Jurisprudence in Dentistry

Dr. Neetu Gupta

PG Public Health Dentistry

1
Contents
 Definition
 Important terms
 Law: Definition & classification of law
 Commonly used words
 Legal vulnerability in Dental practice

2
 Ethics:
 A discipline dealing primarily with moral
duty, conduct, and judgment.

 These are standards of behavior which we

choose to accept for ourselves – not those
imposed by some other authority.

3
Jurisprudence:
 The philosophy of law or a system of laws.
 It deals with the essential principles of law
and legal system.

 Laws are the minimum standards established

by the state.

4
Dental Jurisprudence:
 The system of law applied to dentistry.

 The dentist and the practice of dentistry are

controlled by many laws on the federal, state
and local level.

5
Risk Management:

 The steps taken by dentists to prevent a

patient from bringing legal action against
them.

6
Ethics & Jurisprudence Compared
 Level #1 – A system of law established by society.
These represent a minimal standard of acceptable
conduct.
 Level #2 – A professional code of ethics. These are
a statement of conduct the professional organization
has accepted.
 Level #3 – A personal code of ethics. These
represent the highest standard of acceptable conduct.

7
 Conduct may be unethical and
still be legal. But it cannot be
illegal and still be ethical.

8
Professional Ethics:
 Consistently higher than the standards required
by law.

 Voluntary controls, however, everyone entering

into the profession is expected to adhere to these
professional standards.

 Serve as a method of self-policing, and

enforcement of the code is handled within the
professional organization.
9
Personal Ethics:
 Standards which individuals set for
themselves.
 These are our own “inner rules” for acting
responsibly.
 These standards are reflected in the way we
act, the decisions we make and the values we
hold.

10
A Decision is Ethical if:
1- It enhances integrity and self-respect.
2 – It does not bring harm to others.
3 – It builds understanding and dissolves unreal
barriers between people.
4 – It builds a core of genuine confidence in self
and others.

11
A Decision is Not Ethical if:

1 – It results in an illegal action.

2 – It brings harm to others.
3 – A person is exploited and used as an
inhuman object.
4 – If human potential is belittled, damaged,
or ignored.

12
Law, Legality and justice
 Law may be defined as , “an aggregate of rules
enforceable by judicial means in a given country.”
 Law may be said to be a set of rules, recognized &
enforced by the courts in the administration of
justice.
 Legal: Acts done in accordance with law may be
referred to as legal as opposed to illegal.
 Justice: Justice may be said to a standard of action ,
of and on the part of public officials in accordance
with the entire body of law.
13
Classification of law
 Private law: Deals with legal relation between
individuals or group of individuals. Eg: law of
contracts

 Public law: Deals with power of the state or

authority & the relationship between
individuals and the state like in constitutional
law. Eg: Legislation prohibiting smoking in
public places
14
 Classification of law
 Criminal Law pertains when a person commits a
wrongful act against society.eg: a rash or negligent
dental procedure resulting in death of a patient.

 Civil Law pertains when one person sues another for

satisfaction of a personal wrong done to him or her.
Here civil courts provide relief in form of
compensation. Eg: civil negligence of a dentist
resulting in fracture of jaw following extraction.

15
Classification of law
 Substantative law: is the law relating to rights
& duties. Eg: Indian contract Act (1872),
Dentist’s act (1948).

 Procedural law: deals with the means of

obtaining legal remedy . They outline the
procedural aspects of the law process.eg:
Criminal Procedural Code (CPC), civil
Procedural code (CPC).
16
 Commonly used words
 Statue: It is an ‘Act’ passed by the legislative &
assented by the President of India or Governor of a
State.
 Types:
 Declaratory: which merely explains
 Remedial: which confers a right/favour
 Amending: which alters the existing statutes
 Consolidating: which amalgamates existing statutes.
 Codifying: which reduces the prevalent customs
&/statutes to one set of rules
17
 Bill: A ‘Bill” is a draft form of law moved or to be
moved before Parliament or State Legislature. A
Bill when passed by parliament becomes an ‘Act’.

 Ordinance: It is the law promulgated by the

President of India during the recess of parliament
under Article 123 of constitution of India. It is the
temporary measure passed by President under his
legislative power, based on the advice of the
council of Ministers.
18
 Suit: Any legal proceeding of a civil nature
brought by one person against another is
called a suit.

