Patient Safety Tip of the Week
March 15, 2016 Dental Patient
Safety
We were recently asked why we haven’t done any columns on
dental patient safety. While over the years we’ve encountered a few minor
safety issues in dental cases in hospitals, we’ve never looked at the broader
issue of safety in dental practice where it is usually practiced – outside the
hospital.
So here goes!
A report from Spain on patient safety in dentistry (Perea-Perez
2011) identified several reasons why patient safety has been less
well addressed compared to medicine and surgery and we suspect the same issues
apply in the US:
- The harm produced is
generally less severe
- The patients are
ambulatory (making it difficult to become aware of and follow up on
adverse events)
- There is great dispersion
of dental care, making it difficult to collect data
- Fear of reporting adverse
events
- Lack of a generalized
culture of patient safety in dentistry
A recent systematic review found that the only interventions
in dentistry that reduce or minimize adverse events are surgical safety
checklists and highlighted the need for further research into patient safety in
dentistry across several domains: epidemiological, conceptual understanding and
patient and practitioner involvement (Bailey 2015).
A random sample from 20 dental practices in the Netherlands
showed an overall 4.6% rate of adverse events, with 2.8% deemed preventable (Mettes
2013). The prevalence of preventable adverse events for all patient
contacts was 0.13%. Potentially preventable adverse events included: retained
root fragments, inadvertent removal of a permanent tooth, fractured
instruments, excessive filling, swallowed partial prostheses, and removal of
some teeth without prior X-ray. Of the 18 identified adverse events, 15 were
classified as treatment-related, 10 as diagnosis-related, and one as
communication-related. 37 causes were found for the 18 adverse events, 65%
human and 30% organizational.
While we expected problems related to sedation would head
the list of potential patient safety problems in dentistry, we found a whole
host of reported safety issues:
- Extracting wrong tooth/teeth
- Complications of sedation
- Swallowing crowns, whole
teeth, instruments, etc.
- Failure to use antibiotic
prophylaxis
- Nerve injury
- Adverse reactions to local
anesthetics
- Infection control issues
- TMJ damage?
- Prescribing-related events
- Failure to Address
Significant Comorbidities
- Diagnostic errors
- Staff injuries (eg. needlesticks,
latex/rubber reaction)
- Rare events (eg. latex allergy, malignant hyperthermia)
- Dental amalgam issues
- Staff-related events
- Radiology issues
Extracting the Wrong
Tooth
Given the frequency with which we continue to see wrong site
surgery in hospitals, it should not be surprising that extraction of the wrong
tooth would occasionally occur. Indeed it does. The Doctors Company (a large
medical malpractice insurer) notes it occurs with surprisingly high frequency
and is, in most cases, preventable (The
Doctors Company 2016a).
Prior to dental extractions there should be the same sort of
timeout that we use prior to any surgery or procedure. That should include both
a pre-procedure verification and then the timeout that immediately precedes the
procedure. These include ensuring the correct patient, procedure, and correct
tooth. Teeth have both a name and number so that should make correct
identification easier, but errors still occur. Teeth may also shift when other
teeth are missing, leading to confusion. And don’t forget to make sure there is
a legitimate diagnosis that merits extraction of the tooth!
Copies of radiologic studies should be present (and
correctly oriented) to help verification and the patient should be asked which
tooth is the one to be extracted (though many patients with a toothache are not
quite sure themselves which is the diseased tooth and others may have cognitive
dysfunction that precludes self-identification of the tooth). The tooth to be
extracted should be checked against the referral slip. There should be a dental
diagram with the tooth/teeth for extraction clearly marked. Be especially aware
when contiguous teeth are diseased.
Joint Commission’s Universal Protocol requires marking the
site prior to surgery but one of the exceptions requiring alternative methods
is teeth. It may be impractical to mark individual teeth. So prior to and
during the timeout there is a need to indicate operative tooth name(s) on
documentation and mark the operative tooth (teeth) on dental radiographs or
dental diagrams and document. And the verification should be agreed upon by at
least 2 people (the dentist or dental surgeon and a nurse or dental assistant).
