A bridge too far

GLDI9464-B-Guild-Insurance-Dental-Risk-HQ-Imagery_ARTICLE-IMAGES_A-BRIDGE-TOO-FAR

‘A Bridge Too Far’ is the title of Cornelius Ryan’s epic reconstruction of the British Army’s parachute and armoured thrust across Holland to the Rhine and Germany in late 1944. If it had succeeded it would have shortened the war and incidentally but not coincidentally, made it a British rather than an American victory. In making this thrust, Montgomery ignored his lifetime’s instinct and training and launched this campaign with minimal planning, minimal consideration of the risks, minimal consideration of other options and put the plan into action in less than two weeks. To succeed, the plan required faultless military intelligence, every phase to work perfectly with no breakdowns and the weather to remain fine. Early in the piece one of the parachute generals opined that “it was a bridge too far” but was ordered to get on with it. The general was aware that they had ignored the advice of the Free Dutch Forces, and most of the troops were keen and eager but lacked combat experience. It’s a matter of history that the essential elements all broke down despite the heroism of the frontline troops. There was much pain, sacrifice and loss, the war was lengthened and the Americans re-exerted their dominance.

So, how do the lessons of this military experience relate to Dentistry? Recently, there have been discussions of how on the one hand you should listen to the advice from Guild Insurance warning about the risks of practitioners exceeding their scope and capacity, but on the other hand, if you can’t develop your skills in general practice then you remain professionally underdeveloped. It is accepted that although you can be taught the relevant principles in Dental School, you must be able to enhance your actual skills after registration and indeed, for the rest of your practising life.

Aspects of this were illustrated in a recent interstate medico-legal case in which I was involved as an expert. (The key facts are accurate but it has been modified to protect those involved). A 40ish successful business woman asked a young dentist as to whether anything could or should be done about a single edentulous first molar space in the mandible. The tooth had been extracted long ago but it was only recently that she had the time and finance to do anything about it. The dentist replied that indeed, things could be done, a bridge was the answer and why not start today, so they did. During the bridge construction the lady asked if ever anything went wrong with bridges and was told that “nothing could go wrong”. Indeed it did and was followed by three years of pain and loss, multiple visits to the dentist, various medical and dental specialists and many treatments without result.

Eventually, an interstate expert, an Oral and Maxillofacial Surgeon (guess who) said to her that if the pain had started with putting the bridge in let’s take it out. “At last”, said the lady, so the bridge was removed. Soon after the patient’s pain went but the dentist’s pain commenced as lawyers were consulted. The legal pain went on then for a further three years but wisely just before it came to trial, the matter was settled out of Court.

What are the lessons from this? Although it was quite a nice bridge that the dentist had made he had erred in a number of places. He certainly failed to give the lady the full range of options; namely do nothing as she had been like it for a long time and there would be no problems with doing nothing. This was not an aesthetic issue, minimal (less than 5%) reduction in chewing ability and healthy adult teeth do not drift. A removal or partial denture could be made but is a poor option for a unilateral single tooth loss. A bridge is an option but with some risks and a significant failure rate over time. Alternatively, a single tooth implant could be made but is associated with increased risks. Essentially, the dentist gave her only one choice which is not a choice. Thus legally she could not give informed consent.

He knew that the lady was a bruxist before he started the bridge and learned much more about her intense personality and bruxing habits when she was in pain and in legal pursuit. He also knew that she had a skeletal class three malocclusion with a cross bite but failed to take this into account and in particular, to understand the extreme lateral loads which could be generated by her bruxing on the bridge and its abutments.

He failed to give the lady time to consider the options. Indeed, as a savvy business operator she would have had no difficulty in travelling a few hundred kilometres to a metropolitan specialist for an implant. With careful research, she could have found one with the necessary skills and training not to screw the implant into the mandibular nerve and to graft sufficient bone to replace the marked alveolar atrophy. A specialist in prosthodontics should have been involved to ensure that the crown was not overloaded by her malocclusion and bruxing. Alternatively, as a smart lady, she may well have decided that doing nothing really was the way to go.

