Riskwise June 2019

Risk management from Dental Protection

RISKISSUE 39 | JUNE 2019 WISEAUSTRALIA

The root of the problem or vice versa... Endodontic treatment is an area of dentistry that enjoys more than its fair share of dentolegal risk

Iatrogenic injuries Case studies What can be done to avoid them Practical guidance and learning from real life scenarios Editorial

DR JAMES FOSTER HEAD OF DENTAL SERVICES AUSTRALASIA/ASIA

W ELCOME TO THIS LATEST EDITION OF Australia of increased competition and pricing pressure, it may be RISKWISE, DENTAL PROTECTION’S helpful to reflect upon this. Unfortunately the events of a decade ago in Ireland saw a dramatic increase in the number of claims FLAGSHIP PUBLICATION, WHICH I against colleagues – a substantial number of which were the result HOPE YOU FIND BOTH INFORMATIVE of attempting complex treatments that would have been more appropriate for specialist care, whichever the domain. AND INTERESTING. However, in reflecting on Martin’s text, many of the problems that Feedback we receive from members has consistently shown a strong arise in the field of endodontics can happen even in the best of preference for the case studies with learning points that we include hands. The problem arises with an absence of a documented offer in each edition, and so we have taken this on board and increased the of referral to specialist care, even if refused. A patient’s lawyer may number that we feature – we hope you like the new format. win a case much more readily by proving a breach of duty in relation to the consent process, as opposed to a breach of duty in the actual In this edition, the main article is written by our head of dental treatment provided, which may simply reflect a recognised risk that services for Ireland, Dr Martin Foster, who provides some very helpful the patient has been made aware of. insights and tips on how we can minimise our risk in endodontics. This is followed by a section of case studies reflecting real life issues The same principles apply to all specialist care, and whilst the extent arising for colleagues, together with relevant learning points, which and availability of specialist treatment in Australia is enviable, it we hope are of value. may be worth reflecting on these issues to reduce our risk in general practice in leaner times. One of the most fascinating aspects of an international dentolegal role is seeing the differences in the experience of our profession As we approach a new renewals process, we look forward to from country to country. In general terms the dentistry remains the building on our success and reputation of protecting members in same, but the legal and regulatory environments and remuneration a challenging professional environment. We would like to remind mechanisms for dentists varies, and the cases arising tend to all members of their benefits, particularly the new workshops and reflect these differences. Other external influences have been seen webinars, which are proving very popular. Please refer to our website to influence the experience of claims and complaints– one such for further details of all events and the extensive e-learning that is example was seen following the financial crisis of 2007/8 in Ireland. available to all.

As part of the team handling cases for Irish colleagues at that Thank you for taking the time to read Riskwise and I hope you find it time, the impact of the crisis on the dental profession became very useful. As always, any feedback is most welcome – particularly in clear. Firstly, the demand for cosmetic dentistry and aesthetic relation to other topics you might wish us to include or changes you improvements plummeted. Many practices suffered financial loss, would like us to make to the publication. particularly those offering a more boutique style of treatment as opposed to the solid family bread and butter dental practice – Best wishes whose turnover was maintained through longevity and loyalty. The affordability of specialist care was stretched, and as a result, Dr James Foster LLM BDS MFGDP (UK) fewer referrals were made with more treatments carried out in- Head of Dental Services Australasia/Asia house. Colleagues in general practice were pressurised both by patients and their own financial pressures to provide treatment that [email protected] would normally have been referred on to a specialist. Martin’s article reminded me of this experience, and with the current situation in

2 Contents

The root of the Iatrogenic injuries Is it vital? problem or vice and what can versa... be done to prevent them

Endodontic treatment is an area of dentistry Wherever you are in the world, there is Carrying out a thorough assessment of a that enjoys more than its fair share of generally a legal obligation in place that patient’s oral health. dentolegal risk. sets out the duties of employers to ensure appropriate standards of quality and safety in a dental practice.

Editor Contributors Anna Francis Simrit Ryatt Louise Eggleton Design Alasdair McKelvie Conor Walsh

Print Avoiding Protecting your Professional Print herodontics reputation Services Production Emma Senior

Managing unrealistic expectations from Monitoring comments on social media the outset. platforms.

Cover: ©[email protected] RISKWISE | June 2019 | dentalprotection.org 3 gettyimages.co.uk ©MarioGuti@

The root of the problem or vice versa…

Endodontic treatment is an area of dentistry that enjoys more than its fair share of dentolegal risk. Dr Martin Foster, dentolegal consultant, looks how this risk can be managed and reduced

