As image and personal appearance become more closely associated with social and career success, patients have become ever more unwilling to accept 'substandard' teeth. The British public reportedly spends £5.8 billion a year on dental treatments1 and expectations of what can be achieved by dental professionals have grown.
But with this trend comes the risk that some patients will want their dentist to work miracles, or will expect clinical interventions when a minimally invasive approach would be appropriate. And when patients and dentists are not on the same wavelength, the likelihood of a complaint increases.
Causes of complaint
Of course every complaint has its own unique characteristics but communication breakdown is an underlying factor in the vast majority. This is borne out by the DDU’s study of 3,885 patient complaints notified by members in the two year period 2013-2014 where four allegations featured most commonly.
Inadequate or unsatisfactory treatment: 1,465 (38%)
A significant number of allegations about poor treatment reflected technical failings by the practitioner which led to an adverse incident or post-operative pain or infection. However, the case summaries showed that many patients were unhappy that the treatment outcome had fallen short of their expectations: such complaints included aesthetic concerns such as shade match, as well as practical issues such as malocclusion or ill-fitting dentures. Procedures intended to improve dental appearance also attracted complaints, such as orthodontic treatment (20 cases), veneers (77) and whitening (29).
Sometimes the patient was unhappy with a dentist's minimally invasive management, believing they should have received treatment sooner.
Failure to treat/failure to diagnose: 1,194 (31%)
Many complainants alleged that they had been obliged to have more extensive treatment because earlier opportunities had been missed. This was usually because of a delay in making a correct diagnosis, usually of dental decay or periodontal disease (see box below), but sometimes the patient was unhappy with a dentist's minimally invasive management, believing they should have received treatment sooner. Such allegations of long-term supervised neglect can be difficult to refute if there is no supporting evidence that the dental professional recognised the condition and acted in line with professional standards at the time of the care.
Disputed fee/refund: 715 (18%)
This category included alleged failure to explain the cost of treatment and whether the patient was being charged for NHS or private treatment; not alerting patients to the cost implications when their treatment plan changed; and refusing to offer a refund or discount when the patient was unhappy with the outcome. In the DDU's experience, disputes over fees are common with more expensive elective treatments, such as cosmetic dentistry.
Poor communication: 486 (13%)
Complainants expressed dissatisfaction with the attitude of a dental professional or member of the practice who they felt had been brusque or not listened to their concerns. Others felt they had not been properly informed about the pain and discomfort that a dental procedure might cause or had not been advised about the likelihood of success.
Honest and open dialogue
The complaints study shows that gaining the patient's trust and establishing an honest and open dialogue are often as important as a dentist's professional skill.
As in the case example below, it's also possible to be caught out if you don't listen properly. It's only by encouraging the patient to express their concerns – appearance, comfort, anxiety, and so on – that you can try and address their priorities in your proposed treatment plan.
Such a discussion also provides a golden opportunity to identify and tackle any mismatch between what the patient wants and what can realistically be achieved. He or she may be influenced by a variety of sources – TV, magazines, the internet – where there is plenty of scope for misunderstanding, so even if a patient appears well-informed, don't assume they understand what a particular treatment might involve. For example, a gold crown may be more appropriate for a molar, but the patient might expect the restoration to be tooth-coloured. It's advisable to take as much time as the patient needs to understand the likely aesthetic outcome, the longevity of their restoration and possible complications (and document this discussion in the records). You could also provide them with written material to take home and review before they commit to treatment.
Ultimately, there are many factors that might contribute to an unsuccessful treatment outcome, from a recognised complication to the patient's unwillingness to follow post-operative advice. However, patients will only be prepared for these scenarios if they are explained in advance. If they are only informed after something has gone wrong, these explanations can easily be dismissed as excuses.
Perio problems
Gum disease is a leading cause of tooth loss and can sabotage treatment such as crowns and implants. In this study, at least 185 complainants alleged their dentist had failed to diagnose or properly manage gum problems. The number of periodontal claims is also on the rise, as we reported last year.
The prevalence of periodontal disease and its possible consequences makes it imperative for dental professionals to take this threat seriously. From a dento-legal perspective, you should:
- Follow evidence-based national guidance - organisations such as the British Society of Periodontology and the Faculty of Dental Surgery are good sources.
- Record your findings and treatment plan – document both positive and negative findings from your periodontal examination at each appointment, including periodontal scores and risk factors such as the presence of calculus and a history of smoking.
- Communicate clearly with the patient – advise them how to improve their gum health, including smoking cessation and explain your treatment plan, even if this is only monitoring their condition. Keep a record of consent discussions.
Case study
A 25-year-old patient with no previous fillings registered with a new practice. At her first consultation, a bitewing radiograph revealed a significant carious cavity within the mesial aspect of UR4. The dentist explained his findings to the patient who gave her reluctant consent for a filling, expressing concerns about the effect on the appearance of her teeth.
When the patient returned, the dentist restored the tooth with an amalgam filling but the tooth lost vitality and she eventually required endodontic treatment. She later made a complaint about the adverse aesthetic impact of the silver filling and the failure of the treatment.
A practice investigation revealed a breakdown in communication between the dentist and patient. In particular, the dentist acknowledged that he should have taken more time to highlight the decay revealed on the radiograph image; explained that it was difficult to be certain about its extent; and warned that there was a risk that root canal treatment might be necessary. He also agreed he should have made clear why an amalgam filling was more appropriate in this instance and checked the patient's understanding.
The complaints manager wrote to the patient, admitting the failings in the way her treatment was managed. As a goodwill gesture, the practice offered to partially refund the cost of the patient's root canal treatment. The patient was satisfied with this response and the complaint was resolved.
Eric Easson
Eric qualified in 2001 at Manchester University, gained the dip.MFGDP in 2006 and a Masters in Medical Law (LLM) with merit in 2015. He worked as a clinical teaching fellow at Manchester University from 2004-2020, and has worked in general practice since qualification.
He started to work for the DDU as a part-time dento-legal adviser in 2014, and is a current member of the Faculty of Forensic and Legal medicine [MFFLM], Faculty of Dental Surgery [MFDS] and College of General Dentistry [MCGDent].
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