Objectives

At the end of this case, the reader should understand (i) the difference between adverse clinical events and dental negligence, (ii) what defines the ‘Standard of Care’, (iii) some basic risk management principles and (iv) the importance of dental ethics.

Introduction

A 72‐year‐old female was referred by her general dentist for a consultation to evaluate pain symptoms that had developed two months following the completion of root canal treatment on the lower left first molar (LL6).

Chief Complaint

The patient’s chief complaint was expressed as ‘I am having pain when I chew on my left side’. These symptoms had been present for six weeks (although they had briefly subsided after she had been prescribed a course of antibiotics by her dentist before the symptoms returned). She reported no spontaneous or thermal pain when she first presented to the office for the consultation.

Medical History

The patient reported that she had mild hypertension and mild kidney problems (reduced function of the kidneys). She was currently taking the medication enalapril and reported that she was allergic to sulfa drugs.

Dental History

She presented to her dentist with a toothache. After the tooth had been assessed, root canal treatment had been initiated on tooth LL6. She returned to the office three weeks later and reported that her symptoms had resolved, and therefore root canal was completed. Two months later she developed pain localised to the lower left quadrant and after a discussion she was referred to an endodontist for a specialist consultation.

Clinical and Radiographic Examination

The extraoral examination was unremarkable. The intraoral exam confirmed that the soft tissues were healthy. The LL6 was tender to percussion; there were no other signs of endodontic or periodontal disease in the lower left quadrant. The LL6 was restored with a porcelain fused to metal crown that had an access cavity restored with a composite resin restoration. Periodontal probing depths were all 2–3 mm. Teeth LL5 and LL7 responded normally to all sensibility testing.

A periapical radiograph showed that endodontic treatment had been carried out on LL6. However, the following were noted: (i) a furcation perforation was evident with obturation materials and a separated instrument in the bony furcation area down to the root apex, (ii) the mesial canals were untreated and (iii) the distal canal had been accessed, but the obturation was well short of the canal terminus (Figure 9.2.1a).

On further discussion with the patient, it was evident that she was unaware of the separated instrument that had been left behind from the prior treatment. She also expressed that she was very unhappy with her dentist and that he had refunded her fees incurred for treatment provided on LL6. On review of the referral paperwork, no mention was made regarding the separated instrument from the general dentist’s endodontic treatment.

Diagnosis and Treatment Planning