By Nuala Carney, Dentolegal Consultant, Dental Protection
Estimated read time: 8 mins
Continuity of care is one of the cornerstones of good dental practice. This requires effective communication between members of the dental team and a meticulous approach to record keeping. In an age when dentists work in complex teams, often from a variety of locations, it is crucial that patient records are kept up to date, are readily available, and are reviewed before any intervention.
This was illustrated in a recent case where a 19-year-old patient presented to his usual dental practice for a routine check-up.
The patient had been treated in this practice for many years and had a low caries rate.
The general dental practitioner (GDP) took a set of bitewings and noted that there was an early lesion beginning on the distal of his lower right second molar, where LR8 was now mesio-angularly tilted and causing some food impaction.
It looked like LR8 might upright itself in time and there was space for it to erupt. The patient had experienced no symptoms at all and so, having discussed the fact that it was important to keep the area clean, a decision was made to monitor it for the time being.
The patient next presented two years later, having just completed his formal university studies. He was planning to take a year out to go to Australia and travel around the world.
The patient saw the practice associate for a clean, as the principal was on holiday, and a new set of bitewing radiographs were taken. The associate advised the patient that the radiographs looked perfect.
Unfortunately, the associate did not realise that there were two film bitewings in a paper chart from two years earlier. The practice had converted to a new software system and on the day in question, the old chart was missing, as it had been misfiled.
The associate was therefore unable to compare his own bitewings with those taken previously, and he did not see the handwritten note from the practice principal noting the early lesion on the distal of LR7.
Given that he saw a perfect dentition with only three very small restorations, he was not concerned and did not insist that the admin staff chase up the handwritten records.
The patient next contacted the practice 18 months later, having just returned from his travels in Southeast Asia. He advised the receptionist that he had had a lot of pain on the lower right while he was travelling and presumed it was his wisdom tooth giving problems.
He had been given some antibiotics which had settled things at the time, but he wanted to get it checked out now. He was booked in to see his usual dentist, who he had last seen when he was 19 – three and a half years earlier. The paper chart was now available again.
The GDP was delighted to see him and immediately took a periapical of the LR7/8 area and a new set of bitewings. To his horror he saw that LR8 had continued to cause food packing which had led to a very significant distal lesion on LR7, and there was now a small periapical area on the distal root.
He noted that there had been digital bitewing radiographs taken before the patient had headed off on his travels. When he reviewed these carefully, he realised that the associate had unfortunately missed the distal portion of LR7, and the distal lesion and impacted LR8 were not apparent at all.
It was now clear that the patient was going to need a root canal treatment and potentially a crown on LR7 long term, as well as extraction of LR8. He advised the patient that a root canal was going to be needed and explained how the food packing had led to the caries progressing.
The following day, the practice received a formal complaint from the patient seeking his records and wanting to know why he had been told that ‘everything was perfect’ before he set off on his travels, when clearly everything was not perfect at all.
He wanted to know if the practice would be covering the cost of the root canal treatment and crown, as he felt he had not been made aware that this was likely to occur and would have followed it up in Australia had he known.
The dentist contacted Dental Protection for assistance with the response, as the principal dentist recognised that it would also need input from the associate.
It was clear when the case was reviewed carefully that the associate might be vulnerable to criticism if the matter were to escalate, and that the practice might also be vulnerable to criticism for the questionable filing system and follow up.
In conjunction with the dentolegal consultant at Dental Protection, a letter of apology and explanation was provided to the patient, along with an offer to cover the remedial treatment required, including the endodontic treatment and the crown on LR7.
The patient was willing to accept this and decided not to take the matter any further. LR8 was removed prior to the crown being provided. Both staff members involved, who were both members of Dental Protection, were very grateful for the assistance provided, as they recognised that had the matter progressed, it could potentially have resulted in a successful claim, or a complaint to the Dental Council.