Case discussion

A Dental Protection Member, Dr B, phoned having received a statement of claim from a well known compensation law firm, accompanied by a scathing expert dental report and a demand for a six figure settlement sum. Our Member was devastated and having reviewed the case believed that there was nothing reasonable that he could have done to avoid the unfortunate outcome – paraesthesia of the left side Lingual Nerve distribution following removal of teeth 28, 38 some twelve months prior. Dr B was also confused, as the patient, Ms X a 27-year-old had not attended for post op review and had been lost to regular recall. This was the first time Dr B had become aware of the issue. Dr B did remember this patient well due to a mutual interest in horse jumping, and remembered that the procedure went without complications and he had removed both 28 and 38 simply with forceps using a non-surgical approach. The presenting condition had been described in his records as: 38 - persistent pericoronitis. Dr B also recalled that he had only removed the left side teeth as Ms X was changing careers and had little disposable income, but he had warned her that the right side, which had also been symptomatic, required attention.

Unfortunately on receipt of the clinical records by the Dental Protection Consultant it was evident that Dr B’s memory was better than his record keeping and detail was unfortunately very light. So what did the scathing expert report say?

Well, it started with a criticism of the lack of history taking - 38 –persistent pericoronitis – for how long, how often? What about the 48? Unfortunately the records were silent about this side. Risks and warnings given. What risks and what warnings were discussed, what about the particular risk for this particular patient that the third molar roots were in apparent close proximity to the IDN on both sides? The report commented on the proximity of the IDN to both lower molars and opined that this proximity warranted a referral to an oral surgeon, and although the injury occurred to another nerve (the Lingual N), on the balance of probabilities (in the expert’s opinion) the patient would have been less likely to incur this adverse outcome in the hands of an oral surgeon. Why was removal of all four third molars by an oral surgeon not recommended or even discussed?

Furthermore given the unfavourable root pattern of the 38 and the proximity of the IDN, opined the expert, if our member did carry out the procedure this should have been approached surgically with root division, to decrease the risk to the IDN.

On review of all the records of other practitioners who had seen her, it became evident that Ms X had not returned because after not being able to reach our Member on the provided mobile number, she had presented at the local hospital emergency department with severe neuropathic pain in the tongue three days post op (the weekend of course).

The attending OMFS reported CBCT examination had revealed a significant portion of the lingual bone plate was separated. Again the expert postulated that the ill advised use of forceps in the presence of IDN proximity and unfavourable root pattern had also increased the likelihood (when compared with surgery and root division) of a lingual plate fracture. This fracture had likely caused the Lingual Nerve trauma which presented as a distressing intermittent burning dysthaesia.

It is easy to write a critical report in hindsight knowing the unfortunate outcome, but the flawed consent and record of conversation around why Dr B treated as he did, made defence difficult. Again it was also difficult to defend our Member’s well intentioned forceps approach in view of the IDN proximity and the appearance of the root structure on the OPG. Our Member was trying to make this extraction as simple and as least expensive as reasonable for his patient.

Fortunately the burning dysthaesia subsided, but to a persistent and permanent partial numbness of the tongue. Ms X’s solicitors were able to emphasise the distress that this change to Ms X’s articulation of her words caused her, and the devastation of not being able to continue with her training as communications consultant because of this. In consideration of the ramifications of this injury on Ms X’s lifestyle and psyche, Dental Protection settled for a significant sum.

Dr B remained distressed by the outcome of his wellintentioned treatment and was offered collegiate support and recommended minor oral surgery courses to attend. At Dental Protection’s suggestion Dr B approached the oral surgeon he referred patients to, who offered to let Dr B assist in theatre for a few sessions to hone his skills.