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Misfeasance: A subtle and pervasive reality

Nov. 1, 2020
There is a “gray zone” in which dental treatment outcomes ultimately lend to misfeasance through no fault of the provider or patient. Sagar Shah, DDS, explores the nature of misfeasance in dentistry and how dental professionals can do right by patients.

Not long ago, my wife and I moved into my childhood home. While getting a taste of the financial burden of maintaining an older home, we made many repairs without raising an eyebrow, chalking it up to normal wear and tear. Eventually, a significant problem emerged: a corner of the home’s foundation began to sink. This problem led to a host of other functional and visible problems. While attempting to identify the cause of the foundation issue, a fair amount of finger-pointing led to a common suspect: The neighborhood developers likely compacted the earth inadequately prior to constructing the homes. 

My objective and forgiving side was conflicted in placing blame on any outside party. Perhaps the problem was self-inflicted or inevitable due to a lack of preventative measures taken on my part. However, I learned that many neighbors experienced the same misfortune, so it was highly plausible that the developer played a large role in the overall result. Unfortunately, the nature of the problem left the developers largely absolved—the amount of time that had elapsed diminished their level of accountability. It was nearly impossible for homeowners to have predicted this downward spiral. The average home buyer is not equipped with the knowledge to foresee these problems; a passing home inspection is taken at face value. In the end, in order to salvage my childhood home, I begrudgingly took ownership of the situation.

Practicing in the gray zone

This frustrating experience led to a new inquiry: as a dentist, has the quality of treatment I provide always been exceptional and transparent? Granted, substandard quality can stem from obvious negligence or malfeasance, in which case accountability and future problems are certain. However, perhaps the concept of misfeasance better addresses my question. It has a subtle prevalence that is worth examining. Misfeasance implies no intentional wrongdoing, and may presume dedicated effort by the provider; however, it still accounts for iatrogenic mishaps as a cause for future problems. Analogous to my homeownership story, consequential shortcomings in treatment are inconveniently (or conveniently) removed from the present, unrecognizable to patients and underacknowledged by dentists up front. There is a “gray zone” in which treatment outcomes ultimately lend to misfeasance. It doesn’t necessarily incriminate the provider, as it often occurs unknowingly or due to the nature of the profession. However, accountability is ambiguous, and patients still suffer the consequences. 

To elucidate further, consider the dentist-patient relationship. It’s often characterized by integrity and trust, but also implies a power dynamic. Patients bestow a certain trust, void of any preconceived notion that their treatment will be anything less than ideal. Although treatment quality is seemingly understood to be binary at the outset, subtle shortcomings can be imperceptible and make initial outcomes seem entirely successful; the ramifications then manifest at some point in the future, saving the credibility of the dentist. 

Imagine a hypothetical spectrum of treatment quality. It spans from textbook-ideal on one end, to the other end where patients experience a noticeable concern. In addition to outright pain, the concern can manifest in the form of dysfunction (e.g., high occlusion after a restoration). However, the area in question is the considerable middle ground, coined the “gray zone.” As a disclaimer, this is not to say that treatment is not beneficial; the problem is when patients mistakenly believe the gold standard of treatment has been rendered. Much like a home buyer unable to discover a flaw underneath a new home, patients are not armed with the appropriate knowledge or visibility to identify less than ideal treatment. Moreover, dentists are not forced to acknowledge any shortcoming immediately, and may underestimate the consequences patients may bear in the future. Arguably, the gray zone can give providers an unfair advantage in the dentist-patient relationship, especially when it comes to finances.

Gray zone scenarios are numerous in dentistry, resulting from the seemingly trivial (nicking an adjacent tooth on a class II restoration) to the more severe (a mildly sensitive tooth due to a missed MB2 canal). One can surely brainstorm an example—or even reflect on a personal experience—where treatment falls short of ideal and results in a secondary issue for the patient. The ability to readily cite an example underscores the fraught reality we all face. However, accountability is debatable, as some may argue that misfeasance arises due to the nature of the profession. 

Challenging practices and perceptions

Some clinical examples that illustrate the gray zone and misfeasance are helpful in discerning potential ramifications that patients are otherwise unaware of. Also, depending on one’s perception of the nature of dentistry, true accountability is discretionary, highlighting how confounding and pertinent misfeasance is.