4 n the league table of treatments potential outcomes and costs is a good way CASE ASSESSMENT I giving rise to complaints and claims, of making an enemy. Avoiding these common Assessing any case before starting is the endodontics is near the top of the pitfalls makes a lot of sense: a structured key to managing both clinical and leader board. There are various reasons approach to include appropriate special dentolegal risk. for this. tests, a definitive diagnosis, restorability assessment and a demonstrable, valid It is important not to take on cases beyond First of all, endodontic treatment is consent process reflects good practice. your expertise and to recognise your inherently tricky. Even a straightforward limitations. Risks can arise from being talked case can have a variety of built-in risks and DURING TREATMENT into treatment, wanting to be helpful, feeling pitfalls to get in the way of an ideal outcome. Some complications can arise despite the sorry for patients, not being able to say no or best efforts of the clinician. All dentists know not being able to admit to having concerns No two root systems are the same. Nor are that an endodontically-treated tooth is more about the case. two patients. Both can be unpredictable. brittle and liable to fracture. A dentolegal risk associated with this is the possibility Patients may present with a less than ideal Another important factor is the operator. of a coronal fracture between visits, which root filling on a radiograph, but it is worth Historically, endodontic related cases tended renders the tooth unrestorable. The patient pausing before recommending re-treatment. to be associated with more recently qualified needs to be forewarned of this potential Consider first if you can improve on the dentists. This could lead to an assumption complication to avoid the dentist being clinical outcome. Do you think treatment that contributing factors – such as limited blamed for the loss of the tooth. All too many is necessary? Would the patient actually experience and over-enthusiasm – were cases arise from the patient forming the benefit? The position may be stable and resulting in treatment being embarked upon view that he/she would still have the tooth symptomless. Remember, patients measure that had a poor prospect of a successful if it had not been for the dentist messing up success as a tooth being retained in a outcome from the start. However, more the treatment – particularly if the tooth was functional condition with no symptoms. recently, there has been a trend that symptomless in the first place. suggests the majority of cases actually A structured case assessment – taking into involve more experienced dentists, so it is File fractures and perforations should account clinical and patient factors – can be clearly not quite such a simple picture. not happen, but they do. Taking a careful a very helpful way to avoid wandering into approach will certainly lessen the clinical risk. trouble and questioning what you As well as frequency of complaints and Dentolegal risk can be reduced by warning have undertaken. claims, endodontic cases can potentially be the patient of the possibility of complications costly to deal with. In many instances, the and their practical implications at the outset. One good example of a structured argument is put forward that the dentist Explaining something only after it happens case assessment tool can be found on the was responsible for causing the need for is often seen as an excuse by a patient website of the American Association treatment in the first place. From the patient’s unexpectedly facing additional of Endodontists.1 perspective, the tooth was not painful until treatment costs. the filling was placed. Then, after having A structured approach allows the clinician root canal treatment, the patient learned The best dentolegal defence in cases to categorise the difficulty of the case and that further treatment was necessary (eg a involving hypochlorite accidents or the to advise the patient accordingly. Managing crown, retreatment or even extraction and ingestion/inhalation of instruments or other expectations is an important part of reducing implant placement) all of which incurred an objects is making sure these don’t happen. dentolegal risk, but you can only manage unexpected and unwelcome cost for If they do, defence is… well actually, there is patients’ expectations if you have an idea of the patient. no defence. what to expect yourself.

POST TREATMENT SOME TIPS After treatment, dentolegal risks still remain. These may originate from a patient • Assess the case and manage patient No two root systems are disappointed to be having further problems, expectation. the same. Nor are two or surprised by an outcome that was not anticipated. Another source is from “second • Give a clear explanation of what to patients. Both can be dentist” syndrome – when another clinician expect with regards to outcomes, risks identifies a “problem” about which the and costs and avoid surprises. unpredictable. patient was completely unaware. This may be an issue that was not picked up • Be realistic and avoid herodontics - So how should dentolegal risk be reduced by the treating dentist. It may not actually know what is possible, when to say no when dealing with endodontic treatment? be a problem at all but simply a matter and when to refer. of interpretation of a result. A good post- PRE-TREATMENT treatment radiograph can be a helpful • Avoid too little rubber dam and too little Some dentolegal risks develop before defence against this dentolegal risk. control of hypochlorite. treatment even starts, so it is important that a thorough assessment of the case is made If there is a “sub-optimal” result, it is good to • Check files and canals carefully - if early on to prevent subsequent surprises for spot this at the time so that the situation can there is a fracture or a perforation, you the patient or dentist. be clarified with the patient. Any appropriate must be the first to know… and the steps can then be taken to remedy the patient must be told by you. A less than Making a diagnosis and deciding upon root problem or perhaps simply to keep the case ideal outcome can be made worse if not treatment in the absence of appropriate under review. The main thing is that the noticed/acknowledged or appears to radiographs is asking for trouble. So is patient is made aware of the situation. If on have been covered up. embarking upon a heroic quest to “save” a the other hand, the patient learns of an issue tooth of dubious prognosis. Also, protecting from a third party at a later date, it can be • Try to avoid “second dentist syndrome” the patient from a full knowledge of the risks, viewed as a more serious fault – or worse, a - know how to judge “success” in the cover up. work of others. REFERENCES

1. Endodontic Clinical Resources - American Association of Endodontists. American Association of Endodontists. 2019.https://www.aae.org/specialty/clinical-resources/ (accessed 28 Feb 2019). RISKWISE | June 2019 | dentalprotection.org 5 gettyimages.co.uk ©diego_cervo@

Iatrogenic injuries and what can be done to avoid them Wherever you are in the world, there is generally a legal obligation in place that sets out duties of employers to ensure appropriate standards of quality and safety in a dental practice. Simrit Ryatt, dentolegal consultant, looks into some iatrogenic injuries and what can be done to avoid them

