Satisficing in Dentistry. Who decides? Who benefits? Part 3

Maximizing and satisficing in orthodontics

Examples of ‘maximizing’ in orthodontics include maintaining an unshakable belief that an Angle's Class 1 jaw relationship is the gold standard which ought to be the goal, regardless of what has to be done to achieve that, or equal consideration being given to the well-known problems of relapse, root resorption or other complications.^3,4,5,6 As yet, there is no worthwhile scientific evidence that an Angle's Class1 optimises long-term function of the dentition, or produces greater long-term human happiness or guarantees success in life generally. Various types of aligner technology, which are now frequently used to improve the visible front teeth (which are the most important ones for attraction reasons) have ‘eaten a lot of the traditional orthodontic maximizers’ lunch’ because a pleasing smile ‘satisfices’ for so many patients. Few (if any) patients come skipping along asking for an Angle's Class 1 occlusion, please.

Advertising on various platforms and websites rarely draws enough attention to the possible longer-term implications of some types of orthodontic alignment, including probable long-term instability, or to the destruction of sound tooth tissue, sometimes undertaken by means of progressive interdental stripping to gain space, or to the downside risks, unpredictability and long-term time and costs of achieving and maintaining that desired appearance (Figure 1).^3,4,5,6,7

In many cases viable alternative treatments exist to manage what appear at first blush to be traditional orthodontic problems, including post-orthodontic relapse. Some patients seeking changes in their dental appearance might not be fully aware of many other options of doing ‘sufficient treatment for it to be satisfactory’ (i.e. satisficing) to solve their perceived problems. The old adage attributed to Maslow, ‘to a man with a hammer, everything looks like a nail’, comes alive whenever there is a reluctance to look beyond one's own specialty or field of practice, for preferred solutions – and we can all be guilty of that to some extent.

A satisficing approach to orthodontic relapse is illustrated in the two clinical cases (Figures 2–12).

Clinical Case 1

Risk assessment and management

The teeth could have been left as they were, but having invested a lot of time, money and effort into the originally recommended orthodontic treatment, the patient wanted a quick, inexpensive and low-risk solution. The risks were minimal because of the diagnostic temporary composite bonding, which had confirmed in advance that these proposed limited changes would ‘satisfice’ for him, meaning that it would be ‘sufficient to satisfy him’. The benefits of adopting a ‘satisficing’ approach for that patient were:

The previous incisor irregularities were now less visible and the teeth had not been moved once again to unstable positions. Only the tip of one tooth was reduced, rather than multiple teeth being progressively stripped interproximally.

The now much flatter contact zone shape changes on the lower right central incisor (LR1) labial composite would not allow further drift because the now-wider composite flat contact zone shapes at the LR1 stopped any further drifting or relapse.

All teeth were easily flossable – unlike the outcome likely with a fixed wire retainer (Figure 1) on the inside of all the teeth, and he did not have to wear any removable aligners or removable retainer indefinitely. Incidentally, the patient was completely unconcerned about the upper teeth, but if he had been, they could have been tidied up in minutes with some direct bonding.

The main point of a ‘satisficing’ approach is to personalize the treatment to solve that individual's perceived problem(s) effectively, and to do no more than that. In Part 1 we highlighted the views of Phil Crosby, one of the world's recognized authorities on quality issues, who warned us against harbouring a self-indulgent, inward-facing perception of quality in a technical sense, when we should be measuring quality in terms of how well the product or service meets the needs, expectations and demands of the individual customer.

Clinical Case 2

For consent to be valid, clinicians need to inform patients of the risks, benefits and limitaions of what they are proposing, as well as the options of doing nothing, or considering various combinations of bleaching and bonding, or doing some other possible treatments that might satisfice for that particular patient. Quite legitimately, a clinician might favour a specific treatment approach, but should not recommend or pursue it if it is not in the patient's best interests. The clinician may not be able or prepared to carry out one or more of the possible treatment options personally, but the patient still has the right to know that they exist, and/or choose them, if necessary, from a different provider. The fact that a patient responds to a practice's marketing, and attends specifically requesting the advertised approach, should not be miscontrued as giving their valid consent. Any form of elective ‘cosmetic’ treatment carries particular risks from a consent perspective, as explained in Part 2 of this series.²

Satisficing and maximizing in endodontics

Some endodontists appear adamant that their sometimes dogmatic approaches, involving their preferred design and brand of single-use instruments, gadgets and microscopes, are all essential and required on every occasion to ensure complete instrumentation, copious irrigation and obturation of all variations of all canals to the radiographic apex (or whatever apical area is in fashion this week) (Figures 13 and 14).

