While developments in dental technology, equipment and materials have transformed many dental procedures over the years, the removal of third molars still presents many of the same dentolegal risks as in former years. Perhaps the most significant factor, of which we need to be aware, is that while the procedure itself might be broadly the same, many of the patients involved are not.
The fact that today's patients have greater expectations, and are often more aware and more questioning is only half the story; it is equally important to appreciate that today's patients are generally less forgiving and less tolerant of adverse outcomes.
- Correct diagnosis – if you are considering the extraction of a third molar because of non-specific pain, how sure are you that the third molar is actually the cause of the pain, rather than being seized upon as a convenient scapegoat to explain it, where other investigations have failed to do so?
- Appropriate investigations – include one or more good quality radiograph which not only provides a clear image of the tooth, its root configuration and anatomy, and the surrounding bone, but also the relationship of the tooth to adjacent teeth and to other structures. Significant amongst these are its relationship to the maxillary tuberosity and sinus, to the lower border of the mandible, to the ascending ramus and to the inferior dental (alveolar) nerve bundle within the mandible.
- Check the medical history carefully, and in particular, any relevant risk factors (including medication) that might influence:
Of increasing concern is the potential for postoperative complications related to patients on bisphosphonate medication, which can affect wound healing and increase the risk of medication-related osteonecrosis of the jaw (MRONJ).
- bone and soft tissue healing
- the likelihood of postoperative bleeding, swelling or infection.
- The social history is particularly relevant when contemplating this procedure
and it is sensible to enquire specifically as to the patient's occupation and any important life events. Nerve damage and the associated sensory deficit can have devastating consequences for patients in certain industries where they need their mouths. Pericoronitis is not uncommonly associated with stress and other factors influencing the host response, and with appropriate management, the symptoms will often resolve without needing to extract the tooth at all.
Taking all the above into account, the consequences of any adverse complication need to be carefully balanced against the indications for the extraction(s), in the specific circumstances of each individual patient:
- Are the risks of leaving the tooth in situ greater than the risks of extraction?
- How many episodes of pericoronitis have there been, of what severity, how were they managed and with what success?
- Is there caries in the third molar or in the adjacent tooth?
- Is there any clinical or radiographic evidence of pathology associated with the third molar?
One final consideration in the preoperative assessment is whether the clinician has the necessary skills, experience and competence to carry out the proposed extraction safely and successfully. Where there is any doubt in this respect, a referral to a specialist may be indicated.
Information, warnings and consent
Any surgical procedure has risks. It is important to take the time to explain carefully to the patient, in terms that the patient can understand:
- why the extraction is considered to be necessary
- what the procedure involves
- what the possible outcomes might be
the alternatives, including the alternative of no treatment
the likely consequence of no treatment.
It is equally important to record in the notes the fact that this has been done. Patients will generally not be able to anticipate these complications for themselves, and the clinician has a duty of care to give the patient any explanations and warnings necessary to enable the patient to consent to the procedure with a full knowledge and understanding of what to expect.
Although information leaflets and advice sheets can be very helpful in assisting the patient to understand what the procedure involves, one must bear in mind that each procedure, and each patient, is different.
Patients need to know what the risks are in their individual case, rather than being given information of a general nature, perhaps accompanied by statistical assessments of the incidence of complications reported in the professional literature.
Those who accept referrals from colleagues for the removal of third molars need to be aware that one of the treatment alternatives is still to leave the tooth (or teeth) in situ. There is a danger that both the referring clinician, and the clinician who accepts the referral, will each be assuming that the other is responsible for the consent process, including discussing with the patient whether or not it is sensible to be considering the extraction(s) at all.
There is a commonly held misconception that the raising of a buccal flap only, and avoiding bone removal on the lingual or disto-lingual aspect of the tooth, will avoid any risk of lingual nerve damage. It is true that in the literature, the raising of lingual flaps, the use of lingual retractors and/or the use of relieving decisions in the retromolar area have all been associated with a higher risk of lingual nerve damage. It is equally true; however, that many experienced oral and maxillofacial surgeons use these techniques routinely and yet experience a very low incidence of lingual nerve damage.
In the case of inferior dental nerve damage, where there is close proximity between nerve bundle and root apex, the surgical technique (for example, sectioning the tooth) must be such as to minimise the risk of severing, stretching, tearing or compressing the nerve bundle.
In addition to nerve damage, one needs to be mindful of the risks of fracturing the mandible (or leaving the mandible weakened and vulnerable to spontaneous fracture postoperatively), fracturing the maxillary tuberosity, or damaging adjacent teeth. This can range from dislodging fillings and crowns, to iatrogenic damage from burs and other instruments, to the distal surface of the second molars.
In each of these situations, by remaining alert to the potential risks and taking some simple steps to minimise them, the clinician can help many of the associated problems.
Patients who are not adequately prepared for some of the adverse complications of third molar surgery, can find them very distressing.
The extent of any swelling, pain, bruising and discomfort can vary widely from one patient to another, but altered sensation can be very worrying for patients unless they have been made aware that temporary sensory disturbance of this kind is not unusual, and does not necessarily indicate that anything has gone wrong with the procedure.
Caring and attentive aftercare is the key to preventing this commonly encountered complication, from becoming the basis for a complaint. Where postoperative complications do occur, the records should show clearly what the patient was complaining of, what steps were taken to investigate the problem, the differential diagnosis and the treatment provided or advice given (including any medication given, prescribed or recommended). If a referral for specialist advice / management is considered or discussed, a note of this should appear in the records.
Record negative findings (e.g. 'no lymph node enlargement or tenderness' or 'checked for mandibular fracture/lower border intact') as well as positive findings (eg, 'swelling reduced'). The importance of this lies in being able to demonstrate that all the appropriate investigations were carried out, before reaching the diagnosis and treatment plan.
Postoperative instructions should be given, perhaps with the help of a printed advice sheet, and this fact should appear in the clinical records. If the patient chooses not to follow the advice given, this should also be clearly recorded.
Arrangements to review the patient's progress should be clear, mutually agreed and recorded in the notes.
Each one of the steps described above needs to be meticulously recorded in the clinical notes. In our experience, deficiencies in such records are much more likely to render a regulatory investigation or complaint indefensible, than any shortfalls in the clinical technique itself.
Accurate, contemporaneous clinical notes are critical when dealing with allegations of inadequate postoperative assessment, or a failure to warn appropriately of risks, or problems arising from a poor technique, or shortfalls in postoperative management.