A foreseen fracture

Mr G attended an emergency appointment complaining of acute pain in his upper left quadrant. The dentist identified a carious cavity at tooth 26.

Having undertaken a thorough examination,including vitality testing and exposure of a periapical radiograph, a diagnosis of irreversible pulpitis was made. The dentist noted the curvature of a disto-buccal root,which appeared from the radiograph to be in very close proximity to the floor of the maxillary sinus.

Mr G was keen to have this tooth extracted and the dentist, mindful of her obligation to offer all treatment options, also discussed root canal therapy and suggested that given its complexity, there was also the option of a referral to a specialist colleague.

Mr G was informed of the potential risks and complications of an extraction, and in particular, the possibility of a fracture of the curved portion of the disto-buccal root. The risk of a potential oral-antral communication and the possibility of the retained root being displaced into the maxillary sinus were also discussed. The usual general risks – such as bleeding, bruising and postoperative infection – were explained, with the dentist using the radiograph to support her discussions, so the patient had some visual imagery to help his understanding.

Although the dentist felt competent to extract the 26, she also considered extirpation of the pulp to relieve Mr G’s symptoms, and, as she anticipated a challenging extraction, also discussed the option of a referral to a specialist oral surgeon. However, as Mr G was suffering from acute symptoms, the dentist felt that it was not unreasonable for her to attempt the extraction, and given the circumstances, it was also an appropriate treatment option.

After taking a short time to consider all the information provided, Mr G requested that the dentist proceed with the extraction.He signed a consent form which included information relating to the shape of the disto-buccal root and all the potential risks and complications as discussed with him.

During the attempted extraction, the 26 did fracture and the disto-buccal root remained in situ. A second radiograph confirmed the position and size of the retained root fragment. The dentist did attempt to remove the retained root but was cautious given the high risk of displacing the root into the antrum.Mr G was informed that the extraction was incomplete and that as a piece of the root was retained, it would be necessary to refer him to a specialist colleague.

The dentist provided the necessary aftercare and arranged for a review appointment. During this appointment, Mr G mentioned that he was unhappy about the additional costs that would be incurred in order to complete treatment with the oral surgeon, and asked the dentist to reimburse these additional fees.

The dentist contacted Dental Protection and discussed the case with a dentolegal consultant, who acknowledged the dentist had made comprehensive notes and documented all her discussions with Mr G, including the specific risk of fracture of the disto-buccal root. The records also noted that the patient had declined the option of a referral to a specialist colleague before any treatment had commenced.

Dental Protection advised the dentist that her treatment records clearly reflected that valid consent had been obtained, and whilst the outcome was suboptimal, the dentist had provided appropriate treatment,with a reasonable degree of skill and care, discontinuing the treatment when she felt the removal of the retained root required specialist intervention.

It was agreed that there were strong grounds for the dentist to decline Mr G’s request to reimburse the additional treatment costs, and Dental Protection assisted the dentist in providing an explanation of events in a letter to Mr G. However, while the dentist’s position was strong, it was also suggested that the dentist may wish to consider refunding the fees for the incomplete extraction,purely as a gesture of goodwill to maintain an amicable dentist-patient relationship.

Mr G acknowledged that he had been informed of this possible outcome and had accepted the referral. He also agreed that the aftercare was to his total satisfaction. He accepted the refund of the treatment fee for the attempted extraction and indicated his appreciation of the gesture of goodwill.

Mr G remained on good terms with the dentist throughout, and later informed her that the retained root had been removed uneventfully by an oral surgeon.

Learning points

• By providing the patient with all the treatment options and identifying the advantages and disadvantages of each, along with any associated costs – such as the offer of a specialist referral – a dentist can be confident that the choice made by the patient is properly informed.
• Ensuring all discussions with the patient are recorded contemporaneously allows a dentist to rely on their treatment records to defend their position.
• A dentist should always ensure they are working within their clinical competency and be able to recognise when treatment may have progressed beyond their particular expertise or skillset, and provide prompt referral to a specialist colleague when necessary.
• Whilst in this instance the patient accepted the dentist’s explanation and appreciated the goodwill gesture, if the patient had chosen to escalate their concerns by pursuing a claim for compensation, Dental Protection would have been in a good position to defend against any attempted litigation because of the dentist’s robust treatment records.