Articles Posted in Dental Malpractice

Endodontic Treatment (“root canal therapy” or “RCT”) of mandibular molar teeth has the potential to result in damage to the inferior alveolar nerve due to direct trauma, pressure or neurotoxicity. As an Atlanta dental malpractice attorney, I find that many of these dental nerve injuries are caused by dental malpractice, with the biggest number of dental nerve injuries being caused by root canal overfills or over-instrumentation. Extending the root canal files past the root tip apex and into the lower jaw (mandible) causes damage to the inferior alveolar nerve and extending the root canal files past the root tip apex in the upper jaw (maxillary) can cause nerve damage in the upper face to nerves such as the infra-orbital nerve. Many times, patients who have suffered injuries due to this deviation from the dental standard of care are diagnosed with trigeminal neuralgia. However, this is not a precise diagnosis and a second opinion with a micro-neurosurgeon who specializes in oral surgical procedures may prove helpful.
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As a 2007 study indicates, overfilling the roots with sealant during a root canal procedure can cause permanent nerve damage if not treated promptly. As the article concludes, “early surgical exploration and debridement may reverse the effects of endodontic treatment that is below the standard of care and results in gutta-percha being deposited into the inferior alveolar nerve canal.

In the study, 61 patients who sustained root canal overflow injuries were tracked over an eight-year period. Eight patients were asymptomatic (i.e., they did not report any signs or symptom of an injury even though they sustained the overfill) and received no treatment. Forty-two patients exhibited only mild symptoms or were seen more than three months after undergoing root canal therapy, and they received no surgical treatment. Only 10 percent of these patients experienced any resolution of symptoms. Eleven patients underwent surgical exploration. Five of these patients underwent exploration and received treatment within 48 hours, and all recovered completely. The remaining six patients underwent surgical exploration and received treatment between 10 days and three months after receiving endodontic therapy. Of these patients, four experienced partial recovery and two experienced no recovery at all.

According to WebMD, a root canal procedure is performed as follows:

• First, the dentist will numb your gums with a substance that feels like jelly. After your gums are numb, the dentist will inject a local anesthetic that will completely numb the teeth, gums, tongue, and skin in that area. Sometimes nitrous oxide gas will be used to reduce pain and help you relax.
• The dentist may separate the decayed tooth from the other teeth with a small sheet of rubber on a metal frame. This protective rubber sheet also helps stop liquid and tooth chips from entering your mouth and throat.
• The dentist will use a drill and other tools to remove the pulp from the tooth and will fill the inside part of the tooth below the gum line with medicines, temporary filling materials, and a final root canal filling.
• After the root canal, a permanent filling or crown (cap) is often needed. If a crown is needed, the dentist removes the decay and then makes an impression of the tooth. A technician uses the impression to make a crown that perfectly matches the drilled tooth.
• The tooth may be fitted with a temporary crown until the permanent crown is made and cemented into place.

There are many reasons why a root canal overfill occurs, but since this is a complication that should not happen absent malpractice, there usually exists a dental malpractice case if you suffer from an overfill. If you are suffering from this nerve injury after Root Canal Therapy (“RCT” or a root canal), you should consult with an experienced dental malpractice attorney.
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According to some sources, between 3 and 5 million dental implants are installed each year in the United States. As an Atlanta Dental Malpractice Attorney, I have noticed that the number of injuries to the facial nerves has increased due to the increase in the number of implants being installed.

In layman’s terms, implants are installed by extracting the bad tooth, drilling a pilot hole, installing a post in the pilot hole, allowing the tissue and bone of the jaw to grow around and solidify onto the post (this is known as osseointegration), placing an abutment over the top of the post, and then placing a crown over the abutment.

In many cases, dental malpractice causes injury to the nerves that run along the alveolar ridge (the most common being the inferior alveolar nerve and the lingual nerve). Most of these injuries are caused by the dentist not properly calculating the distance to the nerve from the post. In other words, many of these injures occur because the pilot hole for the post is drilled too deep and into the nerve or the implant is screwed too deeply into the jaw which results in the nerve being crushed.

The are a number of procedures that the dentist should employ if the risk of injury is known. If, during surgery, known or observed trauma (including traction or compression of the nerve trunk) has occurred, the topical application of Dexamethasone is suggested. One to two ml of the intravenous form of Dexamethasone (4mg/ml) may be topically applied. The direct application of steroids will reduce neural inflammation and reduce compression from swelling, which may enhance recovery from neurosensory deficits. No morbidity has been associated with topical steroid application at the nerve injury site, yet significant improvement in post surgery recovery has been observed. This should be followed by a six-day regimen of oral steroids (which many patients know as a steroid pack). If known nerve trunk transection is clinically observed during the surgery, immediate referral to a nerve repair specialist is highly recommended.

