Failure to Evaluate or Refer Patient Allegedly Results in Delayed Oral Cancer Diagnosis and Treatment
Claim Case Study
Practitioner: Insured general practitioner dentist (GP) and a periodontist
Claimant: 50-year-old male patient, reportedly a light drinker with no tobacco use history, no significant medication history
Risk Management Topics: Patient assessment, oral cancer screening/examination, documentation
Facts:
A 50-year-old male patient presented to the GP’s office for urgent care complaining of pain. He reported no significant medical conditions or medications but noted he hadn’t had a physical in four or five years.
A limited exam revealed deep decay under a restoration on the mandibular left side on tooth 19. The GP discussed treatment options, and the patient chose to save the tooth. The GP referred him to an endodontist due to the complexity of the case. The endodontist completed the root canal therapy (RCT) without incident.
Two weeks later, the patient scheduled a comprehensive exam and radiographs with the GP. However, after the radiographs were completed, he rescheduled the examination due to a work emergency. The comprehensive examination was then completed about five weeks after the initial visit.
Over the next year, the patient received restorative care and was referred to a periodontist for periodontal issues in the mandibular right quadrant. Treatment and follow-up spanned approximately three months, followed by alternating hygiene visits at both offices every three months for preventive care and to monitor his response to periodontal treatment.
Just before his one-year recall visit with the GP, the patient rescheduled due to a family matter. The new appointment was set to take place approximately 15 months after the initial urgent care visit.
Shortly before the rescheduled recall visit, the patient consulted an ENT physician for throat pain. While the throat exam was within normal limits, the patient mentioned a persistent sore on the left side of his tongue, which he stated had been present for over a year. The ENT, though not alarmed by its appearance, recommended a biopsy due to its duration. The patient initially declined the biopsy referral to an oral surgeon and took no immediate action.
At the rescheduled GP visit, the patient mentioned the ENT consultation. The GP examined the lesion and agreed with the biopsy recommendation. After further discussion, the patient consented.
At the initial visit, the oral surgeon suspected trauma but proceeded with the biopsy due to the lesion’s persistence.
The biopsy confirmed a diagnosis of squamous cell carcinoma, and the patient was referred to a head and neck cancer specialist. Treatment included hemi-glossectomy with neck dissection (three positive lymph nodes), chemotherapy and radiation. The final diagnosis was stage IVa squamous cell carcinoma.
Following treatment, the patient filed a lawsuit against both the GP and the periodontist, alleging failure to diagnose or refer for oral cancer over the course of more than a year while under their care.
Key Allegations:
Inadequate cancer screening and examination, failure to diagnose or refer for further evaluation, delayed diagnosis leading to advanced cancer and more aggressive treatment
Alleged Injury/Damages:
Progression of cancer leading to extensive and aggressive treatment, surgical disfigurement, physical and emotional pain and suffering, medical expenses and loss of wages. Initial demand: $600,000.
Analysis:
The patient (plaintiff) alleged that, despite multiple visits to both the GP and the periodontist, neither practitioner identified nor addressed the tongue lesion. He claimed to have informed the GP about the sore during the comprehensive exam. Although unsure if he mentioned it to the periodontist, the lawsuit emphasized that a full periodontal exam was performed before proceeding with recommended treatment. Interestingly, the endodontist was not named in the lawsuit.
Defense experts reviewing the GP’s records noted a lack of documentation regarding oral cancer screening or any mention of tongue pain. While it’s possible the lesion wasn’t present during the comprehensive exam, the absence of documentation weakened the defense. Without a record of screening, the plaintiff’s claim that it didn’t occur gained credibility.
Subsequent GP restorative visits also lacked mention of the lesion or patient complaints. Hygiene notes from both offices did reference oral cancer screenings. The first hygiene visit post-periodontal treatment (at the periodontist’s office) documented the tongue sore but recommended no action. Three months later, the GP’s hygiene notes stated the exam was “within normal limits” — a finding inconsistent with the ENT’s referral for biopsy shortly thereafter. Given these findings, inconsistencies and documentation gaps, the defense team recommended pursuing settlement before proceeding with additional discovery.
Outcome:
The periodontist settled separately for an undisclosed amount. The total incurred (settlement plus claim expenses) for the GP was $250,000. The patient survived and was cancer-free at settlement.
Risk management comments and resources:
This case highlights the critical importance of comprehensive documentation and consistent oral cancer screening practices. Several key points emerge:
1. Document All Screenings Clearly
Even if a screening is performed, failure to document it can be interpreted as failure to perform. Notations such as “oral cancer screening” alone are insufficient. Include details of the findings—whether normal or abnormal. This critical part of any examination (oral cancer, radiographic, periodontal, etc.) is very often missing from dental records.
2. Document Methods and Consider Standardized Terminology
Many dental offices use oral cancer screening adjunct technologies as part of their examination process. Use of such devices should be documented. However, use of an adjunct screening device alone does not comply with current clinical guideline recommendations. The ADA 2017 clinical guidelines recommend an intraoral and extraoral conventional visual and tactile examination (CVTE) be performed for all adult patients during evaluation for potentially malignant disorders. Incorporating this terminology into records can help standardize documentation and support defensibility.
3. Follow Up on Patient Complaints
Persistent lesions, even if they appear benign, warrant follow-up or referral. In this case, the lesion’s duration should have triggered earlier concern and action.
4. Coordinate Across Providers
When patients receive care from multiple providers, communication and documentation consistency are essential. Discrepancies may result in oversights that impact patient care and safety, as well as undermine defense efforts in the event of a claim.
5. Educate Staff on Documentation Standards
Ensure that all team members understand the importance of documenting findings and recommendations accurately and thoroughly.
Consider accessing and reviewing current clinical guidelines and additional information available at the following websites:
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Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM
CNA Dental Risk Control
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Dentist's Advantage is a division of Affinity Insurance Services, Inc., a licensed producer in all states; (TX 13695); (AR 100106022); in CA & MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency. Published 12/2025.