WINNEMUCCA — After a three-day trial, a Humboldt County jury found Dr. Jeremy Keener not liable for dental malpractice in a case involving a root canal gone wrong.  The trial began with jury selection on Monday (Jan. 23) and concluded late Wednesday (Jan. 24).

Natasha Stilwell sued the dentist after a root canal temporarily left her face and a portion of her nose with raw sores.  Additionally, she had lockjaw for months and developed a hole in the palate of her mouth.

She suffered no long-term injury as a result of the incident, but Stilwell sued to recover medical expenses as well as compensation for pain and suffering.

In finding Keener not liable of dental malpractice, the jury determined Keener’s actions did not fall below accepted standards of care.

CASE HISTORY:  Both Stilwell and Keener were called to the stand to testify.

Stilwell came to Keener’s office as an emergency patient with a toothache in August 2008.  According to testimony, it was determined she had an infection in a back molar, Keener discussed available options, including extraction, but they settled on a root canal.

The root canal procedure was explained to the jury by Keener and two separate expert witnesses.

A root canal involves removing the decayed nerve tissue, bacteria, and general debris from the inside of the tooth and root canal.  This is done using a series of dental files that are inserted into the tooth and the entire length of the root canal to scrub the infected area.

During the process, sodium hypochlorite is inserted into the area to lubricate the root canal and kill any bacteria.

Sodium hypochlorite, the jury was told, is diluted bleach.  Household bleach is diluted to 6 percent; Sodium hypochlorite is diluted to 4 percent.

During the first stage of the root canal the area is cleaned.   During the second stage, which in many cases is done in a subsequent visit, the tooth is sealed.  Root canals may take multiple visits to the dentist.

In Stilwell’s case, the root canal was cleaned using three files, each smaller than the one before, the sodium hypochlorite was flushed out, the canal was filled with a calcium hydroxide paste (to kill bacteria), and a rubber well was applied to keep the area dry.

Within minutes of the procedure being done, Stilwell asked Keener if it was normal to have blurry vision and crossed eyes.  She began to complain of severe pain.  Keener acted immediately and removed the rubber well and flushed the canal; however, Stilwell continued to complain of pain and her cheek over the location of the procedure began to turn red and puffy and began to bruise, according to the notes made by the nurse.

According to testimony Stilwell became hysterical from pain – so much so that her boyfriend waiting in the office to drive her home was alerted to her condition and came back to see what was wrong.

Keener put an ice pack on her face, gave her pain killers, and prescribed a painkiller.

According to medical records, after going home Stilwell’s condition worsened.  Her check was swollen, red and bruised, it broke out into little white sores, spread to an small area of her nose, and a hole developed in the palate of her mouth. The small sores turned into blisters and eventually scabs.

Additionally, she developed lockjaw and could only drink fluids, but she could not use a straw because of the sore in her mouth.

She went back to Dr. Keener on the Monday after the procedure.  However, after consulting with him, she collected her records and left.

Over the course of the next several months she saw multiple dentists in an effort to determine what was wrong with her.

Although it took four months for her condition to heal, five months before she could completely open her jaw, the cause of the condition was debatable and the subject of the suit.

Under Nevada law (Chapter 41A) if a patient receives a chemical burn, even accidentally, it is presumed the dentist committed malpractice and the burden of proof shifts from the plaintiffs to the defense; that is, the doctor has to prove his or her actions were within the standard of care as opposed to the plaintiffs proving the care was below standard.

THE PLAINTIFF:  Stilwell was represented in court by J. Stewert White who argued his client’s condition was caused by a chemical burn from the sodium hypochlorite (bleach) which corroded the bone, entered the sinus cavities, and worked its way across her face killing cells as it went.

Taking the stand to testify for the plaintiff was Dr. Alan H. Gluskin, D.D.S.

Gluskin is a professor at the University of the Pacific School of Dentistry in San Francisco and chairman of the Department of Endodontics, which is a dental specialty area concerning tooth pulp and surrounding tissue.  Gluskin teaches endodontics and has been published on the issue.

Gluskin testified that he reviewed the files on the case and also Dr. Keener’s records and notes on the procedure.

He explained the process of inserting the syringe into the canal to administer the sodium hypochlorite must be done carefully and the area flushed frequently because it was possible the chemical would begin to corrode what it came in contact with.

He reminded the jury a root canal is completed with a series of dental files, each smaller than the one before, and added his expert opinion the canal needed to be flushed of the sodium hypochlorite and debris after each file.

He said this was the technique he teaches and it was his opinion that was the standard of care.

It is also important, he said, that the syringe not be jammed into the canal in such a way the sodium hypochlorite would pool and corrode. To address this issue, a special syringe is used that allows the chemical to be sprayed out the side.

To allow the needle to be jammed into the canal would also fall below the standard of care.

He testified the injuries suffered by Stilwell were consistent with a chemical burn.  He pointed out there were broken blood vessels and white tissue around the lesions – a sign of dead tissue.

Additionally, the fact Stilwell had problems both with pain and motor function, as was shown with the lock jaw, was indicative of damage done to the trigeminal nerve.

Gluskin rejected Keener’s initial diagnosis that the reaction suffered by Stilwell was an allergic reaction.  He commented, “This was anything but an allergic reaction. This was a major injury.”

He later added of the chemical burn diagnosis, “This was the most extreme case I’ve every witnessed in my career.”

Under cross examination Gluskin acknowledged a chemical burn from sodium hypochlorite was a rare event and estimated there might be 25 reported cases in the last 30 years.  However, he also added his expert opinion that they’re underreported.

THE DEFENDANT:  Although Dr. Keener indicated he thought Stilwell’s condition was might have been caused by an allergic reaction to the sodium hypochlorite, and he indicated in his notes some of the sodium hypochlorite might have gotten into the sinuses, by the time of trial the defense presented a different theory all together.

Testifying for the defense was Dr. Scott M. Forvilly, D.D.S. a Nevada dentist now in private practice but who previously spent six months working at a clinic with HIV patients.  While working there he saw conditions such as the one exhibited by Stilwell, but it didn’t come from a chemical burn.  Instead, it came from a virus that had long been dormant but which was inflamed by dental trauma.

The virus in this case:  herpes zoster -- also known as shingles.

Forvilly told the jury the signs and symptoms suffered by Stilwell were indicative of someone with singles. He noted on the medical questionnaire Stilwell completed before the root canal that she had a history of fever blisters and cold sores.

Under questioning Forvilly explained the virus that caused cold sores and herpes zoster were not the same, but they were cousins.

When asked why the herpes zoster wasn’t active all the time, the dentist explained the virus is kept in check by the body’s immune system. He added the virus lives in the brain stem.  When the person who has herpes zoster because ill or stressed, the virus sometimes moves out along the nervous system and causes an infection.

In this case, the virus moved to the area of dental trauma.

Using a diagram of the facial nervous system, he noted the places where Stilwell suffered were the very places the trigeminal nerves ended: the cheek, jaw, nose, and mouth.

He said Dr. Keener was not negligent for not having diagnosed the problem sooner and commented, “I recognized it only because I’ve seen it so much.”

Forvilly reviewed the case files and said the technique used by Keener was the one he uses in his own office and when asked about the standard of care replied, “He followed the standard of care to a T.”

According to testimony, Keener moved quickly when Stilwell began to complain of pain, flushed the tooth, and provided general care.  Additionally, he called her over the weekend to see how she was doing and said from the stand he would have continued treatment had she not pulled her file and gone elsewhere.

Keener said he cares for his patients and was concerned about Stilwell.