Case Study: Failure to Diagnose and Refer Results in Court and Dental Board Action

Donald Wood, CRNA, CPHRM

Legal and licensure penalties are incurred as a result of inadequate patient safety procedures.

A patient contacted her dentist after experiencing tooth pain. Upon examination, radiographs indicated a fracture of tooth number four. Intraoral photographs indicated that mesial, lingual, and distal margins of the tooth extended below the gingival tissue. The treatment plan included a root canal, post and core, and a crown. The need for the crown lengthening was not included in the dental record.

Subsequently, a root canal was performed by a second dentist, and the patient returned to the original dentist for the post and core placement in preparation for the permanent crown. The original dentist placed the permanent crown.

Several months after the permanent crown was placed, the patient returned to the original dentist and stated that the crown was loose. Radiograph findings indicated a large periodontal bony defect on tooth number three. Adjustments were made to the crown. However, the patient was not provided with a recommended treatment plan or dental referral, nor was this documented in the record.

One month later, the patient returned to the original dentist and complained that the crown was loose again. The dentist removed the crown and replaced the post. However, the second post deviated from the long axis of the tooth, which caused a root fracture.

The patient sought treatment from another dentist. A recurring fistula was diagnosed in tooth number four and required extraction. In addition, the untreated periodontal defect in tooth number three required extraction.

The patient pursued a claim against the original dentist.

When an indemnity payment is made for malpractice, the payment must be reported to the National Practitioner Databank as well as the Florida Department of Health (DOH). The DOH conducted an investigation and filed an administrative complaint against the dentist that alleged the following:

  • Failure to diagnose the need for crown lengthening on tooth number four.
  • Failure to timely refer or treat periodontal defect on tooth number three.
  • Failure to adequately place the dental post on tooth number four.
  • Negligent conduct that resulted in a paid indemnity.

The dentist was penalized with a letter of concern on his dental license, administrative fines, and a continuing education requirement that exceeded standard license renewal requirements.

Risk Management Discussion

Failure to diagnose and failure to refer are common issues seen in dental claims. In this case, the dentist failed to diagnose the need for crown lengthening and failed to treat or refer the patient for the identified periodontal defect. Experts reviewing the case were also critical of the dentist’s inadequate placement of the dental post and determined that proper initial preparation for placing the crown may have prevented the need for subsequent procedures.

The following strategies can help you avoid these issues:

  • Document your findings to support the treatment plan decisions.
  • Do not ignore incidental findings.
  • Refer the patient to a specialist when necessary, and document your referral decision.
  • Facilitate the referral by making the patient’s appointment with the specialist.
  • Track referrals to ensure patient compliance.
  • Document the outcome of the specialist’s treatment.

Contact the Department of Patient Safety and Risk Management for guidance and assistance in addressing any patient safety or risk management concerns.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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