RISK MANAGEMENT


Treatment of Personal Friend Clouds Dentist’s Judgment Results in Missed Diagnosis, Loss of Teeth


by MARIO CATALANO, DDS, MAGD and BY THEODORE PASSINEAU, JD, HRM, RPLU, CPHRM, FASHRM


BACKGROUND Nonadherent (also called noncompliant) patients are nothing new to the practice of dentistry. When patients won’t adhere to treatment plans and/or refuse needed exami- nations or treatment, they place the dentist in a very difficult position: trying to maintain a proper balance of respect for patient au- tonomy while complying with the applicable standard of care. Sometimes, nonadherence results in a poor outcome for the patient. An interesting case from the far west region demonstrates how this can happen.


CASE DISCUSSION


Dr. Y, a nationally respected dentist, maintained an upscale dental practice in an affluent area of a major city. He had recently hired an associate, Dr. R, who was a dentist new to practice. After an appropriate orienta- tion period, Dr. R was left in charge of the practice while Dr. Y gave a lecture in another region of the country.


One of the practice’s patients was a well- known retired professional athlete who had become a close, personal friend of Dr. Y. The patient had suffered numerous injuries during his playing career, requiring many head and neck X-rays and computerized axial tomography (CAT) scans. Because of this ex- tensive radiation, the patient was resistant to having dental screening X-rays unless there was an identified problem.


During Dr. Y’s absence, the patient had a rou- tine recall (prophylactic) visit. Before Dr. R’s oral examination of the patient, the hygien-


18 focus | MAR/APR 2021 | ISSUE 2


ist informed Dr. R the patient was not only overdue for a recall by about a year, but also he had again refused X-rays (it was now four years since his last X-rays). Further, the hy- gienist explained that only limited time was allocated for the visit, so she concentrated on performing a thorough scaling, but was un- able to perform a periodontal screening.


Dr. R recognized the visit had not been complete, but given he was new and the patient was Dr. Y’s friend, he deferred any further treatment and completed his oral examination. Dr. R identified gingival reces- sion on the posterior dentition and advised the patient a more thorough examination (including X-rays and periodontal probing) was needed at his next appointment.


Approximately three months later, as the patient was preparing for a television appear- ance in another city (he had now become a broadcaster), he developed pain and swelling in the upper left quadrant. A local dentist examined him and diagnosed a deep gin- gival abscess at tooth 14. This local dentist explained the problem to the patient and offered to do additional X-rays at that time, and the patient agreed. The X-rays identified furcation involvement and periodontal bone loss at all four maxillary molars. The dentist gave the patient amoxicillin so he could get through the broadcast, and then he advised him to contact Dr. Y’s practice as soon as he returned home.


Upon his return, the patient spoke with Dr. Y, who had reviewed the X-rays and agreed


with the diagnosis. Dr. Y explained this is what can happen when thorough examina- tions are refused. Dr. Y then referred the patient to a periodontist for evaluation and treatment. The periodontist recommended extracting all four maxillary molars, perform- ing sinus lift surgery, and placing four im- plants. This recommendation displeased the patient, especially since the time required for treatment would affect his ability to broad- cast. He sought a second opinion, which concurred with the periodontist’s treatment plan.


The necessary remedial treatment (which was not rendered at Dr. Y’s office) and subsequent healing resulted in the patient having to be furloughed from his broadcast- ing position for several months, resulting in a substantial loss of income. When the patient sued Dr. Y and Dr. R for malpractice, the case was settled by a payment in the high range, with defense costs in the midrange.


RISK MANAGEMENT CONSIDERATIONS


This case resulted in a payment in the high range for many reasons, involving both nontechnical and technical dentistry. A good place to begin is with the relationships. Most of the failures that occurred in this case were on Dr. Y’s watch. X-rays were not taken and periodontal probing was not conducted for approximately four years because Dr. Y al- lowed the patient to refuse them.


The patient’s strong personality, combined with their personal friendship, led Dr. Y to compromise his standards. Dentists must


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