Thoughts from Year One: The Measure of Responsibility

“This is your fault! You’ll be hearing from my lawyer!” These are words nobody ever wants to hear. And 6 months into my first year of practice, I heard them loud and clear.

I consider myself an honest and compassionate provider, but when those words echoed in my ears, I couldn’t help but ask myself, “Am I responsible? Could I have done anything differently to avoid this?” At the time, these were questions I couldn’t answer on my own.

While living and working in the safety net of dental school, I was protected from having to contemplate situations like this one. While in school, we practiced under someone else’s license and were bailed out by those with real world experience. In the name of the educational process, we got free passes for minor mistakes, listened to lectures, and took tests on ethics. For the most part we didn’t have to confront the complexities or responsibilities that are innate to practicing dentistry.

So when blame and the threat of action came my way, for the first time there was no one in the next cubicle to hold my hand. It’s no surprise that I was left in a confused and contemplative state.

In this case, the patient presented with a chief complaint of pain in the upper left while chewing. Visual examination revealed no extraoral or intraoral swellings. Upon testing, tooth No. 14 wasn’t tender to palpation but was tender to percussion, and had no response to cold. The pocket depth around No. 14 didn’t exceed 4 mm and a large MOD amalgam with wide isthmuses and interproximal surfaces was present with no marginal discrepancies. The buccal and lingual cusps and surfaces appeared sound with craze lines noted. Tooth No. 14 displayed physiologic mobility. The occlusion appeared heavy but not traumatic, as no pain was experienced when he closed with and without articulating paper interocclusally. Radiographs revealed no coronal or apical pathologies, but did reveal previous root canal therapy, which appeared clinically acceptable (he estimated that the root canal occurred more than 5 years prior). No caries were detected.

Tooth No. 14 appeared to be displaying symptoms of symptomatic apical periodontitis presumably due to heavy occlusion. I informed him that a build-up and crown would be the ideal treatment. The patient consented and was scheduled to return to the clinic in 5 days for preparation. In the meantime, I advised him to avoid chewing on that side and to take ibuprofen as necessary.

Five days later, when the patient returned for crown preparation, he informed me that since the last visit, they heard a cracking sound while chewing candy on the left side. A re-evaluation of the area showed no noticeable clinical changes. He was anesthetized and the large amalgam filling was removed. Once the existing restoration was removed, a significant vertical fracture was exposed. A perio probe was then inserted into the vertical fracture to a depth of approximately 2.5 mm. Intraoral photos were taken and the findings discussed with the patient. He was informed that the tooth had a poor prognosis for restorability due to the extent of the fracture. I advised him that the most predictable treatment would be extraction of tooth No. 14 and replacement with an implant. The patient was also informed that if he did want a second opinion on the prognosis of the tooth for restorability, an endodontic consultation could be arranged.

At this point, he became very upset and vocal. He angrily asked why the crack wasn’t detected 5 days ago and claimed that it was my fault that the tooth fractured because I didn’t schedule him sooner. I informed him that he was scheduled for the first available appointment and as a result of the location of the fracture and the size of the existing filling, we were unable to detect the fracture clinically. The patient was also informed that in some cases vertical fractures are not detected radiographically, especially if they have developed recently.

The patient was obviously very emotional about the situation and I empathized with him. I informed him that tooth fracture is a known risk for posterior teeth that aren’t crowned after root canal treatment, especially if it was a large filling. I offered to answer any questions or address any concerns he had, but he declined.

I gave the patient three options: 1) I could temporize the tooth so the patient could go home and consider the option of an extraction/implant or an endodontic consultation for restorability; 2) I could temporize the tooth and offer a referral for a consultation with an oral surgeon regarding extraction/grafting/immediate implant placement; or 3) I could extract the tooth that day with a colleague, and we could schedule a follow-up appointment to discuss definitive replacement options.

After sitting in silence for several minutes, the patient opted to have the tooth extracted that day. The necessary arrangements were made and he was advised that it would take about 10 minutes for my colleague to set up for the extraction. As the patient stood up from the chair to head to the waiting room, he looked me dead in the eyes and said, “This is your fault! You’ll be hearing from my lawyer!”

I stood there dumbfounded trying to process what was happening. Once I regained my bearings, I said, “I’m sorry you feel that way. If you have any concerns that I can address, I’d be happy to discuss them with you. Or if you’d prefer to speak with our office manager, I’d be happy to arrange that.” While walking away, the patient responded, “It won’t fix the tooth. I just want it out so I can go home.”

That encounter stayed with me for the rest of the day and well into the next. I poured over my documentation, the radiographs, and replayed the encounter in my head. Had I done something wrong? Had I missed something? Could I have done anything to prevent this patient from losing his tooth?

Fortunately, I was able to meet with one of my mentors to discuss the situation. After listening intently, he asked me a series of questions…

“Were you negligent?”

“No,” I said.

“Did the patient follow the known standard of care after having a root canal?”

“No,” I said.

“Are you responsible for what a patient does outside of the office?”

“No,” I said.

“Then why are you putting that on yourself?”

Having someone else break it down in such simple terms helped me recognize that I was taking on more than my fair share of responsibility.

As trivial as it may sound, this experience provided me with a much-needed reality check. I realized that dental care is an equal partnership between the dental team and the patient. With this understanding, I am now more comfortable approaching difficult situations—both clinically and personally. This situation taught me how to take on the appropriate level of responsibility and how to manage expectations for myself as well as the others involved. Fortunately, I haven’t taken out a second mortgage to cover legal fees, yet.