- Email: [email protected]
Avoiding lawsuits
Fig 2.—Representative pictures of a restoration evaluated on the 22-year follow-up study [3] that was still clinically acceptable (A) or that have been repaired during the follow-up period (B). In (B), repair was considered an alternative to replacement and the restoration was still clinically serviceable 7 years after being repaired. (Courtesy of Demarco FF, Corr ea MB, Cenci MS, Moraes RR, Opdam NJ: Longevity of posterior composite restorations: Not only a matter of materials. Dent Mater 28:87-101, 2012.)
mainly because of secondary caries or fracture of the tooth or the restoration. These may have nothing to do with the material used for the restoration. Secondary caries occur as part of a continuum from primary caries, which respond to effective clinical and patient efforts in prevention. Fracture is partially the result of having a softer base under the restoration, such as a lining. The strongest material with the best fracture toughness should be used to avoid this problem. Good results are being achieved with the currently available posterior composite materials.
Clinical Significance.—Repair is a viable alternative to replacement and can significantly extend the life of a restoration. Composite restorations perform well in posterior teeth, having AFRs of 1% to 3%. The success of these
restorations depends mainly on factors related to the patient and dentist, as well as to the material used. The use of preventive and conservative approaches to replacement helps achieve the best outcomes. Future materials may address the prevention of secondary caries and the reduction in fracture incidence.
Demarco FF, Corr ea MB, Cenci MS, Moraes RR, Opdam NJ: Longevity of posterior composite restorations: Not only a matter of materials. Dent Mater J 28:87-101, 2012 Reprints available from FF Demarco, Graduate Program in Dentistry, Federal Univ of Pelotas, Rua Gonc¸alves Chaves 457, Pelotas, RS 96015-560, Brazil; fax: þ55 53 3222 6690x135; e-mail: flavio. [email protected] or [email protected]
Risk Management Avoiding lawsuits Background.—Patients who have poor outcomes after oral surgical procedures are more likely than patients who are dissatisfied after other types of dental procedures to file a lawsuit against the dentist. These suits also tend to generate significantly higher awards than suits after a general dental procedure. Steps can be taken to minimize the chance of litigation against the dental practice, which will avoid the entire emotional, painful, and time-consuming experience.
Why Sue?—Factors that encourage lawsuits against dental professionals include several trends in society, as follows:
196
Dental Abstracts
Dentists and other health care providers are no longer considered community leaders as they were in the past. Health care providers are considered business people rather than dedicated healers. Lower insurance payments related to managed care contracts mean health care providers cannot afford the luxury of spending significant time with patients to develop meaningful rapport. Patients see litigation as a solution to their financial needs in this weak economy with high unemployment, significant underemployment, and high levels of personal debt.
It is easy to sue because the patient assumes no cost other than time even if they lose. Lawyers who will take such cases are plentiful.
Box 4.—Risk Reduction Checklist
Why Not Sue?—Not all patients who have poor results sue the dentist so factors must exist that persuade the patient not to bring a lawsuit. Patients who are less likely to sue feel the dentist and staff possess important qualities, specifically, competence, commitment, compassion, caring, honesty, collaboration with the patient/family, thoroughness, qualifications, and humanity. They believe the dentist and staff do what they promise and do the best they can. These qualities prompt the patient to give the health care provider the benefit of the doubt even with a disappointing outcome.