This insistence, perhaps deliberately, makes general practitioners more likely to refer patients for endodontics rather than attempt pragmatic, but effective, treatment themselves. Perhaps, less obviously, it also progressively de-skills general practitioners and makes them (and their patients) even more heavily dependent upon their specialist colleagues. The number of registered endodontic specialists (about 380) is clearly insufficient to meet the entire endodontic needs of the UK population (about 68,000,000) and so, as Marilyn Monroe and Dean Martin once pointed out, ‘Something's gotta give’.

Many endodontic gurus promote sundry variations of their beliefs, despite copious evidence from long-term authoritative studies that the coronal seal is probably equally important, or perhaps more important, in determining tooth survival than the endodontic obturation.^8,9,10,11 However, that ardent, apparently altruistic, promotion of the ‘highest possible standards for all patients’ might not survive closer examination, scrutiny and challenge in relationship to conflicts of interests or possibly, commercial bias in some cases.

Whenever there is a claim about ‘a suboptimal root filling’ having to be redone by a specialist, the Van Niewenhuysen study¹² is rarely cited – let alone pronounced – by some ‘endodontic experts’ instructed to act for some parasitic claims company, or by some opportunistic lawyers, or a supposedly well-informed and fair regulator. That Dutch study reported on over 1000 roots over a 6-year period and compared endodontic re-treatment of approximately half of those roots with radiographic monitoring of the other half.¹²

Technical assessment of the endodontic re-treatment group showed that the root filling was improved in about one-third of cases, was identical with the initial treatment in about 11%, and was worse than the first treatment in 3% of the canals. In other words, there was about a 50/50 chance of an improved technical outcome when re-done by a specialist endodontist using all the toys and irrigation, regardless of time and expense involved. Clinical assessment of the re-treatment of symptomatic roots showed that approximately 70% of the re-treatments were judged successful, 18% showed some healing and 2% had failed.

In the control group, monitoring radiographically (median time span 6 years) led to maintenance of the status quo in 95% of cases, healing in 2% and failure in 3% of the canals. When faced with a ‘suboptimal’, but asymptomatic root filled tooth, with a decent coronal seal and based on that rarely cited study, pragmatic ‘satisficers’ – both patients and dentists – might well be content enough to take a 95% chance of having no problems over an average of 6 years, versus about 50% not necessarily getting a technical improvement with endodontic re-treatment, which involves a very significant time and treatment commitment and additional financial outlay. And who could blame them?

Dispassionate ‘satisficers’, given odds of 95% of no problems with the observation approach for adequately coronally sealed, but incompletely root-filled teeth, might choose that approach as being a reasonable option. Taking that sort of pragmatic view would be supported further by the huge studies, involving millions of teeth, in a range of different countries that show that the vast majority of ‘non-ideally’ root-filled teeth with a decent coronal seal survive in a ‘satisficed’ state for a large number of years.^10,11

Getting to the ‘root’ of the problem?

In recent years, the landscape of general dental practice has changed in many ways, but none more so than where endodontics is concerned. Recent graduates and young dentists view endodontics very differently from their counterparts in past generations.

This might be because they do not feel confident to carry out these procedures to an acceptable standard themselves, nor to weather the potential criticism if they were to decide to keep a questionable previous RCT under review. The safer option is to refer the patient to a specialist endodontist, or to consider an extraction. Or it may be the result of fear-inducing stories recounted by indemnity providers, or lectures from hungry endodontists who can display carefully selected high-res images of successful identification and obturation of more canals, accessory canals and lateral canals than most of us will encounter in a lifetime, and actively encourage the dentists to refer because of that subtly generated sense of inadequacy.

But given all of the above well-known evidence from a variety of well-respected sources,^8,9,10,11 why has the fear of ‘underperformance’ and resulting litigation, or possible censure by the GDC, or the threat of hypercritical ‘audits’ by remote NHS agencies, aided by some endodontists’ aspirational ‘maximalism’ (very possibly skewed by their vested interests), resulted in the perverse outcome of the widespread unwillingness of many dentists to undertake pragmatic endodontics to the best of their ability, achieving a reasonable standard of disinfection and then properly sealing the coronal aspects of the teeth? Is that approach often more desirable for many patients than a rapid proposal and appearance of ‘the healing tongs’?

