If you want others to be happy, practice compassion.
If you want to be happy, practice compassion.¹

A friend who owns a small cabling business once told me that no matter how concerned a business-owner is about the welfare of their clients, some decisions that the business-owner makes are more in the best interest of the business rather than the client.

This is an undeniable fact that I agree with. These business decisions all end up impacting the bottom line, or profit, of the business. They range from things like using cheap materials to save on expenses, to unnecessary value-added goods or services, to pure and outright negligence.

Examples from around me? I’ve posted about some of them before, but read through the following groups and see if you can figure out the “ethical” difference of the examples in each group. I haven’t made up any of the examples:

Two examples of how to reduce expenses from a material/supply perspective:

1. On a day tour of cenotes (underground caves) in Mexico we arrived and set up to repel into the largest one of the day. The ladder via which our rope and harness was attached to (about 150 feet above the water at the bottom of the cave) was craftily and skillfully, rung by rung, taped together with duct tape.
2. How about the dentist that I know who orders one colour of white material for fillings. Every one of his patients who gets a white filling gets the same color of white. Not only that, but the excess filling material that is dispensed and doesn’t get used on your tooth, gets used in the next patient’s new filling.

Two examples of how to improve income by value-added services:

1. You decide that you want to learn to waltz. You take a few lessons at a ballroom dance studio. You are then strongly encouraged by the studio owner to pick up a multitude of other dances and a schedule of lessons because these dances will allow you not only to dance to other types of music, but will also indirectly give you training in frame, lead and follow, and floorcraft for the waltz.
2. Your dog while illegally out for a walk with you off his leash, attacks a neighbour’s (who is a friend) dog who is on a leash. The scuffle seems to end uneventfully. The next day the neighbour shows up and says his dog’s eye is swollen shut. You take their dog to a neighbourhood vet who runs a run-down walk-in clinic but is the only one available at that time to see the emergency. Antibiotic eye drops are prescribed along with a return visit in a week. The return visit is “free”. Uh huh. Within the week, the swollen upper eyelid looks almost as good as new. There is a little scar where the injury was, but that will probably continue to improve over time. We take the dog back to the vet for his free recheck. Although the visit is free, the value-added service is another prescription and dispensation of antibiotics for the scar, “just in case.” Antibiotic use for “just in case” is generally frowned upon these days.

Two examples of negligence:

1. In the practice of endodontics, controversy exists between the need for two visits to treat infected teeth, versus one visit. There is research evidence supportive of both sides of the debate. You choose to ignore the evidence supportive of two-visit treatment, treat everything in a single appointment, and present only the research supportive of single-visit treatment as your justification. There is a higher profit margin when teeth are treated in a single visit.
2. You don’t like doing root canals, your patients have a difficult time during the procedure, your patients return again and again after the procedure complaining of persistent symptoms, yet you continue to do root canal therapy as you always have, with no effort to improve your skills or understanding of the process. But…when your wife or kid needs a root canal, they are referred to me, the specialist.

Without turning this post into an ethics course, I think that most of you will agree that the number 1′s are less of a problem along the do-good/do-bad scale than the number 2′s. This probably is because the number 2′s are more fraudulent — they represent actions and situations where either a collective standard of treatment or practice is not upheld, or an outright deception is represented. There is a feeling that you’ve been robbed.

As a professional in business, the imperative to work ethically is a daily challenge for me. I have made good and bad business decisions that have directly involved patients.

So how do I make a split-second decision when deciding on the “right” thing to do? After reading through all of this, you might be surprised to find that the answer is very simple. The answer is the way that I live life daily. It is the Ethic of Reciprocity, or the Golden Rule. But I go one step further. I don’t treat you as I would want to be treated, myself. I treat you as I would want my brother, my mother, or my wife to be treated.

1. Dalai Lama [↩]

I enter the consultation room.

Me: Hi, I’m Peri Apex.

Him: Hi.

We shake hands.

