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dentalprotection.org HongKong Insideissue15 Dentalimplantfeature Learnhowtosteerclearofavoidableproblems914 Risk wise RiskmanagementfromDentalProtection

Riskwis e - Home - Dental Protection · the importance of communicating the real ... Failures in case assessment, diagnosis and treatment planning Deficiencies in the consent process

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Page 1: Riskwis e - Home - Dental Protection · the importance of communicating the real ... Failures in case assessment, diagnosis and treatment planning Deficiencies in the consent process

dentalprotection.org

Hong�Kong

Inside�issue�15

Dental�implant�feature�Learn�how�to�steer�clear�of�avoidable�problems�9–14

RiskwiseRisk�management�from�Dental�Protection

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2

Dental�Protection�Limited�is�registered�in�England�(No.�2374160)�and�is�a�wholly�owned�subsidiary�of�The�Medical�ProtectionSociety�Limited�(MPS)�which�is�registered�in�England�(No.�36142).�Both�companies�use�Dental�Protection�as�a�trading�nameand�have�their�registered�office�at�33�Cavendish�Square,�London�W1G�0PS

Dental�Protection�Limited�serves�and�supports�the�dental�members�of�MPS�with�access�to�the�full�range�of�benefits�ofmembership,�which�are�all�discretionary,�and�set�out�in�MPS’s�Memorandum�and�Articles�of�Association.�MPS�is�not�aninsurance�company

Dental�Protection®�is�a�registered�trademark�of�MPS

Resistance�rulesDr�David�Croser�looks�at�the�importanceof�responsible�prescribing��16–17

Difficult�patient�interactionsDr�Mark�Dinwoodie�explains�how�yourperception�of�difficulty�impacts�oncommunication��18–19

Contact�usWe�love�to�hear�from�you��20

Adult�orthodonticsDr�Alison�Williams�describes�some�of�theproblems�that�can�arise�from�treatingaduts�who�are�short�of�time��4–5

A�root�in�the�sinusDr�Mike�Rutherford�considers�the�bestway�of�managing�such�unexpectedsituations��6–8

The�minefield�of�implant�dentistryHow�to�steer�clear�of�avoidable�problems9–14

Endodontic�instrumentsDr�Shreeti�Patel�explains�why�patientsneed�to�know�that�instruments�canbreak��15

Contents

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Editorial

This edition of RiskwiseWe�have�focused�on�particular�areas�ofpractice�that�are�causing�us�great�concern–�the�minefield�of�implant�dentistry�andshort-term�orthodontic�treatment�carriedout�by�non-specialist�general�practitioners.�

Once�you�have�read�these�articles,�acommon�theme�emerges;�that�of�obtainingvalid�consent.�It�is�essential�to�convey�fullinformation�to�our�patients,�cruciallychecking�for�their�understanding�of�whathas�been�described�and�allowing�themtime�to�consider�what�they�have�heard.This�will�often�mean�giving�patients�time�to�go�away�to�think�about�their�dentalcondition�and�treatment�options,�to�conferwith�family�and�friends�and�then�to�returnto�ask�questions�before�then�making�theirdecision�and�proceeding�with�treatment.�In�today’s�digital�world,�where�patients�willoften�search�the�internet�to�investigate�adiagnosis�or�treatment�plan,�it�is�importantto�give�patients�a�clear�description,�so�thatthey�can�search�for�that�specific�term.

Clearly,�the�more�complex�(and�perhapsexpensive)�the�treatment�is,�the�moreimportant�the�opportunity�for�reflectionand�questions�becomes.�It�is�very�unusualfor�a�medical�negligence�case�to�reach�the�highest�courts,�however�in�the�UKSupreme�Court�the�case�of�Montgomery v Lanarkshire Health Board

1was�decided�in

April�this�year.�In�essence�the�case�sets�outthe�importance�of�communicating�the�realchoices�a�patient�faced�and�giving�thepatient�a�real�choice�rather�than�imposingwhat�the�clinician�believed�to�be�the�bestcourse�of�action.�Although�this�was�anobstetric�case,�the�principle�applies�that�inobtaining�valid�consent�a�patient�needs�tobe�offered�genuine�choices�with�accurateestimates�of�the�costs�where�appropriate.

I recently had the pleasure of visitingthe Hong Kong Dental Associationalong with my senior colleague, JaneMerivale in November. We had a veryuseful meeting in which we discussedthe pattern and frequency of casesthat arise in Hong Kong. I was able toexplain that the mix of cases beingreported both in Hong Kong and therest of the world is gradually shiftingso that in future we will see morecases arising from techniques such asimplants and adult orthodontictreatment, alongside those that havehistorically given rise to concern,notably oral surgery and endodontics

Advances�like�these�accompanied�by�thenew�era�of�digital�communication�pose�newchallenges�and�opportunities�for�patientsand�dentists�alike.�Patients�behave�more�like�consumers�when�seeking,�or�at�timesapparently�demanding,�sophisticatedelective�treatments�to�enhance�theirappearance�rather�than�simply�requestingtreatment�for�dental�disease.

Dr StephenHendersonHead�of�DentalServices,�Hong�Kong

Dental�Protection Riskwise�Hong�Kong�15

A�failure�to�obtain�valid�consent�is�arecurring�allegation�in�dental�claims�andDental�Council�investigations,�thereforethis�is�an�area�of�communication�andrecord�keeping�that�we�need�to�improve�to�be�in�the�best�possible�position�to�haveevidence�that�valid�consent�has�beenobtained.

MembershipsubscriptionsRest�assured,�our�membershipsubscriptions�are�based�on�the�bestactuarial�advice�available,�reflecting�thedental�claims�and�case�experience�in�eachcountry.�Subscriptions�are�set�to�provideprudently�for�the�present�and�future�needsof�our�members�as�claims�may�arise�5,10or�even�20�years�after�the�treatment�weprovide�this�year.�There�is�no�profit�elementfactored�into�the�subscription�you�pay�us.

We�therefore�ask�you�to�be�sure�you�arepaying�the�correct�subscription�for�thescope�of�your�practice�at�all�times.�Yourentitlement�to�the�benefits�of�membershipis�likely�to�be�placed�at�grave�risk�if�you�are�not.�

Future generationsAs�healthcare�professionals,�we�have�aduty�to�act�responsibly�towards�futuregenerations;�hence�we�have�included�atimely�article�on�the�rising�levels�ofantibiotic�resistant�bacteria�and�our�dutyto�think�very�carefully�before�prescribingantibiotics.�It�is�no�longer�acceptable,�when�faced�with�the�evidence�about�theconsequences�of�antibiotic�resistance�inthe�community,�to�prescribe�antibioticswhere�they�are�contra-indicated.�

As�ever,�I�look�forward�to�working�closelywith�the�HKDA�in�the�delivery�of�servicesto�our�members�in�Hong�Kong.

Best�wishes,

Dr Stephen Henderson BDS�LLM�FFGDPHead�of�Dental�Services,�Hong�[email protected]

1Montgomery�v�Lanarkshire�Health�Board�(2015)�UKSC�11

An�opportunity�for�Dental�Protection�tomeet�with�colleagues�from�the�Hong�KongDental�Association.�Left�to�right.�Dr�AlfredYung,�Dr�Haston�Liu,�Dr�Sigmund�Leung�JP,Dr�Stephen�Henderson,�Dr�Jane�Merivale,Dr�Vincent�Leung�and�Mr�Jason�Chan

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Adult�orthodonticsDr Alison Williams describes�some�ofthe�problems�that�can�arise�from�treatingadults�who�are�short�of�time

4

There are three obvious challenges that arise if adultorthodontic treatment is sought:Patient�may�impose�constraints�upon�how�the�treatment�is�tobe�carried�out�(especially�in�terms�of�the�type�of�appliance�andits�visibility).The�treatment�plan�may�be�complicated�by�previousorthodontic�treatment,�missing�teeth,�the�presence�ofrestorations�or�periodontal�disease.�Failure�to�meet�patient�expectations�can�lead�to�complaints.

Adult�patients�who�are�prepared�to�commit�themselves�toorthodontics�will�generally�not�do�so�lightly�and�may�well�be�highlycompliant�and�co-operative�with�the�treatment.�The�flip-side�tothis�is�that�adults�tend�to�become�heavily-involved�in�theirtreatment,�often�scrutinising�every�tooth�movement�that�occursbetween�appointments.�

An�inexperienced�clinician�may�have�to�adapt�the�originaltreatment�plan�as�the�now�“expert”�patient�becomes�more�andmore�aware�of�their�occlusion.�These�“tweaks”�to�the�originaltreatment�plan�tend�to�lengthen�the�treatment�time,�which�can�beunpopular.

Unless�the�clinician�has�sufficient�experience�there�is�a�temptationto�undertake�tooth-movements�that�are�clinically�contra-indicated,�in�an�attempt�to�appease�a�persistent�patient.Unfortunately,�the�problems�identified�during�the�treatment-planning�stage�re-emerge�and�the�objectives�of�the�amendedtreatment�plan�are�still�frustrated.

Unmet expectationsOrthodontic�treatment�as�an�adult,�particularly�in�middle�age,�can�be�costly,�uncomfortable,�time-consuming�and�potentiallyembarrassing.�An�adult�making�these�sacrifices�may�haveunrealistic�expectations�of�the�impact�that�straighter�teeth�canhave�on�other�aspects�of�their�life;�the�stakes�can�be�high.

