OMS Extracts the Wrong Tooth and Faces Litigation

July 28, 2025

Reading time: 8 minutes

OMS has extracted a sick tooth from patient in dental office. Focus on stainless steel dental tongs or pliers and extracted lower tooth in it. OMS

We turn slightly away from our usual format, based upon some ongoing inquiries from our insureds regarding the litigation process, and explore what that process entails from an overview perspective at MedPro. 

While each case situation is treated uniquely due to the individual circumstances, our goal here is to provide a general sense of the start-to-finish approach to the process, with the understanding that not every potential scenario will be addressed here. A set of background facts is provided to set the stage for the potential litigation pathways. These facts involve an oral and maxillofacial surgeon as the defendant, but they could just as readily involve other types of dentists.

Key Concepts

  • General overview of litigation procedure
  • Understanding pure consent policy provision
  • Importance of collaboration in litigation process

Background Facts

T was an 18-year-old male, who recently consulted an orthodontist with esthetic dental concerns, mostly due to an asymmetry of the maxillary teeth that resulted from a congenitally missing upper left bicuspid that skewed the dental midline to his left. The orthodontist concluded that, given the mildly increased overjet as well, T would best be treated with the extraction of the upper right first bicuspid, after which that space would be closed orthodontically with a rightward set of forces that would also set back the upper anterior teeth. 

To carry out the pre-orthodontic treatment, the orthodontist’s receptionist, at the orthodontist’s request, called a local OMS’s “front desk,” and asked that T’s “tooth 5 on the upper right” be extracted. The OMS’s staff member noted the request, exactly as stated, in the schedule for the upcoming appointment. When T presented, the OMS was confused as to whether the orthodontist wanted “tooth #5” or the “upper right 5” to be removed, so she asked her office manager to call the orthodontist’s office to clear that up. In response, the orthodontist’s office manager looked at the chart notes and transmitted back that the OMS should remove “the upper right 5 tooth.” Although still somewhat confused, given dentistry’s multiple systems of numerically identifying teeth, the OMS nevertheless proceeded to obtain informed consent by explaining that “a tooth” would be extracted, and having T sign a “consent form” which listed “tooth extraction” as the procedure, and then uneventfully extracting the upper right second bicuspid (UR5 a/k/a #4). When the patient returned to the orthodontist several weeks later and was examined, the orthodontist called the OMS and said, “I wanted the first bicuspid removed, not the second, and that mistake will make the outcome less desirable in the end.”

MedPro’s Involvement 

Immediately upon learning of the problem from the orthodontist, the OMS (Dr. K), telephone-contacted her malpractice carrier, MedPro, and spoke with the claims intake representative to advise of the situation. Because Dr. K had not, as of that time, been informed by T or a lawyer on his behalf that there was an intention to sue, the situation was noted in Dr. K’s policy file as an incident, with no further steps taken as of that time. 

Less than 3 months later, Dr. K received a letter from T’s attorney, stating an intention to file an action in dental malpractice, unless T was paid a stated sum of money. Dr. K again contacted MedPro and forwarded the attorney’s letter, along with a copy of her records for T. Now, the matter was a claim, and assigned to the claims consultant who manages claims within the state where the events occurred. The claims consultant telephoned Dr. K, and the two had a detailed conversation about the dental events and the potential procedures that might follow. Dr. K made it very clear to the claims consultant that she believed that the communication errors emanated from the orthodontist’s office, and that she was of the opinion that she had “done nothing wrong.” Therefore, she wished to exercise her pure-consent malpractice policy provision and withhold consent to settle “under any circumstances.” The claims consultant explained to Dr. K that, while her right to exercise would be fully respected by MedPro, that meant that, unless a case, if formally started in court, were voluntarily withdrawn by T or dismissed by a court, it would proceed to trial. Dr. K said that she understood and was fervent in her decision.

The claims consultant spoke with T’s lawyer and advised that no settlement offer was forthcoming. Shortly thereafter, a process server appeared at Dr. K’s office and served her with a copy of the initiatory documents, often called a Summons and Complaint, in which T claimed that Dr. K was negligent, thereby causing injury to T, and also asserting a claim of lack of informed consent. Those documents were forwarded to the claims consultant, who discussed with Dr. K that defense counsel would be assigned to represent her as the case moved forward. Dr. K was now the defendant. Upon receiving the case to defend, Dr. K’s new attorney, who was very experienced in defending dental malpractice actions, met with Dr. K to review the entirety of her chart for T, discuss all that took place in terms of the inter-office communications, and explain all that would follow.

