The scene
The patient's history, obtained both from contemporaneous clinical notes and practice appointment schedules, showed he was an irregular attender who had been given advice on oral hygiene and the need for intensive periodontal treatment from 2003. However, he failed to attend follow-up appointments on a number of occasions.
He had seen his dentist, a DDU member, in late 2004 complaining of pain from LL8 which was mobile. The dentist prescribed antibiotics and advised the patient on the need for LL8 extraction, but the patient did not consult the dentist again for another eight months, until the pain from LL8 prompted him to return. Our member again prescribed antibiotics and repeated the advice regarding extraction, for which a further appointment was arranged.
This time, the patient did attend, but decided not to go ahead with the extraction.
However, two years later our member noted that now the LL5 and LL7 were also a source of pain and mobile. The patient said he wanted all three teeth to be extracted at the next visit. Our member prescribed antibiotics again, as infection was evident.
After cancelling or failing to attend two extraction appointments, the patient finally underwent the procedure five months later. The dentist, satisfied no swelling was present, removed LL5, LL7 and LL8. The procedure was uneventful and the patient provided with post-operative instructions.
However, the next day, the patient telephoned complaining of severe pain and swelling from the lower left side of the mouth and the dentist saw the patient as an emergency. He noted that the facial swelling appeared to extend down the patient's neck and that the patient complained of feeling generally unwell, with difficulty swallowing. Our member immediately advised hospital admission where the patient underwent surgery on the same day for incision and drainage of the facial swelling.
He was discharged four days later and his condition settled within the following three weeks. He was, however, left with a scar on his neck as a consequence of the drainage.
The patient brought a claim against the dentist for clinical negligence, alleging 11 specific instances of breach of duty together with pain and suffering caused by the infection and subsequent hospital admission.
The outcome
The DDU instructed a consultant oral and maxillofacial surgeon, with recent experience of general dental practice, to examine the patient and consider the allegations of breach of duty and causation.
The claimant's allegations included failure to diagnose and treat a periodontal condition, but our expert identified evidence that the member had provided advice from 2003 regarding oral hygiene and the need for intensive periodontal treatment, following which the patient failed to attend four appointments. He went on to say that when the patient consulted the dentist complaining of pain from LL8, it was reasonable for our member to have provided antibiotics and advised extraction of the tooth, given that it was mobile.
Within the DDU's detailed letter of response, we asserted that it would not be mandatory for a general dental practitioner to take a periapical radiographs prior to making a decision to extract mobile teeth. We argued that it was not reasonable to expect a dentist to undertake a detailed oral examination of a patient with an acute dental infection where the patient was obviously in severe pain and a diagnosis could be made based on clinical features and past history.
On the allegation of breach of duty regarding consent, we pointed out that the patient had given his informed consent for the extractions to be carried out. On the allegation of failure to diagnose and treat periodontal disease, the notes recorded a succession of complaints relating to the periodontal condition and the patient had clearly been provided with oral hygiene advice and recommendations, but then did not attend as requested. There was no responsibility on the dentist to chase up a patient who cancels appointments or fails to attend.
On the basis of the expert opinion received, we maintained that the adverse outcome described in the letter of claim was not a result of any breach of duty on the part of our member and that the severe post-operative infection experienced was a well-recognised complication of dental surgical treatment in all patients. Our member made a timely diagnosis and provided correct advice once the complication was seen. After consideration, the solicitors for the patient confirmed that they were not instructed to pursue the matter further.
This page was correct at publication on 22/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.