Hands holding an x-ray

Fracture after Implant Sends Patient to Surgery

If a patient doesn't truthfully disclose their health history, whose fault is it when they end up in court?

Laura Messer, 68, had been edentulous for many years. She was growing increasingly unhappy with the full dentures she wore on both arches, but especially the lower ones. She presented to Dr. Grady Archer, a local prosthodontist who had been out of residency training less than a year.

On the first visit to Dr. Archer, Laura completed the customary intake paperwork, including a health history form, which Dr. Archer also later discussed with Laura verbally. On the form, Laura stated that she had high cholesterol which was controlled by a statin, but she denied all other medical conditions mentioned. During the discussion with Dr. Archer, when asked, “Are there any other medical conditions we should be aware of?,” Laura responded with, “Cholesterol,” but nothing more.

Clinical and radiographic examination—a Panorex—revealed a very atrophic, edentulous mandible, with approximately 10-12 mm of bone in the lower anterior region, and merely a few millimeters above the inferior alveolar canal posteriorly. After a lengthy consultation, Laura agreed to Dr. Archer’s suggestion of placing four implants in the anterior mandible, upon which a snap-on type of overdenture was planned. Dr. Archer explained that he had placed and restored many implants, so he would be able to provide the entire course of treatment. He discussed the risks, benefits and alternatives associated with implants, and gave Laura a three-page detailed consent form to take home, read, and bring back with her when she returned for the surgery.

She returned the following week, having read, understood and signed the consent form; Dr. Archer also verbally reiterated its contents. When Laura assured him that she understood what she was getting into, he gave her local anesthesia and uneventfully placed four 8 mm implants into the mandible, two on each side, in the areas of the lower canines and incisors. A Panorex showed parallel placement of the implants, all of which appeared to be in solid bone.

At the first post-operative visit, the patient had no significant complaints and the areas appeared to be healing well. But about two weeks later, she returned to the office complaining of new onset pain in the left canine area. Dr. Archer took an X-ray that revealed a new shadow he thought could represent a fracture, so he referred Laura to a local emergency room.

At the ER, a full series of facial films was taken, and Laura did, in fact, have a non-displaced fracture of the mandible, just posterior to the implant in the left canine site and communicating with the implant. She was taken to the operating room, where the oral surgeons removed that implant and placed plates and screws to fixate the fracture. Significant post-surgical complications including infections and extended hospital admissions ensued.

Legal stance

Laura obtained an attorney who sued Dr. Archer for having committed dental malpractice in the placement of the implants, so as to cause the mandible to fracture. The claim, in essence, was that Dr. Archer should not have placed implants in a mandible with such severe atrophy, as it was destined to fracture. Laura also claimed a lack of informed consent, asserting that she would never have done the procedure if she had known that fracture of the jaw was a potential consequence.

Discovery in the Litigation

Under our system, defense counsel is entitled to obtain medical and dental records of other providers which might reasonably lead to material information. In reviewing the records of the hospital where Laura was treated for the fracture, it was noted that the medical history included “severe osteoporosis history,” therefore, all records relating to Laura’s osteoporosis were requested and received—over strenuous opposition—from Laura’s attorney.

As it turns out, Laura had been hospitalized only five months before seeing Dr. Archer for a spinal fracture. That fracture occurred from simply opening a window. During that hospitalization, she was diagnosed with severe osteoporosis, which the records clearly stated was the cause of the spinal fracture.

The expert retained on Dr. Archer’s behalf believed the implants had been placed properly by him, that the decision to place them was reasonable, and that the very likely cause of the fracture was Laura’s underlying severe osteoporosis, which had not been disclosed to Dr. Archer. Dr. Archer said had he known of that history, he would never have gone forward surgically without a consultation with and approval of Laura’s treating physicians who treated her—up to that day—for the osteoporosis.

Laura’s Deposition

Depositions are sworn question and answer sessions, given under oath, by each party to a lawsuit. At Laura’s deposition, she was asked about the prior back fracture and her osteoporosis. She fully acknowledged those events and also acknowledged that she had still been under care for that as of the time she saw Dr. Archer. She further admitted that her orthopedic doctors had told her that the osteoporosis was the cause of the fracture, and that she needed to exercise care because she was at great risk for fracturing other bones.

During the deposition, Laura also acknowledged that she had signed the consent form, which set forth—in three distinct places—that jaw fracture was a known risk of implant placement in the lower jaw, but did not read or understand it.

When asked why Laura did not disclose to Dr. Archer that she had osteoporosis, she responded simply that, “He didn’t ask.”

Result

The case settled just prior to jury selection and for a nominal value.


What Can We Learn?

This case emphasizes the importance of reviewing a health history with every patient updating it at reasonable intervals.

There are countless health history forms out there and “osteoporosis” is not a commonly listed condition on many of them. But there are more potential diseases and conditions which affect people, so it would be literally impossible to list every one of them on a health history intake form. 

So, how can dentists prevent a situation like this case presents, and what constitutes a violation of the standard of care in this regard? While there is no definitive answer, the best way is to make health history questionnaires as comprehensive as is reasonable, reflecting back to the forms used in dental school and residency training programs to see what academic institutions view as reasonable. Regardless of how comprehensive the form is, there will always be conditions of some patients which are not on the list. Having a follow-up question after the list that asks about other conditions the dentist should be made aware of, is well within the standard of care for dental practice. Patients have responsibilities when seeking care, and it lies with them, just as much as with the dentist, to be fully open, complete, and accurate in their disclosures, because dentists rely on them when treating.

It's also helpful to have a verbal reiteration of that final catch-all question, making it sound as broad as possible and emphasizing to the patient that treatment decisions are often guided by a patient’s medical status, so that the dentist provides the patient every opportunity to disclose what there is to disclose.

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