Lastly, although the dentist could demonstrate that he had made a number of bridges, he could not demonstrate that he had attended any courses in bridgework, occlusal problems or TMD since he had graduated. He had become comfortably isolated as ‘the expert’ in his solo practice. Interestingly, once the bridge was made and the pain started he, and indeed, all of the dental specialists she variously consulted were keen to keep the bridge in situ. Most looked at it as a bridge with the patient’s mouth wide open, rather than infunctional (dysfunctional) occlusion. It took a non-restorative specialist from interstate to indicate that “if in doubt, out”.

So what does a military strategy to end World War II and this dental case have in common? Both failed to adequately consider the options, effectively plan and train and to change the plan when things went wrong. Both did go horribly wrong with much pain and suffering to those involved, one on a macro scale and the other on a micro scale.

So, what should a general dental practitioner do to help their patients with complex problems and to develop their scope? On the one hand, one does need to read and think about the advice given by the dental liability organisations regarding risk. If however a practitioner wants to broaden their scope and knowledge then they should carefully think, plan and improve their skills by attending hands on courses and working with specialist mentors. Indeed, most commonly, the practitioner who gets into trouble doesn’t do any of those things and plunges in with supreme over confidence. If you have reached this spot in the article, congratulations, you probably are already a careful and prudent practitioner. So, you are less likely to attempt a “bridge too far”.

 
 
 
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    This article is written by Kellie Dell’Oro, Principle – Meridian Lawyers

    Case scenario: The patient issued proceedings seeking compensation for the cost of ongoing periodontal maintenance, and the cost of further dental treatment. The patient expressed significant upset with having been to see the practitioner for more than 10 years and then another practitioner advised that she suffered severe gum disease requiring periodontal treatment and potentially, implants and crowns.

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    1. The patient was a regular attendee at the practice, at approximately six monthly intervals.

    2. The patient had an OPG which showed severe bone loss. The OPG formed part of the patient file but there was no record of the interpretation. There was also no record of the advice given to the patient.

    3. The patient had a further OPG two years later which showed additional bone loss. Again, there was no record of the practitioner’s opinion following the OPG review. There was also no record of the advice to the patient.

    4. The practitioner stated that he consistently advised the patient that she had a gum problem and it was important that she visit a specialist but that the patient did not want to see a specialist. However, of the 46 consultations spanning the period there were only two references to her condition, ‘gum inflammation’, and both were very early in the relationship. There were two references to the patient being advised to see a periodontist but only one of these references, late in the relationship, documented the patient’s response: ‘does not see any reason’. And there was no record of the details of the advice given to the patient.

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    • documented the results of the clinical examination, including a check of mobility and regular checks of the pockets as this could provide a baseline to measure any deterioration of the patient’s condition;

    • recommended the patient see a periodontist from at least the time of the first OPG and explained the reasons why that was important; that there were signs of irreversible severe bone loss and two teeth had a questionable prognosis but the risk of losing teeth could potentially be minimised by addressing the inflammation.

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    In this case the practitioner maintained the patient had gum issues throughout the period that she was seen. Had the practitioner documented the results of the clinical examination, including the results of regular testing (as well as his conclusions and advice), this may have provided a further basis to defend the claim, if it supported there having been minimal decline in the patient’s clinical condition.

     


    Checklist

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    • ensuring that referrals are written.

     


    If a patient is refusing to follow advice, it is recommended that practitioners consider providing a letter to the patient setting out their advice, the reasons and consequences of failing to follow that advice. If the patient, having been properly being informed of the risks, decides not to see a specialist or to follow their advice regarding oral hygiene management, then it may be possible to argue that any decline in their oral health as a result, is due to their own failure.

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    5. Can I communicate well with this patient?

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    As always, the Advisory Services welcomes your comments and is here if you wish to discuss any clinical situation. We do not have all the answers all of the time, but many of our conversations end with our member saying “Well, thank you and I’m really glad that I called you today!”

