Ethical and clinical responsibilities of dentists

Drs. Sylvie-Louise Avon and Hagen Klieb provided valuable information for oral health care providers in their recently published article¹ on oral soft-tissue biopsy. However, 2 issues raised in the “Contraindications for Biopsy” section concern us.

The authors state, “It is unwise to proceed if one is uncomfortable with either the surgical procedure or the prospect of relaying devastating results to the patient.”¹ While we agree with the first part of this statement, we feel that the second part may be interpreted as a possible breach of ethics by the dentist. According to 3 Canadian provincial ethical codes,^2-4 a dentist’s first responsibility is a duty of care to patients. As written, the authors’ statement could be interpreted as possibly withholding essential care by placing the dentist’s personal feelings ahead of the well-being of their patient in this particular scenario.

The second area of concern is the concept of “medical clearance” of a patient. The authors state, “standard biopsy procedure may need to be modified and medical clearance obtained in the case of medically compromised patients…”¹ In addition, they state “clearance from the primary medical caregiver and baseline serologic studies should be considered for patients…”¹ We believe these statements perpetuate the false belief that dentists are obliged to obtain a “medical pass” from a patient’s physician in order to provide oral health care for their patients.  According to the authors of Burket’s Oral Medicine,⁵ “a physician’s advice and recommendation may be helpful in managing a dental patient, but the responsibility to provide safe and appropriate care lies ultimately with the oral health care provider.” It is incumbent upon dentists to ask specific questions of the patient’s physician in order to evaluate stability of their medical conditions and/or to consider possible modifications to provision of oral care based on their medical conditions in consultation with the patient’s physician.⁶

Response from the Authors

Drs. Stoopler and Sollecito raise valid concerns that should be further clarified. We certainly did not wish to imply that in the context of perceived devastating results, it is appropriate to withhold or defer essential care. There is no question that one should refer to a specialist when the technical procedure falls outside one’s realm of expertise. Similarly, timely referral to an appropriate clinician is necessary when there is a perceived difficulty, lack of familiarity or an inability to handle the postsurgical care.

This may not only include relaying and discussing a malignant diagnosis but also arranging subsequent referral as well as interim issues pertaining to pain management and nutrition.

We completely agree with the statement in Burket’s Oral Medicine¹ that "the responsibility to provide safe and appropriate care lies ultimately with the oral health care provider." Severe and uncontrolled systemic diseases have the potential to complicate surgery and the course of healing. It is certainly prudent to consult with the physician should there be any questions or concerns that would influence one’s management decisions.

Cite this response as: J Can Dent Assoc 2012;78:c108