Are you sure it couldn’t happen to you?

Below are common scenarios many dentists believe will never happen to them. But claims reported to Guild Insurance tell a different story. These scenarios do happen; often causing considerable distress to the dentists involved.

Case example 1

A patient telephoned her dentist after-hours to report persistent pain and swelling post procedure. The dentist took the call on his mobile phone while driving home from work. He clearly recalls advising the woman to return to the practice the following day if her symptoms hadn’t settled. However, he didn’t make any record of their conversation. As the woman didn’t return the next day, he assumed her symptoms had subsided. Yet she was subsequently hospitalised with a systemic infection and later claimed the dentist was negligent in failing to diagnose her condition and provide adequate post procedure care. She denied he’d told her to return to the practice the following day if her symptoms had not subsided.

Case example 2

An endodontic file broke during root canal treatment, and a small fragment remained in the root. The dentist decided to leave the fragment and complete the filling as it was unlikely to be problematic. Unfortunately, he didn’t think it necessary to tell the patient.  The woman subsequently lodged a formal complaint 18 months later when another dentist pointed out on x-ray the “broken instrument lodged in her tooth”. She claimed the dentist had “deliberately tried to cover-up his shoddy work”.

Case example 3

A patient presented in pain with a deeply carious 37. He refused RCT, preferring extraction. The roots of the 37 were in close proximity to the inferior alveolar nerve. The tooth had a hot pulp and local anaesthesia was given both as a block and as infiltration, as anaethesia proved difficult. The extraction was challenging, but ultimately successful. However, the patient experienced ongoing numbness to his lips and chin. He successfully argued that had he known there was a risk of nerve damage he wouldn’t have agreed to the extraction. He said he’d always assumed extraction was the “simplest and best option”, and the dentist “hadn’t made any mention of nerves, let alone nerve damage”. While the dentist was adamant she’d warned the patient of the risks, there was no mention of it in the clinical record.

Case example 4

A new patient elected to have tooth 36 extracted, rather than try endodontic treatment. Periapical radiographs revealed bulbous roots and as such, the dentist warned the extraction might be difficult and referral to an oral surgeon may ultimately be needed. Unfortunately, the crown did fracture during extraction and the roots were subsequently removed without incident by an oral surgeon. The patient seemed satisfied with the outcome and no further contact was had. However, a year later the dentist received a solicitor’s letter alleging he’d been negligent in using prolonged and excessive force when extracting the tooth, and that he should have referred the man to an oral surgeon from the outset. The man successfully argued that the dentist’s actions had aggravated his previously undiagnosed TMJ condition.

Case example 5

A patient with a fear of dental procedures was prescribed Temazepam 10mg and instructed to take a dose one hour before his appointment. However, the dentist didn’t think to warn him that because the drug is a sedative, he should have someone else drive him to and from his appointment. Don’t assume patients will automatically know what you think is obvious or common sense!

Case example 6

A patient complained about the quality of veneers performed to teeth 11 and 21. At the heart of her complaint was that she “would never have agreed to veneers” had she known they “were not going to be the same size and feel as her natural teeth”. Expert opinion was subsequently critical of the quality of the dentist’s work, along with inadequate dental records and informed consent. It was near impossible to defend the dentist’s actions as she’d recorded next to nothing in the clinical record.

It may be tempting to view these cases as unfair criticism of dentists who “haven’t done much wrong”. But that’s rather short-sighted. Community expectations are driving higher standards of practice for all health professionals, dentists included. And at the same time, dentistry is becoming more complex and financially challenging. So unfortunately, those not willing to embrace necessary changes in practice are more likely to face an uncertain future.

When a patient does make a complaint against you, they’re really saying, “I came to see you and I ended up worse off”. That someone could end up “worse off” after a trip to the dentist never crosses the minds of most people. They just expect that with your credentials and expertise, you’ll be able to fix any problem. So when things don’t go according to plan, they often say, “I’d never have agreed to that treatment had I known that could have happened”.

It’s also tempting to underestimate the impact claims can have on the dentists involved. Not only may they feel hard done by, but their reputation and livelihood can be damaged too. Some people take to social media to broadcast their dissatisfaction, while every year hundreds of others make formal complaints to regulatory authorities like the Dental Board of Australia. And of course, many patients also seek financial compensation from the dentist for what they believe is sub-standard treatment.

