Untreated dental issues in children are a societal problem. Although most dentists are aware of their ethical and legal obligations to at-risk pediatric patients, their professional responsibilities might be unrealized if these children never have access to dental care.
Barriers to children receiving dental care vary, but may include financial constraints, lack of knowledge about the seriousness of a patient’s condition, or parental disengagement.
Dentists need to identify the extent to which they are willing to commit their efforts to the at-risk patient population. The more expansive the investment of time and energy, the more comprehensive the planning will need to be. Following are several examples of elements that should be considered in the development of an at-risk patient plan.
The American Dental Association (ADA), the American Academy of Pediatric Dentistry (AAPD), and state and local dental societies provide a variety of services and resources designed to inform and assist dentists who treat at-risk pediatric patients. At a local level, it is helpful if charitable organizations and free clinics provide standard-of-care dental services and accept dentists’ referrals of needy families.
Dentists who donate their time to community-supported healthcare efforts need to ensure that appropriate standards of care are being met. Policies and procedures for charitable work oblige dentists to engage in the same rigorous diagnostic, treatment, infection control, follow-up, and documentation processes as they would in their own practices.
Often, financial issues create a barrier to children receiving necessary dental treatment. In some instances, children never see dentists until they experience severe dental problems or traumatic injuries. In other situations, parents cannot afford to complete a child’s treatment plan and prematurely terminate the patient’s appointments.
Because of these financial concerns, dentists should be aware of organizations and programs that can help provide access to dental care. Some independent state and local initiatives support emergency pediatric dental treatment. State dental associations can advise dentists whether any such initiatives are available.
Children in families with incomes too high to qualify for Medicaid, but too low to afford private coverage, can get healthcare coverage through the Children’s Health Insurance Program (CHIP). Each state offers CHIP coverage in coordination with its Medicaid program. The amount of money available per child varies by state and amounts covered differ based on whether the dental appointment is preventive or therapeutic. For more information about CHIP, visit Medicaid.gov.
Parental lack of knowledge about a child’s dental needs also can create a barrier to care. To encourage parental compliance, dentists need to reinforce the importance of parental partnership in the treatment of their children.
Every pediatric-focused practice should provide “welcome to the practice” brochures/pamphlets that (a) introduce the dentist(s) and staff, (b) explain the types of services provided, and (c) discuss the ways in which the dental team and the family should work together for the child’s benefit.
Parents may not understand the difference between preventive care and a diagnosis that requires immediate treatment. Further, financial concerns often are an obstacle to parental consent. The dentist should explain to the parents the risks associated with lack of treatment, including the difference between refusal of nonurgent care and refusal of urgently needed care, which may indicate parental neglect.
Unfortunately, many dentists are aware that at-risk pediatric patients are not always the victims of financially distressed circumstances. Parental disengagement can occur in any socioeconomic environment and represents another potential barrier to care.
Legal ramifications are associated with parents that refuse to authorize or follow through on needed care. The AAPD’s definition of parental negligence includes “the willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.” States also may enact their own definitions of abuse and neglect.
Based on each state’s regulations, parental noncompliance may trigger a dentist’s obligation to report suspected child neglect to the appropriate authorities. Failure to do so might increase the child’s risk of a serious condition, such as a life-threatening infection, as well as untreated pain. The higher the risk to the child, the greater potential liability may accrue to the dentist.
As effective liaisons between parents and dentists, well-trained staff members can help parents understand treatment plans and associated costs for their children. In addition, parents might be more willing to discuss their financial situations or their concerns about a proposed treatment plan with a staff member who can (a) assure them of the dentist’s expertise and concern, and (b) facilitate a thoughtful response from the dentist.
If parents do not comply with their child’s treatment plan, their actions should be documented in the patient’s dental record. All instances of noncompliance should be documented, including:
- Skipped or cancelled appointments
- Failure to see a recommended specialist
- Failure to comply with home care instructions, including administration of prescribed medication
- Acceptance or encouragement of a child’s inappropriate behavior that effectively makes treatment impossible
- Refusal to allow urgently needed treatment, including X-rays, antibiotics, and surgery
- Attempts to manipulate the treatment plan after it has been agreed to and initiated
- Withdrawal of the child from care before the treatment has been completed
Poor documentation impedes the defense of a malpractice lawsuit, regardless of the quality of the care provided to the patient. Documentation of interactions with the parents of at-risk pediatric patients is not only a valuable service to the child, but it also is the dentist’s most effective risk management strategy.
If a dispute occurs relative to an at-risk pediatric patient’s poor dental outcome, the dental record will demonstrate the dentist’s attempts to obtain parental cooperation and the results of the parents’ noncompliance.
Lax documentation remains a major factor in many dentists’ decisions to refund money, even when the quality of care was well within acceptable standards. If a dental record does not support a dentist’s contentions or note parental noncompliance, an unanticipated outcome might trigger a lawsuit that could have been prevented.
Many families are under financial stress; health insurance doesn’t always cover dental care and, even when it does, it may be insufficient to cover a family’s needs. Thus, dental care is not always a high parental priority.
Further, parents’ inability to commit to their children’s dental care might result from a lack of understanding about the long-term health risks that may burden a child who doesn’t receive urgently needed dental care.
Dentists who treat children need to plan how they will work with patients and their families to obtain the cooperation essential to the children’s care. These plans often expand beyond clinical issues and may include:
- Assessment of the community’s ability to provide charitable care
- Action plans when local services are inadequate to meet the needs of the at-risk population
- Billing plans that are sensitive to patients’ financial concerns but require that the responsible party acknowledges the dentist’s right to be paid
- Compliance with government and professional guidelines and requirements
- Development of office policies and procedures that ensure consistency and professionalism in the way dentists and staff members educate and work with patients and families
- Documentation of the quality of care provided
Determining how best to work with at-risk pediatric patients and their families can help dentists better facilitate doctor–patient/family communication and minimize risks.
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.
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