Hashim Talbot, Litigation Solicitor at Dental Protection, explains how Dental Protection's legal team stepped in to assist a general dental practitioner when an extraction leads to a claim of clinical negligence.
Mrs R, who was in her late 50s, attended her general dental practitioner Dr V complaining of a lost filling from a previously root-filled UL7. It was recorded that what remained of the tooth was probably un-restorable. A periapical radiograph was taken, which confirmed an additional problem of a failed root filling with evidence of chronic infection around the mesial root. The treatment options were discussed with the patient, which were either re-root canal treatment or extraction. The patient opted for extraction.
Dr V also explained that the extraction could be carried out by either himself, or on referral to an oral surgeon. The risk of tooth fracture and the possibility of a surgical extraction was also discussed. Mrs R opted for extraction with Dr V, but when it was carried out unfortunately the tooth fractured during elevation.
Dr V had the benefit of having access to an oral surgeon at the same practice, so oral surgeon Dr G took over the procedure at the same appointment after discussing the options with Mrs R. It was recorded that Dr G elevated the roots out and there were signs of a small oroantral communication (OAC). Mrs R was informed of the OAC and this was repaired at the time by Dr G.
Mrs R returned on numerous occasions for review appointments and with ongoing symptoms of pain since the extraction of the UL7. After three weeks of symptoms, it was deemed necessary for a referral to be made for more specialist care at the local hospital.
Mrs R subsequently attended the hospital just under a month after the extraction of the UL7, with symptoms of a constant ache around the whole side of the face; she was able to eat and drink but with some difficulty due to the pain. She also reported yoghurt running through her nose after eating it, although there were no signs of this happening when drinking.
An OPG taken at the hospital revealed a retained mesial root from the UL7 and in close proximity to the maxillary sinus. Consent was obtained for extraction of the retained root under general anaesthetic. Extraction of the retained root was carried out and the OAC was also repaired during the procedure.
Unfortunately, despite the procedure at the hospital, Mrs R was still experiencing some residual symptoms from the UL7 region. She continued to attend both Dr V’s practice and the hospital for regular review appointments.
Sometime later the patient attended the hospital and a new radiograph revealed a small bony spicule in the healing socket area. A further procedure to recover the spicule under local anaesthetic was completed successfully.
Two months later, the area in the upper left quadrant was noted to have healed. However, Mrs R was still experiencing some discomfort from the area and it was queried whether she was suffering from TMJ myofascial pain dysfunction syndrome. Mrs R continued to attend the hospital for further management.
The patient makes a claim
Mrs R instructed solicitors a few months later and a request for her clinical records was made by her solicitor not long afterwards. A formal Letter of Claim was then served, containing allegations of negligence against both Dr V and Dr G.
The allegations against Dr V included an alleged failure to obtain consent for the extraction of the UL7 and failing to advise of the risk of an OAC developing. The allegations against Dr G related to the alleged failure to remove all of the roots from the UL7. Mrs R claimed that had she been informed of the increased risk of an OAC and a potentially challenging extraction she would have opted for the procedure to have been carried out by a maxillofacial surgeon at a hospital.
How Dental Protection assisted
The Dental Protection legal team corresponded with Mrs R’s solicitors, relieving Dr V and Dr G from having to respond to various requests within stipulated timescales.
Dental Protection carried out a full review of the records and provided an assessment of the claim. A Letter of Response was sent, putting forward reasons why we were disputing liability based on our assessment. Court proceedings were subsequently served on Dental Protection against both members.
Further investigations were carried out, including the instruction of an independent expert with expertise in oral surgery. A defence was subsequently formally served on behalf of both Dr V and Dr G.
Outcome
After serving a formal defence to the court proceedings, the claim was settled for a modest sum of money on behalf of Dr G, due to a retained root being left in situ and delay in having this extracted at the hospital.
Learning points
It is clear that the extraction of the UL7 was going to be a relatively difficult extraction based on the assessment carried out by Dr V. The radiograph showed that there was not a clear margin of safety in relation to the UL7 and the sinus floor, and the risk of an OAC with appropriate warnings would be expected to be discussed with the patient.
Such warnings, including the heightened risk of an OAC developing, tooth fracture and the possibility of needing a surgical approach to recover what remains of the tooth, are always important when extracting an upper back tooth. Giving the patient the option of being referred if it is deemed to be outside the capabilities of a GDP is always recommended.
There were many parts of the treatment that were carried out in accordance with recommended guidelines. The records evidenced that Dr V provided the option of a referral to an oral surgeon for the extraction. The patient opted for extraction of the tooth within a primary care setting. When the extraction did prove to be difficult and there was an OAC that developed, the GDP used the in-house oral surgeon in order for the OAC to be repaired at the same appointment. This multidisciplinary way of working assisted the patient in this situation.
Unfortunately, despite the efforts of both Dr V and Dr G, there were retained roots still in situ, which were found at the subsequent hospital appointment. This is a useful reminder that if a patient continues to have ongoing symptoms from a difficult extraction, regular review appointments are imperative, along with regular discussions with the patient to inform them of your treatment methodology and reasons for taking a certain course of action. Ensuring that all roots have been removed is also important to eliminate a common cause for post-extraction discomfort.
If, as occurred in this case, the patient’s symptoms are not getting any better, prompt referral to the hospital in accordance with the NICE guidelines is often recommended in order to prevent ongoing pain symptoms. It may be that the hospital can carry out further investigations such as an MRI scan to isolate any other potential issues causing the symptoms, which is especially useful if there is an atypical facial pain component to the symptoms.