A 61-year-old male patient, F, presented to a periodontist, Dr. P, on referral from his general dentist, for evaluation and potential placement of bilateral mandibular implants. The patient reported a benign medical history, but confided that he had not had a medical exam or laboratory studies in years; Dr. P encouraged her patient to have a medical exam as soon as possible, and F assured her that he would. After performing a clinical oral examination, which revealed that the patient was missing all lower molars, Dr. P had a panoramic radiograph taken. Review of the film demonstrated approximately 10-12 mm of mandibular bone superior to the inferior alveolar canals bilaterally, but Dr. P palpated a significant lingual concavity on the left side, so she thought that a CBCT would provide the best assessment of whether implant placement would be a viable treatment, and, if so, what types and sizes of implants could be employed. Because Dr. P did not have a CBCT machine in her office, and she did not feel comfortable interpreting those studies, she referred F to a radiology facility which had an oral and maxillofacial radiologist, Dr. R, on staff.
F made an appointment at the facility after Dr. P advised him that she had discussed the case with Dr. R. Dr. R was asked to evaluate for available mandibular bone so as to be able to place endosseous implants in the posterior regions, preferably 2 fixtures on each side. Dr. R read the study and advised Dr. P, in a written report, that there was adequate bone to place a 12 mm implant at the site where tooth #19 had previously been, and 10 mm fixtures at the sites where teeth # 18, 30 and 31 had been, all of standard (3.5-4.2 mm) diameter. The written report was messengered to Dr. P with the films, but Dr. P reviewed only the report and not the films. Four implants were uneventfully placed, they integrated with bone, and all were restored without complication approximately 9 months after the CBCT was completed.
About 6 weeks after that, F saw an internist, Dr. I, for a physical exam. F’s prostate felt rather hard to palpation, and his PSA was 8.9 ng/ml. Dr. I referred F to a urologist, who had F undergo a work-up, which revealed Stage IV adenocarcinoma with metastases to the left sphenoid bone. F casually mentioned to the urologist that he had a CBCT in preparation for dental implants, and nobody had said anything about any abnormalities in any bones of the head; F obtained those films and provided them to a radiologist recommended by the urologist, who concluded that there had been a suspicious lesion in the left sphenoid which extended into the sphenoid sinus, clearly visible on the CBCT. F opted against the multiple approach cancer therapies once he was told that his chances of survival were poor, given the tumor’s staging, and he passed away in under 2 years.
In his last months, F heard opinions from a number of people close to him that, if the CBCT had been properly read, the metastatic lesion would have been detected nearly a year before it was, which would have allowed him to be successfully treated. He spoke with an attorney, but did not have the willingness to get involved with litigation in his weakened state. However, his family members, as his estate, chose to sue for the pain he suffered before dying and for his premature death.
A lawsuit was begun, naming Dr. P and Dr. R as defendants, asserting dental malpractice against both of them for failing to adequately review and identify the metastatic sphenoid lesion, thereby causing F to be deprived of an opportunity to be successfully treated. Both dentists were provided with legal representation by their malpractice carrier, although separate attorneys were assigned because of the potential that the legal interests of the defendants might not be fully aligned.
Discovery and case resolution
During her deposition, Dr. P took the position that she was not skilled in interpreting CBCT studies, which was the exact reason that she did not maintain her own machine and review studies on her own; instead, as she did here, she always referred patients in need of pre-implant CBCTs to oral and maxillofacial radiologists, who were specifically trained for that purpose. She did not blame Dr. R, but simply persisted that she knew she was not capable of interpreting these studies.
Dr. R acknowledged at his deposition that there was, in fact, a radiographically visible lesion encompassing the sphenoid bone and adjacent sinus, but, at the time of initially reading the CBCT, he was focused solely on the issues surrounding implant placement, so he failed to see the mass which was some distance away from the area of his concentration. Realizing that Dr. R had essentially testified to his own negligence, his attorneys worked to disprove the causation prong of the estate’s claim, namely that a diagnosis a year earlier than it came would have given F a fair chance at survival.
