Periodontal Disease and Diagnosis

I’m back! Been a while due to time constraints but back in the saddle now.

Over the course of the past few years I have done a number of locum tenens assignment (fill in for a doctor who is out on vacation or sick or other reasons). As well over these past year or so I have been teaching at a dental school and one of the topics is diagnosis and treatment planning. At the risk of stating the obvious, actually having  a diagnosis (relative to periodontal disease ) in the chart should be a given. In the near future, it will become the standard of care.  We pound this into the second year student’s head. But time after time I see a failure in the private dental sector to do the same. The diagnosis should be more than “gum disease”. To give you a brief example…..Mild chronic generalized periodontitis is a diagnosis which should be written in the chart. I suspect I am speaking more to the dentists but patients need to be aware of how  accurate their practitioner is being relative to their periodontal or gum status. Next time you are in the hygiene chair ask your hygienist what your diagnosis is and see the response. Just a thought….let me know if you have any questions.

 

 

Unacceptable outcome and standard of care

Over the past few months I have reviewed a couple of cases of dissatisfied patients whom were unhappy with the outcome of their treatment. These cases were pursuing dental malpractice.

Does this mean there is negligence and the patient can recover damages or monies from the dentist? Not always. In fact, the last two cases I reviewed are a good example.

In those cases, the records failed to substantiate the doctors’ care fell below the acceptable standard of care. Judging standard of care is not a personal estimation, but a legal standard. Patients often confuse a poor or personally unacceptable individual result with the legal concept of “standard of care”. Standard of care is the average degree of skill, care, and diligence exercised by members of the same profession practicing in the same or a similar locality in light of the present state of medical and surgical science. The legal definition is concerned with the skill, care, and diligence of the dentist, not with the individual outcome of a particular patient.

Bottom line: the lack of an acceptable result is not and of itself sufficient legally to prove the dentist treatment fell below the standard of care.

Root Canals and Malpractice

Endodontic therapy–or root canal therapy–is a common dental treatment for a number of reasons. These include caries (decay) or fractures of a tooth. Root canals are necessary to save the tooth. In most cases, the options are either root canal therapy or extraction. Loss of teeth is detrimental to the long term oral health (and overall health) of an individual.

Root Canal DiagramNot all teeth are equal when it comes to root canal therapy. Some are easier than others. Some teeth require a specialist. Others can be done by a general practitioner. Usually the GP is the gatekeeper and decides who treats the tooth. If the GP feels he or she can do the case, that is great. It saves the patient from additional appointments and travel to another office. However, if the GP chooses to do the case they are held to the same standard as if a specialist does the case. This is important to remember.

When done correctly, root canals have a greater than 95% success rate. There can be a failure due to circumstances beyond the dentist’s control, namely the fracture of the tooth. However, if you have a failure on your hands, the dentist must determine the cause. Is it iatrogenic (illness caused by physician) due to the standard of care being violated?

If you have a failure and the case was done by a GP and the reason for failure is not evident, seek the opinion of an endodontist. An endodontist is a dental specialist with an additional two years of training and only does root canals. Many times a tooth can be retreated successfully. However, the success rate declines to approximately 75%.

Determine the cause of failure and then decide your options when deciding if dental malpractice has occurred.

What is dental malpractice?

Dental malpractice, by its definition, is the failure of the dental practitioner to meet the standard of care.

Let’s give some examples:

1. Failure to diagnose periodontal disease. Periodontal probing or pocket measurements should be taken every hygiene visit. Gum disease doesn’t appear overnight!

2. Failure to diagnose caries. Large carious lesions (decayed areas) don’t occur overnight. Caries should be detected at early stage and treated appropriately.

3. Dental work which is substandard. Example: all caries or decay not removed from a tooth prior to restoring it. Example: Crown margins which are “open” and don’t fit properly to the tooth.

4. Failure to detect oral cancer. Screening should be done every hygiene visit.

These are some of the major examples but there are others which may vary from case to case but these are the major ones.

Next time we will discuss what to do when the above occurs.

 

 

 

Radiographs (X-rays). Are they necessary?

You bet.

There are two broad types of films. One–general survey film, such as a panorex. The purpose of the panorex is is a broad overview of the jaw, and to some degree the TMJ. It enables the dentist to see the apex of all the teeth for possible infection. Also, other cystic and pathology lesions can be seen. This film should be taken every five years but is not normally used to see decay unless there is a significant amount. Two–bitewings are taken once a year and are primarily used to diagnose decay between the teeth which cannot be seen clinically. Something I always told patients: “without the bitewings, I cannot see 40% of your teeth.”

I see many patients which are penny pinchers and dollar foolish over x-rays. The concern is always money and/or radiation exposure. With the advent of digital films the exposure is very minimum and not an issue.

Finally, the films that are taken at your dentist are yours. If you decide to move or change dentists, your dentist should send a copy to you and/or your new dentists. Sometimes there is a minimum charge, but most times there is not.

Remember…films are a valuable diagnostic tool and will save you from trouble if the future. It’s an easy to correct a problem if caught early!

Periodontal Malpractice and the Standard of Care

As previously discussed, evaluation of a patient’s periodontal (gum) health is one of the primary cornerstones of a comprehensive dental exam.

The exam should include measuring and recording of the periodontal heath.

How is this done?

One major aspect of a periodontal exam includes measuring and recording of all the “pocket depths” in a patient teeth. Suffice to say this includes six (6) measurements around each tooth. These readings measure the amount (or loss of) bone around each tooth. The periodontal probe measures from the height of the tissue to the level of the bone. A normal reading would be 2mm with no bleeding. An unhealthy measure would be 4mm or greater with bleeding. Bleeding of the gums at any time means inflammation is present. Not good! Inflammation is what destroys the bone, and the bone is what keeps your teeth stable.

