DAVID CROSER presents a case study from Dental Protection’s archives, which carries invaluable learning points.

I didn't expect that!

A middle-aged female patient had badly imbricated lower incisor teeth. She was attracted by the practice website of a dentist who stated that he could create dazzling smiles. The website contained many before and after treatment photos and they looked pretty impressive.
After an initial consultation, various options were outlined to the patient, ranging from orthodontic treatment to crowns. The costs and time scales associated with each approach to treatment were also discussed.
The patient had considered orthodontics in the past and ruled that out as a possibility because she had a busy social life and she was really looking for a quick fix. She said that once she had made her mind up to do something she wanted to get on with it. She had been particularly impressed by the photos on the website and was even more impressed when the dentist showed her more of the same. She pointed out that one of the website photos of completed treatment showed exactly the result she was looking for.
She was keen to start her treatment and chose to have her four lower incisor teeth crowned. Such was her enthusiasm that the dentist even juggled some appointments so that her treatment could be accommodated as soon as possible.
On fitting the crowns the patient was not at all pleased. Indeed she was clearly dissatisfied. Although the buccal aspects of the teeth were now aligned, any view from above the incisal edges would reveal a strikingly excessive lingual to buccal width of the two teeth, which had previously been in-standing. The patient, who was rather short in stature, was particularly upset by this increase in the width of the incisal tip. She felt that people already looked down on her and her crowns would now be the focus of their attention.
Not only did the patient refuse to pay for the crowns, she also threatened legal action. On investigating the background to the case, it transpired that the driver for her agreeing to the treatment was the before and after photos. However, none of those had included cases similar to hers where the treatment was only achievable by using crowns with an increased buccal to lingual width. Significantly, there had been no discussion of this fact in the pre-treatment consultation between dentist and patient.
An expert opinion was sought, which stated that, given the original position of the teeth, the only possible way to create a series of crowns with the appearance of well-aligned teeth of normal dimensions would involve devitalising the teeth prior to the use of posts and cores.
This option had not been considered or discussed with the patient and as a result the consent process was flawed and the dentist was vulnerable to a successful claim. Dental Protection assisted the dentist to achieve an amicable settlement with the patient without the involvement of solicitors.

Learning points

  • Spend time with each patient to ensure that their expectations are properly understood and managed; confirm what can and – perhaps more importantly – what cannot be achieved.
  • When using before and after photos to illustrate what can be achieved, be careful to explain any circumstances that might complicate the outcome for the particular patient in front of you.
  • The use of computer-generated images is not without risk because such images can sometimes suggest outcomes that cannot be achieved in reality.
  • The old adage of ‘under promise and over deliver’ still holds true in dentistry.

David Croser is Communications Manager at Dental Protection.