Case study - Bleeding gums... again

Dental case study concerning the missed diagnosis of a dental abscess

Day 1 Mrs M – a 48-year-old woman – calls her dental surgery to organise a routine check-up and clean and is given an appointment with a newly qualfied associate dentist, Mr A. The patient attends the appointment and complains of swollen gums. She is a smoker and has a history of periodontal disease. Mr A explains how smoking can exacerbate the problem with her gums and Mrs M says she has booked a session with a cessation councillor.

Day 30 Mrs M attends the surgery as an emergency having lost a large filling in UL6. Mr A places a temporary filling and the patient returns two days later for the placement of a crown.

Day 37 Mrs M returns to the surgery complaining of swollen gums, pain and bleeding localised around UL6. On examination Mr A finds that some excess cement was left in place when the crown was fitted and admits that this might be exacerbating her pre-existing gum condition. He removes the cement and cleans the area and prescribes a chlorhexidine (CHX) mouthwash.

Day 65 The patient attends the practice again complaining of bleeding gums. Mr A finds bleeding on probing and gingival inflammation throughout the mouth. Mrs M states she has recently quit smoking and the dentist explains that bleeding is a sign of improved blood flow to the gums and this is normal. He reassures her that the bleeding should soon settle if good oral hygiene is maintained and cigarettes are avoided. He prescribes CHX mouthwash again for five days.

Day 81 The practice is phoned by Mrs M to complain that she is very unhappy with the treatment provided by Mr A. Earlier that day she had referred herself to the dental hospital because of the persistent swelling and bleeding in her gums. She said the attending dentist diagnosed periodontal disease as well as an abscess and evidence of cement and pus in her gums where the crown had been fitted at UL6. He prescribed an antibiotic and also informed her that her gum disease had not happened overnight and that she must get immediate treatment. Mrs M is offered another appointment with Mr A but she insists on seeing a different dentist.

 

A WEEK later the practice receives a letter of complaint from Mrs M regarding the dental treatment provided by Mr A. She states that the dentist failed to diagnose and treat her periodontal disease despite seeing her on numerous occasions over a three-month period. Her gums are now in a “deplorable state with irremediable bone loss”. She alleges that had she not attended the dental hospital her condition would have been allowed to deteriorate even more.

The practice manager investigates the complaint and asks Mr A for his written comments in response. The dentist states that on fi rst seeing Mrs M he was aware of her history of periodontal disease and that she had undergone treatment for the condition at the practice over the last three years. In his initial examination the dentist recorded “no gingival swelling” and the treatment plan remained focused on monitoring the patient’s oral condition.

He states that the problem with the crown at UL6 was identified and remedied and that he also provided advice on smoking cessation – both the benefits and temporary side-effects on the gums. Mrs M’s decision to self-refer to the dental hospital and her refusal to see Mr A again meant the he was unable to provide any further advice and treatment.

Mrs M is not satisfied with the practice response and refers the case to the health ombudsman. An investigation is undertaken and the ombudsman upholds certain aspects of her case in regard to dental charges for the treatment but not in regard to the failure to diagnose and treat her periodontal disease.

In examining Mrs M’s dental records an independent clinical adviser finds that the patient was informed of the poor state of her gums on numerous occasions in previous years and that she had undergone treatment with the practice hygienist. Indeed in the period after her initial diagnosis the patient had failed to attend numerous appointments with the hygienist in regard to her condition.

In regard to the treatment to UL6 provided by Mr A, the adviser states that it is possible the fitting of the crown and excess cement may have exacerbated the pre-existing gum disease. However, the dentist could not be said to have caused the condition or contributed to any significant decline in the state of her gums over the period.

The adviser can only fault the practice in perhaps not communicating effectively with Mrs M on the significance and importance of gum disease and the necessary routine care to prevent the condition getting worse.

Key point

• Ensure that patients understand clearly the significance of periodontal disease and the likely outcomes should treatment advice be ignored.

• Avoid the charge of “supervised neglect” by using every appointment as an opportunity to remind patients with gum disease of the need to maintain good oral hygiene.

• Keep adequate notes of home care advice given to patients and the importance of flossing, brushing and smoking cessation.

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