Articles Posted in Dental Malpractice

Many victims of dental malpractice properly request their records and encounter a host of dental terms and abbreviations that make it hard to decipher what the records mean. Some common dental abbreviations used in conjunction with dental procedures which may lead to nerve and other dental injuries are: ALV = alveolar; AMO = Anterior Maxillary Osteotomy; APEO = apicoectomy; B = buccal; BL = bone loss; dg or dx = diagnosis; E or EX or EXT = extraction; ENDO = endodontics; FDS = flap debridement surgery; fom = floor of mouth; FX = fracture; H&P = history and physical; L = lingual; MFP = myofacial pain; P-XR or pano = panoramic x-ray; pax = periapical x-ray; peri = periapical; POT = post-operative treatment; SL = sublingual; and WL = working length.
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Dental procedures in the area of the lingual and inferior alveolar nerves are the most common cause of nerve damage. Negligently placed dental implants and improperly performed root canals in the lower jaw can cause inferior alveolar nerve damage. Other negligent procedures such as wisdom tooth extractions can cause lingual nerve damage. If your dentist has identified nerve damage during or shortly after the procedure, a referral to a qualified nerve specialist should be made as soon as possible. Delay can often result in permanent nerve damage. Surgical repairs, when done within the window of time when they have the greatest chance of success, can often reduce numbness and pain, and bring back normal sensation to the affected areas. That is why it is important to refer out to a qualified oral surgeon or micro-neurosurgeon in a timely manner.

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A recent dental malpractice verdict of over $2.3M was upheld on appeal. The malpractice victim suffered a lingual nerve injury during a tooth extraction which manifested itself with numbness of her tongue coupled with severe pain. This resulted in difficulty in swallowing, speaking and drooling.

Despite undergoing corrective surgery on her lingual nerve, the plaintiff’s symptoms did not resolve and she suffered a permanent nerve injury, and, as is often the case, her pain symptoms intensified after the attempt to repair the nerve.

According to the opinion, plaintiff was twenty-five years old when her doctor suggested that she have her wisdom teeth extracted. The defendant dentist extracted plaintiff’s four wisdom teeth a little over a month after the initial consultation. Defendant performed the extraction after administering an anesthetic that plaintiff described “put [her] to sleep.” Plaintiff testified that when she regained consciousness, she began screaming and felt excruciating pain. Plaintiff was completely asymptomatic before the extraction. Defendant prescribed narcotic pain medication in tablet form; plaintiff testified the medication made her nauseous and caused her to vomit.

At her post-operative visit with defendant three days after the extraction, plaintiff complained of of numbness in the tongue. According to plaintiff, defendant told her that her symptoms were “definitely not normal,” but that “sometimes these things can resolve themselves.” However, plaintiff’s symptoms did not improve. She testified during the trial that her tongue, the floor of her mouth and the gum line were completely numb. She also felt a shooting pain that came from the very back of her furthest tooth on the right side and that the pain and numbness caused her a lot of difficulties.

After consulting with several dentists and related medical professionals, plaintiff decided to undergo another surgical procedure to attempt to repair the damage to her right lingual nerve. The postoperative report noted that a large amount of scar tissue was identified in the area of previously extracted tooth #32;  a neuroma appeared to be present and that the lingual nerve was severed. An attempt was made to identify the proximal segment of the right lingual nerve and re-connect the nerve. Despite the nerve being re-connected, the plaintiff continued to experience the same difficulties she had before the surgery and developed increased pain after the subsequent surgery.

Due to the increased pain, plaintiff was advised to consider exploring medication management so that she might better be able to evaluate the relative benefit and risk of medication management and at the time of trial plaintiff had decided not to undergo further surgery and was attempting to manage her pain and lifestyle limitations through medication.
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The United States Supreme Court recently decided a case that could impact the way the Georgia Board of Dentistry conducts business. The Court ruled on February 25, 2015 that a state regulatory board that is comprised mainly of dental professionals violates federal fair competition laws when it tries to restrict lower cost (non-dentist) competitors from competing with dentists by offering teeth-whitening.

While this case had little to do with Georgia’s Board of Dentistry, it does apply to it and, as the dissenting opinion noted, the decision could have far-reaching effects on what and how dental boards are allowed to regulate.
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As an Atlanta Dental Malpractice Lawyer, I am well aware that injuries caused by dental procedures often manifest themselves with a combination of numbness and pain. Many times, subsequent corrective surgery is not successful, and the client is left with no choice but to manage the pain with pain medications. Tegretol, Lyrica, Topamax, Gabapentin and Cymbalta are just a few of the many drugs used to help manage the intractable pain that many dental nerve injury victims suffer from. While the preferred course after a lingual nerve or inferior alveolar nerve injury is to surgically repair the nerve, the only course of action left after unsuccessful microneurosurgery is pain management.

In addition to surgical repair to reduce the nerve pain and pain meds, those suffering from dental nerve pain have, in varying degrees found some relief from the following:

Steroids –  a course of steroids such as Prednisone is typically recommended, within a few weeks of the nerve injury. 

Clonazepan – For the fastest relief of acute burning tongue, many clients have reported that clonazepan (Klonopin) is effective. 

Topical pain relief – Topical lidocaine or benzocaine. Pain patches can also be made with these topical pain relief medications.

