case report the case for improved interprofessional care: fatal...

Case ReportThe Case for Improved Interprofessional Care: Fatal AnalgesicOverdose Secondary to Acute Dental Pain during Pregnancy

Sarah K. Y. Lee,1 Rocio B. Quinonez,2 Alice Chuang,3

Stephanie M. Munz,4 and Darya Dabiri4

1Department of Prosthodontics, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA2Department of Pediatric Dentistry and Pediatrics, Schools of Dentistry and Medicine, University of North Carolina at Chapel Hill,Chapel Hill, NC, USA3Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA4Department of Oral and Maxillofacial Surgery/Hospital Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI, USA

Correspondence should be addressed to Sarah K. Y. Lee; sarah [email protected]

Received 28 April 2016; Accepted 28 September 2016

Academic Editor: Asja Celebic

Copyright © 2016 Sarah K. Y. Lee et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. Thiscase report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose formanagement of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverseoutcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death frommultiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognizeand optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative andcoordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overallquality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessionaleducation and practice are necessary to enhance the quality of care that will benefit all patients.

1. Introduction

The pregnant dental patient exemplifies the need for collabo-rative practices between health disciplines.The latest nationalconsensus statement regarding oral healthcare during preg-nancy indicates patients can and should undergo routinedental treatment during all stages of pregnancy as “oral healthcare, including use of radiographs, pain medication, andlocal anesthesia, is safe throughout pregnancy” [1]. Whiletreatment rendered during the second trimester provides thegreatest comfort, pregnancy alone is not a contraindication toreceiving dental treatment [1]. For some women, pregnancymay in fact provide the opportunity to pursue their oralhealthcare needs [2, 3]. For example, some states’ govern-ment assistance programs include dental care as a coveredpregnancy-related service [4]. In 2000, the Children’s HealthInsurance Program extended coverage to include pregnantwomen who do not qualify for Medicaid [3].

Despite these progressive efforts to provide prenatal oralhealthcare, inconsistencies between the knowledge and prac-tices of dental and medical providers regarding prenatal oralhealthcare remain. Pregnant patients continue to encounterbarriers that may adversely affect their oral health andnegatively impact their pregnancy [1–11]. This case reportdescribes a sequence of events, precipitated by dental pain, inwhich lapses in patient oral health literacy, the rendering ofdental treatment, and coordination of interprofessional col-laborative treatmentwithin the healthcare system culminatedin the demise of both the fetus and pregnant patient.

2. Case Presentation

A 19-year-old at 17-week gestation presented to her localhospital’s emergency department (ED) complaining ofabdominal pain and nausea. She was diagnosed with acute

Hindawi Publishing CorporationCase Reports in DentistryVolume 2016, Article ID 7467262, 8 pageshttp://dx.doi.org/10.1155/2016/7467262

2 Case Reports in Dentistry

liver failure secondary to acetaminophen overdose for dentalpain management. The admission record indicated, as perpatient report, that she had received dental treatment 2weeks earlier, with the dentist reportedly prescribing 20tablets of Tylenol #3 (acetaminophen with codeine) forpostoperative pain. The patient initially took 1-2 tablets perday, but due to persisting symptoms, she communicatedwith her obstetrician who recommended over-the-counterTylenol for pain management. The patient obtained ExtraStrength Tylenol (500mg acetaminophen/tablet) andfor a 10-day period reported taking 2-3 tablets of ExtraStrength Tylenol, 10 times per day, approximating 20–30tablets daily or 10,000–15,000mg daily. Preliminary EDlaboratory studies indicated acute liver injury consisting ofcoagulopathy and abnormal transaminases with significantlyelevated acetaminophen levels. To address the liver toxicity,N-acetylcysteine (NAC) protocol was initiated at the localED and continued when the patient was transferred to alarger academic center’s pediatric intensive care unit (ICU)(Table 1).

