CASE IN POINT

INFERIOR ALVEOLAR NERVE BLOCK

The plaintiff was a child who presented to the defendant, a pediatric dentist, for a routine check-up and to have a small cavity filled. (Fig 1-1)

Fig 1-1 --- Click on Images to Enlarge
The defendant decided to administer local anesthesia via an inferior alveolar nerve block before filling the cavity (caries). (Fig 1-2)
Fig 1-2
While the defendant was in the process of administering the nerve block, the plaintiff lunged forward, and the anesthesia needle broke inside his gum in the mandibular region. (Fig 1-3)
Fig 1-3

The needle was lodged in a position from which it could not be immediately retrieved. Approximately one year after the plaintiff's initial presentation to the defendant, a surgeon successfully removed the needle from the defendant's jaw.

PLAINTIFF'S CLAIM:

The plaintiff's original claim was that the defendant should not have stabilized the plaintiff using conscious sedation, but instead should have used passive stabilization with the assistance of other personnel.

Later, the plaintiffs changed their theory on the case to say that the wrong type of needle was used. Specifically, a 30-gauge short needle was used, but the plaintiffs claimed that a 27-gauge long needle should have been used instead. The plaintiff was a child but should have qualified as an adult patient based on his size, and therefore using the short needle was a violation of the standard of care. Using a longer needle with a larger gauge would have decreased the likelihood of the needle breaking off as it did, sparing the plaintiff the resulting subsequent pain and further surgical treatment.

DEFENSE'S ARGUMENT:

The defendant exercised reasonable judgment and did not breach the standard of care in using a 30-gauge short needle on the plaintiff. It is not uncommon for a dentist to perform an inferior alveolar nerve block on a pediatric patient with a 30-gauge short needle-they are used all the time. When a dentist is determining what tools will be most appropriate to use, he or she is in the best position to examine and evaluate the patient's individual needs. Inferior alveolar nerve block is a challenging procedure in which the first step to avoid needle breakage is to judge whether the patient is being still enough to give the block. The second step is to decide, based on the patient's size, whether there is an appropriate amount of soft tissue for a 30-gauge short needle versus a 27-gauge long needle. As long as the soft tissue, in the judgment of the dentist, is under 20 mm and the block can be achieved without the needle's hub reaching the soft tissue, a short needle may be used. The defendant used her best judgment in evaluating the plaintiff to determine the most appropriate tools. In this case, the plaintiff suddenly and unexpectedly lunged forward, lodging the needle in his mouth and breaking it off. This is a rare complication, and as such, warning patients about this possibility is not required for informed consent.

VISUAL STRATEGY:

Collaborating with the defense team, Illustrated Verdict created a visual strategy to help illustrate the relevant anatomy, the patient, and the nerve block that was performed in this case.

A few normal anatomy boards of the mouth showed the orientation of the teeth and location of the inferior alveolar nerve.
(Figs 2-1, 2-2, 2-3 and 2-4)

Fig 2-1

Fig 2-2
Fig 2-3
Fig 2-4
 

Another board showed the normal anatomy of a tooth versus small and large cavities. (Fig 2-5)

Fig 2-5

Next, a series of images of anterior views of the plaintiff demonstrated his size and how his mouth appeared at the time of his visit to the defendant, and the detail of the initial needle insertion.
(Figs 2-6, 2-7, 2-8, 2-9)

Fig 2-6
Fig 2-7
Fig 2-8
Fig 2-9
 

Another series of illustrations showed a more detailed view of the location of the inferior alveolar nerve, and the subsequent steps taken to administer the block, including a detail of the length of the needle used. (Figs 2-10, 2-11, 2-12, 2-13)

Fig 2-10
Fig 2-11
Fig 2-12
Fig 2-13
 

A final illustration showed a cutaway view of the inserted needle and the location of the inferior alveolar nerve. (Fig 2-14)

Fig 2-14

The illustrations helped the defense successfully convey to the jury the following key points:

  • The defendant was in the best position to analyze the patient’s size and individual needs, and exercised reasonable judgment in concluding what tools to use for the patient based on her examination of him.
  • Inferior mandibular block is a challenging procedure in which it is common for pediatric dentists to use a 30-gauge short needle.
  • Needle breakage is a rare complication, rendered unavoidable in this case by the patient’s unexpected, sudden movement at the time of the initial insertion.
RESULT:
The jury found in favor of the defense.  

"Defense verdict. The visuals were definitely used - some of them - and very helpful."

- Attorney Michael Bell, Lightfoot, Franklin & White, LLC, Birmingham, AL

 

"Thanks for all of your hard work. It paid off....Defense verdict!! The visuals were very useful. We will certainly be back in touch. Thanks again."

- Paralegal Janet Mitchell, Lightfoot, Franklin & White, LLC, Birmingham, AL

 

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