Ethics: A Unique Ethical Dilemma

Henrik Hansen, DDS

Even with more than 40 years of private practice, a situation came up I’d never encountered before. I did an exam on a long-term patient and noticed that there was distal root decay on the bitewing of tooth No. 14, which had a previous root canal treatment and crown. After the discussion and his consent, I removed the crown and discovered the decay went into the furcation causing separation of the roots. I informed him that the tooth was hopeless and referred him to the oral surgeon. We also had the discussion of replacement options, and he expressed an interest in an implant. I placed a composite over a cotton pellet, did a rough prep and made a custom temporary to hold the space and prevent food impaction.

A few months later, he called and told my receptionist that he hadn’t yet had it extracted because it was without symptoms and, for insurance reasons, he wanted to hold off as long as possible. However, the temporary had fractured and was annoying him. He then proposed that because he had 100% coverage for crowns, why not cement a porcelain crown until he had it extracted. She told him he needed to come in and talk to me about it first. At first, I thought, OK, why not? But something was nagging at me and I finally realized what it was. When I do any kind of permanent restoration, it is with the expectation that it has a reasonable chance for long-term success. In this situation, it is a guaranteed failure. To bill the insurance company, in my mind, is not only unethical, but also insurance fraud.

If I had done this, it would have violated the ethical principles of veracity (truthfulness) and justice (fairness). When I had the sit-down with him, I explained my concerns and added that for him to use a major portion of his annual benefit on a “throw-away” crown also didn’t make sense. He understood and agreed completely. I made another, stronger temp and cemented it with permanent cement to give it the best chance to stay until the extraction.

This was a very unusual occurrence, but I believe that if you practice long enough, you’ll see just about everything.

Henrik Hansen, DDS, is a general dentist practicing in Fairfield, Calif. He served on the CDA Judicial Council and is past chair of the Council on Peer Review as well as a past member of the ADA Council on Dental Benefit Programs.