As dentists we understand that we need to meet or exceed the aesthetic expectations of our patents when performing cosmetic dentistry. But what about those occasions when a tooth is not fundamental to a person’s appearance? What if the crown you place is aesthetically sound, but a patient refuses to accept it due to an overall dissatisfaction with their dental appearance? Or what if the patient complains about your care even before you’ve had the chance to deliver definitive treatment? In this case study we’re reminded that high quality work does not guarantee patient satisfaction, especially in patients who are predisposed to disliking the outcome of care. 

The case 

Ms X, a lady in her mid-40s, was referred to Dr A for an opinion and treatment to her upper anterior teeth due to her concerns around their colour and shape. Her teeth from the 15 to the 25 had a history of cosmetic restorations over the past 20 years, initially in the form of direct composite resin veneers and then, within the past year, placement of indirect zirconia restorations. Ms X remained dissatisfied with those zirconia restorations and sought to have Dr A replace all or some of them using his expertise as a well-regarded prosthodontist. She already had in mind having porcelain veneers placed on the anterior teeth and new crowns on her premolars.

Dr A determined that Ms X’s anterior restorations were slightly too long, had an unfavourable cant to the right, and lacked aesthetic harmony with her remaining dentition, especially due to their opacious and unnatural shade characteristics and lack of characterisation. She also had moderate attrition consistent with self-reported parafunction. Dr A outlined these issues to Ms X and discussed options of leaving the teeth as they were and accepting that result, remodelling two teeth (21 and 23) only, or replacing all ten restorations, depending on Ms X’s budget and preferences. After further discussion, Ms X elected to proceed with replacement of all ten restorations so that her aesthetic issues could be addressed once and for all. A further appointment was booked for a second consultation, quotation and records.

Interim issues 

Soon afterwards, Ms X developed pain in her right posterior segment and her new general dentist noted that tooth 16 was now abscessed; it was extracted the following week uneventfully.

Three months later, a further tooth began to cause Ms X discomfort. She was referred to an endodontist who diagnosed a likely necrotic pulp in tooth 14 and a necrotic 13 with symptomatic apical periodontitis. The endodontist also recommended replacing the zirconia crown on the 13 on completion of endodontic treatment to ensure a sound coronal seal.

Due to these new developments, nothing further occurred with Ms X’s cosmetic rehabilitation.

Limited further treatment 

Dr A had not had any opportunity to assess Ms A’s teeth radiographically due to those records being scheduled for her second consultation with him, which had so far been postponed. Further, no restorative treatment had been commenced to address Ms X’s cosmetic issues.

Ms X presented to Dr A following completion of the root canal treatment on tooth 13 with a fractured zirconia crown in situ, requesting that this be replaced. Dr A advised he could proceed, subject to assessing the underlying tooth’s integrity and restorability. After refining the margins, he placed a temporary crown, with the view that the restorative treatment plan would then commence soon afterwards. He photographed the sections of the pre-existing crown and stored them at the patient’s request.

The plot thickens 

Ms X did not return for another three months, at which time she requested a full copy of her records and the stored crown fragments. At that visit she accused Dr A of losing her original crown fragments and substituting it with someone else’s crown, as to her mind the fragments felt heavier than before. She alleged that Dr A had digitally altered the crown images on file. She made no further appointments for her ongoing care. 

Prior to the visit to collect her previous crown, Ms X had engaged a solicitor, who sent a request to Dr A for a report regarding the quality of Ms X’s previous dental treatment. Specific answers were sought, including Dr A’s opinion about whether the previous general dentist had removed too much tooth structure when preparing Ms X’s teeth. Dr A advised he would be unable to provide such answers until the existing restorations were removed and radiography conducted. He also advised that in the interests of ensuring an impartial opinion about her ongoing treatment, an independent report from another prosthodontist would be wise; this would mitigate any later allegations of a conflict of interest, while also preserving the integrity of the referring dentist’s relationship with him.

Soon afterwards, Dr A received a regulatory notification. In that notification, Ms X complained that Dr A had not cooperated with the release of her records, had substituted the crown fragments with another patient’s and hindered the progress of her seeking legal representation to resolve concerns about her previous dental care.

Resolving a dispute 

At this point, Dr A contacted Dental Protection for assistance. We assisted him with his submission to the regulator. Due to the high quality records he had made of his limited contact with Ms X, including his photographic records of her previous crown, no further action was deemed necessary and the allegations against him were successfully defended. No further contact has ensued from Ms X. 

Learning points 

• Patients who are dissatisfied with past dental treatment can pose a unique management challenge. Patients typically know what they don’t want but rarely know what they really want. Further, on the occasions when they do know what they want, often that expectation is unrealistic and potentially unachievable.

• A patient’s cosmetic treatment decisions can be heavily influenced by emotions and not based on a careful, rational, and objective consideration of all relevant options. It leaves open the questions: “Can I do better than the last dentist at meeting this patient’s high expectations?”, and “Even if I do achieve a better result, how can I be sure the patient will be satisfied?” 

• Patients may have no preexisting relationship with you if they present for a consultation. This affords them little or no reason to trust your opinion. Without any past experience of your care, they have no specific reason to be confident in the care you do provide and may at times be overly critical of you until you have earned their trust. Where patients have past bad dental experiences as a reference point, this can prime them to expect the worst or, alternatively, expect immediate and often miraculous results. Either way, this creates behavioural challenges and leads to pressure on a clinician to perform at a consistently high level, often also involving extensive and time-consuming conversations around proposed care.

• Dr A recognised the risks associated with providing Ms X with comprehensive aesthetic rehabilitation. He conducted a detailed consent process and planned to take detailed records. The limited treatment he did perform was thoroughly documented. Those records proved invaluable in defending Ms X’s allegations surrounding his care. It cannot be underestimated how important the clinical records are (and also how valuable photography and other imaging can be within those records) in recording a patient’s before and after condition. 

• Dr A also showed excellent professional judgement in keeping any opinion about past treatment at arm’s length as he did not know the circumstances around how past care as delivered, the patient’s behaviour, the allocated budget or other critical information.

• Dr A’s experience is a salient reminder that we can be exposed to risk of a complaint or claim even when we have had little involvement in the care of a patient, and despite that care being conservative, of high quality and appropriate. Patients can seek a convenient target to direct blame towards and if you are one of the clinicians who have provided treatment, you may be targeted. The highly emotional nature of aesthetics makes cosmetic dentistry patients an elevated risk in clinical practice, irrespective of the treatment outcome achieved.