For Dentists

How to Respond to a Patient Complaint Against a Dentist

By Matthew Wilton

This article is intended to provide general advice to dentists in responding to patient complaints. Our firm has acted for hundreds of dentists in responding to complaints, since 1991. The majority of our firm’s clients are Ontario dentists. However, our firm has assisted dentists in other provinces in Canada in responding to complaints. All of the colleges of dentists across Canada address the same types of complaints, and all dental regulators in Canada will be primarily obliged to address whether the dentist complained about has met the standard of practice demanded of the dentist in the circumstances. Therefore, our experience will be of benefit to all dentists across Canada, as will this article.

I am setting out below a list of the types of patient complaints our firm has assisted dentists with: 

  1. Recommending unnecessary restorations;
  2. Failing to put a crown on a root canal treated tooth, leading to a tooth fracture;
  3. Failing to obtain an informed consent, in respect of an expensive crown and bridge case;
  4. Failing to monitor the patient’s periodontal status adequately;
  5. Leaving a separated instrument in a patient’s endodontically treated tooth;
  6. Failing to provide follow up care following extraction of a patient’s tooth;
Issues Concerning the Treatment of Children 
  1. In respect of treating a child under sedation, failing to obtain an informed consent from the parent during a procedure, when more work needs to be done;
  2. Releasing information to a step parent or noncustodial parent in the face of the custodial parent’s objection;
  3. Excessively  restraining a child using a papoose board or other restraining method;  
  4. Failing to allow the parent to remain in the operatory during a child’s procedure;
  5. Physically assaulting a child when restraining a child; 
  6. Criticizing a parent for continuing to breast feed an infant, leading to excessive caries; 
  7. Failing to identify a child’s cancerous tumor in a timely manner; 
Sedation Issues
  1. Providing a patient with excessive sedation amounting to an overdose; 
  2. Providing sedation beyond the level that the dentist is authorized to provide;
  3. Failing to keep proper sedation records to record vital signs and oxygen saturation levels; 
  4. Failing to obtain appropriate authorization for the level of sedation provided;
  5. Providing sedation vastly in excess of the clinically recommended maximums; 
  6. After administrating oral sedation, releasing a patient without ensuring the patient is sufficiently recovered to be released;
Implant Issues
  1. Improperly placing implants, without the appropriate pre-treatment investigation to place the implants properly;
  2. Recommending and installing implants, when the patient’s dentition will not support implants;
  3. Failing to obtain a CT Scan before recommending implant treatments;
  4. Poor design of implant supported prosthesis; 
  5. Extracting an excessive number of healthy teeth to facilitate implant treatment;
  6. Improper use of zygomatic implants;
  7. Poor choice of implants; 
  8. Recommending implants where the patient’s pre-existing bone is insufficient; 
  9. Recommending implants and a prosthesis, where patients have been unable to properly clean the prosthesis; 
  10. Puncturing the sinus, during the course of implant treatment; 
  11. Failing to warn the patient of the likelihood of implant failure, due to occlusal problems; 
Orthodontic Complaints
  1. Recommending Invisalign treatment solely for the purpose of benefiting the dentist financially;
  2. Recommending Invisalign treatment in circumstances where the patient is not a good candidate for orthodontic treatment;
  3. Overcharging a patient for orthodontic treatment;
  4. Failing to warn a patient about the risk of root resorption;
  5. A GP dentist failing to advise the patient that the GP is not an orthodontist; 
  6. An orthodontist complains about the standard of care of a GP dentist performing orthodontics; 
  7. One orthodontist fails to accept the transfer of care from another orthodontist; 
  8. Orthodontic treatment takes too long; 
  9. Orthodontic treatment causes permanent jaw damage; 
  10. Not adequately warning a patient, as to the likely cost and length of treatment for orthodontic treatment;
Miscellaneous Complaints 
  1. Patient swallows bur; 
  2. Patient’s lip is cut when drill slips; 
  3. Patient is burned by materials used during a restorative treatment; 
  4. Patient falls out of chair when over sedated; 
  5. Dentist removes the wrong tooth; 
  6. Dentist spent three hours attempting to extract a tooth without success; 
  7. Dentist fractures tooth;
  8. Dentist breaks patient’s jaw during complicated wisdom tooth extraction; 
  9. Making sexually inappropriate comments to a patient;
  10. Touching a patient inappropriately;
  11. Breaching patient confidentiality by disclosing patient information to a relative without appropriate consent;
  12. Improperly performing root canal therapy;
  13. Recommending unnecessary cosmetic treatment where the patient’s dentition or oral health suggests that such cosmetic work is contraindicated;
  14. Being rude to a patient;
  15. Failing to warn a patient about the risk of not treating a particular dental problem;
  16. Billing for a complicated extraction when the extraction was not complicated;
  17. Overbilling units of scaling;
  18. Failing to adequately warn the patient of the risk of parasthesia;
  19. Failing to refer the patient to a dental specialist;
  20. Failing to have adequate infection controls in the office;
  21. Acting in a conflict of interest;
  22. Recommending unnecessary dental appliances, including night guards;
  23. Insurance fraud; and
  24. Insurance overbilling. 

