Court Opinion

ID: 4466213
Source: CourtListenerOpinion
Date Created: 2019-12-20 07:15:28.405787+00
Date Added: 2024-06-11T14:53:44.680007
License: Public Domain

Opinion issued December 19, 2019

                                    In The

                             Court of Appeals
                                   For The

                         First District of Texas
                           ————————————
                             NO. 01-19-00323-CV
                          ———————————
               RICK KLINE, D.D.S. AND KLINE DENTAL
            IMPLANT, PLLC D/B/A SMILE TEXAS, Appellants
                                       V.
                      ANTHONY LEONARD, Appellee

                  On Appeal from the 434th District Court
                         Fort Bend County, Texas
                   Trial Court Case No. 18-DCV-252609

                        MEMORANDUM OPINION

     In this interlocutory appeal,1 appellants, Rick Kline, D.D.S. (“Dr. Kline” or

“Kline”) and Kline Dental Implant, PLLC, doing business as Smile Texas (“Kline

1
     See TEX. CIV. PRAC. & REM. CODE § 51.014(a)(9).
Dental”), challenge the trial court’s order denying their motion to dismiss the health

care liability claim2 brought against them by appellee, Anthony Leonard. In three

issues, appellants contend that the trial court erred in denying their motion to dismiss

Leonard’s claim because he failed to serve them with an adequate expert report.3

      We affirm.

                                      Background

      In October 2011, Leonard underwent dental treatment by Dr. Kline at Kline

Dental, doing business as Smile Texas. Leonard sought restorative dental work and

expressed his desire to keep as many of his existing teeth as possible. Dr. Kline, a

“cosmetic dentist,” recommended a treatment plan called “Teeth in a Day,” which

involved extracting all of Leonard’s teeth and replacing them with implants and

prostheses, at a cost of $50,000.

      On June 14, 2012, Dr. Kline extracted all of Leonard’s teeth and installed

implants and prostheses. Thereafter, Leonard’s teeth were non-functional, his

prostheses repeatedly detached or broke, and he experienced intense pain. Over the

course of the next five years, Leonard returned to Kline for treatment more than 65

2
      See id. § 74.001(a)(13) (“Health care liability claim” means a “cause of action
      against a health care provider or physician for treatment, lack of treatment, or other
      claimed departure from accepted standards of medical care, or health care, or safety
      or professional or administrative services directly related to health care, which
      proximately results in injury to or death of a claimant, whether the claimant’s claim
      or cause of action sounds in tort or contract. . . .”).
3
      See id. § 74.351(a), (b).
                                            2
times, without success.    In October 2017, Kline refused Leonard any further

treatment.

      In January 2018, Leonard sought treatment from another restorative dentist,

John T. Burdine D.D.S., M.Sc.D. Dr. Burdine determined that the dental work

performed by Dr. Kline was non-functional, substandard, and incomplete. Burdine

referred Leonard to a prosthodontist, Dr. Robert Velasco, who found that Leonard’s

prostheses were unstable, ill-fitting, “totally non-functional,” and had caused

Leonard pain and difficulty speaking. Velasco recommended re-construction of

Leonard’s prostheses.

      On June 28, 2018, Leonard brought a negligence claim against Dr. Kline,

alleging that he owed a duty to exercise the degree of care, skill, and diligence

ordinarily possessed and employed by other members of the dental profession in

good standing under the same or similar circumstances. Leonard asserted that Kline

breached the standard of care by failing to advise him of “all treatment options,

including those preserving his existing teeth”; failing to diagnose his periodontal

disease; failing to use ordinary care in his treatment; failing to complete his dental

restorations in a timely manner; and abandoning him prior to completion of the work.

Leonard further alleged that Kline was acting within the course and scope of his

employment with Kline Dental and that Kline Dental was vicariously liable for

Kline’s actions under the doctrine of respondeat superior.

                                          3
      Leonard asserted that appellants’ breaches of the standard of care proximately

caused him physical injury, unnecessary extraction of healthy teeth, pain, anxiety,

and illness. And, as a direct and proximate result, he suffered pain, mental anguish,

and disfigurement, in addition to unnecessary expense.

