Mrs. A, a new patient, visited general dental practitioner Dr. Y, reporting intermittent discomfort in her upper left quadrant. Clinical and radiographic examinations revealed a fractured, grossly carious 18 that was beyond restoration.

Dr. Y diagnosed reversible pulpitis and recommended extraction, which Mrs. A readily agreed to. However, during the procedure, a root apex fractured and could not be retrieved despite Dr. Y’s efforts. He informed Mrs. A about the complication and arranged for her to see a specialist oral surgeon for removal of the apex. At Mrs. A’s request, the referral was made on a private basis to expedite treatment.

Although the specialist completed the surgical procedure successfully, Dr. Y later received a written complaint from Mrs. A, requesting reimbursement for the specialist’s fees. Dr. Y was initially hesitant, arguing that the root fracture was unforeseeable and that Mrs. A had declined a pre-extraction referral to a specialist.

Dental Protection’s Review

Upon reviewing the case, Dental Protection noted:

• Extracting 18 was appropriate, as it was unrestorable.
• However, the pre-extraction radiograph indicated a close anatomical relationship between the root apices of 18 and the maxillary sinus floor, increasing the risk of complications.

Dr. Y’s clinical records showed he had informed Mrs. A about this risk but did not document offering a referral to an oral surgeon before proceeding. This omission meant Mrs. A may not have been given all necessary information or options to provide valid consent, potentially constituting a breach of duty of care.

Additionally, Dr. Y attempted to retrieve the fractured apex without first obtaining a follow-up radiograph. When a subsequent radiograph was taken, it showed the apex had either entered the sinus or was trapped near its epithelial lining, necessitating a surgical procedure for removal. A solicitor could argue that Dr. Y should have paused the procedure at the point of fracture and referred Mrs. A to a specialist immediately, rather than attempting further removal.

If these breaches of duty of care were shown to have caused harm or additional costs to Mrs. A, she would be entitled to compensation. Furthermore, a regulator might critique both the consenting process and Dr. Y’s management of the complication.

Resolution

To protect his professional position, Dental Protection advised Dr. Y to resolve the matter locally, avoiding escalation to a legal or regulatory forum. They assisted Dr. Y in drafting a conciliatory response and indemnified him for the oral surgeon’s fees as a gesture of goodwill. Mrs. A accepted the explanation, apology, and financial contribution, resolving the complaint amicably.

Learning Points

This case underscores key considerations for managing complications in dental practice:

1. Comprehensive Consent Process

   • Inform patients of all risks associated with a procedure.
   • Document discussions about alternative treatments, including referrals to specialists, especially when significant risks are identified.

2. Pause and Reassess After Complications

   • If a complication arises, stabilize the situation and seek specialist input rather than proceeding further. This minimizes the risk of exacerbating the issue.

3. Document Thoroughly

   • Accurate and detailed records can provide essential support in managing complaints or legal challenges.

4. Refer When Appropriate

   • Consider referrals when complications are foreseeable or beyond your expertise. It is rarely in the patient’s best interests to “press on” without specialist input.

Conclusion

Complications during dental procedures are sometimes unavoidable, but careful planning, thorough documentation, and timely referrals can minimize risks and enhance patient outcomes. Cases like these illustrate the value of professional guidance and the benefits Dental Protection members enjoy, including expert support in managing challenging situations.

This article is sourced from: https://www.dentalprotection.org/australia/publications-resources/case-studies/case-studies-display--/a-failure-to-refer-aus