Avoiding Litigation.—Four essential points must be present and proved to succeed in claiming clinical negligence: (1) a duty of care is owed by the dentist to the patient; (2) a breach of duty of care occurred by failing to meet the expected standard of care; (3) the patient suffered harm and/or loss; and (4) the patient’s damages were directly caused by the dentist’s breach of the standard of care. The dentist and staff can take steps to avoid being the target of a lawsuit, focusing on documentation; using good judgment in planning care, referring, and obtaining informed consent; making efforts to provide follow-up and handle complications appropriately; and properly terminating doctor–patient relationships when necessary (Box 4). Complete patient records are not only vital to patient care but also legally required by most state dental boards. Failure to keep such records can lead to a loss of the license to practice. The complete record complies with licensure and accreditation standards, facilitates diagnosis and treatment, provides a defense against potential malpractice claims, serves as the basis for communicating with other health care providers, documents quality assurance information, and provides the basis for obtaining proper reimbursement and substantiating billing codes. Ideal charts measure 8.5 11 inches. Each patient has a separate record that includes all supplementary documents such as radiographs, which should be dated, read, and noted. Entries are made by the dentist in a timely manner and never altered. Altering a record destroys the writer’s credibility. Patient visits are recorded with the date and a note following either the subjective-objective-assessment-plan format or the subjective-objective-opinion-options-assessment-agreedplan format. Because it may be years before a patient brings a lawsuit, the patient record is an essential reminder of what transpired. If the dentist’s handwriting and legibility are not acceptable, dictation and transcription services or computerized recording systems can ensure the record is clear and easily read. Notes taken on radiographs should also be clear and sufficiently descriptive. If the dentist is not comfortable reading the radiographs, an outside service
Always attempt to develop rapport and communication with the patient Before performing any oral surgical procedures, obtain informed (preferably written) consent Document clearly, fully, legibly Always have all necessary equipment (and backups) before beginning surgical procedure Have correct clear and diagnostic radiographs available Never minimize planned surgical procedures— learn to manage patient’s expectations Always provide emergency contact after-hours number and respond timely when called Know when to refer the patient for a second opinion Review all diagnostic laboratory and radiographic studies ordered; if a complication occurs (such as retained root tip, opening into maxillary sinus, patient fracture of adjacent tooth amalgam), tell the patient and document the findings Be knowledgable in the recognition and treatment of common postsurgical complication
(Courtesy of Dym H: Risk management in the dental office. Dent Clin N Am 56:113-120, 2012.)
should be engaged to review them and submit a written report. Before beginning a complicated oral surgical procedure, the dentist should review a mental or written checklist, including the following:
Are the diagnostic radiographs clear? Is all needed equipment ready? Am I certain which tooth needs to be extracted? Have I clearly explained the procedure and possible complications to the patient?
If the general dentist determines that he or she is uncomfortable performing the needed surgical treatment, the dentist is obligated to make a referral. Often patients would prefer not to see a specialist, but it is unethical for the dentist to perform treatments that are beyond his or her training and/or experience. The dentist must document in the chart that a referral was made and record whether the patient followed through with the appointment. If the dentist decides to undertake an oral surgical procedure, he or she must obtain informed consent from the patient. This process produces a well-informed patient who is more likely to have reasonable expectations about
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Issue 4
2013
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the outcome and possible complications. Failing to obtain informed consent can lead to the dentist being held liable to criminal charges such as assault and battery. The treating dentist should be the one who engages the patient in the informed consent process and documents the discussion in the patient’s chart. A printed standard form for the patient to sign is the best way to obtain and document the granting of informed consent after being provided with a diagnosis and treatment options. Educational materials are used as needed. Should the patient choose not to undergo the recommended procedure, this should also be documented as an ‘‘informed refusal.’’ A good patient management practice is to follow-up any significant oral surgical office procedure with a phone call 1 to 3 days later. If the patient’s problem cannot be managed by phone, he or she should be urged to visit the dentist as soon as possible. If the dentist does not followup by phone, the patient should be scheduled for a follow-up office visit at the time of the surgical procedure. If the patient decides not to come for the follow-up visit, this should be documented. If a biopsy was done, the dentist should review the findings, inform the patient, and document the results. If a complication develops, the dentist should inform the patient about the problem and either treat it or refer the patient to a place where he or she can receive treatment. The dentist also documents if the patient refuses to accept the referral. Dentists are not legally obligated and do not have a legal duty to treat every patient they see unless they agree to do so. Those on call for a hospital emergency medicine department or managed by care panels may be bound by hospital bylaws or state laws to accept all patients. Once a doctor–patient relationship is begun, treatment continues until the patient’s condition no longer requires care, the patient leaves the practice, the patient and doctor mutually agree to terminate the relationship, or the doctor chooses to end it. Doctor–patient relationships should not be terminated because of financial disagreements. Patients who are noncompliant, jeopardize the outcome of
care, constantly fail to keep appointments, or verbally or physically abuse the health care provider can be discharged from the doctor’s care, but legal protocols must be observed in this process or the doctor can face charges of abandonment. The dentist should send a letter to the patient via certified mail stating the intention to terminate the relationship. No reason need be given. The dentist must ensure the patient’s condition is stable and not emergent at the time of termination. Patients should be given contact information for a colleague who has agreed to provide care or for a source of health care providers. The patient’s record should document all missed appointments, and so forth. The dentist must also inform the patient that his or her record is available for transfer and that the dentist will be available for emergency care for 2 to 3 months, depending on demographics and the patient’s ability to contact a new dentist.
