Journal 072019 PDF

Journa
July 2019
Patient Safety
Checklists
Legal Perspectives
Emergency Medications
C A L I F O R N I A D E N TA L A S S O C I AT I O N
Safety in
DENTISTRY
Perspectives and Directions
David L. Rothman, DDS
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July 2019 C D A J O U R N A L , V O L 4 7 , Nº 7
D E PA R T M E N T S
421 The Editor/Decorum

425 Impressions
465 RM Matters/Avoid Medication-Related Tragedies
With Comprehensive Health History Forms
469 Regulatory Compliance/Security Incident

Response Procedures
474 Tech Trends 425
F E AT U R E S
431 Safety: It’s Not Exciting but Sure Is Necessary

An introduction to the issue.
433 Introducing Safety in Dentistry: Perspectives and Directions

Safety conventions and initiatives have slowly begun to materialize in dentistry but have
lagged behind their medical counterparts.
Alfa Yansane, PhD; Muhammad F. Walji, MS, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD
439 Checklists as Tools for Improving Patient Safety in Dentistry

Checklists have emerged as practical and effective tools for realizing a safer health
care environment.
Oluwabunmi Tokede, DDS, MPH, and Elsbeth Kalenderian, DDS, MPH, PhD
447 The Cost of Not Practicing Safely: Perspectives in the Legal Profession
This article elucidates the legal ramifications of the unsafe practice of dentistry.
Steven D. Barrabee, Esq.
455 Making Dentistry Even Safer: Understanding the Proper Choice and Use of
Oral health care practitioners and the entire office team must be vigilant in recognizing
signs of patient distress and trained to take appropriate action when needed.
Mark Donaldson, BSP, ACPR, PharmD, and Jason H. Goodchild, DMD
JULY 2 0 1 9 419
C D A J O U R N A L , V O L 4 7 , Nº 7
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July 2019
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420 J U LY 2 01 9
Editor C D A J O U R N A L , V O L 4 7 , Nº 7
Decorum
Kerry K. Carney, DDS, CDE
I
n September 2018, Senate Bill 1343
was signed into law. Beginning Jan.
1, 2019, the law requires expanded The basis of this legislation and the simple principle
training on sexual harassment
prevention for all employees. The
is: Each of us should have the right to have a
impact of SB 1343 will be felt in every personal sense of dignity and well-being at work.
dental practice in California with five
or more employees. The training must
be completed by Jan. 1, 2020, and must
be repeated every two years. SB 1343 That is a summary of the changes Consideration, tact and courtesy: Is
distinguishes between employees with that employers are challenged to comply that really a burden? Surely we should
supervisory oversight and those employees with prior to the Jan. 1, 2020, deadline all expect to operate with the decorum
who are supervised. The former require a and beyond. This is the point at which appropriate for a professional environment
two-hour training and the latter require this article could veer into a diatribe in our dental practices. Why should
a one-hour course. Training must be against regulation. Some folks might rail consideration, tact and courtesy be
completed within six months of hire against the slings and arrows of outrageous viewed as a penalty? Somehow, decorum
or promotion to a supervisory position. fortune that drain energy and attention has taken on a diminished connotation
In addition, beginning Jan. 1, 2020, from providing patient care and divert it of cold indifference or even hostility.
temporary employees will need to be to crossing t’s and dotting i’s in order to Some folks feel that there is something
trained (or show proof of prior compliant remain in compliance with government wrong with striving to foster and support
training) within 30 days or 100 hours of regulations. Some might go on about the appropriate office decorum. It seems
employment, whichever comes first. how this is the least fulfilling part of as if the preferred office behavior, for
Our California law is more our activities as dentists. Some might some, should be casual and family-like.
comprehensive than the federal version. throw up their hands and blame the new It is easy to understand why family-
Our state law specifies strict liability, requirements on a bunch of snowflakes like interactions could cause problems
that is, the employer has no defense if that cannot take a joke … but I will not. in a professional setting. A special field
a manager or supervisor is the harasser. I will not, because I actually think of psychological counseling exists that is
In addition, California includes these new requirements are a good thing. dedicated to marriage and family therapy.
volunteers and unpaid interns within The basis of this legislation and the simple Its goal is to help individuals come to
the group that must receive training. principle is: Each of us should have the terms with familial social interactions.
For a full review of the new right to have a personal sense of dignity This should give us some hint that this
requirements for employers, see Steps and well-being at work. It really is pretty kind of setting could lead to highly
to Harassment, Discrimination and simple. However, assuring dignity and emotionally charged interactions.
Retaliation Prevention Guide on the well-being does not come naturally or Some people feel the interactions
CDA Practice Support webpage. easily for everyone. That may be especially in the office should reflect friendship
CDA has developed a webpage true in today’s normalized climate of and camaraderie not unlike what
dedicated to information that attack and defense, insult and offense. one might experience in a locker
members need to know to comply with Maintaining decorum in the professional room. But the locker room is a
harassment prevention laws. Policy space is really what is being called for. psychosocial minefield of its own.
development, distribution, employee Merriam-Webster defines decorum as I remember complaining to a friend
notice requirements and training are fitness, orderliness and the conventions of in dental school that it was very tiring
all addressed. Members can access polite behavior. The dictionary goes on to having to ignore the sexist jokes and
the information at cda.org/member- define polite as marked by an appearance of graphic posters in our preclinical lab.
resources/practice-support/employment- consideration, tact, deference or courtesy … My friend suggested that the jokes and
practices/harassment-prevention. marked by a lack of roughness or crudities. posters were just manifestations of being
JULY 2 0 1 9 421
JULY 2019 EDITOR
accepted into the “locker room.” It the environment promotes learning In the locker room scenario, most of
meant I was accepted as one of the boys, and establishes a sense of professional the men present probably did not intend
part of the group. But the jokes were decorum. If that is the case, then proper to demean or hurt members of my gender.
not clever and the poster objectified my office decorum should be easily attainable. Yet, had they been able to empathize with
gender. The environment did not feel Creating a workplace environment free how assaultive the behavior might be
welcoming. It did not feel considerate. of sexual harassment for our employees perceived, they might have understood
There was no sense of decorum. It should be what we all strive for. the loss of dignity that some of us
certainly was not polite behavior. It The key stumbling block in achieving experienced. They might have refrained
did not engender respect or dignity. that goal may spring from our tendency from instigating or perpetuating the
I like to think that the discomfort to view behavior through our own lens behavior. They might have even stepped
that some of us experienced as sexual or as a projection of our own intent. If we in to reinterpret and model empathy
harassment in dental school is a thing attempted to extend our understanding to for the targets of the bad behaviors.
of the past. Today’s environment is envelop the experience of others on the For these reasons, I think the
surely more collegial, more welcoming receiving end of a behavior, we might better sexual harassment prevention training
to all students. I am sure that today understand the transaction that takes place. requirements are a positive step. Perhaps
the training can move us beyond
interpreting our behaviors based solely
on our intent or our personal behavioral
habits. It may help us understand that
harassment is not defined by “a line” that
should not be crossed. If training can
improve our ability to understand and
share the feelings of another, then we
might be able to reduce the social and
emotional noise that distorts our everyday
human interactions at the office. After
all, an office that functions with the
appropriate professional decorum fosters
a personal sense of dignity and well-
LIMITLESS being in everyone who works there. ■
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422 J U LY 2 01 9
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Impressions C D A J O U R N A L , V O L 4 7 , Nº 7
Multiple Fee Schedules

David W. Chambers, EdM, MBA, PhD
What a mess! A crown for this patient can be billed at

$1,200 because she is highly motivated and fee for service. The
same crown for another patient is $820, but the patient is
balking at the copay. If the eligibility period is jiggered, the
situation might be improved. A Medicaid patient may not
have any third-party assistance or personal means of affording
badly needed treatment. All of the patients may benefit to the
same extent from a crown, and of course the quality of work
and attending treatment support must be identical in every
case. Surely, there must be an ethical issue here somewhere.
Sometimes we try to solve these problems based on these
assumptions: Patients value treatment exactly the same way
dentists do and “somebody” is supposed to be providing sufficient
funds to keep dentists gainfully employed according to their
standards. The polar-opposite position is equally indefensible.
Dentistry is not a free-market commodity because patients
are not fully informed and uncoerced actors and oral health
burdens are borne to some extent by society as a whole.
Here is a true story that may help untangle this. When
I was a new faculty member at UOP in 1972, Dean Dr.
The nub:
Dale Redig sent me down to the Stanford Business School
1. Value of services is to see if we could get a little consulting help. I met with
Dr. James March, a paragon in business decision-making.
determined by patients and I tentatively inquired about fees and Dr. March quoted
payers, not by dentists. what at the time was unthinkable: $700 per hour.
He recognized my consternation and gave me a three-
2. Cost of providing minute business lesson that was worth well more than $700.
acceptable care to all patients He said he would offer the same advice to General Motors
is determined by dentists. or the Palo Alto YMCA. It would be a bargain for the big car
manufacturer and a bad investment for the YMCA. Lesson:
3. Dentistry works when the The value of any service is determined by the consumer.
Dentists are justified in offering their professional services
fully informed and uncoerced
at any price they deem appropriate, provided that it is the same
value to patients and cost to price and quality to all patients. Patients are entitled to make an
dentists are aligned. informed and uncoerced choice about receiving care. Patients
will value identical care differently based on their personal
values, available subsidies and intangibles such as convenience of
appointments (which may add hundreds of dollars to the nominal
David W. Chambers, EdM, MBA, PhD, is a professor
of dental education at the University of the Pacific, Arthur fee). Third parties, such as employers, the government and
A. Dugoni School of Dentistry in San Francisco and the charitable causes, are justified in tilting the market in favor of
editor of the American College of Dentists. certain groups for social effect by adding money for target groups.
What is not ethical is to cherry-pick patients or mislead
them in an effort to “work around” what dentists may regard as
insufficient funds for the kind of work they would like to do or
to overtreat and overcharge to make things “fair” for them. ■
JULY 2 0 1 9 425
JULY 2019 IMPRESSIONS
New Oral Appliance Helps Sleep Apnea