The most important physiologic therapy at the time of surgery includes removal or repositioning of any irritant (implant, bone screw) in close approximation to the neurovascular bundle. In other words, if the implant was not planned properly and it is invading a nerve canal, it should be removed immediately and re-position so that it does not interfere with the nerve. A radiograph or CT scan immediately after implant placement is warranted to insure the nerve is not violated. If a post operative radiograph indicates the implant may encroach upon the IAN, it may be removed, a steroid introduced into the osteotomy site and then a shorter length implant replaced in the same site in a more ideal location.32 No bone grafting materials should be placed in the osteotomy site, since it may invade the mandibular canal and interfere with nerve repair.

Extreme care should be used by anyone contemplating a dental implant procedure. One should make sure the dentist performing the implant is experienced and skilled — and that the equipment that the dentist is relying on to properly evaluate the distance to the nerve is state-of-the-art, properly calibrated and accurate.
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According to a recent article, dental implants are riskier than many are lead to believe. As an Atlanta lawyer who specializes in dental malpractice, I have seen a wave of dental malpractice claims related to the improper placement of dental implants. To be sure, the technological advancements regarding dental implants are stunning, but the implant is only as good as the dentist who installs it.
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Dental Implants are an effective treatment for missing teeth. In fact, they are the preferred treatment because they integrate into the jaw just like you natural teeth. Unfortunately, with the rise of dental implant procedures, there has been a rise in dental malpractice claims caused by these implants procedures. The following are the most common types of malpractice-related injuries:

(1) Tissue or nerve injury– Dental implants are an invasive procedure. When the implants are screwed into place, common problems include abnormal swelling of the tissue surrounding the implant. If proper care is not taken by the dentist, this tissue can become infected and lead to other complications. Another problem caused by dental implant malpractice is nerve damage. Nerve damage occurs when the implant is placed too close to the nerve, or in extreme cases of malpractice, when the implant is screwed through the nerve canal and into the nerve itself. If this happens, the implant must be “backed out” as soon as possible, but in most cases, if the implant is in the nerve, the resulting nerve damage is irreparable. Explicit recommendations for pre-operative radiographic evaluation prior to placement of implants can help prevent nerve injuries. Cone beam CT scanning, can provide improved imaging for planning implant treatment.  Many dentists also use software to assist in the planning of implants and for the identification of the inferior alveolar nerve “IAN” canal position.  Most cases of paresthesia can be prevented but not remedied. However, when this problem occurs, follow-up must be initiated quickly, since the first few months may determine the degree of nerve healing. Many dentists fail to timely treat or refer injured patients to a nerve specialist in order to try to cover up their mistake, however, this is rarely successful and amounts to nothing more that an additional count of negligence against the defendant dentist in the dental malpractice lawsuit.

(2) Sinus Complications — these occur when the patient receives a maxillary implant (to replace an upper tooth) and the implant “communicates” with the sinus and causes infections and other unpleasant side effects. In many cases, this happens because the dentist failed to do a pre-implant sinus lift which can alleviate these possible sinus problems.

This happens all too often here in Atlanta and in other parts of the country but I rarely take the time to write about it. However, I feel compelled to share what happened recently to help other victims of dental malpractice. I received a call from a very nice woman who clearly had a very serious dental nerve injury from a dental procedure. She was frustrated and troubled because she has had intense pain and paresthesia (numbness) in her lower lip, the corner of her mouth and her facial skin, since a general dentist installed implants in replace of teeth #30 and 31. These are the two last mandibular molars on the right side (assuming that the wisdom tooth and that side has been extracted). The reason for the pain and numbness? The general dentist placed the implants into the nerve canal when installing them. Then he backed them out to weeks later. In other words, the dentist crushed her mental nerve by screwing the implants through the nerve canal and into the nerve itself. Apparently, the dentist did not perform the pre-implant procedure testing and planning that is required by the standard of care for dentists under similar circumstances. This is an implant procedure complication that is almost always caused by malpractice and is easily avoidable.
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As a Georgia trial lawyer who specializes in Dental Malpractice, I represent clients who have suffered lingual and inferior alveolar nerve injuries and other maxillofacial nerve injuries caused by Oral Surgeon dental malpractice. Today, I read that an oral surgeon in Oklahoma who has “voluntarily” closed his offices after health officials began investigating his dental practice.

Despite his office’s “spiffy” facade, this oral surgeon is being investigated for contributing to the spread of hepatitis and the HIV to his patients. State and County inspectors raided the Oral Surgeon’s office and found evidence of employees using dirty equipment, re-using syringes, and administering drugs without a license.

This lack of quality assurance and proper medical protocol is appalling and I must say that it is not the norm. The injuries that I see most often result from dental errors during a number of dental procedures as follows:

DENTAL IMPLANTS

Nerve injuries related to dental implant treatment is becoming an increasing problem. The incidence rate of implant-related inferior alveolar nerve (IAN) nerve injuries varies greatly but can approach 40% of some patients. 25% of edentulous patients (those without any of their natural teeth left) present with a degree of altered IAN function, thus reinforcing the need to follow guidelines and the standard of care on the necessity of pre-operative neurosensory evaluation. 3-D scanning now available in many specialist practices and dental hospitals provides improved imaging for planning implant placement with little radiation exposure.

