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PPP® Sample Patient Termination Letters

One of the most frequent calls we receive on the PPP® Risk Management Support Line is when dental practices seek assistance with dismissing a patient from the practice. When dismissing a patient, it is important to be mindful of the patient’s well-being and your professional obligations to the patient, as well as the safety of you and your staff and the best practices to avoid potential ramifications.

There are a variety of reasons why dentists come to the decision to terminate a dentist-patient relationship, which makes it challenging to have a one-size-fits-all form for each scenario. We’ve created multiple Sample Patient Termination Letters to address the most frequent reasons for patient termination. They include:

• General Termination – no specific reason needed

• Termination for an Overdue Account

• Termination for Missed/Cancelled Appointments

• Termination for a Breakdown of Communication or Trust

• Termination for Inappropriate Behavior

• Termination for Inactive Recall Patient

GOOD RISK MANAGEMENT PRACTICES REDUCE EXTRACTION RISKS

By John Vaselaney, DDS, ARM; Director of Risk Management

Extractions are an essential part of dentistry and are performed countless times each day by dentists across the country. They also continue to be significant drivers of dental malpractice claim activity. Extractions are the second most common dental procedure cited and represent nearly 21% of the total claim dollars spent (third highest) in our program among claims where a dental procedure is noted.

Every dentist and patient wants a safe and successful outcome for every extraction, free of clinical complications and resulting in a satisfied patient. Let’s review the processes and procedures that help achieve those results and reduce your extraction risks.

Identifying and Assessing the Risks

To properly manage extraction risks, we first need to identify the adverse events and outcomes associated with extractions, particularly those that lead

In addition to the Sample Patient Termination Letters, we’ve put together some helpful instructions when executing a patient termination letter, such as best practices when sending the letter, when it’s not recommended to terminate a patient, and being aware of your state’s requirements.

We welcome you to request these documents to utilize in your practice. Please submit your basic contact information here and we will deliver them to you via email.

If you’d like to learn more about effective patient termination, please check out our blog post on the PPP® website.

to malpractice claims. Every dentist knows the most common risks of extraction: pain, bleeding, swelling and infection. Depending on the location of the tooth in question, additional risks may include more serious concerns such as nerve damage in the form of permanent numbness or tingling, a perforation into the maxillary sinus, or jaw fracture.

We can also look at claimed injuries and allegations to help us understand extraction risks. The most significant claim settlements involving extractions have been for postoperative nerve injuries, postoperative bleeding, and complications of sedation done to facilitate extractions.

Other allegations involving extractions include:

• Failure to diagnose the need for extraction, including inadequate or improper patient evaluation, insufficient or poor radiographs, or a missed or inaccurate diagnosis

• Failure to refer to a specialist in oral and maxillofacial surgery, whether before treatment or after a complication or adverse event has occurred

• Inadequate or improper informed consent

• Examples include allegations that the patient was not properly informed of a known, foreseeable risk or complication of the procedure, or that the patient was not properly informed of treatment alternatives such as referral to an oral surgeon.

• The extraction was performed incorrectly or below the standard of care and resulted in an injury.

• Examples of this type of allegation assert the patient suffered a nerve injury, was hospitalized, had an injury to adjacent teeth or soft tissues, or had damage to the maxillary sinuses. It also includes allegations that the incorrect tooth was extracted, the dentist failed to remove the entire tooth, or the dentist improperly managed an adverse extraction outcome.

Managing the Risks

As with most dental procedures, there are a variety of ways to manage the risk, whether you’re avoiding it altogether or taking it on. Looking through a risk avoidance lens, we encourage dentists to select extraction cases that are within their comfort zone of education, training, and clinical ability, and to refer those that are not. For example, consider referring impacted teeth and those with complicated root anatomy, proximity to the maxillary sinus or inferior alveolar nerve, and teeth that are severely damaged that pose an increased difficulty to remove. We also

recommend dentists consider referring patients who have previously had difficulties with extractions and those with medical conditions or concerns that would pose a greater risk.

