Practice More Safely // Risk Tips // Death Following Extraction on Coumadinized Patient

Death Following Extraction on Coumadinized Patient

Case Study

Marc Leffler, DDS, Esq.
July 28, 2025

Reading time: 8 minutes

Background

An experienced oral and maxillofacial surgeon (we’ll call him Dr. A) on the verge of retirement from practice was greeted as he entered his office one morning by a process server who handed him a Summons and Complaint — it alleged that he caused the wrongful death of one of his patients, but it had no further details. At first glance, the oral surgeon had vague recall of the patient whose estate filed the suit, but he did not remember any problems with the patient’s treatment which was over a year earlier.

He immediately pulled the patient’s chart – all handwritten – to review it, in advance of getting in touch with his dental malpractice carrier. He was soon contacted by the assigned attorney representing him, and they agreed to meet the following day, as strict time limits existed regarding when a response on behalf of the oral surgeon needed to be filed.

The oral surgeon’s attorney contacted the attorney for the plaintiff to try to understand the underlying circumstances. The plaintiff’s attorney conveyed back that this was a simple case: Dr. A had extracted the patient’s tooth, which led to a significant post-operative bleeding event on the day of extraction, which caused the need for emergency transport to a local hospital, where the patient (age 77) died. The plaintiff’s attorney suggested a quick settlement to save the family a stressful legal process. As would later be learned, those reported case facts were all true, but critical events – which would guide the entirety of the litigation and its resolution – were left out of the description.

Treatment Background

Dr. A and his attorney went through the dental chart together to work through the course of treatment. The patient initially presented, on referral from a general dentist, for evaluation of a non-restorable tooth. Then, the patient said that he was unable to understand the questions on the medical history form, so the oral surgeon, instead, verbally discussed with his new patient any existing medical conditions: the patient disclosed that he was taking Coumadin due to a history of a “blood clot” (deep vein thrombosis), and Toprol for hypertension. Dr. A simply noted “Coumadin and HTN” in the chart for medical history, and called the patient’s physician after determining that the patient needed an extraction; the physician said a subsequent dental appointment should be scheduled a week later rather than treating that day so that the physician could see and evaluate the patient.

Unbeknownst to the oral surgeon, the physician then told his patient to stop taking Coumadin for 4 days prior to that upcoming dental appointment and to obtain a blood test the day prior to it. The patient did exactly that, and his physician then advised him to tell Dr. A that he may proceed with the planned procedure, and that the patient should re-start his Coumadin 2 days after the extraction. The patient reported to Dr. A only that his physician had told him that he may proceed, but he did not mention, nor was he asked about, Coumadin stoppage and testing. All went forward without complication, with Dr. A having never again communicated with the physician.

The patient next appeared nearly a year later for what would be his final visit, complaining of a loose, annoying upper first molar. Radiographic and clinical examination demonstrated a periodontally hopeless tooth, so the oral surgeon, after calling the patient’s general dentist, suggested extraction and the patient agreed. Dr. A asked the patient how his health was, and he responded – according to Dr. A – that he was doing well, but his blood pressure medication had been changed to better control it. That was the entirety of the conversation, with the issue of Coumadin never mentioned by doctor or patient, although the subsequent medical records clearly revealed that he continued to take Coumadin as of that time.

Dr. A routinely extracted tooth #14 and debrided the associated granulation tissue. He applied gauze pressure to the site and good hemostasis was achieved. The patient was discharged home with a packet of extra gauze, and instructions to place additional gauze on the site as needed. The patient’s son, who knew his father was going to the oral surgeon that day, was unable to reach his father that evening, so he drove to his father’s house, to find him conscious, but lying on the floor with blood seeping out of his mouth. An ambulance was called to transport the patient to a local hospital.

At the hospital, the patient was admitted and transfused. Laboratory values showed that the patient had an elevated INR, as would be expected in a Coumadinized patient. A hematologist managed the patient’s anti-coagulation and was able to medically stabilize him within a fairly short time. However, the laboratory studies also, unfortunately, revealed that the patient had an advanced, aggressive form of leukemia, which had not previously been diagnosed. After a work-up and a discussion of treatment options, the patient agreed to start a course of chemotherapy, but he stopped it several days later due to side effects that he found intolerable. Palliative therapy was provided at the hospital, but he soon passed away.

