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You Be the Judge: The Case of the Lazy X-Rays by Jeffrey J. Tonner, JD

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Header: The Case of the Lazy X-Rays
by Jeffrey J. Tonner, JD

This article is the first in a series in which readers get the facts behind a real-life dental board or civil malpractice case, then compare the verdict they would have delivered with the actual outcome. In consideration of privacy, the names and dates of all involved in this case have been altered.

The case history
"Jane," a 59-year-old patient, had an established long-term, trusted relationship with Dr. Jones, but unexpectedly fractured the porcelain on a lower right bridge while her dentist was on vacation. Jones did not leave a voice-message referral name, so Jane used the Yellow Pages to choose Dr. Smith (the defendant) to do the work.

06-09-14: At the emergency visit, Smith performed a limited examination and smoothed the porcelain. The bridge was intact and needed no further treatment. At the same time, a cursory exam revealed decay and an open mesial margin on tooth #15. Jane remembered that Jones previously had recommended an onlay for this tooth, so the diagnosis was not surprising.

Rather than wait for her dentist to return, Jane authorized a replacement PFM. The tooth was appropriately prepared.

Three try-in appointments were needed. During the first two visits, the crown did not fit and new impressions were needed.

08-21-14: On the actual seating date, Smith's assistant removed the temporary crown and excess cement, fitted the crown on the preparation without cement, and took a bitewing radiograph. It showed an open distal margin.

Smith was alerted to this situation, made adjustments and requested a second X-ray. Again, an open margin was visible. This procedure was repeated a third time, until the radiograph showed closed margins (although the angle was not ideal).

Jane was not pleased with three try-in appointments and three X-rays at the final visit, so she returned to Jones four days after delivery for the specific purpose of examining crown #15. His progress notes read, in pertinent part:

Consult—second opinion on work done at [Smith's dental office]. Pt. explained she recently had LR bridge break. They smoothed the broken porcelain of the broken pontic and did an exam that pt. had not asked for. The Dr. placed a crown on 15. Jones explained that #15 was misdiagnosed, as onlay was placed in 2011. Took PA. Dr. explained that crown [#15] looks OK but the onlay would have been the better restoration.

The PA showed the margins to be closed (although the angle was not ideal).

10-14-14: During a routine hygiene recall appointment with Smith, one bitewing showed an open margin on the distal of crown #15.

Dental board complaint
With Jones' encouragement, Jane filed an administrative action. The board subpoenaed the complete dental records from Jones and Smith, then held two hearings. The board considered three separate issues:
  1. Which of Smith's X-rays showed the true story? The board's initial confusion centered around the three bitewings taken on the delivery date. There were no time stamps, so the sequence could not be determined from the Dentrix software. Smith testified under oath that the closed-margin X-ray was the final one, but Smith's progress notes did not reflect the multiple try-ins. We argued that if the margins were closed on the initial or second X-ray, then further films would be unnecessary.
  2. Did Jones' exam and X-rays four days later provide a complete defense? His PA was angulated and therefore inconclusive. He did, however, clinically examine the crown and found it to be "OK." That is less than a ringing endorsement, but one assumes that any open margins would have been reported then. The board ignored this examination for a long time. One member finally stated that Jones' records did not indicate that he used an explorer, so it concluded that this office visit proved nothing.
  3. If the margin was closed upon delivery, how did it open two months later? This aspect of the case was the most challenging. We proposed that the final delivery film, and Smith's specific examination, showed an acceptable crown; therefore, the reasons why it opened later did not matter. The board believed that a two-month window was too short to signal any conclusion, but that the crown left Smith's office in that condition.
The patient had no dental insurance and paid $676.13 for the crown. Smith had practiced for 10 years with no prior record.

The board ruling
How would you have ruled on this case? Select one of the four options below.
  1. Dismissed the case and ordered continuing education.
  2. Dismissed the case and ordered restitution and continuing education.
  3. Upheld the case and ordered continuing education.
  4. Upheld the case and ordered restitution.
At the first hearing, the board voted to uphold the case and ordered six hours of continuing education in crown and bridge.

The board focused solely on the fact that an open margin, two months after delivery, must have left Smith's office in that condition. Therefore, Smith's X-ray sequence and Jones' intervening examination were both meaningless.

The board is composed of 11 people: six dentists, two hygienists and three laypersons. The vote was 9 to 1; one dentist was absent, one dentist dissented.

With such unified voting, we knew that a complete dismissal was impossible, but requested a second hearing to point out that the "typical" first-time crown and bridge offense earns a dismissal with three hours of non-disciplinary remedial education. The vote was 6–5 to reverse the previous decision. Voting against Smith were three dentists and two laypersons.

Non-disciplinary orders are posted on the board's website for five years for all to view. Many dentists believe that negative reviews affect future new-patient flow, and that the general public lacks the sophistication to differentiate between a case that reflects unprofessional conduct and one that does not, as in this case.

Practice pointer
This entire ordeal could have been avoided with better notes and X-rays. (What couldn't be?)

The progress notes should have reflected the multiple try-ins and that the final bitewing showed the margins were closed. It also would have been ideal if the software could be programmed to reflect not only the date but the time the films were taken.

The more important defense, however, was the X-ray angle. After seating any crown or bridge, bitewings should always be taken. Before the patient leaves the operatory, the staff should show the films to the dentist for approval. If the margins can be visualized and are closed, then the patient can be dismissed. If not, new films are needed.

Controversy surrounds pre- and post-cement radiographs. Some dentists take films before the crown is cemented, while others take them afterward. Although I appreciate that the crown cannot be removed once permanent cement is used, from purely a legal standpoint, the latter is preferred. This case reflects poorly on Jones. Had he encouraged the patient to return to Smith, rather than suggest a dental-board complaint, a replacement crown would have been fabricated and this entire dental/legal mess avoided. Remember—what goes around, comes around. Be good to your fellow dentists, and one day the favor will be returned.

ANSWER A. Dismissed the case and ordered three hours of continuing education in crown and bridge.


Jeffrey J. Tonner
Jeffrey J. Tonner is a full-time dental-malpractice defense attorney in Phoenix who lectures nationally on dental risk management and record keeping. Tonner created Ideal Charting for General Dentists, a prophylactic system that provides more robust templates, consent forms and update and alert bulletins to help dentists prevent malpractice action before they are filed. For more information, go to thedentaladvocate.com.



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