Simrit Ryatt, Dentolegal Consultant, recalls the case of a dentist who sought Dental Protection advice after his aspiring influencer patient opted for treatment abroad.
Dr C was driving home after a busy day, reflecting on the frustrating discussion he had with his last patient Mr W, who had demanded multiple crowns were placed on his upper and lower teeth as soon as possible. Mr W was 29 years old and had moderately overcrowded upper and lower teeth with gingivitis.
Mr W was a huge fan of reality television shows and he had his heart set on becoming an Instagram influencer. He believed that having crowns fitted to his upper and lower teeth was a huge step forwards to fulfilling his ambition. So when Dr C was quite rightfully discussing stabilising Mr W’s gum health first and suggesting alternative treatment options, Mr W began to lose interest and starting scrolling on his phone looking at celebrity pages that inspired him.
Dr C had been discussing what he believed was the best long-term and least invasive option of orthodontic treatment, with a referral to an orthodontist first for fixed braces or clear aligners followed by a course of tooth whitening. Dr C also advised Mr W he would not be happy providing the crowns that Mr W wanted as he believed there would be a significant risk of pulpal damage to the unrestored teeth, many of which were misaligned and would require significant overpreparation to create the aesthetic improvement requested.
Dr C also explained the consequences of pulpal injury and that this complication may arise after the crown work had been completed. He also explained that the need to do endodontic work would inevitably compromise the crowns and their prognosis.
Mr W appeared to be half-listening to Dr C and abruptly got up from the dental chair and remarked that if Dr C didn’t believe he was capable of providing the treatment he would find somebody else who would. Dr C was about to correct Mr W and advise he was clinically competent to undertake all aspects of the work – however he had an overriding ethical duty to act in his patient’s best interests and not undertake treatment that would cause more harm than good. However, the patient in mid-conversation got up and walked out of the room.
One month later
Dr C was in the staff room before his day started, looking through the day list. He was surprised to see Mr W booked in. He presumed that Mr W had seen sense and wanted to discuss stabilising his gingival health and to arrange a referral to a nearby orthodontist. When Mr W walked into the surgery, Dr C was surprised to see Mr W looking quite different, with a glowing tan and upper and lower extremely white, large crowns on his teeth with no buccal corridors.
Mr W advised he had been to Turkey on holiday and had visited a dentist who had provided upper and lower crowns. Ever since the crowns had been fitted, he had been experiencing “jaw ache”, generalised sensitivity and pain associated with four-to-five teeth, and his gums were sore. Dr C could not help but notice that the crowns had also compromised Mr W’s speech.
When he examined the work he noted there was hardly any freeway space on resting and Mr W had generalised gingivitis and sensitivity, with five teeth that were tender to percussion. Dr C reluctantly begun to take radiographs while feeling bewildered that the patient had gone against his advice. He then undertook a detailed assessment of Mr W’s occlusion both at rest and in functional movements.
Two out of the five teeth were most likely to be tender to percussion because of occlusal overloading and, once they had been adjusted with the high-speed handpiece, Dr C believed they would be likely to settle without the need for further treatment. Dr C also noted the upper right canine to the upper left canine six anterior crowns were all joined together.
The periapical radiographs of the other three teeth revealed pathological changes in the apical area from the upper right central tooth (UR1/11) and the upper right lateral (UR2/12) and upper left premolar (UL4/ 24). Dr C advised this was probably indicative of pulpal disease and the three teeth in question would need endodontic treatment. Dr C also advised Mr W’s occlusion needed to be either adjusted or many of his crowns redone. Mr W was in shock and wanted to have time to consider his options; he had also been provided with antibiotics from Turkey and had already been taking them, so his pain was bearable.
How did Dental Protection assist?
Dr C called Dental Protection in his lunchbreak. His initial thoughts were that he wanted to contact Mr W and advise him that although he felt sympathy for his predicament, it was the patient’s own fault as he went against Dr C’s advice and had embarked upon self-destructive treatment. Dr C felt he should advise Mr W that he could no longer provide any further care and Mr W should contact the dentist in Turkey for possible solutions. Dr C also felt the patient’s care would be quite complex due to the patient now having some complex occlusal issues and multiple conjoined crowns.
While the dentolegal consultant (DLC) at Dental Protection understood Dr C’s reaction and agreed the situation was challenging and frustrating, he also suggested that Dr C should consider contacting the patient to revisit the findings from the recent appointment, and discuss the possible treatment options along with their risks/benefits and costings – as he would do with any other existing or new patient.
Dr C would need to explain his main concern was many of the crowns would need to be remade following a detailed occlusal assessment. Dr C also believed the patient would probably need to have multiple root canal treatments. The DLC appreciated that Dr C felt the treatment would now be best managed by a prosthodontist, but he also reminded Dr C that he should still be able to provide urgent treatment and ensure the patient was out of pain. After being able to vent and let some steam off with his DLC, Dr C felt immediately better and acknowledged there were no barriers to him providing emergency care, as he had a duty of care to the patient to ensure Mr W was out of pain.
Mr W attended a restorative specialist from Dr C’s recommendation and went to have many of his crowns replaced, and required multiple root canal treatments. Dr C was also aware the patient was attempting to obtain a refund from the dentist in Turkey, but he was uncertain how successful the patient was.
Points to consider when treating patients who have been abroad
- It is important to provide any patient who presents with complications following the placement of complex elective cosmetic care with an accurate and factual report of the diagnosis and recommendations, including referral.
- It is also important to make clear and detailed records of your investigations and findings, including clinical photographs to highlight various concerns.