S. J.

Henderson1

in brief

Patients expectations of pain, complications

and after care can be managed by careful

discussion.
This article notes complications that
require the patients recognition before
commencement of the procedure.
Medical histories may have a significant
impact on the delivery of oral surgery.
Patients of all ages presenting to primary
care with trauma and avulsed teeth need
specific management.

practice

Risk management in clinical

practice. Part 11. Oral surgery

Oral surgery is often an unpleasant experience for a patient and if managed inadequately can be a cause for complaint or a
claim in negligence. A practitioner can reduce their risk of complaints, claims or even regulatory body investigations by following
some straightforward risk management strategies. Effective communication skills deployed throughout the interaction with
the patient, especially during the consent process, are a pre-requisite, as is a proper understanding of the law on consent. An
honest reflection by the practitioner on their competence to carry out a procedure, considering their skills, the equipment and
support available will result in fewer medico-legal cases. In this article, each stage of the patients journey is discussed and risk
management advice offered for a range of procedures that are regularly encountered in general dental practice.

Oral surgery under local anaesthetic is at

best uncomfortable for the patient and
at its worst an extraordinary and traumatic business. The heart of the conscientious practitioner will sink when the
patients friend or relative helpfully suggests that the proposed procedure will be

RISK MANAGEMENT
IN CLINICAL PRACTICE
1. Introduction
2. Getting to yes the matter of consent
3. Crowns and bridges
4. Endodontics
5. Ethical considerations for dental
enhancement procedures
6a. Identifying and avoiding medico-legal
risks in complete denture prosthetics
6b. Identifying and avoiding medico-legal
risks in removable dentures
7. Dento-legal aspects of orthodontic
practice
8. Temporomandibular disorders
9. Dental implants
10. Periodontology
11. Oral surgery

Specialist in Oral Surgery/Dento-legal Adviser, Dental

Protection Ltd, 33 Cavendish Square, London, W1G 0PS
Correspondence to: Dr Stephen Henderson
Email: [email protected]
1

Refereed Paper
Accepted 20 October 2010
DOI: 10.1038/sj.bdj.2010.1182
British Dental Journal 2011; 210: 1723

fine and wont hurt a bit just as the

operator approaches to provide a local
anaesthetic infiltration.
When considering oral surgery in primary care it is imperative that each practitioner reflects carefully on the following:
Communication
Competence
Consent.
As in many other disciplines, success
or failure can depend on communication
skills. If the anxious patients expectations
can be managed in order to prepare them
for the admittedly unpleasant procedure,
the chances of a claim in negligence or a
complaint will be significantly reduced.
The ability to reflect on ones ability
and competence is a key area of practice
that is necessary when considering the
risk management for any given procedure. If a procedure is proposed that is at
the limit of a practitioners competence (or
beyond it), and the procedure is either not
completed or carried out to a lower than
expected standard, the practitioner is open
to challenge either by the local authorities,
national regulator or the civil courts and
of course the patient directly.
In order to obtain valid consent the
nature, purpose and alternatives to a proposed plan need to be explained, as do the
material risks and consequences of each
choice, with sufficient depth for the patient

to make a clear choice about their treatment. Inevitably, the nature of the consent
is a key area of interest in a claim in negligence, a complaint and an enquiry by the
regulatory body.

Competence
The GDC has approved the curriculum of
undergraduate teaching in the UK and has
an expectation that each registrant has
reached a minimum standard of training.
The Courts in England and Wales have set
the standard that is expected: The standard of reasonable care and skill required
is that of the ordinary skilled person exercising and professing to have that special
skill.1 It is against these standards that
the care of a patient by an individual
practitioner is determined.
Once a diagnosis has been made and a
plan developed and proposed, it is important that the practitioner reflects on their
own ability to execute the plan as agreed
with that patient. In reflecting on this the
practitioner does have an obligation to
inform the patient if, although experienced
in many procedures, they may be relatively
inexperienced in this particular one, giving
the patient a choice to be referred to another
colleague who may be more experienced,
but not necessarily a specialist. An important element of consent is the information
given to the patient, and it follows that the
prudent patient might consider it significant

