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today AEEDC Dubai 2016

science & practice 18 AEEDC Dubai 2016 Be it a careless error or a case of misjudgement, even the most ex- perienced practitioner can make a mistake. In fact, statistics indicate that it is likely that every general dentist will be involved in a mal- practice suit at some point in his or her career. Israeli-based dentist Dr Andy Wolff has worked as a med- ical expert in dental malpractice litigation for many years and has seen almost everything, ranging from slight negligence to severe overtreatment. today had the op- portunity to speak with him re- centlyaboutthesteadyincreasein litigation in the field and simple measures that can help prevent many malpractice incidents in the first place. today: Dr Wolff, you have been a medical expert in dental mal- practice litigation for many years now. Why is it so impor- tant to increase awareness of this topic? Dr Andy Wolff: So much litera- ture 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.Thisaspectisnolessimpor- tant, both for the patient affected and for the clinician, who might be facing legal consequences. Manymaythinkthatitisnotrel- evant to them, but every smart physician knows that things occa- sionally go wrong and no one is im- mune.Bydocumentingdentalmal- practice incidents and by talking and writing about these, I aim to raise awareness and therefore help prevent future incidents. Inyourexperience,whattypesof malpracticearemostcommon? There are definitely many cases in the neurological field. As a med- ical expert, I am confronted with manyinstancesofdamagednerves caused while placing an implant, during tooth extractions or through an injection. It is common andithappensquickly.Typically,it is an inadvertent mistake, because theclinicianwaseitherinhurryor impatient. However, the conse- quences for the patient are mostly verydramaticandoftenbeyondre- pair. Aside from nerve damage, is there an area where mistakes are more likely? If I had to choose one, I would say it is implants. I recently had a very disconcerting case where an oral surgeon did all the prelimi- nary examination work meticu- lously, the CT scan, the radi- ographs, everything. For that rea- son, he knew for certain that he wasworkingwithabonestructure of 11mm, yet he used an implant that was 13mm long in the treat- ment. Maybe he was just mistaken or the assistant handed him the wrong implant and he did not recheck it, but the result was that he hit a nerve. In this particular case, the den- tist was a specialist, an experi- encedsurgeon.Withoutraisingthe questionofguilt—althoughthesur- geonwaswithoutadoubtresponsi- ble for the damage—cases like this show that mistakes really can hap- pen to anybody. So expertise does not preclude mistakes, but there are un- doubtedly 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, buthechosetodoithimself—possi- bly because it earned him another US$200–300 (£130–190)—with the result that the patient now has tolivewithchronicpainfortherest of her life. Can injured nerves regain nor- mal function eventually? Mostly, damage is irreversible. There are exceptions, of course, ei- ther if the damage was not too se- vere or if the nerve was inside a canal. Potentially, an injured nerve can regain function over time. However, if it is an exposed nerve, such as the lingual nerve, the damage is generally irre- versible, although there are some microsurgery procedures that may improve the situation. Inter- ventions like this, however, carry extremely high risks themselves and might even aggravate the situ- ation. With the consequence that pa- tientspartiallylosesensationin the mouth or face? Yes. Another consequential damage, of which I only recently learnt, is loss of sense of smell. Pa- tients whose sinus has been in- jured often lose their ability to smell. Sometimes, they may not evenrealiseitinitially,becausethe sinus runs on both sides of the face and the unaffected side often func- tions normally. Imagine losing your sense of smell completely ow- ing to a defective bilateral sinus lift procedure—that would be a fairly serious impairment of a per- son’s quality of life. Have malpractice incidents be- come more common over the last decades? Iwouldsayso.Atleast,litigation has increased. Of course, there havealwaysbeencasesofmalprac- tice,butpatientstendtogotocourt moreoftennowadays.Perhapsyou could call it an “Americanisation” phenomenon: almost every prob- lem is taken to court, with the re- sult that dentists are paying in- creasingly higher insurance fees because the treatment risks are so high today. How common is legal action in dentistry and what is the com- pensation amount paid com- pared with other medical disci- plines? Itisperhapscomparabletoplas- tic surgery. There are many com- plaints filed for cases in which the result was not what the patient ex- pected it to be. Compensation pay- ments range from US$10,000 to 100,000, which is much lower than those in other medical disciplines. Domorecasesofovertreatment orcasesoferroronbehalfofthe dentist end up in court? These cases have an almost equal occurrence. Of course, overtreatmentleavesthedentistin a bad position. It raises the ques- tionofwhyheorshetreatedthepa- tient unnecessarily in the first place and did so poorly in the sec- ond; it leaves him or her doubly guilty.Ifamistakeoccurredaftera reasonable treatment plan had been formulated, it is compara- tively less bad. Sometimes, even if a patient dies while undergoing therapy, this does not need to in- volve a distinct fault of the clini- cian. An American dentist was re- cently charged because his pa- tient died after he extracted 20 teeth in one procedure. I have performed such exten- sive treatment in the past; it de- pends on the need for the treat- ment and how it is done. Probably, thatcaseintheUSwastheresultof a combination of many things. For instance, did the dentist act in ac- cordancewithstate-of-the-artprac- tice? If not, he is at fault. If he did, one has to remember that dentists cannot rise above today’s level of knowledge and technology. Let us say an impaired patient files charges for something that hap- pened to him 20 years ago that wouldhavebeenpreventablewith the latest medical treatment. He can, of course, make a claim, but the dentist could not be sued for it if he or she treated the patient ac- cording to the best knowledge available at that time. That is a very important aspect when writing expert reports on dental malpractice: did the dentist act to the best of his or her ability and according to the current knowledge or with gross negli- gence? That is what makes the dif- ference. Whatcanmedicalprofessionals do to protect themselves against legal disputes arising from high-risk procedures they intend to perform? Patients should not only be warned of the possible conse- quencesofacertainprocedure,but also be advised of the alterna- tives—andoneofthosealternatives isnotproceedingwithtreatmentat all. In my opinion, the patient shouldalwaysunderstandbothop- tions:therisksofaparticulartreat- ment and what could happen if nothing is done. Only then should thepatientbeaskedtosignadecla- ration of consent. Unfortunately, the reality is of- ten quite different. Patients are of- ten asked to sign declarations of consent on their way into surgery or while already on the dental chair. Even if they had questions then, there would be no time to an- swer them properly. Although it should be of major concern for everydentisttothoroughlyinform thepatientoftherisks,aswellasal- ternative treatment methods, be- foreheorsheisaskedtosignacon- sent form, I am constantly con- fronted with the opposite. So,youaresayingthatconsulta- tion should be of similar impor- tance to treatment? Absolutely. In my opinion, buildingmutualtrustbetweendoc- tor and patient is key for avoiding malpractice and consequential charges. If patients feel that their conditionisbeingproperlytreated, and that money is not the dentist’s first concern, this alone can pre- vent litigation in many cases. Of “Patients tend to go to court more often nowadays” An interview with DrAndyWolff,Israel Dr Andy Wolff 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 Andy Wolff)

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