Teeth cleaning without exam

Started by KOM
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KOM

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My wife was recently trying to schedule a teeth cleaning and couldn't find one dental office out of about five that she called that would allow her to do it without a dental exam. When she asked for a simple explanation they said that they just don't do it. I figure at least they could have explained why.

Reasoning? Thoughts?
 
Some dentists look at just doing the cleaning as a dangerous practice; patients will come in and get a cleaning avoiding any exam until something hurts and it is too late. There are also situations where you would want to complete a procedure prior to doing a cleaning so a dentist might want to do a checkup first to make sure the patient is clear.

Also you have to consider that it is expensive just to keep a dental chair open; I think somewhere I read on dental town that it is $200/hour just to keep the chair available when all overhead was considered (obviously specific to that practice) so there isn't a great incentive to just do cleanings.
 
Yellow Snow said:
Some dentists look at just doing the cleaning as a dangerous practice; patients will come in and get a cleaning avoiding any exam until something hurts and it is too late. There are also situations where you would want to complete a procedure prior to doing a cleaning so a dentist might want to do a checkup first to make sure the patient is clear.

Also you have to consider that it is expensive just to keep a dental chair open; I think somewhere I read on dental town that it is $200/hour just to keep the chair available when all overhead was considered (obviously specific to that practice) so there isn't a great incentive to just do cleanings.
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isn't there also a liability issue? If something bad were to be found 6 months later than would the previous DH or DDS be at risk for not having an exam?

I was a DA for 3 years. EVERY patient that came in for ANYTHING received full x-rays. Even if just 1 tooth hurt, we would do full mouth x rays and then a PA of the tooth in pain. The dentist said that he had a legal responsibility to not miss something that came into his office. Side note: whenever the patients did not have insurance and/or their insurance got angry for all the x rays, he just billed for the PA and wrote the rest off.
 
How do you do a cleaning without doing an exam at the same time? I can't imagine closing my eyes and swirling the Cavitron tip inside the patient's mouth. What if a patient is diagnosed with oral cancer 8 months down the road? What if an MO decay turned into a RCT a couple months down the road? Do you think your peers, the jury, the court will take kindly to your explanation "the patient didn't want an exam"?

If you live in or visit places such as San Jose, Santa Ana, San Diego, Alhambra, there are places advertising exam and prophy for only $1, $5, $20. Once there, you can also bargain composite fillings down to $20 each.
 
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I can respect the liability issue, but for someone without dental insurance and limited funds I feel there should be alternatives.

I don't know if I respect the argument from the dentist's standpoint that there isn't any real financial incentive to do just cleanings. It's a bit to self-serving in my mind...but at the same time I can understand how permitting this in your practice does seem to undervalue the dentist's role in the practice. In fact, this may be exactly what contributes to some hygienists wanting to branch off on their own. Bad for dentists...but bad for patients?

I suppose it definitely becomes bad when hygienists then decide they want to expand their scope of practice.

But, from a patient standpoint, say they are forced to get the exam and the dentist recommends all sorts of treatment that they can't afford anyways or they find that everything is fine. Said patient seemingly just lost the difference. If a patient can find cheap exams as Daurang suggested than I believe it's a moot point.

Anyone heard of dentists using disclaimers stating patient denied exam and only wanted cleaning?

Also - food for thought that I just heard on the T.V...a Harvard report showed that an estimated 1 million people declare bankruptcy each year. Of that, 50% are thought to be due in part to medical expenses.
 
KOM said:
I can respect the liability issue, but for someone without dental insurance and limited funds I feel there should be alternatives.
But, from a patient standpoint, say they are forced to get the exam and the dentist recommends all sorts of treatment that they can't afford anyways or they find that everything is fine. Said patient seemingly just lost the difference.
Anyone heard of dentists using disclaimers stating patient denied exam and only wanted cleaning?
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It comes under the heading of "standard of care". Incidentally, patients do have the choice of not being seen. Patients cannot be forced to obtain treatment any more than a dentist can be forced to do a prophy without radiographs or an exam. Legally, it may be difficult to waive a right when one is ignorant of the significance behind the disclaimer. Several years ago there was a case in CA where a dentist did precisely that. A few years after the initial "disclaimer" the patient develop oral cancer, whereupon she successful sued the practitioner since she claimed she would have consented to a pano had she known the potential consequences of her decision not to have x-ray taken. Since dental insurance does cost, think of all the money a patient is likely to have saved by not signing up for d insurance- certainly enough for a prophy/exam. For now, hold the thought for the next 3 years then come back and re address the issue.
 
To any dentists out there - in what sort of clinical cases that you've seen have you made specific recommendations for cleanings not to be performed? Is it a fairly common occurrence? How often do you give your hygienists specific instructions as to what needs to be done for each patient?

