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Dental cotton roll left in patient’s mouth (14HDC01267)
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Dentist ~ Dental surgery ~ Cotton roll ~ Follow-up ~
Standard of care ~ Right 4(1)
An 87-year-old man attended an appointment with his dentist. The
dentist performed a surface amalgam restoration (silver filling)
for the man's left lower second molar (tooth 37) under local
anaesthetic. The procedure took 45 minutes and was "challenging"
owing to difficulty with accessing the area and moisture control.
The dentist used approximately seven cotton rolls for moisture
control during the procedure, but he did not keep a record of the
number of cotton rolls.
The following day, the man began to experience discomfort and
pain, and had a swollen and sore tongue, which continued to worsen
over the following days. He was unable to sleep, had difficulty
eating and drinking, and commenced antibiotics.
Three days later, the man spoke to the dentist on the telephone.
The dentist recorded that the man intended to visit a doctor, and
advised the man to contact him if his symptoms persisted. That
afternoon, the man's daughter took her father to see a general
practitioner (GP), who examined the man's mouth and neck and
concluded that he had an infection. The GP prescribed pain killers
and further antibiotics and recommended that the man return to his
dentist if there was no improvement over the next two days.
Three days after his appointment with the GP, the man returned
to see the dentist. The dentist undertook an examination of the
man. There was "discomfort/pain on palpation", and the man was
unable to lift his tongue. The dentist took radiographs of the
man's lower left mouth for further examination of tooth 37. The
dentist considered that the man might have an infection, and
prescribed him different antibiotics.
The following day, the man returned to the GP's practice and saw
a different doctor. The doctor considered that, as the man had only
started the new antibiotics the previous day, they should wait for
Four days later, the man sought a second opinion from another
dentist. The second dentist examined the man and located and
removed a dental cotton roll that was tucked underneath the man's
back left bottom molar alongside his tongue. There was a large,
deep ulcer where the cotton roll had been sitting. Having had the
cotton roll removed, the man immediately felt better and, two days
later, was feeling well.
The dentist's management of the man's condition and concerns
following treatment, including the later failure to detect the
retained cotton roll, was suboptimal. It was also of concern that
the dentist failed to account for the number of cotton rolls used
during the man's procedure on tooth 37. The dentist failed to
provide services to the man with reasonable care and skill, and
breached Right 4(1).
The dentist's breach of the Code was due to individual clinical
failings. Accordingly, the dentist's employer was not directly or
vicariously liable for his breach of the Code.