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CASE STUDY: Insufficient Imaging and Poor Communication Complicate Tooth Extraction

CASE STUDY: Insufficient Imaging and Poor Communication Complicate Tooth Extraction

Case Details

The patient, a female who had limited English proficiency (LEP), saw Dr. B, an associate in a busy general dental practice, for extraction of tooth number 32. A dental assistant had taken a periapical X-ray that depicted most of the root but missed the last few millimeters of the apex. The tooth was partially impacted, accessible to the oral cavity, and possessed fused conical roots.

Because Dr. B had removed hundreds of teeth in similar circumstances, she was confident that she could extract the patient’s tooth without difficulty. Further, she did not want to take more X-rays and expose the patient to additional radiation.

Because the patient was not a native English speaker, she experienced some difficulty completing the customary paperwork, including a written informed consent to treat form. Nevertheless, on the day of her appointment, the patient was anesthetized and the procedure was started.

Dr. B had no problem elevating the tooth, and it was exceptionally loose almost immediately. However, because the doctor was unable to deliver the tooth into the oral cavity, she took another X-ray. The radiograph showed that the tooth had a bulbous apex that was preventing a simple excision. Dr. B then sectioned the tooth, removed alveolar bone, and completed the extraction.

After 3 days, the patient called to ask whether it was routine for her to still have numbness in the area. Dr. B requested that the patient return to the office, at which point she reexamined the patient and determined that she was experiencing lingual nerve paresthesia. Following standard protocol, Dr. B allowed for a 2-week waiting period, in the course of which many similar cases resolve.

However, after 2 weeks, when the patient still had no improvement, Dr. B referred her to an oral and maxillofacial surgeon (OMS) for evaluation. The OMS confirmed the diagnosis of lingual nerve paresthesia. Dr. B continued to follow the patient, but the problem persisted. Finally, the patient requested her records and transferred to a new dental practice. Ultimately, the patient brought a professional liability lawsuit against Dr. B, which was settled out of court.


This case illustrates two potential liability concerns for practicing dentists:
(1) commencing therapy based on insufficient clinical information, and (2) not achieving adequate informed consent.

In a typical dental practice, the dentist takes the X-ray (or has it taken) and also interprets the results prior to starting the surgical treatment. Responsibility for an error in interpretation, or for choosing an appropriate treatment plan based on the interpretation, likely rests solely with the dentist. The fact that an image is of poor quality, resulting in misinterpretation, provides a very limited basis for defending an allegation of unnecessary or improper treatment. The takeaway message is simple: The quality of the image must be sufficient to allow the dentist to correctly interpret the results. If the quality is insufficient, the doctor should take another X-ray.

The second liability concern in this case relates to informed consent to treat. Informed consent often is misunderstood as a legal form that must be completed before a doctor can provide care. In actuality, informed consent is an educational process undertaken to ensure that the patient has sufficient information to reasonably decide on one of the proposed treatment options.

A comprehensive discussion of the informed consent process exceeds the scope of this review; however, an essential element of effective informed consent is a legally competent patient. Although legal “incompetency” is normally thought of as involving limited cognitive function, a patient who cannot understand the information provided because of a language barrier also might be considered “incompetent” to give consent for treatment until the information is communicated in a way that he/she can understand.

Limited health literacy is a serious problem that affects people of all ages, races, cultures, incomes, and educational levels — and people who have LEP might be particularly vulnerable. To address this issue, dental practices need proactive strategies for working with patients for whom language barriers might impede comprehension.

Be sure to understand your legal obligations to provide interpreter services for patients who request them. Dentists who receive federal financial assistance and/or funding are generally responsible for providing interpreter services or auxiliary aids at no cost to patients who request them.

If a patient who has LEP does not request an interpreter, the dentist can use other techniques to communicate and ensure comprehension. For example, using the “teach-back” method of communication can be very effective. The teach-back method is accomplished by going through each section of the consent form with the patient and having the patient restate, in his/her own words, the information that has been covered.

By noting gaps or misunderstandings in the way the patient explains the information, the doctor can make any necessary corrections, and then verify and document that the patient has comprehended the necessary information. Ideally, another member of the dental team will witness the teach-back session and provide confirmation of the session in the documentation. With proper teach-back and documentation, the dental team can safely assume that adequate informed consent has occurred.

In Summary

In this case, two factors — poor quality imaging and inadequate informed consent — resulted in a suboptimal outcome for the patient. The first issue could have been resolved prior to treatment if Dr. B had taken another X-ray to obtain a higher-quality image of the tooth requiring extraction. Doing so might have altered her interpretation of the image, as well as the proposed treatment plan.

The second issue in this case involved inadequate communication with the patient. Although the patient signed an informed consent to treat form, she had difficulty understanding the information due to a language barrier. Using a qualified interpreter or a technique to gauge patient understanding might have helped avoid any confusion about the treatment plan and its risks.

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