Decision Report 201407750

Summary

Ms C attended her dental practice complaining of pain from her molar tooth. Ms C elected to have an extraction, which was performed under local anaesthetic. During the extraction, the tooth fractured and part of the root was displaced into the maxillary antrum (the space within the upper jaw bone). This had to be removed by surgery. Ms C said it was not reasonable that the tooth fractured during the extraction because the dentist had an x-ray showing the size of the tooth and its position before undertaking the procedure. Ms C complained that she had to attend hospital eight times because she suffered a severe infection which disfigured one side of her face and caused extreme pain.

We took independent advice from our dental adviser. We found that there was no indication that the fractured root would become dislodged and penetrate the antrum, and that this was a well recognised complication of this kind of extraction. However, there was no evidence in Mrs C's dental records that the possible complications of the extraction had been explained to her before the procedure had been carried out. While we were satisfied by the evidence that, overall, the treatment decisions and management were reasonable, we made a recommendation to the practice given the lack of evidence showing that possible complications were explained.

Recommendations

We recommended that the practice:

• take steps to ensure the possible risks of extraction are adequately explained to patients and recorded in their records.