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Removable prosthodontics II > Risk analysis and management in treatment planning of RPDs > Flashcards

Risk analysis and management in treatment planning of RPDs Flashcards

1
Q

What is risk management?

A

“Risk management is something you do to provide the best possible care for your patients; it is not about avoiding a lawsuit”.

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2
Q

Negligence/ malpractice:

A

The person who suffers an injury is entitled to receive damages from the person or people responsible. In health care/dentistry, the most prominent tort liability is negligence or malpractice. In order for negligence to exist, the following four elements must be found:

  1. A duty (standard of care) was owed by the dentist to the patient.
  2. The dentist violated the applicable standard of care.
  3. The plaintiff suffered a compensable injury.
  4. Such injury was caused in fact and proximately caused by the substandard conduct.
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3
Q

What is risk analysis?

How is this risk connected to Removable Prosthodontics???

A
  1. Human error is almost always involved at some level when things go wrong
  2. This may occur at any stage of treatment:
  • initial diagnosis
  • treatment planning
  • treatment execution
  • long term maintenance of treatment outcome
  1. And it may not be directly relevant to the treatment provided:
  • failure to manage patient expectations
  • failure to ensure the patient is compliant
  • failure to anticipate potential complications
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4
Q

Risk analysis related to human factor:

A
  • Tooth loss is associated with many risk factors; some are related to behavior
  • Oral hygiene, attendance, compliance, dietary habits, smoking may all contribute to tooth loss through caries and/or periodontal disease
  • For long term success of any Prosthodontic treatment it is first necessary to reduce the risk of further tooth loss, by modifying the patients’behavior
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5
Q

Risk Case Assumptions:

A
  • Removable Prosthodontics patients suffer from a severe aesthetic and functional handicap
  • They are ALWAYS in a hurry to finish the treatment
  • May not appreciate your efforts to ensure a long lasting result
  • It is NEVER safe to ASSUME they will meet any promises made with regards to lifelong habits
  • Sufficient time should be allowed for them to DEMONSTRATE they are able to maintain any treatment outcome for the long term
  • Assumptions are also unsafe to make regarding your provided treatment
  • Complications may arise at any stage of treatment
  • If complications arise in a strategically important tooth, this may significantly alter your overall treatment plan
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6
Q

Q: what are the risks for the dentist?

A
  • Cross infection
  • Injury (e.g. by sharps, rotary instruments etc.)
  • Exposure to harmful materials (e.g. monomer, alginate powder, amalgam etc.)
  • Musculoskeletal
  • Work related stress
  • Psychological
  • Eye damage (e.g. by exposure to laser device)
  • Faulty equipment (electrocution, burns etc.)
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7
Q

Q: what are the risks for the dental team?

A
  • Cross infection and sharps injuries are the most common
  • Exposure to hazardous materials
  • Allergic reactions
  • Burns
  • Exposure to radiation
  • As an employer it is the dentist’s responsibility to ensure the health & safety of all staff
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8
Q

Q: what are the risks for the patient?

A
  • Most of those already mentioned for the dentist and team
  • In addition, medical emergencies
  • Direct injury (e.g. by dental instruments); intra oral or extra oral
  • Direct trauma (e.g. jaw fracture during extraction, accidental extraction)
  • Inhalation / swallowing of small instruments, implant components, materials, extracted teeth, restorations etc.
  • Treatment complications
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9
Q

Treatment complications specific to RPDs-

Unsuccessful treatment outcome:

A
  • RPD is un-retentive, unstable or poorly supported
  • RPD is not well fitting
  • RPD is not aesthetically acceptable
  • The patient is unable to eat using the RPD Other / technical complications
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10
Q

Q: what could you do to rectify this problem for the patient?

A

A: not much!

  • Visible metal clasps could have been avoided if precision attachments were incorporated in the crowns #13,23; there are no other abutment teeth to be used!
  • The whole treatment would now have to be repeated from start if the patient cannot accept these clasps
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11
Q

Damage to abutment teeth:

A
  • Plaque accumulation around RPD components may lead to caries and/or periodontal disease
  • This may result to loss of a strategically important abutment tooth
  • The RPD may no longer function effectively
  • Your whole treatment plan may be rendered a failure because of a non-hygienic clasp design!
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12
Q

Damage to abutment teeth:

A
  • Incorrect occlusal rest design or placement may cause crown fracture or fracture of restorations
  • Occlusal interferences may cause abutment tooth fracture or fracture of restorations
  • Pulling forces
  • Inclined planes
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13
Q

Can you think of any other ways RPD abutment teeth may be damaged?