his legal obligation can include a surgery, particularly where the risk has been It goes without saying that personal T delegable duty to team members identified but not corrected for a while. protective equipment at work should protect to make sure equipment used in both the members of the dental team and the treatment is safe and maintained to be No matter how proficient you are, there patients. All members of the dental team in good working condition in accordance are some scenarios that are impossible to play a part in identifying hazards and risks with manufacturers’ instructions. It is predict and are not under your direct control, and reporting them before they cause injury. nevertheless important to emphasise that such as sudden movements or the behaviour Risk assessment and reporting should be it remains the responsibility of the clinician of a patient. In light of this, it is important discussed at team meetings and follow- who is handling a piece of equipment that we manage risk by focussing on the up actions should be notified to all team to ensure a patient is not inadvertently variables that we can control, by ensuring members. It is also important to keep a record harmed, either by operator carelessness or that a regular risk assessment of the surgery of these discussions for future reference. equipment malfunction. equipment and operative procedures is carried out. To help your understanding of how incidents Experience is generally a good thing, as you can occur, we have highlighted some become more comfortable with dealing A good example of how this may be put into examples from our case library. We have also with challenging situations throughout practice is to plan procedures in advance and highlighted the learning opportunities each your working day. It is also worth bearing adopt a checklist approach to ensure that incident provided. in mind that an experienced clinician may the required materials and equipment are subconsciously become complacent about readily available and on-hand. the risk attached to hazards in a dental 6 CASE STUDY - A LACERATION CASE STUDY - A CHEMICAL BURN CASE STUDY - A BURN INJURY TO FOLLOWING AN EXTRACTION Miss C attended a surgery complaining of THE LIP AND CHEEK DURING AN Mr D attended the dentist and during his discomfort at tooth 27 following a dislodged EXTRACTION examination he expressed his wish to have restoration. A radiograph was taken, that During a surgical procedure under sedation, a dental implants to restore the existing space showed that the distal-occlusal cavity dentist caused an accidental injury to the lip he had from the extraction of teeth 45 and was in close proximity to the dental pulp and cheek of Ms W. The surgical procedure 46 around 20 years previously. The dentist and that there was caries present. Miss C involved making gingival incisions, raising a also noted that tooth 47 had fractured was made aware of the radiographic and flap and trimming away bone to remove a beyond repair, but other than that, the clinical findings and informed that root canal partially erupted 48. During the procedure, patient had maintained a good standard of treatment may be indicated. the right cheek mucosa was burnt by oral health. contact with an electro-surgery tip that was As anticipated, during the process of being used to trim some soft tissue. HOW DID THE ACCIDENT excavating caries, the pulp was exposed and HAPPEN? the first stage of endodontic treatment was HOW WAS THE SITUATION At a subsequent appointment, the dentist carried out. During irrigation of the root canal MANAGED? was using a luxator around tooth 47 that system, the irrigation syringe tip detached The wound was carefully cleansed and slipped and lacerated the adjacent soft from the body of the syringe and a small closed with sutures. tissue. The laceration on the inside of the volume of sodium hypochlorite splashed cheek was severe and extensive. over the patient’s face. Miss C was advised The patient's fiancé joined her in the recovery to immediately rinse her face, and the initial room, and although they accepted the HOW WAS THIS MANAGED? stage of the endodontic treatment explanation at the time, they called later that The dentist explained what had happened was completed. evening to complain. to the patient and offered an immediate apology. The area was sutured and a review At the subsequent appointment Miss C A month later the wound had healed fairly appointment was arranged for the following reported some soreness in the area affected well, but there was a residual indentation day. The patient was contacted by telephone by the hypochlorite. The dentist completed remaining which was quite apparent. Ms W later in the evening and he explained he was the endodontic treatment and was satisfied was concerned the indentation would be in some discomfort and was aware of some with the postoperative result. The patient present in four months’ time, when she was swelling in the area of the wound. complained and requested compensation due to get married. The dentist and his clinic for the adverse incident and threatened to agreed to arrange treatment for her with AT THE REVIEW APPOINTMENT escalate her concerns to the AHPRA. a plastic surgeon and they were informed At the subsequent review appointment the there was a good chance the wound would wound was assessed and the swelling noted. After seeking advice from Dental Protection, heal completely with minor surgery. As the injury had been caused by an error in it was agreed that the treatment fees technique, the risk of this type of injury had should be waived and a contribution was Ms W went on to claim for compensation. not been discussed. made by Dental Protection towards the Although the dentist had expressed his cost of treatment provided by a specialist regret at what had happened and arranged The patient subsequently had to take a week dermatologist. for further specialist care, there was still an off from work and advised the dentist of his expectation that the exercise of a reasonable intention to claim for compensation for his LEARNING POINTS standard of care would have meant that pain, suffering and loss of earnings. such an injury would not have occurred. • Reflecting upon his treatment, and with The dentist called Dental Protection and the benefit of hindsight, the dentist LEARNING POINT our team was able to negotiate an early acknowledged he should have used a and appropriate settlement, protecting the rubber dam. The dentist always found • A team meeting was held following the member’s position and avoiding any risk accessing the tooth easier without incident and everyone acknowledged of escalation. a rubber dam and would generally how potentially easy it was to cause place it after gaining access. He did such an injury, especially when patients LEARNING POINT not routinely apply a rubber dam at have been locally anaesthetised and also emergency appointments, and the sedated. In recognising the risk, the • Although the dentist was very incident reminded him of the need to do team were in a position to avoid future experienced, the error was attributed so in future. occurrences. to a lapse of concentration which had unfortunate consequences. On • Always ensure that the irrigation needle reflection, the dentist realised perhaps is fully engaged on the body of the his access to the area could have been syringe and avoid excessive force during improved and his finger rests more the irrigation process. stable and sturdy. His reflection and subsequent analysis was recorded and shared with the rest of the team in the expectation that a similar situation may be prevented in the future. Images left to right: © [email protected], FG [email protected], [email protected]