      On August 6, 2018, appellants answered Leonard’s suit with a general denial.4

      On September 6, 2018, Leonard served upon Dr. Kline and Kline Dental an

expert report authored by Dr. Burdine, along with his curriculum vitae (“CV”).

Burdine, in his report and CV, states that he is a graduate of the University of Texas

Health Science Center, Dental Branch, (“UTHSC”) and has an advanced degree in

periodontology from Boston University-Harvard Medical School. He is currently in

private practice in Houston, specializing in the areas of periodontics,5 oral medicine,

and implantology. He has practiced in periodontics and oral medicine since 1975

and implantology since 1987. He is a Clinical Associate Professor at UTHSC, a

Diplomate of the American Board of Periodontology, and a published author.

4
      “In a health care liability claim, a claimant shall, not later than the 120th day after
      the date each defendant’s original answer is filed, serve on that party or the party’s
      attorney one or more expert reports, with a curriculum vitae of each expert listed in
      the report for each physician or health care provider against whom a liability claim
      is asserted. . . .” TEX. CIV. PRAC. & REM. CODE § 74.351(a) (emphasis added).
5
      “A periodontist is a dentist who specializes in the prevention, diagnosis, and
      treatment of periodontal disease and in the placement of dental implants.
      Periodontists receive extensive training in these areas, including three additional
      years of education beyond dental school.” AM. ACADEMY OF PERIODONTOLOGY,
      https://www.perio.org/consumer/what-is-a-periodontist (last visited December 16,
      2019).
                                             4
      In his expert report, Dr. Burdine states that he is “familiar with the dental

standard of care for dental diagnosis, treatment, and care of patients undergoing full

mouth restoration by virtue of [his] medical education, [his] years of dental

experience, and specific practice in the field of periodontics.”        Burdine has

personally diagnosed, treated, and cared for many patients with the symptomology

Leonard exhibited. Burdine opines that the applicable standard of care “requires that

a complete oral, periodontal, occlusal and restorative exam, with both functional and

esthetic considerations be made prior to any comprehensive treatment, and that all

treatment options be presented to the patient.” The standard of care also requires

that mounted models of the patient’s dentition be created in order to analyze and

determine the options for restoration of the natural dentition. Further, the standard

of care “requires that all oral diseases be identified and treated prior to

comprehensive restorative therapy or oral surgery” and “that a surgeon operate in as

clean an environment as possible.”

      Dr. Burdine states that he reviewed the records of Dr. Kline’s treatment of

Leonard from October 2011 through October 2017 and the dental records of Dr.

Velasco’s treatment of Leonard from February 2018 through June 2018. Burdine

also personally examined and evaluated Leonard’s condition.

      Based on his review of Dr. Kline’s medical records, Dr. Burdine noted that,

when Kline first examined Leonard on October 18, 2011, Leonard reported having

                                          5
no loose teeth and no jaw or tooth pain. Leonard complained that his missing teeth

simply prevented his full smile, and he stated that he wanted to keep as many of his

teeth as possible. The dental x-ray showed that Leonard had 17 teeth remaining,

including an impacted third molar. Kline recommended only that he extract all of

Leonard’s remaining teeth and construct upper and lower prostheses. On June 14,

2012, Kline removed all of Leonard’s teeth and placed 11 implants, and “upper and

lower prosthetic teeth replacements were delivered.” Thereafter, Leonard’s course

of treatment, some 65 appointments, continued until October 2017, without success.

The records reflect that, throughout that period, Leonard experienced infection,

prostheses failure, dysfunction, and pain.

      On January 4, 2018, Leonard presented to Dr. Burdine’s office complaining

of pain, inability to chew, difficulty speaking, and social embarrassment. Leonard

was without teeth, aside from a still-impacted third molar. In his examination of

Leonard, Burdine noted that “[i]ll-fitting dentures were cemented” to implant

abutments and that there was inflammation present around the prostheses. Leonard

reported to Burdine, and Kline’s records reflected, that the prostheses had a history

of detaching and breaking.        Burdine referred Leonard to Dr. Velasco, a

prosthodontist, for treatment.

