Risk management from Dental Protection
ISSUE 18 | OCTOBER 2019 WISE RISK MALAYSIA
The increase in orthodontics WHAT ARE THE POTENTIAL LIMITATIONS AND THE RISKS THAT MIGHT ARISE?
TRIGEMINAL NERVE INJURIES DENTISTRY AND PREGNANCY CASE STUDIES Causes of trigeminal alveolar The fear around treating Practical advice from real nerve injury are varied pregnant patients life scenarios
Contents
The increase in Trigeminal nerve Dentistry and orthodontics and the injuries related to pregnancy risks that might arise restorative treatment
Dentolegal adviser Dr Simon Parsons looks into Professor Tara Renton, specialist in oral surgery, Leonie Callaway, professor of medicine at the the complexity of orthodontics, the potential looks into ‘prevention first’. University of Queensland, looks at the important limitations and the risks that might arise. issue of dentistry and pregnancy.
Case studies
From the case files: practical advice and guidance from real life scenarios.
Editor Production Design Contributors Print Anna Francis Emma Senior Carl Watson Simrit Ryatt / Louise Eggleton / Jim Lafferty Sampoorna Printers
Cover image ©[email protected] Editorial DR JAMES FOSTER Head of Dental Services Australasia/Asia
ELCOME TO THIS LATEST EDITION OF WEBINARS AND WORKSHOPS W RISKWISE, DENTAL PROTECTION’S FLAGSHIP As highlighted in the previous edition of Riskwise, Dental Protection has PUBLICATION, OFFERING THE LATEST been hosting a series of webinars that have proven to be very popular. INFORMATION ON DENTAL TOPICS AND ADVICE These webinars give you an opportunity for real-time question and FROM OUR DENTOLEGAL CONSULTANTS AND answer sessions during the live broadcast and enable you to have the PROFESSIONAL EXPERTS. expertise of Dental Protection brought directly to you.
I have been fortunate enough to have travelled through Asia The latest workshop, ‘Building Resilience and Avoiding Burnout’ recently and had the pleasure of meeting many members. Providing recognises the issues that many practitioners face. We also appreciate presentations based upon our experience of handling cases in Asia for that a case may weigh heavily upon an individual clinician and would several decades is always an honour. I was grateful for the opportunity like to remind members about the counselling service we off er. to use examples of such cases to try and help colleagues to minimise Whether you are suff ering from stress and anxiety as a result of the risk of professional challenge, but at the same time – and through complaints, claims, or dental council hearings, this service is tailored the same processes – build their professional reputation and the to your requirements. It is delivered by fully trained, qualifi ed and success of their practice. registered psychologists and counsellors and is entirely independent and confi dential. ALSO IN THIS ISSUE Professor Tara Renton, who has spoken at many Dental Protection As always, I am keen to receive your feedback about our publications events, has kindly provided an article on trigeminal nerve injuries and, in particular, would like to know what subjects you might like to related to restorative treatment. The article explores the cause of such see featured in future issues of Riskwise. injuries and how we can minimise the risk of them occurring. Please feel free to contact me at the email address below. Professor Leonie Callaway helpfully explores some of the issues around dentistry and pregnancy, where perhaps a lack of clear understanding Best wishes, can limit clinical care, oft en leading to problems, dissatisfaction and the Dr James Foster LLM BDS MFGDP (UK) development of complaints down the line. Head of Dental Services Australasia/Asia [email protected] Following these articles, we have a range of case studies refl ecting real-life situations that members have experienced – all of which are followed by some helpful learning points and guidance specifi c to the circumstances.
The feedback we receive indicates that many dental members aren’t fully aware of the professional development off ered by Dental Protection, so I would urge you to visit our online learning centre, Prism, and see just what is available and how it could be of benefi t to you.
As a member of Dental Protection, you have access to some of the best dental experts in the world. Dental Protection is dedicated to protecting members and their reputations, and with over 40 years of experience and expertise assisting healthcare professionals in Asia, we are best placed to help you should things go wrong.
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 3 [email protected] ©
The increase in orthodontics and the risks that might arise
With the clear aligner market increasing around the world, dentolegal adviser Dr Simon Parsons looks into the complexity of orthodontics, the potential limitations and the risks that might arise.
he worldwide USD $3bn per annum The study concluded that orthodontists and and intrusion or extrusion are ambitious. T clear aligner market is forecast to orthodontic trainees The achievement of a successful aesthetic continue growing by around 21% “…had better judgments for evaluating and functional result may well depend over the fi ve year period of 2018-2023.1 orthodontic case complexity. The high on completing all these actions, and the correlation between orthodontic professionals' treating dentist will be responsible for the General dentists with limited prior perceptions and DI scores suggested that treatment outcome should it fail to meet orthodontic training may be drawn to the additional orthodontic education and training patient expectations. promise of aligner systems that seem almost have an infl uence on the ability to recognize to ‘do it all’ and are increasingly off ering this case complexity”.2 The high costs of orthodontic care, and treatment to their patients. This opportunity the patients’ capacity to evaluate the to augment practice revenue, and grow LOOKING AT THE LIMITATIONS outcome, will go a long way towards the one’s clinical skill set, brings in its wake the Although clear aligner systems have patient’s perception of success. There will increased likelihood of complaints and claims some clinical advantages and are based undoubtedly be high expectations on the when the treatment outcome is compromised on sophisticated technology, they have part of the patient and, if these are not or patient expectations have not been met. limitations in the amount and type of tooth met, referral for specialist treatment may movement that can be achieved.3 be indicated which will incur additional The provision of orthodontic treatment costs. Uncertainty can exist in the minds of by general dental practitioners can be Furthermore, there is some evidence of general dentists and patients as to who is risky, even when it involves modest tooth unexpected risks with aligner therapy, such as responsible for any costs associated with movement. The importance of case breathing diffi culty, swelling of the lips, throat corrective treatment, or when a patient selection cannot be overstated and unmet and tongue and even anaphylaxis.4 These risks transfers to another practitioner prior to expectations can trigger litigation. When must be appropriately managed. completion. So how might dentolegal risk cases arise, it is not uncommon for general be reduced when general dentists consider practitioners to be questioned about the As a third party usually provides the initial off ering clear aligner treatment? extent and adequacy of their training to treatment planning for aligner cases, it undertake orthodontic treatment. may be tempting to delegate the decisions PRE-TREATMENT in a patient’s orthodontic management Making an accurate diagnosis is the fi rst A recent study carried out in the United States to an unseen party who is relying on step in understanding patient suitability for investigated the diff erent perceptions of case supplied photographs, scans and models. treatment by a general dentist. Poor case complexity between orthodontists, GDPs, Inexperienced dentists may not recognise selection is frequently the root cause of orthodontic trainees and dental students. that targets for tooth movement, derotation dissatisfaction down the line. Pre-treatment
