Lost root claim goes to trial

Paula Conwell, Litigation Solicitor at Dental Protection explains how a specialist expert assisted in a case concerning a delayed extraction. 

Miss O attended her practice for a routine examination. Radiographs were taken and they revealed the incidental finding of a radiolucency around the roots of tooth 15 and 16. She was diagnosed with an abscess and given antibiotics. Treatment options including root canal treatment and extraction were discussed and Miss O opted for root canal treatment of the premolar and extraction of the molar. Antibiotics were again prescribed five days later. 

Nine days later, root canal treatment of the 15 was successfully undertaken. Miss O did not want any treatment for the molar at that time, and she was advised to come back for extraction if she had problems. Almost a year later, Miss O was advised to consider treatment of the 16, which she refused. After a further year, Miss O complained of pain and swelling in the upper left quadrant. Tooth 16 was noted to be tender to percussion and there was some swelling and inflammation in the gum. A periapical radiograph again showed radiolucency around the root apex area and she was again given the option of root canal treatment or extraction.

Due to the potential complexity of the treatment, Miss O was referred to another practitioner within the practice, Dr Q. After reviewing the periapical radiograph Dr Q advised Miss O that the root canals were sclerosed and that root canal treatment could only be completed by a specialist endodontist. Dr Q also noted that the floor of the left maxillary sinus extended over the root of the molar and advised Miss O of the risk of displacement of a root into her sinus during extraction. He advised Miss O that he could refer her to an oral and maxillofacial surgeon for the extraction. Concerned by the potential costs, Miss O declined the referral to either the endodontist or the oral and maxillofacial surgeon and agreed to the extraction with Dr Q on that day. Regretfully, during the extraction procedure the palatal root was indeed lost into the sinus.  

Dr Q immediately referred Miss O to an oral and maxillofacial surgeon, who surgically removed the root under general anaesthetic. 

After the procedure, Miss O wrote to Dr Q demanding $20,000 compensation for costs incurred, ongoing pain and time off work. She alleged that he had failed to advise her that she could opt for surgical extraction of the 16 at the outset and failed to refer her to a specialist in the first instance.

While Dr Q clearly recalled the conversation of consent, review of his records quickly highlighted that while he had gone through all the risks and warnings with Miss O, and documented those clearly, he had documented that she did not wish to save the tooth by seeing a specialist endodontist, and he had not recorded in her records that she had been offered a referral to a specialist for the extraction.

Dr Q contacted Dental Protection for assistance regarding how to respond to the request for compensation. While his records were good on most aspects, the absence of mention of the potential consequences of a displaced root, including the need to see a specialist for remedial care and additional costs this would incur, coupled with the lack of mention of the offer of referral to a specialist, did leave Dr Q vulnerable to criticism by a third party, if the matter escalated.

Dental Protection assisted Dr Q in a letter of response, offering to assist with the out-of-pocket costs once appropriately evidenced. Initially, Miss O persisted in her demand for $20,000 but quickly came to understand that this amount was unreasonable, and an appropriate agreement to cover her incurred costs only was reached.

Learning points

Record keeping issues and failures can arise when discussing multiple treatment options with a patient as it is easy for one point to be missed. This is fully compounded when something goes wrong during the patient care, as we may be distracted due to our concern for patient wellbeing, or even distressed.  

Developing a consistent approach to recording patient conversations in the treatment notes can ensure all relevant information is documented.

Consider involving your staff in writing patient records, as while the responsibility for the content remains with you, the dental practitioner, they can capture detail in real time while you are talking to the patient that you may otherwise omit.