If you choose to go ahead with the extraction, you’ll need to address a variety of risks relating to both the patient and the clinical procedure. That begins with a thorough review of the patient’s medical history and physical status. Assess their physical condition and ability to tolerate the proposed extraction. What underlying medical conditions exist and what medications are they taking – and how does that affect your care? Be sure to obtain the vital signs of blood pressure and pulse as part of your assessment.

It’s wise to confirm that patients with compromised or complex medical histories have been evaluated by their physician or primary care provider and that you learn of any recommendations for adding or altering medication regimens that the patient must follow. Some examples include antibiotics for infective endocarditis, anticoagulant therapy, diabetic management, and the use of anxiolytics. If such a medical recommendation has been made, it is essential that you confirm with the patient prior to the delivery of local anesthesia that they have, in fact, followed the recommended course of action.

Now let’s look at some clinical dental procedural steps to improve patient safety and reduce extraction risks. That starts with having a preoperative radiograph that shows the entire tooth, root structure, and surrounding structures. Depending on the location and angulation of the tooth, you may need multiple radiographic views. This may be in the form of multiple periapical radiographs, or it may necessitate a panoramic image or even cone beam tomography to fully assess the tooth and the risks of performing the procedure. We are increasingly seeing CBCT used by oral and maxillofacial surgeons during the assessment of third molar positions and risks.

A frequent allegation is that the wrong tooth was extracted. A simple step to prevent this is to take a timeout before starting – even before the local anesthetic – to verify more

than once that the proper tooth is to be extracted. Check in the examination record that the tooth was charted properly and even ask the patient to confirm which tooth is to be extracted.

Next, plan what you’ll need to do before picking up an instrument. Do you need to section the tooth? Do you need to make an incision and reflect a flap? If so, determine when in your procedural sequence you’ll be taking those steps and just how you’ll accomplish them.

Use sound surgical principles and techniques during the procedure, such as for asepsis, hemostasis, thorough wound debridement, and the atraumatic handling of tissues. Be careful with instruments and avoid damaging neighboring teeth, restorations, and soft tissues.

Remove the tooth completely, including all roots and root fragments, unless its proximity to a vital structure (such as the inferior alveolar nerve or the maxillary sinus) makes it prudent to leave it in place. If you do need to leave a root fragment behind, be certain to inform the patient that you’re doing so and document it in the patient’s chart.

Managing Complications and the Postoperative Period

Not every extraction goes exactly as planned. If you encounter difficulty during the extraction, stabilize the patient and refer if the situation is beyond your skills, experience, or comfort level.

To help prevent postoperative complications, give patients clearly stated postoperative instructions both verbally and in writing, since many patients forget what they are told verbally. Emphasize the aspects of the instructions that are most pertinent to the patient, as this is an excellent opportunity to manage the patient’s postoperative expectations. It’s also wise to require patients to return for a postop evaluation if you wish to assess the progress of their healing.

Part of your postoperative instructions should be to inform patients how to reach you after hours if they have a postoperative problem of some urgency. Providing this information in advance of a problem helps allay many patient worries.

If a patient does develop postop sequelae such as dry socket, infection, or severe swelling, continue to re-evaluate the patient until all issues are resolved and thoroughly document the follow-up care in the chart.

Informed Consent

It is essential that the patient’s informed consent is obtained prior to extracting any tooth. Remember that informed consent is not simply getting the patient to sign their name on a document – it’s the process through which a patient is provided enough information to make an informed, reasoned decision about the proposed care.

Any informed consent discussion must include a number of key topics, including a review of the diagnosis, the recommended treatment, and the benefit to the patient of having the procedure. It also includes a review of the reasonable alternatives and the known risks that have a reasonable likelihood of occurring.

For an extraction, the diagnosis is most commonly pain, caries, or mobility, although other clinical rationales exist. Be sure to inform the patient of those that apply to the extraction at hand. In many cases, a reasonable alternative to extraction is endodontic therapy followed by restoration of the tooth in question. However, there are plenty of instances when there simply is no reasonable alternative to extraction. In those cases, the dentist should state that fact and indicate it on the informed consent form.