4 assessment might include detection possible and helps to avoid escalation of cosmetic component first, it is often wise to of unfavourable facial profiles, marked problems and further patient dissatisfaction. schedule orthodontic treatment towards the asymmetries, a deep overjet and overbite Our experience is that it is wise to refer latter stages of any treatment plan. Ensuring or substantial midline discrepancies which patients to specialist providers promptly all periodontal, endodontic and restorative may prove difficult to manage with clear whenever the efficacy of aligner treatment issues have been addressed first means that aligners alone. It can be tempting to offer seems to be in doubt. This can mitigate the patient is more likely to be a suitable patients an improvement in tooth position the risk of further complications while candidate for orthodontic treatment. through aligner therapy while unknowingly also optimising the chance of a favourable ignoring underlying factors that may make overall treatment outcome. success almost impossible to achieve without LEARNING POINTS specialist care. POST TREATMENT While all orthodontic treatment carries Appealing as it may be to take on a case, risk, some risks may persist upon treatment • Take models/scans, radiographs and it is always wise to discuss alternatives completion. Patients may be unhappy with photographs as part of a preoperative to clear aligner therapy with a patient, the overall treatment outcome and request assessment and evaluate these including such options as no treatment and refinement, retreatment or referral. The thoroughly before discussing the specialist referral. Simply because a patient general dentist will need to evaluate with feasibility of aligner therapy with has attended for a consultation or sought the patient how closely the result matches your patient. information about clear aligners – sometimes with the pre-treatment projection and the as a result of internal marketing – does not individual patient’s long term expectations. • Clearly outline the costs of care, mean that this is the only option that should Retreatment or referral may carry financial including the costs of replacement be considered. The dentist must consider all implications for both parties and is best aligners and retainers. Ensure patients other viable alternatives in consultation with understood before treatment commences understand when payments are due. the patient as part of the consent process. (through an explanation) rather than after • Carefully explain the process, treatment has finished (via an excuse). including composite resin attachments Understanding the patient’s expectations Devitalised teeth, relapse, or – particularly if required, and the importance of from the outset is essential to avoid future with aligners – a failure to achieve compliance. Explain that, occasionally, disappointment. Some patients who seek adequate occlusal contacts may also occur. a specialist referral may be necessary aligner therapy may present with minor Effective retention is essential if relapse is if things do not go to plan. Establish orthodontic needs, but may expect absolute to be avoided. who will be responsible for the costs of perfection in tooth alignment. Indeed, their such a referral. expectations may involve other factors which CASE ASSESSMENT they, themselves, do not fully understand To manage risk with clear aligner cases, • Be on your guard towards such as the shape of individual teeth or careful case assessment is key. Some patients with unrealistically high the colour of some or all of their teeth. Any aligner systems allow prediction of the final expectations or those who seem non-compliance with aligner wear or post- outcome and alteration of the treatment in a hurry to commence treatment treatment retention may compromise the parameters to suit the objectives of without due consideration to their outcome and achievement of ideal results. the patient and the clinician. These are other treatment needs (such as caries The clinical presentation, diagnosis, treatment preferred over a ‘one size fits all’ approach. or periodontal issues). options, risks, benefits and costs, importance Dental Protection recommends any of compliance with advice and tempering of treatment proposal be thoroughly checked • If in any doubt as to the likelihood unrealistic patient expectations should all be prior to finalisation of the treatment plan of success, consider referral of documented in the clinical records together. by the treating clinician to ensure that a patient to a more experienced These entries will be scrutinised in the event proposed tooth movements are within a colleague or specialist. of any investigation or inquiry. predictably reliable range. • If you are not a specialist DURING TREATMENT General practitioners have the advantage of orthodontist, make sure that the Problems such as speech concerns, coordinating a patient’s total dental care, and patient is aware of this and offer a excessive salivation, mouth soreness, aligner this provides scope for considering preventive referral to a specialist as one of the breakage and aligner loss may all impact and restorative needs within the overall options for treatment. on treatment effectiveness. Patients may plan. The general practitioner is well placed dislike attachments placed on teeth, fail to to consider any pre-existing limitations to use elastics or other adjuncts to treatment effective tooth movement, such as implants or decline to undergo interproximal tooth and bridgework, while also understanding reduction. A prospective patient needs to how to manage restoration fracture or loss be aware of these issues, before and during during aligner treatment. Are you able to deal REFERENCES treatment, so that there are no surprises and with complications if they arise? Do you have 1. Reuters.com. (2019). Clear Aligners Market 2018 Global disagreement as treatment progresses. the knowledge and skill necessary to identify Trends, Key Vendors Analysis, Industry Growth, Import - and manage likely complications that might Reuters. 2. Heath EM, English JD, Johnson CD, Swearingen EB, Akyalcin Despite the best efforts of both the patient occur during the treatment phase? S, Perceptions of orthodontic case complexity among and the clinician, sometimes treatment orthodontists, general practitioners, orthodontic residents, and dental students, Am J Orthod Dentofacial Orthop. 2017 does not progress as well as expected. As with any treatment that incurs significant Feb;151(2):335-341. doi: 10.1016/j.ajodo.2016.06.045. Dentolegal risk can be reduced through financial and time costs, it is always prudent 3. Ke Y, Zhu Y, Zhu M, A comparison of treatment effectiveness between clear aligner and fixed appliance therapies. BMC oral regular patient reviews in surgery rather to approach clear aligner therapy alongside health 19(1), 24. doi:10.1186/s12903-018-0695-z (2019) than an ‘arm’s length’ approach of minimal other necessary treatment rather than as a 4. Allareddy, Veerasathpurush et al. (2017). Adverse clinical events reported during Invisalign treatment: Analysis of treatment supervision. Early detection of standalone treatment. Despite a patient’s the MAUDE database. American Journal of Orthodontics and problems enables prompt correction where understandable desire to get on with the Dentofacial Orthopedics, Volume 152, Issue 5, 706 - 710