      Dr. Burdine notes that Dr. Velasco’s records reflect his findings that:

      The prosthes[e]s [were] ill-fitting, with a very poor occlusal scheme,
      causing [Leonard] pain and difficulty speaking. Further, Dr. Kline did
                                             6
      not deliver what was discussed and promised on the original treatment
      plan, as the final prosthesis is cement retained Porcelain Fused to Metal
      (PFM), as opposed to Multilayered full-contour zirconia.
      Both upper and lower prosthes[e]s were totally non-functional, with
      poor fit of each abutment, unstable and hygienically being very difficult
      to clean, due to both poor fit and design. Because the prosthes[e]s were
      so ill-fitting, the patient has to re-cement [them] on his own (at home
      dentistry), and this excess cement caused gingival inflammation around
      the implants and bone loss around the implants.
      . . . . There is a finite life expectancy for the lower implants, as a direct
      result of the bone loss that has occurred since they were done in 2012.

Velasco recommended a treatment plan involving reconstruction of the prostheses,

which Leonard was undergoing at the time of the report.

      Dr. Burdine opines that, based on a reasonable degree of medical probability,

Dr. Kline breached the applicable standard of care by failing to provide Leonard

with appropriate and functional dental treatment. Burdine states that the record of

Kline’s exam, although cursory and limited, indicates “adequate bone on the FMX,”

“minimal pocket probing on the probe chart,” and that the teeth were “stable.” Thus,

he opines, Leonard’s teeth were “clearly salvageable.” However, notwithstanding

that his teeth were salvageable and that Leonard stated to Kline that he “wanted to

keep as many remaining teeth as possible,” “the only recommendation made by Dr.

Kline was to extract all of [Leonard’s] erupted teeth and the construction of upper

and lower prosthetic replacements, at a cost of around $50,000.” And, the medical

records reflect that Kline discussed treatment fees with Leonard even before taking

diagnostic records and formulating treatment options. Burdine explained that such

                                           7
action suggests that Kline utilizes a pre-determined treatment plan, which is “entirely

outside of the standard of care.” And, “there is no indication that models were

mounted,” i.e., that models of Leonard’s teeth were created to evaluate the way in

which they fit together naturally. Burdine opines that Kline breached the standard

of care by not discussing all treatment options with Leonard, such as periodontal

therapy, routine restorative work, partial denture prostheses, implants, and bridges.

      Dr. Burdine further notes that Dr. Kline stated on the anesthesia record that

Leonard had periodontal disease. Thus, opines Burdine, Kline also breached the

standard of care by making “no effort” to refer Leonard for a periodontal evaluation

or to treat the disease before “embarking on this extreme treatment plan.” And,

Kline further breached the standard of care by providing Leonard with ill-fitting,

non-functional implants and prostheses, that, despite at least 65 follow-up visits over

the course of five years, were “never properly completed.”

      Dr. Burdine opines that Dr. Kline’s breaches of the standard of care resulted

in an excessively long course of treatment, during which Leonard experienced pain,

difficulty chewing and speaking, and unnecessary expense. In addition, Kline’s

failure to treat Leonard’s oral disease before beginning the restorations proximately

caused his bone loss, implant failure, progression of infection, and additional pain.

      Appellants moved to dismiss Leonard’s negligence claim on the ground that

Dr. Burdine’s expert report is inadequate. Appellants asserted that Burdine is not

                                          8
qualified to render an expert report in this case because he is a periodontist and Dr.

Kline is a cosmetic dentist. Appellants asserted that Burdine’s expert report and CV

fail to establish that he possesses the knowledge, skill, experience, training, or

education to evaluate Leonard’s treatment. Although Burdine asserts that he is

familiar with the management of restorative work in patients like Leonard and states

that he has “treated many patients presenting with the same symptomology reflected

in [Leonard’s] history,” “[n]one of these statements support his inference that he

would know what a dentist in the same or similar circumstances as Dr. Kline does

do, should do, or can do.” Further, Burdine fails to state that he is trained in

implantology, teeth building, placement, or adjustment, or that he has ever placed

implant prostheses. Rather, Burdine is “only trained in the surgical aspect.”

      Appellants further complained that Dr. Burdine, in his report, fails to identify

the applicable standard of care and offers only contradictory and conclusory

statements, discussed below, with respect to his alleged breaches of the standard.

