Avoiding Malpractice: Forensic Dentist Advises on Maintaining Standards

Dr. John Dovgan, DDS, PC, is a forensic dentist who often serves as an expert witness on malpractice cases. Speaking recently at the American Dental Association’s 2016 Meeting, in Denver, CO, Dr. Dovgan explained what he looks for to determine whether malpractice has taken place. The determination, he said, often hinges on whether the standard of care was upheld.

That begs the question of, how does one define the standard of care? Dr. Dovgan defines the standard of care as what a reasonable and prudent dentist would do in a similar situation. The standard of care, he said, reflects that which is minimally required, and anything less is considered negligent.

If others in dentistry practice in a way that eliminates hazards, then this approach can be used to define the standard of care. Even so, if a malpractice suit is brought against a dentist, a jury will decide if the standard of care is reasonable, and whether the deviation from the custom standard of care was unreasonable to cause harm.

“Standard of care deviations tend to be obvious,” said Dr. Dovgan. He compared the standard of care to a bell curve, saying that being above the standard of care is unachievable by most dentists, and that only 2.5% of dentists are truly below the standard of care. However, for those 2.5%, the deviations from the standard of care are obvious.

The worst type outcome from a deviation from the standard of care results in patient death, Dr. Dovgan said. Patient deaths due to a dentist’s failure to diagnose oral cancer, over sedation, local anesthetic overdose, failure to refer trismus resulting in ludwig’s angina, and COPD/asthma-status asthmaticus, were all true examples discussed by Dr. Dovgan. In all instances, the deviation from the standard of care was obvious.

Lack of monitoring, using the same dose of a sedative in an elderly patient as you would a younger patient, not screening for drug/drug interactions, giving sedation reversal and failing to monitor, not keeping enough reversal drugs on hand in the office, and not using barrier protection during sedation procedures, are just a few examples of the gross deviations from the standard of care that Dr. Dovgan provided.

In addition to the above deviations, Dr. Dovgan presented an extensive list of lines a dentist shouldn’t cross. A few of those are:

• Not taking a health history prior to administering anesthetic
• Not taking x-rays prior to an extraction, endodontic procedure, implant placement, or crown procedure
• Not taking blood pressure prior to sedation, implant placement, or extractions
• Not providing informed consent prior to root canal treatment, extraction, or other invasive procedures
• Telling the patient post-op numbness more than 48 hours post treatment is normal
• Extracting the wrong tooth
• Abrogating the copay for patients with insurance
• Allowing a dentist to practice in your practice below the standard of care
• Not taking post op x-rays to confirm placement of implants or completed endodontic procedures
• Over diagnosis for caries that don’t exist

Given his expertise in the area, Dr. Dovgan provided a list of items he considers when dealing with state board cases and malpractice cases. Some of those considerations are listed below.

History/Clinical

• Is there a signed/dated comprehensive health history with regular updates?
• Are there soft tissue exam notes?
• Are there full mouth periodontal probing’s present?
• Are there regular periodontal updates?
• Is there an oral cancer screen?

Radiographs

• Is there a full mouth series or equivalent?
• Are the x-rays clinically acceptable?
• Do other x-rays exist?
• Are the x-rays clinically applicable to diagnosis?

Diagnosis

• Is there a written, documented diagnosis?
• Is the diagnosis consistent with the treatment plan?
• Is the diagnosis reasonable?

Treatment plan

• Does a written and documented treatment plan exist?
• Is it supported by radiographs and diagnosis?

Mary Lenefsky, PharmD, is a consultant pharmacist and medical writer who specializes in the creation of medical education content for pharmacists, nurses, physicians, and other healthcare providers. She received her Doctor of Pharmacy Degree from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. She then completed two years of post-graduate residency training at Northwestern Memorial Hospital, specializing in the care of the critically ill.