Risk management presentation

STANDARDS OF CARE IN PERIODONTICS,

ENDODONTICS, AND PROSTHODONTICS

Paul Levy, DDS Peter Velyvis, DDS Robert J. Chapman, DMD Barry J. Regan, VP, Claims and Risk Mgmt, EDIC

Standardof Care

Average, qualified dentistWhat a reasonable and prudent

practitioner would do in the same or similar circumstance

Established by:What is taught in dental schoolsWhat is promulgated by the specialty

academies

Standardof Care

To a lesser extent, what is published in peer-reviewed journals

State licensing boardsAnd, unfortunately:

By juries in malpractice actions

Standardof Care

Juries determine standards of care based on information presented during trials:Patient RecordsTestimony of staff and other witnessesExpert witness testimony

Standardof Care

Is there a separate standard of care for a specialist than for a general dentist doing specialty work?

Standards of CarePeriodontology

Paul Levy, DDS

Failure to diagnose and treat periodontal disease falls below

the standard of care.

First, an accurate diagnosis is essential. Then an appropriate treatment plan including etiology and prognosis must be formulated.

Clinical diagnosis, treatment planning, and procedures are decided, whenever possible, on evidence-based data and controlled clinical studies in peer-reviewed scientific literature.

This is somewhat of a controversial statement.

Second, treatment is traditionally divided into 3 phases:

Non-surgical Therapy Surgical Therapy Maintenance Phase

Periodontal surgery when not followed by good professional and personal care, will, in many cases, fail.

Nyman et al, J. Clin. Perio, 1977

Becker et al, J. Perio, 1984 showed that when maintenance is provided, a surgical approach to treatment of moderate to advanced periodontitis is highly successful

Patient compliance, even when optimal, must be reinforced by frequent maintenance and recall.

This requires a team effort by referring dentists, hygienists, and periodontists, which results in tooth retention and successful treatment in most cases.

Lindhe and Nyman, J. Clin. Perio, 198412

Dentistry is not a perfect science. Outcomes of treatment do not have to be ideal to conform to the standard of care.

Treating beneath the standard of care is considered negligence.

Essential Components of Record Keeping

Medical and dental history Chart notes and results of

examinations Professional correspondence Insurance Requests Billing statements Informed consent HIPPA rules Radiographs Models, Photographs

Informed Consent

Patient must understand the options of treatment. Several possibilities usually exist to treat the periodontal problem.

The patient is an “active partner” to the clinician in their own care.

There are 5 Steps to Consent:

1. Their must be an understanding of the problem, the diagnosis.

2. The proposed treatment and alternative treatments must be fully explained.

3. No warranties or guarantees can be given.

4. Authorization must allow for change in plan if unforseen circumstances arise.

5. Discussion of all sequelae or side affects must be given.

Consent may be verbal or written but it must be fully understood by the patient. I use different forms for each procedure.

Beneficence

This is a legal concept that refers to providing the best possible care. If the practitioner is unable to do this, the patient must be referred to a competent specialist for continuing or more advanced care.

Dentists and periodontists are treatment partners.

Record Keeping

All records must be contemporaneous and must be signed and dated. Legally, a professional written record carries more weight than plaintiff’s (patient’s) recollection. If something is documented in the chart, it is claimed to have occurred. Conversely, it is difficult to establish the event, if not documented. Radiographs are important records. The number and timing depends on the severity and activity of the case. The FDA issued guidelines for a full mouth survey every 5 years and bite-wing films approximately every 12-18 months to illustrate periodontal disease and its changes.

Measuring and recording of pocket depths on six locations for each tooth provide the minimum foundation to document the legal responsibility for each patient. These pocket depth recordings are done at the initial exam, on completion of treatment, and once or twice a year during maintenance.

