Patient Blames Oral Surgeon For Trigeminal Neuralgia Diagnosis

Background Facts

K, a basically healthy 58-year-old woman, presented to her general dentist of many years, Dr. J, having not seen him for some 18 months, now complaining about recent and progressing pain in her upper right central incisor (tooth #8), which had been crowned since her early 30s. Dr. J examined K and found the tooth to be tender to percussion, with a sizeable, well-circumscribed periapical radiolucency. The tooth tested non-vital. Dr. J explained to his patient that she needed root canal therapy, which he could at least start that day, if not complete. K agreed to proceed.

With local anesthesia, Dr. J made routine access into the tooth and began to use endodontic files, all with a rubber dam in place. When he removed the second file in his progression, he noted that its end was missing about 4mm, so he presumed that the file had separated. A periapical film confirmed the suspicion that the tip of the file was lodged near the tooth’s apex, with half of its length projecting beyond the apex. Dr. J was very experienced performing endodontics, especially on anterior teeth, so he worked to try to remove the separated file, unsuccessfully.

After doing that for almost an hour, he explained to K what her options were in order to save the tooth: refer to an endodontist to try to complete the root canal therapy, or refer to an oral surgeon to perform an apicoectomy. Dr. J was of the view that an endodontist would not likely be more successful than he had been, and he was concerned about any compromises in the care, due to the large periapical lesion. K opted for the oral surgery route, and immediately went to the office of Dr. W, who had told Dr. J that she would perform the apico as soon as the patient arrived. Uneventfully, Dr. W added additional local anesthetic to the already-numb site, raised a semi-lunar buccal flap, and entered through the thin buccal plate to visualize and then remove the apical 2-3mm of tooth and the partially extruded endodontic file, excising the lesion before placing a retrograde seal and suturing the site.

At K’s post-operative visit with Dr. W, the area was stated to have “chronic dull pain,” but it looked clinically stable, so the sutures were removed, with K given an appointment to return in a month if she continued to have any symptoms. Instead of following-up with either Dr. W or Dr. J, K presented to her primary care physician the next week, complaining of ever-increasing and severe pain. The PCP referred K to a pain management physician, who, after seeing K for several consecutive visits, made a diagnosis of trigeminal neuralgia because of her continued pain despite non-narcotic and then narcotic analgesics. The pain management doctor voiced that “it had to be the dental work” that caused this. K had a brain CT and MRA performed, which showed nothing abnormal, and began a course of a common anti-seizure medication – often also given for neuropathic pain – prescribed by the pain management practitioner. The symptoms never abated, and K even claimed that the constant pain worsened to the point that she could not concentrate enough to read a book, watch a movie, or drive a car.

Legal Action

Encouraged to do so by her family members and friends, K sought out an attorney whom she located on the internet as one “specializing in trigeminal neuralgia cases: if you have trigeminal neuralgia from poor dentistry, we can get you large sums of money.” After K’s first meeting with the attorney, the attorney brought suit on her behalf against Dr. J and Dr. W, alleging negligent treatment that directly led to trigeminal neuralgia. Of note is the fact that the sole physical injury claimed throughout the entire litigation was trigeminal neuralgia, and nothing about any other pain condition at all.

The usual course of discovery ensued, with the taking of depositions and the exchange of documents and expert reports. K’s pain management doctor would draw the causal connection between the dentistry and the trigeminal neuralgia – “it must have been the dentistry” – with her attorney’s frequently-used dental and oral surgery experts claiming that Dr. J used improper and excessive pressure so as to negligently break the file, and Dr. W improperly elevated the buccal flap too high, thereby injuring the infraorbital nerve. Neither of the defendants was willing to entertain the possibility of settlement, both steadfast in their views that the treatment they had rendered was proper in all regards. Each exercised their malpractice policy consent provisions, directing the case to trial.

At trial, K testified to her constant pain, although she never spoke about any trigger that set off a period of increased pain, and she never testified to any sharp, stinging pain. The pain was dull, chronic and constant. The defendants’ dental and oral surgery experts, respectively, explained to the jury that Dr. J and Dr. W used appropriate standard technique at every step in their own procedures, including a discussion as to why and how files non-negligently separate, that the photos of the gingival scar showed the incision made was at the proper location, and that there were likely “dental fixes” to her claimed problems. But K never returned to either of them, depriving them – and K as well – of the opportunity to dentally work toward resolving her complaints.

Perhaps the most significant trial witness for the defendants was a university-based neurosurgeon who had published about trigeminal neuralgia and treated many such patients who came to him from across the country. His testimony was decisive: trigeminal neuralgia, he opined, is not caused by dentistry or any other peripheral act, but instead a result of an intracranial pulsating vessel in close proximity to a portion of the trigeminal nerve, which erodes away the nerve’s sheath, exposing the “wire” portion of the nerve and creating the equivalent of a “short circuit” that periodically creates sudden, short-lasting, and severe sharp pain. A diagnosis of trigeminal neuralgia was, according to the neurosurgeon, completely excluded in K because her non-triggered pain – which he did not dispute as being as described – is not at all what, “by definition,” exists in trigeminal neuralgia patients. Her normal intracranial radiologic studies provided conclusive objective evidence of the absence of the proximate nerve-vessel relationship that occurs in trigeminal neuralgia.

As the jury deliberated, the foreperson sent a note to the judge, asking whether they can consider pain other than from trigeminal neuralgia. The judge responded that, because trigeminal neuralgia was the only claimed injury, they could not. Shortly thereafter, the jury returned a general verdict in favor of both defendants.

Takeaways

Addressing the verdict first, a general verdict is one by which the jury simply concludes “for the plaintiff” or “for the defendant(s),” with no specificity. Special verdicts, on the other hand, require that jurors answer direct questions, such as “was the defendant negligent?,” and “did that negligence cause injury to the plaintiff?”. The difference is jurisdictionally-specific. But in this case, it is certainly fair to hypothesize that, had other types of pain been pled, or had the judge allowed the jury to consider other types of pain besides trigeminal neuralgia, a verdict for the plaintiff seems at least likely. 

This concept leads to two important points: (1) the particularity with which a plaintiff’s attorney pleads the case is critical to a case result; and (2) the defendants’ neurosurgery expert’s precise anatomic testimony, with the guidance of experienced defense counsel, demonstrated itself to be a far cry above and beyond K’s pain management doctor’s claim that “it must have been the dentistry,” implying a mere temporal relationship between the dentistry and the claimed symptoms. The value of well-credentialed experts, who can exhibit true proficiency, cannot be underestimated in the trial setting.

The defendants in this case practiced in different areas of dentistry, so the “sharing” of a single standard-of-care expert between them would be challenging at best, and disallowed in many jurisdictions. But the situation is different when it comes to experts who testify about questions of causation and/or injuries, so when possible and practical – which is far from a common occurrence – the presenting of a completely united front as between the defendants can send the jury a strong message, namely that there is no question that there can be only one way to interpret a certain set of issues.

Trigeminal neuralgia is a devastating disease, and it is described that way in detail by plaintiffs’ attorneys, who claim, as in this case, that dentistry or oral surgery is the culprit in getting there. The internet is replete with large numbers of “trigeminal neuralgia attorneys,” many of whom advertise and argue that they will obtain large recoveries against dentists and oral surgeons, often times relying upon non-scientific claims that garner jury sympathy. Defense teams of attorneys and experts can prevail through approaches that place science above emotion, while still exhibiting empathy for patients who might legitimately experience pain. But there is a real difference between the pain of trigeminal neuralgia and nearly everything else, and that point is one of several which was driven home at this trial. 

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.