Often when the wrong tooth is extracted, root cause analyses
show multiple opportunities to have prevented the incident (Smith 2007).
Smith notes common etiologies of wrong-site tooth extraction include cognitive
failure and miscommunication, multiple contiguous carious teeth (rather than
one identifiable diseased tooth), partially erupted teeth mimicking third
molars, teeth with gross decay that the restorative dentist wants to save,
reversed radiographs, and nebulous tooth numbering systems.
Complications of
Sedation
Those of us who are baby boomers may recall much of our
dental work was done under sedation with – ether! Now we look back and think
how incredibly dangerous that probably was! We don’t recall being hooked up to
any sort of monitoring devices (and they didn’t have pulse oximeters back
then). We doubt the depth of sedation was closely monitored and bet that our
protective reflexes were often rendered ineffective. And outpatient offices are
probably not the greatest place to undertake full resuscitative measures if a
sedation accident does occur.
In addition to the respiratory depression that may occur
with sedation, loss of protective reflexes may predispose to aspiration or
swallowing of crowns, teeth, instruments, gauze, etc.
Today dentists must be certified to do moderate sedation and
go through at least as intensive training in sedation that we require for those
physicians we credential and privilege to do moderate sedation in hospitals.
Yet incidents related to sedation continue to occur…
Deaths in patients who received sedation for dental
procedures make the news every year (Otto
2014, AP
2015). Columns highlighting 8 (ABC
News 2016) and 31 (Bradford
2012) respective deaths related to dental sedation provide some estimate of
how frequently such complications of sedation occur. The most recent incident
was just reported last week (George
2016). In this case a 4-year old girl suffered brain damage after receiving
sedation for a dental procedure while being restrained by a device called a
“papoose”. A CBS News report on this case (CBS
News 2016) notes she was given multiple sedatives in the office for over
seven hours for what was described as a routine dental procedure. Her heart
rate was noted to be as high as 195 and her blood pressure to 168/77 and her
oxygen saturation dropped as low as 49 percent. The “papoose” is a device
confines the child's arms and legs so they can't interfere with the dental
procedure. The CBS report notes that use of such devices for dental procedures
in children is fairly widespread in the US and families and professionals need
to be made aware of the dangers.
Another study, using primarily media reports, found 44
children who died subsequent to receiving anesthesia for a dental procedure in
US dental offices, ambulatory surgery centers, and hospitals between 1980 and
2011 (Lee
2013). Most deaths occurred among 2–5 year-olds, in an office setting,
and with a general/pediatric dentist as the anesthesia provider. In this latter
group, 17 of 25 deaths were linked with a sedation anesthetic. That study
likely significantly underestimates the number of serious complications from
sedation and also did not include children who suffered neurologic injuries,
suffered cardiac arrest, and were successfully resuscitated, or those who
experienced respiratory arrest, but not cardiac arrest. The authors called for
development of a national database for reporting both serious incidents related
to dental sedation and near misses.
In a study of closed malpractice claims in pediatric dental
patients 13 of 17 claims related to anesthesia involved sedation (Chicka
2012). The average patient age was 3.6 years and 6 involved the
dentist as the anesthesia provider and the location was the dental office in
71% of cases. Only 1 claim related to sedation in which physiologic monitoring
was used.
A prospective study of 51 patients needing dental treatment
under oral conscious sedation found that postdischarge
excessive somnolence, nausea, and emesis were frequent complications (Huang
2015). 60.1% of patients slept in the car on the way home and 21.4% of that
group were difficult to awaken upon reaching home. At home, 76.1% of patients
slept and 85.7% of patients who napped following the dental visit slept longer
than usual.
Proper patient selection, adherence to proper sedation
technique, appropriate monitoring, and prompt intervention are obviously
important when using sedation in any setting. The American Dental Association has
guidelines for the use of sedation and general anesthesia by dentists (ADA
2012) and most state health departments have requirements for dentists to
be certified in the use of sedation in the office.
Swallowing crowns,
whole teeth, instruments, etc.
