Severe pan-facial infection from recementing of dental crown

This case involves a thirty-four-year-old female patient who had previously undergone extensive dental work including fitting of crowns to several teeth. The patient called her dentist’s office and reported a missing crown on tooth # 19, the left lower molar. The crown had been missing for nine days and the patient was experiencing a great deal of tooth discomfort which included sensitivity to heat and cold. Her dentist was unable to see her immediately due to his schedule, so the patient sought treatment at a different dentist’s office. By the time the patient made the appointment the tooth had deteriorated further and was showing signs of infection including swelling, an unpleasant odor and taste. The patient was seen by the new dentist who examined the tooth and re-cemented the crown without first taking an x-ray of the decaying and infected tooth. The treating dentist did not prescribe any antibiotics after the procedure. Shortly after the visit the patient developed severe facial pain on the left side of her face and presented to the emergency room. The patient was diagnosed with a pan-facial infection and which required twelve days of hospitalization and the placement of four drains to remove purulent abscess material as well as intravenous antibiotics. The hospital found that the crowned tooth was grossly decayed and was the underlying cause of the patient’s facial infection. The patient required further dental care from an oral surgeon to treat the decaying tooth.

Question(s) For Expert Witness

1. Was it a departure from the standard of care to re-cement the crown without first performing radiological studies?

2. Was it a departure to not prescribe antibiotics after the procedure?

Expert Witness Response E-000921

I routinely perform root canals, extractions and infection control on molar teeth. A tooth that is sensitive to hot and cold indicates a non-vital pulp chamber. Re-cementing a crown on such a tooth is like putting a finger in the dike and driving the infection out of the root and into the bone/soft tissues of the jaws, therefore exponentially worsening the infection. It was certainly a departure of standard of care for the treating dentist to re-cement the crown on a new patient (who was basically a stranger to him) without a radiograph (x-ray). Re-cementing the crown and then prescribing an antibiotic would have not adhered to standard of care. The standard should have been 1. X-ray, 2. Antibiotics, 3. Referral to prior the patient’s original dentist or endodontist or oral surgeon.