An Illuminating Story for Dentists
By: Dr. Ian Aires (Dental Expert Witness)
I recently was asked by the patient’s attorney to review treatment by a dentist for possible malpractice.
The patient claimed that she was not given adequate information regarding her treatment options and the possible risks associated with the recommended treatment.
Here is a short summary of the sequence of events.
The patient presented to the dentist with 15 remaining teeth some of which were not salvageable. Her anterior teeth were discolored and crowded.
She was missing many of her posterior teeth. The main reason for her visit was to improve her aesthetics.
A panoral x-ray was taken. The dentist briefly discussed the panoral x-ray with a Periodontist who agreed the patient was a candidate for the All-On-4 treatment.
The dentist then discussed different treatment options with the patient including partial dentures, fixed bridge work and implants.
The dentist’s recommendation was to remove all the remaining teeth, have dentures made and 6 months later proceed with the All-On-4 implant treatment for the maxillary arch and a snap-on lower denture for the mandibular arch.
The patient agreed and the dentist proceeded to fabricate immediate full dentures prior to extracting the remaining teeth.
Subsequently the dentist removed the remaining teeth and inserted the immediate dentures.
Healing was uneventful and after six months the dentist referred the patient to the Periodontist for the All-On-4 treatment.
The Periodontist then proceeded to take a CBCT scan.( cone beam computed tomography)
He Informed the patient that there was insufficient bone for the All-On-4 treatment and that she would first require sinus grafting.
The grafting was completed but unfortunately one side was unsuccessful.
An oral - antral fistula developed and could not be closed after repeated attempts. The Periodontist then advised the patient that she was no longer a candidate for the all on four treatment.
The patient sued both doctors for Malpractise.
After reviewing the records it appeared that the dentist did not offer the patient immediate extraction and immediate load. Nor did he offer just immediate placement after the extractions. In addition he did not office socket preservation when he extracted the teeth.
There is also no record explaining the possible outcome to the patient that after the extractions and the healing and wearing full dentures for 6 months she may not have sufficient bone for the All-on-4 treatment and that additional bone grafting may be required.
The Periodontist gave his opinion without first reviewing a CBCT scan.
The dentist was deposed and as you can imagine the deposition did not go well for him.
He and his insurance company shortly afterwards settled with the patient for $150,000.
What can we all learn from this case?
When we recommend a treatment option for a patient we must fully understand what is entailed. The All-on-4 option by design is used mostly for immediate load.
1. Whether you believe in immediate load or not the patient should be given the option of immediate load as well as the option of immediate placement. (implants inserted immediately but not loaded.)It’s considered standard of care today in most cities.
2. In addition when planning implants it’s become the standard of care to have a CBCT scan taken. This assumes that there is a CBCT machine in the general vicinity. In this case the periodontist had a machine in his office.
3. Whether you believe in socket preservation or not it’s incumbent on you to offer the patient this option.
4.Your informed consent forms should outline the possible risks and what additional treatment may be needed if there is insufficient bone.
5. In a complex case where extractions and implants are planned it’s advisable to have the implant dentist do both extractions and the implant insertion.
Dr. Ian Aires