Mary Lenefsky, PharmD

Dr. John Dovgan, DDS, PC, is a forensic dentist who often serves as an expert witness on malpractice cases. Speaking recently at the 

American Dental Association’s 2016 Meeting

, in Denver, CO, Dr. Dovgan explained what he looks for to determine whether malpractice has taken place. The determination, he said, often hinges on whether the standard of care was upheld.

That begs the question of, how does one define the standard of care? Dr. Dovgan defines the standard of care as what a reasonable and prudent dentist would do in a similar situation. The standard of care, he said, reflects that which is minimally required, and anything less is considered negligent.

If others in dentistry practice in a way that eliminates hazards, then this approach can be used to define the standard of care. Even so, if a malpractice suit is brought against a dentist, a jury will decide if the standard of care is reasonable, and whether the deviation from the custom standard of care was unreasonable to cause harm.   

“Standard of care deviations tend to be obvious,” said Dr. Dovgan. He compared the standard of care to a bell curve, saying that being above the standard of care is unachievable by most dentists, and that only 2.5% of dentists are truly below the standard of care. However, for those 2.5%, the deviations from the standard of care are obvious.

The worst type outcome from a deviation from the standard of care results in patient death, Dr. Dovgan said. Patient deaths due to a dentist’s failure to 

, over sedation, local anesthetic overdose, failure to refer trismus resulting in ludwig’s angina, and COPD/asthma-status asthmaticus, were all true examples discussed by Dr. Dovgan. In all instances, the deviation from the standard of care was obvious.

Lack of monitoring, using the same dose of a sedative in an elderly patient as you would a younger patient, not screening for 

, giving sedation reversal and failing to monitor, not keeping enough reversal drugs on hand in the office, and not using barrier protection during sedation procedures, are just a few examples of the gross deviations from the standard of care that Dr. Dovgan provided.

In addition to the above deviations, Dr. Dovgan presented an extensive list of lines a dentist shouldn’t cross. A few of those are:

		Not taking a health history prior to administering anesthetic

		Not taking x-rays prior to an extraction, endodontic procedure, implant placement, or crown procedure

		Not taking blood pressure prior to sedation, implant placement, or extractions

		Not providing informed consent prior to root canal treatment, extraction, or other invasive procedures

		Telling the patient post-op numbness more than 48 hours post treatment is normal

		Abrogating the copay for patients with insurance

		Allowing a dentist to practice in your practice below the standard of care

		Not taking post op x-rays to confirm placement of implants or completed endodontic procedures

		Over diagnosis for caries that don’t exist

Given his expertise in the area, Dr. Dovgan provided a list of items he considers when dealing with state board cases and malpractice cases. Some of those considerations are listed below.

		Is there a signed/dated comprehensive health history with regular updates?

		Are there full mouth periodontal probing’s present?

		Is there a full mouth series or equivalent?

		Are the x-rays clinically applicable to diagnosis?

		Is there a written, documented diagnosis?

		Is the diagnosis consistent with the treatment plan?

		Does a written and documented treatment plan exist?

		Is it supported by radiographs and diagnosis?

Mary Lenefsky, PharmD, is a consultant pharmacist and medical writer who specializes in the creation of medical education content for pharmacists, nurses, physicians, and other healthcare providers.  She received her Doctor of Pharmacy Degree from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. She then completed two years of post-graduate residency training at Northwestern Memorial Hospital, specializing in the care of the critically ill.

Articles

What a forensic dentist and expert witness looks for to determine whether there has been a lapse in the standard of care when malpractice cases make it to court.

Avoiding Malpractice: Forensic Dentist Advises on Maintaining Standards

 in Denver, CO, Marty Jablow, DMD, highlighted 5 technologies available for use in the dental practice for the year 2016.

There are multiple digital imaging devices available to detect caries, Dr. Jablow said. The use of LED lights and Doppler radar can produce diagnostic images that allow for the improved detection and the ability to track the progression of a carry over time. Additionally, some devices have the ability visualize fractures.

The Cellerant Best of Class Technology Award for 2016

 detection device with its transillumination technology. Other brands include 

Cone beam technology allows for 3D imaging and also limits the amount of radiation exposure to patients. Additionally, the technology may prove helpful for guided surgery planning, Dr. Jablow said.