And, “[t]here is a huge ‘gap’ between the alleged breach of the standard of care and

the alleged damages.”      They argued: “Even if we make the impermissible

assumption Dr. Burdine makes that Dr. Kline did not inform Mr. Leonard of all of

his options, how did this directly or indirectly cause bone loss? How did the

prostheses allegedly become non-functional?” Further, they assert, Burdine failed

to acknowledge Leonard’s “neurological condition that was the actual cause of his

                                          9
broken prostheses: bruxism.”6 Appellants asserted that Burdine simply did not

explain how Kline’s failure to follow the standard of care led to Leonard’s failed

outcome. The trial court denied appellants’ motion to dismiss Leonard’s claim.

                                    Expert Report

      In their first through third issues, appellants argue that the trial court erred in

denying their motion to dismiss Leonard’s negligence claim against them because

his expert report is inadequate. Specifically, appellants assert that Dr. Burdine is not

qualified to opine as to the applicable standard of care and breach, and Burdine does

not adequately address the elements of the standard of care, breach, and causation.

A.    Standard of Review and Legal Principles

      We review a trial court’s decision on a motion to dismiss a health care liability

claim for an abuse of discretion. See Am. Transitional Care Ctrs. of Tex., Inc. v.

Palacios, 46 S.W.3d 873, 875 (Tex. 2001); Gray v. CHCA Bayshore L.P., 189
S.W.3d 855, 858 (Tex. App.—Houston [1st Dist.] 2006, no pet.). We apply the same

standard to a trial court’s determination that an expert is qualified. See Broders v.

Heise, 924 S.W.2d 148, 151–52 (Tex. 1996); San Jacinto Methodist Hosp. v.

Bennett, 256 S.W.3d 806, 811 (Tex. App.—Houston [14th Dist.] 2008, no pet.).

When reviewing matters committed to a trial court’s discretion, we may not

6
      “Bruxism” is defined as the “habit of unconsciously gritting or grinding the teeth.”
      Bruxism, MERRIAM–WEBSTER’S DICTIONARY (11th ed. 2003).
                                           10
substitute our own judgment for that of the trial court. Bowie Mem’l Hosp. v. Wright,

79 S.W.3d 48, 52 (Tex. 2002). A trial court does not abuse its discretion merely

because it decides a discretionary matter differently than an appellate court would in

a similar circumstance. Harris Cty. Hosp. Dist. v. Garrett, 232 S.W.3d 170, 176

(Tex. App.—Houston [1st Dist.] 2007, no pet.). However, a trial court has no

discretion in determining what the law is or in applying the law to the facts. See

Walker v. Packer, 827 S.W.2d 833, 840 (Tex. 1992). A trial court abuses its

discretion if it acts in an arbitrary or unreasonable manner without reference to

guiding rules or principles. Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010).

      A health-care-liability claimant must timely provide each defendant health

care provider7 with an expert report. TEX. CIV. PRAC. & REM. CODE § 74.351. An

expert report means a “written report by an expert that provides a fair summary of

the expert’s opinions as of the date of the report regarding applicable standards of

care, the manner in which the care rendered by the physician or health care provider

failed to meet the standards, and the causal relationship between that failure and the

injury, harm, or damages claimed.” Id. § 74.351(r)(6). In setting out the expert’s

opinions, the report must: (1) inform the defendant of the specific conduct the

7
      A “health care provider” means “any person, partnership, professional association,
      corporation, facility, or institution duly licensed, certified, registered, or chartered
      by the State of Texas to provide health care, including: . . . a dentist.” TEX. CIV.
      PRAC. & REM. CODE § 74.001(12)(A)(ii).
                                             11
plaintiff has called into question and (2) provide a basis for the trial court to conclude

that the claims have merit. Scoresby v. Santillan, 346 S.W.3d 546, 556 (Tex. 2011).

A report that merely states the expert’s conclusions as to the standard of care, breach,

and causation does not fulfill these purposes. See id. Rather, the expert must explain

the basis of her statements and must link his conclusions to the facts. Wright, 79
S.W.3d at 52.

      If a defendant files a motion to dismiss, challenging the adequacy of a

claimant’s expert report, a trial court must grant the motion if it appears, after a

hearing, that the report does not represent an objective good faith effort to comply

with the definition of an expert report or that it is not sufficiently specific to provide

a basis for the trial court to conclude that the claims have merit. TEX. CIV. PRAC. &

REM. CODE § 74.351(l). The trial court, in assessing the sufficiency of the report,

may not draw inferences, but instead must rely exclusively on the information

contained within the four corners of the expert report or its accompanying

curriculum vitae. See In re McAllen Med. Ctr., Inc., 275 S.W.3d 458, 463 & n.14

(Tex. 2008).

