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Patient Communication

Clear Communication with Parents Key to Avoiding Misunderstandings When Treating Minor Patients

Originally published in the May/June 2010 issue of Dispatch

Case No.1

COMPLAINT SUMMARY

A parent filed a complaint about the care of his minor daughter by a pediatric dentist. The father complained that the dentist:

  • recommended unnecessary restorative treatment to be performed under a general anesthetic;
  • took advantage of him due to his dental insurance coverage;
  • failed to provide him with treatment options;
  • assaulted his young daughter.

DENTIST’S PERSPECTIVE

Notified of the formal complaint, the dentist provided the College with a response and his patient records.

He stated that the child’s father brought his daughter to his office for a consultation appointment on April 2, 2009. The primary concern was a cracked tooth 62 (upper left primary lateral incisor) which seemed to be deteriorating. On examination, he noted very poor oral hygiene with moderate to heavy plaque accumulation and carious lesions on the following tooth surfaces:

  • tooth 55 (upper right 2nd primary molar) occlusal-lingual
  • tooth 54 (upper right 1st primary molar) vestibular
  • tooth 51 (upper right primary central incisor) mesial
  • tooth 61 (upper left primary central incisor) mesial
  • tooth 62 (upper left primary lateral incisor) mesial-incisal-vestibular
  • tooth 65 (upper left primary 2nd molar) occlusal-lingual
  • tooth 75 (lower left primary 2nd molar) lingual-vestibular
  • tooth 83 (lower right primary cuspid) vestibular
  • tooth 85 (lower right 2nd primary molar) vestibular-lingual

The dentist recommended a general anesthetic to properly and safely perform the necessary restorative treatment. This decision was based on the patient’s age, potential behavioural management issues and the type and extent of treatment required.

The dentist explained that radiographs were not taken at this appointment because of the likelihood that the patient would not co-operate and they could be deferred until the general anesthetic appointment.

The member stated that it was customary to inform parents of the possibility of additional treatment at the time of the anesthetic appointment, when the radiographs are reviewed and the treatment plan finalized.

In his response, he denied recommending unnecessary treatment because there was insurance coverage and he took offence at the father’s suggestion in the letter of complaint that he would assault a child.

A copy of the member’s response was sent to the complainant for his information and the child’s father provided further comments disputing the dentist’s version of events.

Additional Information

As part of its investigation, the College obtained records from the previous/ subsequent treating general dentist.

His clinical chart entry dated April 28, 2009 (after the examination appointment with the pediatric dentist) stated:

Spec exam Tx 65 OL caries, 75 L – pit. 83V demineralized, 85 LV demineralization, 55 OL caries, 54 V demineralised, 61M caries, 51M caries, 62 caries, crowded accumulates plaque, passive eruptive, class I, pt has high affinity for decay. Specialist recommends fluoride rinses, does not recommend sealants.

REASONS FOR DECISION

The panel reviewed all correspondence and records obtained during the course of its investigation, including documentation submitted by the parent, pediatric dentist and the previous/subsequent treating general dentist.

In his letter to the College, the parent alleged that the pediatric dentist had recommended unnecessary treatment and took advantage of him due to the anticipated insurance coverage. The panel compared the records of the specialist to those of the general dentist who examined the child a few weeks after the specialist’s examination.

The panel could see that the general dentist had essentially made note of the same possible treatment as the pediatric dentist. Therefore, they accepted that the pediatric dentist, as the specialist, had the experience to recognize the likely prognosis of a patient’s primary teeth given the level of oral hygiene.

In this case, the child presented with poor oral hygiene and abundant plaque. The panel accepted that the member appropriately exercised his professional judgment and his treatment plan was reasonable. However, the panel suggested to the member that it would have been helpful to have had a more extensive discussion with the parent about the areas of demineralization that could quickly develop into areas of decay that required treatment.

In the panel’s opinion, there was no unnecessary treatment recommended and the member did not take advantage of the complainant because of his insurance coverage.

