This case study has been published with the member's permission, but some details have been anonymised.

History

A DDU member faced a claim brought by a long-standing patient, who had attended on many occasions for over a decade. During this period, the patient had received routine dental treatment as well as treatment for periodontal disease.

The patient saw the DDU member several times during a period of around three months because of a gum lesion, with oral candidiasis being suspected as a possible cause.

The patient failed to attend a subsequent planned examination appointment and didn't attend again for over a year. However, when they attended another dentist, an urgent referral to hospital was made for suspected oral cancer; the gum lesion had not gone away, and appeared speckled. The subsequent histology revealed severe dysplasia with changes suspicious of squamous cell carcinoma, while a further biopsy revealed moderately differentiated squamous cell carcinoma.

The patient underwent extensive treatment that included anterior maxillectomy, extraction of multiple teeth, selective neck dissection and reconstruction surgery.

Alleged negligence

The patient pursued a claim for negligence on the basis that if the DDU member had made a referral in the first instance, a diagnosis of dysplasia would have been made when the gum lesion was reported, and the treatment would have been far less invasive.

Expert opinion

The member approached the DDU for assistance in dealing with the claim, and we instructed an independent expert to examine the details of the case and give an opinion on whether the member was in breach of their duty of care.

The expert was critical about the lack of information in the records. They suggested the member should have recorded where candidiasis was seen or suspected, and what it looked like, together with details of whether an attempt was made to rub away the white spots, to differentiate candidiasis from dysplasia.

We also instructed experts on causation, who concluded that if a biopsy had been done when the inflammation did not resolve, the histological examination was likely to have identified dysplasia in the specimen. If this had been the case, there would have been an earlier referral and the treatment would have been less extensive.

The patient also instructed their own independent experts, who separately concluded that the patient had severe epithelial dysplasia during the material time. If they had been referred in a timely manner, they would have been treated for the dysplasia with surgery, and there would have been a higher probability that they wouldn't have gone on to develop cancer.

Outcome

With the DDU member's agreement, the claim was settled because of the vulnerabilities identified by both sides. The eventual settlement amount did, however, take into account factors such as the patient's delay in attending a follow-up examination.

Learning points

This case highlights the importance of establishing an accurate diagnosis based on the clinical presentation, arranging appropriate follow-up appointments, and referring patients to hospital on an urgent basis if oral cancer is suspected.

It further highlights the importance of dental professionals carrying out a thorough and accurate clinical examination and keeping detailed records, especially because of the fact that based on published data, the incidence of oral cancer in the population is increasing.

If important clinical information is not recorded (such as the colour, size, site, shape and texture of the lesion, and unexplained pain or bleeding), and any changes are not accurately monitored (for example, by using previously recorded clinical information about the lesion or good quality clinical photographs), it will be much harder to successfully defend a claim relating to oral cancer if it arises.

It can help any defence when oral cancer is suspected to arrange appropriate urgent onward referral by using the two-week suspected oral cancer pathway.

See our recent analysis of oral cancer claims for more information on the incidence and background to these types of cases.