Inappropriate orthodontic treatment

A DDU dentist faced a claim after a patient alleged a failure to assess his periodontal condition before starting orthodontic treatment, and a failure to detect the periodontal attachment and bone loss that subsequently occurred.

The scene

A 30-year old patient attended a dentist to have fixed braces fitted, which were removed after a year and replaced with removable retainers. The patient wore these for six years, after which he was referred to a DDU member, who reviewed him and placed a fixed retainer spanning UR3 to UL3.

The patient noticed that his UR1 was moving and went back to the member, who noticed it had de-bonded from the retainer, so reattached it. A few months later the member saw the patient again and placed Invisalign aligners with associated attachments, to move the teeth that had drifted out of alignment. A year later the attachments were removed and a fixed retainer placed.

A few months later the patient attended his hygienist, who recorded BPE scores of 4s around the upper anterior teeth and 3s in the rest of the mouth. Heavy subgingival deposits and extensive pocketing were also noted. The patient attended his dentist for further assessment. Generalised bone loss was noted with 60-70% bone loss around the upper anterior teeth. The patient was diagnosed with moderate generalised periodontal disease with severe localised disease around the upper anterior teeth, and was referred to a specialist for treatment.

The claim

The patient brought a claim against the DDU dentist alleging failure to assess his periodontal condition before starting the orthodontic treatment, and failure to detect the periodontal attachment and bone loss that occurred. It was also alleged that the member failed to inform the patient before treatment of the risk of bone loss and tooth mobility, potentially leading to loss of teeth, and that the member's failures had caused worsened periodontal disease, bone loss and tooth loss.

The claim was made for multiple extractions, dentures, bridgework, bone grafting, implants, implant retained bridgework and crowns (plus replacements over subsequent years), IV sedation costs, lifelong hygienist care as well as specialist periodontal care and maintenance appointments.

Responding to the request for assistance, the DDU obtained the member's comments on the allegations and instructed two independent experts (an orthodontist and a restorative specialist) to give an opinion on the issues of breach of duty, causation, condition and prognosis. One expert also examined the patient.

Unfortunately, both experts held that the member should have assessed the patient's periodontal condition before treatment, and should not have provided the orthodontic treatment in the circumstances as this worsened the condition.

However, there were causation arguments to be made, namely that the orthodontics and delay in diagnosis and treatment of the disease had accelerated the future loss of the teeth rather than causing it entirely. The patient would have required significant periodontal treatment in any event, including the replacement of some teeth - just at a later stage.

The outcome

The patient's solicitors made a settlement offer of over £80,000, but this was firmly rejected as being excessive. After liaising again with the experts, the DDU sought the member's consent to settle and served a robust letter of response setting out all of the points in our favour.

It made no admissions of liability, but did include a settlement offer almost five times less than the one first made by the patient's solicitors. This was accepted, with the patient's solicitors legal costs and disbursements coming to more than £25,000.

This guidance was correct at publication 16/08/2019. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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