What This $225K Dental Malpractice Case Teaches Us About Documentation
A patient at a dental practice had two sets of X-rays taken a year apart, in April 2021 and March 2022. Both showed a growing shadow in her lower jaw. Neither the orthodontist nor the general dentists managing her care documented it, mentioned it to her, or referred her to a specialist. It wasn’t caught until June 2023, when a different provider at the same practice noticed it during a routine visit, by which point the lesion had grown significantly.
By the time she reached an oral and maxillofacial surgeon, the damage was done: bone destruction, permanent nerve injury, and a future that now includes tooth loss, implants, and jaw reconstruction. Her experts argued that a diagnosis in 2021 would have prevented all of it.
The case settled for $225,000, resolved through mediation with the general dentist who had primary responsibility for her care. The orthodontist was dismissed from the case entirely. The court ruled that the continuing treatment rule, which can extend the statute of limitations, didn’t apply once her braces came off, even though she’d had a follow-up appointment for a retainer issue afterward.
We asked Dr. Adel Rizkalla, a risk management expert, to weigh in on what this case reveals.
His take goes beyond the obvious “don’t miss the finding” lesson. In his words: “I always stress the importance of documenting both positive and negative radiographic findings. In other words, don’t just document what you see, document important findings that you looked for and ruled out as well. This documentation forces the clinician to exercise appropriate judgment and make referrals when necessary.”
He compares it to how medical imaging reports work. A chest X-ray or CT report doesn’t just flag problems, it also notes when nothing was found. That “clear” language matters. It’s proof the images were actually reviewed and the relevant conditions were considered, not just glanced past.
Dr. Rizkalla also raised a point specific to CBCT imaging that’s easy to overlook: the dentist who orders the scan is responsible for interpreting the entire volume, not just the area they were focused on. An incidental finding elsewhere in the scan can carry just as much weight as the one being investigated. If a dentist isn’t confident reading the full volume, it should go to an oral and maxillofacial radiologist. As he put it, the cost of that read is minor next to the cost of a missed diagnosis and the claim that follows.
He continued “Using a small field of view (FOV) is generally a good practice because it limits radiation exposure and keeps the focus on the area of interest.
Always document why you are recommending a CBCT and why you do not need a wider field of view (e.g., no paresthesia, no expansion, and adjacent vital teeth). That said, it does not completely eliminate risk exposure. There is still the question of what the lesion actually is and how far it extends beyond the area being imaged. If there is any uncertainty about the nature or extent of the lesion, additional imaging or referral may be needed to ensure it is properly evaluated and managed.”
His risk management takeaways, in full:
-
Refer suspicious radiographic findings to the appropriate specialist as soon as possible.
-
Document all referrals, along with the patient’s compliance or noncompliance.
-
Document both positive and negative radiographic findings.
-
Remember that responsibility for a CBCT scan extends to the entire volume, and obtain a specialist interpretation when needed.
-
Consider dismissing patients who repeatedly fail to follow recommendations or referrals.
Cases like this rarely come down to a single bad moment. They come down to a pattern of small gaps in documentation that, individually, look minor, but together end up defining who’s liable and who isn’t.
Thank you to the Virginia Dental Association, our endorser for all VA Dentists, for sharing the original article with us!