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 5 Trigeminal nerve injuries related to restorative treatment
auses of trigeminal alveolar nerve trauma causing subsequent haemorrhage, IDB anaesthesia, particularly for premolar and C injury (TNI) are varied, but many inflammation and scarring, resulting in incisor teeth.1 Similarly, a recent systematic occur that are related to restorative demyelination (loss of nerve lining). review reports that articaine is 3.4 times dentistry. Professor Tara Renton, specialist more effective for pulpitic mandibular molars in oral surgery, looks into ‘prevention first’ Only 1.3-8.6% of patients get an ‘electric when compared with lidocaine, but there is and recommended management of shock’ type sensation on application of an no difference between articaine and lidocaine nerve injuries. IAN block and 57% of patients suffer from maxillary infiltrations or IDBs.5 prolonged neuropathy having not experienced PREVENTION the discomfort on injection, so this is not a Several reports of supra periosteal infiltration Neuropathy caused by local block injections specific sign.2 anaesthesia suggest that it is not only is a well-recognised complication throughout sufficient for posterior mandible implant medicine, anaesthesia and dentistry. However, Routine practice in Europe and USA involves surgery but may be protective of the IAN.6 dentistry is the only specialty that still trains warning patients of potential nerve injury in When it comes to periodontal and implant clinicians to aim for nerves rather than avoid relation to dental injections. surgery, the standard care is infiltration neural contact (often using ultrasound), which LA, while intraligamental anaesthesia for likely explains the continued prevalence of INFILTRATION DENTISTRY extractions and avoiding IDBs is also local anaesthetic (LA)-related nerve injuries AVOIDING BLOCK ANAESTHESIA gaining popularity.7 Paedodontic extractions in dentistry. A 2014 survey of German dental LA practice do not require IDBs as the bone is very found that 74% of dentists were using porous and susceptible to absorption of There is evidence, using ultrasound, that the infiltration dentistry routinely, avoiding the infiltrative anaesthesia. benefits of a proximal injection of LA to the use of inferior dental blocks (IDBs). Improved inferior alveolar nerve (IAN) are not related comfort was reported by patients who had PREVENTION OF LA NERVE to efficacy of the inferior dental block (IDB). a preference for having full lingual sensation INJURIES IS POSSIBLE A close injection to the nerve is therefore and shorter duration LA anaesthesia after These simple steps may minimise LA-related not required. However, what is frequently dental treatment.3 nerve injuries: overlooked is the need to wait for eight to ten minutes for optimal pulpal anaesthesia, and Further evidence to support infiltration • Avoid high concentration LA for IDBs additional repeated IDBs will not improve the dentistry successfully includes a study by (use 2% lidocaine as standard). There success of anaesthesia. Evans, Nusstein and Drum et al4, which found is increasing evidence that higher 4% articaine to be more effective than 2% concentration agents are more neurotoxic A recent report highlights that the prevalence lidocaine for lateral incisors but not molars, and therefore more likely to cause of IDB-related nerve injuries in UK general and a recent randomised and controlled persistent IDB related neuropathy. dental practice is 1:14,000 blocks for trial, which found a statistically significant temporary nerve injury, or 1:56k IDBs with difference supporting use of 4% articaine in • Avoid multiple blocks where possible. patients experiencing permanent lingual or place of 2% lidocaine for buccal infiltration inferior alveolar nerve injury, of which 25% of in patients experiencing irreversible pulpitis • Avoid IAN blocks by using high nerve injuries are permanent.1 in maxillary posterior teeth.4 Other studies concentration agents (articaine) with however – such as that conducted by Oliveira infiltration-only anaesthesia. Infiltration Nerve injury due to LA is complex. The nerve et al – reported no clinical superiority for dentistry avoids the use of IDBs, therefore injury may be physical (needle, compression this injection. preventing LA-related nerve injury, for due to epineural or perineural haemorrhage) which there is no cure. or chemical (haemorrhage of LA contents). There is evidence supporting the significantly Thus the resulting nerve injury may be a increased rates of pulpal anaesthesia using combination of peri-, epi- and intra-neural infiltration anaesthesia, when compared with
There are two main issues currently for LA: changing practice in using tailored LA techniques rather than always reaching for FIGURE 1. (Thanks to Andrew Mason at Dundee University for anatomical picture) the IDB, and consenting patients regarding potential nerve injury. Minimise nerve injuries by using infiltration dentistry and avoid IDBs CONSENT FOR LA Patients are routinely warned of the risk of nerve injury when undergoing epidural or spinal injections. Reports estimated that nerve injury from neuroaxial blocks (epidurals, spinals and combined epidural with spinals) resulted in sensory or motor nerve injury in 1 in 24-54,000 patients (and paraplegia or death in 1 in 50-140,000 patients).8
Germany already has a legal precedent to warn all patients of the risk – something that was originally suggested in the US.9 With Montgomery setting consent principles based upon what is material to the patient, warning patients of the risk of TNIs, and their unpleasant consequences, should now be routine.10
TAILORED LA TECHNIQUE Infiltration dentistry avoids the use of IDBs in most cases. IDBs may only be needed REFERENCES for lower posterior molar complex endo, 1. Renton T, Adey-Viscuso D, Meechan J et al. Trigeminal 6. Etoz OA, Nilay E, Demirbas AE. Is supraperiosteal restorative and extraction procedures, thus nerve injuries in relation to the local anaesthesia infiltration anesthesia safe enough to prevent inferior in mandibular injections. British Dental Journal alveolar nerve during posterior mandibular implant preventing LA-related nerve injury. 2010;209:E15-E15. doi:10.1038/sj.bdj.2010.978 surgery? Medicina Oral Patologia Oral y Cirugia Bucal 2011 2. Smith MH, Lung KE. Nerve injuries after dental injection: May 1;16 (3)e386-9. doi: 10.4317/medoral.16.e386 a review of the literature. Journal of the Canadian Dental 7. Dumbridge HB, Lim MV, Rudman RA, Serraon A. A By avoiding IDBs there is less risk of injury to Association 72 (6) 559-564 comparative study of anesthetic techniques for the lingual and inferior alveolar nerves which, 3. Pogrel M, Schmidt B, Sambajon V et al. Lingual nerve mandibular dental extractions. American Journal of though rare, is debilitating to the patients and damage due to inferior alveolar nerve blocks. The Journal Dentistry 1997;10:275. of the American Dental Association 2003;134:195-199. 8. The National Royal College of Anaesthetists. Audit Recipe has no cure. This technique requires less skill, doi:10.14219/jada.archive.2003.0133 Book 3rd edition. 2012. Accessed 31/07/2019 at: https:// causes less discomfort for the patient during 4. Evans G, Nusstein J, Drum M et al. A Prospective, www.rcoa.ac.uk/document-store/audit-recipe-book-3rd- Randomized, Double-blind Comparison of Articaine and edition-2012 the injection and avoids unnecessary lingual Lidocaine for Maxillary Infiltrations.Journal of Endodontics 9. Orr DL, Curtis WJ. Obtaining written informed consent for anaesthesia after dental treatment. 2008;34:389-393. doi:10.1016/j.joen.2008.01.004 the administration of local anesthetic in dentistry. Journal 5. Kung J, McDonagh M, Sedgley C, Does Articaine of the American Dental Association 1939 136(11):1568-71. Provide an Advantage over Lidocaine in Patients with doi: 10.14219/jada.archive.2005.0090 Symptomatic Irreversible Pulpitis? A Systematic Review 10. Montgomery v Lanarkshire Health Board [2015] SC 11 and Meta-analysis, Journal of Endodontics November [2015] 1 AC 1430. 2015 Volume 41, Issue11, Pages 1784–1794. https://doi. org/10.1016/j.joen.2015.07.001
