Monique Sison

Student #505
12 June 2017

Shared Responsibility

A patient of mine, Mr. Smith, called to make an appointment with me. He reported that

his crown on #8 had become loose and he wanted me to take a look at it. I sat him in the chair

and assessed the crown. It was indeed loose and had an open margin that was visible on the

radiograph. According to the treatment history, this crown was done here at the school 3 years

ago. The patient also reported prior to that, the tooth had been crowned by his family dentist

and the crown lasted for 11 years. I let the patient know that there is a fiber post in the root

canal of the tooth that may be what is holding the crown in place for the time being. Since the

summer break was approaching, I informed the patient that we would not be able to restore his

crown permanently until after the break. For now, he would have to keep an eye on the loose

crown. The patient understood.

A week later, the patient sent me a photo of his crown that had fallen off. When the

patient came in to have a temporary crown put in place, he expressed that he expects that the

school will cover the cost of the crown in full. The moral question in this situation is whether it

is our responsibility to pay for this patients replacement crown.

Looking back on the treatment notes for the crown, they are very sparse and contain no

detail. This patient is a bruxer and has severely worn down his teeth. He should have been

recommended a night guard and been informed of his unique condition. Because he was not

treatment planned a night guard and not informed that he bruxes his teeth, I believe the ethical

course of action is to re-do the crown at no charge to the patient.

 The patients interests include money, time, esthetics, and self-esteem. This is the third

time the patient is having the crown re-done. He would like to save as much money as possible

and have it done in a swift manner. The patient also works in business and interacts with

people on a daily basis as part of his job. He is very concerned with the esthetics of this tooth

because it is in the front of his mouth and very visible. Missing a front tooth also implicates his

self-esteem and confidence in business transactions.

As for me, the student, some of my interests are time and graduation. I would like to

maximize my time with this patient and complete the crown as soon as possible. This would

contribute to my graduation requirements and my clinic production. Another interest of mine is

the well-being of the patient. I would like the patient to receive the proper care and leave the

clinic satisfied.

The school also has interests in this situation. They include money, time, and reputation.

If we decided to charge the patient for the crown and he decided to sue us in return, this would

cost the school more money and more time. This would require time from our faculty, staff,

and possibly students to resolve the case. It would also damage the schools reputation in the

patients eyes and whoever is aware of the case.

The normative principle of justice applies in this situation because the patient must not

be treated unfairly. For the outcome to be fair for the patient, we must consider how he was

wronged and how to make up for this wrong. The normative principle of reparation also applies

because the school must make reparation for practicing outside the standard of care. The

principle of nonmaleficence applies because we do not want to do any harm by this patient. We

may have played a part in the miscare of this patient by not letting him know that he would
need to wear a nightguard to maintain his restorations. If we had done this from the start, it

would have prevented the patient from wasting time and money. Lastly, the principle of

beneficence applies because we want the patient to leave the clinic with a better situation than

when he entered. We would like to do some good for the patient. Re-making the crown at no

cost to the patient would definitely improve the patients esthetics while making up for his time

spent trying to amend the situation. This situation is a moral dilemma in which the normative

principles of nonmaleficence and beneficence come into conflict.

The standard of care for this patient would have been to prescribe him a nightguard and

inform him that he has a condition in which he wears down the surfaces of his teeth. The

patient should have also been informed how this condition could affect the longevity of the

crowns in his mouth and how a nightguard would help to protect these restorations.

Another factor that influences my decision-making is the responsibility that the patient

holds. The patient has the responsibility of coming in for exams every 6 months, maintaining

their oral hygiene, and being conscious of the dentists recommendations. This patient has not

been coming in for regular exams and has put off having an FMX done for several years. He

arrives to appointments 30 minutes late and leaves an hour early. This prevents me from

practicing at the level of dentistry that is required to take proper care of this patient. The way

this patient has been carrying on is outside of what the school considers acceptable patient

care. Furthermore, it is against the way I wish to practice dentistry. Without regular exams and

proper radiographs, it is possible that the previous student dentist did not have the chance to

diagnose this patients problem of bruxism.

 The patient and the school have shared responsibility in this situation. The previous

student dentist should not have let him carry on as a patient this way. He should have been

informed that if he is not willing to arrive to appointments on time, stay for the duration of the

clinic session, and be treated comprehensively, that he would be considered beyond the scope

of the school.

