OPINION

‘Is there anything wrong with my teeth and gums?’

The challenges of the dental examination and care
planning
Robert L. Caplin1

Key points
Patients attend dental professionals with the aim Each stage of the interaction between provider and Regarding treating the common diseases in the
of improving the quality of their lives; they want patient – examination, care planning and disease mouth that affect the teeth and periodontium, or
to be healthier or healthy. This may range from management – presents physical, clinical and ethical the restoration of damaged teeth to function or
the relief of physical pain, discomfort or reduced challenges. the replacement of missing teeth, decisions must
function, to managing the emotional distress of be made as to whether the situation should be
dissatisfaction with appearance. cured or managed.

Abstract
Patients attend dental professionals with the aim of improving the quality of their lives; they want to be healthier or
healthy. This may range from the relief of physical pain, discomfort, or reduced function, to managing the emotional
distress of dissatisfaction with appearance. Health, according to the World Health Organisation, is ‘a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity’, and oral health therefore
becomes an essential component of this definition. To meet these aims, dental practitioners should be concerned
with the desires and expectations of their patients, as well as their clinical needs. To achieve this, a wide range of
knowledge and skills must be employed to first make a diagnosis, then by making clinical decisions to arrive at a care
plan that is appropriate for each individual patient and yet remains within the scope of practice as determined by the
General Dental Council. Each stage of the interaction between provider and patient – examination care planning,
and disease management – presents physical, clinical and ethical challenges. Further, having established the status
of the soft and hard tissues, decisions must be made as to whether it is appropriate to leave the patient with some
level of disease process or impairment of function rather than attempt to eliminate it entirely. Enhancements, the
ever-increasing demand for cosmetic dentistry, and the tension that is created between the desire of the patient and
the clinical, moral and ethical obligations of the practitioner, challenge the dentist not to transition from being a
professional into the world of commercialism. This article addresses these challenges.

Introduction soft tissues of the face, together with the acquire a lot of information about the current
replacement of missing teeth. Whereas the status of all the hard and soft tissues and then
Why do patients attend dental practices? specific outcome for an emergency visit is decide how to manage any deviations from
Sometimes it will be as an emergency with quite easy to define, as shown in Table 1, the the normal.
a specific outcome in mind, or for a routine routine dental check-up and the demand for When presenting for a routine dental
assessment as to the state of their teeth, cosmetic changes pose greater challenges to ‘check-up’, patients are effectively asking us,
gums and mouth. In more recent times, the practitioner in terms of the examination, as their dentists, the following questions:
however, an increasingly common reason diagnosis and care planning. Rather than ‘how are my teeth?’; ‘is my mouth OK?’; ‘is
for a visit has been for improvements in the focus on one issue, the practitioner must there anything wrong?’ or variations on these
appearance of the teeth and surrounding
Table 1 Common emergency situations presenting to the dental practitioner
1
Retired Senior Teaching Fellow and General Dental
Practitioner, London, UK. Emergency episode Aim of treatment
Correspondence to: Robert L. Caplin
Email address: [email protected] Pulp Relief of pain

Refereed Paper. Tooth – enamel/dentine: for example, fracture Comfort; restore function; improve appearance
Submitted 29 March 2022
Appliance: for example, fracture of removable Comfort; restore function; restore appearance;
Revised 19 May 2022 appliance/crown out protect the pulp
Accepted 8 June 2022
https://doi.org/10.1038/s41415-022-4553-7 Soft tissue: for example, swelling/pyrexia/trismus Relief of pain; restore function; prevention of spread

190 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022

© The Author(s) under exclusive licence to the British Dental Association 2022.
 OPINION

themes. These are, perhaps, the most difficult

questions we must deal with as practitioners.
How do we answer these? What criteria do we
apply when replying OK or not OK! Healthy
or not healthy! As dentists and dental health
professionals, we are conscious of the need to
promote and achieve oral health but quite what
this means practically for individual dentists
and their patients is very variable. In dentistry,
as one of the caring professions, we offer our
skills and expertise to improve the quality of
life of others. However, there are limitations
placed upon dentists by the General Dental
Council (GDC) in their Scope of practice
Fig. 1 a, b) Asymptomatic lower left first molar with periodical radiolucency and microscopic
document.1 fractures extending into the roots

