Consent for dental x-rays

RE: Consent for dental x-rays

Michael Woodhouse — Fri, 08 Jul 2016 00:46:25 GMT

[quote user="robloxley"]And they've clearly given a few people the willies. Reminds me of something with a blanket...[/quote]

Michael Jackson?

RE: Consent for dental x-rays

Rob Loxley — Fri, 08 Jul 2016 00:06:16 GMT

[quote user="Evelyn Barbour-Hill"]To be frank I think the editor of the VDS newsletter erred a little too much on the side of fiction with this one.[/quote]

And they've clearly given a few people the willies. Reminds me of something with a blanket...

RE: Consent for dental x-rays

Evelyn Barbour-Hill — Thu, 07 Jul 2016 22:59:45 GMT

[quote user="Sarah Jervis"]

I absolutely agree that if the decision was down to me and I felt that it needed an x-ray, I would ideally just do it. BUT when you've explained to the client what you want to do and why, and that it will cost £x, and they adamantly say 'No, I do not want you to do that and will not pay for it', do you:

a) do the x ray anyway and charge for it, knowing full well the owner will likely refuse to pay, (and possibly get in trouble with the practice for doing so)

b) do the x-ray free of charge, and likely get in trouble for doing chargeable work free of charge

c) not do the x-ray and go against clinical judgement but do as the owner wishes

[/quote]

c) is not an option.

a) or b), I feel it's a pretty lousy practice where you could actually get into trouble for making the wrong choice. A bit of boss grumbling perhaps, but not real trouble. If you are in that sort of practice, throw it back at the boss: go and ask the boss what to do, and tell the client why they are being delayed. Any decent practice would have an atmosphere – a "culture" in the modern phrase – where the assistant sorry the employed veterinary surgeon is trusted to use their intelligence, their initiative, their knowledge and their training to make a decision. And if it's the other kind of practice, this situation should be covered by a written protocol.

It makes me very cross that an assistant should be put in such a difficulty.

I don't see any close parallel with microchipping. If radiography is an integral part of a dental procedure, I don't see why the client should be offered any option. If they say that they do not want any radiography, well, the dental procedure won't be done. Any boss who did not stand by his assistant in that situation is either a moneygrubber or an idiot, quite possibly both.

Sorry, got a bit carried away there.

[quote user="Robin Grimmer"]With cats you can often get away with leaving root in situ, but not in dogs (though I stand to be corrected)[/quote]

In either cat or dog it depends very much upon why you were extracting the tooth in the first place; also upon how much of it you leave behind; also on how much damage you did around the alveolus in the first place.

To be frank I think the editor of the VDS newsletter erred a little too much on the side of fiction with this one.

RE: Consent for dental x-rays

Sarah Bolt — Thu, 07 Jul 2016 21:50:10 GMT

Yeah, that's fair enough. I've not got the exact scenario to hand, but as long as the owner has had it explained and they declined then it becomes their decision, so in that we are agreed :-)

RE: Consent for dental x-rays

Robin Grimmer — Thu, 07 Jul 2016 21:28:26 GMT

I see where you're coming from. But as I understand it, the radiograph was discussed and declined on admission. Which is a bit different if a problem arises during the procedure. They should have contacted the owner, explained there might be a piece of root left behind, advised an x ray and then if they declined it the vet has covered themselves (and of course recorded all of this in the clinical notes.)

With cats you can often get away with leaving root in situ, but not in dogs (though I stand to be corrected)

RE: Consent for dental x-rays

Sarah Bolt — Thu, 07 Jul 2016 20:36:27 GMT

a) do the x ray anyway and charge for it, knowing full well the owner will likely refuse to pay, (and possibly get in trouble with the practice for doing so)

b) do the x-ray free of charge, and likely get in trouble for doing chargeable work free of charge

c) not do the x-ray and go against clinical judgement but do as the owner wishes

I don't feel you can blatantly go against owner wishes if they have been informed of the risks and the reasons why it should be done. My understanding is that if you are presented with a dog that is not microchipped, the advice is that we can't chip it without owner consent, all we can do is advise of the law and advise them that it needs to be done, but if they say no, we can't just chip it for them anyway. So if that advice exists for something that is legal, I don't feel I can take x-rays if the owner has explicitly said not to, even if it is against clinical advice.

I kinda feel like you can pass the buck to the owner if they are fully informed of risks and reasons and they still decline. If I went to the dentist and they said I needed an x-ray and I refused to have it done, I wouldn't consider the dentist negligent for not having diagnosed the problem...

Anyway, that's my thought but feel free to disagree / raise any points I may not have considered :-)

RE: Consent for dental x-rays

Robin Grimmer — Thu, 07 Jul 2016 16:25:07 GMT

Sounds like a bit of a cock-up to me. There's not many occasions when I feel the need to take radiographs for a dog dental, and when I do it's for planning/seeing if a tooth needs extracting, not afterwards to see if I've left any root behind! If you've left some root behind in an extraction in a dog, you would know about it. And I don't think you could pass the buck to the owner saying they didn't give consent. You're the vet - it's your clinical decision to know if it needs an x-ray or not. What would you think if you went to your dentist and he/she asked if you think you needed an x-ray?

