Case Study: Medical Issues Complicate Dental Treatment

Repurposed from The Scope: Dental Edition, Third Quarter 2023.

Initial Treatment

A 68-year-old male with only 12 natural teeth and a Class 3 malocclusion presented to the dentist’s office complaining that he was very unhappy with upper and lower bridges made two years earlier by another dentist.

The dentist discussed treatment options with the patient. While he removed the old bridges and made temporaries for him, the patient elected not to have implants placed at that time. The patient was sent to the laboratory for assistance in properly correcting his malocclusion.

Eleven months later, the dentist took new impressions and inserted new temporaries to obtain a Class 1 occlusion.

The following year, the patient underwent a root canal on tooth #19, with a post and crown to be inserted at the next visit. However, the patient expressed his discontent with the temporary bridges.

Four months later, the patient returned complaining of pain in tooth #11. At this time, he informed the dentist that he had been diagnosed with Stage IV liver cancer. The following week, the post and core were placed in tooth #19, and an impression was taken for the crown. In addition, the dentist began a root canal treatment on tooth #11.

The following month, the dentist took new lower impressions, and the root canal on tooth #11 was completed. By the end of that month, the old bridges were removed. Over the course of the next two weeks, new temporaries were recemented.

One month later, since the patient still had a Class 3 occlusion, new impressions were taken. The notes of the dentist reflect that the patient was advised that his expectations for correcting the malocclusion were unrealistic. However, the patient refused to have a removable prosthetic.

The following month, a new temporary was inserted. When the patient returned three months later, he appeared to be happy with the new temporary, so it was cemented permanently.

Medical Illness Interrupts Treatment

Due to surgical procedures related to the patient’s physical illness, work on the bridges was temporarily halted. By the following month, which was almost two and a half years since the patient had started treatment, the dentist reprepared the post and cores on teeth #s 8 and 11 and realigned the temporary bridge. Four months later, the upper teeth were inserted with temporary cement. The dental notes reflect that when the patient was reevaluated the following month, he had no complaints with either the upper or lower bridges.

The patient did not return to the dentist for almost two years due to his cancer treatment. He complained of pain in teeth #s 27 and 28, with some looseness. A CBCT indicated that a root canal and possible extraction were indicated. There was also reference to periapical pathology on tooth #29 and that the bridge was still loose. Over the course of the next two months, the patient underwent root canals on teeth #s 29 and 10. Three days later, the porcelain bridge broke from the root canal. The dentist told the patient that it would be necessary to remake the bridge when the patient returned after his health improved following a liver transplant.

Two months later, the bridge was tightened by the dentist, but within a month, the patient returned advising that it had broken again and that part of the bridge near teeth #s 10–13 fell out. The dentist recemented the fractured part of the bridge temporarily and recemented it twice more within a month. Four months later, the upper teeth were inserted with temporary cement.

After undergoing a liver transplant, the patient returned. It was now more than five years since his initial visit. The dentist removed the upper bridge, made a temporary and noted that root canals were needed on teeth #s 6 and 7 with a rebuild of tooth #11, as well as impressions. All of this was done the following week.

When the patient returned from North Carolina two months later, the dentist recemented the temporary bridge and inserted posts in teeth #s 6, 7, 10 and 11. By the end of that month, he had also inserted the upper bridge. After 2 months, the dentist made a new lower temporary bridge, which was inserted several months later. At that time, the patient did not want to pay the dentist’s fee. Unfortunately, the upper bridge was loose within two months. However, because the patient was leaving again for North Carolina, the dentist recemented the bridge with temporary cement.

When the patient returned in December of that year, he complained to the dentist that the upper bridge #s 3–13 was loose. The loose bridge was removed and reinserted, and they began to discuss implants. The patient indicated that he would attempt to get clearance from his doctor, after which he would be referred for a consultation. This was the last visit to the dentist’s office.

After Treatment by Subsequent Dentist, Lawsuit Filed

Shortly thereafter, the patient presented to another dental practice. Over the course of several months, he had numerous procedures performed, including the recementing of his bridges, a root canal on tooth #2, removal of the post and cores of teeth #s 6–11, crown lengthening and new posts and cores placed on many teeth, root canals and implant insertion. Ultimately, the patient had seven implants inserted, as well as a denture.

The patient filed a lawsuit against the original dentist alleging negligent dental treatment over the course of 8 years, including claims of improper restorations of teeth #s 3–13 and 20–30, improper root canal treatments of teeth #s 10, 11 and 19, negligent periodontal treatment and lack of cleanings. As a result, he claimed that this led to decay and periapical pathology that necessitated full mouth rehabilitation.

The notes of the defendant dentist reflected that the patient did not want dentures and could not afford hybrid implants while he was going through cancer treatment. At his deposition, the dentist stated that he did the best he could to keep the bridges in the patient’s mouth while the patient was undergoing cancer treatment.

Expert Review and Settlement

The case was reviewed by MLMIC’s Claims Department, as well as by an expert dentist who felt that while the lack of cleanings and periodontal examinations were weaknesses in the dentist’s case, the cause of the failure of the patient’s bridges, the fracture and the ultimate loss of teeth was biomechanical. The occlusal forces were too great, and there was no posterior support to sustain the bridge. He also pointed out that the patient had poor oral hygiene at home, which contributed to the decay and the poor condition of his teeth.

The case was settled on behalf of the defendant dentist.

A Legal and Risk Management Analysis

The patient in this case was experiencing a great deal of stress due to extensive liver cancer treatments that consumed a lot of his time, focus, expense and energy. Those treatments may have impacted his dental care by affecting his ability to heal properly. Therefore, it may have been advantageous for the dentist to consult with the patient’s treating physician as some cancer therapies may affect the treatment a dentist provides, as well as the healing ability of a patient.

It is clear that each time the dentist treated this patient, a good result was unsustainable for any length of time. It is speculative as to whether this was due to repeated failures related to the skills of the dentist, that the patient was receiving chemotherapy or both. Perhaps the safest approach for this patient to have maximized the potential for a more favorable outcome would have been to wait until cancer treatment was fully completed prior to the provision of much of the dental care he received.

Another causative factor in the deterioration of the treatment provided by the dentist was that the patient was unavailable to receive continuous care at regular intervals for extended periods of time, which very likely had a negative impact on his dental health. Repeated instances of procrastination may have also exacerbated his injuries. The patient repeatedly refused to have a removable prosthetic or implants, and he clearly failed to comprehend that a satisfactory result was not possible due to the treatment decisions he was making. Again, it may have been in the patient’s best interests to have received only temporizing treatment until the completion of his cancer therapy when the ability to heal quickly was more likely.

Documentation was lacking as to the risks the dentist should have disclosed to the patient from his persistent delays in receiving cleanings, periodontal probing, root canals and implants. The patient’s financial constraints may have played a role in his decision-making and procrastination, but there is nothing in the record that addressed the likely impact of his poor choices and repeated refusals on his overall dental health. The dentist went along with appeasing the patient for years without addressing the patient’s unreasonable expectations of a favorable outcome.

The dentist and the patient displayed a great deal of patience with one another. The dentist empathized that the patient needed to place dental treatment on hold while confronting a serious medical condition. The patient entrusted the dentist for an extended time frame despite the numerous disappointments and failures of treatment received. The combination of these two individuals’ interactions produced significant issues for both parties.

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