After that meeting, the defense lawyer timely served on T’s attorney a document known as an Answer, in which all claims of malpractice/wrongdoing/lack of informed consent were denied. Dr. K’s defense counsel also served a number of information-seeking documents, to begin the litigation phase of Discovery, during which each party would provide documents and other requested information, all overseen by a judge. The Discovery phase provides each party with the opportunity to learn their adversary’s litigation approach, by having them share demanded information for the ultimate purpose of eliminating any “ambush at trial.” Perhaps the most consequential portion of Discovery is the taking of depositions of all parties, and sometimes of experts as well. Depositions are under-oath question-and-answer sessions during which the person being deposed provides spoken responses to relevant questions put to them by opposing counsel, and which are then transcribed by stenographers. Because deposition responses can be read to trial juries with the same force and effect as though they were stated in court, pre-deposition preparation by counsel of all witnesses – including the defendant dentist – is critical.

Completion of discovery is reported to the judge, at which time a trial date is assigned, with some judges bringing counsel (and sometimes the parties too) together to discuss settlement prospects. If expert reports and theories have not yet been exchanged between the parties, this is the time to do so. Motions seeking dismissal, if made, are generally submitted now. This time, known as the pre-trial phase, lends itself to further discussions between the parties and their attorneys, as well as the insurance carrier, to again consider whether a settlement is to be a consideration. Dr. K continues to be able to exercise her pure-consent provision, thereby moving the case to trial. Defendant dentists often make determinations regarding whether to seek a potential settlement based upon such issues as their assessment of treatment events with all positions now in the open, their weighing of the competing expert opinions, and personal concerns (time out of office for trial, reputational worries, stress, etc.), all in conjunction with their attorneys. MedPro tracks all litigation steps along the way, often seeking and considering dental, medical, and legal viewpoints from in-house or other sources. It is important to note that insured dentists with pure-consent policies can properly withhold consent to a settlement, but if they agree to seek a settlement, the ultimate decisions as to whether to settle and for what amount then lie exclusively with MedPro, as the insurer.

Trial starts with the jury selection process – voir dire – and then proceeds into what is traditionally viewed as the trial proper. At times, certain motions to exclude evidence are presented to the presiding judge, to be addressed outside of the jury’s presence, and then decided. First, the plaintiff presents his case – documentary and other tangible evidence, fact witnesses, expert witnesses – with the defense attorney able to cross-examine all witnesses who appear and testify on behalf of the plaintiff. At the conclusion of “plaintiff’s case,” defense attorneys usually seek dismissal of the entire case, claiming that the plaintiff, who has the burden of proof, failed to meet that burden to the satisfaction of the court. If granted, the case ends. But if denied, as it statistically most commonly is, the defendant’s attorneys present the “defense case,” offering their own evidence and witnesses, the most important of which is the defense expert dentist, to counter the claims that the defendant dentist was negligent, thereby causing injury to the plaintiff.

It is then time for the jury to do its job, after lawyers’ summations are heard and its members are instructed by the judge on the law applicable to the case. But even while the jurors deliberate, a settlement agreement between the parties can still be reached, presuming here that this defendant, Dr. K, waives her consent option, up until the time that the jury renders its collective decision as a verdict. A verdict for the plaintiff is almost always accompanied with an amount of money for compensation, but a verdict for the defendant means that the plaintiff has not proven that he has been injured at the negligent hand of the defendant dentist, and therefore gets no money. Post-trial motions are often presented to the judge by the losing side, either orally or in writing, with reversal of the jury’s determinations fairly uncommon. And then, the option for appeal hangs in the balance, asking a higher court to correct the trial judge’s improper trial decisions and/or the jury’s verdict, occasionally but not frequently resulting in a new trial from scratch or an alteration of dollar amount.

Final Points

To reiterate, it is more than possible, and in fact realistic, that the exact steps as discussed here will be at least slightly different in every case. But this general “big picture” is emblematic of how cases progress, from incident to claim to suit to discovery and to trial. MedPro takes the position that sued dentists, who are as knowledgeable as possible about the litigation process they are about to enter, are better advocates for themselves, assist their attorneys more effectively, and endure less stress until they emerge on the other side.

Finally, we conclude with a couple of points, the first of which was alluded to earlier: while dentists and specialists insured by MedPro may choose to withhold their consent to settle such that it is a trial jury who makes the ultimate determinations, waiving that consent does not force MedPro to settle on their behalf, but rather only permits it, should MedPro determine that settlement is the best approach. The entire litigation process – whether it concludes with a dismissal, a settlement, or a jury verdict – is a collaborative one, between the insured dentist, counsel, experts, and MedPro. MedPro handles more dental malpractice claims than any other carrier and closes 80% of those claims without payment. For the claims that do make it to trial, our insureds win 95% of the time.

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In this real-life case study, oral and maxillofacial surgeons will see how a missed biopsy report led to a devastating outcome and costly litigation. The article explores the clinical and administrative failures that allowed a cancer diagnosis to go unnoticed and offers practical risk management strategies to prevent similar tragedies.

