By Dr Richard Hartley, Dentolegal Consultant, Dental Protection
Estimated read time: 8 mins
Patients are becoming increasingly demanding, not only in terms of their expectation of treatment outcome, but also with regard to treatment choices and how they feel that treatment should be delivered. Thanks to the internet and the growth of patient forums, they can often attend with their own definitive ‘treatment plan’ and strong powers of persuasion. The following cases illustrate how important it is for clinicians to remain firm and not allow patients to dictate treatment, no matter how well informed they may consider themselves to be.
Case 1
A patient attended to see our member with a failing crown at UL1 and requested that it be replaced, as he had lost faith in his previous dentist who had unsuccessfully attempted to root fill the tooth. He just wanted the crown replacing without the root filling, as he wasn’t in pain, had read that root fillings weren’t always successful, and that they can harbour bacteria. He also wanted composite bonding to improve the appearance of the other upper anterior teeth.
The member took a periapical radiograph of UL1 and noted widening of the periodontal ligament space and evidence of an access cavity. He advised the patient that the tooth should be root filled and explained the risks of going ahead in the absence of a root filling.
The patient was adamant that a root filling was not necessary and refused any further attempt, insisting that the member provide the crown only. The member asked the patient to sign a ‘waiver’ in which it was noted that he understood that the tooth required a root filling, and the risks involved in going ahead without one.
The new crown was fitted and the composite bonding completed. The patient was advised that he would require a bite guard to protect the new restorations, which he declined.
Just over a year later UL1 fractured off at gingival level, rendering the tooth unrestorable, and some of the composite bonding had also chipped away. The patient requested a full refund to resolve the matter. The member responded, without seeking Dental Protection’s input, advising the patient that he was aware of the risks at the outset. The member pointed out that the tooth was already compromised, and that the patient had declined to wear a bite guard to protect the restorations. Accordingly, he would not be providing him with a refund.
The patient responded by advising that the member should have provided a post crown which would have avoided the tooth fracturing. He now required the member to fund an implant to replace the tooth, otherwise he would be seeking legal advice. At this stage the member contacted Dental Protection for assistance.
The member was resistant to conceding anything to the patient in light of the warnings he had given at the outset. But he was advised by Dental Protection that he was likely to be criticised for providing dental care that he knew was not in the patient’s best interests, despite the patient signing a disclaimer. The patient stated he would not have gone ahead in the absence of a root filling had he known that a post crown was not possible in those circumstances. Accordingly, while the tooth was likely to have been compromised at the outset, having already been crowned and root canal access already attempted, in order to protect the member’s position Dental Protection agreed to reimburse the member for funding the replacement of the tooth. Fortunately, the patient accepted.
Case 2
A patient attended after visiting a dentist abroad where he had teeth prepared for the provision of a bridge. He had returned to the UK before the bridge could be fitted and had a temporary bridge in situ, which he was able to remove himself and had to keep in place with a denture adhesive.
On examination the member established that UL1,2,3,7 had been prepared for crowns and advised the patient that ideally UL1,2,3,7 should be restored with individual crowns and consideration given to either a denture or implants to restore the space at UL4,5,6 given the edentulous span, and the fact that UL7 was root filled. The patient was determined to have a fixed bridge using all the teeth that had been prepared, in line with the treatment plan he had from the clinic abroad, and refused to countenance any alternative, despite the risks that were outlined to him.
Accordingly, the member asked the patient to sign a disclaimer setting out that he had been advised of the risks associated with proceeding with the bridge and went on to provide the bridge for the patient. Unfortunately, UL7 fractured within a short space of time and was unrestorable. The patient complained that the member was responsible for the loss of the tooth and should cover the costs involved in recrowning UL1,2,3 along with the provision of implants to replace UL 4,5,6,7 as he had been advised that a bridge was no longer possible, following a consultation at another dental practice.
The member wrote back to the patient without Dental Protection’s assistance advising that he was made aware of the risks of continuing with the bridge and so no remedial funding would be available. The patient responded suggesting he would seek legal action and at that stage the member contacted Dental Protection. He admitted that he was reluctant to provide the bridge but had felt coerced into the treatment by the patient, who was rather overbearing, and now regretted it.
With Dental Protection’s assistance, the member wrote back to the patient who agreed to attend a consultation with a restorative specialist, who advised individual crowns at UL1,2,3 and the provision of either a partial denture to replace UL 4-7, or an implant retained bridge to replace UL 4,5,6.
The patient elected to have a partial denture, and agreed to settle the matter on receipt of a full refund for the bridge with which he could then fund the further treatment. He elected not to pursue compensation for the loss of UL7 after the specialist advised that the tooth had a guarded prognosis from the outset.