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Risk management considerations for oral cancer
A BETTER PRACTICE CHARLES P. HAPCOOK SR., D.D.S., F.A.C.D.
Risk management considerations for oral cancer roper patient assessment and documentation are two of the most important risk management concepts for all dentists that I see as the chief executive officer of a malpractice insurance carrier. These risk management concepts are particularly important in light of the ever-increasing concern about the timely and proper treatment of patients with oral cancer. Before addressing these concerns, I must stress that the intent of this column is not to provide a comprehensive guide to the clinical dental procedures associated with oral cancer, but rather to give dentists some insight into the potential for claims and to present risk management advice that will help avoid problems. It is well-documented that oral pharyngeal cancers affect 30,000 people per year in the United States alone.1 Of these cases, approximately 8,000 will result in death. It is important to understand that the greatest number of these deaths occur in people older
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than 40 years and who have a history of smoking, regular alcohol use or both. In addition, oral cancers appear more often in men than in women. Many of the major legal claims against U.S. dentists involve oral cancer, ranging from failure to diagnose to inappropriate posttreatment dental services. An excellent
Carefully following procedures will help dentists avoid legal pitfalls.
guide titled “Performing a DeathDefying Act: The 90-Second Oral Cancer Examination” was published in the Special Supplement to the November 2001 issue of JADA,2 and I recommend that all dentists review it. PROPER PATIENT ASSESSMENT
The first step in patient assessment and treatment planning should be a careful review of the patient’s medical history to note
any predisposing factors. This should be followed by a comprehensive oral evaluation that include careful intraoral and extraoral examinations, which include all aspects of the tongue, floor of the mouth, and the hard and soft palates, as well as palpation of the nodes. This clinical examination should be followed by a review of oral radiographic images to note any possible abnormalities in the dentition and bones of the patient. However, it is not enough to perform this examination. The clinician should document each area carefully and clearly in the patient’s permanent record. Not only should dentists note any abnormalities, but they should record all normal areas as well. Failure to do so could be used by a plaintiff’s attorney as evidence that the dentist did not perform an examination. For abnormalities or suspicious lesions found during the evaluation, the dentist should either schedule the patient for a re-evaluation or properly refer the patient. Failure to follow
www.ada.org/goto/jada November 2005 Copyright ©2005 American Dental Association. All rights reserved.
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these procedures on a timely basis can result in a more severe medical and dental consequence for the patient and an onerous legal consequence for the dentist, especially in the case of oral cancer. PROPER DOCUMENTATION
To meet the basic standard of care, every dentist is required to perform these examinations and to note all of the results affiliated with them. However, a dentist’s responsibility does not end with a diagnosis, recommendation for treatment and the sequence for the treatment. The dentist also must understand the need to take special clinical precautions before, during and after treatment for various medical conditions, including oral cancer. In the case of oral malignancies, these precautions may pertain to the surgery, radiation therapy or chemotherapy a patient may be undergoing.
For example, it has long been known that the necessary extraction of teeth should be performed before radiation therapy for oral cancer. After radiation therapy, there is an increase in the risk of developing postradiation osteonecrosis. This potential necrosis also has been noted after certain chemotherapy treatments. Therefore, it is absolutely essential that the treating dentist contact the patient’s oncologist to determine what special precautions should be taken for the patient before and after he or she undergoes medical treatment such as radiation therapy. It also is imperative that the medical history in a patient’s record include whether the patient has undergone such medical treatment. The record also should note any necessary precautions related to the patient’s dental care. Providing treatment without taking into
B E T T E R
P R A C T I C E
consideration the patient’s medical condition and the precautions necessary because of the medical condition also can result in complications involving both the medical and dental care and could provide the basis for a major legal claim. SUMMARY
Carefully following procedures in their practices will help dentists avoid legal pitfalls and go a long way toward providing a positive clinical service to their patients. ■ Dr. Hapcook is president and chief executive officer, Eastern Dentists Insurance, 200 Friberg Parkway, Suite 2002, Westborough, Mass. 01581, e-mail “[email protected]”. Address reprint requests to Dr. Hapcook. 1. U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Oral cancer. Bethesda, Md.: National Institute of Dental and Craniofacial Research, National Oral Health Information Clearinghouse; 2003. NIH publication 03-5032. 2. Horowitz AM. Performing a death-defying act: the 90-second oral cancer examination. JADA 2001;136:36S-40S.
JADA, Vol. 136 www.ada.org/goto/jada November 2005 Copyright ©2005 American Dental Association. All rights reserved.