Tooth�movements�tend�to�be�slower�in�adults�and�some�are�verydifficult�to�achieve.�Inexperienced�clinicians�who�don’t�have�a�clearunderstanding�of�what�can�and�cannot�be�achieved�withorthodontics�in�an�adult�or�who�skimp�on�the�consent-process�mayfail�to�meet�patient�expectations.�

Clear aligner techniquesThe�concept�of�using�removable�tooth-positioning�devices�forminor�localised�tooth�movements�is�not�new.�Arguably,developments�in�data�technology�have�facilitated�novel�techniquesfor�the�movement�of�teeth.�These�systems�are�particularlyattractive�to�the�“non-specialist”,�without�any�recognised�formaltraining�in�orthodontics.�

Because�the�treatment�plan�and�a�series�of�aligners�are�formulatedfor�the�practitioner,�treatment�can�be�provided�with�a�minimum�oftraining.�This�means�that�patients�can�be�treated�“in-house”�bytheir�own�dentist,�rather�than�having�to�travel�to�another�practiceto�see�a�specialist

A�study�conducted�by�Dental�Protection�in�the�UK�revealed�thatclaims�arising�from�orthodontics�have�been�on�the�increase,�and20%�of�the�new�cases�reported�in�2010�involved�alignertechniques.�Significantly,�general�(ie.�non-orthodontic�specialist)practitioners�accounted�for�80-90%�of�all�aligner-relatedcomplaints�and�claims,�a�worrying�development�given�theirincreasing�popularity�with�patients�and�amongst�generalpractitioners�who�provide�orthodontic�treatment.�

However,�closer�analysis�of�the�cases�reveals�that�underlyingcauses�were�no�different�to�most�other�orthodontic�cases:Failures�in�case�assessment,�diagnosis�and�treatment�planningDeficiencies�in�the�consent�process�(especially�in�relation�todiscussing�alternative�orthodontic�approaches)Inexperience�and�a�failure�to�anticipate�and�recognise�problemsFailure�to�recognise�the�significance�of�interproximal�reduction(interdental�“stripping”)�as�a�means�of�space�creation,�and�theassociated�risks�Failure�to�manage�the�patient’s�expectations�–�perhaps�“over-selling”�the�obvious�benefits�of�clear�aligner�techniques�withoutsufficiently�stressing�the�risks�and�limitations.

Additional�risks�are�introduced�when�the�clinician�is�reliant�on�thecomputer�software�and�the�remote�technician�who�designs�andconstructs�the�aligners;�effectively�taking�over�the�diagnosis�andtreatment-plan�without�ever�seeing�the�patient.�If�that�serviceoriginates�outside�your�own�country�the�risks�associated�withteledentistry�should�be�considered�(Search�for�“teledentistry”�atdentalprotection.org).�

Dentists�with�minimal�recognised�training�in�orthodontics�areparticularly�vulnerable�because�they�are�unlikely�to�have�theexpertise�to�recognise�if�a�treatment�plan�they�receive�from�the“remote”�planner,�is�not�in�the�patient’s�best�interests.�Theproviders�of�these�planning�services�inform�practitioners�that�theycan�reject�the�first�treatment�plan�if�it�is�unsuitable.�But�a�non-specialist,�with�little�orthodontic�training,�may�not�have�theknowledge�or�confidence�to�“argue�with�the�computer”.

••

••

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5Dental�Protection Riskwise�Hong�Kong�15

Dr Alison WilliamsAlison�is�a�specialistorthodontist�whoalso�works�as�apart-time�AssociateDentolegal�Adviserfor�DentalProtection

ComplianceAligner-systems�rely�on�patients�wearing�their�aligners�for�aprescribed�number�of�hours�each�day.�Patients�frequently�fail�toachieve�the�target,�and�so�discrepancies�can�develop�between�theactual�and�the�predicted�tooth�movements�that�each�aligner�isexpected�to�produce.�An�experienced�clinician�will�notice�thediscrepancy�and�amend�the�treatment�plan.�An�untrained�orinexperienced�clinician�may�continue�to�fit�the�next�aligner�in�thesequence�not�noticing�that�there�is�a�problem.�Complaints�can�beinitiated�if�the�clinician�has�to�back-track�through�the�alignersequence,�increasing�the�overall�treatment�time.

RelapseA�major�clinical�disadvantage�with�aligner-treatment�is�that,�inmost�cases,�only�the�crowns�of�the�teeth�are�tipped�whilst�the�rootmoves�far�less.�Cases�are�therefore�prone�to�relapse�if�the�patientfails�to�wear�their�final�aligner�or�a�retainer�for�a�significant�numberof�hours�each�day�as�retention.�Unless�suitably�skilled,�the�clinicianmay�not�recognise�the�risk�of�relapse�in�the�original�assessmentand�treatment�plan�and�may�fail�to�obtain�valid�patient�consent�forextended�retention�or�a�fixed�retainer�from�the�very�outset.�Whenthe�patient�is�presented�with�this�information,�without�anywarning,�at�the�end�of�treatment�they�may�complain.

It�may�also�become�necessary�to�go�onto�a�fixed�appliance�at�theend�of�the�aligner�treatment,�to�correct�the�position�of�the�rootsand�improve�stability.�Without�the�skills�to�predict�this�eventuality,there�can�be�disappointment�when�the�patient�learns�they�willhave�to�wear�a�fixed�appliance�after�all.�If�the�same�clinician�doesnot�have�the�skills�or�materials�to�finish�the�case,�the�patient�mayhave�to�be�treated�by�another�practice�which�could�be�bothinconvenient�and�disappointing.

Embarking�on�aligner�techniques�as�an�alternative�to�developing�aproper�depth�of�knowledge�and�understanding�of�orthodontics,�isinviting�problems.�Like�other�dental�techniques,�there�are�ever-present�dangers�when�something�is�a�lot�easier�to�“sell”�than�to�do.

Short-term orthodontic techniquesShort�term�systems�frequently�include�a�promise�of�the�length�oftime�to�obtain�the�desired�effect�in�their�marketing�material.�Theyare�based�on�fixed�and/or�removable�appliances,�and�are�designedfor�use�by�dentists�with�a�minimum�of�training�to�achieve�limitedimprovements,�usually�based�on�straightening�the�anterior�teeth,for�their�patients.�

The�choice�of�brand�name�used�by�some�systems�seem�to�suggestthat�the�patient�will�only�need�to�wear�the�appliance�for�a�specifiedshort�time�which�makes�it�an�attractive�proposition�to�theconsumer�who�has�a�busy�life.�These�systems�focus�on�improvingdental�aesthetics�alone,�which�is�usually�the�patient’s�main�goal,rather�than�correcting�any�underlying�malocclusion,�which�mightachieve�long-term�stability.

Short-term�systems�are�attractive�to�the�clinician�for�the�samereasons�as�aligner-systems,�in�that�treatment�can�be�provided�“in-house”�with�a�minimum�of�training.�Dental�Protection�has�seensimilar�patients’�complaints�arising�about�these�systems�to�thosefor�aligner�treatment.�Because�the�systems�have�been�designedand�marketed�to�non-specialists�the�complaints�we�see�are�almostexclusively�against�non-specialists.�

It’s in the nameAny�brand�name�for�a�treatment�system�that�references�a�specificperiod�of�months�will�tend�to�raise�patient�expectations�abouttreatment�time.�The�consent�form�provided�by�the�manufacturercan�unwittingly�compound�the�problem�if�it�repeats�a�definedperiod�of�time.�It�is�easy�to�see�how�patients�could�makeassumptions�if�the�treatment�length�forms�part�of�the�promotion,and�how�they�might�feel�upset�if�treatment�takes�longer.�

During�the�consent�process,�practitioners�are�encouraged�to�usethe�consent�forms�and�information�leaflets�provided�by�themanufacturer�but�these�forms�are�not�patient-specific�and�maynot�cover�everything�that�needs�discussion.�

Short-term�orthodontic�appliances�have�the�capacity�to�applyforces�to�both�the�roots�and�the�crowns�of�the�teeth.�In�somepatients�there�is�a�possible�risk�of�root-resorption.�The�clinicianneeds�to�understand�how�to�assess�the�risk.�This�should�bediscussed�separately�and�recorded�in�the�clinical�notes�if�theliterature�from�the�manufacturer�is�silent�on�this�problem.�

On balanceAlthough�the�rewards�to�the�practitioner�for�these�two�forms�ofadult�orthodontics�can�be�high,�there�is�also�an�increased�risk�of�acomplaint�if�expectations�are�not�met.�Support�and�advice�from�aspecialist�orthodontist�or�a�colleague�with�greater�experience,�isone�way�of�helping�you�to�meet�the�patient’s�expectations�within�a�realistic�time-frame.

The�rewards�of�treatment�canevaporate�if�patient�expectationsare�not�met

‘‘ ’’

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6

A�root�in�the�sinusDr Mike Rutherford considers�the�best�way�of�managing�such�unexpected�situations

It’s in the sinus?To�the�general�public,�most�dentalprocedures�are�obscure�events�that�arepoorly�understood.�Considerable�time�andeffort�may�be�required�to�explain�just�howa�root�that�was�once�attached�to�a�toothcame�to�be�in�a�sinus�that�most�peoplewould�not�expect�to�be�anywhere�neartheir�teeth.�A�patient�distracted�by�theprocedure�just�abandoned�and�the�anxietyof�knowing�something�may�have�gonewrong�is�often�a�poor�listener,�and�will�havedifficulty�taking�in�the�avalanche�of�newinformation�presented�by�a�dentalpractitioner�who�may�well�be�somewhattraumatised�themselves�by�thepredicament.

