Friday, May 11, 2007

Who to blame?

I received a frantic call from the oral surgeon today. Patient had woken up from GA and was still experiencing severe toothache and she's accusing the oral surgeon of pulling out the wrong tooth.

Oral Surgeon: You referred Mrs G to me for extraction of 16. I've done that but now she's saying I pulled out the wrong tooth.

I could hardly remember a Mrs G so I had a look on the computer and it all came back to me.

Mrs G was presented with fractured amalgam on a root canal treated tooth in September last year. She said the tooth was "niggling". I can never understand what patients mean when they say the tooth is "niggling". Do they mean it's giving them sharp pain, dull ache, throb or what??? I tried to get her to use other words to describe the sensation but she just kept repeating "You know it's just niggly", "It's not sharp. It's niggling". DUH. Fed up I just patched up the tooth with Fuji IX. The tooth wasn't TTP, neither was there any PA radiolucency on the radiograph. I told Mrs G if she starts getting dull throbbing ache in the tooth she'll either require RCT re-treatment by endodontist or have it extracted. Mrs G doesn't like the idea of travelling 700km to go to the endodontist and would rather have extraction. I do not like the combination of big amalgam restoration + RCT + close proximity to sinus so I told her if she ever require extraction she'll have to go to the oral surgeon. To save her the trouble of waiting 2 months to get in just to obtain a referral letter to the oral surgeon when the tooth flares up I decided to write her the referral letter in case she needs it.

Mrs G also has a deep carious lesion on 14. It had been asymptomatic so I told her she'll have to come back asap to get it fixed before it starts to hurt. She didn't.

My guess is, 8 months down the track she started getting toothache and thinking it's coming from the 16 she went to the oral surgeon. The oral surgeon followed the request on the referral letter and extracted 16 when it was 14 that was giving her pain. What amazed me is that how someone can think a half broken rotten tooth cannot cause pain, especially after being warned by me that she'll experience severe dull throbbing ache if she doesn't get it treated asap.

She came in the the practice today to make an appointment and she's still telling everyone the oral surgeon pulled out the wrong tooth. I feel sorry for the oral surgeon.


Anonymous Anonymous said...

i just came across your blog. and i must say, i immediately went to brush my teeth after a few posts.

12/5/07 3:59 am  
Anonymous Anonymous said...

Why did you write her a referral letter when she wasn't going to do anything about it anytime soon? I'm assuming patients wouldn't know what a 16 is if you wrote it down, she'd probably thought it was a referral to extract any tooth that was giving her pain. And why didn't the oral surgeon ring you up to ask whether or not the treatment was necessary before extracting? There's a little blame on everyone on what has occurred - patient, dentist and oral surgeon

12/5/07 12:15 pm  
Blogger Dentist Down Under said...

anon 1:
Don't forget to floss too. ;p

anon 2:
How would I know when the tooth would flare up? It could be the next day, it could be next year or never. Like I said, I'm booked solid for 2 months if that tooth does flare up she'll have to wait 2 months to come in to see me just for the referral letter that's why I gave her the letter in case she needs it, and she knew exactly which tooth was to be extracted by the oral surgeon (she even knew she has a RCT in that particular tooth) as she initially came in to see me about THAT tooth "with RCT". I wrote the letter addressed to the oral surgeon, not to the patient that's why I used the numbering system. When I discussed it with the patient I didn't refer the tooth as 16, I was referring it as "the tooth with RCT" which was how the patient referred the tooth as when she told me which tooth was "niggling". The decay under the amalgam on 14 was an incidental finding when I took the radiograph, patient didn't know she has decay in 14 when she first came in neither did I, but I told her she has a big hole in the tooth "in front of the gap, the one in front of the tooth with RCT" (pointing it out to her in her mouth with a mirror) has a big hole under the filling and it's infected and if she doesn't come in and get it treated asap she'll experience severe pain once the decay gets into the nerve, I even told her I wouldn't wait for more than a week and even offered to see her during my lunch time, and showed her the radiograph. She made the choice not to come back. The oral surgeon said the tooth was half broken (it wasn't broken before) when he called, so it's baffling why she didn't come in to see me about it. I also told her very clearly why I wouldn't extract "the tooth with RCT" myself and if she wants to have it extracted she'll have to go to the oral surgeon, I even pointed it out to her in her mouth and on the radiograph, so she does have a very clear idea which tooth is to be extracted by the oral surgeon.