With the "hygienist uprisal" we recently dealt with in MN, I started thinking about where a hygienist's scope of practice should end and if operating independently is as severe a detriment to dentistry as many dentists profess.
 
How do you know what type of cleaning to begin with without a periodontal exam, probings, plaque/calc levels, etc..etc.. You have got to be kidding me even thinking a patient can be cleaned without an exam. What if the patient has localized aggressive periodontitis? Misdiagnosed/undiagnosed perio is one of the most common issues that ends up in court and a dentist being creamed. Since when do patients or patients' insurances dictate treatment? If a patient refuses an exam, or even xrays we dismiss them. CYA.
 
KOM said:
To any dentists out there - in what sort of clinical cases that you've seen have you made specific recommendations for cleanings not to be performed? Is it a fairly common occurrence? How often do you give your hygienists specific instructions as to what needs to be done for each patient?

With the "hygienist uprisal" we recently dealt with in MN, I started thinking about where a hygienist's scope of practice should end and if operating independently is as severe a detriment to dentistry as many dentists profess.
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Regardig the hygienist uprisal, these positions already exist in some areas but are mostly unrealized (I think CO and Canada?). The overhead involved for a hygienist to open up his/her own shop is prohibitive. They would have to pay for rent, equipment and a front desk worker. Those deeply discounted cleanings people might expect without the dentist there to "jack up" the prices just got more expensive or impossible.

And regarding the patient just waiving the comprehensive exam, the dental office isn't a libertarian territory; the dentist is expected to act in the patient's best interest sometimes, even if that goes against what the patient wants. Of course the patient can elect to decline treatment. The easiest example is X-rays. The patient doesn't get to decide if they want xrays before the doc opens up that class 1. It is a condition of the treatment. Getting a cleaning usually has some conditions attached.

And the financial argument I brought up earlier, you cant consider it from an isolated viewpoint. Many dentists do perform procedures where they barely break even or sometimes lose money for the good of the patient. But in the case of the cleaning, not only are you probably losing money but you aren't really helping out the patient in the long term. Not really any incentive there.
 
OceanDMD said:
How do you know what type of cleaning to begin with without a periodontal exam, probings, plaque/calc levels, etc..etc.. You have got to be kidding me even thinking a patient can be cleaned without an exam. What if the patient has localized aggressive periodontitis? Misdiagnosed/undiagnosed perio is one of the most common issues that ends up in court and a dentist being creamed. Since when do patients or patients' insurances dictate treatment? If a patient refuses an exam, or even xrays we dismiss them. CYA.
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As soon as the patient sits down on your chair, you're the expert and not them, so you're liable for them even if they sign a disclaimer. Last month I just kicked out two very nice patients, an MD and an attorney, who kept refusing to have xrays taken.
 
Thanks for the reply.

In all three dental practices I've been in (in AK, one in VA, one in IA) the hygienist has been the one to perform pocket depth probing and plaque/calc level charting. Is this common practice? In these cases, does the dentist entrust this skill set to the hygienist, but is still liable for it?
 
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KOM said:
Thanks for the reply.

In all three dental practices I've been in (in AK, one in VA, one in IA) the hygienist has been the one to perform pocket depth probing and plaque/calc level charting. Is this common practice? In these cases, does the dentist entrust this skill set to the hygienist, but is still liable for it?
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These are things hygienists are trained to do. The dentist is liable for the diagnosis made from the data gathering by the hygienist (probing, charting, etc) and is liable for the treatment the hygienist performs.
 
KOM said:
Thanks for the reply.

In all three dental practices I've been in (in AK, one in VA, one in IA) the hygienist has been the one to perform pocket depth probing and plaque/calc level charting. Is this common practice? In these cases, does the dentist entrust this skill set to the hygienist, but is still liable for it?
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I would think both you and the hygienist (your employee) are at fault. However, do you think John Edwards and his buddies will go after the hygienist or go after you?
 
Daurang said:
I would think both you and the hygienist (your employee) are at fault. However, do you think John Edwards and his buddies will go after the hygienist or go after you?
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It depends if you are the babies daddy or not.:laugh:
 
OceanDMD said:
How do you know what type of cleaning to begin with without a periodontal exam, probings, plaque/calc levels, etc..etc.. You have got to be kidding me even thinking a patient can be cleaned without an exam. What if the patient has localized aggressive periodontitis? Misdiagnosed/undiagnosed perio is one of the most common issues that ends up in court and a dentist being creamed. Since when do patients or patients' insurances dictate treatment? If a patient refuses an exam, or even xrays we dismiss them. CYA.
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Daurang said:
As soon as the patient sits down on your chair, you're the expert and not them, so you're liable for them even if they sign a disclaimer. Last month I just kicked out two very nice patients, an MD and an attorney, who kept refusing to have xrays taken.
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Bullseye. 👍
 
Daurang said:
As soon as the patient sits down on your chair, you're the expert and not them, so you're liable for them even if they sign a disclaimer. Last month I just kicked out two very nice patients, an MD and an attorney, who kept refusing to have xrays taken.
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🙄
 
KOM said:
To any dentists out there - in what sort of clinical cases that you've seen have you made specific recommendations for cleanings not to be performed?
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If there's a need for more aggressive perio treatment, the patient may have to have a special treatment plan with a referral, quadrant-by-quadrant SRP, etc. etc.

