This case study on prolonged treatment and poor patient relations is by MLMIC’s Linda Pajonas and Marilyn Schatz, Esq., of Fager, Amsler, Keller & Schoppmann, LLP. It was originally printed in our Second Quarter 2021 issue of The Scope: Dental Edition. Read more articles from the publication here.
A 52-year-old male presented to the MLMIC-insured orthodontist’s office requesting treatment to make his teeth perfect. The orthodontist advised the patient that his bite could never be perfect due to a skeletal imbalance in which his upper jaw was narrow and behind the lower jaw. Treatment options of surgery versus orthodontics were discussed, as well as the risks and benefits of these treatments. The patient opted for orthodontics, but a written consent was not obtained.
The orthodontist’s treatment plan consisted of the extraction of one tooth to relieve crowding, increasing the upper overjet, using lower 4’s as 3’s, and expanding the upper arch with wire. She placed upper and lower brackets that day.
The patient was seen at least once a month by the orthodontist, sometimes twice, although the patient frequently failed to keep appointments and often rescheduled. He was also seen for several emergency visits. After four years of treatment, he regularly expressed concerns about the aesthetics of his teeth. The orthodontist attempted to address these concerns and answer all the patient’s questions.
Six years into treatment, the patient complained that his voice had changed due to the elastics, and that he had developed a lisp. The orthodontist observed and noted in the record that the patient exhibited a lisp only when he discussed the lisp during office visits. She also documented that the patient seemed to be unstable, nervous, jumpy and paranoid, and that he continued to refuse to wear the elastics.
At one visit, the orthodontist asked the patient if he wanted to attend a photo shoot for images to be used at a future American Association of Orthodontics event. The patient initially declined, but then agreed to do the orthodontist a favor and asked her to provide him with event details when they became available.
Seven years after the initial treatment, the orthodontist addressed with the patient the skeletal discrepancy that prevented him from having a “perfect bite,” unless he opted for surgery. The patient wanted to have his braces removed before an upcoming family wedding, to which the orthodontist was invited but had declined to attend.
Social Media and Final Treatment
When the patient and the orthodontist subsequently became friends on social media, the patient learned that the American Association of Orthodontics event had already taken place. He became very upset that the orthodontist had not informed him about the scheduled date. He sent her an email in the middle of the night expressing his disappointment and demanding that his braces be removed immediately.
The orthodontist replied with an email by addressing the importance of maintaining a professional relationship and restating the treatment limitations she had discussed with him when he was first seen. She concluded by stating that the professional relationship had broken down; she considered his care to be complete; the patient should return to her office for removal of the braces; and she would recommend another orthodontist if the patient wanted further treatment.
One month later, the patient returned for his final visit. He stated that he had removed the braces himself using a power thread. The orthodontist then removed any remaining cement, and the patient was pleased with the result. The orthodontist documented that she had informed the patient about her findings of root resorption, but the patient did not appear to be listening to what was said. Impressions were taken for retainers.
Six months later, the patient went to a periodontist, who noted that there were blunted roots at #8-#10 and #23-#27. There was mobility of a total of 10 teeth. The patient presented to another orthodontist, who indicated that no further orthodontic treatment could be provided, and that the patient needed to stabilize his condition. However, the patient was obsessed with the minute aesthetic details of his teeth and he consulted with additional providers. All agreed that he was not a candidate for further orthodontic treatment.
The patient filed a lawsuit claiming that the orthodontist’s treatment was careless, reckless and contraindicated. Allegations included failure to perform diagnostic procedures, negligent performance of orthodontic treatment, failure to refer the patient to an oral surgeon and failure to provide informed consent. The patient sought compensation for pain, mental anguish, TMJ symptoms, malocclusion, periodontal breakdown, loss of bone and root structure and future loss of teeth.
During the orthodontist’s deposition, she conceded that the estimated treatment was 18-24 months, and the average adult orthodontic case lasts two to three years, but that this case went on too long. She also testified that treatment was completed after four years, but she continued to treat the patient to address his concerns.
The District Claims Committee that reviewed the case concluded the orthodontist had deviated from accepted standards of care on multiple levels. It was critical of the absence of a signed informed consent form, the failure to obtain films or review those taken by other dental practitioners, the extended length of time the patient wore braces and the patient’s ability to dictate care.
The orthodontist wanted the lawsuit to be settled, but the patient’s initial settlement demand was $1 million. Mediation was attempted, and the suit was ultimately settled for $245,000.
A Legal and Risk Management Perspective
This malpractice case illustrates the potential implications of crossing professional boundaries. There were many instances of the orthodontist’s conduct throughout the course of protracted treatment that blurred the line between a personal and professional relationship. She fed into the patient’s unrealistic expectations by allowing him to dictate the duration of treatment. In addition, she altered the nature of the professional relationship by extending an invitation to an orthodontic event and friending the patient on social media.
The patient may have misconstrued these overtures, which added insult to injury. He felt further slighted by the orthodontist’s failure to follow up with event details and her refusal to accept a family wedding invitation. All of these disappointments fueled the patient’s anger over an unacceptable outcome, causing him to send the orthodontist an admonishing email in the middle of the night. Removing his own braces may have been proof positive of the patient’s desperation.
It is important to note that Section 2.G. of the American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code) states, in pertinent part: “Dentists should avoid interpersonal relationships that could impair their professional judgment or risk the possibility of exploiting the confidence placed in them by a patient.” Standards of ethical conduct impose a fiduciary duty on professionals to practice basic principles of dental ethics. Complexities that arise out of dual relationships may adversely impact professional conduct and judgment. Violations could result in compromised trust, dissatisfaction, findings of professional misconduct, probation, practice limitations and/or licensure suspension or revocation.
Any interference with a therapeutic relationship could lead to serious consequences. Becoming friends with patients on social platforms in settings outside of the office could convey an inappropriate message and cause an erosion of the professional relationship. Socializing with patients, or exchanging invitations or gifts, could also compromise the integrity of a professional relationship. Any conduct that represents a risk or appearance of exploitation or potential harm to a patient must be avoided.
Dental professionals have responsibilities to patients and the dental profession to fulfill expectations of trust in the provision of competent treatment that meets patients’ dental needs. Proper treatment protocols should always be adhered to, and documentation should be complete relative to informed consent, review of X-rays and referrals to specialists. In addition, it is essential that dental providers maintain distinct parameters with patients, act responsibly, and adhere to ethical principles in a professional environment to prevent complaints, misinterpretation and litigation.