Dentistry fails: How failure leads to success

Failure is not having the courage to try, nothing more and nothing less. Yet, failure is essential to success in any endeavor. Failure tests us and allows us to grow. It offers us lessons and guides us along the path of enlightenment, Robin Sharma [1].

Have you ever had a patient ask, “Doc, will this crown (or any dental procedure for that matter) last forever?” My response is usually along the lines of, “What Mother Nature gave you didn’t last forever, what makes you think we are better than Mother Nature?” A bit of a tongue-in-cheek answer, but we have all been faced with this question.

Historically, dentists are perfectionists; failure is not an option. As we struggle and deal with microns and millimeters, we have difficulty creating an office culture that accepts failure. In many large, successful corporations, learning from failure leads to improving future performance [2]. The wisdom of learning from failure is a truth that goes back as far as the Greek philosophers.

In dentistry and medicine, we lean on evidence-based research to guide us, to help us reduce failure. Evidence-based dentistry can be defined as dentistry that “incorporates the judicious use of the best evidence available from systematic reviews, when possible, with the knowledge of patients’ preferences and clinicians’ experiences to make recommendations for the provision of the right care, for the right patient and at the right time” [3]. Yet, in dentistry, “it has been suggested that as little as 8% of dental care that is delivered is justified by peer-reviewed, published and appropriately analyzed dental research” [4]. There are numerous times we refer to trial and error. So, what I take from this is that we accept failure or deviations, but we do not study them, and because we do not study them, we do not achieve reliable performance.

Dentistry is not unique in the opportunity that learning from failure provides. In fact, there are many organizations that have a preoccupation with failure as a key part of their organization ethos. These organizations are called High Reliability Organizations (HRO) [5], i.e., organizations that have succeeded in avoiding catastrophes despite a high level of risk and complexity. A minor error in HRO organizations, such as nuclear plants or airlines, could have catastrophic and widespread consequences, and they are likely to happen, yet, very rarely do. And while the impacts to a single patient are not nearly to the scale of nuclear plants and airlines, our patients entrust their health to us, and we have a duty to do no harm. In fact, the concept of a High Reliability Organization has influenced the quality and safety culture of many hospitals around the world.

In dentistry, this means we need to build capacity to anticipate, respond, and contain the unexpected. This does not happen, however, by chance; education and training is needed just as much as a mindset shift is needed.

Dweck, in her book, Mindset: The New Psychology of Success [6], describes the closed versus open mindset. Those with open mindsets put energy into learning and are not afraid of failure. In dentistry, these dental offices have a leadership team that creates an open mindset culture in which it is okay to make mistakes and unacceptable not to learn from them. It is important that these concepts cannot be decoupled, especially in healthcare. If a restoration or a craniofacial pain treatment fails from thoughtful application of evidence-based treatment, valuable information that can be used for the betterment of future treatment is generated. However, unless there is an open mindset and a system in place to learn from failures, we usually do not learn from our failures, as too much is left up to individual initiative. In fact, the Agency for Healthcare Research and Quality denotes that “high reliability is an ongoing process or an organizational frame of mind, not a specific structure” [5].

In dentistry, as in many sectors that have adopted HRO mindsets and structures, we are dealing with imperfect actors (our patients), who, for the most part, are unwilling to give up the habits and environmental factors that caused them to be sick in the first place, e.g., the sleep apnea patient who denies obesity is part of their OSA problem (and does not lose weight), the high-risk caries patient who refuses to cut out sugar, or the lung cancer patient who refuses to quit smoking, all have issues that classify them as being sick, but they are not willing to alter the habits that made them sick in the first place. Patient attitudes and actions add the risk, complexity, and chaos that failure thrives in.

And while you could argue that restorative dentistry is reasonably straightforward and the “real” challenges arise when managing craniofacial pain, without an open mindset, we cannot be “guided along the path of enlightenment.” Even in restorative dentistry, where we are faced with decay (or a fractured tooth) and we “know” to restore it (composite restoration, onlay, crown, endodontics, implant, etc.), success and safety in these solutions are not static; they are emergent concepts that are influenced by our skill, the patient’s response, and many external factors that we will never be able to control, i.e., a favorite product being discontinued, an encounter with a piece of hard candy, etc.

The take-home message is never to fear failure; embrace it. This takes a mindset shift and system shift. And at the individual dentist, dental office, and dental community-levels, we would benefit from learning about HROs and the five characteristics of high reliability: a preoccupation with failure, a reluctance to simplify, a sensitivity to operations, a deference to expertise, and a commitment to resilience [5].

Every failure comes with an opportunity to be educated and to become a better clinician. If we are always afraid of failure, we will not be honest about failure, will not study failure, and will get stale in our execution of dental treatments.

Where would we be in dentistry today if Branemark [7] were afraid of failure of dental implants? It is generally accepted that osseointegrated dental implants are 95–98% successful. Where would we be without the science of enamel and dentin bonding if Buonocore [8] were afraid to fail? In craniofacial pain, certainly, our founders, the Gelbs and Stacks of the TMD world, all failed but used that information to build successful systems we follow today.

Do not let fear of failure paralyze your dental practice. People before us have failed many times and applied learning to ensure our dental treatments are successful. We owe the same dedication, mindset, and structures to our patients and future dentists.

So, I end by asking you to channel your fear:

• Use this fear of failure to ensure successful dental outcomes

• Use this fear of failure to learn how not to fail

• Take fear of failure and redirect that energy.