The exam is not to see if a cleaning is required, but to have performed your duty as a dental professional to the patient. You have restored the mouth to a healthier state, both by removing plaque and calculus and by looking for other situations that might cause it to be unhealthy.
 
Another thing -

When obtaining informed consent, the patient must be informed of all of the following -

• A description of the proposed treatment
• The foreseeable risks
• The benefits and prognosis of the proposed treatment
• All reasonable alternatives to the proposed treatment
• The risks, benefits, and prognosis of the alternative treatments

What good is getting it if a patient can just plead ignorance and still win a lawsuit against you? Is it just to cover your butt a little more?

I'm assuming you must get informed consent before each and every procedure is performed, but can it be oral or written? Is written better to have from a legal standpoint? If so, do you need to write out the above information every single time?
 
Daurang said:
As soon as the patient sits down on your chair, you're the expert and not them, so you're liable for them even if they sign a disclaimer. Last month I just kicked out two very nice patients, an MD and an attorney, who kept refusing to have xrays taken.
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I can understand kicking them out. According to the code, if a patient refuses to have X-Rays taken your only discourse is to use informed consent about the risks and consequences of their decision. Ultimately, a dentist is supposed to respect the patient's right to choose, but in your case...you're giving them the choice of taking the X-Rays or choosing another dentist. 👍

As far as getting a teeth cleaning without an exam, I guess from the dental professional's viewpoint the legal risk is also there.
 
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KOM said:
Another thing -

When obtaining informed consent, the patient must be informed of all of the following -

• A description of the proposed treatment
• The foreseeable risks
• The benefits and prognosis of the proposed treatment
• All reasonable alternatives to the proposed treatment
• The risks, benefits, and prognosis of the alternative treatments

What good is getting it if a patient can just plead ignorance and still win a lawsuit against you? Is it just to cover your butt a little more?

I'm assuming you must get informed consent before each and every procedure is performed, but can it be oral or written? Is written better to have from a legal standpoint? If so, do you need to write out the above information every single time?
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One of the best pieces of advice I've ever gotten, from one of the surgeons at my residency hospital: "Informed consent is a process, not a sheet of paper."

If you can demonstrate that you've gone to reasonable lengths to explain the treatment itself, its risks and benefits, and risks and benefits of alternative treatments (including doing nothing), you've met your obligation. It doesn't guarantee that an unhappy patient won't try to sue you if they don't like the results, but it makes your position much more defensible.

Like the other dentists in the thread have mentioned, I won't treat a patient who refuses to let me take appropriate radiographs. I'm happy to explain why I want them and how they'll help me, if the patient is curious or worried, and I would never impinge on their prerogative to refuse, but treating someone with inadequate diagnostic data risks the patient's health and the dentist's career.
 
KOM said:
I can understand kicking them out. According to the code, if a patient refuses to have X-Rays taken your only discourse is to use informed consent about the risks and consequences of their decision. Ultimately, a dentist is supposed to respect the patient's right to choose, but in your case...you're giving them the choice of taking the X-Rays or choosing another dentist. 👍
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What 'code' are you talking about? They didn't trust my professional decision, putting my diagnosis at risk and insulting my judgement, so I asked them to go elsewhere. I had another patient who initially refused xray only to consent after the threat being kicked out; and the xray showed an interpromixal decay. He didn't even thank me for saving him a root canal but continued to be a PIA in other ways to this day. I wish I can find a way to kick him out, too.
 
Daurang said:
What 'code' are you talking about?
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ADA's principles of ethics and code of professional conduct under patient autonomy where "the dentist has a duty to respect the patient's rights to self-determination and confidentiality" and that "professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment"
 
PIA?

My father has always told me it usually only takes one appointment to recognize a patient you don't want anything to do with. Any truth to this?
 
KOM said:
I can understand kicking them out. According to the code, if a patient refuses to have X-Rays taken your only discourse is to use informed consent about the risks and consequences of their decision. Ultimately, a dentist is supposed to respect the patient's right to choose, but in your case...you're giving them the choice of taking the X-Rays or choosing another dentist. 👍

As far as getting a teeth cleaning without an exam, I guess from the dental professional's viewpoint the legal risk is also there.
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The patient can't consent to substandard treatment. They can only consent to Tx options that are all within the standard of care. Radiographs are standard of care unless you can get recent duplicates from a previous dentist.
 
