In Re: Denture Adhesive Cream Appeal of: Brown, G.

J-A20012-15

NON-PRECEDENTIAL DECISION – SEE SUPERIOR COURT I.O.P 65.37

IN RE: DENTURE ADHESIVE CREAM : IN THE SUPERIOR COURT OF
LITIGATION : PENNSYLVANIA
:
:
:
APPEAL OF: GARY L. BROWN, EUGENE :
BUCKLER AND ESTHER BUCKLER, :
THOMAS M. FILLHART AND ANNA M. :
FILLHART, LOLISA JOYNER AND :
JEROME JOYNER, GREGORY N. :
McCOMMON, DONNA OLESKA, JAMES :
C. THOMAS AND SHARRON R. :
THOMAS, LORI WADSWORTH, :
WILLIAM WATKINS, PAMELA :
WORSHAM AND DANA YOUNGBLOOD : No. 915 EDA 2014

Appeal from the Order entered February 18, 2014,
Court of Common Pleas, Philadelphia County,
Civil Division at No. 04534 June Term 2009

BEFORE: DONOHUE, SHOGAN and WECHT, JJ.

MEMORANDUM BY DONOHUE, J.: FILED NOVEMBER 12, 2015

This appeal is filed on behalf of the twelve remaining plaintiffs

(“Appellants”) in the Dental Adhesive Cream Litigation consolidated in the

Court of Common Pleas of Philadelphia County. The Appellants contend that

their use of Fixodent, a denture adhesive cream manufactured and sold by

the Appellees, resulted in a neurological condition identified as copper

deficiency myeloneuropathy (“CDM”). According to the Appellants, Fixodent

contains zinc, the ingestion of which causes copper deficiency, which in turn

causes CDM. The trial court, pursuant to Frye v. United States, 293 F.

1013 (D.C. Cir. 1923), excluded the opinions of the Appellants’ expert
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causation witnesses and granted summary judgment in favor of the

Appellees1. For the reasons that follow, we affirm the trial court’s orders.

In its written opinion, the trial court provided the following useful

background information for this appeal:

On July 2 , 2009, the coordinating judge of the
Complex Litigation Center created the In re Dental
Adhesive Cream mass tort master-docket. The
Third Amended Master Long Form Complaint
contains allegata against eight defendants, which can
easily be distilled into three groups – 1) The Proctor
& Gamble Manufacturing Company and its
subsidiaries, which manufacture and distribute
Fixodent, 2) GlaxoSmithKline and its subsidiaries,
which manufactured and distributed Super Poligrip,
and 3) Defendant Rite-Aid Corporation, which sold
both Fixodent and Super Poligrip. See Third
Amended Master Long Form Complaint at ¶¶ 17-52.

By September 2013, only twelve cases, all filed by
the law firm of Chaffin and Luhana LLP, remained in
the In re Dental Cream mass tort program, and
GlaxoSmithKline and its subsidiaries were no longer
defendants in these cases. On September 17, 2013,
[Appellees] filed an omnibus Motion to Exclude all of
[Appellants’] general causation experts in these
remaining cases. Following extensive briefing by the
parties and the reception of live testimony from Dr.
Lautenbach, the [trial court] heard oral argument on
the Motion.

In these cases, [Appellants] allege their use of zinc
containing denture adhesive creams manufactured
by Proctor and Gamble caused them to develop an
irreversible neurologic condition known as [CDM1].
The parties agree each gram of Fixodent contains

1
The Appellees in the present case consist of the Rite Aid Corporation,
Proctor & Gamble Distributing, LLC, The Proctor & Gamble Manufacturing
Company, and The Proctor & Gamble Company.

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approximately 17 milligrams of zinc bound within a
Gantrez polymer. From this starting point,
[Appellants] allege the following causal chain: 1)
Fixodent contains zinc, 2) some zinc from Fixodent is
absorbed into the blood, 3) excessive zinc in the
blood blocks copper absorption, causing copper
deficiency, 4) sustained copper deficiency for a
prolonged period of time results in [CDM].

[Appellants] identified eight causation experts,
Martyn T. Smith, PhD., Frederick K. Askari, M.D.,
PhD, Ebbing Lautenbach, M.D., M.P.H., Carl F.
Cranor, PhD, M.S.L., David Grainger, PhD, Steven A.
Greenberg, M.D., M.S., Joseph R. Prohaska, PhD,
and Elizabeth A. Shuster, M.D. Although
[Appellants] offer eight experts to support their
theory of causation, only four experts, Dr. Smith, Dr.
Lautenbach, Dr. Askari, and Dr. Greenberg,
submitted opinions linking Fixodent to [CDM]. Three
of the remaining experts, Dr. Cranor, Dr. Grainger,
and Dr. Prohaska authored expert reports which
buttress the conclusion of those experts who do link
Fixodent to [CDM]. For example, Dr. Prohaska’s
report discusses how excess zinc ingestion can lead
to [DCM]; however, Dr. Prohaska’s report does not
link Fixodent to excessive zinc ingestion. Since their
opinions do not link Fixodent to [CDM], but serve
only to bolster the testimony of the experts who do
make such a link, this opinion will not address the
testimony of Dr. Cranor, Dr. Grainger, and Dr.
Prohaska.

