Extraction of tooth

Complaint

The Commissioner received a consumer's complaint through the Dental Council of New Zealand about the care the consumer received from the provider, a dentist. The complaint is that in late July 1997, while extracting the consumer's tooth, the provider:

• Left the room on three occasions to get equipment. On two of these occasions the provider left the door open so people in the waiting room could see the consumer upset with blood over the front of her bib.
• Dropped part of the tooth into the consumer's mouth.
• Commented to the nurse that as she had stitched through the consumer's palate she would have to leave the stitching loose.
• Sent the consumer into the waiting room upset and in pain.
• Sent the consumer home when she was not fit to drive.
• Did not give the consumer a prescription for antibiotics.
• Did not respond when the consumer left a message at the Dental Clinic saying that she would not be returning.

And that:

• The Dental Clinic rang the consumer at work to change the appointment time to 14 days after the surgery to have the stitches removed.

Investigation

The complaint was received by the Commissioner on 3 September 1997. An investigation was undertaken and information obtained from:

• The Consumer
• The Provider / Dentist
• The Dental Assistant
• A General Practitioner
• The Consumer's usual Dentist

The consumer's dental and medical notes were obtained and considered. The Commissioner obtained advice from a dental practitioner.

Outcome of Investigation

The consumer had toothache and saw the provider at the Dental Clinic in late July 1997.

The provider reported she discussed with the consumer the probable causes of toothache, alternatives of treatment and the costs involved. The tooth had a previous fracture and was sensitive to percussion. The consumer wanted the molar to be extracted. She did not want root canal treatment.

The extraction was difficult as the crown of the tooth broke. The provider had to split the roots and elevate them from the socket.

The provider confirmed she had to leave the room at least twice to collect the appropriate instruments, once when the decision was made to extract the tooth and then when the extraction became more complicated and root elevators were needed. The extraction instruments are kept in a central storage area. This allows all dentists in the practice to have access to them.

Three days after this consultation, the consumer consulted her general practitioner as the infection had spread and her glands were swollen. The GP prescribed a course of Augmentin. The consumer saw her usual dentist five days later. Her dentist removed the suture the provider had placed. When questioned in May 1997 the consumer's usual dentist could not recall whether the stitch had been in the palate but said that would be where you would normally put it.

The provider recalls that at some stage during the procedure she noticed the consumer had tears in her eyes. The provider stopped and asked about pain and if the consumer needed more anaesthetic but the consumer told her to proceed. The provider and her assistant reassured the consumer throughout the procedure. The provider denies that anything alarming was said or that anything unusual or shocking happened during the extraction. The provider states it is usual for parts of a tooth to break and fall in the mouth during the course of an extraction but constant suction is used to prevent any harm.

The provider kept the consumer in the chair after treatment to give her time to recover and to hand over and discuss the typed instructions for patients after extractions. The provider did not prescribe antibiotics as in her opinion the infection was localised and the extraction would provide adequate drainage. The provider advised the consumer to report back should further complications arise or pain persist. The provider suggested the consumer rest in the reception area and phone in later to arrange to have the suture removed. The consumer declined these offers making her appointment to have the stitch removed before leaving the surgery.

The provider offered the consumer sick leave for the rest of the day but this was declined, as the consumer wanted to get back to work straight away to make up the wages. The provider suggested the consumer take Paracetamol for pain immediately, before the local anaesthetic wore off, if she planned to return to work.

On the typed instructions it was recommended that if pain increased the consumer should make an appointment as the socket may be infected. There were also instructions about rinsing with hot salt water daily for 5 days after the first 24 hours.

The consumer had access to both the provider and any of the other five dentists at the Dental Clinic to have the suture removed. The provider was available to do this on five days in early August 1997. The consumer rang the Dental Clinic two days after the extraction and cancelled the appointment to have her stitch removed. The call from the Dental Clinic to the consumer was subsequent to this cancellation.