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 7 Dentistry and pregnancy
Leonie Callaway, professor of medicine at the University of Queensland, looks at why it's so important for dentists to understand some of the issues around dentistry and pregnancy
ne of the main difficulties dentists If you ever have a tricky question regarding Most dentists find it reassuring to know that O struggle with is their fear around care for a pregnant woman, feel free to call the care they might consider providing is quite treating pregnant patients. It is an your closest tertiary maternity hospital minor in terms of risk, compared to what emotive time and everyone is aware of the and ask to speak to the obstetric medicine goes on for pregnant women on a day-to- need to ensure the very best outcomes for registrar or physician who is on call for the day basis in hospitals. For example, a dental the foetus. As a result of this fear, and a lack of maternity service. They should be able to radiograph results in a foetal radiation dose of clear understanding, clinical care can often be provide you with advice, and if they do not 0.0001 rads, compared to a chest radiograph more limited than it should be, with a series of know the answer to your question, they involving 0.001 rads. unfortunate and unintended consequences will be happy to point you in the direction of for both mother and child. The purpose of help. Pharmacists can also be invaluable in We teach all medical students that if a writing this is to try to put your mind at ease, providing advice regarding drugs in pregnancy. pregnant woman requires a chest radiograph and provide some clear guidelines about what at any point during her pregnancy, the is and is not okay during pregnancy. THE LEVEL OF CARE REQUIRED radiation dose to the foetus is so insignificant, We know that pregnancy worries many that the risk of not doing the radiograph and My area of expertise is as an obstetric healthcare providers and results in fear-based not assessing the lungs and heart properly physician. We care for women with medical clinical decisions that are often not in the best may far outweigh any minor risk of extremely disorders in pregnancy and therefore have interest of the mother or foetus. As a general low doses of foetal radiation. particular expertise in the issues around observation, pregnant women often do not radiation, drugs and surgery in pregnancy, receive the care they need from a range of Pregnant women who develop cancer are the provision of pre-conception care, and the health professionals, due to misconceptions often given multiple cycles of chemotherapy care of women with high risk pregnancies as about medications, radiology and surgery during pregnancy and women who develop a result of pre-existing illness or illness that during pregnancy. appendicitis, cholecystitis or hypercalcaemia arises during the pregnancy. from parathyroid adenomas are all cared We have seen pregnant women hobbling for with appropriately-timed surgery during Globally, there are obstetric physicians in around with undiagnosed fractures because pregnancy. So, in comparison to the kinds all of the major tertiary obstetric hospitals. their doctor was fearful of doing an x-ray of medications, surgical procedures and We work in multidisciplinary teams with during pregnancy, or struggle with a sudden radiation exposure that is required to care obstetricians, neonatologists, pharmacists, deterioration in their asthma because their for pregnant women on a daily basis, dental radiologists and specialists of all kinds with doctor thought their asthma medication was procedures and dental radiation generally falls an interest in pregnancy (eg rheumatology, unsafe during pregnancy. We also see women into the relatively minor category. endocrinology, cardiology, nephrology with toothache and dental sepsis because and oncology). dentists were afraid to treat them.
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 9 WHAT YOU NEED TO KNOW There are multiple guidelines to encourage under one side of the woman’s back while in There are a few key messages for dentists and reassure dentists about providing regular the dental chair, to ensure the foetus is not providing care for pregnant women or women and emergency dental care for pregnant sitting on top of the vena cava. within the reproductive age range: women. References to these guidelines are on the following page. 5. Non-steroidal anti-inflammatory drugs 1. Women of reproductive age need excellent need care during pregnancy. oral health prior to falling pregnant. 3. Dental imaging should be used when required. In the third trimester (from 28 weeks of Ideally, women considering a pregnancy gestation onwards), non-steroidal anti- should ensure that all major necessary dental Fear of dental radiation during pregnancy is inflammatory drugs (NSAIDs) should be work is undertaken prior to pregnancy generally misplaced. The foetal exposure from avoided, due to significant foetal risks. if possible. dental radiation is vanishingly low. Therefore, if These drugs are associated with persistent there is concern about dental infection during pulmonary hypertension of the newborn Dentists should enquire about pregnancy pregnancy and dental radiation is required due to premature constriction of the plans when women of reproductive age to assist in determining an appropriate patent ductus arteriosus, foetal renal injury, have dental issues identified, and encourage treatment plan, women should be strongly oligohydramnios (reduced amniotic fluid), them to complete treatment plans prior to reassured about the risk benefit ratio of necrotising enterocolitis and neonatal conception. This provides peace of mind for all dental radiation. intracranial haemorrhage. Unfortunately, the involved. Adverse events such as miscarriage, constriction of the ductus arteriosus in the congenital anomalies, growth restriction Untreated dental sepsis can trigger pre-term foetus can be related to even a single dose and premature delivery are common. birth, and result in overwhelming maternal of NSAIDs. People tend to associate adverse events infection. High quality dental care, including with whatever happened to them recently. appropriate dental imaging, can prevent these For dental pain relief, we recommend Providing excellent preconception dental care adverse outcomes. paracetamol. If additional pain relief is prevents women associating their dental care required opioid based analgesia is safer, and with common adverse pregnancy events in 4. Pregnant women from 28 weeks onward we would suggest the use of codeine or their own mind. It also reduces pregnancy need careful positioning in a dental chair. oxycodone. NSAIDs can be considered in the associated anxiety for the dentist, which is a second trimester (12-28 weeks) if absolutely well-documented problem. In advanced pregnancy, women are often necessary. If women have been taking over- very uncomfortable lying on their back and the-counter NSAIDs for dental pain in the 2. Required routine and emergency dental can develop hypotension from the foetus third trimester, encourage them to see their treatment can be carried out at any time compressing the inferior vena cava. obstetrician so an ultrasound scan to assess during pregnancy. Therefore, from about 28 weeks onwards, a foetal wellbeing can be arranged. wedge or rolled up towel should be placed