(Please see section immediately below dealing with insurance audits)

Insurance Audits

One of the most financially and reputationally damaging processes is an insurance audit. Large insurers such as Great West Life, Sun Life and Manulife routinely communicate with dentists concerning specific insurance claims. If they are not satisfied with the response received from the dentist, they often complain to the RCDS/Regulator. The typical process is that an insurance company will send a letter to a dentist asking for particulars with respect to an individual claim, or multiple claims. The dentist will then be obliged to provide a response to the insurer that should address the specifics of the concerns identified by the insurer. As dentists may know, insurers are very proactive about controlling claims costs and eliminating potential abuses. Insurers have entire departments devoted to addressing potential overbilling or mis-billing issues by dentists. Insurers also have created lists of delisted dental service providers. You do not want to be on this list! A delisted provider is a dentist who is no longer permitted to bill a specific insurer, presumably as a result of past insurance abuses. Being on this list could have devastating financial consequences for your practice. In our experience, insurers will typically make written inquiries of a dentist with respect to any specific billing issues. If those written inquiries are not satisfactory, or suggest to the insurer that there has been dishonesty, then the insurer may initiate a complaint to the RCDS. Please keep in mind that insurers are sophisticated, and regular users of the complaint system at the RCDS.

Aside from the risk of a regulatory complaint arising from an insurance company’s inquiry, an insurance audit can be financially damaging to a dentist. In our practice we routinely act for dentists who have received lengthy letters from insurers questioning multiple procedure codes for multiple patients over many years. These letters are typically accompanied by a written request from the insurer to refund large sums of money to that insurer, as a result of alleged overbilling on the part of the dentist. As with any other complaint, our approach to these issues is to meet with the dentist and to review the disputed claims or disputed claims codes. Insurers seem to flag specific dentists who bill well over the provincial average for certain billing codes. In addition, when dentists routinely bill the maximum of a recommended range of fees for any given procedure, this may attract attention from an insurer. For example, dentists who routinely bill multiple surface restorations, or routinely bill the maximum recommended Fee Guide amount for examination codes may attract the attention of an insurance company. Simply put, if you do not have an effective response to the insurer, then you may wish to consider writing them a large refund cheque.

When we advise our dentist clients to refund monies to insurers, we typically do so on the basis that the insurer will provide a release. The release prevents the insurer from making any financial claims against the dentist. In our experience insurers are reluctant to provide a release that also precludes them from making a complaint to the Regulator, such as the RCDS. Insurers are not typically prepared to put this kind ofcontent in a release.

These are just a cross-section of some of the hundreds of complaints our firm has assisted dentists with. We have developed a good understanding of the standards of practice in these multiple areas of dentistry, which will be helpful in assisting any dentists in Canada in responding to a complaint.

Why is it important to make an effective response?

Dentists will be familiar with unfortunate colleagues who have had their names published to the entire profession in respect of findings of professional misconduct. The vast majority of such cases begin with a simple letter or email from a patient complaining about some aspect of their dental care. It used to be a favorite cliché of lawyers acting for dentists to say that for the price of a stamp, a patient could complain about their dentist. Society has evolved, and a large number of patient complaints are now made online. The patient doesn’t even need to invest in a stamp! Patients can complain more quickly, and it is often the case that when the patient comes back from a dental appointment and is angry and in pain, that patient can fire off an online complaint instantly. There is now less time for “cooling off” or sober second thoughts. This, in conjunction with increased patient expectations, have led to complaints against dentists increasing.

Another consequence of the information age in which we live is that negative information gets disseminated widely and quickly. An adverse outcome, even at a Complaints Committee level, can be publicized online by a disgruntled patient on numerous websites. Patients are also going online, in droves, to post reviews on websites such as RateMD or Yelp. When patients read online reviews, they also may learn from such reviews that an RCDS complaint is an option.

In Ontario, the RCDS amended its by-laws effective October 1, 2015 to expand the information available to the public on the College’s Public Register (i.e. the RCDS website). The result of this transparency initiative is that dentists in Ontario who are ordered by the Investigations, Complaints and Reports Committee (the ICRC) to take specified continuing educational or remediation program (“SCERP”) courses as a result of a practice issue raised by a complaint, will have that disposition posted on the Public Register of the RCDS. In addition, dentists who receive oral cautions from the ICRC in any decisions released after October 1, 2015 will have the wording of the oral caution posted on the Public Register.

The legislation in Ontario now provides that information posted on the RCDS Public Register website concerning a SCERP (an order to take courses) or to receive an oral caution will be left on the website permanently. The Registrar does have the discretion to remove this information. Our understanding is that this information will remain on the RCDS website for at least 24 months, or until the Registrar agrees to remove the information. Typically, if a dentist is ordered to take courses in Ontario, there will be a concurrent order for the dentist’s practice to be monitored for 24 months after the courses are completed. Only when the practice monitoring is successfully completed will the Registrar consider removing the information from the Public Register. On our firm’s website you will find our article dealing with the RCDS transparency initiative, which explains in full the nature of these changes.

What is important for Ontario dentists to understand is that it is now more important than ever to deal effectively with responses to patient complaints.