1567
Risk management considerations for oral cancer roper patient assessment and documentation are two of the most important risk management concepts for all dentists that I see as the chief executive officer of a malpractice insurance carrier. These risk management concepts are particularly important in light of the ever-increasing concern about the timely and proper treatment of patients with oral cancer. Before addressing these concerns, I must stress that the intent of this column is not to provide a comprehensive guide to the clinical dental procedures associated with oral cancer, but rather to give dentists some insight into the potential for claims and to present risk management advice that will help avoid problems. It is well-documented that oral pharyngeal cancers affect 30,000 people per year in the United States alone.1 Of these cases, approximately 8,000 will result in death. It is important to understand that the greatest number of these deaths occur in people older
P
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JADA, Vol. 136
than 40 years and who have a history of smoking, regular alcohol use or both. In addition, oral cancers appear more often in men than in women. Many of the major legal claims against U.S. dentists involve oral cancer, ranging from failure to diagnose to inappropriate posttreatment dental services. An excellent
Carefully following procedures will help dentists avoid legal pitfalls.
guide titled “Performing a DeathDefying Act: The 90-Second Oral Cancer Examination” was published in the Special Supplement to the November 2001 issue of JADA,2 and I recommend that all dentists review it. PROPER PATIENT ASSESSMENT
The first step in patient assessment and treatment planning should be a careful review of the patient’s medical history to note
any predisposing factors. This should be followed by a comprehensive oral evaluation that include careful intraoral and extraoral examinations, which include all aspects of the tongue, floor of the mouth, and the hard and soft palates, as well as palpation of the nodes. This clinical examination should be followed by a review of oral radiographic images to note any possible abnormalities in the dentition and bones of the patient. However, it is not enough to perform this examination. The clinician should document each area carefully and clearly in the patient’s permanent record. Not only should dentists note any abnormalities, but they should record all normal areas as well. Failure to do so could be used by a plaintiff’s attorney as evidence that the dentist did not perform an examination. For abnormalities or suspicious lesions found during the evaluation, the dentist should either schedule the patient for a re-evaluation or properly refer the patient. Failure to follow
www.ada.org/goto/jada November 2005 Copyright ©2005 American Dental Association. All rights reserved.
A
these procedures on a timely basis can result in a more severe medical and dental consequence for the patient and an onerous legal consequence for the dentist, especially in the case of oral cancer. PROPER DOCUMENTATION
To meet the basic standard of care, every dentist is required to perform these examinations and to note all of the results affiliated with them. However, a dentist’s responsibility does not end with a diagnosis, recommendation for treatment and the sequence for the treatment. The dentist also must understand the need to take special clinical precautions before, during and after treatment for various medical conditions, including oral cancer. In the case of oral malignancies, these precautions may pertain to the surgery, radiation therapy or chemotherapy a patient may be undergoing.
For example, it has long been known that the necessary extraction of teeth should be performed before radiation therapy for oral cancer. After radiation therapy, there is an increase in the risk of developing postradiation osteonecrosis. This potential necrosis also has been noted after certain chemotherapy treatments. Therefore, it is absolutely essential that the treating dentist contact the patient’s oncologist to determine what special precautions should be taken for the patient before and after he or she undergoes medical treatment such as radiation therapy. It also is imperative that the medical history in a patient’s record include whether the patient has undergone such medical treatment. The record also should note any necessary precautions related to the patient’s dental care. Providing treatment without taking into
B E T T E R
P R A C T I C E
consideration the patient’s medical condition and the precautions necessary because of the medical condition also can result in complications involving both the medical and dental care and could provide the basis for a major legal claim. SUMMARY
Carefully following procedures in their practices will help dentists avoid legal pitfalls and go a long way toward providing a positive clinical service to their patients. ■ Dr. Hapcook is president and chief executive officer, Eastern Dentists Insurance, 200 Friberg Parkway, Suite 2002, Westborough, Mass. 01581, e-mail “[email protected]”. Address reprint requests to Dr. Hapcook. 1. U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Oral cancer. Bethesda, Md.: National Institute of Dental and Craniofacial Research, National Oral Health Information Clearinghouse; 2003. NIH publication 03-5032. 2. Horowitz AM. Performing a death-defying act: the 90-second oral cancer examination. JADA 2001;136:36S-40S.
JADA, Vol. 136 www.ada.org/goto/jada November 2005 Copyright ©2005 American Dental Association. All rights reserved.
1567