February 2014, Volume 10, Issue 2
Published by AEGIS Communications
Learning from Clinical Problems to Improve Your Practice
Failure in all aspects of life is a touchy subject. This is especially true in healthcare, where the stakes are so high—lawsuits, disability, even death. Dental failure consequences usually boil down to discomfort, inconvenience, and pain—not the least of which may be in the wallet.
Inside Dentistry spoke to several experts on the subject—all dentists—who discussed the nature of clinical dental failure. They outlined what can be done by insurance companies, practices, and patients to better understand problematic situations and develop effective solutions in an effort to minimize the missteps that can add up to human misery—as well as wasted time, effort, and money—and maximize approaches that improve patient care.
WHERE DOES FAILURE ORIGINATE?
With such potentially high physical, emotional, and financial stakes, it is useful to examine what constitutes failure and where it comes from.
John C. Kois, DMD, MSD, director of the Kois Center in Seattle, Washington, breaks modes of clinical failure in restorative dentistry down into “two essentially distinct concerns”—what could happen to the tooth and what could happen to the restoration provided by the dentist. Among the listed “continuum of failures” that may ultimately lead to tooth loss are fractured teeth, which commonly signal the beginning of the end (Table 1). Dr. Kois believes strongly that restorative dentists can serve their patients’ interests best by focusing first on preventing the need for restorations—all of which are subject to failure—in keeping with his motto “there’s no dentistry better than no dentistry.” When restoration is necessary, he says, it is important to take the most conservative approach possible.
Cherilyn G. Sheets, DDS, co-executive director of the Newport Coast Oral Facial Institute in Newport Beach, California, focuses especially on the problem of structural failure—either due to cracks in teeth or biologic overload of dental implants—which she says is one of the most difficult types of clinical failure to diagnose. “By the time patients experience symptoms, they may already have a serious coronal or root fracture, resulting possibly in a root canal and crown, or even perhaps an extraction needing an implant or bridge,” she says. Dr. Sheets describes a new risk assessment diagnostic tool, quantitative percussion diagnostics, which she says enables practitioners to diagnose structural problems early enough in the failure cycle to offer effective interventions, or recognize that severe catastrophic damage has already occurred (Table 2).
Allen L. Finkelstein, DDS, chief executive officer of Bedford HealthCare Solutions, who also maintains a periodontics/prosthetics private practice in Great Neck, New York, views the problem both from the standpoint of a dental insurance enterprise and a private practitioner. He says that failures can sometimes be traced to practitioners’ acceding to patient pressure to provide quick esthetic solutions over appropriate plans that put the dentition first, and can sometimes be traced to patients—many of whom shirk their home care responsibility—who are reluctant to do what is best when the solution might be expensive or non-esthetic.
Two components of what Dr. Finkelstein calls a “plan for failure” would include failure to diagnose and treat periodontal disease and failure to consider the patient’s bite/occlusion and how it will function. “To me, everything centers on a stable bite for occlusion, but before restoration, there must be a supporting structure including healthy gums and bone,” Dr. Finkelstein explains.
In addition, Dr. Finkelstein maintains that many dentists design treatment plans “backwards,” with the patients’ benefits uppermost in mind. “The biggest dilemma I see is that instead of basing the treatment plan on a risk assessment, too often plans are based on patients’ benefit package. Dentists let insurance be a limiting factor, not a supporting factor, and this is a major problem for treatment.”
Like Dr. Finkelstein, Douglas A. Terry, DDS, believes that dentists need to make a greater effort to counter the “makeover mentality” noted by Heymann.1 Dr. Terry is clinical assistant professor in the department of general practice and oral health at University of Texas Health School of Dentistry in Houston, where he also maintains a private practice focused on esthetic dentistry. He says that failures in an esthetics practice such as his are often due to neglecting restorative principles and biologic concepts when they conflict with esthetics. In addition, doctors need to partner with patients, getting them to buy in on what’s good for them as part of informed patient consent. “Informed patients make better decisions for their oral health,” Dr. Terry says. “This begins with informing the patient of different restorative procedures available and the potential long-term biomechanical risk factors associated with each procedure.”
