Pinpoint fistula

BACKGROUND: Mrs L attends her dental practice complaining of pain in her upper left jaw, which she feels is getting worse. An associate at the practice – Dr B – examines the patient and finds UL6 very tender to percussion.

An X-ray reveals apical periodontitis in the tooth and Dr B recommends either root canal treatment or extraction. Mrs L opts for extraction and this is undertaken at the same appointment.

Dr B records in the notes that the extraction site is stable with no retained roots and he provides post-operative instructions. Later that month Mrs L attends the surgery for a routine scale/polish and examination but the notes make no reference to the extraction.

Two months later Mrs L attends her GP surgery complaining of recurring headaches. The GP advises that the headaches may be due to the extraction and a possible oro-antral communication (OAC) affecting her maxillary sinus. Mrs L is advised to return to her dentist and request referral to a maxillofacial surgeon.

Mrs L makes an appointment with Dr B, who examines the extraction site and finds no evidence of an OAC – nor do the patient records include any specific mention of pain at this stage. Mrs L is offered reassurance and no further action is taken.

A week later Mrs L re-attends her GP with an acute headache and she is sent to A&E. Subsequent referral to the local dental hospital leads to a diagnosis of a pinpoint OAC. Just over a month later the OAC is closed by a maxillofacial surgeon under general anaesthetic, but her symptoms persist and include low-grade headaches associated with her frontal sinuses and sinusitis.

A letter of claim is received by the practice alleging Dr B was negligent in his treatment of Mrs L. Specifically it claims that the dentist failed to adequately seal the extraction site, and later diagnose and refer Mrs L for specialist treatment to close the suspected OAC. This led to undue pain and suffering over a period of months.

ANALYSIS/OUTCOME: MDDUS acting on behalf of Dr B commissions a report from an expert dental surgeon. After reviewing the patient records the expert concludes that Dr B performed the procedure to an acceptable standard and examined the extraction site to ensure it was stable. In regard to the failure to refer, the expert notes that the clinical records from Mrs L’s second, routine visit to the surgery make no reference to pain or other issues associated with the extraction site.

The expert further notes that Dr B conducted a re-examination of the extraction site when Mrs L returned to the surgery after seeing her GP and found no evidence of an OAC. Records from the hospital later confirmed the OAC was “pinpoint” in nature and the expert opines that it may have been difficult to see and therefore diagnose.

Based on these observations the expert concludes there was no breach of duty in Dr B’s treatment of Mrs L and therefore he cannot be held responsible for her ongoing pain. The expert also advises that doubt could be cast on the OAC being the sole cause of Mrs L’s subsequent symptoms, as the repair does not appear to have resolved them, and thus Dr B cannot be held liable in this regard.

A letter of response is sent to solicitors acting for Mrs L denying liability. The case proceeds no further and is closed on expiry of the limitation period.

KEY POINTS

• Clear and complete records are essential to a sound legal defence.
• A clinician cannot be held liable if providing care that conforms to a standard reasonably expected of a competent practitioner.