“Failure” – it is an ominous word that invokes feelings of disappointment and frustration in any profession. In dentistry, the stakes are inherently higher, as the consequences can extend beyond professional setbacks, affecting the well-being of patients. Yet, it's an integral part of life, a stepping stone for personal and professional growth. Failure in dentistry is not a distant concept; it's a reality we encounter in various forms. While it is an uncomfortable topic to examine, by doing so, we can overcome it.
Examining Three Modes of Failure in Dentistry
Over a decade ago, I was invited to a symposium on the challenging theme of failure in dentistry. Little did I know that this journey would lead me to unravel the complexities of interdisciplinary dentistry and expose the collateral damage that can occur.
In my role as an educator, I was tasked with creating a presentation addressing the vulnerabilities of dental teams and offering practical solutions to common pitfalls. Through this process, I identified three key areas where failure tends to manifest: Communication, Planning, and Execution.
Common causes of communication failures in dentistry may include;
A failure in the planning of treatment may stem from
Finally, failures in communication and planning lead to the execution. This may be exacerbated by;
Overcoming Dental Communication Failures
Challenges of effective communication can impact quality of care and clinical outcomes. For this reason, I installed a big sign on the wall in my office in front of where I sit every day.
I decided to do so when I became aware of the fact that communication hurdles often happen due to our poor listening skills, and I needed a daily reminder.
Contemporary dentistry needs to be patient centric. We must understand their desires and expectations, but also their concerns, constraints, and fears. Only then can we aspire to be heard and understood as well.
Let me share some familiar challenges the dental team often encounters while attempting to communicate:
As dentists, we often succumb to a cognitive bias known as the "Curse of Knowledge." We mistakenly assume that patients possess the background to comprehend the information we convey. But much of our specialized terminology is unfamiliar to them.
Using technical jargon without providing sufficient explanations can easily lead to confusion and misunderstandings. Our teams need to communicate in ways that patients can understand, using clear and simple language while avoiding excessive use of technical terms. Visual aids are also incredibly helpful, providing a clearer explanation of complex procedures or conditions. Tools like our robust dental patient education platform can help you simplify explanations and put patients at ease.
Anxiety and Fear:
Many patients experience dental anxiety or fear, which can impede effective communication. Fear may cause patients to feel overwhelmed or make it difficult for them to articulate their concerns or understand the information being provided. Dental professionals must practice empathy, patience, and active listening techniques to address patient anxiety and establish trust.
Dental appointments are often time-limited, which can pose challenges for effective communication. Dentists may feel pressured to quickly convey information, leaving little time for patients to ask questions or fully comprehend their diagnosis and treatment options.
Dental professionals must allocate sufficient time for communication, ensuring patients have an opportunity to express their concerns and receive comprehensive information. Having the ability to email patients educational videos with customized annotations helps immensely.
Patients may experience a range of emotions during dental visits, including stress, fear, or embarrassment. These emotional factors can affect their ability to absorb information and actively engage in communication. Dental professionals should be sensitive to patients' emotional states, create a supportive environment, and provide reassurance and empathy.
Language and Cultural Barriers:
Language and cultural differences can impede seamless communication between dental teams and patients, particularly for those with limited English proficiency or diverse cultural backgrounds.
To address these challenges;
- Employ interpreters: Interpreters bridge language gaps and enhance communication between dental teams and patients.
- Set cultural competency training: Foster awareness, develop positive attitudes, enhance knowledge, and refine skills through cultural competency training, enabling better understanding and communication with patients from diverse backgrounds.
- Provide translated materials: Use translated materials, like the offerings in our Spear patient education platform with closed captioning in Spanish, to provide accessible information and overcome language and cultural barriers.
Of course, communication isn't just about the words we use. Nonverbal cues also play a crucial role, either impeding or aiding effective communication.
Non-verbal cues, such as body language and facial expressions, play a significant role in communication. Our teams should pay close attention to non-verbal cues, use gestures and visual aids when necessary, and be mindful of patient non-verbal communication.
Our teams should prioritize patient-centered communication, actively listening, and empathize. Creating a supportive and non-judgmental environment is crucial, as is providing ample time for discussion.
Last but certainly not least, we need to encourage patients to ask as many questions as possible and voice their concerns. This approach allows our teams to understand patients' expectations and ensure they are attainable. Unmatched expectations can lead to unfortunate treatment outcomes, often necessitating unnecessary procedure repetitions for both the patient and the dental team.
The other day we saw a patient that required a full mouth reconstruction. A middle-aged woman who recently immigrated from Ukraine who only spoke Ukrainian and Russian. The only way we could communicate with her was through Google Translate. As challenging as this seems, the fact that we were using this method of communication forced us (her and our team) to be clear with every single message we wanted to convey.
