Dental practitioners sometimes utilise third party providers to assist in the planning of certain treatment modalities. What happens then if it all goes wrong?
Dr M, a compassionate and considered practitioner, prided himself on seeking knowledge from a broad number of sources. He had always been interested in the provision of orthodontic treatment in the mixed dentition stage, and actively sought out courses and literature on this subject.
A new and interesting treatment modality came to his attention, devised by an orthodontist based overseas, and designed for use by general dental practitioners. An organisation that Dr M respected arranged for this orthodontist to come to Australia to speak, and to teach. Intrigued by what he had read and comforted by the involvement of a respected third party, Dr M eagerly signed up.
The course was fascinating, and the outcomes shown exceptional. Dr M raised many questions and challenged what he was told. He was disappointed when his concerns were not addressed. Nevertheless, swept along by the concept of care he could provide to his patients, he completed the course and became an accredited provider of this treatment modality.
Shortly afterwards, Mrs Z attended with her 13-year-old daughter, seeking some improvement in her dental appearance and with concerns about her airways. She had these concerns based on some commentary in a mothers’ group on Facebook. Dr M assessed Miss Z and believed her to be suitable for the treatment modality he had recently become accredited in. Appropriate records were taken and provided to the overseas third party for review and treatment planning, in accordance with their protocol. The plan and hardware came back, and Dr M confidently commenced treatment. He did not discuss the potential deleterious effects of orthodontic treatment broadly, nor any associated with this specific treatment modality. He did not offer to refer the patient to an orthodontic specialist for assessment, nor clearly state that he was not a specialist.
Six months later…
Treatment proceeded as planned; however, after about six months some unplanned and unexpected tooth movements began to occur. Dr M contacted the third party who planned the treatment for guidance, and they reassured him that all was well. Two weeks later, Dr M received an early morning call from a distressed Mrs Z. Miss Z had experienced pain over the weekend, so severe that it necessitated a visit to the hospital for pain relief. A CBCT had been taken, and this had revealed Miss Z’s upper 6 anterior teeth to be outside the buccal bone.
Confused by this Dr M tried to buy some time to assess what had happened and talk with the third party who designed the appliances. Regretfully, an emotionally heightened Mrs Z saw this plea for time to be a ‘brush off’ and immediately made a notification to the regulator and simultaneously sought legal advice. A statement of claim for damage was filed. The particulars of this claim, and costs sought, were high, seeking to compensate a 13-year-old girl for the potential loss of some, if not all, of her six upper front teeth.
The regulator assessed the matter and criticised Dr M heavily for his reliance on a third party to plan treatment. Dr M was unable to provide the regulator with any evidence that he had appropriately assessed the patient, or that he had considered the best possible care for Miss Z. In his favour, his records were excellent, and the pre-treatment documentation he provided to the patient clearly set out that he was not a specialist.
Nevertheless, the regulator was deeply concerned by the lack of judgment shown by Dr M, and by the fact that he had watched Miss Z’s teeth move outside the buccal bone, recognised something was wrong, and yet done nothing.
Conditions were placed on Dr M’s registration, requiring him to have a supervisor for all orthodontic treatment, to assess and approve his treatment plans and review his patients during their care. This specialist must be an orthodontist, and the supervision must stay in place for a minimum of 18 months, reflective of the length of time involved in an average course of orthodontic care.
The legal claim has not yet been settled, and under the Australia legislation, Miss Z has until she is 28 years old to formalise her legal claim.
Dentolegal commentary
The length of time for the legal aspect may be of surprise to some readers. A minor is granted this dispensation under the law by virtue of their age and, as a consequence, many orthodontic matters can take years to resolve.
The long-term prognosis and restorative options for Miss Z will dictate the final settlement amount.
In any matter such as this, the practitioner who provides the treatment is held liable, regardless of who planned the care. Dr M is an independent practitioner, and as such holds the responsibility of assessing the appropriateness of the treatment he provides.
Dr M’s comments
I cannot think about Miss Z without feeling sickened with myself. I got into dentistry to help other people, and I know that my treatment has not helped her and has in fact caused her significant harm. As a parent myself, I can truly understand how the worry about loss of the front teeth of my child would affect my family.
I feel really stupid for not challenging the course convener harder. I was dismissed and to be honest, belittled when I questioned the research, and rather than be suspicious about this, I took social cues from the others around me, and sat back down. I know better than that. I let myself down and I let my patients down.
Being placed in supervised practice has been so humiliating. That said, the actual collaborative experience has been incredibly positive. There was so much I thought I knew but didn’t fully understand. I ‘didn’t know what I didn’t know’ and I hurt a child as a consequence. I can’t take that back, but I can be better in the future.