You must be signed in to read the rest of this article.
Registration on CDEWorld is free. You may also login to CDEWorld with your DentalAegis.com account.
Ethics and the law are integral to the practice of dentistry. Clinicians must practice prudently and adhere to standards of care to achieve the best outcomes for their patients and themselves. Moreover, clinicians must accurately and completely document all information collected during patient exams, the diagnoses that follow assessment of these data, and the details of any treatment rendered or refused. Failure to properly document these essential elements of the patient record decreases a clinician’s ability to effectively defend themself in the event that a patient files a complaint to the dental board and/or a civil suit claiming negligence. According to data from the National Practitioner Data Bank, dental malpractice claims in the United States number approximately 1,500 per year, with total yearly payouts averaging $1.7 billion.1
Fortunately, protection from lawsuits and the provision of exceptional care go hand-in-hand. The behaviors and processes involved in both following and documenting standards of care offer robust individual legal protection and lay the groundwork for providing exceptional clinical care. This article includes lessons that the authors have learned from their various roles in dentistry as clinicians, educators, and medicolegal expert witnesses. It discusses the behaviors and processes that form the basis for prudent dental practice as well as highlights the most common failures that put clinicians at risk of practicing outside of treatment standards.
Competency in Care
Dental malpractice claims generally arise from a breakdown in the clinician-patient relationship, which is often caused by unmet patient expectations, such as those related to unfavorable treatment outcomes and intra- or postoperative complications. Therefore, clinicians should work to maintain patient trust and aim to reduce the likelihood of unfavorable outcomes and complications through risk mitigation strategies, including adhering to care standards, practicing within one’s scope of training and competence, and following the most up-to-date evidence-based treatment guidelines. Although much attention is given to “maintaining the standard of care,” it is important to understand that there is no one standard of care for all patients and procedures. The term “standard of care” represents a legal definition meant to describe the care that a reasonable and prudent clinician would deliver under similar circumstances.2 Failure to meet the standard of care constitutes negligence and a breach of the legal duty owed by dentists to their patients.
In addition to adhering to care standards, clinicians must also practice within their scope of training and competence. When it comes to expected treatment outcomes, clinicians should “underpromise and overdeliver,” as the adage goes. General practitioners need to understand that treatment standards for both generalists and specialists are the same. Therefore, if a general practitioner cannot provide the same level of care for a procedure as their nearby specialist, the patient should be referred. Furthermore, even if a generalist has exceptional clinical skills, the principle of patient autonomy requires that patients be informed of options to seek specialty care, if they desire it. Tools exist to aid clinicians in case selection, such as the American Association of Endodontists (AAE) Endodontic Case Difficulty Assessment Form and Guidelines and the Straightforward, Advanced, Complex (SAC) Assessment Tool of the International Team for Implantology.3 Beyond the use of such evidence-based decision trees, clinicians must be aware of treatment options that exist outside of their training and skills. For example, if a provider is unable to offer the restorative, endodontic, or surgical care required to save a compromised tooth, he or she must inform the patient of reasonable treatment alternatives that exist on referral instead of recommending immediate extraction.
Clinicians should also follow the most current evidence-based guidelines with respect to treatment. These are often defined in position statements and white papers from dental professional organizations. For example, the AAE defines general requirements for the completion of nonsurgical root canal therapy in its white paper, Treatment Standards,4 including the use of dental dam isolation, which itself is the subject of a separate position statement.5
Competency demonstrated by adhering to care standards, practicing within the scope of one’s training, and following evidence-based guidelines is not limited to care delivery; it also relates to diagnosis. The ability to diagnose, whether it is disease in an untreated state or a complication that occurs during or following the delivery of care, is crucial to competent practice. Incorrect or missed diagnoses can result in improper treatment and missed opportunities for successful treatment. Complications must be recognized expediently to ensure proper management. For example, failure to recognize a sodium hypochlorite accident can result in continued use of the cytotoxic irrigant and the creation of greater injury, including permanent paresthesias and neuropathic pain, not to mention a delay in the delivery of palliative care necessary to manage these painful incidents.6 Similarly, the failure to recognize and refer mandibular nerve injuries secondary to the extrusion of endodontic sealers can result in immediately poorer outcomes, including a lifetime of paresthesias and dysesthesias.7 Prompt recognition of complications should be followed by immediate efforts to mitigate further effects and long term consequences, including referral to outside dental or medical specialists as needed.
