OMFS and Nerve Damage

[White Zin]

Questions for OMFS residents:

Do you ever worry about hurting someone? Sometimes in the dentoalveolar surgeries (and orthers) ppl can get permanent nerve damage. Do you feel that this happens mostly as a result of negligence? Or is it something that happens unexpectedly? How often does this happen? I'd be intereested in what you think.

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[OMFSCardsFan]

Questions for OMFS residents:

Do you ever worry about hurting someone? Sometimes in the dentoalveolar surgeries (and orthers) ppl can get permanent nerve damage. Do you feel that this happens mostly as a result of negligence? Or is it something that happens unexpectedly? I'm interested in OMFS, but I don't know if I could live with myself if a surgery went awry and I caused permanent numbness. How often does this happen? I'd be intereested in what you think.

Depends on the situation...

For trauma, patient's are usually numb prior to surgery, and it's explained that the numbness may or may not resolve after surgery. For thirds, it's fairly easy to predict who may have a problem with a paresthesia/anesthesia afterwards. If I bagged a lingual nerve doing a set of thirds, I'd be upset about that. If a patient has a carious #17 with roots crossing the canal on the Pano, I'll try to remove the tooth as atraumatically as possible. I won't, however, have difficulty sleeping if they end up with a paresthesia afterwards. Obviously, I would fully explain the risks of extraction prior to doing it.

It's all about risk vs. benefit analysis...it's way too large a topic to really discuss, but hopefully you get the idea...

 

[rrc]

Questions for OMFS residents:

Do you ever worry about hurting someone? Sometimes in the dentoalveolar surgeries (and orthers) ppl can get permanent nerve damage. Do you feel that this happens mostly as a result of negligence? Or is it something that happens unexpectedly? I'm interested in OMFS, but I don't know if I could live with myself if a surgery went awry and I caused permanent numbness. How often does this happen? I'd be intereested in what you think.

Everyone has complications. This is a common one in OMS if you do hundreds of 3rds per year. You need to tell the patient about the risk ahead of time and what the ramifications are. If it happens you need to have proper documentation and know how to deal with it. The same goes for every complication.

 

[White Zin]

Everyone has complications. This is a common one in OMS if you do hundreds of 3rds per year. You need to tell the patient about the risk ahead of time and what the ramifications are. If it happens you need to have proper documentation and know how to deal with it. The same goes for every complication.

So how much per year would you say a typical OS has this happen? I'm talking permanent numbness. Does this drive up the cost of malpractice insurance considerably? How common would you say lawsuits are?


thanks
🙄

 

[north2southOMFS]

So how much per year would you say a typical OS has this happen? I'm talking permanent numbness. :

I would hope less and less as you get older, and i would imagine thats true.

Does this drive up the cost of malpractice insurance considerably?:

No, because most OMFS's have their pts sign consents beforehand, and this makes is very difficult to sue for this. I actually don't know of anyone who's been sued over a numb lip from 3rds extraction.

How common would you say lawsuits are?:

Very rare for 3rds.

 

[OMFSCardsFan]

So how much per year would you say a typical OS has this happen? I'm talking permanent numbness. Does this drive up the cost of malpractice insurance considerably? How common would you say lawsuits are?


thanks
🙄

It's not malpractice if you inform the patient of the possibility beforehand, get his consent for the procedure, and perform the procedure in the way that it is supposed to be done. The overwhelming majority of IAN paresthesia/anesthesias are not by fault of the surgeon, but a complication of a patient's anatomy. I've had several IAN paresthesias since beginning residency, but before all of them, I told the patient that they would be lucky if they DIDN'T get one. When you start looking at Panos of 30 year-olds with fully-formed roots and partially erupted crowns, you'll start to see a lot of IAN and root overlap. This, obviously, increases the chances for a post-op alteration of sensation. When possible, you don't disturb asymptomatic teeth that scream "complication", but unfortunately, some people have symptomatic teeth in these high-risk positions. You show an oral surgeon a Pano, and he'll be able to tell you with a reasonable degree of accuracy which teeth will likely cause a paresthesia and which ones won't.