It�is�a�difficult�time�for�bothparties�to�remain�calm�andcommunicate�effectively

Most�often�the�difficulties�that�lead�to�thedisplaced�root,�and�the�need�to�managethe�accompanying�oro-antral�damage,mean�that�the�dentist�is�running�late�and�isprobably�keeping�another�patient�waiting.Now�is�not�the�time�to�rush.�

Take�a�deep�breath,�slow�down�and�spendthe�time�with�your�patient�to�explaineverything�fully.

Prompted by a recent court judgementthat awarded over $US 500,000 for atooth root displaced into the maxillarysinus, Dr Mike Rutherford considers thebest way of managing such unexpectedsituations

This�case�is�a�salient�reminder�that�whenthings�go�wrong,�it�can�cause�a�chain�ofevents�that�lead�a�long�way�from�thedesired�and�expected�outcome.�It�is�alsoa�reminder�that�such�situations�demandan�early�and�appropriate�referral�forexpert�treatment�of�your�patient.�Timelycontact�with�Dental�Protection�alsoensures�expert�assistance�to�help�youmanage�the�event.

Where did it go?The�displacement�of�a�tooth�root�into�themaxillary�sinus�is,�unfortunately,�one�ofthose�adverse�outcomes�commonlyreported�to�Dental�Protection.�Althoughspecialist�removal�of�the�root�is,�in�mostcases,�accomplished�predictably,�it�is�anincident�that�needs�particularly�goodclinical�and�patient�management.�From�thepatient’s�perspective,�having�alreadyundergone�the�anxiety�and�trauma�of�toothremoval,�they�are�now�being�told�that�theywill�require�further�surgery.

This�surgery�will�be�more�invasive,�moreexpensive�(often�involving�a�generalanaesthetic�with�its�accompanying�risksand�costs),�and�result�in�more�swelling,�painand�bruising�than�the�original�toothremoval.�Instead�of�the�anticipatedafternoon�or�day�off�work�post�extraction,several�days’�work�may�now�be�lost�toconsultations,�day-stay�surgery�andrecovery.�

When did it happen?Most�roots�displaced�into�the�sinus�comefrom�the�first�permanent�molar,�with�thesecond�molar�following�close�behind.�Thepalatal�root�is�the�most�common�root�to�bedisplaced,�and�the�displacement�oftenoccurs�following�decoronation�of�a�molarand�subsequent�attempts�to�remove�rootsthat�may�have�been�separated�eithertraumatically�or�by�sectioning.

Anecdotally,�most�displacements�occur�in‘closed’�root�removal,�that�is�when�asurgical�flap�and�buccal�bone�removal�hasnot�been�performed.�This�may�indicate�aless�successful�technique�or�indicate�a�lessconfident�operator�unwilling�to�approachsurgically.�Understandably,�relatively�lessexperienced�practitioners�are�over-represented.

WarningsInformation�presented�before�the�event�isa�warning;�after�the�event�the�sameinformation�is�often�viewed�as�an�excuse�or�justification.

Forewarned,�your�patient�ismore�likely�to�be�acceptingof�this�adverse�outcome,particularly�if�it�wasdiscussed�as�a�possibility�at�the�outset

Similarly,�acceptance�is�more�likely�if�thealternatives,�including�specialist�referral,were�offered,�but�a�mutual�decision�wasmade�to�proceed�with�the�tooth�removal.

You�will�appear�more�‘on�top’�of�theoutcomes�and�the�procedure�if�the�patienthas�been�forewarned,�than�if�the�first�thepatient�knows�of�this�possible�outcome�isthe�worried�frown�on�your�dentalassistant’s�brow.

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7Dental�Protection Riskwise�Hong�Kong�15

When to stop?There�appear�to�be�three�key�times�whenassessment�of�the�situation�and�referralmay�prevent�this�unwanted�outcome.Unfortunately�the�willingness�of�both�thepatient�and�operator�to�stop�the�procedureusually�becomes�less�likely�at�each�stage.

The�best�and�most�obvious�opportunity�ison�reviewing�a�preoperative�radiograph�andassessing�the�proximity�of�the�sinus.�Whilethis�may�seem�self-evident,�an�honestappraisal�of�one’s�experience�and�thedifficulty�of�the�proposed�treatment�can�behard�and�is�often�prejudiced�by�our�patients’expectations�and�demands,�and�our�ownself-confidence.�Despite�this,�a�timelyreferral�to�a�more�experienced�colleague�ora�local�specialist,�accompanied�by�anassurance�that�it�is�in�your�patient’s�bestinterests,�is�the�safest�option.

The�next�opportunity�to�reconsider�is�ondecoronation�of�the�tooth�during�a�plannedsimple�extraction,�and�the�realisation�thatthe�tooth�removal�has�now�turned�into�amore�difficult�root�sectioning�or�surgicalapproach.�The�practitioner�and�the�patientare�now�involved�in�a�very�differentprocedure�requiring�a�different�skill�set�ofthe�practitioner.�If�a�surgical�approach�hadbeen�assessed�as�a�possibility,�your�patientshould�be�forewarned�of�this�possibility,and�the�alternative�of�a�referral�offered.

The�third�opportunity�arises�when�aplanned�approach�has�not�resulted�in�theremoval�of�the�root,�and�the�practitionerfinds�themselves�‘reaching’�–�that�is,retrying�techniques�with�more�force,�ortrying�more�and�more�instruments�andother�approaches�not�originally�planned.�

Dr Mike RutherfordMike�has�more�than�30�years�experience�in�private�practice,�hospital�clinics,�thedefence�forces�and�supervising�DentolegalAdviser�in�our�Brisbane�office

Sometimes�other�foreign�bodies�haveunintentionally�found�their�way�into�themaxillary�sinus.�They�require�a�similarorganised�response�if�the�patient's�bestinterests�are�to�be�protected

This�is�potentially�dangerous�territory,�andis�generally�accompanied�by�an�uneasyfeeling�-�that�is�the�practitioner�feelshesitant�about�the�process�and�indeedunsure�whether�they�should�be�continuing.In�most�cases�this�is�eventually�followed�bysuccess,�a�feeling�of�immense�relief�and�arapid�return�to�a�confident�demeanour.�

Occasionally�though�the�result�is�disaster�–an�extraordinary�number�of�dentistsreporting�root�in�sinus�incidents�mentionthe�uneasy�feeling�they�had�before�thedisaster�–�“I�knew�I�should�have�stopped”�isa�common�comment.�We�should�be�actingintuitively�and�listening�to�the�little�warningvoice�in�our�head�that�tells�us�to�“get�out�ofthere”�–�it�is�the�voice�of�reason.�This�is�themost�difficult�time�to�stop,�reassess�andrefer�because�of�the�energy�and�emotionalready�invested�in�the�procedure�by�bothdentist�and�patient,�but�it�is�also�probablythe�most�important�time.

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8

A�root�in�the�sinus

What next?A�prompt�referral�to�a�specialist�oralsurgeon�or�an�oral�and�maxillofacialsurgeon�is�essential.�Surgical�retrieval�isbeyond�the�scope�of�most�general�dentistsand�generally�should�not�be�attempted.�Ina�few�cases,�small�portions�of�roots�may�beleft�in�situ�-�this�should,�however,�be�adecision�made�by�an�expert�third�party�andnot,�at�the�time,�by�a�general�dentistwhose�decision�may�perhaps�be�influencedby�wishful�thinking.

Referral�is�part�of�your�duty�of�care�andearly�referral�gives�your�patient�the�bestchance�of�a�favourable�outcome.�It�alsoremoves�the�possibility�of�your�patientthinking�that�they�have�not�been�told�thewhole�story�or�have�been�inappropriatelymanaged.�Specialist�surgeons�are�familiarwith�these�situations�and�can�give�yourpatient�an�expert�opinion�from�a�neutralvantage�point.�If�the�explanation�andadvice�offered�by�the�surgeon�tallies�withthat�already�provided�by�the�dentist,validity�of�both�opinions�can�be�reinforced.

And then…You�need�advice�from�one�of�DentalProtection’s�dentolegal�advisers.

Apart�from�the�requirement�of�yourindemnity�insurance�policy�to�reportincidents�such�as�this,�our�dentolegaladvisers�have�had�the�experience�ofworking�with�many�practitioners�in�similarsituations.�Although�this�will�probably�bean�unfamiliar�process�for�the�practitioner,the�adviser�can�offer�advice�based�onDental�Protection’s�wealth�of�experience�inthese�matters.�They�offer�an�independentviewpoint�and�can�advise�you�how�toachieve�the�best�possible�outcome�for�youand�your�patient,�as�well�as�keeping�yourwelfare�and�reputation�in�mind.

Self-reproach�is�a�frequent�aftermath�of�such�incidents�whilst�fear�of�formalcomplaint�proceedings�can�stifle�apractitioner’s�usual�rational�patientmanagement.�Assistance�in�maintainingcontact�with�your�patient�during�theirremedial�treatment,�choosing�the�rightwords�to�use,�help�with�a�letter�ofexplanation�to�your�patient�andrecommendations�on�financialarrangements�form�part�of�the�advice�thatis�available.�It�is�provided�with�a�view�toreassuring�your�patient�that�they�are�beingcared�for,�and�ensuring�that�you�meet�yourduty�of�care�obligations.

You�can’t�undo�what�has�been�done,�but�you�can�certainly�ensure�that�themanagement�of�the�situation�is�ascompassionate�and�professional�aspossible,�looking�after�the�best�interests�of�the�patient,�whilst�Dental�Protectionlooks�after�you.�

We�should�be�actingintuitively�and�listening�tothe�little�warning�voice�inour�head�that�tells�us�to‘‘get�out�of�there’’.�It�is�thevoice�of�reason

It happensIf�the�root�has�been�displaced,�excellentclinical�and�patient�management�is�nowessential.�Stabilisation�of�the�socket�andthe�accompanying�oro-antralcommunication�should�be�addressed�in�thefirst�instance�using�best�clinical�practice.Once�this�has�been�achieved,�give�yourpatient�and�yourself�a�rest�–�as�previouslymentioned�you�will�almost�certainly�berunning�late�at�this�stage,�but�that�is�verymuch�of�secondary�concern.