RISKWISE | June 2019 | dentalprotection.org 7 CASE STUDY - CRUSH INJURY CASE STUDY Mr K was booked in for a routine extraction - MECHANICAL INJURIES of tooth 27, which had been causing A newly qualified dentist mentioned to her discomfort and was unrestorable. A mesial- principal that the fixation plate that attached occlusal restoration was planned for 36 at the x-ray machine to the wall was not stable the same appointment. and when the arm was fully extended, the pressure on the plate caused some The dentist completed a composite filling in movement. The machine was wall-mounted 36 and then set about extracting the 27. to the left of the patient chair and had to be The procedure took longer than expected, extended fully when taking radiographs on but eventually the tooth was extracted in the right hand side. The arm was not stable one piece. at its full extension and would often drop after it had been aligned to expose the film. Following the extraction, the dentist noticed As a result, the final images were of limited Mr K had developed some bruising around diagnostic value as they did not capture the the lower lip which had been caused by the teeth and surrounding areas. forceps or elevator trapping the soft tissue. The dentist had not noticed this at the time, The young dentist asked for the fixation presumably because of his focus on the mechanism to be repaired or replaced. challenge of the extraction itself, and being The principal resisted this and believed the under some stress knowing that a number of dentist was over-reacting. He suggested an other patients were waiting to see him and ‘alternative technique’ that he thought would that he was now running very late. remedy the problem. His solution was to forcibly wedge the collimator so it would sit HOW WAS THE SITUATION next to the patient and the x-ray arm would MANAGED? not slip down. The dentist immediately apologised and also contacted Mr K later on that day. As Mr The dentist called Dental Protection and K was grateful to have had the problematic a dentolegal consultant suggested the tooth extracted, he did not take the matter member put her concerns in writing to the further and accepted the apology. principal. It was suggested her concerns could be justified by carrying out a risk LEARNING POINTS assessment of the situation to identify what SUMMARY issues could arise and what harm could These case studies highlight the importance • The dentist acknowledged that he had flow from a potential incident. It was also of team work, learning from mistakes and been so focussed on the challenging pointed out that should the dentist believe how risk awareness can reduce the number 27 extraction that he had forgotten the the working environment was hazardous, of injuries that are often avoidable. lower lip was also anaesthetised. As as she was controlling the handling of the they were understaffed, he had been equipment, it would be her responsibility to Where risks can be avoided, such as the sharing a nurse with another clinician ensure it was safe. placement of a well-fitting rubber dam for all and usually his nurse would be on-hand endodontic procedures, it is surprising why to notice an event such as this. At the Before the dentist could consider the advice anyone would risk not doing so. Similarly, next practice meeting this incident was further, she realised her next patient was due when equipment is well maintained this discussed and it was agreed the dentist and required a radiograph. Unfortunately, the reduces the risk to staff and patients. should always be supported by a dental x-ray machine fell off the wall and took the nurse when carrying out extractions surgery chair-light down with it, striking the These examples demonstrate the value and also to be mindful of the risk of soft patient on the head. of a sincere and sympathetic apology and tissue injuries to anaesthetised areas. the importance of professional support. HOW WAS THE SITUATION Although some patient safety incidents may • Complications always seem to occur MANAGED? require additional help in order to resolve when there is time pressure. There The patient was able to have the x-ray in the the situation to the patient’s satisfaction, a should be protocols in place for next room and the principal immediately set telephone call following an incident can go a managing such situations. In this case, about arranging for the x-ray machine and long way to convey care and indicate genuine a collective team decision was made that surgery chair-light to be repaired. concern, and can help reduce the chance of a should a dentist run particularly late, patient taking matters further. patients would be advised of the delay LEARNING POINT and given the option to rearrange their Whether it is in the form of professional appointments or be seen by another • The principal recognised he should have advice, help with writing a response to a dentist if possible. immediately addressed the situation. patient or assistance with arranging formal The patient was not injured but was compensation, Dental Protection is here to unsettled, and the practice called later protect the careers and reputations Images left to right: © [email protected], Keith Brofsky@gettyimages. on that day to ensure they were alright. of members. co.uk, [email protected]

8 Case Study Is it vital?

r R attended a practice as a new She explained to the patient that instrument not have incited such an uncompromising M patient. He reported no symptoms breakage was a recognised complication – response from the patient if he had been although during the examination particularly in curved roots. Mr R became fully informed, and if the diagnosis had been the dentist noted the large composite upset when it was suggested that he would made at the time of the initial examination restoration at 36, which had a small fracture now need to see a specialist to complete the appointment. to one side. The dentist promptly repaired treatment. He left the surgery before the the fracture with composite and placed a dentist could place a temporary restoration, Dental Protection provided support and note on the clinical records to monitor saying that he no longer trusted her. advice to the dentist throughout her case, the tooth. and covered the costs of the remedial She did not hear anything further from Mr treatment with the specialist. Mr R returned six weeks later complaining of R, until she received a treatment plan and pain and swelling on the lower left side of the cost estimate from a specialist endodontist With our advice and guidance, the dentist mandible. The dentist suspected periapical whom the patient had seen. A few days later, was able to demonstrate to AHPRA that she periodontitis at 36 and the diagnosis was the dentist also received a letter from the had reflected on the case and had learned confirmed by the periapical radiograph, AHPRA, notifying her of Mr R’s complaint. from the experience and applied that which clearly showed pathology at the root The dentist immediately contacted Dental learning to her daily practice. This included apices of the 36. Protection for advice. clinical aspects of care, as well as consent and effective communication. As a result, The somewhat unhappy patient was The discussion of the case with one of AHPRA took no action. concerned that he would lose the tooth, but our dentolegal consultants was a good was reassured by the dentist that the tooth opportunity for the dentist to reflect on the LEARNING POINTS could be saved by carrying out root canal incident. She realised that she could have therapy, although she did also advise that undertaken further investigations prior to • The dentist has a responsibility to carry extraction could still be an option. repairing the fractured composite – such out a thorough assessment of a patient’s as a vitality test, and if this was negative, oral health at the time of the initial The dentist extirpated the diseased pulp considered a periapical radiograph to check examination and prior to any treatment, and a temporary dressing was placed. Mr for any periapical pathology. This would including applying any special tests. In R’s symptoms resolved and he returned have revealed the existing pathology at 36, this case, vitality tests could have been at a later date for the completion of the at which point discussions could have taken carried out, which would likely have endodontic treatment. place with Mr R, potentially avoiding the prevented the unfortunate sequence symptoms experienced by the patient some of events. The dentist had previously noted the weeks later. curvature of the mesio-buccal root and • Providing the patient with the necessary suspected the canals may be sclerosed. She The dentist also noted that she had not information – such as all treatment mentioned to the patient that the mesio- followed her normal routine of discussing options available, along with the buccal root could therefore be difficult to all the risks of endodontic therapy with the advantages/disadvantages, risks and navigate and could compromise the quality patient. She had been eager to commence consequences – enables the patient of the root canal treatment. treatment given the patient’s symptoms, and to make an informed decision over had cut short the conversation about the risk what approach they wish to take, and During the canal preparation phase of the of instrument fracture in a sclerosed canal, contributes to obtaining valid consent. treatment, a file fractured in the mesio- meaning that she wasn’t possibly as clear buccal canal. A radiograph confirmed that as she would have wished, and had also not approximately 12mm of the file remained in offered a specialist referral. the root and about 3mm of this was beyond the apex. The dentist was unable to retrieve The precipitating trigger for the complaint the fractured file and informed the patient was the broken instrument, but the other about what had happened. predisposing factors also contributed to this outcome. The fractured file in isolation may

