A bridge too far

‘A Bridge Too Far’ is the title of Cornelius Ryan’s epic reconstruction of the British Army’s parachute and armoured thrust across Holland to the Rhine and Germany in late 1944. If it had succeeded it would have shortened the war and incidentally but not coincidentally, made it a British rather than an American victory. In making this thrust, Montgomery ignored his lifetime’s instinct and training and launched this campaign with minimal planning, minimal consideration of the risks, minimal consideration of other options and put the plan into action in less than two weeks. To succeed, the plan required faultless military intelligence, every phase to work perfectly with no breakdowns and the weather to remain fine. Early in the piece one of the parachute generals opined that “it was a bridge too far” but was ordered to get on with it. The general was aware that they had ignored the advice of the Free Dutch Forces, and most of the troops were keen and eager but lacked combat experience. It’s a matter of history that the essential elements all broke down despite the heroism of the frontline troops. There was much pain, sacrifice and loss, the war was lengthened and the Americans re-exerted their dominance.

So, how do the lessons of this military experience relate to Dentistry? Recently, there have been discussions of how on the one hand you should listen to the advice from Guild Insurance warning about the risks of practitioners exceeding their scope and capacity, but on the other hand, if you can’t develop your skills in general practice then you remain professionally underdeveloped. It is accepted that although you can be taught the relevant principles in Dental School, you must be able to enhance your actual skills after registration and indeed, for the rest of your practising life.

Aspects of this were illustrated in a recent interstate medico-legal case in which I was involved as an expert. (The key facts are accurate but it has been modified to protect those involved). A 40ish successful business woman asked a young dentist as to whether anything could or should be done about a single edentulous first molar space in the mandible. The tooth had been extracted long ago but it was only recently that she had the time and finance to do anything about it. The dentist replied that indeed, things could be done, a bridge was the answer and why not start today, so they did. During the bridge construction the lady asked if ever anything went wrong with bridges and was told that “nothing could go wrong”. Indeed it did and was followed by three years of pain and loss, multiple visits to the dentist, various medical and dental specialists and many treatments without result.

Eventually, an interstate expert, an Oral and Maxillofacial Surgeon (guess who) said to her that if the pain had started with putting the bridge in let’s take it out. “At last”, said the lady, so the bridge was removed. Soon after the patient’s pain went but the dentist’s pain commenced as lawyers were consulted. The legal pain went on then for a further three years but wisely just before it came to trial, the matter was settled out of Court.

What are the lessons from this? Although it was quite a nice bridge that the dentist had made he had erred in a number of places. He certainly failed to give the lady the full range of options; namely do nothing as she had been like it for a long time and there would be no problems with doing nothing. This was not an aesthetic issue, minimal (less than 5%) reduction in chewing ability and healthy adult teeth do not drift. A removal or partial denture could be made but is a poor option for a unilateral single tooth loss. A bridge is an option but with some risks and a significant failure rate over time. Alternatively, a single tooth implant could be made but is associated with increased risks. Essentially, the dentist gave her only one choice which is not a choice. Thus legally she could not give informed consent.

He knew that the lady was a bruxist before he started the bridge and learned much more about her intense personality and bruxing habits when she was in pain and in legal pursuit. He also knew that she had a skeletal class three malocclusion with a cross bite but failed to take this into account and in particular, to understand the extreme lateral loads which could be generated by her bruxing on the bridge and its abutments.

He failed to give the lady time to consider the options. Indeed, as a savvy business operator she would have had no difficulty in travelling a few hundred kilometres to a metropolitan specialist for an implant. With careful research, she could have found one with the necessary skills and training not to screw the implant into the mandibular nerve and to graft sufficient bone to replace the marked alveolar atrophy. A specialist in prosthodontics should have been involved to ensure that the crown was not overloaded by her malocclusion and bruxing. Alternatively, as a smart lady, she may well have decided that doing nothing really was the way to go.

Lastly, although the dentist could demonstrate that he had made a number of bridges, he could not demonstrate that he had attended any courses in bridgework, occlusal problems or TMD since he had graduated. He had become comfortably isolated as ‘the expert’ in his solo practice. Interestingly, once the bridge was made and the pain started he, and indeed, all of the dental specialists she variously consulted were keen to keep the bridge in situ. Most looked at it as a bridge with the patient’s mouth wide open, rather than infunctional (dysfunctional) occlusion. It took a non-restorative specialist from interstate to indicate that “if in doubt, out”.

So what does a military strategy to end World War II and this dental case have in common? Both failed to adequately consider the options, effectively plan and train and to change the plan when things went wrong. Both did go horribly wrong with much pain and suffering to those involved, one on a macro scale and the other on a micro scale.

So, what should a general dental practitioner do to help their patients with complex problems and to develop their scope? On the one hand, one does need to read and think about the advice given by the dental liability organisations regarding risk. If however a practitioner wants to broaden their scope and knowledge then they should carefully think, plan and improve their skills by attending hands on courses and working with specialist mentors. Indeed, most commonly, the practitioner who gets into trouble doesn’t do any of those things and plunges in with supreme over confidence. If you have reached this spot in the article, congratulations, you probably are already a careful and prudent practitioner. So, you are less likely to attempt a “bridge too far”.


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