Dr Suneel Chagger

CONSENT FOR IMPLANT TREATMENT

Consent is an active process of agreement and understanding by an individual for a treatment or procedure to be performed on them. If they are under 16 and/or are unable to satisfactorily give their own consent or not be in a capacity to give consent, a parent or guardian may do it for them. The decision whether the individual is incapable or incompetent of giving the consent lies with the judgement of the professional.
In all instances the professional must do his best to help the patient understand and involve him in the decision and consent process. This can be done by assessing if the person:


-Needs new skills or knowledge e.g. more explanation, more time, or need to be subjected to new experiences.
-Has someone e.g. carer, guardian or parent who can help with the communication process.

If after these steps, the person is still deemed incapable to make a consent a parent or guardian is able to do it for them. Occasionally if the treatment is necessary and in the patients best interest, the health professional can make the decision as long as it would be accepted by a similar peer group. This is usually common in life threatening or hospital environments. When considering the patients best interest, we must try to respect the patients beliefs and ethics eg cultural or religious such as use of animal materials that they would not want used as they are vegetarians or due to religious factors. (1,2)



In todays legal climate it is essential for practitioners to communicate with the patient so they understand and give their valid consent for treatment. In not doing so the practitioner is breaking his moral, ethical and possibly his legal duties. Individuals deemed not in capacity to consent, must still be provided with all the information in simple language that is required to:
1. Understand what the consent is for and what procedures are to be performed and why.
2. Understand the benefits, risks, costs and any alternatives.
3. Understand the risks involved if they were not to consent.
4. Remember the information, if needed have someone present and provide them with relevant literature, or media sources such as web sites /CD Roms etc. They must then be given enough time to absorb this information and understand it. How much time would have to be agreed by both parties.
5. Make a decision without any pressure or persuasion.

There are two types of consent which a patient could express (3)
1. IMPLIED. In this, consent for treatment is given by assessing a patients behaviour. For example if the patient attends the surgery, sits down, mouth open, a dentist may examine him and carry out other types of checks and minor procedures.
2. EXPRESSED. In this, the patient has expressed either verbally or by writing to have a procedure done. This is very important in dentistry where procedures are often physical, irreversible, or incurs some sort of risk or cost e.g. implants, bleaching or extractions. The majority of procedures carried out in dentistry e.g. fillings, scaling etc is done with verbal consent, but they too should have written consent as litigation increases, treatment options are increasing and patients are becoming more prudent and want more involvement in the decisions. For specific treatments such as implants, a verbal consent and a customised written consent should be taken. This is signed and forms a part of the records. This may need to be amended if the course of treatment changes, and in order to re-validate it the patient must again fully understand and consent to the change of treatment. In some situations procedures may change during the treatment for example bone grafting may be required for a minor defect during implant. These situations should be anticipated and the patients consent taken at the onset as it is now not feasible to stop the surgery, raise the chair and go through the whole consent procedure again especially if the patient is temporarily not in capacity to give consent e.g. Numb, sedated, disorientated etc.



Any type of consent can be withdrawn at any time by the patient.

The Implant consent form should be non-clinical jargon as possible so anyone can understand it. Difficulties can occur where terms like Osseo integration, autogenous bone graft or sinus lift are common terms. Possible risks should be mentioned along with how rarely they occur without going too much in depth. Unnecessary information is a high cause of patient stress and the chances are they may go elsewhere or not have the treatment altogether. A study by Casap N et al (4) concluded that patient who were given an overdisclosed documentation on having their wisdom tooth extracted had higher stress levels, measured through blood pressure, pulse and electrodermal activity. Asking patients their opinions as to whether they appreciated the information would help. It must also be set out in a clear concise manor with large clear fonts.


The consent used in our practice:

1. The patient understands everything involved in implants, given enough time to absorb any information and allowed to ask questions before making a decision to consent without pressure.

2. The treatment plan, its risks, benefits, costs and alternatives. These should outline each stage of the implant placement and the approximate times of them. Causes and risks of failure and the terms with which we will cover this, if this was to happen e.g no smoking, trauma not covered, regular checks.

3. Possible outcomes during and post-surgery, e.g. pain, swelling, the need for bone grafting.

4. Patient is able to specifically consent to having photos and the use of the records for other purposes e.g. cases, advertising, education.


This list should form the core of the consent. In the future more may be added when consents start becoming contract like, and healthcare professionals start handing them out as so for every procedure. It is for this reason that we must try to accept and imply the true value of a consent as a procedure through mutual understanding, communication and respect for the benefit of both the patient and the dentist. (5).




References

(1) Department of Health. Good practice in consent implementation guide: consent to examination or treatment.

(2) Department of Health. Reference Guide to Consent for Examination or Treatment.

(3)Yuill R. Consent in dentistry. Dental Profile. 2001;6-8.4

(4)Casap N. Alterman M. Sharon G. Samuni Y. The effect of informed consent on stress levels associated with extraction of impacted mandibular third molars. Journal of Oral & Maxillofacial Surgery. 66(5):878-81, 2008 May.


(5) Terry PB. Informed consent in clinical medicine. Chest. 131(2):563-8,2007Feb.