RISKWISE | June 2019 | dentalprotection.org 9 Case Study Avoiding herodontics

s B was suffering from pain that kept that the tooth had an incomplete root LEARNING POINTS M her awake at night. An examination canal treatment. by the dentist established tooth 27 was the cause of discomfort. The 27 had The first dentist received a letter of • Be alert to patient-led dentistry extensive dental decay and a missing buccal complaint questioning why the endodontic and the demands of strong-willed wall. Ms B had an otherwise intact arch and treatment had not been completed in five patients. Unrealistic expectations was keen to save the tooth – she did not visits and why she had been charged for this should be identified and managed want a dental extraction. incomplete and unsuccessful treatment. from the outset. The reasons why the treatment is inappropriate should be The dentist explained that endodontic The dentist contacted Dental Protection for communicated effectively. treatment carried no guarantee of success, advice on how best to respond. especially with the extent of damage to the • Avoid being coaxed by persistent enamel walls, and extraction was offered as Whilst the clinical records were detailed, patients into carrying out treatments the only realistic alternative. the practitioner was vulnerable in some which have a slim to zero chance areas regarding the clinical care provided. In of success. Ms B was quite persistent in her demands for terms of the pre-operative assessment, the root treatment, along with a full coverage restorability status of the tooth at the outset • Just because a patient consents to crown, and was unwilling to be referred to a was questionable. During the procedure treatment, it doesn’t necessarily mean specialist. The dentist felt pressurised by the the dentist could not place a rubber dam that the treatment is appropriate. patient and embarked upon the endodontic because of insufficient residual coronal tissue treatment against her better judgement. and owing to a lack of anatomical landmarks, • In this particular case, the complaint a perforation occurred. With hindsight, the was resolved by a detailed letter of Five visits later, only two of the canals had practitioner realised that the decision to explanation and a refund of fees. been located and the third may have been carry out root canal therapy intervention had perforated as it bled on instrumentation. been a poor one, and she should not have • In trying to appease the patient, the This was discussed with Ms B and the tooth attempted the procedure in the first place. dentist had spent over three hours was dressed. attempting treatment that was With Dental Protection’s advice and essentially doomed to fail, and then Whilst the endodontic treatment was assistance the complaint was resolved by had to spend even more time managing becoming more complicated, Ms B was still refunding Ms B for the initial endodontic the resulting complaint. unwilling to consider an extraction and was treatment and also contributing towards the forceful in her request for the root treatment cost of the second dentist’s assessment. • This case highlights the dangers of to be completed by the practitioner. attempting heroic dentistry; dentists Had Ms B pursued the matter with a claim are unlikely to be thanked for lack Further explanations were provided, but for clinical negligence, the solicitors could of success. despite this Ms B remained convinced that a potentially allege that Ms B had been crown would solve the problem. She decided subjected to an inappropriate procedure with • Unrealistic expectations should be to visit a second dentist and was informed associated pain and suffering. managed carefully from the outset.

