In the past several years, dental implants have become increasingly commonplace. Dental professionals now use implants as a solution for anything from missing teeth to the replacement of a patient’s entire dentition. Advertisements promote “the perfect smile in a day” services to replace missing dentition. These ads can be very confusing for prospective patients. As a result, they conduct inadequate research on both the procedure and the clinician performing it.
The placement of safe dental implants requires knowledge of multiple specialties within dentistry. Furthermore, good outcomes depend not only on the clinician’s specialty training but also on their actual clinical experience. In regards to litigation, several cases exhibit negligence that has resulted in patient harm.
Inadequate Preoperative Imaging
When it comes to patient injury post dental implants, inadequate preoperative imaging is usually a telltale sign of negligence. To illustrate this type of negligence, consider the following case example.
Case Study
A 35-year-old female patient visits her dentist for the evaluation of site #19 (lower left first molar). The dentist uses a periapical film (small single-tooth x-ray) to evaluate the area and plans for implant placement. On the day of surgery, the dentist prepares the implant site by drilling an osteotomy (hole into bone). At this point, the dentist encounters significant bleeding. In addition,the patient has sudden pain radiating into the lip and chin area.
The dentist administers more local anesthetic and proceeds to place the implant. The patient is discharged with pain medication and antibiotics. The next day the patient calls the office. She cannot feel her lip or chin area. Further, she is still having significant nerve pain. The dentist suspects that the inferior alveolar nerve may have been injured during the procedure. Thus, they promptly refer the patient to an oral and maxillofacial surgeon for evaluation.
First Referral
The surgeon obtains a cone-beam CT scan that indicates the implant has violated the canal. As a result, it is likely compressing the nerve. The surgeon removes the implant and places the patient on high-dose steroids. Six months later, the patient continues to experience loss of sensation and pain. She is referred to a micro-neurosurgical specialist for evaluation.
Second Referral
The specialist finds the patient has a severe nerve injury (Sunderland Grade V). Thus, they deem her a candidate for reconstructive nerve surgery. She undergoes an autogenous sural nerve harvest with Inferior Alveolar nerve reconstruction. Six months after the operation, her pain levels have improved and she experiences some return of sensation. The patient files a lawsuit against the dentist who placed the implant. Had the dentist obtained the appropriate preoperative imaging, the patient’s nerve injury could have been significantly reduced if not completely avoided.
Medication Induced Osteonecrosis of the Jaws
Medication Induced Osteonecrosis of the Jaws (MRONJ) is another poor patient outcome that may arise from inadequate training and/or knowledge. MRONJ is a condition in which medication prescribed post invasive dental procedures impacts a patient’s jawbone. Specifically, the medication at issue is given to decrease bone breakdown. However, bone breakdown can result from either osteoporosis or metastatic cancer that has spread to the bone. Medications used to treat these two conditions vary widely in potency. Consider the following case example involving MRONJ.
Case study
A 67-year-old male patient has a history of metastatic prostate cancer. As part of his treatment for bone metastasis to the ilium and spine, the patient took over 15 doses of IV Zoledronic Acid (Zometa). The patient went to his dentist to have a decayed tooth evaluated (#30, lower right first molar). At the time of evaluation, the patient had no pain nor any symptoms of infection. The dentist was aware of the patient’s medication history but did not realize the significant difference in potency between orally administered bisphosphonates used for osteoporosis. For example, Alendronate (Fosamax), and intravenous forms of the drug used for metastatic diseases, such as Zometa. The dentist thus prepared the patient’s implant placement site with extraction and bone grafting using cadaver bone.
Two weeks later, the patient returned for a follow-up appointment. The dentist noted that the site looked as though it had not undergone any healing. He prescribed the patient another two weeks of antibiotics and scheduled another follow-up. Two weeks later the patient returned once more. Again, the site had not healed and the patient noticed a bad taste in his mouth. Additionally, the patient reported some pain.
Further Imaging and referral
An x-ray revealed signs consistent with osteomyelitis (bone infection). The dentist referred the patient to the local university’s department of oral and maxillofacial surgery. Given the patient’s medical history, the specialist diagnosed MRONJ.
Several months of conservative therapy with antibiotics and minor chairside debridement failed. In addition, the patient developed a pathologic fracture of the right mandible, with osteolytic changes to the entire right side of his jaw. The patient subsequently underwent resection of the affected portion of the mandible, with microvascular free fibula flap reconstruction. This treatment ultimately alleviated his MRONJ.
The patient succumbed to his metastatic disease three years later. The issue of MRONJ could have likely been avoided had the dentist resisted any invasive dental treatment (extraction of tooth #30 and bone grafting) and merely treated the tooth to prevent future infection.
In conclusion, although dental implants represent a safe and reliable option to replace missing teeth, patient selection, and thorough knowledge of the patient’s medical history are essential to ensure an ideal outcome. New reliable imaging techniques such as Cone Beam CT scans decrease the risk to local vital structures. Clinicians should use these advanced modalities, when indicated, to minimize the potential for patient harm.
