The DDU’s Jo-Anne Taylor explores the reasons behind complaints and claims concerning composite bonding, the second in a short series about cosmetic treatments.
Quicker, less invasive and without the price tag of veneers, composite bonding is an extremely popular option for those who want to improve the appearance of their anterior teeth. It is often included in more extensive treatment plans.
Patients who have seen all the before and after photos of discoloured, chipped or ‘gappy’ teeth transformed into a gleaming and even smile might be forgiven for thinking that composites are a miracle fix. However, they are typically not as durable as alternative types of restoration. Dental professionals should be wary of giving this impression.
The following scenario is typical of what can go wrong:
A patient asked his dentist to address a worn lateral incisor which detracted from the effect of his aligner treatment. He readily agreed to the dentist’s suggestion of composite bonding and the procedure was conducted to his apparent satisfaction.
Several months later, the patient returned to complain. Part of the composite had chipped slightly when he bit into a baguette and it was now stained.
The patient wanted the dentist to repair the chipped composite and provide teeth whitening treatment. The dentist explained that the composite would have to be removed because whitening treatment wouldn’t work on the bonding material. Naturally, there would be a cost involved.
The patient was unhappy to hear this and later made a complaint. He argued the treatment was substandard and he was entitled to a refund. The practice investigation found the dentist had carried out the original treatment properly. He could not be blamed for the chip, given the stress placed on the restoration by the patient when eating.
However, there was nothing to show the patient had been warned about the risk of discolouration or chipping.
They agreed to repair the chip and give a partial refund as a gesture of goodwill. This was on the understanding that it would conclude the complaint. The patient accepted the refund but went to another practice to have the composite removed and his teeth whitened.
DDU analysis
The DDU has reviewed 120 case files opened between 2019 and 2022 where composite bonding treatment was provided, which were mainly patient complaints and a small number of claims. The number of files rose sharply over this period from just two in 2019 to 83 in 2022.
Of the 18 claims, all but one were still active and, in several cases, the composite bonding was provided alongside other treatments like orthodontics and tooth whitening.
Where a successful claim was solely about composite bonding, we would expect this to settle for less if costly remedial treatment isn’t necessary. However, such claims may be harder to defend without evidence in the records that the patient gave fully informed consent.
Causes for concern
We have categorised the files by the primary issue raised, although some files included multiple allegations:
- Unsatisfactory treatment/dissatisfied patient – 67%
- Damage to the restoration or natural teeth –16%
- Communication problems/attitude – 9%
- Disputes between dental professionals/practices – 4%
- Periodontal disease/caries – 3%.
Patient dissatisfaction
Patients’ dissatisfaction is stressful and time-consuming to manage and often leads to a complaint, despite your best efforts.
Most cases (67%) concerned patients who were unhappy with the outcome of composite bonding, such as discolouration or an uneven appearance. At least 9% of these files included a dispute about fees or a request for a refund by the patient.
It’s important to have an honest and open conversation with patients at the outset about what composite bonding entails, making clear the disadvantages (such as the risk of chips, staining and the need for ongoing maintenance) alongside the possible benefits and the alternatives.
Try to find out what the patient expects and carefully document all your discussions in the records. Include any steps you’ve taken to illustrate realistic potential outcomes.
Bear in mind that patients who are willing to pay for cosmetic treatments are also likely to be more particular about the outcome – it’s not uncommon for patients to bring in a photo of the look they want to emulate.
However, achieving optimal results with composite bonding is a technically demanding skill and they may not last if the patient doesn’t take care.
In general, it’s better to under-promise and over-deliver than have to explain why the treatment has fallen short of expectation. Careful assessment of potential patients is important. If they are a smoker or have bruxism you could be setting yourself up to fail.
Document the post-treatment advice you give (eg oral hygiene, trying to avoid red wine, coffee, or tea) and consider providing a written information sheet as an aide memoire for the patient once they have left the treatment room.
Damage to composite bonding or natural teeth
Composite restorations can be more vulnerable to chipping when put under undue stress or trauma. Examples include grinding, nail biting or an accident. Of the cases we analysed, 16% contained some reference to this problem, including cases where the damage occurred during a different dental procedure.
Patients often expect the chip to be repaired free of charge regardless of the cause, particularly if they have been given a guarantee. To pre-empt problems, be clear to patients that composite bonded restorations may chip or de-bond over time.
Also advise them how to keep them in the best possible condition, including regular check-ups. Guarantees are best avoided to help prevent getting into a war of words with a patient over ambiguous small print.
Chips can also occur because of problems before or during the procedure. A thorough patient assessment and treatment plan is essential including: identifying and addressing existing gum diseases and caries (which accounted for 3% of cases), taking clinical photos, checking occlusion and shade matching.
The dental professional conducting the procedure should be suitably trained and experienced. However, it’s most important to recognise when a challenging case requires referral to a colleague with greater expertise.
Everyone wants to avoid a situation where the patient has to return multiple times for adjustments.
Communication around composite bonding
Allegations of poor communication, rudeness, or disputes (9% of cases) are a common factor in all dental complaints, not just cosmetic ones. Sometimes the relationship has been deteriorating over time.
For example, the patient has lost confidence in the dentist due to a misunderstanding or perceived lack of sympathy. However, in many cases patients are unhappy because of the response to their initial dissatisfaction or refund request.
This underlines the importance of having an effective practice complaints procedure that enables verbal and written complaints to be managed promptly and professionally. The main purpose of responding to a complaint is to resolve it as quickly as possible.
It’s important to be clear about why the patient is complaining, what they might be seeking, and what you might reasonably say, do or offer to satisfy them. Perhaps an offer to meet face-to-face, a second opinion, a refund or another a gesture of good will. You have no obligation to do this, but if you want to make an offer, you can make it on the understanding that it concludes the complaint.
Seek advice from your defence organisation if you are unsure.
Finally, a handful of cases concern treatment by a dentist who is now at another practice. To pre-empt problems, it’s advisable for practices and departing practitioners to stay in touch for the foreseeable future. This way, queries can be resolved quickly.
An associate agreement with retained fee arrangement can work to everyone’s advantage if properly and fairly administered.
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