CASE STUDY #1
Discussion This is a classic case of failure to diagnose oral cancer. Dr. J. did not pay attention to Mary’s family history of oral cancer, instead assuming that her problem was simply a “denture sore.” The adverse event in this case was failure to diagnose the “denture sore” as oral cancer. In the ensuing litigation, it was determined that Dr. J.’s actions were not consistent with the standard of care for Mary’s case. The new partial denture may have been the initial cause of her discomfort, but after two weeks, Dr. J. should have referred Mary to an oral surgeon for a biopsy, especially given her family history of oral cancer. Early detection may have saved Mary from the destruction caused by this aggressive form of oral cancer. At trial, the jury voted unanimously in favor of Mary Jones, awarding her a large settlement. Dr. J. did not have much of a defense in this case. Although there is no predicting what the progression of Mary’s cancer would have been had she been referred for a biopsy sooner, the six-month delay definitely allowed her cancer to progress. Unfortunately, this case represents a common occurrence, and many oral “sores” are attributed improperly to fractured teeth or removable dental restorations. Mary’s case is obviously an extreme one, but it underscores how easily an error involving failure to diagnose or failure to treat oral cancer can occur. The standard of care in these cases is to perform a biopsy or refer to an oral surgeon when a sore persists for more than 10 to 14 days, especially when there is a family history of oral cancer or when the patient has experienced other forms of cancer. In summary, an adverse event resulting from poor dental management provided by Dr. J. resulted in injury to Mary. The failure to diagnose the oral cancer was caused by operator error and was preventable, so it can also be considered a sentinel event. Dr. J. was charged with dental malpractice because he improperly treated or failed to treat Mary, which violated the dental standards of care. Dr. J.’s provision of care departed from the standard of practice, and this departure resulted in harm to Mary. The jury ruled that Dr. J. failed to provide the level of care to Mary that another general practitioner with similar skills and training and under similar circumstances would have provided.
Mary Jones is a 64-year-old factory worker in good general health who has had extensive dental restorative treatment over the years. She has an edentulous maxillary arch and remaining mandibular teeth from second premolar to second premolar. She has a maxillary complete denture fabricated approximately 10 years ago. She visited Dr. J., a general dentist, to have him fabricate a new maxillary complete denture and a mandibular removable partial denture. The treatment was routine, and she was pleased with the esthetic results. However, within several days of the mandibular partial denture delivery, Mary began to complain of a sore under the right side of the removable partial denture. Because Mary’s father died from oral cancer, she was worried about cancer as a possibility. Dr. J. dismissed her complaints and simply adjusted and polished the acrylic area on numerous occasions during the three months following delivery of her partial denture. Mary claimed that Dr. J. advised her on multiple occasions during the three-month period following insertion to “not wear the partial for brief periods and leave it out of your mouth.” Mary continued to complain and, finally, six months after insertion, Dr. J. made a note in her record for the first time documenting that she had a “denture sore on the mandibular right posterior region.” Again, Dr. J. advised her not to wear her partial so the area could heal. However, four days later, she returned complaining that the sore was larger and she was experiencing more pain. The dentist dismissed her complaints, writing a progress note in her record that stated that the patient was “healing well.” Finally, more than six months after the insertion, Dr. J. referred Mary to an oral surgeon to have her “denture sore” biopsied. The oral surgeon’s definitive diagnosis was infiltrating stage III squamous cell carcinoma. Mary had to have a wide excision of the lesion, including partial mandibulectomy and radical neck dissection followed by radiation therapy. She developed osteoradionecrosis and lost the entire right side of her mandible despite having gone through numerous hyperbaric oxygen “dives.” She had several subsequent recurrences that further disfigured her and eventually she lost her entire tongue.
CASE STUDY #2
Mrs. Walker presented to Dr. S., a general dentist, with the chief complaint of loose dentures. She was a 61-year- old female in good general health. Her oral exam revealed complete maxillary and mandibular dentures that were ill fitting. She had been edentulous for 15 years. Her maxillary ridge appeared to have adequate bony support, but her mandibular ridge had significant bone resorption. The resorption was worse in the anterior region of the mandibular ridge. Dr. S. recommended fabrication of new maxillary and mandibular dentures, along with surgical placement of two titanium implants in the mandibular canine areas, and he had two periapical films taken of her mandibular canine areas. The mandibular denture would have attachments inserted to aid retention. Dr. S. explained the treatment to Mrs. Walker, and she scheduled appointments accordingly. Dr. S. measured the bone levels from the periapical films and surgically placed the implants. Mrs. Walker’s existing dentures were soft relined and worn for two months to allow for osseointegration of the implants. Dr. S. fabricated the new dentures and used locators to attach the implants to the mandibular denture. Immediately after the surgery, Mrs. Walker experienced pain around the implants, and the buccal areas of both implants were inflamed. Dr. S. adjusted the mandibular denture in these areas, but both the pain and inflammation persisted for several months. The implants did not appear to be stable in the bone. After eight months, Dr. S. referred Mrs.
Walker to an oral surgeon. The oral surgeon examined her and took a three-dimensional CT scan that revealed the buccal plate was perforated and there was not enough bone width to support the implants. The implants needed to be removed, and Mrs. Walker needed bone grafts before the implants could be replaced. Discussion Although implant failure is not necessarily an indication of negligence, in Mrs. Walker’s case there is sufficient evidence to suggest negligence on the part of the general dentist. Dr. S. did not complete an adequate diagnostic phase, which should have included a three-dimensional CT scan rather than two-dimensional X-rays. The periapical radiographs do not reveal the amount and quality of the bone available to support the implants or the exact positions of nerves and blood vessels. Bone grafts should have been performed before the implant placement. Dr. S. also failed to have Mrs. Walker sign an informed consent document. The informed consent document should have included the risks, benefits, and alternative treatments available to Mrs. Walker. Dr. S. explained the treatment, but has no proof that Mrs. Walker understood the risks and possible complications. This is a clear case of negligence on the part of Dr. S., and Mrs. Walker has adequate grounds for a malpractice suit against him. Dr. S.’s treatment was below the accepted standard of care.
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Book Code: DFL3024
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