The patient/plaintiff in this case had a consultation with the defendant dentist on July 20th. The dentist recommended the patient have an extraction of teeth numbers 13 and 14, and replacing them with two dental implants along with healing and custom abutments. Although the estimated cost was going to be over $7,300, the patient agreed to the treatment plan. 

The patient returned on July 24th to proceed with the dental plan. On that day, the dentist extracted the patient’s teeth 13 and 14, and attempted to create a proper foundation of bone, bone substitute cartilage, and attach soft tissue to support the placement of two maxillary implants in the upper left quadrant sockets. At the time the dentist placed the implants, a synthetic bone graft material was placed around the neck of both implants and on the adjacent bony ridge. 

On May 13th of the following year, the patient returned to the dentist for the completion of the dental treatment plan, which included the placement of prosthetic abutments to the implants. In order to support a provisional or temporary acrylic bridge, a metal bar was used by the dentist to hold it in place. During this procedure, the dentist had trouble placing or removing the prosthetic abutment from plant number 13. In the process of making these adjustments, the dentist damaged the inner thread of the implant.

Due to the dentist’s negligence in failing to take a model of the patient’s teeth to evaluate the possibility of success from the same gingival point of view, and failure to properly place the implant without damaging the inner thread, the patient suffered from problems with her dental implants. These issues required the patient to undergo further treatment with other dental experts and caused her to experience ongoing pain. 

Defense experts were unable to support the actions of the defendant dentist in this case, and as a result, the case settled for an undisclosed amount. 

Controlling the risks associated with implants
Implant claims consistently involve a greater severity, or dollar value, than most other dental malpractice claims due to the expense of implants and the complex and expensive corrective remedies required to return the patient to his or her preoperative condition. The following recommendations are intended to help dentists manage the risks of implant claims. For more information, please refer to the Dentist’s Advantage and CNA Dental Risk Management Manual.

Clinical risks

• Do not place any implant fixtures unless you, the patient, and the restorative dentist have all agreed on the treatment plan. 
• Select for treatment only those cases that you believe have a good prognosis for long term success.
• Say “no” when an inappropriate candidate insists on having implants.
• Obtain appropriate radiographs and diagnostic models to properly assess the implant site(s).
• Review and understand information on nerve injury prevention and post-nerve injury management, especially for implant placement in the posterior mandible.
• Plan the implant restoration, then create a surgical stent to act as a guide during implant placement.
• Follow a sterile surgical technique during surgery, not simply a clean technique.
• Irrigate copiously during surgery to prevent overheating the bone, a cause of implant failure.
• Use antibiotics, when warranted, based upon your evaluation of the patient and the surgery itself.
• Select an implant size that is appropriate for the implant site and function.
• Place a barrier, such as gauze, in the posterior of the mouth to block dropped or mishandled items from falling back into the pharynx.
• Use high-speed suction with a filter over the tip to keep the patient from aspirating or swallowing hardware and to keep you from losing it.
• Be cautious when attempting to restore implants that have been placed at an incorrect or overly challenging angulation. The poorer prognosis for case success must be disclosed to the patient.
• Encourage patients to return for routine maintenance appointments even if implants and no natural teeth are present.

Communication

• Closely manage patient expectations throughout treatment. If expectations are unrealistic, do not accept the case.
• Ensure that the patient, implant surgeon, and restorative dentist communicate regularly both when planning and during the course of treatment.
• Have a comprehensive informed consent discussion with the patient.
• Discuss finances before beginning treatment. Once you begin treatment, you may be obligated to continue even in the absence of payment.

Documentation

• Thoroughly document treatment, including patient discussions, in the patient healthcare information record.
• Record all specific identifiers of the implant fixture, such as manufacturer, size, type, and lot number.
• Use a written informed consent form and write a thorough progress note reflecting the informed consent discussion. (Please refer to the Dental Office Forms page for access to sample forms on “Discussion and Consent for Implant Placement Surgery” and “Discussion and Consent for Implant Restoration.”)
• Retain models for full arch and difficult or complex cases at least until the statute of limitations in your state expires for that case. Also consult your state practice act regarding specific requirements for retaining dental casts/models.

Case study reproduced with permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298-6288.
 

_{© Dentist’s Advantage, 2022 © The National Society of Dental Practitioners, 2022
Risk Management services are provided by Dentist’s Advantage and the NSDP to assist the insured in fulfilling his or her responsibilities for the control of potential loss-producing situations involving their dental operations. The information contained in this document is not intended as legal advice. Laws are under constant review by courts and the states and are different in each jurisdiction. For legal advice relating to any subject addressed in this document, dentists are advised to seek the services of a local personal attorney. The information is provided "AS IS" without warranty of any kind and Dentist’s Advantage and NSDP expressly disclaims all warranties and conditions with regard to any information contained, including all implied warranties of merchantability and fitness for a particular purpose. Dentist’s Advantage and NSDP assume no liability of any kind for information and data contained or for any legal course of action you may take or diagnosis or treatment made in reliance thereon.}