Riskwise Malaysia

Malaysia
Riskwise
RiskmanagementfromDentalProtection
Insideissue15
Dentalimplantfeature
Learnhowtosteerclearofavoidableproblems914
dentalprotection.org
Contents
Adultorthodontics Resistancerules
DrAlisonWilliamsdescribessomeofthe DrDavidCroserlooksattheimportance
problemsthatcanarisefromtreating ofresponsibleprescribing1617
adutswhoareshortoftime45
Difcultpatientinteractions
Arootinthesinus DrMarkDinwoodieexplainshowyour
DrMikeRutherfordconsidersthebest perceptionofdifcultyimpactson
wayofmanagingsuchunexpected communication1819
situations68
Contactus
Themineeldofimplantdentistry Welovetohearfromyou20
Howtosteerclearofavoidableproblems
914
Endodonticinstruments
DrShreetiPatelexplainswhypatients
needtoknowthatinstrumentscan
break15
DentalProtectionLimitedisregisteredinEngland(No.2374160)andisawhollyownedsubsidiaryofTheMedicalProtection
SocietyLimited(MPS)whichisregisteredinEngland(No.36142).BothcompaniesuseDentalProtectionasatradingname
andhavetheirregisteredofficeat33CavendishSquare,LondonW1G0PS
DentalProtectionLimitedservesandsupportsthedentalmembersofMPSwithaccesstothefullrangeofbenefitsof
membership,whicharealldiscretionary,andsetoutinMPSsMemorandumandArticlesofAssociation.MPSisnotan
insurancecompany
DentalProtectionisaregisteredtrademarkofMPS
2
Editorial Dr Jane Merivale
HeadofDental
Services,Malaysia
Along with my senior colleague, Inrecentyears,thegrowinginvolvement Assomememberstransferoverthe

Dr Stephen Henderson, I have recently ofgeneraldentalpractitionersincertain yearaheadintothesenewrisk-based
returned from a very useful visit to formsoforthodonticsisalsoshowingsigns categoriesthisshouldhelptominimisethe
Malaysia that included a meeting with ofarapidlyemergingnewrisk.Incertain futuremembershipsubscriptionsforother
Dr Chow Kai Foo, President Elect of the othercountriesthisgrewveryquicklyinto memberswhoarenotinvolvedinanyof
Malaysian Dental Association and asignificantproblemsointheinterestsof theseprocedures.Thesoonerwehave
several of his colleagues ensuringfairnessacrossthewholeofour reliableinformationonthenumbersof
membershipinMalaysia,wefeelitis memberstowhomthesecategoriesmight
This edition of Riskwise appropriatetointroducetwonew apply,thesoonerthesebenefitscanbe
Oralsurgeryandendodonticshave categoriesofmembershipthatwould passedontoothermembers,andweare
historicallygivenrisetoconcern,butthere applyfromyourfirstrenewaldateonor naturallyanxiousnottodelaythatmoment
canbenodoubtwewillbeseeingmore after1January2016.Thesecategories unnecessarily.
casesinthefuturearisingfromimplants refertospecifiedproceduresinprivate
andadultorthodontictreatment.Wehave practice: Subscriptions
thereforefocusedontheseparticularareas Restassuredoursubscriptionsarealways
ofclinicalpracticeinthisissuethe Category ISP forMDAmembers basedonthebestactuarialadviceavailable,
minefieldofimplantdentistryandshort- (the equivalent category is S1D for non- reflectingthedentalclaimsandcase
termorthodontictreatmentcarriedoutby MDA members) willapplyto: experience,trendsandlikelyfuture
non-specialistgeneralpractitioners. developmentofclaimsinyourcountry.
Theprovisionoffixedorremovable Subscriptionsaresettoprovideprudentlyfor
Whenreadingthesearticles,itbecomes orthodontics,intheabsenceofany thepresentandfutureneedsofourmembers
quiteclearthatvalidconsentis specialisttrainingandhigherqualifications asclaimsmayarise5,10oreven20years
fundamentaltoavoidingproblems.Itis recognisedbytheGovernmentinMalaysia. afteranytreatmentprovidedbymembers
essentialtoconveyfullinformationto thisyear.Neverforgetthatyoushareinthe
ourpatients,cruciallycheckingfortheir Theplacementofimplantsinthemandible collectiveownershipofthisorganisation,and
understandingofwhathasbeendescribed ormaxilla,includingtheuseofbonegrafts alsothatthereisnoprofitelementfactored
andallowingthemtimetoconsiderwhat butexcludingsinusliftsorbone intothesubscriptionyoupay.
theyhaveheard.Thiswilloftenmean augmentationwhichinvolvesthefloorof
givingpatientstimetogoawaytothink thesinusorextra-oralboneharvesting. Wethereforeaskyoutoreadthe
abouttheirdentalconditionandtreatment informationyouwillreceiveregardingour
options,toconferwithfamilyandfriends Category 2SP (and the equivalent S2D newcategoriesandensureyouarepaying
andthentoreturntoaskquestionsbefore category for non MDA members) will thecorrectsubscriptionforthescopeof
thenmakingtheirdecisionandproceeding applyto: yourpracticeatalltimes.Yourentitlement
withtreatment. tothebenefitsofmembershipislikelytobe
Theplacingofimplantsinthemandible placedatriskifyouarenot.
Thefailuretoobtainvalidconsentand/or ormaxilla,includingsinusliftsorbone
tomaintainrecordssufficientto augmentationwhichinvolvesthefloorof MDA support
demonstratethatthishashappenedis thesinustoincludeboneaugmentation Finally,Iwouldliketoexpressourthanksand
sadlyarecurringallegationindentalclaims andboneharvestingfromanywhereother appreciationtotheMDAfortheirhardwork
andcomplaints. thanthemandibleormaxilla. andprofessionalisminthedeliveryof
servicestoourmembersinMalaysia.We
Altered risk Moredetailsofthesenewcategories gavethemverylittletimetoprepareforthe
Oralandmaxillofacialsurgeryandimplant willbeprovidedaroundthetimeofyour introductionofthenewcategoriesdescribed
dentistryarewellrecognisedascarrying renewaltogetherwithsomeFrequently aboveandIthankthemfortheirsupport,
anenhancedriskandbothhaveresulted AskedQuestionstohelpfurtherexplain understandingandforbearance.Weshare
insomeverylargeandcostlyclaimshere therationalefortheintroductionofthese acommonaimoffairnesstoallofour
inMalaysia. newsubscriptioncategoriesandrates members.
andalsoanexplanationofhowweare
introducingthem. Bestwishes,
Dr Jane Merivale BDSLLM

