Here’s one for you all to debate. This 20-year-old is a new patient in my practice and I have not yet worked up the case. She had 10 upper and eight lower veneers placed at the age of 16. She was advised that the optimal treatment for her situation would be orthodontics and orthognathic surgery. Although her parents were in favor of the process, she refused. The alternative she was offered was the veneers. They were done to correct tooth positions and to give the illusion of closing her open bite. While I don’t have the complete history, my understanding is that there were significant rotations which were corrected by preparation design. The resultant preps were very aggressive. Today, she has had two endos and is facing at least two more. She has poor periodontal health, partly from her neglect and partly from inconsistent marginal integrity of the restorations. Here is the discussion: 1.    Would you have proceeded with the veneers if the patient refused orthognatics/orthodontics? 2.    Would you do this kind of significant dentistry for a 16-year-old? 3.    What are my responsibilities as a clinician to my patient in this circumstance? I do not presume to have a correct answer. I was not part of the original conversations, nor do I understand the family dynamic that was present when the decisions were made. Ethical


Comments

Commenter's Profile Image Mark Gray
October 12th, 2010
I have to say that not only would I work on a 16 year old, I already have. In the case of my patient, she was beauty pagent participant. Her mother and her "coach" agreed that she needed a better smile to actively compete in the competition. She had gaps in her teeth, some slight crowding, and rotations. Nothing severe but certainly something she and her mother were very concerned about. I discussed some composite bonding but they would have none of that. I did some conservative preps on her laterals and centrals. The case came out very nice and she and her mother were very happy. On another note, I have certainly talked people out of having extensive cosmetic work due to their young age. In these cases, whitening and some composite have gone a long way toward fullfilling their esthetic needs while perserving their natural tooth structure. As far as our responsibility as a clinician, we have to say what we see. You have infected gums that need attention. Once we get the infection cleaned up we can assess the condition of the teeth and restorations underneath. She may still be extremely happy with the result and not choose to change a thing. She may be totally unhappy with the current condition of her teeth and want everything removed and made perfect again but this time she wants them really white. I thnk our role as a dentist is always the same. Explain and educate the patient on what is possible and what are the advantages and disadvantages that go along with that treatment. Once the patient is informed and understands their options, then we can proceed with their decision. Thanks again for another real world case!!
Commenter's Profile Image Steve Ratcliff
October 12th, 2010
Thanks Mark, love the comments!
Commenter's Profile Image Jay Stockdale
October 13th, 2010
What I have noticed, is that most teeth that are veneered, end up crowned 20 years later. Everything we place in dentistry breaks down in time. Everytime we replace it we remove more tooth structure. Assuming what we place lasts 20 years (Wildly optomistic) then a 16 year old gets replacements at age 36, 56,76. With this in mild, I try to do as much as possible with bleaching and minimal composites. Preserving natural tooth structure is of paramount importance in my opinion. I think our role goes beyond education, in some cases we need to advocate for what we think is in the patient's long term best interest.
Commenter's Profile Image Barry Polansky
October 13th, 2010
Firstly Steve I agree with your assessment that we don't have the responsibility to give an answer because we weren't there when the case began. However the questions you pose are really food for thought. To answer some of your questions I would like to invoke three Greeks. The first is Aristotle, he believed that the ethical nature of man was defined by the times in which he lived. Voltaire said, "Every man is a creature of the age in which he lives; very few are able to raise themselves above the ideas of the time.” Years ago before the cosmetic Revolution, when medicine and dentistry were just medicine and dentistry and not the business' they have become, these issues may not have occurred. Today, in the age of cosmetic dentistry, and dental marketing and advertising, decisions are being made by dentists all the time to do work that is ethically questionable. The second Greek is Hippocrates who said "Above all do no harm." In this particular case harm was done. The third Greek is Ulysses because he taught us the ultimate "know yourself" lesson, and that was that he had to restrain himself when he passed the sirens because he knew he couldn't trust himself. Today, dentists continue to fight the temptation to do what patients want for the sake of esthetics over health comfort and function. This ethical dilemma is likely to be more prevalent in the future unless the message that you at the Spear Institute, Pete Dawson and the Pankey Institute are heard. Barry Polansky Nichedentalstudio.com
Commenter's Profile Image Steve Ratcliff
October 14th, 2010
Thanks Yoda, :)
Commenter's Profile Image Mike Weisbrod
October 14th, 2010
1. No 2. No 3. I would be compelled to tell the patient that they have periodontal concerns and some failing margins. I would also try to explain any occlusal concerns. But we don't know, and will never know what the parents and patient wanted the dentist to do, or if the previous dentist talked the patient/parents into tx. What is the explanation for the endodontic tx? Was it the treatment provided, or were their pre-existing conditions on those teeth that would make them more susceptible to pulpal involvement? I am not trying to defend the previous dentist necessarily, but haven't we all been in an uncomfortable situation placed on us by the patient to do something we don't necessarily want to do? Whenever I feel uncomfortable, I have no problem saying "I don't know" and punting to the prosthodontist down the hall. Other times I get overconfident and then I get bit in the backside. This all comes down to who talked who into what. And in the end maybe a little Sc/Rp, and margin repairs (and future endo) will fix the problems until the patient/parents learn more about the oral health condition and make better choices for the future.
Commenter's Profile Image Barry Polansky
October 15th, 2010
Refer to Hippocrates above. Barry Polansky nichedentalstudio.com
Commenter's Profile Image Steve Ratcliff
October 15th, 2010
Maybe a better question would be: "Under what circumstances would you do veneers for a 16 y/o patient" Steve
Commenter's Profile Image Barry Polansky
October 16th, 2010
Once again -- Hippocrates With that in mind....very very very minimal preparation. Stay away from the tissue...as endo is one thing, but the perio condition here is beyond hygiene issues. It's hard to justify tooth mutilation but I am sure there may be some circumstances in this esthetic driven culture we live in. If the teeth were extremely discolored and the "embarrassment" factor was that strong, that would be a situation to go forward.Even if the patient were a surgical risk -- possibly composites might be used or non-prep veneers with the help of a wax-up.
Commenter's Profile Image Mike Weisbrod
October 19th, 2010
If the teeth could be corrected/made better with minimal tx- and that tx could be redone or corrected later on without compromising future oral health conditions- I would consider going ahead with tx.
Commenter's Profile Image Steven Roth
November 11th, 2010
WIDIOM Would I do it on me or my 16 year old daughter? the answer is.......... maybe- but probably not. What did she look like before? Where was her self esteem pre-operatively? 16 year olds get nose jobs, lipo, and boob jobs. What would we be saying if it was a stellar, well-fitting case with healthy tissue? This issue is nagging because we are horrified by the results and we recognize the cheeziness of this dentists' decision process. If he was in survival mode and saw the 16 year old's desparation, maybe it was really hard to turn away the cash. i AM NOT CONDONING IT BUT YOU DONT KNOW THE TRUE CIRCUMSTANCES. GREAT THINKING TOPIC