The patient was not in any pain at the time of the visit but the doctor advised her that she needed to have a root canal procedure performed, or, alternatively, extract the tooth due to nerve exposure. The patient chose the tooth extraction and the procedure was met with great complication.

According to the medical note, the root fractured during the extraction and the dentist called in a more experienced doctor to extract a portion of the root tip that had broken off. During the extraction of the root fragment, the patient stated that the doctor repeatedly expressed that he was having difficulty visualizing the area, yet he continued digging into the socket for a long duration of time. The more experienced dentist, however, seemed to be able to remove the root tip quickly and easily.

After the extraction, the patient was in unrelenting facial pain. She was told to return to the dentist’s office where he removed bone fragments from the surrounding gum tissue. The pain continued and increased in severity, which prompted the patient to go to the emergency room where she received a preliminary diagnosis of trigeminal neuralgia. A neurological consultation confirmed the trigeminal neuralgia and the patient ultimately had to undergo a vascular decompression surgery to treat the condition.

Symptomatic forms can have multiple origins. Aneurysms, tumors, chronic meningeal inflammation, or other lesions may irritate trigeminal nerve roots along the major pathways causing symptomatic trigeminal neuralgia. Infrequently, adjacent dental work or dental fillings composed of dissimilar metals may trigger attacks.

1. Can an aggressive and negligent tooth extraction be linked as the underlying cause of the trigeminal neuralgia?

Location: Kentucky B.S., University College, New York University DDS, School of Dental and Oral Surgery, Columbia University Residency, Chief Resident, Oral Surgery, Long Island Jewish Medical Center Board Certification: Oral and Maxillofacial Surgery, Dental Anesthesiology Member, Fellow, Life Member, American Dental Association Member, Fellow, International College of Dentists Member, Fellow, International Association of Oral and Maxillofacial Surgery Published, 50+ book chapters, abstracts, publications Former C**** S******* a** H******* D******** U********* o* L********* S***** o* D******** Former A***** C**** D**** o* O*** a** M************ S****** U********* o* L********* S***** o* D******** Current P******** O*** a** M************ S****** a* m**** d***** i**********

This qualified, board certified oral surgeon has remained in active practice for over thirty years, during which he has been appointed to several high ranking clinical positions including Chair of Dentistry at his institution. He has authored a vast body of publications, and is capable of reviewing the case at hand.

This case involves a twenty-four-year-old female patient who presented to her dentist for a routine tooth filling.

Dentist’s Tooth Extraction Procedure Causes Nerve Damage

This case involves a previously healthy twenty-five-year-old male with no significant past medical history. He presented to a dentist with a sudden onset of tooth pain, trismus, and severe swelling of the jaw. At the initial visit, no x-rays or other diagnostic studies were performed. The patient’s dentist referred him to an oral specialist when he returned to the practice four days later complaining of worsening of his symptoms. The oral specialist prescribed analgesia for relief of the pain and muscle relaxants. No examination was performed at this time despite the severity of the patient’s symptoms. The patient collapsed at home the following day. He was found unconscious by his roommate who called an ambulance. It was apparent that the patient was unconscious for an extended period of time before he was discovered. He was admitted to hospital. Subsequently, a large abscess was discovered two days after admission. A tracheostomy was put in place and surgery for the removal of neck and jaw muscles were required to prevent the spread of the infection to surrounding tissue. The delay in treatment resulted in further radical treatment. The patient now has a permanent injury and facial disfigurement.

As a general dentist, I have many years of dealing with complicated dental issues and significant experience in what a general dentist, or specialist, should be able to diagnose, treatment plan and/or refer. In my opinion, it seems that there may be several errors made by the dentist treating the patient in this case. Based on the first visit, did the dentist refer that same day? Why did the dentist take four days to refer the patient to a specialist? Do the medical records reflect his diagnosis and potential treatment/referral plan? The next observation is what type of records did the specialist take? And thirdly, why did it take the hospital two days after admission to diagnose the abscess? What records or films did they take? In my opinion, this patient could have been diagnosed much sooner, perhaps even at initial presentation to the dentist, however, further review of the patient’s medical records would be needed to confirm this suspicion. Standard of care would involve, at the very minimum, an examination, x-rays and some sort of treatment. Now, that treatment might just be a referral, but no treatment is not appropriate and is a departure from the standard of care. Time is of the essence in an infection of this severity and any delays can lead to increased morbidity, as was the case for this patient, or even fatality.