You�need�your�patient�to�be�able�to�focuson�what�you�are�saying,�and�you�will�wantto�be�calm�and�professional�in�the�process.Patients�can�sense�when�a�dentist�appearsrushed�or�anxious.�This�is�a�time�for�yourpatient�to�appreciate�that�you�are�focusedon�their�welfare�and�not�your�next�patient.

A�patient�who�may�feel�aggrieved�at�theunexpected�outcome�will�undoubtedly�feelmore�so�if�they�perceive�a�rush�to�get�themout�the�door.�Many�a�letter�of�complaintfocuses�as�much�on�dissatisfaction�withthe�dentist’s�perceived�lack�of�care�post-incident,�as�it�does�on�the�incident�itself.�

Full�and�frank�disclosure�isessential�–�an�explanationin�layman’s�termsaccompanied�by�diagramsor�the�use�of�pre�or�intra-operative�radiographs�willhelp�your�patientunderstand�the�relationshipof�the�anatomicalstructures

The�variable�natureof�the�floor�of�themaxillary�antrummakes�it�difficult�to�predict�theoutcome�for�everyextraction

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The�minefieldof�implantdentistryHow�to�steer�clear�of�avoidableproblems

9Dental�Protection Riskwise�Hong�Kong�15

In general, there are three approachesto achieve a safe passage through anyminefield. The first is to find outexactly where all the mines are locatedbefore you start, and then to carefullyplan a safe route – and stick to it. Thesecond is to take your time, proceedwith extreme caution in small,measured stages and not take anystep before knowing for sure that theground upon which you will be placingyour foot is safe. The third (which wedo not recommend) is to ignore signs,keep moving and not ask for directions

Members in the latter group willprobably not be reading this article inthe first place, but for members in theother two groups it will hopefully serveas a checklist, so that they have abetter understanding of the potentialpitfalls, and can thereby avoidbecoming part of the worrying recentclaims statistics arising from implantdentistry

Per-IngvarBrånemark(1929�–2014).�TheSwedish�physicianregarded�as�the‘‘father�of�dentalimplantology’’

We�are�grateful�to

�Nobel�Biocare�fo

r�the�use�of�the�im

ages�on�pages�9–1

4

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10

The�minefieldof�implantdentistry

Standard 7.2You�must�work�within�your�knowledge,�skills,�professional�competence�and�abilities

7.2.1�You�must�only�carry�out�a�task�or�a�type�of�treatment�if�you�are�appropriatelytrained,�competent,�confident�and�indemnified.�Training�can�take�many�different�forms.You�must�be�sure�that�you�have�undertaken�training�which�is�appropriate�for�you�andequips�you�with�the�appropriate�knowledge�and�skills�to�perform�a�task�safely.7.2.2�You�should�only�deliver�treatment�and�care�if�you�are�confident�that�you�have�hadthe�necessary�training�and�are�competent�to�do�so.�If�you�are�not�confident�to�providetreatment,�you�must�refer�the�patient�to�an�appropriately�trained�colleague

The�dental�regulator�in�the�UK�is�the�General�Dental�Council.�This�extract�is�taken�fromtheir�publication�‘‘Standards�for�the�Dental�Team’’

It�is�not�difficult�to�see�how�exposed�ayoung�dentist�would�be�if�they�get�involvedin�implant�dentistry�quite�soon�afterqualifying,�perhaps�off�the�back�of�arelatively�short�course�undertaken�with�noproper�curriculum�or�structure,�supervisionarrangements,�quality�assurance�oropportunity�for�hands-on�mentoring�aftercompleting�the�course.�Were�such�adentist,�with�relatively�little�(narrow)experience�of�clinical�dentistry�toundertake�a�complex�restorative�casewhich�then�goes�wrong,�this�is�almostcertain�to�be�referred�to�the�Dental�Council�in�the�UK,��with�all�the�attendantconsequences.�Any�dentist�who�enters�the�field�of�implant�dentistry�should�beprepared�to�justify�the�adequacy�of�anytraining�they�have�received.

Don’t�overestimate�(or�over-state)�yourcompetenceWhen�an�implant�case�has�gonespectacularly�wrong,�it�can�be�painfullyembarrassing�for�a�clinician�to�beconfronted�(during�the�course�of�anegligence�claim,�or�before�the�DCHK)�withthe�way�in�which�s/he�had�described�theirexperience�and�training,�skill�and�expertisein�implant�dentistry.�This�can�be�the�resultof�a�genuine�lack�of�insight�into�the�level�oftheir�own�knowledge�and�competence,�or�a�wish�for�commercial�or�other�reasons�toappear�more�skilled�or�experienced�thanthey�really�are.

Before you startGet�proper�trainingShort�courses,�perhaps�run�by�manufacturersand�distributors�of�implant�systems�are�animportant�part�of�the�training�“mix”�in�orderthat�practitioners�can�properly�understand�thefeatures�of�a�particular�system,�but�thesebespoke�courses�can�never�be�a�replacementfor�a�broader,�extended�course�which�goesinto�more�depth�and�considers�many�differentimplant�systems�and�their�relative�advantagesand�disadvantages.�Some�commercially�drivencourses�may�be�likely�to�make�the�proceduresound�simpler�and�easier,�and�will�notnecessarily�alert�you�to�the�limitations�andrisks.�The�aim�of�such�courses�is�often�topromote�the�merits�of�one�particular�system,and�to�encourage�the�placement�of�as�manyimplants�as�possible,�in�as�many�sites�aspossible,�for�as�many�patients�as�possible,�asoften�as�possible.�This�is�not�a�recipe�for�soundclinical�judgement�and�practice.

The�best�courses�are�generally�those�whichinvolve�formal,�structured�training�providedby�acknowledged�experts�in�the�field,�over�anextended�period�of�time�(such�as�one�to�twoyears).�It�will�take�time,�effort�andcommitment�and�involve�a�lot�of�study.�If�itdoesn’t,�it�invites�the�question�of�whether�thecourse�is�sufficient�for�its�intended�purpose.�Inan�ideal�world,�implant�training�should�involvesome�kind�of�examination�to�demonstratethe�attainment�of�knowledge�andcompetence�in�the�field,�and�a�period�ofmentoring�(ie.�the�ability�to�practise�implantdentistry�under�both�direct�and�indirectsupervision,�where�help�is�readily�at�hand�ifyou�should�need�it).

Although�the�Dental�Council�of�Hong�Kong(DCHK)�does�not�provide�any�specificguidance�about�implants,�the�regulator�inmany�other�countries�does.�For�example,�inthe�UK�the�General�Dental�Council�isconcerned��about�dentists�who�becomeinvolved�in�implant�dentistry�with�relativelylittle�formal,�structured�training�andmentoring.�Their�existing�guidance�(see�panelabove)�is�clear�in�stating�that�dentists�shouldnot�get�involved�in�treatment�for�which�theydo�not�have�the�relevant�training�and�inrespect�of�which�they�are�not�yet�competent.�

Malaysian Dental Council Professional

The tools for the jobHaving�the�correct�instrumentation�tocarry�out�implant�dentistry�safely�andsuccessfully�comes�at�a�price.�The�higheststandards�of�infection�control�are�essential,and�so�are�good�chairside�facilities�andtrained�nursing�support.�If�you�don’t�haveaccess�to�proper�imaging�(eg.�cone�beamtomography)�in�your�own�practice,establish�where�and�how�you�can�takeadvantage�of�this�technology�if�it�existselsewhere�(see�below).�Trying�to�keep�thecost�down�for�a�patient�by�cutting�corners,isn’t�really�helping�you�or�the�patient�in�thelong�run.

Check�you�have�the�rightprotectionAs�extraordinary�as�it�might�sound,�thereare�still�practitioners�getting�involved�inimplant�dentistry�without�having�protectedthemselves�(and�indirectly,�their�patients)with�any�kind�of�professional�indemnityarrangements.�Other�practitionerssometimes�overlook�their�membershiprenewal�date,�or�decide�to�save�money�bychoosing�an�inappropriate�membershipcategory�that�does�not�fully�reflect�theextent�of�their�clinical�practice,�or�even�byallowing�their�membership�to�lapse.�

Special�categories�apply�in�Hong�Kong�to�implant�dentistry�and�associatedprocedures�such�as�sinus�lifts�and�boneharvesting�from�outside�the�mouth�forgrafting�purposes�-�it�is�a�member’spersonal�responsibility�to�check�at�everyrenewal�date�that�the�category�and�ratethat�they�are�paying�is�still�the�correct�one.Because�these�categories�can�and�dochange,�simply�renewing�your�membershipin�the�same�category�as�the�previousyear(s)�may�be�leaving�you�exposed�oreven�unindemnified�for�implant�dentistry.

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Sharing care – whenmore than one clinicianis involvedThe�need�for�joint�case�assessment�iscritical�where�the�surgical�andprosthodontic�phases�of�implant�dentistryare�being�carried�out�by�different�people.�

In�implant�dentistry,�it�is�helpful�if�theclinician�who�will�be�undertaking�thesubsequent�restorative/prosthodonticphase�is�present�at�the�time�of�the�surgicalprocedures.