B.    Analysis

      1.       Qualifications

      In their first issue, appellants argue that Dr. Burdine, a periodontist, does not

establish in his expert report that he is qualified to opine as to the applicable standard

                                           12
of care or as to any breach thereof by Dr. Kline, a “cosmetic dentist.” Specifically,

appellants assert, Burdine does not establish that he has received training in placing

dental implant prostheses or that he has ever performed any such procedure.

      Whether an expert witness is qualified lies within the sound discretion of a

trial court. Broders, 924 S.W.2d at 151. Not every licensed health care provider is

qualified to testify on every medical question. Id. at 152–53. However, one need

not be a practitioner in the same specialty as the defendant to be a qualified expert

in a particular case. Id. at 153. Under the Rules of Evidence, the test is whether the

offering party has established that the expert has the knowledge, skill, experience,

training, or education to assist the trier of fact in understanding the evidence or

determining a fact issue. See TEX. R. EVID. 702; Broders, 924 S.W.2d at 153; see

also Roberts v. Williamson, 111 S.W.3d 113, 121 (Tex. 2003); Keo v. Vu, 76 S.W.3d
725, 732 (Tex. App.—Houston [1st Dist.] 2002, pet. denied) (“[T]rial courts may

qualify a medical witness of a different specialty to testify if the witness has practical

knowledge of what is usually and customarily done by other practitioners under

circumstances similar to those confronting the malpractice defendant.”).

      In a suit involving a health-care-liability claim against a health care provider,

as here, a person may qualify as an expert witness on the issue of whether the health

care provider departed from accepted standards of care only if the person:

      (1)    is practicing health care in a field of practice that involves the
             same type of care or treatment as that delivered by the defendant
                                           13
             health care provider, if the defendant health care provider is an
             individual, at the time the testimony is given or was practicing
             that type of health care at the time the claim arose;
      (2)    has knowledge of accepted standards of care for health care
             providers for the diagnosis, care, or treatment of the illness,
             injury, or condition involved in the claim; and
      (3)    is qualified on the basis of training or experience to offer an
             expert opinion regarding those accepted standards of health care.

TEX. CIV. PRAC. & REM. CODE § 74.402(b). In determining whether a witness is

qualified on the basis of training or experience, the court “shall consider” whether,

at the time the claim arose or at the time the testimony is given, the witness:

      (1)    is certified by a licensing agency of one or more states of the
             United States or a national professional certifying agency, or has
             other substantial training or experience, in the area of health care
             relevant to the claim; and
      (2)    is actively practicing health care in rendering health care services
             relevant to the claim.

Id. § 74.402(c). Thus, qualification under section 74.402 does not turn on specific

credentialing; rather, it turns on the expert’s competence with the type of care

delivered to the patient and the expert’s knowledge of the standard governing

diagnosis and treatment of the patient’s condition. See id.; Broders, 924 S.W.2d at

153; Keo, 76 S.W.3d at 732.

      The substance of Leonard’s claim is that Dr. Kline improperly performed full-

mouth extraction of his teeth and replacement with implants and prostheses. Dr.

Burdine, in his expert report, states that, “by virtue of [his] medical education, [his]

years of dental experience, and specific practice in the field of periodontics,” he is
                                          14
familiar with the standard of care for the diagnosis, treatment, and care of patients

undergoing full-mouth restoration.      Burdine’s CV reflects that he is a licensed

dentist with an advanced degree in periodontics. Burdine specifically states that he

has been practicing in implantology since 1987. He is currently in private practice,

including implantology, and treats patients four days per week.         And, he has

“personally diagnosed, treated, and cared for many patients, such as [Leonard].”

