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Patient accidentally inhales crown

Post date: 17/03/2023 | Time to read article: 2 mins

The information within this article was correct at the time of publishing. Last updated 28/03/2023

First-year associate dentist, Dr K, is shocked when their patient accidentally swallowed a crown during fitting. Dr George Wright, Deputy Dental Director of Dental Protection recalls the case. 

After completion of foundation training, Dr K was invited to remain at the same practice to work as an associate dentist. After a few months in the role, Dr K’s confidence was growing, and they now had a busy list of patients. One Monday morning, Dr K began preparing Mr J’s lower right premolar for a crown. Treatment was completed uneventfully, and Mr J was booked to return two weeks later for the crown to be fitted.

Unfortunately, whilst trying the crown in place, it slipped from Dr K’s fingers and fell down the back of Mr J’s throat. Dr K sat the patient up and explained that there was a risk the crown had been inhaled and advised him to go to the local Accident and Emergency department for assessment. Mr J was assessed by the medical team and a chest x-ray showed the crown in Mr J’s stomach. Mr J was reassured the crown would pass through his system naturally and went on to make a full recovery.

A month later, Dr K received a letter of complaint from Mr J stating that he had failed to take proper care when trying in the crown and that his actions had resulted in him having to spend 6 hours in A&E.

Dr K received a letter of complaint stating that he had failed to take proper care

How did Dental Protection help?

Dr K contacted Dental Protection for advice and spoke to Dr V, a dentolegal consultant and specialist oral surgeon. Dr V asked Dr K to send in copies of the patient’s clinical records for him to review.

On review of the records, it became clear that Dr K had acted entirely appropriately in managing the situation. Unfortunately, dentistry does carry a small risk of objects being inhaled or ingested and Dr K had been forthcoming in telling the patient what had happened and arranging for prompt assessment at the local hospital.

Dental Protection was able to assist Dr K with a letter of apology and explanation to Mr J which he subsequently accepted together with a refund of fees paid for the treatment as a gesture of goodwill from Dr K.

Learning points

Unfortunately, adverse events do happen in dental practice. Whilst distressing for patients, these events can be equally stressful for clinicians and Dental Protection is here to assist members when things go wrong.

  • It is important to be open and honest with patients when things go wrong.
  • An apology and offer of appropriate redress can go a long way towards nipping a complaint in the bud before it escalates.
  • Detailed clinical records can assist with defending any complaint arising from an adverse incident.


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