Key Concepts

  • Patient communication in OMS offices 
  • Ensuring timely review of lab reports
  • How proactive follow-up prevents patient harm

Underlying facts

B, a 54-year-old longtime smoker, had many teeth removed in her adult life due to inadequate oral hygiene. Whenever she went to the dental office (T), it was almost always because of acute symptoms, so she generally ended up in the hands of the oral surgeon currently working at this large group practice in her town. Dr. I was fairly new to oral surgery practice, so he came to the dental office (T) about once every second or third week, as T's needs dictated, while building his own practice in the neighboring county.

When B presented to T, after having not seen any dentist for some 18 months, she complained to the front desk staff of a persistent "sore" in the floor of the mouth, adjacent to where the second and third molars would have been. B was immediately assigned to see Dr. I, who was there that day. Upon examination, Dr. I noted a 1-1.5 cm centrally eroded area of erythroplakia, which bled on light touching. Dr. I told B that he wanted to take a tissue sample to be biopsied, but, not wanting to make her unnecessarily anxious, he said that this was simply a precautionary measure, albeit not overly concerning, despite his own concerns. With local anesthesia, Dr. I removed a small section of the lesion (which did not require any suturing) and sent it to a local lab for pathologic evaluation.

Before leaving the office, B said to Dr. I, "I assume that you'll call me if it's anything bad," to which Dr. I responded, "Of course." Eight days later, a mailed biopsy report was opened at T's front desk by the staff person who regularly handled mail. That staff member placed the report in the physical paper file for B, without reading it or showing it to any dentist, so the diagnosis of "consistent with squamous cell carcinoma" became known to nobody in the office. Not hearing any news, B presumed that all was fine. By the time Dr. I next worked at T, nearly 3 weeks after his prior visit, he had forgotten about the procedure he had performed on B, and nobody knew to alert him to the contents of the report.

Almost a year after seeing Dr. I, B had a hysterectomy. During her pre-operative evaluation, the anesthesiologist noticed a large sublingual lesion while assessing intubation and airway considerations. The anesthesiologist then started the post-surgical process of having B evaluated by the hospital's otolaryngology department, which led to a complete work-up that revealed that the oral squamous cell carcinoma had metastasized broadly. Despite a hemi-mandibulectomy, neck dissection, and a course of chemotherapy, B passed away approximately 2 years after her visit with Dr. I. She left behind an 18-year-old daughter, E.

Legal action

Distraught over the loss of her mother and in dire financial straits, she contacted an attorney to look into her options. E advised the attorney that her mother was complaining about a sore in her mouth for years, and had it checked out by an oral surgeon, "but it was nothing." The attorney made an application to the court to have E appointed as the representative of B's estate, which was granted, after which the records from T and the pathology lab, among others, were requested and received. E's lawyer immediately saw the biopsy report that had been sent to Dr. I at the office of T but found no evidence of any follow-up. E confirmed that she believed that nobody from the dental office ever told her mother about the biopsy findings.

The attorney enlisted the services of an oral and maxillofacial surgeon, a pathologist, and an oncologist to review the records and offer their opinions about potential liability and causation. The oral surgeon determined that Dr. I acted appropriately in immediately taking a specimen of the lesion and sending it for histologic evaluation, but that he failed to follow up on it, thereby leading to the failure of notifying B so that she could timely receive care and treatment; the office, T, was also criticized for not having a system in place whereby every medical and dental document that came in the mail must be reviewed by a dentist. The pathologist was minimally critical of the treating pathologist for not making a phone call to Dr. I or to T upon his abnormal finding, but in the end, the pathologist was of the view that the standard of care required communication to the treating oral surgeon of an abnormal finding, but that standard did not require any specific method of communication. Finally, the reviewing oncologist concluded that, had B been timely sent on a path for a thorough work-up and treatment following the initial biopsy, she would have been able to be treated by less invasive means and would quite likely have survived.

The attorney filed suit against Dr. I and T, asserting claims of B's wrongful death and of pain and suffering for needing the aggressive treatment she had and for going through a slow, painful course toward her death. Dr. I and T alerted their respective malpractice carriers upon being served with the lawsuit papers, and they were assigned different defense counsel. Discovery went forward, with depositions of E, Dr. I, and T's mail clerk taking place, as well as the exchange of relevant documents and statements of expert opinions.

Those expert opinions on behalf of both defendants, Dr. I and T, were not at all supportive, essentially echoing the opinions of the experts retained by the plaintiff's counsel. Realizing early on in the litigation that a defense would be quite challenging, if even realistically possible, the defendants and their malpractice carriers agreed to work toward settling the case with E, through her attorney, which was accomplished by means of a substantial payment, the majority of which was on behalf of Dr. I, the oral and maxillofacial surgeon.

