Case study – the importance of clinical records in the defence of a claim

The case:

The patient commenced proceedings in the District Court following root canal therapy that was performed by the dentist. As a consequence of the root canal therapy, the patient suffered a penetration of his right maxillary sinus cavity leading to infection, chronic right-sided sinusitis, headaches and nasal blockages.

In May the patient presented to the dentist complaining of pain involving tooth 15. The dentist examined the tooth, took an x-ray and subsequently recommended root canal therapy. The records did not contain any findings of the examination and assessment.

Not surprisingly, the dentist did not recollect the consultation with the patient and therefore was not in a position to give direct evidence about what was discussed with the patient. There was no record of a discussion in the clinical record.

The patient alleged that the dentist used sodium hypochlorite solution during the procedure. The dentist’s clinical records did not record the use of any solution. The patient alleged that he noticed pain and swelling in the area where the solution was injected.

The patient re-attended the dentist in June. At this appointment, the dentist completed the second stage of the root canal therapy. The patient did not return to the dentist after this appointment.

Following the treatment, the patient developed severe symptoms in the right maxillary sinus region and was admitted to hospital with an acute epistaxis in September. The patient consulted with two ear nose & throat surgeons who advised that surgical treatment for ongoing infected maxillary and ethmoid sinuses would be required. The patient had tooth 15 extracted in October the following year.

At the time the tooth was removed, the clinical and radiographic evidence indicated that the patient’s maxillary ethmoid sinus condition had worsened. However, the patient was reluctant to undergo surgery because of the risk of possible loss of vision. In this regard he had already lost vision in his left eye and was particularly concerned about the risk of further loss of vision which was reasonable in all the circumstances.

The outcome:

Both parties (dentist and patient) obtained expert opinion in the matter on the following issues:

  • Whether it was reasonable for the dentist to perform root canal therapy rather than extracting the tooth;
  • Whether the dentist failed to perform the appropriate irrigation technique and use the appropriate instruments during the root canal therapy; and
  • Whether the dentist penetrated of the patient’s right maxillary sinus cavity and whether such penetration was below the standard of care.

Based on the x-ray taken in May and the patient’s version of events, the patient’s first expert considered the long-term prognosis of tooth 15 to be poor and therefore argued that endodontic treatment was not a reasonable option in all the circumstances. The patient’s second expert simply noted that the dentist’s reason for performing the root canal therapy was “unknown” as it was not recorded in the dentist’s clinical records.

The dentist’s expert disagreed with the patient’s experts. He considered the dentist’s decision to attempt to save the tooth was reasonable in all the circumstances. The dentist’s expert commented that in general dental practice, the clinical decision as to whether to extract or perform root canal therapy on a tooth is not absolute. Many variables may contribute to a dentist’s decision including the treatment aims, the patient’s desired outcome, the health of the patient, the prognosis of other teeth and financial concerns. Thus, the dentist’s expert did not believe that the dentist “was necessarily in breach of his duty of care in attempting to save the tooth rather than extract it.”

The patient’s second expert believed that the patient’s symptoms of immediate pain & swelling after the injection were consistent with a sodium hyperchlorite injury and that the dentist had failed to take appropriate precautions to prevent such an injury, given the proximity of tooth 15’s apex to the maxillary sinus. The expert said a side ported needle should have been used (ensuring that the irrigation needle was not blind to the root canal during the root canal irrigation) in order to reduce the risk of sodium hyperchlorite injury. The expert considered the root canal therapy itself to be acceptable. However, he considered the dentist’s alleged failure to take appropriate precautions and prevention of sodium hyperchlorite injury to fall below the standard of acceptable practice.

The dentist’s expert felt that the radiograph (which showed that the root apex of tooth 15 was very close to the sinus floor) should have alerted the dentist to the possibility of perforation or entry to the sinus. The dentist’s expert said that the dentist’s “choice of irrigant and irrigating needle syringe may have directly contributed to the sodium hyperchlorite injury”. The expert suggested that sterile isotonic saline should have been used instead, and that the needle used with the irrigation syringe should have been side ported to reduce the pressure of the irrigant in an apical direction, which is this case, was directly towards the sinus itself.

The patient’s first expert opined that it was likely that during or after the root canal therapy at the second appointment that an infection penetrated into the right maxillary sinus due to the proximity of the dental root to the sinus.

A decision was reached to settle this case prior to the hearing. This decision was made because it was difficult to defend the treatment provided by the dentist when his clinical records did not reflect details of the treatment provided. The dentist did not include any details of why the treatment was necessary, the instruments used or the type of solution used for the procedure. The dentist’s clinical notes simply recorded that he had performed root canal therapy.

Lessons to be learned:

  • Every practitioner needs to review and follow the Dental Board of Australia’s “Guidelines on dental records”. These Guidelines provide that dental practitioners “must create and maintain dental records that serve the best interests of patients, clients or consumers and that contribute to the safety and continuity of their dental care”.
  • In addition to the above rationale, a practitioner’s clinical records are evidence and essential to the defence of a civil claim. In this case the records did not contain any findings about tooth 15 to support the recommendation for RCT. The records did not record any discussion about treatment options. They did not record clinical details about the RCT itself including the solution used. Ultimately the records were of no assistance in the defence of the claim.

Amy Rogerson
Solicitor, Meridian Lawyers

Kate Hickey
Special Counsel, Meridian Lawyers