Read why a Dentist was held liable to pay Rs. 5 lakhs towards Negligence. A worth reading judgment for Dentist and for patients. Adv. ROHiT ERANDE. ©

"Root-Canal without X-ray, Lack of Informed Consent and lack of consensus between the Dentist and the Patient, held to be deficiency in service" .

" The commission relied upon the minority view of 3 member expert committee" 

"The allegations that one of the expert gave contrary opinion due to professional rivalry, also turned down". 

Adv. ROHiT ERANDE. ©

Case Details :

NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION. REVISION PETITION NO. 2736 OF 2012

(Against the Order dated 04/06/2012 in Appeal No. 126/2012 of the State Commission Andhra Pradesh)

M/S. SRAVANI DENTAL HOSPITAL Hyderabad  V/s. ANITHA TANGELLAMUDI & anr. 

BEFORE:

HON'BLE MR. JUSTICE R.K. AGRAWAL,PRESIDENT

HON'BLE DR. S.M. KANTIKAR,MEMBER

Dated : 08 Mar 2022

The judgment Starts with the quote 

"Not everyone can be born with a perfectly aligned smile. If you just changed your smile and nothing else, you would find a dramatic transformation in your personality, grace, confidence,appearance and social presence. When one or more teeth overlap, it can impact the smile and self-esteem."

Facts in short :

1.The issue relates to alleged dental negligence, wherein the dentists at the Opposite Party hospital unnecessarily performed the Root Canal Treatment (RCT) of 4 teeth and provided metal ceramic crowns causing disfigurement of face of the Complainant.

2. The District Forum dismissed the Complaint filed by Ms. Anitha Tangellamudi, the Complainant. But  the State Commission allowed the Appeal & directed M/s Sravani Dental Hospital to pay Rs. 5 lakhs with interest at the rate of 9% p.a. as a compensation from the date of the Complaint and Rs. 10,000/- towards cost of litigation. Hence this Petition. 

3. The case of the Complainant is that, on 27.07.2008, she consulted Dr. Kartik Reddy- the Dentist and Proprietor of M/s Sravani Dental Hospital -the Petitioner -Ori. opponent  for her teeth chewing problems. The RCT for left upper front teeth with crown fixation was advised. She alleged that before commencing RCT correct diagnosis with a high quality long -cone parallel radiograph was mandatory, but no X-Ray was taken before performing the RCT, therefore, her vital teeth were killed. It was alleged that RCT was started on the same day and due to teeth grinding, her front three teeth permanently got disfigured.

4. Thereafter, on 13.08.2008, the doctor gave plastic caps to put on the grinded teeth for 60 days, but she was facing problem during speech and teeth brushing. She had fear of falling caps. On 04.09.2008, the Complainant requested the doctor to provide at least two crowns for two upper teeth and one for lower tooth. Therefore, doctor took impression of her teeth and provided metal-ceramic crowns on 25.09.2008. The Complainant being aggrieved due to alleged negligent dental treatment at the Opposite Party Hospital, filed the Consumer Complaint before the District Forum-II, Hyderabad, seeking compensation of Rs. 20 lakhs.

Defense : 

1. The case of Opposite party - Dr. Kartik Reddy, the Proprietor of M/s Sravani Dental Hospital that the Complainant visited the Opposite Party almost a year back for surgical removal severely decayed teeth in the upper left back region. She again visited on19.07.2008 for pain. She also had forwardly placed lower front teeth as seen in her photograph and needed placement of crowns. 

2. However, it was contended that the Orthodontic treatment for complinanant was not possible because of her age 40 years and also due to her complicated teeth movements, there was every chance of exposure of the pulp(nerve).

3. Therefore, the Petitioner discussed it with the Endodontic specialist and advised for RCT and crowns fixation. RCT was done by the competent Endodontist, one Dr. Shannu Kumar. Therefore, entire allegations were baseless; there was no negligence during her dental treatment.

Held : 

1. The NCDRC went through all the evidence  and record and  We have carefully perused the Orders of both an expert opinion from the board of medical expert, sought by the District Forum. 