It really shouldn’t be surprising that a patient might
inadvertently swallow items during a dental procedure. The local anesthetics
given not only numb the area being worked upon by the dentist or oral surgeon
but also impair the ability of a patient to tell that there is a loose item in
his/her mouth. Anyone who has undergone such procedures knows how easy it is to
inadvertently swallow while the dentist or oral surgeon is working. Also, when
sedation is used there may be a fine line between moderate sedation and deeper
sedation where protective reflexes are impaired, making aspiration or
swallowing items more likely.
During, for example root canal treatment, if the dentist
places a rubber dam around the tooth during endodontic treatment then the risk
of saliva contamination and ingestion of chemicals or aspiration of instruments
is reduced. But there apparently is not a profession-wide consensus about the
importance of rubber dam use (Gilbert
2015). Gilbert et al. suggest the patient safety aspect needs an effort
similar to what has occurred in surgery regarding “never events”.
The Doctors Company recommends the following “if a patient
inadvertently swallows part or all of a tooth, crown, or dental instrument,
inform the patient immediately, and refer him or her for a chest or
gastrointestinal x-ray. Any abnormal results should be reviewed by the
patient’s physician, and a follow-up appointment with the physician should be
scheduled. Document the dental record with any treatments provided and all discussions
of the event, treatment options, and referrals for medical care. Coordinate
arrangements with the patient and the treating medical practitioner for medical
care and x-rays. Communicate with the patient’s physician and maintain a
dialogue with the patient.” (The
Doctors Company 2016b).
Failure to Use
Antibiotic Prophylaxis
Failure to use antibiotic prophylaxis in patients with
artificial heart valves or other foreign bodies that might become infected has
been listed as a safety concern. However, most recent guidelines have actually
done away with prophylaxis in many cases. Compared with previous
recommendations, there are currently relatively few patient subpopulations for
whom antibiotic prophylaxis may be indicated prior to certain dental procedures
(ADA
2016). For example, for those with hip arthroplasties the current
guidelines do not recommend antibiotic prophylaxis prior to dental surgery
unless there have been complications related to the hip surgery.
A joint effort by the American Academy of Orthopedic
Surgeons and the American Dental Association did a thorough review of the issue
of antibiotic prophylaxis in patients with joint implants in 2012 (AAOS/ADA
2012) and came up with the following recommendations:
- Recommendation #1: “The
practitioner might consider discontinuing the practice of routinely
prescribing prophylactic antibiotics for patients with hip and knee
prosthetic joint implants undergoing dental procedures.”
- Recommendation #2: “We are
unable to recommend for or against the use of topical oral antimicrobials
in patients with prosthetic joint implants or other orthopaedic
implants undergoing dental procedures.”
- Recommendation #3: “In the
absence of reliable evidence linking poor oral health to prosthetic joint
infection, it is the opinion of the work group that patients with
prosthetic joint implants or other orthopaedic implants
maintain appropriate oral hygiene.”
Recommendations now for antibiotic prophylaxis during dental
procedures involve primarily patients at highest risk for infective
endocarditis (eg. those with prosthetic valves,
previous endocarditis, congenital heart disease, transplant patients with valvulopathy).
Bottom line: always check to ensure the most up-to-date
guidelines for prophylaxis are followed.
Lingual Nerve Injury
Lingual nerve injury may complicate invasive dental and
surgical therapies, resulting in numbness, dysesthesia, paresthesia, and dysgeusia (Graff-Radford
2003). The authors also note that unexplained nerve injury following dental
procedures, especially tooth removal, may be caused by
intraneural injection, creating permanent damage.
They note that the incidence of lingual nerve injury consequent to surgery
depends upon the procedure being performed, the surgeon's experience, procedure
methodology, and certain patient-specific factors. Such injury is most common
after mandibular third molar removal, the incidence of permanent nerve damage reported
to vary between 0.5% and 2%.
A nice discussion of nerve injuries after dental injection
cited the incidence from the literature as between 1 in 160,571 and 1 in 26,762
mandibular blocks (Smith
2006). Those authors note multiple potential mechanisms, including direct
trauma from the injection needle, hematoma formation, and neurotoxicity of the
local anesthetic.
