Upholding Ethical Standards When Addressing Prior Dental Treatment

Dentists are naturally proud of their profession. After all, they’ve built a life around helping patients improve and maintain their oral health. So, it’s understandable to be a bit disconcerted when they come across questionable work performed by a colleague. 

Recognizing Substandard Work

Occasionally dentists find themselves in an awkward predicament when a patient presents with what appears to be substandard work by another provider. On one hand, patients have a right to be informed about the state of their oral health. On the other, dentists should avoid openly criticizing another dentist’s work, even if that criticism may be justified. Finding the right balance between candidness and refrain can be tricky.

It's important to approach instances of substandard work with empathy and objectivity. Gather a thorough patient history and concrete evidence before making any decisions.

A Case Study

In a case reported to The Dentists Insurance Company, a dentist saw a patient who had mild discomfort on a lower molar. He stated that he had been to three other dentists and they had not been able to help him. The patient insisted on a crown and was convinced that it would make his symptoms disappear. The dentist performed an exam and took radiographs of the tooth in question. Based on her findings, the dentist recommended a root canal. Due to calcification and curvature at the apex, she referred the patient to an endodontist. The patient took the referral slip and left the office.

A few months later, the patient returned to the office with a report from a different endodontist. The report indicated that the tooth was ready to be restored. The dentist did not have a previous working relationship with the other endodontist but had heard from colleagues in the community that this endodontist was known for questionable work and an unwillingness to work collaboratively with other providers.

The patient was adamant about getting the crown done without any further delay. The dentist took a radiograph to assess the status of the root canal treatment. To her surprise, the radiograph revealed a slight overfill. The patient expressed his relief at finally being pain-free and shared that he believed the endodontist he chose did a great job.

The dentist chose not to discuss her findings with the patient, nor did she attempt to reach out to the endodontist to discuss her concerns, as she assumed he would not be willing to speak with her. Because the patient was not experiencing any symptoms and the specialist’s report indicated that the tooth was ready to be restored, she proceeded with preparing the tooth for a crown, although she had concerns about the presence of the overfill.

The patient returned two weeks later to have the permanent restoration delivered. The following day, the office received a call from the patient reporting discomfort with his new crown and feeling that the crown was high. He was seen the same day for an occlusal adjustment. The patient returned for subsequent occlusal adjustments. After each visit, he left the office happy and free from discomfort.

Approximately two weeks after that, the patient returned, frustrated, stating he had been in so much pain that he had to go back to the endodontist. The endodontist told him that the pain was coming from the ill-fitting crown and advised him to go back the dentist to have it redone. The dentist was surprised by the criticism of her treatment from the endodontist given the fact that the root canal he had performed was of poor quality.

The dentist tried to adjust the crown once more but ended up adjusting off an excessive amount of the porcelain layer. She informed the patient and offered to remake the crown at no additional charge. The patient was frustrated annoyed but hesitantly agreed. The dentist removed the crown to take a new impression for a replacement crown.

The patient continued having symptoms for the next few weeks. He canceled his appointment to have the permanent restoration delivered and demanded a refund. He stated he had gone back to the endodontist who referred him to another dentist to remake the crown. Regretting her decision to allow the patient to dictate treatment in the first place, the dentist agreed to provide the patient with a refund.

Communication and Ethical Considerations

TDIC senior risk management analyst Taiba Solaiman explains this case demonstrates the necessity for dentists to inform patients of their findings, regardless of how awkward or uncomfortable it may be. Dentists have an ethical responsibility to be upfront about their patient’s oral health and should feel empowered to provide their professional opinions in an honest manner. That said, dentists must be sure to remain objective. They should avoid finger-pointing and disparaging comments when referring to another dentist’s work.

“While these comments may seem innocent, they can aggravate a patient who may already be emotionally charged,” Solaiman notes.

The ADA’s “Principles of Ethics and Code of Professional Conduct” states: “Patients are dependent on the expertise of dentists to know their oral health status. Therefore, when informing a patient of the status of his or her oral health, the dentist should exercise care that the comments made are truthful, informed and justifiable…A difference of opinion as to preferred treatment should not be communicated to the patient in a manner which would unjustly imply mistreatment. There will necessarily be cases where it will be difficult to determine whether the comments made are justifiable. Therefore, this section is phrased to address the discretion of dentists and advises against unknowing or unjustifiable disparaging statements against another dentist.”

Before determining next steps, it is advised to contact the previous treating dentist, with the patient’s permission, to discover under what circumstances and conditions the treatment was performed. The aim should be not to criticize but collaborate to ensure the best possible care for the patient. This is an opportunity to use active listening to try to understand another provider’s viewpoint.

When you discuss another dentist’s treatment with your patient, be sure the comments are justifiable and based on objective facts and not merely a difference of opinion. Presenting your findings without bias or undue criticism maintains the integrity of your profession and ensures you’re taking the right steps in protecting your patients’ oral health.

Quick Tips from Risk Management Experts

 If you discover an issue with a patient’s prior treatment, follow this guidance from TDIC’s Risk Management Advice Line analysts:

• Prioritize patient safety. Focus on what treatment is necessary to help the patient rather than the other provider’s work.
• Communicate in a non-judgmental way with the past provider(s) and collectively find a solution that benefits the patient.
• Engage in an open dialog. Communicate honestly with the patient about your findings, and in an objective way with the other provider, after the patient has provided authorization to do so.
• Make sure to take pictures, x-ray, models and anything else necessary to establish a baseline for what the patient presented with. These should remain in the patient’s chart.
• Pause and reflect. Take time to consider how you would wish to be treated in a similar situation, both as a provider and a patient. It’s likely that as a provider, you would expect an opportunity to present your perspective before another provider judged your work. And as a patient, you would appreciate an honest assessment of treatment.
• Remember HIPAA compliance. Don’t let your desire to fix a mistake get ahead of maintaining patient privacy. Be sure to get the patient’s authorization for a release of records from past providers. TDIC policyholders can utilize a sample Authorization for Release of Records

Discovering another provider has given treatment to a patient that doesn’t meet your own standards can be a difficult situation, but one that can have better results for a patient when you employ effective communication techniques and observe ethical standards. When in doubt about facing a problem with past treatment or any other difficult situations in practice, contact TDIC’s Risk Management Advice Line.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 1.877.269.8844.