Disclaimer: The opinions expressed in this article are purely personal and do not represent those of any organisation or committee.
This case involved a nerve injury arising from the placement of two dental implants, resulting in permanent partial loss of sensation in the lower lip. The dentist was charged with an intentional and deliberate departure from the standard of care, specifically for failing to undertake proper planning and assessment, and for failing to monitor and review the patient in a timely manner.
Although the permanent partial loss of sensation was the central issue in the case, it was not expressly stated in the charge. In establishing professional misconduct, the actual harm suffered by the patient is not, in itself, determinative. If it is proven that the standard of care was not met, liability may be established even in the absence of harm. Conversely, where appropriate care has been exercised, a charge will not stand even if harm has occurred. This principle may appear counter‑intuitive to those unfamiliar with disciplinary processes.
The practice of medicine and dentistry is an art founded on science. Success cannot be guaranteed in every case, even when treatment is provided by the most skilled practitioners exercising the highest standards of planning and execution. Clinical practice is a service, not a product akin to a television set that comes with a warranty. Indeed, guaranteeing success may itself amount to professional misconduct, as it constitutes misrepresentation. Where a dentist has received the requisite training to provide a service—in this instance, dental implant surgery—and has properly documented the planning process and executed the treatment with due care, an adverse outcome such as permanent numbness does not automatically equate to professional misconduct.
However, where a dentist is shown to have omitted essential steps in diagnosis or treatment planning, he may still be found guilty of professional misconduct even if no harm ultimately results. The reasoning is that such conduct would be regarded as reckless, with the absence of an adverse outcome attributable merely to good fortune. In such situations, complaints are unlikely to arise, which may in turn give the dentist an unwarranted sense of confidence.
The incidence of altered sensation following implant placement in the mandible has been reported to be approximately 13% within the first ten days, decreasing to around 3% after one year. This is a recognised complication that patients should be informed of as part of the consent process. In the present case, there was no dispute regarding consent. Nevertheless, a patient’s consent to accept a risk does not indemnify a practitioner against liability for substandard care. The central question was whether due care had been exercised in performing the surgery. This case therefore served to clarify the expected standard of care in relation to pre‑operative planning and the documentation required in dental implant practice.
Competency of a General Dentist
The second charge concerned the post‑operative management of the patient. Expert witnesses for the respective parties disagreed on whether a general dentist is competent to monitor recovery from a nerve injury. The prosecution’s expert took the view that a general dentist lacks the training and experience necessary to determine whether a nerve injury will resolve spontaneously or requires surgical intervention. Ultimately, however, no evidence was adduced on this charge, as the respondent pleaded guilty without contest.
Had the respondent elected to proceed to trial on this issue, both parties would have had the opportunity to present evidence either in support of, or in opposition to, the assertion that a general dentist is not qualified to monitor nerve‑injury recovery.
The Dental Registration Act does not prohibit general dentists from performing any specific procedures. That said, the SDC’s Ethical Code and Ethical Guidelines require dentists to practise within the limits of their competence and to refer patients to appropriate specialists when necessary. Unless the Act is amended to expressly define the scope of practice for general dentists, it is unlikely that a Disciplinary Committee could impose a blanket prohibition on general dentists performing particular procedures. A more nuanced and fact‑specific approach is therefore required, with both parties relying on precedent from Singapore or other jurisdictions. The individual training and experience of the dentist in question is also a crucial consideration, as general dentists are not a homogeneous group.
The Disciplinary Inquiry
In this final article on the topic, I wish to address a common misconception regarding the disciplinary inquiry process. Prior to the enactment of the Dental Registration Act in 1999, dentistry in Singapore was regulated under the Dentist Act (Cap 76, 1985 Revised Edition). Under that statutory regime, disciplinary proceedings were inquisitorial in nature, and members of the Dental Board were empowered to cancel a dentist’s registration for a wide range of infractions, including “infamous or disgraceful conduct in a professional sense”.
With the introduction of the Dental Registration Act 1999, disciplinary inquiries became quasi‑criminal and adversarial. The Disciplinary Committee (DC), comprising a Chairman drawn from the Panel of DC Chairmen, a Council Member of the SDC, and another senior dentist or oral health therapist, functions as a neutral and impartial tribunal. The DC is assisted on questions of law by a legal assessor and observed by a lay person representing the public interest.
