PPP® Proactive Practice Pointers

In the ever-evolving landscape of dental practice, effective risk management stands as a cornerstone of success, ensuring that both practitioners and patients thrive in a safe and supportive environment. At the Professional Protector Plan® for Dentists, we are dedicated to empowering dentists with the tools and knowledge they need to navigate the complexities of patient communication, meticulous documentation, essential legal concepts (and a lot more!). Led by PPP®'s Risk Management Director, Dr. John Vaselaney, our "Proactive Practice Pointers" serve as a vital resource for continuous improvement, offering insights that are both practical and actionable. We invite you to engage with this dynamic list, which promises to expand frequently with fresh tips tailored to your practice's unique needs. As we foster a community centered on relationship-building and shared experiences, we encourage you to share your own questions and insights related to risk management, knowing that together, we can enhance the quality of care we provide. Feel free to reach out to us at ppp@bbprograms.com.

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1. PATIENT COMMUNICATION: Ask patients what expectations they have for esthetics, function, comfort, time, and costs. Keep in mind that patients will often be more forthcoming with staff members than with the dentist, so encourage staff to talk with patients and be involved in the process. See video

2. EXAMINATIONS: A thorough review of the medical history is an opportunity to confirm your dental patient does not have healthcare issues that must first be addressed prior to your care, and is an opportunity to reasonably determine that the patient is not likely to be harmed by your care. See video

3. LEGAL CONCEPTS: A patient cannot waive a dentist’s duty to meet the standard of care, regardless of what a patient says or signs. A patient cannot consent to a negligent act and thereby waive the professional duty and responsibility of the dentist to meet the standard of care. See video

4. POLICY & COVERAGE: Don’t face a dental board complaint alone! The PPP policy offers disciplinary and licensure coverage to pay the fees, costs and expenses to defend you in actions brought by a dental board that are prompted by an otherwise covered injury or allegation. See video

5. DOCUMENTATION: It's impossible for dentists and staff to recall from memory every aspect of every patient's care. That's why good chart documentation has enough information to permit a reader to know what diagnoses were made, what treatment was performed, and what treatment is still needed. See video

6. UNEXPECTED EVENTS: When something out of the ordinary occurs during care, dentists should focus on what is best for the patient and what prompt actions are required to address the problem. That could mean a change in the treatment plan, additional follow-up care, or even a referral to a specialist. See video

7. INFORMED CONSENT: Dentists should refuse to provide treatment that is beyond their skills and training, regardless of any demands by a patient. Instead, make a referral to a clinician that is known to have the knowledge, training, skills, and experience to provide the care the patient needs. See video

8. CLINICAL CARE: Over 40% of US adults aged 30 or over have periodontal disease. Dentists, be sure your comprehensive and periodic exams include a thorough perio assessment and documentation of your findings. Also document informing the patient of your findings, diagnosis and recommendations. See video

9. PATIENT MANAGEMENT: Dentists should refuse to provide treatment that is beyond their skills and training, regardless of any demands by a patient. Instead, make a referral to a clinician that is known to have the knowledge, training, skills, and experience to provide the care the patient needs. See Video

10. STAFF MANAGEMENT: The dental team are a dentist's partners in patient safety and risk management. It's wise to hire individuals who communicate well, have empathy, and can project the right practice image, as these can be harder to develop than the skills needed to properly perform a job task. See Video

11. CYBER: Every dental practice should have a policy for safeguarding patient information and train all personnel on its compliance. Software, hardware, and virus protection measures should be up to date and secure, and networks with access to PHI should be shielded from public access. See Video

12. EXAMINATIONS: "A picture is worth a thousand words" applies to dentistry, too! Intraoral photos help educate patients of their treatment needs by showing what can be difficult or impossible for them to see on their own. Clinical photos also provide great chart documentation of your diagnoses. See Video

13. INFORMED CONSENT: A dentist’s informed consent discussion with a patient should correlate with the proposed procedure’s complexity and risk. For example, a conversation about an extraction requiring a flap, sectioning, and bone removal will be longer and more detailed than one about composites. See Video

14. PATIENT MANAGEMENT: Making a referral is one way for dentists to avoid risk while still providing a patient the opportunity to receive the dental care they need. A prudent dentist will refer when the needed care is beyond the scope of his or her knowledge, skills, training, experience, or licensure. See Video

