Standard of Care - The Grey Area of Dentistry

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Standard of Care- The Gray Area of Dentistry is first in this blog series dedicated to some confusing legal aspects of the dental profession. In this litigious society, care must be taken to ensure that all phases of treatment are delivered with the highest of standards based on the needs of the patient. Standard of Care, Informed Refusal, Supervised Neglect, “Firing” a Patient, and Malpractice will be included in this series to help navigate the murky waters in preventing and handling a legal situation in your practice.

Standard of care (SOC) by definition is a written explanation outlining actions, rules, or conditions regarding the care of a patient. SOC in dentistry is principles taught by accredited dental schools and accredited hygiene programs and describes standards carried out by the profession.  SOC is determined by each state, and most dentists and hygienists don’t understand its meaning or how it’s determined.

In 1998, a landmark case defined SOC as follows:

  • Maintain an acceptable degree of education and skill comparable to doctors in the surrounding area
  • Use reasonable care and diligence during treatment
  • Be aware of new materials, techniques, and advances, and implement as deemed necessary and prudent
  • Use the best judgment in carrying out treatment and apply scientific-proven knowledge
  • Pursue techniques and education exercised by good standing members of the profession
  • Apply approved and safe methods
  • Educate the patient on their condition, introduce all applicable treatment plans, and advise as to what could happen if they accept or reject the treatment plan

In part two of this blog, we’ll explore some factors and variables of the standard of care.

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Don't Try This at Home - Crazy Things People Do to Alter Their Mouth

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Body modification is the process of purposely altering the body to achieve a certain look or physical feeling. Some body transformations are viewed by society as normal and beneficial such as orthodontics, conventional plastic surgery, Lasik eye surgery, and ear piercing. Alternatively, there are modifications of the body that are considered odd and disfiguring. Following are some of the more unusual things people do to alter their mouth.

  • Gap Band- A gap band is an elastic rubber band usually purchased through a website that is placed around the two front teeth to “close the gap.” The space may close, but there can be many complications. Moving teeth correctly is difficult and precise and takes place over a specific amount of time. Proper orthodontic treatment is orchestrated by an orthodontist who has many years of formal education and experience. If teeth move too quickly or at the incorrect angle, permanent damage can occur to the blood supply, connective tissue, and nerves surrounding the tooth leading to possible tooth loss.
  • Dental Grills & Gold “Caps”- Grills are ornamental covers that fit over the top or bottom front teeth. They are made of gold, silver, non-precious base metals, or jewel inlaid precious metal. Gold caps are cosmetic gold teeth that fit over a single tooth. Kits are available to purchase online that allow consumers to gather the requested information, and an online lab will create the grill or cap. Some are removable (recommended), and others are glued onto the teeth/tooth (not recommended). Because a dentist is normally not involved in these processes, grills and caps are placed over existing teeth without any preparation to allow for the extra space needed for the appliance. The result is that they are ill-fitting and bacteria can grow rapidly between the device and the tooth causing decay and/or periodontal disease. Grills and caps fabricated with non-precious metals can cause serious metal-allergic reactions.
  • Mouth Piercing- Mouth piercing is fairly common in various places in the mouth (tongue, gingiva, frenum’s, and uvula). Even if the piercing is done in an establishment that offers the service, having it done can lead to infection, excess bleeding, tooth damage, nerve damage, aspiration of the barbell or ring, keloids, Hepatitis B or C, and even HIV.
  • Tooth Tattoos- A tooth tattoo is an image printed onto a crown before it’s cemented permanently into the mouth. The crown is fabricated in a dental lab and is cemented on a tooth that a DMD or DDS has properly prepared.
  • Tooth Modification- Tooth modification is very extreme. It’s hard to predict who might perform this service because removing healthy tooth structure in this manner is something most dentists wouldn’t consider. In this process, the front teeth are reduced dramatically thus providing sharp points on the biting surfaces. This action is irreversible and would require major rehabilitation to restore the teeth back to ‘normal.’ Another popular alteration is creating fangs to the canine (eye-teeth) with composite material added to the biting Fangs are more conservative and easily reversed.
  • Tongue Forking- Tongue forking is an extremely invasive procedure where the tongue is split vertically down the middle giving the appearance of a snake’s tongue. As with piercing, even if the consumer is going to a legitimate studio, care must be taken to avoid diseases, permanent damage, and life-threatening consequences.

The bottom line- any process that involves the patient or anyone else who is not a doctor performing an extreme procedure in an unsterile environment and with unsterile instruments should think twice before proceeding.

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It's THAT time of year again - Back to school!

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Believe it or not, school is back in session which means it’s time to get back into the routine. While summer is a time to be carefree and have fun, the school year brings structure and a hectic pace. Part of the transition is resuming proper personal care including oral health.   

