Every year, Dental Protection responds to a number of requests for assistance from members who are facing allegations relating to the delay in identification and referral for management of ectopic permanent canines. All dental practitioners have a duty to monitor the development of the dentition throughout a patient’s childhood and adolescent years and identification of the position of maxillary permanent canines should routinely form part of the dental examination.
Ectopic eruption
The maxillary permanent canines are the most likely teeth to stray from their normal path of eruption. Indeed, the literature suggests that around 1-2% of the population develop an ectopic maxillary canine and the majority of these teeth are palatally displaced. Whilst the aetiology of ectopic canines remains unclear, factors such as family history and abnormality of adjacent lateral incisor (e.g. diminutive size) are associated with an increased incidence of the permanent canine being ectopic.
A delay in identification of the ectopic tooth position can make successful treatment more difficult. Where claims have to be settled, these can result in significant damages being paid; particularly when the impacted/ectopic canine causes resorption or loss of adjacent teeth. Allegations in these cases revolve around the argument that earlier detection would have led to prompt intervention, thereby avoiding the damage or loss of the tooth arising.
If it can be demonstrated, on the balance of probability, that loss of a tooth could have been avoided, the settlement may need to include damages to cover the costs associated with provision of an implant.
The Royal College of Surgeons (FDSRCS) publication, ‘Management of the Palatally Ectopic Maxillary Canine’ provides clear guidance as to the approach that should be undertaken in screening patients for the presence of ectopic canines. Early identification is key and practitioners are advised to be suspicious that a canine is ectopic if it is not palpable in the buccal sulcus by the age of 10-11 years.
When in doubt about the timing of a referral or clinical findings, advice from an orthodontic specialist is invaluable and a record of the advice provided should be clearly noted in the clinical records.
Delayed orthodontic treatment
When there is a delay in the ectopic canine being identified, in turn this can lead to a delay in orthodontic treatment being commenced.
Dental Protection has dealt with a number of cases where, when treatment was finally commenced, the canine tooth was found to be ankylosed. In this situation solicitors may allege the tooth would not have been ankylosed had treatment commenced earlier and the tooth could have been aligned with a routine course of treatment.
Again, claims may include damages for avoidable loss of the canine tooth as well as an implant replacement (if this is a valid treatment option). Delay in referral may also lead to patients claiming they lost the opportunity to receive free, state funded orthodontic treatment. In this situation, patients may also try to claim for the cost of private orthodontic care.
Defending claims
To be in a strong position to defend a claim of this type, the details contained in the records are of paramount importance. It is not uncommon for claims relating to assessment and diagnosis to involve multiple practitioners and a lack of records regarding findings at previous examinations can make it more difficult for other clinicians to understand the full clinical picture and be alerted to any problems that need reviewing.
As a guide, practitioners need to ensure their records are clear and evidence:
• An assessment (including charting) of the developing dentition has been undertaken.
• Any abnormal/delayed development has been identified and any plans regarding monitoring/timing of orthodontic referral are recorded.
• Monitoring and assessment of canine position aligns with current practice and guidance. Both positive and negative findings should be recorded; it is therefore important to note when canines can be palpated in the buccal sulcus, not just the cases where there is a suspicion the canine is ectopic. If there is a valid reason why a clinician departed from the guidance, or why it may not be applicable, it is also important to document this in the records.
• Any issues regarding eruption/development have been discussed with the patient/parent (or person with parental responsibility) alongside any proposals regarding referral. This can be particularly significant if a patient does not return to the practice for several years and alleges they were not aware of the need for a review.
For further risk management advice, members can access our e-learning resources covering topics such as case assessment, clinical records, orthodontics and treating children – visit Prism to find out more.