15. PATIENT COMMUNICATION: Dental patients often overhear conversations and interactions in the dental office, then use that information to form impressions. Make those impressions positive! Dentists and staff should always communicate positively, respectfully, and professionally in the workplace. See Video

16. UNEXPECTED EVENTS: Be prepared for a medical emergency in your dental practice. Develop a plan that has proper training, appropriate supplies and equipment, and designated responsibilities. It's also important to know which of your patients are at the greatest risk of having a medical emergency. See Video

17. EXAMINATIONS: When only a limited dental exam is needed, the dentist does not have to examine and diagnose every tooth and area of pathology in the mouth. However, the dentist does have a duty to advise the patient of any clearly evident dental condition or obvious pathology that was seen. See Video

18. INFORMED CONSENT: Written or electronic informed consent forms are important in dentistry. They help document that the informed consent discussion has taken place, what information was shared between the dentist and the patient, and that the patient agreed to have the dental procedure performed. See Video

19. DOCUMENTATION: Some dental boards have mandatory dental record keeping requirements in the dental practice act. Know what your state’s board requires and ensure all patient records comply. Board complaints expose dentists to scrutiny over their records, in addition to the patient's complaint. See Video

20. CYBER: Dentists should consider having a stringent internet and computer policy that prohibits all personnel from checking personal email or visiting non-work internet sites using office computers and devices. These are common paths for data breaches and hacking schemes that target PHI. See Video

21. PRACTICE MANAGEMENT: Before referring, dentists should first confirm that a tooth was properly identified on the tooth chart as well as properly identified as the tooth to be treated. In doing so, dentists will reduce the chance that the incorrect tooth will be treated by the referral dentist. See Video

22. EXAMINATIONS: When performing a limited dental exam, be sure to inform patients with a general statement about what you saw while doing the exam, such as the presence of perio inflammation and disease, caries, or other pathology. And always document these disclosures in the patient’s chart. See Video

23. UNEXPECTED EVENTS: Promptly respond to dental patients who report post-treatment problems or concerns. It’s wise to examine the patient and assess the problem in the office, rather than doing it over the phone or via messaging. It’s also good to continue follow-up care until the issue is resolved. See Video

24. PATIENT COMMUNICATION: Patients judge their dental care using different criteria than dentists, focusing more on things like how long they waited, how they were treated, and how much it hurt rather than on clinical things like marginal integrity and the interproximal emergence profile of a restoration. See Video

25. STAFF MANAGEMENT: Dental team members help create positive patient experiences and a good practice environment. They also enhance patient care. Dentists should ensure their staff are properly trained, follow practice policies, and comply with all provisions of your state’s dental practice act. See Video

26. INFORMED CONSENT: When discussing treatment risks with patients, dentists should focus on the risks that have a reasonable chance of occurring and which a reasonable patient would want to know. Ask yourself, “If I were the patient, what would I want to know?” and then be sure to share that. See Video

27. PATIENT MANAGEMENT: A negligent referral in dentistry occurs when a dentist knows or should know that another dentist practices below the standard of care but makes a referral anyway. If a dentist sees a pattern of poor care, they have an obligation to avoid referring to that dentist going forward. See Video

28. LEGAL CONCEPTS: If you have an independent contractor dentist in your practice, make clear that the IC doesn’t work for you. If a patient believes that an IC dentist is your employee or being supervised or directed by you, they may try to hold you responsible for the actions of the IC dentist. See Video

29. EXAMINATIONS:To promote early diagnosis of SCC, the ADA says dentists "should obtain an updated medical, social, and dental history and perform an intraoral and extraoral conventional visual and tactile examination in all adult patients." To reduce risk, do this at every non-limited exam. See Video

30. PATIENT COMMUNICATION: When talking with patients about clinical dentistry, use plain, easily understood language. Chose basic words, not technical dental jargon. It’s also helpful to talk in pictures or use analogies, such as comparing brushing without flossing to washing a car but skipping the sides. See Video

31. UNEXPECTED EVENTS: Check your medical emergency kit regularly. Replace any expired medications or supplies and restock items that have been used and not replaced. Also check that all battery-operated devices have an adequate charge and that your oxygen system is well supplied and in working order. See Video