6. Individualised decision-making is often HELPFUL READING Ouanounou A, Hass DA. Drug therapy during required, and communication with other American Dental Association Guidelines on pregnancy: implications for dental practice. healthcare professionals involved in the Dental Care during Pregnancy: Br Dent J. 2016 Apr;22(8);413-417. woman’s care is strongly recommended. https://www.ada.org/en/member-center/ oral-health-topics/pregnancy Kelaranta A, Ekholm M, Toroi P, Kortesniemi Each woman’s situation is unique. There M. Radiation exposure to foetus and breasts are many variables in clinical decision- Oral health care during pregnancy and from dental X-ray examinations: effect of lead making for pregnant women who require through the lifespan. Committee Opinion shields. Dentomaxillofac Radiol. 2016 Jan; medications, imaging and surgical procedures. No. 569. American College of Obstetricians 45(1):20150095. These variables include the woman’s own and Gynecologists. Obstet Gynecol 2013 preferences, the stage of pregnancy, delivery (Reaffirmed 2017);122:417 -22. plans, foetal growth and wellbeing, weighing of risks and benefits, access to specialised CDC National Consensus Statement services, newly published research, variations regarding Oral Health Care During Pregnancy in guideline-based recommendations https://www.mchoralhealth.org/PDFs/ regarding the safety and acceptability of OralHealthPregnancyConsensus.pdf. various medications (eg local anaesthetics, nitrous oxide, antibiotics), decision-making in Guidelines for diagnostic imaging during the context of limited information, and the pregnancy and lactation. Committee Opinion skills of the healthcare providers involved. No. 723. American College of Obstetricians and Gynecologists. Obstet Gynecol CONCLUSION 2017;130:e210 -6. All of the guidelines encourage communication between the dentist and Lowe S. Diagnostic radiation in pregnancy: the woman’s other healthcare providers. We risks and reality. Aust N Z Journal Obstet strongly recommend good communication Gynaecol. 2004. June; 44(3):191-6. with the woman’s obstetrician, general practitioner or pregnancy healthcare team Lopes LM, Carrilho MC, Francisco RP, Lopes in cases where the best plan of action is MA, Krebs VL, Zugaib M. Fetal ductur unclear. We also recommend seeking expert, arteriosus constriction and closure: analysis up-to-date guidance in situations where of the causes and perinatal outcome related the published evidence and guidelines lack to 45 consecutive cases. J Matern Fetal sufficient clarity to guide decision-making in a Neonatal Med. 2016; 29(4):638-45. particular woman’s unique situation.
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 11 [email protected] © Case study A misaligned claim
rs T attended an appointment with Mrs T continued to see the dentist for her Based upon these findings, and the detailed M her regular dentist. The dentist was routine dental care up until the dentist retired treatment records clearly evidencing the already aware through previous five years later. The practice was sold and patient and dentist discussion regarding the discussions that she was considering a course all patients were informed of the dentist’s advice that permanent fixed retention was of orthodontic treatment to address the mild retirement and that a new clinician would strongly recommended, Dental Protection crowding in her upper and lower arch, along continue their care at the clinic. was able to robustly defend the claim on with aligning the upper central incisors that behalf of the retired dentist and demonstrate were mesially inclined. Unexpectedly, three years later the dentist the onus was on the patient to continue to received a letter from a lawyer informing him wear a retainer fit for purpose and her refusal Mrs T informed the dentist that she now was that Mrs T was pursuing him for damages to accept the dentist’s recommendations of ready to move forwards with orthodontic regarding treatment he had provided eight fixed retention all those years ago. treatment. The dentist had considerable years previously. The dentist was shocked experience in providing short-term and disappointed to learn the identity of the orthodontic aligner treatment and carried out patient, who he always felt he had enjoyed a LEARNING POINTS a full orthodontic assessment and provided good professional relationship with. the patient with treatment options, along with • Always ensure you write detailed option of referral for potential fixed braces The dentist immediately contacted Dental records of all key treatment with a specialist colleague. Mrs T declined Protection, who assisted him in obtaining discussions with your patient. In the referral and so the discussion with the more information. this situation, the information dentist was limited to aligner treatment. The provided to the patient regarding patient was also given information about It became apparent that Mrs T had been the recommendation for permanent the anticipated costs of aligner treatment wearing her retainers routinely since the fixed retention – along with the and made aware of the need for permanent dentist provided his initial orthodontic warnings of potential relapse – was retention after treatment had finished. Mrs treatment course all those years ago. recorded. The patient continuing to T was asked to book the next appointment However, Mrs T had complained that she wear a now defective retainer clearly for a further discussion or to begin treatment had experienced a relapse of the orthodontic demonstrated the dentist was not should she wish. treatment and the retainers were no longer liable for the mild relapse. maintaining the alignment of her teeth. At the following appointment, Mrs T said she • Even after retirement from clinical was sure she wanted to begin treatment, so Dental Protection requested that Mrs T was dentistry, a dentist can find themself the dentist carried out the aligner treatment examined by a specialist orthodontist to faced with a legal challenge for over the course of ten months. The patient establish the current clinical situation. The treatment provided a number of was very happy with the final result and the orthodontic report stated that Mrs T had years ago. dentist reiterated his recommendation that experienced a mild relapse in alignment of due to the original position of the mesially the incisors, which had started to become • Occurrence-based protection with inclined upper central incisors, he considered mesially inclined once again. Mrs T was Dental Protection depends on the it necessary to have both permanent fixed requesting that the original dentist pay for date on which an adverse incident retention of the upper teeth and upper and remedial treatment to correct the relapse in occurs, and not the date that the lower removable retainers to guard against alignment of the upper anterior incisors, as matter is reported to us. This is potential tooth movement in the future. she said she was informed the alignment of important because it can often her teeth would be maintained if she wore the be years before a case is brought Mrs T declined fixed retention because she retainer every night. and fully resolved. This type of would not be able to floss. The dentist went protection offers peace of mind, and on to remind her why permanent retention The specialist orthodontist also examined the in this instance, meant that Dental was necessary and the risk of relapse should patient’s retainer which was discovered to Protection was still able to provide she not observe a strict regime of wearing have two fracture lines present and a missing assistance, at no further expense to the retainers each and every night. She still section in the upper anterior buccal aspect, the dentist. refused and so the dentist provided upper that was allowing flex and movement of and lower removable retainers, being sure the retainer. to document all their discussions in the treatment records.
