By Dr Martin Valt, Dentolegal Consultant, Dental Protection.
Mr B presented to general dental practitioner Dr Z at an emergency dental clinic, reporting pain and extra-oral swelling associated with his lower left quadrant. These symptoms had apparently been present for ten days or more, but his condition had significantly deteriorated over the course of the immediately preceding 48 hours.
Analgesics were no longer proving effective, and a degree of trismus had also developed. Whilst the latter rendered clinical examination somewhat challenging, Dr Z was able to identify both 37 and 38 as being grossly carious and clearly beyond restoration. Mr B requested that both teeth be removed immediately. No radiographs were taken, with Dr Z relying on an OPG taken two years previously to assess the proximity of the 38 to the inferior alveolar nerve.
Despite the extra-oral swelling having been documented in the clinical records as “moderate to severe” and the inter-incisal opening apparently having been restricted to no more than 15mm, Dr Z nevertheless considered that he had been able to successfully extract both the 37 and 38 under local analgesia, and accordingly discharged Mr B from his care following the appointment.
Whilst Mr B did not attend or contact the clinic again, a written request for a copy of his clinical records from a solicitor acting on his behalf was received approximately six weeks later. The solicitor also intimated the possibility of a claim for compensation being pursued as being under investigation. It transpired that Mr B had subsequently been admitted to hospital for emergency care two days following the extractions due to increasing facial swelling and difficulty in breathing.
When the hospital records were made available to Dental Protection, these confirmed that, following the intravenous administration of a course of antibiotics, surgical drainage of the left submandibular and parapharyngeal tissue spaces under general anaesthesia had proved necessary, along with transalveolar removal of what appeared to be a retained portion of the distal root of 38. Mr B was discharged from the hospital one week later.
Dr Z’s clinical records were unfortunately extremely sparse. Whilst it might perhaps be considered self-evident that the source of Mr B’s symptoms was an acute periapical periodontitis at the 37, 38 or both, this was not documented. Of far greater significance, these records were not supportive of Mr B having been warned of the possibility of any postoperative complications, particularly that of a spreading cellulitis or breathing issues, arising following the extraction of one, or possibly two, acutely infected teeth under local analgesia in the presence of pre-existing facial swelling and trismus.
No alternative treatment approaches, including that of being referred to an oral surgeon, or oral and maxillofacial surgeon for hospital management from the outset, along with their associated relative benefits and risks, were recorded as having been offered or even considered. Similarly, no consideration appeared to have been given to the provision of a systemic antibiotic or to any aftercare or follow-up arrangements.
Dental Protection was accordingly required to advise Dr Z that each of the above oversights or omissions amounted to breaches of duty of care. In particular, due to the absence of sufficient information having been disclosed to Mr B concerning the potential risk of complications arising out of the proposed treatment and/or any discussion of alternative treatment approaches, his solicitor would without question be able to successfully argue that Mr B was never in a position to give his valid consent to Dr Z undertaking the extractions of 37 and 38 at the appointment in question, despite him having requested that these be carried out immediately.
Beyond this, it was also considered that a suitable preoperative radiograph should have been exposed such that Dr Z would have been better placed to properly assess the likely complexity of the extractions, as the tooth had changed since the previous image. Failure to have done so in this instance amounted to a further breach of duty of care, and it would almost certainly be argued that, had he done so then, at least on the balance of probabilities, the retained root fragment at 38 would not have been overlooked.
Given the loss or harm that Mr B had clearly experienced from these breaches of duty of care on the part of Dr Z, it was considered that it would not be possible to successfully defend the proposed claim for compensation. It was therefore necessary for Dental Protection to settle the claim without admission of liability on Dr Z’s behalf with respect to Mr B’s lost earnings while being treated in hospital and also for a period of avoidable pain, suffering and so-called general loss of amenity.
This case illustrates the fundamental requirement to not only identify any potential complications associated with proposed treatment, but also to communicate these to the patient, along with the relative benefits and risks associated with any other feasible approaches. This information should be clearly documented in the clinical records. Without all this being in place, the dentist is simply not in a position to demonstrate having divulged sufficient information to enable the patient to give valid consent, should they subsequently be called upon to do so. It is also of the utmost importance to appreciate that a patient simply requesting a particular treatment be undertaken at a given time does not in itself necessarily equate to them having provided valid consent.