32. PRACTICE MANAGEMENT: Send handpieces for repair at the first sign of malfunction, particularly if your burs are slipping from the chuck. Dislodged burs can cause intraoral damage or be swallowed or aspirated. If you know a handpiece needs repair, keep your patients safe and take it out of service. See Video

33. PATIENT MANAGEMENT: Many dental liability claims involve the misidentification of a tooth during a referral. To eliminate any questions about the accuracy of tooth numbering, circle or mark the correct tooth to be treated on a duplicate image of a radiograph and share that with the referral dentist. See Video

34. DOCUMENTATION: When dealing with dental postop complications and care, dentists should step up their record keeping. Include patient communications, any missed postop appointments and attempts to reach patients to reschedule, the dentist’s decision making, and any patient noncompliance. See Video

35. CLINICAL CARE: Dentists can avoid treating the wrong tooth or tooth surface by taking a few simple steps. Review the exam record, radiographs, treatment plan, and chart notes for accuracy, then confirm the correct tooth and treatment with your assistant at chairside using a time-out process. See Video

36. INFORMED CONSENT: Dentists’ informed consent discussions with patients generally include disclosing risks such as pain, infection, swelling, bleeding, numbness, treatment complications, the need for further treatment, and the risks of refusing the treatment. If it’s likely, be sure to share it. See Video

37. EXAMINATIONS: The CDC estimates that 70% of oropharyngeal cancers in the U.S. may be linked to HPV. The ADA urges dentists to support the use and administration of the HPV vaccine, recognizing it as a way to help prevent infection of the types of HPV associated with oropharyngeal cancer. See Video

38. PRACTICE MANAGEMENT: Make clear financial arrangements with patients prior to beginning care, especially when dental benefits might not be available due to exclusions or annual maximums. Examples include cosmetic cases and when an endodontist, periodontist, or other specialist has also provided care. See Video

39. CLINICAL CARE: Use reasonable barriers to prevent the swallowing or aspiration of foreign objects during care. That includes rubber dam for endodontics and the use of gauze throat drapes and high-speed suction for other procedures such as extractions, restorative, and implant procedures. See Video

40. PATIENT MANAGEMENT: Trust your judgment when a new patient presents with numerous red flags, such as one who has recently been to other dentists but demands that you not contact them for x-rays or treatment information. They might be overly demanding or have unreasonable treatment expectations. See Video

41. PRACTICE MANAGEMENT: The misidentification of a patient prior to care can lead to significant injuries and liability. To be sure you’re treating the correct patient, verify each patient’s first and last name and date of birth before starting any procedure. For minors, always check with the parent. See Video

42. UNEXPECTED EVENTS: Acid etch gel can cause burns to the lips or face if undetected. Keep in mind that numb patients can’t feel the burn to alert you. Look for any excess etchant on your gloves or instruments that might transfer to tissues. If it does, rinse the area thoroughly for several minutes. See Video

43. CLINICAL CARE: Keep patients safe by placing protective eyewear on them during care. Splattered prophy paste and high-speed debris might just be eye irritants, but dropped instruments and splashed acid etchant can cause serious eye damage. Safety glasses are a simple way to prevent injury. See Video

44. PATIENT MANAGEMENT: Just because you can do a procedure doesn’t mean you should. Use good judgment when selecting which patients to treat and which procedures you will perform on those patients. The avoidance of risk though proper case selection and referral is important in managing clinical risks. See Video

45. LEGAL CONCEPTS: Dentists and staff should avoid making statements in person, online, in advertising, or on social media that guarantee specific treatment outcomes, whether related to esthetics, comfort, or function, as they can lead to allegations of breach of contract or breach of warranty. See Video

46. STAFF MANAGEMENT: Train your staff on a regular basis to keep patients, your practice, and the entire dental team safe. Key subjects include infection control, patient privacy and HIPAA, emergency response, patient communication, and informed consent. It’s a fact that proper training reduces risk. See Video

47. CLINICAL CARE: What do crowns, burs, implant screwdrivers, rubber dam clamps, matrix bands, and teeth all have in common? They’ve all been swallowed or aspirated during care. You can prevent this using patient posture, head tilt, floss ligatures, throat drapes, and high velocity suction. See Video