Informed Consent: Setting Expectations
Competent clinical practice demands accurate diagnosis and the provision of exceptional care. A procedure may be considered routine by the provider; however, it likely represents a unique experience for the patient. Because dental malpractice claims often relate to unmet patient expectations, it is essential to both set patients’ expectations and document that understanding. This is done by obtaining informed consent. Informed consent is not simply getting the patient to sign a document listing the potential risks and complications of treatment. Rather, informed consent is the process of making patients and caregivers aware of the diagnosis, etiology, prognosis, treatment options, costs, and possible outcomes of treatment, including potential additional treatment needs. Proper informed consent must also include information related to the perioperative experience, such as any necessary follow-up care, as well as time to answer the patient’s questions prior to obtaining a signature. It should be a conversation between patient and providers.
Informed consent should include broad treatment considerations but must also reflect the patient’s individual presentation and history. For example, a patient’s malocclusion may limit restorative options and esthetic results. Similarly, chronic pain conditions can prevent complete resolution of painful dental conditions, and immunodeficiencies and certain medications can limit the healing of dental infections. Shared decision-making ensures that patients are informed and involved in their care and partners in treatment planning. When patients feel involved in their care and that their providers are acting primarily in their interest, then trust is built and maintained. Patients are not dentists. Research indicates that patients immediately forget 40% to 80% of the medical information provided by healthcare practitioners.8 Therefore, providing written communication of findings, recommendations (including educational materials), and treatment plans (including costs), as well as clear and concise informed consent documents, helps to ensure a more complete understanding of the care provided.
Proper Documentation
Nearly every case of dental malpractice raises questions regarding the appropriateness of diagnosis, treatment rendered or not rendered, and postoperative management. The clinician’s thought processes and actions should be thoroughly and concisely documented. Ultimately, this documentation is all that legal professionals and their dental experts have for review in the event of a claim. The patient chart is a legal document and should include all written progress notes, charting, photography, radiographic imaging, and administrative and billing information. As such, it can and should serve as a tool to aid the prudent clinician. Written narratives, including progress notes and explanations of in-person, phone, or written conversations, support exceptional clinical care by reminding clinicians of the specific nuances of cases. These notes must be complete and accurate because they can help clinicians defend themselves in situations in which patients misremember encounters and details of procedures. Conversely, an incomplete or inaccurate template filled out by a dental assistant can result in a finding of legal liability, especially in a close case.
Generally speaking, in a lawsuit, the written record holds greater weight than oral reports delivered months or years after clinical encounters because recall likely includes bias. If it isn’t in the notes, it didn’t happen, and conversely, if it is in the notes, one can assume that it did happen. Whenever possible, a trusted team member, such as an administrator or dental auxiliary, can be present during clinical encounters to aid in documentation and serve as a witness. Having staff physically present can help to create unique notes in the patient record and corroborate any discussions. This additional documentation is useful for both internal office communications as well as medicolegal claims that might arise later.
Progress notes should be complete. Components of patient notes that are often missing include updated health histories, exam findings, radiograph interpretations, diagnoses, treatment planning discussions, informed consent documents, treatment details, and witness accounts. Each patient encounter must include appropriate updates to the patient’s medical history, including any new medical conditions or medications. Results of clinical examinations and any diagnostic findings should be recorded and include a differential diagnosis and a presumptive diagnosis if a definitive diagnosis is not obvious and apparent. As with all conversations with patients, treatment planning conversations should be documented carefully as a part of informed consent. Procedural notes should document the use of any specific materials and medications, including details related to dosages.
