Mrs Kim is a cheerful 63-year-old who has been agreeable to any treatment plan you have proposed. Her initial presentation was complex. Her maxillary left canine was extracted in adolescence; consequently, there was a significant maxillary-to-facial midline discrepancy of 4 mm. Bilateral fixed bridges have replaced the absent mandibular first molars. The patient had mild bimaxillary protrusion, with facial convexity that only slightly exceeds ethnic norms. Despite Mrs Kim’s lip incompetence, few would have considered her unattractive. To add to the treatment complexity, there was 50% generalized crestal bone loss that preexisted her treatment course, but her periodontist considered her status to be stable. Also of note is her long-term use of oral bisphosphonates to treat osteoporosis.
You elected to initiate her treatment without extractions. As treatment progressed, you gave Mrs Kim thorough autonomy by discussing the option of premolar extractions to coordinate her midlines and provide incisor retraction. Her consistent response was, “Whatever you think, doctor. I truly trust you.” But at today’s debonding appointment, you feel a bit disturbed. Although she proclaimed her delight with the treatment result, her maxillary midline remains conspicuously deviated to the left and mild protrusion remains. She appreciates the excellent alignment your therapy has provided and confirms her commitment to long-term retention to maintain her result. Is there justification for your own dissatisfaction with her treatment outcome? After all, from a dental health perspective, you’ve successfully managed a periodontally susceptible patient who is on prolonged bisphosphonate therapy—both of which had the potential to increase the risk and complexity of treatment. And an extraction strategy would have involved replacement of both mandibular fixed bridges—a costly endeavor that she is not prepared to face.
Mrs Kim is happy with the result. You had been forthright by repeatedly explaining the shortcomings of the nonextraction plan. How much information about her treatment result should you tell her without undermining her satisfaction? Are you obligated to offer any explanation of her treatment’s shortcomings to fulfill your ethical responsibility? Should her less-than-perfect outcome remain as an emotional burden to you—especially since she has been such a conscientious patient?
The relationship between a patient and the doctor is one of fiduciary responsibility, comprising trust that the commitment between the doctor and the patient will be upheld. By definition, this involves fidelity, but the ethical principles of veracity, beneficence, and nonmaleficence also pertain. As one component of the fiduciary relationship, the patient expects that the doctor will deliver a level of care to the best of his or her ability and be truthful regarding all aspects of treatment. Yet “truth” can often involve not only what is said, but also what is unsaid. Omission of selected details of a treatment result can be misleading or deprive patients of certain aspects of their status that may have future pertinence. For example, is explaining a posttreatment marginal ridge discrepancy between the mandibular first and second molars relevant to a patient? Is your inability to fully correct a unilateral Class II molar relationship or a 60% overbite pertinent? Such a distinction between the relevant and the irrelevant, or the trivial and the consequential, can form a fine line indeed.
Mrs Kim knows nothing about the instability of proclined incisors and is unconcerned about her facial-to-maxillary midline discrepancy. She is delighted that her 2 mandibular fixed bridges do not need to be replaced. And her periodontist is pleased with her recent examination and charting results, confirming that her condition has remained stable despite her 2-year treatment course. Since you have fully disclosed her present status and its shortcomings—and she accepts both—have you fulfilled your ethical duty to maintain your fiduciary responsibility?
Perhaps. But at the very least, your obligation to participate in her long-term maintenance will follow you for years to come.