The 15-Year-Old and the Objecting Father
A 15-year-old patient presents with a fractured permanent first molar, pulp exposure, and swelling. The mother accompanies him and signs a generic 'consent to treatment' that authorizes 'all necessary dental care.' The parents are divorced; the mother has primary physical custody, and the father has joint legal custody. The father calls and says he does not want the tooth extracted because he wants a root canal and crown, and he will not consent. The dentist believes extraction is the only practical option because of the fracture and the family's insurance. The patient is in pain and has a fever of 100.8°F. The record contains no note of a discussion of risks, alternatives, or the father's objection.
1. May the dentist proceed with the extraction over the father's objection? Analyze.
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The dentist should not proceed over the father's objection unless the situation meets Montana's emergency exception. The mother has primary physical custody, but the father has joint legal custody; a generic consent signed by one parent does not resolve a joint-custody dispute for a major procedure. Fever and swelling may create an emergency if there is airway risk, spreading infection, or uncontrolled pain. If the child is stable, the dentist should manage the infection, document the father's objection, and seek both parents' consent or legal authority. If treatment cannot wait, the dentist must document the emergency assessment and why delay would harm the child. Insurance convenience is not an emergency.
2. What informed-consent elements are missing?
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Missing elements include: the diagnosis and basis; the nature of the extraction; risks such as bleeding, infection, dry socket, nerve injury, fracture, and the need for space maintenance or future implant; alternatives such as pulpectomy/root canal, crown, referral, or no treatment; the consequences of refusal; who consented and that person's authority; the father's objection; the patient's assent; and the emergency rationale if invoked. A generic 'all necessary care' form is not informed consent for a specific procedure with material risks and alternatives.
3. How should the record be corrected and what should be documented?
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The dentist should make a late entry, not alter the original record. The entry should include the date and time, the father's call and his stated position, the clinical findings, the emergency assessment, the consent discussion, and the plan. The original generic form should be retained. The dentist should document any consultation, the parents' responses, and follow-up instructions. If the dentist proceeds under the emergency exception, the record must explain the threat to the child's health and why transfer or delay was not appropriate.