The scene
A patient attended his dentist in 2009 for the first time in five years for a routine check-up. The dentist, a DDU member, noted that the patient had a fractured carious UR8.
After taking bitewing radiographs, the dentist recommended that the tooth be extracted. At the extraction appointment a periapical radiograph was taken, and the dentist noted that the tooth was badly fractured with no coronal tooth remaining. He administered local anaesthetic and attempted to extract the UR8.
Unfortunately, the tooth fractured further during the extraction. The dentist concluded that the retained root was not retrievable and would require surgical extraction, should the tooth develop symptoms. He noted in the contemporaneous clinical records that he had informed the patient that part of the root remained in the socket.
The patient returned six weeks later, when the dentist recorded that the UR8 was 'a bit sore' and tender to touch. The dentist suspected infection around the area and prescribed antibiotics and referred the patient to hospital for surgical extraction of the retained root.
Some six months later, the patient attended but did not complain of pain at UR8. He told the receptionist that he no longer wanted the hospital referral and asked her to remove the request, which was noted in his records.
In early 2010, just before the DDU member was due to move on to another practice, the patient was seen for his last appointment with the DDU member, who noted 'pain in the UR8. Refer to OMFS for extraction'. This was done but the patient's notes state that he subsequently cancelled the referral, for a second time.
A further two months passed and by now the site had completely healed, with an examination by a different dentist at the practice finding no root palpable and no symptoms. It was only after a further four months that the patient attended with pain and swelling. He was referred and underwent surgical extraction of the UR8.
The claim
The patient brought a claim alleging that the DDU member had failed to undertake adequate radiographic assessment of the UR8 to confirm whether a conventional extraction was appropriate. It was also alleged that the dentist had failed to inform the patient of the position, and failed to take post-operative radiographs to review the size and position of the retained root. The patient maintained he had no recollection of cancelling hospital appointments.
The DDU instructed an expert to review the case. He commented that the dentist had indicated that the patient should be referred to an oral surgeon, who would have been in a position to take post-operative radiographs. Breach of duty was denied on the member's behalf.
In response, the claimant's expert commented that whether to leave a retained root in situ or refer the patient for its removal depends, among other things, on the size of the root and whether any pathology is present. The only way this can be ascertained is by post-operative radiograph, which is usually sent with the referral. The pre-operative radiograph did not, he asserted, show the entire root complex of UR8 that is necessary to determine whether a conventional extraction was appropriate, or whether the patient should be referred for its surgical removal.
The claimant's solicitors further maintained that failure to have a pre-operative radiograph of a third molar that showed the entire root complex and its relationship to other anatomical features, such as the maxillary antrum, was also a breach of duty. On causation, they claimed that if the dentist had fully informed that claimant of the clinical need for removal of the root and the risks of leaving it in situ, a timely referral could have been made and on the balance of probabilities, the claimant would have avoided the ensuing pain and infection leading up to the eventual surgical extraction.
In the member's defence, the DDU argued that the contemporaneous notes clearly show that dentist advised the claimant of the potential need for surgical extraction in hospital, and of the presence of the retained root at the time of the attempted extraction. The fact that this was noted in the clinical record enabled the DDU to mount a robust and ultimately successful defence of the case.
Outcome
Throughout the course of the claim, the dentist's notes were crucial in rebutting the claimant's arguments that treatment had been negligent.
It was accepted that extraction of a wisdom tooth can be complex, depending on the position of the tooth. However, if the dentist considers conventional extraction is possible, the patient is fully informed of any potential difficulties and, should a root fracture during treatment, the dentist explains the situation and further treatment options, the DDU will be in a better position to defend the claim.
The claimant's solicitors threatened to take the claim to court, but because of the strength of the records the DDU continued to deny liability. The claimant's solicitors finally confirmed that the claim had been discontinued - some two years after it was first brought.
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