guidelines – Beyond the Bite

Latex Precautions in the Dental Setting

by Florida Dental AssociationApril 20, 2017May 30, 2017Leave a comment

By Rosanne Cain, BSN, LHRM, Patient Safety/Risk Manager II, The Doctors Company

Recognizing latex allergies is an important patient safety precaution.

A 43-year-old registered nurse presented to his dentist for a regular teeth cleaning procedure. After several years of daily use of latex gloves and medical supplies, he developed a severe sensitivity to latex that ultimately resulted in anaphylactic reactions to most latex exposures.

Prior to his scheduled appointment, he contacted the dental office and informed the staff about his severe latex allergy. The dental staff made a note in his dental record and prepared the exam room with nitrile gloves. When he arrived, the dental hygienist recommended protective eyewear. The patient asked the hygienist if the foam cushioning around the eyepieces was latex-free. The hygienist could not confirm. The hygienist also failed to note that she placed small rubber bands, which also contain latex, around the handles of her dental instruments.

The hygienist began the procedure. The patient began to itch, which was quickly followed by wheezing. The procedure was stopped, and the patient immediately administered his medication. The patient’s action avoided a severe anaphylactic reaction.

Discussion
During the past 30 years, latex allergies have been recognized as a significant problem for both specific patient and provider populations. The incidence of latex allergy in the general population has been estimated to be between 1 and 6 percent. Some adolescents experience incidences as high as 73 percent (notably those individuals with spina bifida and related pathologies). Women account for approximately 70 percent of latex-related anaphylactic reactions (most commonly during ob/gyn procedures).¹ Adults with spinal cord trauma, neurogenic bladder or documented history of unexplained intraoperative anaphylaxis also can be affected by frequent exposure to latex supplies. Health care workers maintain an incidence of allergic response that ranges from 8 to 17 percent.² Other at-risk populations with repeated exposure to latex gloves include lifeguards, emergency responders, law enforcement professionals and cosmetologists.

In addition, glove powder has been shown to aerosolize latex proteins and increases the risks of a reaction in latex-sensitized patients or staff. The U.S. Food and Drug Administration recently announced a ban of the use of powdered gloves in surgery, powdered patient examination gloves and absorbable powder used on surgical gloves. The ban was issued after an investigation determined that the powdered products present an “unreasonable and substantial risk of illness or injury, and that the risk cannot be corrected or eliminated by labeling or a change in labeling.”³

Although most dentists are familiar with latex allergies, the infrequency of a severe reaction during a dental procedure can cause inadequate precautionary measures in a dental practice. Implement the following risk management strategies to reduce latex-related risks.

Risk Management Strategies

Know your patient’s latex allergy status, and note it prominently in the patient’s medical records. Allergy status should be updated on each patient visit.
Remove toys that contain latex from your practice’s common areas and play zones.
Practice latex avoidance precautions. Create a patient area that is latex-free and educate staff about all dental-related products that are restricted from the room.
Identify dental products that contain latex, including gingival stimulators, irrigation tips, dental dams, bulb syringes, cushioned eye protection goggles, tourniquets, rubber stoppers on medicine vials, adhesive tapes and bandages, water tubing, prophy cups, and rubber toothbrush heads and grips.
Use latex-free carts, bandages, reservoir bags, airways, endotracheal tubes, laryngeal mask airways and ventilator bellows.
Maintain a list of latex-free dental devices and office products and ensure that it is readily available for staff reference.
Remember that touching any latex object can cause transmission of the allergen by hand to the patient.
Ensure that your supplies include emergency medications with non-latex syringes and medicine stoppers.
Perform practice drills with your staff so they are prepared for latex-related medical emergencies.

For a free brochure on latex allergy, contact the American College of Allergy, Asthma and Immunology (ACAAI) by calling toll-free 800.842.7777. Additional information is available on the ACAAI website at http://acaai.org/allergies/types/skin-allergies/latex-allergy.

References:
1. Allergic reactions during labour analgesia and caesarean section anaesthesia. Adriaensens, I., Vercauteren, M., Janssen, L., Leysen, J., Ebo, D. International Journal of Obstetric Anesthesia 2013 Jul; 22(3): 231-242.

2. American Latex Allergy Association, http://latexallergyresources.org/statistics

3. FDA Rule, Banned Devices; Powdered Surgeon’s Gloves, Powdered Patient Examination Gloves, and Absorbable Powder for Lubricating a Surgeon’s Glove, 81 FR 91722, December 19, 2016, https://www.federalregister.gov/documents/2016/12/19/2016-30382/banned-devices-powdered-surgeons-gloves-powdered-patient-examination-gloves-and-absorbable-powder

The guidelines suggested here are not rules, do not constitute legal advice and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Withdrawing from the Dentist-Patient Relationship

by Florida Dental AssociationFebruary 16, 2017May 30, 20171 Comment

By David O. Hester, FASHRM, CPHRM, Director, Department of Patient Safety and Risk Management at The Doctors Company

Using appropriate guidelines can prevent a malpractice claim.

