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Risk Management

Holistic Treatment Gone Awry

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Several years ago, “Dr. A” moved to a west coast community known for its laid back “sixties” lifestyle. Having decided that the "back to nature" atmosphere of the community would support a holistic approach to dentistry, Dr. A opened his practice and differentiated it from other dental offices in the area by advertising that he specialized in "holistic dentistry." In order to differentiate his practice from other more established colleagues, Dr. A even had the local pharmacy compound a distinctive mouthwash, using all natural ingredients, which he dispensed to his patients as yet another distinctly holistic service.

 

As his forays into the holistic side of dentistry were successful, Dr. A slowly began to downplay the importance of sound research in making clinical decisions. In his treatment planning, he began to rely more and more on anecdotal reports from patients and various alternative healthcare providers. At some point, he was introduced to the “therapeutic” benefits of magnets and began to use them in the treatment of myofascial pain and bruxism. Over time, Dr. A became less committed to conventional treatment protocols and increasingly relied on unproven treatment options (eg, magnet therapy) for some of his more acute cases.

 

Then, Dr. A met patient Wayne who presented with a painful tooth. Doctor A diagnosed a periapical infection of tooth #4 but, since holistic dentistry calls for minimal use of radiographs, this diagnosis was made without the benefit of one. The appearance of swelling, percussion sensitivity of the tooth, and a large restoration essentially confirmed the diagnosis of an abscessed tooth. Wayne requested holistic treatment--meaning that he wanted neither antibiotics nor endodontic therapy.

 

Doctor A explained that those would be the best therapies under the circumstances, but Wayne appealed to Dr. A's reputation as a holistic dentist and pushed for a less invasive treatment. As a compromise, Dr. A offered magnetic therapy, which involves placement of a series of magnets of increasing strength on the outside of the cheek and alternating with poultices placed on the buccal mucosa over the apex of the tooth. Remarkably, the magnet-poultice treatment seemed to work. The swelling decreased and Wayne reported that the tooth felt more comfortable. In about four weeks, however, he began to experience symptoms of sinusitis, including a slight yellow-brown discharge from his right nostril. He sought advice at his local health food store, where the staff suggested a tea that, reputedly, soothes the maxillary sinuses. Wayne followed this regimen for about 10 days, but his condition worsened. Tissues around the tooth again began to swell and became increasingly sensitive to percussion.

 

Concluding that the two sets of symptoms might be related, Wayne decided to seek the services of Dr. B, his employer’s dentist, an experienced and respected local practitioner who had a reputation for conservative dental care. Doctor B completed a radiographic evaluation and found that tooth #4 had a large radiolucency over the apex, which was precariously close to the maxillary sinus.

 

He immediately prescribed amoxicillin and referred Wayne to an endodontist in a nearby community. Endodontic treatment was performed and the swelling declined; however, the drainage persisted. Wayne was next referred to an otolaryngologist, who diagnosed a severe sinus infection of dental origin.

 

The otolaryngologist initiated an aggressive antibiotic regimen, but the infection did not heal. Finally, the tooth was removed and the oral antral fistula was surgically repaired. Wayne's recovery from the surgery was unremarkable, but he continued to exhibit symptoms of a chronic sinusitis, which were treated and continue to be treated symptomatically by his ENT physician.

 

Wayne was extremely angry over this turn of events, insisting that he would have had conventional therapy had he known about the potential complications. He sued Dr. A.

 

Unfortunately, Dr. A's notes were problematic. They lacked any discussion of the risks associated with refusal of pre-operative radiographs or endodontic treatment. Very few entries documented clinical management of the case. Without adequate scientific evidence or documentation to support treatment planning discussions between doctor and patient, Dr. A's malpractice insurance carrier was concerned that the case might be difficult to defend. In light of this challenge, Dr. A elected to settle the case out of court.

 

 

Risk Management Assessment: 

When is Holistic Dentistry a Valid Choice? 

 

Kathleen M. Roman, MS 

 

 Complementary and Alternative Medicine (CAM) continues to make rapid headway in the U.S. Adults in the U.S. spend nearly $34 billion annually on out-of-pocket healthcare products and services, according to a 2007 National Institutes of Health survey.1 Holistic modalities--those that focus on treating the entire individual, rather than just one ailment--are an integral part of many types of CAM practice. 

  

 Holistic modalities are not unknown in dentistry, and some dental practices market holistic approaches to patients who claim that they want to take a more proactive role in their healthcare, including the prevention of oral disease. While there is scientific evidence to support the benefits of many CAM therapies, some modalities have not been adequately tested and some may be dangerous. 

  

 The problem in this case is not that Dr. A offered his patients a holistic approach to dentistry; rather, it appears he forgot to consider the core elements of diagnosis and treatment planning. Some elements of care cannot be ignored. Wayne had a significant infection, which could not be resolved without the use of antibiotics. 

  

 Further, it is unclear how assertive Dr. A may have been in suggesting that his patient needed a radiograph or needed to see an endodontist. The reason for this lack of clarity is because Dr. A's records didn't include documentation of any recommended diagnostic workup, the need for endodontic treatment, or the risks that might occur without these needed interventions. Further, the record didn't document Wayne's questions or concerns. 

  

 What the case later showed, however, was that Dr. B apparently had little difficulty convincing Wayne that he needed radiographs, a heavy antibiotic regimen, and finally, surgical intervention. If Dr. A had been able to identify the scope of the infection and convince his patient to seek specialty care, it is possible that the infection could have been promptly treated and appropriately monitored, thus potentially avoiding the need for surgery. 

  

 Dr. A had an obligation to explain to his patient why holistic methods are appropriate for some types of treatment but not for others. He should have explained the need for the radiograph and his rationale for recommending a non-holistic treatment plan. If Dr. A had done a better job of explaining these matters and documenting them, Wayne might have changed his mind and, regardless of the outcome, a lawsuit might have been prevented. When the record is blank or incomplete, it can be very difficult to defend the doctor's actions. 

  

 Settlement of this case was primarily influenced by two factors: a) Dr. A's apparent failure to adequately explain to his patient and to document his rationale for a non-holistic treatment plan, and b) Dr. A's overreliance on an unproven treatment without explaining the potential risks to Wayne and documenting Wayne's questions or concerns. 

  

 Both the American Dental Association2,3 and the American Medical Association4 are supportive of further research and education for healthcare professionals relative to the use of CAM therapies. Since this is an area in which no clear standard of care has been established, it is especially important that patients be informed when a CAM therapy under consideration falls into the category of experimental or untested. Without the doctor's clinical oversight and without the patient's acknowledgement that the proposed treatment may pose unnecessary risks, it could later be alleged that the doctor did not obtain an adequate informed consent. 

  

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

  

 References 

 1.   Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners. United States, National Institutes of Health. National Health Interview. 2007. 

  

 2.   Little JW. Complementary and alternative medicine; impact on dentistry. Oral Surgery 2004;98(2):137-145. 

  

 3.   Wright EF, Schiffman EL. Treatment alternatives for patients with masticatory myofascial pain. J Am Dental Assoc 1995;126(7):1030-1039. 

  

 4.   American Medical Association Policy H-480.964. AMA House of Delegates Resolution 306; June 2006.