HeadofDentalServices,Malaysia
jane.merivale@dentalprotection.org
DentalProtection RiskwiseMalaysia15 3
Adultorthodontics
Dr Alison Williams describessomeof
theproblemsthatcanarisefromtreating
adultswhoareshortoftime
There are three obvious challenges that arise if adult Clear aligner techniques
orthodontic treatment is sought: Theconceptofusingremovabletooth-positioningdevicesfor
Patientmayimposeconstraintsuponhowthetreatmentisto minorlocalisedtoothmovementsisnotnew.Arguably,
becarriedout(especiallyintermsofthetypeofapplianceand developmentsindatatechnologyhavefacilitatednoveltechniques
itsvisibility). forthemovementofteeth.Thesesystemsareparticularly
Thetreatmentplanmaybecomplicatedbyprevious attractivetothenon-specialist,withoutanyrecognisedformal
orthodontictreatment,missingteeth,thepresenceof traininginorthodontics.
restorationsorperiodontaldisease.
Failuretomeetpatientexpectationscanleadtocomplaints. Becausethetreatmentplanandaseriesofalignersareformulated
forthepractitioner,treatmentcanbeprovidedwithaminimumof
Adultpatientswhoarepreparedtocommitthemselvesto training.Thismeansthatpatientscanbetreatedin-houseby
orthodonticswillgenerallynotdosolightlyandmaywellbehighly theirowndentist,ratherthanhavingtotraveltoanotherpractice
compliantandco-operativewiththetreatment.Theflip-sideto toseeaspecialist
thisisthatadultstendtobecomeheavily-involvedintheir
treatment,oftenscrutinisingeverytoothmovementthatoccurs AstudyconductedbyDentalProtectionintheUKrevealedthat
betweenappointments. claimsarisingfromorthodonticshavebeenontheincrease,and
20%ofthenewcasesreportedin2010involvedaligner
Aninexperiencedclinicianmayhavetoadapttheoriginal techniques.Significantly,general(ie.non-orthodonticspecialist)
treatmentplanasthenowexpertpatientbecomesmoreand practitionersaccountedfor80-90%ofallaligner-related
moreawareoftheirocclusion.Thesetweakstotheoriginal complaintsandclaims,aworryingdevelopmentgiventheir
treatmentplantendtolengthenthetreatmenttime,whichcanbe increasingpopularitywithpatientsandamongstgeneral
unpopular. practitionerswhoprovideorthodontictreatment.
Unlesstheclinicianhassufficientexperiencethereisatemptation However,closeranalysisofthecasesrevealsthatunderlying
toundertaketooth-movementsthatareclinicallycontra- causeswerenodifferenttomostotherorthodonticcases:
indicated,inanattempttoappeaseapersistentpatient. Failuresincaseassessment,diagnosisandtreatmentplanning
Unfortunately,theproblemsidentifiedduringthetreatment- Deficienciesintheconsentprocess(especiallyinrelationto
planningstagere-emergeandtheobjectivesoftheamended discussingalternativeorthodonticapproaches)
treatmentplanarestillfrustrated. Inexperienceandafailuretoanticipateandrecogniseproblems
Failuretorecognisethesignificanceofinterproximalreduction
Unmet expectations (interdentalstripping)asameansofspacecreation,andthe
Orthodontictreatmentasanadult,particularlyinmiddleage, associatedrisks
canbecostly,uncomfortable,time-consumingandpotentially Failuretomanagethepatientsexpectationsperhapsover-
embarrassing.Anadultmakingthesesacrificesmayhave sellingtheobviousbenefitsofclearalignertechniqueswithout
unrealisticexpectationsoftheimpactthatstraighterteethcan sufficientlystressingtherisksandlimitations.
haveonotheraspectsoftheirlife;thestakescanbehigh.
Additionalrisksareintroducedwhentheclinicianisreliantonthe
Toothmovementstendtobeslowerinadultsandsomearevery computersoftwareandtheremotetechnicianwhodesignsand
difficulttoachieve.Inexperiencedclinicianswhodonthaveaclear constructsthealigners;effectivelytakingoverthediagnosisand
understandingofwhatcanandcannotbeachievedwith treatment-planwithouteverseeingthepatient.Ifthatservice
orthodonticsinanadultorwhoskimpontheconsent-processmay originatesoutsideyourowncountrytherisksassociatedwith
failtomeetpatientexpectations. teledentistryshouldbeconsidered(Searchforteledentistryat
dentalprotection.org).
Dentistswithminimalrecognisedtraininginorthodonticsare
particularlyvulnerablebecausetheyareunlikelytohavethe
expertisetorecogniseifatreatmentplantheyreceivefromthe
remoteplanner,isnotinthepatientsbestinterests.The
providersoftheseplanningservicesinformpractitionersthatthey
canrejectthefirsttreatmentplanifitisunsuitable.Butanon-
specialist,withlittleorthodontictraining,maynothavethe
knowledgeorconfidencetoarguewiththecomputer.
4
Dr Alison Williams
Alisonisaspecialist
orthodontistwho
alsoworksasa

part-timeAssociate Therewardsoftreatmentcan
DentolegalAdviser
forDental evaporateifpatientexpectations
Protection
arenotmet
Compliance Thechoiceofbrandnameusedbysomesystemsseemtosuggest
Aligner-systemsrelyonpatientswearingtheiralignersfora thatthepatientwillonlyneedtoweartheapplianceforaspecified
prescribednumberofhourseachday.Patientsfrequentlyfailto shorttimewhichmakesitanattractivepropositiontothe
achievethetarget,andsodiscrepanciescandevelopbetweenthe consumerwhohasabusylife.Thesesystemsfocusonimproving
actualandthepredictedtoothmovementsthateachaligneris dentalaestheticsalone,whichisusuallythepatientsmaingoal,
expectedtoproduce.Anexperiencedclinicianwillnoticethe ratherthancorrectinganyunderlyingmalocclusion,whichmight
discrepancyandamendthetreatmentplan.Anuntrainedor achievelong-termstability.
inexperiencedclinicianmaycontinuetofitthenextalignerinthe
sequencenotnoticingthatthereisaproblem.Complaintscanbe Short-termsystemsareattractivetotheclinicianforthesame
initiatediftheclinicianhastoback-trackthroughthealigner reasonsasaligner-systems,inthattreatmentcanbeprovided
sequence,increasingtheoveralltreatmenttime. in-housewithaminimumoftraining.DentalProtectionhasseen
similarpatientscomplaintsarisingaboutthesesystemstothose
Relapse foralignertreatment.Becausethesystemshavebeendesigned
Amajorclinicaldisadvantagewithaligner-treatmentisthat,in andmarketedtonon-specialiststhecomplaintsweseearealmost
mostcases,onlythecrownsoftheteetharetippedwhilsttheroot exclusivelyagainstnon-specialists.
movesfarless.Casesarethereforepronetorelapseifthepatient
failstoweartheirfinalaligneroraretainerforasignificantnumber Its in the name
ofhourseachdayasretention.Unlesssuitablyskilled,theclinician Anybrandnameforatreatmentsystemthatreferencesaspecific
maynotrecognisetheriskofrelapseintheoriginalassessment periodofmonthswilltendtoraisepatientexpectationsabout
andtreatmentplanandmayfailtoobtainvalidpatientconsentfor treatmenttime.Theconsentformprovidedbythemanufacturer
extendedretentionorafixedretainerfromtheveryoutset.When canunwittinglycompoundtheproblemifitrepeatsadefined
thepatientispresentedwiththisinformation,withoutany periodoftime.Itiseasytoseehowpatientscouldmake
warning,attheendoftreatmenttheymaycomplain. assumptionsifthetreatmentlengthformspartofthepromotion,
andhowtheymightfeelupsetiftreatmenttakeslonger.
Itmayalsobecomenecessarytogoontoafixedapplianceatthe
endofthealignertreatment,tocorrectthepositionoftheroots Duringtheconsentprocess,practitionersareencouragedtouse
andimprovestability.Withouttheskillstopredictthiseventuality, theconsentformsandinformationleafletsprovidedbythe
therecanbedisappointmentwhenthepatientlearnstheywill manufacturerbuttheseformsarenotpatient-specificandmay
havetowearafixedapplianceafterall.Ifthesamecliniciandoes notcovereverythingthatneedsdiscussion.
nothavetheskillsormaterialstofinishthecase,thepatientmay
havetobetreatedbyanotherpracticewhichcouldbeboth Short-termorthodonticapplianceshavethecapacitytoapply
inconvenientanddisappointing. forcestoboththerootsandthecrownsoftheteeth.Insome
patientsthereisapossibleriskofroot-resorption.Theclinician
Embarkingonalignertechniquesasanalternativetodevelopinga needstounderstandhowtoassesstherisk.Thisshouldbe
properdepthofknowledgeandunderstandingoforthodontics,is discussedseparatelyandrecordedintheclinicalnotesifthe
invitingproblems.Likeotherdentaltechniques,thereareever- literaturefromthemanufacturerissilentonthisproblem.
presentdangerswhensomethingisaloteasiertosellthantodo.
On balance
Short-term orthodontic techniques Althoughtherewardstothepractitionerforthesetwoformsof
Shorttermsystemsfrequentlyincludeapromiseofthelengthof adultorthodonticscanbehigh,thereisalsoanincreasedriskofa
timetoobtainthedesiredeffectintheirmarketingmaterial.They complaintifexpectationsarenotmet.Supportandadvicefroma
arebasedonfixedand/orremovableappliances,andaredesigned specialistorthodontistoracolleaguewithgreaterexperience,is
forusebydentistswithaminimumoftrainingtoachievelimited onewayofhelpingyoutomeetthepatientsexpectationswithin
improvements,usuallybasedonstraighteningtheanteriorteeth, arealistictime-frame.
fortheirpatients.
Arootinthesinus
Dr Mike Rutherford considersthebestwayofmanagingsuchunexpectedsituations
Prompted by a recent court judgement Its in the sinus? When did it happen?
that awarded over $US 500,000 for a Tothegeneralpublic,mostdental Mostrootsdisplacedintothesinuscome
tooth root displaced into the maxillary proceduresareobscureeventsthatare fromthefirstpermanentmolar,withthe
sinus, Dr Mike Rutherford considers the poorlyunderstood.Considerabletimeand secondmolarfollowingclosebehind.The
best way of managing such unexpected effortmayberequiredtoexplainjusthow palatalrootisthemostcommonroottobe
situations arootthatwasonceattachedtoatooth displaced,andthedisplacementoften
cametobeinasinusthatmostpeople occursfollowingdecoronationofamolar
Thiscaseisasalientreminderthatwhen wouldnotexpecttobeanywherenear andsubsequentattemptstoremoveroots
thingsgowrong,itcancauseachainof theirteeth.Apatientdistractedbythe thatmayhavebeenseparatedeither
eventsthatleadalongwayfromthe procedurejustabandonedandtheanxiety traumaticallyorbysectioning.
desiredandexpectedoutcome.Itisalso ofknowingsomethingmayhavegone
areminderthatsuchsituationsdemand wrongisoftenapoorlistener,andwillhave Anecdotally,mostdisplacementsoccurin
anearlyandappropriatereferralfor difficultytakingintheavalancheofnew closedrootremoval,thatiswhena
experttreatmentofyourpatient.Timely informationpresentedbyadental surgicalflapandbuccalboneremovalhas
contactwithDentalProtectionalso practitionerwhomaywellbesomewhat notbeenperformed.Thismayindicatea
ensuresexpertassistancetohelpyou traumatisedthemselvesbythe lesssuccessfultechniqueorindicatealess
managetheevent. predicament. confidentoperatorunwillingtoapproach
surgically.Understandably,relativelyless
Where did it go? experiencedpractitionersareover-
Thedisplacementofatoothrootintothe Itisadifficulttimeforboth represented.
maxillarysinusis,unfortunately,oneof
thoseadverseoutcomescommonly
partiestoremaincalmand Warnings
reportedtoDentalProtection.Although communicateeffectively Informationpresentedbeforetheeventis
specialistremovaloftherootis,inmost awarning;aftertheeventthesame
cases,accomplishedpredictably,itisan informationisoftenviewedasanexcuse
incidentthatneedsparticularlygood Mostoftenthedifficultiesthatleadtothe orjustification.
clinicalandpatientmanagement.Fromthe displacedroot,andtheneedtomanage
patientsperspective,havingalready theaccompanyingoro-antraldamage,
undergonetheanxietyandtraumaoftooth meanthatthedentistisrunninglateandis Forewarned,yourpatientis
removal,theyarenowbeingtoldthatthey probablykeepinganotherpatientwaiting.
willrequirefurthersurgery. Nowisnotthetimetorush.
morelikelytobeaccepting
ofthisadverseoutcome,
Thissurgerywillbemoreinvasive,more Takeadeepbreath,slowdownandspend
expensive(ofteninvolvingageneral thetimewithyourpatienttoexplain
particularlyifitwas
anaestheticwithitsaccompanyingrisks everythingfully. discussedasapossibility
andcosts),andresultinmoreswelling,pain
andbruisingthantheoriginaltooth
attheoutset
removal.Insteadoftheanticipated
afternoonordayoffworkpostextraction,
severaldaysworkmaynowbelostto Similarly,acceptanceismorelikelyifthe
consultations,day-staysurgeryand alternatives,includingspecialistreferral,
recovery. wereoffered,butamutualdecisionwas
madetoproceedwiththetoothremoval.
Youwillappearmoreontopofthe
outcomesandtheprocedureifthepatient
hasbeenforewarned,thanifthefirstthe
patientknowsofthispossibleoutcomeis
theworriedfrownonyourdental
assistantsbrow.
6
Dr Mike Rutherford
Mikehasmorethan30yearsexperience
inprivatepractice,hospitalclinics,the
defenceforcesandsupervisingDentolegal
AdviserinourBrisbaneoffice
When to stop? Thisispotentiallydangerousterritory,and Occasionallythoughtheresultisdisaster

