Case Study: Lack of Documentation and Proper Medical History Result in a Mandibulectomy

A 62-year-old married male with a complex medical and surgical history was a longstanding patient of the insured general dentist. The patient had been diagnosed in August 2001 with Stage IV squamous cell carcinoma of the supraglottic larynx and base of the tongue. He was receiving care at a major cancer center and was initially treated with concomitant chemotherapy and head/neck radiation therapy, followed by a right modified neck dissection. The patient had a permanent tracheostomy, required PEG feedings and developed xerostomia after his treatment. In December 2002, he was diagnosed with a right-side skull base metastasis. The patient again underwent head/neck radiation therapy through January 2003. Subsequently, the patient was followed regularly by his treating physicians at the cancer center. His condition remained stable, with no evidence of recurrent disease.

After an approximate two-year hiatus, the patient was seen at the dentist’s office on Feb. 18, 2006, for a full mouth series of x-rays. The dentist did not document the patient’s health status, the many medications he took or the condition of his dentition and oral cavity. Although the dentist was fully aware of the patient’s medical history, his record contained scant information regarding the patient’s cancer and subsequent radiation treatment. He also failed to document any discussions with the patient about the proposed treatment plan. The dentist later recounted to defense counsel that the treatment plan was to “…clean the bad teeth, extract the ones that could not be saved and then do implants or other work” at a cost of more than $10,000.

On Feb. 24, 2006, the patient was seen for an “exam and consult.” There was no other documentation in the record. On March 3, 2006, the dentist extracted teeth #30 and #31. The dentist’s notes reflect: “Models taken for flipper. #30 surgically extracted, 3-4.0 chromic gut sutures. #31 one suture.” On March 7, 2006, the dentist documented: “Observation, patient lower right quad small 3mm exposed bone lingual to #31. Removed sutures. RX: Amoxicillin 500 mg and saline rinses.” The patient did not keep his next appointment on March 13, 2006. However, the patient did return to see the dentist a few weeks later. At that visit, the dentist documented that he did the following: “Lower left and lower right quads scaled. Re-cemented #20. Impression for flipper (temp removal partial). Sent to lab. NV: extract #23, #24 and #25.”

The patient cancelled his next appointment and was seen again on June 13, 2006. The record stated: “One carp Articaine. Infiltration, #19 filling. NV: upper right quad and upper left quad scaling and curettage.” On June 26, 2006, the dentist performed: “Upper right quad, scaling and curettage, #6 filling.” On Aug. 7, 2006, the record states: “Polish bony edge.” On Aug. 24, 2006, the dentist documented: “Upper left scaling and curettage. #15 filling. NV: models for flipper tooth #5.” On Sept. 11, 2006, he documented: “#5 models for flipper sent to lab, shade C-3.” On Oct. 30, 2006, he documented: “#5 extracted, one carp Xylocaine. Two 4.0 sutures.”

The patient’s last visit was on Nov. 3, 2006. The dentist documented: “Adjust upper flipper. Lower right quad bone still not covered, lingual to tooth #31. Will contact patient’s MD when patient provides name and number.” However, a week later, the dentist advised the patient by telephone to “consult with an oral surgeon re: lingual exposed bone.” When the patient returned to the cancer center a month later, his physician was advised that he had an area of exposed bone in the #32 lingual region. He referred the patient to an oral surgeon at the facility for evaluation. On Jan. 17, 2007, the oral surgeon documented that the area appeared to be exposed bone and was not a residual extraction site. The patient had marked trismus. Periapical pathology was seen at #18. The oral surgeon decided to initially treat the patient conservatively with antibiotics, Peridex rinses and observation. He was also given mouth opening exercises to treat trismus.

By Feb. 28, 2007, the oral surgeon suspected that the patient had osteoradionecrosis (ORN) of the right mandible. This was subsequently confirmed on panorex. The patient complained of continuous pain over the right mandible. Additionally, he continued to suffer from trismus and was unable to remove his partial dentures. Over the ensuing months, the patient was followed closely by both medical and dental experts at the cancer center. He was treated conservatively with analgesics and Peridex rinses. However, he began to complain of increased jaw pain and persistent trismus. By Nov. 2007, the pain in his right jaw had greatly increased. A CT of his head, performed on Dec. 18, 2007, confirmed progressive ORN with a non-displaced pathologic fracture. On April 22, 2008, panorex studies revealed significant progression of the ORN in the right mandible and confirmed the fracture. Therefore, the patient was advised to undergo a right partial mandibulectomy with reconstruction.

