Inconsistency Between Dentists In Their Practice?

[1994]

I have had several dentists over the years for various reasons (retirement, moving locations, etc.) and have recently had the chance to do some shadowing at a couple of clinics. I've come to notice quite a few differences between how each dentist chooses to approach certain cases. For example, some are more aggressive with treatment plans while others are more conservative. This also extends to smaller things that may not be as significant but do affect patient experience. At one clinic the dentist seemed very thorough, for example flossing/clearing debris between teeth that received fillings. This clinic seemed much more engaging with patients and in general seemed more willing to jump through hoops to enhance patient experience. At another location, a patient with a similar case had to come back soon after the fact to have this done because it wasn't done immediately after the procedure and was causing discomfort.

 

I can list a few more examples, but my question is why is there so much variance between how dentists practice? Is there much room for interpretation when learning about certain procedures in d-school? Are these differences due to differences in the education they received/what school they attended? How are patients able to make informed decisions when one dentist's recommendations starkly contrast with that of another? I understand that what I've seen is quite limited and I have no doubt that the majority of dentists are competent, but having noticed such differences makes me question whether the average person who may not be aware of how different clinics operate are getting the best care/experience possible.

[cleanup]

Dentistry is about as gray as it gets when it comes to medicine and healthcare. There's very little in dentistry that is black and white, and often there are very few answers that are assuredly wrong or are assuredly right. Most decisions made in dentistry are somewhere in-between: good in some ways, not the best in others. 

 

Ask 10 dentists the same question and you'll receive 20 answers.

 

I do think a big factor in the 'variability' of dentistry is that admittedly there isn't as much evidence-based practice in dentistry as there is in medicine. There is a big push toward it and there is still usually considered a 'best' way to do one thing or the other (at least amongst say academic institutions within a region ie. dental schools within Canada or North America), but with less regulation, there's more people deciding to do things differently. This is just as much a good thing as it is a bad thing. 

 

[Edit] Also I removed my response to the whole flossing contacts thing you were discussing earlier. I read your post wrong, my bad. I'll just say it's dumb not to floss contacts and generally a poor decision if you don't do it. You have no idea if that contact is too tight, too loose or maybe non-existent.

[cookiemonster99]

I don't think I can give you a better answer than malkynn or what cleanup has said

 

It's hard to explain to someone that hasn't gone through dental school or practiced dentistry 

 

 

Dentistry is as much an art as it is a science.

The short answer is, yes, there are many many many different ways to practice and you will have to find your own way among them.

It's hard sometimes, especially when working for someone whose philosophies and treatment style you don't agree with, which is common.

How can patients know?
They can't.
Patients tend to trust the work of dentists they like. Recently I had a patient go on and on about how great a certain dentist is, meanwhile I know that this dentist is total garbage because he was both my husband and my mother's dentist and I've seen this dentist's garbage work for myself (and had the displeasure of having to try an fix it)
This dentist is incredibly charming though, so people think they do good work.

Most absolute garbage dentistry will never be noticed by anyone. Patients can't tell what's good work from what's awful.

I have two beautiful porcelain front teeth that I always thought were incredibly well done because they look perfect. I now know that their margins are awful, the root canal beneath one is a disaster, and if I try to fix them, I might lose one of the teeth. They've lasted 14 years, and will likely last many more. Even crap work can last.

You need to figure out what kind of dentist you want to be and do your best to commit to that path.

 

malkynn summerized this beautifully 

 

There is a lot of grey in dentistry in terms of how to approach a certain situation.

 

For example: the one that I can think of is a situation of a filling. If decay JUST reaches the dentin(softer part of the tooth), one of my professors who is an advocate for preventive dentistry argued that if the patient has good oral hygiene and is very compliant, that they can potentially "fix" that decay and nurse the tooth back to health. 

Where on the other hand most dentist will just go ahead and drill it out and place a filling over it. Not that it's wrong, but just different opinions. Neither of them is wrong per say. 

 

There are so many examples of these situations that involves more complex procedures and situations that it gets hard to explain.