Dr. Terry’s “laundry list” of failure causes includes misdiagnosis or improper diagnosis; inadequate treatment planning; and poor communication among team members or between the dental team and the patient, for whom informed consent is the basis for proper decision-making. He also cites lack of scientific knowledge of biomaterials and techniques by the clinician and the use of a unidisciplinary treatment instead of interdisciplinary treatment philosophy.
How common is clinical failure? That’s what a group of researchers at Harvard Dental School wanted to know. One among them is Rachel B. Ramoni, DMD, ScD, informatics strategy lead, department of oral health policy and epidemiology, Harvard School of Dental Medicine. She says that despite a great need for more information about adverse events, reporting has been limited to the most severe of cases. In an effort to understand the causes of common dental adverse events—with the hope of eventually creating interventions to minimize their occurrence—Dr. Ramoni and colleagues created a preliminary tool to measure harm in the dental office.2 They focused on three adverse event indicators, including incision and drainage; implant removal/failing implant or peri-implantitis; and multiple visits—ie, more than six completed visits, including those to specialists, within 6 months. Of interest to restorative dentists, she says, her group learned that the number one reported clinical failure was failed permanent restoration within 5 years of placement, although she says the most common clinical failures will vary across practice characteristics.
William Kohn, DDS, vice president of dental science and policy, Delta Dental Plans Association, was a practicing dentist for 20 years. Dr. Kohn says it’s difficult to get a grasp on failure from insurance records for several reasons. One is that payers only have the information that is submitted on claims, and practitioners frequently don’t submit claims for work they know will not be reimbursed—for example, a filling that fails before the minimum time limit during which the insurance company will pay for its replacement. They are also hindered by dental claim usage of procedure codes but not diagnostic codes. “With procedure codes, we only know the ‘what’ but not the ‘why’. It may represent the failure of an old restoration, new decay, or a variety of other possibilities,” says Dr. Kohn.
Drs. Ramoni and Kohn agree on the need for standard diagnostic codes such as those long used in medicine. The use of such diagnostic codes by insurance companies, Ramoni says, would strengthen the ability to track trends across practices and collect information on why the treatment was provided.
What Clinicians Can Do
Self-examine. Dr. Ramoni explains that individual practitioners can take matters into their own hands by gathering information about failures in their practices. “One really easy way dental practices can get started is by performing regular chart review, randomly selecting the records of 50 patients and reviewing them cover-to-cover, so to speak, and writing down all of the opportunities for improved management they have identified,” she says. Once armed with this information, the practice can formulate a plan to reduce the occurrence of one or more of these negative events.
Document. Although Dr. Ramoni is concerned that practitioners may be reluctant to document mistakes, she insists it is an important part of the solution and that insurance companies should support, not penalize, dentists who thus take steps to improve. “We believe that every negative outcome should be a learning opportunity for the practice. Doctors should ask, ‘What caused this event to happen? Were there factors that prevented the event from being worse than it was? What steps can we take to make sure that an event like this doesn’t happen as often?’”
Focus on treatment planning. A proponent of conservative dentistry, Dr. Terry says dentists should individualize treatment, not adhere to a “molar mechanic” approach of removing predetermined tooth thickness without consideration of anatomic variations and final restorative dimension. This, he says, can result in improper and extensive removal of tooth structure and postoperative sensitivity.
Improve communication. Dr. Terry adds that to ensure proper decision-making, patient communication should include a discussion of long-term biomechanical risks associated with more invasive procedures as well as the importance of routine maintenance visits and improved oral hygiene routine and technique.
When in doubt, refer. Dentists who lack the comfort level or competence to perform a particular procedure—root canal therapy, for example—should refer it out to a specialist, according to Dr. Finkelstein. He is especially concerned about pediatric mismanagement, including early extraction without maintaining space so the new tooth can come in, and inappropriate and expensive treatment in the emergency department.