Legal Steps Taken

Once defense counsel obtained all relevant medical records and had experts review them, it was apparent that Dr. A was negligent in failing to take an adequate medical history at the subject extraction visit — so as to have ignored questioning the patient as to whether he was still taking Coumadin, thereby leading to the bleeding event which hospitalized him. But, it was equally clear that it was the entirely unrelated leukemia which caused the patient’s death.

Defense counsel contacted the plaintiff’s attorney, asking for discontinuance of the action because there was no good faith basis to maintain a wrongful death claim. Plaintiff’s counsel argued that it was the oral surgeon’s negligence which put him in the hospital due to uncontrolled bleeding, but the oral surgeon’s attorney reminded him that the only claim was for wrongful death, which was not caused by the defendant, and that the statute of limitations had expired as to any potential bleeding-related claim, thereby precluding its addition at that point. Ultimately, the plaintiff’s attorney relented, and discontinued the case.

However, the estate executor and plaintiff – the patient’s son – was upset that Dr. A was not held accountable for his negligent actions, so he filed a disciplinary complaint with the State. Disciplinary bodies, unlike courts in malpractice litigation, do not consider what result came of a dentist’s claimed improper actions, but only whether those actions constituted professional (i.e. appropriate) or unprofessional conduct — the latter of which is sanctionable. In this case, the disciplinary agency determined that Dr. A had acted improperly with regard to his record-keeping, specifically relating to his taking and recording of the patient’s medical history at the extraction visit. The oral surgeon was given a stayed suspension and a fine, and was required to take continuing education classes in the subjects of history taking and dental charting during his next license renewal cycle.

Takeaways

Beginning with a legal issue, this case demonstrates the importance of immediate reporting to the malpractice carrier, so that counsel may be immediately assigned — not only for the purpose of filing timely response papers, but to allow counsel to evaluate the lawsuit’s pleadings to assess what the claims specifically are. Here, defense counsel was able to determine that the sole claim involved a wrongful causing of death, so that the review of the oral surgeon’s chart and the subsequent medical records could be focused toward assessment and defense of the pending legal claims. Yes, this patient died after dental treatment – albeit well after that treatment, a fact not initially disclosed by plaintiff’s attorney – but it turned out to be unrelated to the defendant’s care. For a valid claim in dental malpractice, there must be negligent treatment which directly causes the injuries claimed.

A common theme explored in legal case studies is the importance of proper record-keeping, which simply cannot be emphasized enough. In this case, even if Dr. A did appropriately discuss medical history with his patient, he did not record having done so. Therefore, a reasonable inference may be drawn, including by a jury, that what was not recorded did not happen. While that issue did not play out in this malpractice case scenario, it was the focus of the discipline levied against the oral surgeon.

Dental providers are well served to present their patients with printed medical history forms, which are then supplemented through a back-and-forth discussion, so nothing of relevance is omitted; if patients, as here, are unable to complete such forms on their own, then a thorough reading through with the patient is in order. Simply asking a patient, “Are you in good health?”, as is done with surprising frequency, leaves it to the patient to evaluate and report what conditions might be significant. Furthermore, a patient’s failure to disclose on a written form carries far more defense weight before a jury than conflicting stories about what was or was not said. Similarly, if physician consultations are requested, a written response from the physician, or minimally, a contemporaneously documented conversation between dentist/oral surgeon and physician will eliminate issues associated with gaps in patient recall and/or which may confuse a patient.

While the purpose of this case study is not to dictate what actions practitioners should or should not take in given situations, it is worth pointing out that health conditions which might quite reasonably affect dental treatment outcomes should be given due consideration, and that can only happen through careful taking and review of medical histories.

Finally, this case demonstrates the value of open communication and a strong professional relationship between oral surgeon and defense counsel familiar with the subject matters at hand.

