Process Failures Lead to Patient Harm in Dentistry

This case involves a dentist who deviated from the prevailing standard of care in treating a patient’s infection. The study examines the importance of thoroughly documenting the clinical justification for any alternative treatment plan, obtaining informed consent, and providing follow-up care. The discussion covers strategies to help dental professionals prevent patient harm and mitigate risk.

The adult patient contacted a dentist after experiencing severe tooth pain. The dentist’s notes described a “small area of what appears to be infection around tooth number 18.” The dentist did not obtain x-rays. For unknown reasons not documented in the record, the dentist elected to extract teeth numbers 19 and 18 in the area of the pain. He did not have the patient sign a consent form and did not prescribe an analgesic or antibiotic. The patient was not given a follow-up appointment and did not receive follow-up instructions from the dentist.

The patient’s pain continued to worsen. Having lost confidence in the original treating dentist, the patient elected to see another dentist. X-rays taken by the subsequent treating dentist revealed that the infection had spread significantly, and teeth numbers 17 and 20 were now involved. The dentist recommended extracting those teeth and removing a small portion of the gum. With the patient’s informed consent, he performed the procedures and provided antibiotic therapy and pain control. In the second dentist’s opinion, the successful treatment was initiated “just in time, before the consequences could have been much more serious.”

The patient pursued a claim against the original dentist.

Risk Management Discussion

Expert reviewers noted that appropriate care by the original dentist would have included obtaining dental x-rays and placing the patient on antibiotics and pain medication as needed. In this case, the original dentist failed to treat the obvious infection and further complicated matters by undertaking an extraction that subsequent experts found to be contraindicated. Reviewers were also critical of the original dentist’s documentation, noting that justification for deviating from the standard of care should be thoroughly documented.

The following strategies can help dental professionals keep patients safe and mitigate risk:

• Adhere to the prevailing standard of care. If an alternative plan of care is chosen, document clinical justification for making that choice. (See our article “The Faintest Ink: Documentation to Defend Quality Patient Care.”)
• Obtain informed consent from the patient. Provide descriptions of the procedure, alternative treatments, risks, benefits, expected outcome, and the rationale for the proposed treatment using terminology the patient can understand. (See our article “Informed Consent: Substance and Signature.”)
• Use the Institute for Healthcare Improvement’s “Always Use Teach Back!” tools to confirm that patients understand the information discussed by asking them to repeat back a summary of the details. Solicit the patient’s expectations of the outcome.
• Address any misunderstandings and unrealistic expectations. Document the discussion in the dental record and note that the patient was able to demonstrate understanding by teach back.
• Provide written follow-up instructions after a procedure. Use plain language for all patient materials and provide translation if the patient has limited English proficiency. (See our article “Limited English Proficiency [LEP] Patients: Frequently Asked Questions.”)
• Instruct the patient to call the office if the symptoms worsen or do not improve.
• Consider having a member of your office staff call the day after the procedure to check on the patient’s condition and notify the dentist of any questions or concerns.
• Schedule a follow-up appointment at the proper interval to ensure that the patient is healing appropriately. Contact the patient if the appointment is not kept. (See our article “Nonadherent and Noncompliant Patients: Overcoming Barriers.”)

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.