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In this series, CDSBC's staff dentists share their tips and observations to help you improve your everyday dental practice, hone your professional judgment, and deal with some of the unique challenges that practitioners face.

These practice tips are provided for general guidance only. As always, it is up to you as the practitioner to determine whether the information is appropriate to your situation. 

Meet the dentists behind the tips >>

Read the latest practice tip below or scroll down to browse previous tips. If you have questions about any of the tips, please contact us.

Tip #15: What's that clicking sound?

Considerations for management of TMD

Some recent complaint investigations have reinforced the need for careful evaluation of the temporomandibular joint (TMJ) complex.


​A male patient presented for a specific exam with an acutely painful non-restorable tooth. To provide immediate resolution of the patient’s pain, the dentist extracted the tooth during the same appointment. The patient complained when he developed symptoms of temporomandibular disorder (TMD) following the procedure. Unfortunately, because there had been no pre-op assessment of the muscles or joints it was impossible to determine if there was a pre-existing condition, and if so, the nature of the pre-existing pathology.

​Another patient complained when she developed symptoms following extensive prosthodontic treatment provided during a four-hour appointment. This raised the question of whether it was an acute exacerbation of a chronic condition or an acute episode resulting from new or undiagnosed pathology.

​A number of other complaints have also reported exacerbation of existing symptoms following treatment with orthotic appliances. Upon review, these cases raised the following questions:

• What was the differential diagnosis?
• Was an orthotic actually indicated for this patient?
• What factors were considered before deciding on the type of orthotic?
• What follow-up care was planned and provided?
• What other treatments were considered as alternatives or as adjunctive therapy?

​In one very sobering case, a 24-year-old patient presented with severe left-sided jaw pain, associated trismus and a palpable lump in the area of her left masseter muscle. The prescribed panoramic radiograph did not include the left TMJ and a portion of the left ramus and body of the mandible in the field of view. The radiograph was not repeated. The patient was treated with an orthotic to address her joint symptoms and reassessed over the following few months.

A second opinion determined that the appearance of a large irregular radiolucency in the ramus of her mandible and the palpable lump were signs and symptoms of an osteogenic sarcoma, misdiagnosed as TMD. In this case treatment with an orthotic was contraindicated and immediate referral for management of her suspected and potentially life-threatening tumour was indicated.


These cases serve as reminders for all of us as practitioners that any examination needs to be comprehensive, followed by development of a differential diagnosis and a treatment plan based on solid clinical and radiographic findings.

  • Always consider evidence-based conservative treatment first
  • An orthotic is not a panacea
  • Consider that chronic pain management is often indicated
  • Always carefully consider a differential diagnosis

Pre-treatment assessment

While all practitioners know that any treatment may exacerbate symptoms, it is difficult to defend the diagnosis and the subsequent treatment provided when there is an inadequate or non-existent pre-treatment assessment.

Dentists are expected to provide a pre-treatment comprehensive TMJ and muscle assessment and document any pre-existing condition. Not only does it provide the best opportunity for an accurate diagnosis and treatment plan, it also ensures optimum care will be provided. This approach protects both the patient and the practitioner.

A TMJ and muscle assessment should be a part of any routine new patient examination, before any treatment is provided, and has particular significance for surgical extractions, long appointments and orthotic (splint) therapy. If a patient experiences an acute episode of TMD without being presented with the facts before treatment, it becomes difficult to explain, defend or establish that there was a pre-existing condition. The patient will often conclude that the dentist is at fault.

An appropriate initial examination or pre-operative assessment includes:

  • A review of the past medical and dental history, including a discussion regarding parafunction, namely clenching, bruxing, tongue thrusting, nail biting, pain associated with the TMJs, joint sounds or episodes of locking and/or pain associated with the muscles of the jaw, head and neck.
    • If the record clearly documents the specific details of a pre-existing musculoskeletal condition, such as TMD, it can help to explain the significance or progression of any changes that may occur following treatment.
  • Palpation of the TMJs – pain should be rated and recorded as mild, moderate or severe.
  • Palpation of all the muscles of mastication (e.g. masseter and temporalis muscles) – pain should be rated and recorded as above.
  • Assessment of TMJ sounds – e.g. clicking, popping, crepitation, which may be noted as fine or coarse.
  • Maximum range of motion – measured from the maxillary to the mandibular incisal edge, most accurately with a millimeter ruler. Note if this is with or without associated joint sounds.
  • Opening pattern – e.g. straight, deflections to left or right, corrected deviation to left or right.
  • Lateral excursions – with or without associated joint sounds and/or limitation of movement.