Me: Your dentist has asked me to evaluate three teeth on the bottom that have had root canal work. Apparently you need some major restorative work done on them and there’s a question of whether or not the root canal status is stable.

Him: Yes, but let me ask you a question first about teeth that are impossible to freeze. One of the teeth that I’ve had a root canal on is impossible to freeze. At least 4 dentists have tried, but none of them have been able to get it numb and they all start off by saying that they’ll be able to achieve what the previous dentist wasn’t able to. So I had to have general anesthesia to get the root canal.

Me: Yup, sometimes teeth are difficult to numb up because of things like anatomic considerations or nerve inflammation in the tooth.

Him: No, this tooth doesn’t numb up.

Me: Well lower molars can be especially difficult to get fully numb.

Him: No, it was an upper tooth.

Me: Oh.

Him: My lip and cheek and gums were all numb but not the tooth.

Me: Getting teeth that are that sore fully numb is a challenge sometimes.

His voice now starts raising a notch.

Him: No, the tooth was not numb at all.

Me: The tooth was probably a little numb, just not enough to work on.

Now he sits up straighter, voice raises another notch.

Him: No. No. The tooth was not numb one bit. The dentists have told me all about where the nerves run, how they are supposed to be frozen in specific places, but I have a medical condition that prevents that particular nerve from getting affected by anesthetic.

I started raising my voice now because this silly, pointless conversation is dragging out too long. It’s not even one of the areas I’m supposed to check out.

Me: Have you had trouble getting frozen anywhere else?

Him: No, the condition is just with that one nerve in the area there.

Me: Someone told you that you have this medical condition?

Him: No, I know I do.

Me: What’s it called?

Him: I don’t know what it’s called.

Me: So how do you know that you have a medical condition?

I now realize that we’re both really getting pissed at each other.

Him: Because I’m telling you this is what happens when anesthetic is used on the tooth!

Me: How can you say that you have a medical condition like this when you don’t even have a name for it?

He looks at me with this incredulous look now.

Him: What are you talking about? There are lots of medical conditions without names.

Me: Well anyway this conversation is pointless because I’m looking at different teeth today anyway. They shouldn’t have a problem numbing up better if they need work.

Him: No, you don’t get it, the tooth didn’t numb up at all!

Me: The only way you can tell me that the tooth was completely unaffected by the anesthetic was if they tried to drill into it without freezing, then froze you up and then drilled into it again.

Him: Well it was not numb at all.

Me: You know, we’ve got lots of theories about teeth that are resistant to anesthetic; things like pH imbalances, receptor up-regulation, central facilitation and neuroplastic changes that affect receptive fields, but not one medical condition that describes one tiny, single nerve bundle to a tooth that is completely resistant to anesthetic.

Nodding the “whatever” nod at me.

Him: Uh huh.

And so the entire waste of a consultation appointment went. My insight into his argumentative nature became more detailed during this exchange:

Him: What forms of sedation are available here?

Me: Laughing gas, with freezing of course; a pill with or without a little bit of laughing gas; IV sedation via a dental anesthesiologist.

Him: Is freezing included with the pill?

Me: Yes, it’s included with all the sedation modalities. Don’t worry about freezing it’s a given.

Him: But you said laughing gas and freezing, you didn’t say it with the others.

Me: Don’t worry, no matter how deeply you are sedated, you’re getting freezing.

Him: Because of my subconscious maybe feeling stuff still?

Me: Yeah.

Him: Is General Anesthesia an option, do you do freezing with that?

Me: Inhalalation anesthetic is not an option here, but you would get freezing with that too if it were.

So…please do me first and make it quick before he needs to come back for work in that upper area where the medical condition lies.

Written on the referral slip that arrived with this patient was a note from their dentist, “Please perform apical surgery.”

I suppose the dentist was concerned about the post being irretrievable. My concerns were the probable coronal leakage that was causing the apical lesion and the fact that apical resection of the root would put me up against the end of the post — leaving me in a difficult position for a retrofilling. Apical surgery will not hold up against coronal leakage in a predictable fashion.

