Learning objective. A discussion about intentional (malpractice) and unintentional (mistakes) problems in dentistry. A presentation of clinical examples highlighting how to avoid such problems in daily dentistry.
It is a fact that, in medicine, errors occur but they may occur after intentional or unintentional actions. The first group is classified as malpractice. Cases of malpractice are perpetrated by veterinarians who shouldn't be practising. The term, malpractice, implies an intention to perform an inappropriate procedure or willfully neglect to do something that may cause complications. The second group of errors comprises unintentional mistakes which can have profound, and sometimes preventable, effects on health.
How to avoid medical errors? The key way to prevent medical errors is to standardize procedures. Therefore all existing and generally accepted practical standards should be implemented into daily practice and respected by all veterinarians.
Small animal dentistry is a very technically challenging discipline. At each stage of a procedure there are steps, which must not be neglected. For the purposes of this presentation, the author focuses on three of the most popular procedures in veterinary dentistry: diagnostics, prophylactic procedures and extractions. These three procedures statistically comprise 75% of daily dentistry regardless of whether they are performed in general or specialist practice. Since all dental procedures are performed under general anaesthesia and many of them may cause postoperative pain, very strict standards of anaesthesia and appropriate pain management are essential.
An anaesthesia and pain management protocol requires an initial preoperative laboratory workup. The dental procedure always requires intubation, protection of the respiratory tract by insertion of a pharyngeal pack, monitoring of vital functions (pulse, blood pressure, capnography, temperature maintenance) and fluid therapy.
Depending on the extent and severity of the procedure, preoperative pain management is used and an adequate nerve block should be performed. Intraoperatively, the most important way to minimise pain is to use a minimally invasive approach. Postoperative pain management depends on the kind of procedure as well as on the individual needs and conditions of the patient.
Diagnostics. This heading includes clinical assessment and radiography. A complete oral examination and charting is necessary to make a treatment plan for discussion with the client. An initial thorough examination is made in the conscious patient as a reliable assessment of occlusion can be made in this way. After sedation, the oral examination is continued with the use of a periodontal probe, dental explorer, mirror and if necessary retractors. All oral structures must be thoroughly examined and the measurements taken must be charted. It is important during periodontal probing to measure the probe depth in at least six different places around each tooth. Oral imaging is a complementary part of the dental assessment and can include entire head radiography as well as dental radiography. The value of the radiographic evaluation in veterinary patients has been proven in studies, which found 27.8% of clinically important lesions in dogs and 41.7% in cats would be missed without full mouth radiography.1,2 Currently, three advanced diagnostic techniques can be used to obtain optimal information for diagnostic consideration. These are: MRI (Magnetic Resonance Imaging), CT (Computed Tomography) and the newest one which is proven to be excellent for dental purposes: CBCT (Cone Beam Computed Tomography). In patients evaluated after maxillofacial trauma, CT scans demonstrated 1,6 times more injuries in dogs and 2 times more in cats than conventional radiographs.3
Prophylactic procedure. Prior to scaling, an oral rinse with chlorhexidine solution reduces contamination and decreases bacterial load. Mechanical scaling requires the use of appropriate length tips. The application of the tip to an individual tooth must not last for longer than 15 seconds at any one time. The working part of the tip is the distal 1/3 where the area of maximum vibration occurs. The working tip is applied gently to the enamel in a featherlike parallel, not perpendicular, style. For subgingival scaling, only the use of periodontal tips is allowed. Periodontal hand instruments are effective only when sharp. Even careful scaling may result in enamel abrasions and a rough surface. Polishing smoothes the tooth surface. It is performed with a rubber prophy cup with a rotation speed not faster than 3000 rpm and for not longer than five seconds per tooth. Flour of pumice with or without the addition of chlorhexidine is the most commonly used medium for polishing. It is important to use either disposal containers or a dappen dish for each patient, which can be sterilised and reused. Possible complications which may occur during the prophylactic procedure are: overheating of the vital structures which can result in pulpitis or alveolar bone necrosis as well as incomplete removal of dental deposits or incomplete smoothing of a rough surface. The latter allows faster accumulation of plaque immediately after the prophylaxis and worsening of the situation. Such a situation always occurs after anaesthesia free dentistry. According to an AVDC EVDC AVD statement, so-called anaesthesia free dentistry is harmful to the patient and is not acceptable. The final part of the prophylactic procedure is gingival sulcus lavage with saline or 0,12% chlorhexidine solution and optionally fluoridation and/or the application of a barrier sealant. Every client, must receive after-treatment home care recommendations every time and be given a date for a recheck.4
Extractions. An extraction is the most common surgical procedure in the oral cavity and statistically results in the largest number of possible complications due to medical errors. The list of standards to be met is as follows: adequate nerve block; preoperative radiography, gingival attachment cutting, surgical access to the root and periodontal space, cutting and tearing of the periodontal ligaments with the proper use of Luxators and elevators; removal of the tooth, postoperative radiography, alveolar debridement (if required); smoothing of any sharp edges; preparation for closure, tension-free suturing. Neglecting any one of these steps can be interpreted as an error although it may not always cause complications. The list of possible complications following extraction are: incomplete removal of the tooth structure, iatrogenic fracture of the surrounding bone, iatrogenic damage to the surrounding soft tissues, osteomyelitis following excessive tissue damage, dry socket due to contamination left in the alveolus, a nonhealing wound or wound dehiscence, oronasal fistula, traumatic malocclusion, infection, emphysema, malfunction of the mouth or tongue. This list does not include the iatrogenic complications like penetration of eye, jaw fracture or damage of the adjacent tooth. A good example showing the difference between a genuine mistake and malpractice is the situation when an infected root is fractured during extraction. Most if not all dentists have experienced this problem. It is a mistake but very common and not intentional. The key is to evaluate radiographically after extraction and if there is visible root remnant, it should be removed. If it is left in place, it is undoubtedly malpractice, which will be inevitably associated with pain and infection.5
References
1. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am J Vet Res. 1998 Jun;59(6):686–691.
2. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in cats. Am J Vet Res. 1998 Jun;59(6):692–695.
3. Bar-Am Y, Pollard RE, Kass PH, Verstereate FJ. Diagnostic yield of conventional radiographs and CT in dogs and cats with MFT (maxillofacial trauma). Vet Surg. 373;37(3):294–299.
4. Eisner E. Standard of care in North American animal dental service. Vet Clin North Am Small Anim Pract. 2013;43;447–469.
5. Moore JI, Niemiec BA. Evaluation of extraction sites for evidence of retained tooth roots and periapical pathology. J Am Anim Hosp Assoc. 2014;50:77–82.