In recent decades, the evolution of implantology and advanced restorative procedures has permitted dentists in the United States to treat the functional and aesthetic needs of severely compromised dental patients successfully and predictably. Adult and elderly patients alike may suffer from severe periodontal disease and dental caries, requiring full-arch extractions and restorations.
 
Although the etiology of dental caries and periodontal disease typically involves poor oral hygiene and related local factors, the medical history may reveal important systemic factors and disease states that contribute significantly to a patient’s poor oral condition. The prudent dentist must consider the possible negative effect of systemic factors on oral health and treatment outcomes. Further investigation of the patient’s history, and medical consultation when appropriate, may help to prevent adverse outcomes and severe patient injury.
 
Claim Case Study
Practitioner: General practitioner dentist (GP) 
Claimant: Female, age 33, type 1 diabetes mellitus (T1D) since age 7, current smoker (1 pack/day X 20 years), crack cocaine, methamphetamine and marijuana use as a teen and adult (not used for 5 years), extremely poor dental/oral condition.
 
Risk management topics: medical/dental history, management of medically complex patients, medical consultation, informed consent, post-treatment follow-up, and documentation.
 
Facts:
The patient presented to the insured GP for assessment, stating that her teeth were in “terrible condition.” She desired removal of all teeth and treatment to restore her appearance and function. The dentist’s clinical and radiographic examination revealed many missing teeth with the remaining dentition in a severely compromised state, including widespread dental caries and generalized/severe periodontal attachment and alveolar bone loss. In the dentist’s opinion, saving several teeth might be possible, but this would result in a short-term solution to the patient’s condition. After discussing treatment options, the dentist and patient agreed that the best and most cost-effective option for her case would be full-mouth extractions and implant-retained overdentures.
 
The patient disclosed her medical history as previously described. The GP reviewed this information, but did not discuss these matters with, or seek further details from, the patient. Based upon the patient’s relatively youthful age and overall healthy appearance, he did not consider medical consultation. The patient was designated to begin treatment and, after completion of necessary steps to prepare the immediate upper and lower prostheses, the patient was scheduled for surgery and immediate overdenture delivery.
 
According to the patient dental healthcare information record, the dentist extracted 22 teeth, including three partially impacted third molars. He placed four dental implants and delivered immediate upper/lower dentures with no complications. The office provided verbal and written post-op instructions, including the recommendation for the patient to contact the office if she experienced excessive pain and/or swelling, of if she had questions. The patient was scheduled to return to the office in three weeks.
 
Five days after the surgery, the patient’s spouse called the dental office after hours and reached the office answering service. He complained that his wife was in excruciating pain, was very swollen and had been vomiting over the last three hours. The answering service documented the call information and then left a voice message for the treating dentist according to the office protocol. After not receiving a call back from the dentist or dental office over the next 24 hours, the patient sought care at the local hospital emergency department (ED).
 
In the ED, the patient complained of severe pain, jaw swelling and difficulty swallowing. The ED examination and assessment resulted in a number of findings, followed by admission to the intensive care unit (ICU). The healthcare information record confirmed tachypnea (respirations 22), tachycardia (pulse 130) and fever (100^o F). Laboratory tests also confirmed an elevated white blood cell count, consistent with infection. Blood chemistry results pointed to poor kidney function and dehydration. Further, the patient’s glucose level was determined to be in the “critical” range at more than 630 mg/dL, leading to a diagnosis of diabetic ketoacidosis (DKA). Patient-reported symptoms, clinical examination and imaging also resulted in a preliminary diagnosis of submandibular and/or parapharyngeal abscess and sepsis.
 
The patient remained in the hospital for three months. After initial management of the DKA, incision and drainage of the parapharyngeal abscess and two courses of antibiotic therapy, the patient experienced multiple serious and life-threatening challenges. These challenges included bacterial endocarditis, cerebrovascular accident (CVA), cardiac and respiratory arrest, kidney failure and hemodialysis. Although the medical team documented that the patient was “critically ill with high chance of mortality,” ongoing care in the ICU eventually resulted in health improvements.
 
The patient was discharged to a long-term care facility for rehabilitation. Over the course of four months, her health condition fluctuated several times, requiring brief hospitalizations. Within seven months, the patient’s condition stabilized through the efforts of her medical team. Control of her T1D remained challenging, and ongoing cardiovascular and kidney disease issues persisted. She required assistance with activities of daily living due to residual effects of a CVA that she suffered while in the hospital.
 
Approximately 10 months after her dental visit for extractions, the patient and her spouse filed suit against the dentist for “catastrophic personal injuries.”
 
Key Allegations:
Failure to adequately assess a high-risk patient for the recommended dental surgery. Failure to seek medical consultation. Inadequate informed consent. Failure to refer/offer referral for surgery. Failure to prescribe antibiotics before/after surgery. Failure to meet the standard of care for extractions and post-treatment follow-up.
 
