When dental work goes wrong, courts aren't the only place where patients can seek recourse.

In California, patients -- and practitioners -- can bring grievances to a tribunal of dentists through peer review. It's a system of sorting out dentist-client spats used by local and state dental associations across the nation.

In peer review, committees made up of local dentistsinterview patients and dentists, review records and even examine patients. After weighing the evidence the committee recommends resolutions for issues like quality of care and appropriateness of treatment.

The process is free for patients and confidential. Each of California's 32 dental societies offers peer review with oversight and assistance from the California Dental Association (CDA), a statewide professional organization for dentists.

Proponents of the process say peer review saves dentists and patients the emotional and financial expense of a legal battle.

They also tout that the system puts experts in charge of judging a case instead of jurors or judges with no dental expertise.

And patients can still sue a dentist if they're not satisfied with the outcome of a peer review case.

Dr. John Alexander, a Bakersfield general dentist and the chairman of peer review for the Kern County Dental Society, believes the process is fairer to everyone involved than a legal rumble.

"Somebody has to help these people -- help not just the patients but the dentists -- to get together and try and resolve their issues," Alexander said.

LIMITATIONS

But the peer review system has limitations.

Patients can only request a peer review case for a dentist who belongs to the CDA, which claims nearly three-fourths of California's dentists -- 71 percent -- as members.

Unlike damages awarded in civil court, peer review committees can only ask a dentist to pay for the cost of corrective treatment or to give a patient a refund. And a peer review committee won't take on a case if the matter is already in litigation. A peer review case stops if a lawsuit is filed during the process.

Ultimately, a peer review committee cannot force a dentist to pay up or abide by its suggestions. Dr. Henrik Hansen, chair of the CDA Council on Peer Review, said that's because the CDA is only a professional association; it doesn't license dentists or have legal authority over them.

However, Hansen said the CDA Code of Ethics requires members to follow "reasonable requests of councils and commissions," including peer review findings. Hanson said the CDA can discipline dentists via their membership to the association, including expelling them.

From 2010 to 2013, the CDA opened an average of 230 cases a year for peer review. But it's unclear how many dentists those cases are against. Alicia Malaby, CDA director of communications, would not clarify on average how many dentists have cases opened against them in a given year.

"CDA has provided you with the information that we make public regarding the number of peer review cases opened each year and the number of dentists who fail to provide records or comply," she wrote in an email.

According to the CDA, only about four dentists a year disregard a final peer review decision or refuse to provide records at the beginning of a case.

"The vast majority of dentists recognize the value of the peer review system, because frankly, getting it resolved in peer review, whether the finding is against the dentist or not, is a whole lot more pleasant than having to spend time and aggravation going to court," said Hansen, a general dentist with a practice in Fairfield.

And even dentists who hesitate to cooperate with peer review sometimes fall in line when they are referred for discipline to the CDA Judicial Council, the body that enforces the association's code of ethics, Malaby said.

HOW IT WORKS

Nationwide, patients spur most peer review cases, according to an American Dental Association report on 2007 data.

The report found that nearly 97 percent of cases were started by patients and only 2 percent by dentists. Less than 1 percent of cases were initiated by a third party carrier.

Alexander said local patients most often learn about peer review if a subsequent dentist notices something amiss with a patient's past work and recommends it.

Sometimes patients are referred to peer review by attorneys because their case isn't severe enoughfor a lawyer to take on a contingency basis, Hansen said. And, he said, the state dental board has even referred cases to peer review.

Like a civil case, peer review has time limits. A patient must request it within three years of the treatment's completion, or within a year after the problems were discovered.

To start a case, patients call the California Dental Association. The association has eight full-time staff dedicated to peer review.

Then a CDA staffer informs the dentist of the situation and encourages him or her to reach out to the patient, Hansen said.

"Sometimes the dentist is totally unaware that the patient is unhappy" and can work things out with the patient, Hansen said.

Cases deemed appropriate for peer review are referred to local dental societies.

SORTING THROUGH THE FACTS

A local peer review committee must have at least three members examine each case.

The average peer review process takes five to eight months, according to the CDA. A case may be passed on to another dental society if there is a conflict of interest or if there are not enough local specialists involved in peer review to critique a speciality dentist's work, such as an orthodontist or prosthodontist.

Before a committee sends its recommendation to a patient and dentist, at least one of the 12 volunteer dentists from the CDA Council on Peer Review assesses the decision.

The state-level council members can accept, modify or reject a local decision. Hansen said overturning a local committee's recommendation is "extremely rare."

And according to Malaby and Alexander, the resolution of cases is split evenly in favor of dentists and patients.

Patients and dentists who aren't satisfied with the outcome of peer review can file an appeal within 30 days. And patients can still call an attorney or head to small claims court.