Upper front 4 teeth crowned

A patient (Mrs. T) had quite extensive work performed, with  her upper front 4 teeth crowned. Although she was satisfied, she was never told about her lower teeth, then she began to get neck and headaches.

History

because her back teeth didn’t show and although her teeth didn’t touch properly, the patient was OK with that and accepted that, as her  dentist assured her – they would settle in.

A few weeks later however, she started to have severe headaches that seemed to be coming from her neck. Her doctor prescribed painkillers that she had to take although they didn’t seem to work well. Her dentist confirmed that it clearly couldn’t be anything to do with her teeth.

She sought help from a chiropractor, but despite treatment, it didn’t seem to help either. She tried other healthcare providers but got no relief. She never made the connection with her teeth, as it had been a while since they were done and her pain seemed to come from the base of her skull, not her teeth.

A specialist physician diagnosed them as “cervicogenic headaches” (starting in the neck). She was desperate and debilitated.

Quite by chance she found a dentist who suggested that her pain was due to the change in her head posture (and therefore strain on her neck) following the change in her bite bought on by her crowns her bite.

He recommended that the lower jaw be stabilized in its correct position with support for her back teeth too. She was reluctant  to spend more money on “questionable ’ treatment but  proceeded due to the pain. She was amazed that it worked almost immediately. How could it have been missed and why didn’t the dentist who made the upper crowns not know?

Investigation

Her dentist denied any liability saying what she’d done was to a high standard and there must be other things in her neck. The patient was annoyed by her dentist refusing to admit it might be to do with the change in her bite.

After consulting a lawyer, an expert witness was brought in. His investigation showed that the dentists prescription to the dental laboratory simply said, “Do your best as bite is difficult to find due to tooth wear”. The laboratory claimed, (correctly) that they weren’t trained to make those decisions, the dentist should have known, or she shouldn’t have done the work, they said.

Considerations,

Sometimes it’s difficult to determine what should have been known, because people tend to think that dentistry is all about fixing teeth.

Historically this has been the case, and although we now recognize that there’s much more to it than that, the standard of care is still within “what the average dentist would do”.

While the “average dentist” might not know about the possible problems following crowns changing the bite and the head posture, there were three issues that were uncovered.

1. The dentist did not ask about previous jaw joint problems (TMD) and therefore wouldn’t have known if the patient were more prone to such issues. If they had, the fact that the lady had a history of a clicking joint which appeared to have got better, would have indicated that a trial might be prudent before the bite was changed with the crowns.

2. For extensive dental work involving changing the bite using crowns (often following severe wear) it is generally prudent to trial the changes first. While it may cost another few hundred dollars more, the value against potential problems is immense. If the patient refuses to trial changes and signs off against potential problems, the dentist can protect him or herself by allowing the patient to wear temporary crowns for several weeks to ensure that for that period there are no complications.

3. It is unwise to write on a prescription that the dentist is transferring responsibility to someone unable to make that decision. While it is understood that the dentist enjoyed the technical aspects of crowning teeth, she makes clear that her knowledge is “wanting” by making this statement.

4. Just to add insult to injury, the dentist forgot to get a signed consent although he said he remembered talking about the benefits, and that without them her teeth would continue to wear down. This was not written in the patient’s records, just the financial arrangements on that day. 

The procedures were adequately recorded  thereafter, however.

Just as with other dental and medical procedures, failure to provide options leaves all parties are unprotected from legal action. Consent must include all reasonable and known risks.

Clearly the dentist must acquaint the patient to all relevant aspects of his or her therapy before commencing, in this case it appeared that she was unaware of possible problems and it was agreed that if she had proceeded slowly, the problems would probably have arisen in time to make the necessary changes.

It was accepted that to have done so, would fall within the accepted standard of care.

In closing…

The patient doesn’t usually know about the dental aspects of their anatomy and physiology in any detail – it would be impossible to learn in a few weeks or months what has taken someone five years of intensive training and then practical experience and continuing education simply to qualify as a dentist.

Conclusion

In this case, the matter settled out of court as it was decided that defense would be difficult given the lack of consent and comments made to the commercial laboratory.

The cost of a trial appliance and crowns to make the corrected bite changes stable was requested and eventually paid to the plaintiff who did use the funds to complete her dental work, alleviating her pain.

The dentist’s regulatory body recommended that the dentist take post graduate courses on “occlusion” (the bite).

Author – Stephen Bray DDS

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