Chronic gum disease ignored

A 56-year old lady was told that she had “gum disease” and could have a dental implant placed when the tooth was eventually lost. Many years later it was lost, but following her dentist’s retirement, her new dentist said that she couldn’t have an implant as there wasn’t enough bone left now. Does she have a case to be answered?

History

The lady in question (Mrs. J) stated that she had a long history of ‘gum disease’ but she went to her dentist’s office as directed, every 3 months for cleanings assuming it was keeping things stable. Her dentist never indicated a deterioration but did say that she might lose some or all of her teeth due to this ‘vulnerability to gum disease’ but that she should keep coming for the cleanings. She agreed, as it made sense; and continued. One tooth at the back bothered her from time to time but although she mentioned it, nothing was specifically said or done.

Sometime later after her dentist retired, her new dentist indicated that she should have the tooth out immediately as it was affecting the adjacent tooth. She agreed but asked if it could be replaced with an implant, as she didn’t want a denture. She was told that due to the action of her long-term gum disease there was no longer enough bone to support an implant. She asked why she hadn’t been told before, but sadly she lost both adjacent teeth.

Investigation

An independent examination, appraisal, interpretation and Expert Witness report highlighted the fact that had earlier intervention been made, timely treatment would most likely have seen enough bone to place an implant, even if involving some bone augmentation (grafting) services. As it was now, her only options were of a removable nature.

This situation was worsened as following the removal of the back tooth she started to experience some jaw joint problems most likely related to the loss of back teeth and exacerbated by the loss of this. This is not an unusual scenario as 2019 joint, ear and tension type headaches are among the not-uncommon consequences of joint problems (TMD) following back tooth removal (and removal of joint support.

Review

Going to the dentist regularly can be extremely beneficial but can also simply become a routine. There should not only be a clear and practical justification for dental treatment, but also it should be performed to the standard of care expected, and if possible, its progress tracked. In this case it was not tracked, and the results were most undesirable. Sometimes it is difficult in a busy practice to stop and reassess the patient’s needs as if they were new to the practice, however this level of insight is necessary for best care. If legal counsel is taken, a DEW can assist with his knowledge.

Unfortunately, occurrences such as this are not uncommon, and it becomes a question of the duty of,  and the standard of care. If the dentist has simply allowed his patient to remain a fee-paying member of his practice without review and simply “going through the motions”, clearly there is a breach of duty. If there have been inappropriate decisions (or none at all) then there may well have been a breach of duty and standard of care. The new dentist may choose to offer to correct this without cost as part of his transition good will, but he or she may not. Potentially the patient could be out of pocket, or out of luck regarding the dental care they now need.   

Conclusion.

Legal action was commenced against the retired dentist, his insurance company recognized the failure of care and made on offer of settlement. The lawyer requested further information regarding costs which after some investigation I was able to provide regarding who could perform the procedure required. (The x-ray shown reflects the level of bone loss experienced). The lawyer made a counter-offer based on the inadequacy of the initial offer, to cover all of the patients costs including travel to have the work performed, the case was settled out of court. I believe the patient and lawyer were satisfied.

Gum disease is an insidious chronic and usually painless destructive disease which must be screened for regularly and adequately managed when present with careful tracking. Adequate clinical skill, good communication and appropriate referral would likely have avoided this scenario.

Dr Stephen Bray

Dentistry and headaches?

A 17-year old girl experiences chronic headaches and her dentist recommends braces.

History of headache

The dentist of 17-year girl, Ms. B, discussed treatment for her headaches with her mother. Ms. B was fit and well with no significant medical history and had been fitted with braces three years ago, achieving an acceptable cosmetic result before they were removed. She did not wear her retainers provided to her by her orthodontist and her teeth had recently begun to become very slightly crowded again.

She had recently began to experience headaches to which her doctor had prescribed painkillers. Her dentist felt that the headaches would be improved by re-straightening her teeth with “Invisilign® braces”.

