Dental Considerations with a Diabetic Patient
Fall 2017 Dental Insights
Posted in Dental Insights on Tuesday, August 1, 2017
From Dental Insights, Fall 2017
Mary was in her late 40s and a freelance writer when she first visited the group dental practice owned by Dr. Simon. Mary went to the practice at the urging of her roommate Dominique who convinced her of the importance of regular dental care. Mary had only sporadically been to a dentist in the past several years. Dominique was good friends with Dr. Simon’s dental assistant Ella.
Mary was seen on November 28, 2012, by Dr. Coe, an associate of Dr. Simon, who performed an initial examination including radiographs. Dr. Coe then prepared a comprehensive treatment plan that included a “Family and Friends” discount, which he discussed with Mary.
As part of the initial treatment plan, Dr. Coe recommended scaling and root planings to treat some mild to moderate periodontal issues, as well as a possible root canal on the upper right and a few minor restorations. He also advised extracting a lower right molar (tooth 30) that was asymptomatic but was significantly decayed.
Mary indicated on her health history that she was taking metformin for Type 2 diabetes. She was also noted to be overweight.
In conversations with Dr. Coe, Mary indicated she was a controlled diabetic. Dr. Coe did not ask for specific values of diabetes testing, nor did he contact her regular physician. He did note she was not in pain during the visit.
Mary promptly returned for her initial scaling and root planing appointment on December 28, 2012, at the end of which she was directed to schedule a follow-up scaling and root planing appointment as well appointments for her extraction, root canal and restorations. Since she had developed pain from the carious molar, she scheduled her extraction appointment for January 7, 2013, but delayed her scaling and root planing for approximately six months.
The extraction appointment was documented by Dr. Coe as a routine extraction. The postoperative instructions included a 24-hour number for Mary to call with any unusual signs or symptoms, such as swelling, fever or bleeding beyond a few days. Mary was also directed to schedule another appointment for the root canal and restorations.
On January 9, 2013, Dominique called Ella about another matter, and Ella asked how Mary was doing. Dominique said Mary was progressing well—she was using ice for the swelling—but that she had a cold.
Mary had previously asked Dominique about her postoperative swelling, but Dominique told her, “It didn’t look too bad.” Mary also asked Dominque if she could ask Ella for an antibiotic for her cold. In turn, Ella informed Dominique that Mary would need to see Dr. Coe before any antibiotic could be prescribed.
Dominique relayed Ella’s message to Mary. However, Mary had a work deadline and said she would come in if she felt worse. Dr. Coe had told Ella that would be acceptable, but that Mary should call or come in immediately if her symptoms exacerbated.
On January 10, 2013, Mary was able to do some work but she still didn’t feel well. She was unsure if her swelling had increased, but it clearly hadn’t decreased. She finished her work project and went to bed early.
The next morning, January 11, 2013, Mary awoke in a sweat. The right side of her mandible had become red, swollen and warm to the touch. She had also developed increased pain and noticed a discharge from the extraction site. Additionally, the inside of her mouth was painful and swollen. Mary became alarmed and went to the emergency room where she was diagnosed with a postoperative infection of her extraction site.
On admission to the hospital, Mary’s blood sugar level and A1C levels were elevated. Her infection was successfully treated with an extra-oral I&D and she was placed on IV antibiotics. Doctors decided to keep Mary in the hospital a few extra days to regulate her blood sugars.
A lawsuit ensued alleging that Dr. Coe, the group practice and Ella were all negligent in the dental care of Mary. The defense denied any negligence and countered that Mary was contributorily negligent because she failed to follow the dentists’ postoperative instructions.
Discovery revealed that contrary to Mary’s statements to Dr. Coe, her diabetes was not well controlled. Her medical doctor had admonished her on numerous occasions to take her medication as directed, to follow a diabetic diet, to exercise more frequently and to be diligent about keeping doctor appointments.
Mary claimed at the deposition that she had been in much more pain preoperatively than the records indicated. She also testified that the extraction procedure was long and difficult. In response, Dr. Coe testified that although he did not recall the details of the case, if there had been any difficulties or complications, they would have been noted in his chart. He further stressed that the extraction must have been routine as no hand piece was necessary during the procedure.
The expert identified for the plaintiff claimed that Dr. Coe should not have performed the extraction on a diabetic without prescribing an antibiotic because there was no confirmation of Mary’s diabetic condition being under control, i.e., the A1C and blood sugar levels were not known at the time of surgery. The expert also stated that a practitioner was required to obtain this information prior to a surgical procedure. The expert further claimed that in addition to premedication, an extraction of this type on a diabetic should have been referred to a specialist because the diabetes was out of control, and a specialist would have been better able to oversee the treatment. It was also his contention that diabetics were more prone to infection and that this required specialty care. He cited literature to support his positions.
