Accurate Diagnosis and Adequate Treatment Plan are Keys to Addressing Patient’s Dental Health Needs
Originally published in the February/March 2010 issue of Dispatch
Complaints Corner is designed as an educational tool to help Ontario dentists and the public gain a better understanding of the current trends observed by the College’s Inquiries, Complaints and Reports Committee.
These scenarios are an edited version of some of the cases dealt with by the Committee. The law does not allow for either the dentist or the complainant to be identified.
Case No.1
A patient complained about the adequacy of the radiographs taken by her family dentist on which he based his diagnosis and recommended treatment.
DENTIST’S PERSPECTIVE
The dentist was notified of the formal complaint and provided the College with a response and his patient records. In his response, he said he first saw the patient on May 14, 1998 and after that she was seen on a number of other occasions on an emergency basis.
On the appointment in question, April 9, 2008, the patient attended for an emergency examination at which time two periapical radiographs were taken. Because the patient moved, the films were “not perfectly sharp;” however, in conjunction with his clinical examination, he believed that they were of diagnostic value. He did not feel that it would be in the best interest of the patient to retake them.
He observed that tooth 23 (upper left cuspid) had fractured and discussed his findings with the patient. He believed that the tooth was compromised. He explained to the patient what was involved in restoring the tooth, the risks and costs of treatment, including endodontic treatment, post, core and crown or extraction followed by placement of an implant or denture.
According to the dentist, the patient decided to have the tooth extracted and a partial denture fabricated. An appointment was scheduled with an oral and maxillofacial surgeon for the extraction procedure. The patient was given the original radiographs to take to the appointment with the specialist. Copies of these radiographs were not retained.
At the April 9 appointment, the dentist stated that he also spoke to the patient about her reported sensitivity between teeth 26 (upper left 1st permanent molar) and 27 (upper left 2nd permanent molar). He recommended restoration of tooth 27 to close the contact, in order to resolve a food impaction problem. An appointment was scheduled.
In his reply, the dentist noted that the patient later cancelled her appointment with the specialist for the extraction of tooth 23 and contacted his office to cancel her appointment for the restoration of tooth 27.
Concerned about these cancellations, the dentist said he personally contacted the patient on April 23, 2008 to discuss the required treatment. At that time, he discussed the proposed repair for tooth 23 and the option of having a denturist fabricate a partial denture. According to the dentist, the patient stated that she was not feeling well, and, since the tooth did not hurt, she wanted to postpone treatment.
The dentist denied that he was told by the patient that she had changed her mind about the treatment or that she was dissatisfied with the previous consultation.
FURTHER INFORMATION
A copy of the member’s response was sent to the complainant for her information. She provided further comments in which she stated that the tooth in question was not tooth 23, as reported by the dentist, but tooth 24 (upper left 1st bicuspid). When provided with a copy of the patient’s letter, the dentist acknowledged that the tooth in question was tooth 24.
REASONS FOR DECISION
The patient complained about the adequacy of the radiographs taken by her general dentist to recommend treatment. The panel viewed the radiographs in question and agreed that, while they could have been of better quality, they showed that there was a fractured tooth with either caries and/or a fracture of the crown to the bone level. The panel agreed that extraction was a reasonable treatment option.
The panel believed that, in conjunction with the member’s clinical observations, the radiographs taken by him were minimally adequate to make a referral to an oral and maxillofacial surgeon for a consultation regarding the extraction of tooth 24.
Based on its review, the panel decided to take no further action with respect to the complaint.
Case No.2
COMPLAINT SUMMARY
The parents of a minor patient complained about their family’s general dentist alleging that he had incorrectly diagnosed decay in their son’s mouth and had told them that flossing was unnecessary.
THE DENTIST’S PERSPECTIVE
The dentist provided the College with a response to the formal notification of the complaint and provided his patient records. He stated that the child attended his office in August 2007. At that time, he noted that the child’s permanent molars were erupting with fissures that made his explorer “stick.” The parents were advised and a restorative appointment was scheduled for December 6, 2007.
