05 August 2024
Complaints about common treatment complications and evidence-based practice
By Dr Eryn Agnew BDS MDS MRACDS FICD
When reviewing the cases that the CROs manage, several themes repeatedly emerge and often end up with a refund, or worse, expensive retreatment. The ADA states that we practise evidence-based dentistry. However, in the regularly occurring examples below members leave themselves exposed to a claim being substantiated because they do not use evidence as their friend and often do not record discussions with patients in enough detail. Using published data to inform patients is not only sound, it also protects you every time you provide care. The CROs, as present or past practising dentists, fully understand how we as a profession dislike giving patients bad news or outlining potentially poor outcomes. One thing to remember is that it is not you talking, it is the large amount of objective scientific data and research.
These are two common scenarios which give rise to many complaints.
1. Cracked Tooth Syndrome:
The clue is in the name. It is a syndrome which presents with a number of symptoms that are not always consistent, but adding them together and reviewing the history of the tooth can suggest this as the most probable cause. There are numerous articles in the literature, and it is a real thing, yet so many times in the interest of not making patients anxious, we downplay it. In general, if you can see a crack, it is probably bigger than it looks.
Advice: Being a recognised syndrome, documented extensively in the literature and with known poor outcomes, it is risky not to communicate this to the patient. Dentists should address the evidence-based information head on with a patient and outline a realistic - mostly poor prognosis. Not doing so and failing to document this advice leads to an implied lack of informed consent and an exposure to a claim.
Always consider making a referral to an endodontist for assessment of the extent of the fracture and if the patient declines, make sure you note this in the clinical records along with the limitations of prognosis, especially if you commence RCT. Unfortunately, once you touch the tooth the patient assumes you have made it “crack” further. There is a MiTec brochure which discusses Cracked Tooth Syndrome thoroughly.
2. Replacement of large restorations and subsequent pain or pulpal necrosis:
This is something that is dealt with daily, but in many cases the possible outcomes and significant costs should RCT be needed are not adequately emphasised to the patient. Many members discuss these factors in passing without recording them, and when a claim is made they are exposed as having failed to gain informed consent. Again, there is sound and voluminous literature to support treatment sequelae that large aesthetic restorations can be very sensitive for several months, yet usually patients are warned that it might be only for a few days or weeks.
Advice: Outline the possible outcomes in plain language, based on research, and record your discussion in the clinical notes. Often patients say they were never told, and when there is nothing recorded in the notes the practitioner is left exposed to a potential claim.
Any replacement of an old, large restoration has the capacity to lead to symptoms and often does - strong clinical evidence is available to formulate informed consent.
Note: When “exposure to a claim” is stated, it means that under our regulatory and legal system this can be interpreted as negligence or unprofessional behaviour – the CRO’s role is to help protect you against this type of finding and settling claims promptly is the best way to manage these cases. Should there be no exposure or liability, a CRO will be confident in dismissing a claim that can be defended wherever a patient takes it. Please contact a CRO as soon as you are aware that there is an adverse outcome so that we can discuss how it might be managed to protect your professional reputation and to reduce the stress a complaint can cause you. If you are not insured with Guild you will need to contact your own PI advisor for assistance.
Further reading
Clinical and medico‐legal considerations in endodontics - Johnstone - 2023 - Australian Dental Journal - Wiley Online Library. onlinelibrary.wiley.com/doi/10.1111/adj.12984
