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GuardingYourPracticeThroughProactiveRiskManagement

3/3/2016

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Guarding Your Practice Through Proactive Risk Management

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The Course Disclaimer

The following live presentation is dedicated to the education and scholarship of the dental community. It is intended to provide you with information regarding risk management. Because federal , state and local regulations vary by location and situation, and change over time, none of the information in this course is intended to serve as legal advice or to establish standard(s) of care. Legal advice should be sought from knowledgeable counsel in your state. This course does not modify the terms and conditions of your Fortress Professional Liability Insurance Policy. Please refer to your Fortress Professional Liability Insurance Policy for the aforementioned terms and conditions.

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The Course Objectives• Increase understanding of Risk Management and its importance

• Provide guidance on day to day communication challenges

• Understand the legal and ethical considerations in obtaining informed consent and informed refusal, and avoiding supervised neglect

• Review the basic HIPAA/HITECH regulations and identify risk management principles to reduce potential exposure

• Highlight the essential components of good documentation

• Offer identification strategies for commonly missed oral conditions

• Provide guidance on good risk management practices related to opioid management

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The Course Topics

• Claims Data Overview• Risk Management Overview• Communication• Extractions & Implants• Informed Consent • HIPAA/HITECH• Documentation• Failure to Diagnose • Opioid Management

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Fortress Insurance Company

• A nationwide malpractice insurance company that (is):

– Owned and operated by dentists

– EXCLUSIVELY for dentists

– Offers complementary Risk Management guidance in addition to Risk Management education

• Courses: Live and Web‐based

Here To Serve You

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Common Reasons Patients Sue

• Not happy with results

• Financial incentive

• Criticism from a professional colleague

• Impractical expectations

• Communication issues

• Personality conflicts

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The “Unhappy” Patient

• 78 year old male

• Presented for consultation for dentures

– Promised “top of the line” dentures

• A temporary denture was seated

• Small claim and board complaint were filed

– Allegations: “top of the line” dentures were promised, but temporary (“flimsy”) dentures remained in place for “too long”

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The “Financial Opportunist”


• Crown work was performed

• Patient was not pleased with the “time it took to complete” the crown work

– Was told 4‐6 visits but it took 9 visits

– Not Malpractice: No complaints regarding the care and treatment rendered

• Small claim was filed for a refund of $2,500

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The “Bad Mouthing” Colleague

• 29 year old female

• Needs orthodontics, but wants restorations only

• Veneers and crowns placed at #4‐13– Orthodontics were not done

– Patient had problems with restorations

• Patient sees another dentist – Very critical of the 1st dentist

• Suit filed against the 1st dentist

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The “Great Expectations” Patient


• Seen by a number of different dentists

• Presented for treatment plan for poor dentition– She refused recommendations for extractions, root canals and implants but consented to bridge work

– Wax‐up of bridges were fabricated

• Small claim filed because she “didn’t like wax up”

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The “You Never Told Me” Patient


• Presents with pain and decay of tooth #4

– Root canal therapy performed

• A month later the RCT failed

• Encouraged to have an extraction by an OMS

• Patient requests the dentist pay for the extraction, refund him for the root canal and threatens litigation

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The “Bad” Attitude• 15 year old female• Presented with superficial caries of #30

– Apprehensive about dental treatment and local anesthesia

– Treatment attempted without local – Patient began crying– “Stop acting like a child” – Local anesthetic injected and filling was completed

• A board complaint was filed – Allegations: The dentist became impatient and made inappropriate, rude and disparaging remarks to the patient

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Risk Management: Why?

• Patient safety – Improve the quality of care; Avoid patient injury

• Protection against claims– Reduce exposure to a claim; Mitigate damages

• Create valuable defense tools– Make a claim more defensible; Buffer your defense

• Minimize financial loss – Reduce the monetary impact

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Core Principles of Risk Management

INFORMED CONSENT

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Communication

• Guard Your Practice

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Communication: Setting the Stage

• In‐office

• Phone

• Website

• Word of Mouth

• Online Reviews– Yelp, Facebook, Angie’s List, etc.

