It can be convenient for practitioners and staff alike to access dental care at their place of employment. Though treating colleagues can carry a certain amount of risk. Dental Protection Case Manager Kristin Trafford-Wiezel looks at one such example.
Mr A was an oral health therapist in a large group practice, where he predominantly utilised his adult scope within the team providing examinations, restorative and preventative maintenance. The practice was very busy and a spare appointment was hard to come by.
On one particular day, a new dental assistant in the team, Miss K, had the opportunity to see Mr A for her long overdue hygiene appointment in her lunchbreak, due to an opening in the schedule. Mr A ensured that Miss K filled in a full medical history, discussed her dental history and enquired if she had any specific concerns. Miss K indicated it had been some time since her last full check and clean, as over the years in the dental industry, over a number of practices, it had been that her general examinations and hygiene maintenance were performed on an ad-hoc basis, based around patient scheduling and cancellations.
After completing the medical and dental history with Miss K, Mr A undertook a clinical assessment and enquired when the last set of bitewing radiographs had been taken, to assess bone levels and interproximal decay. Miss K indicated that they had not been done for some time, as there had not been the time during her short “squeeze-in” appointments, though she reassured Mr A that she was not experiencing any issues or concerns. Mr A discussed that considering the length of time since her last radiographic assessment, it would be appropriate to update these, to ensure that anything could be caught early, to which Miss K agreed, and a set of bitewings was obtained.
Sadly, both Mr A and Miss K were in for quite a shock when the images were processed. Unfortunately, though Miss K had not been experiencing any symptoms, a serious issue was uncovered. After reviewing and reporting on the images, Mr A referred these images onto the principal dentist for their opinion and advice, as the issue identified fell beyond his scope of practice. The radiographs indicated that a longstanding impacted lower wisdom tooth had unfortunately caused significant resorption of the distal root of tooth 47, which was also exhibiting distal coronal caries, not visible in the mouth.
Consequently, though Miss K had experienced no issues or pain to date, the team was left breaking the bad news to Miss K on the findings and undertaking the difficult conversation on what the options were regarding these teeth. Regretfully, Miss K was advised that it was likely that she would lose both the affected teeth, though a referral was arranged to a specialist endodontist for further assessment. Miss K was understandably very distressed about this turn of events, advising she was feeling it particularly keenly as she was so dentally conscious, and was mortified that she was now in the position of losing two teeth, when she was herself in the dental industry.
Understandably, though Mr A had comprehensively assessed and referred appropriately, this was cold comfort now, seeing his patient in this position. Mr A could not shake the feeling that though Miss K was a ‘regular attender’, the way in which she had accessed and been provided dental care over the years had had serious implications for her dental health.
Learning points
Do you think that Miss K had been cared for well in the past? Or do you think that her plight was a regretful outcome of “squeeze-in” appointments? Can you see the risk to her and the previous treating practitioners who failed to properly examine and diagnose Miss K?
It is imperative that practitioners are aware of our obligations to our patients, irrespective of close personal relationships. In short, all patients are just that: our patients, regardless of any other relationships we may have with them, such as friendships or work relationships.
A helpful resource to better understand this is the Dental Board’s Code of Conduct, section 3.14 – Understanding boundaries, which considers the issues and states:
“Good practice includes recognising the potential conflicts, risks and complexities of providing care to those in a close relationship, for example close friends, work colleagues and family members and that this can be inappropriate because of the lack of objectivity, possible discontinuity of care and risks to the practitioner or patient.
“When a practitioner chooses to provide care to those in a close relationship, good practice requires that:
• adequate records are kept
• confidentiality is maintained
• adequate assessment occurs
• appropriate consent is obtained to the circumstances which is acknowledged by both the practitioner and patient or client
• the personal relationship does not in any way impair clinical judgement, and
• at all times an option to discontinue care is maintained (also see Section 8.2 – Professional boundaries).”1
Of note, no records had been kept for Miss K previously, and I think we would all agree that her previous assessment had been inadequate. Although not relevant in this case, we do also see many cases where a close personal relationship impairs and impacts on clinical judgement.
In short, remember – treat ALL patients as ‘patients’ and next time a colleague asks you for a quick clean up, ensure they are appropriately assessed, following the steps above.
1Code of conduct. Dental Board of Australia