1. Is it within the standard of care to use this linear acceleration radiation to treat trigeminal neuralgia?

Location: Kentucky B.A., University of Kentucky D.M.D., University of Kentucky College of Dentistry Residency, General Practice, Veterans Administration Medical Center Member, American Dental Association Member, American Dental Education Association Member, International Association of Dental Research Member, American Association of Hospital Dentists Current P******** m**** c****** d******** Current D******* C**** G****** D******** m**** c****** o* d******** Current D******* G****** P******* R******** m**** c****** o* d******** Current D******* m**** d******** c*****

This general dentistry expert has been practicing for over 30 years. He is widely published and has lectured and presented extensively on the international, national, regional, state, and local levels. A full Professor at a major medical university, he is not only the Chief of the Division of General Dentistry, but serves as the Director of the General Practice Residency Program as well. This expert also acts as the Director of the same institution's dentistry clinic.

Delayed Diagnosis of Dental Abscess Results in Facial Disfigurement

A neurosurgery expert witness opines on a case involving a patient who was left with chronic pain following a dental procedures and linear accelerator radiation therapy for trigeminal neuralgia. This case involves a fifty-eight-year-old female patient with no significant past medical history who presented to her dentist complaining of pain in the right jaw line and cheek bone region. The pain was originally thought to be from an infected tooth which prompted an extraction by a dentist.When the extraction failed to relieve the patient’s pain she was referred to an oral surgeon by the treating dentist for the removal of a second tooth which was now believed to be the source of the pain. Before the procedure a CT head was performed and read as normal with no masses or lesions present.

Following the second extraction, the patient’s pain became exponentially worse necessitating a neurology consultation. After many visits the patient was finally diagnosed with trigeminal neuralgia. A neurologist recommended that a trigeminal nerve block be performed. The treatment had limited success and the patient continued to experience breakthrough pain despite the nerve block. The patient was then referred to a neurosurgeon who suggested that the patient receive LINAC (linear accelerator) radiation therapy to ablate the trigeminal nerve root. Following surgery the symptoms only worsened further and the patient decompensated neurologically due to radiation necrosis. The patient now displays continued facial pain, stroke-like drooping of the left side of her face, and difficulty walking; she has needed numerous costly additional procedures, and has needed to undergo locomotor training in an attempt to regain her balance and full ability to walk.

Stereotactic radiation is one of the standard treatments for trigeminal neuralgia. About 75% of patients receive initial pain relief and around 50% of patients have durable pain control. The radiation is directed at the trigeminal nerve as it exits the brain stem. The most common side effect from this treatment is numbness of the face and very rarely damage to the facial nerve. Dose delivered is between 70 to 80Gy calculated at the isocenter. The side effect described in the case of this patient could be related to the dose or site of treatment. Another risk factor is the presence of multiple sclerosis which could interfere with the treatment’s mechanism of action, although this does not apply to the patient in this case. I perform these procedures routinely with LINAC based machines for trigeminal neuralgia. It is very uncommon to see the complications that this patient has been left with. Further investigation as to how the procedure was performed, what equipment was used and what dosage was delivered is warranted. It is possible that the patient’s symptoms could be the result of a poorly conducted procedure or improper dosing.

Is it within the standard of care to use this linear acceleration radiation to treat trigeminal neuralgia?

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Trigeminal Neuralgia Expert Witness Case Studies

Dentist’s Tooth Extraction Procedure Causes Nerve Damage

Delayed Diagnosis of Dental Abscess Results in Facial Disfigurement

Neurosurgeon Advises on Radiation Procedure for Trigeminal Neuralgia

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