Thereappeartobethreekeytimeswhen isgenerallyaccompaniedbyanuneasy anextraordinarynumberofdentists
assessmentofthesituationandreferral feeling-thatisthepractitionerfeels reportingrootinsinusincidentsmention
maypreventthisunwantedoutcome. hesitantabouttheprocessandindeed theuneasyfeelingtheyhadbeforethe
Unfortunatelythewillingnessofboththe unsurewhethertheyshouldbecontinuing. disasterIknewIshouldhavestoppedis
patientandoperatortostoptheprocedure Inmostcasesthisiseventuallyfollowedby acommoncomment.Weshouldbeacting
usuallybecomeslesslikelyateachstage. success,afeelingofimmensereliefanda intuitivelyandlisteningtothelittlewarning
rapidreturntoaconfidentdemeanour. voiceinourheadthattellsustogetoutof
Thebestandmostobviousopportunityis thereitisthevoiceofreason.Thisisthe
onreviewingapreoperativeradiographand mostdifficulttimetostop,reassessand
assessingtheproximityofthesinus.While referbecauseoftheenergyandemotion
thismayseemself-evident,anhonest alreadyinvestedintheprocedurebyboth
appraisalofonesexperienceandthe dentistandpatient,butitisalsoprobably
difficultyoftheproposedtreatmentcanbe themostimportanttime.
hardandisoftenprejudicedbyourpatients
expectationsanddemands,andourown
self-confidence.Despitethis,atimely
referraltoamoreexperiencedcolleagueor
alocalspecialist,accompaniedbyan
assurancethatitisinyourpatientsbest
interests,isthesafestoption.
Thenextopportunitytoreconsiderison
decoronationofthetoothduringaplanned
simpleextraction,andtherealisationthat
thetoothremovalhasnowturnedintoa
moredifficultrootsectioningorsurgical
approach.Thepractitionerandthepatient
arenowinvolvedinaverydifferent
procedurerequiringadifferentskillsetof
thepractitioner.Ifasurgicalapproachhad
beenassessedasapossibility,yourpatient
shouldbeforewarnedofthispossibility,
andthealternativeofareferraloffered.
Thethirdopportunityariseswhena
plannedapproachhasnotresultedinthe
removaloftheroot,andthepractitioner
findsthemselvesreachingthatis,
retryingtechniqueswithmoreforce,or
tryingmoreandmoreinstrumentsand
otherapproachesnotoriginallyplanned.
Sometimesotherforeignbodieshave
unintentionallyfoundtheirwayintothe
maxillarysinus.Theyrequireasimilar
organisedresponseifthepatient'sbest
interestsaretobeprotected
Aroot Thevariablenature
ofthefloorofthe
maxillaryantrum
inthe makesitdifficult
topredictthe
sinus outcomeforevery
extraction
It happens What next? Self-reproachisafrequentaftermath

Iftheroothasbeendisplaced,excellent Apromptreferraltoaspecialistoral ofsuchincidentswhilstfearofformal
clinicalandpatientmanagementisnow surgeonoranoralandmaxillofacial complaintproceedingscanstiflea
essential.Stabilisationofthesocketand surgeonisessential.Surgicalretrievalis practitionersusualrationalpatient
theaccompanyingoro-antral beyondthescopeofmostgeneraldentists management.Assistanceinmaintaining
communicationshouldbeaddressedinthe andgenerallyshouldnotbeattempted.In contactwithyourpatientduringtheir
firstinstanceusingbestclinicalpractice. afewcases,smallportionsofrootsmaybe remedialtreatment,choosingtheright
Oncethishasbeenachieved,giveyour leftinsitu-thisshould,however,bea wordstouse,helpwithaletterof
patientandyourselfarestaspreviously decisionmadebyanexpertthirdpartyand explanationtoyourpatientand
mentionedyouwillalmostcertainlybe not,atthetime,byageneraldentist recommendationsonfinancial
runninglateatthisstage,butthatisvery whosedecisionmayperhapsbeinfluenced arrangementsformpartoftheadvicethat
muchofsecondaryconcern. bywishfulthinking. isavailable.Itisprovidedwithaviewto
reassuringyourpatientthattheyarebeing
Youneedyourpatienttobeabletofocus Referralispartofyourdutyofcareand caredfor,andensuringthatyoumeetyour
onwhatyouaresaying,andyouwillwant earlyreferralgivesyourpatientthebest dutyofcareobligations.
tobecalmandprofessionalintheprocess. chanceofafavourableoutcome.Italso
Patientscansensewhenadentistappears removesthepossibilityofyourpatient Youcantundowhathasbeendone,
rushedoranxious.Thisisatimeforyour thinkingthattheyhavenotbeentoldthe butyoucancertainlyensurethatthe
patienttoappreciatethatyouarefocused wholestoryorhavebeeninappropriately managementofthesituationisas
ontheirwelfareandnotyournextpatient. managed.Specialistsurgeonsarefamiliar compassionateandprofessionalas
withthesesituationsandcangiveyour possible,lookingafterthebestinterests
Apatientwhomayfeelaggrievedatthe patientanexpertopinionfromaneutral ofthepatient,whilstDentalProtection
unexpectedoutcomewillundoubtedlyfeel vantagepoint.Iftheexplanationand looksafteryou.
moresoiftheyperceivearushtogetthem adviceofferedbythesurgeontallieswith
outthedoor.Manyaletterofcomplaint thatalreadyprovidedbythedentist,
focusesasmuchondissatisfactionwith validityofbothopinionscanbereinforced. Weshouldbeacting
thedentistsperceivedlackofcarepost-
incident,asitdoesontheincidentitself. And then intuitivelyandlisteningto
YouneedadvicefromoneofDental thelittlewarningvoicein
Protectionsdentolegaladvisers.
Fullandfrankdisclosureis ourheadthattellsusto
essentialanexplanation Apartfromtherequirementofyour getoutofthere.Itisthe
indemnityinsurancepolicytoreport
inlaymansterms incidentssuchasthis,ourdentolegal
voiceofreason
advisershavehadtheexperienceof
accompaniedbydiagrams workingwithmanypractitionersinsimilar
ortheuseofpreorintra- situations.Althoughthiswillprobablybe
anunfamiliarprocessforthepractitioner,
operativeradiographswill theadvisercanofferadvicebasedon
helpyourpatient DentalProtectionswealthofexperiencein
thesematters.Theyofferanindependent
understandtherelationship viewpointandcanadviseyouhowto
oftheanatomical achievethebestpossibleoutcomeforyou
andyourpatient,aswellaskeepingyour
structures welfareandreputationinmind.
8
Themineeld Per-Ingvar
Brnemark
(19292014).The
ofimplant Swedishphysician
regardedasthe
dentistry fatherofdental
implantology
Howtosteerclearofavoidable
problems
In general, there are three approaches

