Is it vital?

Mr R attended a practice as a new patient. He reported no symptoms, although during the examination the dentist noted the large composite restoration at 36, which had a small fracture to one side. The dentist promptly repaired the fracture with composite and placed a note on the clinical records to monitor the tooth.

Mr R returned six weeks later complaining of pain and swelling on the lower left side of the mandible. The dentist suspected periapical periodontitis at 36 and the diagnosis was
confirmed by the periapical radiograph, which clearly showed pathology at the root apices of the 36.

The somewhat unhappy patient was concerned that he would lose the tooth, but was reassured by the dentist that the tooth could be saved by carrying out root canal therapy, although she did also advise that extraction could still be an option.

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

The dentist had previously noted the curvature of the mesio-buccal root and suspected the canals may be sclerosed. She mentioned to the patient that the mesiobuccal root could therefore be difficult to navigate and could compromise the quality of the root canal treatment.

During the canal preparation phase of the treatment, a file fractured in the mesiobuccal canal. A radiograph confirmed that approximately 12mm of the file remained in the root and about 3mm of this was beyond the apex. The dentist was unable to retrieve the fractured file and informed the patient about what had happened. She explained to the patient that instrument breakage was a recognised complication – particularly in curved roots. Mr R became upset when it was suggested that he would now need to see a specialist to complete the treatment. He left the surgery before the dentist could place a temporary restoration, saying that he no longer trusted her.

She did not hear anything further from Mr R, until she received a treatment plan and cost estimate from a specialist endodontist whom the patient had seen. A few days later, the dentist also received a letter from the regulator, notifying her of Mr R’s complaint. The dentist immediately contacted Dental Protection for advice.

The discussion of the case with one of our dentolegal consultants was a good opportunity for the dentist to reflect on the incident. She realised that she could have undertaken further investigations prior to repairing the fractured composite – such as a vitality test, and if this was negative, considered a periapical radiograph to check for any periapical pathology. This would have revealed the existing pathology at 36, at which point discussions could have taken place with Mr R, potentially avoiding the symptoms experienced by the patient some weeks later.

The dentist also noted that she had not followed her normal routine of discussing all the risks of endodontic therapy with the patient. She had been eager to commence treatment given the patient’s symptoms, and had cut short the conversation about the risk of instrument fracture in a sclerosed canal, meaning that she wasn’t possibly as clear as she would have wished, and had also not offered a specialist referral.

The precipitating trigger for the complaint was the broken instrument, but the other predisposing factors also contributed to this outcome. The fractured file in isolation may not have incited such an uncompromising response from the patient if he had been fully informed, and if the diagnosis had been made at the time of the initial examination appointment.

Dental Protection provided support and advice to the dentist throughout her case, and covered the costs of the remedial treatment with the specialist.

With our advice and guidance, the dentist was able to demonstrate to the regulator that she had reflected on the case and had learned from the experience and applied that learning to her daily practice. This included clinical aspects of care, as well as consent and effective communication. As a result, the regulator took no action.

Learning points
The dentist has a responsibility to carry out a thorough assessment of a patient’s oral health at the time of the initial examination and prior to any treatment, including applying any special tests. In this case, vitality tests could have been carried out, which would likely have prevented the unfortunate sequence of events.

Providing the patient with the necessary information – such as all treatment options available, along with the advantages/disadvantages, risks and consequences – enables the patient to make an informed decision over what approach they wish to take, and contributes to obtaining valid consent.