This case study on dental patient management was originally printed in our First Quarter 2023 issue of The Scope: Dental Edition. Read more articles from the publication here. For an overview of high-severity dental liability, read our recent blog.

A disabled 55-year-old female with a history of fibromuscular dysplasia and a subarachnoid hemorrhage from a congenital parietal aneurysm two years earlier was referred to the insured oral surgeon for tooth restoration. She was missing several teeth and then had teeth #3 and #4 extracted with bone grafting facilitated by IV sedation. Notably, there was no signed informed consent form for these extractions.

The patient returned 6 months later to discuss dental implants. It was noted that the patient had a persistently elevated white blood count (WBC) for a month prior to the scheduled implant procedure. Although the oral surgeon and a witness signed the consent form for implants with IV sedation, the patient did not. In addition, the oral surgeon did not obtain medical clearance prior to placing implants at teeth #3, #4, #5, #6, #19, #20 and #21. He gave the patient IV antibiotics and believed her when she assured him she had amoxicillin at home and would take it for the next seven days.

On the first postoperative day, the oral surgeon called the patient who reported that she was taking vitamin B-12 to “treat an elevated WBC count.” On the second postoperative day, the patient called the insured’s office with complaints of constipation. She was advised to stop taking oxycodone. Her spouse reported that the patient exhibited signs of confusion but refused medical intervention. It was at this time that the insured wrote addenda to the patient’s chart to document her post-implant course.

Later that night, the patient fell at home and became unresponsive. Emergency medical services were delayed due to winter weather conditions and unable to intubate the unresponsive patient when they arrived. Aggressive resuscitative efforts continued at the hospital but failed, and the patient was pronounced dead.

Laboratory results indicated a Group A streptococcal infection and a WBC of 20,000. The patient’s spouse declined an autopsy, and there was no definitive cause of death. The spouse reported to the oral surgeon that his wife died of a myocardial infarction secondary to sepsis. An infectious disease expert who reviewed the case concluded that the patient did die from sepsis. An internal medicine expert contended that the patient died from Call-Fleming syndrome, a reversible segmental vasoconstriction of cerebral arteries. The oral surgeon was criticized for failing to obtain a complete patient history, not taking into account her cognitive deficits and treating the patient more like a professional colleague than someone with a history of a ruptured cerebral aneurysm.

Due to multiple weaknesses in the case and defense costs that escalated to $164,000, the suit was settled on behalf of the insured oral surgeon for $600,000.

A Legal & Risk Management Analysis

This case represents significant problems with the dentist’s management of the patient’s treatment.

The first issue was the lack of informed consent. Not only was the patient’s mental capacity to consent to treatment an issue, but she also never actually signed the consent form. Incredibly, both the dentist and an assistant signed the form, which stated that they had witnessed her signature and consent when, in fact, she had never given informed consent nor signed the form. Pre-signing the consent form implies that informed consent, which is a discussion of the procedures’ risks, benefits, alternatives and the risks of these alternatives, never actually took place. The obvious conclusion to be drawn is that there was no informed consent at all.

As previously noted, due to the patient’s underlying medical conditions affecting her mental capacity, it is questionable whether she had the requisite legal capacity to provide consent or the ability to comprehend the attendant risks of the procedures she was to undergo. The dentist should have had doubts about the patient’s capacity, especially since he was familiar with how the patient had previously reacted in various situations, and when the dentist called the patient and learned she was acting confused, he should have urged the patient’s spouse to take rapid and definitive action before she collapsed.

In this case, the dentist did not appropriately investigate the patient’s capacity to comprehend that an undesirable outcome could result unless certain essential steps were taken. This patient clearly lacked the understanding she needed to transfer to a more skilled provider with the necessary training and expertise. The dentist may have also failed to appreciate the severity of the patient’s elevated WBC as indicative of the need for immediate intervention by a medical professional.

This case’s devastating outcome exemplifies the potentially dire consequences of erroneously assuming that no complications will result from the care, treatment and dental patient management rendered by a provider.

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