Technology: as it increases so too does our responsibility, as ethical practitioners, to keep up with the latest innovations and offer our patients the very highest quality in diagnosis and care. But, if we fail to do this are we then doing our patients a dis-service and providing second-tier dentistry?
If you were going to see a specialist you would expect them to have all the information and tools at their disposal to provide you with the optimum level of treatment, rather than them merely saying, “Let’s have a look and see how things go”.
As a specialist if I have the best imaging equipment such as a CBCT scanner, it can give me an enormous amount of information. So I could accurately say, “The reason this restoration is failing is because you have a missed canal” or “you have a fracture running through this tooth... Therefore the treatment I propose is X.”
Of course, that would be the gold standard, and in an ideal world offered to every patient. Unfortunately that level of diagnosis requires exposure to high degrees of radiation, prompting the question of whether I could ethically irradiate each of my patients to such a level just in order to achieve some diagnostic information. Yet if I don’t, am I then failing to provide the highest quality diagnoses?
Risks and benefits
As with everything there are risks and benefits to be considered. The European Society of Endodontology recently released a statement of its position on the matter. It said: “A CBCT scan should have a net bene?t to the management of a patient’s (suspected) endodontic problem.”
It goes on to say that one should only be considered when: “The additional information from reconstructed threedimensional images will potentially aid formulating a diagnosis and/or enhance the management of a tooth with an endodontic problem.”
If it was up to a specialist and radiation wasn’t an issue, every patient would be scanned. Indeed in times to come this may be the case, but for now there must be this ‘net benefit’ that outweighs the radiation risks. Therefore the decision not to undertake a CBCT scan could be equally as ethically significant as the decision to do so.
Cost
So what about when the cost of the latest technology is only financial rather than physical or harmful? Perhaps this equipment should then become mandatory as part of our specialist diagnostic skills, as without it we won’t be providing the highest level of service.
To put this into context, 25 years ago endodontists didn’t all use microscopes, and the old boys would say to us, “You don’t need microscopes; our fingers are our eyes”. Of course this wasn’t good enough, and therefore the specialism became two tiered: those with microscopes and those without. This didn’t mean that the practitioners who didn’t have a microscope shouldn’t have been offering treatments – rather that for particularly complicated procedures, they couldn’t hope to match the successes of those who did.
While these are of course still early days for the technology, there may come a time when if you don’t have a CBCT scanner or have access to one, yours will be a second-tier diagnostic service. You will no longer be playing in the premier division, but lower down the leagues.
Naturally this is all a part of the process of progress; a reciprocating cycle that will continue and continue. New innovation will lead to better quality treatments, leaving those who don’t prescribe to the latest technological advances playing in the lower leagues. As the doctors who didn’t use local anaesthetic or high speed drills eventually lost out to those who did, so too will those who don’t offer the latest dental innovations.
Yet in the profession there appears a reluctance to move on in this sense and that primarily comes from the initial cost, which can be exorbitant. Indeed none of these innovations could possibly be provided on the NHS for instance, as the entry requirement (the financial cost) is so prohibitively high. Thus the divide between private and NHS dentistry is set to become even greater, unless we can address this issue.
For me dentistry is incredibly exciting right now. There is visible progress and real change in the profession, but things are moving on at such a fast pace that if you are underfunded you will be in danger of being left behind. Thus there will always be those ethical questions around the level of service we can provide, and the truth of the matter is that it’s all in the balance of cost versus benefit.
References available on request.