Cases taken from the Texas Dental Journal
Dilemma #1
Chad is a new patient in your general practice. He is fifteen years old, in good health, with only
episodic dental care in the past even though his family has dental insurance. Chad presents with
several small carious lesions, which is remarkable considering his high plaque index and poor
diet. During the summer, he rides with his father who drives a cookie truck and Chad admits to a
heavy diet of cookies.
Besides the small carious lesions, there is a large occlusal lesion on #19 and a 2mm periapical
radiolucency at the apex of the mesial root. There is a history of a painful episode "months" ago,
but Chad is asymptomatic. Your diagnosis after clinical and radiographic evaluation is pulpal
necrosis with chronic apical periodontitis. The prognosis for nonsurgical root canal therapy is
good because of an uncomplicated canal anatomy and excellent restorability. Chad also presents
with a seriously compromised occlusion. He has a Class II malocclusion with moderate-to-severe
anterior open bite. Chad only contacts his molars in maximum intercuspation, so maintaining
these teeth is important to his current function and for future orthodontic care. Your treatment
recommendations include a thorough preventive program, including diet analysis, orthodontic
evaluation, root canal and restorative therapy.
Chad and his mother are in your office for the consultation appointment. Both parents work and
his father was unable to come to the consultation. You present your findings and Chad's mother
questions the necessity of root canal therapy, citing both the poor experiences of her friends and
also the cost. You explain again the importance of this tooth, especially with Chad's compromised
occlusal function, but she seems unable to make a decision as to whether to allow root canal
therapy for Chad. At this point, she turns to Chad and asks "what do you want, a root canal or
would you rather have the tooth pulled?" Chad replies "let's pull it mom." His mother agrees.
Now you are faced with an ethical dilemma. What do you think you should do? Check the course
of action you would follow.
1. You decide to follow the desires of Chad and his mother and extract the tooth.
2. You decide to follow the desires of Chad and his mother and extract the tooth after
having her sign an informed consent for treatment.
3. You again emphasize the importance of maintaining his tooth because of his
compromised occlusal function but she insists that the tooth be extracted. You explain to
her that you will not treat Chad but will see him for emergency care until she can find
another dentist.
4. You recommend that decisions as complicated as this one should be made by both
parents and that you will be available to discuss the therapy with his father. You agree to
provide treatment if both parents agree to either the root canal or the extraction.
5. You offer to his mother the option to seek a second opinion from an orthodontist. Chad is
evaluated by the orthodontist who agrees with maintaining #19. His mother insists that
the tooth be extracted and you agree to extract the tooth after having her sign an
informed consent for this treatment.
6. You offer to his mother the option to seek a second opinion from an orthodontist. Chad is
evaluated by the orthodontist who agrees with maintaining #19. His mother insists that
the tooth be extracted and you explain to her that you will not treat Chad but will see him
for emergency care until she can find another dentist.
7. Other alternative (please explain).
Dilemma #2
Mr. Harold Davies is a patient who has come to your office eager to improve his appearance with
a new set of complete dentures. He is a healthy, sixty-year-old male, who believes that these
dentures will help him feel "younger and more vigorous." You have completed the
maxillomandibular relationship records appointment. As you begin tooth and shade selection, Mr.
Davies states "just give me the whitest shade you have!" With his ruddy complexion you
emphatically inform him that this would not look natural. Mr. Davies insists, "I want the whitest
teeth!"
You are now faced with an ethical dilemma. Check the option(s) you would choose in this . case:
1. show Mr. Davies the "whitest" shade;
2. show Mr. Davies only those shades that you think are appropriate for him complexion
and have him select one of these;
3. insist that if Mr. Davies doesn't trust your judgment that he should find another dentist;
4. other: (describe)
Dilemma #3
Carole Walker is a 35 year-old high school English teacher and is a new patient in your general
practice in a large metropolitan city in Texas. She is in good general and oral health and her
previous care consisted of small amalgam and resin restorations. She has come to your office
because another teacher has recommended you, even though she must drive 45 minutes to your
office. You have been in practice now for four years and enjoy the location and the growth of your
practice.
One of her concerns is sensitivity to cold when she brushes her teeth in the upper right canine
area. She has a cervical abrasion into dentin on the facial surface of tooth #6. She has a clinically
sound distolingual amalgam on #6 that was placed several years ago. The treatment plan is for a
Class V resin and you isolate, prepare, etch, place, and polish the restoration. She is pleased
with the appearance of the restoration and with the appointment.
That evening she calls you and she is in acute pain that started three hours after the appointment
and has been "throbbing" for the last two hours. She is angry and disappointed and asks, "Why
didn't you tell me this could happen?" You prescribe analgesics and see her the next day and
determine that she has an irreversible pulpitis that will require root canal therapy. You try to
explain to her that this dramatic response to the placement of small resin restorations rarely
happens, but she is now upset as she has heard "horror stories" about root canals. She asks,
"Why should I pay the extra expense if l wasn't informed about the possibility of this happening?"
You are now faced with an ethical dilemma. Check the course of action that the dentist should
follow as indicated below.
1.
2.
3.
4.
5.
6.
Refer her to an endodontist for evaluation and treatment at her expense.
Refer her to an endodontist for evaluation and treatment at your expense.
Proceed with the root canal at her expense.
Proceed with the root canal at your expense.
If she continues to be upset, discontinue her as a patient.
Other (please explain)