Cosmetic medicine is not an exact science, and patients occasionally have less than perfect outcomes with dermal fillers. Less experienced providers are more likely to make mistakes such as overfilling and asymmetry. Other side effects such as infection and allergic reactions can occur. Hyaluronic acid fillers such as Juvederm and Restylane products can be partially or completely removed with an enzyme called hyaluronidase. When injected into the affected areas, hyaluronidase dissolves the hyaluronic acid particles and may help in the event of vascular compromise, lumpy or irregular texture, infection in the treatment area, overfilling and dissatisfying results. Hyaluronidase isn’t perfect, and since products tend to be made from animal derivatives, certain patients may be at higher risk for allergic reaction and therefore not good candidates for the treatment. Make sure your patients know to call you immediately if they are experiencing pain, or unusual swelling, or the area feels warm to the touch. These are signs of infection that need to be addressed swiftly. Calcium based fillers can NOT be reversed with hyaluronidase. Each dermal filler product is unique and a wide variety of products are available. If this is a procedure you rarely provide, you might want to consider whether the possible complications are worth it. -Berkley Risk Complications with Dermal Filler Procedures. Is it worth it?
No Child under the age of 12 should snore. If they do, they me be suffering from obstructive sleep apnea. Children can be misdiagnosed with ADHD when in fact they have OSA. Common symptoms of OSA in children are: Sleep in abnormal positions, snore loudly and often, stop breathing, sweat during sleep, behavioral problems. Restless sleep. Headaches in the am and bed wetting. As a dentist some of the oral signs you may notice are: mouth breathing, chapped lips, exaggerated gag reflex and dark circles around their eyes. We as dentists, see our patients more frequently than MD’s do so we can screen and refer to sleep specialists. We can CURE KIDS with OSA with early treatment (tonsillectomy and max expansion with forward maxillary growth) but adults we can only treat. So, Keep your eyes open!!!
By Dr. Lindsay Compton
I knew when I left school I needed a few necessities to practice dentistry. I needed to have passed boards. Check. I needed to apply for my state license. Check. I needed to have malpractice insurance. Sure? Maybe? Kinda?
Myself and my classmates set out on the mad dash to get malpractice insurance, and true to dental student fashion, I needed the best deal. The only problem was that I had no idea what the words in the malpractice policy even meant. Seriously! How could I have endured the trials and tribulations of dental school and not know what the composition or the key terms in my malpractice quote. Further, how am I going to judge if what’s in my policy is what I really need?
Let me simplify your life and give you the skinny on the components and meaning of your malpractice insurance. First, don’t get caught up in terminology. Malpractice insurance and professional liability insurance are the same thing. It’s also the same as errors and omissions insurance. It protects you against a claim that the dentistry you provided was done in error or an omission of treatment. If a claim is made and brought to trial, it will pay for your defense and damages whether the claim was unfounded or not. Keep your auto, home, life, and umbrella insurance. These don’t overlap. It will only cover you in civil matters in the practice of dentistry.
Next up are the really large numbers that the State Dental Board asks for you to have covered. It looks like this: Effective July 1, 2010, the law requires a minimum indemnity amount of $1,000,000 per incident and $3,000,000 annual aggregate per year, or an acceptable alternative as set forth in Board Rule 220.
Let’s break that down. Minimum indemnity amount is the maximum amount an insurance company will pay out for any one claim in one year. At this time, Colorado asks that you have $500,000 of minimum indemnity. An example of this would be if a patient claimed that you failed to diagnose their periodontal disease and therefore they are losing all their teeth. When the insurance company acts to defend you by retaining an attorney and acquiring testimony and other needed items in a civil court case, the most they will pay out is $1,000,000 per case.
Taking that a step further is the annual aggregate per year. This is the total amount an insurance company will spend on defending you in one year. So if you have multiple claims in one year, the insurance company will stop covering the costs at $3 million. You may ask, “What if legal fees are greater than $1 million for one case or $3 million in one year?” In that situation you would then be responsible for the rest of the bill.
As a new dentist myself, I have a couple of words of advice despite the grim topic. Get malpractice insurance from a company where you can talk to a real live person. If something were to happen, you don’t want to be encouraged to send an email or chat online. You will be panicked and you need a voice on the other end of the phone. Sign up with a company that has dentists on their board and is run by dentists. Don’t rely on statisticians and historians to comb through legal cases to see if your claim can be won or not. Have a group of dentists that are on your side and looking out for your ability to practice dentistry. Unfortunately we live in a litigious society and some patients believe that a malpractice payout could secure their financial future. Practice with confidence and only practice with The Trust.
by Dr. Candace DeLapp
Texting has become more common as a means of communication. It’s easy and convenient for all parties. However, it is not without pitfalls. Below are a couple of situations you need to know about texting and malpractice claims.
- A patient texts you or your office with “a quick question.” Avoid the quick answer back. Maybe have the patient in for a face-to-face conversation or let them know you want to investigate further and will get back with them. Patients can and will use text messages against you!