Note that this case presentation includes circumstances from several different closed cases, in order to demonstrate certain legal and risk management principles, and that identifying facts and personal characteristics were modified to protect identities. The content within is not the original work of MedPro Group but has been published with consent of the author. Nothing contained in this article should be construed as legal, medical, or dental advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your personal or business attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

When patients seek a second opinion after an unexpected outcome, even measured criticism from another provider can fuel doubt, escalate into “jousting,” and lead to a malpractice lawsuit. This case study demonstrates how clear documentation, realistic expectation-setting, and a strong informed consent process can help OMS manage malpractice risk.

Key concepts

How "jousting" can stimulate the initiation of malpractice lawsuits
Risks associated with setting unrealistic treatment expectations
Documentation and defending care decisions

Background facts

Dr. Y was one of several oral and maxillofacial surgeons practicing in and around a well-populated suburban community. Although most of her practice involved dentoalveolar treatments and implant placement, she maintained privileges at a local hospital for the rare need to hospitalize her patients. A requirement for maintaining privileges was taking emergency call one weekend every three months, as there were no residents on staff, but emergencies requiring coming to the hospital were few and far between. Dr. Y had done little in the way of trauma surgery in the 14 years since the conclusion of residency.

A multi-vehicle, high-speed accident occurred on a Sunday evening, some 20 miles from the hospital. The most severely injured were taken to a trauma center, but space there quickly filled up, leaving less seriously injured patients to be taken to smaller hospitals, including where Dr. Y was on staff. The only injury found after initial evaluation of T, a 28-year-old bus passenger, was a zygomatic arch fracture on her right side, which apparently occurred when her face hit the back of the seat in front of her. When Dr. Y, who had been called to attend to this patient, examined T, she found significant swelling associated with the right midface that correlated with radiographic and clinical evaluations. Dr. Y noted and documented that there appeared to be a facial nerve deficiency associated with the zygomatic branch of cranial nerve VII.

By way of a face-to-face discussion, Dr. Y explained that she would approach the depressed fracture through an intraoral incision to avoid facial scarring and then tunnel upward with a heavy zygomatic elevator to “pop it back into place.” To allow the bone to heal afterward, Dr. Y would place an external device over the arch so that T would not roll onto it while asleep or otherwise inadvertently put any inward-directed pressure on the area. Dr. Y explained that she “expected everything to be back to normal within a couple of months.” After agreeing and signing a standard generic hospital “consent for surgery” form, T was taken to the OR where, under general anesthesia, Dr. Y uneventfully performed exactly what she had described to T. T was discharged home the following day, with instructions to see Dr. Y in her office the next week.

There were weekly office visits for the first month, with two visits the second month and a final appointment at the three-month mark. The fracture was stable, all swelling had resolved, and T was functioning fully normally, with one exception: T never regained the ability to close her right eye. Dr. Y acknowledged the problem and told T that the nerve's function might not ever return, leaving T with the same condition permanently. T responded with, “But you told me everything would be back to normal by now.” Dr. Y explained that, most often, traumatically induced nerve injuries like this do normalize, “although nothing is 100%.”

T was dissatisfied with both the result and Dr. Y's explanation, which she had not fully set out from the start, so she visited a facial plastic surgeon for a second opinion. That surgeon concurred with Dr. Y's assessment of a low likelihood of nerve recovery, but also commented that, had he been the one treating the fracture, he might have chosen a different approach — without providing the details of that difference — and the nerve might have recovered. T asked the plastic surgeon to put that opinion into a written narrative, which he did.

Legal action

When T saw an attorney who advertised regularly handling medical malpractice cases, she brought the plastic surgeon's note with her. She was distressed by the aesthetic impact of her inability to close her eye and the need for her to use eye drops daily. The attorney concluded that the surgeon's note adequately presented a viable case against Dr. Y, so he proceeded on T's behalf by filing a malpractice lawsuit against Dr. Y. The papers claimed negligence in the type of surgical procedure chosen and performed, and lack of informed consent.

Based upon state-specific rules, the attorneys assigned to Dr. Y by her malpractice carrier were not able to file a motion to dismiss the case until a shortly later stage of the case. At the appropriate time, they did submit such a filing, in which they argued, in essence, that the nerve was already injured before Dr. Y intervened; that the opinion of T's expert included the words “might have” with regard to the two main points of claimed negligence and injury (namely the surgical approach and nerve function); that there are multiple accepted surgical approaches to repair a depressed zygomatic arch fracture, with the choice being wholly within the judgment of the treating surgeon, at the time of surgery rather than looking back on it; and that no reasonable person would have refused surgery to repair a severely fractured facial bone, even if return to normal nerve function would never occur. An oral and maxillofacial surgery expert retained by Dr. Y's attorneys echoed these concepts in the court papers.

