Management of Treatment Complications in Dentistry

It is possible for complications to arise during or after any treatment or procedure. In this case study, we examine risk management issues involving complications that resulted from an extraction procedure and outline strategies to help dental professionals enhance safety while mitigating risk.

A patient presented to a dentist for a scheduled tooth extraction and denture fitting. During the extraction, the patient complained of extreme jaw pain and allegedly stated that it felt as if it had been broken.

The patient was discharged home and returned the following day, presenting with a swollen and bruised jaw and complaining of pain.

A dental x-ray revealed a complete fracture of the left mandible. The dentist referred the patient to an oral surgeon, with a letter outlining the x-ray results and information stating his belief that the fracture may have occurred during the extraction of an ankylosed tooth. The dentist provided the patient with the original x-rays and dental record.

The oral surgeon diagnosed a left displaced mandibular fracture and admitted the patient to the hospital for surgical repair. The oral surgeon performed an open reduction internal fixation the next day, and the patient was discharged a day later.

Subsequently, the patient developed complications that required several additional surgical procedures. The patient continued to have pain and loss of jaw function and became anorexic as a result of an inability to chew properly.

The patient successfully pursued a professional liability claim against the dentist. The patient alleged that the dentist was negligent in failing to properly document the extraction procedure, failing to maintain proper dental records, failing to take adequate x-rays prior to the procedure, causing the fracture by applying excessive force during the extraction, and failing to adequately assess the patient’s complaint by obtaining an x-ray immediately.

Risk Management Discussion

When an undesired result, injury, or serious complication occurs, it is often how the situation is handled that determines the outcome for both the patient and the healthcare practitioner.

In this case, when the patient complained of pain, the dentist did not stop to determine the source or severity of the pain and did not obtain a post-treatment x-ray. Although the dentist stated in a letter to the oral surgeon that he suspected the fracture had occurred during extraction of a specific tooth that was ankylosed, he did not document this information in the patient’s record, nor did he document discussions with the patient following the procedure. Because the dentist provided the patient with the original x-rays and dental record without keeping a copy, it was difficult to determine what information was documented by the dentist and staff.

The following strategies can help dental professionals improve quality and mitigate risk:

• Document the dental record with details regarding any complaint or complication that occurs during or following a procedure. Include your assessment and the actions taken to respond to the complaint or complication. For more information on documentation, see our article “The Faintest Ink: Documentation to Defend Quality Patient Care.”
• Retain all original records and x-rays. When a request is received for records and x-rays, make a complete copy, and retain the originals in the office. When referring a patient to another care practitioner, supply copies of the dental record and x-ray films, but keep the originals. Document that copies were sent to the treating practitioner or given directly to the patient. See our article “Medical and Dental Record Issues: Frequently Asked Questions.”
• Maintain communication with the patient and other treatment practitioners. For known risks or complications, review your informed consent process to determine if the risk or complication was discussed. Continue to provide follow-up conversations and care. In a study of plaintiffs who were asked why they chose litigation against their healthcare practitioner, most responded that they were seeking an apology and an explanation. It is important to provide both to a patient who is injured by a medical, dental, or system error. Because the reason for the injury or complication is often not known immediately, it is equally important that you do not assume blame or point to others as the cause. For more information on patient communication after a known risk or complication or an unforeseeable event, see our “Disclosure Resources.”
• Consult with your professional liability insurer. When an adverse outcome resulting in potential or actual harm occurs, report it to your insurer immediately for risk management guidance. In this case, the dentist did not report the event until the patient had retained an attorney.

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.