As for the parent’s complaint that he was not provided with treatment options, the panel acknowledged that since no radiographs or photographs were taken because of the anticipated lack of co-operation from the young patient, it was reasonable that it was not possible to review and discuss a definitive treatment plan.

With regard to the allegation of assault, the panel did not accept that there was any assault or that performing the recommended and necessary treatment would be considered as assault.

For the reasons stated above, the panel decided that no further action with respect to this complaint was required.

Case No.2

COMPLAINT SUMMARY

A complaint was filed against a general dentist by a mother on behalf of herself and her minor son. With respect to herself, she said that the dentist failed to diagnose and treat the decay present on tooth 18 (upper right 3rd permanent molar). With respect to her minor son, she expressed dissatisfaction with the way that the dentist had spoken with him.

DENTIST’S PERSPECTIVE

The dentist was notified of the formal complaint and provided the College with a response and her patient records for both the mother and the child.

In her response, the dentist stated that the mother attended her office on November 13, 2008, for hygiene treatment performed by a registered dental hygienist. Then, on November 18, 2008, she performed a new patient exam and took a full mouth series of radiographs. The patient did not report any areas of concern at that time. She discussed a treatment plan with her which included distalocclusal restorations for teeth 16 (upper right 1st permanent molar) and 25 (upper left 2nd bicuspid). This treatment was completed on November 27, 2008.

On the same day, the mother returned to the office with her son for his dental appointment. At that time she asked if there was a hole in the upper left quadrant. While the mother was seated in the dental chair, the dentist told her that the tooth had been cut open to remove the decay and a restoration placed. However, as normal, there was a space between the teeth (the interproximal space). The dentist said that the patient appeared to be satisfied with this explanation.

On January 11, 2009, the mother then saw a colleague of the dentist for a same-day emergency appointment. A periapical radiograph was taken and an antibiotic and pain medication prescribed. Arrangements were made for her to see an oral and maxillofacial surgeon on March 5, 2009, for the extraction of tooth 18. The records show that the patient had declined to see another practitioner at an earlier date.

The dentist explained that, on review of the radiograph dated November 18, 2008, she saw the suggestion of a lesion on tooth 18 which had not been clinically visible. She said her usual practice is to view the radiographs on a view box and call out her observations to her assistant to record in the patient chart. The member said that she can only assume that an error was made in this charting. The member commented that, given the extent of decay, it would be likely that the tooth would have required endodontic treatment or extraction in any event. She regretted that the matter was not dealt with earlier.

With respect to the allegation involving the complainant’s minor son, the dentist responded that the office policy is to have parents remain in the waiting room, as some children behave better when their parents are not present.

The member commented that, despite this policy, the mother did come into the operatory during her son’s appointment. It was obvious, the dentist said, that the child was significantly agitated when he arrived for his appointment as his mother had told him numerous times that he would be getting a needle.

As a result, the dentist decided she would not use a needle and instead try to place the restoration without local anesthetic. A topical anesthetic was applied and cotton roll isolation was used along with new dental burs to minimize patient discomfort. It was the dentist’s opinion that the patient seemed to tolerate the treatment well, but was agitated by the level of noise and chaos in the operatory. She also noted that the child’s mother was “simultaneously talking to and vigorously jostling a fussing baby in her arms while chastising her son.”

The dentist explained that her usual practice with child patients is to speak in a soothing, warm and compassionate voice, encourage the patient, provide explicit explanation of what is being done and provide instructions to breathe and relax. Children are given an opportunity to look, touch and understand the tools being used. The member reported that she has an excellent reputation with children and parents using these techniques.

In this case, given the noise level in the room and the multiple authority figures present, the patient’s behaviour worsened. So the dentist altered her usual techniques and used a firm but kind voice to advise the child that, if he could not behave, his Mom and baby would have to wait for him in the waiting room and the fillings would still have to get done. This firm statement was followed by a comment made in a softer voice, such as, “so, let’s just get finished quickly and you get to go home, okay sweetheart.” The member denied threatening, punishing or screaming at the child.