 Jurisdiction: It refers to the place where a suit

can be instituted. Generally it is within the
local limits of where, either
 Defendant resides , or
 Cause of action wholly or in part arise.

19
 Summons: It is the process of court asking
the opposite party to an action to appear and
answer the claim preferred by the party who
has brought the action.

 Warrant : It is issued by a court & directed

to a police officer to make arrest, or search to
do any other act incidental to the
administration of justice.

20
 Cognizable offence: An offence of which a
police officer may arrest without a warrant.
eg: Negligent dental act resulting in death

 Non- cognizable offence: An offence in respect

of which a police officer has no authority to arrest
without a warrant.
 Eg: Simple injury following a dental procedure
like pain or swelling

21
 Bailable offence: In which the accused can be
set free on furnishing a bond or on the
guarantee of the arrested person . Bail can be
demanded as a matter of right. Arresting
police officer has to show reason why he will
not grant bail.

 Non- bailable offence: An offence other than

bailable offence. Certain capital offences
require the accused to be in custody as he may
jump bail or temper with the evidences.
22
 Compoundable: A crime in which a
compromise between the suspected offender
and the victim or his representatives can be
worked out.

 Non – Compoundable: The cases where no

compromise can be made between the
accused and the victim.
Here the crime is of a serious nature & is
against society.
23
 Complaint: Any allegation made orally or in
writing to a magistrate, with a view to his
taking action, that some person , whether
known or unknown has committed an offence,
but does not include a police report.

 Writs: Both Supreme Court & High Court

have writ jurisdiction means they are entitled to
declare a law and set aside any unlawful/
unconstitutional orders, violating fundamental
rights.
24
 Plaintiff (accuser) is a person bringing the
legal action which accuses another of wrong
doing.

 Defendant (accused) is a person whom legal

action is being brought against.

25
 Reasonable (Prudent) Person-A reasonable
person is expected to do those things that are
appropriate in a given situation.

 This includes the use of sound judgment, so that

these actions are fair, proper, just, moderate, and
suitable under the circumstances.

 Malpractice – professional negligence. Failure to

perform one’s professional duties completely.

26
 Negligence – failing to do something that a
reasonable person would do, or doing
something that a reasonable person would
not do.
 Contributory negligence – failure on the
part of the patient to follow the dentist’s
instructions during and after treatment.

27
 Res gestae – Latin term meaning “Things done or part
of the action”
 Statements made spontaneously at the time of the
alleged negligent act are admissible as evidence.

A careless word or statement by an auxiliary can be

as damaging to the dentist as his or her own words.

28
 Res ipsa loquitur
 Latin for "the thing speaks for itself,"

 A doctrine of law that one is presumed to be negligent if

he/she/it had exclusive control of whatever caused the
injury even though there is no specific evidence of an act
of negligence, and without negligence the accident would
not have happened.

 Res ipsa loquitur often arises in the "scalpel left behind"

variety of case.
29
 State Dental Practice Act
 Controls the practice of dentistry only within
that state.

 The primary purpose of the State Dental

Practice Act is to protect the public from
being mistreated or misled from incompetent
practitioners.

30
Provisions of the State Dental Practice Act
 Eligibility for licensure.
 A definition of what is included in the practice of
dentistry within the state.
 Grounds for suspension or revocation of a license.
 Provisions for establishing and maintaining an
administrative board to supervise the practice of
dentistry.
 A means of controlling the assignment of duties,
including extended functions, to auxiliaries.

31
 State Board of Dentistry
 Also known as the State Board of Dental Examiners.
 Primary functions include:
Examine applicants and grant licenses.
Deal with misconduct, incompetence, and related
matters.
Establish and regulate the functions assigned to other
related professionals in dentistry.

32
Reciprocity
A mutual agreement between two or more
states to allow an individual who is
licensed in one state to receive, without
further examination, a license in the other
state entering into that reciprocity
agreement.

33
Grounds for Suspension or Revocation
 Conviction of a Crime

 Unprofessional Conduct

 Personal or Professional Incapacity

34
 Specific Grounds for Discipline
 Permitting unlicensed personnel to perform
dental procedures normally restricted to
dentists.
 Failure to supervise personnel properly.
 False or inaccurate patient records
 Fraud involving reimbursement of patient
expenses by insurance companies of
government programs.