Referral to an oral surgeon is another reasonable alternative that should be offered to patients. Doing so helps obviate potential allegations of failure to refer that are often alleged in extraction claims.

Your disclosure of the risks of the extraction should include those that have a reasonable likelihood of occurring as well as those that a reasonable patient would

want to know about to make their decision. Be certain to include the common risks discussed earlier as well as the more significant risks that may occur based on the patient or the clinical presentation of the tooth to be extracted. Also, if you foresee a complication that is within your skill level and you plan to proceed, inform the patient before the extraction as part of the informed consent process.

These risks should be part of your informed consent discussion with the patient in addition to being listed on the informed consent form the patient signs.

Documenting Your Care

The thorough documentation of extractions from diagnosis through postoperative care is essential to your risk management efforts. To that end, the patient’s chart should show:

• Why the extraction was clinically necessary, including any subjective statements or complaints from the patient in quotation marks

• Your objective clinical findings and diagnosis of the tooth. Remember that “extraction” is a procedure, not a diagnosis.

• What was done during the extraction, including (but not limited to) such tasks as local anesthetic use (agent, concentration, volume, etc.), incision, flap reflection, sectioning, bone removal or smoothing, irrigation, bone grafting, and suturing

• Any unexpected or adverse events that occurred during the procedure or outcomes after the procedure and what was done to address them

• Postoperative medications and prescriptions, including any recommended over-the-counter medications

• Postoperative instructions given, including any recommendations for a return visit

Putting It All Together

Extractions can be challenging procedures that are often needed for challenging patients. Dentists can improve patient safety and reduce the risk of a clinical complication or a claim by using sound risk management techniques that include referrals, sound clinical decision making and care, thorough informed consent processes, and comprehensive documentation.

We’re eager to share our knowledge with you! Our Proactive Practice Pointers offer practical guidance in under a minute, whether you’re at your desk, between operatories or even on your couch. Just scroll through the PPP®’s social media pages or YouTube channel for helpful tips and reminders from our Proactive Practice Pointers!

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PREVENTING WRONG TOOTH EXTRACTIONS - A REVIEW OF CASE EXAMPLES

By Ty Galvin, DDS; Risk Management Consultant

Busy dental offices can be very hectic at times, with tight schedules and a sense of urgency to care for patients in the allotted time. It takes incredible teamwork, organization, and skill to keep a practice on track.

This is why it is essential for dental practices to have the proper protocols –in the form of policies, procedures and training – to avoid an adverse outcome that impacts both the patient and the practice.

The following case examples involving wrong tooth extractions are based on actual calls handled by the PPP® Risk Management Support Line. Let’s take a look at what happened and what steps could have been taken to avoid each circumstance.

Case #1 – A Case of Mistaken Identity

In a busy multi-dentist practice, midway through the morning’s 8-column schedule, a dental assistant stepped into the reception area and asked for “Cody,” a 9-year-old boy. A child popped up, the name “Cody” was confirmed, and the assistant walked him back to the operatory. Parents were not allowed to accompany pediatric patients in this practice, so his mother stayed in the reception area.

The extraction of primary molar #B was on the dentist’s schedule. Cody was nervous, so nitrous oxide was started. A hygienist sat down to numb the tooth (it’s permissible in this state), confirmed that #B was the correct tooth, and administered the local anesthetic. Afterward, Cody rested for a few minutes, awaiting the dentist.

During that time, a second dental assistant happened to come into the operatory. She recognized the patient as being someone named “Cody,” but not the “Cody” who was scheduled for an extraction. She double-checked the chart and confirmed the identification error.

The nitrous oxide was immediately stopped and the patient was returned to the reception area, where the staff explained the identity mix-up to his mother. They told her that Cody’s appointment would need to be rescheduled. This seemed to the staff to be a “no harm, no foul” event, although the mother appeared to be very irritated about the waste of her time.

Three days later, the practice received a two-page, well-composed email requesting payment of $10,000 or else the mother would engage an attorney. She requested compensation for: her lost wages, unnecessary use of the “brain damaging” nitrous oxide, anticipation of years of therapy for the child to recover from the trauma, and the pain and suffering of a dental injection with hours of unneeded numbness.