When transferred, a consultation with obstetrics andgynecology (ObGyn) was completed. A live singleton fetushad been initially confirmed by ultrasound; however, onreevaluation on her second day of hospitalization, no fetalcardiac activity was detected and fetal demise was diagnosed.The following day, a dental consultation was initiated due tothe patient’s complaint of pain on mastication of the rightmandibular dentition. Clinical and radiographic examinationinitially revealed no emergent dental needs, and occlusaladjustments to alleviate symptomswere performed as the firstcourse of action (Figure 1).

While undergoing care the patient was diagnosed withWilson’s disease, an autosomal recessive genetic disordercausing copper accumulation in tissues that can lead tofurther liver complications [12]. Her laboratory findingsconfirmed the abnormally elevated copper levels, which inaddition to her acute liver injury from toxicity resulted in therecommendation for liver transplant. On day 9 of hospital-ization, the delivery of the nonviable fetus was completed,and the patient’s condition was reported as stable. At thistime, a second dental consultation was ordered following thepatient’s report of a “bubble on [the] gum that popped.”

The dental assessment revealed that tooth #30 (perma-nent right mandibular first molar) had a draining sinus tract.Two days following the diagnosis, prophylactic antibioticmanagement was initiated and a pulpectomy was scheduledand completed in the hospital’s dental clinic under localanesthesia. On the scheduled treatment date, the patientreported not feeling well as she had not ingested solid food orsubstantial liquids for more than 12 hours, due to her nil peros (NPO) status as ordered by her medical care team. Whilethis action resulted in delay of treatment, the pulpectomywas completed without complication that same afternoon.At this time, the dental team overseeing the patient’s carediscussed the previously rendered treatmentwith the patient’sgeneral dentist via telephone. The following dental treatmenthad been reportedly completed in a single appointment bythe general dentist and was documented in the patient’selectronic record: dental restorations on 7 teeth (#12, 13, 16,

Figure 1: Panoramic radiograph of the patient’s dental condition onday 15 of first hospitalization.

17, 19, 20, and 21), 3 root canal therapies (#14, 15, and 18),and placement of 2 stainless steel crowns. Further requestswere made to the dentist to share treatment records with thehospital dentistry team. To date, these records have not beenreceived.

Dental clearance evaluation and any necessary treatmentin preparation for a liver transplant were requested by thepatient’s medical team. The following treatment was thenrecommended: endodontic therapy of pulpal necrosis withsinus tract of tooth #30, extraction of tooth #14 (permanentleft maxillary molar) due to nonrestorability, and extractionof maxillary and mandibular third molars (teeth #1, 16, 17,and 32) due to impaction causing operculi and periodontalcomplications.The patient was subsequently discharged fromthe hospital with plans to address dental treatment needs andmanagement of liver failure by the respective care teams onan outpatient basis.

One week after discharge, the patient was readmitted tothe ED for pelvic pain that had been worsening for 3 days.She disclosed, as documented on her electronic record, a lackof compliance with the prescribed medication regimen “asshe does not know what these medications do.” Treatmentfor spontaneous bacterial peritonitis (SBP) was initiated bythe gastroenterology (GE) team but was discontinued after2 days due to lack of correlation of signs and symptomsobserved from laboratory studies and patient history. Duringthis stay, a dental follow-up evaluation was completed. Thepatient reported being asymptomatic for any oral pain and,upon clinical examination, the draining sinus tract adjacentto tooth #30 had resolved. No emergent needs were evident.The patient was discharged after a 4-day hospitalization.

Three days after her second hospitalization, the patientpresented to the dental outpatient clinic for completion ofendodontic therapy for tooth #30 and consultation with theoral andmaxillofacial surgery (OMFS) service for extractionsof third molars and tooth #14 under general anesthesia.Endodontic therapy was completed in the dental clinicwithout complication and the patient was scheduled toreturn to complete other indicated restorative treatments.The extractions were completed in the operating room undergeneral anesthesia by the OMFS service the same weekwithout complications.

Case Reports in Dentistry 3

Table1:Summaryof

thep

atient’scourse

ofillness.

