Atlanta Injury Lawyers Blog

Published on: May 28, 2015

What Type of Doctor Treats Trigeminal Nerve Injury?

Many times, potential clients who have suffered a dental nerve injury are not sure which type of doctor is best equipped to diagnose an injury to the inferior alveolar, lingual or mental nerves. While many specialists are trained to diagnose and treat pain and nerve damage, a microneurosurgeon is, many times, the best equipped for these types of injuries. Trigeminal nerve injury diagnosis, treatment and management is considered a subspecialty of oral and maxillofacial surgery. As such, microneurosurgeons usually possess additional training, experience and clinical skills to treat these nerves after damage caused by dental treatments.

Other medical providers that may be involved in the care and treatment of a dental nerve injury sufferer are neurologists, anesthesiologists, pain management doctors, oral surgeons, general dentists, and in many cases dental physical therapists who may try to address dental nerve injury signs or symptoms much like they do for tempromandibular disorder patients.

It has been my experience that these additionally listed medical providers may be helpful, but that they often lack the expertise that a microneurosurgeon has in regard to the trigeminal nerve injuries that we have focused on in this article which are the lingual nerve, inferior alveolar nerve, the mental nerve and the infra-orbital nerve. The reason for this is the microneurosurgeons usually deal with injuries to these nerves on a daily basis, whether it is examining and diagnosing these nerve injuries or performing subsequent surgery to try to repair the nerves after they have been damaged during a dental procedure. As discussed elsewhere, these dental nerves can be damaged during routine dental procedures such as extractions (especially of mandibular molars, the placement of dental implants, and the performance of root canal therapy. Once the injury occurs, a general diagnosis such as “trigeminal neuralgia’ is not very useful, and a diagnosis of “Bells Palsey” is often harmful and wrong. This is why it is preferable that a micro-neurosurgeon be involved early and, if possible, take the lead in caring for these type of serious injuries.
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Published on: May 21, 2015

Does the Standard of Care in Georgia Require Pre-Procedure Antibiotics For Certain Dental Patients

by Robert J. Fleming

As a recent dental article notes, antibiotics are frequently used in dental practice. To be sure, this is a broad statement and, as we all know, the devil is in the details. While the standard of care in dentistry certainly does not require the administration of antibiotics before and after every dental procedure, it does require this for certain patients who suffer from serious medical and dental conditions who are undergoing certain procedures. In other words, whether it is dental malpractice to not prescribe antibiotics when a dental procedure is performed is very fact-specific and is decided on a case-by-case basis.
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Published on: May 11, 2015

Dental Abbreviations Related to Georgia Records

by Robert J. Fleming

Many victims of dental malpractice properly request their records and encounter a host of dental terms and abbreviations that make it hard to decipher what the records mean. Some common dental abbreviations used in conjunction with dental procedures which may lead to nerve and other dental injuries are: ALV = alveolar; AMO = Anterior Maxillary Osteotomy; APEO = apicoectomy; B = buccal; BL = bone loss; dg or dx = diagnosis; E or EX or EXT = extraction; ENDO = endodontics; FDS = flap debridement surgery; fom = floor of mouth; FX = fracture; H&P = history and physical; L = lingual; MFP = myofacial pain; P-XR or pano = panoramic x-ray; pax = periapical x-ray; peri = periapical; POT = post-operative treatment; SL = sublingual; and WL = working length.
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Published on: May 6, 2015

Common Injuries Due to Dental Procedures in Georgia

by Robert J. Fleming

Dental procedures in the area of the lingual and inferior alveolar nerves are the most common cause of nerve damage. Negligently placed dental implants and improperly performed root canals in the lower jaw can cause inferior alveolar nerve damage. Other negligent procedures such as wisdom tooth extractions can cause lingual nerve damage. If your dentist has identified nerve damage during or shortly after the procedure, a referral to a qualified nerve specialist should be made as soon as possible. Delay can often result in permanent nerve damage. Surgical repairs, when done within the window of time when they have the greatest chance of success, can often reduce numbness and pain, and bring back normal sensation to the affected areas. That is why it is important to refer out to a qualified oral surgeon or micro-neurosurgeon in a timely manner.

