Case Study: Inadequate Laser Training Leads to Complications After Pediatric Frenectomy

The defendant, who was a general dentist, attended several courses in laser dentistry conducted by a manufacturer of laser equipment. These courses ranged from one to several days in length but consisted only of observation of technique. There was no clinical “hands-on” training. At the end of these courses, the manufacturer administered a written examination and presented a certificate of completion to each attendee.

Facts of the Case

Subsequent to the training , the defendant saw the plaintiff, a 12-year-old male, for an examination, prophylaxis and x-rays in March of 2010. His examination was normal, however, the plaintiff’s mother advised the defendant that the patient did not talk very much and was shy. The mother believed this was due to “a tight tongue.” The defendant examined the plaintiff’s tongue carefully. He documented that although the plaintiff’s tongue was somewhat tight, it was not severely so. Further, the plaintiff could extend his tongue out of his mouth.

Despite these findings, the defendant recommended that the plaintiff undergo a laser lingual frenectomy. The plaintiff’s mother consented to the procedure,  althoughthe defendant did not fully explain the potential risks of the procedure to the mother. No informed consent document was signed. The defendant did not believe this was necessary because, according to the didactic courses he completed, there were no serious risks or complications associated with this procedure.

On April 2, 2010, the defendant performed a laser lingual frenectomy under local anesthesia, using 3% mepivacaine without epinephrine. Again, there was no informed consent discussion with the plaintiff’s mother during this appointment. The defendant set the YSGG laser at 2.5 watts, 15% water, and 15% air. The defendant documented that he maintained hemostasis laser precautions but failed to document any other precautions he had taken to prevent injuries. He further documented that he went only to about four millimeters above the floor of the mouth, discontinued the use of the laser and used no sutures. The defendant failed to describe the plaintiff’s pre-operative status in his records, failed to generate an operative report and failed to take pre- and post-operative photographs. The plaintiff’s mother was given post-operative instructions, which consisted only of giving Tylenol for pain.

On July 29, 2010, the plaintiff complained of a “bubble” on the floor of his mouth. The defendant’s examination confirmed that the plaintiff had a lesion under his tongue around tooth #29. This lesion was approximately 8-9 mm and oval in shape. The defendant’s diagnosis, which he did document, was to “rule out mucocele or fibroma.” The defendant recommended evaluation by an oral surgeon, ENT surgeon or oral pathologist to determine the cause of the lesion. The defendant had no further contact with the plaintiff after this visit.

The plaintiff’s mother made an appointment with an oral surgeon for Aug. 5, 2010. Prior to this appointment, the lesion was apparently filled with fluid and ruptured twice. The oral surgeon documented that the “bubble” was due to an injury caused by the laser frenectomy. Scar tissue had developed at the site of the laser procedure. The oral surgeon performed marsupialization of a right ranula at this visit. He also discussed with the plaintiff’s mother the potential need to remove the plaintiff’s sublingual gland if the ranula recurred.

Unfortunately, the plaintiff returned to the oral surgeon on Sept. 11, 2010, due to a recurrence of the ranula. He underwent a second marsupialization. The site seemed to heal well until Nov. 14, 2010, when the ranula again recurred. The plaintiff’s mother was advised to promptly obtain a second opinion from either another oral surgeon or an ENT surgeon. On Nov. 24, 2010, a second oral surgeon saw the plaintiff to evaluate the recurrent ranula. His examination revealed a non-plunging ranula. Because marsupialization had twice failed, this oral surgeon recommended excision of the plaintiff’s sublingual gland. The procedure was scheduled for Dec. 14, 2010, but the plaintiff’s mother canceled the procedure because she felt her son was improving.

The plaintiff returned emergently to the second oral surgeon on Jan. 3, 2011, with acute swelling of the right floor of his mouth. There was a large, bulbous, fluid-filled mass suggestive of a giant ranula. Further, his tongue had been swollen for 3 days. The oral surgeon immediately sent the plaintiff to the emergency room because he suspected an abscessed ranula. The plaintiff was promptly admitted to the hospital and underwent a bilateral incision and drainage of both the floor of his mouth and a right sublingual gland mucous retention cyst, as well as marsupialization of the ranula. The plaintiff was admitted to the Pediatric Intensive Care Unit (PICU) after surgery and remained sedated and intubated for 24 hours. After he was extubated and discharged from the PICU, he received IV antibiotics until he was discharged on Jan. 5, 2011.

