First Do No HarmAs a holistic dentist in practice for more than 30 years, I still find myself referring back to the first thing I learned at USC Dental School, first do no harm.  The Hippocratic Oath remains the Golden Rule of health care:  First do no harm. This is the timeless directive, handed down since the 5th Century BC and is still the basic focus and philosophy behind patient care. It has not changed – nor should it.  It is a universal guideline, to be applied equally to all.  In my eyes, the Hippocratic Oath is simply an extension of the Golden Rule:  ‘Do unto others as you would have others do to you.’

My First Day of Dental School

I remember the first day of dental school in September, 1984.  There we were,  112 ‘wet behind the ears’ students gathered in the main hall, eager to start their dental careers.  Anticipation was in the air.  What was the first lecture going to be that would catapult us into four years of our dental training?  Would it be all the technological changes coming, or the latest and greatest procedures we’d be learning?

To our great surprise we were not going to hear about any of this today.  What we were about to learn was something far more important and helpful than anything else that could have been discussed.  It was as if this lecture was given for me specifically, because I cannot tell you how many times I have thought about it since.

As we all sat there eagerly, someone from the front row finally stood up in his white clinic coat and bow tie and proceeded to walk up the stairs to the stage.  He moved deliberately, with no sense of hurry and when he finally reached to podium, I realized that he was over 6 feet tall and very commanding.  He was built like he might have played collegiate football before becoming  a dentist.

He stared out at us and then down at his podium for the longest time, in silence.  He seemed to be deep in thought and contemplating what he was going to say to the 112 dental students gathered before him.  It was as if he was asking himself, ‘What could I possibly tell these future dentists that would help them in their careers?’

Finally he began to nod his head slightly as he looked out at us and began to speak, his voice so baritone that he could have been an orator in the senate or an actor on stage.  He chose his words carefully, giving each one the weight it deserved.  And after delivering each sentence, he would wait until he was satisfied that it had the intended impact before continuing.

The Best Advice I Ever Got as a Dentist

“If there was one thing I could tell you as future dentists to help you with your careers, it would be this.  First do no harm.  The Hippocratic Oath.  If you remember this one thing over everything else you learn today and in your 4 years here as dental students, you will be ahead of the game.  Granted it seems simplistic and obvious.  But, I’m here to tell you, through my years of experience, that if you practice it and apply it in your day to day practice, it will save you from untold heartache and problems.

In fact if you apply this one principle, you are already half way there as successful dentists and have already learned half of what you need to learn in dental school.  That’s because if you just have the focus of doing what’s best for the patient first, it will save you from many problems and you will have the type of relationship with your patients that will make your practice enjoyable and yes, even more profitable.

I feel so strongly about this that if you first apply this principle before you formulate a plan or open your mouth and discuss all the ways you are going to help your patients, you are already 50% of the way to success both as a practicing dentist and as a businessman.  It’s that powerful.

Think about it, you already know 50% of what you need to do to be successful as a dentist.  So if there is anything that I can tell you to start your dental career, it’s to keep this truth sacred and close to your heart.  If you do, you will find that dentistry is not as hard as many make it out to be.  This is what the remainder of your dental education will teach you over the next 4 years.”

Less Dentistry is Better than More Dentistry

It’s simple, really.  No one wants to do any dentistry if it’s not truly necessary.  That’s only natural and to be expected.  If you give patients what they want, it always goes better than if you recommend treatment that you think they should do.  It’s just common sense.

I can’t tell you the number of times that patients have come to me for a second opinion with a long list of treatment recommended by another doctor.  Sometimes it is right on, and I will recommend they go back to that dentist.

However, more often than not I don’t see the need.  Yes, I might see what the dentist was talking about, but was the treatment necessary to protect or restore the health of the teeth?  Often the answer is no.  In my eyes this is sad because the dentist is recommending treatment that is really not necessary.  It’s also sad because it has happened more times than I want to admit.

There is No Dental Material That is as Good as the Patient’s Own Tooth

The tooth is perfect until the dentist starts working on It.  Doing more dentistry is rarely the right solution.  The main reason for this is that there is no substitute for natural teeth.  The natural tooth is perfectly constructed to withstand stress, wear and even trauma to some degree.  With dentistry, the same does not apply.

Our teeth are perfectly designed to distribute the forces and the micro-flexing experienced during chewing and grinding.  Through its collagen, crystalline and tubular structure a tooth distributes the forces throughout its entire length from the chewing surface all the way down to the end of the root.  Add to this the shock absorbing and distributing capabilities of the thin leather-like ligament around the tooth, and you have the most perfect system of stress distribution possible.  There is just no way dentistry can match that.  There is no way a dentist can match what God and evolution have perfected.

The Crown and Root Canal Dilemma

The key is to save as much tooth structure as possible in order to maintain the resilience and strength that is naturally inherent in the structure of the tooth.  Once that is lost, the tooth is weakened forever and you can’t get it back.  The ultimate example is the crown and even worse is the root canal.  The crown mechanically concentrates the forces at the neck of the tooth like a fulcrum.  The root canal eliminates the blood supply of the tooth and the ligament shock absorber of the tooth as well.

What often happens is that the root canal tooth develops secondary problems due to the additional stress on the tooth and the compromised ability of the tooth to withstand those stresses.  Forces that were tolerable for a normal healthy tooth are now too much to bear, and the tooth ends up failing over time due to re-infection or a fracture that occurs in the roots.  At this point the situation is not treatable and the tooth needs to be removed.

