Video - A failed extraction handled appropriately

Video transcript

David Hartoch: In the following case, a patient went to his dental practice because he was having difficulty eating with a broken tooth. He saw a dentist new to him having already been seen by another associate in the same practice six months earlier.

The new dentist diagnosed deep caries at the lower left seven, and after taking a radiograph to assess the clinical situation, decided the tooth was unrestorable. 

She discussed this with the patient who said the sharp edge was making eating uncomfortable. He did not want treatment because he was not in pain, but requested that the sharp edges be smoothed.

The dentist advised the patient that the tooth should be extracted. 

She explained that she would attempt to remove it, but it was likely to fracture. Three days later, the dentist attempted the extraction and the tooth fractured during the procedure. The dentist attempted to remove the roots and after about 25 minutes decided not to continue. 

She informed the patient about what had happened and referred him to hospital.

Two days later, the patient returned with pain and facial swelling. He was seen by a different dentist who diagnosed dry socket and prescribed antibiotics. A week later, the patient complained about the first dentist. He questioned why she had not prescribed antibiotics earlier and commented that she had been rough during the extraction process. It also emerged that the hospital referral had not been sent.

The original dentist had forgotten.

George Wright: The dentist asked for help from Dental Protection and the clinical records were reviewed by one of our dentolegal consultants, a specialist oral surgeon. She was able to confirm that the clinical records were comprehensive, the consent process had been followed and that the extraction technique was appropriate. 

The dentist was asked if there was any clinical justification for prescribing antibiotics at the time of the extraction. It became clear from the explanation that the patient had been made aware of the risks or potential complications associated with extracting the tooth owing to the extent of the caries and it also became clear that there was no clinical justification for prescribing antibiotics at the time of the extraction. 

David Hartoch: We advised sending a letter to the patient, emphasising he had been made aware of the risks and had consented, the extraction technique was appropriate and the postoperative care was in line with current guidelines. 

The dentist apologised for the delayed referral. The patient took no further action. 

Dr Vanessa Perrott: We strongly advise members to follow a framework such as our ASSIST framework which we cover in our Mastering Adverse Outcomes workshops. This can help you deal with a complaint in an effective way but that's also empathic so that the patient feels that you've understood the reason for their complaint. 

David Hartoch: This case shows it is essential that the patient is informed about and understands what to expect from treatment.   

There should be clear and comprehensive notes about the consent process and the pre and postoperative advice offered to patients, including details of referral and a note to say when it was sent.  In this case, the dentist had acted entirely appropriately, both in her communications and clinical management.  

An apology and explanation can go a long way towards defusing a threat. In this case, the dentist made no attempt to hide her oversight in the delayed referral. With Dental Protection’s help, supported by comprehensive clinical notes, the dentist was able to address the concerns raised to the patient’s total satisfaction.