IDNT3361/3362 FCD III Ethical and Legal Issues Assignment Scenario III

Group Members
Yousr Kanbour Yusef Khadembashi Ilana Kohan Xinyi Lai Ealin Lee Penelope Lindsay Rueda Nicholas Liyanage (20777258) Vernice Lo Chee Kian Loy

In a time where litigation rules our dental practices, it is important to obtain informed consent from a well advised patient. Similarly, it is important for a dentist to only perform treatment that is consistent with their own ability and that they feel is adequate for the patients treatment needs and expectations. With a wide access to information, patients have increasingly become aware of treatment types and have expectations of treatment outcomes. In some cases these expectations are unrealistic and as a dentist it is important to ensure that we provide our patients with the relevant information required to make a balanced clinical judgement about the types, cost, timeframe, implications and consequences of treatment, this protects not only the dentist, but also benefits the patients in the long run. In this scenario, the 22 year old patient has demanded crown treatment, which WHAT FACTORS ARE INVOLVED Treatment options for the aesthetic restoration of anterior teeth can range from minimally invasive procedures to procedures which involve the extensive removal of tooth structure. To decide which treatment that will produce the most optimum outcome for this patient, it is important to consider her age, the state of her existing dentition, the cause of the staining, her caries risk level, her financial limitations, patient education and the dentists skill and willingness to perform the procedure. Age is an important factor to consider - having extensive restorations placed at a young age would mean a lifetime of replacing these restorations, with each replacement removing more tooth structure. It is crucial to examine the state of the existing dentition before deciding what treatment to undertake. Doing extensive restorations on perfectly intact teeth is over treating and unnecessary and alternative options should be considered. The cause of the staining should be investigated - often staining is caused by smoking or diet, and these extrinsic stains can be removed and prevented in the future. The patients caries risk is highly influential in deciding treatment - assessment of their diet and oral hygiene is a necessity. A patient with little motivation to maintain oral hygiene will have their caries and periodontal disease risk elevated by the placement of crowns. Although the patient has stated that cost is not an issue, it is not clear whether the patient has been made known that she may require endodontic or periodontic treatment before her restorative treatment commences. Furthermore there is likely to be expensive ongoing cost such a replacement of the crowns after a number of years, or future endodontic and periodontal problems. The patient needs to be made fully understood that crowns are not a conservative option, there is no way of restoring the tooth structure that will be need to be removed for the crowns and that by having this treatment they will be predisposing themselves to other dental conditions for life. The patient needs to also be educated about other more conservative options before commencement of treatment. It is highly unlikely that the patient is aware that they can achieve a very similar aesthetic result with a much more conservative option such a composite restoration or a veneer, even bleaching. REFERENCES : case selection and overtreatment

OPTIONS YOU WOULD CONSIDER The patient needs to be educated on what other treatment options are available to her, and should be encouraged to pursue a less invasive treatment option. Bleaching could be a treatment that has the potential to lead to a satisfactory aesthetic result. As the teeth are currently minimally restored, bleaching is appropriate as the contour and occlusion of the teeth will not be altered, and minimal risks exist as a result of treatment. If the outcome of bleaching is not desirable, more invasive options could be considered. Porcelain veneers, whilst more invasive than bleaching, can result in greatly enhanced aesthetics. These could be considered as a treatment option if bleaching is unsuccessful, or if contraindications exist to bleaching. The use of composite to build up the teeth is possible, but has limited aesthetic value if the staining is extensive, and therefore the patients presenting complaint has not been fully addressed. Composite would have to be very thick to give an aesthetic outcome, and this would result in changes in the contour and occlusion of the teeth that would most likely be unacceptable. Crowning of all the maxillary teeth is the option that the patient desires, and this needs to be considered as a potential treatment. However, as the indications for treatment are purely aesthetic and the patient is young, crowning of the teeth should really be discouraged. Crowns need regular maintenance, and are unlikely to last for the lifetime of the patient, necessitating the need for more tooth preparation and loss of tooth structure. However, crowns, whether full ceramic crowns or PFM crowns, can lead to a highly aesthetic outcome for the patient. If the patient (after being educated on her options) still is insistent on crowns, a compromise could be made to only crown the teeth that are visible on smiling. No treatment is also an option that needs to be presented, because the patient is in no pain and has no dental disease. The patient needs to be aware that the treatment she is requesting is purely aesthetic, but it will have lifelong biological effects.