The exact mechanism of injury is often not clear until all of the patient records are obtained and studies. However, it is common in dental malpractice cases to see a negligently installed implanted invading the inferior alveolar canal; the lingual nerve or inferior alveolar nerve being severed from an extraction; or root canal material in the nerve. Other possible causes are: (1) direct trauma from the injection needle, wherein the needle contacts the nerve directly traumatizing the nerve and producing a change in sensation. When the mouth is open, the lingual nerve is held taut within the interpterygoid fascia, and because of its fixation, special care and attention must be taken to properly administer the injection; (2) hematoma formation wherein it has been hypothesized that the needle may traumatize the blood vessels in close proximity to the nerve, creating a hematoma; and (3) neurotoxicity of the local anesthetic agent used in the injections wherein some dental experts opine that 4% local anesthetics such as articaine have caused more injuries per use than lidocaine. Both of these anesthetics are supplied at higher concentrations (i.e., they are twice as toxic). Some of the dental literature on this area of injury describe the effect of the 4% solution on the nerve and conclude that the increased risk of these local anesthetics is not worth the benefit, if any. In other words, the literature suggests that it is below the standard of care to subject the patient to an increase risk of nerve injury because there is not clear evidence that these solutions are more effective than Lidocaine.

Published on: May 1, 2015

$2.3M Dental Malpractice Verdict Upheld

by Robert J. Fleming

A recent dental malpractice verdict of over $2.3M was upheld on appeal. The malpractice victim suffered a lingual nerve injury during a tooth extraction which manifested itself with numbness of her tongue coupled with severe pain. This resulted in difficulty in swallowing, speaking and drooling.

Despite undergoing corrective surgery on her lingual nerve, the plaintiff’s symptoms did not resolve and she suffered a permanent nerve injury, and, as is often the case, her pain symptoms intensified after the attempt to repair the nerve.

According to the opinion, plaintiff was twenty-five years old when her doctor suggested that she have her wisdom teeth extracted. The defendant dentist extracted plaintiff’s four wisdom teeth a little over a month after the initial consultation. Defendant performed the extraction after administering an anesthetic that plaintiff described “put [her] to sleep.” Plaintiff testified that when she regained consciousness, she began screaming and felt excruciating pain. Plaintiff was completely asymptomatic before the extraction. Defendant prescribed narcotic pain medication in tablet form; plaintiff testified the medication made her nauseous and caused her to vomit.

At her post-operative visit with defendant three days after the extraction, plaintiff complained of of numbness in the tongue. According to plaintiff, defendant told her that her symptoms were “definitely not normal,” but that “sometimes these things can resolve themselves.” However, plaintiff’s symptoms did not improve. She testified during the trial that her tongue, the floor of her mouth and the gum line were completely numb. She also felt a shooting pain that came from the very back of her furthest tooth on the right side and that the pain and numbness caused her a lot of difficulties.

After consulting with several dentists and related medical professionals, plaintiff decided to undergo another surgical procedure to attempt to repair the damage to her right lingual nerve. The postoperative report noted that a large amount of scar tissue was identified in the area of previously extracted tooth #32; a neuroma appeared to be present and that the lingual nerve was severed. An attempt was made to identify the proximal segment of the right lingual nerve and re-connect the nerve. Despite the nerve being re-connected, the plaintiff continued to experience the same difficulties she had before the surgery and developed increased pain after the subsequent surgery.

Due to the increased pain, plaintiff was advised to consider exploring medication management so that she might better be able to evaluate the relative benefit and risk of medication management and at the time of trial plaintiff had decided not to undergo further surgery and was attempting to manage her pain and lifestyle limitations through medication.
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Published on: March 30, 2015

First Risperdal Trial Results in $2.5M Verdict

by Robert J. Fleming

A jury has awarded $2.5M to an autistic boy’s family. The lengthy trial included evidence of Janssen Pharmaceutical’s alleged plan to obscure evidence for years that the drug was linked to the growth of female breast tissue in adolescent boys.The jury based its decision, at least in part, in its finding that the drug company failed to warn the boy’s parents and physicians of the risks associated with the drug.

