Standard Procedures by Dr. John W. Dovgan

An excerpt from a new four-part CE course on Dentaltown about standards in care in dentistry

by Dr. John W. Dovgan

Editor’s note: Dr. John Dovgan’s CE course on Dentaltown addresses the standards of care for dental procedures and ends the ambiguity over what’s considered by dental boards during malpractice cases. The four-part booklet comprehensively covers the full range of dental treatments and procedures, from radiology to the hierarchy of restorative space required for different kinds of dental implants.

“Consider this book a ‘bible’ for standards of care and how not to get in hot water with the law while performing dentistry,” says Dr. Howard Goldstein, Dentaltown’s director of continuing education. “This is a must for all dentists and their staffs to keep their patients safe from harm—and themselves safe from the law.”

We’ve excerpted the first part of Dovgan’s course, The Ultimate Guide to Dentistry’s Standard of Care, which covers the four “blanket allegations” that make up a consistent component of all specialties and procedures covered. To study the entire course and take the quizzes for the chance to earn 10 CE credits, head to dentaltown.com/ce.

What is the “standard of care”? That’s the elusive question every dentist in the world really wants to know. I’ve spent more than three decades figuring out this question and the amazing thing is, the answer changes. Every time there’s a lawsuit or a dental board case has a ruling, we change the standard of care and up the ante for every dentist. The only constant in life is change.

So, the definition of the standard of care is what a reasonable and prudent dentist would do in a like or similar situation, in a like or similar locale. The standard of care is more like a bell curve, as seen in Chart?1.

If you really examine malpractice cases and dental board cases, you begin to realize that breaking the standard of care requires you to be negligent.

The most common standard of care breach involves record-keeping. How many times do I hear from attorneys that the dentist “normally” does this but was remiss in putting it into their records? Don’t be that dentist who didn’t put the information in the patient chart.

Guidelines for determining the standard of care

First, we must examine the basics. What do I mean? The basics would include what used to be called the “four blanket allegations,” a term used for decades by the Arizona State Board of Dental Examiners.

The categories of the four blanket allegations are:

• History/clinical.
• Radiographs.
• Diagnosis.
• Treatment planning.

These really determine the outcome of everything we do in dentistry; without this basic information, we cannot determine the health of the patient. We cannot determine what was done or needed to be done. We must have a diagnosis or differential diagnosis, and we must have a treatment plan. We also need X-rays to properly diagnose. Without these basic elements, we cannot do dentistry safely.

The health, welfare and safety of the public relies on us doing our jobs. To determine if we have done that job correctly, we must ask ourselves some basic questions when we do our exams. Below is a list of questions to assist in determining if a dentist met the standard of care for the four blanket allegations.

History/clinical

• Does a signed and dated health history exist?
• Is the health history comprehensive?
• Do regular health history updates exist?
• Does there appear to be soft-tissue exam notes?
• Are full-mouth periodontal probings present?
• Do regular periodontal updates exist?
• Was a limited exam done?
• Are existing restorations charted?
• Does a TMJ/TMD evaluation exist?
• Is there an oral cancer screening?

Radiographs

• Was a full-mouth X-ray series or equivalent taken?
• Are the X-rays clinically acceptable?
• Do any other X-rays exist?
• Are the X-rays clinically applicable to the diagnosis?

Diagnosis

• Does a written documented diagnosis exist?
• Is the diagnosis consistent with the treatment plan?
• Is the diagnosis reasonable?

Treatment planning

• Does a written documented treatment plan exist?
• Is the treatment plan supported by the radiographs and diagnosis?

These are the questions you should be asking before doing the procedure being evaluated. Remember, if only a limited exam was done, it is not expected to have existing restorations, full-mouth periodontal probing, etc.; the information listed can be limited to the scope of the specific procedure.

What constitutes “regular” health history updates? Every time a patient comes in, you should update his or her health history. Yes, even if you’re an orthodontist! Updating a health history once every five years is below the standard of care.

What is a “comprehensive” health history? For guidance, look at what the ADA lists for a health history. If your health history has what the ADA recommends, you have a comprehensive health history. If your health history is from 1982, you probably don’t.

What are “regular periodontal updates”? If you have periodontal charting every year, you’re covered. If your periodontal charting is once every five years, you’re in trouble. Consider what a reasonable and prudent dentist would do in a like or similar situation, in a like or similar locale.

What does “Is the diagnosis consistent with the treatment plan?” really mean? If you have a periapical lesion on Tooth #8 and you’re diagnosing acute periapical periodontitis with a treatment plan of root canal therapy or extraction, this is a reasonable diagnosis and treatment plan. If you’re recommending a crown with no root canal therapy, this would not be a reasonable diagnosis or treatment plan. The X-rays should support your diagnosis and treatment plan.

However, specific procedures require much more specific detail.

Example 1: When doing root canal therapy, the radiographic apex can be up to 3mm different from the actual apex.

Example 2: When doing parenteral or enteral sedation, blood pressure needs to be taken a minimum of every 15 minutes. Best practice is every 5 minutes and the procedure should be stopped if the systolic and diastolic blood pressure add up to 300.

Remember, these are only guidelines, and factors such as “aggravating,” “mitigating” and “compelling reasons” are up to the practitioner’s professional judgment.