Occupational Safety and Health Administration

♦Universal precautions and bloodborne pathogens

♦ Hazard communication♦ Waste management♦ Illness and injury prevention

Health Insurance Portability and Accountabilty

Electronic Transaction StandardPrivacy StandardSecurity Standard

HIPAA is enforced by the Office of Civil Rights

Continually Upgrade Skills

Use updated comprehensive text books, continuing education courses, current studies in the scientific literature.

Traditional periodontal treatment including both surgical and non surgical techniques have very high success rates in saving teeth in a healthy, functional and esthetic state. This has been known for over 20-50 years.

Hirshfeld and Wasserman, J. Perio. 1978 Oliver, J. West Soc. Perio. 1969 Goldman, MJ et al, J Perio. 1986

Proper use of surgical regenerative procedures with a variety of grafts and membrane barriers have shown that bone and soft tissue that had been lost to periodontal disease can be regenerated and questionable teeth saved.

Controversial Comments

Using ineffective therapies to avoid traditionally effective ones may result in progression of disease around teeth that may ultimately be extracted.

Before using any new modality, any dentist should have histological, clinical and long-term proof that these procedures are effective.

Do we allow industry and companies with profit motive and little track record to establish the standard of care?

The Keyes technique, many time-released local antibiotics (chlorhexidine in a gelatin chip, tetracycline fibers, docycyline hyclate in a polymer carrier or minocycline microspheres) and even lasers were tested scientifically and found to yield little, if any, improvement over traditional scaling and root planing (without surgical therapy).

New products such as tissue healing modulators, growth factors (BMP-2) and even stem cells are promising additions to currently proven materials and techniques which will require evidence-based research currently being performed.

Implants-Controversy

Implant surfaces and designs make it difficult to find comparable long-term statistics for implants currently being used.

Would you rather have a healthy functioning tooth or an implant?

In 1952, in the JADA, DeVan stated that ”Our objective should be the perpetual preservation of what remains rather than the meticulous restoration of that which is missing.”

When do we place implants?

When periodontal disease is present; how long should we wait to place the implant? How much bone loss do we accept before deciding to place the implant?

There are shades of gray- answers are not always black and white.

Do we place implants when adjacent teeth are virgin teeth?

In circumstances where extraction and implant placement is indicated, the patient should know the options, risks, benefits, anticipated results and potential complications before implant treatment is considered.

There can be complications in implant placement. Pjetursson (2004) reported that 38.7 percent of patients had complications in the first 5 years after implantation

Lang(2004) reported that biological and technical complications with implant-supported restorations occurred in about 50 percent of cases after 10 years in function.

This may dispel the belief that implants are a trouble- free panacea when compared to the retention of teeth that require periodontal treatment.

The standard of care takes into account all of our findings, clinical and radiographic, all our knowledge of diagnosis, prognosis and treatment considerations and alternatives.

Flossophy

Do good work and carry as much insurance as possible.

We are fortunate to be in a profession where we can earn a living and help people.

Periodontal Plastic Surgery:

Framework for the Perfect Smile

Esthetics

Achieving Optimal Esthetic Results

Treatment Options Resective Therapy Augmentation Therapy

Root coverage procedures

Hard and soft tissue ridge

augmentation38

Esthetics

Crown Lengthening

Anterior Crown Lengthening

Pre-restorative For smile enhancementBiologic width sensitivePapillary retention critical

Before

After 41

Crown Lengthening

Before

Crown Lengthening

Before Incisions

Crown Lengthening

Immediate Post-Suturing

One-Month Healing

Crown Lengthening

Before

Incision

Crown Lengthening

Before After

Crown Lengthening

Before

One-Month Postsurgical

Crown Lengthening

Before

Incisions

Crown Lengthening

Immediate Post-Op

Surgical

Crown Lengthening

Before

Incisions

Crown Lengthening

Before After

Augmentation Therapy

Hard and Soft Tissue

Augmentation Procedures

Clinical Indications RecessionDeficiency in Gingival Form•Ridge Collapse•Loss of Papilla

Anterior Extractions54

The presence or absence of papillae can be anticipated by

measuring the distance from the proximal bone o the contact point.

