risk management presentation
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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
1
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
2
Standardof Care
To a lesser extent, what is published in peer-reviewed journals
State licensing boardsAnd, unfortunately:
By juries in malpractice actions
3
Standardof Care
Juries determine standards of care based on information presented during trials:Patient RecordsTestimony of staff and other witnessesExpert witness testimony
4
Standardof Care
Is there a separate standard of care for a specialist than for a general dentist doing specialty work?
NO!!!
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Standards of CarePeriodontology
Paul Levy, DDS
6
Failure to diagnose and treat periodontal disease falls below
the standard of care.
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First, an accurate diagnosis is essential. Then an appropriate treatment plan including etiology and prognosis must be formulated.
8
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.
9
Second, treatment is traditionally divided into 3 phases:
Non-surgical Therapy Surgical Therapy Maintenance Phase
10
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
11
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.
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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
14
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.
15
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.
16
Consent may be verbal or written but it must be fully understood by the patient. I use different forms for each procedure.
17
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.
18
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.
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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.
20
OSHA
Occupational Safety and Health Administration
♦Universal precautions and bloodborne pathogens
♦ Hazard communication♦ Waste management♦ Illness and injury prevention
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HIPAA
Health Insurance Portability and Accountabilty
Electronic Transaction StandardPrivacy StandardSecurity Standard
HIPAA is enforced by the Office of Civil Rights
22
Continually Upgrade Skills
Use updated comprehensive text books, continuing education courses, current studies in the scientific literature.
23
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
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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.
25
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?
26
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).
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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.
28
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?
29
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.”
30
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?
31
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.
32
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.
33
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.
34
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.
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Periodontal Plastic Surgery:
Framework for the Perfect Smile
36
Esthetics
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Achieving Optimal Esthetic Results
Treatment Options Resective Therapy Augmentation Therapy
Root coverage procedures
Hard and soft tissue ridge
augmentation38
Esthetics
Crown Lengthening
39
Anterior Crown Lengthening
Pre-restorative For smile enhancementBiologic width sensitivePapillary retention critical
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Before
After 41
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Crown Lengthening
Before
After
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Crown Lengthening
Before Incisions
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Crown Lengthening
Immediate Post-Suturing
One-Month Healing
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Crown Lengthening
Before
Incision
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Crown Lengthening
Before After
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Crown Lengthening
Before
One-Month Postsurgical
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Crown Lengthening
Before
Incisions
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Crown Lengthening
Immediate Post-Op
Surgical
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Crown Lengthening
Before
Incisions
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Crown Lengthening
Before After
52
Augmentation Therapy
Hard and Soft Tissue
Augmentation Procedures
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Augmentation Therapy
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.
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Augmentation Therapy
Root Coverage Procedures
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Root Coverage
Before
Immediate Post-Op
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Root Coverage
Before
After
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Root Coverage
BeforePrepared Root Surfaces
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Root Coverage
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Root Coverage
Before After
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Root Coverage
Before
After
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Root Coverage
Before
After
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Augmentation Therapy
Root Coverage for
Implants
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Root Coverage for Implants
After
Before
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Augmentation Therapy
Ridge Augmentation
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Root Coverage for Implants
After
Before
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Ridge Augmentation
Before
After
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Ridge Augmentation
Before
Post-Suturing
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Ridge Augmentation
Before
After
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Augmentation Therapy
Site Preservation
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Site Preservation
Before
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Site Preservation/Root Coverage
Before
One-Month Post-Extraction
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Site Preservation
Before
After
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Site Preservation/Ridge Augmentation
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Site Preservation
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Site Preservation
Before After
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Augmentation Therapy
Combination Procedures
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Combination Procedures
Before
After
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Combination Procedures
Before
Suturing
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Combination Procedures
Before After
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Combination Procedures
Incisions
Before
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Combination Procedures
Before
Immediate Post-Suturing
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Combination Procedures
AfterBefore
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Combination Procedures
Before After
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Esthetics with Implants
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Site Preservationfor Implants
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Before
Site Preservation/Implants
Immediate Post-Op
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Site Preservation/Implants
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Site Preservation/Implants
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Implant Placement
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Implant Placement
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After
After
Site Preservation/Implants
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Site Preservation/Implants
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Augmentationand
Implants
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Before
Guided Bone Regeneration
Implant Site Development
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Implant Placement
Gingival Augmentation
Augmentation/Implants
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Augmentation/Implants
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Augmentation/Implants
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Final Results
Augmentation/Implants
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Before After
Augmentation/Implants
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The Key that Brings it Together:
CommunicationInterofficePatient
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Standards of Carein Endodontics
Peter Velyvis, DDSLimited to Endodontics
105
Diagnosis
Evaluation of pulpal and periradicular status must be performed for every tooth to be treated
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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”
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Diagnosis
Pulpal and periradicular diagnosis should be formulated for each tooth to be treated using endodontic terms
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Pulpal Diagnosis
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Periradicular Diagnosis
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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
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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)
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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
114
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
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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
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Antibiotics
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Narcotics
Narcotics should be used to temporarily control breakthrough painThey do little to relieve the source
of the patient’s pain
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Endodontic Treatment
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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.)
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Rubber Dam
• This is the only AAE dictated standard of care
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Anesthesia
• My advice, don’t skimp
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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
123
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.
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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
125
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.
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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.
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Cone Bean CT Scans
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Cone Bean CT Scans
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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
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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
131
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
132
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
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Filling Materials
No more Silver Points
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Filling Materials
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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
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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.
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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
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Post Treatment
139
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.
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Extraction/Implants
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Cracked Teeth
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Cracked Teeth
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Cracked Teeth
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Cracked Teeth
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Documentation
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Standards of CareProsthodontics
Robert J. Chapman DMD
147
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
148
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
149
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
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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
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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
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What Determines Success?
Three things:DiagnosisTreatment planning
OHRQOL - Patient CenteredPrognosis from Evidence Based Information
Informed consentOHRQOL - Patient CenteredPrognosis from Evidence Based Information
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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
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(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
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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
157
American College of Prosthodontics
Not procedural standards but Prosthodontic Diagnostic Index Resources (PDI)
Class IV = refer to a prosthodontist
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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
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Comprehensive Standards
University of Kentucky
Very thorough and complete without being overly detailed
Long but worth reviewing
161
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.
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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.
163
Standards would be impossible to achieve if too
detailed and without exceptions.
Be careful which ones you choose.
164
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.
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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.
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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
167
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
168
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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.
170
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
press
171
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
172
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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Questions
174
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