By Dr Richard Hartley, Dentolegal Consultant
A 25-year-old male patient saw his dentist to discuss options to improve the appearance of his upper teeth, as he disliked the shade of them and also felt that the shape could be improved.
Following a discussion of the treatment options, the patient discounted whitening and porcelain veneers, and elected to proceed with composite veneers to improve both the shade and shape of the teeth.
The dentist recorded in the records: “This treatment is being provided because it is a minimally invasive alternative to porcelain veneers. This means we are adding material to your teeth without any preparation of the teeth. No long-term damage is caused to the teeth and the restorations can be removed in the future.”
The patient was also warned that his teeth would feel bulkier and advised that the veneers could be repaired in the future. They could be expected to last five to ten years.
The dentist did not carry out any additional diagnostic adjuncts such as study models, a wax-up or occlusal analysis, and the patient attended the following week to have composite veneers directly bonded to the teeth, which the member did freehand.
After a week the patient returned to the practice to say that that he disliked the appearance of the veneers, and also commented that some of the composite material had chipped. He requested that the composite veneers be removed and his teeth returned to their original appearance.
The dentist agreed to this and voluntarily offered the patient a full refund of fees for the placement of the composite veneers. Following their removal, the patient complained that there was a small chip on his upper left lateral incisor that had not been there before, and also noted that the appearance of the central incisors was not quite the same as before the composite had been placed.
He requested a second opinion and this was provided by a colleague at the practice, who confirmed that there had been enamel removed from the buccal surfaces of both centrals, and that the upper left lateral had been damaged along the incisal edge. The colleague was reluctant to get involved in the remedial treatment, however, as he felt that the patient would be better served by a dentist with more experience in cosmetic work, given that there was evidence of parafunction.
The patient then put in a formal complaint stating that his teeth had been damaged. He said he would never have agreed to the treatment had he been made aware that there was a possibility that there were risks associated with the treatment and therefore it was not entirely reversible, as had been suggested to him.
The dentist contacted Dental Protection for advice. He had reflected on his actions and now realised that he had perhaps been too ambitious in his treatment plan given his inexperience of cosmetic dentistry. His intention had always been to carry out a reversible procedure and he distraught by the mere thought that he had damaged the patient’s teeth. With our assistance he was able to cover the cost of a referral to a local dentist with a special interest in aesthetic dentistry for some remedial treatment, and the matter was resolved to the patient’s satisfaction.
The dentist acknowledged that the lack of a thorough initial assessment and planning had compromised the clinical outcome and raised some questions in relation to valid consent. He subsequently enrolled on a practical cosmetic dentistry course to improve his knowledge and skills.
Cosmetic cases such as this can often present challenges, both technically and in relation to managing patient expectations, and so the following is essential to bear in mind:
• Take care when managing the patient’s expectations, particularly in relation to elective cosmetic procedures.
• Whilst reversible procedures offer a margin of safety and reassurance for both the patient and the dentist, remember to consider the risks associated with the process of reversal and make sure the patient is aware of them.
• Patients will examine the result of elective cosmetic procedures involving teeth in the smile line more than they might when placing a posterior composite, for example, and even the tiniest of defects is likely to prompt a reaction.
• Ensure that the patient has all the relevant information so that they can make an informed decision when it comes to consenting to treatment.
Only carry out a task or type of treatment, or make decisions about a patient’s care, if you are sure that you have the necessary skills and are appropriately trained, competent and indemnified.