To that end, Dr. R’s counsel retained an oncology expert, Dr. E, who was of the opinion that it was “unlikely” that an earlier diagnosis in this case would have made any difference in the potential for F to have survived, based upon the existence of a metastasis, the usual characteristics of malignancies of this type, and the specific histological features of the primary tumor. However, Dr. E advised the attorneys for Dr. R that other experts might legitimately disagree with him on this issue, as there are speculative and subjective aspects at play.
At trial, before Dr. E testified, Dr. R heard the testimony of the plaintiff’s expert on the issue of causation – that there would have been a real chance for curative treatment, or at least treatment which would have meaningfully extended F’s life, if the lesion had been timely detected on the CBCT – and found it to be compelling and believable, raising a concern that the jury could find against him for more than his policy limits. With his authority, his attorneys negotiated a settlement with the plaintiff’s attorney. Upon reaching that agreement, the case against Dr. P was discontinued, with the plaintiff’s attorney privately acknowledging that it would have been difficult to prove a case against her, given her referral to a specialist regarding an issue about which she openly recognized her own lack of expertise.
One of the overriding concepts addressed by this case study is that the teeth, jaws, and oral cavity as a whole lie close to “non-dental” areas of the body, so conditions related to those other areas may affect that which dentists do. And physiologic or anatomic problems in even distant locations may also have an impact upon areas treated by dentists. So, dentists best serve their patients by maintaining a sense of awareness of the construct that, colloquially speaking, “the teeth are connected to the body”, and vice versa, and with that comes a patient responsibility that extends beyond the teeth, jaws, and oral tissues.
In this case, Dr. P recognized where she had expertise and where she did not, and based upon the latter, made an appropriate referral to a specialist whose proficiencies would be able to fill in the open gap. As we see it, that was the prudent course of action for her to have taken, and that bore out positively for her in this litigation. But that should not be presumed to mean that every referral will eliminate liability in every situation, because all circumstances are fact-based and individual.
What was avoided in this case was jousting – or the “throwing under the bus” – against Dr. R by Dr. P. Unfortunately, one dentist blaming another and voicing that to patients, is far from uncommon and it is a frequent act that leads patients to engage in litigation when results are not what were expected. Here, Dr. P was able to protect her own position without criticizing the actions of Dr. R; doing so meant taking ownership of her own limitations, and that level of professionalism was apparently not lost on the plaintiff’s attorney.
While Dr. P did not know, and could not have known, at the time that pushing her patient to obtain a medical exam would lead to her later being implicated in a malpractice suit, it was, nevertheless, exactly what was in the patient’s best interests. Had she not done so, F’s disease would likely not have been discovered until he became quite ill, so proof of the causation prong would have been far more difficult for the plaintiff’s attorney and expert to achieve, and would likely have stood as a bar to the case having been brought in the first place. But again, Dr. P upheld her ethical obligations, and that is always the proper approach, regardless of the outcome.
Dental and medical specialists exist to maximize the quality of patient care. General practitioners are not expected to be experts in every area of their profession, and even specialists, who may well have high levels of expertise in their limited fields, are not authorities on everything. So, appropriate referrals are always prudent and are hopefully appreciated by patients. Acknowledging limitations in knowledge or ability is not something to be ashamed of, but instead something to be embraced; doing so supports ethical principles which guide the practice of dentistry, benefits patient care, and lessens the likelihood of becoming a defendant in a dental malpractice lawsuit.
Finally, as we have noted in earlier case studies, a plaintiff must prove, through expert testimony, that not only was the defendant dentist negligent, but that such negligence directly caused the injuries complained of. Without expert proof of all of those elements, to the satisfaction of a judge and a jury, the defendant dentist will prevail. So, while Dr. R admitted to his own negligence, that alone was not determinative of the outcome: a causal connection between that negligence and the claimed injuries was required as well.
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