Takeaways

Starting with something of a procedural point, we note that Dr. I and T were represented by different defense counsel. While here, there were different malpractice carriers for both defendants, so the assignment of different counsel seems logical, intuitive, and expected; that is not necessarily always the case. Even if the defendants were insured by the same company, they might also have been assigned different defense attorneys. In some circumstances, different defendants are represented by the same attorney, whether insured by the same or different carriers. The decision is often based upon the important consideration as to whether the various defendants appear to have all of their defense interests aligned, so that they can present a united defense front; otherwise, a potential conflict might well exist between the parties and their attorneys. However, there are times when multiple defendants begin a case with the same attorneys, but that needs to be separated out later in the litigation, if facts or circumstances arise that would lead to a likely conflicting approach to all defenses.

Moving to the clinical issues as they relate to Dr. I, particularly in situations of an itinerant oral surgeon who spends time working in the offices of others, where practice protocols might not be as patient-protective as would be best desired, or as they would be in their own practices. Regardless of the setting in which, as here, a biopsy is performed to assess a concerning situation, the burden of following up on results lies squarely with the surgeon who performed the procedure. Absent that, the patient can easily be inappropriately led into a state of blissful ignorance, as B was in this case study, presuming that nothing was amiss because she did not hear from the office or Dr. I; as a direct result, B carried on as though her health was good, until the ever-growing lesion was serendipitously discovered, by which time cure prospects were no longer viable. Yes, defense counsel could have argued that the time delay until discovery and treatment did not make a difference in the ultimate outcome, of course, based upon an oncology opinion saying so, but such approaches are traditionally difficult to maintain before a jury, whose members might well see it as "making excuses" and "blaming the victim."

The procedures of office T, which directly had a negative impact upon Dr. I as an itinerant, and upon B, allowed non-professional staff to bypass the professionals regarding a document as important as a biopsy report. It is the choice of every office and every practitioner to determine for themselves what are the most efficient and safe ways to ensure that the provision of critical information is not left to processes such as "don't worry if you don't hear from us,” or "call us if you don't feel better." Risk management principles are best carried out by professionals who affirmatively initiate follow-up in all clinical circumstances where awareness of continued symptoms, of worsening symptoms, or of static conditions is critical to the patient's well-being: biopsies, infections, and pain. While office staff can appropriately have a hand in setting up administrative systems that make certain that proper follow-up care takes place, the responsibility for its being carried out rests with the professional.

There is no doubt that practicing as an itinerant, particularly while new surgeons' own practices are growing, has a host of benefits. But what comes with that is at least a modicum of loss of administrative control, which can easily flow into loss of clinical control. The burden of liability does not change, regardless of setting or business ownership.

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In this real-life case study, OMS can learn how patient autonomy and clinical standards may conflict when making treatment decisions. The case points out the risks of prioritizing patient requests over the standard of care, and how such decisions can lead to Dental Board sanctions or malpractice claims.

Key Concepts

  • Sanctions from Board complaints
  • Does malpractice insurance cover Board fines?
  • Patient autonomy vs. the standard of care

Underlying facts

Dr. P was an oral and maxillofacial surgeon who returned to her relatively rural hometown to practice, making her the only such specialist within a nearly two-hour drive. Most members of the community had known her since she was a child, and all were quite appreciative that she had likely sacrificed financially to come home rather than work in the large city where she trained. Late in the afternoon on the last calendar day of the month, W, a local resident, presented to the office in excruciating pain emanating from a grossly decayed and severely periodontally involved lower bicuspid, wanting to have it extracted. Dr. P knew from previously treating him that he had a heart valve replacement years ago and was taking warfarin daily since that surgery. In anticipation of an extraction that day, W took the antibiotics he kept on hand that had been prescribed for him by his cardiologist. However, prior to extractions Dr. P had performed for W in the past, W stopped his anticoagulant days before the procedure, on the advice of his physician, such that his INR would reside below its usual target of 3.5, in the 2.5-3.0 range for surgery, after which the anticoagulant would be restarted a day later.

On the day of presentation, W had not stopped his anticoagulant therapy, and he reported to Dr. P that his most recent INR, about a week or so prior, was "on the high side" at roughly 4.5. Dr. P expressed to her patient that she did not feel comfortable extracting a tooth, particularly one with periodontal disease, at that INR level. Dr. P contacted W's cardiologist who agreed with the oral surgeon's bleeding concerns and suggested deferring surgery. After the call, Dr. P reiterated her concerns, suggesting that W see his cardiologist to dial down the warfarin so that an acceptable INR level could be reached for surgery.

W became upset, complaining about his unrelenting pain and, perhaps more significant to him, the fact that the health insurance policy provided by his employer was expiring the next day in favor of a less expensive medical plan that had a high deductible and did not reimburse for dental procedures. He pleaded with Dr. P to accommodate him, as "a favor from one friend to another." What she would later say was against her better judgment, she gave in and performed the extraction uneventfully and packed the site with a gelatin sponge and a topical coagulating agent known to be effective for that purpose. Gauze pressure was applied, with hemostasis achieved, and W went home. 