Implant�fixtures�are,�of�course,�a�means�toan�end�and�not�an�end�in�themselves.Consequently,�implant�dentistry�needs�tobe�driven,�and�led,�by�the�prosthodontist�–�whether�this�is�a�specialist�or�a�generaldental�practitioner..�Problems�can�arisewhere�the�prosthodontist�is�relativelyinexperienced�in�implant�dentistry,�and�theclinician�undertaking�the�surgical�phase�ismore�experienced�and�perhaps�viewed�asthe�‘senior’�partner�in�the�relationship.

Problems�are�more�likely�to�arise�whenthere�is�no�over-arching�and�mutuallyagreed�treatment�plan�which�comprisesboth�the�surgical�plan,�and�the�restorativeplan.�The�clinician�undertaking�the�surgicalphase�needs�to�make�it�clear�what�is,�and�isnot�possible�(or�advisable)�from�a�surgicalperspective,�and�the�prosthodontist�needsto�make�it�clear�what�is�and�isn’t�possible(or�acceptable)�from�the�perspective�of�thesubsequent�restorative/prostheticrequirements�both�in�a�technical�sense,�andalso�in�order�to�satisfy�the�patient’sfunctional�and�aesthetic�needs.

The�relationship�between�the�specificationand�positioning�of�the�implant�fixtures,�andwhat�could�be�achieved�prosthodonticallyonce�they�are�placed,�is�so�intimate�thatthese�two�processes�need�to�be�viewed�astwo�aspects�of�a�single�process,�ratherthan�as�two�separate�processes�(as�sooften�occurs).

Nowhere�is�the�need�for�this�“seamless”approach�more�obvious�than�in�theconsent�process;�a�patient�needs�tounderstand�all�material�facts�that�relate�tothe�surgical�placement�of�the�fixtures,�andalso�to�whatever�appliance�or�restorationthe�fixtures�will�be�supporting.�A�materialfact�is�one�that�a�patient�would�be�likely�toattach�significance�to,�when�consideringwhether�or�not�to�undertake�theprocedure.

The�important�distinction�to�stress�here,�isthat�one�needs�to�put�oneself�in�theposition�of�the�patient,�and�ask�what�theymight�wish�or�expect�to�be�told�–�asopposed�to�what�we�might�decide�isimportant�in�the�context�of�one�or�otherstages�of�the�overall�process�itself.Consent�is�more�likely�to�be�sound�if�theprocess�is�patient-focused�rather�thanprocedure-focused.

The�fact�that�two�clinicians�might�beinvolved�in�the�same�case�can�actually�beused�to�reduce�the�risk,�rather�thanincreasing�it,�because�two�differentperspectives�and�two�different�sets�ofexperiences�can�be�brought�to�bear�uponthe�consent�process.�This�benefit�will�onlybe�felt,�however,�if�the�two�parties�arecommunicating�with�each�other�and�theyboth�feel�able�to�make�an�activecontribution�to�the�debate.

For�as�long�as�surgeons�andprosthodontists�(or�general�dentalpractitioners)�take�the�view�that�they�haveno�input�into,�nor�responsibility�for,�the�roleof�the�other,�then�patients�will�continue�tofall�between�the�two�zones�of�control.�Byworking�to�eliminate�that�gap�throughcloser�communication�and�mutualconsultation,�the�two�parties�can�bestserve�the�patient,�themselves�and�eachother.

11Dental�Protection Riskwise�Hong�Kong�15

Getting startedSlow�and�easySuggesting�that�any�implant�case�is�“easy”is�probably�misleading,�but�when�makingfor�your�first�foray�into�implant�dentistry,choosing�anything�other�than�the�leastcomplex�case,�is�asking�for�trouble.�Ideally,taking�you�time,�choosing�cases�carefullyand�getting�several�relatively�simple�casesunder�your�belt�is�advisable�beforeattempting�anything�more�ambitious.

MentoringThe�best�introduction�is�to�have�anexperienced�mentor�to�guide�and�assistyou�as�you�take�your�early�steps�intoimplant�dentistry.

The�surgical�andprosthodontic�phases�arebest�considered�as�twoaspects�of�a�single�process,rather�than�as�twoseparate�processes

Collecting�information�about�the�case

Planning

Communication�with�the�patient

The�right�equipment�and�environment

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12

The�minefieldof�implantdentistry

Case assessment andtreatment planningPlan�carefullyAt�least�a�third�of�all�implant�cases�that�areseen�by�Dental�Protection�can�be�tracedback�to�some�kind�of�deficiency�in�the�caseassessment�and�treatment�planning�stageslike�those�listed�below.

In�particularAny�sense�that�a�clinician�has�rushedheadlong�into�the�placement�of�implantswithout�allowing�time�to�get�to�know�thepatient�and/or�consider�and�discuss�anyother�treatment�options.The�absence�of�an�up-to-date�medical�and�medication�history�or�an�apparentdisregard�of�any�absolute�or�relativecontraindications�associated�with�either�of�them�(eg.�Type�1�diabetes,�or�anymedication�affecting�bone�metabolism�or�density,�the�inflammatory�response�or�the�tendency�to�bleed).A�failure�to�elicit�or�act�upon�relevantfeatures�of�the�patient’s�dental�history�–for�example�a�history�of�chronicperiodontal�disease.A�failure�to�screen�for,�assess�and�manageany�relevant�risk�factors,�especiallysmoking.Inadequate�preoperative�investigations(models,�x-rays�and�other�imaging�etc).�A�failure�to�seek�and�act�upon�advice�from�others�(including�specialists)�whereappropriate.�

If�an�adverse�outcome�could�have�beenanticipated�and�avoided�by�the�use�ofadditional�imaging,�the�questions�arise�ofwhether�a�reasonable�body�of�professionalopinion�amongst�those�working�in�the�fieldof�implant�dentistry�would�support�theview�that:the�additional�imaging�was�(or�was�not)necessary�in�the�circumstances�of�thespecific�case,a�responsible�clinician�acting�in�thepatient’s�best�interests�would�proceedwith�placing�the�implants�without�theadditional�imaging�being�available.

Another�example�of�a�step�which�improvespredictability�and�reduces�uncertainty(especially�in�an�edentulous�arch)�is�the�useof�stents�and�other�forms�of�surgical�guideswhere�appropriate,�and�in�more�complexcases,�the�construction�and�use�of�surgicalmodels.�

Spend time validatingconsentThe�patient�should�be�aware�of�thepurpose,�nature,�likely�effects,�risks,�andchances�of�success�of�a�proposedprocedure,�and�of�any�alternatives�to�it.The�fact�that�a�patient�has�consented�to�a�similar�procedure�on�one�occasion,�doesnot�create�an�open-ended�consent�whichcan�be�extended�to�subsequent�occasions.Consent�must�be�obtained�for�specificprocedures,�on�specific�occasions.

a

b

Minimise�risk�anduncertaintyThe�maxim�“Predictability is the key totranquillity”�applies�to�many�stages�in�theprovision�of�implant�dentistry,�but�perhapsespecially�so�in�anticipating�the�potentialrisks�and�complications�at�the�site�wherefixtures�are�to�be�placed.�Conventionalradiographs�suffer�the�disadvantage�thatthey�give�us�a�two�dimensional�image�ofwhat�is�actually�a�three�dimensionalsituation.�We�make�allowances�for�this�asfar�as�we�can,�and�have�developedtechniques�(such�as�the�parallax�technique)to�compensate�for�the�limitations�of�a�staticview�from�a�single�perspective.

Having�a�3-D�view�or�a�multi-perspectiveview�–�by�using�computerised�axialtomography�(CAT�scans)�including�conebeam�CT�or�magnetic�resonance�images(MRIs)�-�transforms�our�knowledge�base,removes�a�lot�of�the�uncertainty�andguesswork,�and�sometimes�makes�us�awareof�potential�hazards�that�we�wouldotherwise�have�been�unaware�of.�Fewersurprises�for�the�clinician�will�generally�meanfewer�surprises�for�the�patient,�which�is�agood�thing.

While�there�is�always�a�cost�attached�tonew�technology,�and�one�must�be�mindful�of�the�obligations�of�Radiation�Ordinance(cap303)�laws�of�Hong�Kong�it�is�not�for�the�clinician�to�deny�the�patient�theopportunity�to�decide�for�themselveswhether�or�not�they�wish�to�incur�theadditional�cost�of�having�this�additionalimaging�carried�out.�Equally,�if�the�patient�isunwilling�to�undergo�this�further�imaging�oncost�or�other�grounds,�the�clinician�has�theright�to�decline�to�provide�the�treatment.�

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Some questions to ask yourself to help ensurethe patient’s consent is validIs�the�patient�capable�of�making�a�decision?�Is�that�decision�voluntary�and�withoutcoercion�in�terms�of�the�balance/bias�of�the�information�given,�or�the�timing�or�context�of�its�provision?Does�the�patient�actually�need�the�treatment,�or�is�it�an�elective�procedure?�If�an�electiveprocedure,�the�onus�upon�a�clinician�to�communicate�information�and�warnings�becomesmuch�greater.�(Placing an implant in a site where a tooth has been missing for several years,without replacement, would be an example of this).What�do�I�think�will�happen�in�the�circumstances�of�this�particular�case,�if�I�proceed�withthe�treatment?�Have�I�communicated�this�assessment�to�the�patient�in�clear�terms?�Can�I�give�an�accurate�prediction?�If�not,�is�the�patient�aware�of�the�area(s)�of�doubt?What�would�a�reasonable�person�expect�to�be�told�about�the�proposed�treatment?What�facts�are�important�and�relevant�to�this�specific patient?�(If I don’t know, then I amprobably not ready to go ahead with the procedure anyway).Do�I�need�to�provide�any�information�for�the�patient�in�writing?�Has�the�patient�expresseda�wish�to�have�written�information?�(Am I relying upon commercial marketing materialproduced by manufacturers and/or suppliers? If so, is this information sufficiently balanced inthe way it is presented?)Does�the�patient�understand�what�treatment�they�have�agreed�to,�and�why?�(by way ofillustration, when a general practitioner is proposing a crown to be supported on an implantfixture placed in association with a bone graft, under sedation and local anaesthesia, thisrequires all the aspects of a proper consent procedure to be covered for each of the sixaspects highlighted – because there are risks and limitations, alternatives and otherconsiderations associated with each of them, that the patient needs to understand beforeproceeding. Some patients may object to certain or any forms of bone grafting on religious orother grounds)Have�they�been�given�an�opportunity�to�have�any�concerns�discussed,�and/or�have�theirquestions�answered?�Do�the�records�support�this?Does�the�patient�understand�the�costs�involved,�including�the�potential�future�costs,�in�theevent�of�any�possible�complications?Does�the�patient�want�or�need�time�to�consider�these�options,�or�to�discuss�your�proposalswith�someone�else?�Can�you/should�you�offer�to�assist�in�arranging�a�second�opinion?If�you�are�relatively�inexperienced�in�carrying�out�the�procedure�in�question,�is�the�patientaware�of�this�fact?�Are�they�aware,�(if�relevant)�that�they�could�improve�their�prospects�ofa�successful�outcome,�or�reduce�any�associated�risks,�if�they�elect�to�have�the�procedurecarried�out�by�a�specialist�or�a�more�experienced�colleague?If�the�technique�(or�implant�system)�is�relatively�untried�or�of�an�experimental�nature,�hasthe�patient�been�made�aware�of�this?�Included�here�are�any�procedures�for�which�theevidence�base�is�limited�or�absent,�including�systems�which�trade�on�the�publishedevidence�relating�to�similar�systems�without�actually�being�supported�by�any�evidencebase�of�their�own.

The surgical phase -placing the implantfixturesGive appropriate pre-operative adviceFollow accepted proceduresStay�within�the�limits�of�your�training�andcompetence.�Recognise when things are not going to planTake�appropriate�steps�to�recover�thesituation�which�in�some�cases�may�involvereferring�the�patient�for�specialist�adviceand�care.Give appropriate postoperative adviceand warningsInform�the�patient�about�the�need�for�earlyreporting�of�any�indications�of�possiblenerve�injury.�In�these�cases�speed�is�of�theessence�and�the�longer�you�spend�keepingthe�situation�under�review�with�the�fixturesstill�in�situ,�the�worse�the�prognosis.Review the patientChoose�appropriate�intervals�following�theprocedure�and�especially�in�the�daysimmediately�following�the�placement�ofthe�implant(s)

13�Dental�Protection Riskwise�Hong�Kong�15

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Regular�monitoring�of�the�bone�height�and�soft�tissuesadjacent�to�the�restored�portion�of�the�implant�will�alertyou�to�the�first�signs�of�peri-implantitis�

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The�minefieldof�implantdentistry

Dental technician

Dentist

Patient

Dental nurse/Dental hygienist

The prosthodontic stageIt�is�beyond�the�scope�of�this�article�tocover�all�the�variations�of�fixed�andremovable�prosthodontics�that�can�besupported�upon�implant�fixtures,�nor�all�theconsiderations�regarding�immediate�ordeferred�loading.�Many�of�the�potentialcomplications�attributable�at�first�sight�tothe�prosthodontic�stage�(aesthetics,function,�soft�tissue�problems�at�the�‘‘neck’’of�the�implant,�maintenance�problems�etc.)can�be�avoided�if�sufficient�time�andattention�is�applied�to�the�caseassessment�and�treatment�planningstages.�

Perhaps�the�best�generic�description�of�theroot�cause�of�many�of�the�problems,�is�thatinexperienced�clinicians�will�sometimeswrongly�assume�that�supporting�crowns,bridges�and�appliances�on�implant�fixtures,is�essentially�the�same�as�placing�them�onnatural�teeth.�

Follow up and monitoringMaintenanceIt�is�essential�that�patients�should�behelped�to�realise�that�implants�need�to�belooked�after�just�as�carefully�as�naturalteeth.�Meticulous�oral�hygiene,�withtechniques�adapted�to�the�specific�needsof�each�patient,�and�(where�applicable)continued�encouragement�to�maintainsmoking�cessation,�are�crucial�ingredientsof�implant�maintenance.

Patients�must�understand�that�attendanceas�recommended�for�review�purposes�willhelp�to�minimise�problems�in�the�monthsand�years�following�implant�placement.They�must�also�accept�responsibility�forthe�potential�consequences�of�not�doingso.

Keep�your�eye�on�the�ballImplants,�once�placed,�are�a�long-termcommitment�for�both�the�patient�and�theclinicians�who�are�responsible�for�their�on-going�care.�The�condition�becoming�knownas�“Peri-implantitis”�is�a�growing�problemnot�just�for�the�clinicians�who�originallyplaced�the�implants�or�placed�restorationsor�appliances�upon�them,�but�sometimesfor�others�who�had�no�part�in�the�originaltreatment,�but�end�up�caring�for�thepatients�in�the�years�following�the�provisionof�that�implant�dentistry.�This�includes�bothdentists�and�dental�hygienists.

Peri-implant�mucositis�is�an�inflammatorycondition�which�in�its�early�stage�isreversible.�There�will�be�redness,�swelling,inflammation�and�the�tissues�around�thefixture�will�not�look�healthy.�At�this�pointthere�is�no�bone�loss.�Improved�oral�hygieneand�better�care�of�the�implants�will�usuallyreverse�or�improve�the�condition.�There�isan�abundance�of�evidence�to�suggest�thatthe�presence�of�keratinised�gingival�tissueat�the�“neck”�of�the�implant�at�the�point�ofemergence�into�the�oral�cavity�is�adesirable,�protective�situation�which�makesthe�initiation�and�further�progression�lesslikely.

Left�uncontrolled,�the�inflammatorycondition�can�progress�to�peri-implantitisandloss�of�crestal�bone,�often�creating�acharacteristic�dish-shaped�bony�defectwhich�is�clearly�visible�on�radiographs.Careful�comparison�of�such�radiographsover�time�allows�the�situation�to�beassessed.�Once�peri-implantitis�has�becomeestablished,�it�is�very�difficultto�treat.

A�failing�implant�will�continue�to�fail�if�noproactive�attempt�is�made�to�rectify�thesituation.�Clinicians�who�played�no�part�inthe�placement�or�restoration�of�the�implantcan�wrongly�assume�that�they�cannot�beheld�responsible�for�the�failure�–�but�theycan�be�held�responsible�both�for�failing�toidentify�the�signs�that�the�implant�is�failing,and�the�failure�to�seek�advice�fromcolleagues�who�have�more�experience�inimplant�dentistry.

SummaryMeticulous�recordsIn�implant�dentistry,�every�stage�of�theprocess�needs�to�be�very�carefullyrecorded.�Especially�important�here�arerecords�of�what�the�patient�was�led�toexpect,�what�information�was�provided�tothe�patient,�what�warnings�they�weregiven�etc.

Your�records�must�meticulously�documentevery�detail�of�the�histories�taken,�theexploration�of�any�possible�risk�factors�thatmight�affect�the�prognosis,�any�tests�andinvestigations�carried�out,�any�liaison�withprofessional�colleagues,�and�all�discussionswith�the�patient.�

Detailed�records�also�need�to�be�kept�todemonstrate�the�meticulous�monitoring�ofthe�status�of�the�implants�(both�hard�andsoft�tissues)�in�the�months�and�yearsfollowing�their�placement.

Stay�up�to�dateImplant�dentistry�continues�to�be�adynamic�and�evolving�field.�Ensure�that�youkeep�your�knowledge�and�skills�up�to�dateand�be�prepared�to�adjust�your�approachwhen�necessary.�

Well-rehearsedteamworkoptimises�clinicaloutcome�for�thepatient�

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Endodontic�instrumentsDr Shreeti Patel explains�why�patients�need�to�know�instruments�can�break

15Dental�Protection Riskwise�Hong�Kong�15

Despite the increased flexibility of the new generationendodontic rotary instruments and a single use protocol,Dental Protection still receives a significant number ofrequests to assist with complaints about broken or fracturedinstruments (instrument separation)

For�many�years,�the�potential�for�fracture�was�considered�anaccepted�complication�of�root�canal�therapy�(RCT)�and�not�in�itselfnegligent.�Times�change�and�in�many�jurisdictions�case�law,�inrespect�of�consent,�now�requires�the�clinician�to�inform�the�patientabout�any�material�risk�of�their�treatment�to�which�they�wouldattach�significance

1.

With�this�in�mind,�instrument�separation�should�be�regarded�as�one�of�the�risks�patients�would�need�to�understand�before�they�couldconsent�to�endodontic�treatment�together�with�the�possibility�ofroot�perforation�or�failure�of�the�treatment�due�to�persistentinfection.

Sometimes,�it�can�be�difficult�to�know�just�how�much�informationour�patients�should�be�offered.

