Section 7Dental Dilemmas
A difficult extraction The outcome
A female patient in her early forties attended a The dentist contacted the DDU, who sought the opinion
new dental practice complaining of a fractured of an expert in maxillo facial surgery. The expert’s view
upper molar crown. Following clinical and was that the creation of an oro-antral communication is
radiographic assessment of the tooth, the dentist a recognised complication of upper molar tooth
advised her that the tooth was potentially extraction which is often difficult to predict or prevent.
restorable following root canal treatment (RCT), He considered our member’s advice to extract the tooth
although this would require referral to a specialist as having been appropriate since the alternative of root
endodontist due to the curvature of the roots. canal treatment had been explored with, and discounted
The dentist also explained the alternative of by, the patient.
having the tooth extracted and, after
consideration, the patient decided to accept this
However, the expert advised that a pre-operative
option.
radiograph can provide some indication of the likelihood
of this complication, based on the size of root mass of
The patient returned some weeks later for the extraction, the tooth, and its proximity to the air space of the
which proved more difficult than the dentist had maxillary antrum.
anticipated. Following an unsuccessful attempt to
remove the complete tooth, he advised the patient that
Unfortunately the dentist’s contemporaneous records
it would be necessary to divide the roots in order to
were incomplete, and a digital periapical radiograph of
facilitate their extraction. Using this approach, he was
the tooth, taken at the initial appointment, had not been
able to successfully remove two of the three roots.
saved and was not available to the dentist at the time of
However, the third was displaced into the patient’s
the extraction.
maxillary antrum (air sinus). The dentist immediately The expert acknowledged that it is not mandatory to
informed the patient about what had happened, have such a pre-operative radiographic view, as most
prescribed antibiotics, and advised her that he would teeth are extracted without complication. However, in
arrange an immediate referral to the local hospital this case, when initial attempts to remove the tooth were
maxillofacial surgery department for assessment and thwarted by the resistance of the surrounding bone and
treatment. the size of the root mass, the expert considered it would
A scanning radiograph taken by the hospital showed a
have been appropriate to take a periapical radiograph to
large proportion of the root mass of the upper molar
reassess why the tooth was not moving.
tooth had been displaced into the lower part of the He also found the dentist to have breached his duty of
maxillary antrum above the tooth socket. The following care by failing to reassess the surgical problem or convert
day, the patient underwent a surgical procedure under the extraction attempt to a surgical approach to expedite
local anaesthetic to remove the retained root from the the delivery of the roots. In his view, the dentist had
maxillary antrum, and close the associated oro-antral misjudged the degree of surgical difficulty involved in
communication. Following the operation, the patient extracting the tooth and the risk of an oro-antral
was prescribed appropriate antibiotics, painkillers and communication.
nasal drops, and provided with instructions to avoid nose
blowing. She was later reviewed to confirm that the
The expert did however state that once the displacement
socket was healing properly.
of the tooth root had been recognised, the dentist had
acted appropriately in informing the patient and making
The patient later made a claim, alleging that the arrangements for her assessment and treatment.
extraction attempt had been difficult and prolonged -
she reported sitting in the dental chair for approximately
With the consent of the dentist, the DDU responded to
two hours. The patient claimed that the dentist should
the patient accepting the dentist’s breach of duty which
not have undertaken the procedure and that he hadn’t
had led to the avoidable need for the claimant to
clearly explained what had gone wrong.
undergo remedial surgery. The patient accepted the
DDU’s offer of £400 compensation, so concluding the
case.
“…root canal treatment had been explored with, and
discounted by, the patient.”
38
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