The Ethical Responsibility of Modern Patient Education

Recently a friend of mine took her toddler son to a dentist appointment with a pediatric dental specialist. He was having some strange issues with his teeth chipping away with seemingly no cause. This happened with multiple teeth in a relatively short time period and my friend was very concerned. During the exam my friend mentioned to the dentist that she still nurses once or twice per day and he immediately told her that the results of her still nursing at 20 months was clearly bottle rot (despite her never using a bottle with her son), and the dentist refused to discuss it any further. He stated that the child’s teeth were breaking because she breastfeeds her child in the evening before bed.

I am not a pediatric dentist- I have zero expertise regarding children’s teeth. But I remember reading an article from a pretty reliable and peer-reviewed source regarding breastfeeding and teeth, specifically whether or not it caused tooth decay. Troubled by her experience with the dentist, I pulled up the article and found several associated peer-reviewed articles from the American Dental Association, International Journal of Paediatric Dentistry, Community Dentistry and Oral Epidemiology Journal, Pediatrics-The Journal of the American Academy of Pediatrics listed as the sources with direct links to the studies. I find these sources to be quite reliable and have high levels of validity- they aren’t clickbait articles that you would find floating around Facebook or Twitter. I may not be an expert on tooth enamel, but grad school did teach me the high value of a reliable source.

Therefore, I found it a bit concerning that in my three minutes of searching my university’s library I could find multiple sources published within the last 5 years completely invalidating the dentist’s claim that breastfeeding was the direct cause of this child’s tooth decay. 

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Clinicians have what I’d refer to as the burden of patient responsibility. This is because the vast majority of public health education occurs within the exam room. This is why we have so many programs that are MD/MPH, PA/MPH, RN/MPH, DDS/MPH- Because the clinicians are primarily responsible for that component of public health that is direct patient education. This is actually quite a scary responsibility.

Health is dynamic. We know this because it is ever changing and influenced by vast amounts of research. How many peer-reviewed articles were published this year in the health field? How many non-reviewed articles are pending publication or studies are ongoing?  We find out something new each day that affects our health, which is a beautiful and terrifying thing. Beautiful because there is something that we know helps or harms our health. Terrifying because we must recognize that we are never done learning.

Clinicians who refuse to embrace this responsibility of educating him or herself have a very limited right to practice in their field. Why? Because clinicians have made a commitment to provide the best care possible to patients- it just isn’t possible to provide the best care if the clinician in question has declined to maintain awareness of the most current recommendations that have been studied and experimented on for years for those topics affecting their field of study. As a clinician the responsibility of making the personal effort to seek further information and education within peer reviewed articles is vital- it means patients and clients receive the most up-to-date recommendations and in turn positively affect public health movements such as the much larger overall goal of reducing child mortality. Car seat recommendations are an excellent example of this as they are constantly changing and constantly being improved.

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Now, back to the dentist example that my friend experienced. The articles I mentioned above discussed bottle rot in depth, stating that the pooling of milk or juice within the child’s mouth causes the tooth decay. However in regards to breastfeeding, with a correct latch a nursing child must work to remove milk from the breast, with the output of the nipple located behind the teeth. A child typically will not experience a slow leak from the breast that causes the same type of pooling of liquid around the tooth as a bottle. The problem I have is that this isn’t new research, and has been repeatedly analyzed. Major studies on this exact topic have been conducted regularly since the 1960’s- or at least as much as I can tell from my 3 minute search.

So why isn’t this clinician providing well known, old research to the patient and the patient’s legal caregiver? What about the new American Dental Association recommendations on brushing teeth? Instead of the old no fluoride until age 2 rule, ADA has recommended a very small smear of fluoridated toothpaste from about the time of the first tooth’s emergence to protect against tooth decay and cavities at an even earlier age. Repeated studies have supported this new recommendation. Many FAQ pages on pediatric dentist pages still state no toothpaste until age 2- we can’t expect immediate updates from our clinicians, but how quickly do we expect to see the implementation of new public health recommendations if our clinicians are resistant to furthering education and maintaining the responsibility of keeping up with such recommendations?

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I understand that we are all busy and doing amazing work. We have a very limited number of hours in each day and many of us do extremely stressful work. Outside of the office we have our personal responsibilities- families who need our attention and love. This responsibility of balancing continued education within our available time is tough and I applaud those clinicians who have truly put an effort into prioritizing continued education and staying up to date on peer-reviewed recommendations. It’s not easy but you’re really helping public health.