Staff Training & Staff Monitoring

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Communication Challenges

• Literacy gap

• Social media

• Online reviews

• Seniors & Minors

• Limited English Proficiency (LEP) & American with Disabilities Act (ADA)

• Miscommunication

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The Literacy Gap

• National Assessment of Adult Literacy:

– 32 million adults in the US cannot read

– 21% of adults in the US read below a 5th grade level

– 19% of high school graduates can’t read

• Leave out the dental jargon

– “cavities” versus “caries”

http://www.statisticbrain.com/number‐of‐american‐adults‐who‐cant‐read/

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Social Media

• Great way to communicate with patients and market to potential patients

• Facebook, Twitter, YouTube, LinkedIn, Instagram, Blogs, Websites, Text Messaging

• Considerations: – HIPAA

– Promises

– Use Professionalism

– Staff

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Online Reviews

• Can be beneficial or harmful to the dentist’s reputation

• Yelp, Angie’s List, Facebook, Google Reviews, Healthgrades, Yahoo, BBB, Your Website

• Considerations: – To Respond or Not To Respond?

• Be PREpared if a response is warranted

– HIPAA

– Monitor your online reputation

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Case Study: Online Review


• Presented for extraction of #1

• Tooth extracted without incident

• Patient is upset with the bill he received in the mail 2 weeks later.

• Creates Facebook page: “Dr _ is a Con”

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Case Study: Online Review

• Facebook page attracts other patients who experienced similar issues

• Patients begin placing comments on wall

Dr. responds to patient’s allegations stating:

“I discussed with you before the appointment what it was going to cost to extract your wisdom tooth. I gave you a discount because you said

you couldn’t afford it.”

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What Can We Learn From This?

• Maintain standards of patient privacy and confidentiality

• Avoid posting identifiable patient information online

• Use privacy settings

• Separate personal and professional content online

• Maintain appropriate doctor/patient boundaries in accordance with professional ethical guidelines

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Seniors & Minors

• The Senior– Medically compromised/Comorbidities

– Polypharmacy

– Consent • Power of Attorney

• The Minor– Compliance

– Consent• Power of Attorney for Minors

• Divorce/Guardianship Challenges

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Case Study: Minor of Divorce


• Presents with rampant decay

• Treatment plan: – Extractions, Endodontics, Restorations and Ortho treatment

• Mother requested and consented to hospital treatment under anesthesia

• The dentist treated the child per the mother’s request

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Case Study: Minor of Divorce

• Dentist was unaware the patient’s parents were divorced

– Per custody agreement: Father was required to pay and consent to treatment

• Father refused to pay

• The case went to court and for several years there was no amicable solution

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• Identify the patient’s legal guardian before you obtain informed consent

• Determine who is financially responsible

• If necessary, require all parties to agree to consent and financial agreements

• Use forms to document this agreement

• Check your state specific and local dental society regulations

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Limited English Proficiency (LEP)

• Must ensure effective communication at NOcost to the patient

• The patient determines if he or she has limited English proficiency

– Read

– Write

– Speak

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LEP Frequently Asked Questions

1. Who decides interpretation is needed?

2. Can an appointment be rescheduled if interpreter is not available?

3. Can the patient be asked to bring in a family member?

4. Do you have to use an interpreter selected by the patient?

5. Who pays for the interpreter?

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American with Disabilities Act (ADA)

• Most prevalent accessibility issues:1. Lack of effective communication

• Complicated and interactive communications may require a Sign Language Interpreter

2. Lack of accessible equipment & services• Health care service, medical equipment and diagnostic tests are accessible to individuals with disabilities

3. Refusal of care• Refusal to treat HIV patients (Bragdon v. Abbott)

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Miscommunication

• The failure to convey relevant dental information to key players in the team

– Dentist to staff/Staff to dentist

• Chain of command, Dental emergencies

– Dentist to referral/Referral to dentist

• No referral document

– Patient to dentist/Dentist to patient

• “The dental shopper(s)”, Medical history omission

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Extractions & Implants

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Dental Extractions: Steps to Success

• Develop an appropriate treatment plan • Manage patient expectations early on

– Communicate the plan and obtain acceptance – Non‐compliance should be discussed and documented

• Use written referrals– Refrain from relying on a layperson’s claim of tooth # or verbal instructions from referrals

• Examine and exercise professional judgment– Be 100% sure which tooth needs to be treated and how

– Avoid wrong tooth extractions

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Wrong Tooth Extractions

• Miscommunication with referring doctors

• Counting errors

• Relying on others to identify which tooth

• Rushing

• Failing to take and/or review x‐rays

• Failing to review referrals

Take Home: SLOW DOWN

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Extractions: Treatment Plan Documentation

• Radiograph(s)

• How many?

