Quality Resource Guide –
Management of Malpractice Risk in Dental Practice 2nd Edition
www.metdental.com
Page 3
Prosthodontic Therapy
Improper placement of crowns and bridges is
another area category of dental negligence. The
placement of permanent or temporary crowns
and
bridges
with
open
margins,
poor
contours, hyperocclusion, and lack of occlusion
or embrasure
space, is negligence. Crowns
placed with open margins generate many legal
suits.
Most of these cases come with a ready-
made expert witness for the patient, namely the
subsequent dental care provider.
Many patients
do not find out about improper placement of
crowns or bridges until a subsequent dental
professional brings it to their attention. Redoing
an improperly placed dental prosthesis can be
very costly and time consuming.
Because
of
the
expectation
that dental care should have been
done right in the first place, and the fact that the
redo is going to be costly, these cases tend to
have jury appeal as consumer protection cases.
Over-Adjustment of the
Occlusion
Dentists increase their risk for a potential
malpractice claim when they perform occlusal
adjustments in a haphazard, non-recorded,
fashion. Legal cases arising from occlusal
adjustment typically involve practitioners who did
not record the results of an examination and/or
a diagnosis substantiating a reason for occlusal
adjustment, or did not create a record of the
teeth that were treated. The adjustments were
usually completed in one sitting and occlusal
stops were not preserved. The patient’s occlusion
was over-adjusted and vertical dimension was
lost.
Rebuilding the bite in these situations is very
difficult. Many of these patients end up seeking
treatment from a plethora of providers in their
attempt to get relief, and many times the final
outcome is clinically undesirable.
Failure to Diagnose and/or
Treat Periodontal Diseases
Cases involving failure to diagnose and/or treat
periodontal diseases are relatively uncommon.
Most involve general dentists who have been
treating a patient for many years. Typically, there is
no evidence of periodic periodontal examinations
Obtained images should be reviewed carefully
and
thoroughly.
Undiagnosed
radiolucent
or radiopaque lesions should be evaluated,
noted, followed and, if appropriate, biopsied. A
diagnostic reason for taking a radiograph should
be documented as well as the findings from
interpreting the radiograph images.
Informed Consent*
Malpractice cases linked to “stand- alone” lack
of informed consent are relatively uncommon.
Typically, lack of informed consent is “bundled”
with negligent diagnosis and treatment claims.
It can be difficult to prove “stand alone” lack of
informed consent.
Informed consent requirements vary from state
to state. Some states, such as Massachusetts,
adhere to the requirement that informed consent
mandates disclosure of “material” risks, including
risks associated with non-treatment.
8
The premise
is that a
practitioner
must
give the patient enough
information to make an “informed” decision. What
is a “material risk”? “Materiality may be said to be
the significance a reasonable person, in what the
physician knows or should know is his patient’s
position, would attach to the disclosed risk or risks
in deciding whether to submit or not to submit to
surgery or treatment.”
9
That “materiality” decision
is left to a judge or jury to determine. There is
no “bright line” percentage, to determine what
is “material”. For example, a statistically low risk
may still be “material”, if it can cause great harm.
It has to be something that a reasonable patient
would want to know, before making a decision
to undertake treatment. For example, permanent
nerve injury following surgical removal of a third
molar, while occurring relatively infrequently, is
something a reasonable patient would want to
know. The plaintiff must also prove that the “risk”
materialized. This information typically requires
expert testimony. Any special risks that the patient
is exposed to, due to his or her medical status
(diabetes, cardiac heart disease) must also be
disclosed, preferably in the consent form.
*
A more specific discussion of informed consent in
the dental office may be found in the MetLife Quality
Resource Guide, Informed Consent.
or obtainment of appropriate diagnostic images.
A conclusion is quickly derived that supervised
neglect has occurred.
The author has seen
cases where a patient
has
gone
from
early
to
advanced periodontitis
over
their
time
with
a
dentist, with no
evidence
of exams
that
would
detect the disease and/or any evidence
of treatment, or referral, for the disease. The
outcome may be loss of all teeth and subsequent
prosthetic replacement. Often these patients
have a history of multiple dental visits and were
scrupulous about attending appointments. It is
usually a subsequent provider that breaks the bad
news to the patient.
Periodic and regular assessment of periodontal
status and appropriate therapy, or referral to a
periodontist, is important to perform and document.
Adequate and accurate records of findings and
recommendations are mandatory. If the patient
does not comply with recommendations, make sure
that the patient understands the consequences of
non-compliance and that this is also noted in the
records.
Failure to Diagnose and
Treat Oral Lesions
Failure to diagnose and treat, or refer, an oral
lesion that later progresses to a point where it
is not curable, is negligence.
7
Cases involving
oral lesions (typically on the lateral border of
the tongue) are usually those that were not
biopsied and progressed to advanced cancer. It
is very important that the practitioner periodically
conduct a review of the medical/dental history
and thorough intraoral exam on every patient.
If the practitioner notes a lesion, he/she should
reschedule the patient in 10-14 days, with follow-
up if the patient fails to keep the appointment.
Do not tell the patient to do self-examination and
return if it does not go away or worsens. Given
the severe damages that result if cancer is left
untreated, it is imperative that the dentist follow
lesions aggressively and perform, or refer for, a
biopsy if the lesion has not gone away within two
weeks. The size, location and a description of the
lesion must be documented as well as all follow
up appointments.