When the distance is less than 5mm (4.2mm), the chances of having a complete papilla is

excellent.

Root Coverage Procedures

Root Coverage

Before

Immediate Post-Op

Root Coverage

Before

Root Coverage

BeforePrepared Root Surfaces

Root Coverage

Before After

Root Coverage

Before

Root Coverage

Before

Root Coverage for

Implants

Root Coverage for Implants

Before

Ridge Augmentation

Root Coverage for Implants

Before

Ridge Augmentation

Before

Ridge Augmentation

Before

Post-Suturing

Ridge Augmentation

Before

Site Preservation

Before

Site Preservation/Root Coverage

Before

One-Month Post-Extraction

Site Preservation

Before

Site Preservation/Ridge Augmentation

Site Preservation

Before After

Combination Procedures

Before

Suturing

Before After

Incisions

Before

Immediate Post-Suturing

AfterBefore

Before After

Esthetics with Implants

Site Preservationfor Implants

Before

Site Preservation/Implants

Immediate Post-Op

Implant Placement

Augmentationand

Implants

Before

Guided Bone Regeneration

Implant Site Development

Implant Placement

Gingival Augmentation

Augmentation/Implants

Final Results

Before After

The Key that Brings it Together:

CommunicationInterofficePatient

Standards of Carein Endodontics

Peter Velyvis, DDSLimited to Endodontics

Diagnosis

Evaluation of pulpal and periradicular status must be performed for every tooth to be treated

Pulp Testing

Indicated tests include thermal, electrical, percussion, palpation and mobility

Occlusal discrepancies should also be evaluated

Reproduction of patient’s symptoms “is desirable, if not mandatory”

Diagnosis

Pulpal and periradicular diagnosis should be formulated for each tooth to be treated using endodontic terms

Pulpal Diagnosis

Periradicular Diagnosis

TreatmentPlan

Patient’s case difficulty as well as dentist’s abilities, experience and equipment should be evaluated before embarking on endodontic treatment

Case difficulty assessment checklist is available through the AAE

Radiographs

Radiographs of diagnostic quality are requiredIf periapical lesion is apparent,

entire lesion should be visualizedMay require additional angles or types of films (bitewing, occlusal, panoramic)

Emergencies

Many emergencies can or even should be initially treated with medication

Pulpotomies are acceptable treatments for vital teeth

Pulpectomies are the indicated treatment for necrotic teeth, with or without periradicular disease

Incision and drainage can be used to relieve pressure buildup in a localized fluctuant swelling

Analgesics

OTC drugs are usually sufficient to control much endodontic-related painNSAIDs , if tolerated, typically offer

more relief than other analgesicsNSAIDs help remove the source of a

patient’s pain- a buildup of inflammation in the jawbone

Acetaminophen is recommended if there is a contraindication to NSAIDs or in combination with NSAIDs for enhanced pain control

Antibiotics

Primary infections tend to be a mixed flora of aerobic and anaerobic bacteriaPenicillin is the first choice

antibioticRecurrent or long-standing

infections are anaerobicClindamycin, or penicillin with metronidazole is a good first choice

Antibiotics

Narcotics

Narcotics should be used to temporarily control breakthrough painThey do little to relieve the source

of the patient’s pain

Endodontic Treatment

Informed Consent

Consent should include the possibilities of post-op discomfort, swelling, need for medication, or complicationsAltered sensation, separated

instruments, blocked or perforated canals, root fractures, damage to restorations

Also included: the need for a subsequent restoration after RCT (filling, crown, etc.)