A
  • Excessive or incorrect tooth preparations
  • Excessive wear through friction against metal RPD components
  • Excessive load where bone support may have been compromised by periodontal disease
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14
Q

Damage of non-abutment teeth:

A
  • In mucosa supported RPDs forces may be transferred to teeth in a non-favourable direction
  • Occlusal interferences caused by metal parts of RPD (such as clasps or occlusal rests) may cause excessive wear of opposing teeth, fracture of restorations or crown fractures
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15
Q

Damage to the soft tissues:

A
  • Periodontal disease
  • Denture Related Stomatitis
  • ‘Burning mouth syndrome’
  • Direct mechanical trauma: sore spots, ulceration, denture related hyperplasia
  • Periodontal disease is probably the most common and one of the most severe complications
  • Removable Prosthodontics patients are high risk patients for periodontal disease and tooth loss
  • RPD may act as a huge plaque retentive appliance!
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16
Q

Damage to the patient:

A
  • Swallowing / inhalation of RPD or components
  • TMJD symptoms
  • Allergic (type) reaction
  • Cross infection
17
Q

Where to start???

A
  • Identifying the risks is the single most significant step
  • For every one of the possible complications, there are known measures to be taken
  • These should all be communicated to the patient
  • Patient involvement in the decision making is crucial
  • Once you have completed the clinical examination and special tests you should have a preliminary prognosis for each individual tooth
  • Following initial periodontal treatment the prognosis for each tooth may be modified
  • Response to treatment and patient compliance must be evaluated over a period of time (usually 6- 8 weeks)
  • Further periodontal treatment may be required, or the patient may enter the maintenance phase
  • Only then will you be able to verify the prognosis for each individual tooth and start planning Prosthodontic treatment!
18
Q

Avoiding damage by RPD to the remaining tissues: general rules

A
  1. Correct abutment tooth preparations
  2. Occlusal forces transferred to healthy and sufficient periodontium down the long axis of the abutment teeth
  3. Only cover as little of the tooth surfaces as necessary with RPD components
  4. Avoid covering gingival margins & soft tissues as much as possible
  5. Maintain 3mm distance between gingival margins and RPD components
  6. Ensure retention, support and stability to minimize movement of the RPD
  7. Avoid creating food traps
  8. Ensure the occlusion is correct!
  9. Monitor regularly and modify
19
Q

Reasons of RPD failure:

A
  • Failure of appropriate evaluation of caries situation
  • Failure of appropriate evaluation of periodontal condition
  • Failure of appropriate evaluation of prosthesis foundation
  • Failure of appropriate evaluation of existing restorations
  • Failure of appropriate evaluation of tooth mobility
  • Failure of appropriate evaluation of tooth inclination
  • Failure of appropriate evaluation of Interocclusal space
  • Failure of appropriate evaluation of trauma from occlusion
  • Failure of designing the appropriate RPD prosthesis
20
Q

Evaluation of tooth mobility:

A
21
Q

Evaluation of prosthesis foundation;

A
22
Q

Trauma from occlusion (TFO)-Definition:

A
  • Trauma from occlusion (TFO) is a separate entity not related to periodontics. However, both conditions may be present simultaneously.

Definition:
When occlusal forces exceed the adaptive capacity of tissues, tissue injury results. The resultant injury is termed as trauma from occlusion. It is also referred by WHO as “damage in the periodontium caused by stress on the teeth produced directly by the teeth of the opposing jaw”

23
Q

Caries & Periodontal disease in RPD Prosthodontics:

A
  • A simple two phase intra coronal restoration may be adequate for restoring a carious tooth.
  • If the tooth is extruded above the occlusal plane because of lack of antagonist then an extra coronal restoration is indicated to improve the occlusal plane If a tooth is not possessing adequate contours for clasping, then a full coverage restoration is indicated. The selection of teeth for rest seat preparation should be made before any restorative procedure is initiated
24
Q

Caries & Periodontal disease in RPD Prosthodontics:

What does Clinical and Radiographic information reveal?