An incorrect diagnosis, resulting in the wrong treatment being prescribed, may cause significant and irreversible harm to the patient. Patients cannot provide full and informed consent without a discussion of the benefits as well as the risks of any treatment. The corollary of this statement is that a dentist has a much weaker defense in the absence of this information.

Remember, in the patient’s mind: before treatment any discussion is an explanation, following treatment it is an excuse.

A note about orthotics: When it is determined an orthotic is the optimum treatment option, appropriate follow-up appointment(s) are a critical component of the treatment. Confirming the adequacy of the working impression for fabrication of the orthotic and follow-up adjustments of intraoral orthotics are the responsibility of the dentist alone. They may not be delegated to your staff, CDAs or dental hygienists.

Inform the patient

When the record clearly documents the specific details of a pre-existing musculoskeletal condition, such as TMD, it can help to explain the significance or progression of any changes that may occur following treatment.

It is important to advise the patient of any pre-existing degenerative or pathological changes diagnosed during the pre-treatment clinical examination and any risks of the proposed treatment. Without this information the patient cannot provide legitimate informed consent to proceed with the recommended treatment. 

When significant joint pathology is identified, consider the wisdom of a referral, before providing any treatment.

From the desk of Dr. Meredith Moores (

Posted 16 August 2017

Tip #14: Pick up that probe

A number of recent complaints have emphasized the absolute necessity for periodontal probing as a routine component of a diagnostic workup.

In one case, without benefit of periodontal probing, the dentist replaced a crown for a symptomatic tooth. There was significant expense to the patient. When the patient returned within two months with no resolution of their symptoms, periodontal probing revealed the presence of a 9mm isolated plunging mesio-lingual pocket. Comparison of pre- and post-treatment radiographs confirmed the radiographic appearance of a pre-existing periodontal defect. The mesio-lingual root was confirmed fractured and the tooth extracted. The patient was understandably angry when she realized the treatment was based on an erroneous diagnosis.

In another case, a dentist provided a “prescription” treatment when she placed four maxillary anterior implants for a patient who was a patient of record in another practice to which she returned after the surgical phase of treatment. She did not provide a pre-operative comprehensive examination and did not assess the patient’s periodontal status. The patient suffered from poorly controlled moderate periodontitis. Within a two-to-three-year period all four implants were lost as a result of severe peri-implantitis and the associated bone loss. The patient suffered a serious clinical failure and significant financial loss. A full periodontal assessment would have contraindicated the treatment provided which would have protected both the patient and the dentist from such a negative outcome.

Periodontal probing is an imperative component of clinical practice. It is an important component of case selection. Not only is it indispensable as a diagnostic tool, it is an important measure of therapeutic efficacy.

Meticulous, evidence-based diagnoses, based on all the available information, will protect you and your patients from poor decisions leading to avoidable clinical failures.

The expectation of the College is that documentation of periodontal probing is included in all patient records as well as in comprehensive or new patient examinations.

From the desk of Dr. Meredith Moores (

Posted 3 April 2017

Tip #13: You are unique – and so is every other dentist

Just a reminder regarding the intent of your CDAnet agreement, which identifies you as an individual practitioner. Our objective is to help you avoid a possible complaint or an insurance audit.

When your administrative staff submit insurance claims on your behalf, it is your CDAnet unique identification number (UIN) which identifies you as the treating dentist. Your College registration number is a part of your UIN.

It's important that your administrative staff fully understand and meet these requirements, because you don't want to be in violation of the CDAnet agreement.

When a partner, locum or associate dentist is providing the treatment, the claim needs to be submitted under their own UIN.

This information is also helpful in avoiding confusion when submitting pre-authorizations. They should always be submitted using the UIN of the intended provider. When the intended provider changes, for any reason, the pre-authorization needs to be resubmitted using the correct provider name and their own UIN.