LEGAL AND MORAL/ETHICAL PRINCIPLES In this case the dentists actions are governed by a series of moral and ethical principles outlined by both of the major Australian Dental Associations. A dental practitioner has a greater level of knowledge in the field when compared to the patient and thus has an ethical and legal responsibility to assist the patient in making a well-informed decision about any potential treatment. The dentist must always provide information regarding the risks, cost and consequences of the treatment they wish to undertake. This is particularly so in cases of cosmetic importance. In the case of the decision to treat generalised staining with multiple full coverage PFM crowns, the patient should be informed about the estimated cost, number of appointments required and problems associated with multiple crowned teeth such as a requirement for more stringent oral hygiene habits. The patient should also be advised of other possible treatment options and what makes them more or less favourable. Effort should be made to provide as much information as is appropriate and relevant. The dentist should always strive to ensure conservation of natural tooth structure to ensure the best possible prognosis for the remainder of the tooth structure. This is a very

important principle in this case. However it is most critical that the patients freedom of choice is respected and that if they have been given the proper facts they can make their own informed decision to receive the treatment they desire. In this scenario if the patient is determined to have all teeth crowned, the dentist must express any concerns regarding this treatment option including the unsuitability of the treatment, and if applicable, inform the patient of your level of experience and expertise as an undergraduate dentist. Medico-legal issues must be considered prior to the commencement of any dental treatment. To best avoid litigation, when the treatment plan has been confirmed the dentist must obtain written consent from the patient. It is also advisable to ensure meticulous record-keeping as proof of all discussions held with the patient.

ADVICE

Her case does not indicate for a crown and bridge treatment in terms of invasiveness of treatment Compare indications of treatment available for tooth discoloration. These include bleaching, porcelain laminate veneers. For bleaching, it is indicated for minimally invasive treatment, whilst for laminate veneers it is indicated when greater aesthetic control is desired. Compare advantages, disadvantages, implications and consequence of the different options available. o In terms of invasiveness, bleaching is the least, followed by laminate veneers and then by crowns. Moreover, with any tooth structure removal, these procedures are irreversible and destructive. And the more destructive the procedure the more care and thought should be given long term prognosis of the treatment. o In particularly, although every treatment will require maintenance, crown needs a greater degree of maintenance. Given her young age, such destructive option undertaken would eventually have implication on long term oral health maintenance. Therefore, made known other options are available, which are less invasive in nature. o Bleaching is not without its risk, compared to laminate veneers, it has limited aesthetic improvement and it has gingival recession risk. o For porcelain laminate veneers, they require resin bonding, despite being cheaper than crowns it still has desirable aesthetic improvement and clinically proven longevity. After providing relevant information, allow patient to make a decision based on free will, eventually the treatment option picked up is dependent on patient choice/demand, which at the same time means the patient has to be responsible for her teeth and the treatment she chooses. Upon which if you as a dentist do not feel comfortable, the patient can be referred. Whilst informing patient of your reason of doing so. Dietary advice - parafunctional habits too. If they want teeth they are happy with, they have to do the right things to look after them

ACTIONS It is of the utmost importance that the patient is thoroughly informed about all of their treatment options and the route of action that the clinician intends to take. In this scenario, the destructive disadvantages involved with such largely invasive treatment significantly outweigh any benefits perceived by the patient. It is the responsibility of the clinician to explain why placing crowns on many healthy teeth is not an appropriate treatment. They must also ensure that they supply the patient with informative literature about the alternative treatment options available to them as well as answering any additional questions the patient may have. The motivations behind the requested treatment are also an aspect that should be considered in the discussion of the available treatment options. Understanding the purpose behind the desired treatment may allow the clinician to assist the patient in making an informed decision. Regardless of which treatment the patient and clinician decide to undertake, treatment of the cause of the staining is of primary importance and must be undertaken. If, even after extensive discussion about the unsuitability of the proposed treatment, the patient decides that she still wants crowns on all her teeth and the clinician does not feel that they have the required skills necessary to carry out the treatment, the patient should be referred to another clinician. If the clinician agrees to go ahead with the proposed treatment, they must ensure that the patient provides the necessary informed consent paperwork as well as keeping detailed records which will be needed in the event of future litigation or grievances.

References