Rubber Dam

• This is the only AAE dictated standard of care

Anesthesia

• My advice, don’t skimp

Magnification

• This could be considered a standard of care, as the AAE requires all endodontists to be trained in the use of magnification and illumination

Magnification

Accreditation Standards for Advanced Specialty Education Programs in

Endodontics

Use of magnification technologies. Intent: The intent is to ensure that students/residents are trained in the use of instruments that provide magnification and illumination of the operative field beyond that of magnifying eyewear. In addition to the operating microscope, these instruments may include, but are not limited to, the endoscope, orascope or other developing magnification.

Apex Locators

Eliminate need for multiple working films

Canal lengths should be verified radiographically before root canal filling is bonded into place

Apex locators do not replace radiographs in confirming that all canals or tortuous canal space has been instrumented

Cone Beam CT Scans

Interpretation

Clinicians ordering a CBCT are responsible for interpreting the entire image volume, just as they are for any other radiographic image. Any radiograph may demonstrate findings that are significant to the health of the patient. There is no informed consent process that allows the clinician to interpret only a specific area of an image volume. Therefore, the clinician can be liable for a missed diagnosis, even if it is outside his/her area of practice. Any questions by the practitioner regarding image data interpretation should promptly be referred to a specialist in oral and maxillofacial radiology.

Cone Bean CT Scans

CBCT should only be used when the question for which imaging is required cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities.

Smaller scan volumes generally produce higher resolution images, and since endodontics relies on detecting disruptions in the periodontal ligament space measuring approximately 200μm, optimal resolution is necessary.

Cone Bean CT Scans

Irrigation

Most common intracanal irrigant is Sodium Hypochlorite (NaOCl)Dilution to 1% or 2.5% is generally

considered a safer concentration in the prevention of “hypochlorite accidents”

Side-venting irrigating syringe should fit into the canals loosely, and never be expressed under pressure

NaOCl has both antibacterial and tissue dissolving properties

Irrigation

Chlorhexidine 2%, EDTA (ethylenediaminetetraacetic acid) and saline are also commonly used during instrumentation

Calcium Hydroxide gel is the most often used inter-appointment medicament

NiTi vs. Stainless Steel

Rotary Nickel-Titanium instrumentation is currently the most common method of cleaning and shaping the root canalsThese do have a higher propensity of

instrument separation than stainless steel hand files.Experience in handling these

instruments is the only way to learn the limits of torque and pressure

Filling Materials

Gutta Percha with eugenol-based sealer is still the most common root canal filling material

Resin based, bonded root canal fillings are becoming more popular, as wellThere does not appear to be any

conclusive advantage to either filling material at this time

Filling Materials

No more Silver Points

Filling Materials

Occlusal Restorations

• The occlusal restoration of a root canalled tooth is as important at preventing infection as the root canal, itself.

• Cuspal coverage minimizes likelihood of root fracture

Occlusal Restorations

• During the time between the onset of root canal treatment and placement of the definitive occlusal restoration, heavy occlusal and lateral forces should be eliminated.

Post-op Radiographs

This is essential to proper endodontic treatmentEntire apex of tooth should be

visible on radiograph to evaluate and confirm treatment of the entire canal system

Post Treatment

Persistent Discomfort

Several days of discomfort post-treatment is not unusual.

Discomfort that lasts weeks or months sometimes resolves on its own, but often indicates either uncleaned irritant in the canal system or other, more serious defects, i.e.cracked root.

Extraction/Implants

Cracked Teeth

Documentation

Standards of CareProsthodontics

Robert J. Chapman DMD

Standards?What do we mean?

Procedural Specific treatments: Example: Crown

preparation = minimal reduction for desired outcome? (esthetics = ?porcelain)

CareOverall care: Treatments which in

toto attempt to deal with all of patients needs or desires

Reasons to Know & Use Standards

• Better possible patient care outcome if followed• Benchmarking to an agreed upon and codified

process and outcome– Generally developed by some recognized

dental organization– Often evaluated and modified over many years

• Guidelines to treatment planning• May offer some (not guaranteed) legal “shelter”

especially in procedural outcomes• If not used can allow for challenge by expert or

institutional (insurance, licensing, educational, peer) review

What Are the Problems with Standards

Not all are agreed upon: What is most important

No Gold Standard to compare toOften address procedural rather

than patient care processes or outcomes

Probably the Most Important Standard Is…

… the Process of Treatment• Findings

– Histories, examinations (intraoral, radiographs, etc.)