Keep in mind, a dentist carries the responsibility to critically evaluate the 3D images. If unclear on how to interpret the images, the dentist should employ the use of a radiologist, or send the images to a company like 

The Cellerant Best of Class Technology Award for 2016 was awarded to 

Many positive outcomes are due to the high accuracy of the digital images, including instant preparation and impression validation, high quality restoration kits, reduced adjustment, and reduced grinding during seating. Additionally, less time to insert, no impression mess, reduced shipping costs, improved clinical results, and better patient acceptance are also positive outcomes associated with the use of digital impressions.

There are many different devices on the market. Cost and size of the device (some are handheld; some are not) will play a role when selecting one.

, depicted in the image at the top of this article (image courtesy of 3Shape).

Dr. Jablow pointed out that costs for lab-made crowns are decreasing. A dentist needs to make more crowns to see a larger return on investment. Therefore, Dr. Jablow questioned the value of in office milling devices. He advised dentists to really consider if a milling device fits into their practice.

 are usually less expensive, and often compatible with multiple materials.  

Software For Social Media Management, Patient Acquisition, and Practice Management

The importance of social media and electronic documentation systems cannot be understated. Many dental offices need to consider increasing their presence on social media. Companies such as 

 produce social media for the dental office. “Social media is not set it and forget it,” Dr. Jablow pointed out. This is an evolving entity that needs to be consistently managed, he added.

There are also software companies that provide patient acquisition and practice management capability. One example of a company like this is 

, which uses social media and other office statistics to provide analytic data. HISCOX provides software management to deal with human resources concerns such as ensuring employees have signed necessary paperwork.

Other companies offer cloud computing allowing for web-based practice management. Companies such as this include 

Despite the advances in technology, there are still instances when servers go down and computers malfunction. It is important to have a backup plan in mind should this occur. 

 received the Cellerant Best of Class Technology Award for 2016. This product can restore practice data in minutes and recover deleted files and corrupt databases immediately.

New technologies and services to take your practice to the next level.

5 Hot Technologies You Will Want for Your Dental Practice

, a dental practice management and motivational consultant, recently offered approaches to increasing treatment acceptance and keeping patients happy at the 

 in Denver, CO. “When patients come into your office, they want you to take them to a better place,” she said. Here is some actionable advice to achieve that goal, according to Englehardt-Nash.

When a prospective patient calls the dental office, the receptionist has approximately twelve seconds to get the patient to like them, Englehardt-Nash said. Some keys to being successful on the phone include using the patient’s name, asking for permission to ask the patient questions, and explaining to the patient 

 you do what you do at the practice. It is important to make the first exam have 

What information are you sending to your patients? Is the informational packet simply a packet of policies? Englehardt-Nash said it is important to emphasize that the documents aren’t policies, but rather office 

. Always remind the patient that the office standards were developed with the patient in mind, and the purpose is to provide them with the best care possible.

When a patient walks into the office, the first people they meet are the team, not the dentist.

It is imperative that the employees in the office have excellent communication skills, Englehardt-Nash said. If team members don’t feel their communication is adequate, enrolling in a communications workshop is something to consider. Just one word, phrase, or action can make the difference between a patient choosing your practice, and walking out the door.

When it is time to present the treatment plan, ask the patient’s permission to let you tell them what you can do for them. Listen to patient concerns, avoid interruptions, and leave out unnecessary details, Englehardt-Nash advised. Begin with the end in mind: describe the benefits of the ideal treatment plan so that they patient knows what’s possible.

Do not leave the patient before all of their questions and concerns have been answered. However, avoid information overload. “The confused mind always says no,” Engelhardt-Nash reminded the audience.

The entire team needs to be involved in helping the patient understand their treatment plan and care. “The decision to accept treatment happens with the clinical team and 

the financial team,” noted Engelhardt-Nash.

When discussing insurance, wording is important. Be 

 when discussing what an insurance policy will pay for. If a patient cannot afford their treatment, it is important to offer external financial options. Never put a patient into financial hardship. If a patient can’t afford a procedure to address a condition that isn’t life threatening, let them know it’s OK to wait until their budget allows for treatment. If a patient complains about the fees, remind them that the fees are based on the skill required to do the procedure well, the materials the office uses, and the time it takes to do the procedure right. Never apologize for your fee structure.