How, in the face of all the relevant evidence,^8,9,10,11 has the prettiness of the radiographic appearance, at one end of the tooth, apparently trumped an equally important, if not more critical, emphasis on producing an effective coronal seal at the other?

One can readily understand the widespread reluctance among some NHS GDPs to be judged by some ‘maximalist’ (private) endodontist's aspirational beliefs, after having doing their best for the insultingly low UDA return in revenue. It is no secret that this has resulted in multiple molar extractions rather than the ‘satisficing endodontics’ being done for many in the UK population previously. All of these questionable molar extractions collectively carry a long-term legacy that is different from (but no less significant than) the restorative legacy of a ’heavy metal generation’ partly created by a previous NHS ‘drill and fill’ culture.

Even after the recent minor enhancements to the calculation of the UDA values for endodontics, the shamefully low financial reward for these demanding procedures, with their above-average operating cost in terms of time, materials and instrumentation, probably combined with fear of censure for anything less than a ‘perfect’ outcome, has crushed compassion out of many dentists and made extractions a more attractive ‘lower risk-higher return’ option for many busy practitioners.¹³

Assessing endodontic outcomes

Another probable cause for the misplaced primary focus on the apical seal and the radiographic ‘evidence’ of its existence, is the third-party monitoring of healthcare delivery by agencies such as the NHS Business Services Authority and Performance Assessment Groups. They use this as a measure of, and proxy for, the quality of endodontic treatment producing effective disinfection of the root canal system. That is not because the exact apical position is critically important or evidence based (the working length diktats change regularly), nor because it is logical to extrapolate in this way (it isn't), but simply because it is convenient and relatively cheap and easy to do remotely.

Unfortunately, it can also be (mis)used as a justification for referrals to the GDC, where those same flawed assumptions come into play for a second time and in some instances, the same experts get a second day out and a second payday. In most of these cases the patient reports no symptoms at all, and in many instances the radiographic appearance of the supposedly ‘sub-optimal’, ‘failed’ or ‘inadequate’ RCT has remained unchanged for many years.^10,11,12 But curiously, that highly relevant and material context is rarely explored or even mentioned, perhaps because you can't see it on a two dimensional peri-apical radiograph.

The clinical records are another ‘proxy’ factor used by an ever-widening group of bodies such as the NHS Business Services Authority, the Dental Performance Advisory Groups of NHS England, some of the in-house, GDC-employed, but supposedly entirely ‘independent’ clinical advisers, and the GDC's go-to ‘hired gun’ prosecution ‘experts’, purportedly to assess the quality of care in endodontics.^13,14 Especially in busy NHS practices where time is at a premium, clinical records can be easy enough to criticize most of the time, which is the main attraction of course, but hardly the fairest or most informative view when it comes to assessing the effectiveness of the equally (or more) important coronal seal of restorations on the treated teeth. Distant assessments based on the radiographic prettiness of readily available two-dimensional imagery are convenient, cheap and therefore attractive to those in this dubious ‘expert witness for hire’ or ‘clinical audit’ industry. But in hard evidential terms, they are a real cop out and a potentially misleading one too.

The process of calling in batches of clinical records for review and ‘audit’ has somehow come to be accepted as a valid proxy for quality assuring clinical dentistry. That myth needs to be busted, and the sooner the better. The methodology started as a clumsy means of validating NHS fee claims and/or the attempted recovery of fees from practitioners, but the authorities quickly realized that this could be widened to provide a cheap, quick and easy means of pressurizing practitioners out of claiming fees to which they were in fact perfectly entitled, on the spurious grounds ‘that if it's not in the records, it didn't happen’.¹⁴ Or worse still, ‘but even if it is in the records you can't assume that it happened’.

In former years the (then) Dental Reference Service had an in-house team of dentists who physically examined patients and provided reports and opinions. But logistically they could only ever reach a very small sample, and in England and Wales, they were eventually deemed not sufficiently cost effective. To compensate for their demise, the myth was perpetrated and actively promoted that the same information could be achieved by looking at paper and electronic records, and this also provided cover for non-dentists to be ‘trained’ to look for specific things and be used to carry out these reviews much more cheaply. Radiographs are, of course, two-dimensional and of variable quality anyway, but they are readily available and cost the authorities nothing and so, as a matter of deliberate policy, disproportionate significance started to be attached to them.