Date

Event

2weeks

before

hospita

lization

Patie

ntob

tainsd

entalcare.Her

dentalprovider

prescribed

20tabs

ofTy

leno

l3forp

ainmanagem

ent.Patie

nttakes1-2

tabs/day

butp

ain

persists.Sh

econ

tactsh

erob

stetricianwho

advisesO

TCacetam

inop

henforp

ainmanagem

ent.Patie

ntob

tainsE

xtra

Streng

thTy

leno

l(500

mgacetam

inop

hen/tab)

andtakes2

-3tabs,10tim

es/day

forlast10days

(20–

30tabs/day).

Firsth

ospitalization

Day

1Patie

ntpresentsto

localemergencydepartment(ED

)for

abdo

minalpain

andnausea.D

iagn

osisof

acuteliver

injury

isassessed.

N-Acetylcysteine(NAC

)treatmentisinitia

ted.

Day

2Patie

nttransfe

rred

topediatric

ICUandliver

managem

entcon

tinuedviaN

ACprotocol.O

bstetricsa

ndgynecology

(ObG

yn)team

identifi

eslives

ingleton

fetusv

iaultrasou

nd.

Day

3Und

etectablefetalheartsou

ndso

rfetalmovem

entb

yObG

yn.Fetaldemise

diagno

sisismade.

Day

4Patie

ntrepo

rtsp

ainon

mastic

ationof

right

poste

riord

entition.

Hospitald

entistry(H

D)con

sultisrequ

estedby

patie

nt’scare

team

.

Day

5HDconsultatio

ncompleted.C

linicalexam

inationrevealsn

oindicatio

nfore

mergent

interventio

nald

entaltreatment.Palliativetreatmentis

rend

ered

viao

cclusaladjustm

ent.

Day

7Wilson’sdiseased

iagn

osismade.Th

epatient

continuesu

ndergoingmanagem

ento

facuteliver

injury.

Day

10Delivery

ofno

nviablefetus

perfo

rmed.

Day

13Patie

ntrepo

rts“bu

bbleon

gum

thatpo

pped”b

utisasym

ptom

atic.

HDconsultatio

ncompleted

andrevealstoo

th#30(right

mandibu

larm

olar)h

asdraining

sinus

tract.

Day

15

Pulpectomyperfo

rmed

ontooth#30in

hospita

ldentalclin

ic.D

entaln

eeds

forliver

transplant

clearance

area

ssessedandschedu

ledfor

treatmento

nan

outpatient

basis.

Patie

nt’soriginaldentist

iscontactedviatele

phon

eand

relay

sthatp

atient

received

dentaltre

atmento

f10leftpo

sterio

rteeth,including

root

canaltherapy

on3molarsin1v

isit.

Patie

ntdischarged

from

hospita

l.6days

afterhospita

lization

Second

hospita

lization

Day

1Patie

ntpresentsto

EDforw

orsening

andpersistentp

elvicpain.

Patie

ntadmitted

form

anagem

entw

ithGastro

enterology

(GE)

team

andspon

taneou

sbacteria

lperito

nitis

(SBP

)treatmentisinitia

tedand

paracentesiscompleted.

Day

2HDconsultatio

nforp

ost-p

ulpectom

yfollo

w-up.Patie

nt’sdentalcond

ition

isstableandpatie

ntisschedu

ledforfurther

dentalmanagem

ent

onan

outpatient

basis

.Day

3SB

Ptre

atmentd

iscon

tinued.

Day

5Patie

ntdischarged

from

hospita

l.

13days

after

hospita

lization

Day

3Oralm

axillofacialsurgery

(OMFS

)con

sultatio

niscompleted

fore

xtractions

underg

eneralanesthesia.

Day

6OMFS

completes

dentaltre

atmentu

nder

generalanesthesia

(teeth1,14,16,17,and

32extracted).

Third

hospita

lization

Day

1Patie

ntpresentsto

EDfora

bdom

inalpain,n

ausea,anddiarrhea.

Patie

ntadmitted

toadultICU

.Day

2Patie

nt’scond

ition

deterio

ratesa

ndpatie

ntisintubated.

Day

3Patie

ntdiagno

sedwith

portalhypertensiv

egastro

pathyandascites.