The expert also disputed that this was a simple extraction. He based this opinion on the patient’s complaints of pain prior to the extraction, which meant there was an acute infection, and her description of the procedure. Also, the records did not contain sufficient detail to support the clinical presentation, how the extraction was performed, how long the procedure took and other details. He claimed that extraction of acutely infected teeth requires antibiotic premedication.
The expert further opined that failure to see the patient after the procedure was a deviation in the standard of care. Based on the patient’s complaints, Mary should have been required to come in, been told of the consequences of not doing so and directed to the nearest ER. He also testified that if the patient had been treated properly or had been seen sooner postoperatively, the infection would have been prevented or been far more manageable. No hospitalization would have been required.
Finally, the expert testified that Ella was at fault for her improper communications with Dr. Coe. Her involvement was confusing to Mary, and was improper in that not all of the details in these calls were properly relayed or documented. In this expert’s opinion, Mary was not at fault as she testified that she believed all her issues had been relayed to Dr. Coe.
The defense team retained a well-qualified general dentist with both practice and teaching experience. He defended the dental care of all of the practitioners and asserted that practitioners can, in a situation like this, rely on their patients to give them an accurate health history. The standard of care did not require referral and pre- or postoperative antibiotics.
The defense expert pointed out that the literature does not indicate that well-controlled diabetics are more prone to infection. A dentist is not required to take steps beyond obtaining an accurate health history that should indicate if patients are diabetic, what medications they are taking and their level of control. The dentist is not required to obtain A1C or blood sugar levels or to call the patient’s physician prior to simple dental procedures. Patients must accept some responsibility for providing their dentists with an accurate health history.
Further, he testified pain from a badly decayed tooth does not equate to a diagnosis of acute infection. Without signs or symptoms of an acute infection, preoperative antibiotics are not required, and indeed the literature suggests that practitioners should not overprescribe antibiotics.
Although postoperative antibiotics were not required, the recommendation for follow-up was appropriate in this case. Indeed, even if antibiotics had been administered, they likely would not have had time to stop this aggressive infection.
Finally, Mary was never told to communicate via Ella. Mary was at fault for failing to accurately advise Dr. Coe and follow his recommendations. Dr. Coe could have done better by calling Mary directly, but that failure was not a deviation in the standard of care in this situation.
The case was tried and a verdict entered for the defense. The jury found the defense witnesses to be more credible than those of the plaintiff and her expert.
What Can We Learn?
In this case, the defense could have bolstered its case in several ways. Specific details about Mary’s diabetic background and the inconsistencies with her diabetic care may have bolstered Dr. Coe’s basis for his decisions. For example, Dr. Coe could have documented certain information provided by the patient, such as: her advisement to him that her diabetes was well controlled, that she took her diabetic medications regularly, that she checked her sugars regularly, that she followed her doctor’s recommendations as directed, that she saw her doctor regularly and that she last saw her doctor on a specific date. Dr. Coe could have also asked her to check her own blood sugar and then documented the result.
More details in Dr. Coe’s postoperative notes would have served to better show the simple nature of the extraction. A call by Dr. Coe to Mary, either on the day of or following the extraction, or after the conversation with Ella, with good documentation of her responses would have provided strong evidence for the defense of Mary’s assessment of her own condition and would have assured that Dr. Coe was well aware of Mary’s postoperative status and whether additional recommendations would have been appropriate.
While not raised as an issue in this case, conversations between the provider and the patient must always be made within the context of patient privacy and HIPAA regulations. Here, conversations between the assistant and the roommate would not have been proper under HIPAA. Care must be taken by the dentist and staff alike to comply with privacy regulations on this critically important issue.
Finally, literature is often used to establish standard of care. However, literature often can be found that will bolster both sides of the case. Therefore, cautious and careful evaluation of literature, timing and the applicability to the case must all be considered in litigation.
This case study was written by Linda Hay, J.D. All names used in Dental Insights case studies are fictitious to protect the privacy of the dentist and the patient.
Linda J. Hay is a partner in the Chicago office of HeplerBroom, LLC. Ms. Hay has practiced in the professional liability defense arena for more than 25 years and has tried numerous cases to verdict. She is actively involved in a variety of defense bar, professional liability and risk management organizations. Ms. Hay can be reached at Linda.Hay@heplerbroom.com.