      Thus, Dr. Burdine’s expert report establishes that, at the time of the report or

at the time that Leonard’s claim arose, Burdine was “practicing in a field of practice

that involves the same type of care or treatment as that delivered by” Dr. Kline. See

TEX. CIV. PRAC. & REM. CODE § 74.402(b). In addition, the report establishes that

Burdine “has knowledge of accepted standards of care for health care providers for

the diagnosis, care, or treatment of the illness, injury, or condition involved in the

claim.” See id. Further, Burdine’s expert report establishes that he is qualified on

the basis of training or experience to offer an expert opinion regarding the accepted

standards of health care because it demonstrates that he is a licensed dentist, has an

advanced degree in periodontics, and is actively rendering healthcare services

relevant to the claim, i.e., implantology. See id. § 74.402(b), (c).

      Appellants argue that Dr. Burdine’s expert report is deficient because it does

not expressly state that his education, which he completed in 1974, included

implantology. We note that a “periodontist” is generally defined as a “dentist who

                                          15
specializes in the prevention, diagnosis, and treatment of periodontal disease and in

the placement of dental implants.” AM. ACADEMY                 OF   PERIODONTOLOGY,

https://www.perio.org/consumer/what-is-a-periodontist (last visited December 16,

2019) (emphasis added). And, again, Burdine expressly states in his report that he

has been practicing implantology since 1987. Appellants provide no authority to

support their assertion that an expert report need itemize specific coursework.

      We conclude that the trial court could have reasonably concluded that Dr.

Burdine’s expert report demonstrates that he is qualified to render an opinion as to

the standard of care applicable to a dentist treating a patient with the conditions with

which Leonard presented and as to breaches of the standard. See TEX. CIV. PRAC. &

REM. CODE § 74.402; see also TEX. R. EVID. 702. Accordingly, we hold that the trial

court did not abuse its discretion in denying appellants’ motion to dismiss Leonard’s

claim on the ground that Burdine is not qualified to render an expert report.

      We overrule appellants’ first issue.

      2.     Standard of Care and Breach

      In their second issue, appellants argue that Dr. Burdine’s report is

substantively inadequate as to the applicable standard of care and breach because

Burdine’s report is “internally inconsistent” and “conclusory.”

      Identifying the standard of care in a health care liability claim is critical:

“Whether a defendant breached his or her duty to a patient cannot be determined

                                          16
absent specific information about what the defendant should have done differently.”

Palacios, 46 S.W.3d at 880. Again, an expert report must provide a “fair summary”

of the expert’s opinion regarding the applicable standard of care and the manner in

which the care rendered by the health care provider failed to meet the standard. See

TEX. CIV. PRAC. & REM. CODE § 74.351(r)(6). “While a ‘fair summary’ is something

less than a full statement of the applicable standard of care and how it was breached,”

it “must set out what care was expected, but not given.” Palacios, 46 S.W.3d at 880.

      In his report, Dr. Burdine explains that “the standard of care requires that a

complete oral, periodontal, occlusal and restorative exam, with both functional and

esthetic considerations being made prior to any comprehensive treatment and all

treatment options be presented to the patient.” And, such discussion “must include

considerations as to the patient’s goals.” The standard of care also requires that

mounted models of the patient’s dentition be created in order to analyze and

determine the options for restoration of the natural dentition. The standard of care

further requires that a surgeon operate in a clean environment and thus that all oral

disease be identified and treated prior to comprehensive restorative therapy or oral

surgery. And, the standard of care requires that restorations be properly fitted and

functional. Thus, Dr. Burdine clearly identifies the pertinent standard of care for

comprehensive, restorative dental treatment. See TEX. CIV. PRAC. & REM. CODE

§ 74.351(r)(6); Palacios, 46 S.W.3d at 880.

                                          17
      With respect to breach, Dr. Burdine opines in his report that, notwithstanding

that Dr. Kline’s medical records establish that Leonard’s teeth were “certainly

salvageable” and that Leonard stated to Dr. Kline that he “wanted to keep as many

remaining teeth as possible,” “the only recommendation made by Dr. Kline was to

extract all of [Leonard’s] erupted teeth and the construction of upper and lower

prosthetic replacements, at a cost of around $50,000.” Burdine opines that Kline

breached the standard of care by not discussing all treatment options with Leonard,

such as periodontal therapy, routine restorative work, partial denture prostheses,

implants, and bridges. And, Burdine notes that “there is no indication that models

were mounted,” i.e., that models of Leonard’s teeth were created to evaluate the way

in which they fit together naturally.