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practice
to know in advance that the person about to
operate, although well versed in the theory,
had not actually carried out the procedure.
The regulatory body considers insight into
a practitioners ability important2 and
criticises registrants who show little or no
insight into the limits of their ability.
Competence in a particular procedure is
a function of experience and training, both
academic and practical. There really is no
substitute for hands-on practical experience in minor oral surgical procedures.
With the advent of widespread fluorides,
better oral hygiene measures and a shift
in the mindset of the public and profession to preserve teeth almost at any cost,
the number of oral surgery procedures a
young practitioner may be exposed to can
be small.
An inexperienced practitioner may be
further hampered by a lack of knowledge
of the appropriate instruments to select or
indeed to hold available within the practice. Incorrect instrumentation incorrectly
used can be potentially disastrous.3,4

Pre-operative assessment
A frequent complaint following oral surgery in practice is that the procedure was
painful both during and afterwards, far
more so than the complainant expected.
The length of time a particular procedure
appeared to take frequently features in
complaints. Claims in negligence relate
principally to damage caused to adjacent
structures, including allegations that the
wrong tooth has been removed or damaged, for example. Many of these complaints and claims can be anticipated
and managed by a thorough, realistic
pre-operative assessment and a valid consent. It is imperative that any preoperative assessment is fully documented in the
contemporaneous record so that it can be
relied on later as a record of the information available at the time of consent and
also of the conversation that took place
between the operator and patient. It is
frequently helpful to be able to refer to a
detailed consent form, signed at the time
of the discussion.
The records should show that a proper
consideration of all the relevant factors,
both local and systemic, has taken place.
This should include a review of the relevant medical history and a note about the
justification for the procedure, the choices
18

available and given to the patient and any

concerns about the vulnerability of local
structures that may be damaged even in
the normal course of the procedure having
been given to the patient. A practitioner
who embarks on a procedure without
appreciating the breadth and depth of the
duty of care owed to a patient is potentially embarking on a long medico-legal
journey that may have been frustrated at
the outset.
The patients journey is rarely straightforward and inevitably the treatment plan
must be varied to suit the particular circumstances depending on the emerging
clinical picture and the choices made by
the patient, including the timetable and
financial constraints. At each stage it is
important that the patient is aware of
any compromise to the ideal standard as
accepted by the profession.
In approaching risk management of
oral surgery it is helpful to put into place
systems which can be used to identify
and eliminate common errors in process that might leave the practitioner and
patient vulnerable. The systems should be
based on the gold standard of care that
a practitioner might want a family member to experience. Any compromise from
the gold standard leaves a practitioner
vulnerable to criticism.

Relevant medical history

A responsible practitioner will consider
the effect of the proposed procedure both
locally and systemically. A review of the
relevant medical history is a key aspect of
this assessment and a failure to identify
or document a relevant medical problem
may have disastrous consequences for the
patient. Complacency is a big danger when
medical histories are not regularly updated,
particularly when there are a number of
concurrent problems, some of which are
under investigation. This is an increasing
problem in an ageing population.
It is a mandatory pre-operative assessment to obtain and update at regular intervals a thorough medical history. Systems
need to be in place to ensure that the medical record is checked, especially where the
procedure may compromise or be compromised by the patients medical condition.
Minor oral surgery procedures engage a
whole raft of medical conditions not challenged by many other aspects of dental

