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Dental TribuneAsia Pacific Edition | 9/201508 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 tooth extractions or through an in- jection. 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. I certainly see many cases in which dentists have carried out a treatment for which they were not qualified. I remember an incident in which a general practitioner in- jured nerves on both sides of the mouth during an implant treat- ment. That is truly unbelievable. I have seen many cases over the years, but nothing quite like that. In another case, a dentist ex- tracted a third molar without the requisite training. He should have referred the patient to a specialist, but he chose to do it himself—pos- sibly because it earned him an- other US$200–300 (£130–190)—with the result that the patient now has to live with chronic pain for the rest of her life. 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? Thesecaseshaveanalmostequal occurrence. Of course, overtreat- mentleavesthedentistinabadpo- sition. It raises the question of why heorshetreatedthepatientunnec- essarily in the first place and did so poorly in the second; it leaves him or her doubly guilty. If a mistake occurred after a reasonable treat- ment plan had been formulated, it is comparatively less bad. Some- times, even if a patient dies while undergoing therapy, this does not need to involve a distinct fault of the clinician. An American dentist was recently chargedbecausehispatientdiedafter he extracted 20 teeth in one proce- dure. Ihaveperformedsuchextensive treatment in the past; it depends on the need for the treatment and howitisdone.Probably,thatcasein the US was the result of a combina- tion of 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 today’s level of knowl- edge and technology. Let us say an impaired patient files charges for something that happened to him 20 years ago that would have been preventablewiththelatestmedical treatment. He can, of course, make aclaim,butthedentistcouldnotbe suedforitifheorshetreatedthepa- tient according to the best knowl- edge available at that time. “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) “I am confronted with many instances of damaged nerves caused while placing an implant, during tooth extractions or through an injection.” DTAP0915_08-09_Wolff 08.09.15 09:46 Seite 1 DTAP0915_08-09_Wolff 08.09.1509:46 Seite 1