Drills, spills, and protocol: when dentistry doesn’t quite go to plan

This blog, Drills, spills, and protocol: when dentistry doesn’t quite go to plan, is part of a series to support your learning and encourage good practice and continuous improvement to achieve positive patient outcomes.

Seen through an idealistic lens, dental procedures would always be perfect, and complications would be a distant myth. However, dealing with mistakes or unexpected events is a part of real-life clinical practice, highlighting the importance of good professionalism. In this blog, I will discuss situations where things may have gone wrong, sharing insights from my experience as a GDC clinical adviser.

What kinds of things are we seeing and what impact are they having on patients?

Professional Duty of Candour; and the importance of an apology

Patients value honesty, especially when treatments do not go as planned. They may feel upset and aggrieved if they are unaware of the outcomes. Sometimes these outcomes may only come to their attention when they are identified by another clinician. Some examples of more common issues of this nature that have been raised with the GDC that I have encountered, include unfilled, under-filled, or over-filled root canals, the presence of separated instruments, and retained roots after dental extractions.

While patients should be informed of the risks of the proposed treatment(s) during the consent process, maintaining an open and candid approach when things do not go as hoped, is vital. This will help to demonstrate professionalism and may help to prevent further issues. Avoiding difficult conversations at the material time could result in worse outcomes.

The GDC expects dental professionals to:

• Inform the patient (or guardian/advocate) about what happened as soon as possible
• Apologise
• Explain potential consequences
• Outline steps to address the issue

This is the statutory Duty of Candour, applicable to all UK healthcare professionals. Transparency protects both patients and your professionalism.

Saying "sorry" can be hard, but an effective apology - acknowledging what happened, expressing remorse, providing an unambiguous explanation, and offering reparation can have a profoundly positive effect. The use of the word "sorry" should, however, not be viewed as an admission of fault or liability.

The importance of keeping calm

Despite providing reasonable technical standard of care, unpredictability in biological responses and variability in patient expectations, their adaptability, and tolerance can occasionally result in unexpected complications. Common issues I have encountered as a clinical adviser during Fitness to Practise investigations include restorations not settling, persistent pain after root canal treatment, and dissatisfaction with cosmetic procedures. Dental professionals may feel frustrated, but addressing patient concerns with empathy, listening, offering reassurance, and clear explanations is crucial. Acknowledging feelings and apologising can build trust and allow for any remedial care to be arranged more readily, such as referrals for a second opinion.

Dental professionals should remain calm and avoid being defensive when dealing with patients. Pain, anxiety, or confusion can lead to anger, and professionals should respond with respect and dignity, being mindful of their tone and body language. Poor behaviour can occasionally trigger a referral to the GDC, where at times, conduct may be scrutinised more closely than the dental professional’s clinical performance.

Effective complaint handling in line with the Professional Standards can facilitate resolution. Providing clarity and explaining proposed measures can support a more positive outlook during early-stage GDC investigations.

Don’t panic

Two illustrative examples include:

Example 1: During an upper molar extraction for a teenager patient provided on referral, a further healthy tooth and a portion of the jawbone were lost, resulting in extensive tissue damage. The patient was discharged without discussion and without making any records or reporting. The guardian discovered the issue due to post-operative bleeding and was understandably shocked and distraught.

Example 2: During a routine filling procedure, a dental bur dislodged and was later found in the patient's lung, requiring surgical removal. The patient was initially knowingly misled about the cause of their symptoms, and due to the resultant delays in seeking the required medical care, more complex surgery was required. The presence of a retained foreign object post-procedure is considered a "never event.” Never events are serious, preventable patient safety incidents which should not occur if available national guidance and safety recommendations are implemented by healthcare providers.

In both cases, the dentists had likely panicked. Acting in the patient's best interest, being transparent, and making timely referrals could have resulted in better outcomes. Referrals (as per the Standards for the Dental Team) should include clear and detailed information. For the second case, a referral to an Accident & Emergency doctor would usually contain details about the object (size, shape, composition, and a photograph) and appropriate information about the incident itself. If a patient declines hospital care, giving them insight into any red flag symptoms and clearly advising them of the next steps would be helpful. Clinical advisers understand mishaps, but the lack of transparency and causing harm may culminate in more criticism, while good professionalism is usually viewed positively.

