waves of stupidity across the nation like a virus. Sadly, aesthetic dentists will often take full advantage of the public’s lack of understanding of the long term costs and complications from aggressive, expensive and harmful veneer procedures. The celebrity is an innocent pawn in the equation and unless I am proven wrong with intra-oral photographs and radiographs, my guess is ‘Snook got took.’

Yesterday, I did a composite restoration on a single central incisor for an 18-year-old girl who was told at another office that she needed six porcelain veneers. She had enough common sense to know her former dentist was recommending treatment that could be suspect. My simple treatment impressed her and only cost about $200, while the veneers could have easily been $6,000 for the first round of many over her life.

I’m terrified that a person like Snooki has such power over our youth…but again we also have gynaecologists on Dr. Oz dictating the required frequency of periodontal treatment. If the dental profession can’t act responsibly then how can we complain about anything at all?

Dentist Brain Plasticity Discovered

Who would have guessed a DT blogger to be in line for a Nobel Prize, but here it goes…just back from my oceanfront lab in Manzanillo, Mexico, and the answer is staring me in the face. I just inherited my wife’s Kindle and for some reason a few things happened in synch and the truth was revealed. It was there all the time and it would be wrong to hog all the glory but I don’t know if the people with the trophies like to give out extras. If they give me time to thank each person at a podium, I will work it into the acceptance speech.

This discovery is one small step to finding a cure for cosmetic dentistry gone wrong. Of course people with a mental illness are extremely difficult to treat but when the safety of the public is at stake we can’t just sit around for another decade or two and let the victims stack up. That goes against what we are supposed to be as ‘professionals.’ So sure it’s a big advance in understanding, and ‘yes’ it will give me even more things to brag about, but shucks, I just have a knack for solving the impossible.

What we have is a dentist with an actual change in perception working on ‘live people’…this is the place where the drill meets the enamel. After this article is published this is going to make a significant leap forward in our understanding of infectious cosmetic dentist brain toxicity ̶ the same disease mentioned in the introduction of my banned book ‘Confessions of a Former Cosmetic Dentist’. Finally I have the science behind the cause of the illness, or at least enough to possibly get the Nobel.

Predicting the future, I would assume there will be a surge in proposals from dental schools for research on this but let’s not go there yet. I would rather get to the point and explain the precise elements of my discovery. The book ‘The Brain that Changes Itself’ by Norman Doidge that nudged me into another round of fame used the terms ‘brain plasticity’ and ‘brain mapping’ so I will add these words here although in my mind ‘silly putty’ may be a better fit. Not that I want the reader to think this is not perhaps the biggest or at least the latest discovery in our field in 2013, but because to most of us ‘plastic’ is injected molded and often able to withstand the heat of sterilization processing.

The same brain changes occur in pornography addicts, so I must assume any discovery will doubly help dentists who are addicted to both cosmetic dentistry and material as seen on www.Dentist.XXX. Don’t be surprised to find treatment centers pop up all over, but I will give you the option of some online therapy to fit almost any budget. The most basic of steps in a cosmetic dentist’s daily life is color selection and my discovery relates to the perception of ‘brightness’ or ‘whiteness’.

I propose that the cosmetic dentist’s brain actually changes and expands the ‘homunculus shade guide’ effectively adding unnaturally white shade tabs onto the map on the cortex of the brain. This relates to actual monkey studies where the area of the brain dedicated to areas of focus or learning become enhanced on the level of the neuron. To complicate matters and perhaps add to my collection of awards, I propose there is a relationship with the pleasure centers of the brain which relates to the color = money association.

This contamination of normal thinking all happens below or above the level of the cosmetic dentist’s consciousness. In fact, it becomes obvious to any of us that pick up cosmetic dental magazines or hardcore S&M that there is something wrong with them. Don’t they see that what they are doing is not ‘normal?’ According to my research the answer is ‘no’. They have developed a distorted pattern of perception which can be explained by the following:

As my own test subject and experimenter I booked a couple weeks at a small resort called ‘Los Suenos Del Mar’ not knowing that it would lead to such a blog blasting event. To keep it short and sweet, I exposed my skin to the sun’s rays to make it look like I had a sunny vacation. Being distracted by my reading I allowed my wife to pull ahead of me in the units of time and her skin reacted with the usual rich brown glow. My melatonin was not activated by my lazy reading in the shade, so on my last day I looked in the mirror thinking ‘I’m not very tan.’ After a four and a half hour flight and in a new environment (my own home) my mirror tells me otherwise. My skin appeared much darker and maybe I did have a tan after all. A different environment can help a person see things with new eyes.

Most readers would not make the association of this experiment and relate it to how some dentists start making teeth whiter and whiter. Perhaps a few dentists are now slapping their heads thinking they could have been the Nobel dentist. Sometimes the answers to big problems are right there in front of us. Please don’t make me explain how this relates to the unreliability of cosmetic dentist’s treatment planning due to the brain changes. The cure will involve, hmmmm let’s leave that topic for another time.