Case study Avoiding patient-led dentistry
s B was suffering from pain that kept The first dentist received a letter of complaint M her awake at night. An examination questioning why the endodontic treatment LEARNING POINTS by the dentist established tooth 27 had not been completed in five visits, and why was the cause of discomfort. The 27 had Ms B had been charged for this incomplete • Be alert to patient-led dentistry extensive dental decay and a missing buccal and unsuccessful treatment. and the demands of strong-willed wall. Ms B had an otherwise intact arch and patients. Unrealistic expectations was keen to save the tooth – she did not want Whilst the clinical records were detailed, should be identified and managed a dental extraction. the practitioner was vulnerable in some from the outset. The reasons why areas regarding the clinical care provided. In the treatment is inappropriate The dentist explained that endodontic terms of the preoperative assessment, the should be communicated effectively. treatment carried no guarantee of success, restorability status of the tooth at the outset especially with the extent of damage to the was questionable. During the procedure the • Avoid being coaxed by persistent enamel walls, and extraction was offered as dentist could not place a rubber dam because patients into carrying out treatments the only realistic alternative. of insufficient residual coronal tissue and, that have a slim to zero chance owing to a lack of anatomical landmarks, of success. Ms B was quite persistent in her demands a perforation occurred. With hindsight, the for root treatment, along with a full coverage practitioner realised that the decision to • Just because a patient consents to crown, and was unwilling to be referred to a carry out root canal therapy intervention had treatment, it doesn’t necessarily specialist. The dentist felt pressurised by the been a poor one, and she should not have mean that the treatment patient and embarked upon the endodontic attempted the procedure in the first place. is appropriate. treatment against her better judgement. The complaint was resolved by refunding Ms • In this particular case, the complaint Five visits later, only two of the canals had B for the initial endodontic treatment and was resolved by a detailed letter of been located and the third may have been contributing towards the cost of the second explanation and refund of fees. perforated as it bled on instrumentation. dentist’s assessment. This was discussed with Ms B and the tooth • In trying to appease the patient, the was dressed. Had Ms B pursued the matter with a claim dentist had spent more than three for clinical negligence, the solicitors could hours attempting treatment that Whilst the endodontic treatment was potentially allege that Ms B had been was essentially doomed to fail, and becoming more complicated, Ms B was still subjected to an inappropriate procedure with then had to spend even more time unwilling to consider an extraction and was associated pain and suffering. managing the resulting complaint. forceful in her request for the root treatment to be completed by the practitioner. • This case highlights the dangers of attempting heroic dentistry; dentists Further explanations were provided, but are unlikely to be thanked for lack despite this Ms B remained convinced that of success. a crown would solve the problem. She decided to visit a second dentist and was • Unrealistic expectations should be informed that the tooth had an incomplete managed carefully from the outset. root canal treatment.
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 13 Case study [email protected] © Delayed postoperative healing following an extraction
rs C attended her dentist for an The press team at Dental Protection was The situation was amicably resolved by M extraction of an unrestorable, asked to assist the member and advised the arranging for another dentist to review Mrs C. fractured 37. The procedure was dentist that if he was contacted by the media This dentist confirmed the diagnosis and uneventful and postoperative instructions for a comment, he should find out: explained to the patient that dry socket was were provided in the usual way. a recognised complication, and that the pain • the journalist’s name would subside within a few days and the She returned a few days later in discomfort socket would heal. and the dentist diagnosed alveolar osteitis. • the name of the publication The socket was irrigated and the dentist It is always advisable to request Dental placed a medicated dressing in the socket. • the aspects of the care and treatment they Protection’s assistance from the outset when The dentist explained the diagnosis, advised were seeking comments on faced with unexpected clinical outcomes Mrs C to take painkillers and offered to book a and/or complications that may lead to a review three days later. • the deadline for a response patient complaint. In this situation, the dentist was able to identify a strategy to manage the Mrs C seemed surprised about this and • the journalist’s contact details, including adverse social media coverage and potential declined the appointment, as she had already phone number and email address. harm to his reputation by contacting Dental taken two days off work to attend the Protection immediately. clinic for the extraction and the emergency The press team also provided the following appointment. As there were no signs of helpful advice: infection, antibiotics were not prescribed, LEARNING POINTS and she left fairly disgruntled. • Do not respond to any questions immediately – instead take some time to • The dentist failed to warn the Her husband returned to the clinic the next consider a response or to seek advice. patient about the possibility of day shouting and behaving raucously. He alveolar osteitis at the outset. complained to the receptionist that his wife • Maintain your professionalism at all Consequently, when the patient was still in considerable pain following the times and do not be tempted to discuss a developed a recognised postoperative extraction of her tooth, and stated that this patient’s treatment in a public domain. If complication she became alarmed was down to the poor standard of treatment you cannot discuss the patient’s treatment and blamed the dentist. provided by the dentist. He threatened to for confidentiality reasons then you should report the dentist to the press and the Dental say so. • An opportunity was also missed Council, and said that he had already posted when the dentist realised that the negative comments about the dentist on • Avoid saying 'no comment' as it sounds patient left the clinic unhappy. various social media sites. defensive. Ensure you come across as co- It may have been worthwhile operative and inform the reporter that you considering contacting the patient The dentist in question was working in will come back to them. later on that evening to enquire how another clinic that day and was informed she was and provide further support of this event by the Practice Manager. He • Contact the Dental Protection press office and advice. then contacted Dental Protection for urgent for advice and liaise with your employer/ advice as he was concerned about the impact practice where appropriate. of the critical social media commentary. He discussed the case with a dentolegal The dentist was reassured that the press consultant and explained that although he team could liaise with journalists if necessary was unaware of any press coverage to date, and provide a statement on his behalf. there were a handful of comments on social media attempting to undermine his credibility Steps were also taken to address the negative and professional reputation. comments made on social media: the administrator of the social media page was contacted and the unfair and inappropriate comments were asked to be removed.