Unless specified differently in a principal/associate or principal/locum agreement, treatment provided by hygienists and procedures delegated to a certified dental assistant should be billed using the principal's UIN. The exceptions are the hygiene examination and interpretation of radiographs, which should be submitted under the UIN of the dentist provider.

Problems may arise when treatment is provided by more than one dentist in the same practice if all the treatment provided is submitted under the principal's UIN. This will inflate the individual dentist's billings and may lead to an insurance audit.

A new staff member joining the team provides an excellent opportunity to remind everyone in the practice about these requirements.

It may be useful to know the following:  It takes up to three business days for the UIN to be communicated to the office and the insurance companies following receipt of an application. A manual submission, without a UIN, is permissible during that time.

Thanks to Dr. Tim Gould and Ms. Angela McGowan from the BC Dental Association for their editorial expertise. For additional insurance audit tips, check the Fall 2015 issue of BCDA's BRIDGE publication.

Related resources: Subscription Agreement to CDAnet (PDF)

From the desk of Dr. Meredith Moores (

Posted 23 November 2016

Tip #12: The treatment plan trap: how to protect yourself

Dentists beware!  Here’s what to do when asked to provide treatment prescribed by another practitioner.

First, carefully consider every aspect of the proposed treatment plan. Review the records including the diagnostic tests, the radiographs and models. Are they current? Are they reproducible?

Then, base the treatment you provide on your own verifiable clinical diagnosis.

Remember, once you initiate treatment, you alone assume the responsibility for:

  • the clinical examination
  • ensuring all appropriate diagnostic tests have been carried out to support the diagnosis
  • the diagnosis
  • obtaining informed consent
  • the provision of effective treatment

You were trained as a professional. Preserve your professional autonomy.

From the desk of Dr. Meredith Moores (

Posted 22 September 2016

Tip #11: Things you need to know when switching to electronic records

Many dentists have been turning to digital solutions for recordkeeping, given the benefits of cost savings and ease in transferring records. CDSBC's Dental Recordkeeping Guidelines apply to both electronic and traditional records. While the rules are the same when it comes to requirements such as confidentiality, sharing and retrieval, and the safe disposal of records, electronic recordkeeping does present some unique concerns. In this tip, I'll address two of the most common questions I receive from dentists who are considering moving to electronic recordkeeping.

Do I have to keep my physical records?

The quick answer is no. That's one of the main benefits of moving to electronic records: you can securely dispose of physical files that may be taking up prime office space or that have become expensive to store. You can confidently dispose of physical records so long as your electronic recordkeeping system meets CDSBC's Dental Recordkeeping Guidelines.

As mentioned in a previous tip, diagnostic or study models are considered part of the permanent patient record. Any models or other records that cannot be stored electronically must be kept in their original form for the duration of the required retention period.

How do I get a digital signature?

Dentists are often concerned about how to handle signatures in a digital recordkeeping environment. Here are a couple of options to ensure that patient documents such as consent forms, medical histories, and treatment plans are appropriately signed:

  1. The popular method in a paperless dental office is to use a digital signature pad or touch screen monitor to get an electronic signature much like you would with pen and paper. There are a variety of practice management systems that allow patients to complete forms on a computer or tablet and digitally sign them using a signature pad or touch screen. The completed form is then connected to the patient's electronic records.
  2. Another option is to print the document, review it with the patient, and have them sign it. The signed printed copy can then be scanned into your computer system.

A final note

As with traditional paper recordkeeping, the dentist is responsible for the accuracy and completeness of his/her electronic records. I recommend setting aside time to review the day's records before leaving the office.

Do you have any other questions about transferring to digital recordkeeping? CDSBC's Dental Recordkeeping Guidelines is an excellent resource where you can find more information, and you can contact me with your questions using the address below.

From the desk of Dr. Garry Sutton (

Posted 30 August 2016

Tip #10: Take a team approach to infection prevention and control

Effective infection prevention and control are top of mind for a lot of the dentists I speak with. In fact, just recently I received a call from a dentist asking about using a particular model of dishwasher to debride instruments. The question highlights one of the exciting things about dentistry – that there are many ways to ensure guidelines are met, and that the choice in how to do so is up to you.

