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A complicated extraction

12 March 2019
A young adult female patient with a congenital heart defect for which an appointment for cardiac surgery was imminent, attended a new dental practice as she had become dissatisfied with her recent dental care elsewhere. Tooth 27 was grossly carious, painful and required extraction. The patient was on Warfarin and had been prescribed a course of antibiotics for dental infection by another dental practitioner.

A periapical radiograph was taken, and in an attempt to accommodate the patient in view of the impending surgery, an urgent appointment was arranged for the patient at the end of the day.

The INR had historically been stable between the levels of two and four, but was not checked in the 72 hours prior to the scheduled dental extraction. The clinical records did not demonstrate that careful radiographic evaluation had taken place.

The extraction procedure was fraught with difficulties and unexpectedly prolonged. After 50 minutes it became apparent that the functionless, periodontally-involved tooth 28 was acting as an obstacle to extraction/potential collateral damage, and would need to be extracted in addition to the original tooth due to their close approximation.

A second dentist was called into the surgery to assist with the procedure and the extraction of tooth 27 and 28 was completed after a further 20 minutes. The patient was told of the complication and did provide verbal consent to the extraction whilst in the chair during the procedure. Haemostasis was achieved prior to the patient leaving the surgery.

In the post-operative period, the patient had a bleed at home and contacted the surgery due to this dental emergency, but unfortunately the practice emergency system was not reactive enough to pick up the call. The patient therefore had no option but to attend the local Emergency Department where she was kept for over eight hours until she was deemed fit to leave, having had the wound cleaned, packed and sutured by the on-call clinician for OMFS.

A letter of complaint was received from the patient, in which she raised the issue of a lack of consent for the extraction of tooth 28 and that she would not have agreed in advance to the extraction of a wisdom tooth so close to her cardiac surgery. She was dissatisfied and alleged poor clinical care, poor aftercare and demanded a full refund. The patient felt badly let down and was very critical of the treatment she had received.

After consultation with Dental Protection, a swift empathic response was sufficient to defuse the matter.

The practice responded in a timely fashion, providing a full apology with an expression of sincere regret and provided a full refund of the private fees.

The patient was reassured that action was taken within the practice to improve the emergency system with the aim of preventing a similar situation happening again.

The cardiac surgery proceeded as scheduled.
Learning points
This case highlights the importance of the following:

  • Thorough preoperative assessment with due adherence to the local medical protocols for managing patients who are on anticoagulants such as Warfarin.
  • Awareness that antibiotics may alter the INR level and ideally an INR record should be available in the 24 hours prior to the procedure if there is any suspicion of instability.
  • The optimum timing of extraction procedures in patients who are likely to bleed.
  • When endeavouring to accommodate patients, it is important that there is nothing to be gained by taking shortcuts. If complications arise you will attract criticism.
There are vulnerabilities in this case with regard to the above and additionally in relation to:

  • the quality of the preoperative case assessment and a careful consent process
  • the quality of the actual clinical care provided
  • the sufficiency of the clinical records, the lack of written evidence of radiographic evaluation
  • the practice’s out of hours emergency arrangements.
Had the patient pursued this matter, there were multiple vulnerabilities that would have resulted in further scrutiny and stress for the member.

Fortunately, the way the complaint was handled was probably the only part of the interaction with the patient that went well for the member. 
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These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
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DPL Australia Pty Ltd (“DPLA”) is registered in Australia with ABN 24 092 695 933. Dental Protection Limited (“DPL”) is registered in England (No. 2374160) and along with DPLA is part of the Medical Protection Society Limited (“MPS”) group of companies. MPS is registered in England (No. 00036142). Both DPL and MPS have their registered office at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. DPL serves and supports the dental members of MPS. All the benefits of MPS membership are discretionary, as set out in MPS’s Memorandum and Articles of Association. “Dental Protection member” in Australia means a non-indemnity dental member of MPS. Dental Protection members may hold membership independently or in conjunction with membership of the Australian Dental Association (W.A. Branch) Inc. (“ADA WA”).

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