Researchers at Hiroshima University Hospital developed a new oral
appliance that is effective at opening the airways of patients with mild to
moderate sleep apnea, according to a study published in the journal Sleep
Disorders in March 2019.
The new appliance brings the jawbone forward to enlarge the air passageways
Identifying Domestic Violence at the back of the mouth. The appliance is custom made for each patient and allows
jaw movement so it doesn’t affect patients’ teeth or change the shape of their face.
Victims in the Dental Office “This is like when you have to use glasses, you have to wear them every time
Dentists are a key factor in helping you want to see properly so patients have to wear this appliance every time they
patients obtain good oral health, but want to sleep better,” said study author Hiroshi Ueda, PhD.
according to new research, they could To further investigate how well the appliance works, the research team
also play an important role when it scanned a group of patients with mild to moderate sleep apnea using multislice
comes to identifying domestic violence computed tomography (MSCT) — a type of X-ray where the machine rotates
victims. A recent paper published in the around an object and takes a picture each time it rotates. This data is then
Journal of Aggression, Maltreatment and combined to see a 3D object and is a fast and precise method of scanning.
Trauma reports that as much as 75% of
Previous research usually measured patients standing up, which does not
head and neck trauma associated with
simulate sleeping conditions. This study measured the change in airway space of
domestic violence occurs with oral injury.
13 patients lying flat. The team found that wearing the appliance almost halved
The paper was written by researchers
the number of times the patients had sleep apnea episodes during the night and
at the University of Arizona College
widened their airways to allow easier breathing.
of Medicine-Phoenix and Midwestern
University, who believe dentists may be Read more of this study in Sleep Disorders (2019);
the first and only health professionals to doi.org/10.1155/2019/8509820.
evaluate a domestic violence victim.
“The overall purpose of the paper is The mandibular advancement appliance.
to bring dentistry and its subspecialties (© 2019 Yu Matsumura et al.)
into the conversation about traumatic
brain injury (TBI), specifically in cases
of domestic violence,” said Midwestern
University dental student Timothy include tears, fractures, breaks and co-author of the paper and director of
Ellis, lead author of the study. chips in the teeth and mouth that are preclinical faculty at the Midwestern
Researchers say an estimated 41.5 inconsistent with personal history. University College of Dental Medicine,
million people will experience some While dentists are in the Arizona. “As health care providers,
type of domestic violence during their unique position to be the first to we are already obligated to report
lifetime and 20.75 million of those detect evidence of assault, they suspected abuse. I do not feel that this
victims will sustain a traumatic brain receive little to no education will add an undue burden to dentists.”
injury. Signs of violence that may about identifying and discussing Researchers continue their study in
indicate brain injury include jaw or domestic violence with potential hopes of helping at least one patient who
tooth fractures, trauma to nerves in victims, according to the paper. may be a victim of domestic violence.
the mouth and jaw as well as damage “All dentists should be educated Read more on this study in the
to the nasal bone. Additional signs on the identification of potential Journal of Aggression, Maltreatment
that could help dentists potentially injuries sustained as a result of domestic and Trauma (2019); doi.org/10.1
identify domestic violence victims violence,” said Sheri Brownstein, DMD, 080/10926771.2019.159580.
426 J U LY 2 01 9
Study Links Mother’s Health to Oral Health of Children

A new study of twins has found that that 1 in 3 Australian children have tooth
genetic makeup does not predispose people decay by the time they start school.
to tooth decay, but it did find that children This was the first twin study that
with overweight mothers are more likely looked at both genetics and early life
to have cavities. The paper, published in risk factors such as illness and lifestyle.
the latest edition of Pediatrics, estimates The study, which followed 173 sets
of identical and fraternal twins from
pregnancy through age 6, found that
1 in 3 twins had dental decay and
almost 1 in 4 had advanced decay.
Higher Atherosclerosis Risk for Children With Researchers also found that genetic
makeup does not influence tooth decay,
Oral Infections with environmental factors, like a lack
Children with oral infections may have a higher risk of contracting of fluoride in water, tending to be a
cardiovascular disease as an adult, according to a study published in JAMA prime cause of cavities. However, the
Network Open and conducted by the University of Helsinki Department of study did show that obesity during
Oral and Maxillofacial Diseases in collaboration with the national pregnancy was a definite marker for
Cardiovascular Risk in Young Finns study research group. increased risk of child tooth decay.
More progressed oral infections and inflammations such as endodontic “The relationship between maternal
lesions and periodontitis are known to be associated with several obesity and child tooth decay is
cardiovascular risk factors and disease risk in adults. Periodontitis in
complex,” said Mihiri Silva, DDS,
lead researcher and pediatric dentist
particular has been studied extensively in adults and currently is considered
at the Murdoch Children’s Research
an independent risk factor for atherosclerotic vascular diseases. However, the
Institute. “Perhaps the mother’s weight
association between childhood oral infections and atherosclerosis had not
has a biological influence on the
been studied prior to the University of Helsinki study, which began in 1980.
developing fetus or perhaps the risk of
That year, researchers documented the number of caries, fillings, bleeding on decay rises because of increased sugar
probing and probing pocket depth of 755 children aged 6, 9 and 12 who consumption in that household.”
underwent oral examinations. Their findings showed that 68% of the 6-year-olds, Dr. Silva stressed the seriousness
87% of the 9-year-olds and 82% of the 12-year-olds had bleeding, caries and of tooth decay due to the clear
fillings with no differences between boys and girls. Slight periodontal pocketing link between child cavities and
was observed in 54% of the children and it was more frequent in the boys than in developing diabetes and cardiovascular
the girls. Only 5% of the examined mouths were completely healthy. disease later in life. She also said
Researchers then measured the cardiovascular risk factors of participants several it was important that tooth decay
times over the next 27 years. The follow-up ended in 2007 when the carotid artery not be considered genetic.
intima-media thickness of participants was measured through an ultrasound “If people think the health of their
examination. The researchers concluded that viral infections were an independent teeth is down to their genetic makeup,
risk factor for subclinical atherosclerosis and their association with cardiovascular risk they may not be prepared to make
factors persevered through the entire follow-up. important lifestyle changes,” she said.
Learn more about this study in JAMA “Our findings reinforce how important
Network Open (2019); doi:10.1001/ it is for pediatricians and other health
jamanetworkopen.2019.2523. professionals to educate children to start
preventive measures early in life, prior to
the onset of damage to dental tissues.”
Read more on this study in Pediatrics
(2019); doi:10.1542/peds.2018-3499.
JULY 2 0 1 9 427
JULY 2019 IMPRESSIONS
Microscopic Robots Remove Dental Plaque

In the age of artificial intelligence, the use of robots has become the new
normal. Robots come in the form of automated vacuum cleaners, self-driving
cars and soon could be cleaning your teeth.
Drinking Water Linked to Conducted by a team of engineers, dentists and biologists from the
Fewer Sugary Drinks and University of Pennsylvania, a study published in Science Robotics details a
microscopic robotic cleaning crew designed to destroy harmful bacteria. The
Calories in Kids researchers believe the robotic system serves many purposes from reducing
Children and teens who drink water the risk of tooth decay and endodontic infections to cleaning water pipes and
are less likely to consume sugary beverages catheters, which are also common areas for bacteria to form.
throughout the day, according to a The research team designed two types of robotic systems, which they called
study published in JAMA Pediatrics. catalytic antimicrobial robots or CARs. The robots are capable of breaking down
Researchers analyzed data from and removing biofilms on surfaces and inside confined spaces. Tested on flat glass
8,400 children and teens aged 2 to 19
surfaces and enclosed glass tubes, the microscopic robots effectively killed bacteria,
collected between 2011 and 2016 as part
broke down the surrounding matrix and removed debris with high precision.
of the National Health and Nutrition
Researchers then tested the systems on hard to reach parts of a human
Examination Survey, which is administered
tooth. The CARs were able to not only degrade and remove bacterial biofilms
yearly by the U.S. Centers for Disease
from a tooth surface, but also from the isthmus, the narrow corridor between
Control and Prevention. Parents and
kids were asked to recall what the root canals where biofilms commonly grow.
children had consumed in the previous “Existing treatments for biofilms are ineffective because they are
24 hours and the calories were totaled. incapable of simultaneously degrading the protective matrix, killing the
One out of every five kids and young embedded bacteria and physically removing the biodegraded products,”
adults reported that they did not drink said Hyun (Michel) Koo, DDS, co-author of the study and professor in the
water in the day prior to the survey. School of Dental Medicine, University of Pennsylvania. “These robots can do
Not drinking water was associated with all three at once very effectively, leaving no trace of biofilm whatsoever.”
consuming an extra 93 calories per day Researchers say plowing away the degraded remains of the biofilm
on average and 4.5% more calories from substantially decreases the chance of it regrowing.
sweetened beverages such as sodas, sports Learn more about this study in Science Robotics (2019); doi:10.1126/
drinks and juice, according to the study. scirobotics.aaw2388.
The number of extra calories
consumed varied by age as well as race
Microrobots cleared a glass plate of a
and ethnicity. Caucasian children who biofilm as shown in this time-lapse image.
didn’t drink water got an extra 122 (Image: Geelsu Hwang and Edward
calories from sugary beverages, while Steager, University of Pennsylvania)
Hispanic children consumed an extra
61 calories and African American
children an extra 93 calories.
The research was not designed
to determine what amount of water With the limitations in mind, elsewhere and all it takes is an extra 70
would prevent kids from drinking the research team stressed that sugar- calories or so per day for a child to gain
sugary beverages but rather whether sweetened beverages add empty calories excess weight and be at risk for overweight
drinking water at all had an effect, to children’s diets and may increase or obesity, according to the study.
explained Asher Rosinger, MPH, PhD, the risk of weight gain, obesity and Learn more about this study in
assistant professor at Pennsylvania State diabetes. Kids who don’t drink water JAMA Pediatrics (2019); doi:10.1001/
University and lead author of the study. are more likely to get their fluids jamapediatrics.2019.0693.
428 J U LY 2 01 9
Study Explains How a Pathogen Causes Hospital Infections

