As the population ages, the incidence of diseases requiring antiresorptive therapy is also increasing. The term antiresorptive therapy refers to the administration of oral or parenteral medications to reduce or stop the loss of bone mass associated with ailments like osteoporosis, osteopenia, metastatic cancer to the bone, and hypercalcemia.

There are two main class of drugs used to combat bone fractures and skeletal related events – Denosumab and Bisphosphonate. The most common complication in patients on antiresorptive therapy is osteonecrosis of the jaw, or medication-related osteonecrosis of the jaw (MRONJ), which can occur after any surgical dental procedure.

At present, there is no effective treatment for MRONJ, so prevention is extremely important. Maximum precautions should be taken in patients who are at the risk of development of osteonecrosis, especially with dental surgical procedures like extractions, retrograde apicoectomies, periodontal surgery, or implant placements. Dentists should keep up to date with the latest prevention guidelines and the risk factors when treating patients who are on antiresorptive therapy.

It’s important to include a question regarding antiresorptive therapy in your medical history form and to incorporate this information into your treatment planning.

EDIC has a Bisphosphonate Consent Form. Here is also a clinical piece, “Antiresorptive Therapy: Roles and Responsibilities of Dental Professionals,” by Reza Radmand, DMD, FAAOM.

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The purpose of expert testimony is to help a jury understand whether the plaintiff has met the elements of a dental malpractice claim. The expert’s main task consists of explaining how the defendant dentist met, or failed to meet, the applicable standard of care. To provide context, the expert will describe the practices and procedures followed by a competent dentist in the specialty at issue. They will then explain how the defendant’s actions met or deviated from the standard of care. An expert can rely on their own experience and knowledge, but they can also integrate academic publications and industry standards to support their opinions.

An expert witness may also be asked to evaluate the merits of a claim before legal action is filed. The expert witness may be tasked to review the dental and medical records and provide a written opinion regarding the standard of care and whether there were any deviations from the standard of care. In the event legal action moves forward, the expert witness may be asked to testify at trial as to their opinion on the standard of care. They may be asked to attend depositions as well as evaluate the opposing side’s expert opinions.

Recently, an EDIC policyholder asked if there are any malpractice implications to providing expert testimony or an expert opinion. The short answer is, No. As the expert is not treating the patient or establishing a doctor-patient relationship, the expert’s opinion about the standard of care has no implications for their own dental malpractice coverage.

However, there are some factors you should keep in mind when deciding whether to act as an expert witness. First, if you’re asked to testify at trial as an expert, you should know that the jury is free to give your testimony as much or as little weight as it chooses, so opposing counsel will work hard to discredit you on the stand. Opposing counsel will ask about your qualifications, your training, how much money you’re being paid to testify, etcetera. The attorney who hires you will prepare you for this cross-examination, however, it may still be grueling and uncomfortable.

Second, some expert witnesses may choose to turn their expertise into a career. In this situation, it may be a good idea to explore separate expert witness liability insurance (often called “errors and omissions” insurance or “E&O”). In most jurisdictions, expert witnesses are immune from suits from the opposing party. Lawsuits by the retaining party against the expert are typically allowed. Therefore, if the attorney who retains the expert believes that the expert provided incorrect testimony, made a scientific error, lied, missed a deadline, or did something else incorrectly that cost them the case, they may choose to sue the expert for negligence. In such a situation case, the EDIC malpractice policy would not respond to cover the expert. Claims arising from expert testimony or opinions are not covered under EDIC’s dental malpractice policy because there is no dentist-patient relationship. Therefore, there are no “dental professional services” rendered. An E&O policy tailored for professional experts, however, would respond to cover claims arising from activities related to providing expert testimony or opinions.

Finally, if you’re a treating provider asked to submit an affidavit or provide factual testimony (as opposed to expert testimony) in a case involving your own patient, please contact EDIC so we may advise you on how to proceed.

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Bisphosphonates are a group of drugs that inhibit bone resorption. They are used to treat a range of pathologies including Paget’s disease, osteoporosis, multiple myeloma, and metastasis associated with breast or prostate cancer. The most common complication in patients on bisphosphonate therapy is osteonecrosis of the jaw, which can occur after any surgical dental procedure.

At present, there is no effective treatment for bisphosphonate-induced osteonecrosis, so prevention is extremely important. Maximum precautions should be taken in patients who are at the risk of developing of osteonecrosis, especially with dental surgical procedures like extractions, retrograde apicoectomies, periodontal surgery, or implant placements. Dentists should keep up to date with the latest approaches or guidelines to prevention and the risk factors, particularly when treating patients who are on bisphosphonates, or who will be taking bisphosphonates.