to achieve a safe passage through any
minefield. The first is to find out
exactly where all the mines are located
before you start, and then to carefully
plan a safe route and stick to it. The
second is to take your time, proceed
with extreme caution in small,
measured stages and not take any
step before knowing for sure that the
ground upon which you will be placing
your foot is safe. The third (which we
do not recommend) is to ignore signs,
keep moving and not ask for directions
Members in the latter group will

probably not be reading this article in
WearegratefultoNobelBiocarefortheuseoftheimagesonpages914
the first place, but for members in the

other two groups it will hopefully serve
as a checklist, so that they have a
better understanding of the potential
pitfalls, and can thereby avoid
becoming part of the worrying recent
claims statistics arising from implant
dentistry
Themineeld Malaysian Dental Council Professional Code of Conduct September2008
PartA:Obligationsandresponsibilities
1Thepatient
ofimplant 1.1Patientselection
dentistry d)Adentalpractitionermayrefuseapatientif:
itisbeyondhiscapacitytomanagethepatientsproblems
heisunabletomanagethepatient
itisinthepatientsbestinterest.
1.9Consultationandreferral
a)Whereadentalpractitionerisindoubtregardingthemanagementofapatient,he
shouldseekconsultationfromcolleagueswhohavetherelevanttraining,competence
andexpertise.
Before you start Itisnotdifficulttoseehowexposeda The tools for the job

Getpropertraining youngdentistwouldbeiftheygetinvolved Havingthecorrectinstrumentationto
Shortcourses,perhapsrunby inimplantdentistryquitesoonafter carryoutimplantdentistrysafelyand
manufacturersanddistributorsofimplant qualifying,perhapsoffthebackofa successfullycomesataprice.Thehighest
systemsareanimportantpartofthe relativelyshortcourseundertakenwithno standardsofinfectioncontrolareessential,
trainingmixinorderthatpractitioners propercurriculumorstructure,supervision andsoaregoodchairsidefacilitiesand
canproperlyunderstandthefeaturesof arrangements,qualityassuranceor trainednursingsupport.Ifyoudonthave
aparticularsystem,butthesebespoke opportunityforhands-onmentoringafter accesstoproperimaging(eg.conebeam
coursescanneverbeareplacementfora completingthecourse.Weresucha tomography)inyourownpractice,
broader,extendedcoursewhichgoesinto dentist,withrelativelylittle(narrow) establishwhereandhowyoucantake
moredepthandconsidersmanydifferent experienceofclinicaldentistryto advantageofthistechnologyifitexists
implantsystemsandtheirrelative undertakeacomplexrestorativecase elsewhere(seebelow).Tryingtokeepthe
advantagesanddisadvantages.Some whichthengoeswrong,thisisalmost costdownforapatientbycuttingcorners,
commerciallydrivencoursesmaybelikely certaintobereferredtotheDentalCouncil isntreallyhelpingyouorthepatientinthe
tomaketheproceduresoundsimplerand withalltheattendantconsequences.Any longrun.
easier,andwillnotnecessarilyalertyouto dentistwhoentersthefieldofimplant
thelimitationsandrisks.Theaimofsuch dentistryshouldbepreparedtojustifythe Checkyouhavetheright
coursesisoftentopromotethemeritsof adequacyofanytrainingtheyhave protection
oneparticularsystem,andtoencourage received. Asextraordinaryasitmightsound,there
theplacementofasmanyimplantsas arestillpractitionersgettinginvolvedin
possible,inasmanysitesaspossible,for Dontoverestimate implantdentistrywithouthavingprotected
asmanypatientsaspossible,asoftenas (orover-state)your themselves(andindirectly,theirpatients)
possible.Thisisnotarecipeforsound competence withanykindofprofessionalindemnity
clinicaljudgementandpractice. Whenanimplantcasehasgone arrangements.Otherpractitioners
spectacularlywrong,itcanbepainfully sometimesoverlooktheirmembership
Thebestcoursesaregenerallythosewhich embarrassingforacliniciantobe renewaldate,ordecidetosavemoneyby
involveformal,structuredtrainingprovided confronted(duringthecourseofa choosinganinappropriatemembership
byacknowledgedexpertsinthefield,over negligenceclaim,orbeforetheDental categorythatdoesnotfullyreflectthe
anextendedperiodoftime(suchasoneto Council)withthewayinwhichs/hehad extentoftheirclinicalpractice,orevenby
twoyears).Itwilltaketime,effortand describedtheirexperienceandtraining, allowingtheirmembershiptolapse.
commitmentandinvolvealotofstudy.Ifit skillandexpertiseinimplantdentistry
doesnt,itinvitesthequestionofwhether (eg.onapracticewebsite).Thiscanbethe Specialcategoriesapplytoimplant
thecourseissufficientforitsintended resultofagenuinelackofinsightintothe dentistryandassociatedproceduressuch
purpose.Inanidealworld,implanttraining leveloftheirownknowledgeand assinusliftsitisamemberspersonal
shouldinvolvesomekindofexaminationto competence,orawishforcommercialor responsibilitytocheckateveryrenewal
demonstratetheattainmentofknowledge otherreasonstoappearmoreskilledor datethatthecategoryandratethatthey
andcompetenceinthefield,andaperiodof experiencedthantheyreallyare.Either arepayingisstillthecorrectone.Because
mentoring(ie.theabilitytopractiseimplant waytheseexaggeratedandmisleading thesecategoriescananddochange,
dentistryunderbothdirectandindirect claimsarenotlikelytodotheclinicianany simplyrenewingyourmembershipinthe
supervision,wherehelpisreadily favoursandmayadditionallybeabreach samecategoryasthepreviousyear(s)may
athandifyoushouldneedit). ofconsumerprotectionregulationsand/or beleavingyouexposedoreven
ofadvertisingstandards. unindemnifiedforimplantdentistry.
TheDentalCouncilsguidance(seepanel
above)isclearinstatingthatdentists
shouldnotgetinvolvedintreatmentfor
whichtheydonothavetherelevant
trainingandinrespectofwhichtheyare
notyetcompetent.
10
Thesurgicaland
prosthodonticphasesare
bestconsideredastwo
aspectsofasingleprocess,
ratherthanastwo
Collectinginformationaboutthecase
separateprocesses
Getting started Sharing care when Nowhereistheneedforthisseamless

