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Dental Dilemma- Fix or Manage?

April 6, 2015

Filed under: Ethics — Tags: , — Barry @ 2:48 PM




In my life, like most people, I have faced some significant health decisions.  Everyday people are asked to make choices on issues that are not clear cut.  Supposedly, as we collect more data our choices will be easier.  Maybe, one day we will reach a point of complete evidence based medicine (and dentistry), but we are nowhere near that point now.

Until that day comes we must depend on our health care providers for their care, skill and judgement.  I first heard that expression at The Pankey Institute some twenty five years ago, and it is more relevant today than ever.  It’s one of the reasons why I am still a voice for fee-for-service dentistry and I write this blog on the values of trust, appreciation and ownership.  It’s all about that sacred doctor-patient relationship…not data.

Recently I saw a long time patient of record for a recare appointment.  Carol has been coming in regularly for over ten years.  She has never missed an appointment.  She was referred to me by a periodontist with whom she rotates appointments.   Her hygiene is immaculate.  Ten years ago she went through pocket elimination surgery and then complete mouth restoration.  She always does well…maybe one crown fractured through the years.

At this recent appointment there was a change.

The margins of all of her crowns were lifted and exposed by a minimum of three millimeters.  I asked her what happened.

She reported to me that the periodontist felt it was necessary to redo the surgery… I asked if she had any symptoms, and she said not before the surgery, but now her teeth were extremely sensitive to cold.

Hmm, so before we were managing a few pockets and now we were managing symptoms.

Now, you may be saying to yourself, “Tell me something I don’t know,” but this little story tells us a lot about health care in America today, from the cardio cath labs of your local hospital to your neighborhood dental office.

It begs the question…when we see a potential problem do we fix it or do we manage it?  And that’s where judgement comes in to play.

When health care providers are asked why they do more procedures and do more tests, they refer, in their defense, to practicing by the letter of the law.  When insurance companies are asked about doctors and dentists doing too many procedures they tell us the doctors do it because procedures and tests are incentivized.  Sounds pretty adversarial to me.

I am not taking a specific stand here, and maybe one day evidence based medicine and dentistry will solve this problem, but the data that exists today doesn’t seem that definitive and there hasn’t been that many randomized trial on many procedures that allow for the differences in patient’s lifestyles, like poor Carol who had excellent hygiene and now has sensitive teeth.

And some decisions really are clear cut.  Caries, anyone?

Listen, it happened to George W. Bush too.  He had a stent placed rather than managing his coronary artery disease as the data suggested.  I was sensitive to that story because I was catheterized early this year….happily, I’m managing.

How about back problems?  Prostate cancer?

You see fixing things can be risky at times…even in the dental office.

I know many dentists out there will cringe when I say this but sometimes it’s better to watch and manage the case.  But that depends on judgement.

I have a patient now who was told over twenty years ago to have her teeth out.  She chose to manage the condition.  She came in for scalings every two months.  The window is closing for her but she doesn’t regret the choice she made.

Most people believe that medical or dental intervention that is directed to fix a problem is more beneficial than one that simply manages a problem.  Especially those who really take care of themselves.

Judgement comes into play when dealing with chronic disease…not injury or acute issues.  Sometimes randomized trials are not available for every circumstance.

The key is to feel good and live longer, for that you need a health care provider that understands the sacred nature of the doctor-patient relationship and exercises good judgement through experience.

Data has its limits and our system is too adversarial.