We had to rely on every element described above, including;
- Providing extended time for her appointments.
- Expressing empathy.
- Being particularly attentive to body language to foster a caring, supportive, and non-judgmental environment.
- Avoiding complex dental terminology ("Curse of Knowledge") and opting for straightforward explanations about her condition and treatment.
- Incorporating visuals like patient education videos.
- Allowing sufficient time for her to process information.
- Encouraging and welcoming her questions.
Even though we are just beginning therapy with her, implementing these techniques has given our team the level of certainty required to embark on a lengthy process that requires interdisciplinary work.
The Pitfalls of Inadequate Planning in Dentistry
There isn’t a more relevant and descriptive way to frame this section than with Benjamin Franklin’s iconic quote:
“If you fail to plan, you plan to fail.”
At Spear Education, we teach a rigorous systematic approach to treatment planning called Facially Generated Treatment Planning (FGTP) taught during our workshop, Treatment Planning with Confidence. This protocol consists of a linear data-gathering process comprising five different areas: Airway, Esthetics, Function, Structure, and Biology (AEFSB).
Any potential condition a patient may present will fall into either one of these well-defined categories. Therefore, failure in dentistry during the planning process means underestimating or downright neglecting data in one of these areas. This translates into blind spots in our preliminary assessment that eventually lead to failure.
The major challenge relies on being able to consistently identify how all these five areas intricately intertwine. Anthropologist Catherine Bateson best defines this problem with the following quote:
“What is there about our way of perceiving that makes us not see the delicate interdependencies in a system that give it its integrity? We don't see them therefore we break them.”
Furthermore, in his seminal book “The Power of Noticing: What the Best Leaders See,” Professor Max Bazerman describes how it is easy to overlook things and realize the damage that can be caused when we fail to notice key details. He emphasizes the importance of honing our noticing skills and understanding why it is such a valuable skill to cultivate.
Inattentional blindness occurs when an individual fails to perceive an unexpected stimulus in plain sight, solely due to a lack of attention (distraction) rather than any vision defects or deficits. A classic example of this type of blindness may happen during dental procedures.
For example, when replacing old crowns due to esthetic concerns, there's a risk of failing to carefully assess the structural integrity of the preps underneath. If we proceed to make impressions and deliver new crowns without thorough evaluation, a patient may return shortly with a fractured abutment and crown in hand. This scenario illustrates a classic case of poor judgment and a lack of “structural planning,” leading to a catastrophic failure of the new restorations and potentially compromising the underlying tooth.
We see examples of both failure in planning and communication when patients with complex dental conditions, such as extensive structural damage and advanced periodontal disease, require comprehensive treatment like implant-supported reconstructions. In these cases, there is a risk of overlooking the importance of reinforcing hygiene instructions, proceeding with necessary therapy, and ensuring proper delivery of the implant-supported prosthesis.
This dual failure in planning and communication highlights the potential biological compromises. It may lead to issues like bone loss and peri-implantitis when patients neglect home care instructions and aren’t included in a short-term recall program.
When Dental Procedures Fail During Execution
In the human body, as in any biological system, nothing is truly 100%. This means that there could be substantial variability among subjects which may potentially influence the outcomes of any given therapeutic technique or procedure, as is consistently described in the scientific literature.
However, unforeseeable outcomes (failure in execution) often result from overconfidence, attempting procedures beyond one's expertise, lack of planning, or misdiagnosing existing conditions.
In his book "The Checklist Manifesto," Dr. Atul Gawande illustrates the prevalence of foreseeable errors leading to thousands of deaths in US operating rooms yearly. He emphasizes the value of checklists in complex environments, highlighting their role in standardizing procedures, improving communication, fostering teamwork, and preventing mistakes. This applies broadly in contemporary dentistry, with sensitivity in adhesive dentistry and Osseointegrated implants, which demand meticulous adherence to protocols to minimize failure and complications.
What We Can Learn from Failure in Dentistry
Examining failure from the perspectives of communication, planning, or execution provides heightened awareness of its potential occurrence. This heightened awareness enables us to be more vigilant, facilitating the avoidance or, at the very least, mitigation of its effects by identifying issues at earlier stages. It serves as a proactive approach, allowing for timely intervention and correction to enhance overall performance and outcomes.
While complete avoidance of failure in dentistry may not always be possible, we can actively mitigate its impact and prepare for potential challenges. Much of this involves emphasizing patient-centric experiences, providing resources, and allocating time for effective communication. Through these efforts, dental professionals can enhance their ability to navigate uncertainties and address issues effectively, ensuring a more resilient and successful practice.
Ricardo Mitrani, D.D.S., M.S.D., is a Spear Resident Faculty member.