[Appellants] also present the testimony of Dr.
Shuster, who treated one of the patients in the
contemporaneous Federal Multi-District Litigation, In
re Denture Cream Products Liability Litigation,
795 F. Supp. 2d 1345 (S.D. Fla. 2011). In the Multi-
District Litigation, Dr. Shuster opined Fixodent
caused her patient to develop [CDM]. Notably, Dr.
Shuster did not file an expert report offering an
opinion as to general causation in these cases;
rather, [Appellants attach] excerpts of her deposition
transcript from the Multi-District Litigation. See

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Moving Defendants Motion at Ex. 13. The fact Dr.
Shuster did not author a general causation expert
report is hardly surprising in light of the fact
[Appellants] candidly admit Dr. Shuster’s
employment contract prohibits her from serving as a
general causation expert. See Plaintiffs’ Response in
Opposition at p. 103 n.33. Nonetheless,
[Appellants’] argue Dr. Shuster’s prior testimony
supports general causation because it logically
follows if Fixodent caused Dr. Shuster’s patient to
develop [CDM], then Fixodent must cause [CDM]
generally. In light of the fact Dr. Shuster did not
author a report offering an opinion as to general
causation in any of the cases currently pending
before this [trial court], Dr. Shuster’s opinions will
not be addressed. Accordingly, this Opinion only
addresses the expert opinions of Dr. Lautenbach, Dr.
Askari, Dr. Smith, and Dr. Greenberg.

1
The [trial court] notes the parties and witnesses
use a number of distinct, yet related, medical terms
to describe the neurological injuries suffered by
[Appellants]. These terms include 1) myelopathy - a
spinal cord disease; 2) neuropathy - peripheral nerve
disease; 3) myeloneuropathy - a combination of
spinal cord disease and peripheral nerve disease,
and 4) copper deficiency myeloneuropathy – a type
of myeloneuropathy caused by copper deficiency.

Trial Court Opinion, 2/7/2014, at 1-3.

In its ruling, the trial court concluded that the Appellants’ “experts

have failed to establish in a methodologically sound manner that denture

cream use, in general, results in [CDM].” Id. at 23. More specifically,

Appellants’ experts “failed to utilize sound methodology to establish a link

between Fixodent and [CDM].” Id. On appeal, the Appellants raise the

following four issues for our review and determination:

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1. Did the trial court abuse its discretion or err as a
matter of law by concluding that it is novel science
that the zinc in denture cream can cause zinc-
induced [CDM] and applying a Frye inquiry to
[Appellants’] general causation experts’ opinions?

2. Even if evaluating the scientific evidence was
appropriate under Frye, did the trial court abuse its
discretion or err as a matter of law by holding that
Dr. Ebbing Lautenbach’s Cohort Study was
inadmissible evidence that [Appellants’] general
causation experts could not rely upon for their expert
opinions?

3. Even if evaluating the scientific evidence was
appropriate under Frye, did the trial court abuse its
discretion or err as a matter of law by holding that
the Fixodent Blockade Study was inadmissible
evidence that [Appellants’] general causation experts
could not rely upon for their expert opinions?

4. Did the trial court abuse its discretion or commit an
error of law by granting [Appellees’] Motion for
Summary Judgment after erroneously granting [the
Appellees’’] Frye motion?

Appellants’ Brief at 6-7.

Our standard of review with respect to a trial court’s decision to grant

or deny a motion for summary judgment is as follows:

A reviewing court may disturb the order of the
trial court only where it is established that the court
committed an error of law or abused its discretion.
As with all questions of law, our review is plenary.

In evaluating the trial court’s decision to enter
summary judgment, we focus on the legal standard
articulated in the summary judgment rule. Pa.R.C.P.
1035.2. The rule states that where there is no
genuine issue of material fact and the moving party
is entitled to relief as a matter of law, summary

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judgment may be entered. Where the non-moving
party bears the burden of proof on an issue, he may
not merely rely on his pleadings or answers in order
to survive summary judgment. Failure of a non[-
]moving party to adduce sufficient evidence on an
issue essential to his case and on which it bears the
burden of proof establishes the entitlement of the
moving party to judgment as a matter of law.
Lastly, we will view the record in the light most
favorable to the non-moving party, and all doubts as
to the existence of a genuine issue of material fact
must be resolved against the moving party.

Thompson v. Ginkel, 2014, 95 A.3d 900, 904 (Pa. Super 2014) (quoting

JP Morgan Chase Bank, N.A. v. Murray, 63 A.3d 1258, 1261–62 (Pa.

Super. 2013)), appeal denied, 108 A.3d 36 (Pa. 2015).

Rule 702 of the Pennsylvania Rules of Evidence governs the

admissibility of expert testimony on scientific knowledge:

Rule 702. Testimony by experts.

If scientific, technical or other specialized knowledge
beyond that possessed by a layperson will assist the
trier of fact to understand the evidence or to
determine a fact in issue, a witness qualified as an
expert by knowledge, skill, experience, training or
education may testify thereto in the form of an
opinion or otherwise.

Pa.R.E. 702. To exclude expert testimony based upon a challenge to the

scientific evidence, a party must file a motion pursuant to Rule 207.1 of the

Pennsylvania Rules of Civil Procedure, which provides as follows:

Rule 207.1 Motion to Exclude Expert Testimony Which
Relies upon Novel Scientific Evidence.

