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Volume 27 , Issue 1
January/February 2012

Page 17

EDITORIAL: Establishing a Standard of Care

Steven E. Eckert, DDS, MS

PMID: 22299074

It is often said that society is becoming litigious in nature. Indeed, most of the folks I know who are recognized as experts in their respective fields of dentistry have been asked to provide professional opinions regarding quality of dental care usually for the purposes of a lawsuit. The attorneys for the plaintiff and for the defendant inevitably ask similar questions and, one has to admit, they are very good at making expert witnesses nervous about their testimony.

A favorite question of attorneys relates to the quality of care that has been provided to a patient. The attorney will usually ask whether the care met the traditional standards of care. Whenever I’ve been asked this question, my answer is inevitably that there is no absolute standard of care within dentistry. Of course, this answer is never satisfactory and the attorney will advise me that, although there may be no published standard of care, there must be some level of care that is standard. It is a nice semantic trick. Being an editor, I find it humorous to hear someone paraphrase what was just asked in anticipation that a completely different answer will be given. But that is another topic.

In some instances, the attorney will define “standard of care” as the care that would be provided by the reasonably prudent clinician for a patient with a specific diagnosis. This brings in an interpretation of what the reasonably prudent clinician would be, which means there is another level of subjective analysis to the question of standard of care. If the interpretation is that the discussion is subjective rather than objective, it may be suggested that not all subjective interpretations are created equally. One of the undeniable statistical facts is that an expert witness has an equal chance of having graduated in the top half of his/her class as in the bottom half. If there is some correlation among class rank, clinical skills, and didactic knowledge, then the subjective analysis of performance based upon the judgment of the reasonably prudent clinician becomes an even more difficult description.

One wonders if standard of care demands a different level of appreciation than what is derived from the courts of law. Should standard of care represent a general agreement among professionals regarding that acceptability of care? If this is the case, then standard of care should be established through consensus. Many of the standards that we hold near and dear might be accepted in a consensus conference. Furthermore, the easiest way to ensure that this happens is to assemble conferences of professionals with similar basic philosophies, as this will ensure the acceptance of that which has already been agreed upon. Indeed, this is the approach taken by most political parties throughout the world.

If standards of care are not established through the courts or through consensus, then we might wonder about alternative methods of creation. Perhaps the most academically pure method is to let the best available evidence dictate the standards. This idea appears logical until systematic reviews are initiated, as the conclusions from most reviews tend to be inconclusive because the quality of evidence is uneven, the included studies are often underpowered, and the comparison groups are sometimes lacking in the category of gold standards.

Perhaps standards of care demand an entirely different genesis. Thinking about standard of care and realizing that, in most instances, dental practitioners are replacing anatomic structures that have been damaged or lost subsequent to disease or trauma, it may be possible to suggest that standard of care is actually the provision of care that creates the most accurate facsimile of that which nature had previously provided. In this regard, tooth replacement would demand the use of intra-alveolar support mechanisms. Moreover, the use of artificial tooth replacement approaches that depend upon mucosal support would be immediately rejected, as it is such a poor replication of nature. If simulation of what nature provides is the target, then implant support of fixed dental prostheses appears to be the standard of care for replacement of teeth. The rationale for acceptance of the implants standard is logical, as the implant simulates the natural tooth root as it is housed in the bone, while it also provides the stimulus for maintenance of the alveolus.

The beauty of this standard is that it will evolve as science evolves. The next logical step in tooth replacement will likely involve the re-creation of teeth through cellular intervention. As this develops, the replacement of nature with nature could never be denied.

Steven E. Eckert, DDS, MS


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