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OVERTREATMENT? YOU BET IT IS!

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Perspectives

In his recent editorial, “Judgingethics ethically” (Journal of

Esthetic and Restorative Dentistry,19:4), Dr. Ronald Jackson takes totask those who would criticize thedirection that the profession hastaken in the extreme marketing,overselling, and overtreatment ram-pant in some cosmetic dentistrypractices, particularly those alignedwith a certain institute. He claimsthat it is not for anyone to judgethat a treatment rendered is exces-sive overtreatment because “[w]eweren’t there for the diagnosis orwhen the treatment options werediscussed and have no idea of theunique issues that had to beaddressed, and perhaps overcome,when the treatment was rendered.”

Well, when I see 10 veneers placedin a 20-something-year-old whenthe preoperative photographs andthe case description clearly showthat the only treatment issue(including esthetic concerns) is astained Class IV resin composite onone central incisor and the authorgoes to great pains to justify treat-ment and the patient’s “consent,” Ido not think I need to know howthe absent “unique issues” wereused to justify treatment. To me, it is the dentist’s responsibility to

discourage patients from suchovertreatment, let alone avoid recommending it.

The author would have us believethat a certain institute (where heteaches, and for which he has been,and apparently still is, a promoter)is doing a valuable service for den-tistry and our patients. My view isthat they take general practitioners(GPs) and train them over a fewdays, using other general dentists asteachers, to carry out full-mouthreconstruction on patients using thediscredited (that is my opinionbased on discussions with topexperts in the field) “science” ofneuromuscular dentistry as “evi-dence” to justify treatment. I reallydon’t believe that a colleague of Dr.Jackson’s stature would seriouslydefend this practice if he saw it thatway.

Yes, I am, and have been for manyyears, a strong critic of this direc-tion the profession has taken. Infact, I would say the proliferation offull-mouth reconstruction treatmentperformed by GPs is one of the mostdangerous trends in the professiontoday. Were this movement (of GPstraining GPs to carry out specialistprocedures on unsuspecting patients

based on shaky science) to continueand even to propagate further, Ibelieve the profession as we know ittoday, with significant levels of pub-lic trust and professional autonomy,is doomed.

Dr. Jackson addresses the topic ofovertreatment by stating that if“masses of patients, who are spend-ing the equivalent of a new car, arebeing hurt every day and are suffer-ing extensive failure, would not asignificant number of these mal-treated patients be highly vocal andtheir lawyers be all over these largenumbers of institute graduates?”

But here he completely misses thepoint. The point is not that thetreatment itself is necessarily badlyperformed; the point is that thetreatment is unnecessary. The pointis not that the patients are “suffer-ing extensive failure”; the point isthat they should not have to gothrough life experiencing replace-ment, repair, or degradation of therestorations and surrounding tooth

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structures because the restorationsshould not have been placed tobegin with. The point is that nomaterial we have is as good as theenamel and dentin we are bornwith (in most cases anyway) andthat to replace virgin teeth withunnecessary crowns, or virginenamel with unnecessary veneers, isunethical, even if the expertlyplaced crown or veneer never fails.The point is that no patient shouldhave to pay $40,000-plus for treat-ments that could have been per-formed more conservatively. Thepoint is that using pseudosciencethat almost inevitably leads to thediagnosis that the bite needs to beopened, and therefore the patientneeds full mouth reconstruction, ismaleficent. So defending overtreat-ment by inferring that the outcomewould necessarily be “extensivefailure” is logically unsound.

Yes, patients may like the result,not knowing that the same resultcould have been achieved muchmore conservatively. Yes, patientsmay not complain because they areembarrassed at being so vain andspending so much money. But thisdoes not support Dr. Jackson’sargument that all must be well inDentalville because the attorneysare not suing the pants off all of us.Almost all such lawsuits end upwith a settlement and a nondisclo-sure agreement, so we have no ideahow many are out there. And justwait! Eventually, one of these suitswill be championed by someonewho refuses the nondisclosureagreement and it will hit the inves-

position that it is overtreatment toplace 28 crowns on patients withminimally restored teeth, with littleor no caries, just to “improve theirsmile,” based on some pseudophi-losophy of occlusion. In such cases,practitioners have been trained toconvince patients that treatment isnecessary to correct a problem thatdoes not exist. The main reason fortreatment becomes that of increas-ing office production. And yes, I will call it what it is—abuse of the patient.

Dr. Jackson and his friends call this“bad-mouthing” and they say it isunprofessional to make “sweepingjudgments based on second-hand,incomplete information andhearsay.” He says we should not“assume the worst in everyone.”Well, I am not. But elective esthetictreatment infers a special highadherence to our unwritten pactwith our patients, which is basedon the hard-earned trust empow-ered from decades of ethical treat-ment by ethical colleagues.