2. The Board was consisting of three experts out of them two have opined RCT was done satisfactorily and justified, whereas, one expert Dr. P. D. Annapurna affirmed the medical negligence of the Petitioner. Therefore, based on the expert opinion, the District form dismissed the Complaint.

3. In the Appeal, the State Commission relied upon the expert opinion of Dr. P. D. Annapurna and held medical negligence of the OP. The State Commission observed as below:

"Taking of X-ray before performing the root canal treatment is very important to know the internal structures of the organs. It appears that no pre-operation X ray was taken by the opposite party or the Endodontist, who performed the root canal treatment. The failure to take pre operation X-ray of the teeth certainly amounts to gross negligence on the part of the opposite party". 

“Further the opposite party has not adduced any evidence to show that root canal treatment can be performed on healthy teeth based on photograph"

4. One of the tree experts Dr. P.D.Annapurna, Professor of Prosthodontics opined as under: "In case of M/s.Anitha (the present candidate under examination); all the five fundamentals are totally neglected by the doctor. The three teeth were ground beyond the requirement and the tooth structure was totally damaged. 

The three teeth were disfigured to such an extent that crowns cannot be placed on these teeth by conventional method (if that amount of tooth structure was not removed, normal crown preparation must have been possible maintaining good stability-grip). The three teeth can give retention (grip) only by special technique by name post core crowns, a technique beyond conventional method of treatment. 

This is not done in the patients to improve the retention. The professor is also of the opinion that the above three teeth do not require any root canal treatment as per the x-rays, as there is no apical pathology and they can be crowned even without root canal treatment. In case of Ms. Anitha the teeth (organs) were unnecessarily killed and made non-vital by way of root canal treatment."

5. It was observed that thus, as per opinion of Dr. P. D. Annapurna RCT was not necessary when the pre-treatment x-ray OPG was normal. RCT was done at the Opposite Party Hospital to the four vital teeth (No 21,22,23 and 41) which became dead.

6. The two experts Dr. G. Hariprasad Rao, Professor and HOD, Dept. of Orthodontics and Dr. Sarjeev Singh Yadav, Associate Professor, Department of Conservative Dentistry jointly examined the complainant and opined that the complainant had overlapped central incisors and the opposite party was justified by not attempting any Orthodontics treatment for correcting it.

Regarding RCT, they opined that on the basis of the OPG x- ray (year 2007), there was no apical pathology the four teeth and the RCT was justified. The clinical radio graphical evaluation of root canal treated teeth showed that the treatment was performed successfully. However, they were not aware about the conversation between the patient and doctor with regard to informed consent pertaining to the teeth will become non vital after the treatment is not known.

7. The Ld. Commission  further relied upon  the final report issued by the Director of Medical Education,Govt. of Andhra Pradesh, Hyderabad stated that RCT was done in three upper teeth (No. 21, 22, 23) and one lower tooth No. 41. The crowns made were metal ceramic and not metal free ceramic. There was no retention capacity in the upper teeth or support. Based on the said opinion, a charge sheet was filed against the Opposite Party on 14.05.2010 for the offences under 338, 430 and 506 of IPC.

8.It is pertinent to note that the two experts Dr. H. G. Hari Prasad Rao and Dr. Sarjeev Singh Yadav, opined RCT was successful, but they are silent to whether the RCT was necessary for the Complainant. It is clear from the opinion of Dr. P. D. Annapurna that the three teeth can give retention (grip) only by Post Core Crowns, a special technique which is beyond the conventional method of treatment. Thus, in the instant case there was no grip for retention of the crowns.

9. It was further observed that  the treatment of the Complainant fell within two specialties i.e. Endodontics for the RCT and Prosthodontics for restoration and replacement of teeth. RCT is a dental procedure to be performed by Endodontics, in which the damaged pulp of teeth is removed and the cavities are filled and sealed to make teeth non vital. The Prosthodontist knows the preparation of RCT then only attend the work for bridge and/or crown treatment. 