Slowandeasy more than one clinician approachmoreobviousthaninthe
Suggestingthatanyimplantcaseiseasy is involved consentprocess;apatientneedsto
isprobablymisleading,butwhenmaking Theneedforjointcaseassessmentis understandallmaterialfactsthatrelateto
foryourfirstforayintoimplantdentistry, criticalwherethesurgicaland thesurgicalplacementofthefixtures,and
choosinganythingotherthantheleast prosthodonticphasesofimplantdentistry alsotowhateverapplianceorrestoration
complexcase,isaskingfortrouble.Ideally, arebeingcarriedoutbydifferentpeople. thefixtureswillbesupporting.Amaterial
takingyoutime,choosingcasescarefully factisonethatapatientwouldbelikelyto
andgettingseveralrelativelysimplecases Inimplantdentistry,itishelpfulifthe attachsignificanceto,whenconsidering
underyourbeltisadvisablebefore clinicianwhowillbeundertakingthe whetherornottoundertakethe
attemptinganythingmoreambitious. subsequentrestorative/prosthodontic procedure.
phaseispresentatthetimeofthesurgical
Mentoring procedures. Theimportantdistinctiontostresshere,is
Thebestintroductionistohavean thatoneneedstoputoneselfinthe
experiencedmentortoguideandassist Implantfixturesare,ofcourse,ameansto positionofthepatient,andaskwhatthey
youasyoutakeyourearlystepsinto anendandnotanendinthemselves. mightwishorexpecttobetoldas
implantdentistry. Consequently,implantdentistryneedsto opposedtowhatwemightdecideis
bedriven,andled,bytheprosthodontist importantinthecontextofoneorother
whetherthisisaspecialistoraGDP. stagesoftheoverallprocessitself.
Problemscanarisewherethe Consentismorelikelytobesoundifthe
prosthodontistisrelativelyinexperienced processispatient-focusedratherthan
inimplantdentistry,andtheclinician procedure-focused.
undertakingthesurgicalphaseismore
experiencedandperhapsviewedasthe Thefactthattwocliniciansmightbe
seniorpartnerintherelationship. involvedinthesamecasecanactuallybe
usedtoreducetherisk,ratherthan
Problemsaremorelikelytoarisewhen increasingit,becausetwodifferent
thereisnoover-archingandmutually perspectivesandtwodifferentsetsof
agreedtreatmentplanwhichcomprises experiencescanbebroughttobearupon
Planning boththesurgicalplan,andtherestorative theconsentprocess.Thisbenefitwillonly
plan.Theclinicianundertakingthesurgical befelt,however,ifthetwopartiesare
phaseneedstomakeitclearwhatis,andis communicatingwitheachotherandthey
notpossible(oradvisable)fromasurgical bothfeelabletomakeanactive
perspective,andtheprosthodontistneeds contributiontothedebate.
tomakeitclearwhatisandisntpossible
(oracceptable)fromtheperspectiveofthe Foraslongassurgeonsand
subsequentrestorative/prosthetic prosthodontists(orgeneraldental
requirementsbothinatechnicalsense,and practitioners)taketheviewthattheyhave
alsoinordertosatisfythepatients noinputinto,norresponsibilityfor,therole
functionalandaestheticneeds. oftheother,thenpatientswillcontinueto
Communicationwiththepatient fallbetweenthetwozonesofcontrol.By
Therelationshipbetweenthespecification workingtoeliminatethatgapthrough
andpositioningoftheimplantfixtures,and closercommunicationandmutual
whatcouldbeachievedprosthodontically consultation,thetwopartiescanbest
oncetheyareplaced,issointimatethat servethepatient,themselvesandeach
thesetwoprocessesneedtobeviewedas other.
twoaspectsofasingleprocess,rather
thanastwoseparateprocesses(asso
oftenoccurs).
Therightequipmentandenvironment
Themineeld
ofimplant
dentistry
Case assessment and Minimiseriskand Ifanadverseoutcomecouldhavebeen

treatment planning uncertainty anticipatedandavoidedbytheuseof
Plancarefully ThemaximPredictability is the key to additionalimaging,thequestionsariseof
Atleastathirdofallimplantcasesthatare tranquillityappliestomanystagesinthe whetherareasonablebodyofprofessional
seenbyDentalProtectioncanbetraced provisionofimplantdentistry,butperhaps opinionamongstthoseworkinginthefield
backtosomekindofdeficiencyinthecase especiallysoinanticipatingthepotential ofimplantdentistrywouldsupportthe
assessmentandtreatmentplanningstages risksandcomplicationsatthesitewhere viewthat:
likethoselistedbelow. fixturesaretobeplaced.Conventional a theadditionalimagingwas(orwasnot)
radiographssufferthedisadvantagethat necessaryinthecircumstancesofthe
Inparticular theygiveusatwodimensionalimageof specificcase,
Anysensethataclinicianhasrushed whatisactuallyathreedimensional b aresponsibleclinicianactinginthe
headlongintotheplacementofimplants situation.Wemakeallowancesforthisas patientsbestinterestswouldproceed
withoutallowingtimetogettoknowthe faraswecan,andhavedeveloped withplacingtheimplantswithoutthe
patientand/orconsideranddiscussany techniques(suchastheparallaxtechnique) additionalimagingbeingavailable.
othertreatmentoptions. tocompensateforthelimitationsofastatic
Theabsenceofanup-to-datemedical viewfromasingleperspective. Anotherexampleofastepwhichimproves
andmedicationhistoryoranapparent predictabilityandreducesuncertainty
disregardofanyabsoluteorrelative Havinga3-Dvieworamulti-perspective (especiallyinanedentulousarch)istheuse
contraindicationsassociatedwitheither viewbyusingcomputerisedaxial ofstentsandotherformsofsurgicalguides
ofthem(eg.Type1diabetes,orany tomography(CATscans)includingcone whereappropriate,andinmorecomplex
medicationaffectingbonemetabolism beamCTormagneticresonanceimages cases,theconstructionanduseofsurgical
ordensity,theinflammatoryresponse (MRIs)-transformsourknowledgebase, models.
orthetendencytobleed). removesalotoftheuncertaintyand
Afailuretoelicitoractuponrelevant guesswork,andsometimesmakesusaware Spend time validating
featuresofthepatientsdentalhistory ofpotentialhazardsthatwewould consent
forexampleahistoryofchronic otherwisehavebeenunawareof.Fewer Thepatientshouldbeawareofthe
periodontaldisease. surprisesfortheclinicianwillgenerallymean purpose,nature,likelyeffects,risks,and
Afailuretoscreenfor,assessandmanage fewersurprisesforthepatient,whichisa chancesofsuccessofaproposed
anyrelevantriskfactors,especially goodthing. procedure,andofanyalternativestoit.
smoking. Thefactthatapatienthasconsentedto
Inadequatepreoperativeinvestigations Whilethereisalwaysacostattachedto asimilarprocedureononeoccasion,does
(models,x-raysandotherimagingetc). newtechnology,andonemustbemindful notcreateanopen-endedconsentwhich
Afailuretoseekandactuponadvice oftheobligationsofthe Malaysianionising canbeextendedtosubsequentoccasions.
fromothers(includingspecialists)where radiationprotectionstandards, itisnot Consentmustbeobtainedforspecific
appropriate. forthecliniciantodenythepatientthe procedures,onspecificoccasions.
opportunitytodecideforthemselves
whetherornottheywishtoincurthe
additionalcostofhavingthisadditional
imagingcarriedout.Equally,ifthepatientis
unwillingtoundergothisfurtherimagingon
costorothergrounds,theclinicianhasthe
righttodeclinetoprovidethetreatment.
12
Some questions to ask yourself to help ensure The surgical phase -
the patients consent is valid placing the implant
Isthepatientcapableofmakingadecision?Isthatdecisionvoluntaryandwithout fixtures
coercionintermsofthebalance/biasoftheinformationgiven,orthetimingorcontext Give appropriate pre-operative advice
ofitsprovision? Follow accepted procedures
Doesthepatientactuallyneedthetreatment,orisitanelectiveprocedure?Ifanelective Staywithinthelimitsofyourtrainingand
procedure,theonusuponacliniciantocommunicateinformationandwarningsbecomes competence.
muchgreater.(Placing an implant in a site where a tooth has been missing for several years, Recognise when things are not going
without replacement, would be an example of this). to plan
WhatdoIthinkwillhappeninthecircumstancesofthisparticularcase,ifIproceedwith Takeappropriatestepstorecoverthe
thetreatment?HaveIcommunicatedthisassessmenttothepatientinclearterms?Can situationwhichinsomecasesmayinvolve
Igiveanaccurateprediction?Ifnot,isthepatientawareofthearea(s)ofdoubt? referringthepatientforspecialistadvice
Whatwouldareasonablepersonexpecttobetoldabouttheproposedtreatment? andcare.
Whatfactsareimportantandrelevanttothisspecific patient?(If I dont know, then I am Give appropriate postoperative advice
probably not ready to go ahead with the procedure anyway). and warnings
DoIneedtoprovideanyinformationforthepatientinwriting?Hasthepatientexpressed Informthepatientabouttheneedforearly
awishtohavewritteninformation?(Am I relying upon commercial marketing material reportingofanyindicationsofpossible
produced by manufacturers and/or suppliers? If so, is this information sufficiently balanced in nerveinjury.Inthesecasesspeedisofthe
the way it is presented?) essenceandthelongeryouspendkeeping
Doesthepatientunderstandwhattreatmenttheyhaveagreedto,andwhy?(by way of thesituationunderreviewwiththefixtures
illustration, when a general practitioner is proposing a crown to be supported on an implant stillinsitu,theworsetheprognosis.
fixture placed in association with a bone graft, under sedation and local anaesthesia, this Review the patient
requires all the aspects of a proper consent procedure to be covered for each of the six Chooseappropriateintervalsfollowingthe
aspects highlighted because there are risks and limitations, alternatives and other procedureandespeciallyinthedays
considerations associated with each of them, that the patient needs to understand before immediatelyfollowingtheplacementof
proceeding. Some patients may object to certain or any forms of bone grafting on religious or theimplant(s)
other grounds)
Havetheybeengivenanopportunitytohaveanyconcernsdiscussed,and/orhavetheir
questionsanswered?Dotherecordssupportthis?
Doesthepatientunderstandthecostsinvolved,includingthepotentialfuturecosts,inthe
eventofanypossiblecomplications?
Doesthepatientwantorneedtimetoconsidertheseoptions,ortodiscussyourproposals
withsomeoneelse?Canyou/shouldyouoffertoassistinarrangingasecondopinion?
Ifyouarerelativelyinexperiencedincarryingouttheprocedureinquestion,isthepatient
awareofthisfact?Aretheyaware,(ifrelevant)thattheycouldimprovetheirprospectsof
asuccessfuloutcome,orreduceanyassociatedrisks,iftheyelecttohavetheprocedure
carriedoutbyaspecialistoramoreexperiencedcolleague?
Ifthetechnique(orimplantsystem)isrelativelyuntriedorofanexperimentalnature,has
thepatientbeenmadeawareofthis?Includedhereareanyproceduresforwhichthe
evidencebaseislimitedorabsent,includingsystemswhichtradeonthepublished
evidencerelatingtosimilarsystemswithoutactuallybeingsupportedbyanyevidence
baseoftheirown.
Regularmonitoringoftheboneheightandsofttissues
adjacenttotherestoredportionoftheimplantwillalert
youtothefirstsignsofperi-implantitis