The answer to questions like the one mentioned earlier lies in whether or not the approach follows CDSBC's Infection Prevention and Control (IPAC) Guidelines. Dentists have an obligation to maintain the profession's standards of practice and, accordingly, they must ensure that the recommended IPAC procedures are carried out in their office.

To this end, it is every dentist in the office's responsibility to ensure that staff are adequately trained in IPAC procedures and that the necessary supplies and equipment are available, fully operational, up-to-date and routinely monitored for efficacy.

Infection prevention and control training should include:

  • all members of office staff
  • office-specific training for providers as part of their initial orientation
  • updates upon the introduction of new treatment techniques and equipment
  • training for exposure risks relating to specific treatment modalities
  • training for exposure risks relating to management of work related injuries (e.g. needle stick)
  • supplementary training when necessary
  • updates at least once a year during staff meetings or through educational courses and self-learning programs 

Keeping the IPAC guidelines posted in the office and advising staff to seek appropriate immunization can further the safety of staff and patients. If delegating infection control to a less experienced or non-certified staff member, dentists must ensure compliance with the College guidelines for protection of staff and patients alike.

It is important to remember that, in addition to his or her professional obligations, dentists also have an ethical duty to maintain a safe and healthy office environment for both patients and staff.  

The guidelines inform dental health care providers on how to properly implement and follow necessary infection control measures in a safe and effective manner. Download CDSBC's Infection Prevention and Control Guidelines & Wall Poster.

From the desk of Dr. Chris Hacker (

Posted 21 July 2016

Tip #9: VELscope®: It can't think for you

The VELscope can act as an aid to identify potential oral mucosal diseases including oral cancer; however, the following must be considered:

  • Every patient and practitioner should clearly understand that VELscope screening is not a standalone diagnostic tool. It assists in the identification and potential diagnosis of an oral mucosal disease, but does not provide a definitive diagnosis.
  • A thorough history, extraoral head and neck examination and intraoral soft tissue examination are essential components of the assessment prior to the use of the VELscope.
  • The head, neck and soft tissue examination should be completed every six months for regular hygiene patients or on presentation to your practice for the occasional patient who is not assessed frequently. 
  • The responsibility to provide VELscope screening lies solely with the dentist. 
  • VELscope screening should be provided in low ambient light.
  • When you suspect the etiology of an identified lesion may be traumatic, infectious or inflammatory based on the history and the clinical examination, a 2 to 3 week follow-up assessment is indicated. If healing is not evident at that time a referral to a specialist is indicated.
  • If a suspicious lesion is identified with the VELscope a management plan needs to be developed including:
    • Toluidine blue staining, which may provide further clinical information.
    • A biopsy, in the case of a practitioner who is competent in this area of practice. In the event of a positive biopsy result, immediate referral is indicated.
    • Referral to an experienced community practitioner, either medical or dental, who will provide a comprehensive evaluation and establish a definitive diagnosis and management plan.

Note: A biopsy may identify cellular changes other than malignancy, such as severe epithelial dysplasia, a precursor to oral cancer, which can provide the opportunity for early intervention. The biopsy result provides the only definitive diagnosis of oral cancer.

Billing: The appropriate code in the BCDA fee guide is 04403 and is listed under Direct Fluorescence Visualization. No other code may be used for the purposes of VELscope screening.

Please refer to CDSBC’s Guideline for the Early Detection of Oral Cancer (PDF) for in depth details.

From the desk of Dr. Meredith Moores (

Posted 29 June 2016

Tip #8: Transfer of records

When a patient is transferring between practices and consents to the transfer of their records, the appropriate protocol is to transfer a copy of the complete patient file including:

  • The complete documentary record, including financial statements, referrals and specialty reports
  • All radiographs
  • Models

This enables a comprehensive review of the patient history and ensures the opportunity to provide continuity of care.

For more details regarding transfer of records, please refer to the relevant section in CDSBC's Dental Recordkeeping Guidelines (PDF).

From the desk of Dr. Meredith Moores (

Posted 12 May 2016

Tip #7: CDA certification and misdelegation of duties

Two recent complaints received by the College raised the issue of non-certified (chairside) dental assistants being employed as certified dental assistants. This places the dentist at risk of misdelegation of duties.

