This case study on good documentation by MLMIC’s Keith Vaverchak and Marilyn Schatz, Esq., and Donnaline Richman, Esq., of Fager, Amsler, Keller & Schoppmann, LLP, was originally printed in our First Quarter 2021 issue of The Scope: Dental Edition. Read more articles from the publication¬†here.

Early Treatment

A 51-year-old woman who had poor oral hygiene presented to the MLMIC-insured dentist. She had undergone routine dental treatment every three to four months over a period of 10 years. These visits included clinical examinations, cleanings, fillings, RCT and crown placements.

According to the insured, the patient preferred to have the dental hygienist perform cleanings and scaling. Although the patient was compliant in keeping her appointments with the hygienist, she continued to have less than optimal home hygiene, despite being educated about this on numerous occasions. This was well documented in the patient’s dental record. Periodontal probing was performed regularly. In general, the probing was within normal limits.

Periodontal Referral

After five years of treatment, she was referred to a periodontist due to chronic plaque buildup. The patient reported to the insured that, although she was found to have chronic inflammation, no treatment was recommended. After another five years of routine examinations, the insured observed and documented that the patient had bone loss and recession on her mandibular anterior teeth. The insured also documented that this area needed to be monitored.

Four months later, the patient reported that she was experiencing xerostomia. The insured promptly referred the patient to a periodontist for further evaluation of teeth #23-25.

Two months later, the patient was seen by the insured and reported that she had undergone a frenectomy and was now experiencing discomfort and xerostomia. The insured documented that the tissue had not healed properly. The patient advised she would follow up with a periodontist for this condition.

The patient was then seen by a third periodontist. He performed extensive treatment. This included extraction of teeth #23-26; implants on teeth #23 and 26; an osseous cartilage graft on teeth #23 and 26; an abutment on teeth #23 & 26; and crowns on teeth #23-27.

Lawsuit Filed

The patient then commenced a lawsuit against her dentist. She alleged that the insured failed to recognize and stop the advancing bone loss; performed improper and inadequate tests and x-rays to diagnose the condition; improperly and inadequately documented periodontal pocket depths; and failed to properly refer the patient to a periodontist in a timely manner, thus causing the plaintiff to undergo extensive periodontal surgery and the eventual loss of four lower anterior teeth. She claimed that she had incurred great expense, as well as pain and suffering, because of his alleged negligence.

After three years, the case went to trial. The expert witnesses for the defendant dentist all opined that none of the defendant’s treatment led to the loss of the plaintiff’s teeth. These witnesses testified that, based upon the documentation in the defendant’s record, the patient clearly had periodontal disease, decreased salivary flow and poor hygiene. Further, the insured dentist appropriately referred her to a periodontist on multiple occasions. The experts were impressed with the insured’s documentation in the records and his comprehensive treatment plan, both of which helped to refute all of the plaintiff’s claims.

After six days of trial, the jury returned with a verdict for the defendant dentist. If not for the excellent documentation of the dental record in this case, the outcome could have been significantly different.