Here's an analogy for the general practice guys: having an IAN nerve paresthesia is like pulping a tooth when deep caries are present. You hope it doesn't happen, but you tell the patient that there's a good chance that it will. Sometimes you pulp the tooth because the decay is there, sometimes you get a paresthesia because the nerve is right there, adjacent to the roots.

Get it now?

 

[adamlc18]

Of course, the whole unlikely to get sued thing goes out the window if a general dentist causes the parasthesia while doing 3rd molar surgery right?

 

[rocknightmare]

why would it go out the window..


from my understand of the law.. if you inform the patient that it could happen. then you should be okay if hte constented..

now if they can somehow prove that you had no really knowlege of what you (competence) are doing even if you informed then you got problems..

somebody correct me if i am wrong.. cause we will be licensed to kill right ?😉

 

[toofache32]

Everyone has complications. This is a common one in OMS if you do hundreds of 3rds per year. You need to tell the patient about the risk ahead of time and what the ramifications are. If it happens you need to have proper documentation and know how to deal with it. The same goes for every complication.

Bagging a lingual nerve isn't negligence as long as you did the procedure the way it should be done.....such as avoiding lingual incisions. This is a known complication which the patient consents to. As long as the procedure was performed correctly,and appropriate follow-up care (and referall if indicated) was maintained, there is nothing you could have done to avoid the complication or improve the outcome.

The interesting part is that several studies have shown that over half the patients who give consent don't remember the details of the conversation a few days later. This is one of the reasons you have them SIGN the form after you have gone over all the elements of the form.

Every procedure has unique risks inherent to the procedure. You explain these to the patient prior to the procedure and you only perform the procedure if they are willing to accept the possible complications.

For what it's worth, I fill out most consent forms with these genereic complications, plus others inherent to the procedure:

"Death, pain, bleeding, infection, scars, damage to adjacent structures, persistence of symptoms, worsening of disease/deformity, need for further surgery."

 

[mdub]

Questions for OMFS residents:

Do you ever worry about hurting someone? Sometimes in the dentoalveolar surgeries (and orthers) ppl can get permanent nerve damage. Do you feel that this happens mostly as a result of negligence? Or is it something that happens unexpectedly? I'm interested in OMFS, but I don't know if I could live with myself if a surgery went awry and I caused permanent numbness. How often does this happen? I'd be intereested in what you think.

That reminds me of the permanent numbness I have on the left side of my lower lip from when I got my wisdom teeth pulled way back when.

 

[mdub]

Of course, the whole unlikely to get sued thing goes out the window if a general dentist causes the parasthesia while doing 3rd molar surgery right?

In medical malpractice, a generalist who does a "specialist's" work, whether it's a formal speciality or not, assumes the standard of care of that field. That would mean a GP would be held to the higher standard of care for the "reasonably prudent doctor/dentist under the circumstances."

 

[mdub]

For what it's worth, I fill out most consent forms with these genereic complications, plus others inherent to the procedure:

"Death, pain, bleeding, infection, scars, damage to adjacent structures, persistence of symptoms, worsening of disease/deformity, need for further surgery."

The problem with laundry lists is that they can dilute the importance of the terms. Just listing everything that could possibly happen is bad because there's no context on the risk. Not listing enough is bad because you run the risk of not meeting your jurisdiction's standard of "informed consent."

You'd probably do well to use something that's been checked by a lawyer in your jurisdiction. That's fairly common. And once it's done, it's done until the law materially changes.

 

[mdub]

[Sorry. Double post.]

 

[White Zin]

So, then what happens to these people? Can they go on to live a normal life? Do they need speech therapy or some other kind of rehabilitation? How significantly does this affect them?