Assuming that the dentist could do a crown with a decent coronal seal, why not take the post out and retreat the root canal work? Retreatment would offer a more predictable solution for the tooth.

Ah, but a deep screw post like this is quite daunting to remove. We worry about the risk of fracturing or perforating the root.

Here’s what your average neighborhood endodontist should be able to do for you:

Microscopes, ultrasonic instruments, and training allow us to deal with cases like this in a conservative, predictable fashion. Orthograde retreatment of cases like these are viable options and should be presented to patients. Jumping straight to the surgical option is a disservice to your patient.

Update (August 14th, 2008): Here’s the post-op film:

Every so often I think about the idiot dentist that we wrote about in this post a while back. For some reason he is one of the few things that aggravates the hell out of me. It is probably because when you mix ignorance and arrogance you get a bully, and when you have a bully working on patients, trouble usually isn’t too far behind.

He has some fairly popular ideas about dentistry and the various subspecialties. He believes that endodontics in particular is merely a technical skill that can be improved upon practice. Continuing to improve your endodontic skills over time will put you at the same level of training as an endodontist.

Basically, as a general dentist, you would take a few hours of continuing education courses. These sometimes consist of weekend courses that involve both a didactic and hands-on component. They are usually taught by endodontists, and are often sponsored by an equipment manufacturer (the one whose equipment the specialist will be teaching about). These courses are meant for general dentists who are interested in how to do good root canal work.

Continuing education courses that specialists take are also given by specialists, but the goal of these courses isn’t usually about how to do good root canal work (since we already know that), but about more academic ideas. The controversies and thoughts that these lectures bring about are responsible for ongoing research in our field. The findings from this research evenutally trickles down to GP dentists through their courses as improvements in patient management and technique.

As much as administering the Canadian Endodontic licensing exam is a real pain in the ass (takes up a lot of time, and I don’t get compensated for it) it is rewarding.

My partner during the oral exams last weekend is the new chief examiner. I am confident that with his leadership we will see some very positive and constructive changes to the examination. The examination brings some of the brightest minds in Canadian Endodontics together — both examiners and candidates. I always find this refreshing because I work alone.

Working alone means that I only have myself to critique my work, I only have myself to toss ideas off of, and I only have myself to decide what journals and articles I should read that are most relevant to what I do. When specialists meet as part of a conference or an examination, we bond through the sharing of each other’s ideas.

But what about that asshole that I mentioned earlier? What does all of this have to do with him? Here is a summary of what it takes to be an Endodontist in Canada.

Now think of yourself as a patient in need of a root canal. Even if the procedure is merely a technical skill (which it isn’t) and your family dentist might have done hundreds to this point, would you not feel more comfortable having it done by an endodontist?

The answer is fairly obvious. The less obvious fact is that millions of root canal procedures are done annually by GP dentists and endodontists. GP dentists are trained to be competent at the procedure but annually as well there are thousands of cases that lie outside of a GP’s competency level. It is for those cases that we specialists exist. Any general practitioner dentist who states that he or she never refers patients to an endodontist leaves me wondering about the standard of care in that office.

It’s that time of the year when storms in Workland can knock power out for seconds to hours. It’s an annual ritual for us to have at least 1 patient per year experience a power failure during a procedure.

I only work during the day and we have lots of windows in the treatment rooms at the office but storm clouds are quite dark and so we usually have to break out the flashlights in order to finish things up. I haven’t needed a power generator…yet. That’s unlike the periodontists next door.

A patient that I saw back in 2005 during a power failure returned yesterday for me to check out an unrelated tooth. Here’s my treatment note from back then:

Here’s my post-op xray of the tooth I worked on (I did the 5 and the 7):

And here’s the tooth as it stands today:

There’s a massive screw post that her dentist has placed almost to the apex. I don’t know how long this tooth will survive before it either splits along the root or bacterial leakage happens alongside the post.

Morale of story? Not really sure, but it has something to do with power failures affecting root canal treatment prognosis less than irresponsible dentistry does.