48. PRACTICE MANAGEMENT: Dental practices should keep detailed records of all biologic testing, equipment maintenance, and incident reports. Accurate documentation demonstrates proactive risk management, helps identify recurring issues for continuous improvement, and supports the defense of allegations. See Video

49. POLICY & COVERAGE: Review your liability insurance annually to ensure coverage beyond malpractice. Be sure you’re covered for things like slips and falls, data breaches, and theft, to name a few. Confirm your limits align with your practice needs, and work with your agent to address any gaps. See Video

50. PATIENT COMMUNICATION: Studies show that when a provider sits at eye level for patient conversations, rather than stands, patients feel more positive about the interaction, have more satisfaction, and have a better understanding of the discussion. So, grab a seat and build that doctor-patient rapport. See Video

51. DOCUMENTATION: A great way to document emergency dental visits is to use the SOAP format for chart notes. SOAP notes provide a consistent approach to both patient care and recordkeeping and help ensure that important information is included in the patient’s chart. And that helps defend claims. See Video

52. LEGAL CONCEPTS: The legal concept of vicarious liability holds that a dentist or employer is responsible for the acts of others working under their authority, such as hygienists, assistants, and office staff. Dentists can reduce their risk by providing proper training, oversight, and coaching. See Video

53. PATIENT MANAGEMENT:Think twice before proceeding when certain patients refuse a referral and say they “want to see you and no one else.” It can be very awkward to have a family member, friend, or neighbor with paresthesia after a difficult extraction that should have been done by an oral surgeon. See Video

54. STAFF MANAGEMENT: Be sure your staff is properly vaccinated to keep them, you, and your patients safe and healthy. Most states require hepatitis B vaccination, and the CDC recommends all healthcare workers be vaccinated for influenza, measles, mumps, rubella, pertussis and varicella zoster. See Video

55. PROPERTY: Water damage is the most frequent property claim for dental practices. To prevent damage, operatories, restrooms, and labs should be checked each day for water leaks and clogged drains. In addition, establish a daily water shut-off procedure and install leak detection sensors. See Video

56. PRACTICE MANAGEMENT: Before sending anyone to collection, assess your ability to fight a retaliatory accusation. Is the chart accurate and complete? Will it help defend you? Have you met the standard of care? Were there any adverse events? What does your staff know? Select collection cases carefully. See Video

57. DOCUMENTATION: Patient financial information, like fees, balances, and collection actions, should not be included in the clinical chart. An exception is when a patient’s treatment decision is based on financial reasons, like when a patient declines endo and restoration in favor of extraction. See Video

58. CLINICAL CARE: Pediatric and elderly patients metabolize local anesthetics slower than an average adult and need lower doses to achieve the same efficacy. Stay below the maximum recommended dose and have a simple scale in the office to get an accurate weight for anesthetic dosing purposes. See Video

59. PATIENT MANAGEMENT: Dentists have an obligation to refer appropriately when a CBCT finding needs further evaluation or treatment. This includes referrals to oral surgeons for dental findings and referral to the patient’s physician when identified abnormalities are outside the scope of dentistry. See Video

60. PATIENT COMMUNICATION: Pay attention to both verbal and nonverbal patient messages. Verbal messages are the words they speak. Nonverbal messages are things such as their facial expressions, posture, eye contact, or even what they’re doing with their hands, like tightly gripping the dental chair. See Video

61. UNEXPECTED EVENTS: If a foreign object went down a patient’s throat but you aren’t sure if it was swallowed or aspirated, it’s a priority to identify just where it is in the body. The best way to do that is to send the patient for medical imaging. Then, follow up with the patient and your agent. See Video

Professional Protector Plan® is a registered service mark of B & B Protector Plans, Inc., National Administrator, Tampa, FL, a wholly-owned subsidiary of Brown & Brown, Inc. The information contained herein is intended to be for informational purposes only. Nothing contained herein is, nor is intended to be, legal or dental advice. Furthermore, it is not intended to, nor does it, constitute a binding contract. Accordingly, Professional Protector Plan® makes no representations regarding the correctness or completeness of this information and accepts no liability for any injury, loss, damage or expense arising out of or in connection with the use of this information. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. No representation is made with respect to coverage in any specific fact, situation or circumstance.