Dear Readers:

Interdisciplinary dentistry provides opportunities to treat patients who would otherwise be untreatable by any individual practitioner. With these opportunities, however, are certain risks. A “double bind” situation is created when any of the available choices are undesirable, and can occur any time there is miscommunication between clinicians, or between clinicians and patients.

At a meeting of a study club that I mentor, a general practitioner asked if she could discuss a dilemma she was having. She presented the records on a male patient who had been in her practice for a significant period and was edentulous in the mandibular arch posterior to the first premolars, and also in the maxillary arch posterior to the upper left first premolar. On the right side he had a first premolar and an over-erupted second molar. He was nearing retirement age and had decided to replace the missing teeth with something more desirable than his ill-fitting RPD. The general practitioner discussed the option of implants to provide at least first molar occlusion. The challenge, however, was that because the posterior teeth had been missing for years there was a question as to whether implants could be placed and, if so, where they would be placed.

The general practitioner referred the patient to an oral surgeon (one with whom she has worked for years) for a consultation about how many implants could be placed and where they could be located, with the assumption that afterward, she and the patient would be able to make a decision about the final treatment plan. When the patient returned after the consultation, she was shocked to find that five implants had already been placed; three in the upper left quadrant in the first premolar, first molar, and second molar positions and two in the lower left quadrant in the second premolar and first molar positions. In addition, a radiograph showed an additional site that had been prepared for a lower left second molar implant, but no implant had yet been placed. The implants on the lower left were exposed and mobile, even though they had been placed 3 months earlier.

All of this surgical treatment had taken place without any communication to the general practitioner or any consideration to her restorative treatment plan. She is now experiencing a double bind. What does she say to her patient, given that perhaps only one of the five implants—the upper left second premolar, which would have some occlusion with the lower left first premolar—could benefit him by being restored? What does she say to the surgeon, to whom she has referred the majority of her oral surgery cases for years, about the fact that her patient had spent a significant amount of money on implants that were now unusable, that had as of yet offered no benefit on the right side and minimal benefit on the left? She has been put in the uncomfortable position of attempting to keep the patient’s trust while explaining the reality of the situation.

This is not to say that the patient may not have benefited from the five implants, especially if the mandibular pair had integrated successfully, but rather the lack of communication between the general practitioner and the oral surgeon created a very difficult double bind. It may well have been that the patient might have chosen to have five or six implants but it is also likely that he might have elected a different treatment plan using a precision RPD or an implant-retained RPD.

The point of this discussion is not to say that the decision made by the oral surgeon to place five implants was the wrong one for the patient. The real problem was the lack of clear and honest communication with the general practitioner and the patient, which deprived both of them the opportunity to make an educated decision on what was in the best interest for each of them concerning the placement of the implants. In my experience, the anxiety and discomfort of being involved in a double bind is always far worse than the anxiety and discomfort of having the open conversation in the beginning of the decision-making process to eliminate the double bind from occurring at all.

Sincerely,


Frank M. Spear, DDS, MSD