Quicker, less invasive and without the price tag of veneers, composite bonding is an extremely popular option for those who want to improve the appearance of their anterior teeth. It is often included in more extensive treatment plans.
Patients who have seen any marketing materials showing 'before and after' photos of discoloured, chipped or 'gappy'' teeth transformed into a perfect smile might be forgiven for thinking that composites are a miracle fix.
However, they are typically not as durable as alternative types of restoration and dental professionals should be wary of giving this impression, as misunderstandings and unrealistic expectations can easily lead to problems further down the line.
A typical case
The following scenario is typical of the sort of things that can go wrong with composite bonding treatment.
A patient who had completed a course of aligner treatment asked his dentist to address a worn lateral incisor, which he said detracted from the overall effect. He readily agreed to the dentist's suggestion of composite bonding and the procedure was conducted to his apparent satisfaction.
Several months later, the patient returned to complain that part of the composite had chipped slightly when biting a baguette, and was now stained.
The patient wanted the dentist to repair the chipped composite and provide tooth whitening treatment. The dentist explained that the patient would need to have the composite removed before he could begin whitening treatment because it wouldn't work on the bonding material and there would be a cost involved.
The patient was unhappy to hear this and later made a complaint, arguing that the treatment was substandard and he was entitled to a refund.
The practice investigation found the dentist had carried out the original treatment properly and could not be blamed for the chip, given the stress placed on the restoration by the patient when eating a baguette. However, there was nothing in the records to show the patient had been warned about the risk of discolouration or chipping or given post-treatment advice.
They agreed to repair the chip and give a partial refund as a gesture of goodwill on the understanding that this would conclude the complaint. The patient accepted the refund but decided to go to another practice to have the composite removed and his teeth whitened.
DDU analysis
The DDU reviewed 120 case files opened between 2019 and 2022 where composite bonding treatment was provided, which were mainly patient complaints along with a small number of claims. The number of files rose sharply over this period - from just two in 2019 to 83 in 2022.
Of the 18 claims, all but one were still active, and in several cases the composite bonding was provided alongside other treatments like orthodontics and tooth whitening. Where a successful claim was about composite bonding only, we would expect this to settle for less if costly remedial treatment isn't necessary.
However, it's also worth highlighting that such claims may be harder to defend without evidence in the records that the patient gave fully informed consent.
Causes for concern
The DDU has categorised the files by the primary issue raised, although some files included multiple allegations.
- Unsatisfactory treatment/dissatisfied patient: 67%
- Damage to the restoration or natural teeth: 16%
- Communication problems/attitude: 9%
- Disputes between dental professionals/practices: 4%
- Periodontal disease/caries: 3%
Patient dissatisfaction
Patients' dissatisfaction is stressful and time-consuming to manage and often leads to a complaint, despite your best efforts. Most of the DDU cases looked at (67%) concerned patients who were unhappy with the outcome of composite bonding, such as discolouration or an uneven appearance. At least 9% of these files included a dispute about fees or a request for a refund by the patient.
It's important to have an honest and open conversation with patients at the outset about what composite bonding entails, making clear the disadvantages (such as the risk of chips, staining and the need for ongoing maintenance) alongside the possible benefits and the alternatives.
Try to find out what the patient expects and carefully document all your discussions in the records, including any steps you've taken to illustrate realistic potential outcomes.
Bear in mind that patients who are willing to pay for cosmetic treatments are also likely to be more particular about the outcome - it's not uncommon for patients to bring in a photo of the look they want to emulate. However, achieving optimal results with composite bonding is a technically demanding skill and they may not last if the patient doesn't take care.
In general, it's better to under-promise and over-deliver than have to explain why the treatment has fallen short of expectation.
Carefully assessing potential patients is important - if they are a smoker or have bruxism, you could be setting yourself up to fail. Document the post-treatment advice you give (eg, oral hygiene, trying to avoid red wine, coffee or tea) and consider providing a written information sheet as an aide memoire for the patient once they have left the treatment room.
In general, it's better to under-promise and over-deliver than have to explain why the treatment has fallen short of expectation.
Composite or tooth damage
Composite restorations can be more vulnerable to chipping when put under undue stress or trauma, such as grinding, nail biting or an accident. Of the cases we analysed, 16% contained some reference to this problem, including cases where the damage occurred during a different dental procedure.
Patients often expect the chip to be repaired free of charge, regardless of the cause, particularly if they have been given a guarantee. These are best avoided to help avoid getting into a war of words with a patient over ambiguous small print.
To pre-empt problems, be clear to patients that composite bonded restorations may chip or de-bond over time, and offer advice on how to keep them in the best possible condition, including regular check-ups.
Chips can also occur because of problems before or during the procedure. A thorough patient assessment and treatment plan is essential, including identifying and addressing existing periodontal diseases and caries (which accounted for 3% of cases in the analysis), taking clinical photos, checking occlusion and shade matching.
The dental professional who conducts the procedure should be suitably trained and experienced, but most importantly, they should recognise when a challenging case requires referral to a colleague with greater expertise. Everyone wants to avoid a situation where the patient has to return multiple times for adjustments.
Communication
Allegations of poor communication, rudeness, or disputes (9% of cases) are a common factor in all dental complaints, not just cosmetic ones.
Sometimes, the relationship might have been deteriorating over time (for example, if the patient has lost confidence in the dental professional due to a misunderstanding or perceived lack of sympathy). But in many cases, patients are unhappy because of the response to their initial dissatisfaction or refund request.
This underlines the importance of having an effective practice complaints procedure that allows verbal and written complaints to be managed promptly and professionally.
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The main purpose of responding to a complaint is to resolve it for all parties as quickly as possible, so it's important to be clear why the patient is complaining, what they might be seeking, and what you might reasonably say, do or offer that could satisfy them.
This might include an offer to meet face to face, a second opinion, a refund or another a gesture of goodwill. There's no obligation to do this, but if you want to make an offer, you can do so on the understanding that it concludes the complaint. If you're a DDU member, you can always ask us for advice on the best way to proceed if you are unsure.
Finally, a handful of cases concerned treatment by a dental professional who is now at another practice. To pre-empt problems, it's advisable for practices and departing practitioners to stay in touch for the foreseeable future so any queries and questions can be resolved quickly. A good contract with a retained fee arrangement can work to everyone's advantage if properly and fairly administered, and DDU members can access our free associate contract checking service to help with this if needed.
An edited version of this article first appeared in Dentistry magazine in June 2023.
Jo-Anne Taylor
Dento-legal adviser
Jo-Anne Taylor
Dento-legal adviser
B.Ch.d (Hons) MSc, PG Cert Medical Education, PG. Cert Medical Aesthetics, SFHEA.
Jo qualified from Leeds Dental Institute in 1991 and spent 16 years providing general dental services in the UK and Australia. She has worked in private and NHS practice as well as in the Community Dental Services. Jo is a senior fellow of the Higher Education Academy and has held several teaching posts in Yorkshire and more recently in Hampshire, where among other roles she worked as Associate Head (Education) at the University of Portsmouth Dental Academy. Jo joined the DDU as a telephone adviser in 2020 and began working as a dento-legal adviser in 2021.
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