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(a) If a party moves the court to exclude expert testimony which relies
upon novel scientific evidence, on the basis that it is inadmissible
under Pa.R.E. 702 or 703,

(1) the motion shall contain:

(i) the name and credentials of the
expert witness whose testimony is
sought to be excluded,

(ii) a summary of the expected testimony
of the expert witness, specifying with
particularity that portion of the testimony
of the witness which the moving party
seeks to exclude,

(iii) the basis, set forth with specificity,
for excluding the evidence,

(iv) the evidence upon which the moving
party relies, and(v) copies of all relevant
curriculum vitae and expert reports;

(2) any other party need not respond to the motion
unless ordered by the court;

(3) the court shall initially review the motion to
determine if, in the interest of justice, the matter
should be addressed prior to trial. The court, without
further proceedings, may determine that any issue of
admissibility of expert testimony be deferred until
trial; and

(4) the court shall require that a response be filed if
it determines that the matter should be addressed
prior to trial.

(b) A party is not required to raise the issue of the admissibility of
testimony of an expert witness prior to trial unless the court orders the
party to do so.

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Pa.R.C.P. 207.1. The proponent of expert scientific evidence has the burden

of establishing all of the elements required for submission. Grady v. Frito–

Lay, Inc., 839 A.2d 1038, 1045 (Pa. 2003).

In Commonwealth v. Topa, 369 A.2d 1277 (Pa. 1977), our Supreme

Court adopted the standard originally set forth in Frye v. U.S., 293 F. 1013

(D.C.Cir. 1923), for the admissibility of scientific evidence. In Frye, the

Court of Appeals for the District of Columbia concluded that scientific

evidence may be admitted only if it is generally accepted in the relevant

scientific community:

Just when a scientific principle or discovery
crosses the line between the experimental and
demonstrable stages is difficult to define.
Somewhere in this twilight zone the evidential force
of the principle must be recognized, and while courts
will go a long way in admitting expert testimony
deduced from a well-recognized scientific principle or
discovery, the thing from which the deduction is
made must be sufficiently established to have gained
general acceptance in the particular field in which it
belongs.

Frye, 293 F. at 1014; Commonwealth v. Nazarovitch, 496 97, 101, 436

A.2d 170, 172 (Pa. 1981). In Topa, the Supreme Court described the Frye

standard as follows: “Admissibility of the [scientific] evidence depends upon

the general acceptance of its validity by those scientists active in the field to

which the evidence belongs.” Topa, 369 A.2d at 1281.

Our Supreme Court has reaffirmed Pennsylvania's continued

adherence to the Frye test on several occasions, including recently in Betz

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v. Pneumo Abex, LLC, 44 A.3d 27 (Pa. 2012), rather than adopt the federal

standard in Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579

(1993). In Betz, the Supreme Court provided the following general guidance

when applying Frye:

There is inherent tension among the various
measures for admissibility of expert testimony. The
threshold common law test requires merely some
reasonable pretension to specialized knowledge. Our
evidentiary rules, on the other hand, suggest trial
courts may take a greater role in assessing whether
the testimony will assist the trier of fact to
understand the evidence or determine a fact in issue,
see Pa.R.E. 702, and in screening evidence to avoid
unfair prejudice, confusion of the issues, or
misleading of the jury, see Pa.R.E. 403. For better
or for worse, however, in the context of the more
conventional realms of science, the Pennsylvania
decisions tend to downplay the courts’ screening
function. A manifestation of this trend is that
challenges generally are vetted through the Frye
litmus, which winnows the field of the attacks by
application of the threshold requirement of novelty.

Various reasons underlie the preference to limit
the courts’ involvement in determining the
admissibility of scientific evidence. There is the
concern that liberality in allowing challenges would
substantially increase the number of challenges (and
cases in which lengthy pre-trial proceedings would
ensue). The competency of trial judges to accept or
reject scientific theories remains a legitimate subject
of controversy. Additionally, a claim or defense in
many cases may rise or fall based upon expert
testimony and, therefore, there is some reluctance
on the part of courts to deprive litigants of their day
in court.

On the other hand, this Court has recognized
the influential nature of expert testimony on complex

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subjects, and the potential that distortions have to
mislead laypersons. It would be naïve, in this
regard, to assume that the possibility for distortion is
limited to the very newest realms of science.

Id. at 52-53. Because Frye is an exclusionary rule of evidence, “it must be

construed narrowly so as not to impede admissibility of evidence that will aid

the trier of fact in the search for truth.” Trach v. Fellin, 817 A.2d 1102,

1104 (Pa. Super. 2003) (en banc ).

A Frye motion requires a trial court to engage in a two-step process.

First, the trial court must determine whether the evidence the moving party

seeks to exclude is “novel scientific evidence.” Id. at 1109. To do so, the

trial court must consider, inter alia, the proffered basis for excluding the

evidence and the evidence presented in support of that basis (per Rule

207.1(a)(1)(iii) & (iv)), and decide whether the moving party has

demonstrated that there is a legitimate dispute regarding the reliability of

the expert’s conclusions. See, e.g., Commonwealth v. Foley, 38 A.3d

882, 888-90 (Pa. Super. 2012). If the trial court determines that the

proponent has offered “novel scientific evidence,” then it must proceed to

the second step, namely to apply the Frye standard to decide whether the

expert’s methodology “has general acceptance in the relevant scientific

community.” Grady, 839 A.2d at 1043–44. Ultimately, the focus is on the

methodologies utilized, not on the conclusions reached. Id. at 1045.