We abuse that trust at the risk ofour professional autonomy.

Richard J. Simonsen, DDS, MS

R E F E R E N C E

1. Jackson RD. Judging Ethics Ethically. J Esthet Rest Dent 2007;19:181–2.

Richard J. Simonsen, DDS, MS, is the deanof the Midwestern University College ofDental Medicine, Glendale, AZ 85308; e-mail: rsimonsen@cox.net

The opinions expressed in this feature arethose of the author and do not necessarilyrepresent those of Midwestern Universityand Blackwell Publishing, Inc.

tigative reporting television shows,resulting in our profession taking ahuge public relations hit. Politicianswill jump in and our professionalautonomy will be constrained.

Another insight into why “thesemaltreated patients” are not“highly vocal” can be found in the following quote from an e-mailI received recently from a patientwho alleges that she was conned bya general dentist into a full-mouthreconstruction. It is clear that thesevictims feel humiliated and embar-rassed that their weakness for thevanity of a beautiful smile led theminto treatment that they should nothave undertaken, and that publicdisclosure would only add to theirpain and suffering.

How [could I] have been so stupidto have fallen for such a con opera-tion[?] I hope to communicate withother individuals that have beenconned out of $50,000+ and learnhow they came to terms with beingvictimized, and how they went onto recover. [The] only response Ican offer at this time is that beingconned by a dentist is embarrass-ing, humiliating and infuriating, allat the same time . . . everyday . . .all day.

I stand by my position that it isovertreatment to place 10 veneerswhen a Class IV composite wouldsuffice. I stand by my position thatit is overtreatment to place fullcrowns in the posterior segments ofthe mouth in a new tooth-coloredrestorative material that has notbeen clinically tested. I stand by my

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Iappreciate and respect Dr. Simonsen’s strong position on

maltreatment of patients. I couldn’tagree with him more. Indeed, I said as much in my editorial,although it appears to have beenoverlooked.

I have written and lectured widelyon the use of anterior and posteriordirect composites as well as the useof bonded onlays versus crowns(when indicated) for over 20 years.I have also taught these techniquesin hands-on courses at the LasVegas Institute for Advanced DentalStudies for the past 10 years. Thesefacts clearly show that Dr. Simonsen and I are in agreement on the importance of conservativedentistry and preserving naturaltooth structure whenever possible.Although he doesn’t name it specifi-cally, much of Dr. Simonsen’sresponse to my editorial is criticismaimed at the Las Vegas Institute(LVI). He apparently believesmalfeasance is taught there includ-ing, in his words, the “discreditedscience of neuromuscular dentistry.”What he says or implies is not true. I know firsthand because I teachthere. Whenever sweeping

judgments like these are made onassumptions or second-handhearsay, they can be, seriously inaccurate. Since the treatment forignorance is knowledge, I invite Dr.Simonsen to visit LVI, review its cur-riculum in detail, talk with full timefaculty member Norman Thomas,DDS, PhD, BSc, OMD, Cert.O.Path,FRCD, FADI, MICCMO, and Professor Emeritus at the Universityof Alberta, so that he can knowwhat is actually taught there andbegin to understand the logical basisof neuromuscular occlusion.

I don’t doubt that there are dentistswho have attended LVI and whotreat patients unethically or whomay not adhere to the philosophyof care taught there. This, ofcourse, could be true for any dentalschool or advanced learning center.For the good of our profession andthe patients we treat, this seriousproblem must be addressed. So, Dr.Simonsen and I agree in principalbut disagree in approach. I do notbelieve broad, angry accusationsmade in print or from the podiumare effective in dealing with individ-ual mistreatment of patients. Ibelieve the peer review process, the

legal system and all of us, as indi-viduals, need to address suspectdentists directly on a case by casebasis, gain the facts and act onthem accordingly. This is what ourprofessional code of ethics advo-cates that we do.

I believe we have heard enough vit-riolic condemnations. Individualsacting as judge and jury, shoutingfrom a distance with only articlephotos or just a patient’s story arenot effective. In my opinion, a den-tist suspected of mistreating apatient should be called, the factsobtained and, if necessary, appro-priate action taken. If Dr. Simonsenis interested in the truth about whatthe Las Vegas Institute forAdvanced Dental Studies teaches,he should accept my invitation tovisit the Institute. This is not onlyan effective way to address his con-cerns; it is the ethical way as well.

Ronald D. Jackson, DDS

Ronald D. Jackson maintains a private practice in Middleburg, Virginia.

The opinions expressed in this feature arethose of the author are do not necessarilyrepresent those of Blackwell Publishing, Inc.

RESPONSE TO PERSPECTIVES