Wednesday, October 4, 2017

Managing Pediatric Dental Patients: Issues Raised by the Law and Changing Views of Proper Child Care


Article Title: Managing Pediatric Dental Patients: Issues Raised by the Law and Changing Views of Proper Child Care
Author(s): Donald C. Bross, JD, PhD
Journal: Pediatric Dentistry – 26:2, 2004 (125-130)
Date: 2004
Major Topic: Informed consent and behavior management
Type of Article: Conference Paper
Main Purpose: To increase awareness for need of proper informed consent, ways to improve current practices including behavior management techniques and where research is needed for future studies.
Key Points/Summary:
Summary: 
- It is no longer possible to provide care to children only on the premise that what dentists do is “for their own good.”
- Rather than reacting only to public pressures for better means of behavior management, the challenge is to exceed expectations via new research and thoughtful anticipation of improvements that can be made.
- Better management of pain, greater certainty of diagnosis, research supporting what is optimal care in different cases, and better-informed consent are all improvements that most reflective people would acknowledge.

Informed Consent Issues:
-When a parent is consenting on behalf of a child, the standard to consider is “what would reasonable parents in the same or similar situation want to know about the risks and benefits to their child before consenting to care.”
 What shoud be included:
      - Equivalent information about probable outcomes, risks, and consequences for each of the feasible alternatives for care is also essential for full informed consent.

It is important to note that some patients will not receive optimal care or any care at all because they “parents” won’t agree to the proposed care. 

-Informed consent allows parents to take responsibility for their children’s actions by indicating circumstances under which the dentist will not be able to provide necessary care with safety unless certain techniques or pharmacological interventions are employed. 

-As we have heard, patients are less likely to file a lawsuit against a dentist they like and trust.

-       Mistakes matter but are frequently accepted when the patient or patient’s parent likes the provider.
-       Communicating what is and isn’t possible is very important if inappropriate expectations of “zero-defect” dentistry are to be avoided.

Key note about Informed consent:
-       There are psychological limits to the process of informed consent for patients. For example, even though the possibility of death or serious impairment due to anesthesia is very remote in terms of probability, the worst possible consequence is something that most people can understand quite well. What most people appear to have trouble understanding is the meaning of probabilities and likelihoods for them as individuals. Thus, many patients sometimes cannot agree to something very beneficial to them, even though the probability of a catastrophic outcome is very slight. If the dentist withholds key informed consent information, even with good intentions, the dentist can assume an unwarranted burden


Behavior Management

-The possible risks involved with behavioral management techniques have not been well studied.
-There is almost no documented risk from most behavioral management techniques, the risks of anesthesia include brain damage and death however as better researched.
- Important to note that patients are anesthetized without death or other severe repercussions every day in the US. Indicating that there is an obvious need for patients/parents to be aware of possible adverse effects of treatments in the rare event it does happen, but to understand the risk/benefit ratio favors treatment.
- Given the amount of time left for pre-op, this can be difficult at times.

Further research topics:
-Research topics that might be considered are:
1. What are the adverse and positive effects from various behavioral management techniques? 2. How does the attitude of dentists towards patient control affect the “negotiation” of care?
3. Can the tradeoffs between various behavioral and pharmacological management approaches—as well as variations in the combined use of behavioral techniques and anesthesia—for the wide range of patients needing treatment be better explored?
 4. How can different pharmacological interventions and a broad range of communicative approaches be best combined for optimal results for different patients?
5. How is the use of behavioral techniques and anesthesia altered as a function of funding type for patient care?
6. How do parental decisions change when anesthesia needs to be paid for by the patient?
7. How do personal safety perceptions, caregiving characteristics, and protocols of dentists and their staff alter the need for specific behavioral techniques and pharmacological management? 8. What common procedures or techniques might be viewed as “shocking” or “inherently harmful” by the public, and how should these perceptions be addressed?


All these above topics need to be researched in order for Pediatric Dentistry to growth as a field to allow better provider/parent/ patient relations.

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