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.

INFORMED REFUSAL

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.

When Orthodontists Attack – Part One

If you read my book ‘Confessions of a Former Cosmetic Dentist’ you would quickly pick up the message that I had a bad attitude related to both cosmetic dentistry and orthodontics. Why would a small time general dentist try to make a stink about the purists and the experts? The real reason was the ADA sat back and allowed a group of doctors to systematically attempt to destroy my practice after I began offering ’shorter term orthodontics.’ It made me question the whole dental profession and the closer I looked the more problems I discovered…I felt they were in no position to cast stones. The experience that I had apparently is not an isolated event, but some dental associations allow disputes to spin out of control and others try to nip turf wars in the bud.

I really had no idea that orthodontists in my area would feel threatened by cosmetic orthodontics, since they had a long list of referring dentists (including myself). My niche is simply people who want to have straighter teeth in a shorter amount of time, usually for a lower fee. My background training was described in another article, but the point here is even in an area where orthodontists are in short supply, they can resort to unsavory tactics to undermine your reputation.

The personalities involved attempted to blackball my practice in what I was told was a coordinated effort. Rather than lie quiet and let them have their way with me, I decided to expose the foolishness recently by posting a ‘Dentist Crime Stoppers Reward for $10,000.’ The levels of arrogance of my attackers combined with their passive-aggressiveness were almost humorous. The attacks were inspiring and gave me a bigger purpose, to lobby for a worthy niche between traditional orthodontics and cosmetic dentistry. I chose to dig in and fight. The Achilles heels of both orthodontic and cosmetic dogma are easy targets, and it is clear that many patients are being mistreated by members of these camps due to twisted ideas that do not hold up under scrutiny.

When I read a specialty journal article that suggested orthodontists should report general dentists to the licensing body for aggressive marketing practices I had to laugh. Besides a possible Guinness Record for the most expensive tooth, I would surely win a second for most marketing complaints for a dentist. The surest way to dry up referrals is to report a general dentist to the marketing authorities. If orthodontists do the math, they will see that it is only their loss. Once a battle is initiated there is no going back but in the end this in-fighting will take the dental profession to a better place. Patients will have another alternative in any brand of STO that has as much merit as all the other choices that are currently promoted by heavily funded groups.

When I recently interviewed Dr. Clifton Georgaklis, who may have been the first to publish the concept of ‘six months cosmetic orthodontic treatment’, he described experiencing a few of the same issues and simply said it was best to ignore it. That’s not what I’m choosing to do.

Time to end Animal Cruelty in the Dental Profession?

Reading a recent article in my favorite orthodontic journal I was shocked to see graphic photos of a dog’s skull dissected to the bone. I wondered if this experiment was really justified. If the dental profession is truly concerned about its public image then the animal studies better have some massive benefits besides giving authors a chance to say their work has been published. It would be a touchy subject…but similar to an endodontist I like touching nerves.

The study was investigating the effect of a couple types of orthodontic implants (TADS) on the jaw bone and comparing inserting them with and without pre-drilled pilot holes. The original article is titled ‘Microdamage of the cortical bone during mini-implant insertion with self-drilling and self-tapping techniques: A randomized controlled trial’ – ((Am J Orthod Dentofacial Orthop 2012; 141:538-46). I never can keep the two types straight, but the scientists made this article unforgettable.

Many readers including PETA would have likely suggested the whole group of researchers from Connecticut and Indiana should be put on trial. Their null hypothesis was that neither technique of implant insertion would have an effect on cracking of the bone. My concern was one or more dogs (hounds as they were referred to in the study) were rounded up, tortured and killed for science. After going back and skimming the whole article I discovered twelve of man’s best friends were slaughtered for this experiment.

We may have all been irritated by a neighbor’s dog barking through the night and thought ‘if he doesn’t shut up I’m gonna kill him.’ In this case the motivation was simply to test a hypothesis with little real world benefit. Pamela Anderson who likely doesn’t read dental journals would be steaming up in her red bathing suit if she could understand the perversity behind our profession’s ‘Mengelish’ experiments.

The researchers were not studying if TAD’s caused cancer or other serious complications. They were not studying a relationship to anything related to clinical performance, which we are easily capable of doing on humans, perhaps with compensation. It was a study that was not thought through. People (or dental students) willingly participate in studies all the time and this one could have easily been completed on a few fresh pig heads while their loins roasted in the oven. Many experiments do not have to be done on live animals (who are usually used as pets).

Being a loose cannon you’d think I would run to the groups who are dedicated to animal protection and serve up some humans.  Impossible. It was only a few weeks ago on a mountain weekend getaway when my wife pulled me into a store for ‘a look’. She wanted to give me a fashion show and in the end I was pulling out my credit card for a sheared beaver…the third fur in the last 12 months. Within that same time I picked up some thick silvery baby seal boots in a Quebec City snowstorm. My wife would also remind me of the time I pushed her pug into the trunk of my new BMW for a short drive to the vet, rather than have his hair contaminate my plush interior. A splash of red paint or critical comment or risk of such leaked atrocities could be argued would keep most sane folks off the keypad.

Hypocritical as it is to now write about this, I also enjoyed a tender beef steak on the weekend. We all break rules of some kind but it may even give me more inspiration to dissect this topic as I come clean about my own transgressions. While I am splitting hairs on this theme, I still encourage you to consider the risk-reward of animal studies and not simply look at this as a black/white issue or worry we can’t talk about it because it will tarnish the profession’s image.

Aware that dentists can be painted with good or bad strokes by each other, the public or the media the profession seems to bite its cheek and tolerate some unusual activity. It is also possible to ‘get away’ with things because we talk in jargon and may be able to fool laypersons as easily as a computer geek talks us into an extended warranty and a few extra gigs. We even fool ourselves and build massive educational cults based on conjecture and the rants of gurus who have sprung from dark places. The animal rights consultants likely didn’t see through the jibber jabber of the groups plea for the death penalties of the animals that should have been spared.

Our profession attracts certain types of intelligent people that enjoy inflicting pain. As children we all do stupid things to small animals and sometimes each other. Two brothers once sadistically tortured me, tying me up and roasting me over a hot gas furnace. They later grew up to become ‘almost normal’ health professionals and they sometimes laugh in reminisce (while I wait for the right moment to extract revenge).

True psychopaths are a small statistical part of any group but we still need to use caution to avoid entertaining activities that could be misconstrued. The researchers in this group may not have been aroused by their exploits (like the recent body part-mailing killer recently captured in a worldwide manhunt). They may not have even aware that their study was of little value. The true value may have been to simply highlight the fact that many animals are suffering at the hands of scientists fixated on finding answers to questions that can be uncovered differently or don’t really matter in the real world.

In dental school I can still recall how one of our elderly clinical instructors paused over a few of us and our slack jaw dento-forms in the back row of operative class. He wondered why I was wearing black leather pants in the clinic…did I own a motorcycle? (No). Then he described doing physiology tests in dental school on live dogs which were later killed. It was obvious that although years had passed and he felt it was a useful learning tool, he was uneasy about it. Like this study in the orthodontic journal, and others going on right now across the world, in some of the cases we don’t have to keep doing this to animals to know the truth.

The dental profession is advancing at light speed with the help of motivated individuals, manufacturers and the needs/wants of the public. Perhaps it is time for researchers to re-think what animal interest groups would say to ensure studies do not cross the line into blatant animal cruelty. The profession needs to watch its step.

Michael Zuk dds

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