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  • The dangers of not recording your advice to patients

    This article is written by Kellie Dell’Oro, Principle – Meridian Lawyers

    Case scenario: The patient issued proceedings seeking compensation for the cost of ongoing periodontal maintenance, and the cost of further dental treatment. The patient expressed significant upset with having been to see the practitioner for more than 10 years and then another practitioner advised that she suffered severe gum disease requiring periodontal treatment and potentially, implants and crowns.

    Why was the claim difficult to defend?

    It was difficult to defend the claim due to the following reasons:

    1. The patient was a regular attendee at the practice, at approximately six monthly intervals.

    2. The patient had an OPG which showed severe bone loss. The OPG formed part of the patient file but there was no record of the interpretation. There was also no record of the advice given to the patient.

    3. The patient had a further OPG two years later which showed additional bone loss. Again, there was no record of the practitioner’s opinion following the OPG review. There was also no record of the advice to the patient.

    4. The practitioner stated that he consistently advised the patient that she had a gum problem and it was important that she visit a specialist but that the patient did not want to see a specialist. However, of the 46 consultations spanning the period there were only two references to her condition, ‘gum inflammation’, and both were very early in the relationship. There were two references to the patient being advised to see a periodontist but only one of these references, late in the relationship, documented the patient’s response: ‘does not see any reason’. And there was no record of the details of the advice given to the patient.

    In summary, the patient had the benefit of being able to establish that there were signs of advanced periodontal disease and progressive bone loss, from the two OPGs that were taken during the period of care. Comparing the results of a later OPG, the patient was able to demonstrate even further bone loss. This formed the basis for her claim that had she been appropriately advised and managed, her condition would not have progressed to the stage of her having to consider extractions of two teeth.

    A practitioner demonstrating reasonable care should potentially have:

    • advised the patient she was suffering from advanced bone loss, noting there was more than 50% bone loss evident around two teeth, from the OPG, and that two teeth had a questionable prognosis as the bone loss was irreversible;

    • documented the results of the clinical examination, including a check of mobility and regular checks of the pockets as this could provide a baseline to measure any deterioration of the patient’s condition;

    • recommended the patient see a periodontist from at least the time of the first OPG and explained the reasons why that was important; that there were signs of irreversible severe bone loss and two teeth had a questionable prognosis but the risk of losing teeth could potentially be minimised by addressing the inflammation.

    In this case, we were unable to demonstrate from the practitioner’s recall or the records, that appropriate advice had been given. We were also unable to demonstrate that the outcome for this patient would probably have been the same, regardless.

    Meridian Lawyers formed the opinion there was a risk that the patient could establish that the practitioner had not provided reasonable advice and management and as a consequence, that she had suffered additional loss and damage.

    In this case the practitioner maintained the patient had gum issues throughout the period that she was seen. Had the practitioner documented the results of the clinical examination, including the results of regular testing (as well as his conclusions and advice), this may have provided a further basis to defend the claim, if it supported there having been minimal decline in the patient’s clinical condition.

     


    Checklist

    Practitioners need to be extremely mindful of the need to make a careful record of the advice given to patients, and particularly for those patients suffering from periodontal issues.

    At a minimum this should include:

    • the conclusions drawn from any OPG and the comparison with any previous OPGs;

    • the results of all clinical examinations, including any check of mobility and pocketing checks;

    • the advice given to the patient at each consultation;

    • any recommendation to see the periodontist and the details of the advice (i.e. why they would benefit from a referral) and the patient’s response;

    • ensuring that referrals are written.

     


    If a patient is refusing to follow advice, it is recommended that practitioners consider providing a letter to the patient setting out their advice, the reasons and consequences of failing to follow that advice. If the patient, having been properly being informed of the risks, decides not to see a specialist or to follow their advice regarding oral hygiene management, then it may be possible to argue that any decline in their oral health as a result, is due to their own failure.

    Disclaimer: This information is current as of June 2017. This information does not constitute legal advice. It does not give rise to any solicitor/client relationship between Meridian Lawyers and the reader. Professional legal advice should be sought before acting or relying upon this content.