These were gross exaggerations, of course. However, the mother was considered a serious risk because of her persistent actions and well-composed email outlining the events. The insured dentist was instructed to file a claim through his PPP® agent so a claims specialist could work toward a more reasonable resolution with the mother.

Risk Management Strategies

• It’s good practice to confirm each patient’s identity before proceeding with care, particularly in multi-provider practices. A simple method is to ask the patient to confirm their birth date,

as is often done in medical practices. Other personal identifiers can also be used, such as the home address or telephone number.

• Review and confirm the proposed treatment with the patient as soon as they are brought to the operatory. In the case of a minor patient, the review should be with the child’s parent or legal guardian.

• Be certain all staff members are informed of key aspects of patients’ care. In this case, a knowledgeable dental assistant was able to intervene and prevent the wrongful extraction because she knew what care was needed.

Case #2 – Don’t Bother Me Now, I’m On Autopilot

A general dentist received a referral from an orthodontist to extract two teeth to relieve maxillary crowding – the upper left primary canine and the upper left primary first molar, teeth #H and I. Instead, he extracted both upper left primary molars, teeth #I and J. His reason? “I had a brain fart. My referrals from the orthodontist usually request the extraction of both the first and second primary molars due to crowding.”

Fortunately, the patient was a 10-yearold boy and the extractions were of primary teeth, so the orthodontic treatment plan could be adjusted. However, the boy’s mother was livid about the error and threatened to report the dentist to the state dental board. Luckily, she cooled down and did not do so.

Risk Management Strategies

• Use a dental version of the two-factor authorization process to confirm the treatment to be performed. In this context, two clinical team members – the dentist and the assistant – should each identify which teeth are being treated at that day’s appointment. We also recommend that steps 1 through 3 from the previous case are followed: properly identify the patient, confirm the treatment plan, and ensure staff participation.

• Be certain referrals are clearly written and understood in both directions. Practices should establish protocols for verifying the patient’s name, the planned procedure, the correct tooth number (written and circled), and the reason for treatment. If necessary, pick up the phone or send a text or email to confirm. The few extra minutes spent doing this can save hours of grief.

Case #3 – Seeing Is Believing

A dentist called the support line and said his patient had presented with a nonrestorable vertical fracture of #19, which he diagnosed as needing extraction. Regrettably, at the treatment appointment a week later, tooth #18 was extracted instead.

How did this happen? The dentist explained that the initial periapical x-ray of the area did not show any of #17, giving him the illusion that only two molars were present even though all three molars were there. When the patient returned for the extraction appointment, the dentist again looked at the initial x-ray, saw only two molars, and began mentally planning to extract the second tooth from the back –what he believed to be vertically fractured #19. Unfortunately, in the mouth #19 was the third tooth from the back and #18 was erroneously extracted.

Tooth #19 was subsequently extracted when the patient’s painful symptoms persisted, and the dentist realized his mistake.

Fortunately, the patient was very forgiving and did not sue. But the restoration of the area was made much more difficult as a result of the error. The initial treatment plan was to do a fixed bridge from #18-20 due to a limited budget. Now the patient required implants for the replacement of #18 and 19, all at the expense of the practice and involving many more appointments.

Risk Management Strategies

• Proper radiographic visualization and confirmation of the tooth to be extracted is critical. While this may seem

obvious, it is not always followed. Dentists are ingrained to heavily rely on radiographic images, so having clear views is important. A second periapical view or even a panoramic or CBCT can prove invaluable during many extractions. Be sure your imaging captures the apices of all roots, the surrounding structures, and the extent of any pathology.

• Interestingly, a different support line caller’s case of “wrong tooth extraction” resulted from a software glitch, whereby the radiographic images were reversed on the screen after being taken. Always confirm that what you see on the screen matches up with what you see in the mouth.

Summary

A few minutes of risk management prevention can prevent hours of future anguish. Follow the guidelines presented for all dental procedures and they will become second nature to you. The question “Why are we here today?” should be able to be answered by everyone in the room – the patient, the dentist, and the dental team members.