      Dr. Burdine also opines that Dr. Kline, after noting on his anesthesia record

that Leonard had periodontal disease, breached the standard of care by making “no

effort” to refer Leonard for a periodontal evaluation or to treat his periodontal disease

before “embarking on this extreme treatment plan.” And, Kline breached the

standard of care by providing Leonard with ill-fitting, non-functional implants and

prostheses, that, despite at least 65 follow-up visits over the course of five years,

were “never properly completed.”

      Appellants assert that Dr. Burdine’s expert report is inadequate because it

contains contradictory statements. For instance, Burdine’s statement that “it was

                                           18
discussed with Mr. Leonard the options of saving versus extracting his teeth, his

periodontal status, and bruxism” contradicts his assertion that Dr. Kline breached

the standard of care by failing to discuss all treatment options. Thus, appellants

assert, “the standard of care does not appear to have been breached.”

      In our analysis of the statutory adequacy of an expert report, we do not

determine whether the expert’s conclusions are correct, but only whether the analysis

used to reach them is reliable. See Keo, 76 S.W.3d at 734; see also Gannon v. Wyche,

321 S.W.3d 881, 892 (Tex. App.—Houston [14th Dist.] 2010, pet. denied) (“Even

assuming conflicts exist between the facts on which [the expert] relies and the

medical records, . . . [a]ccepting the premise that an expert’s report may not

contradict the medical records in such a case would preclude a plaintiff from ever

being able to satisfy the expert-report requirement. Further, the credibility and

weight to be given to the facts supporting the expert’s opinion is an issue for trial.”).

Dr. Burdine opines, based on his review of the medical records, that the only

treatment option that Dr. Kline presented to Leonard was the extraction of all of his

teeth. This is sufficient to satisfy the statute. See Scoresby, 346 S.W.3d a 556.

      Appellants further complain that the report requires impermissible inferences.

For instance, Dr. Burdine infers that Dr. Kline failed to mount models of Leonard’s

dentition based on there being no such models noted in his medical record. Section

74.351 does not prohibit experts, as opposed to courts, from making inferences based

                                           19
upon silence in a patient’s medical record. See Clavijo v. Fomby, No. 01-17-00120-

CV, 2018 WL 2976116, at *10 (Tex. App.—Houston [1st Dist.] June 14, 2018, pet.

denied) (mem. op.) (holding that expert was not prohibited from inferring, based on

lack of documented wound evaluation, that such did not occur); Quinones v. Pin,

298 S.W.3d 806, 813 (Tex. App.—Dallas 2009, no pet.) (holding that medical expert

properly relied on silence in medical record to support inferences); Granbury Minor

Emergency Clinic v. Thiel, 296 S.W.3d 261, 265 (Tex. App.—Fort Worth 2009, no

pet.) (noting that section 74.351 does not prohibit experts, as opposed to courts, from

making inferences based on patient’s medical history); see also Gannon, 321 S.W.3d

at 892 (noting that whether expert’s factual inferences are accurate is question for

fact finder and should not be considered when ruling on section 74.351 motion to

dismiss).

      We conclude that the trial court could have reasonably concluded that Dr.

Burdine’s report represents a “good faith effort” to inform Dr. Kline of the specific

conduct called into question, the standard of care that should have been followed,

and what he should have done differently.         See Palacios, 46 S.W.3d at 880.

Accordingly, we hold that the trial court did not abuse its discretion in denying

appellants’ motion to dismiss Leonard’s health care liability claim on the ground

that Burdine’s expert report was inadequate as to the applicable standard of care and

the manner in which it was breached.

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      We overrule appellants’ second issue.

      3.     Causation

      In their third issue, appellants argue that Dr. Burdine’s expert report is

inadequate as to the element of causation because Dr. Burdine “fails to link the

damages sustained by Leonard to any specific breach of an applicable standard of

care.” Appellants assert that “Burdine’s report never makes clear what actions Dr.

Kline took to cause the alleged damages” and “fail[s] to disprove the possible

alternative that Leonard’s bruxism was the cause of the failed treatment.”

