A 58-year-old male patient with periodontal disease and Type 2 diabetes was referred by his regular dentist to an oral surgeon for crown lengthening on #14 and #15. The procedure was done on 1/3/2023, and as far as we can determine, no antibiotics were prescribed beforehand.
On 1/17/2023, the patient followed up with the oral surgeon, and the areas were reported to be "healing nicely" with no complications. The oral surgeon released him back to his regular dentist to go forward with the crowns in 2-3 weeks.
On 1/24/2023, the patient returned to his regular dentist for #14 and #15 final impressions. The teeth were prepped for Zirconia crowns and provisional crowns were cemented with tempbond. No signs of infection or problems were noted.
On 2/9/2023, the patient returned again to his regular dentist, where an interocclusal space was noted and a pick-up impression was taken "to add porcelain to the occlusal"; the crowns were sent to the lab for changes. No other problems or signs of infection were noted.
On 2/15/2023, the patient went to his local emergency department complaining of new right shoulder pain with tenderness to the shoulder joint and difficulty moving the shoulder. The patient reported a history of frozen shoulder several years earlier. On x-ray showed degenerative changes and a tiny calcification abutting the greater tuberosity, which could be calcific tendinitis. The patient was diagnosed with shoulder impingement syndrome and tendinitis. He was discharged and instructed to follow up with an orthopedist. Later that day, the patient presented at a walk-in orthopedic clinic, where he was given a right shoulder cortisone injection and possibly prescribed oral medication for pain.
On 2/17/2023, the patient followed up with the orthopedist, who changed his medications to tramadol and celebrex, and scheduled an MRI of the shoulder for 2/25.
The patient's pain continued to get worse, and he started having fevers and a sore throat. On 2/21/2023, the patient went back to the emergency department, where he was found to have an extensive infection ranging from his anterior thyroid area to the mediastinum and involving the right sternoclavicular joint. He was eventually diagnosed with osteomyelitis involving the sternum, and right sternoclavicular joint septic arthritis. Blood cultures grew Streptococcus intermedius. The patient was treated with IV antibiotics and underwent repeat surgeries including I&D of a sternoclavicular abscess, partial resection of the right head of the clavicle, partial resection of the manubrium, drainage of mediastinal collections and treatment with a wound VAC. Infectious disease doctors diagnosed him with Ludwig's angina and noted that this was an odontogenic infection.
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Q: Was this procedure performed by an OMS or a periodontist?
A: —
Do you believe there might have been medical error?
I do not believe it is the standard of care to routine prescribe preoperative or even post operative antibiotics patients having periodontal surgery. Even if the patient was a diabetic, if the patient had poor glycemic control, then I would consider antibiotics S. Intermedius is a periodontal pathogen, but it is a pernicious and promiscuous agent, which means it will be difficult to state that the procedure precipitated the infectious process, moreover the history is unclear. did the patient develop ludwigs angina and then have bone borne infection? Was the oral surgeon at fault, probably not From a causation perspective, would pre or post antibiotics avoided this dreadful complication…that’s hard to say, but probably no It would be helpful to know the exact clinical course. I would be surprised if the procedure caused sepsis first and then ludwigs angina. Even if ludwigs were the presenting infectious process, it is extremely rare (like never) for a patient to develop sepsis, let alone osteomyelitis from this procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Did the provider do or not do something to cause the patient harm? The provider did a procedure that was temporally related to the development of an infection It is possible that manipulation of oral tissues including surgery could have caused ludwigs angina, but typically ludwig etiology is from an odontogenic infection. Could antibiotics have influenced the development of an infection? Maybe, but it is not the SOC to give antibiotics to patients prior to periodontal surgery.
What makes you a good expert for this case?
This is not my area of clinical concentration, and probably falls into the general OMFS category of practice
How often do you encounter cases similar to this one in your practice?
Ludwigs angina - every months Osteomyelitis in a distant site from the etiologic agent/process - never, which I why I have reservations about the strength of the claim Mediastinal extension of an odontogenic infection- once every 3-5 years
Do you believe there might have been medical error?
The time from the crown lengthening to the infection was 6 weeks. The patient has periodontal disease( I don't know how extensive) but the worse it is then he is always walking around with chronic infection which is more likely a possible etiology. No dental notes ever found a poor healing or local infection. Even though he has DM and obesity which makes him have a possible increased risk of infection, that does not require antibiotic prophylaxis. It may have more prudent to place him on antibiotics for the dental surgery but it is certainly not mandatory or malpractice.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
6 week time delay for infection onset
What makes you a good expert for this case?
38 years of dentoalveolar experience About 50 case reviews of legal dental cases some of which were infections
How often do you encounter cases similar to this one in your practice?
Never. The closest would be subacute endocarditis (SBE) and prosthetic joint infections
Do you believe there might have been medical error?
This is a common procedure performed for restorative purposes and infection, even severe ones are always a risk.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Without review of the case it is impossible to state whether negligence lead to the patient's infection.
What makes you a good expert for this case?
I have reviewed dozens of cases of infections after dental/oral surgery procedures.
How often do you encounter cases similar to this one in your practice?
Infections after oral surgery procedures do occur even when all best practices are followed.
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