Practice Management Flashcards
What are the ADA’s Principles of Ethics?
Autonomy: Self-governance
Nonmaleficence: Do no harm
Beneficence: Do good
Justice: Fairness
Veracity: Truthfulness
Autonomy
Self Governance
* Pt’s right to self determination & privacy
Tx: Pt’s desires w/in the bounds of acceptable tx
* Obligated to involve pt in their won decision
- Safeguard confidentiality of pt records (HIPAA Privacy Rule)
Informed Consent
Autonomy
Dentist is required to share info with the pt & obtain consent
* nature of procedure
* Benefits vs risks
* alternative tx options (include no tx)
* Not cost of tx
Minors:
Autonomy
<18: can give implied consent, or assent, but NOT actual consent
Exception: if emancipated or Emergency situation
*Married
* Pregnant
* Parent
* Military
Patient Records
Autonomy
Charts/X-rays
* owned and kept by the dentist
* Keep as long as possible
* Legally: 7 years after pt is out of your practice
* Pt has the right to copies of charts/x-rays
Risk Management
Autonomy
Always weigh risk vs Benefits for your practice
Documentation=most essential component
* Specific
* Objective
* Complete
* Timely
* Written by yourself, for your own Tx
* Never delete or change records–> Make addendums & strikethroughs
* Dont write anything you dont want to be read out loud in court
Nonmaleficience
Do No Harm
Keep skills & knowledge up to date w/CE
* Know limits and refer difficult cases to a specialist
Beneficence
Do Good
Act for the benefit of others
* Promote patient welfare
Same ethical standards no matter what the financial arrangement is
Justice
Fairness
Be Fair in dealing w/pt, colleagues, & Society
*deal w/patients justly
* deliver care w/o prejudice
Never Slander another dentist
Veracity
Truthfulness
Be Honest & Trustworthy w/public
* respect trust in dentist-patient relationship
Must not represent:
* Care being rendered
* Fees charged
* any form of advertising in a false or misleading way
Statute of Limitations
Laws that set the max time after an event that legal proceedings can start
Occurrence Rule: SOL starts after the event occurred
Discovery Rule SOL starts after the event is discovered
Witnesses
Expert Testimony: expert in dentistry
* testify to existing Standard of care and how it was breached
Fact Witness: Someone who was there
Good Samaritan Act
Legal Protection to:
health professionals & others that assist people who are
* injured
* ill
* in peril
* Incapacitated
Active Listening
Listen:
* w/no distraction
* Ask questions
Paraphrase
Lean forward
Maintain good eye contact
Rapport
Mutual Sense of trust & Openness
* Be human
* ask about pt’s interests
Disclose personal info when appropriate
Empathy
Ability to understand and share the feelings of others
* acknowledge their concerns and be open minded
DO NOT:
* share personal experiences
* reroute the focus on yourself
Nonverbal Communication
Continuous, automatic, & informative
What is the most common nonverbal reaction of discomfort?
Eye & eyebrow movement=1st & most common run of discomfort
Verbal Communication:
Simple, specific, & direct
Help pt make informed decision:
* Don’t just advise
Don’t falsely reassure!
* Say “Everything will be fine, don’t worry”
Clinical Interviewing
Ask open ended Q’s
* pt explains what important to them
* Closed Questions: Elicit more speicific info
Probing: gather additional info
Laundry List: Ask pt to respond from a list of choices
Leading questions=Bad
* directs the pt to respond a certain way
Treatment planning
Present in descending order of desire
* only present options that are consistent w/your standard of care
* Verify pts understanding (Teach-back method)
ABC Model Of Behavior Change
A=Antecedent:
* Factor that Facilitates behavior
* ex: Food stuck b/w your teeth
B=Behavior itself
* ex: flossing your teeth to get food out
C=Consequences of behavior
* ex: relief
Stages of Behavior Change
- Precontemplation:
* Not considering change - Contemplation:
* **Considering change - Preparation:
* Preparing to take steps
* Desire to change - Action:
* taking action towards behavior change
*requires support - Maintenance:
* maintain changed behavior
Social Cognitive Theory
=motivation to change is influenced by several factors
- Self-Efficacy:
* Cognitive Perception that YOU can execute behaviors necessary for a situation
* Positive Affirmation-tell yourself you can do something - Behavioral Modeling:
* Learn proper behavior from models - Social Reinforcement:
* Positive social consequences
Types of Behavioral Learning
Classical Conditioning
Operant Conditioning
Observational Learning
Classical Conditioning
Based on Stimuli
*ex: Pavlov’s dog
Condition a neutral stimulus using an unconditioned stimulus
Operant Conditioning
Based on consequences
Positive Reinforcement:
* Do a good thing, get rewarded
Negative Reinforcement:
* Do a good thing, remove bad stimulus
