Technical excellence is something that may not be equally appreciated by clinician and patient. Regarding treatment from the patient’s point of view can help, as this case shows...
A middle-aged female patient was referred from a general dental practitioner who had treated her for many years to a specialist prosthodontist. The patient was a bruxist and the increasing frequency of fractured cusps and restorations and recurrent facial/TMJ pain had led the practitioner to realise that the advice and guidance of a more experienced colleague was necessary.
Over months of careful investigations, occlusal assessment, diagnosis and provisional treatment, a comprehensive treatment plan was decided upon and some extensive crown and bridgework was provided.
As the treatment was progressing, the patient found the facebow recordings and pantograph tracings very uncomfortable and, having an acute ‘gag’ reflex, she found the hydrocolloid impression procedures unpleasant.
She certainly did not appreciate the prosthodontist’s rather brusque and dismissive approach when he repeatedly told her not to ‘make such a fuss’. The patient pointed out that her regular dentist had never felt the need for all these procedures, to which the prosthodontist replied along the lines of ‘that’s why I’m a specialist and he isn’t’.
Eventually the final restorations were placed; technically excellent, the occlusion meticulously created and precise, and the patient’s TMJ and facial pain did not re-appear. Unfortunately, the patient did – this time accompanied by her irate husband.
It had never been explained to the patient that there would be visible gold on all the occlusal surfaces of her posterior crowns. She demanded that all the crowns should be replaced immediately with tooth-coloured restorations and she indicated that she would be withholding payment of her entire account until this was done.
The dentist was both angry and frustrated that the patient didn’t seem to appreciate all the time, effort and skill he had invested into this complex course of treatment. Sadly, there was no evidence that the need for visible gold had ever been discussed – in fact, the original letter and treatment plan had referred to ‘tooth-coloured crowns’.
The patient had three or four crowns in her mouth at the time of referral – all porcelain/gold bonded with no visible metal – and her two sets of temporary restorations had also been tooth-coloured throughout. She was able to argue with some conviction, therefore, that she would never have agreed to the treatment had she been made aware in advance that there would be large amounts of gold visible whenever she smiled.
She did not dispute the quality of the work which had been provided, or that her facial pain had now gone. She simply did not like the metal showing on her new crowns.
Being vulnerable both to a negligence claim and a claim for breach of contract, the prosthodontist sensibly waived his fees in their entirety. The patient was referred to another specialist prosthodontist who agreed to complete the treatment at the same fee as that waived by the first specialist.
Approaching a course of treatment in a technical, product-centred way, rather than pausing to look at the treatment through the eyes of the patient, may not empower the patient to appreciate the benefits of the technical excellence of the clinician’s work