This is a key verdict that will play a vital role in the valuation of the thousands of Risperdal cases that have been filed in recent years. Of course, each case is different based on the facts, but this is an important benchmark for valuation. However, the two most troubling side-effects that are the subject of lawsuits and which are reportedly associated with Risperdal are:

Breast Development in Boys

Gynecomastia is enlargement or development of breast tissue in males. It is more common and particularly disturbing in children and adolescents. The development of gynecomastia is usually a permanent change that will require surgical removal by a reconstructive surgeon. Gynecomastia has been attributed to Risperdal’s stimulation of prolactin, a hormone common in women who are pregnant or nursing. Adolescents or boys who develop breast tissue suffer not only physical changes but also severe emotional trauma.

Lactation in Girls

Lactation in girls who are not of child-bearing age and of women who are not pregnant or nursing has been seen with Risperdal use. Girls may develop breast tissue prematurely and the development will be permanent. No long-term damage is seen other than premature development and resulting emotional trauma.

Other less common side-effects reportedly associated with Risperdal are:

Movement Disorders such as akathesia (restlessness), akinesia (inability to move or hesitational movement), Tardive Dyskinesia (abnormal movement of face, shoulders, arms and legs), Parkinson’s like tremors, Torticolis (stiffening of the tongue, which may cause difficulty breathing).

All of the movement disorders may be permanent even after the medication has been discontinued. Many patients also require additional medication to control the symptoms.

Diabetes

Risperdal has been allegedly associated with an increased risk of development or worsening of diabetes. The exact relationship is unknown.

Death in the Elderly

Risperdal has been allegedly associated with mortality in elderly dementia patients. The FDA required a Black Box warning regarding use of Risperdal in the elderly. Patients who have died from Risperdal use had an actual cause of death of adverse events such as cardiac failure, pneumonia and cerebrovascular events (stroke).

Published on: March 25, 2015

Georgia Dental Board Owes Duty to the Public

by Robert J. Fleming

The United States Supreme Court recently decided a case that could impact the way the Georgia Board of Dentistry conducts business. The Court ruled on February 25, 2015 that a state regulatory board that is comprised mainly of dental professionals violates federal fair competition laws when it tries to restrict lower cost (non-dentist) competitors from competing with dentists by offering teeth-whitening.

While this case had little to do with Georgia’s Board of Dentistry, it does apply to it and, as the dissenting opinion noted, the decision could have far-reaching effects on what and how dental boards are allowed to regulate.
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Published on: March 11, 2015

Prescription Drug Errors Not Only Danger For Children

by Robert J. Fleming

The recent children’s drug settlement exemplifies the risk associated with giving any medications to children. As an Atlanta medication error attorney, I am frequently contacted by parents who have filled prescriptions for their children at local pharmacies, only to realize after giving the medication to their kids that they were either dispensed the wrong medication or given the correct medication but in the wrong dosage.

Many pharmacy errors which result in hospitalization are caused by lack of technician training, lack of sufficient quality control that ensures that the prescription that is dispensed is actually what was ordered by the doctor and a simple lack of attentiveness on the part of the pharmacy team involved in filling the prescription. Unfortunately, parents are seldom in a position to catch the pharmacy error and the result can often lead to serious injury to the child and hospitalization.

