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 Practice Tips from the desk of our dentists

 

In this series, CDSBC's staff dentists share their tips and observations to help you improve
your everyday dental practice.

Practice tips are intended to increase awareness of best practice suggestions regarding
specific issues which have come to our attention through the complaint process.

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. 

If you have questions about any of the tips, please contact us.

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Oct 10
Questions from a grieving wife

We can make a difference in the early detection of oral cancer

grieving wifeAll patients, whether they are aware of it or not, arrive in our practices with the expectation of a thorough and complete assessment that informs a definitive diagnosis. Accordingly, dentists have a unique opportunity to positively impact the early detection of suspicious oral lesions which may prove to be oral cancer.

Today I had a difficult conversation with a woman whose husband recently died following a diagnosis of oral cancer. She said their dentist didn't act definitively when an oral mucosal lesion present over a period of some years failed to heal. The patient's wife told me that when he asked their dentist about it he was told "just keep doing what you're doing".

His wife described watching her husband of 49 years suffer as the very late and difficult treatment failed.  He became unable to talk, eat or even swallow without excruciating pain.  She said he dealt with pain, stress, and ultimately, death, with dignity and grace.  Her conclusion was this: "Negligence caused my husband's death."

It is common for patients to blame their dentists when they experience a poor treatment outcome. As complaint investigators we know this does not necessarily mean the dentist did not meet the expected standard. However, the question is always the same: was everything done that should have been done, and in a timely manner?

In this case, the patient's wife wanted answers:

  • Aren't dentists taught to examine the mouth to detect anything abnormal?
  • Don't dentists worry if something doesn't heal?
  • Aren't dentists trained to know when to refer patients if they are concerned something is wrong, or they don't know what it might be or what they should do?

Dentists have a unique and sobering responsibility with respect to early detection. This responsibility is shared with our medical colleagues; however, their training understandably does not place the same emphasis on oral mucosal disease compared to dental training in this area.

Specialists in oral medicine, oral surgery, ear, nose and throat (ENT) and head and neck surgery have particular expertise in this area and frequently examine the patient and provide a biopsy only following a referral from a general dental practitioner. During the course of College investigations, medical and dental specialists have commented that they are seeing patients far too late.

General practitioners are extremely important members of a larger team, all of whom share the same commitment to early detection, resulting in early treatment and best possible outcomes.

The following suggestions are designed to help you serve the best interests of your patients in the early detection of oral cancer:

  1. Never underestimate the critical importance of a careful extraoral and soft tissue examination. Expect the unexpected. Maintain the rigor and attention we were taught to bring to this during our training. Never give it up.

  2. Document, document, document! Record any unusual finding with a description, appropriate measurements, and photographs.

  3. Compare your clinical findings at frequent intervals and don't wait to react to troubling findings, such as progression or poor healing.

  4. Think outside the box: it's not always about teeth or periodontal disease. Consider the possibility of oral mucosal diseases, including oral cancer.

  5. Remember that only a biopsy provides the information necessary to establish a definitive diagnosis.

  6. Refer early, particularly if you are not proficient in providing a biopsy or if there is the slightest doubt in your mind about what you are seeing. If something does not seem right, or you can't explain it to yourself or the patient, get help. Trust your gut. It's okay to tell the patient you are not sure and that another opinion is indicated.

  7. Be prepared for patients to resist referrals or biopsies. Be sure the patient understands your concerns and the reasons for the management you are strongly recommending. Any refusal should be clearly documented in the record.

  8. Present your clinical findings to the patient with confidence. Emphasize the importance of establishing a definitive diagnosis.

  9. Consider sharing your findings and concerns with the patient's family doctor and any other medical or dental specialists also involved in the patient's care.


Remember: general practitioners are important members of a larger team, all of whom share a commitment to early detection, early treatment and best possible outcomes.

From the desk of Dr. Meredith Moores (mmoores@cdsbc.org)

Dr. Moores was a member of the Early Detection of Oral Cancer Working Group that created the Clinical Practice Guideline for the Early Detection of Oral Cancer with the BC Cancer Agency. For guidance about the appropriate use of oral cancer screening techniques to help dentists make informed decisions about screening for oral cancer, please refer to the guideline.

Aug 16
​​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.

​Cases

​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.


Lessons

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 (mmoores@cdsbc.org)

Apr 03
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 (mmoores@cdsbc.org)

Posted 3 April 2017

Nov 23
​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 (mmoores@cdsbc.org)

Sep 22
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 (mmoores@cdsbc.org)

Posted 22 September 2016

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