Prium Non Nocere (“above all, do no harm”) is the principle precept of Medical Ethics and is also found within the ADA’s Principles of Ethics and Code of Professional Conduct under “Nonmaleficence”. The Principle of Nonmaleficence in brief states that the dentist has the obligation to provide the patient with proper diagnosis and treatment and to refer when necessary.

Today’s patients have a higher “dental IQ” than ever before and also have higher expectations regarding the treatment that they receive. There are many reasons which govern whether a procedure is performed by a general practitioner or if that procedure is referred to a specialty practice, but one’s personal economics should never enter into the equation. Likewise the patient’s trust in the general practitioner and fear of being referred to an unknown provider should not sway a dentist to perform a procedure that he or she otherwise would refer. The practitioner has an ethical and legal obligation to self-assess and decide if he or she has the expertise needed to manage a particular dental malady in a timely and predictable fashion. Every dental specialty association offers guidelines to the dental community concerning when it is prudent to treat or to refer a patient. And any local specialist would be happy to provide their general practitioners with lectures that review their specific specialty’s guidelines.

In general, reasons for a referral should be based on the level of difficulty associated with the treatment procedure for that specific case, the dentist’s personal level of expertise and confidence, the patient’s medical history, and/or the patient’s level of anxiety. Conditions specific to a patient such as a heightened gag reflex or limited opening, could make procedures, that otherwise would appear to be routine, very complicated. Proper diagnosis is paramount because only then can proper treatment follow. If the diagnosis was wrong, any treatment rendered, no matter how clinically excellent, is in reality a failure. This could lead to a patient’s loss of confidence in the dentist, the procedure, and in the dental profession. State of the art technology, instruments and the utilization of novel materials are no replacement for clinical skill and experience but are rather adjuncts that a practitioner can employ to reach a desired goal. It is imperative that a careful sequence of case selection and treatment planning be carried out based on the clinical presentation and the dentist’s own knowledge of his or her abilities and limitations1. The bottom line, as mandated by the ADA and VDA, is that the practicing dentist must be able to provide the patient with a level of care or competence that is consistent with the specialists who provide that same care in that same geographic area (this is The Standard of Practice). If a case exceeds one’s training or comfort zone or the general practitioner simply feels that it exceeds a personal level of competence, the patient should be referred. For a reasonable patient, who respects his or her dentist’s judgment and diagnostic skill, when time is taken to explain why a referral is necessary, the patient should be appreciative of the referral. The proper referral will actually allow the dentist more time for other procedures and will enhance the patient’s satisfaction and ultimately the doctor -patient relationship. The patient and the practice of dentistry will ultimately benefit from the ideal and proper treatment that is afforded to our patients.

In order for a referral to be a positive experience for the patient, general dentists need to have a good working relationship with each specialist to whom they refer. Most specialists will go the extra mile to treat an emergency patient in a timely manner. It should be understood however, that providers who regularly refer difficult cases will receive a scheduling priority and providers who only refer cases that had inadequate diagnosis or treatment, and want the specialist to “bail them out of trouble” generally will not receive top priority. A referring dentist should keep the specialist informed (verbally or in writing) of the suspected diagnosis, patient-specific nuances, treatment plan, what you anticipate as a treatment outcome, as well as what you have already discussed with the patient. Following any specialty treatment the general dentist should schedule a follow-up appointment with their patient. Of course the specialist should always provide a report following any treatment that includes appropriate information (as necessary) i.e. pre-op and post op images, histological diagnosis or the potential need for future procedures.

Advances made in dentistry have allowed our patients to maintain a functioning dentition for a lifetime, and any treatment alternatives that we offer our patients must have their wellbeing and health as our primary goal. We must always honestly assess our own level of expertise with regard to every patient’s unique treatment needs, and determine when to treat and when to refer.

1.      Law A.S., Withrow J.C., ENDODONTICS Colleagues for Excellence Spring/Summer 2005