When a patient dies after failing to realize the seriousness of his condition, is the dentist at fault?
Posted in Dental Insights on Thursday, March 28, 2024
John Rogers, 53, had been a patient of general dentist Dr. Jane Smith for over 15 years. On June 4, John presented to Dr. Smith’s office with complaints of a toothache in the area of teeth #18 and #19. Dr. Smith planned treatment for crowns on both #18 and #19 but referred John for endodontic evaluation before proceeding.
John saw endodontist Dr. Mike Jones and was evaluated on June 5. Dr. Jones performed a full evaluation of teeth #18, #19 and #20. The exam for #18 revealed that it was positive for lingering discomfort to cold and moderate discomfort to tooth slooth. It also revealed partial calcification and a widened periodontal ligament. Dr. Jones’ evaluation also revealed that tooth #18 had irreversible pulpitis and required root canal therapy.
Tooth #19 was asymptomatic, but radiographically, the pulp chamber showed signs of calcific metamorphosis. Tooth #20 was also evaluated, and the findings were normal. Dr. Jones was aware that Dr. Smith had planned crowns for #18 and #19, and given the condition of #19, he offered root canal therapy. John declined root canal therapy for #19, but agreed to treatment of #18, which was done on June 7.
Patient Receives Crowns
On June 20, John returned to Dr. Smith’s office for the seating of crowns on #18 and #19. On July 17, several weeks after the crowns were seated, John returned to Dr. Smith’s office with complaints of a new toothache in the area of #18 and #19 that, according to records, “felt like a pulse, for three days been hurting, can’t do anything, no sleep.” Dr. Smith contacted Dr. Jones to see if he could see John for evaluation. Dr. Jones was able to fit him in within a few hours of the referral. Notably, Dr. Jones’ appointment record states that John was coming in for “a quick check.”
Dr. Jones’ treatment note reflected that John presented on July 17 upon the referral from Dr. Smith. He reported “some discomfort” when he would bite down but did not report the significant pain he shared with Dr. Smith only a few hours before.
The treatment note stated: “Pt. returns with some discomfort when he bites down. Permanent crowns were recently cemented. Pt. claims discomfort to biting has increased since crowns were placed. No sign of swelling. Slight discomfort to biting on #19 and #18. Explained that it is not uncommon for teeth to be sore once the crowns are placed. Occlusal adjustments may be required. Recommended that he return to Dr. Smith for occlusal adjustments should the discomfort not resolve. RX: Medrol Dose Pack, 1 (one) pack, take as directed prn dental pain. Quick look in one week after being on Medrol Dose Pack.”
Dr. Jones took a periapical film of #18 that revealed no abscess and the periodontal ligament spacing was normal compared to the previous exam prior to the root canal therapy. Notably, the evaluation documented in the chart reflected that the diagnostic testing was performed on tooth #18 and not #19 or #20. John was scheduled to return on July 27 after completing his course of the steroid. John left the office and filled his prescription.
John’s Condition Worsens
On July 19, two days after seeing Dr. Jones, John texted a friend that he was still “doing the same.” On July 20, he texted another friend, “My root canal got infected and I am taking all kinds of meds including ‘roids. No sleep at all.” On July 21, he texted a friend that he was not feeling well, went to the grocery store, came home, and collapsed. The friend responded that he hoped he didn’t need medical attention. John responded that he thought it was the steroids.
On July 22, John texted a sibling that he was “wiped out. Still can’t sleep because I have a big bump on my tooth. This is crazy.” The sibling told him to call the doctor. He declined, believing that he just needed to finish his steroid prescription. Later that day, he texted that he was having hot and cold flashes, could hardly talk, and the left side of his face was swollen. His sibling told him to call the doctor and was offered a ride to an urgent care. John declined and said he would call the following day.
On July 23, a series of text messages to John’s phone went unanswered. On July 26, after several days of not getting a response, a sibling went to John’s house and found him deceased on the kitchen floor.
The coroner performed an autopsy and ruled that, based on the facial swelling and John’s recent root canal therapy, the cause of death was “dental abscess with sepsis.” The coroner’s testing revealed the presence of bacteria throughout John’s body. He was unable to locate the source of the infection due to the length of time John had been deceased before being found.
The Case Goes to Trial
John’s estate sued Dr. Jones for wrongful death alleging dental negligence for failing to diagnose the presence of infection at the follow up appointment on July 17. Notably, the estate’s claim theorized that tooth #19, not previously treated, became infected and was the source of John’s pain as reported on July 17. The estate argued that Dr. Jones did not perform an evaluation on #19 as evidenced by a lack of documentation in the chart and the note in the appointment book that John was coming in for “a quick check.”
