Dentist Spotlight:

Patient Termination & Referral

Dentist’s Advantage, in collaboration with CNA, has published our Dental Professional Liability Claim Report: 3rd Edition (3rd Edition Report), which analyzes closed dental professional liability claims from 2020–2024. The 3rd Edition Report includes statistical data and case scenarios from CNA closed claim files, as well as risk management recommendations designed to help dentists reduce their malpractice exposures and improve patient safety.
You may access the complete 3rd Edition Report, and additional Risk Control Spotlights.
This Dental Spotlight focuses on our analysis and risk recommendations regarding an important aspect of dental practice - Terminations and Referrals.
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Patient Termination

The standard of care for dentists includes the legal duty to continue caring for patients of record. If an irreconcilable dentist-patient conflict results in a determination that you cannot continue to care for the patient at or above the required standard of care, you are obligated to end the relationship in an appropriate manner. Improper termination of the dentist-patient relationship may lead to allegations of abandonment or failure to treat.

Dental Professional Liability Spotlights

In the months ahead, please access the Dentist’s Advantage Prevention and Education Web page to download the report and Spotlights on key risk topics:

Managing the Risks of Terminating the Dentist-Patient Relationship

The dentist-patient relationship simply does not end when the patient leaves your office or your care. It continues until one party properly ends it. Unless the relationship is legally terminated, the courts may consider it to exist even years after the last communication between the patient and dentist. You may terminate the dentist-patient relationship for many reasons, including when patients become unreasonably demanding, stop paying their bill, miss and/or cancel numerous appointments, refuse your treatment recommendations, or are otherwise difficult for you and your staff.

Abandonment

Abandonment involves the unilateral dismissal of the patient by the dentist in the absence of ample and proper notice to the patient. Abandonment allegations are based upon the patient’s belief that he or she has suffered an injury due to the dentist’s failure to continue to perform his or her professional duty. In addition, laws restrict a dentist from refusing treatment to or dismissing a patient from the practice solely on the basis of a disability, race, color, creed, ethnicity, gender or age. While you may terminate a relationship with a patient who is disabled or otherwise protected by anti-discrimination laws, all patients must be treated equally. Any patient who cannot or will not comply with office policies or treatment recommendations can be dismissed, if the reasons for doing so are fair and the process adequately documented.
Caution: if you refuse to treat a patient of record in need of emergent care simply because the patient owes you money, you may become liable for a charge of abandonment.

Recognizing Risk Factors

Certain patients whom you terminate may be more likely to allege abandonment than others, including those with:
  • Poor or adverse clinical outcomes
  • Unmet expectations
  • Billing disputes
  • Argumentative personalities
  • Litigious personal histories
  • Poor compliance with postoperative care and follow-up appointments

Controlling The Risks

The doctrine of informed consent requires that the patient be given sufficient information about, and consider, three major components, which you are required to disclose and discuss with the patient. They are:

Clinical

  • Evaluate the stability of the patient’s health prior to terminating the relationship, and ensure that the patient’s health is never compromised, including during any termination period.
  • Treatment should be terminated or transferred at a logical point during care when the patient no longer requires emergent care.
  • As a general guideline, complete multiple visits associated with procedures which you have started, such as root canal therapy (obturation), crown and bridge procedures (cementation), orthodontic treatment or postoperative care following surgical procedures.
    • The exception to the general guideline occurs when the relationship is terminated due to the patient’s failure to return for unfinished treatment. In such cases, the dentist may terminate in the midst of active care, following a documented good faith attempt that has been made to get the patient to return for care.
    • Ensure that you have documented in the patient record all attempts to contact the individual before terminating the relationship. This documentation shows that every reasonable and prudent step to continue patient care was taken and helps to defend against abandonment claims.
    • A minimum of three documented attempts to contact the patient regarding the completion of unfinished treatment is recommended. One attempt should take the form of a letter sent to the patient. The others may be documented through telephone calls and/or telephone messages.
  • In most situations, the dentist is legally obligated to assist the patient during the termination of care, even when the patient terminates the relationship.
  • Before terminating care, ask yourself the following questions:
  1. Have I met the required standard of care in my past treatment and management of the patient?
  2. If not, has the patient failed to allow me to provide care that adheres to the required standard of care?
  3. Have I provided care to the point where the patient has no immediate need for emergent dental treatment?
  4. If not, has the patient refused to return for care?