Incidentally, it is apparently not sufficient that you take a good quality radiograph or digital image and retain it for posterity; you must also record why and the fact that you did so, and preferably write a small PhD thesis level of report on what conclusions you drew from it at that time. Even if there were no material conclusions to draw. Maximizing (and duplication) is clearly alive and well in audit land.

The inconvenient truth for ‘maximizing’ endodontists, or some self-styled ‘experts’ acting for no win-no fee law firms and/or the GDC, is that the vast majority of the bacterial load is in the coronal part of the tooth, and is not visible radiographically. Eliminating those micro-organisms effectively by disinfecting that area properly, first with prolonged ultrasonics and then endodontic instrumentation to allow copious irrigation prior to pragmatic obturation, and then stopping any re-infection by effective sealing, would not be evident radiographically. But just doing that probably ‘satisfices’ in more cases than the ‘maximalists’ might care to admit, and probably accounts for why so many supposedly ‘sub-optimally root-filled’ teeth survive for ages in those huge long-term studies (Figure 15).^10,11

Finally, it is pertinent that the endodontic regeneration techniques, now getting increasing publicity, rely mainly on local disinfection and sealing in of bioactive materials with some very effective coronal bonding. Future generations of dentists are likely to express astonishment that, even when only a small part of the pulp was exposed, damaged or locally inflamed, that it was once deemed to be absolutely necessary to undertake aggressive and irreversible endodontic instrumentation for the whole root canal system, regardless of any structural damage done to the tooth in the process. These observers might be surprised that this was done for ‘maximalist’ (perhaps self-interested) beliefs at that time, or possibly for the sole purpose of ‘proving’ to third parties that all the contents of all the root canals had been mechanically removed and (implicitly) irrigated with powerful hypochlorite, prior to three-dimensional obturation. Even when judged on a two dimensional radiograph, which may seem crazy enough now and that might well seem even crazier when viewed by others in the future.

That is/was the nirvana for many (perhaps vested-interest) endodontic specialists, even though sensible ‘satisficing’ approaches, with a decent coronal seal, would probably have saved many compromised teeth for long periods of time, for lots of deserving patients at an affordable cost to them.^8,9,10,11

Satisficing, the law and the GDC

The cost of professional indemnity for UK dentists is among the highest in the world, owing to a combination of a highly consumerist society with a well-developed ‘blame and compensation culture’, a legal environment that makes claims more likely, and a uniquely hostile and heavy-handed regulator in the shape of the GDC.

However, a further contributory factor is, surprisingly, to be found in the plethora of guidelines from a wide variety of sources, the majority of which fail to make clear whether they are intended to be viewed as minimum acceptable standards, or something much more aspirational.^{19, 20} It is entirely understandable that many organizations issue guidelines in good faith, with the laudable aim of driving up standards in a particular area of dentistry in which they have an interest, but ‘best practice’ and ‘minimum acceptable standards’ are very different things, and in the wrong hands can cause a great deal of harm if misunderstood or conflated.

This lack of clarity, even from some apparently ‘authoritative’ sources, some with scarcely concealed vested interests, as we saw in Part 1 of this series,¹ is compounded when evidence-based, objective facts regularly appear alongside wholly subjective opinion of unclear provenance, within the same document(s). This creates a confusing and unhelpful pot-pourri for practitioners, making it more likely that some of that well-intended guidance will be taken out of its proper context, misunderstood and applied inappropriately. But it is also a trap for the unwary ‘expert’ who uses these guidelines and standards as a convenient point of reference without properly investigating and understanding them, or recognizing their inherent potential ambiguity.

A refreshing exception to this was the decision of FGDP(UK) in 2016 to update its suite of Standards documents with clear labelling of the intended interpretation of each stated standard, and this admirable approach has continued through FGDP's transition to the present-day College of General Dentistry (CGDent). At the time of making this change, FGDP explained:

Another laudable example was the Department of Health's original (2009) HTM01-05 Decontamination guidelines, which had clearly distinguished between a minimum standard to have been achieved by a specified date, and a more aspirational ‘direction of travel’ to strive for in the future. Examples like this are both rare and welcome.