A Severe Infection Is Missed
Repurposed from The Scope, Dental Edition, Third Quarter, 2024
Initial Treatment
An 18-year-old female presented to a dental office with complaints of extreme pain at tooth #31. A periapical x-ray showed no infection. Root canal therapy (RCT) was indicated and started that same day by a general dentist in the office but was not completed.
The patient returned three days later to be seen for the first time by the MLMIC-insured dentist. She complained of swelling and pain in tooth #31. This dentist’s examination notes documented that the tooth was positive to percussion, and the dentist prescribed antibiotics and pain medication.
Two days after the patient was examined for her initial complaints, she presented to the office and was again seen by the insured dentist. At this visit, it was noted that the swelling at tooth #31 remained, and the patient now had limited ability to open her mouth. The insured dentist immediately referred her to an oral surgeon, whose office was an hour away from the dentist’s office.
Patient Hospitalized
The oral surgeon immediately sent the patient to the emergency department (ED), where it was noted that the submandibular region was tender bilaterally. A CT scan confirmed an infection, with cellulitis of the mandibular bone laterally, the submandibular area bilaterally and the submental area. As a result, the patient underwent an emergency incision and drainage with extraction of tooth #31. An extraoral incision was done, and a Penrose drain was placed. The patient was intubated, a nasogastric tube was inserted and IV antibiotics were started.
Two days later, the patient had increased swelling, redness and pain in the left side of her neck. A repeat CT scan showed an abscess that tracked from the submental region to the left upper neck. She was returned to surgery and underwent not only a tracheostomy but also an incision and drainage of the left side of her neck and a submental abscess. The patient was hospitalized for 12 days.
Upon discharge, the patient experienced kidney dysfunction, which subsequently cleared up and was left with three scars under her chin and two on her neck.
Lawsuit Filed
The patient filed a lawsuit naming the first dentist, the MLMIC-insured treating dentist and the practice, alleging that the insured dentist failed to appreciate the severity of the infection, which should have resulted in an immediate referral of the patient to a local oral surgeon or ED.
The patient’s mother testified that she had called the dentist’s office the day after the RCT began, stating that her daughter had a fever and increased swelling. She also informed the staff that the dentist had recommended the patient allow the antibiotics 48 hours to work. The office staff testified that they assumed that the insured dentist had made this recommendation and, therefore, also advised her to give the antibiotics more time, but the dentist denied making such a statement. There was no record of this telephone call by the patient’s mother.
The patient was greatly embarrassed by the surgical scars resulting from her treatment, which she now attempts to cover. In addition, due to her hospitalization and subsequent events, the patient also missed her first semester at college.
Expert Review and Settlement
Our experts all opined that the dentist deviated from the standard of care by failing to open tooth #31, reinstrument the tooth, and look for pus. There could have been a further deviation if it were believed that the dentist failed to advise the patient to contact the office immediately for reevaluation or go to the ED if her complaints got worse. By the time the insured dentist last saw the patient, she was in dire need of hospitalization, and the dentist should have sent her to the ED directly from his office.
The settlement demand was $1.5 million, and the case was settled on behalf of the MLMIC-insured dentist within policy limits. The first dentist and the practice were not insured by MLMIC but also contributed to the settlement.
A Legal and Risk Management Analysis
While only 4% of those who present to the ED with dental-related complaints are admitted, a dental infection diagnosis with diseases of the pulp and periapical tissue make up 85% of these admissions.1
To achieve the best outcomes, timely follow-up and expeditious referrals are the best approach for the definitive management of advanced dental infections. When they are recognized and treated early, a good prognosis is often achieved. However, any delay in essential aggressive treatment could lead to an extensive infection and numerous complications that may include severe sepsis, septic shock, bacteremia, osteomyelitis, deep neck space infections, mediastinitis, endocarditis and/or meningitis.2
Complicated dental infections require expedited consultation with an oral surgeon or endodontist for definitive treatment, and serious complications due to extensive delays in treatment may require hospital admissions for medical as well as surgical management.3
After treatment, written instructions should be provided on how to recognize complications and to immediately contact one’s provider should they develop.
Finally, as always, comprehensive documentation to reflect appropriate assessment, diagnosis, treatment and referrals will assist in the defensibility of all malpractice lawsuits.
MLMIC policyholders can reach out to our healthcare attorneys for questions about documentation, discharge instructions or other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.
Our 24/7 hotline is also available for urgent matters after hours at (877) 426-9555 or by emailing hotline@tmglawny.com.
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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.
Sources
- Owens PL, Manski RJ, Weiss AJ. “Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet].” Agency for Healthcare Research and Quality (US); Rockville (MD): Aug 19, 2021. “Emergency Department Visits Involving Dental Conditions,” 2018.
- Erazo D, Brizuela M, Whetstone DR. “StatPearls [Internet].” StatPearls Publishing; Treasure Island (FL): Nov 13, 2023. Dental Infections.
- National Center for Biotechnology Information. “Dental Emergencies.” StatPearls, 2022, https://www.ncbi.nlm.nih.gov/books/NBK589664/ (last visited July 24, 2024).