The American Dental Association’s Code of Professional Conduct states:

“Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.”

The health and well-being of a patient is always a primary concern. However, when it’s necessary to end the relationship, dentists should follow acceptable protocols to withdraw from the dentist-patient relationship. If appropriate protocols are followed, the dentist decreases the probability that a patient’s charge of abandonment will be successful.

Under some circumstances, dissolving the dentist-patient relationship is appropriate. These include, but are not limited to:

Treatment non-adherence. The patient does not or will not follow the treatment plan recommended by the dentist, unrelated to the patient’s ability or circumstances.
Follow-up non-adherence. The patient consistently cancels follow-up appointments or does not appear for scheduled appointments.
Verbal or physical abuse.
- The patient or a family member uses inappropriate language with the dentist or office staff.
- The patient exhibits violent behavior or makes threats of physical harm.
- The patient exhibits extreme anger that jeopardizes the safety and well-being of office personnel and other patients.
Nonpayment. The patient has multiple unpaid bills and has declined to establish a payment plan with the dental practice.

In other circumstances, additional steps or a delay in withdrawing from the dentist-patient relationship may be necessary. These circumstances include, but are not limited to:

Acute treatment phase. Do not withdraw from the relationship when a patient is in an immediate postoperative state or acute treatment phase.
The current dentist is the only option for the patient’s general or specialized dental care. When the dentist is the only source of care within a reasonable driving distance, he or she may need to continue treating the patient for current or follow-up care.
Discrimination. The dentist-patient relationship cannot be terminated solely because a patient is diagnosed with AIDS/HIV, is disabled or for any reason in which a patient is in a protected class. Dentists must follow the requirements set forth in the Americans with Disabilities Act. Dental practices also must follow nondiscrimination rules as set forth by Department of Health and Human Services, including conspicuous placement of the required Americans with Disabilities Act poster in the dental office

When appropriate circumstances exist to withdraw from the relationship, dissolution should be completed formally. The dentist should notify the patient of his/her decision to withdraw from the relationship in writing. The written notice should be mailed to the patient by regular and certified mail, return receipt requested. Maintain copies of the letter, the original certified mail receipt and the original certified mail return receipt, regardless of whether the patient signs for the certified letter. Maintain all forms of written communication in the patient’s dental record.

The written notice should include these components:

Effective date. The effective date of the withdrawal should provide the patient with a reasonable time period to establish a relationship with another dentist. Thirty days from the date of the letter is usually adequate; however, allow for any state regulations addressing termination that may be required in your practice venue. The relationship can be ended immediately under these circumstances:
- The patient has terminated the relationship.
- The patient or family member has threatened the dentist or staff or has exhibited threatening behavior.
Interim care provisions. Offer interim care; however, true emergency situations should be referred to an emergency department.
Continued care provisions. Offer suggestions for obtaining continued care. These suggestions may include referral services such as dental societies and/or community services. Do not recommend another dentist by name.
Requests for copies of the dental record. The written notice should include an offer to provide a copy of the dental record to the patient’s new dentist. Include a HIPAA-compliant authorization form and notify the patient that you will provide a copy of the records when the form has been signed and returned to you.
Patient responsibility. Advise the patient that ongoing dental care is recommended and should be pursued.
Reason for termination. A specific reason for termination is not required. In some instances, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport” or to state, “The therapeutic dentist-patient relationship no longer exists.”

Although there are situations in which it is acceptable to withdraw from the dentist-patient relationship, a dentist should exercise caution to recognize acceptable circumstances before any action is taken. The dentist should ensure that appropriate steps are followed to reinforce that a patient receives ongoing dental care. Also, if established protocol to withdraw from the dentist-patient relationship is followed, it could reduce the probability that a patient will pursue an abandonment claim.

Under all circumstances, it is recommended that dentists exercise caution and request assistance from a patient safety risk manager or the Department of Patient Safety and Risk Management to address specific dentist-patient relationship scenarios.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Challenges for Pediatric Dentistry

by Florida Dental AssociationDecember 1, 2016May 30, 2017Leave a comment

By Kim Hathaway, MSN, CPHRM, CPHQ, Patient Safety Risk Manager, Department of Patient Safety and Risk Management at The Doctor’s Company

Identifying legal guardianship and the rights of parents can reduce risk prior to treating a minor.