Oral health means much more than

Fig. 2 The interaction between the dentist and the patient. Reproduced from Robert
healthy teeth
Caplin, Grey areas in restorative dentistry – don’t believe everything you think!, J and R
Publishing, 2015
In 1948, the World Health Organisation
(WHO) expanded the definition of health Provisional
to mean ‘a state of complete physical, mental diagnosis
and social wellbeing and not merely the
absence of disease or infirmity.’ This places Observing
oral health as a fundamental component of
Listening
health and physical and mental wellbeing.2 Further Refer if
Questioning uncertain
Glick et al.3 define oral health as: ‘multifaceted investigations
and includes the ability to speak, smile, smell, Examining
taste, touch, chew, swallow and convey a range
of emotions through facial expressions with
confidence and without pain, discomfort and Definitive
disease of the craniofacial complex. It is a diagnosis
fundamental component of health and physical
and mental wellbeing. It exists along a continuum
influenced by the values and attitudes of people normal appearance looks like in order to ample evidence that magnification improves
and communities. It reflects the physiological, distinguish this from the abnormal, diseased operative procedures.5,6,7,8,9,10,11
social and psychological attributes that are appearance. Visual and tactile observations In Figure 1, the explanation for this
essential to the quality of life. It is influenced are only applicable to those structures symptomatic lower left first molar, with a
by the person’s changing experiences, that are readily accessible, whereas those periapical radioluscency, could only be found
perceptions, expectations, and ability to adapt beneath the surface can only be assessed after microscopic examination in situ revealed
to circumstances’. Welie4 differentiates between by additional investigative procedures fractures extending along the root. Extraction
treatment and enhancements, considering such as radiographs, cone-beam computed was required.
enhancements as ‘the continuation of medical tomography, sensibility tests and biopsies. It Effectively, this is the difference between
treatment proper beyond the “zero -level” of then becomes possible to perceive two levels looking at the screen of a mobile phone or a
health whereas medical treatment is aimed of answer to the question ‘how is my mouth?’ that of a large television. The challenge arises
at undoing “negative” conditions – diseases, One answer will be based on an assessment as to just how extensive investigations should
illnesses, handicaps, pain, sickness etc – that of the superficial structures and surfaces be in order to be able to say to a patient,
violate the patient’s integrity (health)’. which are directly visible (for example, teeth, with a reasonable degree of confidence, that
periodontal tissues, soft tissues) and one all is well. Should there be, in the absence of
The challenge of accurate will be based on an assessment which also symptoms or clinical signs, an assessment of
observation evaluates the deeper tissues and structures. every tooth – its vitality, its periapical status, its
However, even within the visual assessment, supporting bone – in order to be able to report
It is self-evident that a full and accurate there are two levels of observation: with to the patient, with a high degree of certainty,
assessment of the soft and hard tissues the naked eye and with magnification. the status quo? Without further investigations
in and around the mouth can only be Experience shows that enhanced vision of there will be a presumption of health in the
made if their status can be determined. It carious lesions, restoration margins and deeper tissues and structures as opposed to a
is, therefore, essential to know what the tooth fractures aids diagnosis and there is knowledge of health (Fig. 2).

BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022 191

© The Author(s) under exclusive licence to the British Dental Association 2022.
 OPINION

While there is no consensus on which

radiographic views should be used in any
given situation, the Faculty of General
Dental Practice UK12 addresses this issue
and one approach favoured by Caplin13 is
the radiological examination of all teeth
with indirect restorations or large direct
restorations.
Figures 5 and 6 show periapical radiolucencies
picked up on routine investigation of
Fig. 3 a, b) Clinical appearance of upper and lower teeth without obvious carious lesions asymptomatic crowned teeth. These would
not have been detected by visual and tactile
examination alone.