When I was consulted about an undercover investigation into dentist treatment planning by the television program CBC Marketplace I was shocked by the findings. Not only were dentists pushing all kinds of cosmetic dentistry, but the dental associations were zipping their lips and pretending there wasn’t a problem. Who are we trying to kid? It may be the most dangerous time for patients to see a dentist since the days dentures were the cure all for any dental ailment. Veneers are being glued all over the place and implants are being screwed in by doctors with inadequate training.

Naturally some dentists are threatened by the possibility their advice may be questioned, but apparently there is good reason for alarm. In a separate interview with a money magazine related to the same topic, I confessed that dentists are not always offering patients a reasonable range of choices. Informed consent is the basis for my next book project that will include contributions many prominent co-authors and even a victim of abusive dental care.

On a local level I had an ethical question for a new orthodontist. If treatment on a patient from the previous owner of the practice does not match what he or she feels is appropriate, what responsibility does the orthodontist have to the patient and the referring dentist? I have called and not yet had a response but it is going to be interesting. The case involves a severe Class II skeletal situation where the former orthodontist was attempting to correct it with a Herbst appliance. My opinion is she was too extreme a case and it should have been a surgical treatment. Will the orthodontist continue to torture the child even if he or she feels it is incorrect or will we have a discussion that may be complicated? We’ll soon see how long we can hide these things from the public.

Undercover Dentist Investigation on CBC Marketplace – Dentists behaving Badly or Just Differing Opinions?

When I was contacted by CBC Marketplace to be a consultant to the episode ’Money Where You Mouth Is’ I knew it had the potential to reveal some of the problems we have in our profession. Many of us are concerned about the way some dentists push cosmetic dentistry on patients and in my opinion this is the number one reason we have sunk down in the level of public trust over the years.

Too many have focused on other issues like marketing as the true evil. The black stain on our profession is the way we have allowed commercial interests to dominate the postgraduate education in dentistry. This has been particularly overpowering in the aesthetic dental programs where many have been sponsored by dental labs that are in business to do more ceramic work.

Just as the medical doctors have been led around by big pharma, thousands of dentists have crossed the border to the U.S. and practiced illegally outside their licensure while training in cosmetic dentistry. Patients have flown down with the dentist for smile makeovers and come back with potential complications. The dentists came back overconfident in their skills and in the mistaken belief that they were anointed ‘smile experts.’

The reality is most of the synthesized rules of smile design have led to a large group of dentists who actually make people’s teeth look worse. Why would the undercover patient need veneer treatment for a midline problem? While it is a matter of opinion, the even greater secret is aggressive cosmetic dentistry will lead to premature tooth loss and substantial long term costs and complications to the patient who entrusts the dentist for a Hollywood smile.

This Ugly Truth about Cosmetic Dentists is our dirty secret. We know there are top level cosmetic/oral rehabilitation dentists, and there are also dentists teaching cosmetic dentistry that have used celebrity patients to hide the fact that they are simply veneer salesman. The new phase of cosmetic dentistry will not be based on trying to find excuses to bond porcelain on as many teeth as humanly possible.

This Marketplace episode goes beyond simple honest variations in treatment planning. The 15-year-old patient who was told she lacked enamel on her teeth and needed 25 crowns was an example of malpractice. Recommending the most invasive treatment for a young patient proved that paying more does not mean better care. This would have been a rip off and could have been considered physical battery.

We tolerate aggressive cosmetic dentistry because we have a code of silence. I was told it is bad karma to speak ill of colleagues, but I think it is bad karma to let this abuse continue. The profession is out of control and as an example sponsored cosmetic programs are trying to reach into the dental schools to start the brainwashing even prior to graduation. Why wait? Dentists are just as vulnerable when they graduate. Dentists have been selected for entry by an amazing power of absorption and regurgitation of information, without critical thinking (which is usually punished).

The dental profession is worried about so many little things. What should be a concern is it is neglecting the safety of the public. More undercover investigations are necessary to help understand the level of inconsistency among our members. Dentistry has a long way to go before it can dilute the toxic thinking that has poisoned those who are a little too quick to recommend ‘advanced’ cosmetic treatment. That’s sad.

Maybe Dr. Oz isn’t crazy… dentists could actually be killing people with their X-rays

Like most dentists I cringed when Dr. Oz started fussing over dental radiographs. He talks so fast and shoots out so much information, and some of his guests do the same so a portion of it isn’t always accurate. First the media gets us in trouble with mercury, then Bisphenol-A in composites, back and forth on fluoride and now it’s radiation…but maybe there is a reason to worry.

