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Condition and Prognosis
R M & Co Solicitors RMC/123/2010 1st January 2010 Dr B DAVID COHEN PhD, MSc, BDS, MFGDP, LDSRCS, CUEW, MEWI Specialist in Endodontics Accredited Expert Witness the MALT HOUSE Specialist Dental Treatment Centre Deva Centre Trinity Way Manchester M3 7BD
Tel: 0161 834 8824 Fax: 0161 838 5353 Email: [email protected]
The issues addressed
My investigation of the facts
Discussion and opinion
Statement of compliance
Statement of truth
My qualifications and professional experience
1.1 The writer
My name is Dr Ben David Cohen. My specialist field is Endodontics. I have been in Specialist Referral Endodontic Practice for over twenty years, am a Registered Specialist in Endodontics with The General Dental Council and I am a certificated Expert Witness.
Full details of my qualifications and experience entitling me to give expert opinion evidence are in Appendix 1.
1.2 Summary of the case
This case concerns a lady, Mrs T B, who had an accident when she slipped over a hidden hole in a pathway on 3rd June 2009.
At the time of the accident she fell forwards and damaged her
chin, fractured her mandible
and damaged three teeth, 25
Following the accident, Mrs B attended the Accident and Emergency unit at a local hospital and was subsequently seen by the oral and maxillofacial department at W Hospital.
Subsequently, the mandible
was repaired surgically at W
As a result of the accident, Mrs B now has limited opening of the jaw, residual anaesthesia of the left cheek, lateral deviation on opening, and some sensitivity of the broken teeth.
Mrs B is now concerned about her face on the left side being more swollen than as it was prior to the accident.
Accordingly Mrs B is taking action against the Local Authority.
I have been instructed to prepare a Condition and Prognosis Report with regards to the need for future treatment on her mouth and these affected teeth. I have also been asked to deal with any relevant pre-accident medical history, the injuries sustained, treatment received and the present condition.
I examined the patient on 2nd August 2010.
The purpose of this report is to set out the current dental condition of Mrs B’s teeth, with particular attention to the upper left quadrant. In addition, the purpose of the report is also to
establish the prognosis for these teeth and any treatment that may be required in the future.
1.3 Summary of my conclusions
In my opinion, the 25
were damaged at the time of
the index accident.
The left temporo-mandibular joint
was also fractured and has
been repaired surgically, although it has left Mrs B with limited
opening and some deviation on opening.
Mrs B now needs to attend her general dental practitioner to commence regular treatment.
will require full crown restorations
result of their fracture.
These coronal restorations
will require regular replacement at
ten to twelve-yearly intervals.
Some continuing psychological and physical disabilities have resulted from the accident and some advice has been given by Mr M in that respect.
It is possible, but unlikely, that root canal therapy
required on the 25
Likely costings have been given for current and future treatment.
1.4 The parties involved
1.5 Dental terms and explanations
I have indicated any dental terms in bold type
. I have defined these
terms and included them in a glossary in Appendix 3.
THE ISSUES ADDRESSED
Substance of the instructions
I have been asked to prepare a Condition and Prognosis report as detailed in 1.2.8
Purpose of the report
The purpose of this report is to set out the current dental condition of Mrs B’s teeth, with particular attention to the upper left quadrant. In addition, the purpose of the report is also to establish the prognosis for these teeth and any treatment that may be required in the future.
There appear to be three main issues that need to be addressed in this report, as follows:
What is the current dental condition of Mrs B’ mouth and what treatment, in my opinion, is necessary to render it dentally fit.
What is the likely prognosis for her mouth, and what future treatment, in my opinion, will be required.
Are there any areas of continuing complaint or disability or impact on daily living as a result of the accident.
MY INVESTIGATION OF THE FACTS
History and Consultation
3.1.1 My investigation of the facts has been conducted both by reference to
documents supplied to me by the Solicitors, and a consultation with the patient on the 2nd August 2010.
Documents that I have examined
Copy of medico-legal report by Mr B M dated 28th June 2010.
3.1.2 At the consultation appointment I established that Mrs B is a fit and
healthy forty-six year old lady. She reported to me that she is allergic to Penicillin, Pethidine and Co-codamol and is currently taking a mild antidepressant, Citalopram, for anxiety following the index accident.
3.1.3 At the examination, Mrs B reported that she was a regular dental attender
until the index accident but has not attended since then [approximately fourteen months].
