Minor oral surgery

It is unwise to begin any surgical procedure unless one is prepared for and able to deal with any complications that might arise.

The extraction of teeth, and other kinds of minor surgical intervention, can result in a variety of dento-legal problems and complications. Few of them are serious, but some can be. They can result in both complaints and allegations of negligence.

In both situations, it is not unusual for patients to claim compensation for the 'pain and suffering' they have experienced.

The removal of third molar teeth and the placement of implant fixtures will not be considered here, these topics being covered in other modules in this series (Module 4 - Third Molars: Module 10 - Implants).

The risks and problems associated with minor oral surgery will be discussed under the following headings:

1. Pre-operative assessment and consent issues.

2. Complications at the time of surgery.

3. Post-operative problems and complications.

1. Pre-operative assessment and consent issues

The extraction of any tooth is an irreversible procedure, which creates a particular need to ensure that the decision is taken for the right reasons, in appropriate circumstances, and also that the patient is an active participant in the decision itself, fully aware of the reasons for the decision, and whether or not there is a reasonable alternative.

Tooth extraction and the subsequent healing phase is not always straightforward and predictable - at least, not from the patient's perspective - and it is important that they know what to expect, and are prepared for any adverse outcomes.

Some aspects of the patient's medical history are particularly important when contemplating an extraction, not least those concerned with blood clotting and wound healing, and the patient's ability to deal with any infection. It is important to note any condition that might predispose to a medical emergency during or immediately after the extraction. Also important is any history that might lead to an increased risk of osteonecrosis and osteoradionecrosis. An up-to-date medical history with specific answers being given by the patient to specific questions, and preferably in the form of a written statement or questionnaire signed and dated by the patient, is advisable. If a previous medical history of this nature is being relied upon, the patient should be specifically questioned prior to an extraction to confirm that there has been no significant change, and a note to this effect should be made in the clinical records to confirm that this important check has been made.

Relevant aspects of the patient's dental history relate to whether or not the patient has had any teeth removed previously and if so, whether there were any particular difficulties or complications.

Opinions vary as to whether or not it is always essential to take a periapical x-ray of all teeth that one is considering for extraction.

One view is that such radiological assessment is always necessary; an alternative view is that each clinical situation should be assessed on its own merits. At one extreme it is difficult to justify exposing a patient to ionising radiation when removing one or more mobile lower incisor teeth with advanced periodontal disease, while at the other extreme it is clearly sensible to take a pre-operative x-ray of an extensively broken down upper second molar tooth, in a patient who has a history of difficult extractions. When one considers the complications that could arise from an adverse root configuration, or the proximity of the maxillary sinus, or perhaps the risk of fracturing the maxillary tuberosity, it is clearly desirable that the operator should be in a position to anticipate and plan for these possible complications. and also to prepare the patient for them, if necessary. This is an important element of the consent process.

Relevant anatomical features may be determined from previous x-rays held on file, both in relation to the morphology of the roots of a tooth and the adjacent structures.

If a decision is made to extract a tooth without taking a new radiograph, the clinical records should document the justification for the extraction and the relevant clinical findings.

Patients who attend, perhaps in an emergency situation, requesting or even demanding an extraction, need to be approached with great circumspection. Such patients, however insistent they might seem on having a tooth removed, do need to be made aware of other treatment options such as endodontics (if necessary) or some kind of restorative solution. It is by no means unusual for patients, often supported by the more entrepreneurial firms of lawyers, to argue that they would not have asked for or permitted an extraction, if they had been made aware of alternative ways of dealing with their presenting symptoms at the time. It is the clinician's duty, they will often argue, to make them aware of these possibilities.

The discussion of these alternative solutions does need to take place, in all cases, and this fact should be fully documented in the clinical notes.

Patients who have not previously had any teeth extracted may not appreciate what is involved, either in the extraction itself, or in the post-operative period. It is Patients who have not previously had any teeth extracted may not appreciate what is involved, either in the extraction itself, or in the post-operative period. It is worth asking the patient if they have any particularly important events in their personal or working life in the days immediately following the proposed extraction(s), and if so, to consider whether this timing is acceptable to the patient, allowing for the possibility of any postoperative complications.

Similarly, clinicians need to consider how available they would be themselves, during the post-operative period, and from whom any emergency care could be obtained by the patient, if not from the clinician personally.

Where the treatment plan involves more than one extraction, some planning - in discussion with the patient - needs to go into the timing of the treatment, bearing in mind the location in the mouth of the teeth to be extracted, any plans for existing or new dentures, or immediate replacement implant fixtures, and not least, what difficulties are anticipated in the extractions themselves or during the healing phase. If one or more of the extractions could render an existing partial denture un-wearable, it is wise to discuss the consequences of this with the patient before carrying out the extractions.

Team Exercise A

Consider the following complications in turn and, in discussion with your dental nurse, plan for:

(a) What steps you would take in order to assess the likelihood of each complication.

(b) How you would minimise the incidence of each complication.

(c) How you would manage the complication, were it to occur.

• Fractured maxillary tuberosity.
• Creation of an oro-antral fistula.
• Fracture of the coronal tooth structure, leaving one or more roots in situ.
• Displacement of a root into the maxillary antrum.
• Damage to adjacent teeth or restorations.
• Inability to complete the extraction.
• Fracture mandible.

2. Complications at the time of surgery

Before agreeing to undertake any extraction, or other form of minor oral surgery, it is important to consider and discuss with the patient in advance each of the possible potential complications in turn.