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This two-step process ensures that scientific evidence admitted at trial

is the product of sound scientific research, but is not “senselessly restrictive”

by prohibiting testimony inconsistent with currently prevailing orthodoxy.

See Blum ex rel. Blum v. Merrell Dow Pharmaceuticals, Inc., 764 A.2d

1, 5 (Pa. 2000) (Cappy, C.J., dissenting). The rationale behind Frye is to

measure the quality of scientific evidence prior to its admission because

“there is the danger that the trial judge or jury will ascribe a degree of

certainty to the testimony of the expert ... which may not be deserved.’”

Id. at 1317 (quoting Topa, 369 A.2d at 1281).

In applying this two-step process, judges should generally be

deferential to the scientists, “who are in the best position to evaluate the

merits of scientific theory and technique.” Grady, 839 A.2d at 1045. As

this Court acknowledged in Trach,

Judges, both trial and appellate, have no special
competence to resolve the complex and refractory
causal issues raised by the attempt to link low-level
exposure to toxic chemicals with human disease. On
questions such as these, which stand at the frontier
of current medical and epidemiological inquiry, if
experts are willing to testify that such a link exists, it
is for the jury to decide whether to credit such
testimony.

Trach, 817 A.2d at 1117 (quoting Ferebee v. Chevron Chemical Co., 736

F.2d 1529, 1534 (D.C. Cir.), cert. denied, 469 U.S. 1062 (1984)).

Moreover, “[i]n a courtroom, the test for allowing a plaintiff to recover … is

not scientific certainty but legal sufficiency,” and “the fact that another jury

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might reach the opposite conclusion or that science would require more

evidence before conclusively considering the causation question resolved is

irrelevant.” Id. (quoting Ferebee, 736 F.2d at 1535-36).

Before proceeding to consideration of the issues raised by the

Appellants in this appeal, we must note that a prior panel of this Court

affirmed the trial court’s grant of a previous Frye motion to exclude expert

causation testimony by Drs. Lautenbach, Askari and Smith in another case

on the In re Dental Adhesive Cream mass tort master-docket. In Jacoby

v. Rite Aid Corp. et al., 1508 EDA 2012 (Pa. Super. December 9, 2013)

(unpublished memorandum), this Court agreed that the trial court properly

subjected the expert testimony to a Frye analysis because it was novel

scientific evidence. The panel determined that while the links between

excess zinc and copper deficiency, and between copper deficiency and

neurological injuries, have been well established over many years, “the real

question before this Court was whether Fixodent releases sufficient zinc to

cause [CDM].” Id. at 10-11. With regard to this question, the panel

recognized that the proffered expert testimony contained significant analytic

gaps, including the lack of any basis on which to opine regarding (1) how

much zinc is absorbed into the body from Fixodent ingestion, (2) how much

zinc would have to be absorbed from Fixodent use to result in copper

deficiency, and (3) how low a person’s copper level must be, and for what

duration, before CDM may result. Id. at 15-16. These analytic gaps existed

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in large part because the expert witnesses relied on reviews of case reports

and case series, which is not a generally accepted methodology on which to

base conclusions about the causes of disease. Id. at 17. In one of his own

publications, Dr. Lautenbach had recognized that case reports are anecdotal

and thus at most may serve to “generate hypotheses that may be tested in

future analytic studies.” Id. Dr. Lautenbach also acknowledged that “since

a case report or case series does not include a comparison group, one

cannot determine which characteristics in the description of the cases are

unique to the illness.” Id.

Dr. Smith and Dr. Askari employed ill-defined methodologies they

respectively described as “weight of the evidence” and “totality of the

evidence.” The panel in Jacoby determined that these methodologies are

not generally accepted within the scientific community, and are in fact not

scientific methodologies at all. Id. at 14. These methodologies “are not

verifiable or replicable, but rather are based on subjective judgment”, and

reflect only a “seat of the pants qualitative assessment.” Id. The Jacoby

panel was somewhat less critical of Dr. Lautenbach’s methodology, pursuant

to which he reviewed case reports and classified the results on the Naranjo

adverse drug reaction probability scale. This methodology was not generally

accepted either, however, both because Dr. Lautenbach relied on the same

case reports and case series as did Drs. Smith and Askari, and because he

admitted during his deposition that he was unaware that the Naranjo scale

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had ever been used in attempting to verify a hypothesis that an essential

trace element (like zinc) causes long-term injury. Id. at 19.

In an effort to fill the analytic gaps and other shortcomings identified

in Jacoby, in the present case the Appellants offered new evidence to

supplement the previously submitted expert reports. This supplemental

evidence consisted of: (1) a peer-reviewed article by Alemayehu A

Gabreyes and others, published in the European Journal of Haematology in

2013 (the “Gabreyes Article”); (2) a cohort study performed by Dr.

Lautenbach (the “Cohort Study”) based upon the data in the Gabreyes

Article; and (3) a Fixodent Blockade Study performed by Dr. Askari. See

Global Frye Motion to Exclude General Causation Expert Testimony,

9/17/2013, Exhibit 32 (Alemayehu A Gabreyes et al., Hypocupremia

associated cytopenia and myelopathy: a national retrospective review, 90

European Journal of Haematology (2013)); Exhibit 11 (Lautenbach 2013

Expert Report); Exhibit 3 (Askari 2013 Expert Report).