Subjective quality assurance 

Open margins are a common clinical shortcoming. Radiographs can be incriminating in blatantly evident cases; however, even if visibility or tactility of an open margin is not readily perceptible, one may still exist. Considering the individualized nature of dentistry, quality assurance is highly subjective. The will to definitively seek out an open margin and rectify it is largely provider-dependent. It follows that a clinical shortcoming for one dentist may be negligible to another. As clinical complacency builds and habits are internalized, the gray zone becomes even more relevant. 

The decision to crown is based on increasing tooth longevity. An open margin allows for decay; if the patient is fortunate, the abutment will still be adequate for a new crown. Once that point is reached, it’s worth pondering if the prevailing bias skews toward faulting the patient for a lack of maintenance. To the patient’s disadvantage, the intangibility of open margins can allow enough time to pass to mask any initial defect or accountability. Regardless of the circumstances that allowed for the error, its mere existence can potentially undermine any heroic effort initially.

Demand of technique sensitivity 

Creating a perfect class II restoration is a technique-sensitive procedure. A plethora of techniques and products exist to help mimic natural esthetics and function. Despite best efforts, even minor overhangs, ledges, and subpar contacts may result in restorations landing in the gray zone. The ensuing plaque trap is inevitable. It’s worth pondering if faulting a patient on recurrent caries is entirely deserved or if a provider-centric excuse is justified, due to the complexity involved in producing a perfect restoration.

The notion of technique sensitivity strikes a more empathetic middle ground—providers can treat with honest conviction, yet outcomes can still pose renewed problems. Although patients’ preconceptions may be black and white, the hands-on nature of our craft, coupled with the unpredictability of working inside others’ mouths, means our task is not always such. Nonetheless, patients still live with the aftermath of a faulty restoration, possibly succumbing to re-treatment.

Implementation of advanced treatment

Motivated providers are honing skills that last entire careers. However, limited knowledge or experience in any subject matter can cause treatment to fall short of the ideal outcome. This underscores a dilemma: reconciling empathy for a provider’s pursuit in career advancement and a patient’s full treatment potential. Overall, the reality further confounds the notion of accountability and ideal care. Although the professional obligation to seize new knowledge and apply it should be a constant, one should be mindful that patients are in a precarious position.

Consider the double-edged sword of implant placement and the fervor for placing them. The myriad of adverse outcomes are well documented, and they don’t all stem from a patient’s lack of compliance. Even slight gaps in knowledge and training can result in functional and esthetic concerns in the future, making the discipline highly susceptible to the gray zone.

Elevating both practice and humility

For more perspective, here are some final thoughts. First, forms of “misfeasance” can be present in many services and products. Provided one can identify any shortcomings right away, consumers want the best value. In that case, the consumer is less vulnerable, and the service or company is forced to reckon with an immediate consequence. Fortunately, in many industries, quality assurance is more objective or regulated, division of expertise more defined, or technique is mastered by automation. Food for thought: despite subjectivity in accounting for misfeasance, dentists imaginably expect nothing short of ideal outside of their own profession.

Secondly, the culprits of misfeasance are not limited to certain members of the dental profession, even though there are some common scapegoats (e.g., new dentists, corporate dentistry). Any narrative suggesting that anyone is immune to misfeasance is misguided. Surely any attempt to remain profitable, efficient, or clinically advanced can lead to misfeasance. This can seem like a harsh indictment on the surface, but it takes introspection to accept the truth that all practitioners are justifiably “in practice.” Going out on a limb, it’s also not far-fetched to claim that dental needs are artificially inflated. Like pain and fear, the need for cyclical treatment can understandably create an aversion toward dental services in general. 

Lastly, abundant discourse exists to help elevate new clinical and business skills. There is even occasional ethical discussion around treatment decision-making (e.g., to crown or not, root canal versus implant, etc.). However, unconventional dialogue presented here is rare; it’s subtle, but still significant. Indeed, it’s an uncomfortable conversation to validate weaknesses in one another and the profession, considering all providers believe themselves highly trained and esteemed. The preferable mantra is that dental problems are being fully and flawlessly solved. It takes humility to tweak that misperception. Perhaps the profession cannot fully control every clinical situation, but at the very least, we would do well to humbly acknowledge the fallibility of being in practice and the vulnerability of our patients.  

Sagar Shah, DDS, is a practicing general dentist in the Bay Area. He earned a BS from Vanderbilt University and his DDS from NYU College of Dentistry. He has always been interested in the psychosocial dynamics that surround various subjects. Regarding the dental profession, Shah hopes to explore and encourage critical thinking around topics that are considered outside the box. Contact him at [email protected].

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