Introduction

Dental extractions are challenging and technically sensitive procedures. Negligence during extractions can happen at any stage. Most of the dental extractions are performed by general dental practitioners, but the literature concerning complications related to extractions are usually reported by Oral and Maxillofacial Surgeons [1]. The ethical basis for the standard of care is to recommend the best therapy while minimizing potential harm and avoid placing a patient at an unreasonable risk of maltreatment [2].

Failure in proper care may lead to severe consequences including plaintiffs. Negligence in patients’ treatment may lead to complications drawing attention to medico-legal disputes. In recent times, there is a rapid increase in the number of such medical disagreements. The major cause being lack of effective communication with the patient. Sometimes patients perceive that treatment has gone wrong, and the operator may claim that the complication had nothing to do with the procedure. In these situations, the medical divergence is unavoidable. The complete responsibility of complications is not always due to operator and hence there is a need to classify negligence in dental surgery.

In the study, three patients were treated with foreign bodies (FB) at extraction sites. It was found to be left as a result of previous surgical procedures carried out by unknown practitioners or self-mutilation, highlighting negligence as a cause. The required surgical procedures aiming to retrieve the FB were planned and explained to all the patients and informed written consent was obtained. This article also intends to propose a new classification for negligence in dental surgery and discuss the various aspects including causes, prevention and the role of judiciary subjected to medico-legal negligence.

Case 1

A 60-years-old male reported with a desire to replace the missing teeth in mandibular posterior region on left side. On clinical examination, bluish-black discoloration was observed at the edentulous region (Fig. 1). An intraoral periapical radiograph (IOPA) was obtained, which revealed the presence of two well-defined radiopaque FB (Fig. 2). Local anesthesia was achieved and a crestal incision was placed with distal releasing extension. A full thickness mucoperiosteal flap was raised exposing the healed socket and FB were successfully retrieved (Fig. 3). The stereomicroscopic examination of the retrieved material confirmed to be the pieces of lead (Fig. 4). Curettage, alveloplasty, thorough irrigation with povidone iodine and normal saline followed by closure using 3–0 silk was performed. Patient was kept for follow-up and sutures were removed on 7th day, postoperatively.

Fig. 1
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Clinical presentation showing bluish-black discoloration

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Fig. 2
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IOPA showing well-defined radiopaque foreign bodies

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Fig. 3
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Retrieved foreign bodies from socket

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Fig. 4
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Stereomicroscopic examination of the retrieved material confirming pieces were of lead

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Case 2

A 35-year-old male reported with a complaint of diffuse pain in the mandibular molar region on left side and history of extraction for the same 3 months back at a private dental clinic. Clinical examination revealed inflammation at the site of extraction. For further investigation, an IOPA was obtained which disclosed a triangular radiopaque FB (Fig. 5). Surgical retrieval was warranted; hence, under local anesthesia, a crestal incision was placed in the edentulous region and mucoperiosteal flap was elevated exposing the healed socket. The FB was retrieved with mosquito forceps (Fig. 6), followed by curettage and closure using 3–0 silk. After stereomicroscopic examination, it was confirmed to be a broken tip of a dental elevator (Fig. 7). Suture removal was performed at 7th postoperative day.

Fig. 5
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An IOPA showing singular triangular radiopaque foreign body with first mandibular molar region

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Fig. 6
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The foreign body was retrieved

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Fig. 7
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Stereomicroscopic examination confirming it to be a broken tip of a dental elevator

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Case 3

A female aged 26 years reported complaining of pain in right mandibular third molar region since last 4 days. She gave a history of trans-alveolar extraction of the same tooth prior to 3 weeks. Intraoral clinical examination did not reveal any significant abnormality. Hence an IOPA was obtained, which revealed a radiopaque FB in the socket (Fig. 8). In order to retrieve the FB, a surgery was planned under local anesthesia and crestal incision was placed with an anterior releasing extension. Full thickness mucoperiosteal flap was elevated and exploration of the socked was carried out. A broken head of round diamond bur was retrieved (Fig. 9). Thorough irrigation was done with povidone iodine and normal saline and closure was carried out using 3–0 silk. Postoperatively on 7th day sutures were removed and patient was relieved of pain.

