Does Infection After Tooth Extraction Hurt Again When Healing

Background: Mrs P is a 65-year-old sometime smoker with a history of periodontal illness and bone loss. She visits her dentist, Ms N, with a painful lower correct 2nd tooth. Ms Northward diagnoses periodontal abscess. The tooth is removed and postoperative instruction given.

2 weeks later Mrs P returns to the surgery complaining of pain and a "sour gustatory modality" in the lower right quadrant. An infected socket is diagnosed and the socket is irrigated and drained accordingly. Ms Northward prescribes a course of antibiotics but after iv weeks the socket is however very inflamed. On radiograph the socket appears articulate and normal although there is obvious bone loss effectually the adjacent tooth.

In a later review appointment Ms Due north notes that healing is meliorate but nonetheless not complete. A further review is scheduled for one month and at this appointment Mrs P at present complains of pain in the side by side lower correct first molar. Ms N notes pus around the glue margin and that the adjacent socket is still inflamed. She extracts the first molar and again provides postoperative instruction.

Three weeks later Ms Due north notes that the first tooth socket is healing well just the 2d is all the same very inflamed. More antibiotics are prescribed and another review is scheduled. At that date it is found that healing in the 2nd tooth socket is still not complete and Ms N observes that the inflamed tissue seems "ruby-red and cobbly". She makes a standard dental hospital referral.

An incisional biopsy one month later at the hospital confirms the lesion is squamous cell carcinoma. The patient undergoes all-encompassing surgery followed by facial reconstruction and radiotherapy.

A letter of claim from solicitors acting on behalf of Mrs P is sent to the surgery alleging clinical negligence in the delayed diagnosis and referral for suspected oral cancer. It is claimed that had the condition been diagnosed and treated before the patient would have been spared radical surgery and the need for radiotherapy.

Analysis/OUTCOME: MDDUS commissions two expert reports. A GDP expert considers the intendance provided by Ms Due north and supports the decision to excerpt the 2d molar given the patient'southward history of periodontal disease and the radiographic prove of os loss. He too finds naught inappropriate in the initial diagnosis and treatment of an infected socket and a suggestion that infection in the adjacent molar may take contributed to the tiresome healing.

The expert does nevertheless question why Ms Due north did not consider something more than just a slow-healing socket – peculiarly when the adjacent molar had been extracted with normal healing. His view is that a referral should take been made at this indicate and certainly an urgent referral at week 18.

An proficient report on causation (the consequences of whatsoever breach in duty of care) by an oral maxillofacial surgeon is also not supportive of Ms N's intendance. In his opinion the cancer would take been nowadays earlier the showtime extraction and the failure to human action on the abnormal healing contributed to the delay in diagnosis. This was further exacerbated past the lack of an urgent referral at 18 weeks.

The question of an before diagnosis leading to less radical treatment is not then clear cut. The adept states that the necessary surgery (involving tracheostomy, cervix dissection, admission and free-flap reconstruction) would probable have been similar in scale if carried out earlier only the tumour would accept been smaller and subsequent radiotherapy might not have been indicated. Prognosis in oral cancer is plain better the earlier the diagnosis.

MDDUS negotiates a settlement in the example with the agreement of the member.

KEY POINTS

• Take a loftier index of suspicion in persistent oral fissure ulcers and slow-healing tooth sockets.
• Ensure urgent referral in whatsoever suspicion of oral cancer.
• Consider how chronic periodontal illness might mask other acute presentations.

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Source: https://www.mddus.com/resources/resource-library/case-of-the-month/2018/june/slow-healing-socket

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