The attorney for the plaintiff, T, obtained a further document from the plastic surgeon with whom T had consulted. The surgeon was no more definitive in the second document than he had been in the first. In deciding the motion, the judge explained that the burden of proof, “more likely than not,” must be met by a plaintiff as to each element of the case, with words such as “might have” failing to meet that burden. Furthermore, based upon local doctrines that were applicable here, the “reasonable person” standard regarding informed consent would carry the day, particularly because this was a true emergency situation. The case against Dr. Y was dismissed by the court in its entirety.

Takeaways

Much like already-in-progress procedures taken over from other providers, trauma surgery presents a set of unknowns which, in some sense, the oral surgeon who takes over and completes the surgery “buys” whatever existed as of the start of the second intervention. As this case demonstrates, that does not necessarily equate to liability for what happened previously, but it also does not necessarily mean that plaintiffs and their attorneys will not try to assert and prove such a claim. These types of situations are, for better or worse, part of oral surgery practice, so oral surgeons should be aware of that. Perhaps the best way to set up what might later be needed to defend such allegations is what is greatly helpful in the defense of many malpractice claims — timely, accurate, and complete documentation. That is as good a counter as is possible against an often-used approach by plaintiffs' lawyers that “if it wasn't written, it didn't really happen.”

Exceptions to the need to obtain informed consent vary between the states, sometimes significantly, so it is up to oral surgeons to know, at least basically, what local rules require. It is far from uncommon for exceptions in this regard regarding emergencies to exist, but as with much in the law, interpretations come into play. One person's definition of an emergency can readily differ from that of another person, so those components of the competing arguments are what will likely lead to a judge's ultimate determination. Oral surgeons should not necessarily count on exceptions to statutory concepts like informed consent, so whenever possible, it is most prudent to stick to the true “letter of the law.”

In this case, Dr. Y set up an anticipation of end-of-day normalcy in her explanation to T of what to expect. With the benefit of hindsight, an argument can readily be made that a less definitive and more open-ended “prediction” of future nerve function would have been safer from a risk-protective standpoint. As the (trite) saying goes, words matter, and that is particularly true when discussing all aspects of risks, benefits, and alternatives. The plastic surgeon's words changed the entire trajectory of the litigation, and the words of Dr. Y could just as easily have done the same, but in the opposite direction.

The comments by the plastic surgeon that were critical of Dr. Y's surgical approach are referred to as “jousting,” which is a frequent inspiration for patients to act on taking steps to sue the doctor(s) criticized. Jousters never stood in the shoes of the original treater at the time of treatment, so they do not and cannot know the full story, yet their statements are often potent. Furthermore, it is far from uncommon for jousters to later testify against the sued provider, on behalf of the plaintiff-patient. Of course, they are then subject to cross-examination, when the weaknesses of an after-the-fact assessment will be raised for a jury to hear and consider. The back-and-forth of trial.

(For readers who might be wondering about whether T was able to be compensated by way of a lawsuit regarding the highway accident, complex jurisdictional issues prevented combining that case with the malpractice suit against Dr. Y. So, we have intentionally separated the two actions here, focusing only upon oral surgery treatment considerations.)

Summary of takeaways

Timely, accurate notes can help show what injuries were already present, what decisions were made, and why treatment was appropriate.
Rules vary by state, so oral surgeons should follow the clearest informed consent process possible whenever circumstances allow.
Avoid definitive promises, document risks clearly, and be aware that second-opinion “jousting” can influence a patient’s decision to sue.

In this real-life case study, OMS will learn how a simple communication breakdown between offices resulted in the extraction of the wrong tooth. Learn why accurate referrals, staff protocols, and pre-treatment verification are critical to managing risk.