Con

tinuedmanagem

ento

fliver

complications

inclu

ding

paracentesisandesop

hagogastrodu

odenoscopy

(diagn

ostic

endo

scop

icprocedure

forv

isualizationof

upperp

ortio

nof

GItract).

Day

5Patie

nt’scond

ition

stabilizesa

ndpatie

ntisextubated.

Day

9Paracentesiscompleted

with

4Lof

fluid

removal.

Day

10Patie

nthasa

nepiso

deof

unrespon

sivenesstoste

rnalrub,requ

iring

1.2IV

Narcanadministratio

nbefore

patie

nt’smentalstatusreturns.Th

isincident

isattributed

toPh

energansedatio

n.Day

17Patie

ntdischarged

from

hospita

l.


Table1:Con

tinued.

Date

Event

6days

afterhospita

lization

Fourth

hospita

lization

Day

1Patie

ntadmitted

tolocalE

Daft

erfoun

dun

respon

sivea

thom

e.Patie

nttransfe

rred

toadultICU

andisintubated.

Patie

ntdiagno

sedforseptic

shocksecond

aryto

SBP.

Day

3Patie

ntdiagno

sedforc

ardiac

ischemiawith

developm

ento

fnon

sustainedventric

ular

tachycardia.Multio

rgan

failu

reisob

served.

Patie

ntshow

sintermittentp

rolonged

unsta

blea

rrhythmiawith

ventric

ular

fibrillationandhypo

tension.

Patie

nt’scare

team

discussesp

oorp

rogn

osiswith

family.

Day

4Patie

ntdies.


Three days following the extractions, the patient reporteda three-day history of abdominal pain, nausea, and diarrhea.Laboratory studies indicated evidence of leukocytosis, result-ing in admission to the hospital’s adult ICU. The patient wasnewly diagnosed with portal hypertensive gastropathy withascites, due to portal hypertension with SBP. Complicationsled to degradation of her condition requiring intubationand broad-spectrum antibiotic therapy. After one week, hercondition stabilized and she was extubated. Paracentesis wascompleted to remove 4 liters of fluid. An isolated episodeof unresponsiveness to sternal rubbing occurred. This wasmanaged by administration of 1.2mg IV Narcan and laterattributed to Phenergan sedation. After 2.5-week hospitaliza-tion, the patient was discharged.

The following week, the patient was found to be unre-sponsive at her home and was readmitted to the ICU. Shewas observed to be significantly obtunded and jaundicedwithdistended abdomen and remainedminimally responsive. Shewas eventually diagnosed with septic shock secondary toSBP with new onset of acute kidney injury and hypotension.The option to use continuous renal replacement therapy wasdeclined by the patient’s family. On day 2 of her ICU stay,cardiac ischemia was evident with development of nonsus-tained ventricular tachycardia. She developed intermittentprolonged unstable arrhythmia with ventricular fibrillationand hypotension. The maximum amount of norepinephrinewas administered to counter hypotension and heart failure.After the care teamdiscussed the patient’s poor prognosis, herfamily decided to halt further life-sustaining measures. Aftera 3-day ICU course, the patient died.

3. Discussion

Consolidated guidelines have been established by both sep-arate and collaborative medical and dental organizations tofoster and support care integration, particularly for pregnantpatients [1, 5]. Provision of prenatal oral healthcare mustbe managed in a safe and appropriate manner. The quantityof rendered treatment and the postoperative complicationsprompted the initiation of this patient’s course of illness andmay have contributed to exacerbation of liver symptomsin conjunction with her unknown, preexisting condition ofWilson’s disease. Dentists provide expertise and means fordiagnosing, planning, treating, and educating the patient tooptimize oral health. With the provision of dental care, thehealth risks and benefits of providing an extensive amount ofinvasive treatment, regardless of the patient’s pregnancy sta-tus, must be considered. For the pregnant patient, it is criticalto assess the impact of dental treatment during pregnancyin terms of priority (emergent versus routine), quantity,timeliness, medications involved in rendering treatment,ergonomics while undergoing treatment, andmanagement ofposttreatment complications, including pain. It is especiallycritical that the pregnant patient obtains treatment when shepresents with an acute odontogenic infection, as delays cancarry greater risks than those associated with exposure totreatment and medications required for management. Theuse of local anesthetic, modalities of sedation, and analgesiain the pregnant patient has been complex and controversial

[9]. National consensus statements and recent studies haverendered many of these modalities safe when used properly,in consultation with the prenatal provider when needed [1, 5,9, 13].

