September 10, 2019
by Brian Chapnick, BSc, DDS
The practice of dentistry has changed from the time I entered the profession 42 years ago. Change is important, for without change there can be no progress. On the other hand, not all change is good and we must be able to recognise when changes are not making positive improvements and re-think.
We have witnessed new materials, new technology, and new treatments solving sometimes even new situations, and yet, much is still the same. People continue to lose teeth to decay, have periodontal disease, require endodontic treatment, tooth replacement and orthodontic correction. Every once in a while the media questions the credibility of the profession such as in Readers Digest, 60 Minutes, Market Place and most recently Atlantic Magazine. The public confidence and respect for the dental profession once high, continues to decline. Our associations are quick to respond, as they must but do they also paint an equally distorted view in our defense? In my opinion, our profession is off course and I think we have an opportunity to change direction.
Today, we graduate more dentists than at any time in history. The dentist to population ratios continue to increase in North America and dentists struggle to keep their days full often having to do more treatment for fewer patients to remain busy. There are more and more specialists and they too struggle, expressing concern that fewer patients are being referred for the advanced care they are trained to diagnose and perform because generalists are keeping treatment in their own practices. Many in the profession are forecasting the doom of specialists in dentistry. Some generalists are quite competent in advanced techniques but specialists also treat failed cases attempted by generalists who have less training, cases that may have been better referred in the first place. In an Oral Health editorial titled I Need Help from the June 2016 issue, Dr.Caminiti discusses how people often are unable to recognize their own weaknesses, what they know and don’t know. It has been said that a generalist knows a little about a lot and that a specialist knows a lot about a little. Today a student can graduate without ever completing molar endodontic therapy on a patient. I don’t know about you, but if I need endodontic treatment, I am going to have it completed by an endodontist, who does this multiple times per day, understands the complexities, and is trained and equipped to deal with complications that may arise. Yes, they too have failures, and I have seen many, but for me, I will tilt the table in my favour and for my patients as well. If I require an implant, it will be placed by a surgeon for the same reasons. I treat my patients as I would like to be treated. I am fortunate in that in my geographic area specialists are readily available, and I recognize that in rural areas this may not be the case and generalists must tackle more specialized treatment plans or offer alternate treatments within their abilities, but that is a different issue. At a recent large meeting, I spoke with a dental supplier who was thrilled with the number of patient vital sign monitors he had sold to generalists who are doing sedation in their offices. Would you want a highly trained anaesthetist sedating you or would you be content with a young graduate having minimal experience, doing not only your dentistry but sedation at the same time? What about for your loved ones? Why would anyone place a patient at risk when there are many specialists available who have more expertise? Our medical counterparts recognise the need for specialists. Would your family physician remove your appendix? Would you let him/her? Would you go to a chemical engineer for electrical issues or a patent lawyer for real estate planning? Pilots must be certified to fly at every level of competence. They must have a night rating, instrument rating, multi engine rating, commercial rating and airline ratings. Why do WE continue to fly under the radar?
Corporate dental practices continue to expand and purchase traditional dental practices often employing young graduates who are just beginning their careers. In some cases, those who work these practices are encouraged to meet production targets and promote higher fee procedures when simpler ones may suffice. More than ever, practices utilize locums to keep offices open when the owner is away. Those who provide these services are usually experienced dentists, who have sold their practices and wish to continue providing care. They see treatment plans that may place them in difficult ethical situations because our profession has been unable to agree on when a tooth should be restored , how it should be restored, what it should be restored with and even if it should be restored. Some will espouse that overtreatment abounds but the problem is really in the science, which we have not allowed to keep pace with what we technically are able to do well (rightly or wrongly). As a simple example, studies repeatedly demonstrate an inability to agree consistently on caries seen on a radiograph by different observers and even the same observer. Self-administered, unsupervised orthodontic treatment is available to the public that appears to be successfully avoiding regulatory control, and any dentist can send study models to a company and have appliances sent back to be inserted in their patients mouths to alter occlusions having never done so in a comprehensive training environment. The cost for dental care continues to escalate, dental offices spew into the environment more and more non degradable waste to comply with often unsubstantiated evidence-based infection control guidelines and dentists continue to be on a declining income path with little good news for the future. Our dental associations and regulators continue to grow, hiring more and more people to meet demands that often they create at our expense, touting benefits to the profession and the public. We buy insurance to cover us for what our insurance does not cover. Record keeping which is always important for good patient care is becoming more onerous, time consuming, and costly. It is now just as important to have comprehensive diagnostic and treatment records to protect the provider as it is the patient. For the cost of a postage stamp or an email, a patient can register a concern or initiate a complaint regarding care received, that invariably starts a hugely expensive process even for the most innocent issues , usually taking over one year to review and causing anguish for all parties. Licensing bodies struggle to keep up with volume.
I attend many continuing education programmes and have also taken part in planning and organizing many programmes. The quality of CE available is often very high but there are some questionable programmes that may give unsuspecting participants false expectations of confidence and at times incorrect information. Continuing education is big business and no longer altruistic. I am not an advocate of our regulators monitoring the programmes we take (other than ensuring we are updating our knowledge) or certifying some programmes as better than others. This is a very costly and time-consuming process that has no evidence of effectiveness other than to satisfy overbearing government bodies that have little knowledge of our profession. We should be able to screen relevant programmes on our own if we are indeed professionals and are committed to what we do. The very same can be said of the available literature we read. Some articles and studies may not be accurate, or can be biased or of poor quality.
Who is at fault? The answer is all of us – we as dentists, our associations, our regulators, our schools, the government, and society in general. Compare our good fortunes to poorer nations that struggle to meet basic needs and things can be brought into better perspective. Although we are no longer a self governing profession, only we can take effective control and bring us back to
level flight. It isn’t that hard. It will take time, but we continue to be our worst enemies.
For starters, consider these course corrections. Do what is in the best interest of the patient in line with the science of today. Treat the patient as we would like to be treated and be able to look the patient in the eye and say I have done the best I can do within the limits that have been presented. Don’t express false expectations of success, or impending doom, and be cognizant of not only our own abilities, but the abilities of others. When a patient presents for the first time, don’t suggest big treatment plans. They are usually coming from another dentist and want to know they have been well cared for. If they are unhappy with the care they have had, don’t add fuel to the fire unless of course there is a clear reason for concern. Remember, if you are critical of someone else’s treatment, and the patient initiates a complaint, your records will likely also be called into question. Place patients into holding patterns and bring them up slowly to your level of care.
The bottom line, if patients are happy, the legislators are more likely to be happy and then we can do what we do best.
About the Author
Brian Chapnick graduated from the University of Toronto, Faculty of Dentistry in 1976 and maintains a general practice in Toronto. He can be reached at firstname.lastname@example.org.
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Very well said. Now I just hope you’re not preaching to the choir. This message MUST get out somehow to all the dentists in Ontario. Not all will take it’s advice, but hopefully any dentists “on the fence” will choose the correct ethical side of the fence to continue their career paths on. It is very refreshing to read such a well written article on our general ethics. Kudos to all those teachers who help craft you into the person you are, and to yourself for deciding to follow your path!!!
Thank you Anthony.
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