Mrs Glasgow is the well-to-do owner of your town’s largest jewelry store, which has been in business for 3 generations. Complaining of temporalis pain upon awakening with episodic joint clicking, she was referred to you by her general dentist, who has no interest in treating temporomandibular disorders. Mrs Glasgow’s complaints appear to be linked to her severe bruxing and clenching habits, which are precipitated by stress. Despite her successful management of the jewelry enterprise, her marriage is strained, and she has disclosed to you that her 15-year-old son has recently been expelled from school for alcohol abuse. You are reluctant to become involved in her treatment because of the complexity of her symptoms, but you decide to attempt to help her with conservative therapy. After 3 months of splint wear, physical therapy, and a brief course of muscle relaxant use at bedtime, her symptoms remain refractory to your most earnest efforts. Yet Mrs Glasgow trusts you unconditionally and wants to remain with you for management of her problem. You sometimes wonder whether your value to her is more as a sympathetic ear than as a dental therapist. And she is totally unfazed by the considerable fees that you assess her each time you adjust her occlusal splint. When is it time to cease your service to her and guide her to a resource that might be more effective in meeting her needs?
The delivery of care can generate a level of strong dependence between the patient and the doctor. The patient’s psychological dependence on the doctor—and the financial remuneration enjoyed by the doctor—might encourage an enticing synergy for both persons. There are many situations in orthodontics that lend themselves to dependency between the clinician and the patient. Consider a prolonged continuation of an early treatment regimen extending through full treatment completion: The youngster remains in appliances for years until the orthodontist decides to initiate final correction, with another few years of treatment to follow. Or consider repeated—possibly unproductive—splint modifications for a bruxing habit leading to minimal resolution of symptoms. Even protracted full bonded orthodontic correction for that compulsive patient who resists debonding for psychological reasons, despite your explanation of diminishing returns with continued therapy, is a concern. These are examples of dependencies that should be terminated.
The fiduciary relationship between the doctor and the patient implies a sufficient level of trust to honor commitments made between them. Based on the ethical principle of fidelity, the fiduciary relationship means that the professional must act on a level that places the patient’s interest above his own. The fiduciary relationship includes the doctor’s competence to know when the treatment benefits become self-limiting, as well as the initiative to terminate the treatment if need be. Although such action may be detrimental to the provider, including the loss of income or the cessation of the patient’s dependence, it is essential to protect patient vulnerability.
The problem with fostering unproductive patient dependence is the eventual loss of patient autonomy. The provider who encourages dependency, even inadvertently, deprives the patient of his or her ability for self-governance. The patient with a temporomandibular disorder who is told that she needs occlusal adjustments on a monthly schedule, even though there is no merit in such therapy, may be one such example. The patient’s fear of symptom onset blinds her to the lack of benefit from such treatment.
Although Mrs Glasgow has utmost trust in you and the financial resources to prolong your treatment course, she has lost the objective perspective to realize that her condition is unresponsive to your efforts. Perhaps it is time for you to suggest that she seek another opinion to restore her autonomy and to determine whether your treatment of her is still warranted. You will both benefit from that gesture in the long run.