There can be very few practitioners who have never been faced with a shocked and tearful child, who has just suffered an injury to their front teeth.
Public expectations have grown, and patients (or their parents) are now much less likely to accept a compromise solution.
Fortunately, new materials and techniques have increased the treatment options that are available in an emergency setting.
Implants offer a further dimension to the ultimate treatment options in some cases. This module looks at many of the less obvious dento-legal implications of trauma.
Prevention
Traumatic injuries to the dental and oral tissues are not limited to children, or those involved in contact sports. Cricket balls, hockey sticks, skate boards, roller blades, bicycles, skis of various kinds, horses and ponies, and the shallow ends of swimming pools, have all featured prominently as agents for traumatic dental injuries over the years. Since most of these accidents arise without warning, it is impossible for the dental team ever to prevent all of these injuries from happening in the first place. On the other hand, a conversation in the dental surgery may well point to the fact that a particular patient enjoys one or more activities that carry an increased risk of injury to the dental and oral tissue. It is certainly part of the dentistâs duty of care, to take whatever steps can prevent or mitigate any harm that a patient might otherwise suffer.
The provision of a sports mouth guard/protector might be advised. The design and construction should be appropriate to a particular patient’s needs. If you make such a recommendation, and this is declined on cost or any other grounds, it is prudent to record this fact in the clinical notes.
Emergency situation
In an accident and emergency unit or a maxillofacial unit, clinicians will not infrequently be dealing with unconscious patients. This is unlikely in general dental practice, but in an emergency situation it is important to remember that the patient may well be shocked and distressed (this particularly applies to young children), or perhaps in acute pain/discomfort.
The emergency situation may therefore not be the best time for the patient to be making meaningful long-term decisions about their teeth and oral health.
Nevertheless, issues of consent are just as important in an emergency situation as they are in any other circumstances. The patients best longterm interests should remain uppermost in the mind of the clinical team concerned, even when a patient is distracted by acute and immediate pain, for example.
One way around this dilemma is to adopt a deliberately conservative approach to the presenting clinical situation recommending, wherever feasible, treatment approaches which are reversible, and which preserve as many subsequent treatment options as possible.
This sensibly avoids prematurely committing the patient to a specific irreversible approach (such as an extraction). Even if the patient demands an extraction at the time of the injury, there could still be a problem unless other alternatives have been carefully explained and discussed with the patient.
They may well be able to subsequently argue, with some conviction, that they would never have agreed to proceed with the extraction had they been given other options such as root filling the tooth or reimplanting it, for example.
Children
In the case of traumatic injuries to children, these conversations may well take place with the parent(s) or carers. This introduces the additional hazard of trying to establish whether or not the person who is accompanying the child has the authority to give consent on the childs behalf for the treatment to proceed.
In an emergency situation the clinician may find the child accompanied by a teacher, or by a friend or relative, or even by the parent of another child with whom the injured child was playing at the time in question. If you are in any doubt at all about the authority invested in this adult, a cautious and conservative approach is necessary. The childs best interests must always be the paramount consideration, and the child should be as involved in the discussions as their level of awareness or understanding permits.
These are not always easy judgements for the clinician to make, and with the benefit of hindsight it is easy for third parties (like lawyers acting for the patient, or experts who are advising them) to criticise the way in which these sometimes difficult decisions were approached. It becomes all the more important, then, to record every detail of what happened, of the clinical situation at the time of examination, of any discussions and explanations, and of any specific advice given, in the patients clinical notes.
These notes should always confirm and support the adopted treatment plan step by step.
Records
The records should show that a full and careful clinical examination has taken place noting any cuts, swelling, bruising or other damage to the intra and extra-oral tissues, as well as any damage to the teeth themselves.
Checking for mobility, vitality, any tenderness etc is also important, as is the noting of any fracture lines or crazing of the enamel of any of the affected or adjacent teeth.
Transillumination can be very helpful here, and this can provide a useful clue as to the extent of any impact suffered at the time of the accident. Radiographs will usually be an important investigation, perhaps to check for fractures that may not be clinically apparent, or (in young children) to check the extent to which root formation of permanent anterior teeth is complete.
Another important aspect of the clinical notes is the management of the patient at a human level. If you telephone the patient (or the parents) to check how things are progressing in the days following the injury, record this contact with a specific entry in the patients notes. The notes should always be sufficient to demonstrate a sympathetic and caring approach involving the patient (and parents, where appropriate) at each stage of the consent process, together with a logical and well executed treatment plan and adequate follow up.
Follow up and monitoring
Once a clinician has become aware of the fact that an individual tooth, or a group of teeth, has been traumatised in some way, there can be no doubt that this creates an additional duty of care on the part of the clinician to provide appropriate follow up. In the absence of any reported symptoms, this may take the form of regular monitoring of the appearance of the tooth (or teeth) or its vitality.
Periodic radiographs are sensible, particularly of any tooth whose vitality is in question, or is clearly deteriorating.
Most clinicians take radiographs when the patient first presents after a traumatic injury, but relatively few clinicians will be able to demonstrate a meticulous monitoring of the affected teeth over the months and years that follow. If a large cyst develops and threatens the long-term prognosis of one or more teeth, it may be difficult to defend a negligence claim in the absence of any such follow up. The dentists ongoing duty of care obviously does not end with the treatment of the original trauma, but extends to include all subsequent reviews of the damaged teeth. The findings on each occasion should be noted in the patients record.
Another aspect of trauma, which is important from a dento-legal perspective, is the need to record any reported blows to the patients teeth. Equally important is the need to document any changes in the appearance of the tooth.
Superficial fracture or enamel crazing, loss of translucency or a change in colour even when no immediate treatment is needed (or sought by the patient) at the time should all be noted for your own protection.
For example, a post crown, which fails relatively soon after being fitted, perhaps due to a root fracture, may have been performing satisfactorily and might well have functioned satisfactorily for many years, had the tooth not been injured. It is not unknown for claims to be brought for the alleged provision of an unsatisfactory crown, or an alleged failure to recognise a fractured root at the time of fitting such a crown, when the real reason for the crowns early demise is a traumatic injury of some kind after the post crown was fitted, and which was not reported by the patient.
Some patients are particularly vulnerable to traumatic injuries, or to potentially more serious consequences if such an injury were to occur. The child with a large overjet and prominent upper incisors reflecting a Class II division one relationship, is one example, so is the adult patient with post crowns on all their anterior teeth. If these patients play contact sports, or enjoy other activities, that carry an increased risk of dental injury, then a dentists duty of care extends to stressing the advisability of having a custom made mouth guard. This advice should be recorded in the notes, even if the patient elects not to accept it.
Summary
The management of traumatic injuries highlights the importance of the fundamentals of risk management, and in particular:
- A logical and reasoned approach to diagnosis and treatment planning
- Good communication and careful attention to the consent process
- Careful and meticulous record keeping
- Keeping abreast of current approaches to treatment and standards of care.