MDDUS Case study: Instrument failure
Mr Z attends the dental surgery of Ms J complaining of pain in a lower right tooth, 46. Mr Z advises Ms J that it is particularly painful when biting and chewing. Ms J notes that this tooth had been restored two years’ previous. Ms J carries out a detailed extra-oral and intra-oral examination, concentrating on 46. Following this examination and the taking of and review of appropriate radiographs, a diagnosis of irreversible pulpitis is made. Ms J discusses the treatment options with M Z, including root canal treatment or extraction. Mr Z opts for root canal treatment and an appointment is made for two weeks’ time. Ms J prescribes an antibiotic, aiming to reduce infection and ease Mr Z’s pain.
Mr Z attends for the first visit of root canal treatment of 46. Ms J takes a further pre-treatment radiograph. Appropriate local anaesthetic is administered by her. Ms J proceeds to remove the existing restoration, accessing the pulp chamber and root canal system, removing the necrotic pulp using a barbed brooch. Ms J next employs a lentulo spiral filler to spin Ledermix into the root canals. Unfortunately this instrument fractures and part of it is retained in one of the root canals. Ms J uses another spiral filler to try to remove the lodged fragment, but is unsuccessful in her attempts. Ms J abandons the procedure and dresses the tooth appropriately. A further radiograph is taken confirming the presence of the fractured instrument and Ms J informs Mr Z about this (although this is later disputed). Mr Z is given another prescription for antibiotics and an appointment is made for him to return in a week’s time.
Following administration of appropriate local anaesthetic, Ms J makes a second attempt to remove the fractured instrument from the canal but again is unsuccessful. Mr Z later alleges that Ms J told him that there should be no problem leaving the broken instrument in the tooth as it is sterile. Ms J restores the tooth with an MOD restoration and advises Mr Z that she will refer him to the local dental hospital should further symptoms arise. Ms J does not complete the root canal treatment of the other root canals that do not contain the fractured instrument.
Mr Z returns to the surgery complaining of discomfort in the tooth. Ms J makes a routine, non-urgent referral which is sent by post but is not received at the dental hospital.
Two months on from his last appointment Mr Z phones the dental surgery to inform them that he has not heard anything from the dental hospital. He advises the practice that he is now suffering persistent pain from tooth 46. Ms J makes an urgent re-referral. Mr Z attends the dental hospital and is treated by Dr K who removes the existing restoration, locates the fractured instrument but fails to remove it. A second attempt is made one month later that is also unsuccessful. Following discussions with Mr Z and given the difficulties of treatment so far, Mr Z opts to have the tooth extracted.
Three months’ later Ms J receives a letter of claim from solicitors acting on behalf of Mr Z alleging clinical negligence in the treatment of his tooth. A report has been produced by a restorative dentist that is critical of Ms J’s treatment of the patient. MDDUS advisers and solicitors review the report together with all associated correspondence including the patient records.
It transpires that Ms J’s record-keeping is inadequate and that there is no written treatment plan or reference in the records to the radiographs taken. No note can be found to refute Mr Z’s claim that he was not informed of the instrument failure until a follow-up appointment. An expert instructed by MDDUS to provide an appropriate report is very critical of Ms J in terms of failure to comply with radiographic legislation, failing to comply with antibiotic prescribing guidelines as well as being critical of Ms J’s suggestion that the tooth would be asymptomatic because the fractured instrument had been sterile.
Further discussion with Ms J regarding the paucity of the dental records reveals that she did not report her radiographic findings appropriately, did not record the use of dental dam or any instrumentation or irrigation prior to the use of the spiral filler. This casts doubt on the actual treatment that was provided.
Following detailed discussion with Ms J and considering the identified weaknesses, it is agreed that the claim should be settled. It is accepted that the separation of an instrument during endodontic treatment is not negligent. However, the failings by Ms J in terms of discussion with Mr Z and recording of this highlight her vulnerabilities. An amount is negotiated based on the cost of a single implant to replace the missing tooth.
Ensure that accurate, complete and contemporaneous records are kept of all treatment visits together with treatment plans and discussions with patients.
Memory cannot be relied on in legal defence.
Please be open and up front with patients when complications occur, being mindful of one’s duty of candour.
Aubrey Craig is head of dental division at MDDUS