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Dental Tribune United Kingdom Edition | 4/201514 TRENDS&APPLICATIONS Be it a careless error or a case of misjudgement,even the most experi- enced practitioner can make a mis- take.Infact,statisticsindicatethatitis likelythateverygeneraldentistwillbe involved in a malpractice suit at some point in his or her career.Israeli-based dentist Dr AndyWolff has worked as a medical expert in dental malpractice litigation for many years and has seen almost everything,ranging from slight negligence to severe overtreat- ment.DentalTribunehadtheopportu- nity to speak with him recently about the steady increase in litigation in the field and simple measures that can help prevent many malpractice inci- dentsinthefirstplace. DentalTribune:DrWolff,youhavebeen amedicalexpertindentalmalpractice litigation for many years now.Why is it so important to increase awareness ofthistopic? Dr Andy Wolff: So much literature out there tells dentists how to do things—whether it is placing im- plants or improving efficacy with the newest technology—but there are no books on how not to do things or, more precisely, what can happen when something has gone wrong. Thisaspectisnolessimportant,both for the patient affected and for the clinician, who might be facing legal consequences. Many may think that it is not rele- vant to them, but every smart physi- cian knows that things occasionally go wrong and no one is immune. By documenting dental malpractice in- cidents and by talking and writing about these, I aim to raise awareness and therefore help prevent future incidents. Inyourexperience,what typesofmal- practicearemostcommon? There are definitely many cases in the neurological field. As a medical expert, I am confronted with many instances of damaged nerves caused while placing an implant, during toothextractionsorthroughaninjec- tion. It is common and it happens quickly.Typically,itisaninadvertent mistake,becausetheclinicianwasei- ther in hurry or impatient. However, the consequences for the patient are mostly very dramatic and often be- yondrepair. Aside from nerve damage, is there an areawheremistakesaremorelikely? If I had to choose one, I would say it is implants. I recently had a very disconcertingcasewhereanoralsur- geon did all the preliminary exami- nation work meticulously, the CT scan,theradiographs,everything.For that reason, he knew for certain that hewasworkingwithabonestructure of11mm,yetheusedanimplantthat was 13 mm long in the treatment. Maybe he was just mistaken or the assistant handed him the wrong im- plantandhedidnotrecheckit,butthe resultwasthathehitanerve. In this particular case, the dentist was a specialist, an experienced sur- geon. Without raising the question of guilt—although the surgeon was without a doubt responsible for the damage—cases like this show that mistakes really can happen to any- body. So expertise does not preclude mis- takes, but there are undoubtedly also cases that result from negligence and hubris. Icertainlyseemanycasesinwhich dentistshavecarriedoutatreatment for which they were not qualified. I remember an incident in which a general practitioner injured nerves onbothsidesofthemouthduringan implant treatment. That is truly un- believable.Ihaveseenmanycasesover theyears,butnothingquitelikethat. Inanothercase,adentistextracted a third molar without the requisite training.Heshouldhavereferredthe patient to a specialist, but he chose to do it himself—possibly because it earned him another US$200 to 300 (£130to190)—withtheresultthatthe patient now has to live with chronic painfortherestofherlife. Caninjurednervesregainnormalfunc- tioneventually? Mostly, damage is irreversible. Thereareexceptions,ofcourse,either ifthedamagewasnottoosevereorif the nerve was inside a canal. Poten- tially, an injured nerve can regain functionovertime.However,ifitisan exposed nerve, such as the lingual nerve, the damage is generally ir- reversible, although there are some microsurgery procedures that may improve the situation. Interventions like this, however, carry extremely highrisksthemselvesandmighteven aggravatethesituation. With the consequence that patients partially lose sensation in the mouth orface? Yes. Another consequential dam- age, of which I only recently learnt, is loss of sense of smell. Patients whose sinus has been injured