12/5/07 1:27 pm  
Blogger Dentist Down Under said...

This comment has been removed by the author.

12/5/07 1:27 pm  
Blogger Ameloblast said...

Many of my peers fall into a similar trap. They endo the tooth that the referral slip says to endo.

Unfortunately, if the patient has missing teeth, the number might not be accurate, and also, the referring dentist might not have diagnosed the correct tooth as the source of the problem.

In my opinion, the responsibility lies with the person extracting/ doing the endo to make sure that they are doing the right tooth. You're running a health care facility, not a tooth/money factory. We are all dentists, not technicians, use the brain and try to help the patient...

12/5/07 5:01 pm  
Blogger Dentist Down Under said...


I'm not sure what exactly happened. The 16 could be the source of pain as well who knows. I'm squeezing her in during my lunch time this Thursday so I'll be able to find out what's going on.

14/5/07 5:01 pm  
Blogger Dr. Mommy, D.D.S. said...

i agree with ameloblast. specialists are not drones that simply perform tasks designated to them by the referring dentist. diagnosis must be made by both doctors, both the referring dentist at the person to which you are referring, espcially because sometimes the problem is not so obvious or there are multiple possible sources. he/she should have known better or at least said, "this is the tooth that DDU has referred you to extract, but you also have large caries on this other tooth here, this might be a problem, just to let you know," at the consulation. its the professional thing thing to do, and it also covers his tracks, espcially in cases like this.

good communication between specialist and GP is crucial. i don't know of the relationship you have with this guy, but i possibly would have included in the referral letter a quick blurb about the proposed treatment for the other teeth in that quadrant. this is something that i sometimes do when i write up my specialist letters, esp endo and OS because it prompts the specialist to talk about the teeth in question, like, "OK, yada yada is going to be extracted, i see DDU has marked this one for RCT." it will also leave another paper trail to refer to in a case like this when a patient like that sues. that being said, the guy should have called you to verify.

hmm, interesting situation. i don't think anyone is to "blame" in this case per se, as both teeth were obviously problems anyway - it's not like she wasn't planning to have 16 out (THAT would have been a nightmare!). i think there was just a lack of communication. nothing that can't be remedied. but i would definitely have a nice, long chat with your specialist.

14/5/07 10:32 pm  
Anonymous ozlady said...

I just stumbled across your blog from another, and I'm feeling very guilty about not having been to the dentist in a very very very long time!


16/5/07 9:02 pm  
Blogger GoRetroGirl said...

Actually, I do think the blame falls on the patient. This is a good example of the problems that can arise when you don't practice good oral hygiene and don't see the dentist on a regular basis. She was warned that she had a cavity in another tooth (that was even pointed out to her) that was going to give her problems unless she got it fixed, pronto, and she chose to ignore it. Good grief, if my dentist told me that I'd be peeing in my pants and would want to get it fixed immediately! I have no sympathy for her.

17/5/07 1:10 am  
Blogger Lady_T said...

Ozlady that wouldnt be mine would it? :)

I love this blog, it makes me feel guilty about not looking after my teeth properly and yet I always come back for more!

18/5/07 1:15 am  
Blogger annnie said...

hey your blog is really interesting!
i love the pictures of the teeth and x-rays, it interests me.
its pretty hard to find a proper dentist these days that doesn't rip you off.

18/5/07 5:25 pm  
Blogger Dentist Down Under said...

dr. mommy, d.d.s.,

The oral surgeon is a big shot in town, he's the one and only specialist we have. The closes oral surgeon other than him is as far as the endodontist. It's very difficult to get on to this guy. I've tried calling him several times myself and he's never there, he works when he feels like it and sometimes goes away for weeks. I'll be lucky if I even get to talk to him for 1 minute.

The patient can't sue me because I've wrote down that she had been warned, and everything was recorded in the computer with a date (which I can't change without authorization and password which I don't have). But next time I'll make a note about such things in the referral letter.