3.1.4 Mrs B reported that she was walking her dog in the early afternoon on the
date of the accident, when the weather was light and dry. She was walking along a paved path through a field in H.
3.1.5 Without seeing it, her foot became lodged in a hole in the path, which was
covered in weeds. This caused her to trip over.
3.1.6 As a result of the trip she fell forwards, flat on her chin and tried to break
3.1.7 She reported that she was not aware of losing consciousness. 3.1.8 However, she did hear a “cracking noise” and felt as if her chin had been
3.1.9 She immediately was aware of pain in her left temple and cheek and was
bleeding profusely from her chin. She also seemed to remember that she was possibly bleeding from her gums, although she was not so sure, as no damage appeared to have been done to her teeth.
3.1.10 She remembers that she could talk after the accident but her mouth opening
was very limited according to both her and her daughter who was on the scene very quickly.
3.1.11 She was subsequently taken to the Accident and Emergency unit at S
Hospital by her husband, where they stitched her chin and X-rayed her jaw.
3.1.12 As a result of the X-rays, Mrs B was referred by S Hospital A & E
department to the maxillofacial department at W Hospital, as they reported that she had broken her jaw.
3.1.13 She immediately went to the Accident and Emergency unit at W Hospital,
where she was admitted but released the next day and advised to return one week later.
3.1.14 On her return a week later, she was re-X-rayed and had a CT scan. This
scan revealed a condylar
fracture and dislocation of the left mandibular
3.1.15 As a result of the accident, surgery was carried out another week later by a
consultant, Mr T, to repair her broken jaw.
3.1.16 Further details of the injury have been reported in the medico-legal report
by Mr B M, a consultant maxillofacial and facial plastic surgeon.
3.1.17 Mrs B reported that she has now been discharged by Mr T, although she
3.1.18 These symptoms include an area of anaesthesia/palsy in the area of the left
3.1.19 In addition she has limited opening and is unable to completely articulate
her teeth in the upper right quadrant. For example, she cannot close her teeth sufficiently to tear a piece of cellotape between her teeth.
3.1.20 She also reported sensitivity to hot and cold in the upper left quadrant and
pain in the left temporo-mandibular joint
area when eating. As a result
of this, she is tending to eat on the right side of her mouth, although she is
limited in types of food that she can eat.
3.1.21 Mrs B also reported that she is still off sick from work due to the eye strain
problem, as she tends to work on the phone and at a computer screen.
3.1.22 Mrs B also reported that on a social level she is extremely self-conscious
about her face, as she feels the left face is swollen and different than it was prior to the index accident. She also feels that she is lopsided and has limited her social outings because of this.
3.2 Clinical Examination
3.2.1 On clinical examination I found the following teeth to be present:
3.2.2 Oral hygiene and periodontal
condition were both classified as fair.
There was some bleeding in the lower anterior region and a degree of plaque was present throughout the mouth. Mrs B reported to me that because of the limited opening she found it extremely difficult to brush her teeth properly.
3.2.3 None of the teeth were mobile or tender to percussion. 3.2.4 It was noticed that she had limited opening of approximately 1½ fingers
breadth and I would estimate this to be approximately 60-70% of the
normal opening [this would accord with the finding of Mr M
3.2.5 On palpation, the left condyle
was tender when opening and Mrs B also
reported that it was tender when she was sleeping on it.
3.2.6 The 25
was sensitive to cold air.
have large composite restorations
, all of which had been
, although it is possible that in the case of the 26
is the buccal
walls of the teeth that have chipped away.
3.2.8 A photograph of the affected area was taken at the time of the examination
DISCUSSION AND OPINION
The issues relating to the current dental condition of the anterior teeth,
and what treatment, in my opinion, is necessary to render these teeth
It is clear from my clinical examination and reading of the
correspondence that Mrs B suffered a severe trauma when she had her
accident. It is clear that the jaw was severely damaged, as were three
. There is no indication to suggest that the damage
to the teeth was done at any time other than the time of the index
has been repaired and this is subject to a separate
medico-legal report by Mr B M. Therefore, under the circumstances, I
shall not give any opinion regarding that aspect.
were heavily restored with tooth-coloured composite
prior to the index accident and have obviously been
damaged at the time of the accident.
is sensitive to cold but I was unable to test whether it was
sensitive to hot. In addition, due to the limited opening, I did not feel
it was necessary to take radiographs of the teeth at this time as this
would have to be done at some later stage to establish the condition of
Mrs B reported that she has difficulty cleaning her teeth because of the
limited opening and, as a result, this has caused some periodontal
inflammation which needs attention.
