Failure to Diagnose and Refer Results in Court and Dental Board Action

Failure to correctly diagnose and failure to refer are common contributors to dental claims. In this case study, we analyze the issues surrounding a patient’s injuries and provide strategies to help dental professionals keep patients safe while reducing the risk of legal and licensure actions.

A patient contacted a dentist after experiencing tooth pain. Upon examination, radiographs indicated a fracture of tooth number four. Intraoral photographs indicated that the mesial, lingual, and distal margins of the tooth extended below the gingival tissue. The treatment plan included a root canal, post and core, and a crown. The need for a crown lengthening was not documented in the dental record.

Subsequently, a root canal was performed by an endodontist, and the patient returned to the dentist for the post and core placement in preparation for the permanent crown. The dentist placed the permanent crown.

Several months later, the patient returned to the dentist, complaining that the crown was loose. The dentist adjusted the crown on tooth number four. Incidental radiograph findings indicated a large periodontal bony defect on tooth number three. The record contained no documentation of either a recommended treatment plan or a referral for the periodontal bony defect.

One month later, the patient returned to the dentist and complained that the crown was loose again. The dentist removed the crown and replaced the post. The second post, however, deviated from the long axis of the tooth and caused a root fracture.

The patient sought treatment from another dentist, who diagnosed a recurring fistula in tooth number four that required the tooth’s extraction. In addition, due to the untreated periodontal defect in tooth number three, it also required extraction.

The patient successfully pursued a professional liability claim against the original dentist.

Risk Management Discussion

Because an indemnity payment was made to the patient for the dentist’s malpractice, it was reported to the National Practitioner Databank. The state health department also investigated and filed an administrative complaint against the dentist that alleged the following:

• Failure to diagnose the need for crown lengthening on tooth number four.
• Failure to adequately place the dental post on tooth number four.
• Failure to timely refer or treat the periodontal defect on tooth number three.
• Negligent conduct that resulted in a paid indemnity.

The dentist was penalized with a letter of concern on his dental license, administrative fines, and a continuing education requirement that exceeded standard license renewal requirements.

Failure to diagnose and failure to refer are common issues in dental claims. In this case, the dentist failed to diagnose the need for crown lengthening and failed to identify, treat, or refer the patient for the periodontal defect. Experts reviewing the case were also critical of the dentist’s inadequate placement of the dental post and determined that proper initial preparation for placing the crown may have prevented the need for subsequent procedures.

The following strategies can help dental professionals avoid diagnosis and referral issues:

• Discuss all treatment options with the patient, including the likelihood of success, and develop a realistic and objective treatment plan.
• Conduct a thorough informed consent process. Document the discussion in the dental record, including the patient’s understanding of the discussion using teach back. (For more information, see our article “Informed Consent: Substance and Signature” and a sample Dental Procedure Informed Consent form on our Informed Consent Sample Forms)
• Identify and address incidental findings. Document patient notification and the actions taken.
• Refer the patient to a specialist when necessary and document any referral decision.
• Facilitate the referral by making the patient’s appointment with the specialist and forwarding a referral form, appropriate dental records, and radiologic images to the specialist’s office.
• Use closed-loop tracking for referrals. Follow up with the patient to ensure appointment completion, and with the specialist to obtain the consult note. Review the consult, address the findings, revise the treatment plan (if necessary), and communicate with the patient.
• Document referral tracking communications in the dental record.

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.