What Insurance Companies Can Do
Dr. Ramoni says that insurance companies, which she calls “an important part of the culture of today’s dental practice” can support practices’ efforts to learn from their mistakes “rather than creating a culture of fear in which sharing errors threatens reimbursement.” Dr. Finkelstein agrees that there is much insurance companies can do better, such as individualizing treatment benefits based on risk assessment, rewarding providers who get it right, and creating effective alternatives to wasteful practices such as hospital treatment. He says that patients could be treated more appropriately and more cost effectively by going directly to an on-call dentist for definitive treatment.
Along the line of medicine’s push for pay for performance, Dr. Finkelstein says, dentistry should develop a rewards system for deserving practitioners, such as those who provide patients with lasting restorations, more office hours, and receive fewer patient complaints. “Providers doing the right thing can be rewarded not only with fee schedule adjustments and increases in patient referrals, but by easing restrictions, such as no need for prior authorizations, speeding up the credentialing process, getting rid of some of the red tape of insurance submission,” Dr. Finkelstein suggests. He says that insurance companies should also adjust their fee schedules to pay more for preventive care.
Dr. Kohn says some insurance plans already reward best practices, including preventive measures. “Some plans offer enhanced evidence-based plans—for example, for children with a history of fillings who are considered at higher risk for more, the plan offers additional fluoride treatments plus sealants and more cleanings, and for people at higher risk of periodontal disease—such as those with diabetes—there is coverage for more periodontal maintenance appointments.”
Solutions to the problem of clinical dental failure are multifaceted and depend upon cooperation between all parties concerned—dental team members, insurance companies, and patients. But there is much work to be done to fully assess the problem and create appropriate solutions—including identifying, documenting, and tracking failure, as well as devising lasting and effective long-term approaches to their reduction, providing incentives for conservative treatment and patient education, and, especially, demonstrating outcomes that verify their effectiveness.
1. Heymann HO, Swift EJ Jr. Is tooth structure not sacred anymore? J Esthet Restor Dent. 2001;13(5):283.
2. Kalenderian E, Walji MF, Tavares A, Ramoni RB. An adverse event trigger tool in dentistry A new methodology for measuring harm in the dental office. JADA. 2013;144(7):808-814.
Potential Failures with Teeth and Restorations
Caries—Treatment should focus on managing the ecology of the mouth, taking both an environmental and traditional multifactorial approach. This constitutes caries susceptibility and CAMBRA (Caries Management by Risk Assessment) must be implemented.
Endodontic treatment—Creating more conservative access openings can reduce the risk of tooth loss related to weakened tooth structure. Significant problems are more related to the loss of tooth structure more than the endodontic procedures themselves.
Periodontal issues—Gingival health issues regarding restorative dentistry relate to contour, marginal integrity, and not violating biologic width, whereas recession is more related to an anatomic lability.
Pulpal vitality—Requires managing the inflammatory burden or how the pulp responds to trauma, restorative procedures, or bacterial invasion. Care should be taken to reduce heat generation during tooth preparation and maintain a seal of the dentin tubules.
Structural compromises—To reduce the risk for cracked tooth syndrome, the restorative dentist should make every effort to protect vulnerable cusps when the isthmus width begins to exceed one third to one half of the intercuspal distance.
Tooth fracture—During crown preparations, avoid excessive axial reduction, which increases tooth flexure and potential cement fatigue and washout (recurrent decay).
Tooth sensitivity—The key to prevention is managing dentin permeability and sealing dentin following restorative procedures.
Cement failure—Related to overload of restoration or problems with design elements in preparation, and may not be evident until there is catastrophic event. It can be secondary to microleakage from contaminants following temporary cementation and contaminants (hemostatic agents, blood, saliva) during final cementation. Debonding is primarily related to the dentist’s ability to properly use a chosen adhesive system.
Ceramic veneer chipping—This may occur because the veneering material is weaker than underlying ceramic; risk reduction has been documented with monolithic ceramic choices that have much higher compressive strength—ie, those used without a veneering material.