Therefore, my treatment plan, in view of my clinical examination and reading of the notes, would include the following:
o Attendance at her dental practitioner and his dental hygienist to
undergo dental cleaning and oral hygiene instruction. This should be somewhat specialised in view of the somewhat limited opening.
o Investigation of the sensitivity associated with the teeth 25
, to establish whether root canal therapy
is necessary. In my
opinion, on the balance of probabilities, I would think that root
would not be necessary on these teeth.
o However, if the 25
is found to be hypersensitive to hot, then root
may be necessary to combat that.
o Following establishment of whether root canal therapy
is or is not
necessary on the 25
, then full crown restorations
necessary on the 25
. I would estimate the cost of each crown
to be in the order of £750.
Apart from what I have listed above, I can see no other further dental
treatment being required as a result of the index accident.
The issues relating to the likely prognosis for these teeth and what future
treatment, in my opinion, will be required.
It is now well-established that restorations
of the kind recommended
above have a finite life of between ten to twelve years, and therefore
require regular replacement at those intervals.
Therefore, given the age of the Claimant, I would estimate that the
will require replacing three times each.
I would estimate the cost of each replacement to be £750 per tooth per
replacement at today’s prices.
Apart from what I have stated in the paragraph above, I can see no other treatment being required in the future as a result of the index accident.
The issues relating to any areas of continuing complaint or disability or
impact on daily living as a result of the accident.
As I have commented earlier, Mrs B is still extremely conscious of both her appearance and the anaesthesia in the area of the left cheek. As a result of this, she is still on a mild antidepressant/anti-anxiety medication, which she is unhappy about.
She also feels that it is affecting her social life, in that her appearance is not what it was and she feels that it is somewhat “lopsided”.
In addition, Mrs B is still off sick as a result of the accident and I am unable to give an opinion as to how long this will last.
However, I have advised Mrs B to have a dental examination and oral hygiene treatment, including how to maintain oral hygiene
It is quite clear that a number of disabilities have arisen as a result of the accident, which I have referred to above. These are also well-covered in the report by Mr B M.
STATEMENT OF COMPLIANCE
1. I understand that my duty in providing written reports and giving evidence is to help
the Court, and that this duty overrides any obligation to the party by whom I am engaged or the person who has paid or is liable to pay me. I confirm that I have complied and will continue to comply with my duty.
2. I confirm that I have not entered into any arrangement where the amount or payment
of my fees is in any way dependent on the outcome of the case.
3. I know of no conflict of interest of any kind, other than any which I have disclosed in
4. I do not consider that any interest which I have disclosed affects my suitability as an
expert witness on any issues on which I have given evidence.
5. I will advise the party by whom I am instructed if, between the date of my report and
the trial, there is any change in circumstances which affect my answers to points 3 and 4 above.
6. I have shown the sources of all information I have used.
7. I have exercised reasonable care and skill in order to be accurate and complete in
8. I have endeavoured to include in my report those matters, of which I have knowledge
or of which I have been made aware, that might adversely affect the validity of my opinion. I have clearly stated any qualifications to my opinion.
9. I have not, without forming an independent view, included or excluded anything
which has been suggested to me by others, including my instructing lawyers.
10. I will notify those instructing me immediately and confirm in writing if, for any
reason, my existing report requires any correction or qualification.
1. my report will form the evidence to be given under oath or affirmation;
2. questions may be put to me in writing for the purposes of clarifying my report
and that my answers shall be treated as part of my report and covered by my statement of truth;
3. the court may at any stage direct a discussion to take place between experts for
the purpose of identifying and discussing the expert issues in the proceedings, where possible reaching an agreed opinion on those issues and identifying
what action, if any, may be taken to resolve any of the outstanding issues between the parties;
4. the court may direct that following a discussion between the experts that a
statement should be prepared showing those issues which are agreed, and those issues which are not agreed, together with a summary of the reasons for disagreeing;
5. I may be required to attend court to be cross-examined on my report by a
6. I am likely to be the subject of public adverse criticism by the judge if the
Court concludes that I have not taken reasonable care in trying to meet the standards set out above.
12. I have read Part 35 of the Civil Procedure Rules and the accompanying practice
direction including the “Protocol for Instruction of Experts to give Evidence in Civil Claims” and I have complied with their requirements.
