David Hartoch: As clinicians, it’s essential we deliver patient-centred care and discuss any material risks of proposed treatment provision, making sure patients fully understand.
In this case, an administrator visited the dentist complaining of pain from a broken tooth which she had previously ignored. The crumbling tooth, the upper left three, was the abutment of a two unit cantilever bridge to replace the missing upper left two.
The patient told the dentist that she'd like it removed and to have implants in the near future to close the gaps at the front of her mouth. She also said she didn’t want another bridge.
The dentist examined the patient and took a radiograph which showed a grossly carious upper left three with a periapical area and a buried root at upper left two.
The dentist didn’t record the presence of the root, but he did inform the patient at her second visit that as it wasn’t causing any problems, it could be left alone. He removed her badly decayed tooth surgically.
The patient didn’t return for a review.
Some time later, the dentist received a letter of complaint from the patient. She said six months after the extraction, she’d attended another practice to talk about having an implant. Her new dentist advised that she’d need to first have
surgery to remove the buried root at the upper left two, wait for six months to ensure complete healing and then an implant could be placed.
The patient was confused. She thought she’d had the root removed at the time of the extraction.
George Wright: The patient's complaint was that the first dentist should have identified the presence of the retained root at the time of the initial consultation. She also said that had she been aware of the need to have it removed for the implants, she'd have had it removed at the same time as the initial extractions so as to avoid the need for a second surgery and prolonged healing time.
In his defence, the dentist said that he remembered telling the patient about the root. However, the records did not mention a conversation nor was there a note of the retained root.
Dental Protection highlighted that the dentist's records didn't reflect the nature of the conversation with the patient during her first appointment.
She was also not informed of all of the risks of leaving the retained root in situ or what her options might be including the requirement to have a second surgery should she go on to want an implant in the future. As a result, it could be argued that valid consent was not obtained prior to extraction of the upper left three.
David Hartoch: As the second course of surgery to have the upper left two removed could have been avoided, Dental Protection assisted with a letter sent to the patient, which offered an apology and a contribution towards the cost of the extraction of the retained root.
Dr Vanessa Perrott: Dental Protection recognises that the area of consent is really quite tricky for many of our members, in particular, demonstrating that you have taken into account what patient preferences are. To help support our members, Dental Protection has developed the 6D Model that can guide you through the process of shared decision making and pay particular attention to patient preferences.
The model stands for first D, develop trust with your patient. The second D is discover from your patient what are their ideas, concerns, expectations and treatment preferences. The third D is all about you, so discussing options with
the patient including being explicit about there is the option of doing nothing or the "no action" option.
After that, it's important to double check understanding so that's the fourth D. And then we go into making a decision or perhaps making a decision to defer the decision. The final D is for documentation. If you want to focus either on your communication skills or on the documentation, Dental Protection can support you with some of our educational modules.
David Hartoch: There are some key points we can take from this case.
It is important to report all findings from radiographs and to discuss the findings with the patient. A clinician should make sure that their records accurately reflect the nature of any conversation that takes place including advice given to the patient.
The member in this case should have discussed the implications of the retained root with the patient and her care should have been adapted to take into account her future plans.
She had explicitly said that she wanted to have implants in the edentulous sites and the consequences of leaving the root in situ were not discussed with her. This left the member vulnerable to the patient taking action against them.