In one case an assistant had completed an accredited dental assisting program in July 2014 and passed the NDAEB exam. She assumed she was automatically certified as a certified dental assistant (CDA). She was hired by a dentist who, based on her resume and interview, also presumed she was a CDA certified with the College. The dentist and the assistant confirmed she had been providing the services of a CDA for the past year. Although the dentist had checked the “lapsed certification” list for CDAs, she was not on it as she had never been certified.

In the second case, an assistant contacted the College to ask a question about CE credits, and was told she was not certified with the College. She confirmed she had provided the services of a CDA over the past year. She had been hired by the dentist after she had completed her assisting program and the dentist understood she was waiting for her certification documentation to arrive. The dentist did not follow-up on her certification status, and had misdelegated services to her.

Dentists must ensure their employees who are hired as CDAs have the proper qualifications to perform the appropriate duties of a CDA and are certified with the College. Use CDSBC’s online Registrant Lookup to check the certification status of all prospective CDA employees before hiring. Dentists should also check their CDA's status following annual renewal or call CDSBC to confirm certification.

From the desk of Dr. Sigrid Coil (

Posted 29 April 2016

Tip #6: Patients with cognitive decline

Patients with cognitive decline need to be clearly identified either through direct communication with the front desk, clinical staff and/or following a review of the medical history.

I have recently come across several incidents that emphasize the importance of communication between front office and clinical staff. 

In one case, a patient with cognitive decline was scheduled for oral hygiene by their son or daughter, who informed the front desk that all communication should be through them. The son or daughter brought the patient to the appointment and reminded the front desk about their prior phone call regarding decision making. 

The patient presented for what they thought was a routine cleaning, and came across as jovial and communicative. The dentist performed a complete examination as well as oral hygiene, and the patient information and medical history forms were completed/signed by the patient. Unfortunately, the front desk did not communicate to clinical staff that communication and decision making regarding diagnosis and treatment planning was to be a joint decision with other family members.

The dentist presented treatment options to the patient, who then met with the treatment coordinator to review the options (and associated fees). When they realized what happened, the family was upset that these discussions were done without the appropriate family members being present.


  • Front office staff communication with the patient or caregiver can provide vital information as to why the patient is seeking dental care.
  • When front office staff are dealing with adult children to schedule appointments for a parent with cognitive decline, this may be a good opportunity to politely ask if they are to be present for treatment decisions or if the patient is making decisions on their own.
  • The front office staff should document special considerations or requests in the chart.
  • Clinical staff should review the medical history. When issues related to cognitive decline are recorded, further review and questioning is appropriate to ensure proper care.

From the desk of Dr. Sujay Mehta
(Dr. Sujay Mehta was a CDSBC Complaint Investigator from 2015-16.)

Posted 14 April 2016 

Tip #5: Opioid prescribing

It is recognized that over-prescribing of opioid pharmaceuticals by health care professionals is a problem. For more information on the pharmaceutical opioid crisis in B.C., read the 2015 report Together, we can do this: Strategies to address British Columbia’s Prescription Opioid Crisis (a plain language summary of the report is also available here).

Experts in the medical community support the following guidelines

Before prescribing controlled prescription drugs please give consideration to the following questions:

  • Is there a reasonable non-narcotic alternative?
  • Is there evidence of drug-seeking behaviour?
  • What is the minimum dose and number of the medication necessary to provide pain control for the immediate post-operative period of a few days?

If there is a concern the patient may have been prescribed narcotics by another practitioner or may be exhibiting drug seeking behaviour, consultation with the pharmacist and/or medical practitioner is strongly advised.

From the desk of Dr. Meredith Moores (

Posted 7 April 2016

Tip #4: Charging patients for missed appointments

The College frequently fields calls from angry patients who have been charged a missed appointment fee.

If you decide to charge for missed appointments consider the following:

  • Are patients always advised of the policy and the cost to them?
  • Are all staff aware of the policy?
  • Did your staff first seek an explanation from the patient for their absence?
  • Do you wish to retain the patient and their partner/family?
  • What is your policy goal?