W's wife called Dr. P the following morning, telling her that overnight, W had been taken by ambulance to the nearest hospital due to persistent heavy bleeding from his mouth. There, he was admitted to the medical service (as there was no dentist or OMS on site), where he was fluid-managed and transfused, leading to the stoppage of bleeding and W's hemodynamic stability. Dr. P visited W after her office hours ended, finding W in great distress emotionally, but stable physiologically. W was discharged home two days after admission, with no further complications. His new medical insurance left him with a sizeable bill for emergency transport and hospital care.

Legal action

Quickly forgetting the "favor" given to him, W became angry with Dr. P when she refused to pay for his medical expenses. Unable to find a lawyer who would sue Dr. P, given the lack of permanent physical damage and limited monetary expenses, he filed a lawsuit pro se, serving in effect as his own attorney. Dr. P was assigned counsel through her malpractice insurance carrier, who quickly took procedural steps to have the case dismissed. W did not have the capability to fight legal battles against a lawyer, so the court did, in fact, dismiss the case.

W searched online for other options available to him, and he came upon a Complaint Form which he completed and sent to the state Dental Board. W detailed his version of events, submitting copies of his medical, ambulance, and hospital records. Upon receiving W's complaint, the Board contacted Dr. P, seeking her office records and an explanation of events. With the assistance of the same attorney who had gotten the lawsuit dismissed, she complied.

Dr. P was interviewed by a 3-member Board panel, accompanied by her attorney. The thrust of Dr. P's position was that she was there to serve the needs of an underserved community, which sometimes requires compromises from the ideal. She explained that she had to make an on-the-spot choice, weighing pros and cons, and determined that taking this patient out of severe pain – which she believed could not be adequately accomplished with medications alone – and trying to spare him non-reimbursable oral surgery expenses that he could not easily afford, was her ethical duty under the tenets of patient autonomy and non-maleficence ("do no harm"). She acknowledged that performing the extraction without a known acceptable INR level was against her better medical judgment but in concert with her best ethical judgment.

The Dental Board was unmoved. Its members determined that Dr. P had conducted herself in an unprofessional way, improperly weighing treatment options and succumbing to the desires of a lay person who could not reasonably understand all of the potential ramifications. The report of sanction, which would be posted on the Board's public-facing website, stated that Dr. P mischaracterized the concept of autonomy so as to include patient self-determination at the expense of patient health, and that she created a situation which led to increased patient harm, that could have even ended up worse; "Patients have the right to refuse, but not to dictate." Realizing that suspending Dr. P would hurt the community greatly, the Board's sanctions were limited to a substantial monetary fine and a licensing requirement of continuing education in the areas of ethics and management of medically compromised patients. 

Takeaways

A fundamental concept in this case study is that patients have multiple avenues to seek redress against OMS (and all dental practitioners): suing them for malpractice and/or lodging Board complaints. While malpractice insurance will provide legal representation and financial protection (up to policy limits) in the event of a lawsuit based upon malpractice, the same is not true when a Board complaint is filed. Most malpractice policies will offer legal representation to insureds for Board proceedings, but they do not indemnify for monetary penalties, and they cannot mitigate sanctions, educational requirements, or other levies by state Boards.

Had the malpractice litigation moved forward to be decided by a jury, instead of having been dismissed, it is fair to say that an expert for the plaintiff (patient) would have provided the opinion that, despite all of the underlying factors – change of insurance coverage as of midnight, patient pain, antibiotic prophylaxis having already been taken – Dr. P departed from the standard of care in performing an extraction on a patient with an elevated INR level, to the extent that even she acknowledged was against her better clinical judgment, with that departure directly leading to a true medical emergency. It is also reasonable to expect that W's cardiologist would have testified that he agreed with the stated bleeding concerns of Dr. P and that he suggested holding off on the extraction until the patient was less anticoagulated. To counter those opinions, an expert for Dr. P would need to feel comfortable with the actions taken by Dr. P and be willing to express them in front of a trial jury. A wild card, which is jurisdictionally and factually dependent, is whether the findings of the Dental Board would be permitted by the trial judge to come into evidence. In the end, a jury would make the ultimate determinations.

It is an undisputed reality that oral surgeons often have non-clinical pressures placed upon them – by patients, by referring dentists, by employers, by personal obligations – to take clinical actions that they would preferably not perform. And it is also true that some situations pit ethical concepts against standards of care. Which directions they choose become based upon an unavoidable mix of personal philosophies, professional experiences, and external forces. Realizing these conflicts can go a long way toward making the most idealized choices, although sometimes not easy. Professionalism means placing a patient's best interests, however that might look, ahead of all else. The dentistry and the medicine are often times the simple parts.