In the Gabreyes Article, the authors identified twenty-two patients who

fit the study’s pre-determined parameters: they did not have a pre-existing

cytopenia blood condition, they had their blood copper levels tested by the

Scottish Trace Element and Micronutrient Reference Laboratory (STEMRL),

and their blood copper levels were less than or equal to 6µm. Gabreyes

Article at 2. Of these twenty-two, four were excluded because of a lack of

documentation, and the treating physician(s) for two others declined to

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admit their patients for participation. Of the sixteen participating patients,

the Gabreyes Article reported that “[t]welve of the sixteen remaining

patients had high serum zinc concentrations (>18µm/L), including nine “due

to zinc-containing dental fixatives.” Id. In addition, twelve of the sixteen

patients “had both haematological and neurological features of copper

deficiency.” Id. The Gabreyes authors did not identify the overlap between

the nine patients who had used zinc-containing denture adhesives and the

twelve who had neurological symptoms. In its concluding discussion section,

the Gabreyes Article noted that its findings “again highlight[] the association

between long-term zinc exposure through dental fixatives and the

subsequent haematological and neurological symptoms ….” Id. at 8. The

authors also noted that “copper deficiency is under diagnosed,” and if better

recognized and properly diagnosed, “the actual prevalence is likely to be

higher.” Id.

At the Frye hearing, Dr. Lautenbach testified that he performed his

Cohort Study to determine “the association between denture cream and

[CDM].” N.T., 11/12/2013, at 20. A “cohort study” compares two groups of

people, one exposed to a substance considered to be a possible cause of a

disease, and another not so exposed. Hamilton v. Breg, Inc., 2011 WL

833614, at *4 (S.D. Ohio 2011). While cohort studies are typically

prospective in nature, where the researcher follows the progress of both

groups over a period of time, id., Dr. Lautenbach’s Cohort Study was

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retrospective in nature2 and was based upon the information in the Gabreyes

Article:

So what really enabled me to do the cohort study
was the Gabreyes study. And the reason for that is
that the Gabreyes authors identified the source – the
clear source population, which is the population of
Scotland, and within that population identified all
patients who in a given time period, from ’05 to
2010, developed copper deficiency, and within that
group those that developed copper deficiency – signs
and symptoms consistent with [CDM].

N.T., 11/12/2013, at 20.

In his Cohort Study, Dr. Lautenbach compared two cohort groups,

namely those who used denture cream in Scotland between 2005 and 2010

and those who did not, to determine the rates of development of CDM in

each group. He concluded that the rate of development of CDM was higher

among denture cream users based upon the following analysis: the

Gabreyes Article identified twelve of the sixteen patients with low copper

levels as suffering from CDM, and of these twelve, between six and nine

used denture cream. Based upon statistics regarding the incidence of

denture cream use in the United Kingdom, he estimated that a similar

percentage (10%) of the population of Scotland used denture cream. Given

a Scottish population of 5.2 million, Dr. Lautenbach estimated that roughly

2
At the Frye hearing, Dr. Lautenbach testified that performing a
prospective cohort study would be unethical “because you would be
assigning people to excessive amounts of denture cream exposure. N.T.,
11/12/2013, at 15.

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500,000 people used denture cream between 2005 and 2010. Using the

more conservative number from the Gabreyes Article, six out of 500,000

denture cream users is a much higher rate of developing CDM than is six out

of 4.7 million who did not use denture cream. Accordingly, Dr. Lautenbach

opined that the rate of development of CDM is much higher among denture

cream users than is the same rate among non-denture cream users, even

using the most conservative assumption from the Gabreyes Article data (six

rather than nine). Global Frye Motion to Exclude General Causation Expert

Testimony, 9/17/2013, Exhibit 11.

Finally, Dr. Askari performed his Fixodent Blockade Study to test his

hypothesis that ingestion of zinc-containing Fixodent blocks copper

absorption, resulting in decreased blood (serum) copper levels and increased

copper levels in urine and feces. Twenty-four individuals on controlled diets

received three pills per day for 30 days, during which time blood, urine and

feces levels were regularly monitored. Twelve participants ingested

encapsulated Fixodent, six ingested encapsulated zinc acetate, and the final

six ingested an encapsulated placebo. At the end of the 30-day period,

contrary to Dr. Askari’s assumptions, there were no statistically significant

differences in copper levels in the blood or urine of those ingesting Fixodent

and those ingesting the placebo. On days 31-33, however, there was a

statistically significant difference between the copper levels in the fecal

excretions of those two groups. From this latter finding, Dr. Askari opined

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that the study confirmed his initial hypothesis. Global Frye Motion to

Exclude General Causation Expert Testimony, 9/17/2013, Exhibit 3.

For their first issue on appeal, the Appellants argue that the trial court

abused its discretion or erred as a matter of law in subjecting the opinions of

their expert causation witnesses to a Frye inquiry. According to the

Appellants, the science that zinc-containing denture adhesives can cause

CDM is “now widely accepted among scientists,” and thus is not novel.

Appellants’ Brief at 26. The Appellants’ contend that “today 23 textbooks in

hematology, neurology, internal medicine and other disciplines have

concluded that zinc, including the zinc in denture adhesives like Fixodent,

can cause copper deficiency and resulting hematological and neurological

injuries, including CDM.” Id. at 34. Because diverse and widely respected

sources agree that the science at issue is not novel, the Appellants insist

that no Frye inquiry was necessary or appropriate. Id. at 36.

