Take care to properly obtain and document informed consent
Originally published in February 2013
The issue of informed consent to dental treatment is encountered frequently in complaints reviewed by the Inquiries, Reports and Complaints (ICRC) Committee.
In many cases, the patient complains that if she had all of the facts about the proposed treatment, she would not have proceeded. On the other hand, the dentist complained of will often assert that, even if there is scant or no notation of the informed consent discussion in the patient chart, the discussion did take place and the patient properly consented to the treatment rendered.
The complaint described below demonstrates how such a scenario might occur.
The patient had treatment performed on her upper anterior teeth. She complained that the dentist failed to inform her of the nature of the treatment to be performed. Also, once treatment had started, the dentist had continued even though the patient asked her to stop. The patient later requested that the treatment be reversed.
The patient also reported that she experienced various complications from the treatment, including sensitivity in her upper anterior teeth, difficulty chewing and fused teeth.
At a following appointment planned to discuss the patient’s concerns, the patient noted that the dentist admitted fault for any misunderstanding. However, the patient remained unsatisfied as she felt that not all of her concerns, particularly about cost and long-term complications, had been addressed adequately.
In responding to the complaint, the dentist explained that, after examining the patient, she noted the patient’s bruxism habit and recommended treatment on several upper incisors. Following that initial examination, the patient asked the dentist’s staff if she needed to return for additional treatment and was informed that she needed to return for fillings. According to the patient, neither the cost nor the nature of the treatment was explained to her.
The patient later returned for the planned treatment. However, during the procedures, the patient became uneasy and asked the dentist if she was receiving fillings. To her surprise, the dentist said that she was not, as she did not have caries. The dentist then explained that she was adding composite material to the patient’s teeth in order to protect the existing tooth structure.
In her response to the complaint the dentist explained that she had recommended restorations because several of the patient’s anterior teeth were worn on the incisal edges. She also said that the treatment and the reasons for it were discussed fully before any of the procedures were initiated. At that point the patient advised the dentist that she did not want the treatment, and the dentist reversed the treatment by removing the material that had been added to the patient’s teeth.
In reviewing the complaint, a panel of the Inquiries, Complaints, and Reports Committee noted that there appeared to be some misunderstanding about the term “filling.” The patient appeared to believe that a filling is performed when a tooth is decayed and needs to be restored. However, the dentist noted that the patient did not seem to be aware that adding composite resin to a tooth to protect it, although the tooth may not be decayed or carious, is also a normal part of restoration procedures.
In addition, there was no notation in the dentist’s records about an informed consent discussion with the patient. While the patient appeared to believe that fillings are only used to treat caries, the dentist clearly understood that restorations are also used to treat other dental conditions.
The panel pointed out that despite the miscommunication, the treatment planned and initiated by the member was entirely appropriate. However, the panel did remind the member of the requirement to both discuss and document the patient’s informed consent to treatment.
Accordingly, the panel took no further action after offering and accepting the dentist’s undertaking/agreement to take a course in record keeping, including informed consent. The undertaking/agreement included a monitoring component of twenty-four months, to ensure that the lessons learned in the record keeping course would be implemented in the dentist's practice.