Researchers discovered that three “From a big picture point of view, this is
closely related species of bacteria belonging a huge step forward toward understanding
to the family Enterobacteriaceae outlived microbial social structure and ecology,”
all other oral bacteria in long-term said Wenyuan Shi, PhD, CEO and chief
starvation or a “doomsday” experiment, scientific officer at the Forsyth Institute.
according to a paper published in the Researchers from the Forsyth Institute, the Tile scan of a hedgehog structure in plaque. Image
is a composite of seven fields of view showing a
Proceedings of the National Academy of J. Craig Venter Institute, the University
plaque sample with three adjacent hedgehogs.
Sciences. These results helped answer of Washington and the University of
(Credit: Jessica Mark Welch and Gary Borisy,
the question of how certain dangerous California, Los Angeles led the study. PNAS.1522149113)
bacteria are able to persist in a sterile To create a battle of bacteria, the
hospital environment and infect patients. research team placed hundreds of
samples of oral bacteria from human
saliva into test tubes. The bacteria,
which are accustomed to living in the
nutrient-rich mouth, were starved
Biodegradable Chewing Gum Kills Bacteria, in their new environment. Each day,
Removes and Prevents Plaque scientists checked the samples to see
which bacteria were still alive.
Emily Siegel, a University of Pittsburgh senior majoring in chemical
Nearly every bacterial species
engineering and biological sciences, invented a biodegradable chewing gum that
died within the first couple of days,
kills bacteria and removes and prevents plaque. The gum, called Trek, was
according to the study. But three species
developed for an assignment in a product design class that challenged students to — Klebsiella pneumoniae, Klebsiella
think of a problem and come up with a product to solve it. The memory of multiple oxytoca and Providencia alcalifaciens —
late nights when she was too tired to even brush her teeth sparked Siegel’s idea. survived the longest, with Klebsiella
Trek took the top prize in the most recent Big Idea Blitz, a 24-hour event in pneumoniae and Klebsiella oxytoca
which student innovators recruit fellow students to their teams and work with surviving for more than 100 days.
Innovation Institute entrepreneurs-in-residence to develop their ideas, understand Researchers were surprised to find that
the market need and hone their pitches. Siegel’s winning pitch cited a study by Klebsiella were among the champions of
Delta Dental that found that 37% of adults aged 18 to 24 had gone two or this bacterial combat. In their natural
more days without brushing their teeth. environment of the oral cavity, Klebsiella
Not only does Trek remove and prevent plaque, it’s also better for the are considered an underdog. They account
environment because it creates no plastic waste, unlike disposable single-use for only about 0.1% of all microbes in the
toothbrushes, and is 100% biodegradable. mouth. But in an extreme environment
Siegel envisions that this product not only will benefit busy millennials, deprived of all nutrients, Klebsiella reigned
but also will appeal to travelers, members of the military and people in supreme while the bugs normally found
places where clean water is difficult to come by. Trek’s prize money is in high abundance rapidly died off.
going toward further development of this idea around which Siegel intends How did Klebsiella pull off such a
to create a company and an entrepreneurial career. feat? To answer this question, scientists
Read more about Trek and the Big analyzed the genome of the bacteria on
Idea Blitz at pittwire.pitt.edu/news/ the first day of “battle” and then again
those-too-tired-brush.
on day 100. The researchers found that
the Klebsiella had undergone genetic
mutations that may have allowed
Lauren Yocum and Emily Siegel won the
2019 Randall Family Big Idea grand prize.
them to survive and continue to
(Credit: Tom Altany/ University of Pittsburgh) function, even without a food source.
Read more of this study in Proceedings
of the National Academy of Sciences (2019);
doi.org/10.1073/pnas.1820594116.
JULY 2 0 1 9 429
introduction
Safety: It’s Not Exciting

but Sure Is Necessary
GUEST EDITOR
T
David L. Rothman, his and an upcoming issue of Our day in the dental office is not
DDS,speaks worldwide the Journal of the California much different but we don’t quite
to dental and medical Dental Association are about realize it; we tend not to spend much
groups on anesthesia,
sedation, pediatric dentistry
a subject that most of us time thinking about the safety of our
and dentistry for people spend little to no time dental environment. When most
with special needs. He thinking about: safety. I began writing people think about safety, we remember
is a diplomate of the this and thinking about safety more a kid from elementary school with
American Board of Pediatric than four years ago while sitting on a yellow Sam Browne belt escorting
Dentistry and a fellow of
the American Academy
an airplane traveling nearly 600 mph us across the street — a member of
of Pediatric Dentistry. He at 34,000 feet. At the time, I hoped the “safety patrol” helping us safely
received his dental degree that someone took safety seriously navigate the dangerous crossings.
from the NYU College of when the plane was being designed, We, as practitioners, have to make
Dentistry and completed a built, flight tested and delivered the dental environment safe for our
general practice residency
at Albert Einstein Medical
and before takeoff with the preflight patients, our staff and ourselves. And
Center in Philadelphia, maintenance and walk-around of the though the news media has had lots to
an anesthesia residency plane on the ground. We rarely think write about lately concerning behavior
at the Medical College about the other aspects of flight safety management, anesthesia and sedation
of Pennsylvania and a involving the control tower and air in children, safety is also about dental
pediatric dentistry residency
at Children’s Hospital/
traffic controllers, the acceleration of materials, procedures, medication errors
Oakland and the University the plane, the impact of the tires on and ergonomics. It’s about everything
of California, San Francisco. the runway or the takeoff and flight. we do during our days in the office.
Conflict of Interest As the plane hurtles through the Doing it “like the airlines do it”
Disclosure: None reported. sky, ground control is plotting a safe has always been a safety catchphrase
route avoiding collisions. In the air, and the apex of safety training with
the pilot and co-pilot are checking checklists, safety checks and walk-
and rechecking the instruments, arounds, but recently there have
monitoring the operating functions been chinks in the airlines’ armor.
of the plane as the flight crew The Boeing 737 Max debacle is a
monitors the safety of the passengers. prime example of trying to patch an
JULY 2 0 1 9 431
introduction
old system: not training pilots in a Commission for Accreditation of in setting up and following a culture
known flaw and neglecting to put a Hospital Organizations for hospitals of safety. The simplest concepts of
monitoring light in the cockpit when set requirements and certify facilities “time outs” to verify the patient and
the new system goes against all prior in all areas of the delivery of health procedure and written checklists to
training activities. This violates every care. Our dental offices are little make sure we are fully prepared are
part of safety culture and undermines hospitals with reception, billing, key not just for advanced procedures
and erodes the trust that the public central sterilization, human resources, of sedation and anesthesia but for
puts in the airlines industry. radiology, operating rooms, equipment our daily routines (a variety of
We have similar issues in dentistry and maintenance, IT and other support customizable safety checklists are
and medicine, but dentistry is services, auxiliary staff and building available at adsahome.org). Training
not the only health care related and grounds workers. We are mini and practice must be maintained
business or profession dealing with surgicenters and as such are regulated with records kept. The costs of not
this. The American Association and permitted by local and state practicing safely are very high.
for Accreditation of Ambulatory boards and federal mandates including Although dentistry is at a bit of a
Surgical Facilities for ambulatory OSHA and HIPAA. We can learn disadvantage, being an office-based specialty
surgical facilities and the Joint lessons from these other organizations with limited internal quality assurance,
we can learn from the best practices in
medicine and make them available to our
member dentists. To help you develop a
safer dental practice, the authors of this
issue of the Journal are nationally and
internationally known experts in their
fields of safety and dental education.
Elsbeth Kalenderian, DDS, MPH, PhD,
and co-authors provide an introduction
and overview to safety and the tools
needed in the dental office. Oluwabunmi
Tokede, DDS, MPH, demonstrates the
use of checklists to organize and improve
flow and function, much like pilots do
prior to takeoff. Steven Barrabee, Esq.,
an attorney who frequently works with
dentists through The Dentists Insurance
Company, discusses the actual costs of not
practicing safely. Mark Donaldson, BSP,
ACPR, PharmD, and Jason Goodchild,
DMD, discuss the use of medications in
emergency treatment and provide an
understanding of how and why they work.
This Journal issue and the one
following will start you on your path
to developing a safety program in
your office through an understanding
of the many complexities of the
situation. Because while it may not be
exciting, safety sure is necessary — in
the air and in the dental chair. ■
432 J U LY 2 01 9
patient safety
Introducing Safety in Dentistry:

Perspectives and Directions
Alfa Yansane, PhD; Muhammad F. Walji, MS, PhD;
and Elsbeth Kalenderian, DDS, MPH, PhD
AUTHORS
H
Alfa Yansane, PhD, is an Muhammad Walji, ealth care professionals strive based decision-making is promoted
assistant adjunct professor MS, PhD, is the associate to provide care that adheres and the process of continuous quality
in the department of dean for technology
to the highest standards of improvement (CQI) is always used.11
preventive and restorative services and informatics
dental sciences at the and a professor in the
safety, but unfortunately harm Such safety conventions and initiatives
University of California, department of diagnostic to patients continues to be have slowly begun to materialize in
San Francisco, School and biomedical sciences an obstacle during the administration of dentistry but have lagged behind
of Dentistry. Her current at The University of Texas clinical treatment. Harm as a result of their medical counterparts. Possible
research interests and Health Science Center at
both individual and systemwide errors explanations for the sluggishness to adopt
areas of study include Houston School of Dentistry.
statistical modeling for His research interests are
is common in the provision of dental available patient safety practices in the
clinical information within focused on using informatics care.1–4 Evidence from case reports in U.S. include less severe harms, ambulatory
the electronic health record, approaches to improve the the literature5 as well as an analysis patients (outpatients), difficulty in data
oral health delivery systems quality and safety of oral of data from the U.S. Food and Drug collection, fears regarding retribution
and patient safety. health.
Administration Manufacturer and User for reporting errors and underdeveloped
Conflict of Interest Conflict of Interest
Disclosure: None reported. Disclosure: None reported.
Facility Device Experience database5 patient safety cultures.12 Although
reports that adverse events (AEs) occur mortality and significant morbidity are less
Elsbeth Kalenderian, with regularity within the dental office. likely occurrences in the delivery of dental
DDS, MPH, PhD, is a Medicine has put forth a multifaceted care, the harms as a result of treatment
professor and the chair
approach to address patient safety can produce consequential reductions
of the department of
preventive and restorative
through the formulation of methods in the quality of life for patients.13
dental sciences at the that focus on systemwide improvements
University of California, rather than punitive measures toward Defining Patient Safety for Dentistry
San Francisco, School of individuals.6–8 The concerted effort has There are several definitions of
Dentistry. Her research is
produced less personal censure of health patient safety that attempt to outline
focused on patient safety
and quality improvement.
care practitioners, increased the appetite the topic’s parameters as evidenced
Conflict of Interest for redesigning systems within health care by the study conducted by Bailey et
Disclosure: None reported. delivery, expanded the commitment to al.14 The Institute of Medicine (IOM)
transparency and ushered reevaluations defined patient safety in 2000 to be: “The
of organizational cultures.6,9,10 prevention of harm to patients.” Vincent
Health care has also looked in 2006 defined it to be: “The avoidance,
toward industry for guidance, mainly prevention and amelioration of adverse
borrowing tools from the total quality outcomes or injuries stemming from
management (TQM) framework. The the process of health care.” The World
TQM approach strives to create a culture Health Organization (WHO) in 2011
where all processes are done correctly. defined it as: “The reduction of risk of
The framework demands a significant unnecessary harm associated with health
commitment from management and care to an acceptable minimum.” The
tries to create employee empowerment National Advisory Group on the Safety
through training and recognition. Fact- of Patients in England in 2013 defined
JULY 2 0 1 9 433
patient safety
FIGURE 1. AHRQ
elements of a patient
safety initiative.
Element 1: Element 2:
Identify threats Identify and
to patient safety evaluate effective
patient safety
it as: “Avoiding harm from the care that practices
is intended to help.”14 At their core, the
common themes that permeate each
definition are the prevention, reduction
and/or mitigation of harms to patients Element 3: Element 4:
as a result of provider treatment. Patient Educate, disseminate, Monitor threats to
implement and raise patient safety to
safety has spurred considerable national
awareness ensure that a safe
investment from both governmental
environment
and independent entities like the reports
continues
from the U.S. Department of Health
and Human Services (The National
Healthcare Quality and Disparities
Report and Healthy People 2010,
2020) and the National Academy of
Medicine.4,15 Each has listed patient safety
as a distinct public health priority.4,15 Strategies To Assess Patient AHRQ has developed instruments
As a point of action in 2002, the Safety Culture for an array of clinical settings that have
Agency for Healthcare Research and Thorough and comprehensive methods been used to gauge an organization’s safety
Quality (AHRQ) proposed a four- are required to assess patient safety climate, some of which have been adapted
element patient safety initiative in an within a health organization regardless for dentistry.18,23 Notably, the MOSOPS
effort to curb treatment-related harms.16 of its size. This includes the systemwide instrument, which was tailored to single
This model was used as a framework to engagement of company leadership, the specialty and primary care clinics in the
identify and reduce the risk of harms evaluation of existing safety cultures, the outpatient setting, was most aligned to
associated with medical errors and advancement of education to enhance the dental arena.25 In 2008, Leong et al.
health care system-related issues. The communication and the development sought to assess the safety culture among
model consists of four elements: of reporting systems.7,8,17 High-reliability providers at seven U.S. dental schools
■ Identifying patient safety threats health care organizations are characterized using the MOSOPS and the results were
through rigorous chart reviews by effective communication and shared then compared with those from a similar
and assessing the organizational values for promoting a culture of safety. study conducted in 20 U.S. hospitals
patient safety cultures using the To initiate engagement, encourage in the Midwest.26 Leong found that the
Medical Office Survey on Patient data collection and facilitate reporting, seven dental schools outperformed the 20
Safety Culture (MOSOPS). medicine has developed several hospitals on overall perceptions of safety,
■ Identifying and evaluating instruments intended to measure an management support for patient safety and
effective patient safety practices institution’s safety culture, each consisting teamwork across units.26 Furthermore, the
using root-cause analysis and of items measuring the safety values of dental schools also scored higher than their
health care failure mode and health care providers.18,19 The Patient medical counterparts for the overall score
effect analysis (HFMEA). Safety Cultures in Healthcare Organization from the 12 sections of the survey.26 In 2014,
■ Disseminating and implementing (PSCHO), the Hospital Survey on Patient Ramoni et al. assessed the safety culture
best practices while enlisting Safety (HSOPS) and the Safety Attitudes within the dental office by enlisting the use
the help of organizations Questionnaire (SAQ) are validated of the MOSOPS as well.25 The MOSOPS
and stakeholders. instruments with common dimensions was administered to providers in three U.S.
■ Monitoring threats to patient safety and comparative inference capabilities. dental institutions comparing the results
to ensure that a positive safety Versions of each survey have been used to to those of an aggregated national sample
culture is maintained (FIGURE 1 ). measure the safety culture among nurses, of approximately 1,100 medical offices.27
Each element carefully performed physicians and administrative staff in The study concluded that there was room
plays a key role in the sustainability of a variety of delivery settings (hospitals, for significant improvement in the patient
the safety effort. clinics, inpatient and outpatient).18, 20–24 safety culture of dentistry, particularly
434 J U LY 2 01 9
18
16
16
14 15
Frequency of reported AEs (%)
12 13
12
10
10
8
8
6 7
4 5
4 4 4
2
2
0
Pain Allergy Bleeding Other Infections Nerve Aspiration QoC Other Soft Hard WSPEs
or systemic injury or harm tissue tissue
toxicity complications ingestion injury damage
FIGURE 2 . Adverse event (AE) types.
when compared to the robust patient safety associated with an error or is considered frequently seen AE types were reported
culture in comparable medical institutions.25 preventable.” Causes were defined as: injuries and reported device malfunctions.
These studies show the MOSOPS “Factors that may lead to harm and not To continue AE identification (Element
instruments’ capacity for modification and the harm itself.” The authors identified 1 in FIGURE 1 ), Obadan-Udoh et al. in 2015
that it has been reliably used to evaluate 747 unique AEs and 540 causes. The three sought to report on dental adverse events
safety cultures in varying dental settings. most frequently identified AE types were through a retrospective review of case
“wrong-site, wrong-procedure (WSPE)” reports found in electronic bibliographic
Strategies To Identify Dental-Related at 16%, “hard tissue damage” at 15% and databases.33 The investigators found 182
Harms “soft tissue injury” at 13% (FIGURE 2 ). publications containing 270 adverse event
High-functioning patient safety The three most frequently reported causes cases. The largest types of harm reported
cultures are associated with improved were rule-based errors (43%), skill-based were delayed and unnecessary treatments
general safety metrics, increases in adverse active errors (22%) and knowledge- or disease progression after misdiagnoses.
event reporting and decreases in adverse based active errors (13%)(FIGURE 3 ). Among the reviewed cases, nearly 1 in 4
events and errors.28–30 To continue these The Food and Drug Administration patients experienced a permanent harm
trends, stakeholders must work to align the Manufacturer and User Facility Device adverse event and approximately 1 in 10
organization’s safety culture vision with Experience (MAUDE) database is case reports reviewed (11.1%) reported
the training of all dental providers.31 This another approach used to determine the that the adverse event resulted in the
involves analyses of provider descriptions distribution and type of AEs associated death of the affected patient. The study
of adverse events and how knowledge is with dental devices. The MAUDE concluded that although case reports
transferred to colleagues and the public.7 database contains reports from health are a rich data source for adverse events,
A study conducted by Maramaldi et al. care providers, consumers, manufacturers they represent an incomplete account
contributed to the dental patient safety and user facilities. Manufacturers and of the potential threats to patients.
initiative by developing an inventory of distributors are required to report device- In addition to the database searches,
AEs generated by interviewing dental related AEs to the FDA within 30 days. case reports and incident reports given
providers.5 The authors interviewed dental A study conducted by Hebballi et al. by providers, each of which has its own
professionals and domain experts through in 2015 downloaded and reviewed the shortcomings, the use of the electronic
focus groups where they were asked to dental device-related AEs reported health record (EHR) for retrospective or
identify the types and causes of AEs and to MAUDE over a 15-year period.32 concurrent chart review is a significant
recommend classifications for those that MAUDE received a total of 1,978,056 resource in identifying adverse events.
could occur in dental settings. AEs were reports during the study period and Investigators can select and review random
defined as: “Harm caused to the patient among these reports 28,046 (1.4%) were charts from the EHR to pinpoint adverse
by dental care, regardless of whether it is associated with dental devices. Most events within their respective practices.
JULY 2 0 1 9 435
patient safety
TABLE
Adverse Events Identified in the EHR Through the Use of Triggers

Latent technical Patient-related Adverse event categories AE count
5% other
6% Pain 57
Infection 16
Latent Hard tissue damage 11
organization
11% Nerve injury 6
Rule-based
errors Soft tissue injury/inflammation 5
43% Other orofacial harm 2
Knowledge-based
active errors Allergy/toxicity/foreign body response 1
13% Aspiration/ingestion of foreign body 1
Skill-based
errors Other systemic harm 1
22%
WSPEs (wrong-site, wrong-procedure 0
and wrong-patient errors)
Bleeding 0
Other harm 0
FIGURE 3 . Breakdown of causes. Total 100
Medicine has used random chart reviews one AE. Most AEs were classified as causing harm. Each of these studies showed that the
for adverse event reporting (adverse event temporary harm. In 2018, Kalenderian et al. dental clinic EHR-based trigger approaches
rate of 3% to 4%)1,2 but this method has continued this work by refining the triggers were more effective in AE detection than
been shown to be inefficient because it within the EHR and implementing them manual audit of random charts (TABLE ).
requires considerable resources to audit the within four academic dental institutions.39
large number of records.34 A more focused Eleven EHR-based triggers were developed Future Directions
approach to adverse event detection in and tested for efficiency in adverse event Although dentistry has made progress
the EHR has been the “trigger” method. identification. In order to validate each in patient safety initiatives, there are still
Each trigger is defined by a prespecified trigger, an iterative consensus-based process considerable gaps to fill. In order to fully
set of keywords found within the dental was employed. Two calibrated dental raters achieve the goals set forth in Element 2
charts/records and acts as clues to help independently reviewed a sample of the of the AHRQ model initiative, efforts
providers identify harmful incidents. triggered charts to determine AE status should be made to identify the causes of
The concept of a trigger (or clue) to and subsequent classification. To provide harm that occur within the dental office so
identify adverse events in the medical an additional degree of review, an expert that evidence-based safety practices can be
record was introduced by Hershel Jick panel reexamined the charts. A total of implemented. There are several analytical
in 197434,35 but was later automated and 100 AEs was identified by 10 of the 11 approaches that could be utilized to help
refined for use with the electronic medical triggers. Pain was the most common AE a dental organization establish a stable
record.36 The Institute for Healthcare identified, followed by infection and hard safety footprint. The Continuous Quality
Improvement (IHI) used triggers with tissue damage. As a quality improvement Improvement (CQI) strategies, the Total
manual record reviews in 1999 to identify strategy, pain was reported and classified Quality Management frameworks and the
adverse medication events, and adaptations as an adverse event. Chorney et al. have Institute for Health Improvement (IHI)
of the methodology for other areas of the argued that treating pain as an adverse model describe methods that repeatedly
hospital followed.37 More recently in 2013, event places accountability for patient pain assess an organization’s current state and
Kalenderian et al. created a dental clinic management in the hands of the providers, measures to advance the safety objectives.
trigger tool to compare its AE detection requiring them to perform standard care The analytical approach used in
performance with that of a review of with minimum pain and report instances medicine to ascertain the underlying
randomly selected patient records.38 In when pain management failed.40 The best determinants of dental-related harms is
total, 315 records were triggered, 158 (50%) performing triggers were those developed root cause analysis (RCA). The method’s
of which were positive for one or more to identify infections, allergies and failed purpose is to identify the source factors
AEs while 17 (34%) of the 50 randomly implants, and most AEs (90%) were responsible for the adverse events and
selected records were positive for at least categorized as temporary, moderate to severe provide solutions. RCA focuses on
436 J U LY 2 01 9
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National Healthcare Quality and Disparities Report and Fifth Attitudes Questionnaire — Ambulatory Version. J Gen Intern Med
Anniversary Update on the National Quality Strategy. Rockville, 2007;22(1):1–5. doi: 10.1007/s11606-007-0114-7. THE CORRESPONDING AUTHOR, Elsbeth Kalenderian, DDS, MPH, PhD,
Md: Agency for Healthcare Research and Quality; 2015. 24. Armellino D, Quinn Griffin MT, Fitzpatrick JJ. Structural can be reached at Elsbeth.Kalenderian@ucsf.edu.
JULY 2 0 1 9 437
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checklists
Checklists as Tools
for Improving Patient
Safety in Dentistry
Oluwabunmi Tokede, DDS, MPH, and Elsbeth Kalenderian, DDS, MPH, PhD
A B S T R A C T Safety is not a permanent state of affairs — we relentlessly need to work

