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February 2015

Complications Following Extraction Cause Severe Infection and Hospitalization

Mario Catalano, DDS, MAGD

Background: Although unfortunate, part of practicing dentistry is dealing with the occasional adverse event (that is, a negative, unexpected result from treatment). Sometimes adverse events happen without explanation; other times, they are due — at least in part — to patient noncompliance with the dentist's instructions. In this interesting case, an adverse event occurred as a result of the patient's noncompliance and the doctor's alleged failure to follow-up with the patient in a timely manner.

Case discussion: The patient was a 27-year-old female who had a partially erupted molar (tooth number 32). At the time the patient was evaluated, she was asymptomatic. However, her regular dentist thought that the tooth would cause periodontal problems in the future, so he referred her to Dr. G (an associate in the four-doctor, fee-for-service practice) for further evaluation.

After examining the patient, Dr. G agreed with her colleague's assessment and recommended extracting the tooth. She offered the patient the option of having an oral and maxillofacial surgeon (OMS) perform the extraction; however, the patient was comfortable with Dr. G doing the procedure. Appropriate informed consent to treatment was completed, and the patient was scheduled for the procedure on a Friday.

On the day of the procedure, the extraction proceeded without incident. Once the procedure was completed, the patient was given appropriate pain medication and aftercare instructions. Over the weekend, the patient began to develop pain and swelling, even with the application of ice. She did not contact the on-call doctor, but she did call the office the following Monday and was seen later that day.

Examination showed that swelling was minimal, so Dr. G gave the patient a prescription for cephalexin, with instructions to fill and begin taking it if the swelling increased. The patient also was scheduled for reevaluation the following Friday. The practice did not hear from the patient further until the Friday appointment, which she kept as scheduled.

At that time, the patient presented with significant swelling, resulting from an obvious infection. Dr. G performed an incision and drainage, which was beneficial to a limited extent only. When Dr. G asked the patient whether she had taken the antibiotic that was prescribed, the patient indicated that she had not. Dr. G told the patient to start the antibiotic that day and also gave the patient an additional prescription for clindamycin.

The patient went home from the appointment, and her condition continued to worsen; however, she did not contact the practice. On Saturday, she was in severe distress and went to a local emergency department, where she was admitted and put on further antibiotic therapy. Her condition worsened to the point that she needed a tracheostomy and ventilator support for several days. She eventually recovered fully.

The patient filed suit against Dr. G and the practice, alleging failure to timely diagnose and treat the infection. After 2 years of litigation, the case was settled in the low range.

 


 

Risk Management Considerations

Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

The expert who reviewed this case felt that the poor outcome was a result of patient noncompliance combined with some aspects of treatment that could have been better handled.

Patient noncompliance occurs for many reasons; in this case, possible explanations include a misunderstanding of the doctor's instructions (even though written aftercare instructions were provided), a reluctance to take antibiotics, or possibly even taking advice from a healthcare provider not involved in the case (e.g., a family member or acquaintance).

No one expects a dentist to play "brother's keeper"; however, a wise dentist should always (a) emphasize to the patient the importance of complying with the treatment plan, and (b) be quick to consider noncompliance when a case is not progressing as expected.

When Dr. G first evaluated the patient and recommended an extraction, she offered the patient the option of having an OMS perform the procedure. Although some may interpret this as lack of confidence on the part of the dentist, providing treatment options is good practice. It can help the patient feel like a meaningful participant in his/her care, and it may increase confidence in the chosen provider.

The fact that the procedure was done on a Friday also is noteworthy. Although Friday procedures are certainly appropriate, providers should recognize that procedures done on Fridays include an inherently elevated amount of risk. This is because the practice typically will lose contact with the patient over the weekend. Many patients do not wish to "bother" the on-call dentist unless they are in severe distress. When patients can simply call the practice and speak to the receptionist or another office person about their concerns (as they can during the week), a deteriorating condition may have less opportunity to progress into a major problem. Calling to follow-up with a patient after a significant procedure is probably more important after Friday procedures than at any other time.

The expert for this case also was concerned about two additional aspects of the care the patient received. First, Dr. G's instructions to the patient were to fill and begin taking the cephalexin if the swelling increased. In effect, this required the patient to make a clinical judgment about when to initiate antibiotic therapy.

Patients are obviously quite aware of how much pain they have, and they usually know when medication is needed. However, asking someone to judge whether swelling is increasing and/or abnormal probably exceeds the abilities of most patients. If the doctor was concerned about an infection developing, she should have had the patient begin the antibiotic therapy immediately after the procedure — or, alternatively, the doctor should have scheduled a follow-up appointment with the patient a couple of days after the procedure to assess the treatment site.

Finally, when it was clear that the incision and drainage might not produce the desired result, Dr. G should have evaluated or, at a minimum, talked to the patient within 24 hours. Doing so would have allowed the doctor to make a prompt assessment and refer the patient to an OMS or an emergency department if necessary. "Keeping a case" when it clearly appears to be heading in a bad direction can make the doctor's care very difficult to defend later in court.

Conclusion: In a perfect world, patients would always follow their doctors' instructions and quickly notify their providers if treatment is not progressing as planned. However, in our imperfect world, maintaining close contact with patients who have had significant procedures is important. Additionally, dentists should err on the side of caution when early indications suggest that the patient's care may not be progressing as expected.

Question: What techniques can dentists use to improve patient compliance with aftercare instructions?

 

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