It is not necessary to warn patients about complications that no reasonable and competent dentist would foresee in the circumstances of the individual case, but it is important to be able to demonstrate that such complications were at least considered by the clinician, and thought not to be likely in the case in question. Thinking and planning ahead is the key to avoiding problems in this area of dentistry. In some cases, an extraction would be made considerably easier if a surgical approach is taken from the outset. This allows the operator to visualise the root anatomy more clearly, provides access for any necessary bone removal, and makes it easier to identify and access suitable points of application for the use of elevators.

Even when the need for such an approach is not obvious at the outset, a suitably equipped sterile surgical tray with a surgical handpiece and bur should be readily available to allow a smooth and seamless transition to a surgical approach, should the need arise.

A further consideration is that of how easy it would be to take and develop a radiograph, if difficulties were to be encountered during the extraction (for example, if it proves difficult to locate and remove a fractured and retained root).

Where, for example, complications occur that could have been foreseen and avoided, had an adequate pre-operative radiograph been available, or had the patient been questioned about a particular aspect of their medical or dental history, it becomes more difficult to defend a dentist's actions.

Team Exercise B

Carry out a similar exercise to the one described above, considering each of the following post-operative complications in turn and – in discussion with your dental nurse and anyone else who might take a telephone call from a patient in the post-operative period, plan for:

(a) What steps you would take to assess the likelihood of each complication.

(b) How you would minimise the incidents of each complication.

(c) How you would manage the complication, were it to occur.

• Post-operative pain and discomfort.
• Bleeding.
• Severe and persistent bleeding.
• Localised swelling.
• Dry socket.
• Infection and severe facial swelling.
• Bruising.

It is unwise to begin any procedure unless one is prepared for, and able to deal with, any complications or adverse outcomes that might result. Relevant here might be the quality of any chairside assistance available at the time of the post extraction(s). If one finds oneself working with an inexperienced dental nurse, this consideration would strongly argue in favour of postponing any extraction until such a time when an acceptable level of back-up would be available, in case of unforeseen complications at the time of surgery.

3. Post-operative complications

As part of exercise B, review any pre-operative and post-operative advice sheets that you use. Consider their content, intelligibility and regularity of use.

Wherever such advice sheets are discussed with and given to a patient, the clinical records should be sufficient to confirm this fact.

Other considerations

(a) Retained root - If it does not prove possible to complete an extraction, or retrieve a retained root, the decision may be taken to leave it in situ.

The patient should always be informed, and the option of a referral to a suitable specialist or more experienced colleague should be considered and discussed with the patient, as well as being recorded in the clinical notes.

(b) Extractions under GA/ sedation - There are particular perils in the extraction of teeth under GA or sedation, especially where it is not clear in advance whether or not a tooth can be saved. The problem arises because the patient cannot be consulted at the time of the decision to extract, in which case it becomes all the more important that the patient is informed and prepared for this possibility well in advance of the procedure, while they are still able to assess the advantages and disadvantages of what is being suggested or explained to them, and to make a decision as to whether or not to agree to the extraction.

(c) Extractions on referral  If one is in the position of carrying out one or more extractions, on referral from and at the request of another dentist, it is important to establish with certainty which teeth are scheduled for extraction. This might occur when carrying out extractions on the advice of an orthodontist, or perhaps if working in a specialist oral surgery practice or unit, or one which accepts referrals for the treatment of patients under GA or sedation.

Always check the proposed treatment plan against the patient's mouth, and if any requests for extractions seem illogical or inconsistent, check it with the referring dentist before proceeding.

The same applies if any aspect of the referral documentation is unclear or unambiguous. It is a wise precaution to require all requests for extractions on referral to be made in writing. A further precaution is to ask the patient - or in the case of a child, the parent(s) - which teeth they understand to be the ones that are due to be removed, and to ensure that their proper consent to the procedure has been freely given. Never assume that this is the case without checking; if you take the tooth out, the responsibility becomes yours even if the referring dentist has specified the teeth to be removed.

Ultimately, at least part of the responsibility will often be said to lie with the clinician who carries out the extraction(s), if it transpires that the wrong teeth have been removed.

Other forms of surgery

Many extractions and certain other forms of minor oral surgery, involve the raising and replacement of a mucoperiosteal flap, and usually the placing of one or more sutures.

Some patients have been known to associate the placing of sutures, with the misplaced assumption that something has gone wrong at the time of surgery.

Availability

Some of the postoperative complications that can follow extractions and other forms of minor oral surgery can be very distressing for patients. In many cases the patient's experiences are unfamiliar to them, and fear of the unknown can lead patients to be much more anxious than the actual circumstances might dictate.

This emphasises the need to ensure that patients know what to expect, and that they are well prepared in advance for possible adverse outcomes. It is of minimal reassurance to patients when clinicians explain after an adverse event that a certain problem was 'a recognised complication' of the procedure in question.

Any complication that is 'recognised' by clinicians, and a foreseeable possibility in a given case, can and should be explained to, and discussed with the patient.

All such discussions, warnings and advice should always be recorded in the clinical notes as part of the consent process.

Patients should know how to contact the practice not only during surgery hours, but also at times when the surgery would otherwise be closed. This is particularly important for patients undergoing minor oral surgery; care, consideration and an appreciation of the patient's anxieties goes a long way towards minimising potential problems arising from this area of dentistry.