Clinical Significance.—Not only should dentists possess excellent clinical and technical skill but they should also actively and diligently pursue risk-reduction strategies to avoid litigious situations. They must realize that it is often service-related issues that cause patients to lose confidence in their provision of care and seek legal recourse. If dentists want to perform more complicated oral surgical procedures, they should be prepared to manage postoperative complications, including possible lawsuits.
Dym H: Risk management in the dental office. Dent Clin N Am 56:113-120, 2012 Reprints available from H Dym, Dept of Dentistry/Oral and Maxillofacial Surgery, The Brooklyn Hosp Ctr, 121 DeKalb Ave, Brooklyn, NY 11201; e-mail: [email protected]
Teeth Whitening Professional whitening systems Background.—Smile-enhancing procedures are part of the provision of oral health to patients, helping them to eat, speak, and socialize without embarrassment, discomfort, or active disease. Professional tooth whitening offers the clinician the opportunity to readily improve the patient’s aesthetics. Both in-office and professionally
198
Dental Abstracts
dispensed home products are available. The take-home whitening systems are extremely popular and form the cornerstone of successful long-term smile enhancement. The dental hygienist is an important component in the delivery of professional whitening, whether it is administered at chairside or at home. The best practices and clinical
mainly because of secondary caries or fracture of the tooth or the restoration. These may have nothing to do with the material used for the restoration. Secondary caries occur as part of a continuum from primary caries, which respond to effective clinical and patient efforts in prevention. Fracture is partially the result of having a softer base under the restoration, such as a lining. The strongest material with the best fracture toughness should be used to avoid this problem. Good results are being achieved with the currently available posterior composite materials.
Clinical Significance.—Repair is a viable alternative to replacement and can significantly extend the life of a restoration. Composite restorations perform well in posterior teeth, having AFRs of 1% to 3%. The success of these
restorations depends mainly on factors related to the patient and dentist, as well as to the material used. The use of preventive and conservative approaches to replacement helps achieve the best outcomes. Future materials may address the prevention of secondary caries and the reduction in fracture incidence.
Demarco FF, Corr ea MB, Cenci MS, Moraes RR, Opdam NJ: Longevity of posterior composite restorations: Not only a matter of materials. Dent Mater J 28:87-101, 2012 Reprints available from FF Demarco, Graduate Program in Dentistry, Federal Univ of Pelotas, Rua Gonc¸alves Chaves 457, Pelotas, RS 96015-560, Brazil; fax: þ55 53 3222 6690x135; e-mail: flavio. [email protected] or [email protected]
Risk Management Avoiding lawsuits Background.—Patients who have poor outcomes after oral surgical procedures are more likely than patients who are dissatisfied after other types of dental procedures to file a lawsuit against the dentist. These suits also tend to generate significantly higher awards than suits after a general dental procedure. Steps can be taken to minimize the chance of litigation against the dental practice, which will avoid the entire emotional, painful, and time-consuming experience.
