As you proceed with treatment for another of the Dowd twins, their father asks to speak to you about his recent dental problem. He tells you that one of his molars fractured last weekend, and he’d like you to take a look. A cursory glance shows a coronal fracture of the mandibular left first molar with loss of the entire crown. Given the mesial inclination of the quadrant’s second and third molars, you suspect that the molar had required restoration for some time before it fractured. Mr Dowd says that he receives dental care at a retail clinic in the distant city in which he works. The group comprises several dentists and a periodontist.
As a favor to the family, you produce a periapical radiograph of the region. Twenty percent horizontal bone loss is evident from the film, but the crestal bone is well defined at the terminal molars. There is no bleeding upon probing. Since the second and third molars could be easily uprighted, replacement of the first molar by a fixed restoration would be straightforward. You offer to communicate your recommendation to his dentist and send the film with a short note suggesting your plan.
Five weeks later, Mr Dowd brings his son to you for continued orthodontic care. After updating him on his son’s progress, you ask Mr Dowd whether he has communicated with the restorative dentist regarding replacement of his first molar. “Oh, yes,” he replies. “I forgot to tell you that the periodontist extracted the broken tooth as well as the 2 back molars. He placed 3 implants down there. He told me that the implants can take more force than my own teeth, especially because I once had gum problems.”
You immediately wonder whether the periodontist’s recommendation had been biased by the financial advantage of placing 3 implants vs maintenance of natural teeth.
A conflict of interest is defined as a situation in which a professional’s “judgments or actions regarding a primary interest will be unduly affected by secondary interests.” Primary interests can involve patient care, research, or educational objectives. Secondary interests might be motivated by financial gain, intent for personal aggrandizement, or interest in providing favors for others. Conflicts of interest vary in severity based upon the degree of harm that could result by the affected action. The greater the potential impact of the secondary interest, the more severe is the conflict of interest. Consider a chairperson’s decision to treat clinic patients with a corporation’s newly developed but invasive appliance, before safety approval, in exchange for corporate funding to renovate his clinic. This conflict might be considered more severe than involving a coinvestigator in a toothbrush study who has a strong financial interest in the manufacturer.
Public disclosure of conflicts of interest to minimize bias is now common in academic and research endeavors. Objectivity in such studies may remain questionable, however, and can be potentially harmful if published results of the research are inaccurate or unsafe for clinical applications. These disclosures may not give students, subjects, or patients sufficient information for them to understand the impact of the conflict or provide adequate options if they have concerns about the conflict. In addition to a breach of truth (veracity), conflicts of interest can seed distrust and erode confidence in the specialty. Although conflicts of interest pertaining to financial relationships are easiest to quantify, mistrust in professionals can be more diffuse but equally as destructive.
From the perspective of patient care, nonconflicted patient autonomy is essential in choosing a treatment plan. We need to remember the vulnerability of the doctor-patient relationship. The provider must assist the patient in identifying the most appropriate treatment plan rather than emphasizing a treatment plan that is the most lucrative for the provider. In your own case involving Mr Dowd, a simple call to you by the periodontist might have opened the door to an array of alternative treatment options. Maybe that’s why the call never came.