Experienced Dentist Learns Importance of Following Precautions
Winter 2017 Dental Insights
Posted in Dental Insights on Wednesday, November 1, 2017
From Dental Insights, Winter 2017
Dr. Jones was a general dentist with a certificate in prosthodontics. He owned a general practice, with a significant emphasis on the placement and restoration of implants. As his patient population included many patients with significant dental issues and he had placed hundreds of implants over the years, he considered himself a confident and skilled practitioner.
Mary was 72 years old with a complicated medical history with significant comorbidities when she presented to Dr. Jones for evaluation. She was missing many teeth and had several restorations.
During the next 10 years, Dr. Jones systematically replaced numerous crowns and bridges in Mary’s mouth. Despite these attempts, the patient continued to lose teeth. As the patient lost dentition, Dr. Jones continued to attempt to place fixed bridges. Eventually, the patient lost numerous teeth in the posterior mandibular region. Dr. Jones recommended the patient have a single implant placed for a tooth that had been a removable partial and now would be supported by a fixed partial.
After an informed consent discussion, the patient agreed to the procedure and signed a comprehensive informed consent form.
The patient was administered a local anesthetic. Dr. Jones performed the surgical placement of the implant for tooth number 24. Subsequent to the procedure, Dr. Jones had placed a healing cap; however, he decided to replace it with a larger one. In the meantime, Dr. Jones dismissed his surgical assistant to set up another case because he believed the surgery was complete.
Now alone in the surgical suite, Dr. Jones removed the original cap and proceeded to place and seat the new cap. He placed the implant wrench into the head of the healing cap and then reached behind him to obtain the torque wrench to torque the cap securely into place. Dr. Jones took his hand off the implant wrench to grab the torque wrench. In that brief moment, the implant wrench became dislodged and fell into the patient’s mouth.
The patient immediately felt the instrument in the back of her oral cavity. Dr. Jones helped Mary sit up. She attempted to cough out the instrument without success. Dr. Jones tried to retrieve the implant wrench without success. The patient could still feel the instrument in the back of her mouth. Dr. Jones decided to call the paramedics.
The paramedics arrived promptly and attempted to remove the instrument, but they also were unsuccessful. The paramedics transferred the patient to the hospital. Even though Dr. Jones followed the ambulance to the hospital, he was precluded from seeing the patient.
Dr. Jones later learned the emergency room physicians attempted to retrieve the implant wrench, and they too were unsuccessful. During the retrieval attempts, Mary aspirated the implant wrench, but it was not clear at exactly what point that happened.
The patient was transferred to a higher-level medical institution where the instrument was successfully retrieved through a bronchoscopy. Because of her age and her significant medical comorbidities, Mary spent three nights in the hospital and incurred substantial medical bills. Fortunately, she did not sustain any permanent injuries.
After recovery, Mary did not return to Dr. Jones for restoration of the implant. The implant subsequently became infected and failed. It was removed by a different surgeon who opined that the patient was not a good implant candidate.
Ultimately, Mary sued Dr. Jones. She alleged numerous deviations from the standard of care including negligently performing a dental implant procedure, negligently dropping a dental instrument during the procedure and failing to take adequate measures to prevent the instrument from falling into her mouth. Though the aspiration occurred in the hospital, Mary alleged that Dr. Jones was negligent for attempting to remove the instrument, which caused the instrument to migrate into her lungs.
During his deposition, Dr. Jones testified he had substantial experience in the surgical placement and restoration of implants. He described the patient’s procedure as a simple surgical process, testifying there were no issues with the implant placement itself.
Dr. Jones did admit he took his hand off of the implant wrench for a brief moment, which was when the instrument was lost. Dr. Jones conceded he could have threaded the implant wrench with floss to secure the instrument. He further admitted he could have placed gauze in the posterior aspect of the patient’s oral cavity to prevent the loss of instruments during the surgical procedure.
It became clear that if Dr. Jones would have taken either of these preventative measures, the implant wrench may have been retrievable if dropped. When hard pressed, the doctor was forced to admit he did not comply with the standard of care. He acknowledged he should have taken steps to prevent a situation where a dropped instrument could not be easily retrieved.
Mary presented as a sympathetic and credible witness who had substantial medical bills. Mary testified she was completely unaware of the risk of an instrument being aspirated, and she was terrified when it occurred. She further stated that after the doctor recognized the implant wrench had been lost, he sat her up and slapped her on the back numerous times. There was clearly a dispute as to when she aspirated the instrument.
During the discovery process of the litigation, the matter was resolved by settlement for $150,000. The settlement value was driven higher due to the amount of medical bills incurred, as well as the fact the doctor was forced to admit he did not comply with the standard of care in protecting against such a mishap. Consequently, Dr. Jones was reported to the dental board; fortunately, no formal action was taken after the initial interview by the board.
What Can We Learn?
As dentists progress through their careers, it is natural they will become adept and efficient in performing procedures. Despite this level of proficiency, however, it is vitally important to follow established procedures to prevent patient harm.
Dental procedures have the inherent risk of objects falling into the oral cavity which can result in significant consequences, even death, due to aspiration or ingestion. Therefore these risks should be included in the informed consent process.
In this matter, there was no doubt Dr. Jones was an accomplished implant surgeon. However, his precautions were lacking.
From a risk management/patient safety perspective, aspirations and ingestions can occur. Therefore, keep track of all tools and prostheses and take precautions to avoid aspiration/ingestion by:
- Using a throat pack
- Using dental floss tied to the instrument
- Using rubber dams if practicable
- Maintaining the patient in an upright position, if appropriate
It is important to note that flossing the implant wrench and using a gauze barrier doesn’t guarantee it won’t become loose. However, it is an important step toward minimizing this risk.
What’s more, it is good idea to have a practiced protocol in place for when unexpected situations arise.
- Remain calm and advise the patient to remain calm.
- Explain what you are going to do.
- Call 911 and have staff available to meet the paramedics outside to direct them to the patient’s location. (This is especially important in larger medical buildings.)
A final factor in this case was the surgeon who removed the infected implant after surgery shared his opinion with the patient that she was not a good implant candidate. It is rarely a prudent decision for subsequent treaters to criticize other dentists’ care.
This case study was written by Anne Oldenburg. All names used in Dental Insights case studies are fictitious to protect the privacy of the dentist and the patient. Ms. Oldenburg is a partner with the law firm of HeplerBroom, LLC. Ms. Oldenburg focuses her practice on the defense of healthcare professionals, including all aspects of civil litigation including appeals. She also represents professionals before state licensing boards. She has tried numerous cases to successful verdict and handled many cases through successful appeal. Ms. Oldenburg is a member of numerous bar associations including: The Illinois Association of Defense Trial Counsel (Past President, Executive Board of Directors, Co-Chair of Diversity in Participation Committee, Faculty—Trial Academy, Member of Medical Liability Committee and Fall Seminar Committee) and Association of Defense Trial Attorneys. Ms. Oldenburg’s other professional affiliations include the Defense Research Institute, the Physician Insurers Association of America (PIAA), the American Society of Healthcare Risk Management and the Chicagoland Healthcare Risk Management Society. She is on the Board of Trustees for Elmhurst Memorial Hospital. She has published and lectured extensively on issues relating to healthcare litigation and risk management issues.