Adverse Reactions to Local Anesthetics
Allergic reactions to local anesthetics can, of course,
occur and may be unpredictable if there is no past history of such events. But
other adverse reactions can occur to local anesthetics. Biron (Biron
2000) described toxic overdoses from local anesthetics in dentistry, which
can be manifest by seizures or unconsciousness among other symptoms and signs.
Such may occur from large amounts of local anesthetic injected, too rapid
injections, inadvertent intravascular injection. And don’t forget that many of
the local anesthetic preparations include vasoconstrictors that can cause
adverse events in patients with underlying cardiac problems. The Biron article
includes algorithms for management of toxic local anesthetic overdoses or
reactions to vasoconstrictors.
Infection Control
Issues
Potential contamination and transmission of pathogens is
both a patient safety issue and a concern for staff safety. Concerns especially
apply to potential transmission of hepatitis B virus (HBV), hepatitis C virus
(HCV), human immunodeficiency virus (HIV), methicillin-resistant
staphlycoccus aureus (MRSA) infection, among others (Klevens
2008).
The Doctors Company (The
Doctors Company 2016b) has the following recommendations to reduce the
chance of such transmission:
- Always wash your hands
before donning gloves and again after removing them.
- Change gloves between
patients.
- When gloved, don’t touch
noncritical patient care items that are not barrier protected or cleaned
between patients.
- Wear your personal
protective equipment.
- Use any single-use
disposable instrument only once, and then dispose of it properly.
- Follow the manufacturer’s
directions for autoclaving dental instruments. Perform biological
monitoring, and document the monitoring results. Store sterilized
instruments in a clean, dry, and protected environment.
- Establish a dirty area for
processing and cleaning instruments in preparation for autoclaving to
avoid cross-contamination of clean and sterilized items.
- Select appropriate devices
that reduce aerosol and droplet formation and the potential for sharps
injuries.
- Ensure that everyone
follows universal precautions with every patient.
- Manage occupational
exposure to blood-borne pathogens, including post-exposure prophylaxis for
work exposure to hepatitis B virus, hepatitis C virus, and HIV.
- Check dental unit water
lines, biofilms, and water quality regularly.
Details of cleaning and processing and sterilization of instruments
is beyond the scope of today’s column but CDC has good resources regarding
infection control issues in dental settings (CDC 2015)
and for occupational exposures in dental settings (CDC
2013). Exposure incidents might place dental health care personnel at risk
for hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency
virus (HIV) infection, and therefore should be evaluated immediately following
treatment of the exposure site by a qualified health care professional.
And, of course, dental offices as well as other venues
performing dental or oral surgery procedures must have proper procedures for
medical waste disposal.
TMJ Dysfunction?
Though patients may complain of pain and other symptoms of
TMJ dysfunction following dental or oral surgery procedures, the evidence base
linking the two is very scant. One study (Juhl
2009) was a prospective study to investigate if third molar surgery
is associated with the development of symptoms and signs of temporomandibular
disorders (TMD) during a 6-month post-operative observation period. In the
patient group, they found: reduced range of maximum jaw opening at one week
after surgery, increased characteristic pain intensity 1 week after
surgery, increased disability up to 1 month after surgery, increased
incidence of muscle pain on palpation up to 6 months after surgery,
increased incidence of pain on palpation of the temporomandibular joint up to
6 months after surgery, and increased incidence of painful TMD
6 months after surgery. But, when compared with untreated controls,
subjects undergoing third molar surgery have a statistically insignificant
increased incidence of TMD 6 months post-operatively.
Failure to Address
Significant Comorbidities
For example, excessive bleeding if you failed to note the
patient was taking anticoagulants would be problematic. Similarly, using an
agent to which the patient had a known allergy would also be problematic.
Prescribing Errors
Patients of dentists are vulnerable to the gamut of
medication errors that may occur when any physician or dentist prescribes
drugs. See our many columns on medication safety.