Positive Punishment:
* Do a bad thing, get punished
Negative Punishment:
* Do a bad thing, remove a good stimulus
Observational Learning
Based on Modeling
=Acquire a skill by observing someone else doing it
Behvior Strategies
Change the antecedent (Class floss on the nightstand as a reminder)
Alter consequences
* reward yourself w/videogames after your floss
SHAPING: Set small attainable goals
PREEMACK PRINCIPLE: Make a behavior that has a higher probability of being formed contingent on a behavior w/a lower probability of being performed
Ability to change depends on Lucas of control (Internal & external motivation)
Motivational Interviewing
=Person-centered counsel style
* assist the resolution From ambience to change
OARS:
O: Open questions
A: Affirmations
R: Reflective Listening
S: Summarizing
Stages of Motivational Interviewing
- Engaging:
* Forming a Relationship - focusing:
* Explore Motivation, goals, and values - Evoking:
* Eliciting their own motivations - Planning:
* Exploring how one might move toward change
* Sustain talk: not ready to change
* Change talk: Favors change
* Commitment talk: Ready to change
Stress
Perceived threat to ones well being
Anxiety
More likely to sit still and not say much
* require more interpersonal distance to be comfortable
Stress Management
#1: TRUST: Give pt a sense of control
* tell pt what to expect beforehand
* Develop hand signals
* Time structuring-count down injections
Comfort:
* Knowledge the pts experience
* Empathetic & tactful in initial response
Coping:
* cognitive behavioral interventions
Coping Strategies
Diaphragmatic breathing:
* Deep Breathing triggers physiologic relaxed response
Progressive Muscle Relaxation:
Guided Imagery:
Hypnosis
Rehearsal
Systematic Desensitization/Graded Exposure
Distraction
Tell-Show-Do
Habituation
Rational Response/Reframing/Cognitive coping
Cognitive Appraisal of a threat
How we asses a threat
Controllability:
*how controllable the situation seems to be
Familiarity
* how familiar the situation is
Predictability:
* how predictable the situation is
Imminence:
* situation seems to be approaching
Child Behavior Management
- Create a child-oriented ENVIROMENT
* Toys & Books in waiting area
* Hang posters
* ask about interests
* Silent parent in room - Ask them to be a helper
- Tell-Show-Do
- Ask about fears
- Count
Dental Pain
Anxious patients more likely to report pain & discomfort
Behavioral Pain Management
Start with the Simplest and least invasive procedure first
Give pt choices
Use Hand signals
Respond immediately to signs of discomfort
Pharmacologic Pain Management
rx:
* Mild: Ibuprofen or Acetaminophen
* Moderate: Ibuprofen + Acetaminophen
* Severe: Ibuprofen + Acetaminophen +/- Opioid
Nitrous Oxide:
* Sedation before onset=TINGLING
* Side Effects: NAUSEA
* CONTRAINDICATIONS: COPDS
IV Sedation
Epidemiology
Study of distribution & Determinants of disease
Public Health: Define
Science of Preventing Disease, Prolonging life, & promoting physical health & efficeciency thought organized community efforts
Public Health: Irreversibe & Reversible Measures
Irreversible Measures:
* DMFT
Reversible Measures:
* Gingival Index
* Perio index
* Simplified Oral Hygiene Index
DMFT
Define dental caries in a population
DMFT: Decayed, Missing and filled permanent teeth as a result of caries
DMFS: Decayed, Missing and filled Surfaces due to caries
DEFT: Decayed, extracted and filled teeth due to Caries
dmfs: Decayed, Missing, or filled primary teeth as a result of caries
Gingival Index
Uses 4 surfaces on 6 indicator teeth
0=Normal gingiva
1=Mild inflammation
2=Moderate inflammation
3=Severe inflammation, ulcerated tissue w/tendency toward spontaneous bleeding
Periodontal Index
A lot of different indices
CPITN: Community Periodontal Index of Treatment needs
0=Healthy
1= BOP
2: Calculus
3: Shallow pockets
4: Deep Pocket
doesn’t account for recession, so CAL is inaccurate
Simplified oral hygiene index
Quantifies Debris (DI-S) and Calculus (CI-S)
Oral hygiene ranked as:
* Good
* Fair
* Poor
Early Childhood Caries
Aka baby bottle tooth decay
Define as: 1+ wmfs b/w birth & 72 months old (6 Years)
* most occurs from 3-5 yrs
* Mainly involves MAX INCISORS & PREMOLARS
What is the most common site for Oral Cancer
Tongue
Stages of Prevention for oral diseases
Primary Prevention:
* Prevent disease before it occurs
* Ex: Sealants, Fl in water
Secondary Prevention:
* Eliminates or Decreases after it occurs
* Ex: Restorations
Tertiary Prevention:
* Rehab a pt after a disease has occured
* ex: Prosth
Community Water Fuoridation
Most cost effective & most practical preventive measure to prevent tooth decay
IDeal: 0.7-1.2 ppm
Schold Water Fluoridation
4.5x concentration of community water
Kids only at school for part of the day, so need Increased Fl
Salt Fluoridation
Not recommended to combine this w/water Fl.