Key concepts

Referral communication breakdowns and risk management
How vicarious liability applies to staff errors
Why “time out” protocols help prevent treatment errors

Background facts

Dr. Q is a restorative dentist in a suburban community. While she used to practice the full spectrum of general dentistry, over the last few years she has focused exclusively on restorative cases, referring patients who need all other areas of dental care to other providers. P was a 37-year-old man who had been a patient of Dr. Q's for nearly a decade.

During a weekend soccer game, P "headed" the ball to a teammate, and it struck the right mid-face, somewhat lower than the forehead area he intended. There was some lingering pain on P's face for the remainder of the game, but he did not think much of it. At dinner that evening, he found himself with shock-like discomfort emanating from his upper right teeth, although he could not pinpoint a specific tooth as the source. When the situation did not resolve after several days, he presented to see Dr. Q.

When Dr. Q examined the quadrant, she noted tooth #2 to have a large 3-surface amalgam in place, but she could not elicit any abnormal responses through percussion or palpation, nor could she find anything unusual on radiograph or with an explorer. On the other hand, #3, which was a virgin tooth, was tender to all modalities, and it clinically exhibited a probable vertical MB root fracture beginning at the furcation and extending apically. Dr. Q concluded the tooth to be non-restorable, so she suggested its extraction — by an oral surgeon — with an implant and crown for replacement. Dr. Q entered her electronic note, explaining the situation regarding both teeth #2 and 3, and handing P a handwritten referral card, asking Dr. E, an oral and maxillofacial surgeon, to extract #3 and place a bone graft so that she (Dr. Q) could later place an implant and restore it.

Dr. Q's front desk staff member called Dr. E's office to say that "we're sending over a patient, P, for an extraction.” Dr. E replied, "OK.” Either before or during the short drive to see Dr. E, P misplaced or lost the referral card. All he knew was that an upper right tooth needed to come out. P "frantically" called Dr. Q's office to ask that a fax be sent to Dr. E with the information as to the tooth to be extracted. Dr. Q's office manager quickly scanned the newly written note from just a few minutes prior, focused solely on the first portion of the chart entry, which stated that tooth #2 had a "large, old MOD amalgam,” presumed that was the tooth in need of treatment, and faxed "please ext tooth #2,” unsigned, on Dr. Q's letterhead. After taking a periapical radiograph of teeth #1-3 (distal half only of #3 captured), obtaining P's signature on a consent form for "extraction upper right molar,” and giving local anesthesia, Dr. E did exactly what the letter from Dr. Q asked him to do. A post-extraction periapical more clearly and completely showed tooth #3, adjacent to the new extraction site, with an apparent vertical MB root fracture.

Dr. E immediately called Dr. Q after realizing his error, and the two concluded that he ought to explain the event to P and then extract tooth #3. Dr. E asked P to initial the newly modified consent form, which added the letter "s" to "molar." P complied. Drs. Q and E would work together to provide 2 implants with 2 crowns, all at no cost. Those treatments later went forward uneventfully, with P being able to function without limitation, although he always worried about his dental future. It is worth noting that P had been in family therapy — for totally unrelated reasons — prior to these events, but he began to talk extensively with his therapist about his upset over the dentistry, with all of that recorded in the therapy chart.

Legal action

P was clearly aware that he would have no out-of-pocket expenses due to the wrongly extracted tooth. In fact, whereas he would have paid for the 1 implant and 1 crown for tooth #3 had there been no error, he no longer had to, based upon the goodwill gestures of both doctors. But it was no longer about money needed for the dentistry: he wanted to be compensated for the stress of the entire situation. P was unable to find an attorney willing to take his case against Drs. Q and E, so he decided to file a malpractice lawsuit in City Court, which, in his jurisdiction, was a level higher than Small Claims and a level lower than the general trial court, and which readily enabled him to handle the case on his own, as a pro se litigant. The City Court's "DIY" web page set out the procedures to abide by, the most important of which was a reasonable degree of relaxation of rules of evidence. For example, copies of medical and dental records could be introduced without the author being present to testify about and certify them. A judge would preside and would render a verdict.

At the trial, both of the defendant doctors were represented by attorneys assigned to them by their malpractice insurers, as malpractice policies generally provide, regardless of the level of the court. P argued, essentially, that he was an unwitting victim, with no role in any wrongdoing, but with both doctors being careless — either personally or through their employees — so as to directly cause the wrong tooth to be extracted. The impacts of that error became part of the case evidence when the judge allowed the detailed chart entries of P's therapist, which described his emotional distress, to satisfy his claim for damages.