Case study I told the patient… but I didn’t write it down
r L visited his dentist complaining risks; however, neither he nor his team could M of pain in the posterior maxilla area remember if a discussion had taken place LEARNING POINTS under his existing partial denture. on this specific occasion, and he had not Clinical examination revealed redness and recorded any warnings in the records. • If there is a lack of documentation tenderness over his upper left second molar. that warnings had been given to the The records and radiographs were patient, in a dispute it becomes the A radiograph taken at the time of the examined by one of Dental Protection’s patient’s word against the dentist’s examination revealed a buried root, that experts and, despite all efforts to assist the and the patient will often have was clearly being irritated by the denture. dentist in defending the case, the lack of greater credibility. It is therefore As a temporary measure, the denture was documentation made the case difficult imperative to record the details of adjusted and Mr L was advised that the to defend. the specific warnings given. retained root should be removed. In court, the lack of appropriate records • We have a legal and ethical The radiograph also revealed the floor of the meant that it was the patient’s word against obligation to disclose risks to maxillary sinus was in very close proximity the dentist’s – and there is a real risk of a patients and to keep comprehensive to the root. Whilst the extraction appeared judge preferring the patient’s oral evidence. records. Without adequate records to have been completed without too much Good record keeping is an example of good being made of patients being warned difficulty, unfortunately unbeknown to the care, so inadequate records could create an about possible treatment outcomes, dentist, Mr L developed problems associated impression of poor care, extending to the it is very difficult to provide a robust with an oroantral communication (OAC). Mr consent process. defence against a claim or Dental L did not return to the practice and obtained Council investigation, as this further treatment elsewhere. This denied case illustrates. the dentist the opportunity to discuss this complication with Mr L and to resolve any • A dentist could be tempted to alter potential concerns at an early stage. or add to a patient’s record should they become aware that the record Mr L’s lawyer claimed their client was not is to be scrutinised. With modern warned of the risks of developing an OAC and technology such changes are easily that he should have been referred to see a recognised, and the courts and specialist. The dentist suggested that it was dental registration bodies take an his normal practice to tell patients of such extremely serious view of non- contemporaneous records being submitted as originals in evidence.
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 15 [email protected] © Case study Leaving a sour taste in the mouth
ssociate dentists leave their current Mr L became upset when asked to pay for A practice for a variety of reasons, polishing the composites and raised the issue LEARNING POINTS and occasionally this can be due to with the principal, who passed the complaint a breakdown in communication and issues to his former associate. The associate • This case study demonstrates the surrounding working relationships within the offered to review the patient and provide importance of clear records and how practice. When an associate leaves a practice the necessary treatment at no cost, but the beneficial it is to maintain a good on bad terms this can be the catalyst for a patient was unwilling to travel to see him. relationship with colleagues. burst of patient complaints. This scenario can be exacerbated if there is no agreement in This scenario was not an isolated example; it • There should be a signed associate place with the practice principal in relation to was a recurring story involving a number of agreement that includes a clause how to manage remedial treatment. patients who required similar maintenance regarding the retention of fees for work. Rather than completing this work as a remedial work when an associate It is common practice for an agreed sum of gesture of goodwill to maintain the reputation leaves a practice. This avoids money to be withheld by the principal for of the practice, the principal encouraged disputes and disagreements that an agreed period of time when an associate every minor concern to develop into a may arise after the departure of leaves a practice, to allow minor problems to complaint that required a formal response an associate. These disputes are be resolved. from the associate. The fact that the patients exaggerated where the working were being charged an over-inflated cost for relationship has soured. CASE STUDY maintenance treatment by the principal only The relationship between a principal and an added to the patients’ dissatisfaction. • When a dentist leaves a practice, associate had deteriorated to such an extent inevitably there has to be a point that the associate had left the practice. The associate contacted Dental Protection where any further treatment and, with the benefit of hindsight, realised that provided by a subsequent clinician The associate was clinically very competent he had not made it clear to Mr L – or to the becomes chargeable. When and experienced, and had completed a other patients – that ongoing maintenance planning treatment that which number of challenging ‘tooth wear’ cases. would be chargeable. He recognised that requires ongoing maintenance, there had been no clarity regarding what clear explanations should be given One particular patient, Mr L, had been treated aspects of the treatment were covered by the to the patient and documented in with composite build up restorations on original fee and, as a result, patients had made the record. This should include an numerous teeth to conservatively address their own assumptions. explicit statement as to what the his tooth wear and the finished result was initial fee includes and what charges satisfactory. Whilst the associate’s clinical Dental Protection advised the associate to may apply in the future. This should records reflected the merits and limitations of talk to the principal and to try and come to be set out clearly in writing for the composite resin versus porcelain restorations, an agreement, to avoid further incidents that patient and a copy retained in the there was no mention that further charges could be harmful to both their reputations. records so everyone knows what would apply for the maintenance and/or to expect. If there are any queries repair of these restorations. The associate and principal reached after an associate has left, the an agreement between them to cover principal and the new dentist have When Mr L required some fairly minimal the reasonable cost of post-treatment the necessary documentation to general polishing of the composite maintenance/polish appointments. support future interventions and restorations due to surface staining, he said related charges. he had not been informed that additional charges would apply and did not expect the • Financial disputes between the owner of the practice to charge him for principal and an associate should this treatment. be resolved between the two parties and not involve the patient. This aspect should be a ‘back office’ function and disputes should not be played out in front of the patient.
