The patient attended the general dentist requesting porcelain veneers on her upper and lower front teeth. The dentist performed an examination and deemed she was a suitable candidate. The veneers were cemented four months later and the patient said she was happy with the result.
So what went wrong? ….a peer review of the treatment plan revealed a number of inadequacies in the planning, treatment and review stages.
At the outset the patient’s request for “white and bright” teeth was agreed to by the practitioner without first performing an assessment of the condition of the patient’s mouth with no periodontal charting and/or OPG prior to treatment starting. The practitioner was not in the habit of doing so and the Dental Board and the independent experts agreed this was unacceptable. The failure to perform an adequate examination meant that the practitioner was not aware of signs of periodontal disease (estimated to be pockets up to 5mm and recession up to 4mm) and ultimately several teeth had to be extracted after the veneers were placed. The dentist was criticised for carrying out extensive restorative treatment on someone who had ongoing and untreated periodontal disease.
The veneers were placed on the upper 13 – 23 teeth and the lower 43 – 33. After the veneers were cemented, root canal therapy was performed on 5 of the 6 lower teeth. Approximately three months later the 41 veneer had to be redone.
Adequacy of the planning process for veneer placement
The dentist was not in the practice of preparing temporary veneers or a diagnostic wax-up and this was found to be “significant problem” by an independent expert because “there is no idea as to what the technician should make it to as well as whether the patient knows whether she will be happy with the proposed restorations”. The dentist’s practice was to only send a photograph of the patient to her laboratory and leave it to the technician to make the restorations. This was not held to be an acceptable practice by the Board who commented that “there was minimal communication with the dental laboratory in relation to the design of the restorations”.
A second expert opined that study casts and diagnostic wax-ups of the proposed restorations were “mandatory in planning extensive treatment”. Providing the patient with the opportunity to review a mock-up of the veneers allows the patient the opportunity to consider the look and feel of the veneers before the tooth is prepared.
Poor outcome of the veneers
The final restorations were examined by an independent dentist as part of the Board’s investigation. That dentist found that the upper and lower veneers were over-contoured and had overhanging margins labially and interproximally. The twelve restorations were also found be substandard in fit, form and function.
The upper veneers were found to have affected the patient’s facial profile and appeared to be at least 1mm thicker than the external profile of the estimated previous line of the arch. The contour of the veneers appeared square and not in general keeping with the shape of the face. It was found that the level of the 13 and the 23 were not equal and the 13 was longer. The level of the teeth did not follow the profile of the lower lip.
Overall the veneers were found to be unsatisfactory and it was recommended that they be re-made.
After the restorations were placed, the patient attended for an emergency consultation claiming to be in “agony” with reference to a number of the lower teeth that had veneers placed on them. The dentist performed RCT to 5 lower anterior teeth. The Board ultimately found that that the endodontic treatment was “technically inadequate” because a number of the teeth had to be re-done. The expert periodontist found that a number of the endontically treated teeth were underprepared and under-filled which meant that the root filling did not fill all of the root canal system.
Whilst the dentist says she was only trying to help a patient presenting in extreme pain, she ultimately conceded to the Board that she rarely performed RCT and as a result of this investigation gave an undertaking that she would no longer perform endodontic treatment and would refer patients to a specialist.
Outcome of the Dental Board’s investigation and civil claim
The dentist was found to have behaved in a way that constituted unsatisfactory professional performance and was cautioned. She was also required to undertake education with a specialist approved by the Board at her own expense.
In the ensuing civil claim the independent experts retained on behalf of the dentist all agreed that the final outcome of the veneers and RCT was unsatisfactory and this patient required a significant amount of further restorative treatment. The claim was eventually resolved for approximately $35,000 which was based upon the estimate of further dental treatment by the independent experts.
Lessons to be learned
- Don’t be blindly guided by the patient’s wishes for restorative treatment without first performing a thorough assessment to determine the patient’s suitability for the treatment as well as advising of any alternative treatment options;
- A patient cannot be said to have provided you with informed consent in the absence of being adequately assessed and provided with the pros & cons of the requested treatment and the viable alternatives;
- When providing veneers the Board expects that the planning process will include study casts and diagnostic wax-ups of the proposed restorations. Sending a photograph to the laboratory is not sufficient. Allowing the patient to try-in the restorations is a vital checkpoint in the planning process.
- Even if a patient presents for emergency treatment you should still consider whether you feel comfortable providing that treatment and whether a referral is warranted.