By Dr Richard Hartley, Dentolegal Consultant, Dental Protection.
A 65-year-old lady attended the dentist as she was unhappy with the appearance of her upper anterior teeth, given they were no longer as visible when she smiled. On examination it was noted that the upper six anterior teeth were veneered. The patient advised that they had been in situ for 17 years.
The dentist was keen to improve the situation for her and offered to replace the veneers with longer ones, although he advised he would also need to replace the lower partial denture in order to create some inter-occlusal space and stabilise the posterior support. Radiographs showed that the upper anterior teeth had approximately 25% horizontal bone loss, although the periodontal status was stable and oral hygiene good.
The patient agreed and the treatment proceeded without incident. The patient was pleased with the outcome, but unfortunately, the veneers on both upper laterals fractured after two weeks. The dentist then replaced all six veneers, as the patient decided she wanted them to be slightly longer and a lighter shade.
The veneers were fitted, and the patient was delighted with the appearance, although she returned after one month as the veneer on the upper left lateral had fractured and the tooth was now slightly mobile. A periapical radiograph showed no pathology or fracture, so the dentist replaced the veneer and advised the patient that he would provide her with a bite guard to wear at night while the lower denture was removed. Before this could be fitted the patient lost confidence and attended another practice for a second opinion, where it was identified that the upper left lateral incisor was Grade 2 mobile and likely to be lost, that the veneers on all upper incisors had an unfavourable crown to root ratio and that there were occlusal interferences on lateral and protrusive excursion.
The patient then put in a formal complaint, stating that she would never have agreed to the treatment had she been made aware of the possible consequences. She said she would have been happy simply to accept the lower lip line, as her new dentist had explained that it was a natural consequence of ageing.
How Dental Protection assisted
The dentist contacted Dental Protection, admitting that although he was very experienced, he had perhaps been persuaded by the patient’s enthusiasm to provide treatment that was inappropriate. He accepted that his initial assessment and treatment planning was less than ideal, as he had failed to carry out a full occlusal assessment, or considered articulated study models or a wax-up to assist in diagnosis and treatment planning.
With Dental Protection’s assistance he was able to cover the cost of a referral to specialist prosthodontist for remedial treatment, which satisfied the patient.
The dentist acknowledged that the lack of initial assessment and planning had compromised the consent process, and subsequently carried out targeted professional development.
Learning points
Cosmetic cases such as this can often present challenges, both technically and in relation to managing patient expectations. The following points are essential:
- Take care when managing the patient’s expectations to avoid making statements that cannot be substantiated.
- Ensure that the patient has all the relevant information, so that they can make an informed decision to consent to treatment.
- If things don’t go to plan, then step back and take stock to identify what may be happening so the same errors aren’t repeated. As the old adage goes, if you are in a hole, stop digging!
- Only carry out a task or type of treatment, or make decisions about a patient’s care, if you are sure that you have the necessary skills and are appropriately trained, competent, and indemnified.