Therefore, how do parents get their children back into the groove? When it comes to oral health care, here’s a checklist of things to consider to aid in resuming the daily schedule easily:

  1. Supplies- Just like pens, pencils, and backpacks, kids need the right tools when performing oral health care. A new toothbrush, floss, toothpaste, fluoride rinse, mouthwash, and any other aids are in order. If your child is in orthodontic treatment, other devices may be necessary such as a power brush or an irrigation device.
  2. Lunch & Snacks- It’s prudent to review your child’s lunchbox and snacks. Start the year off right by packing healthy food and snacks in their lunchbox such as fresh fruits and veggies that can be dunked into a healthy dip. Seemingly good snacks, such as dehydrated fruits, should be eaten
  3. Regular Bedtime- Although it doesn’t seem directly related to oral health care, sleep is very important. With exhaustion and improper sleep patterns comes the probability of clenching and grinding the teeth. When short-lived, bruxing and clenching isn’t too problematic. However, if it becomes a long-term habit, it can be very detrimental. Stress the importance of sleep and reasonable bedtimes to your child.

Going back to school doesn’t have to be a dreaded experience. As long as you’re prepared, the new schedule won’t be too difficult to integrate, and the entire household will be in sync and happy.

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Pre-rinsing before dental procedures? Yes, please!

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Do you have patients pre-rinse before each dental procedure? If not, it may be time to add this simple step to the appointment because it greatly reduces cross-contamination of harmful microbes. Today, we’ll discuss who, what, and why rinsing right before treatment is beneficial.

Who- The patient being treated should rinse with an antimicrobial product for 30 seconds before the procedure. By swishing beforehand, the number of microorganisms present in the mouth is reduced thus decreasing the number of contaminants entering the patient’s bloodstream. Furthermore, the treatment site heals better and with fewer complications.

What- During any procedure in a dental office, splatter and aerosols come out of the patient’s mouth and contaminate everything and everybody in the treatment room.  The Centers for Disease Control (CDC) reports that utilizing antimicrobial pre-rinses decrease the level of microbes. The CDC also recommends at least one of the following ingredients in the mouthwash to diminish contaminants:

  • Chlorhexidine gluconate
  • Povidone Iodine
  • Alcohol and essential oils
  • Cetylpyridinium chloride

Why- The amount of aerosol that comes out of the patient's mouth while drilling, power scaling, polishing, and using any other aerosol producing instrument is astounding. This aerosol contains harmful bacteria, fungi, viruses, and biofilm that contaminates everything and everyone in its path. Providing mouthwash beforehand significantly reduces the number of harmful contaminants for the patient and the clinicians.

Providing mouthwash before treatment is extremely cost-effective and simple. It may seem like one more thing to add to the appointment, but the benefit far outweighs the minimal time and effort.

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Are dental professionals overlooking the importance of mouth rinses?


Toothbrush, toothpaste, and floss are given to most patients at their prophylaxis appointment, but are clinicians overlooking a key element in homecare? Mouth rinses are available in every store and are usually chosen by the patient based on TV commercials or ads on mobile devices. While using mouthwash isn’t a replacement for brushing and flossing, it can be a helpful adjunct to the oral health routine. Rinses are relatively inexpensive, easy to use, and take around 30 seconds. They flow into hard-to-reach areas and have ingredients based on varying mouth conditions. Becoming familiar with mouthwashes is important for the dental team so that they’re ready to recommend a product based on the patient’s diagnosis.

Therapeutic and cosmetic are the two types of mouthwashes. There are sub-categories for each type, and some are over-the-counter while others are prescription only. Children under the age of six shouldn’t use mouthwash because of underdeveloped swallowing reflexes which could lead to ingestion of the product. If a doctor recommends a rinse for a child six and under, extreme care must be taken to avoid ingestion unless the doctor recommends swallowing the product.

Therapeutic rinses contain active ingredients that help control plaque, halitosis, gingivitis, and reduce the incidence of caries. These active ingredients include chlorhexidine gluconate, essential oils with alcohol, peroxide, fluoride, and cetylpyridinium chloride. Chlorhexidine gluconate and essential oils with alcohol assist in controlling plaque and gingivitis. Peroxide is useful in whitening rinses. Fluoride is an excellent choice in helping to prevent decay. Cetylpyridinium chloride is used to treat halitosis. All of these are sold over-the-counter except for chlorhexidine which is by prescription only. Cosmetic mouth rinses are mainly used to freshen the breath and do little to assist with serious mouth conditions.

One other crucial factor when considering mouthwashes is whether they have earned the American Dental Association’s (ADA) Seal of Acceptance. This seal assures that the product is safe and effective based on scientific evidence and approval from the ADA Council on Scientific Affairs.

As with toothbrushes, toothpaste, and floss, it’s best to educate the patient as to why adding mouthwash to their home regiment is essential.  Once the benefits, ease of use, and cost-effectiveness are pointed out, the patient should see that adding this step at home is beneficial to their oral health.

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