On May 29, 2008, the patient was admitted to the hospital for a right partial mandibulectomy and right intraoral reconstruction using a pectoralis major myocutaneous flap and split thickness skin graft to his neck. He subsequently required many months of recovery and rehabilitation from this surgery.

The Lawsuit

During the pendency of the lawsuit, the dentist admitted to his defense counsel that he did not have much experience with cancer patients. The dentist advised that the “rule of thumb” is for a patient to complete dental work prior to undergoing cancer treatment, especially extractions. He also believed that no treatment should be done for six months following cancer therapy. Although there was no supporting documentation in the patient’s dental record, the dentist claimed that he consulted with an oral surgeon about performing extractions and then placing implants in a patient who has undergone chemotherapy and radiation. He further claimed that the oral surgeon advised him that no precautions were required because the radiation had occurred several years before.

This case was difficult to defend for several reasons. First, the dentist’s records contained inadequate documentation of the patient’s medical history, cancer treatment, complaints, observations, a discussion of the treatment plan and an informed consent containing the alternatives to extraction. Additionally, due to the dentist’s lack of experience treating patients who had received radiation for head and neck cancer, he should have obtained pre-operative clearance from the patient’s oncologist.

The dentist was misinformed in his belief that the extractions could be performed after radiation therapy without consequence. The effects of radiation are permanent, and that the damage to irradiated bone does not improve with the passage of time. Therefore, it is always preferable to avoid injuring previously irradiated bone. Additionally, there was a delay in referring the patient to a specialist once the dentist observed the exposed bone at #31. Perhaps the most significant weakness in the defense of this suit was revealed upon reviewing the X-rays of teeth #’s 30 and 31. These teeth were salvageable and could easily have been treated with root canal therapy and, in fact, did not require extraction.

This case was ultimately settled within the dentist’s policy limits.

A Legal Perspective

This case presents several legal and risk management issues. Since lawsuits look retrospectively at what occurred, poor documentation is always a significant weakness in evaluating the defense. When there is little to no documentation, settlement may be indicated due to the lack of credibility of the defendant’s testimony as to recollections after many years have passed and after seeing many other patients in the interim.

The most serious problem with the defendant’s documentation was the absence of a thorough medical history. Although the defendant was aware that the patient had been treated for cancer of the head and neck, he did not document a detailed history of the type and extent of radiation treatment. His treatment notes were also quite sparse. There was no documentation that he had given the patient a written treatment plan and reviewed it with him. Further, he failed to document any informed consent discussion. Because of his complicated medical history, the plaintiff should have been given the option of having his treatment performed by an oral surgeon. Other reasonable alternatives should have been presented, which were not only less expensive treatment options (such as root canal treatment) but also less drastic than extraction. The particular teeth involved here were potentially salvageable with root canal treatment. The cost of that would be much less than the planned $10,000 cost of extractions and implants. Unfortunately, the plaintiff could have argued that only extraction was offered as a treatment option because it would result in greater financial benefit for the defendant.

Finally, the documentation did not describe the plaintiff’s complaints prior to extraction. If the defendant had thoroughly evaluated the plaintiff’s complaints, he may have suspected that the patient’s pain was not related to the tooth decay but rather was an initial symptom of the bony mandibular necrosis. This, too, might have led to a prompt referral to an oral surgeon.

Another major deficit in the defendant’s care was his failure to contact the patient’s oncologist, before proceeding with the extraction, to determine whether extraction was in fact appropriate. If he had done so, he might have learned that the plaintiff had twice undergone radiation to his head and neck due to tumor recurrence. Therefore, the development of bony necrosis was a highly likely possibility. Although it does not seem reasonable that the patient would not know the name of his oncologist when asked, the defendant failed to pursue obtaining the physician’s name from the plaintiff.

Finally, this case illustrates how important it is to promptly refer patients with complex medical problems for medical clearance prior to treatment or post treatment when a problem in healing is identified. The generally accepted dental protocol is to refrain from performing extractions post-radiation treatment for cancer. The dentist’s failure to follow this protocol was a clear deviation from the standard of care. When the bone was exposed after the extractions were completed and the operative areas were not healing, the defendant should have made the necessary referral in a timely manner.

Lack of referral to a dental specialist for either consultation to determine the appropriate treatment, or to complete the necessary treatment with a medically complex patient, is also a deviation from the standard of care. Had the defendant obtained the necessary consultations or appropriately referred the plaintiff to a specialist for treatment, the plaintiff might not have suffered serious complications.

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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.