Lightning Dental is publishing this recurring series built on real dental board complaints and disciplinary actions. It is designed to help general dentists reduce risk, strengthen their documentation practices, and reduce their exposure to potential dental board complaints.
Case Study 1: SRPs Ordered Without Sufficient Support
A dentist billed for scaling and root planing (SRPs) based solely on pocket depth measurements. But during the state dental board’s initial review of the patient complaint review, the board noted the absence of radiographic bone loss, no clear periodontal diagnosis, and missing supporting data such as bleeding on probing or recession. According to ADA radiographic guidelines, pocket depth alone is not a sufficient indicator of periodontitis.
The board determined that the treatment was not clinically justified. The patient’s condition was more consistent with gingivitis, which does not meet the threshold for SRPs. As a result, the dentist was sanctioned for misdiagnosis and inadequate charting.
This scenario is increasingly common in dental board complaints. It is imperative that records clearly reflect the rationale behind treatment decisions as this is a frequent source of dental board oversight; it’s also why our dental charting software is purpose-built to provide a fast and thorough platform for dentists.
Why This Matters: Periodontal Charting Requirements Are Often Mishandled
Of all diagnostic categories, periodontal disease is among the most frequently misdiagnosed. Boards look for compliance with periodontal charting requirements and want to see a clear connection between clinical findings and diagnosis.
What board reviewers expect:
- A definitive periodontal diagnosis supported by clinical and radiographic evidence
- Documented rationale for SRPs within the progress notes
- Adherence to dental charting best practices and current dental record keeping guidelines
Key clinical details to include:
- Pocket depths
- Bleeding on probing
- Bone loss confirmed by radiographs
- Recession
- Mobility and furcation levels
- Interpretation aligned with ADA radiographic guidelines
The most defensible records follow a clear logic: findings → diagnosis → treatment plan. When vague notes or missing data cannot support that logic, dentists often find themselves facing potential problems.
Case Study 2: Staff Credentialing Gaps
In this case, a dental assistant who took radiographs was found to have no license. The board held the dentist-owner responsible, noting that there was no clear process for monitoring or confirming staff certifications.
In the board’s view, dental assistant certification is no longer something that can be handled informally. Boards expect dentist-owners to verify credentials and document this process. Failure to do so — even unintentionally — can result in sanctions.
Make sure your practice has a documented process for verifying and updating assistant certifications and other credentials. The same applies to dental hygienists. As an initial or a continued employment condition, ask the assistant or hygienist to produce a copy of all required certificates. Receiving only oral assurance without verification can create an avoidable liability.
Key Takeaways
- SRPs must be clinically justified with both periodontal and radiographic evidence — pocket depths alone are not enough.
- The most common issues in dental board complaints stem from documentation failures, not necessarily poor clinical care.
- Accurate, complete periodontal documentation is essential for treatment planning, legal defensibility, and insurance reimbursement.
- Dentist-owners are ultimately accountable for ensuring that dental assistants are properly certified to perform delegated tasks. The same applies to hygienists.
- Practicing risk management for dentists means prioritizing compliance, documentation, and clarity in every record.
Continue Exploring the Dental Board Report
We’re publishing real-world case studies and lessons from dental board complaints to help dentists protect their licenses and improve documentation practices.
- Read our initial Dental Board Report article to learn more about this series.
- Read out latest blog in the series here.
- Check our blog regularly for additional articles on dental charting mistakes and how you can prevent them.