10 Case Study A foreseen fracture

r G attended an emergency During the attempted extraction, the 26 did Mr G acknowledged that he had been M appointment complaining of acute fracture and the disto-buccal root remained informed of this possible outcome and had pain in his upper left quadrant. The in situ. A second radiograph confirmed accepted the referral. He also agreed that dentist identified a carious cavity at tooth 26. the position and size of the retained root the aftercare was to his total satisfaction. He fragment. The dentist did attempt to remove accepted the refund of the treatment fee for Having undertaken a thorough examination, the retained root but was cautious given the the attempted extraction and indicated his including vitality testing and exposure high risk of displacing the root into the antrum. appreciation of the gesture of goodwill. of a periapical radiograph, a diagnosis of Mr G was informed that the extraction was irreversible pulpitis was made. The dentist incomplete and that as a piece of the root Mr G remained on good terms with the noted the curvature of a disto-buccal root, was retained, it would be necessary to refer dentist throughout, and later informed her which appeared from the radiograph to be him to a specialist colleague. that the retained root had been removed in very close proximity to the floor of the uneventfully by an oral surgeon. maxillary sinus. The dentist provided the necessary aftercare and arranged for a review appointment. LEARNING POINTS Mr G was keen to have this tooth extracted During this appointment, Mr G mentioned and the dentist, mindful of her obligation to that he was unhappy about the additional • By providing the patient with all the offer all treatment options, also discussed costs that would be incurred in order to treatment options and identifying the root canal therapy and suggested that given complete treatment with the oral surgeon, advantages and disadvantages of each, its complexity, there was also the option of a and asked the dentist to reimburse these along with any associated costs – such referral to a specialist colleague. additional fees. as the offer of a specialist referral – a dentist can be confident that the Mr G was informed of the potential risks The dentist contacted Dental Protection choice made by the patient is properly and complications of an extraction, and in and discussed the case with a dentolegal informed. particular, the possibility of a fracture of the consultant, who acknowledged the dentist curved portion of the disto-buccal root. The had made comprehensive notes and • Ensuring all discussions with the risk of a potential oral-antral communication documented all her discussions with Mr G, patient are recorded contemporaneously and the possibility of the retained root being including the specific risk of fracture of the allows a dentist to rely on their displaced into the maxillary sinus were also disto-buccal root. The records also noted treatment records to defend discussed. The usual general risks – such that the patient had declined the option of a their position. as bleeding, bruising and postoperative referral to a specialist colleague before any infection – were explained, with the treatment had commenced. • A dentist should always ensure they dentist using the radiograph to support her are working within their clinical discussions, so the patient had some visual Dental Protection advised the dentist that competency and be able to recognise imagery to help his understanding. her treatment records clearly reflected when treatment may have progressed that valid consent had been obtained, and beyond their particular expertise or skill Although the dentist felt competent whilst the outcome was suboptimal, the set, and provide prompt referral to a to extract the 26, she also considered dentist had provided appropriate treatment, specialist colleague when necessary. extirpation of the pulp to relieve Mr G’s with a reasonable degree of skill and care, symptoms, and, as she anticipated a discontinuing the treatment when she felt • Whilst in this instance the patient challenging extraction, also discussed the removal of the retained root required accepted the dentist’s explanation the option of a referral to a specialist oral specialist intervention. and appreciated the goodwill gesture, surgeon. However, as Mr G was suffering if the patient had chosen to escalate from acute symptoms, the dentist felt that it It was agreed that there were strong grounds their concerns by pursuing a claim for was not unreasonable for her to attempt the for the dentist to decline Mr G’s request to compensation, Dental Protection would extraction, and given the circumstances, it reimburse the additional treatment costs, have been in a good position to defend was also an appropriate treatment option. and Dental Protection assisted the dentist in against any attempted litigation providing an explanation of events in a letter because of the dentist’s robust After taking a short time to consider all the to Mr G. In addition, it was suggested that treatment records. information provided, Mr G requested that the dentist may wish to consider refunding the dentist proceed with the extraction. the fees for the incomplete extraction, He signed a consent form which included purely as a gesture of goodwill to maintain an information relating to the shape of the amicable dentist-patient relationship. disto-buccal root and all the potential risks and complications as discussed with him.

RISKWISE | June 2019 | dentalprotection.org 11 Case Study gettyimages.co.uk

©yacobchuk@ A delayed postoperative healing following an extraction

rs C attended her dentist for an The press team at Dental Protection was Dental Protection recognises that patients M extraction of an unrestorable, asked to assist the member and advised that increasingly use social media channels to fractured 37. The procedure was if the dentist was contacted by a newspaper highlight concerns about their treatment uneventful and postoperative instructions for a comment, he should find out: and care, where previously this would were provided in the usual way. have been privately communicated to the • the journalist’s name practice. We would encourage members to She returned a few days later in discomfort respond to both positive and negative online and the dentist diagnosed alveolar osteitis. • the name of the publication feedback. Responding to online comments The socket was irrigated and the dentist demonstrates you are listening and care placed a medicated dressing in the socket. • the aspects of the care and treatment about feedback; however, you should The dentist explained the diagnosis, advised they were seeking comments on always express a willingness to address any Mrs C to take painkillers and offered to book concerns offline where confidentiality can a review in three days later. • the deadline for a response be respected.

