At the consultation the patient reported having had some discomfort for a while, but that she had been kept awake the previous night. She now "could not touch her back tooth", indicating her upper right third molar.

On examination UR8 was acutely tender to percussion but the other teeth appeared sound. Bitewing and periapical radiographs of UR5 – UR8 were taken. These revealed a large carious lesion in UR8. A diagnosis was made of acute apical periodontitis due to caries and irreversible pulpal pathology. The patient was given the option of root filling and restoration, but requested extraction of the tooth, which the dentist then carried out under local analgesia. The agreed private fee was paid.

The patient contacted the dentist again the following Saturday afternoon requesting a further emergency consultation. She still had no NHS registration but stated she was still in some pain. The dentist agreed, as a gesture of goodwill, to see her on a private basis but without charge.

In the surgery the patient now complained of poorly localised pain in the right side of her mouth that responded to hot and cold. On examination none of the upper or lower teeth were tender to percussion but UR6 gave a positive response to an ice stick, with lingering pain. A fracture line was clinically visible in this tooth and the evidence of a pulpitis suggested that this communicated with the pulp. As previously, the dentist gave a choice of root canal filling and restoration at a future time, but the patient chose to have the tooth extracted, under local analgesia.

During a subsequent course of treatment with the vocational trainee of the dentist, the patient questioned whether UR8 might have been extracted unnecessarily. The vocational trainee reviewed the radiographs with the patient and discussed the source of the severe pain that she had initially complained about.

Claim made

Over a year later, solicitors acting for the patient began pursuing a claim for compensation. They alleged that the dentist had failed to properly assess the cause of pain on the second visit and that the extraction of UR6 was carried out without adequate clinical evidence that this was the appropriate treatment option. They also alleged that there was a failure to obtain valid consent to the extraction of UR6 as no alternative treatment options had been discussed with the patient.

The solicitors asserted that the most likely cause of the patient’s continuing pain at the time of the second visit was post operative inflammation following the previous extraction at UR8. Application of an ice stick was not considered to support a diagnosis of irreversible pulpitis and the suggested presence of a fracture line was unsupported by radiographic evidence. The solicitors noted that the vocational trainee had at a later time recorded that a number of teeth had superficial fracture lines and it was suggested that the fracture line recorded by the treating dentist was also superficial. Finally the patient was now contending that if she had been aware of the availability of root canal treatment, she would have chosen this in order to avoid losing another tooth.

The outcome

Clinical advice obtained by the DDU confirmed that the hypersensitivity to cold, remaining after the stimulus was withdrawn was a classical presentation of irreversible pulpitis that would require either root canal treatment or extraction of the tooth. It was not a symptom likely to be associated with a nearby extraction socket.

The dentist had recorded within his contemporaneous notes an observation of a crack fracture and this was consistent with a moderate occlusal amalgam restoration previously in UR6.The DDU clinical advice also confirmed that a fracture line in a molar tooth is almost never in the plane of an X-ray beam and therefore a radiograph would not be diagnostic on its own. The ice stick test in conjunction with the previous radiographs and the observed fracture line adequately confirmed the diagnosis made by the dentist.

Whilst the dentist did not specifically record in his contemporaneous notes that root canal treatment was an option for UR6, he maintained that the patient had been made aware of this option. But even if it was ultimately found by a court that the option had not been discussed with the patient, it was considered most unlikely that she would have chosen this, as she was apparently not in a position to fund ongoing private treatment and her ongoing pain was sufficient for her to seek an emergency private consultation on a Saturday afternoon. It was also noted that the patient had previously lost LL6 and UL6, suggesting a preference for extractions rather than conservative dentistry.

With the agreement of the dentist, the DDU used this clinical advice to give a full letter of response denying all liability. After considering this response, the solicitors for the patient subsequently confirmed that they would not be pursuing the matter further.

Management of dental pain

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