35
 Giving or receiving rebates related to patient fees.
 Transmission of disease by improper sterilization
procedures.
 Improper communication of confidential patient
information.
 Improperly prescribing, handling, or selling
controlled substances.
 Patient neglect or abandonment.

36
Respondeat superior
 “Let the master answer”
In addition to being held responsible for
his or her own acts, under the doctrine of
respondeat superior, the dentist/employer is
also held responsible for the acts of his or
her employees – if that wrongdoing was
committed within the scope of their
employment.
37
Who may be sued?
A dental assistant who is guilty of
negligence is responsible for his or her own
actions, and the injured party may sue both
the dentist and the assistant.

The dentist’s liability insurance will not

cover the auxiliary if they are sued for
negligence!!

38
Levels of Supervision
 Direct supervision – a licensed dentist is present
in the room.
 Indirect supervision – a licensed dentist is
present in the office.
 General supervision – under the direction of a
licensed dentist though not present in the office.
 Undefined supervision – under the direction of a
licensed dentist, but supervision id not defined.

39
 Legal Vulnerability in Dental Practice

Criminal (Quasi- Civil

Criminal)

Tort
Contract

Unintentional Negligence Intentional

Assault & Misrepresentation Defamation Breach of

Battery (Deceit) Confidentiality
40
Criminal & Quasi Criminal Vulnerability
 Violation of statutory law are termed crimes.
 They may be misdemeanors or felonies.
 It includes penalties such as loss or suspension of licence,
mandatory continuing education fines or even jail.

 Violation of administrative laws (rules or regulation of

administrative agencies eg: state board) are termed as
quasi-crimes or non criminal offence.
 Penalties include all as in crimes except loss of personal
freedom (jail).

41
Civil Law
 Contract Law – division of civil law covering
specific agreements between people and
violations of same.

 Tort Law – division of civil law covering the

rights and duties of people toward each other
and wrongs committed in violation of these
rights and duties.
42
 Contract Law
 Those entering the agreement must be legally
competent.
 The act covered by the agreement must be a
lawful one.
 There must be a consideration involved in the
contract.

43
 Types of Contracts
 Implied – A contract is made by certain
actions on the part of the parties concerned,
even though the essentials for a legally
binding contract have not be discussed.
 Expressed – A contract in which there is oral
or written agreement as to the terms of the
contract.

44
Breach of Contract

Breach of contract occurs if either party fails

to keep their part of an expressed contract,
either written or oral.

When this happens the other party may sue

for breach of contract.

45
 Four “D’s” of Tort Law
 Duty – a legal duty must be owed by someone to
another
 Dereliction – the duty owed must have been breached
by the accused
 Damage – the plaintiff must have been hurt in some
way
 Due to – the plaintiff must be able to prove that the
defendant’s action, or lack of, were the proximate
cause of the damage

46
Establishing a Legal Duty

A dentist-patient relationship (legal duty)

does not exist in law until the patient seeks
service from the dentist, and the dentist, by
some words or action, accepts the patient.

47
 Patient of Record
 A patient of record is someone the dentist has
already accepted as a patient.

 The dentist is not legally compelled to accept

or treat a new patient just because an
emergency exists, however, the dentist is
obligated to provide emergency treatment for
a patient of record.

48
TORT
 It may be intentional or unintentional.

 Unintentional: is one in which harm was

not intended.eg: Negligence
 Intentional: It contains the element of
intended harm.

49
 Negligence /Malpractice
1. Professional misconduct
2. Any unreasonable lack of skill
3. Lack of fidelity (faithfulness) in
performance of professional duties
4. Practice contrary to established rules

50
Malpractice May Be Due To:
1. Ignorance or neglect

2. Lack of skill

3. Neglect in applying these skills

51
NEGLIGENCE

 Negligence is a failure to exercise the care

that a reasonably prudent person would
exercise in like circumstances.

52
HOW ARE DOCTORS LIABLE
FOR NEGLIGENCE?

Doctors are liable under 4 heads:

1.Tortious liability
2.Contractual liability
3.Criminal liability
4.Statutory liability

53
1.TORTIOUS LIABILITY (CIVIL LIABILITY)

It is of 2 types:
Primary liability
Vicarious liability

54
PRIMARY TORTIOUS LIABILITY
 When a doctor or dentist is directly liable for
an act of negligence in his clinic or hospital it
is called primary liability.