– Identify the tooth number

• Any concerns?

– Discussion with the patient (i.e. tooth is impacted)

– Consult with specialist (if applicable)

– Patient’s decision

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Implants: Steps to Success

• Develop an appropriate treatment plan

• Communicate the treatment plan, repeat when necessary and ensure the patient accepts his/her role and responsibilities

• Execute “the plan”

• Document the treatment plan, complications, and compliance

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Implants: Treatment Plan Documentation

• Subjective– Patient desires– Patient complaints

• Objective– Medical history– Physical exam– Imaging– Diagnostic models

• Assessment/Outcome• Plan/Options

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Implants: Pre Op Planning Documentation

• Communication with other team members– Implant company, type, connection

– Respective responsibilities

– Surgical guide

• Implant size– Written in progress notes

– Radiographic documentation of implant size• Traditional imaging (Pano, PA)

• Advanced imaging (CBCT)

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Implants: Imaging

• The purpose of any radiograph is to add useful information and aid in the clinical decision process

• Implant treatment planning can be accomplished with a clinical exam and a plain radiograph (panorex/periapical)

• Cone Beam CT Scans (CBCT) might be indicated and useful in some cases

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Case Study: The Implant


• Extensive medical and surgical history

• Presented for extraction of tooth #31

• Treatment plan:

– Extraction of #31 and subsequent implant placement

• Tooth #31 removed without issues

• 18 months later implants placed at #30 and 31

– Antibiotics were prescribed prophylactically

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Pre – Procedural Panorex

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1 Week Post – Procedure

• Patient disputed implant at #30

– “This was never discussed with me”

• She has continued post‐op pain and swelling

– Antibiotics are changed

• Referred to an OMS

– Patient has submandibular swelling

• Admitted to the hospital for IV antibiotics

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2 Weeks Post ‐ Procedure

• Readmitted to the hospital for submandibular swelling

– I&D performed

– IV antibiotics administered

– Implants were removed

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2 Months Post ‐ Procedure

• Admitted to another hospital for non‐healing implant site

– I&D performed (again)

– IV antibiotics administered (again)

• Patient now has a perforation of the lingual plate near the implant site

– Teeth #28 and 29 were extracted

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Subsequent Treatment

• A resection of the mandible was performed

– After a total of 4 unsuccessful I&Ds

– About 5.5 cm of the mandible was removed

– IV antibiotic treatment continued

• Several months later, mandibular reconstruction was completed using bone graft from the leg

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Litigation

• Suit was filed against the dentist

• Allegations:

– Informed consent was never obtained for the implant surgery – alleged battery

– Perforation of the lingual plate led to the prolonged infection and the need for subsequent surgeries

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Expert Review & Resolution

• Expert review:

– Negative on the issue of informed consent

– Ambiguous on the issue of causation regarding the infection

• Resolution:

– Settled before trial

• Primarily because of the lack of consent issues

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• Document a detailed differential diagnosis/treatment plan for procedural guidance – Another dentist should be able to follow along

• A patient should be well informed before deciding to proceed with treatment

• Refer out early

Lawyers don’t have to prove injury based on “malpractice” if they can prove “battery” related to a lack of informed

consent

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Informed Consent: What is it?

• The PROCESS of communication between a patient and doctor that results in the patient’s authorization or agreement to undergo a specific treatment or procedure

American Medical Association, 1998

• The opposite of Paternalism

– “The doctor knows best” approach

– Eliminates patients’ right to choose

• Violates the patient’s autonomy and self‐determination

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Informed Consent: Why do we need it?

• The Law

• Ethical obligation

• Accomplishes two important goals:

– A tool to develop rapport and trust with each patient

– A tool to confirm the patient’s acceptance of commonly known inherent risks and complications of a procedure selected by the patient

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Informed Consent: The Process

• Informed Consent is a PROCESS

– The Discussion

• Advising the patient and obtaining voluntary, knowledgeable oral consent for a procedure

– The Form

• Obtaining voluntary, knowledgeable written consent for a procedure

– The Documentation

• Recording the process in the health record

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Informed Consent: The COMPLETE Process

• Pre‐procedural• In layman’s terms (6th grade level)• Includes:

– Diagnosis/Prognosis– Procedure/Treatment– Risks, Benefits, & Alternatives (incl. no treatment)– Signatures: patient, witness (if applicable) and doctor

