Dr. Fischman raises some points from a dental perspective regarding our article. We would like to respond to them from a broader medical and legal perspective.
The purpose of our article was to discuss ways of ensuring that dental patients were provided necessary information about the need to seek medical evaluation for HIV and how to ensure that such provision of this information was properly documented.
Dr. Fischman is in agreement with us that patients with potential systemic illness should be referred to physicians for further evaluation. He disagrees on the use of the form and is also concerned that we advise telling the patient upsetting information about potential HIV infection.
We agree with Dr. Fischman that, in the ideal case where the patient runs directly from the dentist’s office to an appointment with a physician, the form and the detailed warning are not necessary. However, dentists do not practice in an ideal world.
In today’s world of managed care it can take months to get an appointment, and patients without obvious symptomatic disease frequently give up before actually seeing a physician. In this world, patients must be given full disclosure to ensure that they will persevere and finally see a physician. In the (hopefully) rare case when the patient does not go to the trouble to see a physician, the form serves as documentation that the patient was properly warned.
Without the form, the dentist must rely on the dental record alone to document the conversation. Even if such records are very complete and detail the risks and other information given the patient, they are suspect as self-serving. If they consist of little more than "told patient to see a physician about HIV," they will be discounted by a jury for a simple reason: to a jury, HIV is so serious that the only reason a dental patient would fail to get a medical evaluation is that the patient was not really told about the significance of the risk.
Dr. Fischman may be correct in asserting that patients may be alarmed or insulted if they are informed that they have a condition that might be associated with HIV infection. However, it has been more than two decades since the courts have allowed patient fears to be used as an excuse for not providing full information about serious illness.
Dr. Fischman is certainly correct in saying that candidiasis is found in patients with other conditions (diabetes, use of certain antibiotics, xerostomia and others). These disorders or contributing conditions should also be evaluated, and the patient should be given proper information, perhaps including a patient information form that is analogous to the HIV form.
However, these conditions do not pose as serious a legal problem for the dentist because they are not communicable and thus do not put others at risk of contracting a fatal disease. Because of this important difference, the courts would treat HIV infection more strictly than other candidiasis-related conditions.
Dr. Fischman also raises the question of informing patients about the risks to themselves and others from potentially having diabetes. We would certainly disagree with the idea that the patient should be kept ignorant of the dentist’s concern about a potential medical condition and that the dentist should not discuss this concern with the patient.
We also think that a dentist could be legally liable (and professionally remiss) if he or she did not refer the patient for medical evaluation in the case of potential diabetes. This is the same argument that we made with regard to potential HIV infection and, as noted in the article, patient information sheets are a good idea for all potentially serious illnesses, including untreated diabetes.
While HIV poses special legal risks, dentists are vulnerable every time they fail to document that patients with potentially severe systemic illnesses were fully informed of the risks and the necessity of immediate medical evaluation.
Dr. Fischman also suggests that the dentist should not enter into the diagnosing and management of a patient’s diabetes. We would certainly agree that the dentist should not get into the realm of medical management except for the diagnosis and management of oral diseases that could affect the success of the overall management of the diabetic patient.
In the same fashion, we did not and would not argue that the dentist should offer an opinion on which laboratory tests or drugs should be used to medically manage HIV infection. However, in both cases, we will argue that the dentist needs to inform the patient of potential medical concerns and to refer the patient to a physician. This is essential to avoid being successfully sued for malpractice and, most importantly, for the patient’s well-being.