care. Common health conditions such as

diabetes, hypertension and aspirin therapy
may all impact more or less significantly
without really altering regular dentistry.
Common causes for complaint in dentolegal practice, such as post-operative
bleeding and incorrect prescribing to
allergic patients, can be anticipated and
addressed with simple risk management
steps, such as a routine to ask any patient
being issued with a prescription whether
or not they are allergic to the particular
medication, having previously checked on
the dental record. It is a simple fallback
procedure that should be repeated at the
dispensing pharmacy.
Post-operative bleeding should, ideally,
be anticipated and dealt with intra-operatively, with local haemostatic measures,
sutures, haemostatic gauze etc, and above
all a clear written instruction sheet bearing a telephone number for the patient
to obtain out of hours advice. This is an
example of how patient expectations can
be managed so that they understand what
to anticipate following a procedure, as part
of the consent process. All that the written
instructions provide are a confirmation of
everything that has been said and the provision of a telephone contact number.
A thoughtful practitioner must reflect on
the risks that the patient may be exposed
to during oral surgery procedures, keeping up to date with evidence of emerging
risks such as bisphosphonate therapy5 and
a variety of new drugs, particularly anticoagulants. The British National Formulary
(BNF) and other useful resources6 ought to
be easily accessible in order to review the
effects and side effects of any prescribed
medication and any health impact of the
proposed treatment.
A correct assessment of the risk of carrying out a procedure within the practice
rather than offering or firmly suggesting
a referral should be part of the consent
process. For example, no-one in secondary care would criticise a primary care
practitioner for referring on a patient with
unstable angina who required oral surgery.
However, a referral based on an overanxious or incorrect assessment of a stable,
existing condition only causes inconvenience to patients and secondary care providers, leading to avoidable complaints. It
follows that practitioners must have an up
to date working knowledge of medicine.
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practice
Ignorance is not an adequate defence in a
claim or regulatory enquiry.2
Bearing in mind the stresses which can
be experienced by patients undergoing oral
surgery, the practice must be adequately
prepared and rehearsed to deal promptly
with an acute medical event.7

Diagnosis, treatment
planning and consent
Errors and near misses are not uncommon
in minor oral surgery procedures. Many
can be risk managed by careful reflection
on the working diagnosis, ensuring that
the correct tooth is being treated, having
obtained sufficient information to have
confidence that the correct plan has been
offered to the patient. In order to deal
with an enquiry afterwards, it is necessary to show enough information has been
recorded to be able to explain the decision
to a third party. Common difficulties are
the absence from the records of adequate
radiographs, and an absence of vitality or
sensibility tests.
Acute pulpitis can be very difficult for
a patient to localise to a particular tooth,
therefore if extraction is proposed as the
definitive management of the problem
detailed records of the investigations will
be necessary in order to deal with a claim
for wrongful extraction. This is important where a number of teeth may be
grossly carious.
It is appropriate to consider other, more
uncommon causes of dental pain before
committing a patient to an extraction.
While relatively rare, atypical odontalgia
or atypical facial pain can be sufficiently
distressing for a patient to demand an
extraction. A trial of local anaesthetic, to
see whether or not a pain is abolished, is
invaluable in this particular group. A valid
consent is necessary as the patient must
understand that although they are going
to receive a local anaesthetic, there may
be no other active dental treatment carried out and no short-term or immediate
resolution of the pain.

Equipment
Simple risk management techniques must
be applied to the availability of equipment for a proposed procedure. If you do
not have the equipment or instruments to
complete the surgery, including managing the regular complications, it would

be unwise to start the procedure. It goes

without saying that any instrument
or item of equipment should be fit for
purpose and used for the purpose it was
designed for only. Air turbine high speed
handpieces should never be used intraoperatively to section teeth or remove
bone. Surgical emphysema3,4 is a sudden
and potentially life threatening complication of third molar surgery. It can also
be a complication of maxillary molar
removal. Winters forceps have fallen out
of favour, to the point that it would be
considered a breach of duty of care to
deploy this instrument in contemporary
practice. The mandible and alveolar bone
of the maxilla is vulnerable to fracture
when exposed to the forces developed by
Winters forceps.
It goes without saying that standard
cross infection procedures (SCIP) should
be used in oral surgery in the primary
care setting.

