Top five reasons for dental claims: extractions

In the first of a series of articles, Greta Barnes and Debbie Herbst look at the main causes of dental claims

A lot has changed in the dental landscape in recent years, such as the popularity of cosmetic treatments and technical advances in orthodontics and endodontics. Despite this, many of the allegations of clinical negligence made against Dental Defence Union (DDU) members relate to routine aspects of treatment such as extractions and root canal treatment.

During 2017, just five aspects of dental care resulted in 80% of claims notified by general dental practitioners to the DDU. They were:

1. Extractions – 24%
2. Root canal treatments – 20%
3. Caries and fillings  – 17%
4. Periodontal disease – 10%
5. Implants – 9%.

Even though dental cases are often carefully selected by firms specialising in dental claims, during 2018, in 69% of dental claims the DDU made no compensation payment.

However, there are steps dental professionals can take to minimise risks if they understand where issues can arise.

In the first of a series of articles examining common reasons for dental claims, we look at claims involving extractions, which represent around a quarter (24%) of general dental practitioner claims notified to the DDU in 2017.

Extractions are generally the final port of call for a tooth that is not restorable or mobile due to periodontal disease or trauma. Teeth may also be extracted electively for orthodontic reasons. Where compensation is paid, payments can reach the tens of thousands of pounds if liability is established, because claims costs can include:

• Compensation for pain and suffering as well as loss of the tooth
• Provision of a replacement to fill the gap, which for an implant may include the cost of bone grafting and implant maintenance
• Travel costs and loss of earnings in relation to remedial treatment.

Before starting treatment

The DDU frequently sees claims regarding alleged breaches of duty in the steps leading up to an extraction. As with all dental procedures, the steps taken prior to beginning an extraction can drastically alter the outcome for the patient.

Common allegations made by patients about the pre-treatment stage include:

• Failure to appropriately assess the condition of the tooth, which did not require extraction
• No advice about alternative treatment options, meaning the patient was not able to opt to preserve the tooth
• Extraction of the wrong tooth because of a notation mistake, an unclear instruction in referral letter, or a misinterpretation or mistake by the treating dentist
• Failure to anticipate the potential risks and complexities of the extraction. This may be because of inappropriate clinical and radiographic assessment to determine root morphology or the proximity of important anatomical structures
• The treating dentist should have referred the patient to a colleague as the extraction was outside their competence level
• Delay in recognising a tooth that requires extraction. This can result in prolonged pain, infection, and other complications and, in extreme cases, patients may need hospital treatment for excision and drainage of abscesses, surgical extraction and treatment to deal with spreading infection, often under general anaesthetic. In rare cases, patients may be left with scarring on their necks or faces, requiring further treatment or infections, which can spread to the brain or other parts of the body, causing endocarditis or other problems. Settlements in such cases can range between £10,000 and £20,000
• Failure to treat an existing infection prior to extraction. If the infection worsens or spreads after the procedure, it can lead to further complications. There is therefore a careful balance to be reached between relieving the patient’s pain swiftly and ensuring they are not placed at higher risk of further problems.

Complications during the extraction

As with any treatment, complications can occur during extractions. However, it is possible to defend a treating practitioner’s management if the complication and its outcome were unforeseeable and if the dentist took all the necessary precautions, correct treatment steps and provided appropriate advice and care following the complication.