Photographs, radiographs, and diagnostic casts are similarly part of a patient’s record and should be included or referenced appropriately. All exposed images must be interpreted by the ordering provider, which includes recognition of normal and abnormal findings. A radiograph is a diagnostic test, and failure to interpret a diagnostic test is considered a deviation of the standard of care. This is particularly important if cone-beam computed tomography (CBCT) imaging is used. When large field-of-view CBCT images are exposed, the full field must be interpreted, even if the area of clinical interest is limited. For example, tooth No. 14 may be a candidate for root canal therapy. That does not exclude the possibility that the CBCT scan will reveal an ameloblastoma in the area distal to tooth No. 32. Although outside radiologic services can be useful for findings outside of a clinician’s area of expertise, they do not obviate risk in interpreting and acting on relevant findings. Careful and thorough documentation is a strong indicator of practice systems that steer clinical processes toward anticipated patient outcomes. On the other hand, a lack of documentation suggests that successful patient outcomes happen despite these processes rather than because of them.
Common pitfalls in recordkeeping include incomplete documentation of findings. In the age of digital software, templates may include items that go neglected during patient encounters. Templated items, such as medication and allergy lists, can be a common source of errors or omissions and require deliberate updates at each patient encounter. The fact that a patient provided a history of taking blood thinners for a cardiac condition does not mean that the patient took his or her medication that day or even that week. If a patient was told to stop taking blood thinners prior to a dental procedure 3 years ago at a different practice, then he or she may have simply done this again without medical advice. When bad outcomes occur, any failures, inconsistencies, or inaccuracies in recordkeeping create increased legal liabilities that are avoidable and unnecessary risks. Proofreading documents the day of a patient encounter can help ensure that the sealed record is accurate and complete.
As an example of the hazards of relying on templates to complete chart notes, a recently reviewed chart included the following statement: “Quality and quantity of bone was visually inspected and determined to possibly be suitable for proper implant stability and osseointegration.” This statement is qualitatively uncertain at best. A later note in the chart states, “Implant was placed and torques [sic] to DFU. Primary stability was (or was not) achieved.” This failure to update the templated note makes it impossible to determine if primary stability was achieved or not. It clearly shows the limits of the defensibility of a chart note. Rather than helping, the clinician’s obvious failure to attend to a very important detail undermines his or her position in a lawsuit and even calls into question the veracity of other notes.
Effective Communication
Patients are far less likely to sue providers that they like, and effective communication represents the best means of maintaining favorable relationships between patients and providers. The use of respectful, kind, and clear language from providers and auxiliaries is essential to create appropriate patient expectations. Care in communication should also extend to administrative team members who might discuss financial matters with patients. Clinical team members, including the doctor, should utilize professional but clear and understandable messaging. When it comes to esthetics and pain management, the adage “underpromise and overdeliver” is more important than ever. The subjectivity of esthetic results requires careful setting of reasonable expectations. Similarly, differing levels of postoperative pain should be expected after many dental procedures. Protracted or persistent pain is also possible, particularly if a patient presents with preoperative risk factors for significant pain or underlying chronic pain conditions.9
The development of complications from treatment is an unfortunate part of dental practice, even when exceptional care has been delivered. A discussion of any potential complications should occur as part of informed consent. Providers should anticipate the potential complications for each and every procedure and patient because a lack of such forecasting can magically transform an explanation into an excuse when an adverse outcome occurs. Once a complication has been recognized, appropriate management strategies should be discussed with patients, including expedient referral to a dental specialist or medical provider if that is what is required. Failure to recognize complications such as sodium hypochlorite accidents, subcutaneous emphysemas, swallowed or aspirated instruments, and material extrusions can have life-threatening consequences; however, expedient referral to emergency medical services can help to mitigate and reverse potential damages. Similarly, patients with recognized nerve injuries should be promptly referred for appropriate neurologic or surgical interventions.
Effective communication goes beyond patient and provider interactions. A team approach with referral parties, including specialists and medical providers, helps to ensure effective and efficient continuity of care. Clinical notes and imaging, including photographs and radiographs, as well as medical histories and demographics should be shared with referring parties. When clinicians take charge of communication, it unburdens patients from having to recall diagnoses and reasons for referral. Appropriate follow-up to confirm that messages and referrals were received can help to ensure that patients receive necessary care without delay.