• Give the patient time to review the form • Ensure all questions are answered• Consider other languages, pre‐medications, etc.• Avoid words like “Routine” “Simple” “Guaranteed”

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Case Study: The Extraction

• 40‐year‐old male

• History of pericoronitis surrounding tooth #32

• Presented to the dental office and requested the tooth be extracted

– Deep vertical impaction with part of the crown exposed

– X‐ray did not show the apex of the root

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The Procedure

• Extraction was initiated– After an hour only ½ the tooth was removed

• Patient referred to an OMS and seen immediately– Panorex: Apex of the root millimeters from the inferior border, involving the inferior alveolar canal, fracture

– Pain medication and antibiotics given

– Further treatment delayed to assess potential nerve damage

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Post Procedure• The next day, the patient returned to the OMS complaining of numbness

– The remaining root was removed

– A severed nerve was repaired

– A fracture was reduced

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Litigation

• Patient filed suit

– He never regained full sensation

• When deposed, the dentist conceded a referral out may have been the better option

• Settled before trial

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• Consider your level of comfort and experience

– Procedures can become more difficult than expected

• Refer out early

• Obtain adequate radiographs before treatment

– Make sure you can see what you need to see before you begin treatment

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Case Study: The Implant


• History of thyroid problems

• Presented for implant consultation

• Treatment plan:

– CT scan

– Implant placement at site #13, 14 and 20

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Pre – Procedure CT Scan

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The Procedure

• Implants were placed

• A prescription for Vicodin was given

• Four months later restorative work was done

– 3 unit bridge (12‐14) is seated, adjusted and cemented, and a crown is placed on #20

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Post – Procedure

• Complaints of food getting stuck under 12‐14 and difficulty flossing around 20

– Bite Wings: Implant #20 intersected the root tip of #21

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Post ‐ Procedure

• 1½ months later bridge was redone

– Patient does not like it

• “Still not right… looks like a really fake tooth straight across”

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Post – Procedure

• Four months later, the patient was still unhappy

– Complaints:

• Can’t clean the bridge

• Food gets stuck

• It’s bloody and smelly

– Request for a FULL refund

• A partial refund for possible new bridge was offered

• The patient left to seek a second opinion

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The Second Opinion

• Allegations:

– The bridge was fabricated incorrectly

– #20 implant was placed into the root of #21

• New treatment plan:

–Removal of #21

–Removal of #20 implant

–New implants in the areas of #20 and #21

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Post – Procedure CT Scan

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The Third Opinion

• The patient saw a periodontist – Agreed with the second opinion

• She obtained an attorney– A monetary demand was made but denied

• The subsequent treaters sent consultation reports to the primary dentist in support of the patient– The dentist followed up with a letter to the patient

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The Dentist’s Response to the Patient

“I am sorry you feel my bridge is inferior. I feel it is just fine…”

“I want another Dentist – any Dentist you chose to tell me my Bridge is not right and that he can do better. I want a 2nd opinion if indeed my bridge is inferior –

have him call me and I will pay for it.”

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The Second Letter

“Your lawyer broke protocol by calling my office –twice. Therefore I don’t feel bad about writing you

this letter…”

“…I want you to go to another implant Dentist. If you choose not to – then it’s courts, lawyers, motions

being filed… I have malpractice. My lawyer is paid for.”

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The Outcome

• The patient’s attorney sent the Dentist a letter

– Suggested malpractice and a violation of HIPAA

– A 2nd monetary demand was made

• The case was settled before litigation

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• Listen to the patient… often times if a patient is unhappy they will let you know before they seek legal counsel– This patient had a number of issues she expressed to the office, but she felt as if she was ignored

• Do not engage in a back and forth with a patient in writing– Can be used against you if litigation occurs

– HIPAA violation

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HIPAA & HITECH

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In the News

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What’s a violation?

AIDS

Doe, Jane

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What is HIPAA & HITECH?