All too often patients come to me reporting that their dentist wants to do a root canal before doing a crown.  Sometimes these root canals don’t need to be done.  The moral of the story is to avoid root canals at all costs, unless they are truly necessary.  To do a root canal proactively to prevent a future problem is not a good strategy.  It’s almost always preferable to avoid more aggressive treatments like root canals if at all possible.  Another way to say this is: do the least aggressive treatment necessary to restore the tooth.

Do Most Dentists Follow the Hippocratic Oath?

Most all dentists would say that they do adhere to the principle behind the oath.  In my experience, it is not lip service for the vast majority of dentists out there; they take it seriously.

Dentists, for the most part, are a pretty benevolent group.  Sure we have our problems: sour grapes, docs that break the rules, the tenets of good practice, and even the law sometimes.  However, on average you would be hard pressed to find many dentists that don’t do right by their patients and, for the vast majority of the time, do really top notch work.

The Art and Science of Dentistry

That’s not to say that treatment always goes as expected or perfectly.  Far from it.  While dentists always strive to do excellent work, dentistry is not an exact science.  Yes there is science involved.  This is where established and researched protocols come in and should be adhered to, as literally a ‘best practice’ approach to any procedure being done.

With this said, there is also an art to dentistry.  Any health related discipline takes judgment and experience and applies it to patient care.  This is where a practitioner brings all his/her abilities to bear to achieve a successful result.  As every patient and situation is different, the skill and experience required to achieve success may vary wildly.  This is where the ‘art’ of dentistry comes in.

The truth is, if you are missing the technical skill and know-how to do the work required correctly and consistently, there are going to be problems that arise and treatments that will not work.  Everyone has failures.  The key is to try to minimize them as much as possible.  If you have 2% to 5% failure rate that is acceptable and is to be expected.

However, if you have a 10-20% failure rate, that is just too high and is not acceptable.  This is not sustainable on a number of levels.  First, it is not fair to the patient.  Second, it is not economically viable to have to redo dental work that fails and if a dentist is experiencing a high failure rate, that practice will not be around for long.

Running Dentistry as a Business – When Profit Drives Your Decisions

In my opinion this is what causes problems in dentistry.  There is nothing wrong with making money and making profit as a business.  However when it is the primary focus, that is when a practice runs into trouble.  It usually always comes down to over diagnosing in one form or another.  In my experience doing too much dentistry is never the solution.  The most common instances of over diagnosing are:

  • Calling stained pits and grooves decay when they can be easily watched or monitored and
  • Recommending deep cleanings when there is no gum pocketing or evidence of gum disease

It’s important to have confidence in your dentist, as most of the time their recommendations are sound.  However, if you have questions there is nothing wrong with getting a second opinion.  Sometimes this is just part of the process of educating yourself.

Is Your Dentist a Lifetime Learner?

The primary focus of any practice should be on service, doing quality work, and education of the patients, staff and most importantly the doctor.  Education should be a lifelong commitment and practice to keep up with advances in technique and technology.  Otherwise you will eventually become obsolete and passed up by more dynamic and usually younger practitioners who are hungry and motivated.  Basically, you will become obsolete and like the dinosaur will become extinct.  This is usually what happens to practitioners when they stop learning and keeping up with the times.  Sometimes ‘extinction’ means retirement.

Does Your Dentist Listen and Answer Your Questions?

In my practice I only recommend treatment that I would do for myself or a family member.   I often say, “If this were me, this is what I would do.”

Building trust is paramount to a healthy doctor/patient relationship.  If the patient knows that the dentist has always got his/her best interests at heart then the patient feels safe and can be receptive when the dentist recommends treatment.  My focus with dental care is a ‘holistic’ approach combined with a conservative, ‘First do no harm’ philosophy.

Will Your Dentist Replace Dental Work That Fails?  

It’s important to know that your dentist will stand behind their work.  In my practice if a restoration breaks certainly within 3 years of placing it, I will usually redo it for the patient at no charge.  I don’t want to charge my patients twice for the same procedure.  Just doesn’t seem right to me.

Does Your Dentist Explain Things and Give You Options?

All possible options should be discussed before treatment commence.  You need to understand the treatment being recommended.

All the above are aspects of the doctor/patients relationship that make for successful treatment.  They are also aspects of the central theme of this article, which is doing the best by each and every patient who entrusts you with their care.  Again, the holistic approach is significant in my experience because you are always dealing with the ‘whole’ person to the best of your ability, training and experience.  When this ‘prime directive’ is fulfilled, then the spirit of the Hippocratic Oath has also been fulfilled.

Very Short History of the Hippocratic Oath

The text of the Hippocratic Oath is one of the oldest known documents in existence. Written in the 4th or 5th Century B.C..  Its principles are held sacred by practicing doctors to this day.  Most graduating medical-school students swear to some form of the oath during their graduation ceremony, although it may be a modernized version. Compare this with just 25% of the medical students taking the oath 100 years ago.

The Most Popular Version in Use Today

One third of the medical schools use a modern version called Lasagna’s oath.  This oath was written in 1964 by Louis Lasagna who was the Dean of the School of Medicine at Tufts University.  A shortened version of this oath reads as such, “I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug,”

Lasagna’s version also calls on doctors to, “Admit when they don’t know the answer; prevent diseases; and to take responsibility not just for the patient’s health, but for the way an illness affects a patient’s family stability and to take into consideration the patient’s ability to pay.”

The Full Text of the Modern Hippocratic Oath

The long version of Lasagna’s Hippocratic Oath is written out below:

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Hippocratic Oath: The Classical Version

This is the original version attributed to Hippocrates, although he most likely was not the author.  Hippocrates lived during the 5th century B.C. and the Hippocratic Oath is believed to have been written in the 4th century B.C.  Here is the text for those interested in a bit of history:

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

—Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

post