Only what's necessary - dental case study

BACKGROUND: Mr Z has attended his regular dentist for three years, mainly for routine scale and polish. His dental health has always been judged as good, with satisfactory oral hygiene and only minor gingivitis. He phones the practice in early June to ask for a routine check-up as he is going on an extended holiday to visit family abroad.

The practice is extremely busy and cannot give him an appointment before his departure so Mr Z makes an appointment at another practice. Here he is seen by Mr H. The patient notes record that Mr Z complained of pain in the upper right side of his mouth and Mr H notes an exposed root on the upper right molar, UR7.

An X-ray is taken covering three teeth: UR5, UR6 and UR7. The dentist tells the patient that this has revealed “some holes” that he will fix. No further explanation is given nor any indication of how many teeth are involved. Mr H carries out root treatment on UR5 and UR6 and submits a claim to Practitioner Services.

Mr Z returns to the surgery two days later aware that he cannot close his teeth properly, and the bite is adjusted in the fillings. The patient expresses concern that Mr H has carried out unnecessary treatment on his teeth.

Three months later Mr Z returns to his regular dentist for a check-up and discusses his worry about the treatment carried out by Mr H. The dentist expresses his surprise as he had noted no problems with the teeth in previous consultations with Mr Z.

Six months later Mr H receives a letter from solicitors acting on behalf of Mr Z requesting a copy of his patient records. This is later followed by a letter of claim alleging negligence in the dentist’s treatment of Mr Z, along with an impartial expert report on the case.

ANALYSIS/OUTCOME: Mr H sends copies of the letter and the report to an MDDUS adviser who reviews the material along with an in-house solicitor. Mr Z claims that he was subjected to unnecessary dental treatment including the root-filling of two teeth – and this conclusion is supported by the expert opinion.

Among his criticisms of Mr H’s treatment of the patient, the expert points out that the patient notes are "very sparse" and record no clinical/radiological reasons why the treatment was necessary, no results or evaluation of the radiographs taken and no recording of the working lengths for the root fillings of UR5 and UR6.

Examining the pre-treatment radiograph he finds that it is "coned off", providing no useful view of UR5 and no evidence of decay or pathology present in UR6. Nor is an existing filling in UR6 near the nerve (pulp) chamber. Working length radiographs of both teeth taken during treatment are poor, having missed most of the roots. Both should have been retaken.

Later radiographs taken of the two teeth show that Mr H has also failed to adequately obdurate all of the root canals of UR5 and UR6. The expert judges that both will need to be retreated. He concludes that the dentist has failed in his duty of care to Mr Z.

MDDUS advisers and lawyers judge the allegations indefensible and in discussion with Mr H decide to settle the case for a modest amount.

KEY POINTS

• Provide justification in the notes for all treatment undertaken.
• Record discussions with the patient regarding informed consent and the treatment plan.
• Record evaluation of radiographs including working lengths.
• Consider retaking poor radiographs if used to justify treatment decisions.