It’s important to include a question regarding bisphosphonates in your medical history form and to include this information in your treatment planning.

EDIC has developed a new Informed Consent for Treatment of Patients on Bisphosphonate Drugs. All EDIC members have direct access to the form from their online portal.

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What happens if, in the interim, you’ve changed malpractice carriers? Or you’ve retired?

An occurrence policy provides coverage for a covered claim that occurs during the policy term, no matter when the claim is reported. Even if the dentist no longer has the policy in force, as long as the claim occurred when it was in force, the claim will be covered.
On the other hand, a claims-made policy provides coverage for covered claims that are first made against an insured dentist and reported to the company during the current policy period. The claim must have occurred on or after the retroactive date and on or prior to the termination date of the current policy. If a claim is reported after the claims-made policy has ended, it won’t be covered. How can you fix this coverage gap?

“Tail” coverage, also called an Extended Reporting Endorsement, is an endorsement that you add onto an expiring claims-made policy. It’s essentially an insurance policy rider that protects dentists against claims that arise even after the policy has ended.
When an EDIC-insured dentist with a claims-made policy leaves the EDIC program for any reason, they should purchase tail coverage. This endorsement provides a single set of limits for all future claims. A dentist needs a tail if they are leaving dentistry (e.g., retirement) or if a new employer does not pick up and provide “prior acts coverage.”

If you have been with EDIC for five years and retire over age 50, EDIC will give you the tail at no cost. Similarly, if you become disabled and are unable to practice dentistry, the tail is free. Otherwise, the cost of the tail is based on a percentage of the underlying policy premium. It’s a one-time payment for an unlimited tail—it does not expire.

Your employment contract may include a provision about tail coverage. It’s worthwhile, when you’re negotiating your employment contract, to try to specify that your employer will pay for your tail coverage. In some cases, your employment contract may state only that the employer will provide professional liability insurance, and it won’t specifically mention the tail. Sometimes the employer is creating that ambiguity on purpose, and it’s up to the employee dentist to bring it up and negotiate the details. Contracts may also list different conditions that affect tail coverage payment, including length of employment and the reason for termination of the employment relationship, e.g., for cause. EDIC strongly recommends that you seek out an employment attorney to help negotiate your contract.

One final thing to know about tail coverage is that if you change jobs but keep the same insurance carrier, it probably won’t be necessary to purchase tail coverage. Your policy should continue without a gap. Further, if you change insurance carriers, sometimes the new insurer will provide “prior acts coverage,” which eliminates the need for the tail. (“Prior acts coverage” would continue the coverage with the same retroactive date as the prior policy.)

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So, you just started your first job as a new dentist and, while you know your stuff, you have just a few questions about practice management. Well, here are some answers!

How long should I keep clinical records?

You should keep active patient records forever. There are several reasons to maintain a patient’s clinical record:

• For clinical use. Continuity of care requires that a dentist have access to a patient’s record, sometimes even after the patient leaves the practice.
• For legal reasons. Patients have a right to obtain a copy (not the original) of their records.
• For malpractice defense. A dentist’s records are a vital part of their defense should a patient bring a claim of malpractice or a Board complaint.

For inactive patients, we generally recommend keeping clinical records for adult patients for 10 years past the date you last saw the patient. Your state has a statute of limitations defining the timeframe in which a patient has the right to bring a claim. In general, a patient has two to three years after the care has been rendered to bring a claim. However, some circumstances may act to lengthen the statutory limits, such as a claim that the alleged negligence was not discovered until much later.

For minors, we recommend keeping records for either 10 years or until 3 years after the patient reaches the age of majority (18), whichever time period is longer. The statute of limitations does not begin to run until the minor has reached the age of majority.

I have a patient posting bad reviews on social media sites. What do I do?

It is always unsettling when patients post bad reviews on social media sites, but it’s important to deal with the issue correctly. A specific response about the complaint could potentially result in divulging information that would be subject to a HIPAA claim about confidentiality. It is a good idea to respond, but you can do it in a way that reflects well on you and your office.

We suggest something like, “Because of privacy regulations, we can’t discuss any specifics about your comments. However, we are committed to providing high quality care, and we take your feedback very seriously. Please contact our office directly. We are happy to discuss additional details to resolve this matter with you.”

I received a credit dispute on payments by credit card company. How do I handle that without violating HIPAA?