Asymptomatic periapical lesions

Perhaps the most common asymptomatic

unseen disease process in the mouth is
that occurring around the apices of teeth.
Huumonen et al.14 point out that the diagnosis
and management of periapical lesions
requires a thorough clinical and radiographic
examination.
It has been shown that pathological
Fig. 5 Long cone periapical radiograph of
processes within cancellous bone do not show
asymptomatic 26 with apical periodontal
membrane widening
on the standard view because of the density of
the overlying cortical plate of bone. Only when
some of the cortical plate has been lost will the
lesion become apparent, but even then, the
lesion will generally be larger than it appears
on the radiograph. The practical implication of
this is that many teeth may have asymptomatic
periapical lesions that have not been detected
by the examining dentist. Furthermore, it has
been shown that asymptomatic periapical
lesions may exist around the apices of teeth
but not be visible on periapical radiography.
Can we genuinely say whether the patient is
healthy or not?15 This is the challenge of clinical
decision-making.
Fig. 6 Long cone periapical radiograph
Had these radiographs not been taken, the
of asymptomatic 22 with a periapical
radiolucency examining dentist would not be aware that
there was a disease process around the apices of
Fig. 4 a, b, c) Clinical appearance of upper and
lower teeth with damaged and missing teeth the teeth and so could have advised the patient
the patient mentioned previously; the need to that all was well and healthy, when in fact, this
know what is going on in unseen areas. was not the case. What should be relayed to
For the 23-year-old patient in Figure 3, In the first patient, there would be a the patient and whether there should there
presenting for the first time and requiring a presumption that in the absence of clinical be active intervention moves on to the next
‘check-up’ with no visible signs of carious signs there will be healthy roots and bone; phase after the examination, which is clinical
enamel or dentine, a decision must be made as a presumption but not knowledge! This decision-making.
to whether bitewing radiographs are required highlights the dilemma that all health
or are desirable and whether any other further professionals face – that in order to obtain as Clinical decision-making/
investigations would be warranted. much information as we can about the status judgement
However, there would probably be general of the tissues, we do not unintentionally
agreement about the need for further contribute to the medicalisation of society With a wide range of clinical situations
investigations for the patient in Figure 4 and with investigations that do not alter presented to the dental professional and the
yet, the information required is the same as in care plans. wide range of options available to manage

192 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022

© The Author(s) under exclusive licence to the British Dental Association 2022.
 OPINION

these, the clinician must exercise clinical A landmark decision by The Supreme
judgement, that is, clinical decision-making Court of the United Kingdom finally ended
within the context of the patient. medical/dental paternalism. In the case of
Decision-making is a broad term that Montgomery v Lanarkshire Health Board,
applies to the process of making a choice it was established that, rather than being a
between options as to a course of action. matter for clinical judgement to be assessed
Clinical decision-making/reasoning is the by medical (dental) opinion, a patient should
process used to make a judgement about what be told whatever they want to know, not what
to believe and what to do about the symptoms the health professional thinks they should
and signs that a patient presents with to enable be told.20
a diagnosis to be made and treatment options This requires honesty by the practitioner Fig. 7 Gross hard tissue loss
considered. Facione and Facione16 considered about the risks and benefits of any proposed
clinical reasoning as a process ‘that in order treatment or alternatives and the option not
to arrive at a judgement about what to believe to do anything. The practitioner is, in effect, being asked to
and what to do, a clinician should consider the predict the future and to decide what would be
unique character of the symptoms (evidence) The challenge of disease the most acceptable way to deal with a tooth
in view of the patient’s current health and life management so that it lasts as long as possible. Restoring
circumstances (context), using the knowledge it is not necessarily the fall-back position as
and skills acquired over the course of the With the current approach within dentistry treatment can inflict more distress on the tooth