Mrs C seemed surprised about this and • the journalist’s contact details – phone The situation was amicably resolved by declined the appointment as she had already number and email address. arranging for another dentist to review Mrs taken two days off work to attend the C. This dentist confirmed the diagnosis and clinic for the extraction and the emergency The press team also provided the following explained to the patient that dry socket was appointment. As there were no signs of helpful advice: a recognised complication and that the pain infection, antibiotics were not prescribed and would subside within a few days and the she left fairly disgruntled. • Do not respond to any questions socket would heal. immediately – instead take some time to Her husband returned to the clinic the next consider a response or to seek advice. It is always advisable to request Dental day shouting and being very raucous in his Protection’s assistance from the outset behaviour. He complained to the receptionist • Maintain your professionalism at all when faced with unexpected clinical that his wife was still in considerable pain times and do not be tempted to discuss outcomes and/or complications that may following the extraction of her tooth, and a patient’s treatment in a public domain. lead to a patient complaint. In this situation, stated that this was down to the poor If you cannot discuss the patient’s the dentist was able to identify a strategy to standard of treatment provided by the treatment for confidentiality reasons then manage the adverse social media coverage dentist. He threatened to report the dentist you should say so. and potential harm to his reputation by to the press and the Dental Board, and contacting Dental Protection immediately. said that he had already posted negative • Avoid saying 'no comment' as it sounds comments about the dentist on various defensive. Ensure you come across as LEARNING POINTS social media sites. co-operative and inform the reporter that you will come back to them. • The dentist failed to warn the patient The dentist in question was working in about the possibility of alveolar osteitis another clinic that day, so did not have an • Contact the Dental Protection press at the outset. Consequently, when opportunity to provide an explanation to Mrs office for advice and liaise with your the patient developed a recognised C’s husband. He did however contact Dental employer/practice where appropriate. postoperative complication she became Protection for urgent advice as he was alarmed and blamed the dentist. concerned about the impact of the critical The dentist was reassured that the press social media commentary. He discussed team could liaise with journalists if necessary • An opportunity was also missed when the case with his dentolegal consultant and and provide a statement on his behalf. the dentist realised that the patient left explained that although he was unaware the clinic unhappy. It may have been of any press coverage to date, there were Steps were also taken to address the worthwhile considering contacting the a handful of comments on social media negative comments made on social media; patient later on that evening to enquire attempting to undermine his credibility and the administrator of the social media how she was and provide further professional reputation. page was contacted and the unfair and support and advice. inappropriate comments were asked to be removed.

12 gettyimages.co.uk ©ivanastar@

Case Study Leaving a sour taste in the mouth

ssociate dentists leave their current charges would apply and did not expect the The associate and principal reached A practice for a variety of reasons, owner of the practice to charge him for an agreement between them to cover and occasionally this can be due this treatment. the reasonable cost of post-treatment to a breakdown in communication and maintenance/polish appointments. issues surrounding working relationships Mr L resented being asked to pay for within the practice. When an associate polishing the composites and raised the issue LEARNING POINTS leaves a practice on bad terms this can be with the principal, who passed the complaint the catalyst for a number of unexpected to his former associate. Although the • This case study illustrates the patient complaints. This scenario can be associate had moved over 100 kilometres importance of maintaining professional distressing and difficult to manage if there away, he offered to review the patient and relationships and taking the time to is no agreement with the practice owner in provide the necessary treatment at no agree how patient care can, and should, relation to how to manage post-treatment cost, but the patient was understandably be handed over when a dentist leaves issues that would otherwise be addressed by unwilling to travel to see him. a practice. the dentist had they remained at the practice. This scenario was not an isolated example; it • There should be a signed agreement was a recurring story involving a number of that includes a clause regarding the It is common practice for an agreed sum of patients who required similar maintenance retention of fees for remedial work money to be withheld by the principal for work. Rather than completing this work when an associate leaves a practice. This an agreed period of time when an associate as a gesture of goodwill to maintain the avoids disputes and disagreements that leaves a practice, to allow minor problems to reputation of the practice, the principal may arise after the departure of be resolved. encouraged every minor concern to develop an associate. into a complaint that required a formal CASE STUDY response from the associate. The fact that • When planning treatment that The relationship between a principal and an the patients felt they were being charged requires ongoing maintenance, clear associate had deteriorated to such an extent an over-inflated cost for maintenance explanations should be given to that the associate had left the practice. treatment by the principal only added to the patient and documented in the their dissatisfaction. record. This should include an explicit The associate was clinically very competent statement as to what the initial fee and experienced, and had completed a The associate contacted Dental Protection, includes and what charges may apply in number of challenging ‘tooth wear’ cases. and with the benefit of hindsight, realised the future. This should be set out clearly One particular patient, Mr L, had been that he had not made it clear to Mr L – in writing for the patient and a copy treated with composite build up restorations or to the other patients – that ongoing retained in the records, so everyone on numerous teeth to conservatively maintenance would be chargeable. He knows what to expect. manage his tooth wear and the finished recognised that there had been no clarity result was satisfactory. Whilst the regarding what aspects of the treatment • Financial disputes between the principal associate’s clinical records reflected the were covered by the original fee, and as a and an associate should be resolved merits and limitations of composite resin result, patients had unilaterally made between the two parties and not involve versus porcelain restorations, there was no some assumptions. the patient. mention that further charges would apply for the maintenance and/or repair of these Dental Protection advised the associate to restorations. When Mr L required some fairly talk to the principal and to try and come minimal general polishing of the composite to an agreement so as to avoid further restorations due to surface staining, he said incidents that could be harmful to both he had not been informed that additional their reputations.

Case Study Protecting your reputation

dentist provided functional The patient attended another practitioner LEARNING POINTS A orthodontic treatment for a ten- and it became apparent that the patient’s year-old patient. mother had posted a Google review about • Dental Protection is here to support the first dentist, alleging he was a terrible you, and as we have the legal resources The treatment did not get off to a good start dentist; that he caused harm to her and her on hand to support members when it due to the patient failing to fully comply with son; and that his motivation was financial. matters most, we can act quickly to advice and instructions on the requirement advise and protect your professional to wear the appliance. As well as the defamatory comments reputation. published on Google, the patient’s mother The mother wished to discontinue treatment also sent a number of threatening emails to • Practices should remain vigilant and so she could seek care elsewhere for her the dentist. monitor any comments on websites and child, in the hope they would have better social media platforms and seek advice success. The dentist thought he had resolved The dentist worked in a small, close-knit if they have the potential to damage the the situation amicably by providing a copy of community, and news of these harmful, professional reputation of the practice. the records to facilitate ongoing care and a critical reviews spread quickly and started to full refund of fees. have a negative effect on the popularity of • If you receive a request for clinical the practice. records, be aware of any latent and underlying concerns and try and resolve Shortly after the dentist contacted Dental these within the practice. This is an As well as the Protection, a barrister was instructed to example of risk containment. assist. The barrister prepared a strongly defamatory comments worded letter to the mother to ‘cease and • Whilst a refund of fees can prevent the desist’ her actions, consequent to which the escalation of a complaint, be aware published on Google, reviews were removed and the persistent, that patients can seek redress in other the patient's mother threatening emails stopped. ways, including commenting on their experience on websites. also sent a number of • It is important that patients are fully threatening emails to informed of charges and fees but be the dentist. aware that information about costs should be presented in a way that does not suggest to the patient that it has primacy over other discussions. This may lead to the perception that a dentist is interested only in the fee.

