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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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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Accommodating patients under the Americans with Disabilities Act has been largely facilitated (making buildings and offices accessible to patients in wheelchairs, etc.) to the point where one need not worry too much about it. But one disability that sometimes doesn’t hit everyone’s radar is hearing impaired patients. Many people don’t know that a hearing-impaired patient can rightfully require the dentist to provide an interpreter for his or her appointment. If a patient requests this, the dentist must provide the interpreter at his or her own cost. It is the law. The charge cannot be passed along to the patient, even if it exceeds the fee for the appointment.

Not all hearing-impaired patients request this. Some patients read lips, others communicate by writing notes back and forth, and others will bring interpreters with them. You need only provide an interpreter when the patient requests it. Telling patients you are not able to provide an interpreter may result in a claim against you for discrimination.

It is important to be aware of this regulation and adhere to it to keep your patients and yourself safe.

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Can I still charge the patient if I did the procedure to the wrong tooth? Can I withhold a procedure to a patient who hasn’t paid in full? Will it make me look liable if I return a fee to a patient? We receive various questions into our claims department on a yearly basis. Here are the answers to these commonly asked questions.

I did endodontics on the wrong tooth. Can I still charge for it?

No, the implied contract here between you and the patient was to perform endodontics on another tooth. Since you did not uphold your end of the bargain, there should be no obligation for the patient to pay for this mistake on your part.

Can I refuse to insert a bridge or a crown until the patient has paid his fee in full?

No, this refusal would be abandonment. Dentists can make whatever financial arrangements the patient agrees to prior to beginning treatment, but once a tooth or teeth have been prepared and the crown or bridge is fabricated, it must be inserted to avoid any potential further damage to the patient. The dentist should insert the crown or bridge and attempt collection afterward.

If I return a fee to a patient would it be viewed as an admission of negligence?

Dentists can return fees in a manner that avoids any further liability. Simply state to the patient, and follow it up in writing, that the offer to return fees is a gesture of goodwill and not an admission of any negligence.

The more you know, the more protected you and your patients will be.

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When you document your clinical records, you should be completely objective. Remember that patients have a right to obtain their records. If you have a particularly unpleasant patient and write, “Mrs. Smith was very nasty at her appointment and did not cooperate at all,” you can imagine her reaction if she read the note.

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