Dentist’s Choice of Antibiotics Leads to Adverse Outcome for Patient

Background Facts

S was a 43-year-old healthy woman who presented to her general dentist, Dr. A, with a 2-day history of increasing pain and buccal swelling adjacent to her upper left first molar tooth. This was her first visit to the dentist since the COVID pandemic, having shied away due to fears based upon online blogs that she often read. Following clinical and radiographic examination, Dr. A determined that tooth #14 had decay which had invaded the pulp, thereby causing an infection. Dr. A explained the dental options available to S, namely endodontic therapy (RCT), followed by a post and crown, or extraction followed by various potential restorative choices. S did not want to lose the tooth, so she opted for RCT.

Dr. A was fully supportive of that approach, but he did not perform molar endodontics as part of his practice, so he referred S to Dr. Y, a local endodontist with whom Dr. A had frequently worked. S was seen by Dr. Y the same day, and the root canal was performed. Purulence was discharged immediately upon Dr. Y having entered the pulp chamber. Dr. Y explained to S that she thought antibiotics were indicated, given the symptoms present, so she provided a prescription for Metronidazole, with instructions for S to return in a week.

On the third post-treatment day, S called the office and told the receptionist that, despite her taking the antibiotics, she had a fever and her swelling was persistent. The receptionist responded, without discussing the issue with Dr. Y, that this was not a concern because “this often happens.” S was told to continue what she was doing and come to the office for her previously scheduled visit. At that visit, now a week after treatment, Dr. Y found continued and possibly increased swelling, so she changed the antibiotic to Clindamycin, and advised hot compresses and warm saline rinses. S complied and her oral symptoms abated, but she began to have blood-tinged loose stool 5 days later. She called the office again, and this time, she spoke directly with Dr. Y, who said that, because her oral condition was improving, she should continue the antibiotics for the remaining 5 days, telling S that intestinal problems frequently occur with antibiotics.  

S followed that advice, but had severe abdominal pain 3 days after the prior conversation with Dr. Y, so she presented to a local hospital’s emergency department. Based upon a complete clinical and radiographic work-up by an emergency physician and a gastroenterologist, S was diagnosed with a perforated colon due to pseudomembranous colitis (PMC). In conjunction with being given medications to counter the overgrowth of Clostridium difficile, she underwent a partial colectomy, with the colostomy reversed some weeks later, after a protracted hospital stay.

Legal Action

While still in the recovery phase, S retained an attorney. The attorney investigated a potential claim with the assistance of experts in the fields of endodontics and gastroenterology, who reviewed all of the records. A dental malpractice claim was filed against Dr. Y and her office entity, citing several assertions of negligent treatment, which had been set forth by the experts: (1) Dr. Y’s initial antibiotic choice – Metronidazole – was an improper and inadequate choice, “because it only covers anaerobes, and the vast majority of dental infections have an aerobic component,” (2) Dr. Y’s use of Clindamycin, while likely providing coverage for the bacteria causing S’s infection, did not come with a warning from Dr. Y of its potential severe gastrointestinal side effects, (3) the office receptionist’s transmittal of medical advice without discussing the patient’s concerns with Dr. Y was not only inaccurate, but it reflected poor office policy by vesting in non-dental staff members the authority to offer guidance that was well beyond the knowledge base of an office administrator, (4) Dr. Y’s “soft sell” regarding intestinal complications that can accompany antibiotic use revealed an inadequate acknowledgement of the potential severity of such complications and the need to quickly act, likely by referring her to a medical colleague, and (5) the sole causes of the PMC and the surgery undertaken as a result were Dr. Y’s failure to recognize signs of Clindamycin’s well known side effect and act upon it before it went as far as it did.

Discovery and Case Resolution

After Dr. Y was assigned counsel by her malpractice insurance carrier, attempts to retain defense experts to oppose the opinions of S’s experts took place. The potential endodontic defense expert was unable to refute the claims of negligence, and, in fact, essentially agreed with them. However, the potential defense gastroenterology expert was of the opinion that the timeline to support the plaintiff’s causation claim was lacking because, while PMC can begin to show symptoms within a couple of days of the start of an antibiotic such as Clindamycin, that more commonly does not occur until a week or so later. This picture would have left defense counsel with what is often referred to as a “causation defense,” meaning that because a plaintiff must prove negligence causing injury, the case would have to be upended with an expert argument that, although there were several negligent actions on Dr. Y’s part, those actions were likely not the cause of the PMC. Rather, “something else was at play.”

With the approval of the insurance carrier, defense counsel consulted with a second gastroenterologist to test the causation theory approach of the previously retained gastroenterology expert. This physician did not believe that the suggested model would be successful because it was not in line with the majority of current thinking.

After discussing all of these issues with Dr. Y, she agreed to have her attorney try to settle the case, and with the input of a mediator and approval of the carrier, that came to pass.

Takeaways

A dental practitioner’s decision as to whether antibiotics should be prescribed in a given situation, and if so, which ones to prescribe, lies totally within the judgment of that practitioner, who is in the best position to make determinations based upon clinical conditions. We do not comment on those professional judgments, other than to point out that most jurisdictions’ malpractice laws do not view “judgment calls” any differently than any treatment determinations or actions. In other words, “judgment calls” should align with the standard of care – what a reasonable practitioner would or would not do under similar circumstances. What we do speak to here is the concept that all decisions relating to treatment ought to be well thought out and able to be justified according to accepted science-based approaches to practice, rather than what is colloquially referred to as “junk science.”

When it comes to prescribing medications, or treating a patient on medications with which the dentist is not particularly familiar, or planning/performing treatment upon a patient with medical abnormalities, the burden to familiarize with regard to all of those situations rests upon that treating dentist. That is not necessarily to say that such a dentist must develop a true level of expertise when it comes to all medications or all medical conditions, but it is to say that the dentist needs to have a reasonable understanding of the implications presented, and that the dentist might, therefore, need to consult authoritative sources or engage with the patient’s treating physicians. If a patient is injured as a result of a treating dentist’s lack of knowledge on medical or pharmacological matters, that dentist could well be held liable for those injuries.

It should come as no surprise that experts playing a role in malpractice litigation often legitimately hold differing, even opposing, opinions on issues critical to the lawsuit. When that occurs prior to trial, as it did here, experienced defense counsel will thoroughly evaluate its significance to try to determine whether those divergent views will realistically be able to be overcome, or whether it is likely to pose a concerning result when placed before a trial jury. The value of proficient defense attorneys cannot be overstated, both during the discovery phase of litigation and at trial.

Finally, we echo the lesson put forth by the plaintiff’s endodontics expert as to the duties of the often numerous people carrying out widespread roles within a dental practice. There is no doubt that non-professionals in dental offices – receptionists, insurance filers, secretaries, office managers – are critical to the efficient running of dental practices. The limits of their roles need to be clearly established by the dentists who oversee the day-to-day management, and spell them out to all employees. Most basic is that only dentists address dental (and sometimes medical) issues with and regarding patients, leaving the administrative tasks to administrative, non-clinical personnel. When non-dentists offer clinical advice, and harmful effects result from that advice, the legal principle of vicarious liability – errors on the parts of employees are viewed as though the employer erred – takes hold. Whether the employer is a dentist or an entity, the ultimate responsibility falls upon that “higher-up.”

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.