Orthodontic extractions
Orthodontic extractions present difficulties
as information is transmitted between two
(or more) practitioners who each have a
duty of care to the patient. The form of
transmission is a source of error and near
miss. Ideally a referral for elective extractions of healthy teeth should be written
in two forms, both symbolic and written
longhand. Charting on no-carbon paper is
not foolproof, and incidences have been
known where the bottom copy is sent to the
surgeon but the paper had slipped, resulting in the contra-lateral premolar being
removed. Simple typographical errors can
occur when letters are typed and if the
letter is not checked against the record,
incorrect teeth may be extracted. Each
operator should have a system to ensure
the correct tooth is removed, assuming the
letter of instruction is correct. Errors can
creep in where the initial charting is, for
example, incorrect and a premolar tooth
is either congenitally missing or has been
extracted earlier. In other words, it is prudent to check the records, the letter, the
mouth and finally with the patient and/or
their parent before obtaining consent for
extraction of a particular tooth or teeth.
Naturally an extraction of a wrong tooth
is by definition treatment without consent,
as the consent was specifically obtained to
remove the neighbouring tooth.

Pre-operative radiographs
If a reasonable practitioner would expect
to have sight of a pre-operative radiograph before obtaining a valid consent, it
is a logical position that a prudent patient
would want to know what information
might be gleaned from such a radiograph.
It is also fair to say that a clinical decision
to extract a tooth does not necessarily need
a contemporary radiograph to establish
the tooth anatomy and its relationship to
adjacent structures. There are exceptions;
where pathology is developing and changing rapidly, an up-to-date image can be
helpful. The key is to be able to assess the
anatomy of the tooth and the neighbouring structures sufficient to anticipate any
potential difficulties or complications. It
is important that the whole of the root
anatomy is visualised clearly on the film.
In third molar surgery and mandibular
premolar surgery, where there is a very
real risk of nerve damage if the neurovascular bundle is traumatised during the
surgery, a reasonable operator would want
to know about the relationship of the tooth
to the nerve trunk. In order to achieve a
valid consent the patient should have the
measurable risk of intra-operative nerve
injury explained and quantified. It follows
that a radiograph which does not provide
all the information to obtain a valid consent falls below an acceptable standard,
as it exposes the patient to the possibility
that avoidable harm may occur during the
proposed procedure.
As in all radiographic investigations, a
proper justification should be documented
in the records, along with an assessment of
the quality and diagnostic yield and also a
report of the film.

Pre-operative warnings
In order to obtain a valid consent, patients
must have sufficient information to decide
that they will agree to the proposed
course of action, having weighed up the
alternatives and risks of each choice.
In assessing and communicating the
risks it is helpful to consider the prudent
patient and what information that prudent patient would like to have before
reaching a choice. It is also important
to understand what view the law takes
about pre-operative warnings.8 Every procedure has consequences and risks. It is
an expectation on a day-to-day basis that

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practice
the risk of complications will not come
to pass. It is also an expectation that if
the consequences do occur, there will be
no long lasting difficulty. In obtaining a
valid consent, the patient must have been
given sufficient information to be able
to understand the normal consequences
and the risks of complications developing with an insight into the long-term
effects of the complication should it come
to pass and the chances of that risk taking
place. The greater the effect of the risk, if
it occurred, the more thorough the explanation needs to be. The Courts expect
that if a risk is foreseeable, a warning
should be given.
This means that careful risk management requires a reflection with the patient
about the consequences and the risks of
any procedure and equally importantly the
consequences and risks of not doing the
proposed procedure.
Take for example the risk of a fractured
mandible during an extraction; it is foreseeable when extracting a deeply buried
third molar or second premolar, and a
specific warning is appropriate in those
circumstances, but in the straightforward
extraction of an erupted first or second
and partly erupted third molar tooth it
would be a theoretical risk, but a reasonable practitioner would not normally
expect to warn.
Ultimately, a patient may decide not to
give consent for a particular procedure and
instead, seek a referral to a more experienced colleague. A practitioner must bear
in mind their obligations under Standards
for dental professionals2 not to interfere
with the voluntariness of consent by
putting a patient under duress to permit
that practitioner to carry out a procedure
in these circumstances.

