Case study – the importance of performing a thorough examination and not just the requested treatment

The case:

The patient attended the general dentist seeking treatment for multiple broken and sore teeth. The initial treatment plan was to extract the 44 root stump, place a crown on the 14 and make an upper and lower denture. The upper denture was to support the missing 15 tooth and the lower denture was to support pontics/false teeth in the 37, 36 and 44.

The treatment plan was revised after the dentist examined the OPG and following further discussion with the patient. The patient said he did not want an upper denture and preferred something permanent so the dentist suggested he was a suitable candidate for a bridge. The patient also preferred not to have the 44 root stump extracted so the dentist said he would try to smooth down the root stump so as not to interfere with the lower denture. The dentist said he warned the patient that leaving the stump could ‘cause trouble’ with the denture.

The dentist took impressions for the upper bridge and lower denture and the upper bridge was eventually cemented. The lower denture was fitted and all seemed ok. The patient did not return for the planned 6 month check-up.

The patient’s complaint to the Health Commission painted a very different picture of the treatment provided by the dentist. The patient did not return to the dentist because he says he was so upset by the final product of the upper bridge and lower denture.   He says that the upper bridge had never felt right since it was placed.

The patient ended up attending a public dental service a little over 7 days after the upper bridge was cemented and lower denture issued. He was found to have a severely infected 47 which required extraction. Further radiology showed that the 17 had a periapical abscess and was also extracted.

The dental service found that the bridge was in “hyper-occlusion and high in normal occlusion/bite”. The dental service adjusted the bridge abutment on tooth 16. The dentist’s opinion of the restorative treatment performed on 16 was that the “bridge in this section appears not to be have been seated properly or too large (poor fit) for tooth preparation”.

A subsequent review by an independent expert found that the dentist had failed to examine and treat the underlying infections to the patient’s teeth in the upper and lower right quadrants. These teeth required extraction shortly after the treatment was completed by the dentist and the expert reached the conclusion that there must have been signs of infection apparent at the last consultation with the dentist.

With respect to the upper bridge (which was to replace the missing 15) it was noted that the dentist did not conduct vitality testing to the abutment teeth 16 or 14. The dentist says he did test for vitality but was not in the practice of recording that he had done so in his notes (unless there was a problem finding).

The expert was critical of the dentist for failing to take a periapical radiograph to review the root filling on the 14 prior to bridgework. The expert queried why the dentist had gone ahead with the bridge ‘when visible apical radiolucencies were associated with teeth 17 and 47 both of which subsequently required extraction’. The dentist was forced to concede that he did not take x-rays of the area where the bridge was being placed because it was his practice to only take x-rays if the OPG showed areas of concern.   This explanation was not accepted by the expert.

The independent expert ultimately found that the 14 should not have been used for the bridge because it was a root-filled tooth and too weak to be an abutment tooth.

The 16 was used to support the bridge’s ‘rest’ and that failed due to the nature of the patient’s oral condition. It also appeared that no recess was made available in the filling of the tooth 16 to accommodate the bridge’s rest, with the result being a rest that sits ‘above’ tooth 16 rather than sits passively ‘within’ the tooth as a stress-breaker. Either way, the bridge was found to have failed and the 16 required urgent attention because of its use as a rest tooth for the bridge.

The expert expressed the opinion that the dentist’s justifications for his treatment choices “demonstrated a basic lack of comprehension of pulp sensitivity testing and raised real concerns about the dentist’s ability to even understand basic endodontic diagnosis”. The expert found the dentist’s choice of bridge design was “difficult to justify” especially because the practitioner could not produce treatment records to support his explanations, and because there was no evidence of charting and no study casts.

The outcome

The case eventually settled for approximately $15,000 which included an allowance for pain and suffering (given the amount of time the patient had the unsatisfactory bridge and denture placed) and the costs of restorative treatment involved in the placement of the bridge.

Lessons to be learned

  • It is expected that practitioners’ records will record the advice given to the patient on treatment options and the patient’s consent. It is important that the records contain all diagnostic information relevant to that discussion. Working casts for items such as a bridge ought to be retained and practitioners must be able to demonstrate that the bridge design and insertion produced an appropriate fit for the patient.
  • The case reinforces the expectation that general dentists must be competent with their diagnostic skills including radiographic interpretation as part of treatment planning.
  • It is crucial that the treatment records include proper charting and the diagnosis following radiographic evaluations and all diagnostic tests, including vitality tests, percussion tests etc. and even where the results are ‘normal’.

It was noted that this dentist’s CPD activities consisted exclusively of on-line podcasts with his peers. The expert commented that practitioners benefit from interaction with their peers and attending education events in person can be of “immense benefit”.

Caroline Tuohey
Senior Associate
Meridian Lawyers

Kellie Dell’Oro
Meridian Lawyers