A

Clinical information reveals:

  • Bleeding Indices
  • Probing Depths
  • Edema
  • Erythema
  • Gingival Architecture

Radiographic information reveals:

  • Amount of bone present
  • Condition of the alveolar crest
  • Bone loss in the furcation areas
  • Width of the PDL space
  • Local factors which can cause or intensify periodontal disease.
25
Q

Patient Selection:

A
  • Practice within your comfort zone – Refer patients as appropriate
  • Anticipate situations that might compromise care
  • Provide patient centered care
  • Meet our patient’s needs and expectations
  • Develop good doctor‐patient relationships
26
Q

Risk Management Tips:

A

Be cautious with comments related to:

– Necessity of referring to a specialist

– Practicing beyond level of competency

– Substandard treatment, misdiagnosed problems

  • Avoid commenting on another’s work. We all have cases that have turned out less than perfect
  • You can only comment on what you see today and propose a plan
27
Q

Informed consent:

A

Consent in dentistry is described by Dental Protection* as a communication process by which patients can give their voluntary and continuing permission for specific treatment based upon a reasonable knowledge of the purpose, nature, likely effects, consequences, risks, alternatives and costs of that treatment. Removable dentures require teamwork and the result benefits from effective communication.

28
Q

Patient’s needs and wishes:

A

Acceptance of complete dentures depends significantly on patient skill, tolerance and adaptability. Most clinicians have experienced patient rejection of a well-fitting denture in a favorable mouth and equally, patient acceptance of a technically unsatisfactory denture, in an unfavorable mouth. It is this paradox that makes removable dentures one of the most difficult disciplines in dentistry. This applies both to patients new to dentures and to patients with denture wearing experience.

29
Q

Aesthetic Needs:

A
  • If the consultation reveals that the patient has high aesthetic expectations, it is wise to address these as soon as possible. Denture teeth set up on a study cast will show both clinician and patient whether they can agree on the result.
  • For immediate replacement a patient’s apprehension at loosing visible front teeth can be alleviated by customizing the replacement denture teeth in advance with the patient’s input.
30
Q

Hygienic Principles:

A

The advantages of hygienic design are universally accepted. They are backed by evidence in the literature and should be considered a medico-legal requirement. Avoid unnecessary coverage of the gingival tissues. Where this is not possible, it is advisable to design the denture elements so that they impinge as little as possible on the gingival tissues.

31
Q

Continuing Care:

A

The stability of the finished treatment should be observed over a period of time, together with the patient’s anility to maintain thedenture environment. Once the patient is comfortable, there should be follow-up at three, six and twelve months to assess the interval for monitoring and maintenance in the future. Where possible, it is sensible to include the cost for follow-up visits in the original fee of the treatment.

32
Q

Record Keeping:

A
  • All patient records should be clear accurate contemporaneous and complete. This can not be stressed enough.
  • According to the CQC one of the fundamental criteria used to manage risk in Dental Practice is keeping good quality clinical records.
  • This should include a patient’s current medical history. Patients records should be audited systematically leading to insight into areas ofimprovement. The FGDP’s guidance on Clinical Examination and Record-Keeping is a useful key to use.
33
Q

Characteristics of a True Professional:

A
  • Specialized knowledge of value to society
  • Intensive academic course of study
  • Standards of practice
  • Code of ethics
  • Organized association
  • Service orientation
34
Q

Additional Legal and Ethical Considerations:

A
  • Informed Consent
  • Falsification of Records
  • Confidentiality
35
Q

Informed Consent:

A
  • A dentist has a legal, ethical and moral duty to respect patient decision
  • Disclose all information that enables the patient to evaluate all options available and weigh the risks
  • Withholding information creates legal exposure
  • Contributes to better treatment outcomes and reduces malpractice risk
36
Q

Falsification of Records:

A
  • NOTHING destroys your credibility like altering a record!
  • Generally sufficient to show actual malice
  • Sends the wrong signal to jurors, can shatter credibility
  • Creates the presumption of negligence
  • Can lead to criminal charges (spoliation)
  • Infers gross malpractice
37
Q

Confidentiality:

A
  • Verbal and written communications
  • Protected Health Information (PHI) should not be disclosed without patient’s permission
  • HIPAA requires a signed Notice of Privacy Practices or authorization as appropriate
  • Violation could incur liability

Removable prosthodontics II (13 decks)

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