SECTION II: ETHICAL, LEGAL, AND PRACTICAL MATTERS IN

THE MANAGEMENT OF PERIODONTAL PATIENTS

CHAPTER 84
Legal Principles: Jurisprudence
Brian P. Kamel and Mark B. Lieberman

CHAPTER OUTLINE
DEFINITIONS
COMMON PERIODONTAL MALPRACTICE ISSUES
LEGAL ELEMENTS OF MALPRACTICE
Standard of Care
Informed Consent
Beneficence
Abandonment
Record Keeping
PRACTICAL COMPONENTS IN LITIGATION
LEGAL PROCESS

DEFINITIONS
Jurisprudence is the legal process in the United States (US). It
addresses any damage, injury, or harm to an individual. This is
termed a tort, and it becomes the cause to initiate legal action. All
professionals, including dentists, are held to the community standard of care when rendering care. When care by a dentist falls
below that standard, the dentist becomes liable for all damages
resulting from that conduct. It is important to understand the
principles and practice of the legal system to avoid its pitfalls
(Box 84-1).

COMMON PERIODONTAL
MALPRACTICE ISSUES
Some malpractice problems are rare, but most periodontal missteps
occur more frequently. Recognizing these common problems can
help avoid them. When practicing periodontics, it is always prudent
for dentists to stay within their reasonable level of competency.
Patients should be referred to the appropriate specialist when there
is uncertainty whether the practitioner possesses the appropriate
level of experience and competency to perform the procedure or
when complications first appear.
1. The most common periodontal malpractice issue involves the
failure to diagnose, treat, or refer periodontal disease processes. Most
malpractice cases center on this issue. To avoid this pitfall, it is
critical to recognize and document the periodontal disease process,
as follows:

768.e36

MEDIATION VERSUS ARBITRATION

BINDING ARBITRATION AGREEMENTS
SMALL CLAIMS CASES
MALPRACTICE INSURANCE
AVOIDANCE OF LAWSUITS
PEER REVIEW
FEDERAL LEGISLATION
Occupational Safety and Health Administration
Health Insurance Portability and Accountability Act
SUMMARY

Scrupulous records, including charting of all significant findings and documentation regarding the taking of x-ray films,
must be obtained.
Appropriate treatment must be recommended and
performed.
Referral to a periodontal specialist should be given if careful,
conservative treatment is unsuccessful.
Monitoring patients receiving long-term maintenance
therapy is especially important. With the aid of a conscientious, well-trained hygienist, these patients can be well
treated. It is important to detect and remove any local irritants (e.g., plaque, calculus). Detailed home care instructions
must be repeated, and any changes must be noted and followed carefully to allow for appropriate care.3,9
2. The other main cause of malpractice actions usually involves
general dentists attempt to treat beyond their level of competence.
Although periodontal surgical procedures are taught in dental
schools, it is important for dentists to be able to discriminate
between surgical procedures they are qualified to perform and those
they are not qualified to perform. Further, when unforeseen problems or consequences arise, the use of a specialist can not only
salvage a case but also can prevent a subsequent malpractice lawsuit.

LEGAL ELEMENTS OF MALPRACTICE

The determination of whether malpractice has occurred depends
on several legal elements. These factors act as signposts in the
American legal system. To prevent lawsuits, it is critical to the

CHAPTER 84 Legal Principles: Jurisprudence

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BOX 84-1 Glossary of Legal Terms

Abandonment: Deliberate desertion of a patient without proper
notice.
Actual damages: Compensation for losses that can be proven to have
occurred and for which the injured party has the right to recover an
amount given for real loss or injury.
Allege: To make a contention in support or denial of a claim or
accusation that has not yet been proven.
Battery: Unlawful and unwanted touching of one person by another
with the intention of bringing about harmful contact.
Beneficence: Practice of doing good; an act to benefit the patient.
Compensatory damages: Compensation to replace the loss caused by
the wrong or injury.
Deposition: Testimony that is made under oath, but not in open court,
by a party or witness in response to oral examination and that is
recorded by a court reporter.
Discovery: Methods used by parties to a civil or criminal action to
obtain information or evidence held by the other party that is
relevant to the action.
Expert witness: Professional who has knowledge not normally
possessed by a layperson or other professionals regarding the topic
that they are to testify about.
Informed consent: Agreement by a patient to undergo a medical or
dental procedure after having an understanding of the relevant
facts, benefits, and risks involved in the performance of that
procedure.
Jurisprudence: The philosophy or science of the law; the knowledge
of the laws, customs, and rights of men and women in a state or
community.
Litigation: A legal action, including all proceedings; a contest in a
court of law to determine and enforce legal rights.
Malpractice: Professional misconduct or breach of duty that results in
injury or damage to an individual.