In Jacoby, this Court considered and rejected a substantially similar

contention based upon a review of most of the same textbooks and related

sources now cited by the Appellants. Jacoby, 1508 EDA 2012 at 10-11.

The law of the case doctrine provides, inter alia, that judges of equal

jurisdiction sitting in the same case should not overrule each other’s

decisions. Commonwealth v. Starr, 664 A.2d 1326, 1331 (Pa. 1995);

Ario v. Reliance Ins. Co., 980 A.2d 588, 597 (Pa. 2009); Mohney v. Am.

Gen. Life Ins. Co., 116 A.3d 1123, 1132 (Pa. Super. 2015). As a technical

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matter, the law of the case doctrine does not apply here, as this is not the

“same case” as Jacoby. The Appellants, however, have provided us with no

basis to reach a result contrary to that of the Jacoby panel. The

publications cited by the Appellants acknowledge the widely-accepted

associations between the ingestion of zinc and the incidence of low copper

levels, and between low copper levels and CDM. They do not, however,

firmly establish an association between the use of Fixodent and CDM. Most

of these publications do not mention denture adhesives at all, and those that

do fail to mention Fixodent in particular.

More importantly in this regard, in Betz our Supreme Court reminded

us that the test for novelty is whether the trial court “has articulable grounds

to believe that an expert witness has not applied accepted scientific

methodology in a conventional fashion in reaching his or her conclusions.”

Betz, 44 A.3d at 53. To the extent that the publications cited by the

Appellants do suggest a causal link between Fixodent and CDM, 3 they

provide no indication of the scientific methodologies used to establish such a

link, including whether the methodologies employed were mere reviews of

3
The Appellants cite to a publication from the U.S. National Institutes of
Health (NIH) that, while not mentioning Fixodent specifically, does indicate
that while regular use of zinc-containing denture adhesive creams as
directed is not of concern, “chronic, excessive use can lead to zinc toxicity,
resulting in copper deficiency and neurologic disease.” Appellants’ Brief at
33. The NIH publication does not identify what levels of denture cream use
would constitute “chronic, excessive use” or describe the bases for this
opinion (including the methodologies employed or by whom).

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case reports and case series, which, as noted in Jacoby, has routinely been

rejected as not constituting a generally accepted methodology. See, e.g.,

Betz, 44 A.3d at 55. As a result, to determine the novelty (or lack thereof)

regarding the science at issue here, we will look only to the new evidence

proffered by the Appellants, including Dr. Lautenbach’s Cohort Study and Dr.

Askari’s Fixodent Blockade Study, to determine whether they, per Betz,

apply accepted scientific methodology in a conventional fashion. As we

conclude hereinbelow, they do not, and thus the trial court did not err in

proceeding with its Frye analysis.

For their second issue on appeal, the Appellants claim that the trial

court erred in its ruling that Dr. Lautenbach’s Cohort Study does not provide

a methodologically sound basis for an opinion that the use of Fixodent

causes CDM. According to the Appellants, Dr. Lautenbach designed and

conducted the Cohort Study using generally accepted methodologies and

population data routinely employed by epidemiologists, and that any

criticisms of the Cohort Study go to its weight rather than its admissibility.

Appellants’ Brief at 27-28.

Based upon our review of the certified record, we must agree with the

trial court that Dr. Lautenbach’s Cohort Study is not based upon generally

accepted methodologies. In their appellate brief, the Appellants attempt to

support the general acceptance of Dr. Lautenbach’s methodologies in

constructing his cohort study by citing to excerpts from Methods in

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Observational Epidemiology by Jennifer L. Kelsey. Id. at 48. Dr. Kelsey’s

book, however, suggests that the data contained in the Gabreyes Article was

insufficient to provide the basis for conducting a retrospective cohort study.

As in prospective cohort studies, selection of the
most appropriate groups to study in retrospective
cohort studies requires careful attention to both
practical and theoretical issues. … The group
selected must be one in which a large number
of people has been exposed to the agent of
interest. A sufficient number of these people must
have been exposed at high enough levels that
important excess incidence for the diseases under
investigation is likely to be detected.

Global Frye Motion to Exclude General Causation Expert Testimony,

9/17/2013, Exhibit 85 at 115 (emphasis added). The Gabreyes Article

involved a mere sixteen participants, only twelve of whom reported

neurological symptoms, with as few as six of these twelve having used zinc-

containing denture cream. The Appellants have not directed us to any

evidence that it is a generally accepted methodology to perform a

retrospective cohort study based upon the exposure of just six individuals to

the agent of interest.

In addition, contrary to the Appellants’ contentions, the Gabreyes

Article does not itself contain any epistemological evidence based upon

generally accepted methodologies. The Appellants claim that the Gabreyes

Article “itself found an association between long-term zinc exposure through

dental cream use and subsequent neurological injuries such as CDM.”

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Appellants’ Brief at 25. The authors of the Gabreyes Article made no similar

claim, however, describing their work “as a retrospective audit of clinical

practice rather than clinical research” and indicated that “the audit was

observational, based on retrospective review of case records.” Global Frye

Motion to Exclude General Causation Expert Testimony, 9/17/2013, Exhibit

59 at 2. As such, the Gabreyes Article was a review of a small number of

case reports, which even Dr. Lautenbach concedes does not constitute the

basis for an epidemiological finding of causation.