The need for effective communication does not stop when the patient leaves the dental office either. Follow-up phone calls or check-ins provide patients with a touch point with their provider. This way, questions don’t go unanswered, and complications don’t get ignored. A simple phone call to patients the evening of or day following treatment not only demonstrates to them that clinicians care about their well-being but also serves as a great practice builder. Whether in the days, weeks, or months following delivery of care, patients should be seen for necessary, in-person follow-ups to address refractory symptoms or concerns. These follow-up calls and visits help to cement the care and compassion that translates to trusting relationships between patients and providers as well as prevent accusations of patient abandonment.
Conclusion
Above all else, clinicians must first do no harm. Maintaining oral health is crucial to nourishment, confidence, and overall health. Dental clinicians are obligated to provide care to the highest level possible. Patients should be regarded as team members in their care via shared decision-making and informed consent. Recognition of these tenets may not remove liability from the practice of dentistry, but it can both reduce the chances that malpractice claims will be filed and improve the odds of their favorable resolution when they are.
Practitioners should approach care systematically and with good reasoning up to the standards of a similarly prudent practitioner. A thorough exam leading to clear diagnoses, followed by thoughtful treatment planning discussions and informed consent should precede the delivery of care. Clinicians must practice within the scope of their training. Complications that occur must be promptly recognized and managed, and patients should be informed and involved in all facets of this care. Dental practice in this manner ensures that all patients and providers mitigate risk for the best outcomes possible.
Queries regarding this course may be submitted to authorqueries@conexiant.com
Acknowledgement
The authors would like to extend special thanks to Hugh Koerner, JD, and Zameera Fida, DMD, for their professional insight and advice in writing this article.
About the Authors
Mark Knott, DDS
Master
Academy of General Dentistry
Associate Fellow
American Academy of Implant Dentistry
Medical Staff
Mt. Ascutney Hospital and Health Center
Windsor, Vermont
Private Practice
Woodstock, Vermont
Brooke Blicher, DMD
Assistant Clinical Professor
Department of Endodontics
Tufts University
School of Dental Medicine
Boston, Massachusetts
Lecturer
Department of Restorative Dentistry and Biomaterials Science
Harvard University
School of Dental Medicine
Boston, Massachusetts
Cofounder
Pulp Nonfiction Endodontics
Upper Valley Endodontics, PC
White River Junction, Vermont
Rebekah Lucier Pryles, DMD
Assistant Clinical Professor
Department of Endodontics
Tufts University
School of Dental Medicine
Boston, Massachusetts
Lecturer
Department of Restorative Dentistry and Biomaterials Science
Harvard University
School of Dental Medicine
Boston, Massachusetts
Cofounder
Pulp Nonfiction Endodontics
Upper Valley Endodontics, PC
White River Junction, Vermont
References
1. Cui W, Finkelstein J. Using big data analytics to identify dentists with frequent future malpractice claims. Stud Health Technol Inform. 2020;270:489-493.
2. Vanderpool D. The standard of care. Innov Clin Neurosci. 2021;18(7-9):50-51.
3. American Association of Endodontists. Case assessment tools. AAE website. https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/. Accessed August 26, 2025.
4. American Association of Endodontists. Treatment standards. AAE website. https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/04/TreatmentStandards_Whitepaper.pdf. Accessed August 26, 2025.
5. American Association of Endodontists. Dental dams. AAE website. https://www.aae.org/specialty/wp-content/uploads/sites/2/2024/06/DentalDams_PositionStatement_updated.pdf. Revised March 1, 2024. Accessed August 26, 2025.
6. Guivarc’h M, Ordioni U, Ahmed HM, et al. Sodium hypochlorite accident: a systematic review. J Endod. 2017;43(1):16-24.
7. Pogrel MA. Damage to the inferior alveolar nerve as the result of root canal therapy. J Am Dent Assoc. 2007;138(1):65-69.
8. Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219-222.
9. Nixdorf DR, Moana-Filho EJ, Law AS, et al. Frequency of nonodontogenic pain after endodontic therapy: a systematic review and meta-analysis. J Endod. 2010;36(9):1494-1498.