In my banned book, Confessions of a Former Cosmetic Dentist, I brought up the concern about our new ‘super-X-rays’, the 3-D images we get from new technology such as the i-CAT brand. These extremely sophisticated instruments are known to be the latest ‘must-have’ for surgery, implants and orthodontics. The question is, are they over-used and are patients being exposed to risky levels of radiation that could lead to cancer? The answer in my mind after doing some research is ‘yes’.

There are a number of issues related to this and let me start with choice. Dentists purchase these devices based on reputation, presentations, sales skills and endorsements. Naturally dentists cannot trust a sales presentation sponsored by a particular company to be unbiased. Popularity contests are also unreliable, so a ‘Dental Village Award’ may be more reflective of the company sales skills and market penetration that an independent comparative study.

What speakers choose to talk about certain brands may be affected by special relationships. It costs money to run around doing seminars, so many of us are on the payroll. Just because a guru purchased a particular brand doesn’t mean your decision should not be scrutinized. I suggest that if you do not already own an imaging device, you may have dodged a bullet. The number one thing you need to consider is patient safety and this will include choosing technology that reduces exposure to harmful conditions and using it appropriately.

At this point in time dental professionals have been ‘wowed’ by the technology, and they are shamed into thinking they are prehistoric without it. Rather than going through a comparison of the various makes and models that change with time, I will say you need to look carefully at radiation exposure and diagnostic benefits. The most popular machines may or may not be the smartest choices if you care about patient radiation dosages. I have done some investigations of my own and suggest you may be surprised at the findings.

On another front, I wonder if dentists are buying these machines with the hopes of snapping $600 3-D pictures on everyone they can for a fantastic ROI. Of course that would be part of any sales presentation, and while dentists are business people these items are not amusement park rides. There is no doubt that many dentists try to be first to have new gizmos with the hopes of appearing to be ‘high-tech’. This technology potentially could bite them and work in reverse if not used very carefully.

The idea of substituting a 3-D scan for the usual radiographic series may be determined to be abusive. An educated person may feel that the dosage of radiation is not worth the benefits. This would be particularly true if prior radiographs did not suggest any concerns that required intense scrutiny. My guess is that any dental professional that has the technology will try to use it.

In a related matter, there may be doctors that add a staff incentive for specific procedures, namely ‘how many expensive dental images can we do this month?’ To make staff develop new habits, dentists often use financial incentives tied to specific actions. I would caution anyone who even thinks about anything related to prolonged radiation exposures of the public. A disgruntled employee could make you look like Dr. Josef Mengele.

The overuse of ionizing technology is a concern and a dentist who has spent a small fortune could lose sight of responsible usage. I would bet that over 50 percent of the ’3-D radiation rides’ could be reduced if doctors really considered the pros and cons without thinking about the bottom line. Just because the risk of causing cancer is low doesn’t mean we can line people up and shoot them through.

Orthodontists are a group who have invested heavily in this area, and because they are exposing young children to radiation levels of significance it is important to consider the protocols employed. According to recent articles, many orthodontists are substituting a single high-dose scan for the lower dose images of a panorex and ceph. The practice of doing this is being questioned as is the use of ‘cone-beam tomography (CBCT) as a routine diagnostic modality—i.e., for every patient irrespective of malocclusion or other patient-specific factors—as some orthodontic postgraduate programs in the United States seem to do. (D. J. Halazonetis, Am J Orthod Dentofacial Orthop 2012; 141: 402-11, Smith, Park, Cederberg- An Evaluation of Cone-Beam, J Dent Educ 2011;75:98-106).

The same initial article cited above explains how the British Orthodontic Society suggestions ‘the routine use of CBCT even for most cases of impaction of teeth…cannot be recommended.’ So we can re-visit the idea that many new orthodontic graduates are being taught that 3-D scans are the state of the art during school, and naturally that would lead to an extra lease payment upon graduation.

Manufacturers are not stupid. They understand one of the best ways to control how doctors spend their money is to get them early…ideally prior to graduation. Even aggressive cosmetic dental education programs sponsored by labs are trying this idea. This means some of the potential liability falls back on the orthodontic graduate schools. Is a 3-D imaging unit donated to a college a smart idea? You better believe it.

Even if the 3-D images are done for patients at the same cost as older diagnostic records, the level of radiation is still a concern. However, there are other issues which include the fact that dental professionals do not have the adequate skills they need to diagnose the information in these advanced images. One study found that even after additional training the orthodontists in the study missed radiographic lesions at up to ten times the historical average for general radiologists (Am J Orthod Dentofacial Orthop 2012; 141: 459). The bottom line is if you miss something (and you will) you now will be held accountable. In the consent form it would be wise to strongly advise that the image be forwarded to a radiologist for interpretation after the ‘basics’ have been distilled for the practitioner’s purposes.

As millions of trusting people go through the turnstiles and line up for our profession’s futuristic diagnostic rides, should we be telling more of them they essentially aren’t tall enough yet? Or can we even be trusted to make these complicated decisions? Maybe not…so here’s one for Dr. Oz.