Mediator: Professional who intervenes between two parties in

disagreement in an effort to reconcile them; a negotiator.
Negligence: Failure to use the degree of care considered reasonable
under the circumstances, resulting in unintentional injury.
90 Notice of Intent letter: Correspondence from a lawyer on behalf of
a client that requires payment or some other type of action; if such
demand is not met, formal legal action will follow within 90 days.
Plaintiff: The party who institutes or introduces a legal action or claim
against another.
Punitive damages: Compensation in excess of actual and
compensatory damage awarded in cases of malicious or willful
misconduct, used to punish the defendant or set an example for
similar wrongdoers; these damages are typically not covered by
professional liability policies.
Standard of care: Degree of ability that is expected in a particular
situation, specifically in the performance of medical, dental, and
legal matters in the community. If the professionals conduct falls
below this level of care, the person is responsible for any resulting
damages or injuries.
Subpoena: Court order requiring an appearance at a certain time and
place to give testimony regarding a certain matter or to produce
records.
Tender: Presentation of proposed legal action to the defendants
malpractice insurance carrier initiating defense proceedings.
Tort: Damage, injury, or a wrongful act done deliberately, negligently,
or in circumstance involving strict liability (e.g., hazardous,
defective products causing injury).
Trial de Novo: A form of appeal in which a new trial is held as if the
previous trial never occurred.

SCIENCE TRANSFER
All clinicians have an ethical and moral obligation to provide the
best possible care to all their patients. This requires a sound scientific basis for decision making; development of the highest
clinical skills coupled with an acceptance of the need, in some
cases, for referral to more qualified specialists; and a commitment
to the patients needs as the center for all treatments. Patients
need to be educated and informed of the value and consequences
of all treatment options and the provision of treatment at the
minimum of the standard of care, which is the same for all practitioners, both specialists and generalists. Standard of care is a
legal requirement and not a hard and fast documented scientific
definition of ideal patient management. It is time dependent and

is the level at which the average clinician in that location should

provide patient care. It is subjective and somewhat ethereal and
may vary in each malpractice case according to the evidence
provided by the defendant and the plaintiff.
Thorough and detailed documentation of the patients status
is essential. In periodontics, the lowest level of acceptable documentation of periodontal status should include the recording of
pocket depths on six location for each tooth; the noting of abnormalities in gingival margins and quality, including bleeding and
suppuration; the inclusion of tooth mobility and occlusal abnormalities; and evaluation of plaque levels.

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PART 9 Complementary Topics

Figure 84-1 Patient was not diagnosed as having periodontitis. Radiograph shows bone loss, subgingival calculus, and furcation involvement.
Failure to diagnose and treat periodontal disease falls below the standard
of care.

practice of periodontics that these legal elements are followed and

are not violated.

Standard of Care
Standard of care is the primary element in determining malpractice
suits. Two major components must be considered, as follows:
The care rendered to a patient must be given with the same
skill, expertise, and comprehension as would be provided by
a comparable practitioner in the dental community.
The results of the treatment must be equivalent given the
limitations of the case.
It is important to note that general practitioners are trained to
perform many periodontal procedures, but their legal standard of
care must also be equal to that of a periodontist.
The care given to patients being treated for periodontal disease
encompasses many areas. First, an accurate diagnosis is essential,
and then an appropriate treatment plan, including etiology and
prognosis, must be formulated. Traditionally, treatment is divided
into three phases: nonsurgical therapy, surgical therapy, and the
maintenance phase. All must be performed satisfactorily and to the
standard previously cited. It is common knowledge that dentistry
is not a perfect science; therefore, outcomes of treatment do not
need to be ideal to conform to the standard of care.9 Treatment
rendered below the standard of care is considered negligence and
can become grounds for a malpractice action. It is incumbent on
each dentist to make sure that every patient is treated with the skill
and care to ensure a satisfactory result (Figure 84-1).

Informed Consent
Informed consent is the other primary issue in any malpractice
lawsuit. Before patients can be treated, they must give informed
consent. The reason for obtaining consent involves the concept that
patients are active partners with the clinician in their own care.
They must feel comfortable and safe with their choice of treatment.
To give consent, the patient needs to be given all appropriate
information by the dental office under the auspices of the dental
practitioner. The consent has the following five areas:
1. There must be an understanding of the problem, that is, a
diagnosis.
2. The proposed treatment and any alternative treatments must
be fully explained.
3. No warranties or guarantees should be given.