 Most dental negligence would come under

this category.

 A breach of this duty resulting in injury can

invite a suit for negligence.
55
 VICARIOUS LIABILITY
 The dentists who are employed by a hospital
or institution are often not primarily
responsible for negligence. They may be said
to have vicarious liability through hospital.
 The hospital has the liability for the
negligence of an employee.

56
2. CONTRACTUAL LIABILITY
 In a doctor- patient relationship an implied
contract is established when a doctor accepts a
patient for treatment.
 A breach of any aspect of this implied contract
where the doctor is under duty to:
1. Treat with care
2. Continue to treat and not terminate until patient
is cured or the patient discontinues treatment.

57
 May be considered a contractual liability.
However, in most instances if there is no
written contract their liability will essentially lie
within the realm of tortious liability.
 If there is a written consent than any breach by
the doctor will be a contractual liability.

58
3.CRIMINAL LIABILITY
 This liability normally lies with an identifiable
individual or groups of individual.

 Criminal liability is penal and involves

punishment in the form of imprisonment or fine or
both.

 Criminal negligence is considered to be a crime

against society and not just the aggrieved party.
59
The important offences inviting criminal liability
with regard to negligence are:
Sec 304 A (IPC) – Negligent homicide. A rash or
negligent act resulting in death, e.g. death on the dental
chair.

Sec 336 (IPC) – An act endangering the life of person.

(even if there is no injury), e.g. extracting a tooth for a
patient with valvular heart disease without antibiotic
prophylaxis against endocarditis. (even if he does not
develop endocarditis).

60
 Sec 337 (IPC) – A rash or negligent act causing
simple injury, e.g. pain and swelling after
extraction due to negligent extraction.

 Sec 338 (IPC) - A rash or negligent act resulting

in grievous injury, e.g.. fracture of jaw during
extraction due to excessive or improper force.

61
 4. STATUTORY LIABILITY
 A legal term meaning that someone can be held
responsible for a certain action or omission
because of a related law.
 A doctor or nursing home is liable if there is
any infringement of statutes. They can become
accountable to a statutory body.
 There are many statutes dealing with practice o
doctors and dentists as well as hospitals.e.g.
Tamil Nadu private practitioners Act.
62
Liability can also be classified as:
 General Liability: relates to the
negligence associated with injuries that
result from the physical structures within
the office.

 Professional Liability: relates to injuries

that result from the treatment of patients.

63
 Risk management Principle applied to
malpractice prevention are:
 Do not undertake T/t beyond your ability and training,
even if the patient insists.
 Do not undertake T/t unless patient follows your
recommendation to obtain speciality care.
 Legal risk increases if you undertakes a T/t which
should have been provided by a specialist.
 Legal risk increases if you treat the patient without the
diagnostic aids you recommend.

64
Dentist’s Responsibilities to the Patient
 Must be properly licensed
 Must exercise reasonable skill, care and judgment
 Must do only those things consented to by the patient
 Must refer unusual cases to a specialist
 Must use standard drugs, materials and techniques
 Must complete agreed upon treatment within a
reasonable time
 Must hold inviolate the patient’s privacy
 Must give adequate instructions to the patient.
 Must make a reasonable charge for the services
rendered
65
Withdrawal from a Case or Patient
 Written notification – containing the reason, the
withdrawal date, the need for further care, an offer of
help or assistance, and signature.

 Proof of mailing – letter must be sent certified mail

with a return receipt requested.

 Documentation on file – a copy of the letter and the

signed postal receipt are kept with the patient’s record.

66
Patient’s Responsibilities to the
Dentist
 Must follow instructions during and after
treatment

 Must pay a reasonable fee or a fee agreed

upon between dentist and patient

67
Intentional Tort

1. Tresspass to the person (Assault & Battery):

A threat to harm (Assault) & unauthorized
touching (Battery).

Eg: The use of physical restraints in the T/t of

uncooperative children

68
 Intentional Tort
2. Misrepresentation (Deceit) / Mislead:
Patients must be kept informed of their T/t status.
Eg:
Failure to inform the patient when a file breaks off
in a root canal.
When a fractured root tip remains in the jaw.