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Patient care is complex and personal, which is why it can lead to malpractice risk for oral and maxillofacial surgeons (OMS). That’s why preparing to face malpractice claims before they arise is an essential aspect of risk management. By implementing proactive strategies, OMS can better protect their practice and their patients.

Key Concepts     

  • What is an OMS malpractice claim?
  • Preventing OMS malpractice claims
  • Securing OMS malpractice insurance

Oral surgery is an essential healthcare service. As an OMS, you play an important role in your patients' well-being. However, the responsibility of patient care comes with the risk of malpractice claims.

Malpractice claims can be financially draining and damaging to your professional reputation. That's why it's helpful to know the risks and identify ways to reduce them in your practice. In this article, we will share tips to help reduce the likelihood of malpractice claims in oral surgery and discuss the importance of malpractice insurance for OMS.

Understanding OMS malpractice claims

Malpractice occurs when an OMS fails to provide treatment in conformity with the standard of care, thereby making it negligent, resulting in harm to a patient. This can include incorrect or missed diagnoses, improper treatment, or improper choice of or planning for a procedure. To avoid these situations, it's vital to have a comprehensive claim prevention strategy in place.

Acquiring OMS malpractice insurance is a crucial aspect of your claim prevention strategy. It can provide financial protection against claims, covering legal fees, settlements, and damages awarded after a trial. Choosing the best malpractice insurance requires thorough research of available coverage options.

MedPro Group offers tailored malpractice insurance for OMS, ensuring that you have the protection you need to practice with peace of mind.

Key strategies for preventing malpractice claims

In addition to getting a malpractice insurance policy, what can you do to help prevent malpractice claims? Here are some useful strategies to consider:

Keep detailed patient records

  • Maintaining detailed and accurate patient records is essential. This includes documenting patient histories, examinations, treatments, and any communication. Keeping thorough records is important for providing consistent care and can be crucial in a legal dispute. Records should never be altered. Complete and contemporaneous documentation is a key factor in maintaining professional credibility.

Stay informed and educated

  • Continuing education allows you to stay up to date with the latest oral surgery techniques and standards of care. Going to workshops and classes can help you take better care of your patients and reduce the possibility of mistakes.

Manage your practice effectively

  • Continuing education allows you to stay up to date with the latest oral surgery techniques and standards of care. Going to workshops and classes can help you take better care of your patients and reduce the possibility of mistakes.

Communicate clearly with patients

  • It's important to talk openly with patients about their treatment. Obtain comprehensive informed consent for all treatments, ensuring patients understand what to expect, including possible risks, from the proposed treatment. Clear communication can help prevent misunderstandings that could lead to malpractice claims.

Practice within your scope and abilities

  • As an OMS, it's important to only practice within the scope of your expertise and licensure. Avoid offering treatments or advice outside of your professional capacity, as this can increase your malpractice risk. Similarly, non-professional office staff should never be permitted to provide any dental or medical advice to patients. If you feel as though the patient's condition or treatment would be better handled by a practitioner with particular expertise regarding the issue at hand, refer the patient out.

Follow the standard of care

  • Adhering to the standard of care – what a reasonable practitioner would do under similar circumstances – can help minimize the chance of mistakes and your malpractice risks. 

Prioritize patient safety

  • Always prioritize patient safety during treatments. Be mindful of techniques that pose risks, especially for patients with pre-existing conditions or complex medical histories. If you're uncertain about a particular treatment, seek a second opinion or refer the patient to a dental specialist.

How to handle an OMS malpractice claim

In the unfortunate event of a malpractice claim, it's important to act promptly and professionally. Here are some initial steps to consider:

Contact your insurance provider

Immediately notify your OMS malpractice insurance provider if you receive a claim or have reason to believe a claim is imminent. Avoid discussing the claim with anyone before contacting your insurance carrier. They will help guide you through the process and provide legal representation if necessary.

Do not alter patient records

A clinical note should be completed as contemporaneously as possible with treatment. If you notice an error in your original note or omitted information, do not alter the original note. Rather, make an addendum and reference the date of the original note and the date of treatment, and then explain your addition. Altering records can be seen as an attempt to cover up the facts and can severely harm your ability to resolve a claim.

Cooperate with your claims consultant

Work closely with your malpractice insurance carrier’s claims team. Provide them with all the necessary documentation and information to address the claim

Check out this article for more information on what to expect from a malpractice claim.

Malpractice insurance considerations

Facing malpractice claims in oral and maxillofacial surgery can be daunting, but acquiring the best malpractice coverage can help you manage risk. By being proactive, you can keep your patients safe and practice with confidence.

When purchasing OMS malpractice insurance, keep the following in mind:

Coverage limits

  • Make sure your policy provides adequate coverage to protect your assets and practice in the event of a claim.

