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A near miss

15 September 2023

By Dr Martin Valt, Dentolegal Consultant, Dental Protection.

Mrs C presented to a specialist in oral surgery, Dr W, having been referred by her general dental practitioner. The referral correspondence requested that her painful 47 be extracted under local analgesia, with the adjunct of intravenous sedation, as Mrs C was somewhat apprehensive about undergoing the procedure.

Clinical examination revealed two standing molars in the lower right quadrant, and the OPG radiograph supplied by the referring dentist confirmed extensive recurrent caries in both these teeth. While no acute symptoms were reported at the time of this assessment, Dr W was able to identify a diffuse periapical radiolucency associated with the more distal of the two molars, and accordingly ascribed Mrs C’s historic symptoms to a periapical periodontitis associated with this tooth.

On this basis he was entirely satisfied that removal of this tooth was in accordance with Mrs C’s best interests and outlined a number of potential risks and postoperative complications associated with doing so for her as part of the consenting procedure. The sedation process was similarly explained in considerable detail and a consent form duly completed.

When Mrs C returned to the practice reception area to arrange the appointment, she told her husband, who had been waiting there for her, that Dr W was planning to take out her “back tooth”. It transpired that her husband was a retired dental technician, who was immediately concerned that the tooth which had apparently been scheduled for extraction was not that which had previously caused his wife a considerable degree of intermittent discomfort.  

Mr and Mrs C were accordingly invited back into Dr W’s surgery, where the former was able to explain his concerns. On reflection, Dr W was happy to acknowledge that,  while he had simply assumed that the two standing molars were 46 and 47, they could equally have been charted by the referring practitioner as 47 and 48. Were this to have been the case, then 47 would have been the more anterior or mesial of the two teeth, rather than the more distal.

This distinction was not readily apparent in the referral correspondence. Given especially that Mrs C would have been sedated throughout the procedure, it is unlikely that she would have been aware of which tooth was being extracted until after the event. An incorrect tooth would therefore have been unwittingly extracted had it not been for the fortuitous intervention of a third party. A brief telephone discussion with the referring dentist clarified that Mrs C’s symptoms had been those of a reversible pulpitis associated with the more mesial of her two lower right molars, and that he had indeed charted this as 47. An amended treatment plan was drawn up and Dr W subsequently removed the correct tooth without further incident.

Practitioners who undertake treatment on referral are unlikely to have significant personal familiarity with any given patient’s dental history. It is therefore of the utmost importance that they ensure from the outset that they are entirely clear about the treatment that has been requested, and that this correlates with the patient’s understanding of the situation. Should any potential discrepancies come to light, these should be addressed with the referring dentist prior to proceeding. It is of course similarly incumbent upon referring practitioners to ensure that the treatment is requested in unequivocal terms. In this particular instance, confusion could have been avoided by making it absolutely clear that the two molars had been charted as 48 and 47. Alternatively, a more descriptive request for the “most anterior/mesial” of the two standing lower right molars to be extracted would presumably also have proved entirely unambiguous.      

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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