Articles and Position Statements
I Have Had Enough
April 27, 2010

Until recently, I have had the opinion that dental professionals and those companies involved with them were working for the good of the public; that service was a major purpose for a profession-not money; that advertising in professional publications was observed carefully by editors to weed out any hint of dishonesty; that the "peer reviewed" dental literature contained only scientifically acceptable, non-commercially oriented information; that the public trusted the dental profession; and that dentists treat their patients like they would like to be treated themselves. WOW, have I been misinformed!

On the positive side, as I start this written tirade, dentistry has made unbelievable progress during my career so far. As I look back at the profession when I became a dentist, the ability of dentists to serve patients was only partially developed when compared to today. The introduction of highspeed tooth cutting, implants, tooth-colored restorative materials, porcelain-fused-to-metal restorations, staff involvement in clinical procedures, advanced surgical procedures, and great strides in preventive dentistry have made dentistry fulfill my three favorite words for patient caredentist. However, in my opinion, the ethics of the dental profession have taken a real "dive" during the same time. At the beginning of my career, dentists and dentistry used to be ranked by pollsters at the top of the list of professions the public trusted. Now, in numerous surveys of public respect, we are reported to be far down on the trust scale.


"In my opinion, the ethics of the dental profession have taken a real 'dive.'" 
- Gordon J. Christensen, DDS, MSD, PhD

This editorial discusses the relatively recent and obvious degeneration of ethics in the dental profession and calls for a change of direction by all parties involved. The following actual documented examples do not name specific individuals or companies to avoid confrontations. I present the following information as examples of the problems I see in the ethics of our profession. If the shoe fits-wear it! Let's examine some of the negative situations that are contributing to this degeneration.

Overtreatment

I was one of the original instigators of the recognition of esthetic dentistry, over 25 years ago. However, my pet subject has turned into a monster with unbelievable overtreatment of unsuspecting patients. This problem of overtreatment is not limited to esthetic dentistry. It is spread throughout the profession. I will list a few current examples.

Convincing patients that removal of amalgam restorations is mandatory for systemic health reasons is not a legitimate or logical practice in most situations. Yet, many patients go through that elective procedure with the hope that some miraculous cure of a systemic condition will be accomplished. Of course, there are a few situations in which amalgam removal may actually be indicated for reasons other than esthetics.

Recently, a patient was examined by me and my staff for a second opinion on an "esthetic upgrade". She had traveled several hundred miles to have the exam, and she did not inform me of her reasons for requiring a "second opinion" until later. We suggested a treatment plan that included scaling, polishing, at-home bleaching, minor esthetic tooth recontouring, a few anterior and posterior tooth-colored resin-based composite restorations, and two elective veneers. When the plan was presented, she sighed in disgust. Just a few hundred miles from Utah, she had received a treatment plan for twenty-eight veneers and a total occlusal rehabilitation, equal to the cost of a very good new automobile. If this were a singular occurrence from one less-thanreputable dentist, I could understand it, but this has happened to me several times in the recent past from various practitioners. Dentists are actually being taught by popular speakers on how to do the same overtreatment to their own patients. I have had the unfortunate challenge to redo several of these over-treated cases after the fracture failure of the ceramic restorations, debonding of veneers placed over grossly overprepared dentin surfaces, or degeneration of the occlusion that appeared to have little occlusal adjustment after seating the restorations. If treatment plans containing all of the treatment alternatives are presented to patients, including the advantages, disadvantages, risks, and costs of each alternative, and if the consenting patient accepts and demands a radical plan, the treatment becomes more understandable. It is well known that patient's elect to have radical esthetic plastic surgery on various parts of their bodies, knowing that the procedures are elective. But, oral overtreatment in the name of esthetic dentistry without total informed consent of patients, primarily for dentist financial gain, is nothing less than overt dishonesty in its worst form. You cannot put tooth structure back after it has been removed.

Solution: Dentists should evaluate their diagnosis and treatment planning procedures to ensure that all of the various treatment options are presented to patients. If patients choose a radical, elective treatment plan, primarily for appearance purposes, they should be told all of the negatives before they choose to initiate the treatment plan, including potential premature failure, occlusal problems, and need for re-treatment in just a few years. Informed consent should be thorough and complete. Treatment plans should be separated into mandatory treatment and elective treatment, and patients should have a complete understanding of the difference. Financial income to the practitioner should be related to the needs and decisions of the informed patient, not the needs of the practice.

Advertisements in Dental Journals and Magazines

As I thumbed through a current "cosmetic" magazine, I noted the presence of ads for several light enhanced in-office bleaching devices, touting their superiority to other bleaching techniques. It must not matter to some manufacturers that it has been proven and published that the tested bleaching lights do not effect a greater tooth color change than the bleach solution alone. I find it amusing that one manufacturer actually advertised that his product could be used with or without the light. Dentists are not without guilt in this situation. Recently, I talked to a practitioner in a course who blatantly told me that he knew the lights did not improve the bleaching, but he thought that patients accepted bleaching fees better if bleaching lights were used. At some time in the future, bleach-light combinations may be found that will allow faster and better tooth lightening than the bleach alone. We are still waiting.


Overtreatment in the name of esthetic dentistry without total informed consent of patients, primarily for dentist financial gain, is nothing less than overt dishonesty in its worst form." - Gordon J. Christensen, DDS, MSD, PhD

Solution: I suggest that editors of journals and magazines recruit thoroughly informed, honest consultants, who have had actual clinical experience with the concept being studied, to screen the advertisements, weeding out the misleading or overtly dishonest ads. Additionally, dentists need to be wary of advertising from companies known to exaggerate product characteristics or to misrepresent the advantages of their products in ads. Companies should realize that honest advertising is clearly evident to inform readers, and similarly dishonest ads are soon disproved by clinical results. When clinical research and experience do not confirm the claims in the ads, dentists lose confidence in believing any future ads from the company involved.