• Health Insurance Portability and Accountability Act (HIPAA)– Mandate standards to protect confidentiality of health care information, reduce fraud and abuse and promote smoother transfer of health insurance

• Health Information Technology for Economic and Clinical Health Act (HITECH)– Advances safe and secure use of electronic medical records

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The Health Record Should…

• Be secured

– Take reasonable steps and precautions

• Failed to protect personal information and properly dispose of records containing personal information

• Violated Indiana Privacy Laws and HIPAA

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HIPAA/HITECH “Compliance”

• MANDATORY Security Risk Assessment

– www.healthIT.gov

• Designate a HIPAA Officer

• Train Staff

• Create policies

– Office & Sanction

• Establish: BA Agreements, Encryption, Usernames, Passwords, Screensavers

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HIPAA/HITECH “Compliance”

• Credible document destruction process

• Secure the server

• Secure the wireless network

• Data “backup” restoration – Be PREpared not POSTpared

• Have a plan

HIPAA/HITECH series in the e‐Learning Center

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DOCUMENTATION

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Health Record: The Story

• History

• Exam

• Diagnosis

• Treatment

• Consent

• Follow Up & Progress

Good records tell a story of the care provided

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Charting Basics: History

• Health history form– All pertinent medical/dental conditions (TMJ symptoms)

– Medications (i.e. Aspirin, Plavix, Bisphosphonate)

– Dietary Supplements, Herbals, Vitamins, etc.

– Allergies

– A comment section

– Signatures (including doctor)

• Ensure all questions are answered

• Audit for relevancy routinely

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Sample Health History

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Charting Basics: Exam & Diagnosis

• Exam

– Patient’s subjective remarks (chief complaint)

– Oral exam findings

– Lab results (if applicable)

– Imaging (films, scans)

• Diagnosis

– The differential diagnosis

– Prognosis considerations

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Charting Basics: Treatment

• Treatment Note: – Informed Consent discussion

• Include recommended intervention(s), advice & patient response

– Any changes to treatment plan based on exam

– NPO status (if applicable)

– Use of surgical guide, pre‐medication, etc.

– Medication(s) provided during the treatment

– Complications

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Charting Basics: Follow Up & Progress

• Follow Up & Progress Notes: – The suggested return date

– Referral to specialist(s)• Be specific and clear (include “who” and “why”)

– Clinical correspondence

– Test results & patient notification

– The patient’s status• Don’t forget the good news (“healing well”)

– Patient compliance• Cancellations, No‐shows, etc.

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Electronic Health Records

• Beneficial

• Risks– Templates

– Copy & Paste

– Cyber Issues

• Considerations– “Lock” system

– Backup system daily

– Conduct audits of the system

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REMEMBER:Your best defense in a claim

is your chart notes

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FAILURE TO DIAGNOSE

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Oral Cancer: Incidence & Survival• Over 43,000 people diagnosed with oral cancer in US in 2014– Mouth, oropharynx, lips

• Rates have increased for 8 consecutive years• Every year:

– 30,000 new cases diagnosed – 8,000 deaths

Early detection saves lives5‐year survival for localized disease is 76%

5‐year survival for metastatic disease is 19%National Oral Cancer Foundation

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Oral Cancer: Warning Signs

• Leukoplakia• Erythroplakia• Lump or thickening of oral soft tissue• Soreness or “lump” in throat• Difficulty chewing or swallowing• Ear pain• Difficulty moving jaw or tongue• Hoarseness• Numbness of tongue or mouth• Swelling of the jaw

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Oral Cancer: Suspected?

Regular cancer exams are important• If you note something suspicious, assume it could be cancer unless and until you rule it out

• Refer to specialist for consultation, biopsy or monitoring

• Schedule a return visit in a few weeks to check progress (follow up if the patient is a no show)

• DOCUMENT! DOCUMENT! DOCUMENT!

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Oral Cancer: Documentation

• Note specific symptoms and complaints

• Provide details about the onset– History of onset? Other causes? Treatment?

• Exam findings:– Location, size, characteristics (Pictures)

• Differential Diagnosis (if appropriate)

• Instructions (referral)– What to do? When to return? What to look for?

• When a suspicious lesion is gone

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Case Study: Oral Cancer


• Social history: – Smoking (1/2 pack of cigarettes/day)

– Alcohol use

• Presented for routine prophylaxis/dental care– Treated on a routine basis for 10 years

– Mainly received cleanings by Dental Hygienist

• No references in the chart to indicate any screenings for oral cancer

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The Last Visit

• The patient presented for his routine prophylaxis– He had a large lump on the left side of his neck– When questioned, he said “this will go away, won’t it?”