Anyway, I saw the patient on Thursday. She said the tooth with RCT had a "big crack" and she was having pain so she went to the oral surgeon but after the extraction she was still having toothache. She then said she knew the 14 has to go and just wanted to know whether I can extract it or whether she has to go back to the oral surgeon. She had stopped blaming the oral surgeon and didn't say anything about him pulling out the wrong tooth, so I didn't ask her why she was kicking up such a big fuss last week. She later said the oral surgeon charged her $1000 to have the tooth extracted, and get charged more for the "closure" (she had an oral-antral communication) than the extraction itself. Maybe she was trying to get out of paying the bills by accusing the oral surgeon.

18/5/07 11:54 pm  
Blogger Dentist Down Under said...

ozlady & Lady_T:
Time for a check up!

Yes, blame the patient, it's always the patient's fault coz it's never my fault. :p

Don't trust anyone

19/5/07 7:30 am  
Blogger pavlova said...

just wondering... after having the extraction she had toothache line...
could it possibly be confounded by dry socket too???
1000?? whoa.. that's a high price.. our o/s here charges 400 approx.

19/5/07 7:49 am  
Blogger Dentist Down Under said...


No there's no dry socket, I checked the exo socket and it was healing up pretty well, any pain from surgery is normal and expected. :p You can't have surgery and no pain, unless you're Claire Bennet in Heroes. :p

19/5/07 1:23 pm  
Blogger Dentist Down Under said...

Besides you don't get dry socket immediately after surgery, that usually happen few days after.

19/5/07 1:23 pm  
Anonymous Anonymous said...

chanced upon ur blog, interesting post u have, gave me a greater insight. (:

keep blogging!

26/5/07 2:16 am  
Blogger s0hp0h said...

haven't been to ur blog for a long time.. hmmm.. so if u do a referral, they will just follow ur request without doing a routine exam?? or is that a redundancy?/ hmm.. interesting case.. as a student, i'm always unsure bout referrals.. lol..

2/6/07 11:02 pm  
Blogger Dentist Down Under said...


I think you should direct that question to the specialists receiving the referral letters :p

5/6/07 10:24 pm  
Blogger bunkowilly said...

Wow! A Chinese dentist "down under!" I came across your blog by accident when searching for dental articles.

Excellent blog. You have a great sense of humor(scathingly funny:)) and have thought of a good way to help people out without putting your professional life on the line.

I am a 33 yr old Cantonese American dentist working out of New York City. Here the dental population is much more crowded, loaded with GP's and specialists. My father, also a dentist, graduated from Sydney University, and lived in Sydney for a while but moved to the U.S. for familial reasons. He didn't mention anything about different about Australian vs. U.S. dentistry except that removable prosthetics is more popular in Australia, whereas fixed prosthetics is more popular in U.S.

By the way, you are not at fault at all in this case. This kind of B.S. happens all the time. But when backed up by x-rays and proper written documentation, there is nothing to worry about. In the U.S. dentists get sued quite a bit, but the cases are often without merit.

Keep up the good work! I look forward to reading your blog when you have the time to update it.

20/6/07 2:02 am  
Blogger Dentist Down Under said...


Just curious, what article are you searching?

Removable pros is still more popular here because ppl seem to think it's cheaper. Whenever I give them a quote for crown they'll tell me to "pull out that damn tooth". After several episodes of "pull out that damn tooth" they finally realise they can't eat properly and when quoted the cost of implants vs bridge vs dentures they'll go for the dentures. -_-

28/6/07 10:56 pm  
Blogger bunkowilly said...

I was researching articles on rotary endo... I think... maybe not, sorry not really sure.

6/7/07 1:48 am  
Blogger Dr Sasha said...

Nobody to blame here. It just happens. We all know the communication between GP and specialists has to be clear, but many times we don't think of it (and, thanks God, things most usually go well). A written referral is useful (it's an evidence!), but the phone call is sometimes even more useful (just to be sure).

One of my professors said something about how different tooth notation systems can also make a confusion, and therefore, if we're not sure the specialist would understand, we should also write for example dens molaris primus superior... Too much writing, but saves trouble.

27/8/07 11:15 am  
Anonymous Anonymous said...

That really sucks!!!

15/9/07 2:57 am  

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