Themineeld Well-rehearsed
teamwork
optimisesclinical
Dental technician
ofimplant outcomeforthe
patient
dentistry Dentist
Patient
Dental
nurse/
Dental
hygienist
The prosthodontic stage Keepyoureyeontheball Summary

Itisbeyondthescopeofthisarticleto Implants,onceplaced,arealong-term Meticulousrecords
coverallthevariationsoffixedand commitmentforboththepatientandthe Inimplantdentistry,everystageofthe
removableprosthodonticsthatcanbe clinicianswhoareresponsiblefortheiron- processneedstobeverycarefully
supporteduponimplantfixtures,norallthe goingcare.Theconditionbecomingknown recorded.Especiallyimportanthereare
considerationsregardingimmediateor asPeri-implantitisisagrowingproblem recordsofwhatthepatientwasledto
deferredloading.Manyofthepotential notjustfortheclinicianswhooriginally expect,whatinformationwasprovidedto
complicationsattributableatfirstsightto placedtheimplantsorplacedrestorations thepatient,whatwarningstheywere
theprosthodonticstage(aesthetics, orappliancesuponthem,butsometimes givenetc.
function,softtissueproblemsattheneck forotherswhohadnopartintheoriginal
oftheimplant,maintenanceproblemsetc.) treatment,butendupcaringforthe Yourrecordsmustmeticulouslydocument
canbeavoidedifsufficienttimeand patientsintheyearsfollowingtheprovision everydetailofthehistoriestaken,the
attentionisappliedtothecase ofthatimplantdentistry.Thisincludesboth explorationofanypossibleriskfactorsthat
assessmentandtreatmentplanning dentistsanddentalhygienists. mightaffecttheprognosis,anytestsand
stages. investigationscarriedout,anyliaisonwith
Peri-implantmucositisisaninflammatory professionalcolleagues,andalldiscussions
Perhapsthebestgenericdescriptionofthe conditionwhichinitsearlystageis withthepatient.
rootcauseofmanyoftheproblems,isthat reversible.Therewillberedness,swelling,
inexperiencedclinicianswillsometimes inflammationandthetissuesaroundthe Detailedrecordsalsoneedtobekeptto
wronglyassumethatsupportingcrowns, fixturewillnotlookhealthy.Atthispoint demonstratethemeticulousmonitoringof
bridgesandappliancesonimplantfixtures, thereisnoboneloss.Improvedoralhygiene thestatusoftheimplants(bothhardand
isessentiallythesameasplacingthemon andbettercareoftheimplantswillusually softtissues)inthemonthsandyears
naturalteeth. reverseorimprovethecondition.Thereis followingtheirplacement.
anabundanceofevidencetosuggestthat
Follow up and monitoring thepresenceofkeratinisedgingivaltissue Stayuptodate
Maintenance attheneckoftheimplantatthepointof Implantdentistrycontinuestobea
Itisessentialthatpatientsshouldbe emergenceintotheoralcavityisa dynamicandevolvingfield.Ensurethatyou
helpedtorealisethatimplantsneedtobe desirable,protectivesituationwhichmakes keepyourknowledgeandskillsuptodate
lookedafterjustascarefullyasnatural theinitiationandfurtherprogressionless andbepreparedtoadjustyourapproach
teeth.Meticulousoralhygiene,with likely. whennecessary.
techniquesadaptedtothespecificneeds
ofeachpatient,and(whereapplicable) Leftuncontrolled,theinflammatory
continuedencouragementtomaintain conditioncanprogresstoperi-implantitis
smokingcessation,arecrucialingredients andlossofcrestalbone,oftencreatinga
ofimplantmaintenance. characteristicdish-shapedbonydefect
whichisclearlyvisibleonradiographs.
Patientsmustunderstandthatattendance Carefulcomparisonofsuchradiographs
asrecommendedforreviewpurposeswill overtimeallowsthesituationtobe
helptominimiseproblemsinthemonths assessed.Onceperi-implantitishasbecome
andyearsfollowingimplantplacement. established,itisverydifficult
Theymustalsoacceptresponsibilityfor totreat.
thepotentialconsequencesofnotdoing
so. Afailingimplantwillcontinuetofailifno
proactiveattemptismadetorectifythe
situation.Clinicianswhoplayednopartin
theplacementorrestorationoftheimplant
canwronglyassumethattheycannotbe
heldresponsibleforthefailurebutthey
canbeheldresponsiblebothforfailingto
identifythesignsthattheimplantisfailing,
andthefailuretoseekadvicefrom
colleagueswhohavemoreexperiencein
implantdentistry.
14
Endodonticinstruments Dr Shreeti Patel
Shreetihasa
practicelimitedto
Dr Shreeti Patel explainswhypatientsneed endodonticsand
toknowinstrumentscanbreak alsoworkswith
DentalProtection
asanAssociate
DentolegalAdviser
Despite the increased flexibility of the new generation Should you refer all endodontic
endodontic rotary instruments and a single use protocol, treatment to a specialist?
Dental Protection still receives a significant number of Ideally,thefollowingsituationscouldbeconsideredforreferralto
requests to assist with complaints about broken or fractured amoreexperiencedcolleaguewithenhancedskillsandequipment:
instruments (instrument separation) patientwithlimitedmouthopening
toothwithacrowndisguisingtheoriginalanatomicallandmarks
Formanyyears,thepotentialforfracturewasconsideredan Arootwithcurvaturegreaterthan30degreesoranSshaped
acceptedcomplicationofrootcanaltherapy(RCT)andnotinitself canal.
negligent.Timeschangeandinmanyjurisdictionscaselaw,in
respectofconsent,nowrequiresthecliniciantoinformthepatient Protect yourself
aboutanymaterialriskoftheirtreatmenttowhichtheywould Intheabsenceofthoroughrecordkeeping,acomplaintorclaim
1
attachsignificance . canonlybedefendediftheinformationhasbeengiventothe
patientandmoreimportantly,theyhaveunderstoodit.Asigned
Withthisinmind,instrumentseparationshouldberegardedasone consentformintheabsenceofdiscussionwillnotsufficefor
oftheriskspatientswouldneedtounderstandbeforetheycould purposesofconsent.Invitingthepatienttoaskquestionscan
consenttoendodontictreatmenttogetherwiththepossibilityof indicateiftheyhaveunderstoodtherisksandnotethisinyour
rootperforationorfailureofthetreatmentduetopersistent records.
infection.
Minimising the occurrence
Sometimes,itcanbedifficulttoknowjusthowmuchinformation Updatingclinicalskills,andunderstandingofthelimitationsofnew
ourpatientsshouldbeoffered. endodonticsystems.
Usingmagnification,achievingstraightlineaccessandadequate
Consent and explaining the risk canallubrication
Onesizedoesnotfitalliftheclinicianistoensurethattheyhave Limitingfileuse,followingmanufacturersinstructions.
obtainedvalidconsentfromthepatientsittinginthechairabout
toconsiderendodontictreatment.Naturally,allthepreoperative Management of a broken file
considerationsthatarediscussedshouldbedetailedintheclinical Tellthepatientandrecordthisintheclinicalnotes
records.Therecordsshouldalsoincludetheclinicalandradiographic Discusstheoptionsformanagement,whichwillincluderemovalof
assessmentofthetooth,thedegreeofrootcurvature,andpatency theseparatedpiece,by-passingorleavingthefragmentinsitu,
orsclerosisofcanals,whichcouldincreasethelikelihoodoffile fillingrootcanaltocoronallevelofthesegmentorsurgery.
separation.Ifyouanticipatethepossibilityofsucharisk Riskassessingtheclinicalsituationeg.thepresenceofapical
materialising,thenanexplanationastohowthesituationwouldbe disease,mayreducetheprognosisinthepresenceoffilefracture.
managedshouldbeofferedtothepatientinadvanceandanote Notethestageofcanalpreparationwhenfileseparationoccurs,
made. especiallyininfectedcasesandconsiderhowmuchdisinfectionhas
beenachieved.
Informingpatientsinamannerthatmaintainstheirtrustisof Intheabsenceofapicaldiseaseandsymptoms,leavingthefilein
utmostimportance.Aswithallriskmanagement,communication situmaynotreducetheprognosis.
isthekey.Thedifficultyarisesindescribingthelikelihoodofthe Specialistreferralshouldbeconsidered,magnificationand
event.Onemightarguethat,inthehandsofaspecialist expertiseisusuallyrequired
endodontist,theincidenceoffileseparationmaybelessthanin Thedecision-makingprocessforthemanagementshouldbe
thehandsofadentistwhoisusinganewendodonticfilesystem discussedwiththepatientinanhonestandsympatheticmanner.
withlesshands-onexperience.Butregardlessofspecialisation, Dontbepressuredintotryingtoretrievethefragmentwithout
theincidenceoffilebreakagecanbeminimisedbycarefulpre- adequateexpertiseandequipment,asthecomplicationsarising
operativeassessmentofthetooth. fromthismaybeevenmoredetrimentaltotheoutcomeandcould
lead,forexample,torootperforation.
1
MontgomeryvLanarkshireHealthBoard(2015)UKSC11 Summary
RogersvWhittaker(1992)67A.L.J.R.47(HighCourtofAustralia)
Assessandadequatelydiscussthendocumentthechancesoffile
separationpriortotreatmentineachcase.Informationgiven
beforetheprocedureconstitutesawarningwhereasthesame
explanationafterafileseparatesislikelytobeinterpretedbythe
patientasanexcuse.
Resistancerules
Inabidtoslowtheglobalshifttowardsantibioticresistance,itisvitalthatdentists
ensuretheyprescriberesponsibly
With every decade that passes, we discover new ways Short on time?
in which technological developments can impinge on the Indentistry,thepatientinpainissometimesofferedaprescription
quality of life directly or indirectly sometimes for forantibioticswhenthereisinsufficienttimetofullyinvestigate
generations not yet born; a by-product perhaps of our theprobleminthehopethepainwillrespond.
desire for an easy fix to lifes challenges
DentalProtectionhasnoticedthatwhilstentriesinpatientrecord
Globalwarming,forexample,servestohighlightthedilemma cardsmaywelldescribethetreatmentgivenforacutepainor
posedbyweighingupthebenefitstoapopulationwithadesirefor swelling,thereisoftenagapinthelogicaldiagnosticprocess.
unlimitedaccesstoenergyagainsttheresultingimpactonthe
environment. Thepatientscomplaintandsymptomsaredocumented,together
withanyteststhathavebeenundertaken;thetreatmentsimilarly
described.However,indentalinfectionstheclinicalsignsand
Medicineisnoexception.SinceFleming symptomsrequireaproperassessmentofthecause,extentand
natureoftheinfection(localisedorspreading)andwhetherthe
discoveredpenicillin(consideredthefirst patientisunwell.Veryoften,thediagnosisonwhichthetreatment
trueantibiotic)in1928,theworldhasseen hasbeenbasedismissing.
drugresistancebecomeasignificantand Possibly,theemergencypatienthasbeentreatedonthebasisof
undesirablefeatureofmodernlifewith aprovisionaldiagnosispriortoasubsequentlongerappointment
toreviewthesituation.Whentimeisshortandwiththepainof
thenumberofalternativeantimicrobials earlyonsetintheabsenceofanobviousinfectionitis
effectiveintreatinginfectionslimited questionablethatanantimicrobialprescriptionwillbeofbenefit.
Ananalgesicismorelikelytoprovidepainreliefuntilsuchtime
whenalongerappointmentisavailable.
Andso,asantibioticeffectivenessischallenged,cliniciansneedto
bemindfulofthefactthat,byencouraginglimitedandappropriate Weknowthattheinflammatoryprocessinvolvedinpulpitisdoes
antibioticuseinprimarycare,theycanhelptostemthetideof notrespondtoantimicrobials,butwillrespondtoananalgesic.On
risinglevelsofantibiotic-resistantbacteria.Therefore,inthe theotherhand,thepainfromanacutedentalabscesswillrespond
absenceofadiagnosis,practitionersarealwaysadvisedtothink veryquicklyiftheabscesscanbedrainedbyextraction,root
verycarefullybeforeprescribingantimicrobials. treatmentorincision,regardlessofanyprescriptionthatmight
subsequentlybegiven.
International rescue
Therehasbeenaninternationalmovetoaddressthisgrowing Inabusydentalsurgery,itcanbedifficulttoundertakethe
publichealthproblemwhicharisesbecause,whilethenumberof definitivetreatmentonthedaythatthepatientpresents,but
infectionsduetoantibiotic-resistantbacteriacontinuestogrow, patientswithaspreadinginfectionneedadefinitivetreatment
thepharmaceuticalindustryssupplyofnewantibioticsdoesnot evenwhentimeisshort.Nottodosocouldleadtoadditional
lookpromising.Itcertainlypresentsableakoutlookonavailability complicationsthatcouldleavetheclinicianvulnerabletocriticism.
ofeffectiveantibiotictreatmentforthefuture.
Dentistshavetofindenoughtimetotakeahistory,examinethe
AccordingtotheWorldHealthOrganisation,theoveralluptakeof patientandmakeanappropriateassessmentofthepatients
antibioticsinapopulationaswellasthewayinwhichantibiotics condition,beforemakingadiagnosisonwhichthetreatmentcan
areconsumedhasanimpactonantibioticresistance. bebased.Thediagnosisisessentialifthebestuseofantimicrobials
andanalgesicsistobeachieved.
Experiencefromsomecountriessuggeststhatreductionin
antibioticprescribingforoutpatientshasresultedinconcomitant Thiscontributiontoreducingtheescalationofantimicrobial
decreaseinantibioticresistance.Unnecessaryantibiotic resistanceservesthebestinterestofpatientsandformspartofa
prescribinginprimarycareisacomplexphenomenon,butis biggerpicture,inwhichcliniciansarebeingaskedtocreateasea-
probablyrelatedtofactorssuchasmisinterpretationof changebyreversingaworldwideproblemthatalsoconstitutesa
symptoms,diagnosticuncertainty,timeandperceivedpatient majorthreattopublichealth.
expectations.
16
Dr David Croser
Davidworkedas
ageneraldental
practitionerbefore
becoming
Communications
ManagerforDental
Protection
Flow chart Antibiotics: handle with care