Additionally, we have to think about the patient's financial constraints when treating them. Don't offer them a $40,000 treatment plan when you know they can't afford it but ethically I think you should say something like "in my opinion the best treatment for you is this and this is the cost associated with it, however if you are looking for something more economical, here's 2 more alternatives( if the situations allows for multiple treatment plans).

 

if you're interested cbc marketplace did a whole 20 min youtube video on it 

have a watch: 

[cleanup]

For example: the one that I can think of is a situation of a filling. If decay JUST reaches the dentin(softer part of the tooth), one of my professors who is an advocate for preventive dentistry argued that if the patient has good oral hygiene and is very compliant, that they can potentially "fix" that decay and nurse the tooth back to health. 

Where on the other hand most dentist will just go ahead and drill it out and place a filling over it. Not that it's wrong, but just different opinions. Neither of them is wrong per say. 

 

Just to expand on this a bit, since this is literally bread and butter dentistry and most people can vaguely understand the concepts of cavities & fillings:

 

Dental cavities within enamel only (the outer-most hard tissue of a tooth) do not progress terribly quickly, and with proper hygiene can be 'arrested' in their progression. The etiological factor can be removed via homecare and the enamel can actually remineralize & repair itself to a limited extent, provided that hygiene is good. This is usually only possible if there's some fluoride exposure going on (whether through fluoridated water, home products like toothpaste or fluoride that can be applied by a dental office). The caries becomes "arrested" and it doesn't really progress further unless once again hygiene begins to falter.

 

If the decay reaches the dentin (the next layer of hard tissue down in the tooth), it progresses much, much faster and is generally not treatable via hygiene. It's also inaccessible to topical fluoride exposure so we lose that modality of treatment. This is where a filling/restoration is decidedly needed in order to remove all of the infected tissue and arrest the progression of the cavity.

 

The argument is at what point do we decide its past the point of being treatable via preventive measures or homecare? X-rays actually underestimate the amount of decay within a tooth, and even if caries is assuredly NOT all the way through the enamel into the dentin, who's to say it won't be by the time you see the patient again? A lot of factors play into that including how often they visit, their level of oral hygiene and compliance, and even vague, unquantifiable individual factors like genetics. This is where a lot of variability is introduced in practitioner decision making. If a dentist thinks that the patient won't be able to stop the decay for whatever reason, then one could argue the better option is to fix it now, before it gets worse. On the other hand, is removing the ability for a less-invasive method of treatment a bad thing? Or are we actually being conservative by deciding to do the more invasive treatment earlier rather than later? That's up to you to decide.

 

One thing to note is that this ambiguity is usually in the case of interproximal caries, or cavities that appear between teeth, where they touch in the arch. Lack of flossing --> interproximal caries. If I see incipient (or enamel-only) caries on a smooth surface of a tooth (for example the surface that you see when you smile, or on the inside next to the tongue or palate) then I can reasonably assume oral hygiene is very poor, since food/bacteria don't tend to hang around smooth surfaces of teeth. These surfaces are EASY to clean, and are naturally cleaned by your tongue & saliva. If I see decalcification or some other form of early caries on a smooth surface, I'm personally more inclined to restore it (do a filling) than I am to leave it. Then again, someone else might say "But if it's easy to clean, wouldn't it be easier for the patient to arrest?". Neither reasoning is wrong.

[Lactic Folly]

Great discussion of the nuances of professional judgment in dentistry. I'd love to see such commentary were available on patient-focused websites, as this would answer many common questions about differences in treatment plans. Having such treatment philosophies available might also help patients find a good fit - when searching for a new dentist, it's hard to find out this information except perhaps word-of-mouth recommendations.

[Lactic Folly]

I was referring to degree of conservatism rather than specific procedures. 

Are you saying that the same person who would recommend watching an area of decay instead of filling it (as in cleanup and cookiemonster's example) could also be the same person to recommend 14 crowns instead of one crown (as in your example)?

[Lactic Folly]

Only an unethical dentist would replace a bunch of fillings that don't need to be replaced, but that doesn't mean that all dentists who recommend replacing a bunch of fillings are unethical.