Treatment of a child with parents involved in an acrimonious divorce can present a dentist with unique challenges. When only one parent accompanies a minor patient for dental care, the practice may not anticipate custody issues. Parental disputes may be revealed only after care has been rendered. For example, the other parent might demand a copy of the dental record, object to the care rendered, or refuse payment for services provided without his or her knowledge or consent.

Disputes also can arise when minor patients arrive at the practice with someone other than a parent. A child may attend a dental appointment alone or with a surrogate care provider, such as a stepparent, relative, family friend or older sibling. In any of these circumstances, a practice should always identify the person who can provide consent by proxy.

Scenario 1
A father presented with his 5-year-old child and requested an evaluation to treat dental caries. The child previously had been evaluated by a dentist who recommended a treatment plan to include restoring teeth under IV sedation. The new dentist evaluated the child and advised that the restoration could be safely accomplished with oral sedation in two stages. The first stage was successfully completed and an appointment was made to complete the second stage. In the interim, the dentist received a letter from an attorney who represented the mother of the child and requested a deposition with the dentist. Conflict between the parents resulted in a decision that treatment for the child’s remaining dental restorations and method of sedation would be determined judicially. Because of the hostility and aggression from the mother’s attorney, the dentist was reluctant to provide future care for the child.

Scenario 2
A 10-year-old child had been under the care of an orthodontist for several years and was in the middle of the course of treatment with full orthodontic appliances. After several missed appointments and payments, the office manager called the patient’s home to discuss the issues with a parent. The office manager was informed that the parents were in the process of a divorce and that the father was responsible for the bill. When the office manager called the father to request payment, the father responded that he would not pay for the orthodontic care. The subsequent options for the dental practice were to continue to provide care for the patient without payment, remove the orthodontic appliances prior to the completion of treatment or risk that the patient would not return for treatment.

Scenario 3
An 11-year-old patient and her mother presented to the orthodontist with a complaint that the child’s teeth were crowded and crooked. The treatment plan was discussed with the mother, who signed the proposed plan during the visit. The orthodontist initiated phase one of the treatment, and monitored and managed the orthodontic appliances for several months. A surrogate care provider escorted the child to each office visit. As the development and eruption of the canine teeth progressed, it became necessary to extract the temporary canine teeth. The orthodontist discussed the extraction plan with the surrogate, and the practice called the patient’s mother, who provided permission for the extractions over the phone. Later, when the child’s permanent teeth had not yet appeared, her parents consulted with the orthodontist and expressed concern that the absence of canine teeth would negatively affect her appearance. The orthodontist explained that it might be a year before the teeth fully erupted. Upset by this response, the parents requested a copy of the dental record to present to their attorney. While preparing the record, the dentist realized that the surrogate care provider was the only person who had signed treatment consents. Further review of the dental record revealed that it did not contain documentation giving the surrogate the right to consent for treatment. A parental signature was limited to the treatment and financial plan.

These scenarios illustrate some of the situations that can be encountered when providing treatment to minor patients. Dentists need to understand the rights of parents and the complexities related to the legal consent of minor patients. Many risks can be mitigated through execution of a proper informed consent, and dentists should be familiar with consent laws in their state.

Risk Management Guidelines
The following strategies can help dentists recognize family situations when the individual holding legal consent is difficult to ascertain.

Identify the individual who holds legal consent for the minor and document this in the dental record. If this isn’t a parent, find out who has the legal right to consent to treatment.
If there is a question regarding custodial rights or minor consent, insist that the parents provide the legal document or court order.
Review patient dental records to determine the existence of any documents that establish the status of a custodial parent or legal guardian (divorce decree, restraining orders, etc.) and request a letter from the attorney that describes your legal obligations. Update the information on a regular basis.
Develop a “Conditions of Treatment” agreement for parents who are divorced or separating, consider including the following statements on your website, and execute the agreement prior to first visit:
The dental care of your child is the first priority.
Maintain an open dialogue regarding your child’s dental treatment.
The custodial parent has financial responsibility for dental payments.
Both of you are entitled to treatment information if you share joint custody.
If one parent has exclusive medical decision-making authority, the parent must provide a copy of the court order to the dentist to include in the patient record.
If you are not amicable, the dentist can terminate your child’s dental treatment.
Require a written consent by proxy when an individual other than the custodial parent or legal guardian accompanies the child. Request updated information on an annual basis regarding individuals who are authorized to accompany the child during treatment visits.
If permission or consent is obtained via telephone with a parent or legal guardian, document the communication.