 

Acting in the affirmative on points one and three may help provide evidence that you took steps to meet your responsibilities.

Communication

  • At the outset of the dentist-patient relationship, inform patients of your practice rules, including reasons why patients may be asked to leave the practice. Providing a practice brochure to all new patients as a standard procedure should suffice for this purpose.
  • Make reasonable attempts to resolve patient conflicts and document those attempts.

Documentation

  • Document in the patient record all attempts to contact the individual before terminating the relationship.
  • If a patient terminates the dentist-patient relationship for any reason, clearly and fully document the patient’s decision in the dental record, including verbatim comments from the patient or copies of patient correspondence.
  • If the dentist terminates the relationship, notify the patient in writing by mail. Send two copies of your letter: one via certified mail, return receipt requested, and the second via standard first-class mail. Even if the patient refuses to sign for the certified letter, the first- class mailing will be delivered. The letter should include the following information:
  1. Clearly state that the dentist-patient relationship is being terminated and indicate the specific date that the relationship will end.
  2. Indicate the current status of care and any further treatment needs of the patient, including the risks of not receiving the needed treatment.
  3. Offer to provide emergency care to the patient for a reasonable period of time, which must be sufficient for a reasonable person to secure an appointment with a new dentist (30 days is generally sufficient in most areas).
  4. Indicate how the patient can find a new dentist, such as the telephone directory or the local or state dental society referral service, if one exists where you practice.
  5. Offer to forward copies of records to the patient, or to the patient’s next dentist, upon written request of the patient. Be sure to retain the original records. You may not refuse to supply copies even if the patient has an outstanding balance.

 

Although you are entitled to charge a “reasonable fee” for duplication and mailing, we strongly encourage you to provide a copy of the record free of charge when terminating a patient. This approach avoids any (additional) ill will between you and the patient that may trigger a malpractice action or dental board complaint.

 

  • Keep a copy of the letter and any related correspondence or documented discussions in the patient’s dental record.
  • Retain the certified mail receipt as part of the file whenever you send correspondence by certified mail.
  • If your certified letter is returned to you unopened, retain it unopened in the patient chart. Your previously sent first-class letter will serve as notification for the patient.

Referrals

Dentists refer patients to other practitioners when treatment or patient management is beyond their personal experience and expertise, or when a second opinion is desired. By referring the patient to a dental specialist or to another dental practitioner with advanced experience in a non-specialty discipline, the dentist provides patients with an opportunity to receive the specific care they need. By offering referral to a specialist when appropriate, the dentist may reduce being exposed to a potential dental malpractice lawsuit.
Many referral problems can be avoided by assessing and correcting referral methods and improving communication with both the patient and the referral dentist.
Claims involving referrals may allege:
  • Failure to refer to a dental specialist
  • Failure to refer in a timely manner
  • Unnecessary treatment performed by the specialist, based upon an erroneous or unjustified referral request
  • Advising treatment of the wrong tooth by the referring dentist, or treatment of the wrong tooth by the referral dentist
  • Advising inappropriate treatment on the correct tooth, such as endodontic therapy on a non-restorable tooth
  • Negligent referral to a dentist who practices below the standard of care
In failure to refer cases, typical allegations include that the adverse consequences would have been avoided if the dentist had referred the patient to a specialist with additional training and experience in a timely manner either for further evaluation or to perform necessary treatment.

Managing the Risks of Referrals

Recognizing Risk Factors

Dental procedures customarily performed by specialists are most often associated with dental malpractice claims alleging a general dentist’s failure to appropriately refer the patient to a dental specialist. These procedures include: endodontic therapy, extractions, treatment of periodontal disease, oral surgery, implant placement and/or restoration, treatment of temporomandibular disorders, and orthodontic treatment. Analysis of current professional liability claim trends indicate that three procedures are the most common and costly: molar tooth root canal therapy, impacted third molar extractions and placement of dental implants.

Controlling The Risks

Risk Avoidance ›
Risk Avoidance ›

Communication With the Patient ›

Communication With the Patient ›

Communication With the Referral Dentist ›

Communication With the Referral Dentist ›
Documentation ›
Documentation ›

Case Study: Failure to Refer for RCT

The practitioner in this case was a general dentist. An established patient presented with pain from biting pressure related to a mandibular first molar. The insured dentist (dentist 1) obtained an intraoral periapical radiograph and recommended root canal therapy (RCT). Following the completion of the RCT, dentist 1 placed a composite restoration at a subsequent visit. Several months later, the patient sought care for two painful areas— one in the posterior maxilla and the other in the mandible, near the prior RCT. While dentist 1 was out of the office for several days, the patient sought care from another dentist (dentist 2).

