A fairly simple form may be obtained from the local component of the American Dental Association. You may call (800) 621-8099 for the society in your area.
Present your concerns and offer a resolution that seems fair. The committee addresses inquiries that range from the quality of care to insurance coverage conflicts.
The inquiry will be evaluated for appropriate action or referral (e.g. an ethics violation) and an appointment made for an examination by a minimum of three impartial dentists. You will be given an opportunity to express your concerns in a relaxed setting. You will not see or need to confront the dentist. No decision will be made at that time.
The peer review committee will examine all pertinent information and records, later affording the dentist an opportunity to present his standard of care.
After a review of the proceeding is made by the central committee to insure that all procedures were carefully observed, a notification will be sent to all parties.
If the committee determines that the standard of care was not rendered, it will order that a refund be made, or payment for corrective treatment, if necessary. Dentists must comply with the decision, or risk disciplinary action. Matters of inconvenience, lost time or wages or "pain and suffering" are not considered in the decision.