Problematic extraction - dental case study

A 53-year-old-woman – Mrs P – attends her dental surgery complaining of a sharp pain in an upper right molar when chewing. The dentist removes a large amalgam filling from the tooth and notes a fracture line running along the base of the cavity, close to the pulp chamber. He places a temporary filling but the patient returns two weeks later still in pain.

The dentist discusses treatment options including root canal therapy but explains that the prognosis for any restoration may be poor if the fracture extends into the pulp chamber. Mrs P opts to have the tooth extracted. During the procedure the crown fractures off the tooth. The dentist decides not to carry out a surgical procedure but instead divides the roots using a surgical bur to extract them separately. He notes that the roots are very close to the maxillary sinus as he can identify the sinus lining at the apex of the extraction site. A periapical radiograph is taken to ensure all the roots have been removed. Sutures are placed to assist with wound closure. Mrs P is sent home with a prescription for antibiotics and is advised "not to sneeze".

Just over a week later Mrs P returns complaining of tenderness in the area and the dentist removes four sutures and some necrotic tissue and prescribes a further course of antibiotics. Over numerous visits in the next two months it becomes clear the extraction site is not healing. Mrs P also reports “feeling air” in the socket and that when gargling she finds mouthwash trickling out her nose. The dentist confirms the presence of an oro-antral fistula and records that the patient should be reviewed every six months with eventual referral to hospital if necessary.

Five months later the patient attends a different dentist who notes that the oro-antral fistula is still present. She is referred to hospital where further X-rays are taking showing a significant loss of alveolar bone. Radiographs on the unaffected left side also reveal that Mrs P has a low-lying maxillary sinus that would make any upper molar extraction problematic.

Over the next six months Mrs P undergoes three surgical procedures attempting to repair the fistula but all end in failure. Given the degree of alveolar bone loss only a graft, probably from the hip, offers any chance of success.

Solicitors acting for Mrs P contact the dentist regarding a claim for dental negligence. Among the specific allegations is a failure to obtain informed consent for the extraction. Mrs P claimed that she was pressured into the procedure as the dentist told her that treating the tooth with root canal therapy could “cost thousands” and with no guarantee of success. She claims also that no mention was made of the associated risks of extracting an upper molar.

It is further alleged that there was a failure of reasonable care and skill in not taking a pre-operative radiograph to assess the risk of an oro-antral fistula. Had the dentist done so, the low-lying nature of the maxillary sinus would have been noticed and Mrs P could have been referred to a specialist and been made more aware of potential complications. The claim also cites a failure to refer Mrs P in timely fashion after it was clear the defect was not healing thus avoiding a long period of pain and suffering.

Analysis and outcome

The dentist contacts MDDUS and a dento-legal adviser commissions an expert report from a specialist in oral surgery. He examines the patient records and all relevant notes and finds fault with the dentist’s treatment in a number respects.

In failing to take a pre-operative radiograph in order to judge the degree of difficulty of the extraction, the dentist was not able to provide Mrs P with an adequate assessment the risks such that she could give informed consent. Knowing the risks of extraction might have affected her decision to not opt for root canal therapy. The surgeon could also see no justification in the long delay before referring Mrs P to hospital.

Given the criticisms by the expert it was deemed best by the MDDUS adviser and lawyers to negotiate a modest settlement with Mrs P’s solicitors.

Key points

• Take pre-operative radiographs to assess risk for dental extractions, if appropriate, and ensure that taking such a radiograph can be justified.
• Make a timely referral in any case of a non-healing oro-antral fistula.
• Ensure patients are fully aware of the risks and potential complications before assuming consent.