When multiple practitioners are involved in a patient’s care, or events outside of a dentist’s control conspire to postpone treatment, a patient’s continuity of care can be compromised. Dr Simon Parsons, Dentolegal Consultant at Dental Protection presents a case study where both factors come into play and can be seen to contribute to an allegation that the treating dentist failed to diagnose dental caries in a young child.
Five year old Master X attended for a check-up appointment with Dr Y, having been seen previously at six-monthly intervals by other colleagues at the practice until just before the age of four. At many of those check-up appointments it was noted that Master X’s teeth had significant plaque deposits. Unfortunately, lockdowns throughout the city associated with Covid-19 resulted in Master X missing two scheduled check-up appointments.
When Dr Y examined Master X, she noted two clinically apparent carious lesions in his deciduous molars. To aid in the diagnosis of any other lesions, Dr Y attempted to take bitewings, but Master X could not tolerate them. Due to time limitations, Dr Y did not attempt any other investigations at that appointment and instead asked Master X’s parents to make a follow-up appointment to have these two restorations placed, with the intent of addressing those lesions promptly.
Master X only returned three months later and was seen by Dr Y’s colleague, Dr Z, who again unsuccessfully attempted bitewings, offered an OPG (which was declined by the parents) and then decided to refer Master X to a paedodontist, due to concerns that other treatment may still be required and his somewhat difficult behaviour in the chair.
By the time Mst X saw the paedodontist and had an OPG taken, multiple teeth (including one of the two teeth diagnosed as requiring a restoration by Dr Y) now had advanced caries. Indeed, one deciduous tooth now required extraction and several others required pulpotomies and stainless-steel crowns.
Mst X’s parents were extremely disappointed that their child, who had been routinely seen at the practice over much of his short lifetime, now needed such extensive and expensive dental treatment under general anaesthesia. While falling short of blaming Dr Y and Dr Z directly for Mst X’s rapid dental deterioration, they alleged that his condition was not diagnosed in a timely manner, nor were the oral conditions such as poor oral hygiene communicated sufficiently for them to manage them appropriately with their child. They sought unspecified compensation for the costs they had incurred with the paedodontist, otherwise they indicated they would escalate their concerns about Dr Y’s care and that of the other practitioners at the practice. This prompted Dr Y to contact Dental Protection for advice on how best to manage the situation.
In discussion with us, it soon became apparent that while neither Dr Y nor Dr Z were directly responsible for Mst X’s rampant caries, there were still multiple vulnerabilities around the documentation of his visits, including the discussion of risk factors and the implications of not seeking very prompt follow-up care. Further, the absence of any radiographs or photographs being on file at the practice made it extremely difficult to determine the onset of Mst X’s caries and whether it was a recent phenomenon or had, instead, been missed. Dr Y could not adequately explain why an OPG was not offered when the bitewings were unable to be taken, and it was apparent that had such imaging been on file, not only would it have been helpful in diagnosing the full extent of Mst X’s dental caries, but Dr Y would have been in a much better position to decide if specialist referral was already indicated. This might have made a material difference to the subsequent extent of Mst X’s specialist treatment.
While it is uncommon for radiographs to be taken on young children, on some occasions it can be justified, particularly when ongoing evidence of risk factors such as poor diet and oral hygiene are present. Further, children can take time to develop trust and cooperation with their treating doctor and dentist, and it is always desirable to build rapport through continuity of providers. Dental Protection recommends that where doubts exist about a child’s clinical conditions, an offer of appropriate further investigations is made. Should those investigations be refused, we recommend that this is clearly documented in the treatment notes along with an explanation of the implications of that refusal, such as the inability to reliably diagnose incipient interproximal caries and missing permanent teeth.
Unfortunately, it is increasingly common for parents whose children require specialist paedodontist care to direct liability to the child’s previous treating dental practitioners. This is especially an issue where teeth are so compromised that they are deemed to require extraction. The parents typically ask, “Why wasn’t this picked up sooner by you, especially since he/she has been coming to see you so often?”
With the assistance of Dental Protection, Dr Y provided a detailed letter to Mst X’s parents, explaining a timeline of his care and defending the approach taken by the practitioners at the practice. Given the vulnerabilities surrounding the communication of Mst X’s condition, an offer of a refund of the fees paid for the consultations with Dr Y and Z was made and accepted by the parents, along with an offer to pay the difference between the specialist fees and the practice’s fees for the treatment of the two deciduous molars. This was accepted by Mst X’s parents and nothing further was ever heard.
Learning points
- Continuity of care is nearly always protective as it builds trust and rapport and also provides a consistent clinical approach to a patient’s care. This can be especial advantageous in young patients who may otherwise be difficult to manage in the chair
- Comprehensive notes about what was both done and not done can be useful should it later become necessary to explain why care was not performed or only performed at a much later date
- A balance between conservative treatment and effective diagnosis can sometimes be difficult to achieve. Investigations such as radiographs, pulp tests, plaque disclosing and photographs not only enable clinicians to establish sound diagnoses, they are also invaluable in educating and informing patients and key decision makers, while being crucial in helping to explain or defend a clinician’s care when challenged.