A Wake up Call

In the quest to provide the best possible care for patients, dentists have long been attracted to the claims for new techniques, materials, equipment, and instruments featured either by manufacturers in their advertising or by clinicians in their educational presentations.

We also obtain information or try out materials or techniques based upon recommendations by colleagues whom we respect. Descriptions of excellent clinical results by trusted colleagues are often a motivating factor for trial of new products and techniques, particularly in the world of general dentistry.

There is nothing inherently wrong with the approach of adopting new materials and techniques recommended by noted clinicians or colleagues, as the willingness to share new information is an attitude that was originally espoused by none other than Pierre Fauchard. However, the increasingly rapid rate at which new developments are adopted, and the manner in which information on them is shared with the profession, have changed significantly from the days of Fauchard. As a result, it has become a responsibility for the practitioner to more carefully evaluate the information he or she receives in order to avoid pitfalls, some of which have an ethical implication.

The impetus for my comments in this space comes as the result of my attendance at an excellent presentation by Richard Simonsen, DDS, at the recent California Dental Association Scientific Session in Anaheim. In effect, Dr. Simonsen issued what I believe to be an important wake-up call to our profession, and I credit him for the outstanding message he delivered. My purpose here will be to focus on one of the important issues he raised, which I believe leads right back to a very important professional ethical responsibility.

One of the communication resources that has become a major source of new information, particularly to the general dentist, are the large-format tabloid-type journal publications. While the questionable activities Dr. Simonsen identified and we discuss here are not limited to occurring exclusively in these publications, a proliferation is evident within their pages. We refer to large, full-color advertising that proclaims, in emotionally descriptive terms, the merit of the product, equipment, or technique being promoted. Missing in most of these promotions is any evidence or reference to scientific information that would support the advertising claims. Unsupported claims such as superb translucency fill the advertising display. There is no accompanying data on the translucency rating of this or competing products for the dental office purchaser to evaluate. The marketing specialist figures, I presume, that dentists with little time to research the possibilities will take the good words to heart and order the product immediately.

However, this plain form of advertising isn’t quite as objectionable to us as the type that heavily features testimonials by clinicians who are well-known (usually by virtue of their visibility on the educational circuit). In one recent publication, we counted 12 advertisements, each of which included testimonials by three to six dentists (complete with photos) extolling the virtues of a given product or product line. For example, an ad with several dentists proclaimed superior results in "study after study." There was no reference to the specific studies mentioned in the ad.

If we questioned them about their claims, we are certain that the marketers would suggest that many dentists inquire or research this information before purchasing. However, we know that the prevalence of this type of advertising strongly suggests that it is successful, it is profitable, and few dentists probably take the time to make the comparisons that could place the unsubstantiated claims into question.

A further look at the testimonial type of advertising showed that the majority of the ads featured multiple clinicians. This approach apparently is perceived to provide greater credibility to a claim than one well-known dentist alone can. It is also perplexing that many dental readers are naive enough to fail to discount the likelihood that those quoted have either received complimentary products or compensation in return for their "testimony." It is also likely that many, if not most, of the testimonials attributed to dentists are actually written by the marketing experts.

To this point in our discussion, we have limited our comments to the "obvious" advertising of the display format. We hope that some of our colleagues, through the process of critical thinking, are able to recognize and discount the importance of these display-advertising claims, because after all, it looks like advertising. But what about the more-sophisticated and subtle advertising that occurs in the short articles that are commonplace in these publications? We refer to articles that describe materials or techniques that carry the name of a known clinician. The "author" may or may not have authored the piece. Nonetheless, the author often has received compensation from a company for conducting some form of clinical research or consultation on product(s) featured in the article. Even if a connection is disclosed, we suspect that many of our colleagues make their decisions on a new product purchase based upon their connection with the known clinician and not on the quality of the evidence. (It should be mentioned here that author disclosures of any financial interests or contractual arrangements with companies or products discussed in manuscripts in this CDA publication are required and subsequently published with the article.)

This discussion leads us back full circle to our responsibilities of professional ethics. A new product is often rushed into the marketplace with only an approval for patient safety. If we base our decision to use it without reviewing scientific data that supports its efficacy as a long-term restorative treatment, are we abandoning at least some ethical responsibility we hold to the patients we care for?

As Simonsen pointed out, in restorative dentistry we have conventional materials that have been proven successful for many routine applications. If for example, we abandon use of a conventional crown for a new crown material that promises "unsurpassed esthetics and biocompatibility" based solely upon the testimonial of a clinician compensated for this opinion, are we fulfilling our ethical responsibility to our patients? We believe that we might be failing in our responsibility if we neglect to conduct complete research about the new materials we adopt. Only if we search for data that provides us with a clear indication that the material has been tested and proven to maintain the same qualities in addition to the promises of new advances will we have fulfilled our responsibilities to our patients.

If we fail to heed Simonsen’s wake-up call and instead use materials and adopt techniques without regard to evidence supporting their efficacy, we will be allowing a third party (a company offering a product) to make our treatment decisions.

We must be more vigilant in our efforts to require evidence and disclosure from those who educate us about new materials and techniques if we are to fulfill our ethical responsibilities to our patients.