Subjectivity in the Object of Dental Health Care

The dental profession is combination of a great many things—science, medicine, art, psychology, and business. The list goes on and on. But it is also the center of a paramount struggle between subjectivity and objectivity. And no place is this more abundantly clear than in dental school. From the very early wax labs of first year, it became clear to me that dental school would not be nearly as cut and dry as any previous learning experience. One wax-up or sim lab crown prep could be deemed perfectly acceptable by one faculty member yet found to be perfectly horrific by another. Anyone who has weathered the many labs of dental school knows the familiar sting of rejected projects and grades all because they may have fallen upon the wrong eyes on the wrong day. Evaluations attempt to become standardized with grading rubrics and faculty calibration, but that only goes so far. When it comes down to it, each faculty member (and dentist) has a slightly biased opinion on what they find favorable and what they think works. That’s a completely natural and understandable phenomenon—they have multiple years actually practicing dentistry and have witnessed what is and isn’t clinically favorable in their hands. Not to mention there are multiple studies and research literature to help back their clinical actions and thought processes.

And, to you underclassmen, unfortunately this trend continues well into the clinic chairs during third and fourth year. A treatment plan can be created under one faculty, changed by a different faculty three appointments later and turned inside out again until you’re ready to consider a career change to professional badminton. It can be immeasurably frustrating. Part of that frustration is that most of the time, no one is really wrong. You can restore a tooth one way or six. The prognosis can be good with any path you take; it just comes down to picking a path.

This proves to be both a blessing and curse for dentistry. On one hand, it is insanely awesome that we have multiple options for caring for a patient’s oral health. Patients nowadays can choose from a variety of treatment options (favorability for that individual pending). Take for example a necrotic tooth. That tooth could receive endodontic therapy, be extracted and replaced with an implant, extracted for fabrication of a fixed dental prosthesis, etc. Dentistry does not always operate on a strict binary. This is something strikingly different from more physician-led medicine where many times an ailment comes with a diagnosis, and that diagnosis comes with a black and white regiment of certain medications or a rigid treatment plan. Dentists, more times than not, have the luxury of being flexible in treatment plans to cater them individually to a patient’s needs, whether those are medical or financial.

This is a notion that seems strange to the healthcare setting. Shouldn’t a patient’s health issues call for an exact and standardized course of treatment? Yes and no. Sure, there are standards of care in dentistry, but in many cases there is more than one way to achieve that acceptable level of care. And this is not without its issues. It’s no great secret that dental professionals disagree on a variety of treatment mindsets. Centric relation, ceramic material science, and timing for orthodontic interventions come briefly to mind. These are just the tip of the iceberg.

Matters only become more intricate when each dental discipline attempts to outmuscle each other. Perio becomes annoyed with restorative. Prosth scoffs at perio. Endo argues with oral surgery. And ortho just smiles and ignores everyone else. Therein lies a problem related to subjectivity in dentistry. No longer are the disciplines as strictly divided by an objective dental role. With in-office technology, it is now possible for an oral surgeon to cement a crown or for a general practitioner to place implants. The lines have become blurred. Dentists and specialists have been given the opportunity to subjectively decide what kind of care they should perform as opposed to adhering to a more tightly bound scope of practice. While there still are standards of care that every dental professional must meet regardless of standing or specialty, it has become more difficult to make those designations. There is, of course, nothing wrong with a single provider offering a variety of treatments, but we must be cautious, as one insightful professor stated, that the dental realm does not “turn into Wal-Mart.” We are here to provide excellent patient care. We are not here to cherry-pick sub-standard procedures out of convenience.

There are days when practicing dentistry can feel like opening Pandora’s box. Treatment plans, patients, and faculty all snap and snarl around your head making an organized train of thought nearly impossible. But it is important to also embrace the unique subjectivity that dentistry has to offer. We have the ability to explore various avenues in treating patients and benefit from the eclectic mix of guidance and experience that our mentors—whether faculty members or other practicing dentists—have to offer. Accordingly, we must understand and appreciate each dental discipline in order to allow them to exist symbiotically so that refined and effective comprehensive care is created.

*Image credit to Karen Mooneyhan--Colorado's finest post-modern artist.