Why Sue?—Factors that encourage lawsuits against dental professionals include several trends in society, as follows:
196
Dental Abstracts
Dentists and other health care providers are no longer considered community leaders as they were in the past. Health care providers are considered business people rather than dedicated healers. Lower insurance payments related to managed care contracts mean health care providers cannot afford the luxury of spending significant time with patients to develop meaningful rapport. Patients see litigation as a solution to their financial needs in this weak economy with high unemployment, significant underemployment, and high levels of personal debt.
It is easy to sue because the patient assumes no cost other than time even if they lose. Lawyers who will take such cases are plentiful.
Box 4.—Risk Reduction Checklist
Why Not Sue?—Not all patients who have poor results sue the dentist so factors must exist that persuade the patient not to bring a lawsuit. Patients who are less likely to sue feel the dentist and staff possess important qualities, specifically, competence, commitment, compassion, caring, honesty, collaboration with the patient/family, thoroughness, qualifications, and humanity. They believe the dentist and staff do what they promise and do the best they can. These qualities prompt the patient to give the health care provider the benefit of the doubt even with a disappointing outcome.
Avoiding Litigation.—Four essential points must be present and proved to succeed in claiming clinical negligence: (1) a duty of care is owed by the dentist to the patient; (2) a breach of duty of care occurred by failing to meet the expected standard of care; (3) the patient suffered harm and/or loss; and (4) the patient’s damages were directly caused by the dentist’s breach of the standard of care. The dentist and staff can take steps to avoid being the target of a lawsuit, focusing on documentation; using good judgment in planning care, referring, and obtaining informed consent; making efforts to provide follow-up and handle complications appropriately; and properly terminating doctor–patient relationships when necessary (Box 4). Complete patient records are not only vital to patient care but also legally required by most state dental boards. Failure to keep such records can lead to a loss of the license to practice. The complete record complies with licensure and accreditation standards, facilitates diagnosis and treatment, provides a defense against potential malpractice claims, serves as the basis for communicating with other health care providers, documents quality assurance information, and provides the basis for obtaining proper reimbursement and substantiating billing codes. Ideal charts measure 8.5 11 inches. Each patient has a separate record that includes all supplementary documents such as radiographs, which should be dated, read, and noted. Entries are made by the dentist in a timely manner and never altered. Altering a record destroys the writer’s credibility. Patient visits are recorded with the date and a note following either the subjective-objective-assessment-plan format or the subjective-objective-opinion-options-assessment-agreedplan format. Because it may be years before a patient brings a lawsuit, the patient record is an essential reminder of what transpired. If the dentist’s handwriting and legibility are not acceptable, dictation and transcription services or computerized recording systems can ensure the record is clear and easily read. Notes taken on radiographs should also be clear and sufficiently descriptive. If the dentist is not comfortable reading the radiographs, an outside service
Always attempt to develop rapport and communication with the patient Before performing any oral surgical procedures, obtain informed (preferably written) consent Document clearly, fully, legibly Always have all necessary equipment (and backups) before beginning surgical procedure Have correct clear and diagnostic radiographs available Never minimize planned surgical procedures— learn to manage patient’s expectations Always provide emergency contact after-hours number and respond timely when called Know when to refer the patient for a second opinion Review all diagnostic laboratory and radiographic studies ordered; if a complication occurs (such as retained root tip, opening into maxillary sinus, patient fracture of adjacent tooth amalgam), tell the patient and document the findings Be knowledgable in the recognition and treatment of common postsurgical complication
(Courtesy of Dym H: Risk management in the dental office. Dent Clin N Am 56:113-120, 2012.)
should be engaged to review them and submit a written report. Before beginning a complicated oral surgical procedure, the dentist should review a mental or written checklist, including the following:
Are the diagnostic radiographs clear? Is all needed equipment ready? Am I certain which tooth needs to be extracted? Have I clearly explained the procedure and possible complications to the patient?