Policy types

  • The coverage you need is unique to your practice and specialty. That's why MedPro Group offers both Occurrence and Claims-made policies tailored to meet the specific needs of OMS. Read this article to learn more about policy types and choosing the right one for your career and practice.

Pure consent

  • For greater control during the claims process, look for a malpractice insurance policy that includes a pure consent provision. This means you’ll have the right to refuse to settle a claim. Not all carriers offer pure consent, so make sure to check if it’s included before signing on the dotted line. At MedPro, our insureds always have pure consent to settle.

Customer service and support 

  • Excellent customer support goes a long way. Your carrier should guide you through the process of handling claims and answer any questions you may have. MedPro Group offers hands-on, reliable service so OMS can feel confident in their coverage. Additionally, our OMS on our Advisory Board help provide ensure the products and services we offer continue to meet the needs of today’s OMS.

Carrier strength 

  • Your malpractice insurance carrier should have the financial strength and expertise to defend you from claims. MedPro Group is a carrier with an A++ financial rating (AM Best) and has a trial win rate of 95%.

Get the right coverage from MedPro Group

MedPro Group, the nation’s leading malpractice insurance carrier, offers coverage options tailored to the unique needs of OMS. With the industry’s best claims team and 125+ years of malpractice expertise, we have the experience and resources to protect your good name.

Secure your peace of mind today with a free quote.

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In this real-life case study, oral and maxillofacial surgeons will see how a missed biopsy report led to a devastating outcome and costly litigation. The article explores the clinical and administrative failures that allowed a cancer diagnosis to go unnoticed and offers practical risk management strategies to prevent similar tragedies.

Key Concepts

  • Patient communication in OMS offices 
  • Ensuring timely review of lab reports
  • How proactive follow-up prevents patient harm

Underlying facts

B, a 54-year-old longtime smoker, had many teeth removed in her adult life due to inadequate oral hygiene. Whenever she went to the dental office (T), it was almost always because of acute symptoms, so she generally ended up in the hands of the oral surgeon currently working at this large group practice in her town. Dr. I was fairly new to oral surgery practice, so he came to the dental office (T) about once every second or third week, as T's needs dictated, while building his own practice in the neighboring county.

When B presented to T, after having not seen any dentist for some 18 months, she complained to the front desk staff of a persistent "sore" in the floor of the mouth, adjacent to where the second and third molars would have been. B was immediately assigned to see Dr. I, who was there that day. Upon examination, Dr. I noted a 1-1.5 cm centrally eroded area of erythroplakia, which bled on light touching. Dr. I told B that he wanted to take a tissue sample to be biopsied, but, not wanting to make her unnecessarily anxious, he said that this was simply a precautionary measure, albeit not overly concerning, despite his own concerns. With local anesthesia, Dr. I removed a small section of the lesion (which did not require any suturing) and sent it to a local lab for pathologic evaluation.

Before leaving the office, B said to Dr. I, "I assume that you'll call me if it's anything bad," to which Dr. I responded, "Of course." Eight days later, a mailed biopsy report was opened at T's front desk by the staff person who regularly handled mail. That staff member placed the report in the physical paper file for B, without reading it or showing it to any dentist, so the diagnosis of "consistent with squamous cell carcinoma" became known to nobody in the office. Not hearing any news, B presumed that all was fine. By the time Dr. I next worked at T, nearly 3 weeks after his prior visit, he had forgotten about the procedure he had performed on B, and nobody knew to alert him to the contents of the report.

Almost a year after seeing Dr. I, B had a hysterectomy. During her pre-operative evaluation, the anesthesiologist noticed a large sublingual lesion while assessing intubation and airway considerations. The anesthesiologist then started the post-surgical process of having B evaluated by the hospital's otolaryngology department, which led to a complete work-up that revealed that the oral squamous cell carcinoma had metastasized broadly. Despite a hemi-mandibulectomy, neck dissection, and a course of chemotherapy, B passed away approximately 2 years after her visit with Dr. I. She left behind an 18-year-old daughter, E.

Legal action

Distraught over the loss of her mother and in dire financial straits, she contacted an attorney to look into her options. E advised the attorney that her mother was complaining about a sore in her mouth for years, and had it checked out by an oral surgeon, "but it was nothing." The attorney made an application to the court to have E appointed as the representative of B's estate, which was granted, after which the records from T and the pathology lab, among others, were requested and received. E's lawyer immediately saw the biopsy report that had been sent to Dr. I at the office of T but found no evidence of any follow-up. E confirmed that she believed that nobody from the dental office ever told her mother about the biopsy findings.