At trial, the estate focused the claim on the absence of a documented evaluation of tooth #19 on July 17. The estate’s expert compared the June 5 evaluation record that reflected testing on teeth #18, #19 and #20, with the July 17 evaluation record that only revealed diagnostic testing on tooth #18. Accordingly, it was the estate’s position that “if it is not documented, it did not happen” and, therefore, no evaluation of #19 took place. The estate argued that this was consistent with the fact that Dr. Jones only viewed the appointment as a “quick check” and not a full diagnostic exam.
In the absence of documentation reflecting that #19 was evaluated, the defense had to rely almost exclusively on Dr. Jones’ testimony to establish that he did perform the evaluation. Along with his testimony, evidence was introduced of the periapical film taken of #18 that also captured #19 and reflected no evidence of infection. Also, Dr. Jones’ progress note indicated that he performed a bite testing on both #18 and #19 and it supported his evaluation of #19.
Dr. Jones’ main defense was his testimony. He testified that he did not document testing on #19 because he had just performed that testing only weeks before and he would only document that which was different than the findings from the June evaluation. Thus, at the July 17 appointment, Dr. Jones charted the differences on #18 because its evaluation results were dramatically different post-endodontic treatment. Indeed, it would be significant for #18 if the PDL space remained widened or it is still had sensitivity to cold weeks after the endodontic treatment. Consistent with this, Dr. Jones documented the discomfort that was present in #19, during the bite test, because that was different than the prior test results. While not documented in the chart, Dr. Jones testified that he ran floss between #18 and #19 but it was exceptionally tight, and he was barely able to do it. Based on his evaluation, Dr. Jones concluded that it was the fit and occlusion of the crowns that was leading to the discomfort.
In addition to the above defense, John’s text messages established that his own comparative negligence outweighed any alleged negligence of Dr. Jones.
After five days in trial, the jury returned a verdict in favor of Dr. Jones finding that he was not negligent. The jury did not make a finding as to any comparative negligence of John.
What Can We Learn?
Communication between the provider and the patient is critical.
This case presented a very unusual circumstance that very few providers or patients could predict. Yet, there are several facts that suggest better communication between the patient and the provider could have avoided the tragic outcome. It was clear that John did not believe it necessary to contact Dr. Jones when he began experiencing symptoms of infection. His text messages were a clinical study on the progress of an infection. He was simply not aware of the seriousness of his condition.
Providers should ensure patients understand areas of concern and when to reach out.
Involve the patient in their care. The more the patient understands the treatment, the more likely that it will be successful. If the patient understands the treatment, the patient will know what to expect and will be more aware when something is not right.
It is critical that providers establish rapport and relationships built on trust and openness with the patient.
John provided a very different impression of his condition when speaking with Dr. Smith, a female dentist, and Dr. Jones, a male dentist. Dr. Smith’s record reflected that John had experienced constant significant discomfort that prevented him from sleeping for days. Yet, just a few hours later, John presented to Dr. Jones and stated that he had “some discomfort” when biting. The presentations are starkly in contrast with one another. The answer is not clear. If he had been more comfortable with Dr. Jones, perhaps he would have been more open about his symptoms.
Documentation could prevent a lawsuit.
Had Dr. Jones documented a specific evaluation of #19, as he did with #18, this case might never have been filed. There wouldn’t have been anything for an opposing expert to speculate upon. The absence of documentation of the evaluation that was performed on #19 permitted speculation that it didn’t occur. Thorough documentation is essential. It is also critical to understand that in absence of documentation, a jury is left to weigh the evidence and determine credibility of the witnesses and arguments.
Assumptions can lead to tunnel vision.
It’s important to keep an open mind and document differential diagnosis. In this case, the evidence supported that there was no indication of any infection on July 17. However, the fact remains that the patient died from sepsis only 5-6 days after he was evaluated. Finding no infectious basis for the patient’s symptoms, Dr. Jones focused on the recent crown seatings to conclude that the patient’s pain was the result of the crowns as opposed to any other source.
Presentation in front of a jury can impact the outcome.
Dr. Jones presented as an outstanding witness. He was honest, sympathetic to the family and came across as a knowledgeable and authoritative expert in the clinical practice of dentistry. The jury liked him. Had Dr. Jones come across as condescending, impersonal, or dismissive of the family’s loss, the verdict could have been quite different.
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