We all know what informed consent is. Some of us do this verbally; others have it written and even signed by the patient. But your informed consent is only as good as your ability to anticipate what you expect to happen as well as the unexpected, but even more importantly, how your patient will respond when it happens. I recently had a situation with a female patient, let’s call her Justine. Justine came to me right when we first re-opened after COVID-19 closures, and she wanted me to “fix a broken filling”. Her upper second left molar had a massive old leaking resin and a portion of the palatal cusp fractured off. It also had a large overhang, causing severe food impaction and tissue swelling and bleeding. The first molar looked practically the same, with a similar overhang, and decay everywhere at margins, and this one had been previously endodontically treated. So I talk to her about having two crowns done, show her photos and her x-rays, describe in detail the overhang and food impaction, the decay present, and the need to crown due to limited healthy tooth structure remaining. After a long conversation, since she had endless questions, I advise her that the second molar is close to the nerve and could result in the need for root canal therapy depending on amount of decay found under the current filling as well as how her tooth responds to treatment. She then picks up her cell phone to call her husband to ask him what to do but doesn’t tell him anything but that I said she needs two crowns and the fee I quoted her. So I leave the room. I don’t get why people who rely on another person to tell them what to do don’t bring the decision maker with them to the appointment. But I leave and figure she will schedule the treatment or not schedule it and there is no point in me being in the room. We send her the estimate along with a templated Written Informed Consent I use for each patient needing a crown, and we email this to everyone we talk to about crowns. It contains all the info you need: why they need the crown, what to expect, what could happen, what are the other options, what to do in case they have pain or difficulty, etc. All is in there in detail, and my discussion with her documented in her clinical chart.

She comes back a couple of weeks later for the two crowns. The broken piece of tooth and the food impaction is really bothering her and she “can’t nurse her baby properly because of this”. So I do the two crowns. Massive decay underneath the old resin. I take intra-oral photos. Tissue between the two teeth is so inflamed it won’t stop bleeding. I manage to control the bleeding, remove all the decay, do the crowns, and tell her there is possibility of root canal on the back one since it was so deep. Give her my usual verbal post-op instructions that include hot and cold sensitivity for a few days, bite may need adjusting, to let me know in a week or two if teeth are still sensitive. We also send her the Written Post-op Instructions that have all that info in detail. So you would think I’d be covered, right?

Nope, she sends me a novel by email, describing in detail, which foods cause what type of sensitivity, and how it’s impacting her mental health. Long email to basically say she is having pain. So I tell her to come in. She comes in and then, again, describes every single disappointment that she has with the crowns and the pain she’s been in since I did them. She also reminds me that she didn’t have any pain before I touched the teeth so it’s my fault that she is in this pain now. So after beating me down for fifteen minutes, she finally allows me to look at the teeth. I check her bite, and she is heavy on the buccal cusps especially on the second molar. I tell her this and explain that this could cause sensitivity so I want to adjust this out. But I also want to do a cold test. She agrees. I do the cold test, she responds normally. She doesn’t seem to be experiencing the pain that she described to me, despite me putting ethyl chloride at the margin of the crown, tapping on the crown, blowing cold air at the cervical area of the crown, or chewing on a cotton roll. So I go to do the adjustment. Surely, if she is in such “excruciating pain”, she will not be able to tolerate the adjustment. I run my high speed with water, adjust out the interferences on the cusps, and nothing. I polish with the bumpy slow-speed. Nothing. She is totally fine. I ask her if she is ok and she says “yes”. I say “give it a few days more to settle” and tell her to let me know next week.

Next day, not week, I get another novel by email. She can’t “nurse her baby” because of the “pain I caused her”. She wants a prescription for Ketorolac. The manufacturer of this medication states that this is “contra-indicated when nursing” so I tell her that. She blows up in a barrage of 5 more emails before I can finally respond, practically freaking out on me and how it’s all my fault that she “can’t nurse her baby”. I tell her to come in. I check the crowns again, do all the testing, all normal. I tell her I am referring her to an endodontist to assess the tooth and remind her of the possibility of endo. And then she starts again about the baby. On and on how she can’t nurse the baby because she is in so much pain. Where is the pain? It’s everywhere. Show me. Just everywhere. I let her talk, vent, cry. She is crying now, big wet tears coming down her face babbling on about her baby, and how she won’t stop crying and her husband won’t help. And then I realize, finally, what’s really going on. I remember now that I had the same thing. When my baby was born, she never slept and I was exhausted. I was so exhausted that I didn’t eat, I didn’t sleep, and I felt everything. I was hypersensitive, and it was from pure exhaustion. So Justine is beyond exhausted. Her baby won’t stop crying, won’t nurse properly, her husband is freaked out and doesn’t know what to do so he does nothing, and Justine is a complete mess. And now, I did these two crowns, and her body can’t take any more so she can’t tolerate anything else.

Can you anticipate this? Maybe, sometimes, but there are times we just can’t. Some patients, no matter what we say, how much we tell them, no matter what they sign, they can still come back and haunt us. So how do you anticipate and how do you manage expectations? This is how I do it, and maybe this will help you with your protocols in your office.

For any dental work that I discuss with a patient, I have a standard verbal protocol. I say the same thing to each patient. What to expect, what the possible outcomes are, what they may experience, and what to do if unexpected happens. This gets documented in their clinical chart as I am saying it by my hygienist that is present in the room. My hygienist is writing in the chart what I advised the patient, and since what I say is the same thing each and every time, my hygienist can pretty much template it as they type. We then email the patient the Written Informed Consent that we have templated when we schedule the appointment. That way they have my verbal (documented in chart) and the written to read when they get home, and we document that we emailed the written in their chart. This way, everyone in the office, when they open the clinical notes, can read what I said to the patient. When they come in for their appointment, I then review the basics of treatment and what to expect and let them know I will go over everything at the end again. I then take intra-oral photos to show progression and, especially when deep or extensive decay is present, those photos get taken and documented in the chart as well. When I am done the procedure, I then show the patient the photos, discuss possible outcomes, and what to expect, as well as to contact me right away if the unexpected happens. This also gets documented by my assistant in the room as I am saying it to the patient, and we then email them templated Post-op Instructions, which also contain all that info. And we document that in the clinical notes.

Does this protect you from the “crazy” or the “exhausted”? Not completely, but it does help if they take it further. So template what you say, template the written instructions, make sure your patients get the paperwork, and document document document. Clinical notes are key not only in helping patients remember what was said to them previously, but also in helping others who may need to refer to those clinical notes to ensure that you did everything you could to manage expectations.