May 2015

High-Risk Case Results in Poor Outcome and Patient Dissatisfaction

Mario Catalano, DDS, MAGD

Background: In general dental practice, some patients are at high risk for a suboptimal outcome because of personal habits, medical or dental history, or other factors. Dentists should communicate closely with such patients to ensure they have realistic expectations about the outcomes of their treatment. Close communication includes engaging patients in thorough informed consent discussions. This interesting case from the Northeast shows how a patient can become dissatisfied when treatment does not go as expected.

Case discussion: Dr. C was a new dental school graduate who took a position with a dental staffing company. She was soon assigned to cover for a solo practitioner who would be out of the office for several weeks for medical reasons.

During her first week at the office, Dr. C saw a 41-year-old male patient who had pain and swelling around a fixed bridge running from tooth number 2 to tooth number 5. The bridge had been placed to compensate for tooth number 3, which previously had been lost. X-rays and clinical examination showed periapical pathology in teeth 4 and 5, necessitating root canal therapy for both teeth. Additionally, because the patient smoked a pack of cigarettes a day, the X-rays also showed approximately 50 percent bone loss around teeth 4 and 5.

At the patient's next appointment, he completed a standardized informed consent form, the bridge was successfully removed, and endodontic treatment was accomplished on tooth number 4. Following treatment, the bridge was reattached with temporary cement.

The patient returned a week later for treatment of tooth number 5; however, when the bridge was removed, Dr. C realized that tooth number 4 had adhered to the bridge and been removed along with it. She explained this to the patient, and it was decided to remove the root from tooth number 4, retain it as part of the bridge, do the root canal therapy on tooth number 5, and reattach the bridge. All of this was accomplished at this appointment.

Approximately 10 days later, the patient returned to the office complaining that the bridge was loose. Examination showed that tooth number 5 had been loosened during the treatment process at the previous appointment, resulting in an inadequate anchoring of the bridge. Ultimately, the patient required removal of the bridge, bone grafting, placement of implants for teeth 4 and 5, and construction of a new bridge.

The patient sued Dr. C and the practice, alleging inadequate informed consent and malpractice in the technical performance of the aforementioned procedures. With Dr. C's consent, this case was settled in the low range, with legal expenses in the midrange.



Risk Management Considerations

Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

This case raises several interesting points. Although it is beyond the scope of this article to provide technical dental advice, this case clearly should have been regarded as high risk because of the bone loss identified on the X-rays. Whether excessive force was used in the removal of the bridge when tooth number 4 was dislodged and tooth number 5 was loosened is impossible to say. However, the potential for this outcome was readily identifiable prior to treatment.

Given the extent of bone loss, it might have been appropriate for Dr. C to refer the patient to a prosthodontist who had expertise dealing with high-risk cases (and who had more time to devote to the patient's care). However, because Dr. C was new to practice and in her first week of covering for the solo practitioner, she may not have felt the freedom to make such a referral.

Because of the technical challenges associated with this case, good communication between Dr. C and the patient was essential. It certainly was appropriate for Dr. C to use a consent form as part of the informed consent process prior to treatment. However, most informed consent forms are general in nature; when a case is somewhat atypical (as this case was), it might be necessary to go a step beyond the use of a basic informed consent form.

Counseling of the patient should have occurred, accompanied by thorough documentation in the patient record. Further, it would have been appropriate for Dr. C to explain the patient's condition, as well as the particular risks of treatment, in a separate letter to him. The goal of such communication is to provide the patient with sufficient and understandable information so that he can make informed decisions about care and have reasonable expectations about treatment outcomes.

When a case is high risk and the opportunity exists for referral, the dentist should explain — and, if appropriate — recommend this to the patient. Then, if the patient chooses to stay with the general dental practice (and the general dentist is comfortable with his or her ability to deal with the case), it is appropriate to proceed.

Not every case will go exactly as planned. Sometimes it is not possible to predict or prepare for complications. However, in any high-risk case, close communication and a cautious approach is prudent.

Conclusion: Complications or suboptimal treatment outcomes cannot always be predicted. However, when factors are identified that make a case more high risk than usual, careful attention to technical performance, thorough documentation of treatment, and close communication with the patient may help minimize the doctor's risk exposure and the likelihood of a disappointed patient.

Question: When a case presents with complicating factors that make the dentist uncomfortable with proceeding in the general office setting, how should the dentist communicate this information to the patient?


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