While decay may cause pain and trigger some timely treatment, periodontal disease ( the lay term is Pyorrhea) is very insidious. By the time it causes pain, much damage is done. Essentially, if you lose enough bone around a tooth, it will become mobile.

So….what would be the violation of the standard of care? A provider’s failure to take and record the measurements and to assign a Periodontal Classification to each patient. Periodontal disease doesn’t come on overnight. If one day your dentist says, “you have advanced gum disease,” there is a problem.

How is this avoided? Initial periodontal charting and subsequent charting at all your recall or follow up hygiene appointments. Anything less than this is unacceptable.

Questions or comments always welcome. Next time I will discuss X-rays.

Initial Exam: Meeting the Standard of Care

So you have selected your provider and it’s time for the initial exam. Prior to your visit, you should have your previous records (last five years) forwarded the new dentist. This provides some background for the new dentist who can do a comparative analysis with the findings of the new exam.

Let’s review the definition of standard of care:  A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.

The initial exam should include but not be limited to:

1. Review of previous dental and medical records

2. Review and update of current medical history to include:

a. Review of systems to include heart and lungs

b. Hospitalizations in the past five years

c. Current medications.

d. Allergies to medications or latex

3. Review of past dental history

4. Head and Neck exam to include palpation of the swollen lymph nodes. Any external crepitus (crackling, popping, or grating sound) in the TMJ

5. Range of Motion of the TMJ recorded. Any deviations on opening should be noted

6. Oral Cancer exam

7. Complete periodontal exam to include pocket depth measurements (six per tooth) and noted bleeding. Any lack of attached gingival should be recorded.

8. Existing restorations (fillings and crowns) charted.

9. New caries (decay) or cavities recorded

10. Panoramic film taken and reviewed

11. Bitewings radiographs taken and reviewed

Depending on the number of findings, the results of the exam can be discussed or deferred until next appointment, which should be a hygiene or cleaning appointment. I am not a big fan of combining initial exam appointments and hygiene appointments unless appropriate time is allotted.

Next time I will discuss periodontal disease and the basis for many dental malpractice suits.

As always….questions and comments welcomed.

 

Tips for Selecting a Dental Provider

Dental toolsA critical component in avoiding dental malpractice is the right selection of a dentist for you and/or your family.  The criteria use by patients looking for a dentist is sometimes not the best. Amazing how many patients select their health care professionals based on their insurance and its coverage. Don’t get me wrong…..fees are important, but if you select your dentist on insurance alone, this can lead to trouble. Always remember, dental insurance has nothing to do with dental health. Insurance is a business agreement between your employer and an insurance company. The insurance company doesn’t care about your dental health.

What would I look in a dental provider:

1. Graduated from a good dental school.

2. Has at least five years of experience. While recent graduates can pass all the tests and licensing boards they lack the clinical experience and judgment of someone who has been in practice for a longer period of time. What I discovered when I entered into private practice is that dental school only prepares you to learn. And learn I did for the first year. It was a real eye opener for me. This is not to say you can’t use a dentist who is fresh out of school. You can. But if you have a complicated case or dental difficulties you should look for a dentist with more clinical experience.

3. A dentist who has communication skills.  Don’t be afraid to pick up the phone and talk to the dental office about questions you have regarding the potential dentist. You should always feel free to discuss your overall health and dental help with your dentist.

4. Check with the state board to see if any actions have been taken against the dentist. I’m not talking about complaints which have been lodged, but if a complaint was made and the board took action because the standard of care was violated.

5. Just as important, but not the sole determinant, is recommendations from friends or family. Did they have a good experience? But remember…your friends and family cannot always evaluate the competence of your dentist.

Next time I will discuss the initial dental exam and what it should include to meet the standard of care.

As always feel free to post or send any dental questions you might have on your mind.

Dental Malpractice Blog….”Let’s get started!”

While you have probably viewed my website, let me take this opportunity to introduce myself. I am Eugene Young, DDS. I grew up in a small town in western North Carolina as one of seven children. Went to public schools, to University of North Carolina for college, and continued onto UNC School of Dentistry which was ranked #1 in the United States at the time. Subsequent to graduating, I went into private practice in 1977 in my hometown. My practice grew quickly from two employees to include two other dentists and twenty three employees by the time I retired. During the course of my private practice, taught part time at the UNC Dental School in the Department of Restorative Dentistry. This included being a clinical instructor with third and fourth year students.

In 2013, I retired from active practice when I sold out to my associates. Not one to sit still, I still serve as a locum tenens from time to time and teach part time at a private dental school in Florida. I reside in Sarasota, Florida.

Why Dental Malpractice

Why did I decide to be a expert witness in dental malpractice? Over the course of my career, I have seen it all! Sometimes I am surprised. Sometimes not. I have always been reticent to criticize dental work or results as I wasn’t there when the procedure(s) was performed. Dentistry is not easy and outcomes can different due to the many variables. A bad outcome does not always mean the provider was negligent. Sometimes bad outcomes occur even when the standard of care was followed, as with any medical profession.

However, some dentists have bad outcomes and don’t adhere to the standard of care. How is standard of care defined? It specifies appropriate treatment based on scientific evidence and collaboration between medical/dental professionals involved in the treatment of a given condition. When this happens the patient has the possible grounds for a legal action against his provider.

Stay tuned…..next topic…..how to resolve a problem with your dentist without going to court.