This lack of epidemiological support is significant. In Trach, this Court

agreed that the expert’s use of extrapolation was a generally accepted

methodology because it was based upon sound epidemiological evidence. In

particular, we permitted an expert to extrapolate, based upon evidence

generated from methodologically sound clinical trials, that a medication

known to cause certain adverse effects at a lower (recommended) dose

could cause increased levels of the same effects if taken in a massive

overdose. Trach, 817 A.2d at 117-18. More recently, however, our

Supreme Court refused to permit an expert to extrapolate based upon

unsound epidemiological data (“case reports, animal studies, and regulatory

standards”). Betz, 44 A.3d at 55-57. Here, as in Betz, Dr. Lautenbach’s

Cohort Study is not based upon any supporting epidemiological evidence

produced using generally accepted scientific methodologies.

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The trial court focused on another of Dr. Kelsey’s requirements for

conducting a generally accepted retrospective cohort study, namely the need

for sufficient data to obtain an accurate measure of exposure. Trial Court

Opinion, 2/7/2014, at 13. The trial court criticized Dr. Lautenbach’s use of

the Gabreyes Article as the basis for the Cohort Study because it failed to

provide Dr. Lautenbach with certain types of seemingly important data,

including the type of denture adhesive used, the amount used, the

frequency of use, the time-frame between use and the onset of neurological

injuries, and whether the use preceded the neurological symptoms. Id. at

13-14. Particularly troubling for the trial court was the failure to distinguish

between the use of Fixodent and Super Poligrip, in substantial part because

Super Poligrip contained twice as much zinc as did Fixodent. Id. According

to the trial court, even one of the Appellants’ own experts (Dr. Grainger)

agreed that the use of Super Poligrip resulted in the delivery of a greater

amount of zinc into the body than did Fixodent. Id. at 13 n.4 (citing Global

Frye Motion to Exclude General Causation Expert Testimony, 9/17/2013,

Exhibit 7 at 9). Given the difference in exposure levels and the lack of data

regarding which denture adhesive the Cohort Study participants used, the

trial court found that Dr. Lautenbach’s conclusion that 45% of the

neurological injuries reported in the Gabreyes Article were caused by the use

of Fixodent (because Fixodent had 45% of the relevant market share)

constituted “faulty logic and clear litigation bias.” Id. at 14.

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At the Frye hearing, however, Dr. Lautenbach testified that the lack of

data identified by the trial court had no effect on his ability to use the

Gabreyes Article as the basis for his Cohort Study. N.T., 11/12/2013, at

105. According to Dr. Lautenbach, this data was unnecessary because the

authors of the Gabreyes Article relied upon the diagnoses of the treating

physicians that their patients’ high zinc levels (and low copper levels)

resulted from the use of denture adhesives over time. Id. In other words,

it was not necessary for Dr. Lautenbach or the authors of the Gabreyes

Article to make independent determinations that the high zinc/low copper

levels were caused by the use of denture adhesives because the patients’

treating physicians, as a normal part of their clinical practices (including

taking patient histories), had made these causation determinations. Id. at

106. According to Dr. Lautenbach, in each reported case, the treating

physician assessed all possible causes and made a clinical assessment that

the use of zinc-containing denture adhesives was the cause of the patient’s

high zinc and low copper levels. Id. at 112.

Dr. Lautenbach testified that reliance on the diagnoses of treating

physicians when performing a cohort study is a generally accepted

methodology. Id. at 157 (“Yes. That’s very, very commonly what we do.”).

On appeal, the Appellants likewise insist that Dr. Lautenbach’s reliance on

the diagnoses of treating physicians is “unquestionably methodologically

sound.” Appellants’ Brief at 44. Other than citing to Dr. Lautenbach’s own

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testimony, however, the Appellants provide no substantial support for this

contention, as their various citations to the record refer us back to their

briefs filed in the trial court and to publications apparently not contained in

the certified record on appeal.

Moreover, Dr. Lautenbach’s testimony at the Frye hearing, including

both during cross-examination and in response to questioning by the trial

court, provided several reasons for the trial court to question the credibility

of Dr. Lautenbach’s contention that his reliance on the diagnoses of treating

physicians is a generally accepted methodology. For example, Dr.

Lautenbach admitted that the treating physicians did not apply consistent

diagnostic criteria for diagnosing copper deficiency, and the authors of the

Gabreyes Article agreed that they were unaware of the “extent the treating

clinician applied … diagnostic criteria in the management of their patients.” 4

N.T., 11/12/2013, at 108-09. At the completion of the study, the authors of

4
In addition, the treating physicians in the Gabreyes Article lacked a
consistent case definition of CDM. N.T., 11/12/2013, at 108-09. The
Gabreyes Article does not even refer to CDM specifically, instead reporting
only that twelve patients displayed “neurological features of copper
deficiency.” Gabreyes Article at 2. Despite this, Dr. Lautenbach assumed
that the twelve patients suffering from said “neurologic features” all suffered
from CDM, even though (given the lack of a consistent case definition) some
of these patients may not have had the same symptoms or even the same
disease. Global Frye Motion to Exclude General Causation Expert Testimony,
9/17/2013, Exhibit 11 (Lautenbach 2013 Expert Report) ¶ 43. Cf. In re
Denture Cream Products Liability Litigation, 795 F. Supp. 2d 1345,
1361 (S.D.Fla. 2011) (“There are very good reasons to believe the cases
reported in the literature suggesting an association between denture cream
and neurological symptoms included people who were not suffering from
[CDM].”).

