Picking up the pieces

THE first interaction with any new dental patient can present numerous challenges, but these can be particularly acute with a patient with extensive treatment needs. These patients may have poor oral health for various reasons, whether it’s through a prolonged lack of self-care or perhaps due to sub-standard treatments and/or supervised neglect from dental care practitioners.

These patients may also attend with dental anxiety, which will likely be heightened by the unfamiliar surroundings. The resulting tension can lead to communication issues, which hinder the essential consenting process and can in some cases lead to distrust.

Differing treatment plans

A common trigger for a dispute is the presentation of the new treatment plan. In particular, patients who have been used to years of “light-touch” dentistry rarely take kindly to being advised that they now have extensive treatment needs.

Of course, the disparity between current and historical treatment recommendations could arise from lifestyle changes, bad luck or simply differences in clinical opinion. However, on occasion, the new patient may have been on the receiving end of sub-standard treatments and/or supervised neglect, which in turn will necessitate extensive remedial work. In these circumstances you, as the new dentist, are faced with the twin problems of identifying an appropriate management strategy and explaining to the (rather upset) patient what has gone wrong.

Initial assessment

The obvious starting point is to conduct a standard, comprehensive examination which should allow the construction of a complete clinical picture. Depending on your findings, you may then decide that additional investigations are warranted, for example, teeth may be vitality or percussion tested. Additional radiographs may be justified or even onward referral. Each of these measures must be carried out with the patient’s informed consent and be carefully recorded.

Once the full extent of the presenting problems has been assessed, a suitable explanation must be offered to the patient. This can be a fraught conversation. Some patients may be highly sceptical, believing that they are being fed scare stories in order to optimise revenue. With little in the way of an existing working relationship, it can be difficult to convince these patients (even after the offer of a second independent opinion) that you are providing a genuine account of your clinical findings. Conversely, some patients returning to your practice after a long absence may already have had reservations regarding your predecessor (which is why they moved in the first place). Often they will attempt to recruit you as their advocate in the fight against the last ‘bad guy’.

Explaining your findings

Charting a course through these troubled waters is rarely easy and it is important to convey your advice in a neutral, empathetic manner. It is not your job to pass judgement on the patient’s previous dentist or whoever was responsible for poor treatment. Equally, you are not obligated to try to persuade the patient to engage with your recommendations. It is advisable to provide a comprehensible and professional account of the identified issues, their potential ramifications and the relative merits of all viable management options. This last point leads us into two further areas of contention.

It is critically important to recognise the limitations of your own clinical skills. Logic and common sense suggest that it may be harder to replace, for example, a failed root filling than carry out primary endodontics. If the task seems to be at the limit of your experience, referral to a specialist may be the appropriate way forward.

This approach will incur additional expense which can be problematic for those patients who believe that they have been/are being ripped off. But it is important to stand by any decision that the involvement of someone with greater expertise is appropriate.

Avoid patient-led treatment

This firm yet compassionate approach has wider applications. Patients, perhaps in their desperation to avoid tooth loss, may pressure you to undertake treatments that you believe simply will not work. The voice inside your head is telling you to decline but a misplaced sense of obligation may tempt you to agree. This way madness lies. Patients are entitled to make an informed choice from a list of justifiable, appropriate options (including non-intervention or deferred treatment). They are not entitled to treatment which you do not believe to be an appropriate or justifiable option. If the patient continues to insist on treatment you believe will not work, inform them clearly of the reasons why not (and carefully document your discussion) and advise them of their right to seek a second opinion.

Complaints

It is fair to say that disappointed patients are more likely to complain. They may accuse their dentist of creating a treatment plan that prioritises commercial interests. If so, it is worthwhile providing further clarifications and reassurances. If these are not sufficient, you should be able to successfully defend a complaint provided you have made a comprehensive and logical assessment and have taken thorough notes.

Alternatively, patients who are alleged victims of negligence at the hands of a previous clinician may decide to pursue a claim against them. In these circumstances you may be asked for a report in the expectation that it will support the patient’s case. This can place dentists in a difficult position. You do, of course, have a duty of candour towards the patient, but you should avoid criticising the actions of other clinicians unnecessarily. You should simply disclose the records upon receipt of a written patient request. You should not provide a written report regarding prior care, and you should avoid speculation.

Finally, there is the perennial risk that your corrective treatment will fail. Working from the time-honoured ‘if you touched it you own it’ principle, the patient may decide that you are liable for the entire problem. Obviously, you are liable for your own clinical standards. If errors have occurred at your hands, you must fulfil your duty of candour and aim to identify a practicable and equitable solution. However, bearing in mind the likely difficulties in trying to fix existing dentistry that is of a poor standard, the patient’s decision to complain, though regrettable, may have been unavoidable. If so, any complaint can often be resisted if the records confirm that material risks were identified and explained before treatment commenced.

Conclusion

Most adults will receive dental treatment at some stage in their lives and the majority will be completed to an acceptable standard. Deficiencies can arise through wear and tear, possibly augmented by the patient’s poor cooperation and a penchant for deep-fried Mars bars (other confectionary is available).

However, there will be occasions when all has not gone according to plan. Caries may have been missed. Root filings may be short. Crowns may not fit. If a patient who has received this type of treatment attends your practice, the likelihood of disagreement and clinical complications is usually increased. Therefore, it is important to proceed with particular care. Communicate diplomatically yet with complete transparency regarding your findings. Do not be bounced into injudicious comment or treatment planning. If necessary, take time to reflect, talk to colleagues, seek second opinions and, of course, call an MDDUS adviser.

Doug Hamilton is a dental adviser at MDDUS and editor of SoundBite