- Do not conduct business via texting. Your office should not be texting billing statements (balances due) or any private information via a text. A personal phone call or statement should be sent. Speak with the patient in person (don’t leave a detailed message) and ask them to return your call. HIPPA and privacy issues come in to play here. Have you ever dialed the wrong number?
- Appointment reminders are acceptable via texting, but no personal information should be included. Just the day and time of the dental appointment. No details as to what is to be performed. Again, this is a privacy issue. You don’t know who has access to the text.
It’s important to remember that anything stored on a phone can be retrieved and used as evidence.
Be careful what you text!
By Dr. Todd Pickle
I am sure you have never had a situation where two or more implants are either too close together or angled into each other to the point that you cannot get the metal impression copings on at the same time. But if this ever does happen, I have found the best thing to do is use a plastic version of the impression coping if your implant company makes one, which many do. This will allow you to cut the copings so that they all fit and you can pick them up in one closed-tray impression.
Plastic impression copings are single-use anyway, whereas metal copings that you have to cut are usually not usable again. They are not accurate enough for multi-use and the plastic components deform during use beyond their elastic ability to accurately be used again. But if you cannot find a plastic version of the impression coping, you should try to find a plastic TEMPORARY coping. These can be customized with resin ‘blobs’ so that they will pick-up in the impression and serve the same purpose.
Make sure you decide if you need engaging or non-engaging copings before you make the impression. Some companies call these parts “bridge copings”. Only single unit crowns need engaging copings, so stick with non-engaging components for everything else, including impressions.
Use this tip to make a good impression!
By Dr. Todd Pickle
Polytetrafluoroethylene is a truly amazing material used in many industries and has lots of uses in dentistry and everyday life!
The #1 best use in Dentistry: Closing screw access holes in implant abutments, crowns and hybrids prostheses! PTFE is very hydrophobic and does not collect microorganisms like cotton pellets or retraction cords, or heaven forbid wax! It can be packed and condensed, and then other restorative materials placed over it and they won’t stick to it. It will protect the implant screw so that your implant components are retrievable, which is a prime benefit of dental implants over teeth.
It is important to place the PTFE tape starting in the deepest portion of the screw access hole directly on top of the implant screw head. Then continue to pack the tape (start with a long piece about 2 inches) until you have about 2-3mm remaining of the occlusal portion of the screw access hole. This will allow enough space for adequate filling materials (interim or permanent) to be placed over the PTFE tape and not always falling out and needing replaced. But it also means you don’t have to dig very deep when you need to take it out.
Other dental-related uses include: Using it in endodontic access holes, blocking out undercuts or adjacent teeth around composite placements, covering sutures while making impressions (instead of rubber dams). “Gore-Tex” sutures are PTFE because they are strong, do not attract microorganisms and do not resorb.
And of course, threading pipes for plumbing! And best of all it is cheap and you can get it at Home Depot!
By Dr. Sarah D. Parsons
Dentistry is personal. It’s personal to us because we put our heart and soul into treating patients and growing our business. We have dedicated our life’s work to cultivate our dental practices.
But, there is a patient that is unhappy. A variety of reasons can make a patient unhappy. There is a miscommunication with a team member, a disagreement over finances, or a perceived bad experience by the patient of some type. The patient calls or comes to the office and they are unhappy, so how should you handle this?
First, it is important to stay calm. We as clinicians take these situations very personal. But we must put on our “doctor hat” and try to diffuse the situation in a professional manner without bringing our personal feelings into the situation. We may feel the patient does not understand the situation or does not have all the information. This may be true; however, most unhappy patients just want to be heard.
Invite them into a consultation room or treatment room away from other patients. Hear them out. Let them tell you in their own words why they are upset and unhappy. Your job is to just LISTEN! Many times this diffuses the situation immediately; do not interrupt or try to correct them. Let them tell their perceptions of the situation from beginning to end. Let them know that your hear them and you understand their frustrations. Reassure them that you will be taking the time to review their grievances and that you will help find a way to make it right.
DOCUMENT, DOCUMENT, DOCUMENT! Do not wait. Immediately document the situation with the patient and write their exact words in quotes. Be sure to call Dr. Randy Kluender or Dr. Candace DeLapp to discuss the situation and the best way to resolve your issue.
We know that your dental practice is personal. That’s why we make it our mission to take these situations as personal as you do. We have licensed dentists who have been in private practice who understand your day to day business. We make it our mission to always take your practice as personal.
By Dr. Candace DeLapp
Senate Bill 22 (SB18-22): Clinical Practice for Opioid Prescribing was signed in to law May 2018.
Briefly, its impact on the practice of Dentistry is:
Initial prescription must be limited to a seven-day supply if the prescriber has not written an opioid prescription for the patient in the last 12 months.
The limits on initial prescribing do not apply if, in the judgement of the dentist, the patient:
- has chronic pain that lasts longer than 90 days or past the time of normal healing, as determined by the dentist, or following transfer of care from another dentist who prescribed an opioid for the patient;
- has been diagnosed with cancer and is experiencing cancer-related pain; or
- is experiencing post-surgical pain that, because of the nature of the procedure, is expected to last more than fourteen days.