Complications during the procedure that can lead to claims include:

• Roots may fracture, resulting in ongoing pain or infection and meaning a second procedure or referral for removal is required. Roots can also be accidentally displaced into the maxillary sinus, causing oroantral communications. The proximity of tooth roots to nearby nerves may result in temporary or permanent nerve damage or symptoms of pain, tingling or numbness. Claims for nerve damage can range from £5,000 to £20,000 or more, depending on the extent of the injury
• Fractures of the maxillary tuberosity and, in rare cases, mandibular fractures. In one claim involving a member, a maxillary tuberosity fracture occurred during the extraction of a UL7. The DDU was able to successfully defend the case as the clinical expert evidence showed there was no reason for the dentist to expect the extraction to be difficult or beyond their expertise. There was also no evidence that the dentist’s extraction method was inappropriate. The expert concluded that the patient had provided valid consent for the extraction, that risk had been unforeseeable, and that the patient received appropriate postoperative care
• Surgical emphysema due to air entering the tooth socket by inappropriate use of dental equipment. This may result in a claim for swelling, pain, distress and a hospital visit
• Damage to other teeth in the mouth during an extraction either by the instruments used or force applied, causing them to require otherwise avoidable treatment or extraction
• Lacerations, both internal and external, causing pain, bleeding, scarring and sometimes the need for remedial procedures. External scars may mean the claimant needs a lifetime supply of camouflage makeup products, scar revision treatments and sometimes treatment for psychiatric damage.

Post-treatment management

Following an extraction, haemostasis should be achieved and clear postoperative instructions provided to the patient. If the patient experiences unforeseen complications during an extraction it is important not only to empathise with them but to also apologise, where appropriate, to ensure the patient receives a full explanation of what happened and to arrange appropriate follow-up care. For example, providing immediate treatment such as antibiotics or sutures and referring the patient for any further care required.

Other post-extraction issues include pain and infection, which may be a localised ‘dry socket’ or more extensive soft or hard tissue infection. Failure to diagnose, treat or refer at this stage can be crucial in preventing spreading infection, which could result in hospitalisation.

Patient’s medical history, including conditions and medications that could affect their post-extraction recovery, should be carefully considered in collaboration with their GP or hospital consultant as appropriate.

Minimising risks

To help dental professionals reduce the risk of an extraction error, the DDU recommends the following:

• Consider using a consistent form of tooth notation in the patient’s records when referring to the tooth or teeth to be treated. When referring for extractions, including longhand instructions such as ‘upper left first premolar’ can avoid confusion. Flag key identifiers of the tooth if needed, for example if the teeth have moved from their normal position or if the patient has supernumerary teeth
• When obtaining consent, take time to explain the risks of treatment and alternatives, such as root canal treatment. Make a careful note of the discussion in the records
• Before beginning treatment, ask the patient to confirm which tooth they believe is being treated, and then cross-reference with the clinical notes, any other documentation such a referral letter and the radiograph. Involve your dental nurse in this identification, and request that they stop you at any point if they have concerns that the tooth you are treating is incorrect
• Recognise the limits of your own clinical skills. Be prepared to refer the patient to an appropriate colleague if complications are likely, or if the patient has a complex history
• For extractions under sedation or general anaesthetic, the treating dentist should see the patient before administration of anaesthesia or sedation, checking the tooth to be treated and that the correct clinical documentation, including a consent form, is available. The GDC Standards require patients’ written consent where treatment involves conscious sedation or general anaesthetic
• If treatment is requested by another dentist, satisfy yourself that the treatment plan appears reasonable and in the patient’s best interest before proceeding. If there is any doubt, consult with the referring dentist
• Be open and honest with the patient if an unforeseen complication or error occurs during an extraction. You should immediately tell the patient (or their representative), apologise, and offer an appropriate remedy or support to put matters right, if possible. Explain fully to the patient the short- and long-term effects of what has happened
• Be aware of the statutory duty of candour that applies to your practice or service. Certain incidents may need to be investigated or reported according to the duty
• Get advice from the DDU or your own dental defence organisation if you need any further advice or support with extraction problems.

The DDU’s expert claims handlers and dentolegal advisers understand how stressful facing a claim is, as well as the importance of mounting a robust defence of your position. The DDU has an excellent track record of successfully defending cases. During 2018, in 69% of dental claims it made no compensation payment. To keep up to date with the latest dentolegal news, guidance and advice, follow the DDU’s Twitter and Facebook pages or download the DDU member app.