Consent and explaining the risk“One�size�does�not�fit�all”�if�the�clinician�is�to�ensure�that�they�haveobtained�valid�consent�from�the�patient�sitting�in�the�chair�about�to�consider�endodontic�treatment.�Naturally,�all�the�preoperativeconsiderations�that�are�discussed�should�be�detailed�in�the�clinicalrecords.�The�records�should�also�include�the�clinical�and�radiographicassessment�of�the�tooth,�the�degree�of�root�curvature,�and�patencyor�sclerosis�of�canals,�which�could�increase�the�likelihood�of�fileseparation.�If�you�anticipate�the�possibility�of�such�a�riskmaterialising,�then�an�explanation�as�to�how�the�situation�would�bemanaged�should�be�offered�to�the�patient�in�advance�and�a�notemade.�

Informing�patients�in�a�manner�that�maintains�their�trust�is�ofutmost�importance.�As�with�all�risk�management,�communication�is�the�key.�The�difficulty�arises�in�describing�the�likelihood�of�theevent.�One�might�argue�that,�in�the�hands�of�a�specialistendodontist,�the�incidence�of�file�separation�may�be�less�than�inthe�hands�of�a�dentist�who�is�using�a�new�endodontic�file�systemwith�less�“hands-on”�experience.�But�regardless�of�specialisation,the�incidence�of�file�breakage�can�be�minimised�by�careful�pre-operative�assessment�of�the�tooth.�

Should you refer all endodontictreatment to a specialist? Ideally,�the�following�situations�could�be�considered�for�referral�to�a�more�experienced�colleague�with�enhanced�skills�and�equipment:�patient�with�limited�mouth�openingtooth�with�a�crown�disguising�the�original�anatomical�landmarksA�root�with�curvature�greater�than�30�degrees�or�an�“S”shapedcanal.

Protect yourselfIn�the�absence�of�thorough�record�keeping,�a�complaint�or�claimcan�only�be�defended�if�the�information�has�been�given�to�thepatient�and�more�importantly,�they�have�understood�it.�A�signedconsent�form�in�the�absence�of�discussion�will�not�suffice�forpurposes�of�consent.�Inviting�the�patient�to�ask�questions�canindicate�if�they�have�understood�the�risks�and�note�this�in�yourrecords.

Minimising the occurrenceUpdating�clinical�skills,�and�understanding�of�the�limitations�of�newendodontic�systems.�Using�magnification,�achieving�straight�line�access�and�adequatecanal�lubricationLimiting�file�use,�following�manufacturer’s�instructions.

Management of a broken fileTell�the�patient�and�record�this�in�the�clinical�notesDiscuss�the�options�for�management,�which�will�include��removal�ofthe�separated�piece,�by-passing�or�leaving�the�fragment�in�situ,filling�root�canal�to�coronal�level�of�the�segment�or�surgery.Risk�assessing�the�clinical�situation�eg.�the�presence�of�apicaldisease,�may�reduce�the�prognosis�in�the�presence�of�file�fracture.�Note�the�stage�of�canal�preparation�when�file�separation�occurs,especially�in�infected�cases�and�consider�how�much�disinfection�hasbeen�achieved.In�the�absence�of�apical�disease�and�symptoms,�leaving�the�file�insitu�may�not�reduce�the�prognosis.�Specialist�referral�should�be�considered,�magnification�andexpertise�is�usually�requiredThe�decision-making�process�for�the�management�should�bediscussed�with�the�patient�in�an�honest�and�sympathetic�manner.Don’t�be�pressured�into�trying�to�retrieve�the�fragment�withoutadequate�expertise�and�equipment,�as�the�complications�arisingfrom�this�may�be�even�more�detrimental�to�the�outcome�and�couldlead,�for�example,�to�root�perforation.�

SummaryAssess�and�adequately�discuss�then�document�the�chances�of�fileseparation�prior�to�treatment�in�each�case.�Information�givenbefore�the�procedure�constitutes�a�warning�whereas�the�sameexplanation�after�a�file�separates�is�likely�to�be�interpreted�by�thepatient�as�an�“excuse”.�

Dr Shreeti PatelShreeti�has�apractice�limited�toendodontics�andalso�works�withDental�Protection�as�an�AssociateDentolegal�Adviser

1Montgomery�v�Lanarkshire�Health�Board�(2015)�UKSC�11Rogers�v�Whittaker�(1992)67�A.L.J.R.47�(High�Court�of�Australia)

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Resistance�rulesIn�a�bid�to�slow�the�global�shift�towards�antibiotic�resistance,�it�is�vital�that�dentistsensure�they�prescribe�responsibly

Short on time?In�dentistry,�the�patient�in�pain�is�sometimes�offered�a�prescriptionfor�antibiotics�when�there�is�insufficient�time�to�fully�investigatethe�problem�in�the�hope�the�pain�will�respond.

Dental�Protection�has�noticed�that�whilst�entries�in�patient�recordcards�may�well�describe�the�treatment�given�for�acute�pain�orswelling,�there�is�often�a�gap�in�the�logical�diagnostic�process.

The�patient’s�complaint�and�symptoms�are�documented,�togetherwith�any�tests�that�have�been�undertaken;�the�treatment�similarlydescribed.�However,�in�dental�infections�the�clinical�signs�andsymptoms�require�a�proper�assessment�of�the�cause,�extent�andnature�of�the�infection�(localised�or�spreading)�and�whether�thepatient�is�unwell.�Very�often,�the�diagnosis�on�which�the�treatmenthas�been�based�is�missing.

Possibly,�the�emergency�patient�has�been�treated�on�the�basis�of�a�provisional�diagnosis�prior�to�a�subsequent�longer�appointmentto�review�the�situation.�When�time�is�short�–�and�with�the�pain�ofearly�onset�–�in�the�absence�of�an�obvious�infection�it�isquestionable�that�an�antimicrobial�prescription�will�be�of�benefit.An�analgesic�is�more�likely�to�provide�pain�relief�until�such�timewhen�a�longer�appointment�is�available.

We�know�that�the�inflammatory�process�involved�in�pulpitis�doesnot�respond�to�antimicrobials,�but�will�respond�to�an�analgesic.�Onthe�other�hand,�the�pain�from�an�acute�dental�abscess�will�respondvery�quickly�if�the�abscess�can�be�drained�by�extraction,�roottreatment�or�incision,�regardless�of�any�prescription�that�mightsubsequently�be�given.�

In�a�busy�dental�surgery,�it�can�be�difficult�to�undertake�thedefinitive�treatment�on�the�day�that�the�patient�presents,�butpatients�with�a�spreading�infection�need�a�definitive�treatmenteven�when�time�is�short.�Not�to�do�so�could�lead�to�additionalcomplications�that�could�leave�the�clinician�vulnerable�to�criticism.

Dentists�have�to�find�enough�time�to�take�a�history,�examine�thepatient�and�make�an�appropriate�assessment�of�the�patient’scondition,�before�making�a�diagnosis�on�which�the�treatment�canbe�based.�The�diagnosis�is�essential�if�the�best�use�of�antimicrobialsand�analgesics�is�to�be�achieved.�

This�contribution�to�reducing�the�escalation�of�antimicrobialresistance�serves�the�best�interest�of�patients�and�forms�part�of�abigger�picture,�in�which�clinicians�are�being�asked�to�create�a�sea-change�by�reversing�a�worldwide�problem�that�also�constitutes�amajor�threat�to�public�health.

With every decade that passes, we discover new ways in which technological developments can impinge on thequality of life – directly or indirectly – sometimes forgenerations not yet born; a by-product perhaps of our desire for an easy fix to life’s challenges

Global�warming,�for�example,�serves�to�highlight�the�dilemmaposed�by�weighing�up�the�benefits�to�a�population�with�a�desire�forunlimited�access�to�energy�against�the�resulting�impact�on�theenvironment.

And�so,�as�antibiotic�effectiveness�is�challenged,�clinicians�need�tobe�mindful�of�the�fact�that,�by�encouraging�limited�and�appropriateantibiotic�use�in�primary�care,�they�can�help�to�stem�the�tide�ofrising�levels�of�antibiotic-resistant�bacteria.�Therefore,�in�theabsence�of�a�diagnosis,�practitioners�are�always�advised�to�thinkvery�carefully�before�prescribing�antimicrobials.

International rescueThere�has�been�an�international�move�to�address�this�growingpublic�health�problem�which�arises�because,�while�the�number�ofinfections�due�to�antibiotic-resistant�bacteria�continues�to�grow,the�pharmaceutical�industry’s�supply�of�new�antibiotics�does�notlook�promising.�It�certainly�presents�a�bleak�outlook�on�availabilityof�effective�antibiotic�treatment�for�the�future.

According�to�the�World�Health�Organisation,�the�overall�uptake�ofantibiotics�in�a�population�–�as�well�as�the�way�in�which�antibioticsare�consumed�–�has�an�impact�on�antibiotic�resistance.

Experience�from�some�countries�suggests�that�reduction�inantibiotic�prescribing�for�outpatients�has�resulted�in�concomitantdecrease�in�antibiotic�resistance.�Unnecessary�antibioticprescribing�in�primary�care�is�a�complex�phenomenon,�but�isprobably�related�to�factors�such�as�misinterpretation�ofsymptoms,�diagnostic�uncertainty,�time�and�perceived�patientexpectations.

Medicine�is�no�exception.�Since�Flemingdiscovered�penicillin�(considered�the�firsttrue�antibiotic)�in�1928,�the�world�has�seendrug�resistance�become�a�significant�andundesirable�feature�of�modern�life�–�withthe�number�of�alternative�antimicrobialseffective�in�treating�infections�limited

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17Dental�Protection Riskwise�Hong�Kong�15

Flow chartA�flow�chart�for�the�management�of�acute�pain�may�help�ensurebest�practice�in�cases�where�the�initial�diagnosis�is�provisional.�So,�be�sure�to:

Allocate�sufficient�time�to�form�a�diagnosisRecord�the�diagnosis�and�the�treatment�indicatedEducate�the�patient�on�your�approach�if�antibiotics�are�notprescribed,�particularly�if�they�had�originally�requested�themSchedule�an�appointment�for�the�definitive�treatmentAudit�your�prescribing�to�see�the�correlation�between�theprescriptions�and�the�conditions�diagnosed.

