Greta Barnes and Debbie Herbst from the DDU look at the main causes of dental implant claims
Implant treatment is a complex area of dentistry and one that is evolving as a result of advances in materials, techniques and procedures.
Claims involving implants placed or restored by Dental Defence Union (DDU) members made up approximately 9% of general dental practitioner claims notified in 2017. Implants are also often the remedial treatment of choice for patients who have suffered tooth loss as a result of alleged negligence.
Compensation for implant cases can be significant because of the ongoing cost of addressing failed implant treatment. Remedial procedures, such as bone grafts and explantation of implants, may be needed to correct damage to surrounding areas, nerve damage or infections.
However, if you face a claim you can be assured the DDU’s expert claims handlers and dentolegal advisers understand how stressful this is and the importance of mounting a robust defence of your position. Even though dental cases are often carefully selected by firms specialising in dental claims, we have an excellent track record of successfully defending cases. During 2018, in 69% of all dental claims we made no compensation payment.
Nevertheless, there are steps dental professionals can take to minimise risks if they understand where issues can arise.
Lack of appropriate training/experience
It is not uncommon for claims about implant treatment to include criticism about the training or experience of the treating dentist. For example, that the treating dentist failed to consider referral to a more experienced colleague for bone grafting procedures, or for assessment if difficulties are encountered during or after treatment.
Inadequate assessment and treatment planning
When making a claim, patients may allege they were inadequately assessed for their suitability for implant treatment because there was a failure to perform a full assessment. This may include a clinical examination, the application of any special tests, and the use of radiographs and other procedures to assess the anatomy and characteristics of the bone.
Patients may also allege they were not advised about the full range of treatment options available, so were not able to give valid consent.
It is important to fully document your discussion with patients prior to beginning treatment, along with the details of the assessment undertaken; including appropriate dental charting, periodontal assessment, occlusal analysis, photographs, radiographs, CT scans, ridge mapping, articulated study models and diagnostic wax-up models.
Your discussions with patients regarding proposed treatment, including the potential benefits, material risks, complications, costs and other treatment options, are fundamental to a patient being able to provide valid consent. These discussions are especially important in relation to extensive elective treatment, such as implants, and comprehensive records of the consent process are essential.
Inappropriate choice and location
The appropriate type (length and width) number and location of implants to support the planned superstructures are all key to successful implant treatment.
Claims can arise if too few or too many implants are placed to support a superstructure. The types of implants used and their position frequently appear in allegations of unsuccessful treatment.
Problems during implant placement
The inappropriate choice and placement of implants can result in damage to the surrounding area, including adjacent teeth and nerves.
In one claim, a patient returned soon after having an implant placed, complaining of numbness, tingling and discomfort. It was alleged that the implant was placed too far distally and an appropriate safety zone was not maintained between the implant and the inferior dental nerve. A lack of postoperative radiograph meant the nerve injury was not detected immediately and the implant not removed promptly.
The patient had ongoing neuropathic symptoms as a result. Depending on the extent of the patient’s ongoing condition, settlement of claims in such cases may be in the tens of thousands of pounds.
Failure of implants
Implants can sometimes simply fail, even when all appropriate steps and precautions have been taken. However, sometimes failure can be as a result of inappropriate assessment, planning or provision of implants or monitoring of treatment related to the implant or superstructure.
Patients making a claim may allege that implants were placed despite the evidence of active periodontal disease, or into insufficient bone without consideration of bone grafting. Allegations may also relate to the timing of various phases in implant treatment, including the placement and loading of implants.
Insufficient aftercare and monitoring
After implants have been placed, a patient should be provided with adequate information, advice and support to facilitate successful healing of surgical sites and osseointegration.
Patients should also understand how to care for the implants and superstructure. This advice and ongoing monitoring will help to prevent – and enable early detection of – potential problems, such as peri-implant mucositis and peri-implantitis.
The need for effective communication between colleagues involved in a patient’s implant placement, restoration and ongoing care is also essential to enable any potential problems to be addressed in a timely and appropriate way.
To help dental professionals reduce the risks of implant treatment, the DDU’s recommendations include:
• Always obtain and record a detailed patient history, and be alert to the potential contraindications for implant treatment. This can include untreated and active periodontal disease, inadequate bone quality or quantity, poor oral hygiene, immunosuppression, and smoking
• Explain the benefits, risks, complications and alternative options (including no treatment) to patients as part of the consent process and record all discussions in the clinical notes
• Provide a written treatment plan and fee estimate, and warn patients of the cost implications if circumstances change
• Give patients a cooling-off period to consider their decision and review any informative documents or treatment plans they have been given
• Offer referral to a more experienced colleague if you lack the necessary training, experience or technical competence to provide treatment, or in relation to problems arising during or after treatment
• Ensure the patient is provided with appropriate ongoing care following the provision of implants, and communicate with colleagues to facilitate this.
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