It is very likely a patient will go home after their first appointment and have a lot of unanswered questions. A great strategy to address that is a post-new-appointment phone call. Explain to the patient that the doctor wanted to make sure all of their lingering questions were answered, and you are available now to answer anything that has come up since they left the office. This is a simple strategy that doesn’t take much time, and really shows the patient you value and care about them.

All these strategies can help to increase treatment acceptance and patient satisfaction with your dental office. Engelhardt-Nash finished her presentation with the following thought: “Spend more time on people work than on paperwork.” 

When patients come into your office, they want you to take them to a better place, said Debra Englehardt-Nash, a dental practice management and motivational consultant.

ADA 2016 Update: Boost Treatment Acceptance to Get Paid for Your Work

 is expected to double by 2020. “We need to consider that recreational drug users of the ‘60s are still practicing the same behaviors of today,” said Ann Eshenaur Spolarich, RDH, PhD, in her recent presentation at the 

Below are important pharmacological considerations in the elderly as well as tips to appropriately manage patients currently using medications/substances with a high risk of abuse, according to Dr. Spolarich.

Important pharmacologic principles to consider in the geriatric population 

In the elderly, many typical drug doses act at 

 levels, and starting at a lower dose is appropriate, Dr. Spolarich advised. A decline in kidney and liver function occurs, meaning metabolism and excretion of many dental medications decreases. Elderly patients are therefore prone to greater sedation and increased psychomotor impairment.

Many drug classes increase the risk for falls in the elderly, including antihypertensives, sedative hypnotics, benzodiazepines, opiates, and antidepressants.

The elderly tend to use many prescription drugs, usually filled at different pharmacies. This increases the likelihood of drug interactions.

When in doubt, Dr. Spolarich advises, refer to the 

, which is a document listing medications that should be avoided in elderly adults.

Benzodiazepines are commonly prescribed for anxiety. Dentists need to be aware that a common benzodiazepine, diazepam, has an active metabolite and sticks around in elderly patients longer.

If a patient takes a benzodiazepine and an opiate, Dr. Spolarich recommended to reduce the dose of the opiate by at least a third when the benzodiazepine is added, and to counsel the patient to avoid 

Long term benzodiazepine use can worsen COPD, GERD, and increase fall risk. Possible side effects include fatigue, drowsiness, xerostomia, and additive effects with other CNS depressants.

Dentists must realize that not all pain is the same, and will not respond to the same medications. If a patient’s pain is unresolved or continues to worsen despite dose escalation, there is the possibility of disease progression, diversion, or pseudo-addiction.

The current practice among dentists is to prescribe a 3-day supply of opiates, a sufficient amount for many dental procedures.  

Alcohol and tobacco cause more medical problems than all other drugs combined.

Forty percent of older adults drink alcohol, and use tends to increase with age.

As the physiology of the body changes, alcohol is metabolized differently. The elderly tend to have decreased total body water and lean body mass, leading to a higher concentration of alcohol in the blood. Alcohol is metabolized slower and stays in the body longer. Side effects secondary to alcohol are more likely to occur with increasing age.

Dr. Spolarich mentioned that the alcohol limits recommended by the National Institute on Alcohol Abuse and Alcoholism may not apply to elderly. Age-appropriate alcohol limits have not been established for the elderly.

Chronic alcoholism in elderly adults can lead to biological brain disorders, systemic health problems, and increases risk of certain cancers. It can also lead to poor oral hygiene from neglect, enlarged parotid glands, increased bleeding if liver failure is present, fungal infections, glossitis, and angular cheilitis.

Common drug interactions with alcohol include NSAIDs, acetaminophen, and antihistamines.

A history of lifetime smoking reduces life expectancy by approximately 13-15 years, contributes significantly to heart disease and stroke, COPD, cancer, the development of dementia and Alzheimer’s, and can increase the risk of developing cataracts.

Of note, cessation aids have not been tested in older adults, and this can pose a challenge to healthcare providers.

Every patient 60 and over should be screened for alcohol and drug abuse as part of their regular exam. The warning signs of abuse are easily confused with concurrent/chronic conditions. Therefore, it is vital to be actively involved in your patient’s care and always be prepared with resources specifically for geriatric patients.

