Informed consent: When, how, and why

Feb. 1, 2009
Informed consent in endodontics is the legal and moral standard of care.

by Richard Mounce, DDS

For more on this topic, go to and search using the following key words: informed consent, patient trust, communication, Dr. Richard Mounce, The Endo File.

Informed consent in endodonticsis is the legal and moral standard of care. It's the basis upon which patient trust is established and long-term relationships are maintained. I've long held the opinion that a lot of marketing wouldn't be necessary if there were optimum communication between patients and doctors. Rather than expensive marketing to attract new patients, it would be beneficial to focus on communication between clinicians and existing patients, to keep and grow the patient pool through optimal internal communication.

In an endodontic context, it's not uncommon for patients to arrive at a specialist's office with little communication between them and their general dentist. In these cases, patients have only a vague notion of what a root canal is and what it implies regarding time, cost, the actual process, and the future ramifications of the tooth (a crown, periodontal surgery, etc.).

In any event, having patients arrive for a root canal without knowing any details means a breach of communication between the clinician and patient. If dentists intuitively think about why patients leave our practices, it's almost always related to a lack of communication and patients having unmet expectations. Perhaps patients come in with unrealistic expectations. Perhaps they hear something (true or not) that plants an unrealistic idea in their mind.

These are just a couple of many possible communication breakdowns. Clearly, some patients will take more time to develop a relationship, but a one-size-fits-all system for managing patient communication is bound to lead to many patients slipping away.

The clinician should be certain of a diagnosis when addressing informed consent. Diagnosis means that the clinician has correlated the chief complaint with an evaluation of the restorability of the tooth with the percussion, palpation, mobility, probings, and thermal tests, and that the patient's chief complaint has been recorded and reproduced.

Being absolutely sure of the diagnosis allows the clinician to confidently address the patient regarding what needs to be done. Doing this can only improve case acceptance and the long-term success of the procedure.

The conversation with the patient should include a discussion of the planned treatment, the alternatives and risks, and all the patient's questions should be answered. A discussion of the planned treatment should include how long it will take, the cost, expected postoperative care, expected postoperative discomfort, postoperative restoration, and more.

Patients should have a complete understanding of where they are and where they're going with regard to the endodontic diagnosis. If the clinician is using an innovative instrument system like the Twisted File* or bonded obturation with RealSeal One Bonded Obturators*, it's good to mention this to patients. They'll feel reassured if they know they're receiving what the clinician believes is the highest standard in materials and methods.

Clinicians should not say anything to patients if they're unsure of the diagnosis, especially in the case of a tooth that will be referred to an endodontist. It would be better to delay judgment and let the specialist discuss the case with the patient rather than to tell the patient inconsistent information that may later be contradicted by the specialist.

Clinically, this scenario is prevalent in patients who have been in pain several weeks, yet are told that the doctor “didn't see anything on the X-ray,” and are prescribed Tylenol No. 3 and antibiotics. If the endodontist diagnoses and treats these cases quickly, patients are led to believe they were in pain unnecessarily and were mismanaged.

Early referral when the diagnosis is uncertain is the best path to take. The clinician can tell the patient that he or she is uncertain about the clinical situation and make an early referral, which is very different than saying, “I don't see anything on the X-ray.” This way the chain of communication is kept intact, the patient's expectations are met, and the patient is properly informed at all times.

I welcome your feedback.

*SybronEndo, Orange, Calif.

Dr. Mounce offers intensive, customized, endodontic single-day training programs in his office for groups of one to two doctors. For information, contact Dennis at (360) 891-9111 or write [email protected]. Dr. Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash.

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