A major stance taken by Dr. Q's counsel was that she had done everything properly, and it was solely because P was careless in losing the referral card which led to the office manager's hurried documentation mistake, but Dr. Q had performed no dentistry in a negligent fashion. Dr. E's counsel took the position that P agreed to have both teeth removed, as demonstrated by his signature and initials on a form which gave Dr. E permission to extract upper right "molars" (plural). But when the judge questioned P about the specific events involving the consent form modification, and had that confirmed by Dr. E, she disallowed the consent form in its entirety, ruling that informed consent is a pre-treatment process, which must be voluntary to be valid, and this document, in the form presented, represented neither pre-treatment nor voluntary (because by the time P initialed, he no longer had any choices).

In the end, the judge held both doctors liable and awarded P a modest sum for the emotional distress he suffered, but nothing for actual costs, as there were none. The judge said that, even though Dr. Q did not herself, but through an employee, make a transcription error, the concept of vicarious liability meant that actions taken by Dr. Q's employee, as part of employment, were as though the erroneous actions were committed by Dr. Q. The judge then turned to Dr. E and suggested that his mid-procedure attempt to make it seem as though this had all been planned in advance was misleading to the court, at best. For this reason, she levied the majority of the responsibility against Dr. E.

Takeaways

By way of the concept known as vicarious liability, a dentist (and/or a practice entity) is responsible for the acts of those who work under the dentist's supervision, whether that supervision is direct or simply implied. Therefore, even though Dr. Q did not perform any negligent act herself, it is as though she did. It is important for practitioners to be aware of this in the course of overseeing the actions of all of their staff members that are involved with patient contact to any degree. And it is critical that they be aware of which duties may be properly delegated and which must not. Here, had the office manager who wrote the replacement referral shown it to Dr. Q for a final sign-off, the ultimate dental error would likely have never happened. As an alternative, Dr. Q could have established office policy that would have avoided the mistake, namely making and keeping a chart copy of the referral card initially given to P. If that had been done, the office manager would have simply been able to fax a copy of what Dr. Q actually created, eliminating any chance of interpersonal miscommunication altogether.

Informed consent is a process, often and hopefully memorialized with a signed writing, that gives a patient decision-making authority before the start of a procedure, once made aware of risks, benefits, and alternatives: it is not valid after a procedure or during the procedure, by which time there are no longer any true choices to be made. Engaging in the process any time other than prior to its start is a mere pretext, which, at least in this judge's courtroom, was legally invalid. The viewing of Dr. E's actions in this regard as misleading is not necessarily anything but the assessment of one person, who happened to be the judge, but it might well also be reflective of how jurors might view it and act. This clearly demonstrates why every part of a patient record should be created, not only truthfully, but with an eye toward who might someday read and evaluate it.

Wrong-site treatment, especially surgery, has become an increasingly frequent event among dentists in all practice areas. The "time out" concept — to assure proper patient, proper site, and patient-chart match - before a procedure starts, as our medical colleagues do well and fairly consistently, cannot be overstated as a critically important step. In doing so, all members of the team should be encouraged to alert the treating doctor, in a way that does not alarm the patient, any time something seems amiss, with no repercussions for a "false alarm.”

Finally, given dentistry's multiple and sometimes confusing tooth numbering systems, identifying a tooth by its name, rather than by a number, can provide true simplicity and better accuracy. It would be difficult to argue against the clarity of saying "upper right first molar" as compared with Universal #3 or Palmer upper right 6 or FDI 16. It's easy to clear up those muddy waters every time.

Summary of takeaways

OMS may be held responsible for staff actions, so referral information should be clearly documented, preserved in the chart, and reviewed before it is sent to another provider.
Informed consent must be obtained before treatment begins. Attempts to modify consent forms during or after a procedure will weaken credibility and likely render defensibility unsuccessful.
Wrong-site treatment can nearly always be prevented with a consistent “time out” process and clear tooth identification using plain-language names instead of numbers alone.

