Medico-Legal Risk Management Guide

Scientific advances have the power to change the faces of dentistry, medicine and law, and to bring with them new rules, standards and accountabilities. These welcomed advances necessarily bring with them changes in diagnostic and clinical treatment protocols, clinician and practice behaviors, and in the way health disciplines work together. They also invite scrutiny and cross examination from attorneys and other legal “watchdogs”, the courts, and professional boards and regulatory bodies - especially when patient health outcomes are, shall we say, “undesirable!”

The emerging science is sufficiently strong to show the tightening connections between periodontal disease and general health conditions in the body. Systemic inflammation is now seen as a common thread which connects many seemingly disparate medical diseases, including gum disease, pregnancy complications, cardiovascular disease and diabetes to name a few.

Chronic local periodontal disease has shown the ability to elevate circulating levels of proinflammatory cytokines (i.e. CRP), a situation which is now intensifying the focus on multi-disciplinary management of these diseases, as well as increasing medical- legal scrutiny.

Standards of care can and do shift quickly as science drives legal precedent, disciplinary actions, and risk-management strategies. Despite the incompleteness of any research, the strength of the current evidence is sufficient to convince liability risk managers as well as malpractice attorneys that this new arena is one deserving of closer attention and oversight.

The Indian Dental Association (IDA) beautifully summarizes the current state of the science related to the oral-systemic connection. It also presents clinical recommendations to physicians and dentists on when and how to co-manage their patients who respectively have heart disease risk factors and/or periodontal disease. Dentists would do well to read and follow these policy recommendations.

The available research strongly suggests that failure to effectively co-manage these related conditions compromises patient care. In brief, physicians are now expected to inquire about the oral health status of their medical patients and refer at-risk patients to a dentist for proper evaluation. Conversely, dentists are now also expected to be proactive in referring periodontal patients to a physician for proper medical evaluation.

Certainly none of this has been lost on the medical malpractice legal system. Right or wrong - the reality is that many in the legal profession believe their role is to persuade an already overburdened medical/dental profession to provide better care. Of course, at the same time it has created additional revenue streams for the legal establishment. Simply put, the science now demands a higher level of care and more collaboration between physician and dentist. It is precisely this same science which attorneys, courts, state boards and other regulatory bodies use in supporting their positions.

What this means is that patients who suffer heart attacks and afterward learn that they could or should have been referred for evaluation and further care will raise “interesting” questions to their respective dentist or physician. Additionally, the stage is perfectly set for patients and their legal council to ask new questions about the quality of patient care - especially as it pertains to interdisciplinary health management.

What are lawyers looking for? In short they are looking for patients who have survived heart attacks, strokes, disabling diabetes complications, and pregnancy complications – whose physicians didn’t refer them to a dentist for a periodontal evaluation. They are also looking for dentists who didn’t properly refer their patients to a physician for medical risk evaluation or co-management.

• Was there a medical or physical injury where risk could have been reduced with periodontal treatment or proper sleep apnea treatment?
• Was there an “incident” (death or medical disability) which could have been prevented with proper co-management of patient health risk factors?
• Did the event or condition produce significant loss?
• Can it be shown that the patient had periodontal disease prior to the event?
• Should the physician/dentist have been expected to know about the increased risk?
• Did the physician/dentist refer for risk evaluation?
• Was there mis-management of oral airways, such as prescribing and fitting snoring devices in the absence of proper sleep apnea testing and diagnosis?

When injury or death extends to third parties involved in traffic accidents due to undiagnosed or improperly handled health issues it may become a cause for litigation.

Four Easy Steps to Legal Risk Management

• educate and screen patient,
• make a proper referral for risk evaluation,
• send a letter of communication to the respective physician/dentist, and
• document these actions in their patient’s chart.

With the advent of this new scientific understanding, wise physicians and dentists are seeking to collaborate together and to make each other aware about the medical conditions which affect their mutual patients. The science, licensing boards, courts and liability risk managers will inevitably encourage this higher degree of interdisciplinary cooperation between medicine and dentistry because it saves lives and keeps health professionals safe.