The cost of care can be considered in many terms, including fiscal and biological costs. There can of course be untold costs too – the cost of stress, or maybe potential reputational damage as a result of patient dissatisfaction.

The case 

Ms A presented to Dr B for a cosmetic consultation. He was impressed by her, finding her to be a well-educated and articulate professional. During their consultation, Ms A told Dr B that his practice had appealed to her due to their smart and innovative advertising and focus on modern techniques. She went on to say that she was seeking veneer treatment to manage the misalignments of her upper anterior teeth. She had undergone orthodontic treatment as a teenager and had unhappy memories of the pain of adjustments. On assessment, Dr B couldn't help but feel that veneer preparations on the current tooth position would necessitate excessive destruction of enamel, and that a more conservative and appropriate treatment option should start with pre-prosthetic orthodontics. Ms A was unsure, as her teenage memories had heavily polluted her view of orthodontics, but Dr B persisted, imploring her to consider this step, and trust his judgement, emphasising the biological cost of enamel destruction and quoting the ‘daughter test’ explaining that he could not in all conscience proceed with treatment that he would not perform on his own child. Ms A was convinced and grudgingly gave consent to proceed as Dr B had recommended, signing a consent form indicating she understood all of the risks and warnings that had been outlined to her. Of note, the inclusion of pretreatment orthodontics increased her estimated costs by over 50%, necessitating the use of a finance company. 

Unfortunately, the treatment did not proceed smoothly, with the first lot of aligners failing to fit. Then, Dr B remained unhappy with the final tooth position, requiring two rounds of refinement before he was willing to proceed. Ms A was concerned about the gums of her lower teeth, bringing to Dr B’s attention that they looked like they were pulling away from the teeth. Dr B reassured her things would settle and proceeded with the planned veneer preps. The postoperative sensitivity was excruciating and Ms A struggled to both eat and drink. She contacted the practice on no fewer than five occasions to raise her concerns, and each time was reassured that all would be well. It was not. 

Ms A initially reported herself thrilled with the aesthetic outcome of her treatment and indicated that she understood the sensitivity to be transient, and it was now within manageable levels. However, at the off-boarding appointment, a completely different conversation ensued, with Ms A now stating that the sensitivity was interfering with her life and her coworkers had said that her veneers were too white and unnaturally perfect. . Dr B reviewed the treatment, and other than some residual cement was unable to find anything wrong with the care. He emphasised that Ms A had selected shade OM1 against his recommendation, and produced the series of forms she had signed to indicate her acceptance and willingness to proceed at key stages during the procedure. Ms A was dissatisfied with his attitude and explanations but reluctantly left the practice to see if she could learn to live with the outcome. She couldn't. 

To make matters worse, the pain persisted, becoming more than an inconvenience, as it started to impact not just on her eating, but also her sleep. Inevitably, Ms A attended another dentist for a second opinion, and their examination revealed that 22 had devitalised, now requiring endodontic intervention. The treatment plan provided also extended to gingival grafting with a specialist periodontist to cover recession of the lower anterior teeth. Ms A asked how this could have occurred, querying if she had been scrubbing her teeth too hard. The new dentist advised it was more likely that the second course of orthodontic treatment had led to this attachment loss. 

Ms A was devastated. The aligner and veneer treatment had been funded through a third-party payer, and she still had multiple instalments to go before she could consider the endodontic and gingival grafting costs, and her health fund was tapped out. Ultimately, Ms A sought the assistance of a lawyer friend, to assist her in writing to Dr B, requesting a full refund and more besides on the grounds that: 

• He had coerced her into unnecessary orthodontic treatment, against her better judgement and for financial gain.
• Ultimately, this treatment had led to the death of one of her teeth, and the loss of gingiva around her lower teeth, which were needlessly involved in her treatment, and both now required specialist intervention. Ms A was of the view that the biological cost of the treatment provided to her was unnecessarily high, and higher than veneers without orthodontic treatment would have been.
• She therefore sought a full refund of fees paid, including Dr B settling her payment plan with the third-party provider and all costs associated with the use of this payee on her behalf. That Dr B cover the costs of her specialist appointments, the root canal treatment, and gingival grafting costs. And further, an amount be provided for all future maintenance and review appointments as these were only required due to Dr B’s coercion of Ms A. Plus an allowance for endodontic re-treatment, a subsequent post core and crown plus the cost of an implant to be factored into the compensatory figure as the tooth had died needlessly, as a consequence of the pre-prosthetic orthodontic treatment, and would ultimately require replacement. That Dr B cover the cost of a new set of veneers, as the ones provided were unaesthetic and an unnatural colour. 
• All costs associated with her travel and time off work for the unnecessary orthodontic treatment and the specialist remediation be covered, and an additional compensatory amount be paid for the pain she suffered as a consequence of Dr B's failure to diagnose the death of tooth 22 and his misattribution to tooth sensitivity. 
• A final compensatory figure in allowance for additional expenses and trauma and embarrassment suffered by Ms A. 

Dr B was stunned to receive this letter and quickly picked up the phone to Dental Protection. A review of the records by the Dentolegal Consultant demonstrated that the provision of pre-prosthetic treatment was indeed the lowest biological cost option that could have been provided. Further, risks and warnings had been clearly articulated to Ms A, although the issue of gingival recession had not been addressed well. However, the consent forms alone were insufficient to navigate past the suggestion of coercion. As consent must be given freely this, along with the lack of appropriate consideration of the gingival tissues did create a problem for Dr B. With this in mind, Dental Protection’s lawyer responded on Dr B's behalf, setting out his position and offering a refund of fees only. Ms A's lawyer responded that the cost for this required specialist retreatment must also be covered. After some to and fro, ultimately this matter was settled for a refund of fees plus modest compensatory payment only. 

Learning points 

• It can be difficult to balance patient autonomy with working in the patient's best interests, and while appropriate information must be provided, practitioners must also take care not to place too much weight on their preferred or believed best option. 
  

• When selecting veneer shade, it can be helpful for the patient to bring a friend or family member with them to help them choose. Likewise at cementation.
  

• Consent forms alone do not form the basis of valid consent, although they are a helpful tool in supporting the conversation of consent and essential to use in elective treatment procedures. 
  

• Second opinions can be a helpful tool when consulting a patient who has strong views about their treatment.