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Consent or refusal: What every dental

practice should know


By Marianne Harper, and Colleen Rutledge, RDH

We in the dental field know the importance of accurate and complete documentation. We strive
to do our best to paint a picture of the patients condition, what treatment(s) are recommended
and performed, and the dentally necessary reasons for that treatment. If your practice has
implemented dental-medical cross coding, then the medically necessary reasons for treatment
must also be documented. However, there may be steps that some dental practices are missing
obtaining signed consent for treatment forms and signed refusal of treatment forms.
---------------------------------------------RELATED ARTICLES:
Tips on how to improve your dental treatment consent form: A legal perspective
Informed consent and informed refusal in dentistry
--------------------------------------------Informed consent implies that a patient has been given enough information to make a meaningful
decision based on the benefits vs. the risks of a proposed dental treatment. This information is
given verbally or on a form. Legally speaking, certain criteria should be met to be a legally
sound informed consent. Not all states have specific requirements to follow in this regard, but
they do require that some form of consent be obtained for certain types of dental procedures.
Often the criteria are set by dentists and their professional organizations. But the law still plays a
part by requiring dentists to provide enough information for patients to make informed decisions
about their dental care, and this information must be consistent with a professional standard of
care. The following should always be included in this information:
The reason why the dental treatment is necessary
What the proposed treatment will be

Any alternative treatments


The benefits vs. risks of the treatment
Who will perform the procedure
A way for patients to ask questions
The

question

then

becomes

whether this consent should be


verbal or written. It is accepted
that verbal consent is often times
sufficient for less complex dental
procedures.
documentation

However,
of

the

verbal

consent must be thorough. Verbal


consent can also be given over the
phone, but it must include all of
the elements mentioned above and be thoroughly documented.
Major dental procedures are best handled with a written consent. In either case, the information
must be presented in clear language that all patients can understand. Keep in mind that some
patients may not capture all that is presented verbally. A written form can be easier for some
patients to understand. Practices that use specific consent forms for different procedures cover all
bases by making sure there is a record of that consent. Practices in a multicultural area should
have these forms available in the major languages spoken in that area. These forms should be
dated, timed, and signed by the patient, dentist, and witness.
Not all patients have the capacity to provide consent, so practices should obtain consent from
someone legally allowed to do so. In addition, parties with power-of-attorney for health care for
those patients who are not mentally able should be the ones to give consent when it applies.
We must remember that patients have the right to refuse treatment. Dentists should discuss the
risks of no treatment to be sure that the patient understands the consequences. If this fails to

change the patients mind, then a refusal of treatment form that details the risks of no treatment
needs to be given to the patient and handled in the same manner as the informed consent form.
Consent/refusal forms for dental radiographs also require consideration. In 2012 the ADA, in
collaboration with the FDA, released updated recommendations for taking dental radiographs.
Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting
Radiation Exposure, which was updated in 2004, is available on the ADA website, giving
patients leverage to refuse dental radiographs. Using a dental X-ray refusal form allows patients
to make an informed decision, and gives dental professionals a chance to explain (in detail) how
radiographs serve to detect dental problems early.
Both consent and right to refusal forms may include various procedures, from smile makeovers,
veneers, dentures, crowns, bridges, and partial reconstruction and complete reconstruction, to
nonsurgical periodontal therapy and dental X-rays.
In the courtroom, medical records are witnesses whose memory never dies. Pubmed and other
sources provide this quote as a reminder of the importance of thorough documentation of
patients medical and dental records. Legally speaking, if it isnt documented it may not be
considered as done. Today it is absolutely necessary to document discussions with patients in the
patients records. The use of informed consent and informed refusal forms makes it a certainty
that this has been addressed.
Because different types of dental procedures require different types of information to accurately
complete the form, there are times when a standard form will not work. Examples of informed
consent and informed refusal forms follow. More forms and templates are available by
contacting the authors of this article.

Examples:
CONSENT FOR NONSURGICAL PERIODONTAL THERAPY
I have been informed by Dr. ___ that I have periodontal disease, and I agree to the following
treatment that includes but is not limited to the following:
1. Nonsurgical periodontal therapy in either one appointment, or two to four separate
appointments using:

Ultrasonic scaling and tongue disinfection with irrigationHost modulation


Periostat Rx, literature, and verbal information

Locally applied antimicrobials in all infected periodontal pockets

Noninjectable periodontal gel

Assessment of grinding or clenching habit

Periodontal risk assessment

2. My treatment can be maintained with routine three-month periodontal maintenance visits


with the hygienist
3. I am aware that some areas are more severely affected and referral to a periodontist may
be

necessary

to

achieve

optimal

oral

and

systemic

health.

I am willing to undergo all recommendations and have a good understanding of my


periodontal condition and my role in the success of my periodontal treatment.
___________
Date

_______
Time

______________________________
Signature of patient or authorized individual

_______________________________

Relationship of authorized individual

___ The patient or authorized individual has read this form or had it read to him/her
___ The patient or authorized individual states that he or she understands what is stated in the
form
___ The patient or authorized individual states that he or she has no other questions
___________
Date

___________
Date

___________
Time

______________________________
Signature of Dentist

___________
Time

______________________________
Signature of Witness

----------------------------------------------------------------------------------------------------------------------------------------------

INFORMED REFUSAL FOR PERIODONTAL THERAPY


I have been informed by ________ that I have periodontal disease, a gum condition that if left
untreated can progress and lead to further jaw bone destruction and tooth loss.
I have been encouraged to ask questions pertaining to my gum condition and was informed of the
strong correlation between periodontal diseases and other systemic diseases and total body
health.
Having been thoroughly informed of my periodontal condition, I voluntarily refuse to undergo
periodontal therapy, surgery or referral to a periodontist.
___________
Date

_______
Time

_______________________________
Signature of patient or authorized individual

_______________________________

Relationship of authorized individual

___ The patient or authorized individual has read this form or had it read to him/her
___ The patient or authorized individual states that he or she understands what is stated in the
form
___ The patient or authorized individual states that he or she has no other questions

___________
Date

___________
Date

___________
Time

___________
Time

______________________________
Signature of Dentist

______________________________
Signature of Witness

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