Miss N was a relatively new graduate and had recently begun work as an oral health therapist in a private practice. The end of year holidays had just begun, and an influx of children were attending for their annual check-ups.
Six-year-old H, a new patient, arrived at the practice for his check-up with his mother. Mrs H explained she had no concerns but felt it was time for his first visit. Miss N began chatting to both Mrs H and her son but soon realised that this may be a difficult appointment as H was hiding behind his mother and avoiding looking at Miss N.
After much desensitisation and the production of many stickers, Miss N was finally able to conduct a limited exam with H sitting on his mother’s lap on the dental chair. This exam revealed a number of areas of occlusal caries in his primary first and second molars, as well as some grey interproximal shadowing on his upper primary central incisors. Due to the difficulty in reaching that point, no bitewing x-rays were attempted.
After the examination was completed, Miss N explained her findings to Mrs H, which were H’s high caries risk and the potential difficulty achieving the compliance necessary for treatment. With this in mind, Miss N advised that the best course of action would be referral to a paediatric dentist to complete H’s extensive treatment under a general anaesthetic, and this could be arranged by the principal dentist at the practice.
Mrs H was openly shocked with this turn of events as she had not thought that H would require any treatment, as he had not complained of any pain. Mrs H was concerned about the finances associated with a referral to a specialist and requested that treatment be completed with Miss N at the practice, especially as H had finally begun to warm to her. Miss N felt compelled by Mrs H’s situation and advised that they could at least attempt some desensitisation and treatment in the chair, but advised that this may result in less than optimal treatment if compliance was an issue; in that case, a referral would then still be necessary. Mrs H agreed with this and thanked Miss N for trying to help them by treating H herself.
A treatment plan was compiled to complete the four posterior occlusal restorations, two interim fissure sealants on lower six-year-old molars and a prophylaxis and fluoride remineralising treatment. It was agreed that their next appointment would be for H’s professional clean to attempt to ease him into treatment.
H returned with his mother for his professional clean. The appointment proceeded with some improvement of the patient’s compliance but he was still highly anxious and needed significant explaining, encouragement and rewards. Miss N was overall quite happy at the progress and three further appointments were made to complete the restorative phase of treatment, as well as in-depth oral hygiene and dietary advice. These appointments proceeded with varying levels of patient co-operation, making treatment difficult and requiring the use of ART in some instances. Finally, with much relief from all parties, the treatment was completed and H was placed on a short recall schedule, to monitor the treatment and oral hygiene as well as continue with regular exposure to the dental setting.
The holiday season passed and with the beginning of the New Year came a surprise letter for Miss N, who was shocked to be in receipt of a notification from AHPRA, with a complaint regarding her treatment of H a few months prior. Unfortunately, not long after H’s treatment was completed with Miss N, H began experiencing pain and attended another practice. At this time, H’s behaviour was much improved and the practitioner was able to take a set of bitewing radiographs. These radiographs showed numerous interproximal areas of caries requiring treatment, and Mrs H was upset that these had not been dealt with in their previous appointments with Miss N. The situation was then compounded in that H’s Commonwealth Dental Benefit Scheme allowance had been almost fully utilised, and they were now experiencing the possibility of significant out of pocket expenses, which they could not afford.
Miss N was rightly concerned about the best course of action and contacted Dental Protection for advice. We assisted Miss N with her response to AHPRA, which included an explanation of the decisions she had made and an apology for the distress to the family. Fortunately, Miss N’s records were very thorough and detailed surrounding the discussions she had with Mrs H and, consequently, AHPRA dismissed the matter, albeit with a caution to Miss N.
Clear communication with parents and patients about the implications of treatment that is influenced by limited patient compliance is an essential component of treatment.
It is important to follow through with radiographs when able, to ensure thorough planning and treatment. As above, clear communication and advice to parents and patients about the implications of treatment without radiographic assessment is vital.
Be aware of the pitfalls of feeling pressured into providing treatment for patients when you don’t believe you can offer an acceptable treatment outcome in their best interest.
This case underlines the importance of documenting all discussions in the clinical notes.