Proper Diagnosis or Too Aggressive?

Have you ever known a dentist whose treatment plans seemed a bit aggressive?

I’m a firm believer in comprehensive treatment planning.  I aim to properly diagnose all conditions and effectively communicate them to the patient along with various courses of action.  I think that’s what we all strive for.  But aren’t some dentists just a bit too harsh with their assessments?

There’s an old saying from dental school that if you ask five professors for a treatment plan you’ll get six answers.  Of course there will always be some variability in the diagnosis and treatment planning in all branches of health care.  But I think we can we safely say that some people cross the line.

For example: a dentist who tells all patients with mild crowding of their mandibular anterior teeth that they need Invisalign or their teeth will fall out due to periodontal disease.  Let’s agree that is way too aggressive and bordering on malpractice.  Yes, patients with crowding are more prone to gingivitis and periodontitis.  Yes, orthodontic treatment would help improve hygienic access for these patients.  But here’s what’s wrong.  That treatment plan:

(1) is given to patients with even mild crowding

(2) is given to all patients with mild crowding, regardless of other patient factors

(3) is stated as if there is no alternative, such as improving home care

But let’s consider a more common and subtle example that many of us face every day.  Take a look at this:

Amalgam restorations

A patient presents with no signs of decay and no symptoms.  He has pre-existing MOD and DO amalgam restorations on #14 and 15, respectively, but your explorer cannot detect any voids or catches.  Think about what you would say to this patient.

There are dentists out there who would say, “You have some old silver fillings here and they’re starting to break down.  We need to treat these teeth.”  There are other dentists who would think that no treatment is necessary just yet and would put a “watch” on these teeth.  Still other dentists wouldn’t say or do anything about #14 and 15; everything seems to be holding up fine.

Where do you fall in the spectrum between too aggressive and too conservative?  There’s a good chance these teeth could fracture at some point and require crowns (or even endo, etc.) but we’ve also seen teeth like these hold up for decades longer.  Of course if a patient has clear disease or an unstable condition, it’s a different story.  I will stress the importance of taking action to keep them healthy.  But what do we do in a case like this?

Here’s my approach in these situations.  I take a breath and remember that it’s not my job to decide the course of treatment for the patient.  My duty is to inform the patient of what I see so that we can decide the course of treatment together.  So in this case, I first show the patient an intraoral photograph of their teeth.  Then I’d say something like:

“We see a couple teeth on the top left that have some large silver fillings.  They seem to be holding up fine.  We can see some signs of wear and tear on the teeth <point to a craze line>.  There’s a good chance these fillings will hold up for years to come, but there’s also a chance that the teeth can break.  We can choose to be proactive and take care of them now, or we can wait and see what happens.”

That would begin an honest conversation with the patient about their condition.  Perhaps they have no other anticipated dental needs this year and they want to maximize their insurance benefits.  Perhaps they are proactive and don’t like the idea that the teeth might break down at an inconvenient time.  Or perhaps they’re on a tight budget and they’d prefer to hold off on treatment that isn’t absolutely necessary.

Whatever their response in this case, I’m here to support their decision.  We’ve made an informed decision together as a team.