Some specific surgical

procedures
Removal of maxillary teeth
A full assessment of the site-specific
issues should be carried out at the preoperative or planning visit. In the case of
the maxillary molars and premolars, the
site-specific concerns are the relationship of the tooth/teeth to the maxillary
antrum and maxillary tuberosity. The
morphology of the tooth/teeth in relation
to the alveolar bone and antrum must be
20

considered and discussed with the patient,

especially if it is reasonably anticipated
that it will be a difficult procedure, perhaps
involving an endodontically treated and
crowned tooth.

Warnings
Root into antrum. Although the risk
of displacing a root or root apex into
the antrum may be low, because the
consequences of such an event are
significant for the patient, who may
require a hospital admission to remove
the root, it is reasonable to offer a
specific warning
Oro-antral communication. A
communication between the antrum
and the socket is not an unusual
consequence of a dental extraction
in the maxilla. In a relatively small
number of patients a fistula develops
where the epithelial lining of the
antrum joins the oral mucosa, ensuring
a patent communication. As with
a displaced root, the consequences
for the patient are significant,
requiring remedial surgery to close
the communication with a local
flap including the possibility of
remedial sinus surgery. A reasonable
practitioner would therefore be
expected to warn the prudent patient
of these specific risks
Fractured tuberosity. A fracture of
the maxillary tuberosity is a regular
consequence of an extraction of a third
molar, however it is the size of the
fractured piece of bone that determines
the significance. In many cases a
small bony injury is not significant,
nor even noticed by the patient. In
more significant cases where either
the whole of the tuberosity or even
the distal segment of alveolar bone
is fractured, careful management is
necessary. Since complainants make
much of a fractured jaw it is prudent
to explain, putting into perspective
the risks of significant consequences,
when seeking consent for third molar
extractions in the maxilla. In cases
where there is a lone standing molar
in a resorbed maxilla and there is a
real risk of a fracture of the alveolar
bone which, if it came to pass, would
dramatically affect the choice of
restoration later, full warnings and

a choice of onward referral should

be offered
Retained apices. A pre-operative Xray
will show whether or not a tooth
has apices that may be vulnerable to
fracture during routine exodontia. The
consequence of a retained apex on
future treatment can be significant,
particularly where the bone is being
used to site an implant or adjacent
teeth will be moved by orthodontic
movement through the bone. Retained
apices can compromise both of these
treatments and where appropriate, the
patient should be aware of these risks,
and an offer to refer to an experienced
colleague considered carefully. The
failure to offer a referral
pre-operatively is now a common
element in complaint and claims.

Rare complications
All of these complications are foreseeable
but unlikely, however an assessment of the
risk to local structures does need to be carried out and a note made of the discussion
with the patient about the relevant risks.
The risks can be minimised by careful
surgical technique.
Dry socket. Although rare, a socket
that is not healing needs to be assessed
and managed correctly. The differential
diagnosis, retained root/apex
malignant change, unusual infections
and osteonecrosis/osteoradionecrosis
must be carefully considered and
eliminated. If there is any doubt
about the cause of delayed healing,
experienced opinion should be
sought promptly
Torn palatal mucosa. It almost
goes without saying that the best
management of a torn mucosa is
prevention. There are occasions where
even the most experienced surgeons
cause a small tear in the palatal
mucosa when removing (typically) a
third molar. The careful practitioner
and the assistant will keep a regular
review of the adjacent structures
during a surgical procedure, allowing
a prompt alteration of the technique
to minimise the tear and manage
it correctly. In significant tears,
extending well onto the hard or soft
palate, there can be dramatic bleeding
requiring careful management of the
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palatal artery and veins. Palatal tears
are often associated with fractured
tuberosities and fractures of the
alveolar bone
Prolapsed antral lining. This is not an
immediate complication, but needs to
be identified and managed correctly in
order to avoid a fistula developing
Trauma to floor of nose. The removal
of impacted maxillary canine and
incisor teeth which are close to the
floor of the nose can be associated
with damage or trauma to the floor
of the nose. Epistaxis during a dental
extraction, which appears to be related
directly to the extraction, should be
investigated to that appropriate wound
closure can take place. It may be
necessary to make an urgent referral to
an experienced colleague or a
local specialist.

