Treating a Medically Compromised Patient

Originally published in the February/March 2012 issue of Dispatch

In the course of your professional career, you will regularly encounter medically compromised patients. These patients have special medical and/or dental needs that could directly impact their medical condition. The following case from the Inquiries, Complaints and Reports Committee (ICRC) illustrates how difficult treatment decisions become when a patient is medically compromised.

An elderly patient, 82 years old, presented with a significant medical history, including coronary artery disease and the use of many medications. She wanted extensive treatment involving her upper crowns and made clear her choice was replacement, not repairs, as the treatment was largely for esthetic reasons. During the treatment discussion, she seemed knowledgeable about dental matters. She was asymptomatic and appeared to be medically under control.

The treatment plan was discussed, including at least two appointments for work-up and consultation, as well as the cost of over $13,000. The patient was provided with a written estimate and a treatment information form. Since the patient needed help to get to the appointments, she asked the dentist to perform the treatment over a shortened period of time. The dentist agreed.

Her initial treatment appointment lasted five hours, during which eleven crowns were prepared. This long appointment included at least one hour for lunch and several brief breaks. The dentist used five carpules of local anesthetic, administered in intervals as he worked on individual teeth. The treatment appeared to go smoothly and the patient did not report any post-treatment discomfort.

About three weeks later, the patient returned for another appointment that was about two hours long. This time the member used two carpules of anesthetic. Again the patient took a number of short breaks during the treatment. After the appointment, the dentist was not contacted about any complications or concerns.

Unfortunately, only one week after the second treatment appointment, the patient died of a stroke.

A complaint from the patient’s representative followed, in which it was alleged that the dentist:

• did not properly advise the patient of the high stress associated with the treatment she wanted;
• did not inform the patient that the treatment was potentially fatal;
• did not offer to perform the treatment during a number of shorter appointments;
• administered too much local anesthetic, given the patient’s age and medical history;
• provided unnecessary treatment.

During its review of the complaint, the ICRC panel sought the opinion of an expert in dental anesthesia. The expert’s opinion was that the two hour appointment was acceptable, but the five hour appointment was inappropriate for a patient with cardiac illness. In addition, during this appointment, the dentist had not monitored the patient’s blood pressure and heart rate properly.

However, the expert said that, although much of the treatment could be considered unnecessary, ultimately the dental treatment could not be linked to the stroke suffered by the patient one week after the treatment was completed.

Despite the expert’s conclusion, the panel was concerned about the dentist’s management of this patient as there was a failure to record some of his discussions with the patient and it was not clear that she had received sufficient information about the treatment. Also, the records did not provide clear justification for the treatment.

The panel concluded that, when a medically compromised patient is being treated, particularly if that treatment is extensive, the dentist must take great care to obtain and document the patient’s informed consent to treatment.

The panel also noted that the dentist allowed the patient to dictate treatment, instead of using his professional judgement to determine the timing and duration of the appointments.

The complaint was resolved when the member agreed to refresh his knowledge of proper recordkeeping practices and to take a course in the treatment and management of medically compromised patients