Exploring Dental Claims

Two areas where claims can arise following dental treatment are in relation to nerve injuries and dental implants.

Nerve Injuries

In clinical negligence claims, nerve injuries are most commonly seen following wisdom tooth extractions. There are two main nerve injuries and these are lingual nerve injuries and inferior alveolar nerve injuries.

The lingual nerve provides sensation to your tongue and parts of your gum. It is not directly responsible for taste however injuries to this nerve can affect some taste ability. This type of injury is usually seen in cases where the nerve is damaged during wisdom tooth extractions, when bone removal has been needed.

When considering how to approach such a removal there are often two schools of thought with dentists. The first is to protect the nerve with a metal retractor which goes between the tooth and nerve, to prevent the drill from touching nerve during the removal. Other dentists do not use a retractor and instead will approach from the buccal side, not going near the lingual nerve, in order to prevent any risk of damaging the nerve during the treatment or with the retractor itself. Both of these methods are currently considered to be reasonable options when having a wisdom tooth extraction.

If the nerve is damaged this can cause complications. This can include a numb tongue, unconscious biting of the tongue, nipping the tongue between the cusp of your molars and interference with speech. Whilst this nerve doesn’t provide motor functions, people can have difficulties in telling where the tongue is and as a result speech can be affected. Many patients also find that they suffer with a loss of taste or a disturbed taste as a result of the damage to the nerve. Those who are worse effected can get numbness and dysesthesia (abnormal pain and pain reactions).

There are several circumstances where the damage to the nerve may be due to negligent treatment. These can include –

1.       Where there was no indication for extraction in the first place. The removal of wisdom teeth is usually where there is a sudden pain and/or where the wisdom teeth are impacting other teeth. If there is no medical indication for the removal of the tooth, then it would be considered negligent to have proceeded with the treatment.

2.       Where there is no warning, as part of the consent process, that there may be such risks as above, or no warning that these symptoms may be permanent then this would be considered negligent. Similarly, providing a warning and then reassuring a patient  immediately after, such as telling you the risks but that they have never heard of this happening before or that this has never happened under their care, can be considered negligent. These cases can be difficult to prove as you would be required to prove that you would have otherwise not had the removal, which can be a high standard to meet.

3.       If the dentist opts for the first method, where they are using the metal retractor, but in trying to protect the nerve fail to do so then this could be negligent. If the retractor is placed correctly, they should not be able to damage the nerve so if this is damaged during the procedure this may be due to the retractor being used or placed incorrectly.

4.       It would be considered negligent if the dentist were not to try to protect the nerve using the retractor but then goes in behind the wisdom tooth or goes in lingually (distal or tongue side of the tooth). This would not be a usually accepted practice.

The second type of nerve injury that can occur is an inferior alveolar nerve injury. This nerve supplies sensation to the lower teeth and lower lip. Again there are similar circumstances in which damage to this nerve can be negligent as noted above. They can however also include the failure to recognise the apparent proximity between 2D and 3D imaging, not using a cone beam CT scan, not offering a coronectomy if appropriate, not referring the patient to a specialist where relevant and also not referring them for a repair within around 4-6 months if this is found to be required.

Implant Claims

The use of implants is a relatively new practice over the past 20 years. Implants are usually made from sterile titanium and following the procedure the bone in the surrounding jaw area will grow around the implant which secures it in place. Implants do usually last for life, with the crowns used on implants lasting around 20 years. Given that the crowns are attached to the titanium implant these often fit better than normal crowns and, as there is no tooth left at this stage, they cannot get decay underneath the crown; this results in a longer lasting crown.

However, as there is no ligament remaining, if there is an infection in the gum around an implant this can spread around the tooth/implant within a shorter time period. Periodontal disease with a natural tooth can take years to spread and develop however, around an implant, this can take months.

There are a number of potential aspects of the care involved with implants which may result in negligent care:

1.       Not treating concurrent periodontal disease. As noted above the speed of progression of the disease when you have implants is significant and so, if periodontal disease is present when an implant is being considered, this should be treated before the implant is completed. If periodontal disease is noted following an implant, then this will need treating at the earliest stage to prevent this spreading around the implant.

2.       It is accepted that implants can be placed at the same treatment session as removing periodontally involved teeth, if the sockets are curetted. However, as noted above, it would be considered negligent if an implant is placed where other teeth have unstable and ongoing periodontal disease.

3.       When considering an implant a smoking cessation protocol must be advised. The patient should be advised not to smoke in the weeks before and the months after an implant to maximise the success of the implant. Smoking can pose risks including the increased risk of infection and the weakening of the bones which can interfere with the implant and the bone fusing.

4.       If the dentist is aware that there is not enough bone for the implant, then the implant should not be attempted as the success of the implant is dependant on the bone and titanium section of the implant fusing to create a solid support for the crown.

5.       If there are any doubts regarding the bone or the area then scans should be completed before attempting to place a dental implant. CT or CBCT scans are used before an implant to measure bone depth, bone density and bone thickness. This assists with deciding not only whether there is sufficient bone but also the strength of the bone and for planning the appropriate placement of the implant.

6.       Sinus and nasal perforations during the procedure.

7.       Nerve injuries including to the inferior alveolar nerve.

Historically there has also been potential negligence surrounding the failure to use the relevant surgical guides for the planning the procedure. These surgical guides however are now not always necessary if the dentist is using dedicated implant software, as this provides the guidance and planning tools for the procedure.

If you do believe that there was a failure in your treatment by your dentist then please do not hesitate to contact the team for some no obligation, no win no fee advice.

 Click here to read a related article on Dental Mismanagement Claims: Periodontal Disease and Caries Mismanagement.