Tricky extraction leads to hospital admission

Hashim Talbot, Litigation Solicitor at Dental Protection, explains how Dental Protection's legal team stepped in to assist a general dental practitioner when an extraction leads to a claim of clinical negligence.  

Mrs R, who was in her late 50s, attended general dental practitioner Dr V complaining of symptoms from tooth 27. Examination revealed that the distal aspect of the amalgam restoration had fractured with no mobility. A periapical radiograph was taken and revealed deep caries towards the pulp. Treatment options were discussed with the patient, including either re-root canal treatment or extraction. The patient opted for extraction. 

Dr V also explained that the extraction could be carried out by either himself, or referral to a specialist. The risk of tooth fracture was also discussed. Mrs R opted for extraction with Dr V, however, regretfully the tooth fractured during the procedure. 

Dr V had the benefit of having access to a colleague on a surgical specialist training pathway at the same practice. This colleague, Dr G, came into the surgery and took over the procedure with Mrs R’s consent. Dr G elevated the roots out and there were signs of a small oroantral communication (OAC). Mrs R was informed of the OAC and this was repaired by Dr G.

Mrs R returned on numerous occasions for review appointments complaining of ongoing symptoms of pain since the extraction of the 27. After three weeks of symptoms, Dr V referred her to see an oral and maxillofacial specialist at the local hospital. 

Mrs R subsequently attended the hospital just under a month after the extraction of the 27, with symptoms of a constant ache around the whole side of the face; she was able to eat and drink but with some difficulty due to the pain. She also reported yoghurt running through her nose after eating it, although there were no signs of this when drinking. 

Examination revealed an OAC present at the extraction site, and an OPG taken at the hospital revealed a retained mesial root of the 27 in close proximity to the sinus. Consent was obtained for extraction of the retained root under general anaesthetic. Extraction of the retained root was carried out including a buccal flap pad advancement. The OAC was also repaired during the procedure.

Unfortunately, despite the procedure at the hospital, Mrs R continued to experience residual symptoms from the region of the 27. She continued to attend both Dr V’s practice and the hospital for regular review appointments.

Sometime later at a hospital review, a repeat radiograph was taken which revealed a small bony spicule in the site. This was believed to be a contributing cause of her symptoms and consequently, open debridement was carried out and the piece of bone was removed at the hospital.

Two months later, the area in the upper left quadrant was noted to have healed. However, Mrs R was still experiencing some discomfort from the area. A referral was made to an oral medicine specialist to assess and treat the cause as it was not believed to be dental in origin.

The patient makes a claim

Mrs R instructed solicitors a few months later and a request for her clinical records was made by her solicitor not long afterwards. A formal Letter of Claim was then served, containing allegations of negligence against both Dr V and Dr G.

The allegations against Dr V included an alleged failure to obtain consent for the extraction of the 27 and failing to advise of an OAC developing. The allegations against Dr G related to the alleged failure to remove all of the roots from the 27. Mrs R claimed that had she been informed of the heightened risk of an OAC and retained roots, she would have opted for the procedure to have been carried out by a maxillofacial surgeon at a hospital.

How Dental Protection assisted

Dental Protection swiftly instructed a panel lawyer to corresponded with Mrs R’s solicitors, relieving Dr V and Dr G from having to respond to the multiple and various requests, required within stipulated timescales.

Dental Protection carried out a full review of the records and provided an assessment of the claim. A Letter of Response was sent, putting forward reasons why we were disputing liability based on our assessment. The claimant’s solicitors did not agree with this assessment, and the matter proceeded. 

Further investigations were carried out, including the instruction of an independent expert with expertise in oral surgery. A defence was subsequently formally served on behalf of both Dr V and Dr G.

Outcome

After serving a formal defence to the court proceedings, the claim was settled for a modest sum of money on behalf of Dr G, due to a retained root being left in situ and delay in having this extracted at the hospital. Critically, this settlement was made on a non-admission of liability basis. 

Learning points

Retrospective review of the radiographs revealed that the extraction of the 27 was always going to be relatively difficult. The radiograph showed that there was not a clear margin of safety in relation to the 27 and the sinus floor, and appropriate warnings would be expected to be discussed with the patient. Neither Dr V or Dr G discussed the risk of an OAC, nor the potential future treatment this may require, and additional costs that this may occur. 

Such warnings, including the heightened risk of an OAC developing, tooth fracture and the possibility of retained roots, are always important when extracting teeth, as is giving the patient the option of being referred if it is deemed to be outside the capabilities of a GDP. Critically, these warnings also need to be documented in the patient’s clinical records. 

Unfortunately, despite the best efforts of both Dr V and Dr G, there were retained roots still in situ, which were found at the subsequent hospital appointment. This is a useful reminder that if a patient continues to have ongoing symptoms from a difficult extraction, regular review appointments are imperative along with regular discussions with the patient to inform them of your treatment methodology and reasons for taking a certain course of action. Ensuring that all retained roots are also removed by assessing the area is also important.