How Dentists Can Avoid Getting into Hot Water

As with any self-regulating profession, conflict between the interests of its members and the general public must be resolved in favour of the public. The dental profession has been exemplary in this regard, as evidenced by its successful promotion of preventive oral health measures. No other profession has worked as hard to eliminate the need for its services.

Dentists are ranked among the top professionals for honesty and ethical standards, higher than physicians, lawyers and even the clergy. Why is this so? In my opinion, it is because of the high standards and ideals dentists impose upon themselves. With few exceptions, the profession is composed of hard-working, highly ethical people whose principal concern is the welfare of their patients.

Why then are there so many disciplinary proceedings across the country? Although the number of formal complaints regarding failure to meet standards of care seems to be declining (in fact, the proportion of contraventions of the legislation in comparison to the number of dental services rendered is extremely small), there has been an increase in complaints regarding “lack of professionalism.” Allegations of abuse (both physical and sexual), of rude and demeaning behaviour, of insurance exploitation, of lack of treatment explanation, and of discrimination based on nationality and socio-economic status are on the rise.

Subjects of public concern that can negatively affect dentists include the following.

Sterilization and Infection Control

Patients commonly complain about dentists not changing gloves between patients, blood splatter on surfaces, filthy floors, and stains on the clothing of the dentist or the assistant. It is extremely important that the patient not associate any visible signs of treatment with the previous patient. Wash your hands in view of patients, or nearby where they can hear the water running, and make sure they see you dry your hands and put on gloves. Every so often, sit in the dental chair and look through the eyes of your patients. Keep your office clean; obviously, overflowing waste receptacles give a bad impression.

Emergency Visits

When seeing an emergency patient whose regular dentist is not available, treat the pain or infection only and advise the patient to return to his or her dentist for follow-up care. Do not request that the patient return for root canal treatment, a complete examination or any other treatment. It is appropriate professional conduct to contact the patient’s dentist to advise of your clinical finding and emergency response.

Patient Dismissal

Patients have the right to seek treatment from their dentist of choice and dentists have the right to treat patients of their choice, within the bounds of human rights legislation. A dentist can refuse to accept a patient or can dismiss a patient provided notice is given and alternate care arranged in a case of potential abandonment. Patient dismissal should always be done in writing and presented as being in the patient’s best interest.

Transfer of Records

When requested by the patient, you have an ethical obligation to provide records or reports of clinical information to the patient or to whomever the patient directs. Original records should be retained and a duplicate provided. This includes radiographs (most recent bite-wings, Panoramic, etc.) exposed within the last two years. It is unethical to withhold or refuse to transfer patient records because of an outstanding balance on an account.

Insurance Claims

Dentists must not submit claims to an insurer for a service that has not been given. While it seems unnecessary to make such a statement, it happens. Root canal therapy is complete when the canal has been obliterated, not at the time of initial instrumentation; a full crown restoration is complete when the crown has been cemented, not when the tooth is cut down.

Child Abuse

Child abuse is the subject of increasing concern. In some complaints, parents suggest that they didn’t know what treatment was being provided, that their child was being physically abused (restrained), that they couldn’t speak directly to the dentist, and that the assistant was the only contact they had. Almost without exception, these types of complaints can be eliminated if the dentist places more emphasis on communication. If it is your policy to keep parents out of the operatory during treatment, be sure it is perfectly understood and accepted. Once you have reached an accepted treatment plan, inform the parent of the procedures you will do at each appointment. If the treatment plan changes, consult with the parent before proceeding. Advise the parent if an injection is necessary, if you expect the child to feel pain or to cry, what degree of restraint you feel is necessary and acceptable, and how long you expect the procedure to take. After each appointment, describe how things went and explain any post-operative instructions. Ask if there are any questions — no surprises will mean no complaints.

These are but a few of the areas that can result in patient complaints. Responding to a patient complaint in the dental office is not a pleasant experience, but having to address a complaint through a review by the regulatory authority is even less pleasant. An intra-professional discipline proceeding can be very upsetting and expensive.

What can a dentist do to minimize the chances of patient complaints and avoid getting into hot water with a regulatory authority? Following these “dental commandments” will help:

1. Nobody bats 1000. Recognize that we all make mistakes. Inform your patient and right the wrong.

2. Know your limitations. When in doubt — refer. This is not a suggestion that you lack ability; rather, it demonstrates to your patient that his or her best interest is your primary concern.

3. With emergency visits, address the immediate problem first and then follow up. Upset patients have suggested that they received an examination, cleaning, fluoride application and x-rays, but still left the dental office with their toothache!

4. An informed patient is a better patient. Every patient is entitled to a thorough examination, a competent diagnosis, an explanation of the pros, cons and costs of all treatment options, and the opportunity to reach an informed decision on the proposed treatment. If you take the few extra minutes necessary to fulfill this responsibility, there will be little cause for complaint.

5. Never guarantee results. It is impossible to unconditionally predict the result of any health care service. To guarantee the success of operations, appliances or services is a contravention of the code of ethics.

6. Never suggest that a procedure is routine or simple. There is no such thing in dentistry.

7 When treatment requirements go beyond examination and prophylaxis, a written consent is advisable.

8. Thorough record keeping is mandatory. If the provision of a service to the patient is not referenced in the dental record, it didn’t happen!

9. Don’t let an ego trip lead you into court.

10. Even when the patient is wrong, the patient is right.

Dr. Bonang is registrar of the provincial dental board of Nova Scotia.