Professional Reputation

Are dentists obliged to redo at no charge treatment that fails? What do our professional codes say about this? Should dentists guarantee their work and, if so, for what length of time?

The majority of the respondents chose to replace Ms. Allen’s fixed partial denture at no charge. A few chose to either have Ms. Allen pay only for the laboratory fee, or 50% of the full replacement fee. None of the respondents would have Ms. Allen pay the full replacement fee.

Are dentists obligated to “stand behind their work?” The following three ethical issues provide a context for analyzing this complex case: (1) appropriate function; (2) guarantee or informal consent; and (3) promise­-keeping.

Appropriate Function/Technical Considerations

One of the predicaments dentists face is satisfying both the functional and esthetic demands of the patient. Some patients have extremely high esthetic expectations without an appreciation for the limitation of the materials and technique. A few of the respondents challenged the selection of porcelain occlusion in this case and discussed the possibility of dental laboratory error as a source of failure of this prosthesis.

Porcelain occlusion is contradicted in some circumstances.¹ One respondent wrote that the dentist “should not have made that type of bridge in that part of the mouth in the first place.” Porcelain occlusion has the inherent characteristics of high­ compressive but low-shear strength. It is more difficult than metal to establish occlusion and is contraindicated in cases where the patient bruxes, has short clinical crowns, or large pulp chambers.^2,3 Although Ms. Allen has “excellent periodontal health, a stable Class I occlusion, and no evidence of bruxism,” the risk of brittle fracture exists and may be attributed to the dental laboratory technique.

“Bare metal is a laboratory error,” one respondent wrote, and his lab would not charge to redo this case. A failure at the metal-oxide/opaque interface, characteristically the strongest interface, indicates the possibility of a dental laboratory error that could include: (1) excessive or inadequate metal oxide formation; (2) contamination of the metal surface: (3) porcelain/metal coefficient of thermal expansion mismatch; and/or (4) improper framework design that leaves the porcelain over 1.0 mm thick. ^1,2,3

However, both the dentist and the dental laboratory technician are restricted by the clinical parameters of the patient and the physical requirements/limitations of the dental materials and techniques. Ms. Allen’s case highlights the importance of communication and teamwork between the dentist and dental laboratory technician as they both strive to accomplish the rehabilitation of form, function, and esthetics in complex clinical situations.

A few dentists wrote that their laboratory would redo at no charge, in one case up to five years after cementation. One dentist wrote that after one year, redoing the case would be at full charge to the patient, although they would make an exception in Ms. Allen’s case.

Should the dentist also guarantee his or her treatment and for what period of time?

Guarantee or Informed Consent

The ADA Council on Insurance advises dentists not to guarantee treatment but rather to involve patients in treatment decisions as recommended by the ADA Principles of Ethics.⁵

Guarantees infer that dentists provide a product or commodity as in any business, rather than a valued professional service. The dental educator Nash⁶ described the business of proprietary culture in dentistry as “selling cures” in contrast with the professional culture rooted in a tradition of “curing.”⁶ Along this theme, the philosopher Pellegrino⁷ observed that one of the emerging sociocultural forces in medicine is, “the partial reconceptualization of medicine as a business, replete with providers and consumers and increasingly controlled by market forces or governmental regulations.” Moreover, making claims that a health professional can “guarantee” a successful treatment does not acknowledge the inseparable role of the patient’s attitude and aptitude in the successful maintenance of his or her own health.

Training may help to explain why dentists often focus on the procedure rather than the person. Traditionally, the clinical training of dentists is technically-oriented, with success or failure measured more by the fit of the margin in microns and the completion of required numbers of clinical procedures than restoration of health itself. If the crown doesn’t fit, the dental student will redo the crown until it is acceptable. If we perceive dentistry as simply the selling of services and procedures, rather than the restoration of health, we could move dentistry into a marketplace where guarantees and warranties are expected by the patient.