Figure 84-2 Patient must be informed of all possible cosmetic sequelae

after periodontal treatment.

4. Authorization must allow for a change in plan if unforeseen

circumstances arise.
5. Discussion of all sequelae and side effects must be given.
The consent can be verbal or written, but it must be fully understood by the patient.4 More recently, many practitioners are using
videos to explain the informed consent to be sure the patient is fully
informed. When such a video is shown to the patient, documentation that the video was shown should be made in the treatment
chart. Lack of informed consent is a cause for malpractice action,
and without it, battery (unlawful touching) can be alleged. In practical terms, this means physically or emotionally harming the
patient. The dentist must never perform any procedure on a patient
without first receiving consent from the patient (Figure 84-2).

Beneficence
Beneficence is the legal concept that refers to providing the patient
with the best possible care. If the practitioner is unable to do this,
the patient must be referred to a competent specialist for continuing or more advanced care. General dentists are currently treating
more patients with mild-to-moderate periodontal disease, so they
must ensure that treatment results or outcomes are at an acceptable
level.
As of 2005, there were 4937 periodontists in the US, and they
currently perform the bulk of the periodontal specialty procedures.1
All cases in which there is any question as to the degree of difficulty
or outcome should be referred to the appropriate specialist. It
appears that the most significant roadblocks preventing appropriate treatment seem to be the patients anxiety, fear, lack or education
and lack of acceptance of being referred.2 Regardless, dentists must
use periodontists as treatment partners to avoid legal pitfalls
(Figure 84-3).

Abandonment
Abandonment or desertion of a patient is a breach of the legal
standard of care. Not all professional relationships are tenable. In
some situations, the dentist and patient cannot agree on treatment
strategies or goals, but patients cannot be dismissed during the
process of active treatment. Therefore it is important to understand how legally to dismiss or stop treating a patient. Any discharge should be in writing and well documented and sent by
registered mail, return receipt. Dismissal requires the following
four elements:
1. The dentist must state a reasonable cause for the dismissal.
In the US, the Americans with Disabilities Act, a federal

CHAPTER 84 Legal Principles: Jurisprudence

768.e39

BOX 84-2 Essential Components of Record Keeping

Figure 84-3 General dentists should refer complex surgical procedures,

such as periodontal plastic surgery, to the appropriate specialist.

statute enforced by the US Department of Justice, prevents

the dentist from discriminating against any disabled group.
2. The dentist must provide the patient with the names of three
competent new caregivers such as a private dentist, dental
school, or dental clinic/group.
3. A time frame for dismissal is required (usually 30 days). Also,
the dentist must state that emergency treatment will be
provided while the patient finds a new dentist during the
30-day period.
4. The dentist must inform the patient that all records (or
copies) will be forwarded to the new caregiver. (Nominal
clerical fees for forwarding the records may be charged, but
this is not recommended when the discharge is due to a
relationship that has deteriorated.)

Record Keeping
Records are the most important piece of evidence needed in the
defense of a dental malpractice lawsuit. Written records, including
medical and dental history, chart notes, correspondence, informed
consent, insurance request, and billing statements, as well as radiographs, photographs, and models, are the only available guidelines
from which to determine the accuracy of what transpired at the
time of treatment. Because they are written contemporaneously
with the treatment, it holds the most weight in a he said/she said
argument regarding what occurred on a specific date of treatment.
As a result, meticulous treatment records should be kept (Box
84-2). All records must be contemporaneous, and they must be
signed and dated by the author of the entry. Legally, because a professionals written records carry more weight than a plaintiff s (patients)
recollections, the importance of keeping good records cannot be
overestimated.10 If something is documented in the chart, it is
deemed to have occurred. Conversely, if it is not documented, it is
difficult to establish the event. The alteration of any records typically increased the value of the case and also commonly results in
an adverse verdict. Also, punitive damages can be awarded to punish
the dentist in these circumstances (see later discussion).
Radiographs are important records. Appropriate radiographs
are needed to diagnose and document a case properly. Their
number and timing depend on the severity and activity of the case.
The US Food and Drug Administration (FDA) issued guidelines
advising full-mouth or panoramic x-ray surveys approximately
every 5 years. Bite-wing films taken approximately every 12 to 18
months are sufficient to illustrate periodontal disease and its
changes.