Removal of mandibular
third molars
Surgery to remove third molars should be
considered carefully in the context of the
nationally accepted guidelines.9 The significant risks associated with third molar
surgery are related to the tooths proximity
to local anatomical structures.
A significant nerve injury either to the
inferior alveolar (IAN) or lingual (LN)
nerves can be very distressing for the
unfortunate patient.10,11 Careful pre-operative assessment and surgical technique
can minimise the risk of a nerve injury.
Lingual nerve injury occurs either while
the nerve is being protected, the soft tissue
flap having been reflected and retracted,
or by direct trauma from a bur, hand
instrument (couplands elevator or luxator incorrectly used) or sharp bony margin
during bone removal and/or tooth elevation. Techniques have been described12
that significantly reduce the risk of nerve
injury in flap elevation and retraction by
employing a wholly buccal approach. As
these techniques are increasingly taught
and recommended, the Courts are likely
to be increasingly critical of a practitioner
who has not altered their technique for
third molar surgery.
IAN injury is caused either by direct
trauma from the root being elevated and
crushing/compressing the nerve canal and
its contents, by a direct contact from the
bur or as a consequence of a fracture and

the subsequent treatment of an iatrogenic

fractured mandible.
Coronectomy13,14 has been proposed
as an alternative technique, designed to
reduce the risk of IAN. In this technique,
the crown is sectioned from the roots,
which are likely to be intimately involved
with the IAN. The crown is removed and
the roots left in situ to exfoliate naturally, be resorbed or remain insitu. There
does not appear to be an increase in dry
socket or other infection with this technique. When considering this technique,
the documentation of a careful and thorough consent is mandatory because the
patient needs to be clear about the decision
to leave the retained roots and the reasons
for that decision. Equally, the patient needs
to fully appreciate that notwithstanding
the best efforts of the surgeon, the roots
may still need to be removed if, for example, they have become mobilised during
the coronectomy, with the attendant risk
to IAN.
In a negligence action the claimant must
show that there has been a breach of the
operators duty of care. A failure to use
an accepted technique or the careless use
of an accepted technique would normally
be considered a breach of duty. When
an unorthodox technique is considered,
a detailed explanation with appropriate
warnings should be given and documented
clearly in the record.

Surgical extractions of mandibular

molar and premolar teeth
The extraction of lower molars and
premolars often appears to be a straightforward procedure. However, a careful
review of the anatomy of the roots, the
extent of caries and/or restoration and a
history of endodontic treatment, making a
tooth brittle, means that on occasion this
is a far from straightforward problem. It
is important to bear in mind the relationship to the local anatomical structures,
notably adjacent teeth and in particular
the mental nerve.
While the mental foramen may be
relatively easily palpated, the presence
of a buccal infiltration of anaesthetic
reduces the ease with which the foramen
can be identified. It is also important to
remember that the nerve itself is vulnerable during the raising of a mucoperiosteal flap. Therefore flap design and

technique is important if the mental

nerve is not to be damaged by a scalpel,
elevator or bur. Equally where the flap
might tear, the nerve trunk and branches
are vulnerable.

Common complications
Haematoma
Bleeding
Retained root
Dry socket.

Rare complications
Mental nerve injury
Osteonecrosis
Actinomycosis
Fractured mandible
Surgical emphysema.
A general practitioner should not be
surprised by post-operative bleeding, certainly if it occurs within 12 or 24hours of
the surgery. A full pre-operative medical
history should have identified any medication or medical condition that increases
the risk of post-operative bleeding, notably hypertension and anticoagulant therapy. Simple intra-operative measures can
anticipate the majority of causes of postoperative bleeding and reduce the risk of
this complication, for example the formal
raising of a flap, rather than permitting
the mucosa to tear, and a careful review
of the socket to ensure that there are no
signs of significant bleeding during and
immediately after the surgery is complete.
The medico-legal risk of a rare complication is that the practitioner fails to identify
that a complication has occurred and therefore delays both diagnosing and treating
the complication. Practitioners need to be
alert to odd patterns of healing and other
unusual outcomes of surgery. Osteonecrosis,
osteoradionecrosis and actinomycosis can
present several weeks after the surgery and
are difficult to confirm. However, the pattern
of pain and/or infection never quite resolving with a short course or two of antibiotics
should raise a concern warranting further
investigation. A detailed review of the
medical history may unearth a previously
undisclosed condition.
Surgical emphysema3,4 is caused by compressed air from the high speed air rotor
handpiece (or a 3:1 water spray) being
forced below the periosteum and into, for
example, the submandibular space, lateral