at it. A health care system truly focused on health demands continuous attention to
patient safety. Against this backdrop, checklists emerged as practical and effective
tools for realizing a safer health care environment.
AUTHORS
S
Oluwabunmi Tokede, Elsbeth Kalenderian, afety is not a permanent state to repair iatrogenic harm have been
DDS, MPH, is a clinician DDS, MPH, PhD, is a of affairs — we relentlessly estimated at 17,757 euros per accident.4
and researcher. His professor and the chair need to work at it. A health The average dental claim is reported
research interests lie in of the department of
dental informatics, quality preventive and restorative
care system truly focused on to range from $30,000 to $50,000.5
of care and patient safety. dental sciences at the health demands continuous Although the sentiment is starting
He has authored and University of California, attention to patient safety.1 Though to change, with more focus on defective
co-authored multiple peer- San Francisco, School of the concern for not harming patients systems rather than flawed people,6,7 there
reviewed publications. Dr. Dentistry. Her research is has been a fundamental factor in is still the pervasiveness of a culture that
Tokede has also been PI/ focused on patient safety
co-investigator on many and quality improvement.
health care since it first began, the makes it difficult for medical or dental
NIH/NIDCR-funded Conflict of Interest 1999 publication of To Err Is Human: professionals to admit that errors can be
research projects, mostly Disclosure: None reported. Building a Safer Health System2 by the made. This refusal to acknowledge that
revolving around dental Committee on Quality of Health we make (and will continue to make)
quality and patient safety, Care in America of the Institute of errors compromises patient safety. A study
and has spoken worldwide
about those topics. He
Medicine, catalyzed a patient safety documented that dental practitioners
currently practices at the and quality revolution in medicine. make on average two errors per day and
Harvard Dental Center in Dentistry has been slow to embrace 1.4% of these errors lead to an adverse
Boston. this patient safety revolution. There are event where the patient could potentially
Conflict of Interest only a few structured or well-studied be harmed. The safest systems do not rely
Disclosure: None reported.
data regarding patient safety or adverse upon the practitioner to avoid making
events in dentistry. The existing body errors, but have a series of safety barriers
of literature describes isolated clinical that prevent errors from occurring.2 The
cases or short series on the basis of which dental community needs to invest in the
empirical clinical recommendations creation of a more effective environment
are made.3 Dentistry, however, must for the application of knowledge to health
become more involved in issues that care provision and delivery. Published
pertain to patient safety. A study reported studies affirm the need for tools that will
that the amount of resultant costs of help us consistently meet well-accepted
revision procedures and services required clinical guidelines and principles.8
JULY 2 0 1 9 439
checklists
Content/construct validity testing Discussion of results

by experts/users from testing by checklist
Closed questions: development team
■ Clarity
■ Comprehensiveness
■ Ease of use
Creation of first draft of ■ Fairness
Usability testing (field test run)
checklist (version 1) ■ Parsimony
■ To observe how it will work
■ Literature search ■ Pertinence
■ Expert consensus, etc.
within the clinic
Open-ended questions:
■ Strengths/weaknesses
■ Missing items
■ Recommendations for improvement
(Leading to version 2) Finalized checklist
FIGURE 1. Schematic for checklist development.
Checklists and Their Use in Medicine Checklists are used as cognitive aids preventing wrong-site surgery/wrong-
Against this backdrop, checklists to guide users through accurate task tooth extractions;24 in oral radiography to
emerged as practical and effective tools for completion. Checklists generally outline help improve the quality of radiographic
realizing a safer health care environment. criteria to be considered for a particular exposures, thereby impacting patient
Checklists have since transformed process. They function as a support safety by limiting unnecessary exposure
medicine, as they did aviation and resource by delineating and categorizing to radiation;25 and in prosthodontics26,27
engineering. They function as support items as a list — a format that simplifies to improve clinic-laboratory
resources by sorting items as a list — a conceptualization and recall of communication. Nevertheless, checklists
format that simplifies understanding and information.14 The use of checklists is are not commonplace in dentistry.
recall of information. From the earlier founded on the principle that human error
days when a surgery and intensive care is inevitable15 and checklists have proven Characteristics and Types of Checklists
unit (ICU) team was guided through the to be effective in various aspects of A checklist is a list of action items,
entire process of saving a girl who was lost performance improvement and error tasks or behaviors arranged in a consistent
beneath an icy pond for 30 minutes in a prevention and management.16–18 High- manner that allows the evaluator to record
small Austrian suburb5 to how in 2006 intensity disciplines such as the airline the presence or absence of the individual
they helped (via the Keystone initiative) industry and the military broadly employ items listed. Typically, each item is checked
to reduce the quarterly infection rate of checklists to decrease errors of omission off as it is completed, verified, identified or
central lines to zero, saving an estimated and improper implementation of answered by placing a mark in a designated
$175 million and more than 1,500 lives procedures and protocols and to decrease space. A sound checklist highlights the
in 18 months,9 checklists have proven human error under stressful conditions.18 essential criteria that should be considered
to be effective at improving safety and in a particular area.28 There are many
preventing errors. Consequently, the Checklist Use in Dentistry different types of checklists. Examples
World Health Organization (WHO) in In dentistry, there have been isolated include task lists, troubleshooting lists,
2009 engineered a “safe surgery” checklist cases of checklist use in the diagnostic coordination lists and to-do lists, each
and applied it around the world with workup of dental patients accepted for useful in different situations. In terms of
staggering success.10 Checklists now exist aesthetic dental treatment;19 in dental timing of use, checklists can either be read-
throughout medicine and are increasingly implantology20 to aid in minimizing risk do or do-confirm. In the former, people
being used to reduce occurrence of errors and increasing implant success rates, carry out the tasks as they check them off.
of omission, create reliable evaluations especially for inexperienced practitioners; For the latter, team members perform their
and, most pertinently, improve quality in endodontics21 for standardizing jobs from memory and experience, often
and use of best practices.11–13 endodontic procedures; in surgery22,23 for separately, but then pause at predetermined
440 J U LY 2 01 9
1. Focus the checklist task

Define the content area of interest.
Define the checklist’s intended uses.
Reflect on and draw upon pertinent training and experience.
Study the relevant literature.
Engage and have conversations with experts in the content area.
Clarify and justify the criteria to be met by the checklist (e.g., pertinence, comprehensiveness, clarity, concreteness, ease of use,
parsimony, applicability to the full range of intended uses and fairness).
2. Make a candidate list of checkpoints
List descriptors for well-established criteria of merit.
Briefly define each of the initial checkpoints.
Add descriptors for checkpoints needed to round out a definition of merit for the content area.
Provide definitions for each of the added descriptors.
3. Classify and sort checkpoints
Write each descriptor and definition on a separate 4-inch by 6-inch card.
Sort the cards in search of categories.
Identify the main candidate categories and label each category.
4. Define and flesh out categories
Define each category and its key concepts and terms.
Write a rationale for each category.
Present relevant warnings about being overzealous in applying the checkpoint.
Review the checkpoints in each category for inclusiveness, clarity and parsimony.
Add, subtract and rewrite checkpoints as appropriate.
5. Determine order of categories
Decide if order is an important consideration regarding the intended uses of the checklist.
If so, write a rationale for the preferred order.
Provide an ordering of the categories.
6. Obtain initial reviews of checklist
Prepare a review version of the checklist.
Engage potential users to review and critique the checklist.
Interview the critics to gain an in-depth understanding of their concerns and suggestions.
List the issues in need of attention.
7. Revise checklist content
Examine and decide how to address the identified issues.
Rewrite the checklist content.
8. Delineate and format the checklist to serve the intended uses
Determine with potential users whether category and/or total scores are needed or desired.
Determine with users what needs exist regarding differential weighting of categories and/or individual checkpoints.
Determine with users any checkpoints or categories of checkpoints that must be passed for a satisfactory score on the overall checklist.
Determine with users what needs exist regarding profiling of checklist results.
Format the checklist based on the above determinations.
9. Evaluate the checklist
Obtain reviews of the checklist from intended users and relevant experts.
Engage intended users to field test the checklist.
Generally, assess whether the checklist meets the requirements of pertinence, comprehensiveness, clarity, applicability to the full range
of intended uses, concreteness, parsimony, ease of use, and fairness.
10. Finalize the checklist
Systematically consider and address the review and field test findings.
Print the finalized checklist.
11. Apply and disseminate the checklist
Apply the checklist to its intended use.
Make the checklist available via such means as journals, professional papers, web pages, etc.
Invite users to provide feedback to the developer.
12. Periodically review and revise the checklist
Use all available feedback to review and improve the checklist at appropriate intervals.
FIGURE 2 . Checklists Development Checklist (CDC) as itemized by Stufflebeam.32
JULY 2 0 1 9 441
checklists
Endorsements Evaluation (continuous)

