Dr Colm Harney, Dentolegal Consultant at Dental Protection, looks at a case of a well-handled complaint.
Dr C had seen Mr V as a new patient six months previously.
His presenting complaint was occasional (about once every two weeks) sharp pain to bite on 46 over the last six months – the pain resolved immediately, and he managed it by avoiding anything very hard on that side of his mouth.
Mr V was 68 years old, grew up in a rural community with no fluoride in the water and had a heavily filled dentition with many large amalgam restorations in his upper and lower molars, most of which were done in his teens and early 20s. He had moderate occlusal wear and was missing 36, which he said had a root canal 30 years ago that then cracked and required a difficult surgical extraction that he had never forgotten – he didn’t believe root canals work as the same thing happened to his wife.
Mr V had wearing and chipping of his incisal edges, which didn’t cause him any problems, and he was not concerned about the appearance of them. Mr V reported he brushed twice daily and used interdental brushes two to three times per week, and examination revealed he had moderate levels of lower lingual calculus but no pockets greater than 3mm. Soft tissue exam revealed a small amalgam tattoo buccal to the missing 36 and cheek bite lines and tongue scalloping. He had occasional asymptomatic TMJ clicking and large masseters. He tried a splint 15 years ago and couldn’t sleep with it. His GP had been recommending he have a sleep study for the last few years but he had not got around to it.
Examination and radiographs confirmed the heavily restored dentition with no obvious caries or failing restorations. 46 had a large deep occlusal amalgam with a fracture line running over the mesial and distal marginal ridges. The distal-lingual cusp was repeatedly tender to bite on a crack finder with all other cusps being asymptomatic.
A provisional diagnosis was made of cracked tooth syndrome on 46; the suggested treatment was to remove the old restoration to investigate the extent of the crack and restore using a bonded restoration with cusp capping over the DL cusp. The unpredictability of cracks was explained as was the possible need for a full coverage restoration and/or a root canal treatment if the tooth became more symptomatic – an appointment was booked for the procedure and a clean. Dr V gave a written plan for an adhesive restoration with cusp capping and a verbal estimate for the costs of a crown and root canal treatment.
The original treatment
When Mr V attended he asked if the crack couldn’t just be repaired without removing the filling and was adamant that he was not going to have a root canal treatment. Dr C explained again about the unpredictable nature of cracks and that he was doing this treatment to try to avoid having more extensive treatment in future or having the tooth split like 36 did.
Mr V agreed to proceed and Dr C removed the old filling – it was caries free but a crack was noted running mesial to distal over the mesial and distal marginal ridges. Dr C carried out a more extensive bonded restoration than planned with more extensive cusp capping, which he explained to Mr V but did not charge more than he had estimated as a goodwill gesture. He explained that the tooth would need to be monitored for symptoms as the crack was deep and he was unsure how far it went or whether there was pulpal involvement – he explained that the crack could already be allowing bacteria to get into the pulp chamber.
Dr C explained that there was likely to be some post-op sensitivity as the tooth settled down, which was to be expected in a deep large filling like this but should resolve. Dr C did not have time to do the clean, as the procedure took longer than planned, and he booked Mr V in for the clean a week later, which he explained would also give him a chance to review 46.
Mr V returned a week later for his cleaning – he reported that the tooth was indeed sensitive to cold but had not resolved; if anything it had got slightly worse over the week. He was now at the point where he could feel it with any cold drink or even after brushing his teeth in cold water.
Dr C checked the filling – it appeared to be well sealed and was not high on the bite or excursions. It was sensitive on the occlusal and lingual to cold air from the 3in1 and was particularly sensitive when using the ultrasonic scaler in this area. A periapical radiograph showed no apical pathology and a deep composite filling with no apparent deficiencies.
Dr C diagnosed reversible pulpitis and explained to Mr V that he would prefer to take a conservative approach by trying desensitising agents and giving it some more time rather than doing anything more interventive. He applied topical fluoride and issued desensitising toothpastes to use topically, and fitted Mr V in for an early morning review in 10 days.
On the day of appointment there was a note that Mr V had confirmed and also stated to the receptionist that he was upset and wanted something done as the tooth was still sore – it wasn’t sore before the filling and was now very painful to eat or drink anything hot or cold.
Dr C had only a short appointment booked for review – the tooth was now more temperature sensitive but there was no spontaneous pain or waking at night, nor was it sore to bite or TTP. Dr C suggested booking Mr V in to remove the filling and place a dressing but Mr V insisted that something be done now as the impact was significant to his quality of life, and he was going on holiday the following week.
Dr C gave anaesthesia and carefully removed all the composite filling, which took a significant amount of time – he had to reschedule the next patient who couldn’t wait and knew he would be running significantly late for the rest of the morning. Dr C placed a ledermix dressing over the crack and a large glass ionomer interim restoration – he only charged Mr V a discounted fee for the limited exam.
Dr C called Mr V two days later, who reported that the symptoms were significantly improved and he was happy to leave things for his holiday and return for review in three weeks. Dr C suggested if the tooth was asymptomatic then he would book Mr V for a crown for long-term tooth coverage, and to try to prevent the crack from progressing.