Applying the Driving Home Test, I would be reflecting upon my decision to replace the

crown for free. I would be contemplating if the crown is really our responsibility. It is difficult to

guarantee a crown for a patient because we cannot control what happens outside of the clinic.

It is like selling a car. We cannot guarantee that the car will not get into an accident. All we can

do is guarantee the car before it leaves the lot. In some ways, our situation is similar, but it

differs in that we are centered around patient care. We allowed the patient to slip through the

cracks, which led to the outcome of the crown becoming loose and breaking off. Because we let

this happen, we should replace the crown for this patient for free.

This decision would also pass the publicity test. I do not think this decision would reflect

badly on the school or the student in any way. We are making reparations for a previous

mistake and taking measures to ensure this does not happen again.

The first course of action would be to replace the crown free of charge. A second course

of action would be to bill the patient for the crown. A third course of action would be to BTS the

patient from the school.

I prefer the first course of action. First of all, I believe it is the right thing to do. Second of all,

the patient has previously expressed to me that he was very close to suing his previous dentist.
If he is unhappy with the outcome, it is likely that he will threaten to sue again. I believe that

the 2nd and 3rd courses of action will provoke this patient do do so.

In resolving this situation, I spoke with my GPL to ask whether or not we will be able to

write off the cost of the crown. I also spoke to the patient and attempted to manage his

concerns as best as possible.

Conversation with Dr. Kenyon:

Me: Hi Dr. Kenyon, do you have a minute to speak to me about one of my patients?

Dr. K: Sure Monique. What can I do for you?

Me: Well, my patients #8 crown has fallen off. It was done by us 3 years ago and now has a

horizontal fracture line on the facial. He would like to know if we will re-do the crown for free.

Dr. K: Do you have it treatment planned?

Me: Yes.

Dr. K: Alright, go ahead and send me the patients chart number and well write it off.

Me: I will do that. Thank you, Dr. Kenyon.

Text conversation transcript with patient:

Patient: Hi Monique, unfortunately the defective crown came off tonight. Good news is that I

didnt swallow it, found it and it is intact. Please contact me tomorrow text or phone so we can

discuss a game plan for my visit on 06/01. Thanks so much.

Me: Hi Mr. Smith. We will do our best to make you a temporary crown when you come in. Will

you be able to stay for the full length of the appointment (3 hours)?

Patient: Yes absolutely will stay for the entire appointment.

Patient: Hi Monique, I will plan on seeing you tomorrow morning at 10am. I will be expecting

to leave with a well made temporary crown in anticipation of having a permanent replacement

made in a timely manner. Thanks so much and see you tomorrow.

Me: I will do my very best, but I cannot guarantee that your temporary crown will be ideal

because there is not much tooth structure left. As for the timing of the crown, it will be done as

fast and efficiently as possibly, but there are factors out of my control that may delay the

process.

Patient: Monique, all we can do is our best. This is not your fault however I am not pleased. It

is unclear to me after why it was not recommended by your supervisor that I come in on an

emergency appointment rather than this long uncomfortable wait over the holiday weekend. I

will be expecting to discuss this as well as the crown structural failure with Dr. Kenyon or

whomever is in charge when I am there, thank you.

Me: Just to make sure I am understanding you correctly, you are asking why you were not told

to come into emergency clinic? Also, I already spoke with Dr. Kenyon and the cost of the crown

will be covered in full.

Patient: Yes, thats correct. I am pleased that you have already spoken to Dr. Kenyon. It is the

right thing to do and I appreciate your efforts.

Me: You are always welcome to come into emergency clinic. I believe Dr. Fendler said that if

the crown were to come off over the summer break, you could come in and we could make you

a temporary since we have models of your teeth. Emergency clinic also requires checking in

early in the morning and waiting a couple of hours until you are seen. When you told me the
crown fell off, you mentioned having a game plan for our appointment tomorrow. I thought that

meant that you were alright with waiting until that appointment.

Patient: Yes, that was explained to me. Since I have never been to your emergency clinic

however I did not know how that worked and you are right, I wouldnt have cared much to

check in early and wait several hours. Lol. As it turned out I have been able to keep this

fractured crown intact enough to be able to wear it although it has come off several times.

Tomorrow then is now soon enough and no worries.