• Diagnosis• Treatment planning

– What do patients want?– Can it be achieved?– Informed consent

• Risks, benefits, potential outcomes

Second Most Important Standard

Information and communicationAsk What the patient wantsLet them know their needsWhat are the risks associated with

treatment of either needs or wants

What Determines Success?

Three things:DiagnosisTreatment planning

OHRQOL - Patient CenteredPrognosis from Evidence Based Information

Informed consentOHRQOL - Patient CenteredPrognosis from Evidence Based Information

Radiographs and Study Casts with Dx Wax-ups

Follow ADA/AAOMR Radiographic Guidelines

RC 9154

Good preparations.Good marginsGood maintenance plaque control electric brush flossingPatient over 65 so use risk-reducing high fluoride contenttoothpastes and varnishes

All ceramic-1st premolar to 1st premolar

PFM- premolars & 1st molarsGold - 2nd molars

(My) Guidelines

• Use some guideline/standard that has been developed by some recognized group

– American College of Prosthodontists, AAGD, Dental School (nearby/community/accredited, graduated from), state, other

– Fairly recently developed or revised– In some way addresses patient concerns and your

communication to them

• Treatment guide is evidence that is literature basedwhenever possible

– CorchoranCollborative reviews,– Research at some level above technique, case report, or bench

study articles

• Communicate– Write in record– Write letters

Diagnosis

• After your findings, determine if you wish to proceed

• Diagnostic Codes will SOON be a reality– Introduces new level of documentation– Electronic health records (Standard in 2014)

well help • Insurance companies and lawyers will be

looking at Dx codes related to treatment plans– Not lists of required tx’s but possibilities

• document tx reasons related to findings for paper or electronic record

American College of Prosthodontics

Not procedural standards but Prosthodontic Diagnostic Index Resources (PDI)

Class IV = refer to a prosthodontist

Good preparations.Good marginsGood maintenance plaque control electric brush flossingPatient over 65 so use risk-reducing high fluoride contenttoothpastes and varnishes

All ceramic-1st premolar to 1st premolar

PFM- premolars & 1st molarsGold - 2nd molars

Comprehensive Standards

University of Kentucky

Very thorough and complete without being overly detailed

Long but worth reviewing

University of Kentucky College of Dentistry - SOC

FULL CROWN COVERAGE (All Porcelain )The Full Crown Coverage-(All Porcelain) restoration is an indirect restorative procedure involving full replacement of the functional clinical crown. The crown is fabricated from different porcelains without a metal substructure. These restorations are usually limited to single unit crowns and are indicated when maximum esthetics is desired for a full coverage crown.Indications1. For restoration of tooth defects from either dental caries, tooth fracture, developmental defects, or replacement of defective restorations.2.When full coverage is required and the esthetic demand is paramount. 3.Retainer for a fixed partial denture. 4.Retainer and rest seat for removable partial denture clasp. 5.Patient preference.Contraindications1.Patient has a demonstrated allergy or medical intolerance to a component of the restorative material.2.Poor periodontal prognosis for tooth retention. 3.Presence of a direct pulp cap. 4.Patients with high and/or poorly controlled caries activity. 5.When there is insufficient sound tooth structure to support and retain the restoration. 6.Excessive or abrasive occlusal function. 7.Patient preference. 8.Patient economic resources. Outcomes Assessment1. No evidence of caries beneath or adjacent to the Full Crown Coverage-(All Porcelain) restoration.2.Normal occlusal functions and tooth contours are maintained. 3.The restoration remains intact and continues to function acceptably.