Alleged Injury/Damages:
Post-surgical infection, abscess, and sepsis. CVA, resulting in partial paralysis, partial blindness, cognitive impairment and required assistance with activities of daily living. Claimed damages included current/future medical expenses, lost wages, pain and suffering, and loss of consortium. The plaintiff’s settlement demand exceeded the policy limits of the insured dentist and dental practice.
 
Analysis:
Although the patient appeared to be in overall good health before treatment began, she was diagnosed with T1D at 7 years of age. Due to early T1D disease onset, patients are at greater risk for cardiovascular disease and related negative health outcomes, with the highest excess risk in women.
 
The patient also presented with a significant history of substance use. In addition to the potentially severe impact of either diabetes or substance use on dental and oral health, a prudent dentist should consider how each of these issues - or the two issues combined - may affect a patient’s overall health and the proposed dental treatment. A 2021 article in the journal Heart reported on diabetic patients and their risk for early-onset cardiovascular disease. A few points to consider from the hyperlinked article are:

• Substance use disorders are associated with an acceleration of the aging process.
• Growing evidence suggests that these disorders include vascular aging, contributing to early onset atherosclerotic and ischemic heart disease, ischemic cerebrovascular disease, and peripheral arterial disease.
• Both cocaine and methamphetamine substance use are associated with serious and potentially fatal effects on arteries and blood vessels.
• Polysubstance use significantly increases the risk of early onset cardiovascular and cerebrovascular disease and associated adverse outcomes.
• Research indicates that women with a history of substance use are at significantly greater risk for premature cardiovascular disease outcomes than men.

 
Most dental professional liability claims involving patient injury are associated with injuries arising from the dental procedure. Several examples include cases involving nerve injury, wrong tooth extraction, inadequate restoration design and/or material failure. With the growing complexity of both dental treatment and dental patient co-morbidities, an increasing number of claims and lawsuits involve complex standard of care questions about what a prudent dentist would or would not do under the same or similar circumstances.
 
Although technical aspects of the surgery performed seemed to have met the standard of care, two dental experts agreed that the dentist failed to fulfill the standard of care in this case. The most critical concerns included:

• Failure to investigate the patient’s medical history - primarily with respect to T1D and polysubstance use. Doing so would have revealed significant medical concerns that emerged during discovery and during the patient’s hospitalization. A key factor included the patient’s poor T1D control. Moreover, notwithstanding recommendations of her primary care physician, the patient failed to seek a cardiology work-up for the two years prior to the dental procedure.
• Failure to prescribe antibiotics. There are no specific dental evidence-based clinical practice guidelines addressing recommendations for prophylactic or post-surgical antibiotics for a patient with T1D. Nevertheless, both dental experts agreed that a prudent dentist would have investigated the patient’s T1D medical history - -especially considering her past polysubstance use and the potential effect on her overall health. The issues revealed by such an investigation would have strongly supported both prophylactic and post-procedure antibiotic coverage.
• Inadequate informed consent. The insured dentist stated that his custom and practice is to discuss the benefits and risks of surgery with patients, including infection, before proceeding with care. However, there was no documentation of an informed consent discussion and no written/signed informed consent form in the dental healthcare information record. Although a “custom and practice” defense to support informed consent may be successful in the defense of negligence cases, the multiple standard of care concerns and the patient-friendly trial venue precluded the ability to pursue the matter at trial. In addition, although the surgical treatment seemed to have met the standard of care, the dentist did not offer the option of seeking specialty care for the dental extractions. This raises the question of whether consent for the surgery was “informed.”
• Post-treatment management. This case demonstrates the importance of an effective post-treatment and after-hours dental emergency management protocol. For cases involving infection, timely intervention can mean the difference between effective management and sepsis with severe or life-threatening sequelae.

 
Outcome:
Considering the facts of the case and the lack of defense expert support, the insured dentist and defense teams agreed that seeking early settlement represented the best course of action.
 
Although the initial demand significantly exceeded the policy limits, mediation led to a successful conclusion of the case before trial. The total incurred (settlement payment plus claim expenses) was less than $2,000,000.
 
Risk Control Comments:
Remember that obtaining an accurate, comprehensive, and current medical history from the patient represents an essential tool in providing safe, quality dental care. However, this important protocol is of little use in the absence of a thorough review and doctor-patient discussion, followed by medical consultation when appropriate, in order to determine if treatment benefits outweigh the risks. It is in the dentist’s best interest to consider that medical consultation will help to inform a dentist’s risk assessment, and that the dentist is responsible for dental treatment recommendations, rather than the physician.
 
In addition to the hyperlinks included in the case study, dentists may wish to review these additional resources:

• American Dental Association (ADA) website. Dental care for patients with diabetes.
• The Center for Disease Control and Prevention (CDC) website. National Diabetes Statistics Report.
• ADA CDT Codes D0411 and D0412. In-office Monitoring of Patient Blood Glucose and HbA1C.
• MedlinePlus. What is a Hemoglobin A1c (HbA1c) Test?

 
Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM
CNA Dental Risk Control
 
^{Disclaimers
These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
 
“CNA” and Dental Expressions® are registered trademarks of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. 
 
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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.}