Perspective: Dr Kia Pajouhesh

Media item: profile article

Date published: 1 September 2013

Subject of profile: Dr Kia Pajouhesh

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What this page records

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What follows is general information on a subject that determines more about the quality of dental care than almost anything else, and which is barely understood outside the professions: what informed consent actually requires in Australia. The practice's own account of the process is at Understanding Your Treatment.

Consent is a conversation, not a form

This is the single most important sentence on this page.

A signature on a form is evidence that a conversation happened. It is not consent. If the conversation did not happen, or did not cover what it should have, the form does not fix it. See How important is communication in dentistry?

For consent to be valid, three things must be true:

The person has capacity to make the decision.
The consent is voluntary — given without pressure, including the pressure of a discount that expires today. See Patient payment plans: the next big disruption on the dental horizon.
The person is informed — which is where the law does real work.

The duty to warn: Rogers v Whitaker

Australian law on this was settled by the High Court in Rogers v Whitaker (1992), and it set a standard that is patient-centred rather than profession-centred.

The principle: a practitioner has a duty to warn a patient of a material risk inherent in proposed treatment.

And a risk is material if either:

a reasonable person in the patient's position would be likely to attach significance to it, or
the practitioner is or should reasonably be aware that this particular patient would attach significance to it

That second limb is the important one, and it is why a practitioner should be asking what matters to you. A small risk of altered appearance is material to a professional singer, a public speaker or a wind musician in a way it may not be to someone else — but only if they know, which means you should say.

The standard is not "what other dentists usually mention". It is what this patient would want to know.

The Civil Liability Acts in each state have since modified aspects of negligence law, but the patient-centred approach to the duty to warn remains the foundation, and it is reflected in the Dental Board's code of conduct. The consequences of a failure to refer are illustrated in Record payout to patient for failure of GP's duty of care to refer to a specialist.

What a proper consent conversation covers

For any treatment beyond the routine:

The diagnosis, in language you understand
What the treatment involves, how long, how many appointments — see Meshel & Tommy Show: Tommy's Appointment for what an examination covers
The material risks and complications — specific, not "there are risks"
The realistic outcome, including that no result can be guaranteed. Where appearance is the point, The Mock-Up Reveal lets you see a proposal before anything irreversible happens.
The alternatives, including the least invasive option — see Can you reverse tooth decay? Do I need a filling?
What happens if you do nothing — every option has this, and a plan that omits it is not offering you a choice
The cost, itemised, with ASDS item numbers — see the Price Guide
Who will perform the treatment, and their registration — see Dentists & Registered Specialists and Our Team
What happens if it fails, and what that costs
Time to think, and the freedom to seek a second opinion — see Second Opinions and Corrective Dentistry

The risks that specifically should be warned about in dentistry

These are the ones most commonly under-disclosed, and each has generated real complaints:

Extractions and implants: nerve injury causing numbness of the lip, chin or tongue — usually temporary, occasionally permanent; dry socket; sinus involvement. See Wisdom Teeth and Oral & Maxillofacial Surgeons.
Any surgery, for anyone taking antiresorptive medication (bisphosphonates and similar): medication-related osteonecrosis of the jaw.
Crowns and veneers: the amount of tooth structure permanently removed; the risk the tooth later needs root canal treatment; the finite lifespan and the replacement cost. See Porcelain Veneers & Crowns, How long do porcelain veneers last? and 'Like a set of piano keys': why Australians are opting for veneers.
Whitening: that it does not change restorations, and that existing crowns or fillings may need replacing afterwards to match. See Teeth Whitening and Why should I go to a dentist for whitening?
Orthodontics: root resorption, decalcification, and that relapse is expected without lifelong retention — plus the ongoing cost of retainers. See Orthodontics and Will my teeth move if I've had braces and retainers?
Root canal treatment: the success rate for that specific tooth, and that a crown is usually needed afterwards, at additional cost. See Root Canal and Everything you need to know about root canal treatment.
Implants: peri-implantitis, and that the failure rate is higher in smokers and in people with untreated gum disease. See Dental Implants and What is periodontal disease?
Sedation and general anaesthesia: their own risks, and the separate anaesthetist and facility fees. See Sleep Dentistry and what sedation adds to your dental bill.

Consent for children and for people who cannot consent

For a child, consent is generally given by a parent or guardian. The child's own views should still be sought and given weight, increasingly so with age and understanding, and a mature minor may in some circumstances consent for themselves. See Children's Dentistry and Paediatric Dentists.

Where an adult lacks capacity, Victorian law provides for medical treatment decision makers and advance care directives. A family member is not automatically the decision maker — there is a legal order of who may decide. See Oral health care for children with special needs.