Fig. 8
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A radio-opaque foreign body embedded into socket

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Fig. 9
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Broken diamond round bur retrieved from the socket

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Discussion

Incidence of foreign body in maxillofacial region is increasing at an alarming rate. However, this condition is under-reported in the literature, possibly due to its medico-legal implications. The informed incidence of FB in maxillofacial region is 0.3–2.8% till date [3]. To the best of our knowledge, the incidence of this condition is not reported for India till date. Such incidences were found to be occurred due to trauma, tendency of causing self-harm, iatrogenic during therapeutic interventions, dental restorative materials and broken instruments left behind during surgical procedures [4].

Exodontia is a clinical procedure, and it is associated with numerous complications. But, the FB in extraction socket is a complication which is clearly an outcome of negligence. These conditions may lead to severe consequences; though it depends upon the type of FB. Usually, it does elicit no or minimal inflammatory response, if found to be inert. Nevertheless, retained for a prolonged duration, it may cause persistent and distressing symptoms such as infection, sinus and fistula formation, peripheral nerve damage, pseudoaneurysm and synovitis [5,6,7]. Apart from these complications, the surgeon may also fall into medical disputes.

The initial method of examination solicited for detection of FB is conventional plain radiography, mainly because of low cost and easy access. [8] In the present study, all the cases were diagnosed on plain radiographs; still, approximately one-third of all FB were reported to be missed or misdiagnosed as they cannot be detected in conventional radiographs. [9] Radiographs have a detection rate of 69–90% for metallic FB, but for organic origin, such as wood, they are of limited use with a detection rate of 0–15% [10]. When plain radiographs fail to diagnose, other modalities like magnetic resonance imaging, computed tomography scan and ultrasonography should be advised [11].

Still, conventional radiography is the primary tool to find out such complications. Among the cases presented here, the complete responsibility of complications is not associated with the dental surgeon. There are several other factors that can result in negligence and subsequently complications. Hence, a classification is required to subdivide it for management purpose and elucidate its utility in medico-legal legitimacy (Fig. 10). Here, considering all the factors, a classification of negligence in oral surgery has been proposed.

Fig. 10
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AJs’ Classification of negligence in oral surgery

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AJs’ Classification of Negligence in Oral Surgery

Professional Negligence (PN)

Professional negligence is regarded as failure to exercise adequate care toward patient if possible, in one’s professional skills. The main cause of PN is lack of knowledge and/or lack of skill on the part of dental surgeon or the auxiliary or both. For instance, leaving instruments and gauze pieces in the surgical site is negligence on the part of professionals. Treatment of the wrong tooth, inappropriate method leading to iatrogenic fractures, paresthesia or any other complications are few examples of PN in dental surgery. Here, cases 2 and 3 represents this type of negligence.

Negligence from professionals is a grave mistake, which should be avoided and the operators had better be updated regarding the medico-legal aspects of it. To avoid this kind of negligence, surgeon must be prepared for the case; he must perform the procedure with standard protocols and in accordance with a widely accepted method only. A surgeon cannot adopt any practice just because he perceives it to be better. PN also comes from continuing an outdated and rejected practice. The operator should always keep himself updated with new instruments, modified techniques and literature. Recruiting uneducated people as auxiliaries is a common practice in India. There is an urgent need to stop this malpractice and initiate a structured training course for the auxiliary staffs.

Clear, concise and contemporary note with all clinical and radiological data should always be recorded and preserved for any future medico-legal proceedings and clinical follow-up. In the presented case, such kind of negligence does not even get support from Bolam test in medico-legal consideration [12]. Justice Mc Nair had ordered a judgment in Bolam vs. Frien hospital management committee (1957), and it proved to be a landmark decision in deciding cases of medical negligence and is known as the “Bolam test.” Bolam test states that before naming the act of doctor as negligent, the act of another doctor in the similar circumstances and facilities as existed with the treating doctor should be considered. Also, the professional knowledge and skill of the treating doctor should be compared with another doctor having same educational background. In a multiple number of cases worldwide, courts have settled such issues aptly [13].

