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Quick thinking avoids a claim following a perforated root

05 June 2020

A new patient, Ms Y, attended a practice complaining of pain from an upper lateral incisor that had been recently crowned at another practice. The new crown was aligned with the arch and when questioned about her dental history, Ms Y said that she had not wanted to have orthodontics to correct the slightly tilted and crowded lateral, so had decided upon a crown to realign it.

Dr O examined the patient and it was clear that the tooth was very tender to percussion and there was slight swelling and redness in the buccal sulcus. A periapical abscess was diagnosed, and Dr O discussed the need to access the root canal and begin RCT to alleviate symptoms at that visit.

Dr O was confident of the diagnosis and started access once local anaesthetic had been provided somewhat distal to the swelling to avoid injecting into the infected area. He planned to provide temporary relief at this appointment and did not consider a radiograph was necessary, as the diagnosis was predictable and there was little time left to provide the emergency care required.

Access seemed a little difficult; there was eventually some bleeding and exudate from the tooth, which was subsequently dressed. Unfortunately, Ms Y returned the next day still very much in pain and unhappy that the crown had fractured in separate pieces, leaving the tooth preparation visible. In wishing to help Ms Y as best he could, Dr O set aside time to reopen the tooth and investigate further to see if more drainage could be obtained before providing a temporary crown.

This time he placed a file to obtain a working length and was planning to instrument and clean appropriately. To his horror, the radiograph revealed that there was a clear perforation of the root approximately halfway to the apex. He also realised that the root was acutely angled in relation to the crown he had drilled through the day before. Dr O had not taken a preoperative radiograph or probed the root surface to establish the angulation, despite the patient’s history.

Dr O was very concerned and a little panicked, but he was able to access the root canal and dressed the tooth. He informed the patient that there was difficulty with the procedure and that he would book them in for a review the next day.

Given the error, Dr O approached Dental Protection for advice on how best to handle the situation clinically and with regard to the management of the patient. In discussing the matter with a Dental Protection dentolegal consultant, Dr O was advised to meet Ms Y, be honest and open with her by apologising that the situation had occurred and reassure her of onward care to resolve the problem.

A referral to an endodontist was made, which Ms Y would not have to pay for, and an opinion would be sought about the best way forward. Naturally Ms Y was not happy; however, Dr O showed true concern and integrity, and Ms Y was agreeable to the recommendation. Unfortunately, the endodontist’s opinion was that the size and position of the perforation rendered the tooth unrestorable and recommended it be extracted and replaced by a single tooth implant.

Having discussed the situation further with Dental Protection, Dr O advised Ms Y that he would ensure she was not financially disadvantaged and that an implant would be provided for her without cost. A colleague removed the lateral incisor and placed the implant, which was successfully restored to the patient’s satisfaction. The treatment was subsequently paid for by Dental Protection and the matter resolved without escalation to either a claim in negligence or a regulatory complaint.

Dental Protection’s use of discretion allows us to resolve matters at an early stage and prevent escalation. Embracing the issue early on means we can proactively manage the problem rather than wait until a claim is received and, in this example, had the patient not been offered remedial treatment from the dentist – who stayed with her on the journey and who demonstrated genuine regret and empathy – then the outcome would have been very different.

When a patient instructs a lawyer to pursue a claim, the matter becomes adversarial and a sour taste is left with all parties following a protracted antagonistic episode. If resolution can be achieved with the relationship still intact, then the stress and anxiety for the member (and indeed the patient) in the long run is much reduced.

Dental Protection has the ability to intervene using discretion to assist members in a multitude of situations, and we would urge members to contact us as early as possible when a potential conflict arises. Early advice and intervention can be invaluable.

Learning points

For emergency appointments, ensure enough time is allowed and avoid being pushed into cutting corners, as errors with long-term consequences can occur.

When an adverse outcome happens, it is advisable to inform the patient at the time and to ensure suitable steps are taken to deal with the consequences. Members are advised to contact Dental Protection before making any promises of a financial resolution.

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. 
For more detailed advice on any issues, contact us