Although Ms. B. wasn’t keen on braces having experienced them previously, the dentist felt that this was the only way forward and felt it worthy of performing. They proceeded and the headaches did initially improve. However, after a few months the headaches returned, “worse than before”, and the dentist suspended treatment and instructed her to leave her braces out. The pain diminished slightly and the dentist said he’d only charge the mother for the cost of the diagnosis and manufacture of the braces. The mother spoke to a lawyer who in turn suggested obtaining an Expert Witness’ Report.

Investigation of facts

Ms. B was examined and a report prepared. The investigation illustrated that her headaches had in fact commenced following her original orthodontic treatment some time ago; when teeth were removed and her crowded teeth straightened. Her history went on to show that these earlier low-grade but chronic headaches had worsened into “migraines” (as described by the mother) but there was no connection made with the orthodontics – and the orthodontist had blamed them onto stress.

The worsening of her initial headaches relating to her orthodontics did seemed to coincide with exams at school which were therefore considered their cause.

The Expert Witnesses’ report indicated that these might indeed be tension type headaches but felt that chronologically, physiologically and from his own anecdotal experience, there was most likely a connection between the initial orthodontics and headaches.

With no evidence that orthodontics would manage headaches, the general dentist chose to refund all monies to the mother.  

A discrepancy between Ms. B’s bite (jaw position) when her teeth were apart and then by comparison when her teeth were closed together was noted, appearing as a shift of her lower jaw backwards and to the side, upon tooth ‘closure’. This was considered as significant, as literature does support this as a ‘possible’ factor in precipitating headaches.

Clinical Case Review

The orthodontist refused to consider that his treatment might be related to Ms. B’s headaches. The report made recommendations as to present and future options which included a short-term splint to align her jaws according to their correct position (not where her teeth fit together). This alleviated the pain immediately and it was suggested that she wear it, decreasing wear each week.

Recommendation to close the case

In this case the Expert Witness suggested that the chance of winning the case was compromised due no precedent of s successful action, despite widespread publicity against the removal of teeth – it was said, “to give enough room for the remaining teeth”.

Legal questions arising

It may be possible to prove a cause and effect relationship (despite the strong belief held by orthodontists that their treatment cannot cause headaches and/or dysfunction) because the judge is not an orthodontist, however the orthodontic fraternity is a strong one and the case, unfortunately and unreasonably though it may seem, was likely to be robustly and aggressively contested and defended in order that there be no precedent despite the chronologic evidence.

The role of the Expert Witness is to give honest and impartial evidence, but where science is not involved his (or her) opinion and recommendations should be based on likelihood. In this case it is extremely unlikely that the case would have received a successful outcome for the plaintiff.

Author – Stephen Bray DDS

Multiple injuries all the same?

Eight people sustain similar whiplash type injuries in a two-car accident.

Accident History

Eight people (four in each car) sustained similar type injuries when two cars collided late one evening at a poorly lit intersection. No drugs or alcohol were believed to be involved although none of those injured spoke English, so determination of the facts was harder to achieve. Each had claimed that they’d hit their mouths but since little damage appeared to have been done to the cars, the insurance company asked the DEW to review the case.

Accident Investigation

The people were examined but inconsistent findings noted. Further careful investigation of previous dental records by the DEW revealed a previous and similar accident in which two of these eight claimants were also involved. The facts were incorporated into the DEW’s report and submitted to the defendants counsel. A pretrial meeting saw the case dropped by the claimants counsel. The defendant’s counsel intimated the possibility of a counter claim but it was not pursued.

Review

From the Dental Expert Witness’ Report it was clear that the “accident” was a scam. Such actions may drive up the cost of insurance premiums. While whiplash injuries are sometimes less easy to apportion costs to than direct and more “obvious” injuries (like a fractured bone), an experienced clinician can often determine the likelihood of injury. Experience (and a degree of insight) can allow the Dental Expert Witness to investigate appropriate records and discover aspects of a case that would otherwise not likely come to light.

Q&A

Would this claim have been immediately considered spurious when in fact the occupants may have had legitimate claim?

