The Top Five Complaints Oral Surgery

Extractions and Oral Surgery

This article relates to complaints reported to ADA SA during 2022/23. The aim is to alert you to areas of potential risk in your practice.

What is an adverse event?

Every GP dentist understands the normal sequelae of a dental extraction. Usually, such symptoms are minor and temporary in nature (eg: post-operative pain, swelling, bruising and infection) and can be effectively managed by the treating clinician. Occasionally, however, post-operative symptoms are of much greater magnitude or duration than normal and may then represent an adverse treatment outcome. In summary, an adverse event is a detrimental or negative consequence of treatment and is not a usual/expected outcome of the procedure.

There are other sequelae of extractions (such as prolonged bleeding, retained roots, development of an OAC, jaw fracture or paraesthesia’s) which are less commonly encountered. These will also be less likely to be within the remit of a GP practitioner to manage and would be characterised as adverse events.

What to do following an adverse event?

TIP: Whenever a complication or adverse event occurs, the patient should be seen and advised of the diagnosis as soon as possible and a management plan developed. If you are unsure of the diagnosis/appropriate treatment, or if it is outside your scope of practice to manage well, you should seek immediate advice from a specialist colleague – usually, this will be an OMFS.

What are the issues: pre-operative assessment:

It is important to recognise the skill and technical ability required to effectively treat patients requiring a dental extraction. Often, they are new patients who present in pain. Emergency patients are amongst the most challenging to assess and treat and, where possible, are best seen by experienced and confident clinicians.

An important factor in providing adequate care relates to the time allocated for the appointment. Clinicians should not feel rushed or compelled to provide treatment – sometimes the best outcome for the patient can be achieved by deferring treatment (to a more suitable time or location) or by referring the patient (to another practitioner or facility).

Some of the most serious/significant complications reported to ADA SA include entirely preventable scenarios – such as failing to take into account the patient’s reported medical/medications history. During your pre-operative assessment, make sure to always ensure the medical and medications history is up-to-date and is taken into account when prescribing treatment.

When conducting a pre-operative assessment, an evidence-based diagnosis and treatment rationale needs to be established. In their article “The wisdom behind third molar extractions” Kandasamy et al 1 evaluate past and present knowledge regarding the removal of wisdom teeth and conclude that “the removal of third molars to avoid late incisor crowding is not justified. “ The authors further recommend that “Asymptomatic partially or fully erupted third molars are to be monitored periodically.” This article serves as a reminder that we must remain cognizant of emerging research and current best-practice treatment rationales to justify our treatment recommendations.

What are the issues: Intra-operative complications:

Numerous complications can arise procedurally during a tooth extraction. The most commonly reported issues to ADA SA include:

• Failure to obtain adequate anaesthesia
• Extraction of the wrong tooth
• Damaging an adjacent or opposing tooth, prosthesis or restoration
• Root separation (where retained root/s cannot be retrieved)
• OAC (with/without displacement of tooth/root into the sinus)
• Fracture of the mandible, tuberosity or lingual plate

In many of the situations outlined above, the patient will require referral to an experienced OMFS colleague for ongoing management.

TIP: Signed patient consent forms will not protect you from the consequences of an adverse event.

Example: if a root tip snaps off during an extraction and is then delivered safely with no other issues, this would be regarded as a simple complication, appropriately managed. If, however, in this same scenario, the root tip could not be retrieved and was left in-situ, then this would be considered an adverse treatment outcome. Importantly, our duty of care to fully inform the patient of all complications and appropriately manage complications which occur is not negated by the patient’s signature on a consent form: making a mistake/error vitiates the consent and renders it void.

What are the issues: Post-operative sequelae:

A serious complication of extracting lower molars is injury to the inferior alveolar nerve (IAN), with a reported incidence in the literature of 4-5% ² It is crucial that patients who sustain any type of nerve injury are managed early by a practitioner who is able to conduct a comprehensive assessment, make an accurate diagnosis, and initiate the appropriate treatment and monitoring required.2

An emerging issue is antibiotic resistance in our society whereby a patient may suffer a severe (life-threatening) odontogenic infection. Experienced and knowledgeable researchers and surgeons (such as Professor AN Goss)³ recommend that any patient presenting with significant facial swelling with pain and trismus are immediately referred to hospital for management.

