11.5 Emergency Treatment: Access During and After Business Hours

The ethical rule

ADA Section 4.B (Emergency Service):

Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record. Dentists shall be obliged when consulted in an emergency by patients not of record to make reasonable arrangements for emergency care. If treatment is provided, the dentist, upon completion of treatment, is obliged to return the patient to the patient's regular dentist unless the patient expressly reveals a different preference.

The CDA Code, Section 8, says the same, and Advisory Opinion 8.A.1 adds that a dentist treating a patient not of record "shall recommend to the patient to continue treatment with the original treating dentist unless the patient expressly reveals a different preference." The CDA also notes that failing to arrange emergency care can lead to charges of patient abandonment.

"Reasonable arrangements" does not always mean treating the patient yourself. It can mean seeing them, arranging a covering dentist, or directing them to the right level of care.

During business hours (K2161)

1. Triage every call the same day. Front-desk staff should use a written protocol and escalate to the dentist when they hear these red flags:
   • Facial swelling spreading to the eye or neck, trouble swallowing or breathing, or fever: possible airway-threatening infection. Send the patient to the emergency department or call 911 now.
   • Uncontrolled bleeding after surgery.
   • Avulsed permanent tooth: tell the caller to replant it or store it in milk or saline and come in immediately.
   • Severe pain, dental trauma, a broken appliance causing injury, or a post-operative problem.
2. Hold emergency slots in the schedule so patients of record can be seen promptly.
3. Patients not of record: see them, or arrange care elsewhere. Emergency treatment is usually palliative: relieve pain, control infection, stabilize. Then return the patient to their regular dentist.
4. Before the exam: B&P § 1684.5(a)(1) allows an auxiliary to take emergency radiographs on the dentist's direction before the dentist has examined the patient. Other treatment waits until the dentist examines, diagnoses, and plans.
5. Unpaid balances do not justify refusing emergency care to a patient of record. Handle collections separately.
6. Medical emergencies in the office follow the emergency plan in Section 5.3.

After hours and when the dentist is away (K2162)

Methods that meet the "reasonable arrangements" standard:

A recording that says only "The office is closed; call back Monday" is not a reasonable arrangement for patients of record. Sending every caller to a hospital emergency department is appropriate only for true medical emergencies, because many emergency departments cannot provide definitive dental care.

Related legal points

• Good Samaritan protection: a dentist who in good faith gives emergency care at the scene of an emergency outside their practice, or who treats a complication of another dentist's care at that dentist's request, is not liable for civil damages from their acts or omissions (B&P § 1627.5).
• CURES and prescribing rules still apply to emergency prescriptions, though several exemptions cover short, nonrefillable supplies (Section 9.1).
• Documentation: record after-hours calls, advice, and prescriptions in the chart the next business day.
• Reporting: if an emergency results in a patient's hospital transfer, check whether B&P § 1680(z) requires a report within seven days.

Treating another dentist's patient

When you treat someone else's patient in an emergency:

• Take a full medical history and get the patient's consent, even for palliative care.
• Ask who their regular dentist is and, when practical, contact that office about recent treatment.
• Limit care to what the emergency needs, unless the patient asks for more after an informed discussion.
• Send a report and any radiographs to the regular dentist after treatment. Sharing for treatment purposes is permitted (Civil Code § 56.10(c)(1)).
• Avoid disparaging comments about prior care (ADA 4.C) and return the patient to their dentist (CDA 8.A.1).

Worked scenario

At 9 p.m. Saturday, a patient of record calls. Her face has been swelling since the afternoon extraction, and she now has trouble swallowing.

• The on-call dentist tells her to go to the emergency department immediately, because trouble swallowing suggests a spreading infection that may threaten the airway, and calls ahead if possible.
• On Monday the office follows up, obtains the hospital records, and documents the call and advice.
• If the same patient had called with mild pain and no swelling, the on-call dentist could advise analgesics, schedule a morning visit, and document the call.