Changing the conversation and changing the bar – restorative dentist James Darcey looks at what constitutes as ‘good enough’ dentistry

The world of dentistry is changing at pace. The internet and social media provide unparalleled access to education, peer support and updates on techniques and clinical advancements. Everyone’s opinion appears to be equally valid and the ‘expert’ can often offer no better contribution than the generalist. This gives clinicians the ability to partake in the bigger conversation and broaden their knowledge base. This may, however, come at a price.

The nature of this type of learning often leads towards excellence, with clinicians posting cases that raise the bar of quality to a level that is worthy of the highest praise, but one that may be unattainable by the masses. Dentistry in these forums can often be glamourised and invariably unattainable. There also remains the huge question of publication bias; clinicians rarely discuss their failures in their postings.

Being ‘good enough’

The British psychoanalyst, Donald Winnicott, coined the term “good enough mother”.¹ The phrase began to change the vernacular about how we raise our children. Implicit in this was the concept that perfection is not always, if at all, possible. Going one step further, Bruno Bettelheim, in his book A Good Enough Parent, wrote that perfection may not be a healthy pursuit:²

“In order to raise a child well one ought not to try to be a perfect parent, as much as one should not expect one’s child to be, or to become, a perfect individual. Perfection is not within the grasp of ordinary human beings. Efforts to attain it typically interfere with that lenient response to the imperfections of others, including those of one’s child, which alone make good human relations possible.”

Seeking perfection focuses the parent on the problems and not the aspects of nurturing, support and key milestones that are good and healthy. Every failure and every blemish is subject to microscopic scrutiny. We live in a world with infinite independent variables beyond our control and it should quickly become apparent that no mortal could lay claim to be independent of these.

What does this mean for dentistry?

It may be time to change the conversation from ‘perfection’ to ‘good enough’ dentistry. There will be times when we must strive for perfection, but we may have to settle for ‘good enough’. This doesn’t mean lowering our standards, but rather identifying a threshold supported by a group of fundamental minimal standards, from the examination to the discharge of the patients in our care. If we operate above this threshold, this gives patients a high quality service and great outcomes.

Fortunately, we do not have to leave this to chance; frameworks exist by which we can establish baseline parameters of good clinical practice. Look no further than the pillars of clinical governance.

So, what constitutes ‘good enough’ clinical dentistry?

In principle, it consists of:

• A robust dental history and examination

Treating all patients like new patients is a good starting point: it’s easy to be complacent with long-standing patients and drop one’s guard. Using a template helps to ensure a logical progression through the history and ensures all points are covered. With new BSP guidelines, consideration must be given to full pocket charting on patients with intra-oral evidence of periodontal disease.

Dentists are fortunate that investigations are largely limited to percussion, sensibility, mobility, colour, attachment loss and radiographic examination. Ethyl chloride should be abandoned in favour of the more specific and sensitive colder sprays such as Endo Ice or Endo Frost at -50 degrees. Radiographs should be justified, graded and reported on.

• Accurate diagnoses

There can be no treatment plan without a clear list of diagnoses. These can be both general diagnoses, such as periodontal health, and more specific tooth level diagnoses. The diagnoses should be supported with risk assessments to document the likelihood of future disease.

• Treatment planning –broken into urgent care, primary disease stabilisation and definitive treatment

This sets out a plan for the patient that prioritises their care, establishes their ownership for oral health and disease prevention, and provides the appropriate treatment at the appropriate time. A patient presenting with quadrant caries is not a patient who should be offered quadrant conservation until they have made changes that will improve the predictability of restoration and reduce the risk of future restorations. Active caries may be stabilised with provisional restorations and an appropriate preventive regimen established.

• A conversation about disease aetiology and a management strategy and, where choices present, a reasonable conversation about the risks and benefits of these choices

This should be inclusive of all core options, with a focus on the likely outcomes of each option. The consent should be tailored to the particular situation, not generic, and it should be an honest reflection of the clinician’s ability. When consulting on the likely success of root canal treatment or the likely outcomes of implant surgery, it is becoming less appropriate to reference text books or journals, but rather the focus should be on one’s own success rates. If those success rates are lower than that of the specialist, the offer should be made to refer. This may be a more involved process for the new patient who is disease active, or it may be a very simple process for the established, stable patient. 

• Delivery of care

In principle, this should be painless or made as comfortable as possible. Though the patient may be unaware of the clinical quality delivered, they will be aware of the care and attention dedicated to the process. The importance of the patient’s perception in this regard should not be underestimated. Ultimately, however, you should ask yourself how would a colleague judge this standard of care? Would they think it was good enough, even perhaps excellent, or would they find criticism? We should aim to provide a standard of care that we are proud of and that we would be proud to show other clinicians. Nonetheless, there are operating guidelines that can help us work with pride.

• Discharge and follow-up:

Follow-up regimes should be planned according to risk. That risk should take into account the caries risk, periodontal risk, tooth surface loss risk and oral cancer risk. It’s sensible to offer and document shorter follow-ups when treatment plans are more complex or treatment has not progressed as smoothly as anticipated. Patients suffering complications should be more closely monitored, and at the very least, offered an immediate review.

• Good documentation of all of the above

• Referral for care

When there is uncertainty about a diagnosis it is important to seek help, be it from a colleague within the team or from the wider referral network. If a decision is made to refer, the patient should be informed of the reason why and any likely time delays and costs for future treatment.³

Conclusions

It is possible to work in healthcare and offer high quality clinical care, but there will be times when excellence is impossible and compromises are necessary. Nonetheless, there are baseline parameters of clinical care from history and examination to delivery of treatment that, if adhered to, allows good enough dentistry to be provided.

If such core principles are adhered to, excellence will quickly follow.

References

1. Winnicott, D. W. (1953). Transitional objects and transitional phenomena; a study of the first not-me possession. The International Journal of Psychoanalysis, 34, 89-97.

2. Bettelheim B. A good enough parent. New York: : Vintage Books 1988.

3. (2006). "European Society of Endodontology, Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology." International Endodontic Journal 39: 921-930.