Top 10 learnings from claims

It may surprise you to know, thousands of dental claims reported to Guild Insurance highlight the same recurring themes year after year. While there are no surprises in the top 10 learnings, it seems many dentists are still reluctant to heed the warnings. Don’t fall into the trap of thinking it couldn’t happen to you.

  1. Poor communication undoubtedly tops the list.

Our claims clearly show that if dentists don’t manage patient expectations from the outset, they significantly increase their risk of serious complaints.

Don’t assume that what’s clear or obvious to you is understood by your patients. You’ll often need to explain the same information more than once throughout the course of treatment.

  1. Informed consent to treatment runs a close second.

What’s an acceptable risk to one person may be completely unacceptable to another. And it’s the dentist’s responsibility to ensure each patient has the right information to make an informed decision about their treatment and associated costs. Avoid the temptation to assume you know what the patient considers to be reasonable or acceptable. And don’t simply ask someone if they understand, as in many cases they’ll say yes even if they don’t! Ask them to tell you what they’ve understood from the discussion.

  1. Claims reported to Guild Insurance make a compelling case for improving dental records. Hundreds of cases every year are extremely difficult to defend because the dentist’s records are so poor. The patient and the dentist often have different recollections of what happened, so in the absence of good records, the patient’s views tend to hold sway.No prizes for guessing this one … yes, dental records!

Yet our claims experience also shows that a dentist’s version of events is more likely to be accepted, if they can demonstrate that good record keeping is part of their usual practice. Not just for the patient in question, but for all patients.

  1. Don’t be tempted to perform procedures unless you can demonstrate the requisite training, skills and experience.

When sub-optimal outcomes occur, the quality and appropriateness of the treatment is frequently called into question. Importantly, you’ll be judged against what the dental profession considers appropriate standards of practice and training.

Therefore, it’s imperative that you keep pace with changes in dentistry and seek supervision when needed. It’s surprising how many dentists we meet who are not fully aware of their professional obligations.

  1. Similarly, resist the temptation to embark on overly ambitious treatment plans.

Take the time to think through the pros and cons of each possible treatment and your level of expertise in delivering what the patient expects. Many claims reported to Guild Insurance focus on allegations of poor quality treatment, where the patient seeks reimbursement of not only the initial treatment costs, but the cost of replacement or corrective treatment too.

Consider referring the patient to a specialist where appropriate, and carefully explain the difference between what you can offer and what a specialist can do. Likewise, weigh up the risks of adopting new techniques or equipment – don’t be blinded by commercial opportunities.

  1. Don’t be pushed into doing things against your better judgement.

There’s a common misconception that if a patient insists on a course of treatment, despite being warned against it, the dentist can’t be held accountable for poor outcomes. For instance, a patient may insist on treatment without undergoing the preferred radiographs. But don’t be fooled, as a registered dentist you’ll still be held accountable for the care you provide, even if the patient pressured you into it.

  1. Likewise, don’t be coerced into providing complex care during initial or ‘emergency’ appointments.

It’s important to carefully explain to patients what can and can’t be done during these appointments. Written material for them to take home also helps emphasize the need to return for a follow up appointment to further assess their oral health and agree a plan of care.

  1. Don’t agree to treat patients under The Child Dental Benefits Schedule (or any other program) without fully understanding your obligations first.

As dentists well know from the CDDS, there can be serious consequences for non-compliance. An updated guide for helping dentists to understand their responsibilities is available via the Department of Health website.

  1. Resist the temptation to make off the cuff comments to patients about the treatment they’ve received from another dentist.

Check your facts first! It’s possible the clinical situation you’re seeing is different to what the other dentist faced. Where possible, contact the dentist involved, or the ADA, to discuss your concerns before sharing them with the patient.

  1. Don’t rely on social media to inform your clinical decision making.

Much of this content is unchecked and unregulated. It’s always preferable to participate in recognised CPD and make use of the formal networks promoted by the ADA and special interest groups.

Furthermore, when making any posts on social media, carefully consider how your comments may be perceived by your colleagues, patients and regulatory authorities. Despite the often casual nature of social media, the rules of professional practice still apply.

Finally, seek regular feedback from your patients and staff about their experiences in your practice. They may see opportunities for improvement that you don’t!

For more information, please contact your ADA state branch or Guild Insurance on 1800 810 213.

Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them.

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