Focused Standards

• Delta Dental– Quality of Life (recently validated)

• Published but not used• Not embraced by community

• Dental schools, offices– Process promises

• We promise to do our best• We will communicate• We’ll be nice• Etc.

Standards would be impossible to achieve if too

detailed and without exceptions.

Be careful which ones you choose.

What are minimal procedural standards for prosthodontics

we could all feel comfortable with?

Preparation Know anatomy of tooth so as not to over-

prepare Look at recent literature, i.e.

Full crown preparation removes approximately ~ 67 -75% of coronal tooth structure:Toothstructure removal associated with various preparation designs for posterior teeth.Edelhoff D, Sorensen JA.Int J Periodontics Restorative Dent. 2002 Jun;22(3):241-9.

Biologic Health Potential (analysis of in vitro information) after crown preparation of 1.5 mm depth

Enamel & Dentin Thickness (mm)* with 1.5 mm removed and numbers in parentheses what remains from prep to pulp

incisal thickness mid-crown 1 mm above CEJ(tip of pulp to incisal edge) Labial Lingual Labial Lingual

Maxillary Central Incisor 4.2 - 1.5= (2.7) 2.4(.9) 1.7 (.2) 2.7 (1.2) 3.2 (1.7)

Maxillary Canine 5.5 - 1.5 = (4.0) 2.8 (1.3) 2.7 (1.2) 2.9 (1.4) 3.1 (1.6)

Mandibular Incisor 4.6 - 1.5 = (3.1) 2.0 (.5) 1.5 (0) 2.4 (.9) 2.4 (.9)

Mandibular Canine 4.6 - 1.5 = (3.1) 2.8 (1.3) 2.3 (.8) 2.9 (1.4) 2.9 (1.4)Prognosis:Green = good;Blue = fair;Pink = marginal;Red = bad,

*Modified from: Shillingburg HT, Grace CS. Thickness of enamel and dentin. J South Calif Dent Assoc 1973;41:33.

If Pulp Exposure Happens Anyway

Tell patient beforehand of risks and what will happen if a pulp exposure resultsEndodontics, post, etc

Do or refer endodontics and don’t charge

Probable Agreement for Fixed and Removable

• Occlusion: normal comfort ,function and bilateral simultaneous contact Beyron, H, 1959

• Esthetics: Fits within the remaining tooth structure

• Materials: those which are least likely to fail according to most recent literature

• Communication with patient:– Informed consent – At least discussion noted in record as to

potential problems and longevity

Continuing Education: Always Good to Have Recorded

• Keep up with state CE requirements• Go to programs that are relevant to patient

care and keep copies– Hands-on can be good– Jump-in with new procedures or

products at peril unless research outcomes are well documented

• DON’T base a Standard , or any other treatment, on what some lecturer says! Won’t hold up in court no matter what the Speaker’s reputation.

What’s in the Future

• Implants– With dentures: likely yes, but with limitations – bone,

patient health– Fixed prosthodontics: Soon but with limitations as above– Grafting – not many longitudinal studies but some

• CaMBRA– Yes and very soon

• TMD?– Unlikely although research data is getting better

• CAD/CAM?– Too early to tell in popular literature

• Amalgam v. Composite– No current research evidence but a lot of buzz in popular

Council on Dental Accreditation – CODA

• One of main Standards is to teach to evidence based care– Cochrane Collaborative= highest level of

research reviews = http://www2.cochrane.org/reviews/

– National Library of Medicine website: pubmed.gov http://www.ncbi.nlm.nih.gov/pubmed/

• CODA will de facto determine the standards of care for procedural outcomes within the next 10 years as this mandated dental school accreditation standard will go into affect 2013

Review at Leisure But Do It!

http://jada.ada.org/cgi/content/full/135/10/1449JOSEPH P. GRASKEMPER,

D.D.S., J.D. 2004 ADA This article on standards is excellent. If recommendations followed can help avoid problems

Review literature: pubmed.gov

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