Recommendations�for�auditClinical�audit�is�a�quality�improvement�toolthat�aims�to�encourage�reflection,�reviewand�changes�to�practice�that�enhancepatient�care.�Topics�for�audit�should�bechosen�carefully,�to�provide�informationthat�will�improve�the�quality�of�themanagement�of�patients�with�acute�dentalproblems.

Topics�include:Antibiotic�prescribing�for�acute�dentalproblemsAnalgesic�prescribing�for�acute�dentalproblemsMedical�history�recording.

Dr David CroserDavid�worked�as�a�general�dentalpractitioner�beforebecomingCommunicationsManager�for�DentalProtection

Antibiotics: handle with careWorld�Antibiotic�Awareness�Week�aims�to�increase�awareness�of�global�antibiotic�resistance�and�to�encourage�best�practicesamong�the�general�public,�health�workers�and�policy�makers�toavoid�the�further�emergence�and�spread�of�antibiotic�resistance.

A�global�action�plan�to�tackle�the�growing�problem�of�resistance�toantibiotics�and�other�antimicrobial�medicines�was�endorsed�at�theSixty-eighth�World�Health�Assembly�in�May�2015.�One�of�the�keyobjectives�of�the�plan�is�to�improve�awareness�and�understandingof�antimicrobial�resistance�through�effective�communication,education�and�training.

The�theme�of�the�campaign,�Antibiotics:�Handle�with�Care,�reflectsthe�overarching�message�that�antibiotics�are�a�precious�resourceand�should�be�preserved.�They�should�be�used�to�treat�bacterialinfections,�only�when�prescribed�by�a�certified�health�professional.Antibiotics�should�never�be�shared�and�the�full�course�of�treatmentshould�be�completed�–�not�saved�for�the�future.

WHO�is�encouraging�all�Member�States�and�health�partners�to�jointhis�campaign�and�help�raise�awareness�of�this�issue.�

Key factsAntibiotic�resistance�is�one�of�the�biggest�threats�to�global�healthtoday.�It�can�affect�anyone,�of�any�age,�in�any�country.Antibiotic�resistance�occurs�naturally,�but�misuse�of�antibiotics�inhumans�and�animals�is�accelerating�the�process.A�growing�number�of�infections–such�as�pneumonia,�tuberculosis,and�gonorrhoea–are�becoming�harder�to�treat�as�the�antibioticsused�to�treat�them�become�less�effective.Antibiotic�resistance�leads�to�longer�hospital�stays,�higher�medicalcosts�and�increased�mortality.

Sir�AlexanderFleming�celebratedon�a�stampsfrom�the�FaroeIslands

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Referenceswww.who.int/drugresistance/en/

Scottish�Dental�Clinical�Effectiveness�programme�Management�of�Acute�DentalProblems�http://www.sdcep.org.uk/index.aspx?o=3243Antimicrobial�prescribing�for�General�Dental�Practitioners�-�available�fromwww.fgdp.org

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Difficult�patient�interactions�Dr Mark Dinwoodie investigates�how�the�perception�of�difficulty�can�affectinteraction�with�the�patient

Depending on how regularly you workin the same dental practice or clinic, a brief scan through the list of namesof patients on your morning list mayreveal a few that are familiar. Forthose that you recognise you are likelyto form a very quick assessment as tothe likely challenge of the forthcomingclinical encounter, largely based onyour previous contact with the patient.For many on the list this will provoke a neutral or positive feeling

However�it�is�natural�to�predict�that�someof�these�encounters�will�be�morechallenging.�This�can�be�for�a�variety�ofreasons�that�might�be�clinically�related�–but�in�some�cases�it�may�be�because�youhave�already�labelled�the�patient�as‘‘difficult’’,�largely�based�on�behaviours�theyexhibited�or�attitudes�that�they�expressedwhen�you�last�saw�them.�Preconceptionsand�assumptions�are�therefore�alreadybeing�formulated�in�your�mind,�based�onthis�label�–�even�before�the�patient�hasbeen�seen.

On�meeting�the�patient�you�make�furtherrapid�judgements.�Negative�perceptionscan�occur�quickly,�often�subconsciously,fuelled�by�previous�experience�andtriggered�by�words,�behaviours�and�visualcues.�It�becomes�easy�to�quicklystereotype�or�label�a�patient�and�makeassumptions�about�them,�both�at�a�clinicaland�interactional�level.�In�your�mind�youmight�be�thinking:�“This�is�a�typical�patientwith�condition�A,�characteristic�B,behaviour�C�or�attitude�D.”

One�image�may�have�made�you�feel�moreuncomfortable�than�the�other.�It�isextraordinary�how�quickly�perceptualjudgements�around�difficulty�are�madeand,�in�this�case,�simply�based�on�the�facialexpression.�It�is�this�feeling�of�discomfortthat�can�translate�into�a�judgement�aboutthe�patient’s�level�of�difficulty,�ie,�this�lookslike�a�potentially�‘‘difficult’’�patient.�It’s�alsointeresting�that�the�patients�that�onedental�team�member�describes�as‘‘difficult’’�are�often�different�in�someoneelse’s�opinion.�

This�variation�and�the�example�abovesuggests�that�it�is�our�perception�of�theinteractional�difficulty�that�results�in�uslabelling�the�patient�as�‘‘difficult’’:�it�mayreflect�past�experience�with�this�or�similarpatients,�our�training�and�any�underlyingprejudices�we�have.

Difficult�interactions�can�make�healthcareprofessionals�feel�frustrated,�resentful,angry�and�sometimes�helpless�oroverwhelmed.�They�can�also�contribute�to�long�term�stress�(Bodner�2008)

But does this matter?Evidence�suggests�that�once�a�healthcareprofessional�judges�a�patient�to�be‘‘difficult’’,�their�verbal�and�non-verbalinteractional�behaviours�can�shift�into�astyle�that�is�higher�risk.�This�increases�thechance�that�the�patient�may�indeedrespond�in�an�unhelpful�manner,�be�lesssatisfied�and�more�likely�to�complain(White�2005).

Our�perception�of�difficulty�can�affect�our:Greetings:�less�warm/friendly/no�smileNon-verbal�messages:�lack�of�eye�contact;preoccupation�with�their�dental�record�orsomething�other�than�the�patient;�closedbody�languageDegree�to�which�we�listen:�less�activelistening�with�frequent�interruptions;increase�in�closed�or�leading�questions;talking�over�the�patientInformation�we�provide:�less�verbalinformation�and�explanation�offeredInvolvement�of�patient�in�decision-making:more�directive;�less�exploration�of�patientvalues,�concerns�and�preferences;�feweroptions�discussed

Such�behaviours�can�lead�to�a�downwardspiral.�The�consultation�is�a�dynamicinteractive�process�and�patients�andhealthcare�professionals�will�respond�toeach�other’s�behaviours�in�ways�that�willeither�help�or�hinder�the�interaction�(Krebset�al�2006).

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19Dental�Protection Riskwise�Hong�Kong�15

Dr MarkDinwoodieMark�is�the�Head�ofDental�Protection/MPS�EducationalServices

Potential outcomes from difficultinteractionsIncreased�investigations�and�referralsDecreased�patient�satisfactionUnmet�expectationsIncreased�dentolegal�risk

Difficult�interactions�can�be�distressing�forboth�patients�and�members�of�the�dentalteam.�They�can�be�a�catalyst�forcomplaints�and�claims,�and�dealing�withthem�effectively�can�lead�to�a�betteroutcome�for�patients�and�members�of�thedental�team.

Our�Mastering Difficult Interactionsworkshop�allows�greater�exploration�ofthese�challenges�and�offers�skills�andstrategies�to�minimise�the�risks�involved.For�more�information�and�booking,�pleasevisit�dentalprotection.org/hong-kong

ReferencesKoekkoek�B,�van�Meijel�B,Hutschemaekers,G�DifficultPatients�in�Mental�Health�Care:�A�Review,�PsychiatricServices Vol�57,�No�6�June�2006.�Pp�795-802

Krebs�EE,�Garrett�JM,�Konrad�TR,�The�Difficult�Doctor?Characteristics�of�physicians�who�report�frustrationwith�patients:�an�analysis�of�survey�data,�BMC HealthServices Research Vol�6,�No�128.�October�6�2006

Bodner�S,�Stress�Management�in�the�Difficult�PatientEncounter,�Dental Clinics of North America,�52:579-603(2008)

White�AA,�Pichert�JW�et�al,�Cause�and�Effect�Analysisof�Closed�Claims�in�Obstetrics�and�Gynaecology�ObstetGynaecol.�2005;105:1031-8

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The�way�you�see�them�is�the�wayyou�treat�them�and�the�way�youtreat�them�is�the�way�they�oftenbecome�(Zig�Ziglar,�See�You�at�the�Top)

‘‘ ’’

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London33�Cavendish�Square,�London�W1G�0PS

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Edinburgh39�George�Street,�Edinburgh�EH2�2HN

Telephone+44�(0)20�7399�1400Facsimile+44�(0)131�240�1878

Opinions�expressed�by�any�named�external�authors�hereinremain�those�of�the�author�and�do�not�necessarily�represent�the,views�of�Dental�Protection.�Pictures�should�not�be�relied�upon�asaccurate�representations�of�clinical�situations

Editor�[email protected]©�Dental�Protection�Limited�December�2015

ContactsYou�can�contact�Dental�Protection�for�assistance�via�the�websitedentalprotection.org or�at�anyof�our�offices�listed�below