A patient attended a new practitioner for the first time and a routine examination was completed. The patient reported previous problems from both lower wisdom teeth which had caused discomfort, swelling and infection, for which antibiotics had previously been prescribed. However, the patient was not reporting any specific problems at that time.
As part of the examination, the dentist took the view that an assessment of the wisdom teeth would be advisable, and after discussion with the patient it was agreed to the exposure of two periapical radiographs. The x-rays were processed and, as was usual practice, the dental nurse placed the films into a plastic film packet. The LL8 was identified to be carious, however was incorrectly recorded in the records to be the LR8.
The LR8 displayed an area of radiolucency around the crown of the tooth which suggested to the dentist that there had been repeat episodes of infection, and that potentially in the future, this tooth would need to be removed. The patient was informed that the LL8 was unrestorable and needed to be removed.
The patient was aware of the reason for removal and booked an appointment to return the following week to have the tooth removed.
One week later the patient returned and the dentist checked the records and x-rays, informed the patient what was involved in the procedure in so far as numbing the tooth and removing it, and of his impression that it would be a straightforward removal.
The dentist checked the records which corresponded with the x-ray and proceeded to numb the LR8 and the tooth was removed without complication. Postoperative advice was given and the member checked the area for haemostasis. During a review of the socket and mouth, the dentist identified that the carious tooth was still present.
The dentist checked the records and radiographs, as well as the tooth that had just been removed and identified the mistake. The patient was informed immediately of the error and an entry of the same was documented in the records. The dentist apologised profusely and the patient understood and accepted the situation.
The dentist later called Dental Protection to seek advice on whether anything further needed to be done and how to follow up on the error made. As there was no complaint letter, the advice was that the patient should be contacted again to ensure that they were healing well and invited to attend a review appointment. A letter was drafted by Dental Protection offering an apology and explanation for the situation which had arisen.
The member was advised to discuss the issue at the next practice meeting and to carry out a risk assessment and analysis to determine how a repeat situation could be avoided in the future. It was also recommended that a clinical incident form was completed in relation to the situation. The patient accepted the letter and there was no further outcome.
This case highlights:
- The importance of double-checking radiographs with an intra-oral examination.
- All records should be completed contemporaneously to reduce the risk of incorrect recording.
- You should be honest and open with patients when treatment does not go as planned.