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We have probably all experienced examples, in our personal and professional lives, of something that happened which, with hindsight, could easily have turned out very differently. But at the time, for some reason, we were unable to anticipate the consequences of sometimes split-second, and often quite minor decisions or external events.
Lessons that we learn from personal experience are frequently more powerful than those we discover second – or third – hand. As a logical extension of that idea, it would be beneficial if we could also accept that lessons are there to be learned in the first place. By adopting this idea it is then possible to personalise those lessons so that we can put them to practical effect in our own life.
The Case
A 45-year-old patient is concerned about the chipping of his upper teeth and so he visits his dentist.
Scenario 1
On examination, the dentist notes considerable tooth surface loss associated with a number of teeth. He questions the patient extensively but as so often happens with the multi-factorial aetiology of tooth surface loss, the dentist cannot identify the exact cause. He uses a questionnaire and scores the wear he sees. He notes the probable cause of the aetiology which is suggestive of erosion and details in his notes the prevention advice he gives the patient before restoring the upper front teeth with composites to improve their appearance.
The patient has a number of posterior teeth missing and two removable partial dentures are provided to increase the vertical dimension. The treatment is carefully staged, using articulated models and wax mock-ups, and the patient is informed about the importance of wearing the dentures to separate the jaws and thereby avoid excessive loading on the front teeth.
Some time later, the anterior composites are replaced with crowns at the patient’s request. The patient is warned about the possible loss of vitality, particularly as these teeth have extensive dentine exposure. Along with the rest of the details, the dentist records these warnings on the computer.
To the dentist it was clear that this was going to be a complicated case which could possibly take some time to complete. He senses that the outcome is not predictable and that the treatment plan might need revision since the patient was busy and there would be a number of phases necessary in order to complete this treatment. The dentist used his notes to refresh his memory of the agreed plan as it was executed.
Scenario 2
On seeing the patient, the dentist feels confident about the solution for the chipped front teeth. He had completed a number of complex courses of treatment in the past and feels he can manage this problem without too much difficulty
He forms an easy relationship with the patient and the planned treatment involving composite restorations, dentures and crowns went well. He is sure of his diagnosis and he explains in great detail about erosion and gives the patient appropriate warnings and preventive advice. In his desire to deliver the treatment in a relaxed manner and chat affably to the patient, the dentist is not particularly assiduous in keeping any detailed clinical records.
On completion of the treatment, a recall date is offered to the patient.
The Claim
Within a short time, pieces of the front crown began chipping off and eventually the upper left central incisor crown snapped off with the tooth inside leaving a stump. Naturally the patient is unhappy and he makes a claim through his legal representatives.
Scenario 1
The computerised records kept by the dentist in the first take ensured that no further action was taken. The notes confirmed that the patient had been warned that the crowns were vulnerable because of the increased occlusal vertical dimension and the limited tooth tissue to support them. His photos confirmed this.
The case was dropped when the patient’s legal team saw the records made by the dentist.
Scenario 2
The patient claims not to have any recollection of warnings and whilst the dentist was adamant he had given appropriate warnings and advice, there is no evidence of this in the records.
To make matters worse, the few records he did have were not found on the computer system back-up when it was requested – only payments and appointment times had been recorded. Only the earlier paper records survived and these were incomplete following the practice’s move to computerised record keeping.
A settlement was made on behalf of the dentist – but this could have been avoided with a complete record of the patient’s treatment.
Based on an article featured in the Dental Protection 2012 Annual Review