The Extraction and the Antibiotic
Dr. Priya Nair, DDS, extracts a mandibular third molar in a 58-year-old patient with type 2 diabetes and a history of prosthetic knee replacement. The patient is on metformin and reports no antibiotic allergies. Post-operatively, the patient develops swelling and a low-grade fever. Dr. Nair prescribes amoxicillin 500 mg three times daily for seven days and tells the patient to return in one week. The patient calls two days later stating the swelling has worsened and asks whether the 'girl at the front' can look at it. Dr. Nair is out of town and asks her dental assistant, who has been trained in expanded functions, to 'check the site and tell the patient to keep taking the antibiotic.' The assistant has not been formally delegated this task in writing.
1. Did Dr. Nair's antibiotic prescribing comply with the standard of care and Arkansas requirements?
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The prescribing decision must be based on an appropriate clinical evaluation. Dr. Nair evaluated the patient and prescribed amoxicillin, which is within the scope of dental practice for a post-extraction infection. However, the standard of care requires reassessment when symptoms worsen. The patient's worsening swelling and fever after two days on antibiotics suggests possible progression, and Dr. Nair should have arranged for a covering dentist to evaluate the patient in person rather than delegating to an assistant. Additionally, if the patient's knee prosthesis raises concerns, consultation with the patient's physician may be indicated. The prescription itself is not inherently improper, but the failure to ensure timely in-person reassessment is a standards-of-care problem.
2. Can the dental assistant examine the surgical site and advise the patient to continue the antibiotic? What are the delegation rules?
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No. A dental assistant may perform only those duties authorized by the Dental Practice Act and any expanded-function certification, and only under the supervision level specified. Examining a surgical site, assessing for infection, and giving clinical advice about continuing an antibiotic are professional judgment tasks reserved to the dentist or, where authorized, the hygienist. The assistant has not been formally delegated this task in writing, and even with written delegation, the assistant cannot independently assess a worsening infection. Dr. Nair should have arranged coverage by another licensed dentist who could examine the patient. Delegating clinical assessment to an assistant is unprofessional conduct and a supervision violation.
3. What records should have been created, and what should Dr. Nair do now?
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Dr. Nair should document the original extraction, the prescribing rationale, the patient's call reporting worsening symptoms, and the arrangements for coverage. She should arrange for a licensed dentist to see the patient promptly, and if the patient cannot be seen, direct the patient to urgent care or an emergency department. She should also document the delegation decision and correct the record to reflect that the assistant did not provide clinical advice. The record should include the antibiotic name, dose, duration, and the patient's response.