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practice
phayrygeal space and ultimately into the
mediastinum and pericardial space. It
presents with a sudden dramatic swelling of the face and cheek, closing the eye,
acute chest pain and shortness of breath.
In the short-term, until proven otherwise,
this is an acute medical emergency. Once
the medical emergency is stabilised the
condition is potentially a surgical emergency with oral organisms and waterline/
airline organisms having been forced into
the mediastium and pericardium. The
patient should be referred for assessment
and management.
As with many complications, surgical
emphysema is avoidable by correct instrumentation and risk assessment. There is no
scope for short cuts in surgery.
A fractured mandible is a rare complication of oral surgery15 in primary care. A
simple risk assessment of the factors that
might indicate an increased risk should
result in a referral to a local specialist.
Occasionally an unforeseen fracture can
occur, therefore it is good practice to
review the socket on each occasion to confirm that there is no sign of a fracture, and
when the review is carried out, it should be
specifically documented in the records.

Apical surgery
When a practitioner considers a particular
course of action or referral for that course
of action, they should be able to justify
that decision having considered a differential diagnosis and following appropriate
investigations, a working diagnosis. In the
case of apical surgery where alternative
and less invasive treatment may be available, it is imperative that patients are given
a clear explanation of both the diagnosis
and treatment choices available with a
considered discussion about the prognosis
(and cost) of each choice.
With the improvement of endodontic
techniques and the ability to remove both
cast and prefabricated posts, the circumstances where apical surgery is considered
as a first line treatment for an apical lesion
have reduced significantly.
In order to deal effectively with a claim
following apical surgery, the records will
need to demonstrate that, after all the
other options have been discussed and
considered, a reasonable practitioner
would accept that there was no alternative to that surgery. It will be important
22

to show that the option to re-do the

orthograde root canal treatment has been
carefully considered and excluded as a
viable alternative. In contemporary dentistry there are very few circumstances
where orthograde endodontic treatment
cannot be considered for remedial treatment, especially with the access to microscopes and nickel-titanium rotary file
techniques. It is crucial to eliminate both
vertical root fractures and a breakdown of
the coronal seal as a cause for failure of
endodontic and crown and bridge treatments, and where surgery is contemplated
to explore a failing or failed root filling,
appropriate warnings about the chances
of identifying a fractured tooth should be
given and documented.
Where there is a radiographic indication
that a periapical lesion may be suspicious,
it is prudent to arrange for a biopsy to be
carried out, especially if there is any doubt
that a lesion may be malignant.

Acute infections
Antibiotic therapy for an acute infection
suits everyone as a first line of management; it is simple for both practitioner
and patient, avoiding a surgical approach.
This is an approach that is frequently used
incorrectly, where incision and drainage is
necessary. Systemic illness and significant
local spread warrants the prescription of
systemic antibiotics, although it may not
be necessary for the patient to complete
the full course of antibiotics.16 Incision and
drainage must be timed correctly otherwise
it produces misery for the patient because
it is painful and, wrongly timed, produces
no great benefit. However, correctly timed,
a collection of pus can be drained allowing
a dramatic improvement.
When planning incision and drainage
it is important to take care to consider
the local anatomical structures, particularly the mental and infraorbital nerves.
These are vulnerable to both the incision
and also the expansion of the tissues to
achieve drainage. Bearing in mind that this
procedure is not pleasant for the patient,
the choice of anaesthesia and information
given in the consent process are crucial
choices. Remember the extent of the anaesthesia may well be extremely limited and
the (necessary) expansion of the tissues to
ensure proper drainage can be very painful.
Equally, planning the anaesthetic approach

for incision and drainage is important. If

a local anaesthetic needle is inserted right
through the middle of a collection of pus,
that abscess may be spread.