Advertisement ■ Utilization of the
Education A checklist
D ■ Effect on quality of
care (adherence to
best practices)
Implementation for Checklist C
use within the clinic D development team
B
Revised checklist E
FIGURE 3 . Proposed schematic for checklist implementation.
intervals to run the checklist and confirm ■Clarify the criteria to be Implementing a Checklist
that everything that was supposed to be met by the checklist. Beyond content, the other critical
done was done. Checklists are different ■ Validate the checklist. factor in the success of a checklist
from algorithms, care maps and protocols Validation of the checklist should is its implementation.34 The science
and educational tools; therefore, they take the form of a critical feedback survey. of implementation involves the
are not useful in all situations.29 Good Participants should be asked to assess the study of methods that promote
checklists are precise, efficient, to the checklist using closed- and open-ended the systematic uptake of scientific
point and easy to use even in difficult questions that are based on Stufflebeam’s evidence into routine practice and
situations. They do not try to spell out evaluation criteria (constructs)32 including thereby help to improve the safety,
everything, rather they provide reminders applicability to the full range of intended quality and effectiveness of health
of only the most critical and important uses, clarity, comprehensiveness, ease of services and care.35 The gap between
steps — the ones that even the highly use, fairness, parsimony and pertinence developing and identifying evidence-
skilled professionals using them could miss. (FIGURE 1 ). Each closed-ended question based best practices and improved
Good checklists are, above all, practical.30 should utilize an interval-response format quality of care is bridged by proper
from strongly disagree to strongly agree. implementation. F I G U R E 3 shows a
Developing and Validating a Checklist For the open-ended questions, participants sample implementation scheme with
The early stages of the development must be encouraged to write directly on an execution and an evaluation arm.
of the checklist should center on content the checklist answering four questions, As depicted in F I G U R E 3 , the
(FIGURE 1 ). The goal of the checklist will one each focusing on its strengths, the initial execution stage (A) will
ultimately define its content. Content can areas that need improvement, items involve obtaining endorsements
be obtained from literature sources (peer- that are missing and those that appear as from clinical champions, vigorous
reviewed guidelines, consensus of experts confusing. The data from the closed-ended advertising and education of all the
in the domain or stipulations by dental questions should be summarized using would-be users. This education/
governing bodies) and/or professional descriptive statistics while qualitative training campaign will include a
experience.31 This will generate an all- data should be analyzed using Hsieh and demonstration/hands-on training for
inclusive list of items for the evolving Shannon’s summative content analysis.33 every relevant subgroup and include:
checklist. The next steps are to: For this qualitative data analysis, recording ■ Evidence of checklist
■ Define the context of the units of analysis should be categorized success in other similar
checklist — checklist protocols into the same criteria that served as the aspects of health care delivery.
that are prospectively tailored basis for the closed-ended questions ■ The development process
to the context in which they are so that responses can be compared. and main concepts of
to be used are more likely to be A detailed stepwise list of potential the checklist.
used and sustained in practice. considerations during checklist ■ The checklist’s modality of
■ Define the checklist’s intended uses. development is shown in FIGURE 2 . use within the clinics.
442 J U LY 2 01 9
Following training, the checklist The mere existence of a policy and fulfilling its role as a support resource
should be implemented (stage B) within checklist does not ensure patient safety. and error management tool, a checklist
the clinics. After implementation, To be clinically effective, there needs could begin to unnecessarily complicate
there needs to be a continuous to be a strong, committed leadership processes and decrease reliability by
mechanism whereby questions, to patient safety, standardization of adding a secondary layer of complexity.
feedback and comments (stages processes, cross-checks, monitoring To suggest strict adherence to checklists
C and D) can be directed to the and measuring compliance, sharing in all situations is impractical and to
checklist team for consideration and lessons from incidents, reviewing do so could compromise the efficacy
necessary modification (stage E). processes, educating and empowering of a clinical process or procedure and
Regarding evaluation, the checklist team members, measuring effective risk infringing on efficient clinical
development team should assess: team communication and feedback judgment. Careful selection of
■ The utilization of the checklist from frontline staff.22 The sustained checklist topics and consideration
within the clinic. use of checklists is more likely to of clinical judgement in the content
■ The effect of checklist use on the occur when staff are actively engaged. design process can help avoid these
predetermined/desired outcome. Involving clinicians in tailoring the potential downfalls.38 Being realistic
checklist to better fit the context in implementation means focusing on
Final Considerations of the practice and giving them the what can be done and setting aside what
Checklists are malleable. As opportunity to reflect and evaluate may seem desirable but not feasible.39
such, it is difficult to anticipate every the implementation intervention In conclusion, “… all learned
clinical situation in which they would enables greater participation and occupations have a definition of
be appropriate or useful. In dentistry, ownership of the process.36 professionalism, a code of conduct. It
however, they can potentially be Although the implementation is where they spell out their ideas and
used by all subspecialties for varying of checklists has not always directly duties”40 — ours include beneficence,
purposes as standardizing processes, correlated with significant improvements patient autonomy, veracity, justice
preventing errors, enhancing recall, in patient care and decreases in and most pertinently, nonmaleficence.
facilitating communication, etc. The human error,37 no published data to “These codes are sometimes stated,
authors are currently evaluating the date indicate that checklists have sometimes just understood. But
impact of implementing a five-list contributed to adverse events, such they all have at least three common
e-checklist on the completeness of as imposing a burden on the primary elements. First is an expectation of
clinical record-keeping. As indicated care providers, delays in treatment selflessness — that we (dentists, lawyers
earlier, checklists do not try to spell because of lengthy checklists or errors or soldiers, etc.) will place the needs
out everything; rather, they provide of omission. Rather, they are largely and concerns of those who depend
reminders of only the most critical considered important tools to condense on us above our own. Second is an
and important steps — the ones that large quantities of knowledge in a expectation of skill/competence —
even the highly skilled professionals concise fashion, reduce the frequency that we will aim for excellence in our
using them could miss. Therefore, of errors of omission, create reliable knowledge and expertise. Third is an
they are very context-specific. and reproducible evaluations and expectation of trustworthiness — that
Potential adopters of checklists need improve quality standards and use of we will be responsible in our personal
to evaluate their system and identify best practices. There are, however, behavior toward our charges. Aviators,
the specific point at which the instances in which excessive use of however, add a fourth expectation:
checklist intervention would be useful. checklists could become a hindrance in Discipline — discipline in following
Also, inasmuch as we have outlined the health care setting. If each detail prudent procedure in functioning with
specific steps in the development and of every task were targeted for the others.”30 That is a critical component
implementation of checklists, these are development of a checklist, clinicians to why flying remains the safest way
mainly guidelines and not protocols. may experience “checklist fatigue,” to travel. Discipline is hard. We have
Smaller institutions/practices can whereby they become overburdened to work at it.30 The consistent use of
adopt much simpler, abridged steps. with completing these lists. Rather than a checklist requires discipline. ■
JULY 2 0 1 9 443
checklists
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Incredible Wisconsin 15. Pinsky HM, Taichman RS, Sarment DP. Adaptation of 10.1186/1748-5908-7-71.
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up to date technology, state of the art
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21. Diaz-Flores-Garcia V, et al. Proposal of a ‘checklist’ for
This compensation package also includes endodontic treatment. J Clin Exp Dent 2014 6(2):e104–9. THE CORRESPONDING AUTHOR,Oluwabunmi Tokede, DDS,
health benefits, dental benefits, paid 22. Saksena A, et al. Preventing wrong tooth extraction: MPH, can be reached at oluwabunmi_tokede@
maternity leave, vacation, retirement Experience in development and implementation of an hsdm.harvard.edu.
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If you are a dentist who values high for ambulatory oral surgery. Int J Oral Maxillofac Surg
quality and continuity of care for patients 2011 40(9)949–54. doi: 10.1016/j.ijom.2011.04.004.
and work/life balance for yourself and Epub 2011 May 19.
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with Edge Advisors. Your future awaits! interventions in dentistry. BMC Oral Health 2015 15:152.
doi.org/10.1186/s12903-015-0136-1.
E-mail: drpeter@edgeadvise.com 25. Nenad MW, et al. A Dental Radiography Checklist
Cell: (920) 917-2566 as a Tool for Quality Improvement. J Dent Hyg 2016
90(6):386–393.
26. Bresciano ME, et al. Efficacy of a Checklist for Office-
Laboratory Communication: A Clinical Study on Quality
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444 J U LY 2 01 9
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legal ramifications
The Cost of Not Practicing

Safely: Perspectives in
the Legal Profession
Steven Barrabee, Esq.
A B S T R A C T The unsafe practice of dentistry can cause injures to patients,

