Legal Matters
Refusing the Red-Flag Patient — When Substance Use Complicates Treatment By Jake Kathleen Marcus, Esq.
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n AGD member recently wrote seeking guidance about managing a patient who arrived at his office apparently impaired. According to the dentist: The patient has come to the practice for appointments while intoxicated and occasionally reeks of alcohol. At her last appointment, she admitted to taking tranquilizers before coming in. Because the patient drives herself to and from appointments, I am concerned that she might harm herself or someone else. How should I proceed? Given the prevalence of substance use and abuse, this is a scenario that will likely happen to most dentists, and it presents legal, ethical and practical challenges.
Legal Considerations Perhaps the most basic legal issue concerning patients impaired by drugs or alcohol is that they cannot provide valid informed consent. Any treatment performed therefore fails to meet the standard of care and exposes the dentist to malpractice action and dental board sanction. From a medical standpoint, an impaired patient may have: • Altered vital signs. • Unpredictable drug interactions. • Decreased pain tolerance or responsiveness. • Complications due to drug interactions with local anesthetics or sedatives. • Inability to follow postop instructions. Treating an impaired patient therefore increases the risk of complications such as drug interactions, adverse reactions and aspiration. A poor clinical outcome may be deemed foreseeable and preventable, and therefore negligent, resulting in civil liability, disciplinary action by the state dental board or increased malpractice insurance costs. However, if the patient requires emergency care (e.g., uncontrolled bleeding, infection or trauma), the dentist is ethically bound to perform limited treatment, which is a defense against civil or dental board action. The nonelective treatment should: • Stabilize or provide minimal necessary treatment. • Avoid medications that could interact with suspected drugs. • Consider referring to a hospital or emergency clinic if impairment is severe. Whether a procedure is emergent or elective, a dentist is potentially liable for both the danger a substance-impaired patient poses
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AGD IMPACT
SEPTEMBER 2025