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J-A20012-15

the Gabreyes Article destroyed the clinical records of the patients, and thus

Dr. Lautenbach could not independently evaluate the correctness of the

treating physicians’ diagnoses. Id. at 103. The Gabreyes Article also did

not identify the treating physicians by name, and thus Dr. Lautenbach could

not assess the skill level or ability of these particular physicians to diagnose

the causes of disease generally or CDM specifically, including, among other

things, whether the treating physicians adequately considered alternatives to

the use of denture adhesives to explain their patients’ high zinc levels. Id.

at 149.

Finally, while the Gabreyes Article purported to identify cases from

2005 through 2010, it did not identify when specifically the patients

identified as having copper deficiency caused by the use of zinc-containing

denture adhesives were identified and included in the study. Id. at 149.

This left open the possibility that most or all of the treating physicians may

have diagnosed the use of denture adhesives as the cause of the low copper

levels after 2008, when articles speculating on a possible association

between denture cream and CDM began to appear, including an influential

June 2008 article in Neurology that reviewed four case reports. Global Frye

Motion to Exclude General Causation Expert Testimony, 9/17/2013, Exhibit

37 (S.P. Nations et al., Denture Cream: an unusual source of excess zinc,

leading to hypocupremia and neurologic disease, 71 Neurology 639 (2008)).

As the authors of the Nations article acknowledged, “[w]e speculate that

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the copper deficiency in these four patients was secondary to ingestion of

denture cream.”). Id. at 642 (emphasis added).

For these reasons, we must agree with the trial court’s determination

that Dr. Lautenbach’s Cohort Study is not based upon generally accepted

methodologies. As described herein, the Gabreyes Article did not provide

sufficient data on exposure to the agent of interest (zinc-containing denture

cream) to provide the basis for a retrospective cohort study. To this end, we

do not agree with the Appellants’ contention that the trial court’s criticisms

of the Cohort Study go to its weight rather than to its admissibility. A Frye

analysis requires the trial court to evaluate whether the expert’s

methodologies have general acceptance in the relevant scientific community.

The trial court here properly concluded that Dr. Lautenbach did not apply

generally accepted methodologies, and instead attempted to convert a

limited number of case reports into a retrospective cohort study without

sufficient data to do so. No relief is due.

For their third issue on appeal, the Appellants claim that the trial court

abused its discretion or erred as a matter of law in its ruling that Dr. Askari’s

Fixodent Blockade Study does not provide a methodologically sound basis for

an opinion that the use of Fixodent increases zinc exposure and blocks the

retention of copper in the body. As described in detail hereinabove, in the

Fixodent Blockade Study, twelve participants ingested encapsulated Fixodent

three times a day, six ingest encapsulated zinc acetate three times a day,

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and six ingested an encapsulated placebo three times a day. While there

were no statistically significant differences in copper levels in the blood or

urine of those ingesting Fixodent and those ingesting the placebo, there was

a statistically significant difference between the copper levels in the fecal

excretions of those two groups. From this data, Dr. Askari opined that

Fixodent blocks copper retention and thus causes CDM.

The trial court found that the Fixodent Blockade Study provides no

firm basis for concluding that the ingestion of Fixodent causes CDM. Trial

Court Opinion, 2/7/2014, at 18-19. We agree. At best, Dr. Askari’s analysis

of the results of the testing of fecal excretions establishes that the ingestion

of Fixodent may result in a temporary negative copper balance for a short

time immediately after ingestion, during which the body excretes more

copper than it retains. There is a significant “analytical gap” between a

narrow finding that the ingestion of Fixodent may result in a temporary

negative copper balance in feces excretions and the broad proposition that

the ingestion of zinc-containing Fixodent every day for many years may

result in a copper deficiency in the entire body severe enough to result in

neurologic injuries.

Identifying Fixodent as a cause of a temporary negative copper

balance could potentially be one intermediate step in proving that Fixodent

causes CDM, but it would, at a minimum, also require proof of a

demonstrable link between a temporary negative copper balance and a

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copper deficiency of sufficient severity to cause neurologic injury. Because

Dr. Askari’s Fixodent Blockade Study does not establish any such link, it

cannot serve as the basis for a scientific opinion that the ingestion of

Fixodent causes CDM. Accordingly, we conclude that the trial court did not

abuse its discretion or err in its decision to exclude the Fixodent Blockade

Study on the grounds that it failed to utilize a generally accepted

methodology to opine as to a causal link between Fixodent and CDM.

For their fourth issue on appeal, the Appellants argue that the trial

court erred in granting the Appellees’ motion for summary judgment.

Having concluded hereinabove, however, that the trial court properly

excluded the reports and testimony of the Appellants’ expert witnesses on

causation, the Appellants’ fourth issue on appeal is without merit. The

Appellants do not contest that proof of causation is an element of all of the

causes of action asserted against the Appellees, and contend instead only

that the trial court erred in excluding the testimony and reports of their

general causation witnesses. Appellants’ Brief at 62. Having concluded that

the trial court did not so err, the trial court properly granted summary

judgment in favor of the Appellees.

Orders affirmed.

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Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

Date: 11/12/2015

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