employees or the general public that can adversely affect a dentist’s ability to
practice. Violations of administrative rules can result in monetary penalties.
Violations of safety regulations, willful misconduct or negligence can result in
lawsuits by government prosecutors or injured parties. The dental board may
sanction dentists for violation of safety ordinances. This article elucidates the
legal ramifications of the unsafe practice of dentistry.
AUTHOR
W
Steven Barrabee, Hastings College of the e often hear from the dental profession, that the treating
Esq., is a shareholder in Law. He has lectured on our colleagues and dentist acted in an unreasonable manner
Bradley, Curley, Barrabee business law matters and
professional liability issues
clients that it’s to cause their injury. The Dental
& Kowalski PC, a health
care law firm in Larkspur, at the University of the impossible to operate Board of California was established
Calif. He specializes Pacific, Arthur A. Dugoni a dental practice in with the overarching requirement to
in advising dentists in School of Dentistry and the California. This, it is believed, is due protect the public by exercising its
dental practice purchase University of California, San to the myriad regulatory requirements licensing, regulatory and disciplinary
and sales, formation Francisco.
Conflict of Interest
and the risk of malpractice lawsuits functions.1 Legal liability in the form of
of partnerships and
corporations, management Disclosure: None reported. that require the practice of defensive administrative penalties, tort liability,
service relationships, leases dentistry. This perspective is often based sanctions against dental license and, in
and employment issues. on the belief that safety regulations rare circumstances, criminal liability
He is also a trial attorney place an unnecessary burden on a are the enforcement mechanisms
who defends dentists in
practice and the cost of compliance used to ensure compliance with safety
professional liability/
malpractice lawsuits far outweighs the risk for which the standards. The reason dentists fail to
throughout Northern standards were enacted. Regulatory comply with safety regulations range
California. Mr. Barrabee safety standards were enacted to prevent from ignorance of the law, costs savings
is a graduate of the recurrent, preventable injuries. Liability and long-term custom and habit in the
University of California,
for dental malpractice arises from an way they have always practiced. This
Santa Barbara and the UC
injured person’s belief, proved through article highlights the significant legal
evidence presented by a member of ramifications of practicing unsafely.
JULY 2 0 1 9 447
legal ramifications
Federal and State Statutes, Rules chemicals used and stored, maintenance a number based on the number of times
and Regulations Governing the of material safety data sheets for each such a violation has occurred. Willful
Practice of Dentistry chemical and employee training.7 violation can result in penalties that are
The most obvious rules governing The presence of radiation (X-ray multiplied by five with fines ranging from
safety in the dental practice are the worker equipment) requires the adoption of a $9,090 up to $127,254 per violation.11
safety rules established by state and federal plan and implementation of a program The need to control bloodborne
administrative agencies. Safe-workplace to achieve occupational doses and doses pathogens and infection-control
rules and regulations are imposed through to members of the public that are as low provisions contained in OSHA regulations
state and federal Occupational Safety as reasonably achievable.8 These include are well-known by dentists. Failure to
and Health Administration (OSHA) restricted areas to limit employee exposure, follow such precautions, if found to be
rules, rules governing the prescription duty to wear personal radiation disclosure willful, can result in additional penalties
of medications (CURES 2.0) and devises and proper labeling of rooms.9 separate and apart from OSHA fines.
health and safety code provisions. The law requires some form of inspection Repeated, serious and willful OSHA
The most pervasive safety rules of dental equipment every five years.10 violations may increase a dentist’s
governing the dental office are contained insurance rates for workers’ compensation
in Cal/OSHA and federal OSHA rules insurance premiums. While injuries to
and regulations. Cal/OSHA and OSHA workers are generally handled under the
rules are designed to protect employees no-fault workers’ compensation system,
from workplace injuries. While OSHA
Violation of Cal/OSHA the amount of an injured worker’s award is
rules are designed to protect employees rules can not only harm increased by 50% if the injury was caused
as a corollary, they affect how patient employees and/or patients, by willful violation of OSHA.12 In the
care is provided. OSHA rules have but also can result in significant more serious cases, criminal actions may
been developed to limit the spread of be brought against the OSHA violator13
bloodborne pathogens,2 handling of and administrative penalties. for death or permanent injury due to
communication concerning the use of a willful violation of OSHA safety or
hazardous substances,3 the use of nitrous health standards. Penalties for violating
oxide4 and the use of formaldehyde.5 radiation-control laws are considered a
OSHA provisions for bloodborne Violation of Cal/OSHA rules can not crime with fines not to exceed $1,000
pathogens require universal infection only harm employees and/or patients, but and, in severe cases, imprisonment up to
control including the creation of written also can result in significant administrative six months.14 If the violation is deemed
exposure-control plans updated annually, penalties. Cal/OSHA violations vary willful or through gross negligence,
the use of universal infection-control depending upon whether they are classified the fines can increase to $5,000.15
precautions, consideration and use of as regulatory (permit, posting or record- In a new expansion of liability for
safer needles and sharps, the use of keeping), general (direct relationship to OSHA violations, the California Supreme
masks, gloves and protective clothing, safety and health of employees), serious Court allowed a separate cause of action
proper use and disposal of sharps and (could cause death or serious physical to be brought based on violations of
proper handling of blood or other harm from an actual hazard created by OSHA regulations outside of the workers’
potentially infectious materials. Further violations) or willful (employer had compensation system. The court allowed
requirements include proper cleaning actual knowledge of an unsafe condition a local district attorney to obtain damages
and decontamination of the worksite, and made no attempt to correct or the against an employer for an industrial injury
employee hygiene and vaccination to offender is a repeat offender). Fines for a in which the employer violated OSHA
protect employees from hepatitis B.6 regulatory violation range from $500 to standards using the Unfair Competition
The use of hazardous chemicals in $12,756 per violation. General violations Law of California16 and false advertising
the workplace to which employees may range from $1,000 to $12,726 per law.17,18 This ruling expands the class of
be exposed creates an obligation to violation and serious violations range from people and remedies that may be sought for
create a written hazard-communication $18,000 to $25,000 per violation. Repeat OSHA violations and avoids the limitations
plan, creation of a list of hazardous offenders have their fines multiplied by in remedies in the workers’ compensation
448 J U LY 2 01 9
system. This ruling likely allows employees purpose of this law is to require health Regulatory penalties and fines are
to sue their employers as a private attorney care practitioners to check the CURES not the only risks of failing to comply
general to seek restitution and attorney’s database to obtain patient activity reports with safety statutes. The laws themselves
fees for a violation of OSHA regulations. to verify the identity of other providers of can be used to establish the standard of
Safety provisions related to the duty such medication and the amount being care. If a dentist violates safety standards
to warn of hazardous products used in the used. This data request must be undertaken resulting in an injury to a third party, the
dental office require employees and patients upon first prescription of the medication injured party’s attorney, through an expert
to be informed that they may be exposed and every four months if the medication witness, will likely use the safety statute
to chemicals that can cause cancer or continues to be used.23 It is suggested that to demonstrate the standard of care, and
reproductive harm. That statute requires the checking of this database be noted a statutory violation will be a basis for an
that “no person in the course of doing in the treatment records. No specific acts opinion that such conduct constitutes
business shall knowingly or intentionally are mandated following review of the negligence. In certain situations, a
expose an individual to a chemical known patient activity report, but appropriate statutory violation can eliminate the need
to the state to cause cancer or reproductive recommendations are needed when for expert witness testimony as negligence
toxicity without first giving a clear and can be presumed from a statutory violation
reasonable warning to such individual, if the person suing is the type of person
except as provided in Section 25249.10.”19 that the safety statute was designed to
The main chemicals mandating warning protect.25 This rule, generally known as
in a dental office appear to be mercury and
The main chemicals the doctrine of negligence per se, means
nitrous oxide. The obligation to provide mandating warning that where the court has adopted the
these warnings applies to businesses with in a dental office conduct prescribed by statute as the
10 or more employees. The governmental appear to be mercury standard of care for a reasonable person,
body that enforces these requirements is a violation of the statute is presumed to
the Office of Environmental Health Hazard and nitrous oxide. be negligence.26 This presumption can
Assessment (OEHHA). The OEHHA has a be negated by proof that the statutory
warning on its website (www.P65warnings. violation was reasonable but the burden
ca.gov) that it recommends for use in dental of proving it is reasonable is placed on
offices discussing the effects of mercury and evaluating the patient’s medication use. If it the person who violated the statute.
nitrous oxide. The cost of noncompliance is believed that medication use is excessive, Strict compliance with regulatory
is severe. Legal actions enforcing these counseling of the patient for appropriate statutes is required to prevent fines
provisions can be brought by either the care, including pain management or and, in rare cases, criminal penalties.
attorney general’s or district attorney’s substance abuse treatment, is recommended. Failure to comply may form the basis for
office or can be enforced by any person If other providers prescribing controlled a lawsuit to compel such compliance,
in the public interest.20 Remedies include substances are found, communication and or if someone is injured it may form
injunctions to require compliance with coordination of prescriptions is suggested. the basis of a negligence claim.
the provisions and fines in the amount Enforcement of these statutes is left to the
of $2,500 per day for each violation with dental board and the failure to comply with Liability for Negligence Based on
the maximum fine of $912,500 (based on this statute does not create a private cause Unsafe Practices
a one-year statute of limitations). Private of action against a health care provider.24 Failure to practice safely can result
individuals are encouraged to bring such Notwithstanding, in a lawsuit involving in liability for negligence. Two types of
suits as they are entitled to retain 25% of injuries that could have been avoided with negligence may be implicated: general
the civil penalties plus attorney’s fees.21 the use of the information in the CURES negligence or professional negligence.
Another regulatory statute that database, a patient’s attorney will likely General negligence principles apply
attempts to foster safe practice is the contend that this section is the standard to negligence that does not arise from
Controlled Substance Utilization Review of care for monitoring medications and the rendering of services for which the
and Evaluation System (CURES) designed managing such usage and a failure to health care provider is licensed (i.e.,
to reduce prescription drug abuse.22 The comply with the statute is negligent. general safety violations applicable to
JULY 2 0 1 9 449
legal ramifications
all businesses). Professional negligence question arose when a rail on a hospital dentist’s monitoring of the heat buildup
applies to any acts that have an integral bed failed to prevent a patient from and the dentist’s technique in allowing the
relationship to the provision of health falling out of the bed. The court found handpiece to contact the patient’s skin.
care.27 The differences between these in that case that the standards of medical It is incumbent on the dentist to ensure
types of negligence can profoundly affect negligence applied as the patient’s injury that devices are properly cleaned and
proof and damages. General negligence resulted from the “alleged negligence in maintained. This necessitates the dentist’s
allows a jury to determine liability based the use and maintenance of equipment awareness of the manufacturer’s instructions
on whether they believe the tortfeasor needed to implement the doctor’s order for the cleaning postprocedure and proper
acted reasonably under the circumstances. concerning her medical treatment.”28 maintenance including lubrication and
Medical negligence requires expert Safety in the dental office mandates professional inspection. These requirements
testimony by a licensed dentist to prove that the dentist trains staff and ensures vary by manufacturer and change over
a breach of the standard of care and is compliance with safety practices in the time requiring the dentist to read package
governed by the provisions of the Medical office to protect patients. Examples include material and warnings sent by the
Injury Compensation and Recovery Act the creation of rules and compliance manufacturer to ensure compliance with
(MICRA), which limits damages and company recommendations. Secondly, to
imposes other procedural requirements. prevent injury, dentists must monitor heat
General negligence is limited to a buildup during procedures. They should
dentist’s failure to maintain their office. General negligence also ensure that the devices are not used for
Cases have included slip-and-falls in or allows a jury to determine an excessive period of time and that proper
around the office that result in patient irrigation is used. If a handpiece overheats,
liability based on whether
injuries due to a failure to repair broken it should be promptly taken out of service
sidewalks, failure to clean up spilled liquids, they believe the tortfeasor and sent for repair. Lastly, the dentist
failure to ensure clean restrooms or failure acted reasonably under should ensure adequate retraction and
to properly maintain office furniture. These the circumstances. proper positioning to ensure that the patient
types of injuries are likely governed under is not touched by the hot handpiece.
general negligence standards. Safe dentistry Other issues arose in a series of cases
requires that a dentist as a business owner involving severe necrosis of the mandible
be aware of risks in and about their property with procedures in the use of bed rails for and maxilla during metal post removal.
and take reasonable precautions to warn of patients recovering from anesthesia post- In three cases, patients experienced
such risks and in a reasonable time repair oral surgery to prevent a patient rolling off severe bone and tissue necrosis following
those conditions. Similarly, dentists must of the bed. Other cases have arisen when post removal using piezoelectric devices.