The Dental Assistant confirms the extraction was difficult but not unduly so. The Dental Assistant confirms that when the provider left the room to get instruments the door was not left open. The Dental Assistant says the consumer wanted to get back to work, and refused to sit and rest.

When the consumer phoned the Dental Clinic two days after the extraction to cancel the appointment to have the suture removed, the receptionist offered to have the provider call her. The provider did not do this as the consumer had indicated she would never visit or be treated at the Clinic again.

The dentist who provided advice to the Commissioner noted that the removal of an abscessed tooth can be more uncomfortable than a regular extraction as the inflammation associated with the infection can block some of the action of the local anaesthetic. As well as this there will always be some pain or discomfort for a few days after a difficult extraction.

Antibiotics are not necessarily prescribed following extractions of abscessed teeth as the removal of the tooth establishes drainage and this often resolves the infection. The consumer had been given oral and written instructions to return if she had any concerns but chose to see her general practitioner who prescribed antibiotics.

My advisor added that the issuing of a sickness note is generally at the request of the patient. In this case the provider did offer and the offer was declined.

My advisor also said it is common to keep oral surgical equipment in a central area where there is more than one dentist, and added it is common for a piece of tooth or root to fracture and fall into the mouth during an extraction.

Code of Health and Disability Services Consumers' Rights

RIGHT 1
Right to be Treated with Respect

2) Every consumer has the right to have his or her privacy respected.

RIGHT 4
Right to Services of an Appropriate Standard

2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.

RIGHT 10
Right to Complain

3) Every provider must facilitate the fair, simple, speedy, and efficient resolution of complaints.

?
6) Every provider, unless an employee of a provider, must have a complaints procedure that ensures that -

a) The complaint is acknowledged in writing within 5 working days of receipt, unless it has been resolved to the satisfaction of the consumer within that period; and
b) The consumer is informed of any relevant internal and external complaints procedures, including the availability of

i. Independent advocates provided under the Health and Disability Commissioner Act 1994; and
ii. The Health and Disability Commissioner; and

c) The consumer's complaint and the actions of the provider regarding that complaint are documented; and
d) The consumer receives all information held by the provider that is or may be relevant to the complaint.

Opinion: No Breach - Provider / Dentist

In my opinion the provider did not breach Right 1(2), Right 4(2), Right 10(3) or Right 10(6) of the Code of Health and Disability Services Consumers' Rights.

Right 1(2)
The provider did respect the consumer's privacy. On the first occasion that the provider left the surgery the extraction had not started. As to the subsequent occasion or occasions I accept the provider's and dental assistant's assurances that the door was not left open.

Right 4(2)
The consumer experienced a difficult extraction. The provider asked if the consumer required more anaesthetic. The consumer was kept in the chair to allow her to recover; was offered a note for sick leave; was offered the option of resting in the reception area; and it was suggested she phone in later to arrange a time for the stitch to be removed.

Another dentist has indicated that there was nothing untoward about the suture he removed a week after the extraction.

In my opinion the service provided by the provider did not breach the Code of Health and Disability Services Consumers' Rights.

Right 10(3)
The receptionist at the Dental Clinic offered to get the provider to call the consumer when she rang after the extraction. The provider did not do so. The provider did not find out about this call until she returned to work a week after the extraction. At this time the provider discussed the consumer's appointment with the receptionist and the dental assistant and formed the opinion that the consumer wished nothing further to do with her or the Clinic. The provider accepted this decision and felt it was not appropriate to ring the consumer.

Opinion: No Breach - Dental Clinic

Right 10(6)
The receptionist and the provider formed the opinion that the consumer was terminating her relationship with the Clinic and the provider.

In my opinion this was reasonable and there has not been a breach of the Code of Health and Disability Services Consumers' Rights.

The phone call from the Dental Clinic to the consumer at her place of work was made after the consumer had rung and cancelled her appointment. The consumer's call to cancel her appointment is recorded; the call to the consumer is not recorded. The making of this call and the fact it is not recorded do not breach the Code of Health and Disability Services Consumers' Rights.