13. I am aware of the practice direction on pre-action conduct. I have acted in accordance
STATEMENT OF TRUTH
I confirm that I have made clear which facts and matters in the report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinion on the matters to which they refer.
My qualifications and professional experience
Bachelor of Dental Surgery (BDS)
Licentiate in Dental Surgery of the Royal College of Surgeons (LDSRCS)
Member of the Faculty of General Dental Practitioners (United Kingdom)
Registered Specialist in Endodontics (General Dental Council)
Certificate of Expert Witness Accreditation (Cardiff University)
General Dental Practice
Honorary Research Associate, Department of
Restorative Dentistry, Manchester University
Clinical Assistant in Restorative Dentistry,
University Dental Hospital of Manchester
Lecturer (Part time), Department of Restorative
Visiting Fellow, Singapore Ministry of Health,
funded by the Health Manpower Development Plan
Restorative Dentistry, Manchester University
President of the British Endodontic Society
Member of the American Association of Endodontists
Treasurer of the North West Endodontic Study Circle
Certificate of Expert Witness Accreditation, Cardiff University
Author, or co-author, of over 15 refereed papers
Holder, or co-holder, of 4 international dental materials patents Currently
Specialist Endodontic Practice
Honorary Research Fellow, Department of
Restorative Dentistry, Manchester University
the upper left (UL5) second premolar tooth
anterior open bite
a space between the front teeth when the back teeth are biting
surgical removal of the tip (apex) of the root, usually associated with a retrograde root filling
tooth that is completely knocked out due to impact-trauma
x-ray taken to show the biting surfaces of top and bottom teeth at the same time
the front, or outer, surface of the teeth and gums
fixed prosthesis attached to a sound tooth/teeth to replace a missing tooth/teeth
on a tooth used to support an artificial crown
qv) replacing a missing tooth
a hole into the pulp of the tooth produced by caries dissolving away tooth structure
the part of the tooth which is visible in the mouth, excluding the
white filling material, usually adhesive
the bacterial seal created around a filling or crown
of a tooth.
a collection of fluid within an epithelial (skin tissue) lined sack
the bulk of the hard substance of the tooth beneath the enamel and over the pulp
removable prosthesis with artificial teeth
describes the back facing side of the tooth
the visible hard white layer of the tooth
the science of treating the root canal space in the tooth
dental specialist who carries out root canal treatment
surgical removal of the cyst sack and all its contents
removal of vital pulp tissue from the root canal (often used as
a chronic (non cancerous) lesion which may occur around the apex of the tooth following root treatment, and which is a type of scar
titanium root analogue implanted (fixed) into the jawbone to replace a missing tooth
complete white line of bone surrounding tooth
master apical file – the final instrument used to shape / clean
surgical, long term, drainage of a true cyst
describes the top lateral corner of an incisor tooth
describes the front, or midline facing side of the tooth
relationship of how the arch of the upper teeth meet the arch of the lower teeth when the mouth is closed
the approach to the root canal through the tooth
a number of radiographs taken at different angles to give a more 3D effect
the gentle tapping of a tooth with a dental instrument to test for tenderness
x-ray taken to show the end of the root in bone
perforation of the root
an artificially created hole through the root of the tooth
supporting tissues of the teeth, gums and jawbone
layer of supporting fibres surrounding the root of the tooth, and visible on radiographs
loss of supporting tissue around the tooth, but underneath the gum
dental specialist who carries out gum treatments
the artificial replacement tooth unit of a bridge
an artificial porcelain facing or cap constructed and adhered to a tooth
a space within the root canal prepared to take a post
post retained crown
fitted to the tooth, which is retained by a pin or post
fitted within the root canal space
a filling material built over a post to form an artificial tooth,
usually covered with a crown
small side chewing tooth, between molars and canine teeth
specialist dentist who provides dentures, crowns
the centre part of the tooth containing its nerve and blood supply
pulp vitality tests
test that assess the health of a nerve in a tooth
extent of fracture involving the centre-part (pulp) of the tooth
a shadow on a radiograph which infers a lesion is present e.g. an abscess
transparent to x-rays, therefore appears black on a radiograph
the approach to the end of the root of the tooth through the gum and bone during surgery
root canal therapy
root treatment (filling)
the process of removing any nerve in the tooth then cleaning, disinfecting and filling the root canal space with a semi solid material
a hole in the side of the root created inadvertently
a hole in the gum through which pus & / or tissue fluid can drain out
an artificial porcelain or composite
facing or cap constructed
and adhered to a tooth
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