Sample Case Evaluation Reports - Dentistry Expert Witness


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Root canal with broken file in root, and chronic pain.

On the original x-rays taken at the patient's first visit for a chief complaint of pain on the lower left side, there can be seen recurrent decay under an old filling apparently encroaching on the nerve canal of the tooth. The dentist who cleaned out the caries (cavities) and the old filling found a pulp exposure and recommended a root canal, which is absolutely the proper treatment. The patient continued to have pain following the attempted root canal during which a file was broken in the mesial buccal canal. An endodontist recommended that the tooth be removed as the canal could not be bypassed. Following removal of the tooth, the patient has experienced excruciating and continued pain.

One theory of the pain that has been placed forward by one of the doctors is that in manipulating the canal with the root canal files, one of which is broken in the root canal, not a bur, that the dentist manipulating the root canal files pierced the mandibular nerve. This is very, very highly unlikely and almost impossible to do with a root canal file. First of all, to do that you would have to pierce through the tooth, out the end of the canal of the tooth, through approximately a quarter of an inch of solid bone, through the wall of the canal, and then through the vein and artery before you reached the nerve. There is no indication on the panographic x-ray of perforation through the root socket, through the bone, and into the canal. You would be able to see a tract on the x-ray. Therefore, damage to the nerve of the jaw by use of root canal files is completely ruled out in this case as there is no indication of a tract on the x-ray through the bone and into the nerve canal.

Secondly, the patient had the tooth removed and the pain has continued. The cause of the patient's continued pain can probably be attributed to a couple of factors, none of which include the broken root canal file within the tooth which has now been removed. These factors are:

1. The patient may be brewing a very, very mild but painful osteomyelitis (bone infection) with necrosis, and this would take time to show.

2. On the preoperative x-ray before the tooth was removed, you can see an increased lamina dura space, that is, a dark space between the root and the bone. This would be indicative of a pericementitis, inflaming the entire socket and causing pain.

3. The patient had already lost a tooth on that side. The other two teeth on that side had started tipping forward, and now that #18 is gone, #17 is tipping even more forward and putting increased pressure on her left temporomandibular joint. This could be exacerbating her pain and even causing quite a bit of her pain.

I think that for a positive, definitive diagnosis as to the cause of the patient's pain now, the following should be done:

1. Another panographic x-ray should be taken and should be reviewed in the original state, not as a copy.

2. An MRI should be done of the left temporomandibular joint to see if there is any dislocation of the disk, subluxation of the disk, or derangement of the disk causing her pain and increasing her pain.

3. If either of these is negative or if they are both negative, a nuclear scan of the left side of the mandible should be done which would immediately show the presence of any osteomyelitis.

Finally, in going over the pertinent points of the records and reviewing them again, I don't really find any deviation from the standard of care in the treatment of this patient. Even the broken root canal file, which is within the tooth which was extracted, is not a deviation of care when taking into consideration the tortuous nature of the mesial buccal canal in #18. The endodontist who saw the patient following the attempted root canal by the dentist recommended extraction and the tooth was extracted. There is no indication on any of the x-rays of a broken jaw, of a root left in place, or anything like that. I feel that this is an unfortunate circumstance of postoperative pain and sequelae, combining both possible osteomyelitis with possible left temporomandibular joint disease due to collapse of the bite on the left side.

All of the previous explanation has to be taken with one caveat, however. That is, was there informed consent from the dentist to the patient, did the patient know the informed consent, agree to it, and sign off on it? I do not have a copy of it in the records from the treating dentist. I do have a copy from the endodontist who did not actually do any work on her, but I would like to know if there is an informed consent from the treating dentist. If there is, then absolutely there can be no one held liable for any cause of anything here.

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Cavity drilled too deeply enters root canal and causes serious infection.

A minor patient was taken by her parents to Dr #1, a Family Dentist for a six-month check-up. They were told she had a cavity. She was then brought back on an appointment basis, and according to the complaint, the Dentist, Dr. #1, told the father at that time that he had drilled too deeply and he was sorry for this. He said he would take care of everything, and if she had any problems, they were to give him a call.

The patient had varying symptoms from that time on until a few weeks later when she received root canal therapy performed by Dr. #2, to whom she had been referred by Dr. #3, after he had seen her. Dr. #3 diagnosed an abscessed upper left permanent first molar, and he sent her to Dr. #2 who is a Specialist in Endodontics. The endodontic procedures were performed, and she is to get a crown at a later date.

There are no x-rays accompanying the records. Everything is here from all of the Dentists except for x-rays.

The question here of whether the Dentist lived up to the standard of care in performing his therapy on the patient would basically hinge on whether the x-rays showed a non-restorable upper left first molar that needed to have a root canal and a crown or whether the x-rays showed an upper left first molar that just had a deep caries which could have been repaired. According to the patient's father, the Dentist who originally saw her and put the first filling in represented to him that he had drilled too deeply. This would indicate that the patient should not have needed to have a root canal and a crown but could have gotten away with just a filling.

This would be appropriately diagnosed by a General Dentist studying at the original preoperative, pre-root canal, pre-filling x-ray. If he did drill too far down and the x-rays show that there was no caries to the pulp, then obviously he is negligent and did not live up to the standard of care.

If the x-rays show that the caries extended to the pulp and that he could not avoid having a pulpal involvement with the drilling, then he still should have informed the father and sent the patient immediately for a root canal instead of putting her on antibiotics and a painkiller. Either way, he did not handle it correctly. One way he handled it below the standard of care, and the other way he handled it so that it did not seem like a Dentist doing something wrong.

The x-rays that were taken before any fillings were done on tooth #14 -- the preoperative bitewings and/or periodontal x-rays -- should be obtained, and they should be reviewed by a General Dentist who could tell you if the caries went down to the pulp or not.

I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Personality Inventory) which have been given to millions of people would further support that opinion before a jury.

Dictated but not read.

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