Slipping standards

CUTTING corners and taking shortcuts is something we are all probably a bit guilty of at some point in our lives, but on most occasions no harm is done. Anyone who has ever taken driving lessons, for example, will remember being taught to “feed the wheel”, but how many drivers can honestly say we still do so once our test has faded from memory?

It is common to make judgements on what risks we are prepared to take by weighing up the likely benefits against any potential harm. But what happens if we start to cut corners in dentistry? What are the risks of deviating from our training when carrying out assessments or providing treatment for our patients?

There is no doubt that, over time, as our experience and ability increase this will inevitably lead to changes in our clinical practice. Occasionally however, these changes might not be made for the right reasons – i.e. to speed up treatments or increase profit – and this could lead to problems. Patients may be adversely affected, prompting complaints, and you could find yourself in professional difficulties with the General Dental Council if your clinical practice is not in line with their guidance.

At the root of many dento-legal cases dealt with by MDDUS are a handful of basic errors and omissions – or sloppy habits – that, if avoided, could have prevented a lot of trouble for our members.

Rubber dam

Top of the list when it comes to sloppy habits has to be not using rubber dam for root canal treatment. Can anyone remember doing an RCT at dental school without it? No, me neither! But what about now? Are all your root canal treatments still done under rubber dam? Have you ever been tempted to access a canal with a file without rubber dam? Some dentists don’t bother using it because they find it difficult to place and believe they can work just as effectively without it.

I am a great fan of rubber dam and find that once you get used to applying it (it’s easier if you get your nurse to help) lots of types of dental treatment are so much easier. Root canal treatment is actually much simpler with rubber dam. It keeps slobbery wet tongues at bay and, by popping in a saliva ejector underneath, your nurse can concentrate on assisting you rather than aspirating every two seconds. Once you’ve cleaned and irrigated the canals they don’t fill straight up with contaminated saliva and you’ve got half a chance of your treatment being successful.

Of course one of the most important functions of rubber dam is airway protection. There is simply no defence for an inhaled or swallowed file during root canal treatment performed with no rubber dam in place. Here at MDDUS we see a steady trickle of cases where endodontic instruments have been ingested because of a lack of rubber dam and it’s always a stressful situation for all concerned.

The patient clearly has a serious medical problem if they have swallowed or inhaled an endodontic file and the dentist is in the awful position of explaining that the patient now has to make an urgent visit to hospital for assessment and possible surgery to retrieve the file. Not surprisingly, patients are not happy about this and often complain or raise a claim through solicitors.

Periodontal pitfalls

Another treatment that can fall victim to complacency is omitting to carry out a BPE (basic periodontal examination) for new patients and as part of regular check-up appointments which could lead to a failure to spot an emerging periodontal problem (see page 12). The BPE is a simple and quick way of checking the state of the patient’s periodontal health and is an essential component of patient management. Claims for cases relating to undiagnosed periodontal problems usually run into thousands of pounds.

Retraction cord or equivalent material

Other slightly sloppy habits we can get into include failing to use retraction cord, or an equivalent, if needed during crown preparations with inevitable resultant poor margins and poor fit of restorations. This might not prove problematic for a year or two but patients are likely to remember how much they paid for their crowns and expect them to last.

Matrix bands

Wedging matrix bands is another technique that can often become a distant memory of dental school. This easy and quick method helps ensure a decent profile for restorations and stops your toes curling with embarrassment when you have to report on your bitewings and comment on that blob of amalgam clogging up the interproximal areas!

History

Don’t forget to check medical histories at each appointment. It’s really easy to get sloppy over this one but many patients have medical histories that need careful handling. It’s at best embarrassing to be called by the local pharmacist to say you’ve prescribed penicillin to an allergic patient and at worst downright dangerous. And don’t wait until you’ve extracted a couple of huge molars to discover that your patient is on warfarin or bisphosphonates.

Non-clinical issues

Not all problematic sloppy habits relate to clinical work. Other common causes of patient complaints concern the financial side of dentistry. It’s an important requirement that patients receive a treatment plan and an estimate of their treatment costs. Any estimate should be clear as to whether charges are for private or NHS work. Without a clear plan and estimate in place, there is scope for confusion or even disagreement once treatment is completed.

Dental records

Another recurring issue is dental record keeping. Indemnity organisations are always banging on about this, but it’s true to say that if it’s not in the records then the assumption is you didn’t do it. Memories fade and the only way to be sure of what you did and didn’t do is to write it down. Don’t get sloppy with your records – take a note of what you discussed with the patient, particularly if the treatment is complex or expensive; record the options you discussed and record what warnings you have given to the patient concerning likely prognosis of treatment. If things go wrong with treatments, and occasionally they will, tell the patient and make a note in the records that they have been informed.

The most important advice when considering cutting corners is to ask yourself if you are changing your practice for the benefit of the patient or for your own financial or other benefit. And you know what my next piece of advice will be… if it’s not for the benefit of the patient then it’s not the right thing to do. So don’t rush to forget everything they taught you in dental school and perhaps consider enrolling on a rubber dam course instead!

Claire Renton is a dental adviser at MDDUS