If the general dentist determines that he or she is uncomfortable performing the needed surgical treatment, the dentist is obligated to make a referral. Often patients would prefer not to see a specialist, but it is unethical for the dentist to perform treatments that are beyond his or her training and/or experience. The dentist must document in the chart that a referral was made and record whether the patient followed through with the appointment. If the dentist decides to undertake an oral surgical procedure, he or she must obtain informed consent from the patient. This process produces a well-informed patient who is more likely to have reasonable expectations about
Volume 58
Issue 4
2013
197
the outcome and possible complications. Failing to obtain informed consent can lead to the dentist being held liable to criminal charges such as assault and battery. The treating dentist should be the one who engages the patient in the informed consent process and documents the discussion in the patient’s chart. A printed standard form for the patient to sign is the best way to obtain and document the granting of informed consent after being provided with a diagnosis and treatment options. Educational materials are used as needed. Should the patient choose not to undergo the recommended procedure, this should also be documented as an ‘‘informed refusal.’’ A good patient management practice is to follow-up any significant oral surgical office procedure with a phone call 1 to 3 days later. If the patient’s problem cannot be managed by phone, he or she should be urged to visit the dentist as soon as possible. If the dentist does not followup by phone, the patient should be scheduled for a follow-up office visit at the time of the surgical procedure. If the patient decides not to come for the follow-up visit, this should be documented. If a biopsy was done, the dentist should review the findings, inform the patient, and document the results. If a complication develops, the dentist should inform the patient about the problem and either treat it or refer the patient to a place where he or she can receive treatment. The dentist also documents if the patient refuses to accept the referral. Dentists are not legally obligated and do not have a legal duty to treat every patient they see unless they agree to do so. Those on call for a hospital emergency medicine department or managed by care panels may be bound by hospital bylaws or state laws to accept all patients. Once a doctor–patient relationship is begun, treatment continues until the patient’s condition no longer requires care, the patient leaves the practice, the patient and doctor mutually agree to terminate the relationship, or the doctor chooses to end it. Doctor–patient relationships should not be terminated because of financial disagreements. Patients who are noncompliant, jeopardize the outcome of
care, constantly fail to keep appointments, or verbally or physically abuse the health care provider can be discharged from the doctor’s care, but legal protocols must be observed in this process or the doctor can face charges of abandonment. The dentist should send a letter to the patient via certified mail stating the intention to terminate the relationship. No reason need be given. The dentist must ensure the patient’s condition is stable and not emergent at the time of termination. Patients should be given contact information for a colleague who has agreed to provide care or for a source of health care providers. The patient’s record should document all missed appointments, and so forth. The dentist must also inform the patient that his or her record is available for transfer and that the dentist will be available for emergency care for 2 to 3 months, depending on demographics and the patient’s ability to contact a new dentist.
Clinical Significance.—Not only should dentists possess excellent clinical and technical skill but they should also actively and diligently pursue risk-reduction strategies to avoid litigious situations. They must realize that it is often service-related issues that cause patients to lose confidence in their provision of care and seek legal recourse. If dentists want to perform more complicated oral surgical procedures, they should be prepared to manage postoperative complications, including possible lawsuits.
Dym H: Risk management in the dental office. Dent Clin N Am 56:113-120, 2012 Reprints available from H Dym, Dept of Dentistry/Oral and Maxillofacial Surgery, The Brooklyn Hosp Ctr, 121 DeKalb Ave, Brooklyn, NY 11201; e-mail: [email protected]
Teeth Whitening Professional whitening systems Background.—Smile-enhancing procedures are part of the provision of oral health to patients, helping them to eat, speak, and socialize without embarrassment, discomfort, or active disease. Professional tooth whitening offers the clinician the opportunity to readily improve the patient’s aesthetics. Both in-office and professionally
198
Dental Abstracts
dispensed home products are available. The take-home whitening systems are extremely popular and form the cornerstone of successful long-term smile enhancement. The dental hygienist is an important component in the delivery of professional whitening, whether it is administered at chairside or at home. The best practices and clinical