June 2014

Patient Disregards Dentist’s Recommendations, Resulting in Suboptimal Outcome

Mario Catalano, DDS, MAGD

Background: This edition of Malpractice Minute discusses a case in which an inexperienced dentist allows a patient to talk him into performing a procedure that may not have been the best treatment option.

Case discussion:  The patient presented to Dr. G with a chief complaint of discomfort in the left mandible. The patient’s history indicated that she had not seen a dentist in 4 years, was diabetic, and was significantly dental phobic. The patient had previously been treated for periodontal disease and was missing tooth number 30.

The patient also had a large composite restoration on tooth number 19, and a radiograph indicated subgingival recurrent caries of the distal surface and periapical pathology. The patient was prescribed an antibiotic, pain medication, and premedication for anxiety in anticipation of her next appointment, which would include a complete set of radiographs, a comprehensive exam, and treatment planning.

At the next appointment, Dr. G performed a thorough exam and developed a treatment plan that included the removal of tooth number 19 (due to the extensive caries and the probability of a prosthetic failure if the doctor attempted to restore the tooth). In addition, Dr. G recommended a fixed prosthesis for teeth 29–31, four additional restorations, and root planing.

When the patient received the recommendation to remove tooth number 19, she became very agitated and insisted that the doctor restore the tooth. She explained that she had had a “terrible experience” with the previous removal of tooth number 30. After further conversation with the patient, the doctor (who had limited experience handling severely phobic patients) agreed to attempt a root canal procedure and a crown.

The patient presented as scheduled for her endodontic therapy. After administering block anesthesia, Dr. G applied a rubber dam and began the procedure. However, within a few minutes, the patient could not tolerate the rubber mask across her face, and the doctor removed it to complete the root canal procedure.

During the course of the root canal, the doctor observed significant calcification of the distal canal, which prevented him frominstrumenting the tooth to its apex. He placed medication in the access opening and covered the area with cotton and a temporary restoration. Two weeks later, the patient had reported no adverse reaction, and the doctor placed the root canal filling. However, because of the calcification, he was only able to negotiate the distal canal to within about 5 mm of the apex.

A month later, Dr. G placed the crown, but he had difficulty impressing his preparation because of the proximity of the margin of his preparation to the alveolar bone. Two weeks after that, Dr. G inserted the fixed bridge for teeth 29–31 and finished the restorations. At that point, the patient discontinued further treatment (before the root planing commenced).

About 9 months later, the patient began experiencing discomfort in the area of tooth number 19, and she called Dr. G’s office. It was a Friday afternoon, and the receptionist informed the patient that the doctor did not have office hours that day. She scheduledthepatient for the following Monday. About an hour later, the patient called the office again and informed the receptionist that if she wasn’t seen immediately, she was changing dentists.

Dr. G happened to be doing paperwork in the office that afternoon. When he was informed of the patient’s unhappiness, he took her call and discussed the problem with her. He offered to see her that afternoon — but, at that point, the patient was so agitated she hung up.

The patient then called the oral and maxillofacial surgeon who had removed tooth number 30 and her third molars. She explained the problem to his receptionist, who scheduled her immediately. The surgeon took a panoramic radiograph and diagnosed a significantperiapical infection and cellulitis around tooth number 19.

The surgeon drained the area, and explained to the patient that she required an extraction of tooth number 19. This, he explained, was due to the underfilled distal root(which resulted in a significant infection and bone loss around the distal root) and recurrent decay around the distal margin of the crown (which was decayed below the alveolar crest). The tooth was extracted a week later, followed by immediate placement of a root form implant.

Because the patient was displeased with the results of the root canal procedure and felt that Dr. G had initially put off seeing her when she called, she consulted with an attorney and ultimately sued Dr. G for malpractice. With the doctor’s consent, the case was settled in the midrange.

 

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Risk Management Considerations

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

This case resulted from two failures on the part of Dr. G: (1) the failure to properly assess and manage this patient, and (2) the failure to recognize and deal with a clinical case that may have exceeded his capabilities.

When they first met, the patient gave Dr. G cues that she was going to be, at best, a challenging patient. When he first proposed the removal of tooth number 19, she became very agitated — not a normal response to a proposal for a fairly routine (albeit not an enjoyable) procedure. As such, it would have been wise for Dr. G to immediately inquire about what made the extraction of tooth number 30 such a “terrible experience.”

Although we can only speculate about what her answer would have been, Dr. G might have been able to identify whether some sort of untoward event occurred during the extraction, or whether her impression was simply a manifestation of her dental phobia. Finding that the extraction had been performed locally, he could have called the oral and maxillofacial surgeon who performed the extraction to see whether anything unusual had occurred and to determine the surgeon’s “take” on this patient.

Many patients are dental phobic, and dentists generally become quite adept at handling them. Frequently, this takes the form of pharmacologic intervention, which Dr. G utilized in this case. Some patients, however, may actually suffer from some form ofgeneralizedanxiety disorder or other emotional disorder, which can further complicate treatment. That may have been the case in this situation. The mere mention of the extraction causing the patient to become very agitated, her intolerance of the dental dam, and her poor impulse control when speaking to the receptionist and Dr. G all may indicate a larger problem.

Although the premedication prior to the endodontic treatment was certainly appropriate, additional sedation once the procedure commenced was probably in order. If the patienthad been further sedated, she might have been tolerant of the dental dam, which would have eliminated the risk of a foreign object entering the oral cavity during the course of the endodontic treatment (a surprisingly common occurrence).

The final issue to consider is how the actual endodontic procedure was handled. When Dr. G encountered the calcification short of the root tip and was not able to fully accomplish the procedure, it may have been appropriate to abort the procedure and refer the patient to an endodontist. This is a clinical judgment that, of course, is easy to second-guess after the fact. However, it appears that if Dr. G had aborted the procedure and referred the patient to an endodontist, the infection and cellulitis could have been avoided, tooth number 19 may have been salvaged, and a malpractice suit might have been prevented.

Conclusion: Difficult patients are part of dental practice, and they can be challenging even under the best of circumstances. The combination of a difficult patient and a complex clinical case presents a situation that is exceptionally high risk for patient dissatisfaction and a poor clinical outcome.