Avoiding problems:

• CHECK the medical/medication history and manage appropriately.
• Consider who, when and how the procedure might be performed and discuss the alternatives with your patient.
• Make sure the specific risks of the procedure are considered, discussed, and understood.
• Always offer referral to a specialist.
• Consider alternate forms of sedation/anaesthesia.
• Do not proceed where treatment is beyond your scope of practice.
• Ensure the reason for tooth removal is clear and evidence-based.
• Attend training (CPD) courses and seeking mentoring from experienced specialists to help you to confidently expand your scope of practice.
• Manage complications early and seek assistance when needed

What to do if you receive a complaint:

Adverse events and complications arising during an extraction can result in considerable negative effects such as permanent injury or disability – even loss of life. Such incidents not only impact patients and their families but can also affect the health and well-being of the treating dental team. Practitioners and their staff, families and friends can access confidential, free 24/7 mental health support from Dental Practitioner Support | 24/7 support for Australian Dental Practitioners (dpsupport.org.au).

If you receive a complaint or experience an adverse event during treatment, you can contact the ADA SA for advice and support on 8272 8111. Adverse treatment events and complaints must be reported to your PI insurer. For Guild-insured dentists, your ADA SA advisor will liaise with your insurer on your behalf. Please don’t hesitate to get in touch if you have any queries or concerns or to obtain assistance.

** ADA SA acknowledges and thanks OMFS Professor Alastair Goss and Principal, Merdian Lawyers, Kellie Dell’Oro for their generous assistance and expertise in the preparation of this article.

*References are available upon request

References:

1. Kandasamy,s and Rinchuse, DJ: The wisdom behind third molar extractions. Australian Dental Journal 2009; 54: 284–292
2. Robinson PP. Nerve injuries resulting from the removal of impacted teeth. In: Textbook and Colour Atlas of Tooth Impaction. Andreasen JO, Peterson JK, Laskii DM, eds. Pub. Munksgaard, 1997; pp.469–490.
3. Uluibau, IC, Jaunay,T and Goss, AN: Severe odontogenic infections: Australian Dental Journal 2005;50 Suppl 2:S74-S81

Other references:

1. (Australian Dental Journal 2009; 54: 284–292)
2. (Australian Dental Journal 2003;48:(2):89-96)
3. (Australian Dental Journal 2014; 59: 296–301)
4. Teoh L, Moses G, Nguyen AP and McCullough MJ: Medicationrelated osteonecrosis of the jaw: Analysing the range of implicated drugs from the Australian database of adverse event notifications. Br J Clin Pharmacol: 2021 Jul;87(7):2767-2776
5. Ruggiero SL, Dodson TB, Fantasia J, et al: American Association of Oral and Maxillofacial Surgeons position paper on Medicationrelated osteonecrosis of the jaw--2014 update. J Oral Maxillofac Surg 72:1983-1956, 2014.
6. Wan JT, Sheely DM, Somerman MJ and Lee JS. Mitigating osteonecrosis of the jaw (ONJ) through preventive dental care and understanding of risk factors. Bone Research (2020)8:14
7. (Australian Dental Journal 2015; 60: 528–531)
8. (Australian Dental Journal 2018; 63: 202–207)
9. (Aust Dent J 2005;50 Suppl 2:S4-S13)
10. (Australian Dental Journal 2001;46:(3):174-182)
11. Megumi Hayashi, Yoshinari Morimoto, Takatoshi Iida, Yohei Tanaka, Shuntaro Sugiyama: Risk of Delayed Healing of Tooth Extraction Wounds and Osteonecrosis of the Jaw among Patients Treated with Potential Immunosuppressive Drugs: A Retrospective Cohort Study. Tohoku J Exp Med: Vol 246, Issue 4 pp 257-264, 2018. 
12. ADA July 2019 No. 488)