Case study: Slow healing socket

BACKGROUND

Mrs P is a 65-year-old former smoker with a history of periodontal disease and bone loss. She visits her dentist, Ms N, with a painful lower right second molar. Ms N diagnoses periodontal abscess.

Following a detailed discussion about treatment options and with the consent of the patient, the tooth is removed and postoperative instruction given.

Two weeks later Mrs P returns to the surgery complaining of pain and a “sour taste” in the lower right quadrant. An infected socket is diagnosed and it is irrigated and dressed appropriately.

At a review appointment, some four weeks later, Ms N irrigates the socket again, redresses it and prescribes a course of antibiotics, as it is quite inflamed and there is some mild swelling and tenderness in the cervical lymph node region. On radiograph, the socket appears clear and normal although there is obvious bone loss around the adjacent molar.

In a later review appointment, Ms N notes that healing is better but still not complete. A further review is scheduled for one month and at this appointment Mrs P now complains of pain in the adjacent lower right first molar. Ms N notes pus around the gum margin and that the adjacent socket is still inflamed. She extracts the first molar and again provides postoperative instruction.

Three weeks later Ms N notes that the first molar socket is healing well but the second is still very inflamed. More antibiotics are prescribed and another review is scheduled. At that appointment it is found that healing in the second molar socket is still not complete and Ms N observes that the inflamed tissue seems “red and cobbly”. She makes a standard dental hospital referral.

An incisional biopsy one month later at the hospital confirms the lesion is squamous cell carcinoma. The patient undergoes extensive surgery followed by facial reconstruction and radiotherapy.

A letter of claim from solicitors acting on behalf of Mrs P is sent to the surgery alleging clinical negligence in the delayed diagnosis and referral for suspected oral cancer. It is claimed that had the condition been diagnosed and treated earlier the patient would have been spared radical surgery and the need for radiotherapy.

ANALYSIS/OUTCOME

MDDUS commissions two expert reports. A GDP expert considers the care provided by Ms N and supports the decision to extract the second molar given the patient’s history of periodontal disease and the radiographic evidence of bone loss. He also finds nothing inappropriate in the initial diagnosis and treatment of an infected socket and a suggestion that infection in the adjacent molar may have contributed to the slow healing.

The expert does however question why Ms N did not consider something more than just a slow-healing socket – especially when the adjacent first molar had been extracted with normal healing. His view is that a referral should have been made at this point (i.e. at follow-up review after first-molar extraction) and certainly an urgent referral at the next review.

A second expert report is obtained from an oral maxillofacial surgeon to consider the likely timing of the development of the cancer and the impact of any delay in diagnosis. In his opinion, the cancer would have been present before the first extraction and could have been diagnosed had appropriate investigations been instigated at the follow-up appointment after the second (first-molar) extraction.

The question of whether an earlier diagnosis could have resulted in less radical treatment is not so clear cut. The expert states that the necessary surgery (involving tracheostomy, neck dissection, access and free-flap reconstruction) would likely have been similar in scale if carried out earlier but the tumour would have been smaller and subsequent radiotherapy might not have been indicated. Prognosis in oral cancer is obviously better the earlier the diagnosis.

MDDUS negotiates a settlement in the case with the agreement of the member.

KEY POINTS

• Have a high index of suspicion in persistent mouth ulcers and slow-healing tooth sockets.
• Ensure urgent referral with any suspicion of oral cancer.
• Consider how chronic periodontal disease might mask other acute presentations.