In the usual course, if patient compliance is still not attained, the dentist said a referral is made to a pediatric dentist.

The member apologized for not discussing the voice modulation technique with the child’s mother before she used it. She had thought that the complainant would inherently understand what she was doing. The member also said that she was sorry that the mother was not aware that being in the treatment room was a privilege and not the office’s usual protocol. The member commented that her experience with this minor child confirmed for her the benefit of the practice protocol of not allowing parents in the treatment room.

Along with her response, the dentist provided a letter from her colleague and her dental assistant recounting their recollection of the patient and her child.

A copy of the member’s response was sent to the complainant for her information.

Additional Information

As part of its investigation, the College obtained correspondence and records from the complainant’s subsequent treating general dentist. In his correspondence, the general dentist stated that the complainant attended the office on January 19, 2009, for a consultation appointment regarding discomfort in the upper right side of her mouth.

An examination and radiograph revealed buccal decay on tooth 18 and a periapical radiolucency around the apex of the tooth. The patient was provided with the treatment options and later another dentist removed tooth 18 under general anesthesia.

REASONS FOR DECISION

The panel reviewed all correspondence and records obtained during the course of its investigation.

As for the patient’s complaint that her general dentist failed to diagnose and treat decay on tooth 18, the panel could see from the records that the patient had gross calculus on her teeth when she first attended the office. Therefore, the panel suspected that the hole she perceived could have been due to calculus removal.

The panel acknowledged that the dentist did agree that she failed to note the caries on the buccal of tooth 18 and/or that the carious lesion was not recorded in the chart. The panel viewed the pre-treatment radiograph dated November 18, 2008, and agreed that the presence of decay was clear on the film and that it should have been noted in the chart and treatment plan.

The panel could also see that the subsequent treating practitioner appropriately addressed the complainant’s pain in tooth 18. Unfortunately, although the oral and maxillofacial surgeon to whom the patient wished to be referred had a long wait list, the complainant declined to be referred elsewhere.

The panel accepted that it was an unfortunate and inadvertent occurrence that the decay on tooth 18 was not documented nor treatment planned. The panel took the opportunity to remind the dentist that she must thoroughly document areas of concern and suggested she might wish to review her treatment plan with patients when they returned for treatment.

The complainant was also dissatisfied with the member’s conduct towards her minor son. The panel reviewed the information related to this allegation, including the corroborating information from the dental assistant. The panel accepted that the member’s conduct was appropriate, noting that the appointment in question was obviously a stressful situation for all involved.

The panel noted that the dentist used known and widely accepted patient management techniques. The panel suggested that it is a matter of choice for an office to determine whether or not parents are allowed in the operatory during treatment of their child. They noted that the mother could choose to seek care for her son at a different office if she was dissatisfied with this office’s child management practice.

Based on its review and deliberation of this matter, the panel decided to take no further action with respect to this complaint.

Learning points
  • It is important that office policies regarding child management philosophies and practices are communicated to parents of current and future patients so there are no misunderstandings. This might be done with a “Welcome to Our Office” information package. Parents who are not comfortable with these policies would then have an opportunity to seek services elsewhere for their child/children.
  • In situations with a very young child with rampant caries when it is impossible to do a clinical examination and radiographs without a full examination, radiographs and treatment under sedation or anesthesia, it is crucial that parents understand the uncertainty of the treatment needs and that a full and final treatment plan will not be possible until the sedation/anesthesia appointment.
  • In addition to this explanation, as part of the informed consent process, the parents also need to be informed of the worst case scenario as it may not be possible for the dentist to leave the operatory when the child is sedated/under anesthesia. Extra time and attention needs to be taken to make sure that there are no misunderstandings, financial or otherwise, once the treatment is provided.