8 February 2011

With a team of 50 dento-legal advisers available to answer members’ enquires, Dental Health has selected some recent enquires they have received to see what the experts at Dental Protection have to say. The situations have been fictionalised to ensure confidentiality.

Q. I have been asked to provide smoking cessation advice to a patient who is to have multiple implants placed in six weeks time. The patient has smoked 20+ a day for over 14 years and has never expressed any wish to stop smoking during that time. The new associate is keen to place the implants and the patient is very keen to have the work done, but not so keen to give up smoking. The patient has periodontal breakdown in all quadrants and I feel that the implant is quite likely to fail. Should I tell the patient this? The clinician placing the implants wants me to provide a series of appointments to encourage him to give up smoking. I am uncomfortable with this, please advise.

This looks like a classic ethical dilemma in every aspect and certainly on the basis of the information provided it does look as though it is going to end in tears. The decision to place implants does have to rest with the treating clinician who must ultimately assume all responsibility. Dental treatment is a team effort, however, and no more so than when the placement of implants is concerned. The opinion of the hygienist and other members of the dental team is therefore an important factor that a good team leader must take into account.

The dilemma for the hygienist is clear. For many year now smoking has been regarded as a contraindication to the placement of implants, although a small amount of research is now available that would contradict this. How valid that research is remains to be seen but it is likely that an expert reviewing this case (if the treatment has failed) might well be critical of the clinician who placed the implants unless it could be clearly shown that every effort had been made to address these issues.

Many implantologists also argue that the benefit of doubt should be given to the patient and it is not difficult to have some sympathy with this point of view. Leopards may not easily change their spots but offering a patient a second chance (to change their habits) is not an unrealistic suggestion. It should also be clearly explained to the patient that their smoking habit and perhaps their previous poor oral hygiene that led to the periodontal disease in the first place, are both contraindications and could well lead to a significantly increased risk of failure. If the patient fully understands this and the dentist is still willing to place the implants, then it is perhaps not for the hygienist to question the treatment plan.

In broad terms then the advice to the hygienist has to be to discuss this matter with the clinician who is going to place the implants and raise with them whatever concerns he or she may have. The smoking cessation appointments (which are presumably linked with oral hygiene instruction) can then go ahead and a re-evaluation made by the dental team once the outcome of this advice is known. If the patient still continues to smoke (as is likely to be the situation in this case) then the final decision rests with the clinician who will place the implant.

The hygienist of course could refuse to become involved but in that situation I think it might be difficult to argue that he or she was acting in a patient’s best interest. That decision may be the correct one if the implant fails due to poor patient selection but it could also look rather ridiculous and difficult to defend if the treatment turns out to be successful.

There is no suggestion that the hygienist should blindly follow the dentist’s lead and in the majority of good dental teams, the dentist about to undertake a course of treatment ,for which an optimum level of periodontal health is required, will probably want the hygienist’s input in any event. Good clear records should be kept of each of the appointments and in particular a record of the discussion and advice that was provided for the patient.

Dental Protection Limited is registered in England (No. 2374160) and is a wholly owned subsidiary of The Medical Protection Society Limited (MPS) which is registered in England (No.36142). Both companies use Dental Protection as a trading name and have their registered office at 33 Cavendish Square, London W1G 0PS.

Dental Protection Limited serves and supports the dental members of MPS with access to the full range of benefits of membership, which are all discretionary, and set out in MPS’s Memorandum and Articles of Association. MPS is not an insurance company. Dental Protection® is a registered trademark of MPS.

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