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A difficult patient interaction

15 August 2018

A young male patient attended a local dental practice with toothache. The dentist diagnosed the source of the pain as irreversible pulpitis from an extensively carious tooth, the upper right first molar (16), which had a large fractured amalgam restoration. The patient did not wish to have an extraction and, as there was sufficient tooth left to restore, the dentist carried out a root canal treatment and placed a gold shell crown.

All was well for many years, tooth 16 remained symptom and pathology free. The dentist subsequently sold the practice. The patient then returned after some years suffering from a periapical abscess on the same tooth and the new owner advised the patient to have a re-treatment of the root, which would cost more than the sum originally paid ten years earlier.

The first dentist received a letter of complaint, alleging negligent care and demanding full reimbursement for the subsequent treatment costs. The patient also alleged that he had been informed, at the time of the original treatment, that it would be 100% successful.

The dentist contacted Dental Protection, feeling aggrieved because the tooth he had treated had remained functional and symptom free for more than ten years. The root treatment had been carried out using a standard technique, and the radiographs demonstrated a well obturated root canal filling with sound crown margins.

However, the clinical records made by the member only contained information about the actual treatment provided and had no documented record of the consent process to help him challenge the allegations made by the patient. On the other hand there was sufficient information and evidence to demonstrate that the actual treatment had been provided to an appropriate standard. It clearly helped that the tooth had been free of pathology and symptoms for over ten years.

With Dental Protection’s help, the original dentist responded to the patient, explaining that no ‘medical’ intervention has a 100% guarantee and that the clinical care provided was in line with standard procedure and protocols.

This approach clearly contradicted the position taken by the patient around the guarantee. Had the patient also suggested that he should have been made aware of the consequences of failure from a financial perspective, and if so, would have taken a different treatment decision at the time by seeing an endodontist, then our approach to the resolution of this matter might have involved a refund.

Fortunately the patient accepted an empathic response and took the matter no further. Had that not been the case, then our strategy would have turned on our member’s recollections and his usual practice when providing information to patients about predicting success in endodontic procedures. Such an approach carries risk and without documented evidence of the consent process it is entirely possible for a Court or the HPCSA to prefer the patient’s version of events. It makes sense then to manage expectations around treatment outcomes and record the salient points of those discussions. The unpredictable nature of healthcare interventions may be obvious to us as practitioners, but may not be to some patients.

Learning points

  • Be aware of the unrealistic expectations of some patients and their persistence in pursuing dentists many years after treatment. You can help protect yourself from this by carefully documenting all relevant discussions with the patient.
  • Patients should be given advice regarding the long-term prognosis of proposed treatment, and this should be documented in the clinical records.
  • Clinical records are vital in detailing discussions about consent.
  • Even when the clinical care is satisfactory, if there is a flaw in the consent process dentists can be vulnerable.
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These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
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