It is said that, “All presumptive evidence of felony should be admitted cautiously, for the law holds that it is better that ten guilty persons escape than that one innocent suffer”. Do you think this example is unique? The Dental Expert Witness may throw fact on what may appear frivolous, can prepare a report for a defendant or claimant (plaintiff).

Author – Stephen Bray DDS

Car accident and headache?

A 45-year old lady involved in a rear end car accident starts to get headaches immediately after it.

Accident History

When stopped in a traffic jam on a bridge entering a B.C. City, Mrs. A was involved in a rear end collision.

She was stopped and the impact was estimated to be around 30 mph. She felt shaken up and dizzy when the ambulance arrived but had not lost consciousness. She was sent to hospital. As nothing significant was found, she was sent home but told to come back if any problems arose.

She saw her doctor regarding headaches that came about shortly there after, who prescribed physiotherapy. Mrs. A. tried that, but preferred her chiropractor’s treatment which improved but did not resolve her problems. Her headaches persisted.

She commenced a personal injury claim against the other motorist and his insurance (ICBC). Her lawyer recognized the possibility of jaw joint involvement and contacted an Expert Witness in Dentistry.

Investigation

The DEW determined that Mrs. A. had experienced some jaw joint dysfunction previously after an earlier MVA and it was her lawyer’s concern that the defense’s argument would be that the injury occurred then, not at the recent accident.

The expert witness was able to estimated the degree of dysfunction and likelihood of further damage based on fact and science illustrating that further and significant damage had most likely occurred at the recent accident.

His report was prepared in readiness for court but upon reading the report, evidencing the likelihood of headaches and dizziness by that injury and that intervention would be required, ICBC chose to “settle out of court”.

Accident Review

Without involvement of a Dental Expert Witness the degree of injury sustained during the injury could not have been compared to that sustained during the previous accident, nor indeed that which may have been present prior to even that.

Equally so, the connection between the jaw injuries and her apparently unrelated symptoms would likely not have been made. There is a clear connection between jaw joint pain and dysfunction (temporomandibular dysfunction – TMD ), and Whiplash Type Injuries (WTI).

Without his report to assist in presenting the facts, the offer made by ICBC would likely have been lower, the case may have gone to court and Mrs. A’s symptoms may have not been identified as treatable.

Investigation outcome

Did Mrs. A’s claim benefit from the expert witness’s’s report?

The plaintiff’s lawyer believed so and has used that expert witness successfully on more than one occasion subsequently.

Author – Stephen Bray DDS

Workplace Injury

A 30-year old man slips at a construction site, banging his mouth. Two teeth are lost as a result of the accident.

History

Working on a BC construction site a 30-year old man Mr. C. slipped and hit his mouth on a wooden plank, loosing two front teeth. Mr. C. was covered by site “work safe” insurance and claimed through a local dentist for treatment to replace them.  His dentist immediately submitted a claim to replace them. After hearing comments made in the local bar, the site manager suspected something was amiss, as it appeared that Mr. C was soon to leave his employ and move to a different Province.

Investigation

A Dental Expert Witness Report was requested by the company’s legal counsel and upon his clinical examination; the sockets from which the teeth were lost appeared advanced in their healing. There was therefore some question as to whether the teeth were actually lost at the time of the reported accident. Careful investigation uncovered dental records indicating that the teeth had been removed as an emergency procedure a week prior to the alleged accident, by a dentist in Mr. C’s home Province (to which he would be moving back shortly) thus demonstrating that the loss of the teeth was not due to the alleged fall. Upon discussing this with Mr. C. he said that he’d seen blood and thought they were two different teeth. His claim for a replacement fixed bridge was withdrawn.

Review

Such actions drive up the cost of insurance premiums and the cost of “doing business” for companies. Relying on honesty may not work for everyone – both the alleged injured claimant and the dentist claiming for the work to be performed, can make ‘mistakes’. The use of an Expert Witness’ Report is often a responsible and prudent response to personal injury claims be it workplace or other.

Author – Stephen Bray DDS