If your objective is to reduce short-notice cancellations you might consider speaking to the patient to find a mutually satisfactory solution. For example, placing them on a short notice cancellation list, or the first or last appointment of the day. If you wish to dismiss the patient from the practice, please consult CDSBC’s information sheet: Dismissing a Patient – Practical and Ethical Concerns (PDF).

From the desk of Dr. Garry Sutton (

Posted 19 February 2016

Tip #3: The importance of continuity of care

Several patient complaints related to principal-associate communication have recently come across the CDSBC complaints desk.

In one case, a patient was examined and treatment planned with the dentist who owned the practice. The same patient was then scheduled for treatment with the associate dentist. The associate met the patient for the first time on the day of the treatment. During treatment, the associate realized that the caries on severely periodontally impacted teeth was much more extensive than suggested on the original treatment plan. The associate altered the plan with the patient’s verbal consent; however, the patient later became upset when they realized the cost difference between the original plan and the updated plan.

Although the owner provided the original treatment plan, the treating dentist should have reviewed the chart, radiographs and treatment plan prior to seeing the patient to ensure they agreed with the plan. The treating dentist is ultimately responsible for the diagnosis and treatment plan.


Proper communication between dentists in the office is critically important.   

  • Consider weekly staff meetings to discuss treatment plans of patients that may be switching dentists. Having an opportunity for dentists to discuss complex treatment plans and review treatment options can be helpful in minimizing problems, surprises and complication – and in the long run may help the practice by preventing patient concerns and complaints. 
  • The dentist who owns the practice should keep in mind that open communication between the treating dentists in the office improves patient care.
  • Associates should understand that the treating dentist is responsible for the diagnosis and treatment plan. If you are treating from another dentist’s treatment plan, you should review the patient chart and radiographs before the treatment appointment, and you are responsible for reviewing the costs associated with any changes in the treatment plan.

From the desk of Dr. Sujay Mehta
(Dr. Sujay Mehta was a CDSBC Complaint Investigator from 2015-16.)

Posted 19 February 2016

Tip #2: Case Classification System for endodontics

Before you progress…assess and eliminate stress

Many factors can influence the degree of difficulty and the risks of endodontic therapy. Pre treatment assessment of these factors will enhance your clinical judgment.

The Canadian Academy of Endodontics (CAE) has created a useful diagnostic tool for endodontics. Their Case Classification System Form guides you to record your findings and evaluate the level of difficulty and degree of risk for each case prior to initiating treatment.

The form assigns a level of risk (average, high, or very high) to various factors that are categorized into three areas: patient considerations, tooth considerations, and additional factors.

Assessment example

The pre-treatment radiograph below shows a tooth (3.6) with factors that indicate it would be a higher risk to treat.

 Assessment using the Case Classification System Form:

  • There is a crown present = very high risk
  • The tooth has 3+ canals = very high risk
  • The tooth is a 1st/2nd molar = high risk
  • The tooth has reduced visibility of the canal to the apex = high risk
  • Isolation of the tooth during treatment = high risk

Restorability of the tooth should also be considered before treatment. Assigning risk factors helps you to determine the predictability of the endodontic treatment, and the decision to provide the treatment yourself or to refer the patient should become clear (if in doubt, refer). The treatment outcome for this example can be seen in the post-treatment radiograph below. Note that the radiograph shows an untreated distal canal, indicating that all the risk factors noted above may not have been addressed by the treating dentist.

From the desk of Dr. Sigrid Coil (

Posted 15 January 2016

*This form was extracted from Section II of the CAE Standards of Practice:  

Tip #1: The disappearing molar

Review and compare, the answer could be there!

Develop a habit of carefully comparing previous radiographs with
the current images. You may be amazed by what you find.

Take, for example, the radiographs below. In the second radiograph,
where did tooth number 4.8 go? Hint: it was not extracted.


There can be significant tooth movement as a result of an expanding tumor or cyst. Like the canary in a coal mine alerts the miners to impending danger, this may alert you to a lesion with a potentially serious outcome for your patient. In the case above, the patient complained of lower right symptoms over many years.

In the words of a seasoned medical radiologist: “Being smart is good, but having old radiographs is better”.

From the desk of Dr. Meredith Moores (

Posted 30 November 2015

* These practice tips are provided for general guidance only. As always, it is up to you as the practitioner to determine whether the information is appropriate to your situation. 



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