KOM said:
PIA?

My father has always told me it usually only takes one appointment to recognize a patient you don't want anything to do with. Any truth to this?
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So your father's a dentist? Why are you asking us the same question just to get the same answer? I am sure your father probably told you the same thing.
 
KOM said:
ADA's principles of ethics and code of professional conduct under patient autonomy where "the dentist has a duty to respect the patient's rights to self-determination and confidentiality" and that "professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment"
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This doesn't exactly play out to well if you're on the witness stand being questioned by the patient's attorney as to why you didn't treat the problem earlier that caused their client the "great pain" and "debilitating loss of function" because of how advanced it had gotten. You can document the patient's refusal all you want in the chart, but the majority of the time if it leads to you delivering care which is below what is accepted as the standard, just about any prosecuting attorney out there will be able to have their way with you on the stand if something happens as a result.

That's the cold hard reality of this situation.
 
Screening good and bad patients should be one of the highest priorities. There are legal ways of IDing "bad/troublesome patients" and making it so inconvenient to get Tx for you, that they would not want to go to your office (although there is a stigma of word of mouth), but if you can keep it mostly positive, shouldn't the business have a great reputation overall?

It is definitely unfortunate that we may be heading into medicine in such a litigious society. However, I have heard that lawyers will often perform a check on your assets and see if you are worth suing. If you are able to employ effective asset protection, you may be able to appear poor. In terms of liability, it is natural to file a lawsuit against the entity with the most money(i.e why sue a McDonalds employee when you can sue McDonalds);
 
indentition said:
It is definitely unfortunate that we may be heading into medicine in such a litigious society. However, I have heard that lawyers will often perform a check on your assets and see if you are worth suing.
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You're absolutely right !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

...and I hope that every dentist will do everything in their utmost power to prevent a litigation lawsuit against you.

I've been sued under my father's car-insurance policy for something that would "normally" be considered kibbles and bits.

They got a taste of "dentist" under the policy name however, and a 15mph impact became a life threatening complication.

Protect yourself from these free-loaders. They are out there.
 
KOM said:
My wife was recently trying to schedule a teeth cleaning and couldn't find one dental office out of about five that she called that would allow her to do it without a dental exam. When she asked for a simple explanation they said that they just don't do it. I figure at least they could have explained why.

Reasoning? Thoughts?
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I am a dental hygienist and in the state I practice in, it is illegal for me to perform treatment of any kind on a patient without the consent of a dentist or if the dentist has not performed an exam within a certain amount of time. Therefore, without any examination at all, it's illegal for me to do a cleaning. It's a legality and liability issue. I would think that this is a general rule in most of the states in which dental hygienists practice under direct or general supervision of a dentist.
 
KOM said:
PIA?

My father has always told me it usually only takes one appointment to recognize a patient you don't want anything to do with. Any truth to this?
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my father has also said this to me. I will take 30+ years of experience as truth.
 
I am really glad to see this thread revived. I actually just dealt with this exact situation the other day. I had a patient come in for a prophy and when I was reveiwing their chart noticed we needed updated probings and x-rays. Explained to the patient we would need to do an exam instead of their cleaning today (our exams require several checks, hard to do both an exam and a cleaning at one appointment) and apologized for the inconvenience. Patient got upset, said they wanted their cleaning or nothing at all, then got up and left. I tried to explain the reasoning behind why we needed updated information and how I can’t clean their teeth without an exam but they didn’t care. They got up and left.

I didn’t feel that I did anything wrong. I had almost the exact same situation the day before. Patient came in for a prophy but noticed we needed updated perio charting and xrays. Explained to the patient we would need to do an exam and take xrays. Patient understood the need for the exam and agreed. During the exam it was determined they had periodontal disease and would be needing 3 quads SRP 1-3th. Had I just proceeded with the prophy on this patient without doing an exam, I would have been operating below SOC and would have left periodontal disease untreated. I will never force a patient to do something they do not want to do, but I am also not going to feel bad for holding a standard that says regular exams need to be completed prior to any kind of dental work, including cleanings.
 
KOM said:
My wife was recently trying to schedule a teeth cleaning and couldn't find one dental office out of about five that she called that would allow her to do it without a dental exam. When she asked for a simple explanation they said that they just don't do it. I figure at least they could have explained why.

Reasoning? Thoughts?
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First we diagnose and then we treat. "Cleaning" is treatment, extent of which is determined by the diagnosis. The best way to save-on-teeth is to see your dentist regularly
 
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