Diagnostic Errors
Just as in any field of healthcare, diagnostic errors may
occur in dentistry and oral surgery. In the Netherlands study noted above (Mettes
2013) many of the adverse events were noted to be diagnosis-related.
Most often diagnostic errors might arise from failure to obtain appropriate
dental radiographs prior to dental extractions. But there are other more
complex symptoms that often masquerade as dental problems. We’ve often seen
patients with atypical facial pain or even classic trigeminal neuralgia who
have had dental procedures performed inappropriately for the pain before the
patient ultimately sees a neurologist.
Rare adverse
reactions
Some events that occur in other surgical settings might also
be anticipated to occur rarely in dental practices. One such example might be
latex allergy since patients might be allergic to latex in gloves of the
dentist or hygienist or to the latex in a dental dam. Another theoretical event
that might be precipitated by local anesthesia is malignant hyperthermia,
though local anesthetics are said to be relatively safe in patients with known
malignant hyperthermia by history. Nevertheless, it behooves all dentists and
oral surgeons to be aware of the symptoms and signs of these rare events (latex
allergy, malignant hyperthermia) since they require immediate interventions.
Dental Amalgam Issues
You are all familiar with the long-standing controversies
over the relationship between dental amalgam and a variety of medical conditions.
A review (Brownawell
2005) uncovered no convincing evidence pointing to any adverse
health effects that are attributable to dental amalgam restorations besides
hypersensitivity in some individuals.
Staff-related events
Dentists, hygienists, and others are exposed to bodily
fluids (saliva, blood) that put them at risk for contracting pathogens like hepatitis
B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and
others. These can occur from needlesticks, bites,
scalpel injuries, and perhaps even through aerosolization
during drilling. Use of proper personal protective equipment is obviously the
most important strategy to reduce the risks. But dental offices need to have
protocols for dealing with such injuries, just as hospitals have.
Other potential staff risks include latex allergies and
radiation exposure. While the radiation dose from typical dental x-rays is
small, the cumulative dose over long periods could be significant. Therefore,
it is crucial that all dental offices take appropriate steps to avoid radiation
exposure.
Radiology Issues
In addition to the radiation exposure potential noted above,
other radiology issues may occur. These might include use of equipment that
provides suboptimal images, viewing images backwards, wrong-patient issues, and
others that might lead to diagnostic or therapeutic errors.
Summary
Yes, we were surprised at the spectrum of patient safety
events that may occur in the dental office or other venues where dental work or
oral surgery are performed. It’s too bad there are no current ways to quantify
the frequency of these various incidents. Nonetheless, simply being aware of
the potential events and having systems in place to prevent such events or deal
with such events when they do occur is important.
References:
Perea-Perez B, Santiago-Saez A, Garcia-Marin F, et al. Patient safety in dentistry: Dental care risk
management plan. Medicina Oral Patologia Oral Y Cirugia Bucal 2011; 16(6):
E805-E809
http://www.medicinaoral.com/pubmed/medoralv16_i6_p805.pdf
Bailey E, Tickle M, Campbell S, O’Malley L. Systematic
review of patient safety interventions in dentistry. BMC Oral Health 2015; 15:
152
http://www.biomedcentral.com/1472-6831/15/152
Mettes T, Bruers
J, van der Sanden W, Wensing M. Patient safety in dental care: A challenging
quality issue? An exploratory cohort study. Acta Odontol Scand
2013; 71(6): 1588-1593
http://www.tandfonline.com/doi/abs/10.3109/00016357.2013.777471?journalCode=iode20
The Doctors Company. Preventing Wrong Tooth Extraction.