RE: Consent for dental x-rays

Anthony Todd — Thu, 07 Jul 2016 13:41:38 GMT

[quote user="Evelyn Barbour-Hill"]A whole mouthful of pulp exposures. Yikes.[/quote]

I'm not sure they were even "planed" low enough...

The funny thing was the cat was "fine" and was in for something else.

RE: Consent for dental x-rays

Martin Atkinson — Thu, 07 Jul 2016 11:41:47 GMT

As a slight aside, I wonder how much we should discuss VDS newsletters here. A rather hypocritical question I admit as I have commented on the OP but it does say 'Members Only' at the top and I believe that appeared in response to a letter I once wrote to VT criticising one report some time ago. Its all anonymous but not sure if non-VDS members should be privy to the information regardless.

RE: Consent for dental x-rays

Evelyn Barbour-Hill — Thu, 07 Jul 2016 01:25:41 GMT

[quote user="Anthony Todd"]mouths I've seen where the teeth have just been "planed" above the gum lines, with all roots in situ.[/quote]

A whole mouthful of pulp exposures. Yikes.

RE: Consent for dental x-rays

Sarah Bolt — Wed, 06 Jul 2016 20:14:31 GMT

Thanks for all the replies, puts my mind at rest. I use the same approach as Stephanie describes in terms of both what I discuss with owners and my use of dental rads, and it sounds like it's what most of you are doing too, so reassures me that I'm not doing anything unusual :-)

RE: Consent for dental x-rays

Anthony Todd — Wed, 06 Jul 2016 17:01:40 GMT

[quote user="Martin Atkinson"] I've not had an abscess of problems due to a retained root in my career.[/quote]

Perhaps with the odd exception of a "loose" broken root sitting well exposed.

+1 ,and that includes mouths I've seen where the teeth have just been "planed" above the gum lines, with all roots in situ.

I'll be fashionable and blame it on "a locum".

RE: Consent for dental x-rays

Martin Atkinson — Wed, 06 Jul 2016 16:52:58 GMT

If I am aware of the possibility I have left a root fragment behind it is noted in the clinical history and the owner advised. In practice this applies to cats 90% of the time with partially resorbed FORLS. We will then give free dental checks to monitor it. I can't recall leaving a dog tooth root behind. There comes a point where the surgery to remove a retained root outweighs the risk of leaving it behind. I've not had an abscess of problems due to a retained root in my career.

RE: Consent for dental x-rays

Rob Davis — Wed, 06 Jul 2016 15:22:21 GMT

[quote user="Stephanie Fursland"]If I take a tooth out and it goes fine and all the roots are whole, I assumed this is enough to rule out roots being left behind... Should I be taking routine post extraction pictures?[/quote]

I have seen one or two Americans suggest that it is negligent not to take post-extraction radiographs. I don't subscribe to this view myself, and will only radiograph post-extraction if I have any concerns.

RE: Consent for dental x-rays

Evelyn Barbour-Hill — Tue, 05 Jul 2016 23:38:33 GMT

[quote user="Stephanie Fursland"] If I take a tooth out and it goes fine and all the roots are whole, I assumed this is enough to rule out roots being left behind...[/quote]

Yes, me too.

[quote user="Stephanie Fursland"]Should I be taking routine post extraction pictures?[/quote]

No, I can't think why.

RE: Consent for dental x-rays

Martin Atkinson — Tue, 05 Jul 2016 23:33:35 GMT

The expert witness used by the VDS stated that it was not possible to be certain that a root fragment would not be left behind after an extraction with or without x-ray. If you don't have dental x-ray where does that leave you?

RE: Consent for dental x-rays

Evelyn Barbour-Hill — Tue, 05 Jul 2016 23:31:30 GMT

Yes, I read that item in the VDS newsletter and thought it was very odd.

I've never yet asked specific permission for radiographs as part of a dental procedure and can't offhand think of any reason why I would.

I try to tell the owner in advance everything I'm going to do – as much as anything to make them appreciate it – so they know that radiographs are involved, in fact they generally appreciate already that radiography is just an integral part of dentistry. Radiography is not listed specifically on the consent form (although "including extractions" is specified, although that's another thread altogether!).

If for some odd reason the owners did state that they were withholding permission for radiographs, I'd politely explain that the job could not be done without, and if they persisted I would send them away.

And I don't charge separately for radiography, the charge is built in to the fee.

RE: Consent for dental x-rays

Stephanie Wellings — Tue, 05 Jul 2016 23:27:35 GMT

Ps sorry for answering your question with another question :-)

RE: Consent for dental x-rays

Stephanie Wellings — Tue, 05 Jul 2016 23:26:08 GMT

I tell owners that we x-ray if necessary - and I always say when admitting dentals that we can't tell how extensive the procedure will be before a full examination is done so signing consent for a dental is 'anything from a scale and polish to extracting a lot of the teeth' so I kind of feel like that covers x-rays at my discretion. We only charge about a tenner per radiograph or fifty for full mouth so I haven't had any objections on cost. Reading this did raise a bit of a question for me though - if you extract a tooth and you are sure all the roots are out, should you then x-ray? I use radiography for 1. Determining if a tooth that is 'questionable' needs to be extracted, 2. Looking for FORLs in cats and 3. If I am having difficulty or anticipate difficulty to check for abnormal roots etc. If I take a tooth out and it goes fine and all the roots are whole, I assumed this is enough to rule out roots being left behind... Should I be taking routine post extraction pictures?