December 2015

How Misdiagnoses Can Result in Inappropriate Treatment

Mario Catalano, DDS, MAGD

In the practice of dentistry, proper treatment depends on accurate diagnosis. This is only possible when all necessary information is gathered and properly evaluated. Let's consider how a young dentist failed to consider all possible causes of a patient's pain, which resulted in misdiagnosis and inappropriate treatment.

Case to Consider: An 82-year-old female patient presented to Dr. Carter, a recent dental school graduate. The patient was complaining of pain in tooth number 19. The tooth had a large restoration and was tender to touch, including when the buccal gingiva and mucosa were palpated. An X-ray was taken and the large restoration was noted. The periapical portion of the X-ray didn't demonstrate any obvious pathology. Because the tooth also was sensitive to percussion, Dr. Carter concluded that an inflammatory process was likely causing the patient's symptoms. He prescribed antibiotics, pain medication, and he told the patient to return if the pain didn't subside.

About a week later, the patient returned because she was still in pain. Dr. Carter performed another clinical exam and took another X-ray. After the clinical exam and X-ray, Dr. Carter noted no additional findings. Dr. Carter put the patient on a broad-spectrum antibiotic and told her to return if the medication didn't alleviate her symptoms.

Approximately five days later, the patient returned and complained that the pain was worse than ever. Dr. Carter suggested that the next step would be root canal therapy. However, the patient said that she couldn't afford that procedure. Instead, she opted to have the tooth extracted that very same day.

When the patient returned a week later for the removal of her sutures, Dr. Carter was surprised to find that she still had some pain around tooth number 19, and she was beginning to have discomfort in the area of tooth number 14. In response, Dr. Carter prescribed an anti-inflammatory medication and instructed the patient to return within ten days for a follow-up evaluation.

After four days on the anti-inflammatory medication, the patient's pain continued to increase, so she returned to Dr. Carter's office. Dr. Carter noted that the patient was now experiencing more pain in the area of tooth number 14. He also noted that the symptoms were similar to what she had experienced with tooth number 19, and the X-ray also was inconclusive. Thinking that tooth number 14 might have been the problem all along, Dr. Carter prescribed antibiotics and pain medication and advised the patient to return in a week.

When the patient returned, she indicated a slight improvement in her symptoms, but stated that she was still uncomfortable. She insisted that Dr. Carter do something to help relieve her pain immediately. After further conversation, they concluded that the preferred course of treatment was the extraction of tooth number 14, which was done that day.

Even after the removal of tooth number 14, the patient was still in pain. So, instead of returning to Dr. Carter, she had her sutures removed by Dr. Hammond, another general dentist recommended by a family member.

In addition to removing the sutures, Dr. Hammond completely reviewed the patient's dental history, performed a clinical examination, and acquired a panoramic X-ray. While taking the patient's dental history, Dr. Hammond discovered that the patient had fallen about three months earlier, striking the left side of her face on the pavement.

After Dr. Hammond evaluated all of the patient's information, she concluded that severe spasms of the masseter and temporalis muscles, as well as other muscles of mastication, were the likely cause of the patient's pain. Dr. Hammond prescribed muscle relaxants, anti-inflammatory medication, and the application of moist, warm heat. After ten days of this therapy, the patient reported significant improvement in her symptoms. After thirty days of continuous treatment, she was symptom-free.

The patient sued Dr. Carter for negligent diagnosis and treatment that resulted in pain, suffering, and the unnecessary extraction of two teeth. This case was settled in the midrange (between $20,000 and $50,000).

 

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A Lesson in Risk Management

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

Using hindsight and risk tools, we can identify some practices Dr. Carter might have done differently in order to avoid inappropriate treatment.

1. Patient's Full History: The importance of a complete and accurate medical and dental history cannot be overemphasized. Unfortunately, in many dental practices, the completed history form receives a cursory review by the dentist – if nothing "jumps out," the dentist might proceed with examination and treatment.

The approach that emergency physicians use to gather medical history is a useful benchmark. Emergency physicians typically use general questions to start collecting a patient's history. If an affirmative response is received, the physician will ask increasingly specific questions until he or she can determine whether the information is significant. For example, if a patient has chest pain, it is common to inquire whether he or she has experienced any trauma to the chest in the recent past. The physician would ask this question regardless of whether the patient has any indication of physical injury to the chest. The question is simply part of the elimination process.

In this case, when Dr. Hammond inquired about any history of trauma, she received a positive response that led to the correct diagnosis. She asked this question even though the patient had no visible indication of any trauma on her face or inside of her mouth. This is critical because delayed symptoms of trauma often are subtle in their presentation.

2. Follow-up Evaluation: When a dentist's prescribed treatment doesn't produce the expected result, it is important to step back and ask why. When the patient had no improvement with the broad-spectrum antibiotic, Dr. Carter would have been wise to stop and review all available information before proceeding with treatment that was irreversible (such as root canal therapy or extraction). It's a risk to proceed with irreversible treatment without being confident about the source of the pain.

If Dr. Carter couldn't identify the source of the patient's pain, it would have been best to refer the patient to an appropriate specialist — particularly in relation to tooth number 14, since tooth number 19 had already been extracted with little improvement in the patient's condition. Ultimately, proceeding to irreversible treatment without a clear and appropriate diagnosis resulted in a poor outcome for the patient and a malpractice suit that was difficult to defend.

Key Takeaway

When a patient's treatment is not progressing as expected, you should proceed slowly and carefully. You should consider all available information from the medical and dental history, test results, and the clinical examination. In the face of uncertainty, consider a consultation or referral to ensure the patient receives the most appropriate diagnosis and care. The use of a consultant is not a sign of weakness or inadequacy. Rather, it is an indication of a savvy practitioner with the patient's best interest at heart.

Question to Consider

How should you explain to a patient that treatment is not producing the expected/desired result?