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.

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.

Are my Roots Straight Enough Yet?

It was interesting to read that the American Board of Orthodontists does not have special requirements for the facio-lingual inclination of roots (and my spell check won’t let me even type it without a hyphen). On the other hand “general root parallelism is required, and points are deducted…” (Am J Orthd Dentofacial Orthop 2012;142:139). This same article was discussing the use of cone beam technology to access the root positions of the teeth.

A few journal issues ago a different author revealed that the need to have roots parallel for stability was a myth. In the real world it is nice to simply be able to keep the roots within the bone and gums, and have the part that is covered with enamel stick out without attracting attention. When a layperson (your patient) doesn’t like something it doesn’t matter how many points you get from the rule books.

Being the person that quietly questions the commandments of the dental niches, I always felt there was something odd about the center of rotation theory. Rather than believing the ‘2/3 down the root’ idea, I proposed an alternative concept where a lateral force applied to the tooth would cause the tooth to effectively fulcrum off the alveolar crest. Proof for this theory which I called the ‘alternative center of rotation theory’ or ‘Z spot’ for obvious reasons.

Proof or support for my idea came in another article which tested the various energy within a periodontal ligament with applied force. The researchers found a higher force in the ‘Z spot’ although they did not seem to make the connection. Pleasured by this data I emailed one of my orthodontic gurus who responded that it could have some merit.

Rather than discuss the possible abuse potential of extended treatment times needed due to the difficultly in moving roots, and the radiation exposure that could kill off some of our clients, I am going to relax and have a cigarette and leave that to the reader to ponder.

The Magic Mandibular Growth Pill

As I am doing a routine dental check-up on one of my young patients, I feel her despair. I also am biting my tongue, as the orthodontist her father decided to take her to is using the magic Herbst appliance to grow her deficient mandible. In my mind, I am thinking things that I could not say without risking a slander lawsuit.

The orthodontic journals still contain articles where the authors are proclaiming stimulation of mandibular growth, when most authorities agree that it is not what really is happening. An orthodontist friend came across a patient who was in a Herbst for a prolonged period of time. The patient had severe deterioration of the TMJ but repeated requests for radiograph evidence were ignored. Are we trying to keep something secret?

If we use facial analysis and determine that a deficient mandible is the cause of a ’bad bite’ what options should dentists offer? If a patient is a teen are we really allowing children to be tortured by convincing the parent orthodontics is the cure, when often it only gives the impression of a correction. Posturing the mandible forward is an unnatural state and doctors use certain techniques they may be venturing into voodoo science.

Decades ago my cousin fell asleep at the wheel and was ejected from his vehicle. His left leg was hanging by a thread, but they pieced it together rather than amputating. The bone fragments healed, but the damaged leg ended up three quarters of an inch shorter than the unaffected side. He could have had it surgically lengthened but instead he either walks with a limp or wears a shoe that corrects the discrepancy with a thicker heel.

These compromises are similar to what we can offer in dentistry for a deficient mandible. We can offer a surgical advancement (high risk-text book results- but numbness and death are compromises), correct any anterior alignment concerns (cosmetic ortho -compromises), dabble with ‘camouflage’ treatment (compromises) or even pretend to grow the mandible with appliances.

If the mandible cannot be stimulated to grow, then this treatment is as silly as charging my cousin $8,000 to teach him to correct his gait with an uplifted heel (walk on your tip toes if you want to be taller Mr. Tom Cruise).

The limited post-orthodontic supervision time may serve to protect the orthodontic practitioner from legal responsibility and from seeing the truth that the treatment often falls short of the claims. It is one thing to say you can do something, another to lie when you know you can’t and another to fool yourself into thinking you can do it even when the science says it doesn’t work.

With all the stink about general dentists doing ‘shorter term braces’ I simply shake my head. The ones making the most fuss are often doing things that are using outdated techniques that need to be put in a museum. I see an ad for an upcoming convention where periodontists and orthodontists are getting together…why are they excluding the best referral source they have on the planet?