At that appointment, 36 (lower left 1st permanent molar) and 46 (lower right 1st permanent molar) were restored using a shallow preparation and composite resin. At the same time, the dentist observed general decalcification on two other recently erupted molars and three primary teeth.
He informed the child’s parents and advised them of the need to restore the other permanent molars more aggressively.
A restorative appointment was scheduled for June 19, 2008. It was also agreed that other changes in the decalcification would also be evaluated during the June restorative appointment.
The dentist stated that, in his experience, waiting six months to complete restorative treatment allows for increased psychological maturation of the patient which results in better co-operation. He added that he has found that waiting this amount of time does not appreciably change the status of the teeth to be treated.
In this particular case, the dentist said he believed that the child was at risk of caries to not only the three primary teeth, but also the immediate adjacent teeth. He said it would be preferable to restore all of the teeth at the same time should that become necessary.
The dentist denied telling the parents in August or December 2007 that everything was “great.” He said that he informed the parents of the decalcification and the need for restorative treatment. He also denied telling the parents that flossing of the child’s teeth was unnecessary. He explained that the dental hygienists on his staff stress the importance of flossing and this was confirmed in the patient’s chart.
The dentist said that, when the child returned to his office in May 2008, he was surprised and disappointed that there was such a significant change in such a short time. That was why he felt it in the patient’s best interests to refer him to a pediatric dentist in order that treatment could be carried out expeditiously.
FURTHER INFORMATION
A copy of the dentist’s response was sent to the child’s parents for their information. They disputed his version of events. The dentist provided further comments confirming that he recognized the problem and referred the patient accordingly.
As part of its investigation, the College obtained records from the patient’s subsequent treating pediatric dentist. The records showed that the child attended the pediatric dentist on May 26, 2008 for a specific examination, as a referral from the family dentist. The pediatric dentist noted the need for pulpotomies and stainless steel crowns for teeth 74, 54, 84 and two surface amalgam restorations on teeth 75, 55 and 85.
REASONS FOR DECISION
The panel reviewed the member’s radiographs and records and noted decay on numerous teeth. There was no real change in the radiographs taken by the member and those taken six months later by the treating pediatric dentist.
The panel was concerned that these multiple areas of decay were not noted on the original odontogram and were not treated by the member. In their view, he failed to diagnose and treat large rampant decay, failed to inform the patient’s parents that he was in need of treatment and failed to offer a timely referral to a pediatric dentist, if he did not intend to treat the child himself.
In order to address the panel’s concerns about his diagnosis and treatment planning, the dentist voluntarily signed an undertaking/ agreement to restrict his practice such that he would not perform an examination, render a diagnosis nor provide treatment for pediatric patients 12 years of age and under.
The restriction on his certificate of registration was to remain in place until such time as the College was satisfied that he had taken and successfully completed a comprehensive course or courses in pediatric dentistry, specifically including diagnosis, treatment planning and referral protocols.
The dentist also agreed that, following his successful completion of the course(s), the College would monitor his practice for a period of two years to ensure that the knowledge gained had been applied in his practice.
The panel felt that, with this skill upgrading, the dentist would benefit and the public interest would be protected.
The panel was unable to determine exactly what was said by the dentist or his staff to the parents about the flossing of the child’s teeth. However, the panel agreed that oral hygiene instruction at an early age is beneficial to a young patient’s dental well-being and certainly it is a good idea to instill oral practices, such as flossing, in patients at an early age.
Learning points
Dentistry is one of only a handful of health professions, regulated under the Regulated Health Professions Act, that has been assigned the controlled act of communicating a diagnosis to a patient. So it is imperative that this important aspect of patient care is thoroughly and thoughtfully carried out and patient records document the factors considered in formulating the diagnosis and treatment plan.
Failure to carry out a comprehensive examination and to document the findings, diagnosis and related treatment options and to communicate all of this information to patients may call into question that the informed consent process was used.
Miscommunication and misunderstandings with patients and/or their parents or substitute decision-makers can result when there is a lack of attention to the examination, diagnosis and treatment planning details and the communication of such information to patients and/or parents or substitute decision-makers.