Defining success can be a difficult thing in dentistry, and very rarely is it ever a simple case of black or white. Even scientific literature fails to fully define what success really means. For example if we are talking about implants, then the language we use would not be centred on ‘success’, but on ‘survival’ instead – in other words, is the implant still there?
In my own field of endodontics, there have been many different versions of success described by the profession. In the early days our field defined it as absolute bone healing with no lesions, no pain and no symptoms. However it was later recognised that this is an extremely stringent criterion, and the definition was changed to recognise the fact that shrinking lesions with perhaps some scar tissue is also a success of sorts.
When some implant dentists talk about their high success rates, they talk about survival and not about other adverse outcomes such as bad taste, bad smell, or bone loss. I think this adds a great deal of confusion to the debate and certainly doesn’t help in forming a fair and accurate description of the treatment’s outcome.
A lot of this discussion then boils down to the sorts of questions we ask, and how we ask them. This reminds me of a survey conducted by one laser eye surgery company many years ago. At first they quoted a success rate in the region of 80 per cent. The question they were asking however was ‘Are you happy with your surgery?’ A lot of patients were happy, particularly because they didn’t have to wear glasses again, so this gave the company a very high number of positive results. However the success rates were much lower when asked about peripheral vision and night-time vision. Yes they had thrown away their hated glasses, but not all was rose-tinted.
So, it would seem then that our definition of success is very closely tied to the sorts of questions we ask and the way we ask them. In dentistry we might ask a patient if something hurts, and if the patient says ‘no’ then that’s a triumph in our book. But as soon as we start to consider a broader picture, or look at more complex areas such as the patient’s X-rays, function and lesions, our own definition of success starts to change.
One part of the whole success debate that is particularly hard to quantify is the skill and experience of the practitioner carrying out the treatment. I do endodontics day in day out. There may be a dentist down the street who does an endodontic procedure once every five years. Is it right then for him to quote the literature to patients that the success of this procedure is 90 per cent? Maybe as a profession we should change the language that we use. A better phrase might be to say, ‘The success rate in certain hands is 90 per cent’ or, ‘The success rate using the latest equipment, with no compromises and the ideal patient is 90 per cent.’
It is clear that there is a lot more to success than either what’s stated in the scientific literature, or indeed what we consider to be good rules of thumb. Context is absolutely vital, and as a profession, we need to be completely open and honest with patients about our own level of skill, our understanding of a procedure, and the long-term prognosis given all the many factors that need to be taken into account.
With dentistry becoming much more of a business, as clinicians we need to be very careful when we look at the figures that are presented to us by manufacturers and those working in sales. We should recognise that numbers can be manipulated in many different ways, and can shine a positive light on almost anything. Suppose I was only to do a single procedure that worked, can I then claim a 100 per cent success rate? The same applies to manufacturers who are always keen to sell us new products and so put a positive spin on numbers that aren’t always necessarily wholly positive.
Ultimately if patients are to be able to make a ‘true’ decision on a treatment plan, then they need to be presented with the most accurate, and appropriate figures possible. This means as clinicians we should be aware of the many factors pulling us to make a treatment suggestion one way or another. We should also ask ourselves if our personal preferences are leading us to suggest a patient pick one treatment ahead of another. For the most accurate definition of success then, I suggest we all look no further than our patients. If we can hand-on-heart say that they’ve received the very best treatment possible – if you’d be happy if you’d received the same treatment in their position – then that to me is a success; as professionals we can do no more.