Malpractice Minute

Patient Noncompliance and Dentist’s Inexperience Produce Suboptimal Outcome and Lawsuit

Mario Catalano, DDS, MAGD – June 2018

Background
When starting a dental career, it is an ideal arrangement for new dentists to associate with more experienced dentists for mentorship. The value of an experienced practitioner’s support and mentorship cannot be overstated. However, unless the experienced dentist devotes a significant amount of time overseeing a new dentist’s work, the new dentist may still be vulnerable to making “rookie mistakes.”

Case Discussion

Dr. R, who had graduated from dental school 5 months prior, was an associate in an established dental practice. To expand his practice, Dr. R decided to provide clear aligner services to his patients under the tutelage of his mentor (the practice owner). He took a few courses from different manufacturers and awaited his first case.

Dr. R saw a 54-year-old female patient who was a bank executive and had an unremarkable medical/dental history. She had veneers on teeth 7-10 that required replacement, but she wanted to get her lower anterior teeth straightened first. Dr. R consulted with his mentor, who recommended for him to inform the patient that it would be more efficacious to provide alignment of both upper and lower arches by means of banded orthodontics for long-term stability as well as a more aesthetic result. Unfortunately, Dr. R did not follow this advice, and thus he did not inform the patient.

Dr. R told the patient that she needed to faithfully wear clear aligners to straighten her upper teeth. Because of her high-visibility position, the patient was somewhat reluctant to wear upper appliances (and partly because she was not adequately advised regarding the importance of the arch alignment). She stated she would wear them as much as possible.

During the next 5 months, the aligner therapy proceeded—but not as planned. The patient seldom wore her upper appliances, but did not disclose that fact to the doctor. Her lower anterior teeth also did not move as planned, and she became more difficult to satisfy. Finally, after about 5 months, the patient cancelled the remainder of her alignment therapy and requested that her veneers be completed.

In response to the patient’s request, Dr. R removed the existing veneers and prepared the teeth for new veneers. He had some difficulty with the removals and reduced the teeth to where he thought he had solid tooth structure on the buccal. He also removed additional enamel on the palatal surfaces because of the irregular alignment of the lower anterior teeth. He finished the case and put the patient on a recare schedule.

Unfortunately, while on a business trip, the patient needed emergency dental care to repair the bonding on one of her veneers. The treating dentist explained that she would re-bond the veneer, but cautioned that the bonding may be compromised because of the reduction of the tooth into dentin. While checking the occlusion, the treating dentist also noted heavy contact of the lower anterior teeth with the palatal surfaces of the veneers. She told the patient that she may need orthodontics to restore the appropriate alignment of her lower anterior teeth.

When the patient returned home, she contacted the practice manager to express her displeasure. During the conversation, she inquired about Dr. R’s experience with previous cases. The practice manager said that Dr. R had been practicing for less than a year and did not have extensive experience with clear aligners, but did consult with the senior doctor at the practice (his mentor).

The patient was not satisfied with this explanation. She consulted with another dentist, who said the veneers demonstrated marginal leakage. That dentist recommended lower arch banded orthodontics as well as replacement of the veneers with crowns. The patient accepted the treatment plan and was successfully treated.

The patient sued Dr. R and the practice for lack of informed consent, failure to disclose Dr. R’s level of experience, and improper tooth preparation for veneers. The case was vigorously defended—primarily based on the patient’s noncompliance—and was eventually dismissed without payment.

Risk Management Considerations

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

The combination of the patient’s noncompliance with Dr. R’s instructions and Dr. R’s relative inexperience (especially with clear aligners) created a “perfect storm” that ended with a poor result.

The patient’s noncompliance appears to result from two things: (1) some misunderstanding of her overall clinical situation, and (2) her unwillingness to fully comply with what she knew she needed to do. When dealing with a potentially noncompliant patient, the dentist should ensure that the following steps are accomplished:

  • First, the dentist must thoroughly educate the patient regarding his/her clinical circumstances and the treatment plan.
  • Second, the doctor should carefully monitor the patient’s compliance; if noncompliance is identified, the dentist should counsel the patient appropriately.
  • Third, if the noncompliance continues, depending on its severity, the dentist may have to reconsider providing continued treatment.
  • Fourth, and in every case, the dentist should carefully document all aspects of the noncompliance and the efforts to manage it.

The best opportunity to educate the patient regarding the circumstances of her case—and what her role would be in her treatment success—is during the informed consent conversation. Nothing can replace the value of a face-to-face meeting. Although dentists are not obligated to divulge how many times they have performed a certain procedure, they should answer any such inquiries truthfully. Well conducted informed consent conversations have demonstrated more realistic patient expectations of treatment and improved compliance with instructions.

Some aspects of the technical dentistry could have been performed better, and this is where frequent communication with the experienced dentist can be invaluable. In many cases, young professionals (in any field) “don’t know what they don’t know.” Asking for advice early and often can prevent problems that may escalate into possible lawsuits.

Conclusion
Like any learned profession, dentistry requires skills that are perfected over time. Young dentists should work hard to master the fundamentals and lean heavily on an experienced practitioner to help them further perfect their technical skills.

Question
What options do young dentists have to improve their skills when they are working in an environment in which a mentorship is not available?

This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.