Manufacturer’s Negligence (MN)

Complications can occur intra-operatively due to number of factors including improper handling of instruments and sub-standard or aged tools. Yasuhara et al. [14] registered 7 incidences of instrument breakage caused by defective surgical instruments, out of 548 operations over 2 years. An example of MN was observed by us wherein the patient had reported with a broken dental elevator tip in the socket. Kluess et al. [15] suggested any incident with orthopedic surgical instruments should be reported to the manufacturer and the health authorities for sufficient processing and risk assessment of the complication. To get rid of this kind of negligence, there must be some guidelines for the manufacturers to be followed. Moreover, quality control must be done and surgeons must buy the instruments which are duly passed by quality control check. Manufacturer should follow optimum standards, particularly in the case of dental, medical and surgical instruments which could cause serious injuries to patients. Also, alterations in manufacturing techniques and/or ineffective quality control may lead to MN [16].

In case of some reusable metal instruments both titanium alloys and stainless steel (SS) have the high-performance range. The SS is the most widely used material in manufacturing of instruments and according to surgical requirements, its alloys vary the most frequent being martensitic and austenitic SS. Biomedical cutting instruments are often made of martensitic SS due to its pronounced durability coupled with acceptable corrosion resistance. Surgical instruments that may be subjected to high pressure forces, such as a dental elevator, is composed of austenitic SS as it is less brittle [17]. Surgical instrument manufactures should carry out strict quality controls and have their instruments bear a visible mark as a sign of guarantee.

Patient’s Negligence (PN)

The third type of negligence in dental surgery is patient’s negligence. This is purely on the part of patient, and the professionals hold no responsibility for the mishap surfaced. It includes ignorance and lack of knowledge toward a dental problem and avoiding a visit to a dental surgeon, use of toothpicks and bobby pins in interdental area, not following dental surgeons’ advice after treatment, using household remedies which are actually not beneficial and on the contrary presents’ further complications. The case 1 show particles of pencil lead in tooth socket is a classic example of it.

Negligence on the part of patients also includes visiting quacks for dental treatment. Quackery has been defined as “the fraudulent is representation of one’s ability and experience in the diagnosis and treatment of disease or of the effects to be achieved by the treatment offered” [18]. Street dentistry is a form of quackery that is in practice in the rural and remote areas in India [19, 20]. Half-educated people often fall prey to the quacks. Major reasons that most of the patients are drawn toward quacks are high cost of dental treatment, illiteracy, lack of awareness, poor accessibility to dental clinics, and repeated dental appointments.

To avoid this kind of PN, proper education should be provided in schools and various camps should be organized to spread awareness regarding proper dental care. Such measures are being carried out but they need to be more frequent and more areas should be covered. Mass communication and social media are great platforms to spread awareness in today’s age which should be utilized positively.

Role of Judiciary

Table 1 shows various Indian Penal Codes for Medical Negligence according to Constitution of India [21].

Table 1 Indian Penal Codes for Medical Negligence according to Constitution of India
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Do’s and Don’ts

Table 2 shows the Do’s and Don’ts about the negligence in dentistry;

Table 2 Do’s and Don’ts about the negligence in dentistry
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It is always advisable to use good quality and reliable brands for any instrument. Whenever any retention of a broken metal instrument is suspected, an imaging radiological study will indicate its position and help to avoid potential surgical complications. Preoperative and postoperative monitoring of instruments warranted and if any damage found it should be discarded.

This study is just a step forward in reporting negligence by dental professionals, manufacturers and patients, which would motivate others avoiding such incidences and managing it appropriately. These incidences occur unknowingly as pitfalls can happen by human errors. Also, it is an attempt to put forward the medico-legal aspects and its implications.

Conclusion

Foreign bodies (objects) should be identified and localized. Plain radiographs are useful to confirm the presence of FB, determine the location, and confirm the size and shape of object. If not detected, advanced radio-imaging modalities should be used. Retrieval of FB should be the prime priority.

To conclude, FB in dental socket regions may be due to following reasons:

  1. 1.

    Professionals-.

    • Surgeon should have updated knowledge and good standard of practice. Also, should use the instruments of standard quality.

    • Surgeon should take care intra-operatively and do proper investigations as well as obtain the informed consent to prevent the medico-legal cases.

    • Auxiliaries should have proper qualification and training to avoid improper instrumentation care.

  2. 2.

    Manufacturing-

    • Instruments should pass the standard quality control check and then only to be supplied in the market.

  3. 3.

    Patient-

    • Should have basic knowledge of maintenance of oral hygiene.

    • Education to be given at health care centers for maintaining oral hygiene and care.

    • Patient education should also be given to the school level by the government and health care professionals.