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This real-life OMS case study illustrates how patient anatomy, clinical judgment, and external pressures can turn a complex treatment plan into a malpractice claim. Learn why it’s critical to trust your professional judgment, recommend only viable treatment options, and prioritize patient safety when weighing surgical risks and alternatives.

Key concepts

All-on-4 procedure leads to serious complication
Trusting your clinical judgment
Risk management lessons for implant dentistry

Background facts

R was a 61-year-old generally healthy man who had worn maxillary full dentures for years, but was becoming increasingly dissatisfied with them, both functionally and esthetically. His lower arch posed no problems for him: other than a 3-unit fixed bridge on the right and a 4-unit bridge on the left, he had natural teeth in place. In the past, he was a nearly pack-a-day smoker, but he had since overcome that habit. He presented to a multispecialty dental office he had seen advertised locally, seeking to improve the condition of his maxilla.

He initially saw a prosthodontist, who evaluated the mouth and concluded that an implant-supported prosthesis would work well for R. Per office policy, the on-site oral surgeon would handle the implant aspect of treatment, with the patient then returning to the prosthodontist for the restoration. That same day, the OMS, Dr. G, met with R, ordered a CBCT study, reviewed it, and discussed the available options. Because of the paucity of maxillary bone — especially posteriorly — and "low-lying" maxillary sinus cavities, a traditional implant arrangement would not be possible. So, 2 options were available: (1) perform bilateral sinus lifts with bone grafting, allow for an adequate healing period, place 3 implants (potentially) on each side, and then restore the maxilla prosthetically after osseointegration; or (2) do an all-on-4 procedure using the pterygoid bones bilaterally for both posterior implants, place a provisional prosthetic appliance that same day, and later convert to a permanent prosthesis after integration.

The office management encouraged the most time-efficient case completions possible. With that in mind, Dr. G and the prosthodontist discussed the available options, with Dr. G expressing some concern about the radiographically appearing rather thin pterygoids, particularly on the right side. However, the prosthodontist did not want to wait for the entire sinus lift process to play out, and encouraged the OMS to do the all-on-4 approach, despite her stated concerns. Dr. G (reluctantly) agreed, and so did R, after they had a full discussion about the most common risks, benefits, and options, with R signing a consent form.

On the day of treatment, R took the oral sedative prescribed for him by Dr. G, just before leaving home. Dr. G injected local anesthetic solution buccally and palatally across the entire upper jaw. Because she is left-handed, Dr. G began with her preferred side, the left, because access was easier. Referring to the CBCT images, she uneventfully placed 2 implants on the left side, 1 at the approximate site where tooth #11 had been, and 1 angled into the pterygoid: both were clinically stable. She then turned to the right side to place 2 implants before the prosthodontist placed the ready provisional. The implant near the prior site of the upper right canine was smoothly placed. In performing the right pterygoid osteotomy, Dr. G's concern came to fruition, as the bur, which had initially been met with typical bony resistance, suddenly fell into a void, which she presumed to be the pterygopalatine fossa. When she backed out the handpiece, bright red, pulsating blood heavily flowed into the mouth, clouding the entire field.

Her initial approach was to pack the site with gauze strips, which did slow the flow, but the gauze quickly filled with blood and continued to do so despite repeated packing. Dr. G believed that she had pierced into (a branch of) the right maxillary artery. With her being unable to gain hemostatic control, and being in an outpatient setting with an awake patient, she attempted to gain access to the source of the bleed by entering the maxillary sinus through a Caldwell-Luc approach, and then cutting a window through the posterior sinus wall to enter the fossa. But doing so only provided a second outlet of significant bleeding, leading her to conclude that ligating the artery required in-hospital care by a head and neck surgeon. R was transported by ambulance to a nearby medical center, with Dr. G accompanying him to try to maintain site pressure as they travelled. R was emergently taken to the OR, where he was induced and intubated, and where an ENT surgeon unsuccessfully attempted access to the torn vessel endoscopically, ultimately ligating the vessel some 2 hours later by way of a preauricular approach infratemporally. R remained in hospital for a week, and missed work for more than a month, left with a scar and always feeling limitations to his usual exercise routine.