Articles in Journals

A recent research paper published on the most commonly used esthetic dentistry procedure in a prestigious "peer reviewed" journal, and showing positive characteristics for the product evaluated, was funded by the company selling the system. In some situations, this may be legitimate, but in this case, studies from other researchers published in the same issue with the commercially supported paper would certainly have made the results more credible. Most companies are doing their best to be honest and sincere, but the few who flagrantly try to promote their products by "bought research" soon become identified by practitioners.

A popular, well accepted technique was denounced in another research paper in a "peer reviewed" journal. Immediately, dentist participants in continuing education courses asked why the clinically successful technique, which most of them were using, didn't do better in the research. After reviewing the paper, it was found that a third-party payment company, with obvious vested interests to reduce the use of the popular concept, had funded the research. You have read many scientific projects that test a group of commercially available products, and find one product to be the best. It should not be a surprise to find that the product from the company funding the study had the most positive results.

Unfortunately, dental education and dental educators have always been under funded. Dental manufacturers provide much of the funding for university-based dental research. Although not impossible, it is difficult for a dental faculty member to remain totally unbiased, when accomplishing a research project, if all or a major portion of his/her salary comes from the research grant. Additionally, when a company-funded project can be delayed or stopped by the funding company. The recent tobacco research fiasco is manifestation of this problem on a larger scale. Such information is lost to the public of practitioners until someone else happens to study the same question.

Peer review of research in dentistry, with a few exceptions, is not a guarantee that a published paper has legitimate conclusions. In my opinion, peer review in dentistry is in need of major revision, bringing in many more practicing clinicians along with their academic counterparts, and using more than a few persons as reviewers on controversial topics.

Solution: Dentists - wake up! How many companies can produce an unbiased research project? I know a few, but there are many that are questionable. Editors - publish more than one paper on the same subject when a company-funded project is published in your journals, recruit peer reviewers who have expertise in the specific subjects of the papers, and expand your review teams to include more "real world" practitioners who know clinical dentistry. Companies - just be honest. We practitioners soon discover dishonest research by simply observing our clinical results, and you and the patients will be the losers.

Evaluation of Products

Most dental journals and magazines have product endorsements in them from companies or individuals that have been paid to evaluate the products they are endorsing. If independent companies want to evaluate dental products and report on them, honesty in the results would be increased if these evaluations were accomplished without fees paid to the evaluating company by the manufacturer that produced the product. The evaluating companies should obtain their income from publication of their data, or other means. The lay group, Consumer Reports, is a prototype for such evaluations. This company does not allow publication of their data for commercial purposes, but it is readily available from the company. Some dental companies use information from published papers in their product advertisements. With the permission of the author/researcher, and if the information is used in fairness to other similar products in the study, such inclusions in ads appear to be appropriate. Reference to the published paper should be included.

Solution: Again, dentists beware! Analyze the source of endorsements carefully. When the endorsement in an advertisement looks questionable, money has probably changed hands. Companies, be honest! Your good products sell by word of mouth about clinical success. Honest, conservative ads are appreciated, and you are respected when practitioners read them.

Speakers on the Lecture Circuit

After spending roughly 40,000 hours on the circuit, I can probably comment on this one with some experience. Can you smell a paid-off speaker? If you can't, you are pretty naive. Although for most of the larger meetings, speakers have to sign a statement that they are not being paid by companies producing products contained in their lectures, there are many devious ways to get around that challenge. How about paying spouses or other relatives, funding children in college donating to favorite charities in the speaker's name (this is okay if the money is donated in the company name and the speaker does not get a tax deduction), using company condos, cabins, or planes, paid vacations, and many other manufacturer perks? It is relatively easy to observe when a speaker favors one company or another in lectures. It is obvious when the speaker is selling his or her own dental product to the exclusion of other products in the course.

Solution: Do not attend lectures of speakers who appear to be on the "take". These speakers soon expose their financial commitments by their overt favor of products, companies, or commercial techniques. I have seen hundreds of speakers come on the circuit and burn out within a couple of years. Suggest reliable speakers to your colleagues, especially younger dentists.

Summary

I apologize for making some of you nervous, and perhaps even resentful, but I HAVE HAD ENOUGH! I do not like the new unethical face of my profession, where incessant seeking of more money has replaced service to the public, honesty, and self-respect. Numerous areas of major ethical concern in dentistry are identified in this article. The ongoing, if not accelerating, degeneration of professional ethics in dentistry is clearly evident to even casual observers. Improvements in professional ethics are necessary to regain our self-respect and the respect of the people we serve. All of us need to improve, including practitioners, speakers, dental schools accomplishing research, manufacturers, editors, and evaluation groups. It is time to return to honesty and to dealing with our fellow men and women in the way we would want to be treated ourselves. I do not think it is too late.

Dr. Gordon Christensen, a prosthodontist in Provo, UT, is Co-founder and Senior Research Consultant of Clinical Research Associates (CRA). Dr. Christensen is also the Director of Practical Clinical Courses, a continuing education career development program for the dental profession at Brigham Young University and the University of Utah. You can contact Dr. Christensen at: Practical Clinical Courses, 3707 North Canyon Rd., Suite 3D, UT, 84604-4587. Fax (801) 266-8637. Visit his website at gordonchristensen-pcc.com.