DIAGNOSIS: TWO TEETH TOO MANY
BACKGROUND: Adam is nine years old and attends the dental surgery with his mother for a regular check-up, having been a patient at the practice for the last four years. His dentist – Dr G – notes (for the first time in the records) that Adam still retains his upper baby central incisors (A/A), although the contralateral lower adult incisors have erupted. Examining further she finds the unerupted adult upper incisors (1/1) are palpable buccally. In the notes she records: “Watch 1/1”. Six months later Adam is back at the surgery for another
check-up and his mother expresses concern that he still hasn’t lost his front baby teeth. Dr G exams the teeth again and finds they are “slightly mobile” and she advises there is no call to intervene just now but to keep monitoring the situation. Nearly a year later Adam returns to the surgery still with
“wobbly front teeth” and in an appointment two weeks later Dr G extracts A/A under local anaesthetic. Dr G tells Adam’s mother that the boy’s adult incisors should erupt soon. Ten months later Adam is back in the surgery for an
emergency appointment with a toothache in a back molar. Dr G restores the carious tooth. She notes that 1/1 are still unerupted and arranges for a referral to the local dental hospital. Adam is now age 12 and attends the dental hospital.
Radiographs reveal impacted central incisors caused by two upper supernumerary teeth (sn/sn) – one is palatal to unerupted 1/ and the other is in the /1 position with that adult incisor significantly ectopic, lying horizontally close to the floor of the nose. A treatment plan is formulated to remove sn/ to allow for eruption of 1/, and to surgically expose /sn and in time apply a veneer. A letter of claim is received two months later from solicitors acting on behalf of the patient claiming clinical negligence on the part of Dr G for failing to diagnose the presence of the supernumeraries so they could be removed allowing normal
eruption of the adult incisors. The delay has meant that /1 has been pushed so far out of line by /sn that is now impossible to align this tooth. It is alleged that Adam now faces the prospect of having unnecessary surgery including future removal of /1 with replacement by a single tooth implant at around age 18.
ANALYSIS/OUTCOME: MDDUS commissions an expert report from an orthodontist who examines the patient records from the practice and the dental hospital. He is of the opinion that there were several missed opportunities by Dr G to take radiographs when it was clear there was delayed eruption of the adult upper incisors (normally between ages six to nine years). Guidelines from The Royal College of Surgeons of England call for intervention in cases when eruption of the contralateral teeth occurred six months previously or there is deviation from the normal sequence of eruption (e.g. lateral incisors erupt prior to central). The expert believes these conditions applied at the time of Adam’s first consultation with Dr G regarding his upper front teeth. Radiographs taken at this time would have revealed the supernumerary teeth and allowed for extraction (along with the deciduous teeth) with a reasonable chance that the adult incisors would have come down normally into position. Given the unsupportive expert opinion it was decided in consultation with the member to settle the case for a sum commensurate to the cost of future remedial treatment.
KEY POINTS •
Ensure treatment decisions are backed up by appropriate diagnostic investigations.
• Re-consult guidelines when uncertain over treatment course.
• Be prepared for the unexpected.
CONSENT: NO BLOOD WANTED
BACKGROUND: Mr J is a fit and healthy 46-year- old company director who lives and works in Birmingham. He makes an appointment with his local GP surgery to discuss a “confidential matter”. In consultation with the attending GP – Dr K – he states that he is a Jehovah’s Witness and requests to have a refusal of blood products card added to his patient records. Dr L contacts MDDUS for advice on the matter.
ANALYSIS/OUTCOME: An MDDUS adviser discusses the matter with the GP by phone and follows up with an advice letter. The England and Wales the Mental Capacity Act 2005 entrenches the right of an individual to refuse treatment through an advance decision and as such the practice is advised that it should include the
AUTUMN 2016
document (or documentation of the decision) in the medical records as it relates to the ongoing care of the patient. It is unlikely that the practice will be required to intervene acutely where urgent care with blood products might be required but it may be contacted by a secondary care provider seeking clarification of the patient’s advance decision. The practice is also advised to document any discussion about this decision, noting the patient’s capacity to make such a decision.
KEY POINTS •
•
Respect any competent patient’s right to refuse particular forms of treatment.
Ensure advance decisions regarding treatment and any discussion are highlighted in the patient notes.
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