Medical and dental history

Chart notes and results of examinations
Professional correspondence
Insurance requests
Billing statements
Informed consent
HIPAA release
Radiographs
Model, photographs

PRACTICAL COMPONENTS IN LITIGATION

Once a malpractice lawsuit is filed against a dentist, a complex legal
maze is opened. A dental practitioner needs the help of a competent attorney who specializes in dental malpractice litigation. The
legal process moves more quickly now than it has in the past.
Courts typically place a case on a track in which the case will typically be brought to resolution either through mediation, arbitration,
or trial within 12 to 14 months. A calm, experienced attorney is
important to guide the dentist through this stressful period. Most
lawsuits are won by the dentist, and those that are settled before a
court trial can have their costs defrayed by appropriate dental
malpractice insurance. The best defense is avoiding the lawsuit in the
first place.

LEGAL PROCESS
The legal process starts when a patient perceives a poor treatment
outcome and cannot obtain satisfaction from the dentist. A plaintiff s (patients) attorney is hired, who first investigates the case. All
the dentists records will be subpoenaed (legally requested) and
reviewed by the plaintiff s expert dental witness, who is usually a
dental specialist. The review, along with the information from the
dentist, determines if formal legal action is warranted. If warranted,
a letter of demand will be sent to the dentist requesting an amount
of money to repair the alleged damage and to compensate the
patient for the pain and suffering allegedly endured.
At this point the dentist must tender, or report, the malpractice
action to the malpractice insurance carrier.10 If timely notice to the
insurance carrier is not made, the insurance carrier may deny coverage for the claim. The insurance carrier will start its own investigation to determine how best to defend the case and whether a
resolution should be explored. The dentists input is needed to assist
the insurance carrier with evaluating the case from the outset.
Often times, insurance carriers have dental consultants that provide
preliminary reviews of the case. An important decision for the
practitioner involves the right to demand that the case be defended
all the way to a judicial or courtroom verdict, rather than allowing
the insurance company to settle the case for a reasonable amount
either before the commencement of litigation or during the litigation of the case before the case reaches trial. When a case goes to
trial, the practitioner is expected to be present, since the absence of
the dentist at trial can give a jury the impression that he does not
care enough to be there. Dental malpractice trials typically last 5
to 7 days.
Virtually every insurance policy contains a consent clause. This
means that a dentist must provide consent to the insurance company
before a lawsuit can be settled. In some rare situations in which the
insurance policy does not contain a consent clause, the insurance

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PART 9 Complementary Topics

carrier can settle a case without the permission of a dentist. Also,

in some policies, a hammer clause is included that gives the insurance carrier the authority to settle the case if the company thinks
that the dentist is withholding consent unreasonably. However,
these clauses were seen more often years ago, and they are typically
not seen in todays policies. Also, all awards and settlements are
reported to the National Practitioner Data Bank.6 Individual state
data banks have thresholds below which awards are not reported.
It is often crucial to the dentist that the award be below that
amount because a negative entry in the data bank can hinder applying for a teaching position or receiving hospital privileges. When
a large settlement or judgment is reported, there is a risk that the
State Dental Board will file an accusation against that dentists
license that could result in probation, suspension, or in some rare
instances, revocation.
As the suit progresses, discovery occurs. This involves finding all
other facts pertinent to the case. Records from other prior and
subsequent treating dentists are obtained. Also, medical records can
reveal other problems with the allegedly injured plaintiff. Depositions, or statements in front of a court reporter, are taken under
oath. The plaintiff s attorney will meticulously question the defendant dentist regarding his or her qualifications, competence, and
veracity and the accuracy of the dentists records (see Box 84-2).
The plaintiff s attorney may be adversarial. Depositions are also
obtained from all the experts. The experts usually examine the
patient and the records, and they testify to the standard of care
being met or breached in the case.
When both sides have all the necessary information, the attorneys will attempt to reach a settlement, sometimes with the help
of a court-appointed mediator, who will try to obtain a compromise
from both sides. Another venue for resolution involves binding
arbitration. This is a quasi-court trial process decided by a courtappointed arbitrator or judge. Insurance carriers and attorneys try
to avoid this because it is rarely enforceable, and there are typically
very few outright verdicts for the defense. This arbitration also lacks
the right of appeal. As a result, if the selected arbitrator or judge
makes an error during the course of the quasi-court trial, there is
no right to appeal that error.
If no settlement is forthcoming, the case goes to trial. If a
negative verdict is reached, the court awards monetary damages.
The rule of thumb is to award actual damages, which represents the
cost of re-treatment plus any future needed treatment. This
amount is often multiplied by a factor of three to include an
approximate amount for pain and suffering. Other compensatory
damage amounts involve loss of plaintiff s earnings, loss of conjugal rights, and loss of enjoyment of life. Special damages can be
awarded as well. Punitive damages can also be awarded in more
extreme cases. As the name implies, the court awards these
damages to punish the defendant dentist. These are applicable
only in onerous cases in which the dentist committed fraud (i.e.,
alteration of records), intentional injury was inflicted, or battery
occurred. These awards are not covered by malpractice insurance,
and there is no cap on the amount. Malpractice suits can be very
expensive (Figure 84-4).

