OMS Reprimanded for Failing to Check Patient’s Blood Pressure

Underlying Facts

T, a 63-year-old man, presented to an oral and maxillofacial surgeon, Dr. B, on referral from his general dentist, for extraction of a badly decayed lower right first molar. Dr. B was an experienced OMS of many years, nearing his planned retirement. The tooth involved was nonrestorable. T agreed to the planned treatment at a prior consultation visit.

From a medical background standpoint, T was a type-II diabetic on medication for control, and he suffered from hypertension, which was difficult for his internist to manage, despite his having been prescribed several antihypertensive medicines over the years. T provided all this information to Dr. B, who, at the prior visit asked T about his recent blood pressure readings. T responded that he was usually in the range of 150-160/90-95.

On the date of treatment, T was seated in the dental chair by an assistant, and asked if he was “ready to go,” to which he said that he was. With nothing more asked or performed, Dr. B anesthetized T by means of a mandibular block and buccal infiltration using 2 carpules of 2% lidocaine with 1:100,000 epinephrine. Because there were no signs of an effective block, Dr. B repeated the process, this time obtaining adequate anesthesia.

Within a few minutes of the second set of injections, but before any dentistry was begun, T reported that he was feeling ill, with a headache and ringing in his ears. Dr. B gave his patient oxygen via nasal prongs, but the feelings did not dissipate. Dr. B decided that he ought to get EMS involved, so he asked his assistant to call 911. The ambulance and its staff arrived in less than 10 minutes. An EMT placed a pulse oximeter, and took T’s blood pressure, which read 180/105. T was transported to a local hospital.

In the emergency department, T was intravenously given several drugs which, within hours, acted to lower T’s blood pressure to 150/95, consistently. T was discharged home the same day to the care of his wife, who came to the hospital shortly after her husband’s arrival. No further problems related to T’s blood pressure are known to have occurred, but he never returned to see Dr. B.

Legal Steps Taken

T contacted an attorney who advertised on local radio stations as handling medical malpractice cases. The attorney contacted Dr. B by letter, requesting his records for T, and Dr. B complied in a timely manner. Similarly, the attorney obtained the EMS, hospital, and internist’s records before forwarding a review request to an oral surgeon whom he had employed before for potential and ongoing dental malpractice actions.

The attorney soon advised her client that the oral surgery expert was of the opinion that Dr. B was negligent in his care by virtue of his failing to obtain a blood pressure reading of T before giving the local anesthesia, which “might have” revealed a blood pressure elevation that would have contraindicated any treatment at all that day. The expert further criticized him for failing to assess any vital signs while waiting for EMS to arrive. But the attorney declined to accept the case because the damages were limited to EMS and hospital charges, which were essentially covered by T’s health insurance.

Frustrated that he had no recourse against Dr. B, he asked his attorney for options. She told T that he could file a Dental Board complaint, which T did. After a complete review of the matter, including an interview of Dr. B (in the presence of an attorney assigned by his malpractice carrier), the Board sent Dr. B a letter of reprimand – which it posted on its website – and required that Dr. B undertake coursework involving medical complications in dental practice. The thrust of the letter of reprimand was based upon certain published dental association “guidelines,” which the Board inferred to be the standard of care, that elective dental procedures should be cancelled when the patient’s pre-procedure blood pressure exceeds 160/100. The Board followed by stating that, because Dr. B had not taken T’s blood pressure, especially knowing T’s hypertensive history, he could not have known T’s blood pressure before beginning an elective dental procedure.

Takeaways

Some organized dentistry groups periodically distribute “guidelines” regarding a variety of aspects of dental/specialty practice. In doing so, these associations either directly or otherwise suggest that, even though their “guidelines” might be viewed by some courts or other tribunals as the “standard of care,” they are not meant to act as such. The Dental Board involved here clearly seems to have drawn that equivalence, to the detriment of Dr. B. Whether courts or Boards should be considering guidelines to be standards is beyond the purpose of presenting this case study.

But what is litigation reality is that a plaintiff’s dental/oral surgery expert – in court or at a Board hearing – might well testify that such “guidelines” are, in fact, standards of care, whether referring to publications (if permitted) or simply by incorporating the concepts into their opinions. From a risk perspective, oral surgeons should be aware that this scenario is certainly a possibility.

Accepting, solely for the sake of discussion, that dentists and dental specialists ought to cancel elective dental procedures when their patients’ blood pressures exceed 160/100 mm Hg, what is subsumed in that concept is that dentists and specialists ought to be taking their patients’ blood pressures before every procedure is begun. Intuitively, patients with hypertensive histories, especially when labile, function daily with elevated blood pressures. Perhaps less intuitive is the fact that many patients, even presumed healthy ones, present for dental, and especially surgical, treatment in a stressed state, such that they might have a temporary elevation at the very time that treatment takes place. There is no question that patients undergo physiologic stress when oral surgery is being performed, and even in its lead-up.

The importance of identifying blood pressure elevation cannot be overstated. Hypertension is well-known to cause strokes and TIAs as sudden events, and to cause more chronic organ problems over time. So, by knowing the patient’s immediate status in this regard, oral surgeons can prevent potentially devastating outcomes by employing a simple, noninvasive, and quick assessment. Furthermore, taking blood pressure readings on every patient can alert patients to the fact that they might be hypertensive – or tend in that direction – even though they might never have been so diagnosed. In that vein, oral surgeons can provide a valuable benefit to the community, well beyond surgical treatment, by referring known hypertensives and previously unknown hypertensives for appropriate and necessary medical care.

We conclude by noting that the potential expert for T stated that taking his blood pressure before proceeding “might have” revealed T’s blood pressure to be elevated. That opinion is inadequate as to what is known by lawyers as a standard of proof. To prove a case of dental malpractice, a plaintiff’s expert must articulate evidence of all elements of dental/oral surgical malpractice – inadequate treatment which directly causes injury – as being “more likely than not” (or similar concepts that the States might employ), rather than something less, including that which “might” be the case. Unless and until a plaintiff, through expert testimony, reaches that threshold, no valid case against the oral surgeon will lie.

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.