Patient’s Failure to Obtain Pre-Procedure Testing Results in Serious Injury

This case study exemplifies the potentially serious consequences that can arise when a dentist allows a patient to dictate treatment by failing to undergo a recommended pre-procedural study due to cost.

Facts of the Case

A 47-year-old single male had been a patient of the periodontist for more than 20 years. His treatment primarily consisted of general dental care and periodontal maintenance. The patient’s medical history was essentially unremarkable, except for cigarette smoking.

In November 2010, he presented to the dentist’s office complaining of mobility in tooth #24. At that visit, the dentist discussed treatment options to replace the tooth. However, the dental record does not specify exactly what options were discussed with the patient. The patient agreed to pursue a plan for extraction of tooth #24, including placement of an implant. The dentist referred the patient to a dental radiologist to undergo a 3D scan of the mandible prior to the planned treatment.

On a telephone call in January 2011, the patient advised the receptionist that he could not proceed with the extraction and implant at that time. In April 2011, the patient was again seen, and the dentist’s documentation reflects that tooth #24 was extremely mobile. While it, again, was not documented, the dentist recalled that he once more discussed with the patient the proposed plan for extraction and placement of an implant. Also not documented was a telephone conversation between the patient and the dentist’s receptionist in mid-June of 2011. The patient told the receptionist he did not intend to undergo the recommended and prescribed 3D scan prior to the extraction and implant due to the added out-of-pocket cost. However, the patient requested that the replacement tooth be ready at the time of extraction.

On June 30, the patient presented for the planned extraction and implant. Although the dentist took a preoperative digital X-ray of the anterior mandible, he proceeded with the implant despite the fact that not having the 3D scan was against the dentist’s custom and practice, as well as the dental standard of care. He gave the patient a local anesthetic and extracted tooth #24 by forceps without complication. The acrylic denture was tried and adjusted. The dentist then created a mucogingival buccal and lingual flap to expose the bone in the area of tooth #24. Based upon his visual inspection of only a bone, the dentist determined that the bone was sufficient to proceed with a 10-millimeter x 3.3-millimeter implant.

The dentist drilled an access hole approximately 2 millimeters deep utilizing a round surgical bur. This was then followed with a 2-millimeter bur to establish length. At approximately 10 millimeters, the patient jumped, stating that he “felt something.” The dentist observed excessive bleeding through the osteotomy hole and immediately applied pressure with gauze to the area. After about 10 minutes, the bleeding appeared to be under control. The patient was given Tylenol and an antibiotic. However, the dentist observed that the floor of the patient’s mouth began to swell. It became quite apparent that the patient was hemorrhaging. The dentist immediately contacted an oral surgeon to see the patient, and the dentist’s office manager drove the patient several blocks to the oral surgeon’s office. The oral surgeon quickly diagnosed a dissecting hematoma of the right and left sublingual spaces and the right and left submandibular spaces. He also documented the presence of an apparent perforation into the sublingual space with a laceration of the left sublingual mucosa and uncontrolled bleeding. Further, he documented bulging of the right and left submaxillary glands, which suggested an acceleration of the hematoma. The patient’s tongue was swollen bilaterally and elevated, partially occluding the oral pharyngeal airway. He immediately called 911.

The oral surgeon gave the right and left mental blocks before the EMTs arrived but was unsuccessful in attempting to drain the accumulating blood from the submaxillary spaces. The patient was taken by ambulance to the nearest medical center, where a trauma team awaited him. The emergency department physician determined that he needed immediate placement of an airway. The patient was rushed to the operating room and underwent an “awake” emergency tracheostomy. He received “last rites” in the operating room.

The patient was then intubated and sedated. A head and neck angiography demonstrated extravasation in the distal perforating branch of the lingual artery, which was successfully embolized. The patient was then transferred to the ICU, where he remained sedated and on a ventilator but was hemodynamically stable.

The following day, the patient was weaned to a tracheostomy collar. Initially, he could not take fluids or food by mouth and received nutrition only through a nasogastric tube. On the fifth day post-tracheostomy, he was advanced to pureed food. The swelling of his tongue and face gradually subsided, and the patient progressed well without complaints except for anxiety, for which he received Xanax. Throughout the hospitalization, the dentist was in contact with the patient’s family. The dentist also visited him several times.

On July 11, the patient was discharged with a fenestrated tracheostomy tube in place. He remained on a pureed diet and continued to take Xanax for anxiety. Following the patient’s discharge from the hospital, there was no further contact between the dentist and the patient.

The patient continued to heal well at home. At the end of July, the tracheostomy tube was removed, and he was advanced to solid foods. By mid-August 2011, he was able to return to work. As a result of this event, his treating physician diagnosed him with post-traumatic stress disorder and referred him to a psychologist. However, at his deposition, the patient testified that he had not seen, nor did he plan to see, a mental health professional. However, he admitted he was now terrified of any further dental treatment.

The Lawsuit

The patient commenced a lawsuit against the dentist. He alleged negligent implant surgery in the area of tooth #24, causing laceration of his tongue and lingual artery, which resulted in a hemorrhage, severe edema of the mouth and tongue and obstruction of his airway. As a result of these injuries, the patient required an awake emergency tracheostomy with placement on a ventilator, embolization of the lingual artery and a 10-day hospitalization. The patient was left with a scar from the tracheostomy, tightness in his throat when swallowing, numbness in his lips and post-traumatic stress disorder.

Expert Reviews

Experts who reviewed the case on behalf of the dentist felt there was simply no possible defense to the lawsuit. Their criticisms of the dentist’s care focused on the patient’s refusal to undergo the 3D scan, which would have provided the dentist with views of the bone not seen on the PA digital X-ray. Further criticism included the dentist’s placement of the implant without first considering bone augmentation. Additionally, the dentist should have immediately recognized the seriousness of the patient’s hemorrhage and called 911 rather than sending the patient by car to the oral surgeon. This delay in obtaining immediate medical intervention placed the patient’s life and health at great risk. Earlier treatment may have prevented the patient’s need for a tracheostomy. Because this procedure had to be performed emergently and while he was awake, the patient had been additionally subjected to substantial physical and emotional distress.

Another crucial weakness in possibly defending the dentist was the inadequate documentation in the patient’s record. There was no discussion of the treatment plan, the potential options offered, and, most importantly, the failure by both the dentist’s staff and the dentist to communicate and document the patient’s refusal to obtain the 3D scan before the procedure. In hindsight, the dentist might have opted not to proceed with the implant.

Further, by proceeding without the scan, which the patient allegedly refused due to its cost, the dentist did not dictate the patient’s care. Rather, the patient did so. That is neither acceptable nor reasonable. Because the dentist clearly had no viable defense to any of the allegations, the litigation was settled prior to the dentist’s deposition.

Takeaways

Patient noncompliance is one of the most difficult challenges for healthcare providers. It may include missed or canceled appointments, failure to follow a plan of care, failure to take medications as prescribed or failure to obtain recommended tests or consultations.

Patients’ reasons for noncompliance vary but often include denial that there is a dental problem, the cost of treatment, fear of the procedure or diagnosis or not understanding the need for care. Dentists need to identify the reasons for noncompliance and document their efforts to resolve the underlying issues. Documentation of noncompliance helps to protect providers in the event of an untoward outcome and allegations of negligence in treating a patient.

To review MLMIC’s risk management tips regarding managing patient noncompliance look here.

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This document is for general purposes only and should not be construed as medical 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, medical or professional obligations, the applicable state or federal laws or other professional questions.