We need to consider that recreational drug users of the 60s are still practicing the same behaviors of today, said Ann Eshenaur Spolarich, RDH, PhD, in her recent presentation at the American Dental Association's 2016 Meeting.

Opioids and the Elderly: How to Address Addiction Risk in Your Practice

 most common malignancy in the world. Classical SCC carries a 5-year survival rate of approximately 55%. As described by Dr. Mark Lingen, DDS, PhD, at the 

 in Denver, CO, the treatment plan for SCC must include early detection and improved modalities for prognostication and prevention, affording the greatest chance of survival for the patient. Dr. Lingen gave his presentation on Thursday, October 20 at the conference.

Performing patient screening is the backbone of early detection, Dr. Lingen said. Screening tests are not diagnostic tools, however. Additionally, oral cancer screening is not a stand-alone test. It is part of the dentist’s 

 exam, including both visual and physical or tactile components, used to identify any abnormalities or pathologies of the oral and/or maxillofacial region. A typical medical education does not teach comprehensive oral pathology. It is left to dentist to take sole responsibility for monitoring the oral mucosa of his/her patients.

The table below highlights additional methods currently available to assist in detection of oral cancers. All methods listed are to be used in 

 with the visual/physical exam. The devices below are “cleared for marketing” via the FDA 501(k) program. This program is for noninvasive devices and requires the device to demonstrate safety, but 

 (scrape cells from mucosa, place on a slide, send out for analyzation)

						Useful for individuals with multiple lesions

						Useful for patients unlikely to be compliant with recommended follow-up

 (Patient rinse with acetic acid, use light to evaluate lesions)

						Capable of seeing lesions not seen with incandescent light

 (wavelength of light shone into mouth, looking for loss of autofluorescence)

						May help to define surgical markers

						May detect a range of mucosal abnormalities

						Clinically relevant now distractors recognized

 (combination of the two individual components)

						Unclear if disease is acute or chronic

						Unclear if HPV DNA is “episomal or integrated”

(genetic markers, RNA/DNA, or proteins in the saliva)

Dentists must take responsibility for monitoring the oral mucosa of their patients, Dr. Mark Lingen said at the ADA's 2016 meeting.

Use These Methods to Effectively Screen for Oral Cancer

The American Dental Association (ADA) provides educational modules to help dentists with specific practice management topics. One of the courses offered is titled “Managing Patients,” which was reviewed on October 20 at the 

 in Denver, CO by Dr. Jean Creasey, DDS, Dr. Diane Metrick, DDS, and Cynthia Kluck-Nygren of the ADA. The module is available free online to ADA members and can be found on the 

. Below is a summary of the main points from the module. 

The first opportunity to have a positive impact on a patient is over the phone, the presenters said. The practice employee taking the call must be the warm and welcoming. Collecting basic information about the patient’s medical and dental history before the visit will help make the process seamless. If the office has requirements for first-time appointments, relay those ahead of time so that there are no surprises when patients arrive.

It is important that the doctor be relaxed and not rush when first meeting the patient, the presenters advised. The dentist, having reviewed the medical chart prior to the appointment, can discuss any questions or concerns with the patient. He or she must treat the patient as an equal. The doctor must take the patient step-by-step and present information in small pieces. It is imperative that he or she always be honest and up front, the presenters said. For example, if the doctor is running behind schedule, and the appointment will be delayed, the doctor must let the patient know. Transparency is key to creating a trusting relationship. If the dentist is going to recommend particular treatment, explain what is recommended and why. He or she must make sure the patient understands how the procedures will be beneficial, according to the presenters. Dentists must be transparent about the expected financial costs as well as the time required for each option presented. Invite questions from the patient and respect their decision to research the options presented and discuss with others.

When speaking with the patient, the presenters said the dentist should use open-ended questions, avoiding questions with yes or no answers. This allows for the patient to explain in detail. Equally important is active listening. Using positive body language and engaging the patient creates a feeling of trust. Finally, it is important for the doctor to minimize technical terms the patient may not comprehend.

It is important for a dental practice to develop a system for recare/confirming future appointments, the presenters suggested. Having the patient pre-appoint at the end of current treatment is one option. Using reminder phone calls and/or text messages may also prove useful. Ask patients for their confirmation preference, they advised.

