Chapter

15

Informed Consent

James Q. Swift, DDS

People will forget what you said to them, but they will always remember how you made them feel.

Nelson Mandella

In order for people to undergo treatment to optimize oral health, they must present to oral health care providers. By doing so, the dental patient places confidence and trust in the individual who is willing to offer and provide his or her knowledge, skills, and experience to do so. A great privilege extended to dentists, dental hygienists, dental assistants, and dental therapists is that the patient surrenders self and puts self in a vulnerable position as they submit to oral health care treatment.

Think about it. The dental patient endures fear and anxiety due to anticipated discomfort, many times unjustly associated with a visit to the dentist. The dental patients allow the provider to ask pertinent questions about their health, habits, family, and relationships. They recline in a dental chair, allow the dentist to place hands on their head and neck, and open their mouths and by doing so limit their ability to communicate. They allow the dentist to place sharp objects in their mouths, insert needles into very highly sensory enervated body parts, administer local anesthesia that takes away the stimulus generated by the procedure to be provided, and then succumb surgical manipulation of oral hard and soft tissues. They anticipate that once the local anesthesia is metabolized and sensation returns, they may suffer residual pain and discomfort, which is expected for many dental procedures. They may have facial edema and ecchymosis, which is difficult to hide from public scrutiny. They may have alterations in their speech and inability to have normal oral function for a brief or perhaps extended time. It is an extreme example of trust and faith.

It is the responsibility of the oral health care provider to inform patients of their health and disease and to describe the options that exist for that disease to be treated. Because dental patients place trust and faith in their dentist, they expect that the dentist will be honest, fair, and ethical and make decisions in the best interest of the patients and not in the best interest of themselves. But it can be difficult, if not impossible, for the dental patients to determine that is the case.

Many dental disease processes do not have definitive symptoms. Inflammatory disease associated with oral microflora infections in many situations creates minimal pain or discomfort, yet the disease progresses. Many men and women have sustained significant periodontal disease to the point significant loss of periodontal support, tooth mobility, and finally tooth loss without significant pain, discomfort, or awareness that the disease was present. Dental caries can create significant loss of enamel and dentin before there is pain as the process progresses toward the dental pulp. Partially erupted impacted third molars can contribute to periodontal support loss on the distal aspect of second molars without ever sustaining a clinical case of pericoronitis. Jaw cyst and tumors can develop in the maxilla or mandible without any tumescence, thereby making the dental patient oblivious to its presence. It is not uncommon that many men and women are surprised when extensive and comprehensive treatment plan is offered in the absence of any symptomatology.

Oral health care procedures are routinely rendered after administration of some type of local anesthesia with implementation of additional techniques of pain and anxiety control. This may include minimal or moderate sedation techniques or in some situations general anesthesia. The oral health care patients may be unaware of the complexity or severity of procedures being performed. They cannot see what is being done due to anatomic location. They cannot feel what is being done when they are anesthetized.

Outcomes of appropriate and effective dental treatment may not be fully appreciated, as the dental patient cannot determine whether a dental surgical treatment procedure is acceptable or unacceptable. Dental restorations are miniscule and placed in areas that are difficult if not impossible to visualize. There are many dental patients who submit to treatment and accept the word of the dentist who informs them that the treatment they received was acceptable and in concert with the accepted standard of care. If the dental patients are without any symptoms, especially pain, they may perceive that the care rendered was acceptable or even exceptional. Often however, the absence of pain may not indicate that successful or acceptable treatment was rendered.

The onus of providing informed consent becomes even more demanding due to these facts associated with providing dental care and maintaining dental health. The dental patient must place complete trust and confidence in the oral health care provider to be honest and ethical. In the health care environment, the expectation of ethical behavior is elevated beyond that in other professions or situations, because a dental patient surrenders himself or herself to the provider and is subjected to the care provided without having knowledge as to whether the procedure is performed effectively or correctly.

Informed consent mandates that the patient is responsible for decision making regarding dental treatment. There are always at least two options from which the patient can select. They include the dentist’s recommended treatment and no treatment. Both options have risks and potential benefits. The dentist has an inherent responsibility to make sure that his or her patient has been given all of the pertinent information necessary or requested so that the dental patient can make the decision as to how to proceed.

When presenting treatment options to patients, the dentist should not be “selling dentistry.” It is important to provide information regarding the benefits of dental care. The idea that the dentist should convince the patient to undergo care only then compensation will be gained is unethical. The informed consent process, if properly conducted, limits such unethical behavior.

Because oral health care providers are trained to provide a broad range of procedures and treatments and are not dependent on other providers to deliver comprehensive care for the dental patient, the informed consent process is controlled and rendered individually. The responsibility rests almost entirely with the person who will be performing the procedures.

Elements of Informed Consent

There must be a doctor–patient relationship. The dental patient gives the doctor or oral health care provider implied consent by presenting to the dental office, requesting care, completing demographic and medical history paperwork, and then submitting themselves for a clinical examination.

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