Absolutely - I was not trying to imply this at all. I've had quite a bit of work done, and have had no qualms about proceeding when I've felt comfortable with the plan. This is mainly related to the quality of explanation I've received - having someone go through the factors that lead to their recommendation (the posts above do an exemplary job) increase my confidence in the quality of professional judgment (and customization of care as you said), versus simply being told the plan without acknowledging the nuances above or volunteering to discuss pros or cons of different options. This is different and not necessarily correlated with personality or likeability. I've edited to make it more clear that this is the major factor, as per my original post in the thread. 

[cleanup]

Sure, an LVI grad and a Pankey grad might carry certain themes through their style of practice, but there's as much variability among them as between them.

 

I attended LVI Core I. I think LVI might be that exception where there's more variability between LVI and the rest of the dental field than within LVI.

 

It was weird. I'm not saying I disagreed with everything they were saying, but a lot of it flew right in the face of things I had accepted as doctrine and even more of it felt very bogus. I was very, very wary.

[cleanup]

This is a mild, but quick example of patients not knowing what's going on in their mouths.

 

Both maxillary central incisors were restored with buccal composites last year. The tooth front and center is after I fixed one that had fallen out, immediately post-operative. The one to the left of it (or above it, in the photo) still has the old restoration intact. You can see at least visually how it has poor margins, already has marginal staining (a sign not necessarily that the filling is poor but in this case it's fairly clear-cut), and just fails to reproduce anatomy.

 

No actual caries, no pain, no sensitivity, but one had fallen out during a scaling, which is a sign it wasn't properly done. Inadequate depth of preparation, poor bonding technique, and poor margins and finishing. 

 

But if it hadn't fallen out, the patient could've lived with these for years. It's not perfect, but it could work. The restorations look bad, and are technically more likely to get recurrent decay or fail in some other way compared to my replacements, but that's not a guarantee. But given her oral hygiene habits, we decided to do a better job for her. Was that wrong? Who knows.

 

Arguably I did a better job, but in the end would it have made such a large difference? That's very difficult to say. Personally I just want to be the type of dentist who doesn't cut any corners and consistently does very high quality work.

 

[cookiemonster99]

This is a mild, but quick example of patients not knowing what's going on in their mouths.

 

Both maxillary central incisors were restored with buccal composites last year. The tooth front and center is after I fixed one that had fallen out, immediately post-operative. The one to the left of it (or above it, in the photo) still has the old restoration intact. You can see at least visually how it has poor margins, already has marginal staining (a sign not necessarily that the filling is poor but in this case it's fairly clear-cut), and just fails to reproduce anatomy.

 

No actual caries, no pain, no sensitivity, but one had fallen out during a scaling, which is a sign it wasn't properly done. Inadequate depth of preparation, poor bonding technique, and poor margins and finishing. 

 

But if it hadn't fallen out, the patient could've lived with these for years. It's not perfect, but it could work. The restorations look bad, and are technically more likely to get recurrent decay or fail in some other way compared to my replacements, but that's not a guarantee. But given her oral hygiene habits, we decided to do a better job for her. Was that wrong? Who knows.

 

Arguably I did a better job, but in the end would it have made such a large difference? That's very difficult to say. Personally I just want to be the type of dentist who doesn't cut any corners and consistently does very high quality work.

 

 

 

My approach to this patient would be a bit different to yours and this is where the "inconsistency" lies

 

Depending on the patient's oral hygiene practices, medical conditions, diet, compliance, caries risk I would temporary restore with GIC to stabilize the caries rate(if she is a high risk patient) and when she shows evidence of improvement in her oral health. I would then restore with composite. <--- this approach isn't wrong either, it's just a different opinion. In this case it looks like she got tooth brush abrasion which I would just restore with composite. 

 

Another issue is what the patient wants. If this is an esthetic case, then I would recommend bleaching the teeth and using a lighter shade of filling material once that's done or even veneers. There's nothing wrong with any of these approaches just different opinions on what you wanna do.