In the first example, an additional tooth was also extracted. Although ‘wrong tooth extractions’ are no longer classified as never events by NHS England, they remain serious patient safety incidents and are sometimes reported to the GDC. In my experience as a clinical adviser, these incidents have often resulted from errors in clinical records, referral letters, or from inadequate assessment procedures. As part of sharing learning feedback, thoroughly reviewing patient’s clinical notes and radiographs before proceeding, resolving any miscommunication, and securing informed consent may be helpful. The patient or guardian should confirm which tooth is being treated, especially for referrals. If there are any doubts, it is best not to proceed.

In the event of an incorrect extraction, in line with the Duty of Candour, it is appropriate to offer a sincere apology. Conducting a significant event analysis to identify key learning points and to aid preventing future incidents can be helpful for the examples above. For never events or permanent alterations to the patient's body, relevant third parties may also need notification. 

Risk assess appropriately

Proper risk assessment and understanding boundaries are important. On one occasion, a general dentist offered to undertake laceration repair to patient's injured limb; their actions nearly culminated in a serious permanent disability. Whilst incidents of this nature are rare, this example underscores the relevance of careful assessment and thoughtful decision-making to prevent harm, ensuring any care proposed or undertaken is not out of scope.

Concerns have been raised by patients about the risks of dental hygienists working without the regular support of a dental nurse and how this may impact on their safety. Dental professionals must be appropriately supported when treating patients, except in exceptional circumstances. Absences due to annual leave or training are not exceptional. While constant chairside support isn't required, those working alone must conduct a risk assessment and plan for support in case of a medical emergency to the patient or themselves. Providing this information can be helpful if a challenge arises.

Solutions and burns

Concerns about chemical spillages and accidents are occasionally reported to the GDC. Facial burns can occur from acid etchant gels that accidentally spill or rub off from the operator’s glove. Eye splatters may also result following the use of 3-in-1 syringes to remove some chemicals, where eye protection has not been provided. Management solutions may include, expressing regret, acknowledging the cause, providing first aid, and referring for medical attention if needed. Familiarity with COSHH (Control of Substances Hazardous to Health) safety sheets and conducting a SEA may also be helpful.

Burns from overheated instruments, scalding from heated equipment used to cut away excessive root canal filling material and soft tissue lacerations from burs during procedures are also reported (when that area of their mouth may have also been numbed by local anaesthesia). As part of sharing learning feedback, areas where the care may have been lacking include not offering an apology, not providing the necessary first aid (e.g., cleansing and suturing lacerations), not reassuring the patient and/ or the option to stop the treatment at the material time. Arranging follow-up calls and review appointments can be helpful; details of these incidents should also be logged.

The importance of preparing clear documentation and good record keeping

Good records are also vital if a concern is raised with a third party. As GDC clinical advisers, our views are limited to the materials (records and correspondence) supplied and without any direct contact with any stakeholders. When an issue arises, it is important to make and keep comprehensive, contemporaneous, and accurate records of:

• The incident or concern
• Communication with the patient/guardian
• Steps taken to address the issue
• Any follow-up or referrals

It is important to ensure these records are dated, objective, and free from speculation or emotional language.

Where can professionals go if they need more help or want to know more?

If you are unsure how to proceed, or if the issue could result in a formal complaint, it may be helpful to contact your dental defence organisation immediately. Early support is crucial, and indemnity providers can guide you on communication, patient management, and documentation. You may also consider seeking advice from colleagues, mentors, or wider services.

Reflect on the situation:

• Were there missed red flags during consent or treatment planning?
• Could communication have been clearer?
• Was it a systems issue rather than a human error, and how could recurrence be prevented?

The use of tools like significant event audits, huddle sheets, or peer review sessions may help to improve systems and prevent repeat issues. Demonstrating learning and change may be viewed positively if a complaint or investigation occurs.

Mistakes and complications happen, but your response may be of critical importance. Clarity, compassion, and professionalism are as important as diagnostic and technical skills. When things go wrong, take a breath, follow protocol, and let good values lead. The best way to stay safe is by doing the right thing.

The following information may be helpful:

• Standards for the dental team
• Being open and honest with patients when something goes wrong
• Complaint handling
• Revised Never Events policy
• Significant event analysis and incident reporting | Practice
• Huddle sheets and supporting guidance
• LocSSIPs Toolkit Dental Extraction

This blog is part of a series by Shamir Mehta, please see his other blogs:  

How patient consent can help build trust and confidence

Dental record keeping: what is professional, reasonable and in the interest of patients? 

Clear aligner treatment: What can we learn from complaints and concerns?