Ethics & Law · patient case question
A patient irradiated for a head and neck cancer ten years ago requests an extraction and REFUSES a radiograph. What is the most appropriate action?
Patient case: The business of the practice
Patient: Practice and population-level scenarios
Chief Complaint: Not applicable.
Background: A prescription is being written for prophylaxis. The practice insurance portfolio is under review. Rising floodwater is entering the building. A crown is being placed in a better material than quoted, at no extra charge. A patient irradiated for a head and neck cancer ten years ago requests an extraction and refuses radiographs. The local council is consulting on water fluoridation. A published cohort study is being appraised.
Findings: Not applicable.
Show answer and explanation
Correct answer: D. Do not proceed; consult the oncology team about the radiation field and dose, and explain to the patient why imaging is essential before any extraction
- A. Documenting a refusal records a decision; it does not license substandard care. A well-documented negligent extraction is still a negligent extraction.
- B. Imaging a patient who has explicitly refused is a battery. The refusal must be respected even where it is clinically unwise — the remedy is persuasion and, failing that, declining to treat.
- C. Dismissal without addressing an urgent problem abandons the patient. Explain, offer alternatives, and refer appropriately.
- D. CORRECT, and for two independent reasons. First, a patient may refuse a radiograph, but a dentist may NOT provide treatment that falls below the standard of care — and an extraction planned without imaging does. Informed REFUSAL means explaining the specific consequences of declining; if the patient still declines, the correct response is to decline that treatment, not to perform it unsafely. Second, the history transforms the risk: radiation-induced changes in bone are PERMANENT, leaving the mandible hypocellular, hypovascular and hypoxic, so the risk of OSTEORADIONECROSIS after extraction is LIFELONG and does not diminish with time. Whether the mandible lay in the treatment field and what dose it received — above roughly 60 Gy the risk becomes substantial — determines whether this extraction belongs in general practice at all, and that information comes from the oncology team.
Note: If extraction in irradiated bone proves unavoidable it goes to a specialist for atraumatic technique with antibiotic cover; hyperbaric oxygen is considered, though the evidence supporting it is genuinely contested.