Medical providers also contribute expertise to the preg-nant patient’s oral healthcare. Just as dental providers musttake themodifications and potential complications associatedwith rendering dental care of any patient into consideration,medical providersmust also address the oral health needs thatmay arise in their own patient management. As a providerwho also consistently manages the patient throughout herpregnancy, the medical provider is able to identify the needfor the patient to be referred for dental care [1, 5, 7, 8, 10].Themedical provider serves as a source of disseminated informa-tion that may encourage prevention and early interventionof oral health problems such that these problems and theirconsequences can be better managed [1, 5]. This providercan also communicate with the dental provider on systemichealth considerations such that care can be rendered safely[1, 5].

Evidence-based dental management of the pregnantpatient continues to be practiced inconsistently [1, 7, 8,10, 11, 14–16]. Many pregnant patients are still unable tofind a dental provider willing to treat them due to remain-ing misconceptions regarding oral healthcare. Concerns ofunfounded risks to the fetus with dental treatment heightenissues of premature induction labor, lack of knowledge inthe safety of treatment, and potential legal risks if negativebirth outcomes occur [4, 6, 8, 10, 11]. These are commonlyperceived deterrents [8, 10]. Limitations based on incorrector insufficient knowledge of perinatal oral healthcare by thetreating dentist have been shown to have the strongest directeffect on preventing pregnant patients from obtaining dentalcare [11]. Dentist-imposed barriers to accessing reasonablecare can lead to deleterious effects and create greater riskmanagement issues.

Medical professionals have similar hesitations whenaddressing their pregnant patients’ dental status. Generalhealth practitioners, midwives, and obstetricians reportedtheir lack of knowledge in understanding the safety of pre-natal dental treatment as the most significant limitation [10].These providers also reported feeling unqualified to addressdental issues due to insufficient familiarity and knowledge onoral health topics [8], highlighting the importance of propertraining and the need to address these topics in medicaland dental curricula. Many educational institutions amongthe health disciplines exhibit organizational infrastructure,logistical barriers, and isolated education that continue tosupport a discord at oddswith current recommendations [13–15, 17].

While each profession maintains management practicesspecific to its discipline, it is significant to acknowledge theinterrelatedness of the health professions and how care coor-dination impacts the pregnant patient’s overall health. Preg-nancy, as a sensitive period in which compromises in oral-systemic health can readily occur, typifies the importance ofestablishing andmaintaining coordination betweenmedicineand dentistry as well as other healthcare professions. Adverseoutcomes occur as a result of discordant care among the


health disciplines. Pregnant patients and their fetuses areplaced at greater risks when preventive and intervening ther-apies are not provided in a timely and appropriate manner[1, 4]. In this case, for example, the patient’s unnecessaryplacement on NPO status revealed a misunderstanding andlack of communication between the teams coordinating hercare. As a result, the patient’s treatment was delayed due toher poor disposition. Additionally, missed opportunities forcollaboration reinforced the separation of health disciplinesand the notion of integrated general health in the mindsets ofboth providers and patients.

It is important to recognize that while healthcareproviders carry many responsibilities in managing a patient’shealth, the patient is also an active participant in the out-comes that emerge from care. Acetaminophen, a perinatal-appropriate painmedicationwith a recommendedmaximumdosage of 4 g in a 24-hour period [18], was independentlyprescribed by her medical and dental providers, but misusedby the patient.Thismisuse led to an overdose that precipitatedthe adverse chain of events. As a first-time pregnant, low-income adolescent, this patient belonged to a population thatismore susceptible to adverse health outcomes resulting fromlow health literacy, defined as the “degree to which peoplehave the capacity to obtain, process, and understand basichealth information and services that are needed to makeappropriate health decisions” [6, 7]. Low health literacy hasbeen associated with poorer health knowledge that can beattributed to poorer health behaviors and outcomes [6, 7,19]. While undergoing care to manage complications thatresulted from the overdose, this patient exhibited noncom-pliant behavior that further compromised treatment. Thesekey instances reflect a misunderstanding and misuse on thepatient’s part of the information and resources available toher.

