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DX Horribilis: What Went Wrong?

My sincere thanks go to Dr. Joel Fransen who took the time to prepare and share this important case with our Oasis audience. Such unfortunate situations happen and it’s great to be able to share them and learn from them. 

Dr. Fransen is a seasoned endodontist in Richmond, BC and a frequent contributor to CDA Oasis. 

I hope you find the information presented valuable. Please share your thoughts, questions and suggestions with us at oasisdiscussions@cda-adc.ca

Until next time!

Chiraz Guessaier
CDA Oasis Manager

Please email us (see email address above) to get the code to view the case. 

Dr. Fransen’s Notes

This case demonstrates how things can cascade out of control for what, upon first glance, appears to be innocuous. A thirty-something gentleman reports vague pain in quadrant three. The medical/dental histories are unremarkable save a car accident ten years prior that required extensive restoration of many teeth. There were no overt signs of infection or other problems. The dentist reports pulp and periradicular testing revealed 36 as the culprit. The pulpectomy was uneventful and Tylenol No. 3 was prescribed. Nevertheless, over the proceeding days and weeks things deteriorated to such an extent the patient spent ten days in ICU.

There are a litany of lessons that can be gleaned from this case. Generally speaking, whenever a response to endodontic treatment or extraction is suboptimal, be wary and consider further radiographic investigations (i.e. CBCT, angled PA’s) and second opinions from colleagues or specialists. Post-op fascial space involvement, numbness, vomiting, sleep disruption, and the like are serious sequelae warranting a comprehensive re-evaluation of the diagnosis and treatment to-date. A delay in an accurate diagnosis and decisive treatment can have dire consequences.

Full Case Presentation (32.03″)

 

 

16 comments

  1. Superb presentation. Lots of good clinical tips even for an experienced dentist.
    I hope to hear more of these cases where we could learn from things that went wrong
    I think Dr Fransen is a very good lecturer and I hope he will be back on Oasis

  2. Excellent Presentation. Well done, will most certainly share it with my dental students.

  3. Good presentation and well thought out.
    I believe that Staphne defects occur below the IAN, not at the apices of lower molars

    • Hello Dr. Blackman, You are indeed correct about the typical location of the Stafne bone cyst. In my presentation I may have overstated the relevance of this radiolucency. I meant to raise it as a possible complicating factor when evaluating the health of apical periradiculum of mandibular molars. I did not mean to suggest that I know the defect to be a Stafne bone defect but it is a possible complicating factor that could lead to misdiagnosis. I apologize for my clumsy handling of this point.
      All the best, Joel

  4. It was stated that there was a legal situation here. I do recognize that the focus of the talk was to talk about how to avoid problems, however I am concerned that the vagueness of that comment may cause some unnecessary fear. Was it that the treating dentist got sued? What was the reason? Whomever got sued or sent to the college, I am curious of the result. Did the Emergency Physician get sued?

    So one dentist diagnosed and another initiated endodontic treatment? Is this a case against corporate/group practices? Dr. Fransen do you have a recommended consent form for general practitioners to use? I would love to see it.

    I also loved the comments at the end of how to think of the problem. Talking about the facial spaces, to be honest, was not something on my radar. Also love the recommendation for more PA’s, perio prob, pulp test and record the results.

    • Hello Brian,

      Thank you very much for taking the time to leave your comment. I have forwarded it to Dr. Fransen and he should reply to you on this site.
      All the best,
      Chiraz, CDA Oasis

    • Hello Brian,

      I apologise if it seemed I was stoking the fire of fear. That was not my intention. This problem became ‘legal’ because the things went so wrong. I am not aware of any College issues related to this case as my involvement was limited. As you can imagine the patient felt left down by treatment she had received and was seeking compensation. I am unaware of the final result and as far as I know only the dentists were the subject of legal proceedings.

      It is my understanding the practice was privately owned by a dentist with no corporate co-ownership.

      The BCDA has a great consent form on its website that is freely availalbe to BC dentists and I believe other dentsits too. My concern with consent forms is that no one form is perfect or could possibly cover every possible eventuality. Thus, I prefer efficient and succinct forms. If you like this could be a good topic for a future Oasis presentation?

      Thank you for your kinds words about the presentation. I did my best to present this most interesting case efficiently and effectively. On a side note, I find that patients who decline radiographs will consent with the rationale is explained to them. Although, sometimes the conversation is easier than it is at other times.

      All the best,
      Joel

  5. Pierre-Luc Michaud

    Very interesting case; very well presented. Thank you for taking the time to do this.

    I am interested in getting the references of the research findings you discussed where teeth with shallower amalgam restorations were found to fracture with less force than teeth with deeper amalgam restorations.
    Thank you.

  6. As a periodontist with 52 years in practice I have come across and diagnosed endodontic involvement of lower molars based on numbness in the IAN distribution quite a few times. Good radiology will confirm that there is a periapical lesion causing pressure on the nerve. This recent case demonstrates how easily one can become fixated on the first diagnosis. It is a good rule when symptoms change to take a step back and carefully reassess. Excellent case, well presented.

  7. You are absolutely correct Dr. Munns. It appears that faith in the original diagnosis was so strong here that the clinicians were blind to seriousness of new developments.

    All the best,
    Joel

  8. Graham McMillan

    I agree with the last comment. This is a case of too many cooks spoiling the broth – a diagnosing dentist and a treating dentist, resulting in the blurring of the responsibility for the treatment and a bad outcome.

    In this case, the diagnosing dentist diagnoses the problem wrongly and the second treating dentist, likely a lower-time dentist, goes in and does the treatment as instructed, trusting wholeheartedly that the diagnosis is correct and definitive.

    The problems begin when the procedures by the treating dentist don’t alleviate the pain – the diagnosing dentist is worried that he made a wrong diagnosis, and the treating dentist is worried about what the diagnosing dentist will think of his treatment.

    Neither dentist wants to open up the possibility of being wrong (a misdiagnosis or substandard care) in front of his patient or to each other for that matter, so they both continue on with the wrong treatment.

    In the aviation world this is referred to as “Get-Home-itis”, wherein a pilot gets so focused on flying home that he will continue on despite obviously deteriorating conditions only to fatally crash.

    As Dr. Fransen so rightly points out, if something isn’t going as expected it is always wise to step back and reevaluate the situation and perhaps call in the expertise of a specialist.

  9. Dr. Benjamin Lin

    An important point not mentioned is that Eikenella is resistant to Clindamycin.

    • You are absolutely correct Dr. Lin and I meant to bring that point up during the presentation but forgot to refer to it at the time. During the first fifteen days the Clindamycin appeared to be more effective than the Amoxicillin. But the Amoxicillin was not given adequate time to prove its effectiveness and I did not like how the antibiotics were switched back and forth so haphazardly during the first twenty post-op days. The decrease in effectiveness of Clindamycin likely speaks to the growing influence of Eikenella in this case.

      I think the trauma from chewing of the cheek, the two large horizontal incisions, and extraction of the mobile 7 with frank marginal exudate were opportunities for Eikenella corrodens to enter into the mix. It is impossible to know for sure but that is my suspicion.

      The Eikenella involvement may speak to the delay of a decisive diagnosis and treatment in this case and is something to be weary of in similar cases. It is good to also be cognisant of the fact that Clindamycin, like all antibiotics, is not a cure-all and it is best to not rely too heavily on them.

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