A 16-year-old attending alone, cosmetic request and an unexplained tongue patch

Consent position:

• Eighteen is the usual age of majority for consent to treatment in this jurisdiction; a 16-year-old is a minor unless emancipated (for example by marriage) or unless the mature-minor principle is applied by the clinician and can be justified.
• Veneers for fluorosis are elective, irreversible and aesthetic - not urgent, not medically necessary. They remove sound enamel permanently and commit her to a lifetime of maintenance and possible replacement.
• A practice policy of treating over-16s 'as adults for routine care' is an administrative convenience, not a legal authority to perform irreversible elective treatment on a minor without parental involvement.

What I would do:

1. Complete an examination and record the findings.
2. Explain, in a way she can understand, that the mottling is mild and that alternatives exist - no treatment, bleaching, microabrasion, or resin infiltration, some of which are reversible or minimally destructive.
3. Explain that because she is a minor and the treatment is elective and irreversible, I need her parent or guardian to be involved in the consent discussion, and invite her to bring them.
4. Give her time. There is no clinical urgency, and her request may change once she understands the alternatives.

What I would not do:

• I would not prepare teeth or place veneers at this appointment.
• I would not simply refuse and discharge her; the second, more important, problem needs to be addressed.

Significance: a white-and-red patch on the lateral border of the tongue present for two months is a red flag. The lateral border and ventral surface are the highest-risk sites in the mouth, and any ulcer or patch persisting beyond two to three weeks without an identifiable cause must be investigated.

Differential:

• traumatic or factitial ulcer (no obvious cause found here, but ask about tongue biting, chewing habits and sharp margins)
• oral lichen planus or lichenoid reaction (usually bilateral, reticular)
• chronic hyperplastic candidosis
• frictional keratosis/leukoplakia
• squamous cell carcinoma - uncommon at 16 but not impossible, and the site and duration make it the diagnosis that must be excluded
• less common: tuberculosis, syphilis, haematinic deficiency, Crohn disease

Urgency: high. This meets the criteria for an urgent suspected-cancer referral, not a 'review in three months'. She should be seen by an oral medicine or oral and maxillofacial unit within two weeks for assessment and, if indicated, incisional biopsy.

What I must not do:

• Do not prescribe an antifungal, chlorhexidine or a 'trial of treatment' and review later; delayed diagnosis is the commonest cause of harm in these cases.
• Do not excise or biopsy it in a general practice setting as a first step.
• Do not photograph it for social media or teaching without consent.
• Do not record it as 'anxiety-related' and move on.

I should also record the clinical description, size, site, duration, and the fact that the patient was informed and advised.

Confidentiality: a 16-year-old is entitled to confidentiality in principle, and I should not casually breach it. But confidentiality is not absolute, and it is not the main problem here - the main problem is that a young person may be declining investigation for a potentially serious lesion.

Approach - least intrusive first:

1. Explain plainly, at her level, why the patch matters and why waiting is risky. Explore her fears - fear of parents, fear of cancer, fear of the procedure - and address them.
2. Ask permission to speak to her parents with her present, or offer to see her with a parent and to let her decide how much is shared. Most refusals soften when the young person is supported rather than confronted.
3. Offer written information, a leaflet on urgent referral, and a direct route back - an open appointment.
4. If she still refuses, she is a minor and lacks the legal capacity to refuse necessary investigation outright; in her best interests, and where a serious diagnosis is possible, informing a parent or guardian is justified and is the expected course. Share only what is necessary for her care, and tell her what you are going to do and why before you do it.
5. If no guardian can be engaged, contact the oral medicine/OMFS unit for advice on how to proceed and consider whether local safeguarding procedures apply.

Documentation - contemporaneous and factual:

• full description of the lesion (site, size, colour, margins, induration if palpable, duration) and the examination performed;
• the differential diagnosis and why urgent referral is needed;
• that she was told the findings and the recommendation, in language she could understand;
• that she declined, her stated reasons, and the alternatives offered (parental involvement, written information, open appointment);
• who was contacted and when, and the outcome;
• any safeguarding or consultant advice obtained.

Poor documentation, not the refusal itself, is what creates the professional and legal exposure later.