Case study on recordkeeping

January 21, 2025

Mr. A has been a regular patient of Dr. B for over a decade. Despite his limited financial resources and lack of dental insurance, Mr. A regularly attended his routine hygiene appointments every six months.

While Dr. B was away on vacation, Mr. A visited another dentist because of soreness in his lower tooth. That dentist extracted the tooth and informed Mr. A that he may likely lose most of his other teeth over time and discussed the possible option of implant-supported complete dentures.

Upset by this prognosis, Mr. A filed a complaint to the College against his long-time dentist, Dr. B.

In his complaint, Mr. A alleged that Dr. B:

Failed to advise him in a timely manner that he had “gum disease”.
Failed to recommend treatment that could have prevented the disease from progressing.
Was negligent in not referring him to a periodontist.
Was responsible for the loss of his teeth and therefore should cover the cost of the implant-supported dentures.

Dr. B was notified of the formal complaint and provided the College with her response along with the complete dental records of Mr. A.

In her response, Dr. B stated that:

Upon Mr. A’s initial visit, she performed a complete examination which included full mouth periodontal charting.
She did inform Mr. A of his periodontal condition during that new patient examination.
She advised Mr. A that scaling and polishing alone would not suffice and that he will most likely need further periodontal therapy such as root planing under local anesthetic or periodontal surgery.
She reiterated these recommendations several times over the years.
She discussed the option of referring to a periodontist at some point in time.
Her dental assistant provided a written testimony to confirm these discussions had occurred.
Mr. A consistently declined any referral or additional treatment beyond “just a regular cleaning every six months” citing his limited financial resources.
She respected her patient’s decision and provided “regular cleanings” as he requested.
In her view, although it was not the ideal treatment, receiving regular scaling and polishing was better than no treatment at all.

The chart review revealed that:

Dr. B appropriately documented all her clinical findings (e.g., pocket depths, mobility and periodontal bone loss) during the new patient examination and subsequent recall examination.
Bitewing radiographs taken annually for the past ten years showed gradual horizontal periodontal bone loss.
Full mouth periodontal charting completed at least every two years, documented the gradual worsening of the periodontal pocket depths.
Dr. B’s initial treatment plan included root planing under local anesthetic and periodontal surgery.
Mr. A received scaling and polishing every six months.
During these scaling appointments, Dr. B documented the presence of abundant plaque and tartar, as well as the patient’s poor oral hygiene.
There was no documentation of a clear diagnosis for Mr. A’s periodontal condition.
There was no documentation of any discussion with the patient regarding his periodontal condition.
There was no documentation that the patient consented or refused her recommendations.
There was no documentation of any referral to a periodontist.

Panel’s decision

The panel has considered all correspondence and records obtained during the course of its investigation.

While the panel did not believe this to be a case of supervised neglect, nor did they feel that Dr. B breached the standard of practice of our profession, they did raise some concerns regarding Dr. B’s recordkeeping and informed consent practices.

Rationale for the decision

Although Dr. B initially recorded clinical findings, she did not formulate a clear periodontal diagnosis that would have supported the rationale for her treatment plan.

The details of the conversations she supposedly had with the patient regarding his periodontal condition and treatment recommendations were not documented.

Although Dr. B stated that she offered a referral to a periodontist, there was no documentation of any such referral or suggestion in the patient’s chart. The panel felt that even if Mr. A declined the verbal referral at the time, this should have been documented in the clinical notes.

Dr. B also failed to document that she advised the patient of the potential consequences of not proceeding with further treatment, specifically that he could lose all his teeth. The panel felt that this information was important and should have been part of informed refusal process.

Outcome

The panel accepted the voluntary Remedial Agreement Dr. B signed to complete a selfreflection paper in the areas of recordkeeping and informed consent.

Conclusion

This case illustrates how dental recordkeeping practices could either support or hinder a dentist’s defence during the complaint process. One of the most common errors is failure to document the informed consent conversation with a patient.

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Questions?

You can contact the Practice Advisory Service by email at practiceadvisory@rcdso.org or phone at 416-961-6555 ext. 5614.