First, review the office financial policy or contract with the requesting entity for their legal right to information. If need be, the office may require the entity to provide an authorization signed by the patient. HIPAA allows doctors to disclose protected health information as necessary to obtain payment for health care and does not limit to whom such a disclosure may be made.

What is said next depends upon the specifics of complaint. Services were charged that weren’t delivered? Services delivered that were not authorized? Services were quoted at a lower figure and charged at a higher figure? Dentist did not apply an adjustment that was promised?

Once the credit card company has the authorization to discuss the facts, you should be prepared to explain the circumstances of how the charges were incurred. It can be important to show that the patient accepted the treatment plan, the services were delivered within the standard of care, that consent was obtained without guarantee of any specific success or longevity, and, if applicable, a change in conditions or outside trauma affected the treatment and changed the plan. You can show invoices and receipts, any agreements the patient signed, and any documented customer service interactions (e.g., emails or texts), among other proof.

You do have a duty to keep the disclosed health information to a minimum, so share only what you need to prove that the transaction was authorized by the cardholder and the goods or services were delivered.

The post New Dentists FAQs appeared first on Eastern Dentists Insurance Company (EDIC).

Yes, you should have written informed consent for local anesthesia injections. This can be a paragraph in your specific consent form (e.g., your extraction form) or in your general consent form (e.g., for a basic filling). It can also be a separate form encompassing solely local anesthesia risks, benefits, and alternatives.

Why is Informed Consent Important?

There are risks associated with injections of anesthetics into the mouth that range from allergic reactions to traumatic injuries to nerves and blood vessels. These risks should be shared with your patient.

Dentists generally inform patients about both simple, common risks and rare risks that can occur with a proposed dental procedure. While local anesthesia is extremely safe, negative outcomes may occur. In the event of a negative outcome, the difference between a “complication” and a “mistake” in the eyes of a patient is informed consent.

Example of Language in Informed Consent Forms

For example, the paragraph below can be inserted into your General Consent and Specific Consent forms:

“DRUGS AND MEDICATIONS. I understand that I may receive a local anesthetic and/or other medication. In rare instances, patients can have a severe reaction to the anesthetic, which may require emergency medical attention. Patients can also find that it can reduce their ability to control swallowing. This increases the chance of swallowing or aspirating foreign objects during treatment. Depending on the anesthesia and medications administered, I may need a designated driver to take me home. Temporary or permanent nerve injuries rarely result from an injection.”

As always, remember that informed consent is a process and not just a form. You should discuss the risks, benefits, and alternatives of your proposed dental treatment with your patients. You should also allow the patient to ask questions before you ask them to sign the form. Don’t forget to document your discussion with your patient in your notes!

For more information on the topic of informed consent and local anesthesia, log into the customer portal and watch Dr. Patricia Blanton’s webinar, “Dental Local Anesthesia: Potential Risks and Risk Mitigation: A Clinician’s Guide.” Watching this webinar will earn you two CEUs, plus a two-year discount on your EDIC premium.

To access EDIC’s dental consent forms, log into the customer portal and click on Resources.

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General dentists are often the first doctors to examine oral cancer disease conditions. Patients rely on their general dentists to examine lesions closely, order biopsies when appropriate, and refer them to specialists.

American Dental Association: Oral Cancer Precautions

Currently, the American Dental Association advises:

• Clinicians should obtain an updated medical, social, and dental history and perform an intraoral and extraoral conventional visual and tactile examination in all adult patients.
• For patients with suspicious lesions, clinicians should immediately perform a biopsy of the lesion or refer the patient to a specialist.
• Salivary and light-based adjuncts are not recommended for evaluating lesions for malignancy.

If you refer a patient to a specialist for a biopsy of a possible oral cancer lesion, make sure you follow up with that patient to ensure compliance with the referral. If the patient refuses the referral, you must warn them of the likely consequences of that refusal, such as a cancer diagnosis that is too late to treat effectively, the loss of their jaw or their eyeball, or death. Please be sure to document that discussion in your notes.

Noncompliance

When patients are non-compliant, it increases the risk that the dentist will be held responsible for adverse outcomes related to that noncompliance. Warning the patient of the likely consequences of noncompliance and documenting that discussion puts the onus back on the patient, and not the dentist. For more on this topic, log into your customer portal and watch Dr. Daniel Oreadi’s webinar, “Diagnosis and Management of Oral Cancer,” and earn two CEUs plus a two-year discount on your EDIC premium. Policyholders, check out EDIC’s oral cancer case studies here.

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