What consent is not

Not a form. See above.
Not permanent. You can withdraw consent at any time, including mid-procedure. Agree a stop signal — see Dental Anxiety.
Not a waiver. Signing a consent form does not sign away your right to complain or to competent treatment.
Not transferable. Consent to one procedure is not consent to another found along the way. If the practitioner discovers something different, the right course is generally to stop and discuss it, not to proceed.
Not something to be given under pressure. "This price is only good today" and consent do not belong in the same conversation.

If it went wrong

Raise it with the practice first, in writing — Contact Us.
The Health Complaints Commissioner (Victoria) handles complaints about health services, including cost and communication.
AHPRA and the Dental Board of Australia handle concerns about a practitioner's conduct, performance or health. Anyone can make a notification. See Finding a dentist online in Australia on using the register.
Every registered practitioner must hold professional indemnity insurance as a condition of registration.

Common questions

What numbers should I be given before agreeing to porcelain veneers?

Survival at stated time points, not a number of years. A systematic review pooling 25 studies and 6,500 porcelain laminate veneers put the 10-year cumulative survival at 95.5%. A second systematic review shows how wide the published spread is: studies followed for 10 to 12 years reported survival "ranging from 53 to 94.4%", and studies of 5 to 7 years a range of "47 to 100%". Both reviews are honest; the difference lies in case selection, what each counted as failure, and whose hands did the work. So ask three things: how much enamel is removed, whether the preparation stays within enamel — survival is "negatively affected by veneer preparations extending into dentin" — and what one replacement will cost you.

How likely is numbness after a lower wisdom tooth is removed?

A review of inferior alveolar nerve injury reports paraesthesia of any duration in about 0.35% to 8.4% of lower third molar extractions, and neuropathy at "1 - 20% temporary and 0 - 2% permanent", with permanent injury — sensory loss beyond six months — put at "less than 1%". The radiograph moves those odds more than anything else: overall 2.5% per tooth removal, but 0.8% when the nerve is classed as distant, 0.9% close and 11% when it is intimate, and 4.7% for horizontally impacted teeth against 0.9% for vertical ones. That is why the useful question is not the average but my film.

If my lip is numb afterwards, how long before it stops being temporary?

Most of it recovers, and quickly: the same review reports that 96% of inferior alveolar nerve injuries recover within four to eight weeks, with recovery rates barely affected by age or sex. Complete recovery usually occurs six to eight weeks after the injury, though it can take up to 24 months. The threshold to note is the two-month mark — "if paraesthesia is not completely resolved within about 2 months, the probability of a permanent deficit increases significantly". Age shifts this too: in one cited series everyone aged 29 or under recovered fully, while permanent dysfunction was significantly more frequent over 30.

What success rate should I be told for root canal treatment?

Ask which measure is being quoted, because the same treatment yields very different figures. Pooled success under strict radiographic and clinical criteria is 74.7% (95% CI 69.8–79.5%); under loose criteria it is 85.2% (82.2–88.3%) — reported success runs about 10.5 percentage points lower when strict criteria are applied. Tooth survival is a different measure again, reported at 82% to 95% over 2 to 10 years. Two further findings are worth raising: cited evidence puts 5-year survival at 98.1% when treatment was carried out by an endodontist against 89.7% by a general practitioner, and posterior root-filled teeth crowned four months after treatment were extracted at three times the rate of those crowned within four months. Delay in the restoration is part of the risk.

What should I be told before an implant, and what is the ongoing risk?

Two separate conversations. For early failure, a meta-analysis identified smoking, implants shorter than 10 mm and placement in the upper jaw as significant risk factors — which is why honest answers about smoking change the plan rather than the price. For the years afterwards, the risk is biological rather than mechanical: across eight cohort studies, peri-implantitis and soft tissue complications occurred in 8.6% of patients at five years, and in one smaller set of studies 11.7% of implants. Ask what the maintenance schedule is, what it costs, and who pays if the implant is lost.

Who is legally allowed to whiten my teeth?

Concentration decides it. The Dental Board of Australia states that "Australian laws mean only registered dental practitioners can use or supply high-concentration teeth whitening products (over 18% carbamide peroxide or 6% hydrogen peroxide)". A beauty salon or shopping-centre kiosk offering results that sound clinical is either using a product below those thresholds or operating outside the law — and that is a question you are entitled to ask before anything goes in your mouth. Verify the person treating you on the AHPRA register, free, at ahpra.gov.au.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. See also Our Location.

Every practitioner's registration can be verified free on the AHPRA public register at ahpra.gov.au.

This page records a published profile and its date. The archive does not preserve the content of the article, and the information above is general information rather than a summary of it. It is not legal advice, and the law varies between jurisdictions and changes over time. It is not a diagnosis or a treatment plan. Figures quoted from published research describe study populations, not individuals. Third-party published content is not reproduced.

Smile Solutions trades under ABN 28 193 514 103.