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Risk Management

The Importance of Consultation with the Patient's Physician

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As you work toward your dental degree, give credence to the importance of physician consultation.  If you don’t, you may find yourself in court.  One experienced dentist--we will refer to him as “Dr. William”--learned this lesson when he deemed it unnecessary to consult with a patient’s physician during extended dental treatment.  Dr. William was an accomplished implantologist and surgeon who had treated the patient--we’ll call her “Cecilia”--on several occasions over a 12-year period.

 

During this timeframe, Dr. William had performed periodontal surgery on Cecilia, as well as an extraction, with no postoperative complications.  Sometime in 2007, Cecilia made an appointment to consult with Dr. William about the possibility of restoring her mouth with a fixed implant prosthesis.  During this visit, she stated that she could no longer wear her mandibular removable partial denture due to decreased salivary flow and dry mouth.

 

An update to her medical history, completed during this consult, revealed that some of her oral complaints were likely associated with her medical status, which included a diagnosis of scleroderma and lupus.  Cecilia also had been treated for breast cancer, had received systemic bisphosphonate therapy, and was currently receiving oral maintenance therapy of this drug.

 

Having successfully operated on Cecilia twice before, Dr. William decided that she would be well served with an implant and made this recommendation to her. The surgery was scheduled to include placement of an implant in the position of tooth #28, which would be used to create a fixed appliance incorporating teeth #25 and #26 as abutments, and replacing tooth #27 with a pontic.

 

Surgery was scheduled and performed. Following surgery, the patient was placed on antibiotics and released from the hospital.  Healing appeared to go well.

 

At six months, the implant was uncovered but it had not integrated, thus necessitating its removal.  More important, however, as a result of the patient's reduced salivary flow, she now had significant carious lesions on teeth #23, #25, and #26.  In an attempt to address the situation, Dr. William recommended an even more aggressive treatment plan, consisting of removal of the remaining mandibular anterior teeth and a lower right molar, and replacing the entire quadrant with a fixed prosthesis.

 

Because he had treated this patient on several occasions over a 13-year period, Dr. William did not think that consultation with her physician was necessary. On the basis of his knowledge of the patient and his experience performing these types of procedures, he believed that none of these conditions contraindicated implant placement.  Dr. William decided, therefore, that the surgery would be in Cecilia’s best interest.

 

Early in 2008, Dr. William removed four teeth and placed five root-form implants.  Even though Cecilia had been given prophylactic amoxicillin, the site became infected almost immediately after placement.  Within 30 days, all five implants were lost.  Compounding the problem, the wounds did not heal and it was determined that Cecilia either had osteomyelitis or osteonecrosis secondary to the bisphosphonate therapy.

 

Cecilia was referred by Dr. William to the oral surgery department at a major teaching hospital where she underwent a series of surgical procedures--all unsuccessful. Eventually it became necessary to remove the right half of her mandible.  Reconstruction was deemed too risky, and so she was taught to function with only the left side of her mandible.

 

Cecilia filed suit, naming Dr. William as the sole defendant.  Interestingly, she made no allegations relative to his surgical skills; rather, her complaint focused on his failure to consult with her physician prior to treatment.

 

Cecilia's physician testified at trial that he would have recommended against surgery, not because of any one of her ailments, but based on the overall picture of her medical health, including the multiple disease entities.

 

Unfortunately for Dr. William, the jury agreed with Cecilia and her doctor, and awarded her $1.3 million.  The case was not appealed.

 

This case provides several important lessons. Most obvious is the value of consultation with other healthcare providers based on the patient's medical status.  Certain diseases or conditions should trigger automatic discussion with the patient's physician.  Second, an updated medical history is a key component of any treatment plan; for patients with co-morbidities, its importance cannot be overstated.  Third, all patients have the right to sufficient information and consultation so that they can give a truly informed consent.  For the high-risk patient, additional discussion and deliberation may help him or her understand the potential risks, especially when the conversation takes into account input from the patient's physician(s) or other providers.

   

Management of the High-Risk Patient 

Kathleen M. Roman, MS 

 

When you become a practitioner, you may complain--as some dentists do--that patients don't recognize the relationship between oral health and systemic wellness.  This concern poses an excellent opportunity for patient education.  At the same time, it challenges dentists to practice what they preach as they assess the medical status of patients who need dental care.

 

In this case, Dr. William made a number of assumptions--most of which turned out to be incorrect.  Following are some practical tips that might have helped him prevent the serious injury to his patient and the unfortunate legal consequences.

 

  1. Implement a policy that ensures periodic review and update of the patient's medical history.  No one's health status remains the same forever and sometimes significant health changes can occur within a relatively brief period of time.  Example: Mr. Smith is mid-stream with a series of extractions, restorations, and implants.  You saw him last month and his next appointment is scheduled for tomorrow.  Last week his physician started him on a blood thinner.  Odds are that Mr. Smith won't remember to tell you that he's started taking this drug--unless you ask.
  2. Develop a personal checklist for patients whose health conditions put them at high risk for dental complications.  While most dentists would automatically add HIV, autoimmune diseases, and cancers to this list, other conditions such as morbid obesity, high blood pressure, diabetes, and mental disorders are sometimes ignored--with dangerous consequences.
  3. Stay current with advances in medicine as well as in dentistry.  If a patient reports that he or she has a condition you're not familiar with, do some research.  Many genetic disorders, for example, have oral health implications.  And, new procedures and drugs may significantly alter a patient's candidacy for dental treatment.
  4. Consider whether or not the patient is capable of complying with treatment-related instructions.  Find out what obstacles may stand in the way of the patient's full cooperation.  Ask.
  5. Do your best to include the patient in treatment planning by discussing the anticipated benefits and the potential risks associated with treatment options.  Take into account the patient's specific health conditions and personal health objectives.
  6. Encourage patients to obtain second or even third opinions in high-risk cases.  This advice should include dental specialists as well as consults with medical experts, if advisable.
  7. Document all of these interactions.  Documentation will help you remember important elements to be considered while planning treatment.  It will help identify differences in your expectations as compared with the patient's.  It will help keep you and the patient's other healthcare professionals on the same page.  And, it will likely be your very best witness if a less-than-satisfactory outcome turns into a dispute.

 

* Kathleen M. Roman is Risk Management Education Leader, Medical Protective, Indianapolis, IN.