Among the largest pharmacies in the United States are Walgreens, CVS, Rite Aid, Walmart, Kroger, Safeway, Target, Publix, Costco, and Sam’s Club. Many of these chains compete on price. This puts tremendous pressures on their pharmacists and technicians to fill more prescriptions in the same amount of time and for the same pay. This often can lead to errors. Errors, theoretically, should be detected in many cases by the quality control systems in place. These would include protocols that the workers in the pharmacy are supposed to follow to uncover prescription errors before the medication is dispensed to the patient, and computer-related programs which are designed to catch errors such as drug interactions or allergies that are not detected by the pharmacist or pharmacy technicians. I say, “in theory” because many of the protocols and computer aides are ignored by the over-worked employees, which effectively renders them useless.

On the opposite end of the spectrum, we find errors being made in smaller pharmacies that are not part of a chain, which go undetected allowing the wrong medication to be dispensed because these smaller pharmacies do not utilize any of the protocols or computer aides that the larger pharmacies have in place (but often fail to use). Either way, the prescription errors are not detected.
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Published on: February 4, 2015

Paint Management For Dental Nerve Injuries

by Robert J. Fleming

As an Atlanta Dental Malpractice Lawyer, I am well aware that injuries caused by dental procedures often manifest themselves with a combination of numbness and pain. Many times, subsequent corrective surgery is not successful, and the client is left with no choice but to manage the pain with pain medications. Tegretol, Lyrica, Topamax, Gabapentin and Cymbalta are just a few of the many drugs used to help manage the intractable pain that many dental nerve injury victims suffer from. While the preferred course after a lingual nerve or inferior alveolar nerve injury is to surgically repair the nerve, the only course of action left after unsuccessful microneurosurgery is pain management.

In addition to surgical repair to reduce the nerve pain and pain meds, those suffering from dental nerve pain have, in varying degrees found some relief from the following:

Steroids – a course of steroids such as Prednisone is typically recommended, within a few weeks of the nerve injury.

Clonazepan – For the fastest relief of acute burning tongue, many clients have reported that clonazepan (Klonopin) is effective.

Topical pain relief – Topical lidocaine or benzocaine. Pain patches can also be made with these topical pain relief medications.

Anti-inflammatories – Aspirin, Tylenol, and other anti-inflammatory medications can provide relief by blocking the pain signals and reducing inflammation.

Anti-depressants – In addition to Cymbalta, Prozac, Lexapro, Paxil, Effexor,Norpamin, Lyrica, Zoloft, or Elavil have proven effective in helping clients deal with dental nerve pain. Many clients have also reported good pain relief with Gabapentin, Neurontin and Tegretol.

Vitamins, Homeopathic, and Alternative therapies – Many dental nerve injury sufferers believe that vitamins such as vitamin B are helpful in dealing with dental nerve pain. While I have not seen any literature to support this, it may be worth a try. Similarly, certain supplements such as St. John’s Wart has been suggested as helpful, however I am not aware of any peer-reviewed literature which support this.

As with most pain management treatments, a lot depends on trial and error. What might work for one person with one specific nerve injury, may not provide any benefit for another. Sometimes, a medication will be effective in relieving pain, but the side-effects (constipation, drowsiness, irritability, depression, anxiety, etc.) are too limiting and a lesser dosage of the effective drug or a different medication must be tried. The goal is to find a medication which is effective in dealing with the pain, but which does not cause side-effects that limit what one can do while on the medication in a way that effects their family and work life.

Published on: January 23, 2015

Atlanta Facial Nerve Pain Misdiagnosis

by Robert J. Fleming

As the past year comes to an end and we start a new year, I want to write about a common misdiagnosis for those who have suffered a dental nerve injury from malpractice. Bell’s Palsy is often the diagnosis given to patients who have suffered an injury to one of the trigeminal nerves in the face due to a negligent dental procedure such as a root canal, dental implant or tooth extraction. Unfortunately, this common diagnosis is often a misdiagnosis and ignores the source of the nerve problem (trauma to the nerve from a negligent dental procedure). The more accurate diagnosis for these patients who, many times, are suffering from numbness and pain at the same time, would be to identify the nerve that is damaged (i.e., inferior alveolar nerve, mental nerve, lingual nerve, or infra-orbital nerve) and diagnose it as an injury.
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