Legal action

R's newly retained attorney obtained all of the relevant dental and medical records, and sent them on to an academic-based OMS for review. That expert passed on his conclusions to the attorney who hired him: that Dr. G succumbed to external pressures and performed a procedure that she knew was concerning and risky, given the specific anatomy presented, and that the preferred set of procedures for this patient would have begun with the sinus lift and graft approach. The attorney also contacted the treating ENT, who was willing to provide his opinion that the bleed and the resultant surgery and after-effects were due to an ill-conceived surgical treatment plan by Dr. G.

Dr. G contacted her malpractice carrier when she provided records to R's attorney, and again when she was served with papers that initiated the lawsuit against her. She had personally been deeply upset by the events, now some months ago, and she told her assigned attorney that she was eager to put this behind her, partly for the personal impact but also because she realized that she had not exercised her best judgment.

Settlement moves began quickly, with an agreement reached before discovery even started. In addition to money, which covered medical costs, physical and emotional distress, and lost income, R made a somewhat unusual request: that Dr. G write an apology and explanation to him, which he felt that he needed to close the chapter. Despite her attorney advising Dr. G against doing so, explaining the potential impacts upon a Board complaint (which never happened) or hospital credentialing, she did as R had asked, because she, too, needed the closure.

Takeaways

Pressures are frequently placed on practitioners, including oral surgeons, from sources as diverse as patients, dental or medical colleagues, and practice supervisors and owners. The reasons for the responses to those pressures are equally diverse, from the need to maintain employment, to conflict aversion, to ego. In the end, though, all that really matters on the legal side of practice are adherence to standards of care and principles of ethics. Perhaps, a safe approach for practitioners to take is that if something simply does not feel right, stay away from it. While that might not always be practical, it can at least be an internal starting point, if not ultimately the end point.

It is the general rule, rather than the exception, that there are most often multiple options/alternatives to overcome dental and surgical problems. Principles of informed consent dictate the requirement to advise patients of, among other things, available alternatives. But that does not mean every alternative, only the viable ones. And if an alternative is not viable for any reason, whether because of patient anatomy, underlying patient medical conditions and social habits, or provider limitations (based upon ability or experience), that alternative falls out of the realm of informed consent. Here, the anatomy of R's right pterygoid and, perhaps (reading between the lines) her own limitations, Dr. G seemingly knew that an all-on-4 plan was not viable for R. Fighting her better judgment was a clear factor in the events and injuries.

All procedures carry risk. It is part and parcel of healthcare delivery, particularly when surgery is involved. Practitioners appropriately take specific risks into account when weighing the potential coming to fruition of those risks against the benefits of doing the procedure. There is no one-size-fits-all formula to use to come to a decision, but instead a subjective process that is individual to every surgeon, considering a host of factors. Many risks come to pass (in the form of injury) in the absence of any negligence, with that concept being a foundation for much of malpractice defense, but when injuries occur because of negligence, that often becomes the very basis for plaintiffs' cases against doctors.

Decisions about settlement versus trial are extremely case-specific, with the insurer, counsel, and all litigants playing significant roles. Practitioners who have "pure consent" policies are permitted, per policy language, to withhold consent to a settlement, in favor of going to trial. But in cases where practitioners do provide their consent to settle, that does not mean that the malpractice carrier must then settle the case, but simply that it may agree to a settlement. Think of it as a permission slip, but not a requirement slip.

Summary of takeaways

External pressures should never outweigh clinical judgment when determining the most appropriate treatment plan.
Not every treatment option is suitable for every patient — anatomy, provider experience, and overall risk must be carefully evaluated before proceeding.
When complications occur, treatment decisions that fall outside the standard of care can increase liability exposure and lead to malpractice claims.

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Key concepts

How "jousting" can stimulate the initiation of malpractice lawsuits
Risks associated with setting unrealistic treatment expectations
Documentation and defending care decisions

Background facts

Legal action

Takeaways

Summary of takeaways

Timely, accurate notes can help show what injuries were already present, what decisions were made, and why treatment was appropriate.
Rules vary by state, so oral surgeons should follow the clearest informed consent process possible whenever circumstances allow.
Avoid definitive promises, document risks clearly, and be aware that second-opinion “jousting” can influence a patient’s decision to sue.

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This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

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