Realizing the Risks With Emergency Dental Care

An emergency has been defined by Miriam-Webster as:

1:  an unforeseen combination of circumstances or the resulting state that calls for immediate action

2:  an urgent need for assistance or relief

Most frequently, the patient seeking emergency care is in pain.  It is important to realize that such pain may be physical or emotional. 

For example, consider the young patient who chips a central incisor biting down on a fork.  While the tooth may not be painful physically, there is emotional distress and pain associated with injury to his persona. Another patient may present with an acute buccal space swelling related to one or more dental abscesses. Both are emergencies. Managing emergencies in the general dental practice is often challenging for a host of reasons.

By its very nature, an emergency is never convenient for the clinician or for the patient. It usually requires some form of treatment that must be “thrown in” to the daily schedule, which may compromise time allotted for another patient.

Challenges faced when treating emergency dental patients

For practices that operate on a philosophy that expects emergencies, time for emergencies may be built in to the schedule. However, for practices that are geared primarily toward comprehensive or restorative dentistry, time for an emergency can be difficult to find. Efficient collaboration and teamwork among the office staff is essential for managing emergencies with a clear understanding of the scope of care that typically will be rendered during an emergency visit (e.g., provisional restorations vs. definitive restorations, incise and drain vs. antibiotic therapy, impressions for bite splints vs. prescription for muscle relaxants, etc.) Obviously, some leeway is needed depending on the emergency.

A second challenge is that new patients may be different than patients of record who present with emergencies. For example, there is typically an understanding of the patient's philosophy of care for a patient of record. If the dentist knows that a patient is an, “I come in only when there’s a problem” type of patient, then a more definitive action might be taken, like placing a direct restoration in a broken tooth.

However, if the dentist understands that the patient is a regular comprehensive care patient, decisions will likely be made as to how the challenge created by the emergency fits into or alters the working treatment plan. (Incidentally, in this author’s experience, comprehensive patients tend to have much fewer emergencies because anticipated crises have been managed early in the treatment process and have been planned proactively.) 

In contrast, the new patient who presents with a toothache may have a great deal of “baggage” that must be managed. New patients with emergencies may have many combinations of circumstances that that have led to their current state of crisis. Neglect, of their own doing or even by well-meaning previous dentists who have tried to appease a patient's predilection to lack of value for dental health, is often a cause that may manifest in the patient's negative recounting of previous dental care. 

They may have allostatic factors that alter their view of dental health (e.g., psychological disorders, social pressures from spouse or family, etc.). New patients also tend to present with multiple oral health crises requiring urgent care, but they only focus on one chief complaint (such as a broken tooth) when several abscesses and active periodontal disease are also present.

This poses a challenge of education and management strategy that may seem insurmountable to any clinician, because there is a conflict of values between the patient and the dentist. While the dentist is ethically and legally obliged to manage the potentially life-threatening conditions preferentially, the patient in this example values treatment of the obvious condition to them over issues that, from their perspective, are not pressing.

Risks associated with managing emergency dental patients

There is also a significant amount of risk associated with accepting an emergency patient and with managing the emergency. For example, many lawsuits have been settled or ruled in favor of the plaintiffs who have complained that the wrong tooth was extracted or treated. Many of these cases were problem-focused, or emergency, cases where the well-meaning and often well-trained clinicians were confused by confounding additional dental problems that may or may not have been the direct cause of the chief complaint. 

For example, one tooth hurts so bad that it masks pain coming from another tooth in the same quadrant. Once the primary tooth is extracted, the second tooth continues to hurt and worsen. In the patient's mind, the cause of the initial pain was not treated effectively in spite of the fact that it actually was - but this is a new problem.

The best defense against this type of claim is to document the presentation (including the chief complaint), the diagnosis of the specific problem treated (supported by the observations from the exam and interpretation of appropriate diagnostic tests and aids, e.g. radiographs, photos, etc.) and the informed discussion and treatment and/or referral rendered. The lack of appropriate documentation, especially in emergency cases, is a significant trigger for malpractice claims. For more information about documentation, check out Spear's articles on making sense of the clinical dental record and reading complete treatment notes.

Along with the legal risk associated with emergency care, the court of public opinion also presents risk. Today, social media allows an outlet for many people to vent about unexpected outcomes simply and without much accountability to truth.

For example, if a patient does not immediately get out of pain from an infection for which they are prescribed an antibiotic, they may immediately post a negative review about the treating clinician - even though antibiotic therapy typically takes 24 to 48 hours to take effect.

 Another example would be pain after endodontic debridement of a necrotic “hot” tooth.  Even though it is well-documented in the literature that post-op pain is very likely if an endodontically-involved tooth presents with pain, patients expect an immediate resolution to a problem that developed outside of the clinician’s control.

The problem is that, due to HIPAA and local privacy laws, clinicians are prohibited from “setting the record straight” with a response to explain their side of the story. This is an unfortunate reality that all healthcare practitioners face. 

