Complex Dental Care in a High-Risk Patient Results in Mandibular Fractures and Malpractice Allegations
Claim Case Study
Practitioner: General dentist
Claimant: 70-year-old female patient with a history of obesity, smoking, alcohol use and osteoporosis on oral alendronate.
Risk Management Topics: Patient assessment and selection, informed consent, patient management, and documentation.
Facts:
A 70-year-old female patient presented with a complex medical and dental history. She had been diagnosed with osteoporosis many years before and was undergoing alendronate therapy for the past five years. However, this part of her medical history was not disclosed to the dentist. Her medical history also included chronic smoking, regular alcohol use, and obesity.
The patient sought dental restorative care to improve her oral function and quality of life. During the initial dental assessment, it was noted that the patient’s maxillary dentition was intact up to the first molar bilaterally with moderate bone loss, but she exhibited severe mandibular bone loss with only four remaining teeth. The mandibular condition along with the patient’s medical history collectively contributed to an increased risk for dental complications.
Following his assessment, the dentist proposed mandibular extractions followed by the placement of an implant-retained overdenture. The treatment plan involved extracting the remaining mandibular teeth and placing four dental implants before fabrication of the overdenture. The patient agreed with the plan and treatment proceeded.
Unfortunately, the treatment did not progress as smoothly as anticipated. A few weeks after the extractions and implant placement, two of the four implants failed due to infection, necessitating their removal and replacement. Shortly after replacement of the failed implants, the patient suffered a mandibular fracture.
The fracture required surgical intervention for repair with the use of stabilizing plates and internal fixation. The oral surgeon stated in his deposition that he suspected the fracture resulted from implant placement in an atrophic mandible, which defense experts later questioned.
Despite the fracture, the dentist decided to place another implant soon after the repair. This decision proved to be detrimental, as it led to a second mandibular fracture. Experts later reviewed the case and agreed that placing another implant so soon after the fracture repair was ill-advised. The timing and fracture location supported that implant placement directly caused the second fracture. This fracture also required internal fixation.
Key Allegations:
Negligent implant placement; inadequate informed consent regarding risks, treatment options and specialty care; delayed fracture diagnosis resulting in nerve injury.
Alleged Injury/Damages:
Mandibular fractures, permanent nerve injury, related future medical expenses, pain and suffering, mental anguish.
Analysis:
As discovery for the lawsuit proceeded, two defense experts reviewed the dentist’s records as well as records from two subsequent treating dentists. Their analysis questioned the overall treatment plan, opining that the patient was a poor candidate for such an aggressive approach due to her medical history and compromised bone health.
From a defense perspective, the patient did not disclose her full medical history, including her osteoporosis and alendronate treatment. Although osteoporosis and alendronate therapy would not necessarily contraindicate implant placement, experts agreed that medical consultation would have been appropriate prior to treatment. Further medical information would have allowed the dentist to better gauge the treatment benefits and risks, given the patient’s history of smoking, alcohol use and obesity.
Regarding consent, discovery revealed that there was no written treatment plan or informed consent form or documented discussion. The dentist maintained that discussing a treatment plan and the benefits, risks and treatment alternatives with patients are his custom and practice. Even so, without adequate documentation of these processes, the experts opined that they would not be able to state that the standard of care was met.
The treating dentist failed to consult with the oral surgeon who treated the mandibular fractures, and, therefore, the timing and placement of the implant that allegedly caused the second fracture could not be supported. Additionally, based on the patient’s deposition and the lack of documentation regarding the patient’s left side chin and lip numbness complaints, experts believed that discovery of the second mandibular fracture was delayed by more than two months. The lack of documentation and imaging would limit defensibility related to the nerve injury allegation.
This case underscores the importance of comprehensive patient assessment, especially in individuals with complex medical histories. It highlights the need for:
- Thorough Risk Assessment: Understanding the patient's overall health and the potential impact on dental treatment outcomes.
- Informed Consent: Ensuring that patients are fully informed about the risks and benefits of the proposed treatment, with documented evidence of these discussions.
- Conservative Treatment Planning: Considering less aggressive treatment options for high-risk patients to minimize complications.
- Detailed Documentation: Maintaining clear, detailed, and accurate patient records to support clinical decisions and enhance communication with patients and among the dental team.
- Interdisciplinary Collaboration: Consulting with medical professionals, such as the patient's primary care physician or specialist, to ensure an integrated approach to patient care.
This case emphasizes the need for careful consideration of patient-specific factors, thorough documentation, and effective communication to ensure optimal outcomes and minimize the risk of complications. By adhering to these principles, dental practitioners can enhance patient safety and improve the quality of care provided.
Outcome:
The case ultimately settled with a total incurred cost (indemnity plus claim expenses) of $375,000.
Additional information:
Although this patient’s history of bisphosphonate use did not result in medication-related osteonecrosis of the jaw (MRONJ), readers may be interested in additional information for review.
Here are some key considerations and resources:
- Alendronate, a bisphosphonate, and certain other antiresorptive agents have been associated with MRONJ, a rare but serious condition that involves the death of jawbone tissue and can be triggered by invasive dental procedures like implants.
- Bisphosphonates like alendronate can impair the integration of dental implants into the jawbone. This is due to their effect on bone metabolism, which can reduce the bone's ability to heal and integrate with the implants.
- At 70 years old, the patient's bone density and healing capacity may be naturally reduced, which can further complicate implant success.
- Long-term use of alendronate or other antiresorptive medications may increase the risk of complications. Patients who have been on bisphosphonates for more than two years are at higher risk for MRONJ.
Resources:
________
Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM
CNA Dental Risk Control
________
Disclaimer.
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions, and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. “CNA" is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the "CNA" trademark in connection with insurance underwriting and claims activities. Copyright © 2025 CNA. All rights reserved. Any references to non-CNA websites are provided solely for convenience and CNA disclaims any responsibility with respect thereto. Published 01/2026.