Misdiagnosis or Missed diagnosis? Or neither? Recently retired Dentolegal Consultant, Dr Mike Rutherford , sets it out.
Often allegations of mis or missed diagnoses are cut and dried:
- You missed the long-standing ulceration on my palate that turned out to be Squamous Cell Carcinoma
- You provided me with a dental examination for twelve years straight without ever mentioning the advancing periodontal disease and bone loss
- You extirpated the wrong tooth when I presented with toothache
Yet often the reality and the reasons behind a dentist’s actions or inactions can be more subtle, and the decisions made may not be so obvious to the lay person – particularly if there is insufficient communication with the patient about the thought processes involved in a dentist’s decisions. When a patient believes that an incorrect diagnosis has been made (often because they are still in pain) – in their mind, they have tangible evidence – continuing pain - that the correct decision was not made. In the absence of warnings or explanations to our patient PRIOR to the treatment being provided or the release of a patient from our care, it can be very difficult to alter perceptions after the event.
Case study
Mr X attended his new and younger dentist after his usual dentist of 20 years had retired. Mr X had seen Dr Y before for a check-up but never for treatment and they did not have an established relationship. This time, the attendance was for relief of increasing pain that Mr X had experienced for a couple of weeks now on his upper left teeth at the back. Pain when he lay down to sleep, pain on biting together, pain on chewing. Dr Y established the history of this pain and the symptoms and when asked where he felt the pain Mr X pointed at the 26, then the 27 then back to the 26 – “there!”
Both the 26 and 27 were tender to percussion but not overly, and the 25 slightly - both the 26 and 27 tested very slowly to cold testing and PA radiograph showed no apparent abnormality of the periodontal ligament or apices of the two teeth. 26 was heavily restored whereas 27 had a modest MO restoration. Dr Y also noted a low outline of the maxillary sinus and Mr X’s nasally voice. “Do you have a cold Mr X?” Dr Y palpated the suborbital region and this elicited bilateral discomfort. “I think you have sinusitis Mr X” Dr Y declared and explained his reasoning – suggesting nasal decongestants and patience in the absence of definitive signs that this was a tooth related issue. Somewhat relieved at this simple (and inexpensive) diagnosis, Mr X left, only to return in severe pain two days later – he now had a throbbing pain when lying down and could not bite together at all.
Dr Y reviewed his notes, retook all specialist tests and compared his findings – both 26 and 27 were more TTP particularly 26 but again cold testing was ambiguous. Dr Y was still not positive of his diagnosis but the extensive restoration in 26 and the heightened symptoms made this the likely candidate. Unfortunately, he did not share his slight doubts with Mr X who had already chipped him about “getting it wrong” the first time around. He considered an endodontic referral but none were close to his regional town practice, and Mr X’s pain and demands were acute.
After explanation, risks and warnings and consent, Dr X opened the 26 and was relieved to find a necrotic and slightly smelly pulp tissue which he mentioned to Mr X as confirmation of the problem. After advising Mr X of the likelihood of some continuation of symptoms, he dismissed Mr X with a recommendation that he return in a week or two for further treatment.
Dr X was therefore astounded when several weeks later he received a notification from Ahpra asking for a response to Mr X’s allegation of twice making an incorrect diagnosis. Mr X had had rapid swelling on a Sunday three days after seeing Dr X and had presented at his local hospital – the OMFS registrar had drained the left buccal space odontogenic infection associated with tooth 27 after CBCT scanning established its origin. The OMFS referral to a specialist endodontist, and the endodontist’s report of a non-vital 27 with vertical fracture through the pulpal floor was included along with a vehement account of Mr X’s anguish, time in hospital and detailed account of Dr Y’s incompetency.
Dr Y contacted Dental Protection for advice, thoroughly shaken by this unexpected turn of events.
The Dentolegal Consultant (DLC) requested a summary of events and a copy of the clinical notes. The clinical notes in this case proved to be comprehensive, detailing test results, signs observed and thought processes behind Dr Y’s decisions. With the assistance of the DLC, Dr Y was able to demonstrate to Ahpra that even if his diagnosis may have been incorrect in determining the origin of the toothache, the conclusions reached, and treatment offered were all consistent with the information available to Dr Y at the time. Ahpra agreed, and in a constructive manner suggested that if Mr X had been informed as comprehensively as the written word, perhaps Mr X would have been more understanding of this very unfortunate outcome. Ahpra dismissed the matter with no further action.
Learning points
- While we may not agree with the suggestion made by Ahpra, what cannot be denied is that a comprehensive written account of ambiguous findings and the reasons for our decisions, whatever they are, are more likely than not to support us in the face of criticism of our treatment.
- Communication counts. Always. If you have a diagnostic dilemma, ensure you communicate it to the patient clearly, even it if is not what they want to hear.
Please view our Webinar Series on diagnosis, available for members on Dental Protection's online learning platform.
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