Too much Fl
Fluoride Supplements
</= 3: Fl drops (easier to swallow)
> 3: Fl tabs & lozenges
> 6: Fl mouth rinse
Fluoride Supplement Dosage
Rule of 6’s: No supplemental systemic Fl if:
Fl level in drinking water is >0.6 ppm
Pt is < 6 most old
Pt is > 16 y.o.
Fluoride Toxicity
RULE of 5’s
* Toxic dose: 5mg/kg
* Lethal dose: 5g for adult
Toothbrushing
children <6 y.o. should be monitored during brushing
Diet
Frequency of sugar consumption is more important than amount (Stephan curve)
Prevalence
Proportion of a given population that is affected by that condition at a given time
Cross-sectional study
Survey/measurement taken to represent a snapshot in time
Measures: Prevalence
What are the different types of Longitudinal studies?
Case-Control Sttudy
Prospective Cohort Study
Retrospective Cohort Study
Cross-Sectional Study
People w/a condition(cases) are compared to people without it (Control) in the past (Retrospective study)
Risk of getting. disease w/already known exposure factors
Measures: Odd Ratio
Prospective Cohort Study
Cohortt is followed through time to see who develops a disease
Measures: Incidence & relative risk
Retrospective Cohort Study
Look back after following the cohort & decide what disease you want to look for.
Reliability
PRecision
Are you getting consistent results from the tests?
Validity
Accuracy
How close to the truth are the results?
Sensitivity:
Test is Correctly identify the disease
2 S’s in density and disease
Specificity
Test is Correctly identifying ppl who DONT have the disease (Healthy)
P<0.05
Reject the null hypothesis
Statistically significant
P>0.05
Accept the null hypothesis
Not statistically significant
What type of error: If the Null hypothesis is rejected (P<0.05), but the null hypothesis is true
Type 1 error (alpha)
What type of error: If the Null hypothesis is accepted (P>0.05), but the null hypothesis is false.
Type II Error (Beta)
Sterilization
=Destroy all life forms including bacteria, viruses, and spores
Glutaraldehyde
Sterilization
Cold solution used for Heat sensitive items
* requires long soak time
Pressure Sterilization
Aka Autoclave
121C at 15 PSI for 20 mins
Biologic monitors:
* Test strips w. spores to test efficacy
* weekly
Process Indicators:
* Temp and Pressure
* With each load
Dry Heat Sterilization
160C for 60 mins
Ethylene Oxide
Sterilization
Low temp
* can penetrate materials to sterilize prepackaged items (PSP Plates)
Disinfection
Destorys MYCOBACTERIUM TUBERCULOSIS not spores
Antisepsis
Used on living tissue to decrease bacterial load
Antisepsis: Methods
Alcohol: Most common
Chlorhexidine: Substantivity (Continuous long lasting effect)
Detergents: loosen & removes microbes from surface
Quaternary ammonium compounds (Quats): Does not Kill endospores, TB, or non-enveloped viruses
Spaulding Classification System
Critical: Contacts sterile tissue or vascular system
*requires sterilization
* ex: needles
Semi-Critical: Contacts mucosa
* Minimum oh high-level disinfection
* if heat stable material=Sterilization
* Ex: Mouth mirror
Non-Critical: Contacts Skin
* requires disinfection
ex: BP cuff
Airborne Particles
Splatter:
* visible >/= 50 um
* falls w/in 3 ft of pts mouth
* can carry blood borne pathogens (HIV, HEP B/C)
Aerosols
* invisible, < 50 um
* remain floating in air for hours
* can only carry respiratory infections (TB)
Water Lines
Do NOT recommend flushing lines at beginning of clinic. DOESNT MAKE A DIFFERENCE
Anti-retraction valves
*prevent retraction of fluid from a pt into hand piece and water spray
Balance Billing
Dentist charges the remaining balance from total fee and what insurance covered
Balance after deductible + Co-pay + Insurance coverage
Unbunding
Fraud Term (Dentist)
Separating of a dental procedure into component parts
Upcoming
Fraud Term (Dentist)
Reporting a more complex or higher cost procedure than what was actually preformed
Overbilling
Fraud Term (Dentist)
Charging more than legally or ethically acceptable
*Dentist doesn’t charge the copay to the pt, but still bills the insurance company the full fee
HMO
Health Maintenance Organization
Insurance option that:
* Limits coverage to care provided through specific providers who are under contract
* Drs are paid on CAPITATION PLAN
PPO
Preferred Provider Organization
=Panel of providers who agree to accept less than usual fees in exchange for a higher volume of patients
Open panel plans vs Closed Panel Plans
Open Panel Plans:
* Dentist can see any pt in addition to ppl in the organization system
Closed Panel Plans:
* Dentist is contracted and can ONLY see patients who are members of the HMO.
If you do not obtain informed consent, what happens?
Assault and Battery