The respondent dentist is represented by legal counsel, either appointed through a professional indemnity provider such as Dental Protection Ltd or engaged privately. The SDC appoints a prosecutor through a tender process. Each party presents its case in a manner akin to criminal proceedings in the State Courts. As with a criminal trial, the burden of proof lies with the prosecution, and the respondent is presumed innocent unless proven guilty.
The role of the DC is that of an impartial adjudicator, with no vested interest in whether the prosecution or the respondent succeeds. Although DC members are dentists—and often specialists in relevant fields—they are not to assume the role of expert witnesses. Their clinical knowledge serves to assist them in appreciating the nuances of the evidence presented, nuances that may not always be readily apparent to a judge in a conventional court. Nonetheless, DC members must approach each case with an open mind, deciding matters solely on the evidence adduced, and not on assumptions regarding issues that were not raised. In matters of law, they must defer to the legal assessor.
While the Dental Registration Act provides that the DC is not bound by the Evidence Act, respondents retain a right of appeal to the High Court. Accordingly, both the conduct of proceedings and the written grounds of decision must be capable of withstanding judicial scrutiny.
The sanctions available to the DC following a finding of guilt are prescribed by statute and include suspension from practice for periods ranging from three to thirty‑six months, removal from the register, and fines of up to $50,000, guided by the SMC Sentencing Matrix. These sanctions are primarily punitive in nature. In my view, however, there is merit in considering the incorporation of a rehabilitative component in sentencing going forward.
Expert Witnesses
In disciplinary proceedings involving clinical issues, expert witnesses play a pivotal role. The Academy of Medicine Singapore conducts an annual Medical Expert Witness course to prepare doctors and dentists for this responsibility. Although experts are engaged by the respective parties, they are required to act impartially and to provide independent opinions regardless of who has instructed them. An expert’s overriding duty is to the court.
An expert report must set out the expert’s qualifications, identify the literature relied upon, and, where there is a range of professional opinion, summarise the differing views together with the reasons underpinning the expert’s own conclusions.
An expert’s authority derives from objectivity and independence. Experts should confine their opinions strictly to matters within their expertise and remain detached from the outcome of the proceedings. They are not advocates, nor are they “hired guns” for either side. Opinions must be supported by evidence and relevant medical literature, rather than by reputation or seniority alone. The Rules of Court also permit experts appointed by opposing parties to confer, with a view to identifying areas of agreement and disagreement and producing a joint statement summarising those points.
The Respondent
In my experience, respondents generally fall into three broad categories: the indignant, the fearful, and the comparatively rare calm respondent. The indignant respondent is firmly convinced that he has done nothing wrong and feels deeply aggrieved at having to endure the disciplinary process. This attitude often manifests in the tone of exculpatory statements, courtroom demeanour, and impatience during cross‑examination. Such behaviour is typically counterproductive. A respondent appears before a disciplinary tribunal because a Complaints Committee has already found probable cause. A confrontational stance may suggest a lack of insight or remorse and can create the impression that the respondent poses a continuing risk to the public.
Fearful respondents, by contrast, may defer entirely to their lawyers and elect to plead guilty simply to avoid the ordeal of cross‑examination. This approach is similarly unhelpful, both for the respondent and for the disciplinary system as a whole. Clinical cases are seldom clear‑cut, and a thorough examination of the evidence benefits not only the respondent but also the profession and the public. While cross‑examination is undoubtedly stressful, calm and candid testimony may, in some cases, mitigate what might otherwise develop into a career‑threatening episode.
Conclusion
Having served in numerous disciplinary hearings—first as an SDC member and later as Chairman—I have observed that some cases arise from a series of unfortunate events, compounded by a succession of minor yet erroneous decisions that ultimately culminate in serious professional lapses. These cases are often the most difficult to adjudicate. Others, however, involve conduct that clearly amounts to an intentional and deliberate departure from the standard of care and are correspondingly more straightforward to determine. That said, all else being equal, the adversarial system inevitably favours the party with stronger legal representation and more persuasive expert evidence. Regardless, prevention is always better than cure. Ongoing education and training, an ethical mindset that prioritises patients’ interests, respect for patient autonomy and self‑determination, and meticulous documentation can significantly reduce the risk of adverse outcomes.