10.2 Presenting Current Conditions and Treatment Options, and Disclosing Iatrogenic Changes

The duty to inform (K2021)

The CDA Code, Section 1F, says: "A dentist has the obligation to inform patients of their present oral health status." The ADA Code frames the same duty through veracity (Section 5) and patient involvement (Section 1.A). Presenting findings and options is where these duties meet business pressure, so the codes set guardrails.

Presenting options ethically

1. Start with findings, then diagnosis, then options. Show the patient the radiograph or intraoral photo, name the problem in plain language, and explain its significance.
2. Present every reasonable option, including less costly ones, phased care, referral, and monitoring or no treatment, with the benefits and drawbacks of each. The CDA Code (Section 9) extends this to options outside the patient's insurance network or plan limits.
3. Separate recommendation from pressure. You may say which option you recommend and why. You may not exaggerate urgency, use scare tactics, or offer "today only" discounts to push clinical decisions.
4. Be truthful about materials and techniques. ADA 5.A bars representing care in a false or misleading way. Advisory Opinion 5.A.2 says claiming a treatment can diagnose, cure, or relieve conditions without accepted scientific support is unethical.
5. Disclose financial interests. ADA Advisory Opinion 5.D.2 says dentists who sell products must not exploit patient trust, must independently verify product claims, and should disclose whether the product is available elsewhere and any financial incentive.
6. Avoid disparaging prior care (Section 11.1). Describe the current condition factually.

Second opinions

Patients sometimes arrive for a second opinion on another dentist's plan, often at an insurer's request. ADA Advisory Opinion 2.B.1 says the dentist should give the opinion under the Code and, "in the interest of the patient being afforded quality care," should not have a vested interest in the resulting recommendation. Present your findings and the reasonable options neutrally. Do not use the visit to recruit the patient or to criticize the first dentist without justification (Section 11.1).

Iatrogenic changes (K2022)

An iatrogenic change is one caused by treatment: a separated endodontic file, a perforation, a fractured adjacent restoration, a lingual nerve injury, an extraction of the wrong tooth, a sinus exposure, an allergic reaction, or a restoration placed on the wrong surface. The outline asks about the ethical obligation to notify patients of these changes.

Why disclosure is required:

• Veracity: hiding a complication is a misrepresentation of the care given (ADA 5.A).
• Obligation to inform: the patient's "present oral health status" now includes the complication (CDA 1F).
• Autonomy and nonmaleficence: the patient needs the information to make decisions, such as seeing a specialist to retrieve a file or getting early treatment for nerve injury, and delay can worsen the harm.
• Trust and records: an honest, dated chart entry is required anyway (Section 2.2). The worst response is to change the record to hide the event.

How to disclose

1. Promptly, ideally at the same visit, once the patient is stable.
2. Factually: what happened, what it means for the tooth or health, and what can be done.
3. With a plan: referral, monitoring, or correction, and who pays for corrective care if appropriate.
4. Documented: record the event, the conversation, the patient's questions, and the plan.
5. Follow-up: check on the patient and coordinate with any specialist.

California's apology statute (Evidence Code § 1160) makes statements or gestures expressing sympathy ("I'm sorry this happened") inadmissible as evidence of liability in a civil action arising from an accident. A statement of fault is not protected. Dentists should notify their professional liability carrier as the policy requires, but the ethical duty to tell the patient the facts does not wait for the carrier.

When the Board must also hear

Some adverse events carry a separate legal reporting duty: a patient's death during a procedure, a death related to treatment, or a hospital or emergency transfer (always, for sedated patients) must be reported to the Board within seven days (B&P § 1680(z)).

Worked scenario

During root canal treatment on tooth #30, a file separates in the mesiobuccal canal short of the apex. The dentist attempts retrieval without success.

• Tell the patient at that visit that a small instrument fragment remains in the canal, explain that it often does not affect healing, and describe the options: completing treatment and monitoring, or referral to an endodontist for retrieval or surgery.
• Document the event and the discussion, and refer if the patient chooses.
• Saying nothing and writing "RCT completed" would violate veracity and the duty to inform, and could support discipline if discovered later.