MLMIC DENTAL CASE STUDY: Poor Documentation Provides a Scapegoat

Repurposed from The Scope, First Quarter, 2026

This case involves a 26-year-old male who presented to the MLMIC-insured orthodontist looking for “perfect teeth.”

Initial Treatment

Upon examination, it was noted that the patient had an impacted maxillary right cuspid due to a deciduous cuspid that was affecting the right central incisor, causing root resorption.

Three treatment options were provided. The first was to extract #8 and the deciduous cuspid, force the eruption of #6, and move it to a central position with the implant placement at #8. The second option presented was to extract #8 and the deciduous cuspid, move and crown #7 to #8, and place an implant at #7. The third option was to extract the impacted #6 and leave both #8 and the deciduous cuspid with a guarded prognosis.

However, it appears that the treatment plan that was agreed upon, which was not one of the previous options, was to extract the deciduous cuspid and #6 for the placement of an implant. It was noted that the treatment plan was compromised due to the resorption of #8 and that treatment would be 20 to 24 months.

While not documented, the insured advised that all options were discussed with the patient, and it was understood that he would need an implant once the orthodontic treatment was completed due to the root resorption at #8. There was no written informed consent.

A prescription was provided to extract the deciduous cuspid. Thereafter, the chart became confusing, as it appears that appointment dates were pre-written into the chart and, if these appointments were cancelled, the insured inadvertently placed treatment notes for the next visit under the cancelled date.

The patient was seen once or twice a month for adjustments, which were simply noted as “adjusted” or “retied” the archwire.

A year and a half into treatment, and after a Panorex was taken, the treatment plan changed to #7 being moved to #6, with extraction and implant placement at #8. This change in treatment plan was undocumented.

Monthly adjustments continued, and the upper right cuspid, or upper-right lateral incisor, was periodically checked.

At some point, the lower brackets were removed but not documented.

Just shy of three years after the initial examination, the insured advised that the patient was instructed to have #8 extracted. However, this was not documented.

The patient presented a few days later and refused to leave the office until the upper brackets were removed and a refund was provided. The insured’s office typed up a release that reimbursed the patient for his orthodontic treatment as well as the cost of the implant, with restoration to be carried out by his general dentist. The upper brackets were removed, and no retainer was provided. It appears that the study models went missing after being left in the room while the patient was unsupervised.

The patient was subsequently seen by his general dentist, who noted his hygiene was poor and recommended that he start periodontal treatment, but the patient declined due to the cost. The patient’s #8 had severe root resorption, and the plan was to extract #6-9 and place implants, but again, the patient did not follow up. Eventually, he had #8 extracted and a flipper placed. Multiple teeth were later extracted; however, that was almost three years after the insured’s treatment.

Lawsuit Filed

The patient filed a lawsuit against the MLMIC-insured orthodontist alleging negligent orthodontic treatment resulting in root resorption of #5-10, which caused mobility and the loss of multiple teeth, with the resulting need for implants.

MLMIC’s experts all opined that the orthodontist was not at fault for the eventual extractions that took place a few years after his treatment ended and that they were due to the patient’s periodontal disease.

However, all experts also agreed that the orthodontist’s records were far below the standard of care. Neither the orthodontist, nor any of the employees, could decipher the chart. There was no informed consent and no clear treatment plan.

Further, the overall treatment was not as effective as it could have or probably should have been. The experts could not determine which treatment options the orthodontist was intending to use, and the movement he utilized was less than effective, as it did not do enough to bring the impacted tooth down and place the back teeth into the right position.

The District Claim Committee agreed with the experts that the patient’s allegations were unfounded. However, the committee members believed that the insured’s chart would make it exceedingly difficult to defend the case. Further, they found the orthodontist’s responses to their questions confusing.

The matter was ultimately settled.

A Legal and Risk Management Analysis

The Dental Record

This case demonstrates the importance of the dental patient record when defending a dental malpractice lawsuit. Creating complete, accurate, and organized patient records is one of the most important steps dentists can take to limit the risk of malpractice lawsuits. The extremely deficient dental record in this case played a large part in the decision to settle rather than defend the case. While the experts agreed that the patient’s claim had little, if any, merit from a clinical perspective, they also agreed that the dentist’s record keeping fell well below the standard of care.

The records should have been detailed enough so that the experts could at least determine what treatment was provided and the reasons for this treatment. In this case, even the dentist could not decipher the patient’s records. For each visit, there should have been documentation of the scope and nature of examination, any notable findings, an assessment of the patient, including the identification of any conditions that would require a change in the treatment plan, and the treatment provided.

Informed Consent

The records should also have included evidence of informed consent. Demonstrating informed consent is key to defending a malpractice claim. If a known complication occurs after informed consent, it is difficult for a patient to prove malpractice. The informed consent process requires discussion about the nature of the proposed treatment, the potential benefits and risks associated with that treatment, any alternatives to the proposed treatment, and the potential risks and benefits of alternative treatment, including no treatment. All discussions should be summarized in the patient record, dated, and signed. In this case, the dentist documented alternative treatment plans, but there is no evidence that the patient understood or consented to any of the alternatives. In fact, the dentist went with an entirely different treatment plan without documenting the clinical decision- making involved in choosing the alternative plan or the patient’s understanding and consent.

Takeaways

Documenting essential information, including informed consent, in the dental patient record is a key factor for risk management. This case may have been defensible had the dentist created accurate and complete patient records. Absent these records, the experts could not adequately defend the case, and settlement was required.

MLMIC policyholders can reach out to our healthcare attorneys for questions about informed consent, documentation, or other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

Our 24/7 hotline is also available for urgent matters after hours at (877) 426-9555 or by emailing hotline@tmglawny.com.

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This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical, dental or professional obligations, the applicable state or federal laws or other professional questions.