Esthetics (color-matching)—Typically evident during the try-in appointment, precluding cementation. These problems are relative to the different optical properties of the ceramics being used, the talent and artistic abilities of the ceramist, and the underlying problems of managing very dark teeth that show through the more translucent ceramic restorations, which is why monolithic restorations typically do not succeed.
Fractured restorations—Generally, fracture due to overload from the occlusion could occur when the restoration is prematurely placed in the envelope of function or due to chewing hard foods or other habits—eg, chewing ice—that place excessive load on the restoration. Core fracture may occur when the fracture strength of the core ceramic is inadequate, causing a cohesive failure.
Ill-fitting restorations—Can be prevented with current impressioning options and laboratory modalities. This should never be a problem if the dentist’s focus is on the complete seating of the restoration.
Joint fracture—With any type of restoration, joint dimensions are critical for long-term success. Typically for metal the joint dimension must be a minimum of 4 mm2. For ceramic restorations, the joints must be considerably larger—4 mm occlusal gingivally is considered a normal benchmark.
Loose abutment (preparation design)—Adhesive restorations depend on management of the two substrate surfaces—ie, tooth structure receiving bonding and material used to fabricate the restoration. In cohesively retained restorations, preparation design engineering principles are more important than the luting agent.
Provisional/crown falling off—This may be related to the design of the underlying preparation or the occlusion that was established. Any restoration that is inadvertently placed in the envelope of function is likely to break free prematurely.
Recurrent caries—Caries found underneath the restoration—ie, not apical to the margins—are due to cement fatigue and washout, which is more related to the occlusal management or excess loading of the restoration.
QPD: A Novel Approach to Tracking Fractures
Fractures in teeth and early loss of osseointegration in implants need not ultimately lead to catastrophic failures if caught early in the breakdown cycle, maintains Cherilyn Sheets, DDS. She and her partners in their Newport Beach, California, prosthodontics practice now test and monitor patient’s teeth on a routine basis using quantitative percussion diagnostics (QPD). The medical device measures the structural integrity of teeth and implants, precisely quantifying their outward and internal stability. Problems can be discovered long before clinical symptoms become apparent, maintains Dr. Sheets.
For many dentists, tapping on a tooth with the back of a mouth mirror determines whether an implant is a success, explains Dr. Sheets. However, she says, the problem is that biology does not conform to a black or white simplistic test. “The reality is that all ‘successful’ implants are not equally successful. There is an entire range of bone support that can be considered clinically successful, but until now, we have never been able to precisely determine the mechanical strength of implants that are ‘successful,’” Sheets explains.
Due to modern technology, she says, QPD makes it possible to use percussion in a more quantitative way. The data generated from a light buccal tapping instrument produce several indications of stability: the loss coefficient (shows how tightly the object is in the bone) and an energy return graph (in a structurally solid tooth or implant, this is a bell-shaped curve). Weakened structures produce micromovement, which shows up as irregularities in the shape of the graph. From this data, a defect index (DI) is calculated by the computer—the higher the DI, the more damaged the tooth or implant.
QPD offers practitioners the opportunity to diagnose micromovement outside or inside the tooth or implant. Once discovered, preventive or restorative therapies can be instituted to protect, stabilize, or even reverse damage. Dr. Sheets says that the beauty of this type of structural wellness monitoring system—much like periodontal probing—is that practitioners can see failures that are beginning to occur prior to visible signs on radiographs, clinical examinations, or other traditional methods. Early diagnosis means early intervention and better longevity.
How does this fit into practice? With data proving its effectiveness, Dr. Sheets says she and her practice partners are incorporating the test into their daily practice. “We feel that we have a new risk assessment tool in QPD that is providing information that has not been previously available to clinical dentists. Every patient in our practice is being tested to establish a structural wellness baseline showing high/low risk sites and provide diagnostic data for current treatment plans.” Teeth and dental implants can be tested at any stage with QPD—so a lifetime of structural monitoring is possible.
An added benefit, Dr. Sheets notes, is that the test results “make structural weaknesses visual and personal for patients.” Faced with proof of the damage they are doing to their teeth, compliance with preventive practices and therapeutic recommendations greatly improves.