The crown
Dr C spoke to Mr V three weeks later – he had a great holiday and his tooth had “95% settled” – an appointment was booked for a review and crown preparation in three weeks. By that time the tooth was still the same and on exam and radiographic review both Dr C and Mr V were happy to proceed to having a crown, as Mr V did not want to have a root canal or split tooth like 36.
On insert appointment the tooth was stable and a well-fitting crown was inserted. Dr C called Mr V two days later and he reported that the symptoms had settled completely.
The fallout
Four weeks later Dr C saw that Mr V had booked an emergency appointment and was “in agony” with the crowned tooth. When he saw Mr V he was in a lot of pain, had been awake the previous night and could not touch his teeth together due to the pain – Mr V reported the pain as being the same as when 36 was painful and he could vividly remember that from 30 years ago – he was visibly upset that this was happening again.
Dr C diagnosed an acute periapical periodontitis – he presented options of do nothing, extirpation or extraction – while Mr V had previously expressed reluctance to have RCT, Dr C advised that it could be reasonable to have an extirpation to relieve the acute pain and then see an endodontist to assess the crack and the viability of the tooth, now that the crown had been placed. Dr C said that if extraction was the preference he would have to refer to a specialist to remove the tooth as he was concerned about the possibility of crown fracture, necessitating a surgical removal (especially with the history of a difficult surgical for 36). Mr V reluctantly had the extirpation and Dr C booked Mr V in with his preferred endodontist for assessment once the pain had settled.
Dr C received an email from Mr V three weeks later stating he had received a large estimate for the specialist RCT of $2,850 – he said that he had budgeted a little more than the $1,500 that Dr C had quoted him for RCT, but not that much. He stated that the tooth only became very sore when filled and he held Dr C at least partially responsible for the large bill (on top of what he recently paid for the crown). His wife had an implant the previous year and it was not much more in cost than the filling, crown and specialist RCT – and after all of that the specialist had said that the prognosis was still uncertain due to the deep crack.
The advice
Dr C contacted Dental Protection and the dentolegal consultant requested to see the email and all the dental records including the clinical notes, consent documents and any radiographs and photos. When reviewed it was clear that Dr C’s records were reasonably comprehensive and he had documented risks and warnings related to the unpredictability of cracked teeth. He had also issued ADA pamphlets on cracked tooth syndrome and RCT and noted that Mr V had declined to take one on RCT.
Dr C had also trained his DA in dental photography and she had taken excellent quality clinical photos of 46 once the old amalgam was removed, which clearly demonstrated the cracking underneath the old amalgam restoration.
The dentolegal consultant discussed with Dr C the value of his records and the clinical photos to demonstrate the pre-existing condition and conversations of consent around the unpredictability of a cracked tooth. On that basis a decision was made to contact Mr V to offer a time to discuss the treatment, show the photos and explain the pre-existing nature of the condition, which had been unmasked by the restorative treatment. Another option was to respond in writing but Dr C was satisfied to meet with Mr V face to face.
Dr C was also happy to offer a refund of the out-of-pocket costs of the filling and extirpation as a gesture of goodwill, in acknowledgement of the unsatisfactory outcome despite all reasonable care having been taken. Dr C was advised by the dentolegal consultant to adopt a stance of empathy and understanding, rather than proving that he had done all the right things – if Mr V felt heard and understood he was much more likely to listen to and understand Dr C’s perspective. Dr C was instructed in avoiding the use of dental jargon and did a short, rehearsed explanation of his treatment to the dentolegal consultant, who assisted him to find appropriate terminology and analogies to use. Dr C was also encouraged to use other forms of communication such as visual (use of pamphlets or diagrams) or tactile (demo models of cracked tooth, crowns).
The conversation
Dr C and his experienced DA attended a meeting with Mr V and his wife (he was advised by Dr C that he could bring a support person, if needed). Dr C allowed Mr V to speak first, and he listened to his concerns without interrupting or contradicting anything Mr V or his wife said. Dr C apologised for the outcome that Mr V had and acknowledged the impact it had on him, including causing him to recall his previous bad experiences and the escalating financial costs.
Dr C was able to explain his diagnosis and treatment rationale, and Mr V and his wife were accepting and understanding, especially when Dr C explained the work he did without charging full fees. When Dr C offered to refund the previous out-of-pockets, while not significant, Mr V and his wife were very appreciative and explained that they were having some financial difficulties, and this would assist greatly to have the RCT completed (which had been progressing well).
Mr V remained a patient of the practice and in fact his wife started attending, as her dentist had recently retired.
Learning points
- Good up front explanation of treatments with unpredictable outcomes such as cracked teeth is essential, as is excellent documentation of treatment, especially any pre-existing conditions, using clinical records, radiographs and photography.
- Use of pamphlets, diagrams and demo models to explain complex concepts or conditions can be incredibly helpful in obtaining consent.
- It is appropriate to stay with the patient on the journey and see promptly when they are in pain, as is acknowledgement and understanding of unwanted outcomes, even if not directly responsible.
- Excellent communication including effective listening, avoidance of jargon and empathy will take a practitioner far.