Health literacy is not wholly dictated by the patient’sindividual characteristics such as socioeconomic status andlevel of education; the degree of literacy is influenced byestablished systems of communication for information dis-semination and patient education [19, 20]. Social and culturalmisconceptions about undergoing care during pregnancy [13]and the lack of awareness of their oral health status andits impact on their pregnancy and general health [4, 8] arecontributing barriers that prevent patients from accessingand utilizing care.

Healthcare entails the overall management of the well-being of a patient in aspects of education, treatment, andmaintenance. Historically, dentistry has been a very separatebranch of healthcare [13–17, 21], practiced on different edu-cational infrastructure, clinical management, and financialmodels more than medicine [16]. Unfortunately, the dispar-ities in care that have resulted from persisting separationof disciplines are still evident in modern day healthcarepractices.

Efforts to integrate dentistrywith other health professionshave increased with recognition of oral health implicationsin general health by the medical community, developmentof collaborative medical-dental training, and incorporationof oral health in medical settings. Unfortunately these effortsremain limited in the educational arena, in part because of

the segmented and isolated educational systems between thehealth branches that have fostered gaps in knowledge andclinical practice between oral and general health [22, 23].

A survey of US dental school indicated a willingnessby educators to incorporate prenatal oral health, but clin-ical experiences remain limited. Barriers included lack ofpregnant patients and faculty expertise [24]. Similarly inCanadian dental schools, only 40% of schools report havingdesignated time in their curriculum to cover this topic [25].Initiatives such as the Prenatal Oral Health Program (pOHP)at the University of North Carolina show promise in helpingeducate the next generation of providers in a collaborativeapproach in practice and thereby, improve the quality ofrendered care and patient outcomes [26, 27].

Standardization of coordinated care within clinical andeducational institutions is likely to be a prolonged processwhere results may not be rapidly realized. Attitudinal andbehavioral practice changes of dental providers to address theneeds of high risk populations for adverse health outcomes,aswell as prioritizing collaborative effortswith healthcare col-leagues and educational initiatives across health professionalschools, are essential for tangible, meaningful progress in oralhealth disparities to occur.

4. Conclusion

This case highlights how practice misconceptions, barriersin collaborative care and communication, and insufficienthealth literacy are interconnected and complicated by oneanother. Though specific to the pregnant dental patient, thiscase offers lessons that can be readily translated to any typeof patient, especially other susceptible populations, includingthe frail elderly, patients with medical complexity, and thosewith disabilities. Oral health is one part that contributes tooverall health. As such, it is important to recognize that apatient’s well-being relies on the coordinated efforts of allthe health disciplines. This case report highlights some ofthe challenges of incorporating dental and medical practiceswithin the current healthcare environment. Most prevalentof these issues were the dental and medical providers’ incon-sistencies in patient management, the segmented, noncol-laborative infrastructure of communication and care coor-dination between these providers, and the patient’s lackof knowledge and understanding of her health status. Thecoordinated efforts between specialties made in the latterpart of this patient’s care are evidence that collaboration,albeit challenging, is readily possible and critically necessary.Greater emphases on interprofessional education, practice,and systems changes are needed to help address some of thecurrent clinical challenges and disconnects among healthcareprofessions.

Abbreviations

ED: Emergency departmentNAC: N-AcetylcysteineICU: Intensive care unitObGyn: Obstetrics and gynecologyNPO: Nil per os


SBP: Spontaneous bacterial peritonitisGE: GastroenterologyOMFS: Oral and maxillofacial surgery.

Competing Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgments

The authors gratefully acknowledge Rachel Tambunan Chu,DDS, Si On Lim,DDS, Jayashree Srinivasan, DMD, andCarolWiese, DDS for their clinical contributions.

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