Greta Barnes and Debbie Herbst from the DDU look at caries and fillings

With around 6.8 million courses of treatment involving direct restorations in 2017/18, according to NHS statistics, it’s hardly surprising that issues surrounding the treatment of caries and provision of fillings is the third most common reason for Dental Defence Union (DDU) members to notify claims.

The treatment of caries accounted for approximately 11% of general dental practitioner claims notified to the DDU in 2017, with a further 6% involving fillings.

While unfortunately allegations of negligence are not uncommon, it is important to bear in mind that the DDU has an excellent track record of successfully defending dental claims, even though cases are often carefully selected by firms specialising in these claims.

Delayed diagnosis

A large number of cases stem from allegations of delayed diagnosis of dental caries, leading to the need for a filling or in some instances more invasive treatment such as root treatments, crowns or extractions.

Claims about failure to diagnose, monitor and treat caries will take into account:

  • The impact on the tooth’s short- and long-term prognosis
  • Future treatment costs
  • Any pain the patient has already, or will likely suffer
  • The impact on the patient’s future dentition as a whole.

Commonly, claims for delayed diagnosis of caries will allege a lack of appropriate assessment and/or monitoring, often including a failure to take radiographs at intervals recommended in relevant guidelines and based on the patient’s history and clinical presentation.

Another common allegation is that radiographs were not interpreted correctly and the patient was not advised of the findings.

Technical difficulties

The technical execution of direct restorations can also lead to criticism. Issues such as choice of restorative material and placement and adjustment of the restoration can lead to difficulties. These can include occlusion, difficulties with cleaning due to overhangs, or inadequate marginal sealing leading to sensitivity, pain or secondary caries.

The patient should be fully informed about any difficulties with the restoration, which may lead to future problems or affect the prognosis of the tooth. Any postoperative advice should be noted in the patient’s clinical records.

Infections

Undiagnosed and untreated caries, or those that have been inadequately monitored or treated may lead to dental infection. The consequences of infection may result in patients experiencing mild discomfort, more significant pain or spreading infection requiring antibiotics. In the worst cases, patients may experience facial and neck swelling, causing breathing and swallowing difficulties. This may require hospital treatment for incision, drainage, debridement and other procedures.

In one case, a female patient who had a tooth inadequately restored with a filling that fractured, attended a DDU member’s practice over several months complaining of pain. Unfortunately, by the time the tooth in question was diagnosed with periapical infection, the patient needed to be admitted to hospital for drainage of the associated submandibular abscess and extraction of the tooth under general anaesthetic. Complex hospital treatment and inpatient costs were factored into the potential value of the claim, which was settled by the DDU for tens of thousands of pounds.

Minimising risks

To help dental professionals reduce the risk of problems when treating caries or providing fillings, the DDU recommends dental professionals try to ensure the following:

  • Caries are diagnosed and treated promptly and completely to avoid a potential delay in diagnosis
  • Patients are fully informed about the extent of caries in order to be able to provide valid consent for treatment options
  • Patients are fully informed of any early lesions that are being monitored. Carefully chart these and document the fact that the patient has been notified along with any advice given
  • The tooth is restored using an appropriate restorative material and that the technical execution of the restoration is correct
  • Patients are informed of any difficulties associated with the restoration of a tooth, and its potential prognosis
  • Patients understand the importance of looking after their own oral health. In dealing with a claim, the patient’s attendance patterns, diet, oral habits and factors such as smoking, drinking, medications and comorbidities will be considered. If a dentist has provided (and records) regular and appropriate advice about diet, oral hygiene and other factors that may impact on restoration such as difficulties with  occlusion and parafunctional habits, it can assist in defending the claim
  • An explanation and apology is provided if things have gone wrong. The offer of appropriate remedial treatment at no further cost to the patient and/or a refund of fees or other goodwill gesture can often help to resolve a patient’s concern and prevent
    a claim.

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