By MaryAnn Digman, RN, MSHA, and Gail Harris, RN, MS, MA for MedPro Group
As patients are living longer, it is likely that they will develop medical conditions that could be problematic for dental care. Therefore, it is of paramount importance that dentists obtain, review, and update their patients’ health history at each visit. Dentists also should obtain complete medication lists from patients for all care, including routine oral healthcare.
Reviewing medical histories and medication lists is essential for patient safety as well as avoiding any allegations of practicing below the standard of care. In some situations, dentists also might need to seek medical clearance from a patient’s medical provider prior to commencing dental treatment. Likewise, dentists occasionally are asked to provide dental clearance for a patient prior to medical treatment or surgery, such as cancer therapy, total joint replacement, or cardiac surgery.
MedPro’s insured dentists commonly ask questions about medical and dental clearance. To provide an easy reference, this article includes the most frequently asked questions from insureds as well as answers from MedPro’s dental patient safety and risk consultants.
What is medical clearance?
Medical clearance is communication with a patient’s medical provider to validate that planned dental treatment is safe for the patient and to review possible changes to the patient’s medication regimen. This clearance may include laboratory tests, completion of a medical clearance form, and — in some cases — direct communication between the dentist and the medical provider.
When is medical clearance advised?
Medical clearance is advised whenever a patient’s medical diagnosis and/or medications could compromise his/her safety for dental procedures, including risks related to sedation or anesthesia during the dental procedure. For example, dentists should seek medical clearance prior to dental treatment for patients who:
- Use a continuous positive airway pressure (CPAP) device
- Have been diagnosed with sleep apnea
- Have any sort of pulmonary compromise
- Have coronary artery disease with symptoms
- Take anticoagulants
- Use bisphosphonate (either intravenous or oral)
Dentists should use their best clinical judgment to determine the criticality of medical clearance.
How should a dentist communicate with a patient’s medical provider?
A dentist’s location and familiarity with a patient’s medical provider might determine how information is communicated. Smaller communities may allow for direct phone contact while others may require the dentist to send a form to the medical provider.
Regardless of the communication process, the dentist should document the results in the patient’s health record — either by documenting the conversation that took place or including the completed medical clearance form in the health record. Sample medical clearance forms are available on the internet for reference.
What should a dentist communicate to a patient’s medical provider?
The dentist should tell the medical provider about the planned dental treatment and use of local anesthetic (including the use of epinephrine), any anxiolytics, nitrous oxide, and/or any sedation. The dentist also should specifically ask whether the patient is using any anticoagulants. If so, the dentist should ask the medical provider about the most recent international normalized radio (INR) or prothrombin time (PT) and the provider’s interpretation of the stability of the blood tests. (Dentists should understand the appropriate range of the blood tests.) Additionally, the dentist might want to ask the medical provider for a recommendation regarding continuation of the anticoagulant.
Is it acceptable to rely on the patient’s interpretation of the blood tests for anticoagulation?
No, in nearly all circumstances, a dentist should not rely on a patient stating that blood tests are stable or “okay” for dental care.
What should a dentist do if a medical provider does not follow through with a request for medical clearance?
MedPro Group strongly recommends that the dentist contact the medical provider’s office and ask to speak directly with the clinician. If the medical provider’s assistant is taking the message because the clinician is unavailable, the dentist should document the assistant’s name and title along with the message in the patient’s health record. It is the dentist’s prerogative to accept that message or insist on speaking to the clinician directly, depending on the patient’s health condition.
Has MedPro Group had malpractice cases involving medical clearance?
Yes, MedPro Group has had cases in which medical clearance was a factor. Most of these cases involved dentists who did not obtain medical clearances and patients who subsequently had adverse outcomes. Some cases involved anticoagulants, some revealed undisclosed pulmonary issues with a poor outcome after sedation, and some included patient cardiac arrest during treatment or grand mal seizure activity.
What is dental clearance?
Dental clearance is communication between a medical provider and a patient’s dentist to validate that planned medical/surgical treatment is safe for the patient and to review the potential need for dental treatment prior to the medical/surgical treatment. This clearance may include a current dental examination as well as treatment and completion of a dental clearance form. In some cases, direct communication between the dentist and the medical provider may be necessary.
For questions or more information
MedPro-insured dentists may call 1-800-463-3776 (press 3 for risk management) to obtain assistance and recommendations from an experienced dental patient safety and risk consultant.
As the nation’s leading dental malpractice insurance carrier, MedPro Group has unparalleled success in defending malpractice claims and providing patient safety & risk solutions. MedPro is the nation’s highest-rated malpractice carrier, rated A++ by A.M. Best. The Berkshire Hathaway business has been defending dentists’ assets and reputations since 1899 and will continue to for years to come.
This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.
MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and/or may differ among companies.
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