health sciences training and practice (methods, of prevention and minimal intervention for and its supporting structures.
conceptualisations), anticipate the likely effects the management of dental disease, the dental
of a chosen treatment action (consideration practitioner faces the challenge whether to A state of complete physical,
of evidence and criteria) and finally monitor monitor or treat diseased tissue and whether mental and social wellbeing
the eventual consequences of delivered care a cure is either possible or desirable where
(evidence and criteria)’. Trowbridge et al.17 cure means a complete restoration of Most criticism of the WHO definition of
extend this by seeing clinical reasoning not only health.21 Treatment, on the other hand, refers health2 concerns the absoluteness of the
as a conscious process but with the healthcare to a process that leads to an improvement word complete in relation to wellbeing. The
worker also interacting with the patient and in health but may not include the complete problem is that it unintentionally contributes
the environment at an unconscious level. elimination of disease.22 There are, indeed, to the medicalisation of society. According to
Critical thinking, defined by The American several measurable aspects of disease and Smith et al.,25 ‘the requirement for complete
Philosophical Society 18 as ‘the process of their initiating factors, such as plaque and health would leave most of us unhealthy most
purposeful, self-regulatory judgement which bleeding scores, tooth mobility and tooth of the time because it lowers the threshold
gives reasoned consideration to evidence, surface loss. How much of this information for intervention, inviting treatment for
contexts, conceptualisations, methods and should inform the clinical decision-making abnormalities at levels that might never cause
criteria’, shows how this process is integral to will follow a full and frank discussion with illness’. Tinetti and Fried26 are concerned that
clinical reasoning and decision-making. the patient of the risks and benefits of any ‘the emphasis on preventing and treating
The challenge is to arrive at a care plan that intervention proposed, alternative options individual diseases leads to overtreatment’,
is appropriate for the patient, meeting their and finally, the option not to do anything. an issue shared in dentistry according
needs and expectations and at the same time, Huber et al. 23 make the point that the to Holden. 27 They suggest that clinical
not compromising the ethics and morals of the requirement for complete health would decision-making should be predicated on
practitioner. The care plan for a young adult leave most of us unhealthy most of the time the attainment of patient goals and on the
with a high plaque score, several bleeding sites and that health should be seen not as a static identification and treatment of modifiable
and several new sites of carious enamel and state but a more dynamic one, based on the biological and nonbiological factors, rather
dentine might be quite different for an older resilience or capacity of the individual to than on the diagnosis, treatment, or prevention
patient with a similar clinical situation but with cope, that is, to adapt and self-manage. of individual diseases.
multiple health problems, inability to undergo Although caries, periodontal disease, broken They see the patient’s complaints as
lengthy procedures in the dental chair and lack teeth, missing teeth, etc are deviations from the generating three questions by the practitioner
of manual dexterity. A defining time in the normal, the philosophy that it is essential to to whom they go for care:
relationship between the dental practitioner restore to what was ‘normal’ is questionable. It 1. In what ways are the complaints bothersome
and the patient came with the publication of is essential to weigh the benefits of treatment – what is the effect on the patient’s physical,
Standards for the dental team by the GDC.19 against the risks and to consider the long-term psychological and social functioning?
Within this document is a requirement to implications of any interventions. Caplin24 uses 2. What does the patient hope to achieve from
‘give patients the information they need, in a similar situation to Figure 7 as an example medical (dental) treatment? What trade-
a way they can understand, so that they can of the range of options available to patients in offs is the patient willing to make? In the
make informed decisions’ and ‘make sure that any given clinical situation, with a range from case of prevention, does the patient value
patients (or their representatives) understand no intervention to the extensive further tooth ‘down the road’ benefits more, or does the
the decisions they are being asked to make’. tissue loss of providing a crown. patient have more immediate concerns?

BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022 193

© The Author(s) under exclusive licence to the British Dental Association 2022.
 OPINION

Fig. 8 Tooth 11 with clinically satisfactory Fig. 9 Gold crowns provided on intact healthy Fig. 10 Gold crown provided on an intact
restoration teeth healthy tooth

3. Are psychological or social factors further or dentine is detectable; the tooth has a (before preparation, the teeth were intact
impeding health and functioning? satisfactory root-filling; and the patient and healthy). In their thirties, both bitterly
does not mention the appearance of the regretted having had these crowns. Was this
The challenge for the dental practitioner tooth. Some feel strongly that aesthetic appropriate treatment? Whose interests were
is to be sure that irreversible procedures are dentistry should be included as part of the being served?
only undertaken when the patient’s answers recommendation in the care plan.29 Dentistry may be defined as ‘the art or
to all these questions have been thoroughly If in clinical practice the dental professional profession of a dentist’34 and as such, dentistry
assimilated and the care plan discussed with embraces the quality-of-life concept (the can be more subjective than objective and
the patient. degree to which a person enjoys the important more of an art than a science,35 although
possibilities of life)30,31,32 and applies the the practitioners should always conduct
Replacement of missing teeth definition of oral health, it could be concluded themselves as professionals. In the context of
that the practitioner is thereby challenged to enhancements, it is important to understand
Although more obvious in the aesthetic zone, undertake any treatment that the patient feels what being a member of a profession means
the request for the replacement of missing will improve their life. Can the practitioner and the challenges that it presents.
teeth more posteriorly may stem from a reasonably refuse the patient’s request assuming A profession is ‘an occupation whose core
perceived loss of chewing function. Although it to be legal and ethical? However, it should be element is work based upon the mastery of
nature provides us with 32 teeth (most of remembered that the practitioner has a choice a complex body of knowledge and skills. It
the time), the loss of posterior teeth should and even though a patient has autonomy, is a vocation in which knowledge of some
not automatically lead to their replacement. their wishes are not absolute and binding on a department of science or learning or the
The shortened dental arch concept accepts a practitioner. The dentist has the legal right not practice of an art founded upon it is used in
reduced number of naturally interdigitating to provide a certain procedure if it is considered the service of others. Its members are governed
units, thereby reducing the need for their that it will not benefit the patient or even harm by codes of ethics and profess a commitment
prosthetic replacement with the subsequent the patient (non-maleficence). to competence, integrity and morality, altruism
morbidity that a prosthesis or implants can The ‘Daughter Test’ can be a very powerful and the promotion of the public good within
produce. Patients can and do manage without influence in planning decisions. 33 At its their domain. These commitments form the
the full complement of natural teeth. In these simplest, in relation to elective aesthetic basis of a social contract between a profession
situations, the patient can still be considered dentistry, is the question: ‘knowing what and society, which in return grants the
as functionally healthy. 28 But what if the I know about what this procedure would profession a monopoly over the use of its
patient is adamant that the missing teeth involve to the teeth in the long term, would I knowledge base, the right to considerable
should be replaced? carry out this procedure on my own daughter autonomy in practice and the privilege of self-
(or any other close relative)?’ Morals, values, regulation. Professions and their members are
Should we meet the patient’s request? culture and philosophy will influence each accountable to those served and to society’.36
As health care providers, embracing the individual practitioner. The applicability of this definition is
emotional and psychological wellbeing of challenged by Welie,37 who concludes that
our patients places an additional burden The challenge of enhancing whereas dentistry qualifies as a profession,
on the route to successful dentist-patient it is also exhibiting a trend to again become
outcomes. Are we healing and/or enhancing The area of dentistry concerned with the a business, as it was before the nineteenth
those who come to us for care? Furthermore, ‘improvement’ of the appearance of teeth and century. He points out that ‘not every treatment
in the absence of clinical need, should we soft tissues presents enormous challenges to performed by dentists is aimed at relieving
be informing those who come to us for care the practitioner. Who is it that decides what serious pain or threat to the patient’s health.
of treatments that could potentially change looks good or acceptable – the patient and/or Indeed, more and more of the treatments
(improve) the patient’s smile? This dilemma the dentist? now performed by dentists are cosmetic
is highlighted in Figure 8. Clinically, the For the female patients in Figures 9 and interventions. However, ugliness is not a medical
margin of the restoration at the upper right 10, gold crowns were desirable and a socially indication; it does not necessitate medical
central incisor is intact; no carious enamel acceptable appearance when they were young treatment in the same way that a toothache,

194 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022

© The Author(s) under exclusive licence to the British Dental Association 2022.
 OPINION

gingivitis, or oral cancer does. Dentistry does

Table 2 Commercialism versus professionalism
not qualify as a profession when and to the
extent that the interventions performed are Commercialism Professionalism
purely elective instead of medically indicated.
It therefore behoves dentists who focus their Competitors Colleagues