The management
of malignant disease
The key factor in the management of a
lesion that might be malignant is to recognise ones limitations and if in doubt
refer early for a specialist opinion. The
patients consent is required for any
referral to secondary care, and in order to
obtain a valid consent it is necessary to
discuss the differential diagnosis with the
patient and the importance of attending
any appointment offered. When writing
a referral letter it is preferable to provide
as much information as possible to the
specialist. This ensures a correct decision
being made about the urgency of the proposed appointment. In general terms, even
if you are extremely experienced in carrying out biopsies of potentially malignant
lesions and you have contemporary storage and transport media, most consultant
surgeons like to see the extent of the whole
lesion themselves so that they can select
a representative sample for analysis. With
advancing histopathology techniques in
secondary care, which can have a significant effect on both the diagnosis and subsequent management of a lesion, it would
be prudent not to compromise the patients
care by delaying a referral while waiting
for a suboptimal biopsy specimen to be
examined and reported.
Occasionally, a socket does not heal normally following an extraction. It is important to maintain a high index of suspicion
when considering non-healing sockets.

Trauma
Primary care practitioners are regularly called upon to provide first aid and
definitive management of localised dental
trauma, including subluxed and avulsed
teeth. Ideally each practitioner should
keep a weather eye on changing protocols
developed from regular reviews of the literature. Trauma cases are the bread and
butter of personal injury lawyers, so it is
therefore invaluable to have made detailed
and accurate notes of the clinical findings,
both at the time of the first involvement
and at subsequent reviews. Appropriate
photographs and radiographs make
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2011 Macmillan Publishers Limited. All rights reserved.

practice
report writing, particularly in relation to
prognosis, much more straightforward.
Any dental trauma case must have some
element of head injury assessment documented, and an early referral made if there
is any possibility of a significant head
injury requiring medical advice. As with
any dental procedure, competence is the
key. Every practitioner dealing with trauma
patients ought to be able to carry out an
initial assessment and make a referral to a
local accident and emergency department
if there are any concerns.
Be suspicious of a more serious injury
when examining a patient following a
traumatic event. If in doubt about the possibility of a fractured mandible or maxilla, seek advice from a local specialist. It
is particularly important to examine the
condyles of a child who has landed on
their mandible. A review of the current
occlusion and palpation of the condyles
should be documented in the records, noting whether there is any sign of swelling,
tenderness or limitation of movement of
the mandible. In a child or young adult, an
undetected fractured condyle can seriously
interfere with the growth centre and lead
to significant facial asymmetry and malocclusion. If an opportunity to identify and
manage the injury was missed, it would
difficult to defend a claim in negligence
in the absence of detailed records and a
referral to a specialist.

Lacerations to the soft tissues should be

managed carefully, with proper debridement and closure in layers. If there is any
doubt about the complexity of the reconstruction, simply clean the wound and
arrest bleeding with some simple interrupted sutures and refer the patient to a
local specialist. A prudent practitioner will
explore any laceration gently in order to
exclude the possibility of a retained foreign body, for example the crown of a
fractured tooth.

Conclusion
When minor oral surgery is contemplated
and/or necessary in order to manage a
patient in pain, it is incumbent on the
practitioner to reflect, both on their own
limitations and equipment.
Are you adequately equipped, prepared
(and supported) to carry through the
procedure that has been proposed, and
can you deal with any complications
that might arise during the surgery?
If not, is the patient aware and have
they made a positive choice to have
treatment, knowing that it may be
complicated? In other words, has an
adequate consent been obtained from
the patient?
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2011 Macmillan Publishers Limited. All rights reserved.