ROOT CANAL PROCEDURES

Any tooth requiring endodontic treatment that is in close proximity to the IAN canal should be given special attention by the dentist. If the canal is over prepare’ or the apex opened, chemical nerve injuries from irrigation of root canal materials is often the result.

WISDOM TOOTH EXTRACTIONS

Third molar surgery or extraction-related inferior alveolar nerve injury is reported to occur in up to 10 % of all extraction cases. Factors associated with IAN injury are age, difficulty of surgery and proximity to the IAN canal. If the tooth is closely associated with the IAN canal radiographically, i.e., it is superimposed on the IAN canal, darkening of roots, loss of lamina dura of canal, or deviation of canal  which is probably due to interference of the root with the inferior alveolar nerve canal, then the risk of nerve injury doubles according to some reports in the dental literature.
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Injury to a nerve is the most common problem I encounter as an Atlanta Dental Malpractice Attorney. This type of injury is caused by the implant being too long for the application or being screwed too far into the bone and compromising the inferior alveolar nerve canal.

Unfortunately, this type of dental nerve damage is almost always permanent. While damage to skin tissue or bone often heals, the same cannot be said for nerve injuries. This underscores the need to avoid the malpractice that causes these injuries in the first place by, for instance, not relying solely on x-rays (which sometimes lack the clarity needed to know the exact distance to the nerve canal). There are a number of more advanced and more accurate tests that can be performed prior to conducting dental procedures that place the inferior alveolar nerve, mental nerve and lingual nerve in danger. Often, the dental malpractice standard of care requires that these tests be performed prior to the procedure to protect against damaging these nerves. In addition, the standard of care requires a number of procedures to be performed after the dental procedure to ensure, despite the dentist’s best efforts and proper pre-procedure planning and testing, that the nerve has not been injured.

In addition the resulting numbness, many patients suffer from debilitating pain. Many find this hard to comprehend (i.e., how can I be numb and have severe pain at the same time in the same area). Suffice to say that the interaction between the central nervous system and sensory nerves are extremely complicated and that there is a very complicated medical explanation, but we can leave it at: it is possible and it does happen to many of my clients who are the victims of dental malpractice while undergoing dental implant procedures.
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With the new year upon us, many people contemplate dental work as a way to have a new beginning or to get ready for the new year. As an Atlanta Dental Malpractice lawyer, I am far too aware of injuries that can result from botched dental work.

Dental implants, root canals, and wisdom tooth extractions are just three of the many dental procedures that result in serious nerve injuries to the lingual and inferior alveolar nerves. It’s a simple (not simplistic) error that dentists make that cause these injuries. Most times, the injury occurs because the dentist does not take into account the distance between the tooth root and the nerves, or worse yet, doesn’t even bother to take pre-procedure x-rays or CBCT scans to make sure there is sufficient room between the tooth roots and the nerve or nerve canal.

Dental implant procedures are “in” these days and they are effective, if performed within the standard of care. Unfortunately, we are seeing a lot more clients coming into our office complaining of dental nerve injuries after the dental implant was placed too deep into the jaw. Many doctors who treat these nerve injuries, refer to them as trigeminal neuralgia or trigeminal nerve injuries. While this is a rather imprecise diagnosis in my opinion, it is widely used by neurologists and other medical professionals who do not treat dental nerve injuries on a regular basis because the trigeminal nerve supplies the face, eyes, mouth and scalp with  sensations such as touch, pain, and temperature.

According to the Trigeminal Foundation, trigeminal nerve injuries can cause episodes of intense, stabbing, electric shock-like pain in the areas of the face where the branches of the trigeminal nerve are distributed: the lips, eyes, nose, scalp, forehead, upper jaw and lower jaw. Sometimes you may notice pain with touch or when a cold breeze hits your face. This is a common complaint of clients who have suffered this type of dental injury.

Eating, speaking, drinking, brushing your teeth, shaving or applying makeup may all be difficult because of the changes in feeling. Examples of some patients with these nerve injuries.
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Most people don’t consider that dental malpractice lawsuits make up a considerable portion of the overall number of medical malpractice lawsuits filed in Georgia. Dental malpractice suits make up their own category, and like all other healthcare professionals, dentists are legally responsible when unacceptable treatment services are rendered.

The total number of dental malpractice claims continues to rise each year. Some examples of injuries that cause dental malpractice lawsuits to be pursued are injuries to the jaw (such as a broken jaw), lip and tongue nerves, injuries associated with anesthesia and death.

For example, a dentist must make sure that his or her patient has no prior medical conditions requiring special treatment before giving anesthesia or if the dentist fails to detect oral cancer or other oral diseases he/she is liable.