MEDIATION VERSUS ARBITRATION

During the course of the defense of a lawsuit, the Court can often
order a case into mediation. Often, the Court can give the attorneys
the option of a Court panel or a private mediation. Over the years,
the private mediators have been more effective, typically based on
their experience handling professional malpractice claims. When
there is a Court panel member assigned, there is little way to

(Perceived) unsatisfactory result

DDS corrects

DDS does not correct

Claimants attorney:
Investigation and/or
demand letter

DDS pays or goes

to peer review

Insurance defends DDS

Insurance settles

Defense lawyer investigates

No settlement
Mediation/arbitration
determine liability/award

DDS loses

Settlement

Court trial

Verdict

DDS wins

Award (actual, compensatory, punitive damages)

Report to data bank

Figure 84-4 Anatomy of a malpractice claim.

control whether that individual mediating the case is experienced

in the dental malpractice field or not.
In previous years, arbitration was popular. However, it is now
rarely used. One of the problems with arbitration is that it is often
difficult to get an arbitrator who is sufficiently experienced to
understand the case. Also, because either party can file a trial de
novo (appealing the result) within 30 days after the ruling, thus
moving the case back onto the path of trial, the number of trial
de novo filings has contributed to parties rarely engaging in this
process anymore. Arbitration can also drive up the cost of litigation
by having to present a case with the expert twice, once at the arbitration, and then again at trial, if the arbitration does not resolve
the case.

BINDING ARBITRATION AGREEMENTS

Many practitioners use binding arbitration agreements in their
office. However, such agreements are only enforceable when both
the dentist and the patient have signed the agreement. Further, in
situations in which the patient and the dentist execute a binding
arbitration agreement at the outset before a consultation is performed, there have been successful challenges to the enforceability
of the agreement over the years. Be aware that binding arbitration
agreements are sometimes problematic in that there is no right to
appeal an adverse result, even where the arbitrator made an error
in judgment. This has been an area of the law that has made some
attorneys uncomfortable with binding arbitrations.

SMALL CLAIMS CASES

Often a patient will file a small claims court case against a dentist
rather than go through the retention of an attorney and proceed
through municipal or superior court. In situations these situations, the dentist is not permitted to have an attorney present for

CHAPTER 84 Legal Principles: Jurisprudence

the small claims court trial, although an attorney prepare the
dentist for the hearing. Most insurance policies cover the defense
of the dentist and any judgment in a small claims court case. It is
important to be aware that a patient, as the plaintiff bringing the
action, does not have the right to file an appeal if he or she is not
satisfied with the result of a small claims court judgment.
However, the dentist, as the defendant, does have the right to file
an appeal if he or she is not satisfied with the Courts judgment.
In situations in which an appeal is filed by the defendant dentist,
he or she can be represented by an attorney at the small claims
court appeal, which is typically filed in the Superior Court in the
same venue in which the original small claims court case was
filed. When a dentist files a cross-complaint against the plaintiff
for monies owed after the plaintiff s filing of the small claims
court case, and an appeal is filed, the entire case is re-tried.
Therefore filing a cross-complaint against the plaintiff in a small
claims case is sometimes not strategically a good idea, unless the
dentist feels very confident about the care rendered to the patient
in the case.

MALPRACTICE INSURANCE
In the US, malpractice insurance is essential for all practitioners.
The cost of premiums spiralled out of control in the 1980s.11
Organized dentistry has been instrumental in helping enact legislation to contain costs. Many states now have a law, the Medical
Injury Compensation Reform Act (MICRA), that places a monetary cap on noneconomic awards. In 2005 in California, the
amount was $250,000. Insurance covers the costs of the defense,
as well as any awards to the plaintiff. It is important to use the
insurance companys expertise very early in the process. The
dentist should have no further contact with the patient once
the lawsuit is initiated. The dentist also must start a separate file
in communicating with the attorney because these attorneydentist communications remain protected by the attorney-client
privilege.

