Quality of Care

Disclaimer: Facts are based upon an actual dental board investigation.  This case is presented for educational purposes only and does not constitute legal advice or a legal opinion.

Performance of oral surgery without proper diagnosis

Areas of Impact: Quality of Care; Standard of Care; Patient Safety; Professional License to Practice

Case Summary:

State board allegation against a dentist for being incompetent or negligent by failing to meet the minimum standards of performance and diagnosis and treatment when measured against generally prevailing peer performance, including, but not limited to undertaking of diagnosis and treatment for which the dentist is not qualified by training or experience.

Circumstances of the Case:

A patient of record had a cleaning, examination and two bite wing x-rays in a general dental office. The patient was then referred to the dentist of record for extraction of all third molars within the same practice.

The dentist performed a preoperative examination and noted that teeth # 1 and 16 were partially impacted and teeth # 17 and 32 were full bony impacted with a mesial inclination. No further X-rays were taken.

A complication occurred during the surgical extraction of # 32. The dentist diagnosed the patient with the mandibular fracture at # 32 and referred the patient to the oral surgeon.

Outcome of the Case:

The dentist was found in violation of the state Dental Practice Act by failing to keep written dental records and a medical history justifying the course of treatment. The prevailing standard of care and the state Dental Practice Act in this state require that at a minimum the written record must include an appropriate medical history, results of clinical tests and exam including the presence or absence of disease, any radiographs used for diagnosis and treatment, a treatment plan and the treatment rendered to the patient.

In addition, the dentist was found in violation of failing to meet the minimum standards of performance and diagnosis and treatment when measured against generally prevailing peer performance in one or more of the following ways:

  • By embarking upon surgical removal of partial and fully bony impacted third molars without adequate preoperative radiographs.
  • By failing to take a Panoramic X-Ray preoperatively and embarking upon the surgical extraction of partial and fully bony impacted third molars, surrounding and nerve canal.
  • By performing surgical extraction of patients third molars without any x-ray that captured the surrounding anatomy or size of the mandible.

What could have been done differently?

Here are several points to consider:

  • In hindsight, what additional radiographs should have been taken?
  • What additional items could have been documented in support of the diagnosis?

Risk Management Take-Aways:

  • When treatment is identified and/or diagnosed during a dental hygiene appointment, the diagnosis must be clearly noted in the record.
  • A medical history review must be completed and documented by the dentist at each visit.
  • The necessary radiographs must be taken in order to support and validate the diagnosis.
  • Exercise caution when performing treatment that could be referred to a specialist, such as oral surgery, if a general dentist is not qualified by training or experience.

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