Is it vital?

Mr S attended Dr A’s practice as a new patient. He reported no symptoms and simply wished to have a check-up, as he had not seen a dentist for two years. Dr A took two bitewing radiographs to check for caries and assess bone levels. The dentist noted the presence of a large, deep composite restoration at UR6 and made an entry in the clinical records to keep this under observation. No mention of this was made to Mr S at the time.

Mr S returned six weeks later, complaining of pain and tenderness on the right side of the upper jaw. On investigating this, Dr A suspected a periapical abscess had developed at UR6 and the diagnosis was confirmed by a periapical radiograph, which clearly showed pathology at the apices of the roots of the UR6.

Mr S was disappointed that pain and tenderness from this tooth had appeared within a short time of his examination appointment, at which he had been advised that his oral health was good and that he did not require treatment.

Dr A sought to explain the situation and the findings regarding tooth UR6. Treatment options were discussed. Extraction was mentioned as a possibility, but as Mr S did not wish to lose the tooth, Dr A reassured him that the tooth could be saved by carrying out root canal treatment.

Dr A extirpated the diseased pulp and a temporary dressing was placed. Mr S’s symptoms resolved and he returned for the completion of the endodontic treatment at a later date.

At this appointment Dr A noted the marked curvature of the mesio-buccal root of the UR6. The patient was advised that this may cause difficulties in achieving a successful completion of the root canal treatment, but Dr A assured Mr S that the tooth would be preserved.

During the canal preparation phase of the treatment, a file fractured in the mesio-buccal canal.

A further radiograph confirmed that a fragment of the file approximately 10mm in length remained in the root canal.

The dentist was unable to retrieve the fractured file and informed the patient about what had happened.

Dr A explained to the patient that the breakage of a file was a recognised complication of root treatment, particularly in teeth with curved roots. Mr S was unhappy that this had not been explained to him prior to the treatment and became angry when a referral to an endodontic specialist was suggested, on account of the further treatment costs that would be involved.

He left the surgery without allowing Dr A to place any temporary cover on the tooth.

Dr A had no further contact from Mr S until he received a letter of complaint enclosing a copy of a treatment plan, including costs, from a specialist endodontist who had seen Mr S.

Three weeks later Dr A received a communication from the Dental Complaints Resolution Service (DCRS) seeking a response to a complaint from Mr S. At this point Dr A contacted Dental Protection.

The case was discussed with the dentolegal consultant who was handling the case and providing support for Dr A. On reflection Dr A realised that there was some vulnerability in the treatment and advice provided for the patient.

There had clearly been some concern about the condition of UR6 at the time of the examination, which would have justified further investigation such as vitality testing,and consideration of a periapical radiograph. The findings could have formed the basis for advising the patient of the need for further treatment or warning of the possibility of symptoms developing.

Even if further investigations had not been carried out, the fact that there were concerns about the condition of UR6 could have been flagged up to the patient.

With respect to the endodontic treatment, Dr A had not in fact fully discussed the risks of root canal treatment, and despite the root curvature, had inadvertently raised the patient’s expectation that treatment would be straightforward. No mention had been made of the possibility of a file fracture nor that in the event of complications arising and a consequent specialist referral being required, further costs may be incurred. It was noted that in view of the marked root curvature, consideration could have been given to specialist referral.

Although the factor that triggered the complaint was the fractured instrument,this happened against a background lack of understanding on the part of the patient,which was caused by Dr A’s oversight in not fully informing the patient.

The fractured file and a specialist referral may not have created such an angry reaction from Mr S if he had been fully informed of this risk, and therefore prepared for it arising, in advance.

It would also have been reduced if advice on the condition of UR6 had been provided at the time of the examination appointment. The weakness in Dr A’s position stemmed from a lack of valid consent as the patient had not fully understood the risks of treatment – including cost implications –before proceeding.

Dental Protection provided support and advice for Dr A in dealing with the complaint via the DCRS. This included covering the costs of the remedial treatment with the specialist as a gesture of goodwill. The result was that the matter was resolved successfully and no further action was taken by the patient.

LEARNING POINTS
• The dentist has a responsibility to ensure a thorough assessment ahead of the provision of treatment, such as the special investigation of a vitality test in this case, which would have prevented the unfortunate sequence of events.
• Providing the patient with the necessary information - such as treatment options and the subsequent advantages/disadvantages and consequences -enables the patient to make an informed decision over what approach they wish to take, and contributes to obtaining a valid consent.