Accessed February 26, 2016
http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/Preventing-Wrong-Tooth-Extraction
Smith RA. AHRQ Web M&M. Mark My Tooth. Published
July-August 2007
https://psnet.ahrq.gov/webmm/case/156/mark-my-tooth
Otto M. Dentist under investigation after sedated child
dies. Association of Health Care Journalists. January 13, 2014
http://healthjournalism.org/blog/2014/01/dentist-under-investigation-after-sedated-child-dies/
AP (Associated Press). Dentist charged in death of patient
getting 20 teeth pulled. FoxNews.com Published February 18, 2015
ABC News. Children in Danger at the Dentist. ABC News. Accessed
March 7, 2016
http://abcnews.go.com/Blotter/photos/children-danger-dentist-16763974/image-16764081
Bradford H. Dental Sedation Responsible For At Least 31
Child Deaths Over 15 Years. Huffington Post 2012; July 13, 2012
http://www.huffingtonpost.com/2012/07/13/dental-sedation-child-deaths_n_1671604.html
George C. Mom says dental restraint device led to child's
brain damage. Preschooler remains hospitalized, conscious, but unable to talk,
get up. Houston Chronicle 2016; March 10, 2016 Updated: March 11, 2016
CBS News. 4-year-old girl suffers brain damage after dentist
visit, family says.
CBS News March 14, 2016
http://www.cbsnews.com/news/4-year-old-girl-suffers-brain-damage-after-dentist-visit/
Lee HH, Milgrom P, Starks H, Burke
W. Trends in death associated with pediatric dental sedation and general
anesthesia. Pediatric Anesthesia 2013; 23(8): 741-746
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JB, Mathu-Muju KR, et al. Adverse events during
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insurance claims. Pediatr Dent 2012; 34(3): 231-238
Huang A, Tanbonliong T. Oral
Sedation Postdischarge Adverse Events in Pediatric
Dental Patients. Anesth Prog
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Sedation and General Anesthesia by Dentists. 2012
https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/anesthesia_use_guidelines.ashx
Gilbert GH, Riley JL, Eleazer PD,
et al. Discordance between presumed standard of care and actual clinical
practice: the example of rubber dam use during root canal treatment in the
National Dental Practice-Based Research Network. National Dental PBRN Collaborative
Group. BMJ Open 2015; 5: 1
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The Doctors Company. Patient Safety Challenges in General
Dentistry. Accessed February 26, 2016
ADA (American Dental Association). Antibiotic Prophylaxis
Prior to Dental Procedures. February 18, 2016
http://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis
AAOS (American Academy of Orthopedic Surgeons) and ADA
(American Dental Association). Prevention of Orthopaedic
Implant Infection in Patients Undergoing Dental Procedures. Evidence-Based
Guideline and Evidence Report. December 7, 2012
http://www.aaos.org/Research/guidelines/PUDP/PUDP_guideline.pdf
Graff-Radford SB, Evans RW. Lingual Nerve Injury.
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http://onlinelibrary.wiley.com/doi/10.1046/j.1526-4610.2003.03189.x/abstract
Smith MH, Lung KE. Nerve Injuries after Dental Injection: A
Review of the Literature. J Can Dent Assoc 2006;
72(6): 559-566
http://www.cda-adc.ca/jcda/vol-72/issue-6/559.pdf
Biron CR. Adverse reactions to local anesthetics. RDH
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Klevens RM, Gorwitz
RJ, Collins AS. Methicillin-Resistant Staphylococcus aureus. A Primer
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1328-1337
http://jada.ada.org/article/S0002-8177%2814%2965410-6/abstract
CDC (Centers for Disease Control and Prevention) Infection
Control in Dental Settings. Last updated September 18, 2015
http://www.cdc.gov/oralhealth/infectioncontrol/index.htm
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Asked Questions - Bloodborne Pathogens - Occupational
Exposure. Last updated October 25, 2013
http://www.cdc.gov/oralhealth/infectioncontrol/faq/bloodborne_exposures.htm
Juhl GI, Jensen TS, Norholt SE, Svensson P. Incidence
of symptoms and signs of TMD following third molar surgery: a controlled,
prospective study. Journal of Oral Rehabilitation 2009; 36(3): 199-209
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2842.2008.01925.x/abstract
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S, Brent RL, at al. The potential adverse health effects of dental amalgam. Toxicol Rev 2005; 24(1): 1-10
http://link.springer.com/article/10.2165/00139709-200524010-00001
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