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The retained root and consent

20 July 2018
A patient attended at a new dentist for the first time complaining of problems with a broken tooth. The patient had not seen a dentist for many months prior to that and was aware that the tooth had been progressively breaking and as she was now experiencing discomfort, wanted the tooth to be removed. The tooth which was breaking was the UL3 and was a cantilever bridge retainer for a missing UL2. The patient explained that she was keen to have implants provided in the near future as she did not want gaps at the front of her mouth and did not want another bridge.

The dentist carried out the usual assessments and investigations and took a periapical x-ray of the area which identified a grossly carious UL3 with a periapical area. Even though the x-ray image was not clear, with good lighting, a buried root could also be seen at UL2. The dentist did not record that a retained root was present at UL2 however he did recall telling the patient of it at the subsequent appointment, advising that as it was deeply buried and not causing problems it could be left in situ. At the appointment to remove the grossly carious
UL3, surgical removal was required as the tooth was so grossly decayed. The dentist raised a flap, removed the tooth and sutures were placed. The patient did not return for a review and the dentist did not see the patient again.

Two years later, the dentist received a letter of complaint. The patient reported that six months after removal of the broken tooth (UL3), the patient had attended another practice to discuss implant treatment at the site of the UL23. The new practitioner had advised the patient that in order to go ahead with dental implant treatment, she would need to have the retained root (UL2) removed first as it was at the site where an implant would be placed. This would involve a surgical procedure, followed by a period of healing prior to implant placement. The patient was confused as she was not aware of the other root and understood that the root had already been removed six months earlier. The new dentist showed the patient the retained root, identified following a cone beam CT scan and which on careful review was also visible on a PA fi lm which had been exposed.

The patient’s complaint to the earlier dentist was that he should have identified that there was another root present six months earlier and, had the patient been told of its presence or that it may need to be removed to have implants, she would have opted to have it removed at the same time even when there were no symptoms.
The patient would have preferred to avoid a second and additional surgery and could have avoided waiting another six months for healing. The dentist could recall telling the patient about the root, however the records did not reflect the conversation and there was no report in the records that a retained root at UL2 was present. The dentist’s view was that even if he had identified it, as it was asymptomatic at the time, he would not have removed it as there was no indication for its removal and this would have been the advice given to the patient.

It was identified to the dentist by Dental Protection that his records did not reflect the nature of the conversation which took place with the patient when she first attended with the broken UL3. This was identified as an area of vulnerability. Concern was also raised in that the patient was not informed of all the risks or options of leaving a root in situ, including that a second surgical procedure would be required if it needed removal in the future prior to implant placement, and therefore it could be argued that valid consent was not obtained when the UL3 was extracted.

Learning points
  • Ensure that the records accurately represent the true nature of any conversation that takes place and the advice given.
  • The material risks need to be discussed with patients, which should be tailored to the specific patient.
  • In this case, the patient had explicitly expressed that she wished to have implants placed in the edentulous sites and the material risk of leaving the root in situ was not identified or discussed.

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 Protection members enjoy as part of their subscription. 
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