The plaintiff, a 64 year-old woman, was referred by her general dentist to the defendant oral and maxillofacial surgeon, for extraction of an impacted third molar due to advancing periodontitis in the area. Before the August 9 extraction, the plaintiff was told of the standard risks of infection and rare potential for fracture of the jaw along with the increased risk of inferior alveolar nerve injury from third molar extraction. The extraction resulted in numbness to the distribution of the inferior alveolar nerve.
In early September, the plaintiff’s general dentist identified a tooth or bone fragment in the extraction socket which appeared to be associated with additional pain and swelling. The defendant oral surgeon debrided the socket of the tooth fragment and chronic granulomatous material on September 11. A follow up appointment six days later revealed reduced swelling and pain. However, a return appointment on October 1 reflected some worsened swelling and tenderness at the site. A panorex taken on that date revealed some bone resorption below the extraction socket suggestive of osteomyelitis. Oral antibiotics were re-started.
By October 10, an increase in swelling was noted along with continued tenderness, increased fatigue and difficulty swallowing. A CT on that date revealed an aggressive osteomyelitis along with adjacent extensive soft tissue swelling, and a probable abscess with associated enlarged lymph nodes.
The defendant obtained the recommendations of an infectious disease specialist on October 12 and additionally performed a second debridement of the site on that date with IV antibiotic coverage. During the October 12 debridement, a significant loss of buccal bone from osteomyelitic resorption was visualized. A biopsy confirmed osteomyelitis.
Despite the institution of high dose oral antibiotics for three additional weeks, an associated pathologic jaw fracture was identified on an October 30 follow up CT. Accordingly, on November 5, the defendant undertook a fixation of the pathologic fracture via bone plate reconstruction. A third debridement was also performed. A six week course of daily IV antibiotics was initiated on that date.
The bone infection was eradicated within a month, and a bony union was achieved within 18 months of the fixation. It is unlikely that the fixation plate and screws would need to be removed or replaced.
Plaintiff filed suit and her expert opined that the defendant fell below the standard of care: 1) by recommending the extraction of an asymptomatic third molar on a 64 year-old, 2) by not informing the plaintiff that there existed a 50% chance of permanent IAN injury, 3) by not informing the plaintiff that she had an increased risk of post-operative infection because of her age, 4) by failing to obtain a biopsy at the first debridement on September 11, 5) by failing to obtain a CT scan 4 weeks earlier on September 11, and 6) by failing to order IV antibiotics 7 weeks earlier on September 11.
The defense denied that the standard of care was violated. The defense took the position that the extraction was warranted in an attempt to curb progressive periodontitis and that the position of the inferior alveolar nerve only slightly increased the risk of permanent nerve injury. Because the plaintiff was not medically compromised, the defense expert opined, there was no increased risk of infection. During the first debridement, the bone underlying the extraction socket appeared healthy and no infected tissue was observed at that time, and therefore, there was no need for a CT scan at that time and nothing of note to biopsy on that date. The defense expert further stated that IV antibiotics were administered in a timely fashion and in keeping with the recommendations of the infectious disease specialist.
The jury returned a defense verdict.
With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298-6288.