Cancellations inevitably occur. However, they can be mitigated by communicating expectations to the patient, the presenters said. Displaying the office appointment policy and including the policy in the new patient packet will set expectations and explain consequences of a cancellation. A dental practice can employ follow-up phone calls, text messages, or perhaps emails to help decrease cancellations, the presenters advised. Many patients think their mouths are healthy and many don’t value their appointment. It is important to stress the educational component as to why oral health care is beneficial. Always remember to provide the ADA Patient Bill of Rights and Responsibilities to all patients.

If the practice is having trouble retaining a patient, it is best to reach out directly to the patient. Be proactive. Whoever knows the patient best in the practice can be the person to open up dialogue. It is important to act out of an authentic concern for their oral health and to nurture the relationship, the presenters said.

Complaints typically result from a breakdown in communication. Usually the outcome is different than the expectation of the patient. When the patient has questions, the presenters said, being willing and open to discussion is key to maintaining a trusting relationship.

If a patient is to be dismissed from a practice, it is important to not place blame or fault on anyone, the presenters cautioned. The dentist must remain cordial and professional, always showing compassion and ending the relationship on a neutral level. A patient should always be respected and valued. Remember that adequate notice of dismissal must be given to a patient per state laws or regulations, and that documentation is vital. 

The ADA provides free resources to its members to help dentists better manage their practices.

ADA's 2016 Conference Offers Tips on Practice Management

There is due diligence on the part of the healthcare practitioner to obtain an accurate medication history from a patient. Numerous medications interact with dental drugs or complicate dental procedures, as outlined by Harold Crossley, DDS, PhD, in his presentation on Thursday, October 20 at the American Dental Association’s (ADA)  2016 meeting in Denver, CO.  (See Table 1 for some common medications patients may be taking. Note: this list in not all inclusive, and does not include all medications in a particular medication class.)

Important points to consider with respect to antibiotics:

Dr. Crossley also made some important points regarding antibiotics patients may be taking. As practitioners know, some examples in which prophylaxis prior to an invasive dental procedure is necessary, include an artificial heart value, history of infective endocarditis, congenital heart disease, or a cardiac transplantation with a heart valve abnormality. Administer the antibiotics 30-60 minutes prior to the procedure. However, if the patient did not receive antibiotics prior to the procedure, they can be administered up to 2 hours after the procedure and will still provide a fair degree of protection. Appropriate antibiotics include amoxicillin, or if the patient has a penicillin allergy, perhaps cephalexin or clindamycin, azithromycin, or clarithromycin.

Dr. Crossly brought to the audience's attention the fact that if the patient is already taking an antibiotic for another indication, the dentist will need to prescribe an additional antibiotic with a 

Some examples in which no prophylaxis is needed are mitral valve prolapse, rheumatic heart disease, bicuspid value disease, ventricular septal defect, atrial septal defect, or hypertrophic cardiomyopathy.

Typically, no antibiotic prophylaxis is needed in patients with stents.

Per the ADA, there is no support for routine prophylaxis in patients with joint replacements undergoing dental procedures, unless the person has had a comprising situation in the past with respect to the prosthesis.

 on the use of prophylactic antibiotics that can serve as reference for dental practitioners.

TABLE 1: Common Medications & Side Effects

						Only ONE NSAID at a time (aspirin taken for cardioprotection is okay to take with other NSAIDs)

						Similar medications: ketoprofen, meloxicam

				Serotonin norepinephrine reuptake inhibitor (SNRI)

						Efficacy measured via International Normalized Ratio (INR)

						 Foods high in vitamin K content can affect INR

						Many drug-drug interactions: NSAIDs, statins, tetracyclines, metronidazole

						Idarucizumab (Praxbind) is the reversal agent

						Andexanet alfa (AndexXa) is the reversal agent for all Xa inhibitors- NOT FDA APPROVED

						Similar medications: Apixaban (Eliquis), Endoxaban (Savaysa)

				Platelet aggregation inhibitor, blocks ADP (P2Y12) receptors on the platelet 

						Prodrug- converted to its active form in the body

						Similar medications: Prasugrel (Effient), Ticagrelor (Brilinta)

It is imperative for dentists to know the risks of potential interactions of patients' medication with dental drugs, said speaker Harold Crossley, DMD, at the recent ADA 2016 Meeting in Denver, Colorado.