Ingested instrument fragment

01 September 2008

Mr K attended his dentist for root canal therapy on an upper incisor. The dentist was using a Gates Glidden instrument in the initial stages of the treatment. As the instrument was being withdrawn from the canal, an additional burst of power was inadvertently applied to the handpiece. This caused the instrument initially to stick on an obstruction in the canal and then to fracture. Unfortunately, the loose fragment could not be located.

The patient was immediately referred to the nearest A&E department for review. It was determined that the fragment was in the gastrointestinal tract. Despite the lack of physical injury to Mr K and a generally friendly and apparently unconcerned attitude on his part, a claim for compensation was intimated.

Analysis and outcome

Mr K’s claim alleged negligence on the part of our member and demanded that the upset and psychological distress suffered by him be addressed.

The dentist consulted the MDDUS. It was determined that the risk of instrument failure in such cases was well known and foreseeable. The dentist had taken no precautions to prevent such an event or any consequent injury to the patient. We advised that the claim could not be defended and should be settled.

Key points

• Conduct risk assessment on relevant treatment.
• Take action to eliminate risk of inhalation or ingestion.
• Keep records of all discussions with patients regarding potential risks and benefits.