often losetheirabilitytosmell.Sometimes, they may not even realise it initially, because the sinus runs on both sides of the face and the unaffected side often functions normally. Imagine losingyoursenseofsmellcompletely owing to a defective bilateral sinus liftprocedure—thatwouldbeafairly serious impairment of a person’s qualityoflife. Have malpractice incidents become morecommonoverthelastdecades? I would say so. At least, litigation has increased. Of course, there have alwaysbeencasesofmalpractice,but patients tend to go to court more of- tennowadays.Perhapsyoucouldcall itan“Americanisation”phenomenon: almosteveryproblemistakentocourt, with the result that dentists are pay- ing increasingly higher insurance fees because the treatment risks are sohightoday. How common is legal action in den- tistry and what is the compensation amount paid compared with other medicaldisciplines? It is perhaps comparable to plastic surgery. There are many complaints filedforcasesinwhichtheresultwas not what the patient expected it to be. Compensation payments range from US$10,000 to 100,000, which is much lower than those in other medicaldisciplines. Do more cases of overtreatment or cases of error on behalf of the dentist endupincourt? These cases have an almost equal occurrence.Ofcourse,overtreatment leaves the dentist in a bad position. Itraisesthequestionofwhyheorshe treated the patient unnecessarily in thefirstplaceanddidsopoorlyinthe second; it leaves him or her doubly guilty. If a mistake occurred after a reasonable treatment plan had been formulated, it is comparatively less bad.Sometimes,evenifapatientdies while undergoing therapy, this does not need to involve a distinct fault of theclinician. An American dentist was recently chargedbecausehispatientdiedafter he extracted 20 teeth in one proce- dure. I have performed such extensive treatment in the past; it depends on the need for the treatment and how it is done. Probably, that case in the USwastheresultofacombinationof many things. For instance, did the dentist act in accordance with state- of-the-art practice? If not, he is at fault. If he did, one has to remember that dentists cannot rise above to- day’slevelofknowledgeandtechnol- ogy. Let us say an impaired patient fileschargesforsomethingthathap- penedtohim20yearsagothatwould havebeenpreventablewiththelatest medicaltreatment.Hecan,ofcourse, make a claim, but the dentist could not be sued for it if he or she treated the patient according to the best knowledgeavailableatthattime. That is a very important aspect when writing expert reports on den- tal malpractice: did the dentist act to the best of his or her ability and according to the current knowledge orwithgrossnegligence?Thatiswhat makesthedifference. What can medical professionals do to protect themselves against legal disputes arising from high-risk proce- durestheyintendtoperform? Patientsshouldnotonlybewarned of the possible consequences of a certainprocedure,butalsobeadvised ofthealternatives—andoneofthose alternatives is not proceeding with treatment at all. In my opinion, the patient should always understand bothoptions:therisksofaparticular treatment and what could happen if nothingisdone.Onlythenshouldthe patientbeaskedtosignadeclaration ofconsent. Unfortunately, the reality is often quite different. Patients are often asked to sign declarations of consent on their way into surgery or while already on the dental chair. Even if theyhadquestionsthen,therewould be no time to answer them properly. Although it should be of major con- cern for every dentist to thoroughly informthepatientoftherisks,aswell as alternative treatment methods, before he or she is asked to sign a consent form, I am constantly con- frontedwiththeopposite. So, you are saying that consultation should be of similar importance to treatment? Absolutely. In my opinion, build- ing mutual trust between doctor and patient is key for avoiding mal- practiceandconsequentialcharges.If patients feel that their condition is “Patients tend to go to court more often nowadays” An interview with Dr Andy Wolff, Israel Dr AndyWolff talking to Group Editor Daniel Zimmermann.© Kristin Hübner/DTI Displacement of dental implant into the maxillary sinus of a 70-year-old male patient.© Dr AndyWolff DTUK0415_14_16_Wolff 10.09.15 15:18 Seite 1 DTUK0415_14_16_Wolff 10.09.1515:18 Seite 1