Treatment decision making – the Icarus questions

To promise too much and overstep your competency can be paralleled with stories from Greek mythology writes NSW Advisory Services Peer Advisor, Dr Roger Dennett

Greek mythology tells the tale of Icarus and his father Daedalus, who attempted to escape from a tower prison via wings made of feathers and wax. Icarus’ father warns him first of complacency and then of hubris, asking that he fly neither too low nor too high, lest the sea’s dampness clog his wings or the sun’s heat melt them. Icarus ignored his father’s instructions not to fly too close to the sun, and when the wax in his wings melted, he fell into the sea to his death.

The parallels in dentistry are strong – promise too much, overstep your competency, and you’re just as likely to tumble out of the sky as deliver on your promises.

Practitioners mindful of this tale should consider the following questions when deciding on the patient’s treatment:


  1. Can I do it well? (GP Orthodontics)


Advisory Services have seen a lasting upsurge in the number of complaints involving general practitioner orthodontics. The Australian Society of Orthodontics is on record as stating that the only way that GP dentists should be doing orthodontics is after completing the MDSc programme in orthodontics. Whilst this is not necessarily the view of ADANSW, practitioners need to remember the Code of Conduct 7.2, which states:

“Development of knowledge, skills and professional behaviour must continue throughout a practitioner’s working life. Good practice involves keeping knowledge and skills up to date to ensure that practitioners continue to work within their competence and scope of practice.”


In situations involving GP orthodontics that have gone wrong, it usually comes to light that a proper and full clinical assessment of the patient’s orthodontic condition was not carried out and that the treatment plan was ill-advised and thus ineffective. Specialist retreatment usually occurs with invariably good results. This can be an expensive learning exercise for all concerned.


  1. Can I do it efficiently and effectively? (Endodontics, Oral Surgery)


Advisory Services have dealt with many complaints involving GP dentists doing molar endodontics, where the main issue is a lack of locating, and subsequently treating, all of the canals. This often results in many “dressing” appointments, delaying a final result which proves to be unsatisfactory, necessitating specialist retreatment or the loss of the tooth. When this occurs – and without appropriate pre-op warnings being given – the result may be an expensive claim against the practitioner.


Third molar surgery has been another area where enthusiasm and hubris may result in a clinical disaster. A simple example of this is where there is a lack of proper assessment of the difficulty of the case, resulting in unexpected difficulties during the operation, leading to a surgical ordeal for the patient and an extended procedure outside of the expected norms.


In a more complex case, a lack of proper assessment and understanding of the position of the IAN and its proximity to the wisdom tooth roots can result in damage to the IAN. In addition, an improperly placed incision can increase the chance of post-operative lingual nerve neuropraxia or neurotmesis. Sometimes it is better to refer to a more experienced colleague than have to spend time with your professional indemnity insurance-appointed solicitor!


  1. Can I do it without harming the patient? (Implant Surgery)


Members may be aware that insurers have identified GP implant surgery as a high risk area for claims, so much so that those GP dentists who perform this pay a higher insurance premium than those who don’t. Sadly, this is based on the number of expensive claims involving implant placement by GP dentists with poor results and complications, resulting in patient dissatisfaction.


Implant dentistry is expensive and patients have a reasonable expectation of high levels of competence and a good outcome. These cases are expensive to retreat when unexpected consequences occur. Such consequences were usually not discussed at the planning or diagnostic phase. By way of example, the Advisory Services Team has seen cases:


  • where a single implant has been placed such that it impinges on the periodontal ligament of an adjacent tooth, resulting in pulpal necrosis, pain and an unhappy patient
  • where the implant was buried at the time of placement (and not being able to be used prosthodontically) due to inadequate torque being obtained at placement
  • where a mandibular posterior implant was placed into or up against the inferior alveolar canal, resulting in ongoing pain. Removal of the implant (if done quickly) may result in abatement of the symptoms, but there may be permanent damage to the mandibular nerve in such situations. Either can lead to an expensive claim


  1. Would I recommend this treatment for myself or a member of my family?


If you wouldn’t want the treatment for yourself or a member of your family, why recommend it to a patient? Heroic treatment to try to save a tooth which is unrestorable doesn’t make sense, yet the Advisory Services continues to see examples of this.


In like fashion, if your treatment plan is complex and difficult (e.g. sinus lifts and implant treatment), consider referring the patient to a more experienced colleague or specialist – if only for a second opinion. Do you have a mentor or a senior colleague whose experience and opinion that you value? Why not approach them and present the case? Dentistry can be a challenging profession for many reasons, not the least because of the professional isolation in which some of our colleagues practise.


  1. Can I communicate well with this patient?


As Buddha said, “the cause of suffering is desire”. As dentists we deal with desire and patient expectations every day!


Thoughts to ponder – Are you aware of what the patient expects as a result of the treatment that you are recommending? Are those expectations reasonable? Are there cultural barriers to their understanding and your communication with them? Do they have capacity to consent to the treatment, you having explained the known risks, limitations, outcomes and complications? Have you obtained informed financial consent, as well as informed consent?


Informed consent is a process where the parties reach a mutual decision about what treatment the patient is to have, and where the material risks of the recommended treatment have been discussed and understood by the patient. Simple treatment requires a simple (verbal) consent. Complex and expensive treatment requires written information to the patient (prior to a decision being reached) and a signed consent form.


We sometimes see cases where the treatment does not appear to be in the patient’s best interests with a high likelihood of failure and problems. Often in such situations, a prescriptive patient who thinks that they know best prevails on the dentist to carry out the treatment they want. This is a recipe for disaster and in such cases the practitioner should remember that he/she always has the right to refuse treatment!


As always, the Advisory Services welcomes your comments and is here if you wish to discuss any clinical situation. We do not have all the answers all of the time, but many of our conversations end with our member saying “Well, thank you and I’m really glad that I called you today!”


Contact the NSW Advisory Services Team on (02) 8436 9944 or email