• Dentist advised that he see a physician immediately– The patient did not have medical insurance

• Follow up calls were made by the dentist– The patient had received public insurance and saw a physician

• The patient did not see this dentist again

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The Diagnosis

• The physician identified a lump the size of an orange on the patient’s neck– Patient said he had problems with his neck for about ten months

• An MRI was ordered and a biopsy was performed– A mass of the patient’s left tonsil (4.5cm) was found– Pathology: Stage IVB squamous cell carcinoma of the left tonsil

• PET scan revealed wide spread metastatic osseous disease of the thorax, lumbar spine, ribs, sternum and pelvis

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The Treatment

• Recommended palliative chemotherapy:

– Erbitus, Carboplatin and Taxol for months

• Chemotherapy was continued and tolerated with some reduction in size of the neck mass

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Litigation

• While undergoing chemotherapy, the patient filed a claim against the dentist

• Allegations:

– Failure to recognize or detect the oral cancer

– Failure to perform & document appropriate oral cancer exams

• During his deposition, the patient admitted that cancer screening had been performed

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Litigation

• The dentist testified at a deposition

–He performed oral cancer screenings regularly

–He advised the patient to stop smoking

–He referred the patient to a periodontist

• No follow through with either recommendation

• No documentation to support his claim

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The Outcome

• The patient expired prior to the trial date

• The medical negligence action was dismissed

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• Document all communications with a patient that pertain to their treatment– Refusal of recommended treatment

– Regular oral cancer screenings and negative findings

– Follow up calls made to “check – in” on the patient (have a procedure in place)

– If necessary, warnings of consequences of not immediately following up with an OMS or MD: call, warn, write, chart…

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• Any suspicious lesion or mass that does not resolve itself in two weeks should be reevaluated and considered for biopsy to obtain a definitive diagnosis

– Identify how long it has been present

– Schedule a return appointment

– If patient no‐shows, document efforts to reach out

– When in doubt… REFER OUT

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Oral Cancer: Contributing Factors

1990 – 2000

• Male : female = 2:1

• Approx. 95% > 40yrs

• Average age at presentation 60 yrs.

• Classic carcinogens were tobacco and alcohol

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Oral Cancer: Contributing Factors

Present:

• Significant increase in the incidence of SCC of the tongue, base of tongue, and tonsils in white patients between 20‐44 years of age

“New” Carcinogens:

• Marijuana (debatable)

• Human Papillomavirus (HPV)Shiboski CH, Schmidt BL, Jordan RCK: Tongue and tonsil carcinoma.

Increasing trends in the US population ages 20‐44 years.Cancer 103: 1843‐1849, 2005.

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Oral Cancer: “New” Carcinogens

80% of women are HPV+ by the age of 5050% of American males are HPV+

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Oral Cancer: Conclusions

• No longer exclusively a disease of elderly men who smoke cigarettes and drink alcohol excessively– HPV associated oral cancers largely occur among nonsmokers and nondrinkers

• Classic carcinogens still represent a neoplastic threat

• HPV explains the etiology of some oral cancers and many oropharyngeal cancers

Gillison ML, D’Souza G, Westra W et al: Distinct risk factor profiles for human papillomavirus type 16‐positive and human papillomavirus type 16‐negative head and neck cancers. J Natl Cancer Inst 100: 407‐420, 2008.

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Prevalence of Gum Disease in the US

Gum Disease47%

Health Periodontium

53%

CDC Report

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Periodontal Disease: Steps to Success

• Assess patient risk factors

• Develop office protocol for screening for periodontal disease

• Regularly update patient radiographs to assist in diagnosis

• Document patient non compliance

• Refer to specialists when necessary

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Case Study: Periodontal Disease


• Dental history includes extraction of 4 wisdom teeth, 4 bicuspids (orthodontic treatment plan) and tooth #18

• Patient presented for routine exams and cleanings– Moderate to severe recession observed on the lingual side of the maxillary arch

• Periodontal charting not done

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The Visits

• Two years after initial presentation

– Patient was referred to a periodontist for “implant consult”

• The patient did not see the periodontist

• Over the next 3 years the patient presented regularly for exams and cleanings

– “great OH”; “flosses daily and wears NG faithfully”

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The “Problem”

• On one visit the patient presented for a limited evaluation of his mandibular anterior teeth

– One of his lower front teeth became “loose” after biting a carrot

– An x‐ray showed bone loss on teeth #22‐26

– He was referred to a periodontist

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The Periapical Radiograph

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The Periodontist Treatment Plan

Thank you for referring [name] to our practice to evaluate his overall periodontal condition. With your permission, I have recommended the following treatment:

Phase 1: ‐Osseous Surgery UR and LRPhase 2:‐Osseous Surgery UL and LL

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The Next Visit

• When the patient presented back to the dentist, he had a cleaning and perio charting

– This was the first time perio charting was performed

– Probe depths: 2‐6mm

– This was the last visit to this dentist

• The patient opted to have a second periodontist opinion

– He discontinued treatment with the 1st periodontist as well

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The Subsequent Periodontist• The findings:

– Periodontal disease

– Some pockets over 7mm

• Pocket depths in excess of 9mm at the lower anterior

– Recession at #3 (2mm), 4 (3mm), 14 (3mm), 15 (3mm), 20 (3mm), 28 (3mm), 30 (2mm) & 31 (2mm)

– Bone loss in all four quadrants

• Recommended osseous surgery in all 4 quads

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Litigation

• The allegations:

– Although patient had routine dental care over a number of years…

• He had progressive periodontal disease over that time, but was never informed about it

• No periodontal screening was performed before referral to a periodontist

• Surgery on all four quadrants was required to treat the disease

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The Outcome

• The patient had the surgery and #22‐27 were splinted.

• He had several follow up visits and two years later his pocket depths were 3‐4mm

• The case was settled before trial

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• Refer early and follow up with the referral and the patient

• Document! Document! Document!

– In this case, the dentist alleges he had multiple conversations with the patient advising he see a periodontist, but none of them are documented

– “If it wasn’t documented… It was never done”

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Supervised Neglect

ADA Ethical Code: Beneficence:

“The dentist has a duty to promote the patient's welfare... The most important aspect of this

obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs,

desires and values of the patient…”

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Informed Refusal

• Patients have a right to refuse treatment

• Patients have a right to change their mind about treatment

– Even if in the middle of treatment

• The patient MUST have capacity to refuse treatment

• Refusal of treatment requires the same type of “informed” discussion

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Informed Refusal Process

• Similar process to Informed Consent

– Who can make the refusal?

– What information should be provided?

– What should you document?

• Use a formal Informed Refusal Form

• Have the patient/representative sign the form

• Document the refusal and reason

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OPIOID MANAGEMENT

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Prescribers of Immediate Release Opioids

12%

15%

12%

10%8%6%4%

3%

30%

Dentists

Family Practice

Internal Medicine

Orthopedic Surgery

Osteopathic Medicine

Emergency Medicine

General Surgery

OB/Gynecology

All Others

IMS Institute for Healthcare Informatics

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Screening for Potential Drug Abuse

• Incorporate screening process into routine practice

• Develop a referral network

• Watch for signs and symptoms of substance use disorders

• Use Prescription Drug Monitoring Programs

• Involve responsible family members and PCPs

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Opioid Considerations

• Follow responsible and tailored prescribing practices

• Secure all prescription pads when not in use

• Consider alternative medications

• Discuss the patient’s substance use history when referring the patient for specialized dental surgery

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Case Study: The Recovering Addict


• Recovering heroin addict but said he was “clean”

• Extraction of #24 and #25

• Prescribed 15 tablets of Vicodin 5/500mg with 1 refill

• Outcome: Patient died 16 days later from a heroin overdose. Claim is filed. Family alleges the reintroduction of opioid medications caused relapse

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• Prescribe with caution

• Educate patients on safe disposal of unused medication

• Involve responsible family members and PCP’s when appropriate

• Consider available resources when patient abuse is suspected

– Treatment Referral Hotline: 1‐800‐662‐HELP

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Case Study: The Codependent Dentist

• Dentist routinely prescribes “family friend” Vicodin unnecessarily

• Patient is recovering addict; dentist struggles too

– Prescriptions split between patient and dentist

• Outcome: Dentist arrested and a claim was filed by the patient’s family alleging he was responsible for the patient’s relapse

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• Monitor supplies and employee access

• Seek help for you and others

• Prescriptions you write are monitored

• Writing prescriptions outside the scope of treatment is illegal, even if your intentions are good

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Recognizing Drug‐Impaired Co Workers

• Excessive amounts of time spent near a drug supply

• Heavy “wastage” of drugs

• Sloppy recordkeeping, suspect ledger entries and drug shortages

• Inappropriate prescriptions for large narcotic doses

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FORTRESS ONLINE RISK MANAGEMENT RESOURCES

Staff & OthersRegister with “Guest User Registration”

www.dds4dds.com

PolicyholdersUser ID: Policy number

(begins with 3)

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QUESTIONS?

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