Anti-inflammatories –  Aspirin, Tylenol, and other anti-inflammatory medications can provide relief by blocking the pain signals and reducing inflammation.

Anti-depressants – In addition to Cymbalta, Prozac, Lexapro, Paxil, Effexor,Norpamin, Lyrica, Zoloft, or Elavil have proven effective in helping clients deal with dental nerve pain. Many clients have also reported good pain relief with Gabapentin, Neurontin and Tegretol.

Vitamins, Homeopathic, and Alternative therapies – Many dental nerve injury sufferers believe that vitamins such as vitamin B are helpful in dealing with dental nerve pain. While I have not seen any literature to support this, it may be worth a try. Similarly, certain supplements such as St. John’s Wart has been suggested as helpful, however I am not aware of any peer-reviewed literature which support this.

As with most pain management treatments, a lot depends on trial and error. What might work for one person with one specific nerve injury, may not provide any benefit for another. Sometimes, a medication will be effective in relieving pain, but the side-effects (constipation, drowsiness, irritability, depression, anxiety, etc.) are too limiting and a lesser dosage of the effective drug or a different medication must be tried. The goal is to find a medication which is effective in dealing with the pain, but which does not cause side-effects that limit what one can do while on the medication in a way that effects their family and work life.

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As the past year comes to an end and we start a new year, I want to write about a common misdiagnosis for those who have suffered a dental nerve injury from malpractice. Bell’s Palsy is often the diagnosis given to patients who have suffered an injury to one of the trigeminal nerves in the face due to a negligent dental procedure such as a root canal, dental implant or tooth extraction. Unfortunately, this common diagnosis is often a misdiagnosis and ignores the source of the nerve problem (trauma to the nerve from a negligent dental procedure). The more accurate diagnosis for these patients who, many times, are suffering from numbness and pain at the same time, would be to identify the nerve that is damaged (i.e., inferior alveolar nerve, mental nerve, lingual nerve, or infra-orbital nerve) and diagnose it as an injury.
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The risks of toxic materials used during root canal therapy causing permanent dental nerve damage are many. However, some of the most common are: (1) inadequate imaging of the proximity of both borders of the inferior alveolar nerve canal. In fact, a common cause of dental malpractice is to assume that the visualized border of the inferior alveolar nerve canal is the superior (top) border when only one border is visible; (2) inadequate cone measurements, and (3) not limiting filling materials to the confines of the shaped root canal space. Other instances of potential dental malpractice during root canal procedures are:

• The pre-treatment radiograph not being of acceptable quality, both as an “angle of taking the radiograph” not adequately showing the visibility of the root tips and the contrast of the image;
• The post-treatment radiograph not being of acceptable quality, both as an “angle of taking the radiograph” not adequately showing the visibility of the root tips and failing to clearly show, not only the extensive root canal filling material in the inferior alveolar canal, but also the close and intimate proximity of the IA canal to the root tips of the tooth; 
• Not adequately measuring working length. The measurement of the length of the root is called the working length. The measurements in the chart must be accurate. If there are no “working length” radiographs or indication of the use of an electronic apex locator, it is below the standard of care and would likely lead to an over obturation of the canals. Based on the radiographs that usually appear in the patients chart, the working length of the tooth can be determined after the fact and can show if over-instrumentation was a cause of the nerve injury. This instrumentation (i.e., the root canal cleaning and shaping instruments, both with hand files and rotary driven files) beyond the apex of the roots would in itself cause significant damage to the inferior alveolar nerve
• Using the wrong root canal filling material, which can lead to an overfill of the filling material. Even worse, over-filling into the inferior alveolar canal using root canal cement, which, if in contact with the IA nerve, would cause anesthesia. 

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The inventor of the modern-day dental implant, Dr. Per-Ingvar Branemark has died. He was a true pioneer in dentistry, even though he was not a dentist. Perhaps the biggest advance that Dr. Branemark contributed was his discovery and development of the concept of “osseointegration.” This, in effect, allowed the widespread use of dental implants because osseointegration is the process in which the implant fuses to the jaw.
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As the year winds to a close, I have looked back at the new dental malpractice cases during the past year. Once again, the two most common forms of dental negligence which lead to facial nerve injuries are the placement of dental implants and root canal therapy. Most times, the negligently placed implant and the negligent root canal therapy are performed on the lower jaw (i.e., the mandible) and involve injury to the mandibular nerve, which is also known as the inferior alveolar nerve and its extension, the mental nerve.
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As a Plaintiff Georgia Dental Malpractice Lawyer, I am approached by many potential clients who believe that they may be the victim of dental negligence. Even though many of these cases involve serious (and often devastating) injuries, at the end of the day I turn down many more cases than I take. In fact, the vast majority of cases that are presented to us are turned down. The primary reason: although there is a severe injury, there is little indication based on what is told to me, that the injury was caused by malpractice.

Of the instances of malpractice that we do see, all of the malpractice that occurs in Georgia stem from 2 reasons: (1) A dentist does not possess a reasonable degree of education, training and skill to act prudently; or (2) despite reasonable education and training the dentist acts with unreasonable carelessness or fails to act as a reasonable and prudent dentist would under the circumstances.
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