Rule:
Never lie to patient about T/t, Keep them informed.
A note on patient’s record should be made & signed
by patient hat patient is informed. 69
Intentional Tort
3.Defamation (Damage the good reputation):
This is not of major concern in dentistry.
Opinion about the patient should not discuss with
others unless it is essential to successful treatment.

4. Breach of Confidentiality:
Information obtained from the patient in the
course of diagnosis or treatment must remain
confidential.
70
 Illegal Practice
 Criminal offense committed by a person not
necessarily dentist or by a dentist in
practicing the profession without first being
authorized in accordance with the Dental Act

71
 Acts constituting Illegal Practice
 Person practicing without a certificate of registration.
 Any person presenting as his own, the certificate of
registration, of another
 Any person who shall give any false or forged evidence to
the Board in obtaining a certificate of registration.
 Any person who shall impersonate any registrant of like or
different name
 Any person who shall use a revoked or suspended certificate
or registration
 Any person who shall use or advertise a title or degree
without having been conferred by a university

72
 Malpractice Vs Illegal Practice

• Committed by a person
• Done by duly licensed who practices the
professional profession without the
• Plaintiff who seeks to professional license
recover damages issued by proper
authorities

73
“Happy patients
don’t sue
their doctors.”

74
Ten Rules of Risk Management
 When in doubt say nothing
 Never say anything that implies a guarantee or
that will give the patient unrealistic expectations
as to the result which the dentist can achieve
 Never comment on the quality of care provided
by your employer or any other dentist.
 Establish a rapport with the patients

75
 Maintain accurate, complete and legible records
(they are the dentist’s best defense!)
 Keep all of your skills up-to-date
 Always perform all of your duties to the best of
your ability
 Be prepared to assist in any kind of emergency

76
 Patient Records
The patient’s dental record, commonly referred
to as “the chart”, provides a chronological
record of, the clinical justification for, treatment
received by the patient.

These records are important legal documents.

77
 Part of the Patient’s Clinical
Record
 Medical and dental histories
 Examination findings and treatment plans
 X-rays (properly identified and dated)
 Any letters from, or about, the patient regarding
treatment
 Copies of prescriptions
 Written consent or refusal of treatment forms
 Notation of broken appointments or any failure to
follow the treatment or advise of the dentist

78
Not Part of the Patient’s Clinical
Record
 Any records that are kept for financial
reasons only
 Financial information such as the record of
charges, payments and the current balance
 Insurance claim forms
 Irrelevant materials, such as post cards
from the patient

79
Guidelines For Clinical Record
Entries
 Use the next available line
 Make the entry as soon as possible after the
patient’s visit
 Date the entry
 Sign or initial the entry to clearly identify who
made the entry
 Make the entry clear, concise, and complete
 The entry must be typed or in ink (blue or black)
 Handwritten entries must be legible

80
 Changes to the Clinical Record
 Never change a chart entry without the doctor’s permission;
however, an error should be corrected as soon as possible
after it is discovered
 Draw a single line through incorrect material. The original
entry must still remain readable.
 Add your initials (to show who made the correction) and the
date (to show when the correction was made)
 On the next available line, explain the reason for the change.
Initial and date this entry.
 On the following line, enter the correct data. Initial and date
this entry.
81
Five Rules for Safeguarding Patient
Records
 Do not allow any unauthorized person to
remove, read copy, or otherwise tamper with
any record at any time.
 Never leave an open file folder on your desk
when an unauthorized person could read it
 Always lock file cabinets and/or rooms
containing files at the end of the day

82
 Refrain from answering queries regarding
patients from third parties such as a lawyer.
Refer all third party inquiries to the doctor
 Do not allow original patient charts to
leave the practice.

83
 The patient chart is created by the dentist
for his or her own use. Under law, these
records are considered to be the dentist’s
property. What the patient pays for is the
dentist’s professional skill in interpreting
these records

84
Professionalism
 No matter what your relationship with the
doctor, always address him or her as
“doctor”
 Adult patients are always addresses using
the more formal, courteous form of address
such as Mr., Mrs., or Ms.
 Always introduce yourself to someone new

85
THANK YOU

86