Aflowchartforthemanagementofacutepainmayhelpensure WorldAntibioticAwarenessWeekaimstoincreaseawareness
bestpracticeincaseswheretheinitialdiagnosisisprovisional. ofglobalantibioticresistanceandtoencouragebestpractices
So,besureto: amongthegeneralpublic,healthworkersandpolicymakersto
avoidthefurtheremergenceandspreadofantibioticresistance.
Allocatesufficienttimetoformadiagnosis
Recordthediagnosisandthetreatmentindicated Aglobalactionplantotacklethegrowingproblemofresistanceto
Educatethepatientonyourapproachifantibioticsarenot antibioticsandotherantimicrobialmedicineswasendorsedatthe
prescribed,particularlyiftheyhadoriginallyrequestedthem Sixty-eighthWorldHealthAssemblyinMay2015.Oneofthekey
Scheduleanappointmentforthedefinitivetreatment objectivesoftheplanistoimproveawarenessandunderstanding
Audityourprescribingtoseethecorrelationbetweenthe ofantimicrobialresistancethrougheffectivecommunication,
prescriptionsandtheconditionsdiagnosed. educationandtraining.
Thethemeofthecampaign,Antibiotics:HandlewithCare,reflects
Recommendationsforaudit theoverarchingmessagethatantibioticsareapreciousresource
andshouldbepreserved.Theyshouldbeusedtotreatbacterial
Clinicalauditisaqualityimprovementtool infections,onlywhenprescribedbyacertifiedhealthprofessional.
thataimstoencouragereflection,review Antibioticsshouldneverbesharedandthefullcourseoftreatment
shouldbecompletednotsavedforthefuture.
andchangestopracticethatenhance
patientcare.Topicsforauditshouldbe WHOisencouragingallMemberStatesandhealthpartnerstojoin
thiscampaignandhelpraiseawarenessofthisissue.
chosencarefully,toprovideinformation
thatwillimprovethequalityofthe Key facts
Antibioticresistanceisoneofthebiggestthreatstoglobalhealth
managementofpatientswithacutedental today.Itcanaffectanyone,ofanyage,inanycountry.
problems. Antibioticresistanceoccursnaturally,butmisuseofantibioticsin
humansandanimalsisacceleratingtheprocess.
Agrowingnumberofinfectionssuchaspneumonia,tuberculosis,
Topicsinclude: andgonorrhoeaarebecominghardertotreatastheantibiotics
Antibioticprescribingforacutedental usedtotreatthembecomelesseffective.
Antibioticresistanceleadstolongerhospitalstays,highermedical
problems costsandincreasedmortality.
Analgesicprescribingforacutedental
References
problems www.who.int/drugresistance/en/
Medicalhistoryrecording. ScottishDentalClinicalEffectivenessprogrammeManagementofAcuteDental
Problemshttp://www.sdcep.org.uk/index.aspx?o=3243
AntimicrobialprescribingforGeneralDentalPractitioners-availablefrom
www.fgdp.org
SirAlexander
Flemingcelebrated
onastamps
fromtheFaroe
Islands
Difcultpatientinteractions
Dr Mark Dinwoodie investigateshowtheperceptionofdicultycanaect
interactionwiththepatient
Depending on how regularly you work Onmeetingthepatientyoumakefurther But does this matter?
in the same dental practice or clinic, rapidjudgements.Negativeperceptions Evidencesuggeststhatonceahealthcare
a brief scan through the list of names canoccurquickly,oftensubconsciously, professionaljudgesapatienttobe
of patients on your morning list may fuelledbypreviousexperienceand difficult,theirverbalandnon-verbal
reveal a few that are familiar. For triggeredbywords,behavioursandvisual interactionalbehaviourscanshiftintoa
those that you recognise you are likely cues.Itbecomeseasytoquickly stylethatishigherrisk.Thisincreasesthe
to form a very quick assessment as to stereotypeorlabelapatientandmake chancethatthepatientmayindeed
the likely challenge of the forthcoming assumptionsaboutthem,bothataclinical respondinanunhelpfulmanner,beless
clinical encounter, largely based on andinteractionallevel.Inyourmindyou satisfiedandmorelikelytocomplain
your previous contact with the patient. mightbethinking:Thisisatypicalpatient (White2005).
For many on the list this will provoke withconditionA,characteristicB,
a neutral or positive feeling behaviourCorattitudeD. Ourperceptionofdifficultycanaffectour:
Greetings:lesswarm/friendly/nosmile
Howeveritisnaturaltopredictthatsome Oneimagemayhavemadeyoufeelmore Non-verbalmessages:lackofeyecontact;
oftheseencounterswillbemore uncomfortablethantheother.Itis preoccupationwiththeirdentalrecordor
challenging.Thiscanbeforavarietyof extraordinaryhowquicklyperceptual somethingotherthanthepatient;closed
reasonsthatmightbeclinicallyrelated judgementsarounddifficultyaremade bodylanguage
butinsomecasesitmaybebecauseyou and,inthiscase,simplybasedonthefacial Degreetowhichwelisten:lessactive
havealreadylabelledthepatientas expression.Itisthisfeelingofdiscomfort listeningwithfrequentinterruptions;
difficult,largelybasedonbehavioursthey thatcantranslateintoajudgementabout increaseinclosedorleadingquestions;
exhibitedorattitudesthattheyexpressed thepatientslevelofdifficulty,ie,thislooks talkingoverthepatient
whenyoulastsawthem.Preconceptions likeapotentiallydifficultpatient.Itsalso Informationweprovide:lessverbal
andassumptionsarethereforealready interestingthatthepatientsthatone informationandexplanationoffered
beingformulatedinyourmind,basedon dentalteammemberdescribesas Involvementofpatientindecision-making:
thislabelevenbeforethepatienthas difficultareoftendifferentinsomeone moredirective;lessexplorationofpatient
beenseen. elsesopinion. values,concernsandpreferences;fewer
optionsdiscussed
Thisvariationandtheexampleabove
suggeststhatitisourperceptionofthe Suchbehaviourscanleadtoadownward
interactionaldifficultythatresultsinus spiral.Theconsultationisadynamic
labellingthepatientasdifficult:itmay interactiveprocessandpatientsand
reflectpastexperiencewiththisorsimilar healthcareprofessionalswillrespondto
patients,ourtrainingandanyunderlying eachothersbehavioursinwaysthatwill
prejudiceswehave. eitherhelporhindertheinteraction(Krebs
etal2006).
Difficultinteractionscanmakehealthcare
professionalsfeelfrustrated,resentful,
angryandsometimeshelplessor
overwhelmed.Theycanalsocontribute
tolongtermstress
(Bodner2008)
18
Dr Mark
Dinwoodie
MarkistheHeadof
DentalProtection/

