The essence of patient consent is that they understand the options and communicate an informed choice, as this case illustrates...
A dental practitioner had a standard system in place for evaluating and treatment-planning his new patients. This involved taking the written medical history and the completion of an evaluation form by the patient prior to treatment.
Using a series of questions, the practitioner collected information about the likely demands and expectations of the patient, which proved very useful in his aesthetically-based practice. It was a requirement of the practice that all patients saw the hygienist on their second visit, but it was rare that any record of the actual periodontal condition and its response to treatment was kept.
It was also standard practice that the patient received a letter enclosing a treatment plan prior to their next visit to the dentist, which explained the treatment advised and the reason for it. Although patients often self-referred for specific items of aesthetic treatment, a comprehensive treatment plan was often supplied to indicate the whole course of treatment that could be provided.
Seeking aesthetic improvements
In one particular case the patient’s evaluation indicated that she wished to improve the colour of her natural upper and lower anterior teeth but was happy with the shape, appearance and function (occlusion) of the teeth.
The treatment plan was to veneer the upper teeth and to bleach the lower teeth in due course. The letter with the treatment plan explained the technique that was not the provision of laboratory-prepared veneers to bond to the teeth after reduction of an equivalent amount of enamel to maintain the tooth contour, but the provision of layers of composite to build out sufficient material to mask the original colour and create a new lighter shade.
The patient was also given a list of other treatment required to put the rest of the mouth in good order. The letter did not explain that the teeth would be bulkier as a result of the layers of composite, but did suggest that as the composite was etched onto the enamel, the technique was totally reversible.
The patient agreed to the treatment on the basis that the dentist was merely changing the shade by use of a ‘veneering technique’ and that the technique was totally reversible.
After the treatment, the patient was dissatisfied not only with the appearance (contour and shape) of her teeth but was now experiencing considerable periodontal problems around the veneers. Her complaint was that not only were the veneers inappropriately fitted but also that the dentist had not secured appropriate consent because the patient had been misinformed. Her teeth had been damaged and the process was not reversible.
Explanations must be honest, complete, demonstrable and accurate. In this case expert evidence confirmed the teeth were very bulky with large ledges cervically which were retaining plaque. It was felt by the expert and by the individual undertaking the remedial treatment that not all the composite could be removed from all the teeth without some aspect of the surface of the original enamel being damaged. A suitable settlement was subsequently negotiated.
Consent is only achieved by providing the patient with sufficient accurate information about the various treatment options available, from which they can make an informed choice before acknowledging comprehension and communicating that choice to the dentist.
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