On April 13, 2011, the plaintiff again returned to the oral surgeon. He had a large recurring ranula of the right floor of his mouth, which extended to the posterior right lingual vestibule. The oral surgeon performed an incision and drainage and placement of a drain in his office. Two days later, the oral surgeon removed the drain. He documented that the swelling had decreased. However, he strongly recommended that the plaintiff be evaluated by an ENT surgeon to determine whether his lingual and sublingual glands should be removed because of the continuing recurrence of the ranula.

The plaintiff saw the ENT surgeon on April 28, 2011. An MRI revealed a plunging ranula that had submerged deep into the floor of the mouth and significant scar tissue. The surgeon recommended trans-oral surgery to incise, drain and dissect the ranula. On May 17, 2011, plaintiff underwent the recommended surgery. However, because of the large amount of scar tissue, transoral dissection was too difficult. The surgeon then converted the procedure to an open trans-cervical approach. He removed the submandibular, lingual and sublingual glands as well as the plunging ranula. The plaintiff was discharged on May 21, 2011.

The Lawsuit

Although the plaintiff recovered from this surgery, he sustained chronic xerostomia and permanent scarring of his neck. Further, he was no longer able to pursue the saxophone studies in which he had been deeply engaged. His parents then commenced a lawsuit on behalf of this minor plaintiff, alleging that the defendant failed to obtain informed consent for the procedure and negligently employed the laser.

Dental experts who reviewed the case criticized the defendant’s failure to obtain informed consent from the plaintiff’s mother, his failure to initially refer the plaintiff to an oral surgeon to determine whether a laser lingual frenectomy was, in fact, indicated and his use of a laser despite inadequate training and experience. In addition to the deficits in the clinical aspects of the care provided, the defendant’s documentation of the procedure was also inadequate.

A specialist in the field of laser dentistry also reviewed the case. He opined that because the training courses offered by laser manufacturers provided no hands-on clinical experience, the defendant should not have used the laser. Proper credentialing of a dentist in the use of a laser requires both an academic course as well as clinical experience. The defendant should have been required to pass the type of examination offered by the Academy of Laser Dentistry, not the manufacturer’s exam. This expert further criticized the defendant’s failure to take proper precautions to prevent injury to the floor of the plaintiff’s mouth based upon the defendant’s failure to document that he had done so. He also indicated that laser procedures of this nature should be performed under general anesthesia to prevent movement by the patient, which may well result in laser injury. Finally, the expert concluded that the damages suffered by the plaintiff in this case were consistent with the direct use of the laser on the floor of the mouth, which was a clear departure from good and accepted practice. Due to the very serious deficits in the defendant’s care, the MLMIC claims examiner felt there clearly were far too many significant obstacles to mount a viable defense. Therefore, the case was settled within the dentist’s policy limits.

A Legal Perspective

This case clearly confirms the risks of performing a procedure without adequate training and experience and how poor documentation can seriously impact the ability to defend a case.

In this case, although it is not known precisely what training was given to the defendant in the use of lasers, it was known that the program he attended did not include a hands-on training component. This was a serious flaw in his training. Proper education is essential for using lasers in dentistry. The plaintiff could easily establish that the defendant did not have the requisite training to perform this laser procedure in the office. Instead, he should have referred the patient to an oral surgeon for evaluation and treatment.

Many laser injuries can be traced back to poor adherence to established safety protocols. This case is no different. As one of the expert reviewers noted, the patient should have been sedated to avoid movement during the procedure. Based on the injury itself, it appears that the defendant was negligent in his technique. Further, the failure of the defendant to take both preoperative and postoperative photographs, together with his failure to accurately and fully document what he did and how the site looked before and after the procedure, allowed the plaintiff’s counsel also to claim the procedure was not indicated.

Finally, there was an obvious failure to obtain informed consent to the frenectomy from the patient’s mother. The lack of any informed consent itself forms the basis of a claim for malpractice under New York Public Health law 2805-d. Lack of informed consent means the defendant failed to disclose to the patient the reasonably foreseeable risks and benefits of the procedure, as well as any alternatives. A reasonable dental practitioner under similar circumstances would have disclosed this information in a manner permitting the patient to make a knowledgeable evaluation in determining to undergo the procedure. Here, there was no documentation that any risks were discussed with the mother or that alternatives were considered. Even if the defendant did have adequate expertise in performing a laser frenectomy, he should have asked the patient’s mother to sign an informed consent document outlining the risks, benefits and alternatives to the treatment.

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Sources:

1. https://www.laserdentistry.org/
2. New York Public Health law 2805-d

This document is for general purposes only and should not be construed as dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, dental or professional obligations, the applicable state or federal laws or other professional questions.