practices on aesthetic interventions to clearly Buyers/consumers Patients

state that they are not professionals’. This view
anticipates the morphing of the relationship Trade secrets Sharing of knowledge – freely done
between that of the dentist and patient to that
Sales promotions/advertising to coax or stimulate business Patient education
of dentist and consumer.
As patterns of dental disease show
decreasing levels of dental caries in many parts of meeting the desires and expectations Ethics declaration
of the world,38 it is unsurprising that dentistry of patients. There is a tension between the The author declares no conflicts of interest.
is viewed increasingly as a commodity. demands of the patient and the recognition
by the practitioner of the need to aim for oral References
Professionalism versus health, as well as the preservation of healthy 1. General Dental Council. Scope of Practice. 2013.
tissue. Often, these may be diametrically Available at https://www.gdc-uk.org/docs/default-
commercialism source/scope-of-practice/scope-of-practice.pdf
opposed. Since most aesthetic procedures (accessed July 2022).
The incompatibility of these two approaches carried out in dentistry are within the 2. World Health Organisation. Basic Documents: forty-fifth
edition. Geneva: WHO, 2005.
is articulated by Lyons39 (see Table 2). private sector and hence subject to financial 3. Glick M, Williams D M, Kleinman D V, Vujicic M, Watt
Additional recognition of the conflict negotiation, there is the ever-present risk R G, Weyant R J. A new definition for oral health
developed by the FDI World Dental Federation opens
of values comes from Holden: 40,41 ‘the that the decision-making process by the the door to a universal definition of oral health. J Am
professional ideals that the dental profession practitioner will be highly susceptible to Dent Assoc 2016; 147: 915–917.
4. Welie J V. “Do You Have a Healthy Smile?” Med Health
would seem to support and promote, contrast financial consideration: ‘money corrupts the Care Philos 1999; 2: 169–180.
sharply with the values of the commercially process of reasoning’. The practitioner must 5. Mamoun J S. A rationale for the use of high-powered
driven consumer society; the same society be alert to this and be aware of whose interests magnification or microscopes in general dentistry. Gen
Dent 2009; 57: 18–26.
that the profession states it serves without are being served when undertaking any 6. Bud M, Jitaru S, Lucaciu O et al. The advantages of the
self-interest. The introduction of mental and procedure but especially so when aesthetics/ dental operative microscope in restorative dentistry.
Med Pharm Rep 2021; 94: 22–27.
social wellbeing brings into focus the aspect cosmetics are the driving force. 7. Sheets C G. The periodontal-restorative interface:
of enhancing or cosmetic dentistry and the Where the elimination of existing enhancement through magnification. Pract Periodontics
Aesthet Dent 1999; 11: 925–931.
implication that this has for the relationship disease may not be possible or desirable, 8. Whitehead S A, Wilson N H. Restorative decision-
between the dentist and the person coming the practitioner has to decide at what point making behavior with magnification. Quintessence Int
1992; 23: 667–671.
for care, from patient to consumer. The intervention should take place. How much 9. Forgie A H, Pine C M, Pitts N B. Restoration removal
dentist is no longer being asked to deal disease to accept should be based on a with and without the aid of magnification. J Oral Rehabil
2001; 28: 309–313.
solely with the effects of dental disease but thorough understanding of the person who
10. Eichenberger M, Biner N, Amato M, Lussi A, Perrin
to deal with the flawed smile’. He concludes has come for care and their attitude to their P. Effect of Magnification on the Precision of Tooth
that ‘cosmetic dentistry is undeniably part mouth, as well as the desire or the ability Preparation in Dentistry. Oper Dent 2018; 43:
501–507.
of the professional purpose of twenty-first of such a person to attend on a regular 11. Reinhardt J W, Romine J J, Xu Z. Factors contributing to
century dentistry’ but cautions that ‘this is or frequent basis in the future in order to student satisfaction with dental loupes and headlights.
Eur J Dent Educ 2020 24: 266–271.
conditional upon the professional conduct maintain health. 12. Faculty of General Dental Practice. Selection Criteria for
of dental practitioners remaining resilient What should the response be to the implied Dental Radiography. 3rd ed. 2018. Available at https://
cgdent.uk/wp-content/uploads/2021/08/FGDP-SCDR-
to commercial practices not compatible question – how is my mouth? This can only ALL-Web.pdf (accessed July 2022).
with professional obligations’. The obvious be answered honestly after an accurate 13. Caplin R L. Grey Areas in Restorative Dentistry – Don’t
Believe Everything You Think! J and R Publishing,
challenge for all undertaking this type of assessment of the hard and soft tissues has
2015.
clinical work is to retain the barrier between led to clinical decisions that incorporate an 14. Huumonen S, Ørstavik D. Radiological aspects of apical
being a professional or a commercialist. understanding of the needs and wants of periodontitis. Endod Topics 2002; 1: 3–25.
15. Tsesis I, Goldberger T, Taschieri S, Seifan M, Tamse
the patient. Fundamentally, dentists should A, Rosen E. The dynamics of periapical lesions in
Conclusion enhance the lives of those that come for endodontically treated teeth that are left without
intervention: a longitudinal study. J Endod 2013; 39:
care. We want our patients to be free from 1510–1515.
The routine dental examination and the pain, to be able to chew and speak well, to 16. Facione N C, Facione P A. Critical Thinking and Clinical
Judgement. In Critical Thinking and Clinical Reasoning
subsequent formulation of a care plan be comfortable with their appearance, to feel in the Health Science: An International Multidisciplinary
present the dental practitioner with several good about their mouths and to have the Teaching Anthology. pp 1–13. San Jose: The California
Academic Press, 2008.
challenges. The practical challenges in knowledge and understanding to maintain
17. Trowbridge R L, Rencic J J, Durning S J. Teaching
accurately assessing the state of the hard their mouths in a healthy condition. The best Clinical Reasoning. Philadelphia: American College of
and soft tissues, the care planning challenges dentistry is no dentistry; to see or not to see; Physicians, 2015.
18. Facione P. Critical Thinking: A Statement of Expert
in the management of deviations from the to plan or not to plan; to intervene or not to Consensus for Purposes of Educational Assessment and
normal, and the ethical and moral challenges intervene – these are the challenges! Instruction. American Philosophical Society, 1990.

BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022 195

© The Author(s) under exclusive licence to the British Dental Association 2022.
 OPINION

19. General Dental Council. Standards for the Dental Team. 26. Tinetti M E, Fried T. The end of the disease era. Am 34. Merriam-Webster. Dentistry. Available at https://www.
2012. Available at https://standards.gdc-uk.org/Assets/ J Med 2004; 116: 179–185. merriam-webster.com/dictionary/dentistry (accessed
pdf/Standards%20for%20the%20Dental%20Team.pdf 27. Holden A C L, Adam L, Thomson W M. Overtreatment September 2021).
(accessed July 2022). as an ethical dilemma in Australian private dentistry: A 35. Caplin R L. Dentistry – art or science? Has the clinical
20. The Supreme Court. Montgomery v Lanarkshire Health qualitative exploration. Community Dent Oral Epidemiol freedom of the dental professional been undermined by
Board [2015] UKSC 11. 2015. Available at https://www. 2021; 49: 201–208. guidelines, authoritative guidance, and expert opinion?
supremecourt.uk/cases/uksc-2013-0136.html (accessed 28. Manola M, Hussain F, Millar B J. Is the shortened dental Br Dent J 2021; 230: 337–343.
July 2022). arch still a satisfactory option? Br Dent J 2017; 223: 36. Cruess S R, Johnston S, Cruess R L. “Profession”: a
21. Merriam-Webster. Cure. Available at https://www. 108–112. working definition for medical educators. Teach Learn
merriam-webster.com/dictionary/cure (accessed 29. Levin R P. Doing More with Less. J Esthetic Restor Dent Med 2004; 16: 74–76.
August 2021). 1998; 10: 50–51. 37. Welie J V. Is dentistry a profession? Part 1. Professionalism
22. Merriam-Webster. Treatment. Available at https:// 30. Bennadi D, Reddy C V K. Oral health related quality of defined. J Can Dent Assoc 2004; 70: 529–532.
www.merriam-webster.com/dictionary/treatment life. J Int Soc Prev Community Dent 2013; 3: 1–6. 38. Frencken J E, Sharma P, Stenhouse L, Green D, Laverty
(accessed August 2021). 31. Raphael D, Brown RD, Renwick R, Rootman I. Quality of D, Dietrich T. Global epidemiology of dental caries and
23. Huber M, Knottnerus J A, Green L et al. How should we Life Theory and Assessment: what are the implications severe periodontitis – a comprehensive review. J Clin
define health? BMJ 2011; DOI: 10.1136/bmj.d4163. for health promotion? In Issues in Health Promotion Periodontol 2017; DOI: 10.1111/jcpe.12677.
24. Caplin R L. Dentistry and COVID-19 – Time to Rethink Series. Toronto: University of Toronto, Centre for Health 39. Lyons H. Commercialism; professionalism. Viva la
our Prescribing Patterns? Dent Update 2020; 47: Promotion, 1994. difference. Va Dent J 1983 60: 16–17.
703–704. 32. Baiju R M, Peter E, Varghese N O, Sivaram R. Oral Health 40. Holden A C L. Cosmetic dentistry: A socioethical
25. Smith R. The end of disease and the beginning of and Quality of Life: Current Concepts. J Clin Diagn Res evaluation. Bioethics 2018; 32: 602–610.
health. 2008. Available at https://blogs.bmj.com/ 2017; DOI: 10.7860/JCDR/2017/25866.10110. 41. Holden A C L. Consumed by prestige: the mouth,
bmj/2008/07/08/richard-smith-the-end-of-disease- 33. Kelleher M G. The ‘Daughter Test’ in aesthetic (‘esthetic’) consumerism and the dental profession. Med Health
and-the-beginning-of-health/ (accessed July 2022). or cosmetic dentistry. Dent Update 2010; 37: 5–11. Care Philos 2020; 23: 261–268.

196 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 3 | August 12 2022

© The Author(s) under exclusive licence to the British Dental Association 2022.