Dentist 2 recommended that the root canal filling in the mandibular first molar be removed and that the tooth be re-treated. A radiograph showed a slightly underfilled distal canal with a small periapical radiolucency. The patient then returned to dentist 1. Since the patient’s discomfort had subsided, dentist 1 scheduled appointments to complete preventive and restorative care over several weeks, before addressing the RCT re-treatment.

Following completion of the re-treatment procedure with dentist 1, the patient had a reoccurrence of pain and presented to dentist 2, as dentist 1 was not available that day. Dentist 2 administered a local anesthetic for pain relief, removed occlusal contacts from the first molar tooth, prescribed an antibiotic and suggested referral to an endodontist, or extraction of the tooth.
A few days later, the patient sought care at a local hospital emergency department (ED). Examination revealed substantial swelling and fever due to an apparent infection in the vicinity of the re-treated first molar tooth. The swelling required a visit to the operating room for incision and drainage, as well as removal of the offending mandibular first molar. The diagnosis: lateral pharyngeal abscess with hematoma, extending into the floor of the mouth. Post-surgery, the patient continued to seek treatment for ongoing paresthesia, hyperalgesia, and other complaints.
The total incurred (indemnity payment plus legal fees and other claim expenses) was approximately $150,000.

A review of the records and expert opinions for this claim highlight a number of risk management topics, including the following:

Recordkeeping and documentation.
When RCT or any other treatment is recommended, objective clinical findings, test results and diagnosis must support the treatment plan and be adequately documented. While a radiograph was taken to aid in the diagnosis in this case, the findings were not recorded. Moreover, as RCT may be complex, it should be performed only after obtaining and documenting the patient’s informed consent, including disclosure of the nature of treatment, treatment alternatives and foreseeable risks (such as tooth loss and infection), as well as the risks associated with no treatment. The patient record did not include a written/signed consent form or a supporting progress note.
Specialist treatment/referral.
hile all dentists may perform root canal therapy, non-endodontists should offer referral to an endodontist as a viable treatment alternative to reduce the risk of a failure-to-refer allegation. Dentists must honestly assess their own skill and experience and discuss the alternatives with the patient. In this case, file sizes and file lengths were not documented, and no post-fill radiograph was produced or documented in the records. Later radiographs revealed radiolucent areas associated with other teeth with RCT performed by dentist 1. Root canal fillings were well short of the root apices. Although dentist 2 recommended that the patient consider re-treatment of the molar RCT by an endodontist, the patient returned to dentist 1, CNA and Dentist’s Advantage Dental Spotlight: Patient Termination & Referral 8 having been a long-time patient at the insured’s office. However, re-treatment was delayed for unknown reasons and other treatment needs were addressed instead. If a referral to a specialist was suggested or made prior to the initial RCT or re-treatment, it was not documented.
Abandonment.
Dentists should inform patients how to access care in the event of a dental emergency, whether it occurs during customary business hours or after hours. Treatment may be provided by the dentist or by colleagues with whom the dentist has made such arrangements. In this case, the dentist was not available to manage the patient’s pain and swelling immediately after the root canal re-treatment, and he failed to inform the patient of emergency care options. He subsequently failed to examine the patient, who later sought care at a local hospital ED. Failure to effectively manage the patient’s post-treatment emergency care needs left dentist 1 open to an allegation of abandonment.

Refusal of Referral

When a patient refuses a referral, he or she must be informed of the potential consequences. A detailed note should be made documenting the discussion and the patient’s informed refusal. If you elect to proceed with treatment after the patient has refused the referral, you will ordinarily be held to the standard of care of the dentist to whom you intended to refer. If you are unable to treat to this standard, it would be prudent to avoid beginning treatment.

Conclusion

Whether ending a dentist-patient relationship or coordinating care through referral, the primary goals are to protect patient welfare and ensure continuity of care. Dentists can reduce the risk of abandonment, failure-to-refer, and related professional liability allegations by communicating clearly with patients and colleagues, documenting all significant discussions and clinical decisions, and following a consistent process for termination and referral. Thoughtful planning, timely communication, and thorough documentation remain the foundation of effective risk management in these situations.

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