The attorney enlisted the services of an oral and maxillofacial surgeon, a pathologist, and an oncologist to review the records and offer their opinions about potential liability and causation. The oral surgeon determined that Dr. I acted appropriately in immediately taking a specimen of the lesion and sending it for histologic evaluation, but that he failed to follow up on it, thereby leading to the failure of notifying B so that she could timely receive care and treatment; the office, T, was also criticized for not having a system in place whereby every medical and dental document that came in the mail must be reviewed by a dentist. The pathologist was minimally critical of the treating pathologist for not making a phone call to Dr. I or to T upon his abnormal finding, but in the end, the pathologist was of the view that the standard of care required communication to the treating oral surgeon of an abnormal finding, but that standard did not require any specific method of communication. Finally, the reviewing oncologist concluded that, had B been timely sent on a path for a thorough work-up and treatment following the initial biopsy, she would have been able to be treated by less invasive means and would quite likely have survived.

The attorney filed suit against Dr. I and T, asserting claims of B's wrongful death and of pain and suffering for needing the aggressive treatment she had and for going through a slow, painful course toward her death. Dr. I and T alerted their respective malpractice carriers upon being served with the lawsuit papers, and they were assigned different defense counsel. Discovery went forward, with depositions of E, Dr. I, and T's mail clerk taking place, as well as the exchange of relevant documents and statements of expert opinions.

Those expert opinions on behalf of both defendants, Dr. I and T, were not at all supportive, essentially echoing the opinions of the experts retained by the plaintiff's counsel. Realizing early on in the litigation that a defense would be quite challenging, if even realistically possible, the defendants and their malpractice carriers agreed to work toward settling the case with E, through her attorney, which was accomplished by means of a substantial payment, the majority of which was on behalf of Dr. I, the oral and maxillofacial surgeon.

Takeaways

Starting with something of a procedural point, we note that Dr. I and T were represented by different defense counsel. While here, there were different malpractice carriers for both defendants, so the assignment of different counsel seems logical, intuitive, and expected; that is not necessarily always the case. Even if the defendants were insured by the same company, they might also have been assigned different defense attorneys. In some circumstances, different defendants are represented by the same attorney, whether insured by the same or different carriers. The decision is often based upon the important consideration as to whether the various defendants appear to have all of their defense interests aligned, so that they can present a united defense front; otherwise, a potential conflict might well exist between the parties and their attorneys. However, there are times when multiple defendants begin a case with the same attorneys, but that needs to be separated out later in the litigation, if facts or circumstances arise that would lead to a likely conflicting approach to all defenses.

Moving to the clinical issues as they relate to Dr. I, particularly in situations of an itinerant oral surgeon who spends time working in the offices of others, where practice protocols might not be as patient-protective as would be best desired, or as they would be in their own practices. Regardless of the setting in which, as here, a biopsy is performed to assess a concerning situation, the burden of following up on results lies squarely with the surgeon who performed the procedure. Absent that, the patient can easily be inappropriately led into a state of blissful ignorance, as B was in this case study, presuming that nothing was amiss because she did not hear from the office or Dr. I; as a direct result, B carried on as though her health was good, until the ever-growing lesion was serendipitously discovered, by which time cure prospects were no longer viable. Yes, defense counsel could have argued that the time delay until discovery and treatment did not make a difference in the ultimate outcome, of course, based upon an oncology opinion saying so, but such approaches are traditionally difficult to maintain before a jury, whose members might well see it as "making excuses" and "blaming the victim."

The procedures of office T, which directly had a negative impact upon Dr. I as an itinerant, and upon B, allowed non-professional staff to bypass the professionals regarding a document as important as a biopsy report. It is the choice of every office and every practitioner to determine for themselves what are the most efficient and safe ways to ensure that the provision of critical information is not left to processes such as "don't worry if you don't hear from us,” or "call us if you don't feel better." Risk management principles are best carried out by professionals who affirmatively initiate follow-up in all clinical circumstances where awareness of continued symptoms, of worsening symptoms, or of static conditions is critical to the patient's well-being: biopsies, infections, and pain. While office staff can appropriately have a hand in setting up administrative systems that make certain that proper follow-up care takes place, the responsibility for its being carried out rests with the professional.

There is no doubt that practicing as an itinerant, particularly while new surgeons' own practices are growing, has a host of benefits. But what comes with that is at least a modicum of loss of administrative control, which can easily flow into loss of clinical control. The burden of liability does not change, regardless of setting or business ownership.

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Additional Risk Tips content

A real-life case study showing how a missed biopsy report in an oral surgery setting led to a fatal cancer outcome and costly litigation. Learn key risk management strategies to prevent communication failures and protect patients.

A real-life case study exploring the ethical and clinical challenges faced by an oral surgeon when a patient on anticoagulant therapy demanded an emergency tooth extraction. Learn how patient autonomy, standard of care, and legal implications intersect in high-risk scenarios.

Patient care is complex and personal, which is why it can lead to malpractice risk for oral and maxillofacial surgeons...

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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