Technique Tips: Improving record keeping and patient safety

As part of our on-going continual care for our patients, within the profession, we are required to have complete and accurate well-documented records.^1,2,3,4,5 This technique tip complements such records.

A 68-year-old man presented with a mobile tooth in the upper right quadrant (URQ). There was no soreness, swelling or discharge. He was medically fit and healthy, with no medications or known allergies. I/O: mobility – Class 2, periodontally involved. The radiograph showed a horizontal fracture in the mid to apical third, but there was no history of trauma.

The patient was shown the radiograph and it was explained that the tooth had poor prognosis, and ultimately, would require an extraction. It was also explained that, owing to the nature of the horizontal fracture, the tooth might require removal in sections. There were discussions with the patient about possible complications. The proximity of the tooth to the maxillary sinus meant that there was the possibility of an oro-antral fistula, which, if it occurred and was minimal, would be managed by the clinician on review, but if more severe, then referral to secondary care or to a specialist would be necessary. Local measures should be taken, such as the avoidance of excessive exertion, such as sneezing or coughing. Suturing of the area was a possibility. Other complications, such as the possibility of pain, swelling, bruising, trismus, bleeding and infection were also mentioned. The patient fully consented to treatment.