The prescriber may exercise discretion for a second seven-day prescription.
The prescriber must check the Prescription Drug Monitoring Program (PDMP) database except under specific requirements:
- the patient is experiencing post-surgical pain which routinely exceeds 14 days;
- the patient has cancer or cancer-related pain;
- the prescription is administered by an in-patient facility
- the patient is in hospice or palliative care
For more information on opioid prescribing contact The Trust:
Dr. Kluender [email protected]
Dr. DeLapp [email protected]
Or read the bill here.
By Dr. Lindsay Compton
Dentists don’t practice alone or in a bubble. That would be boring and I personally feel that I would be missing out on a lot of fun and comradery. I consider my hygienist leader in my dental team and sometimes an appendage of my body. For me and my practice philosophy, I wouldn’t practice without a hygienist.
As an important practitioner in the dental office, does the hygienist need malpractice insurance? The oversimplified answer is no. In most instances, the dentist’s professional liability or malpractice insurance will cover the employed dental hygienist. You’ll notice that I said the words “in most instances,” which means not always. Which means there probably was a time when the hygienist was liable. Which means there exists a situation when the hygienist needs their own malpractice insurance.
Let’s look at an example of this. Let’s say that your hygienist was placing sealants on a patient. Unfortunately the etch tip was not securely placed on the tube. As they were carrying it from the patient tray to the patient, the tip popped off and etch was expressed all over the patient’s face and eye. Did I say they patient was not wearing eye protection as well? To make matters worse, the patient had a horrible reaction between their face cream and the phosphoric etch and their face became scarred. The patient not only needed emergency treatment for their eye, but they also needed cosmetic facial and reconstructive surgery to cover up the scar created from the unsecured etch tip. In this instance, the dentist and the hygienist were both listed on the civil law suit. The legal fees and medical fees were over the required state coverage. Therefore both the dentist and hygienist were responsible for the difference in damages because both were listed on the case.
Could just a hygienist be named in a law suit? Yes they can. It would look something like this next example. An elderly patient gets up from a patient visit and uses the back of the patient chair to steady themselves as they exit the operatory. Unfortunately as they reach for the headrest on the chair, they instead only grab the headrest cover that wasn’t secure enough for the needs of the patient. The patient falls and hits their head on the counter top. They end up needing stitches in their head and sue the hygienist, not the dentist, because it was their responsibility for the upkeep of the operatory. Since only the hygienist was named on the law suit, the dentist’s malpractice insurance will not cover the hygienist.
Outside of the scope of this blog is the hygienist that practices independently. Without the direct supervision of a dentist, the hygienist is the sole care provider and is solely liable and must carry their own professional liability insurance.
If your hygienist is weary of the threat of a lawsuit, he or she may purchase professional liability insurance that would cover them if any of the above examples, or situations like them, become true. A resource in Colorado to find out more would be the Colorado Dental Hygienist Association.
By Dr. Sarah D. Parsons
Many patients report to our offices with PTSD. These patients have undergone perceived severe mental or physical abuse that elicits mental, physical, or combined responses. It can be challenging to treat these patients due to their fear and intolerance of pain and anxiety. Often times we seek additional sedation measures such as nitrous, minimal, moderate, or even deep/hospital sedation.
Profound local anesthesia is the cornerstone to management of any dental case in general but is especially important to any successful management of PTSD. The more that we as clinicians can deliver successful and profound anesthesia, the better outcome our cases achieve. Never as a clinician should we dismiss a patient’s reporting of discomfort or pain during a procedure. Rather in these instances, we should consider and evaluate our anesthesia.
Sedation of any form is not a replacement for profound local anesthetic but rather an adjunct to help ease the anxiety of the dental patient. Prior to additional doses of sedatives, profound anesthesia should be confirmed. Many patients tolerate more complicated procedures and sedation cases are more successful, if profound anesthesia is achieved.
Adequate interviewing of a patient with PTSD is helpful prior to any dental procedure performed. This can also aid us in the decision of what sedation level is appropriate. Many clinicians believe that only moderate to deep sedation will be useful to treat a PTSD patient. However, this is not always the case and a comprehensive examination and treatment plan should be performed prior to any dental procedure.
Here are some questions you may want to consider in your interview with a patient that has PTSD prior to any dental treatment:
- May I inquire the reason for your PTSD diagnosis
- Are there any specific lights, sounds, or situations which trigger your PTSD?
- During your procedure, there will be clinicians whom will be female/male or both. We will be over you and looking down at you during the procedure. Will this trigger your PTSD? Would you be more comfortable with an all male or all female team?
- What are some calming measures you use during a PTSD episode? If you are triggered during this procedure, what measurements would you like me to use to help you through your episode?
- Do you feel you should be more sedated or more awake for your procedure?
Management and treatment of PTSD patients can be successful in your dental practice. These patients can become loyal and long term great patients. If you manage your treatment of these patients successfully with profound anesthesia and appropriately sedate to the level they require, they will return and become some of your practice’s biggest fans and cheerleaders.