AVOIDANCE OF LAWSUITS
All lawsuits are detrimental to the practitioner and the profession.
Not all treatment outcomes are satisfactory to the patient, so dentists must make every possible attempt to educate patients and
make them comfortable. Many lawsuits are not initiated because
of an honest mistake; rather, they occur because the dentist was not
empathetic, frank with information, or helpful in correcting the
problem. A poor bedside manner is a key factor in the initiation of
many lawsuits.
Further, money is an important factor in the initiation of a
malpractice action. When a patient is truly injured or believes
that he or she was damaged, collection of the patients fees by
the dentist must be carefully scrutinized and is rarely recommended. An appropriate refund, reduction of fees, or even paying
out of pocket to repair real or perceived damage is a practical
alternative to years of litigation. Remunerating patients is not
viewed by the legal community as an admission of guilt; rather, it is a
form of goodwill or compromise. However, it is important that a
signed release be obtained from the patient at the time the refund
is made. Otherwise, a refund absent a signed release could be
construed as an admission of liability or wrongdoing if a lawsuit
is filed. Also, sending a patient account to collections can trigger
a lawsuit. If there is a pending dispute between the patient

768.e41

and dentist, referring a patients account to collections is not

recommended.

PEER REVIEW
Peer review is another alternative to the legal process. Local dental
societies have a panel of impartial, expert dentists (peers) who will
review cases for member dentists. Their goal is to mediate a satisfactory solution for both the patient and the dentist. They are not
interested in assigning blame, only in correcting the problem. If
they decide that the dentist has improperly treated the patient, they
award the amount of money needed to rectify the problem. This
amount is not covered by insurance but may be well worth the cost.
However, a downside to the process is that there have been some
occasions where the State Dental Association has filed a lawsuit
against the dentist to enforce the peer-review finding in which the
dentist refused to comply.

FEDERAL LEGISLATION
Occupational Safety and Health Administration
The Occupational Safety and Health Administration (OSHA)
enforces federal legislation designed to protect workers in all industries. Dentistry is of special concern because of the danger of infections. OSHA legislation covers the following four areas8:
Universal precautions and blood-borne pathogens
Hazard communication
Waste management
Illness and injury prevention
These regulations have a significant impact on the workplace
and definitely make the dental office safer. The American Dental
Association (ADA) has partnered with OSHA to ensure that dentists can follow the regulations in a practical manner. Violations
can result in fines.
The Centers for Disease Control and Prevention (CDC) in
Atlanta issued an update for office infection control in 2004.7

Health Insurance Portability and

Accountability Act
The Health Insurance Portability and Accountability Act (HIPAA)
is federal legislation designed to reduce health care administrative
costs. With the increase of electronic data interchange, patients
protected health information must be in standardized form and
carefully protected. HIPAA includes the following three
standards:
Electronic transaction standard
Privacy standard
Security standard
HIPAA is enforced by the Office of Civil Rights.5 These regulations have a significant impact on the office workplace and are
important in protecting patients privacy. Again, violations can
result in fines.

SUMMARY
Untoward or unsatisfactory outcomes can occur when treating
dental or periodontal patients. Dental practitioners must be aware
of the legal elements of malpractice, and they must strive to prevent
their treatment from falling beneath the standard of care. The legal
process is difficult and stressful to navigate, so it is best to avoid
this whenever possible. A system of jurisprudence exists to determine liability and to award damages.

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REFERENCES
1. Christensen G: What is the role of specialties in dentistry? J
Am Dent Assoc 134:1517, 2003.
2. McGuire MK, Scheyer ET: A referral-based periodontal practice: yesterday, today, and tomorrow, J Periodontol 74:1542,
2003.
3. Position statement and guidelines for soft tissue management
programs, 1996, www.perio.

4. Sfikas P: A duty to disclose, J Am Dent Assoc 134:1332, 2003.

5. www.aspe.hhs.gov.admnsimp/
6. www.bhpr.hrsa.gov/dqa/
7. www.cdc.gov/oralhealth. (Accessed March 8, 2010)
8. www.osha.gov. (Accessed March 8, 2010)
9. www.perio.org/resources-products/pdf/parameters.pdf.
(Accessed March 8, 2010)
10. www.thedentists.com. (Accessed March 8, 2010)
11. www.kamelandmaxwell.com (Accessed March 8, 2010)