The best practice for avoiding this is to make sure the patient clearly understands that the emergency exam is limited in focus to his or her chief complaint. They must also understand the scope of treatment that will be provided for that specific emergency situation and what they should expect for future follow-up. 

Ideally, the patient should be educated about the opportunity to have a comprehensive evaluation and explore the possibilities to improve their oral health more thoroughly as soon as possible. At least if the treatment results in a negative review online, an appropriate and accurate professional reply can be made. An example may be something like:

“Dental emergencies are never convenient, and we regret that sometimes discomfort that may or may not result from the urgent treatment required cannot be avoided. The best way to prevent dental pain is to keep regularly scheduled maintenance appointments and follow through with recommended treatment of dental disease as soon as it is recognized.”

The following case report illustrates an actual case where, despite appropriate care, the philosophical disconnect between the dentist and the patient (combined with unreasonable expectations) resulted in an unfavorable relationship.

CASE REPORT: Treating the emergency dental patient

SUBJECTIVE:

A 28-year old mother of three presents to the office for “a toothache” as a new patient. She had been informed by the receptionist that she has been “worked in for an emergency exam, and we can’t make any promise of any definitive treatment today.” During the initial interview and medical/dental history review, the patient states that she actually has two teeth that are hurting and points to the maxillary right second premolar and the left premolars (finger points to the embrasure between the maxillary left premolars). 

She states that it is very important to her to save her teeth and states that the tooth on the upper right hurts “real bad and swells sometimes. The upper left tooth hurts sometimes, too, but it hasn’t hurt for a week or so.” The patient reports that several dentists have “messed up” her teeth. In general, the presentation suggests a history of problem-focused dentistry; the patient reported that she has seen several dentists over the past few years because she has moved around the nation for her husband’s job. In fact, this patient is presenting with at least two dental emergencies in the time allotted for one specific problem.

OBJECTIVE:

A cursory dental exam reveals several missing teeth, multiple anterior maxillary veneers with composite repairs, and multiple large direct composite posterior restorations. The maxillary right and left second bicuspids have large restorations with caries and lingering cold sensitivity, and the right second bicuspid is sensitive to hot that lingers but not to cold. Two periapical radiographs reveal normal periapices, multiple areas of recurrent caries and deep restorations.

ASSESSMENT:

Tooth #3 has mesial caries with reversible pulpitis. Tooth #4 has a necrotizing pulp with acute dentalgia. Tooth #12 has irreversible pulpitis and recurrent distal caries. Tooth #13 has deep mesial caries and irreversible pulpitis. The patient is partially edentulous and has high esthetic expectations. The patient's husband, as discovered through unreasonable phone calls after initial triage care, creates significant allostatic pressure for the patient. There is an unrealistic expectation of a quick definitive solution, but the patient does not desire extraction of teeth.

PROCEDURE:

After an appropriate Informed Consent discussion, triage care was initiated on the most severe condition due to time constraints of the emergency appointment, which required rescheduling another patient. A gross pulpal debridement via a conservative access opening through the existing composite restoration in tooth #4 was completed followed by calcium hydroxide intracanal medication placement followed by cotton pellet and Cavit as an interim restoration. 

A glass ionomer restoration was placed after gross caries debridement of tooth #3. A prescription for a steroid was prescribed post-operatively as well as a prescription for penicillin VK due to the pulpitis related to caries on teeth #12 and #13, and an appointment for pulpal debridement was scheduled for five days later at the next available appointment time.  

Three days later, the patient called the dentist after-hours complaining that “the tooth broke completely.” The dentist agreed to see the patient after-hours that day to evaluate the situation.  During that visit, it was discovered that the entire existing composite restoration in #4 had come out (suggesting failure of the original bonding), but the buccal and lingual walls of the tooth were still intact, and the access opening was still sealed with Cavit. 

A glass ionomer provisional restoration was placed to stabilize the tooth at no charge to the patient.  The patient remarked at that appointment that she was “in no pain at all.”

The patient failed to show for the appointment to debride the pulps of #12 and #13 and did not reschedule. Three weeks later, the patient's husband called and demanded a full refund, stating, “My wife’s been in there two times, and she’s still not had her pain taken care of and her teeth are falling out. She’s going to another dentist who knows what they’re doing.”

DISCUSSION:

The issue here is not whether or not the patient was managed appropriately. It is an issue of lack of understanding on the patient's part, or on the part of the primary decision maker for the family. It is a fundamental misunderstanding of what constitutes appropriate and ethical care compounded with unreasonable expectations. 

The request for refund is, of course, unreasonable. However, the public consequences and potential for negative reviews on social media of holding firm with the fees charged must be weighed against granting the refund upon receipt of an appropriate Release of All Claims form that can be obtained from malpractice insurance carriers.