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  • Understanding social media risks

    Reading relevant articles can count towards your required continuing professional development hours.  Therefore, reading the article below may assist you to achieve these required hours. (see more below)

    Social media is an ever increasing form of communication for many people in both their personal and professional lives. It presents people with many benefits in allowing them to communicate a variety of messages to many people with great speed and efficiency. However, those benefits need to be balanced with the many risks social media presents.

    Social media is a very broad term which includes any websites and applications which allow users to interact with other people as well as create or share information (text, photos, videos etc.).

    There are endless examples where people appear to have not stopped and thought before they’ve posted on social media. Poorly considered social media posts can and do affect the personal and professional reputation and image of individuals as well as a businesses; even if the post isn’t directly related to a business.

    The following tips will assist individuals and businesses manage their risks when using social media.

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    2. Business social media should be based on business requirements, not personal views
    Business owners and managers need to be sure that when they make a decision on whether to use social media for their business, this decision is based on the needs of the organisation, not the owner’s/manager’s personal views of social media.  For example, a person who chooses to not use Twitter for personal use may still decide it’s a great tool for them professionally.  Business decisions and personal decisions regarding social media use should be separated.

    3. Create clear business guidelines and processes regarding who is able to post on social media and how this is to be done
    Due to the risks associated with social media interactions, it’s very important that businesses have a clear process for who is responsible for posting on social media.  The person undertaking this role needs to understand when social media is an appropriate form of communication and what sort of messages are to be shared using social media.  This process should also provide guidance on how often social media is monitored and responded to and how to respond to negative comments.

    4. Consider training for those staff responsible for social media
    It’s often assumed that young people are well versed in social media use however this isn’t always the case.  Also, not all users of social media understand appropriate business use and its associated risks.  Therefore it’s worth considering training in social media communications and its risks for the responsible staff members.

    5. Understand the social media site you’re using
    There’s a wide variety of social media sites available to businesses, all providing similar yet different benefits.  When a business is using any of these sites, it’s very important they understand the various functions within that site.  Not fully understanding how a site works is going to increase the risks of using it.

    6. Consider what messages should be shared using social media
    All businesses have various ways in which they communicate with their customers and clients.  Social media is generally designed for short sharp messages, yet not all information suits this style of communication.  When businesses are communicating with their customers, they need to carefully consider how that particular message should be shared.

    7. Carefully consider the implications of engaging with clients on social media
    Professionals and businesses should consider if social media is an appropriate forum for them to be communicating with clients, both through business or personal accounts.  Engagement through personal accounts can blur professional boundaries.  When using business accounts, some conversations may not suit social media, especially if the conversation appears in a public setting.  It’s important to consider what conversations are best had away from social media and when to take a discussion off line.

    8. Your business social media use must adhere to the AHPRA Advertising Guidelines
    AHPRA regulated professionals need to adhere to AHPRA’s Advertising Guidelines with all of their advertising.  This includes any advertising or promotion done using any social media site.

    9. Understand that you can no longer separate personal and professional use
    Unfortunately many people hold a view that what they write within a personal social media account in their own time will have no bearing or impact on them professionally.  However this is not the case.  Whether fair or not, professionals are always representing their profession and professional self; personal social media posts can be considered to be representing a professional view.  Therefore the professional impact needs to be considered before any personal post is made.

    10. Don’t believe that any post is ever private
    Too often people post information on social media which they intended to remain private and not be seen widely.  However social media can never truly be private.  Many online groups claim to be private and state that members require approval.  However non-approved users don’t need to be particularly savvy to access these groups and then share or copy information being posted.  Professionals need to remember that if they don’t want their colleagues, clients or competitors seeing a social media post, it should never be posted on either personal or business accounts.

    11. Never post in haste, all posts need to be carefully considered
    As mentioned earlier, social media is designed for quick short messages to be shared widely.  This means social media can encourage messages to be shared with little thought or planning which on occasions leads to poorly worded messages which are easily misinterpreted.  It’s important to pause and think through a message before it’s shared.

     

     

    Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791.  This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them.

     
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