10. The commission rejected the contentions of the Doctor  that Dr. P. D. Annapurna, who was not a specialist in RCT, gave her adverse opinion because of professional rivalry and to falsely implicate the Opposite Party. Also it is wrong to presume about the professional rivalry just because the private clinic of Dr.Annapurna and the clinic of Dr. Kartik Reddy situated near by to each other.

11. It was held that Dr. Kartik Reddy was a Periodontist, he was neither Endodontist nor Prosthodontist. When it comes to overlapping teeth, the right approach is determined by the degree of overlap. He advised the patient for RCT and it was successfully performed by an Endodontist, Dr. Shannu Kumar for the overlapping upper front teeth 21, 22,23 and 41 which were vital. Therefore, we do not find any fault with the Endodentist. 

However it was held that the type of treatment adopted by the Opposite Party was not a deviation of standard of practice, if the doctor chooses any accepted mode of treatment. This view dovetails from the decision of Hon'ble Supreme Court in the case of Achutrao Haribhau Kodwa Vs State of Maharashtra [(1996) 2 SCC 634] , wherein it was held as below:-

"the very nature of the profession is such that there may be more than one course of treatment which may be advisable for treating a patient. Courts would indeed be slow in attributing negligence on the part of a doctor if he has performed his duties to the best of his ability and with due care and caution. Medical opinion may differ with regard to the course of action to be taken by a doctor treating a patient, but as long as a doctor acts in a manner which is acceptable to the medical profession and the court finds that he has attended on the patient with due care, skill and diligence and if the patient still does not survive or suffers a permanent ailment, it would be difficult to hold the doctor to be guilty of negligence."

12. With respect to Crowns, according to the Opposite Party; with the consent of the Complainant, the crowns were prepared from her dental impressions; therefore the question of permanently disfiguring the teeth does not arise. The complainant also signed on the paper and agreed for the shade and shape of the crowns required in her own writing. The metal free ceramic crowns were fixed for two teeth, whereas in the expert medical committee report three metal ceramic crowns were mentioned. 

It was held that the presumption of Opposite Party that the Complainant must have got the treatment from outside and had cleverly got the teeth grinded to a level that they can be restored by post core technique to demand money from the opposite party. In our view, it was a baseless presumption of the Opposite Party and it is not acceptable.

13. Lastly it was held that relied upon the expert opinion and evidence, the Doctors were held liable on 3 counts. :

Firstly, there was no grip/retention capacity of crowns in upper teeth, therefore more chances of felling of the crowns during talking, brushing etc. which certainly an embarrassment. 

Secondly, it was unfair on the part of Opposite Party that the crowns are not metal free ceramic as promised and billed by the Opposite Party but they are metal ceramic and 

thirdly, the Complainant was not informed about the implications of RCT as to the teeth would be made non-vital. 

Thus, in our considered view, it was failure of duty of care and deficiency service as well unfair practice from the Opposite Party.

14. the Last observations of the Hon. commission are very important, that the consensus between dentists and patients is essential to standardize treatment plans and methods. In dental treatment, patients often ask orthodontists if they will look more beautiful and have doubts about the ultimate aesthetic effects. Also there is need to calibrate the perception between dentists and patients about the classification of aesthetics into unpleasant, acceptable, and pleasant; otherwise there may be some conflicting views on expectations and treatment. The teeth are only part of the face and it cannot be simply concluded that the whole face will become more beautiful once the teeth become neat.

15. Thus, based on the afore discussion the Opposite party is held liable for medical negligence and deficiency in services. The Complainant suffered facial disfigurement after dental treatment and in our view the compensation awarded by the State Commission is just and proper, however the rate of interest is on higher side, therefore in ends of justice it is modified to 6% from the date of filing.

The Medical Negligence cases are common, but the cases related to dental treatment are not common. But this judgment, is an eye opener for all the Dentists and the patients too as the  Root Canal has become the most common treatment. The Commission has also denied the allegations of professional rivalry allegations between the Expert Doctor and the Opponent !! this case also emphasizes the importance of informed consent in Dental Treatment too.. 

Thanks and Regads,

ADv. ROHiT ERANDE

Pune. ©