MPSEducational Thewayyouseethemistheway
Services
youtreatthemandthewayyou
treatthemisthewaytheyoften
become(ZigZiglar,SeeYouattheTop)
Potential outcomes from difficult

interactions
Increasedinvestigationsandreferrals
Decreasedpatientsatisfaction
Unmetexpectations
Increaseddentolegalrisk
Difficultinteractionscanbedistressingfor
bothpatientsandmembersofthedental
team.Theycanbeacatalystfor
complaintsandclaims,anddealingwith
themeffectivelycanleadtoabetter
outcomeforpatientsandmembersofthe
dentalteam.
OurMastering Difficult Interactions

workshopallowsgreaterexplorationof
thesechallengesandoffersskillsand
strategiestominimisetherisksinvolved.
Formoreinformationandbooking,please
visitdentalprotection.org
References
KoekkoekB,vanMeijelB,Hutschemaekers,GDifficult
PatientsinMentalHealthCare:AReview,Psychiatric
Services Vol57,No6June2006.Pp795-802
KrebsEE,GarrettJM,KonradTR,TheDifficultDoctor?
Characteristicsofphysicianswhoreportfrustration
withpatients:ananalysisofsurveydata,BMC Health
Services Research Vol6,No128.October62006
BodnerS,StressManagementintheDifficultPatient
Encounter,Dental Clinics of North America,52:579-603
(2008)
WhiteAA,PichertJWetal,CauseandEffectAnalysis
ofClosedClaimsinObstetricsandGynaecologyObstet
Gynaecol.2005;105:1031-8
Contacts
YoucancontactDentalProtection
forassistanceviathewebsite
dentalprotection.org oratany
ofourofficeslistedbelow
London
33CavendishSquare,LondonW1G0PS
Telephone
+44(0)2073991400
Facsimile
+44(0)2073991401
Leeds
VictoriaHouse,2VictoriaPlace,LeedsLS115AE
Telephone
+44(0)2073991400
Facsimile
+44(0)2073991401
Edinburgh
39GeorgeStreet,EdinburghEH22HN
Telephone
+44(0)2073991400
Facsimile
+44(0)1312401878
Opinionsexpressedbyanynamedexternalauthorsherein
remainthoseoftheauthoranddonotnecessarilyrepresentthe,
viewsofDentalProtection.Picturesshouldnotberelieduponas
accuraterepresentationsofclinicalsituations
Editor
david.croser@dentalprotection.org
DentalProtectionLimited
December2015

Riskwise Malaysia

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Along with my senior colleague, Inrecentyears,thegrowinginvolvement Assomememberstransferoverthe

Dr Jane Merivale BDSLLM

When to stop? Thisispotentiallydangerousterritory,and Occasionallythoughtheresultisdisaster

It happens What next? Self-reproachisafrequentaftermath

In general, there are three approaches

Members in the latter group will

the first place, but for members in the

Before you start Itisnotdifficulttoseehowexposeda The tools for the job

Getting started Sharing care when Nowhereistheneedforthisseamless

Case assessment and Minimiseriskand Ifanadverseoutcomecouldhavebeen

DentalProtection RiskwiseMalaysia15 13

The prosthodontic stage Keepyoureyeontheball Summary

Flow chart Antibiotics: handle with care

Potential outcomes from difficult

OurMastering Difficult Interactions

Вам также может понравиться

Riskwise Malaysia

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Malaysia

Along with my senior colleague, Inrecentyears,thegrowinginvolvement Assomememberstransferoverthe

Dr Jane Merivale BDSLLM

When to stop? Thisispotentiallydangerousterritory,and Occasionallythoughtheresultisdisaster

It happens What next? Self-reproachisafrequentaftermath

In general, there are three approaches

Members in the latter group will

the first place, but for members in the

Before you start Itisnotdifficulttoseehowexposeda The tools for the job

Getting started Sharing care when Nowhereistheneedforthisseamless

Case assessment and Minimiseriskand Ifanadverseoutcomecouldhavebeen

DentalProtection RiskwiseMalaysia15 13

The prosthodontic stage Keepyoureyeontheball Summary

Flow chart Antibiotics: handle with care

Potential outcomes from difficult

OurMastering Difficult Interactions

Вам также может понравиться

Along with my senior colleague, Inrecentyears,thegrowinginvolvement Assomememberstransferoverthe

Dr Jane Merivale BDSLLM

When to stop? Thisispotentiallydangerousterritory,and Occasionallythoughtheresultisdisaster

It happens What next? Self-reproachisafrequentaftermath

Before you start Itisnotdifficulttoseehowexposeda The tools for the job

Getting started Sharing care when Nowhereistheneedforthisseamless

Case assessment and Minimiseriskand Ifanadverseoutcomecouldhavebeen

DentalProtection RiskwiseMalaysia15 13

The prosthodontic stage Keepyoureyeontheball Summary

OurMastering Difficult Interactions