      An expert report must provide a fair summary of the expert’s opinions

regarding the causal relationship between the failure of a health care provider to

provide care in accord with the pertinent standard of care and the injury, harm, or

damages claimed.      TEX. CIV. PRAC. & REM. CODE § 74.351(r)(6).            A causal

relationship is established by proof that the negligent act or omission constituted a

substantial factor in bringing about the harm and that, absent the act or omission, the

harm would not have occurred. Costello v. Christus Santa Rosa Health Care Corp.,

141 S.W.3d 245, 249 (Tex. App.—San Antonio 2004, no pet.). However, an expert

report need not marshal all of the plaintiff’s proof necessary to establish causation

at trial, and it need not anticipate or rebut all possible defensive theories that may

ultimately be presented to the trial court. Wright, 79 S.W.3d at 52; Cornejo v.

Hilgers, 446 S.W.3d 113, 123 (Tex. App.—Houston [1st Dist.] 2014, pet. denied).

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The expert must simply provide some basis that a defendant’s act or omission

proximately caused injury. Wright, 79 S.W.3d at 53. And, the expert must explain

the basis of his statements and link his conclusions to the facts. Id. at 52. “No

particular words or formality are required [in the expert report], but bare conclusions

will not suffice.” Scoresby, 346 S.W.3d at 556.

      Again, in assessing the sufficiency of a report, a trial court may not draw

inferences; instead, it must exclusively rely upon the information contained within

the four corners of the report. In re McAllen Med. Ctr., 275 S.W.3d at 463 & n.14.

However, section 74.351 does not prohibit experts, as opposed to courts, from

making inferences based on medical history. Clavijo, 2018 WL 2976116, at *10.

      In his expert report, Dr. Burdine opines that Dr. Kline’s failure to discuss with

Leonard all of his treatment options and to heed Leonard’s desire to keep as many

teeth as possible, caused Leonard to unnecessarily consent to the extraction of all of

his teeth. Burdine opines that the record of Kline’s exam, although cursory and

limited, indicates “adequate bone on the FMX,” “minimal pocket probing on the

probe chart,” and that the teeth were “stable.” Thus, he opines, Leonard’s teeth were

“certainly salvageable.”

      Dr. Burdine further opines that a periodontist acting with ordinary care would

have foreseen that Leonard, having not visited a dentist for five years prior to

presenting for his initial treatment, would have a build-up of debris and

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inflammation in his mouth. And, Dr. Kline noted on his anesthesia report that

Leonard had periodontal disease. Burdine opines that Kline’s failure to refer

Leonard for a periodontal evaluation and failure to treat his disease before extracting

all of his teeth caused the progression of his infection, implant failure, soft tissue

loss, bone loss, and pain.

      Burdine further opines that Dr. Kline’s breaches of the standard of care with

respect to providing Leonard’s implants and prostheses caused his “excessively long

course of treatment,” failed outcome, pain, difficulty speaking and chewing, social

embarrassment, and loss of an exorbitant amount of time and money on a failed

restorative treatment and repair.

      Appellants assert that the report is inadequate with respect to causation

because Dr. Burdine does not address the alternative possibility that Leonard’s failed

restoration was caused by bruxism, i.e., grinding or clenching his teeth. Again,

however, an expert report need not anticipate or rebut all possible defensive theories

that may ultimately be presented to the trial court. See Wright, 79 S.W.3d at 52;

Cornejo, 446 S.W.3d at 123.

      We conclude that the trial court could have reasonably concluded that Dr.

Burdine’s expert report represents an objective good faith effort to inform Dr. Kline

of the causal relationship between his failure to provide care in accord with the

pertinent standards of care and the injury, harm, or damages claimed. See Palacios,

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46 S.W.3d at 879; Kelly v. Rendon, 255 S.W.3d 665, 679 (Tex. App.—Houston [14th

Dist.] 2008, no pet.) (emphasizing that expert reports “are simply a preliminary

method to show a plaintiff has a viable cause of action that is not frivolous or without

expert support”).    Accordingly, we hold that the trial court did not abuse its

discretion in denying appellants’ motion to dismiss Leonard’s health care liability

claim on the ground that the expert report is inadequate with respect to the element

of causation.

      We overrule appellants’ third issue.

                                     Conclusion

      We affirm the trial court’s judgment.

                                               Sherry Radack
                                               Chief Justice

Panel consists of Chief Justice Radack and Justices Landau and Hightower.

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