16 Case study
Considering CBCT ©[email protected]
One of the most spectacular examples of new technology in modern dentistry is the increasing use of cone beam computed tomography (CBCT). Dentolegal consultant Jim Lafferty looks at the technique’s potential pitfalls and key risks
he improvements in assessment, In the accompanying case report, you will see The family complained to the regulator, T diagnosis and treatment planning that it is very important to establish who will and the oral surgeon contacted Dental that come with the use of CBCT be reporting on the image. Protection. He was particularly concerned, are well known – in the fields of implant as his records of the patient’s treatment placement and third molar surgery we have The key points dentists should consider in the were somewhat brief and generally of a low seen significant uptake, and our endodontic area of CBCT are: standard; however, with assistance from specialist colleagues are now also seeing the Dental Protection the member was able to benefits of using it and how it can improve • Arrangements – who will be responsible show that he had ordered specialist reports, results for patients. for reporting? and that the developing neuroma had been missed in the original scan. It was put forward The use of such technology to improve patient • Assess – a CBCT without clinical that the responsibility for failing to diagnose care and reduce risk will be an attractive examination is very difficult to defend. the tumour was not the oral surgeon’s. We proposition to all involved, but there are then worked closely with the member on potential pitfalls – awareness of these is vital, • Balance – the risks of ionising radiation developing a CPD programme around record particularly given the high costs associated against the clinical information gained. keeping, so that by the time of the hearing, he with purchases of this type. was able to demonstrate that he had shown • Minimise – can the same information be insight and taken steps to remediate. There is a considerably higher exposure to obtained with a lower dose x-ray? ionising radiation that increases the risk of Naturally the member was keen to emphasise developing a malignancy, so we should all be • Justification – record in writing the reason in his response to the Dental Council how able to justify why any CBCT is being used, for taking the x-ray. distraught he was at hearing the news, but even if you are prescribing the imaging to he did not consider the complaint showed be taken elsewhere. In some jurisdictions • Report – there should be a written any wrongdoing on his part. This was there is now a legal requirement to record report, leading to the normal recording of recognised by the Dental Council and the this justification in writing. Members in those diagnosis, treatment options discussion, risk case was dismissed. territories report that this means they are discussion, treatment planning and consent. more careful to consider both the benefits and the risks associated with CBCT and, as CASE STUDY LEARNING POINTS a result, have reduced the number of CBCT Mr D was referred to an oral surgeon for images that they take, reducing the amount pain related to his temporomandibular joint • By having the image reported on of exposure to ionising radiation. (TMJ) issues. During the early assessments, a by an appropriate specialist, the CBCT was prescribed, carried out in a remote responsibility for spotting pathology If you are responsible for assessing the CBCT and imaging centre, with a specialist outside the area of interest is not resulting image you should ensure that you radiologist report ordered. Over a year later, the dentist’s. can demonstrate that you have suitable a further CBCT was ordered from the same training for this and make a written record centre when symptoms had spread. • All x-rays should have a written of the assessment. There are enormous report. amounts of information to be gleaned from The patient went on to develop a cancerous these x-rays, and the person reviewing the neuroma in his tongue, which by now had slices has the responsibility to check for spread into the lymph nodes, and was pathology in all those slices – even at sites considered inoperable. distant to the area of interest.
RISKWISE 18 | OCTOBER 2019 | dentalprotection.org 17 [email protected] ©
Case study An unexpected surprise
s C visited her dentist, requesting The sensitivity continued, so Ms C obtained Our advice to the member was that a M an improvement on her overall a second opinion and was advised that both refund of his treatment fees would not be smile and the specific appearance crowns had not been fitted correctly. The sufficient to resolve this matter, so we made of the upper lateral incisors. They report from the new dentist was supported a contribution towards the additional costs of had been restored with porcelain veneers by radiographic evidence confirming a the remedial treatment. some years previously and the colour match substandard marginal fit – which explained with the natural adjacent teeth was now the sensitivity reported. The crowns were unsatisfactory. replaced by the new dentist and a letter of LEARNING POINTS complaint was sent to the original dentist Ms C, an aspiring actress currently living from the patient. She clearly felt that she had • The law on consent provides a overseas, had been regularly attending this been more involved in the latest treatment framework that protects patients’ particular dentist since childhood. The dentist decision than she had been when the rights to make an informed decision had placed the existing veneers more than zirconium crowns had been discussed, stating about all aspects of their treatment. 12 years ago as she had peg-shaped lateral that she had not been fully informed about In this case, the choice of zirconium incisors. At a previous visit Ms C had obtained how much of the additional tooth would crowns instead of veneers was not some home tooth whitening gels that she be sacrificed in order to accommodate the adequately discussed, nor was there had been using, and the veneers were now crowns, and what impact this might have anything in the records that we a good few shades darker than the rest of long-term. She did not reference the fact could use to defend the dentist’s her teeth. that the dentist had been willing to rectify position. Had the patient obtained the situation, and that it had been her own legal advice, she would have been She told the dentist she wanted all of her scheduling difficulties that had caused the told of her right to compensation teeth to be a uniform, very light colour. When problem to remain unresolved. and it made no sense to allow this the dentist removed the existing veneers he situation to escalate, where legal noted the underlying vital tooth structure The dentist contacted Dental Protection fees would dwarf the cost of paying was particularly dark, suggesting there had for advice and assistance on how he might for the remedial treatment. been some longstanding bond failure. He manage the complaint, as Ms C was now had recently treated a patient with a similar seeking a refund of his fees and a payment • Unlike a tightly-worded contract of problem, and so was acutely aware of how covering the cost of her remedial treatment. insurance that may only respond challenging it was to replace veneers on a Notwithstanding his offer to replace his faulty to a claim, the use of discretion like-for-like basis and create the aesthetic work, he felt it was unfair that he should be means that in some situations outcome the patient desired. expected to finance the remedial treatment we can proactively manage a case as well. Having lost the trust of the patient, by providing financial assistance He therefore made a decision to provide a the dentist lost the chance to recover the towards the remedial treatment. full coverage zirconium crown on each lateral situation, particularly where there was factual In doing so, we protected the incisor. For some reason – possibly because evidence of a poor fit. He also accepted that interests of the member and his he was overloaded with distractions at the the consent process had been undermined by reputation. We also protect the fit appointment and was running late – he his failure to identify how much information mutual fund and the interests of the failed to check the contact point distally at the patient needed, specifically around the wider membership by containing 22 and had not noticed that this crown did long-term risks attached to a more aggressive unnecessary legal costs. not sit correctly. Ms C returned a few days tooth preparation compared with a like-for- later complaining of sensitivity and a deficient like replacement of two veneers. margin palatally that she could feel with her fingernail. It was agreed that this crown would In her complaint, the patient stated that had be replaced; however, it became impossible the correct information been given at the time for an appointment to be scheduled due to she had the veneers replaced, she would have the patient’s overseas commitments. made a different decision.
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