Case Study Short term orthodontics

iss N attended an examination The dentist accepted that progress had Although the treatment was initially an M appointment with a new dentist, been slow and offered to refer her to elective procedure, Miss N’s occlusion was unhappy with the appearance of an orthodontist. now unstable and further treatment was her upper teeth. She informed the dentist necessary. Dental Protection discussed with that she’d had an assessment with an The orthodontist advised that due to Miss the member whether he would be prepared orthodontist a few years ago and was told N’s crowding and the skeletal profile, tooth to refund the treatment costs in view of the fixed appliances were necessary. Miss N extraction and fixed appliances were patient’s dissatisfaction, and he agreed. wanted a ‘quick result’ as she was getting necessary in order to correct the treatment. married in six months and was aware the The patient was extremely upset and With Dental Protection’s advice and dentist provided a clear aligner treatment complained in writing. She alleged that the assistance a letter was sent to Miss N. system. The dentist carried out some checks dentist had misled and misinformed her at It included an apology and the case was using the clear aligner system programme the time of the initial examination about the resolved by a refund of treatment fees and a and informed her about the costs of the duration of the treatment to achieve the contribution from Dental Protection towards treatment, indicating a good result was desired result. She requested the dentist the additional cost of further treatment with possible within six months. Miss N was happy refund the treatment fees and cover further the specialist orthodontic consultant. to proceed on this basis. costs to continue her care with the specialist orthodontist. Miss N indicated that she LEARNING POINTS Treatment continued for four months, with was prepared to escalate her complaint Miss N becoming increasingly frustrated to the Dental Board or consider a claim for • Ensure all treatment options - and any at each review by the lack of progress. The clinical negligence if she did not receive what appropriate referrals - are offered to dentist queried whether she was wearing she believed to be a fair and satisfactory the patient, along with the advantages the aligners for the prescribed periods of outcome. and disadvantages of each, in order to time. Miss N reassured the dentist she was demonstrate a valid consent has indeed wearing the aligners for the correct The dentist contacted Dental Protection been achieved. periods of time and was anxious to have for advice. A close scrutiny of the patient’s the treatment finished due to her wedding clinical records indicated that these were • Be aware of your professional drawing near. The dentist continued to insufficient and incomplete and therefore limitations and work within the limits reassure her and consulted with the clear it could not be shown that an appropriate of your competence. aligner programme mentor who advised that examination and subsequent diagnosis had additional aligners were now necessary. been made, or that a suitable treatment • Assess each case carefully to avoid plan had been formulated. As a result, the attempting treatment beyond your The dentist relayed this to Miss N at dentist would be vulnerable in the event clinical capabilities, even if the patient the following review. Although she was of an escalation and further inquiry. The demands it. extremely disappointed, she still wanted to records suggested that treatment options continue treatment and accepted this would – such as fixed appliances and/or referral • Do not agree to unrealistic or not be finished by the time of her wedding. to a specialist orthodontist – had not been impracticable treatment times. discussed, which amounted to a failure A further five months passed and it became in obtaining valid consent. A specialist apparent that the case was not progressing orthodontic report concluded that due to how Miss N had expected. She also began Miss N’s severe crowding, she would always to experience occlusal problems and had have needed fixed orthodontic treatment to developed an anterior open bite. achieve a satisfactory outcome.

RISKWISE | June 2019 | dentalprotection.org 15 CONTACTS

You can contact Dental Protection for assistance dentalprotection.org

Membership services Telephone 1800 444 542 [email protected]

Dentolegal advice Telephone 1800 444 542 [email protected]

DPL Australia Pty Ltd (“DPLA”) is registered in Australia with ABN 24 092 695 933. Dental Protection Limited (“DPL”) is registered in England (No. 2374160) and along with DPLA is part of the Medical Protection Society Limited (“MPS”) group of companies. MPS is registered in England (No. 36142). Both DPL and MPS have their registered office at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. DPL serves and supports the dental members of MPS. All the benefits of MPS membership are discretionary, as set out in MPS’s Memorandum and Articles of Association.

“Dental Protection member” in Australia means a non-indemnity dental member of MPS. Dental Protection members may hold membership independently or in conjunction with membership of the Australian Dental Association (W.A. Branch) Inc. (“ADA WA”).

Dental Protection members who hold membership independently need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDA National Insurance Pty Ltd (“MDA”), ABN 56 058 271 417, AFS Licence No. 238073. DPLA is a Corporate Authorised Representative of MDA with CAR No. 326134. For such Dental Protection members, by agreement with MDA, DPLA provides point-of-contact member services, case management and colleague-to-colleague support.

Dental Protection members who are also ADA WA members need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDA, which is available in accordance with the provisions of ADA WA membership.

None of ADA WA, DPL, DPLA and MPS are insurance companies. Dental Protection® is a registered trademark of MPS.”

05/19