By contrast, informed consent establishes a professional relationship which acknowledges both the patient’s awareness of his or her own goals or values and the dentist’s expert knowledge of the risks and benefits of dental treatment. The dentist seeks to involve the patient in treatment decisions by making the patient aware of the risks and benefits of the recommended treatment, reasonable alternatives, and the risk of no treatment. ^4,8,9 In Ms. Allen’s case, we do not know if she insisted on porcelain occlusion over the dentist’s objection, if she was informed that the risk of failure due to fracture was higher for porcelain over metal occlusion,¹⁰ or if she was informed about any replacement policy in the office before treatment was started.

These three factors define some of the risks of treatment and may have prevented Ms. Allen’s angry response. As for the longevity of restorations, patients should be informed that there are no absolute standards as reflected by the varied responses to this case. There may be individual standards, however, established by dental insurance companies or dentists practicing in a community.

By involving patients in treatment decisions, dentists fulfill their promise to the patient to work in his or her best interest.

Promise-Keeping/Fidelity

Although the ADA Principles of Ethics do not explicitly describe the dentist’s responsibility in Ms. Allen’s case, they do challenge dentists to be “caring and fair in the contact with patients.”⁵

The moral obligation to keep promises is an “important part of the dentist-patient relationship, just as it is in any other interpersonal relationship.”¹¹ Ms. Allen’s question, “Do you stand behind your work?” focuses on whether the dentist is working in her best interest and questions the very trust that is essential for a healthy dentist-patient relationship. As one dentist said, “She trusts you would do the right thing.” Another dentist wrote that he tries to base his decision on “looking from the patient’s perspective.” Considering the amount of therapy he does during the year, redoing the case, even if he had to pay the laboratory, the cost would be “minuscule” in relation to his total practice.

Dentists also realized if they were not sensitive to her plight it could result in damaging the dentist’s image in the community as the patient expressed her dilemma with others.

Conclusion

Ms. Allen’s dilemma causes us to consider our obligations to patients when treatment fails, and that others, such as dental laboratory technicians, may share in this responsibility. The case also asks us to reflect on, and acknowledge, the reality that our treatment may fail and there are no absolute standards for longevity.

Preparing the patient includes educating the patient about these risks. Finally, although the ADA Principles of Ethics offers no explicit advice for this situation, the fact that dentists responding to this case considered Ms. Allen’s loyalty as a factor in replacing the prosthesis at a reduced or no fee, provided evidence that they were concerned about being “caring and fair” with Ms. Allen.

References

1. Shillingburg HT, Hobo S, Whitsett LD. Fundamentals of Fixed Prosthodontics. Quintessence Pub, Chicago 1978: 319,323.
2. Tylman SD, Malone WFD. Theory and Practice of Fixed Prosthodontics. Seventh Ed. C.V. Mosby, St. Louis; 1978:630–635.
3. McLean JW. The Science and Art of Dental Ceramics. Vol. I Quintessence Pub, Chicago 1979:83- 85, 197-200.
4. Council on Insurance. Informed consent; a risk management view. J Amer Dent Assoc 19 87; 115(10):630-635.
5. ADA Principles of ethics and code of professional conduct. Revised January, 1994.
6. Nash DA A tension between two cultures… dentistry as a profession and dentistry as proprietary. J Dent Ed 1994; 58(4):303.
7. Pellegrino ED, Siegler M, Singer PA. Future directions in clinical ethics. J Clin Ethics 1991;2(1):5-9.
8. Pollack BR, Marinelli RD. Ethical, moral, and legal dilemmas in dentistry: The process of informed decision making. J Law and Ethics Dent 1988;1(1):27-36.
9. Smith TJ. Informed consent doctrine in dental in dental practice: A current case review. J Law and Ethics Dent 1988; 1(3):159-169.
10. Cheung GS. A preliminary investigation into the longevity and cause of failure of single unit extracoronal restorations. Abstract J Dent 1991: 19(3):160-3.
11. Kahn JP, Hasegawa TK. The dentist-patient relationship. In Dental Ethics. Edited by BD Weinstein, Philadelphia, Lea & Febiger 1993:61-62.