 

[El Guapo78]

So, then what happens to these people? Can they go on to live a normal life? Do they need speech therapy or some other kind of rehabilitation? How significantly does this affect them?

If you're still talking about IAN nerve damage I can say they will be fine. I have some paresthesia on my right side from a BSSO performed about 10 years ago. I don't really even notice it now unless somebody asks me. It doesn't affect function or speech, it is just sensation. Even though my nerve was damaged it was not severed, and I still have about 40% feeling. People will be just fine and adapt to this type of nerve damage, facial nerve damage is a different story though. 😕

 

[toofache32]

The problem with laundry lists is that they can dilute the importance of the terms. Just listing everything that could possibly happen is bad because there's no context on the risk. Not listing enough is bad because you run the risk of not meeting your jurisdiction's standard of "informed consent."

You'd probably do well to use something that's been checked by a lawyer in your jurisdiction. That's fairly common. And once it's done, it's done until the law materially changes.

That where I got it.

 

[Extraction]

Questions for OMFS residents:

Do you ever worry about hurting someone? Sometimes in the dentoalveolar surgeries (and orthers) ppl can get permanent nerve damage. Do you feel that this happens mostly as a result of negligence? Or is it something that happens unexpectedly? I'm interested in OMFS, but I don't know if I could live with myself if a surgery went awry and I caused permanent numbness. How often does this happen? I'd be intereested in what you think.

IAN paraesthesia on 3rd extractions is between 1-3% and lingual nerve damage is 0.5-1% depending on the literature you read. It happens and is not always avoidable. For negligence to have occured you have to grossly violate the standard of care. ie lingual approach to 3rd (unless you live in the UK), cutting the nerve with the burr, putting an implant or sargenti paste into the IAN canal. If you have SIGNED informed consent and follow standard protocol you should be fine legally.

A great example of negligence: A general dentist in the city I reside recently had a patient sent to our hospital for an air ephesema while trying to surgically extract a tooth with a highspeed handpiece. That is an indefensible malpractice suit and gross negligence as the dentist should have used a surgical handpiece or striker that doesnt blow air into the surgical site.

If you are a general dentist doing 3rds, it is good to always offer referal to a specialist. In my experience , most patients will decline a referal to an oral surgeon based on the price difference. Post-op follow-up appointments and communication is key.

I've extracted alot of impacted 3rds under local in private practice while moonlighting. Patients tend to be reasonable if you are upfront and discuss complications beforehand.

Also be sure to document your diagnosis and reason for extracting, partial exposure, history of pericoronitis etc. Do not do stuff beyond your skill, or that is high risk of nerve damage and elective. ie a distoangular #32 with 5mm bone coronally with obvious nerve involvement (discontinuity of the canal on the pano) that is asymptomatic.


I've had a few paraesthias that have resolved. If you have a paraesthia, follow the patient and know when to refer to a microneurosurgeon... (ie 3 months)

Finally, if you are worried about hurting patients and things going awry, you need to reconsider your career choice. You can do alot of things in general dentistry, or any medical field for that matter, that can potentially harm a patient. You can give a patient a paraethesia from local anesthesia, bag someones IAN nerve with endo, give someone a malocclusion and TMD, put someone into anaphalactic shock from an antibiotic perscription.

 

[12YearOldKid]

why would it go out the window..


from my understand of the law.. if you inform the patient that it could happen. then you should be okay if hte constented..

now if they can somehow prove that you had no really knowlege of what you (competence) are doing even if you informed then you got problems..

somebody correct me if i am wrong.. cause we will be licensed to kill right ?😉

Theoretically, the GP is held to the same standard as the specialist, but the reality is that the GP is held to a higher standard. It is almost toooo easy for a lawyer to tear apart a GP and make him look like a cowboy who is pushing the limits in order to pad his bank account. It is a little harder to cast aspersions on the expertise of a specialist.

It may not be fair, but that's the way it is. If you want to do procedures that are typically done by a specialist you are completely within your rights, but you are also assuming some significant risk.