maintain reasonable inspection plans and patients were wheeled out of the office in Questions arose as to the cause of these
identify, clean up and warn of dangerous wheelchairs that had no arms, resulting injuries and the reasonableness of the
conditions that they are informed of or in patient falls. In an unusual case, it was dentists’ monitoring of the heat buildup.
should have been aware of on their property. alleged that a staff person failed to ensure Testing revealed that rapid temperature
They should also know the limitations of that a postsurgery patient could walk to rises can occur if copious irrigation is not
their furniture and equipment and promptly have a standing X-ray taken. In that case, utilized. Questions arose in these cases
repair malfunctioning equipment. the person fell, which caused a fractured as to how long the piezoelectric device
Most of the injuries that occur in or jaw. Thoughtful safety plans and staff could be used before the post needed to
around the dental office will be governed training can prevent these acts or omission be checked for heat buildup and how
by the rules of professional negligence. that can result in preventable injures. such monitoring should be undertaken.
Examples of cases that create questions as Tort liability may also arise from the use Safe dentistry requires foresight as to
to general and medical negligence occur of dental equipment that may cause injury. the possible risks and reasonable actions
when proper practices are not maintained Examples of this type of injury are patients to protect patients from injuries.
to protect patients from injuries when experiencing facial burns due to overheated Other situations that have resulted
they are in vulnerable conditions before handpieces. Common issues in these cases in injuries include common occurrence
and after treatment. In a recent case, this involve the cause of the overheating, the not recommended by manufacturers. An
450 J U LY 2 01 9
example occurred when a dentist purposely patient filled all his prescriptions at the the pathology in the mouth, confusion
bent an anesthetic needle to facilitate same pharmacy (a circumstance that the on tooth numbers based on missing or
mandibular block injections. In that case, dentist cannot rely on) and the pharmacist migrating teeth, confusion in the anatomy
the bent needle contacted the ramus should have been alerted to the potential due to the presence of supernumerary
causing the needle to separate. While adverse reaction but either ignored or did teeth or impacted teeth and the dentist
bending needles is performed by many not receive the warning. This case resulted mistakenly extracting the wrong tooth.
practitioners, no manufacturer will ever say in litigation involving both the dentist The incidence of this type of injury can be
that is proper for their equipment. In this and the pharmacy. The safety lessons reduced by undertaking a necessary timeout
case, the initial problem was exacerbated learned were not to prescribe medications to ensure receipt of a written referral,
as the dentist used a short rather than long over the phone, to verify all medicines a radiological and clinical verification of the
anesthetic needle. The result was that patient is taking before prescribing and correct tooth to be removed and patient
following the separation the needle could to not rely on the patient or pharmacy to agreement as to the tooth to be removed.
not be retrieved and it became imbedded in identify adverse interactions. This case If there is any confusion or inconsistency,
the soft tissue. Due to proximity to nerves occurred before the ubiquitous presence of the referring dentist may be contacted
and other vital structures, oral surgeons to seek clarification and, preferably, to
were hesitant to remove it. The needle have this documented in writing and
migrated and was eventually removed placed in the patient records. The best
using an extraoral approach that caused Safe practice requires the way to prevent wrongful extractions is
nerve damage and permanent scarring. dentist to be aware of all for the general dentist to send written
Safe use of properly sized equipment referrals to the surgeon and the surgeon
medication a patient is taking
could have prevented this injury. ensuring receipt of such referrals before the
Preventable injuries may also occur in and to verify that a new extraction and to take a timeout to verify
the use of medications. Dentists should medication will not cause that the correct tooth is being removed.
not rely on pharmacists to identify the a known side effect. Safe practice also requires dentists to
risk of adverse drug interactions. Safe recognize their competence to provide a
practice requires the dentist to be aware procedure and to refer when appropriate.
of all medication a patient is taking and Many dentists may, for financial or other
to verify that a new medication will not cellphones and tablets that allow for easy reasons, seek to ensure that all treatment
cause a known side effect. In one case, access to electronic records and software is provided in their office. If a general
a dentist was called late at night by a programs to verify drug interactions. dentist performs treatment in the realm
patient complaining of pain and swelling. A common and preventable injury that of a dental specialist, the standard of care
The patient refused to come to the office could be eliminated with adequate safety applied is what a reasonable and prudent
for immediate evaluation, so the dentist procedures is the treatment or extraction dental specialist would have done in the
prescribed an antibiotic over the phone. of the wrong tooth. The correct tooth same or similar situation. Safe practice
The patient was taking many medications should be verified during a timeout prior requires a general dentist to know how
and the dentist did not have access to the to beginning any procedure. The causes to treat the condition and to know how
treatment records at home to verify those of wrongful extractions are numerous to recognize and treat any complications
medications. The patient provided an and range from receiving a referral by that arise. If the general dentist cannot
incomplete history of the medications he telephone with the incorrect tooth noted manage a complication, prompt recognition
was taking when talking to the dentist. The in the appointment book, failure to place and referral to a qualified dental specialist
dentist prescribed an antibiotic the patient emailed referrals into the treatment records, is required. In practices that utilize in-
had used in the past but was unaware the incorrect information provided by insurance house specialists, the safety of the patients
patient was taking a new medication. The authorization identifying the tooth to be mandates that the dentist evaluate whether
patient was diagnosed with rhabdomyolysis extracted, reliance on the patient to identify treatment requiring specialty care can be
a few weeks later, which resulted in kidney the tooth to be removed, the extracting delayed until the in-house specialist is in
failure complicated by a heart attack that dentist relying on his or her judgment the office or if prompt care is necessary. In
almost resulted in the patient’s death. The as to the tooth to be removed based on addition, the patient should be informed
JULY 2 0 1 9 451
legal ramifications
of the option of prompt treatment by an practice, but it also may reduce the risk of standard of infection control.30 These
outside specialist versus delayed treatment liability or adverse dental board findings. minimum standards were codified in
by the in-house specialist. Failure to utilize Patients’ attorneys and dental board the California Code of Regulations.31
proper judgement in these situations investigators are less likely to bring lawsuits These rules require that all dental health
may result in a finding of negligence. or accusations if the treatment records are care personnel comply with minimum
Safe practice also requires dentists complete and legible and clearly document requirements that include the use of
to allocate sufficient time to perform proper evaluation and rationale for care. personal protective equipment, needle and
thorough examinations and appropriate Thorough and safe practice is reasonable sharp safety, sterilization of instruments,
review of X-rays. This allows for the practice that may avoid liability for disinfection of the dental office, proper use
creation of comprehensive treatment negligence and prevent lawsuits. Monetary of dental unit waterlines and the handling
records that document pertinent findings penalties by regulation or legal actions and disposal of contaminated waste
and, if necessary, the need for future are not the only compulsion to practice products including needles and sharps.
evaluation. Desire or compulsion to safely. Unsafe practice can also result in The dental board rules also include
maximize production can result in dentists sanctions against a dentist’s license. establishing minimum educational
failing to diagnose pathology evident in standards for the admission practice
intraoral exams or X-rays resulting in of dentistry.32 The dental board rules
significant liability. In a recent case, failure preclude performing dentistry by an
to diagnose pathology evident in an X-ray unlicensed person and governs the
taken during a free orthodontic screening
Even if a limited examination issuance of special permits, including oral
exam resulted in delayed diagnosis of is performed, safe practice surgery permits, for persons practicing
pathosis. Even if a limited examination requires comprehensive under a dental license.33 To further protect
is performed, safe practice requires evaluation of all pathoses the public, the dental board mandates that
comprehensive evaluation of all pathoses all personnel using radiation equipment
evident in that exam or X-ray. The desire evident in that exam or X-ray. complete radiation safety courses.34
to maximize efficiency is not an excuse for The dental board further seeks to
failure to perform a thorough examination. protect patients when dentists utilize
Overscheduling can lead to the unsafe sedation and anesthesia. This includes
practice of dentistry and legal liability. Dental Board and Safe Dental specific permits for general anesthesia,35
A further necessity for safe practice Practices conscious sedation36 and oral sedation.37
is adequate documentation in a legible Another component of the legal Each of these permitting requirements
fashion. This is true in all practices, but in consequences of safety in the dental requires minimum education to obtain
particular in a multi-dentist office when office is the regulatory function of the permits and subsequent continuing
patients are not always seen by the same the dental board to ensure the safe education to maintain such permits.
dentist. A dentist cannot be expected to practice of dentistry and to discipline The dental board rule-making authority
recall what a patient’s prior conditions practitioners who do not practice safely. also extends to the use of restorative
are and if there is any condition that was The stated purpose of the dental board is dental materials and the need for patient
to be monitored at future appointments to protect public safety.29 The regulatory education through requirements for fact
that will not be performed unless such function of dentistry includes its powers sheets to educate patients on the risks and
conditions are noted in treatment records. of rule-making, its requirements of efficacy of different dental materials.38
Not only is it necessary for the treating proper education for licensure, proper The dental board has the power
dentist to verify a patient’s subjective permitting to allow dentists to perform to enforce these safety regulations by
complaints, objective findings, assessment specific acts and the right to discipline the power to revoke or sanction the
of treatment options and plan for future those dentists who practice unsafely. licensee who violates safety standards or
care, referring dentists or future dentists An example of the dental board who commits unprofessional conduct,
also need this information that can be rule-making function to promote patient is incompetent, grossly negligent or
gained through comprehensive treatment safety is its mandate for establishing rules undertakes repeated acts of negligence
records. Not only does this foster safe and regulation governing a minimum or other causes for violations.39
452 J U LY 2 01 9
The Dental Practice Act enforced scope of practice and proper training of 6. 29 Code of Federal Regulations 1910.1030; California
by the dental board establishes specific staff to ensure compliance with this scope Code of Regulations Title 8, Subchapter 7, Group 16 Article
109 §5193.
acts that constitute unprofessional of practice is a necessary component
7. 29 Code of Federal Regulations 1910.1200; 8 California
conduct, a number of which require of safe dentistry and a particular focus Code of Regulations, Subchapter 7, Group 16, Article 109,
the safe practice of dentistry. Safety- for dental board investigators. §5194.
related acts of unprofessional conduct 8. California Health and Safety Code §115061.
include ensuring that licensed personnel Conclusion 9. 29 Code of Federal Regulations 1910.1096.
10. Health and Safety Code §115085.
practice dentistry lawfully;40 the While most dentists desire to practice 11. 8 California Code of Regulations, Chapter 3.2,
proper procurement, dispensing and safely, there are multiple forces that may Subchapter 1, Article 4, §336.
administration of dangerous drugs or result in dentists’ failure to meet all safety- 12. Labor Code §4553.
controlled substances in violation of related requirements. Compulsions to 13. Labor code §6425.
14. California Health and Safety Code §115215(a).
the law;41 unsanitary or unsafe office practice unsafely due to financial pressures,
15. Health and Safety Code §115220.
conditions as determined by the ignorance or inattention can damage 16. Business and Professions Code §17200.
customary practice and standards of the a practice as the law provides multiple 17. Business and Professions Code §17500.
dental profession;42 the failure to properly avenues to sanction the unsafe practice 18. Solus Industrial Innovations Inc. v. Superior Court of
use nitrous oxide;43 and the knowing of dentistry. Multiple governmental Orange County, (2018) 4 Cal. 5th 316.
19. California Health and Safety Code §25249.6.
failure to protect patients by failing agencies also retain regulatory power to 20. California Health and Safety Code §25249.7(c) and (d).
to follow infection-control guidelines sanction unsafe practice, which is enforced 21. 11 California Code of Regulations, Division 4, Chapter 3
including bloodborne infectious disease with fines and administrative penalties §3201(f) and §3203(a).
standards and OSHA regulations.44 particular in the area of employee and 22. California Health and Safety Code §116.
The dental board also specifically seeks patient safety in the workplace. If the 23. California Health and Safety Code §1165.4(a)(1)(A)(i).
24. California Health and Safety Code §1165.4 (d)(2).
to protect the public by precluding unsafe acts of the dentist injure a patient 25. California Evidence Code §669.
use of instruments or devices not in or other third party, the legal system 26. Casey v. Russell (1982) 138 Cal. App. 3d 379, 383.
accordance with customary standards.45 allows private lawsuits for damages to 27. Murillo v. Good Samaritan Hospital (1979) 99 Cal.
The dental board has the right be obtained for such safety violations. App.3d 50.
28. Flores v. Presbyterian Intercommunity Hosp. (2016) 63
to perform inspections particular in Lastly, the dental board retains regulatory
Cal. 4th 75.
the areas of anesthesia and radiation powers to impose penalties including 29. Business and Professions Code §1601.2.
safety as another means to ensure limitations or, in the worst cases, 30. Business and Professions Code §1601.6.
safety in the dental practice. revocation of the right to practice dentistry 31. 16 California Code of Regulations Division 10, Chapter
The actions of the dentist are not if a dentist practices unsafely. This triad 1 Article 1 §1005.
32. 16 California Code of Regulation Division 10, Chapter 1
the only focus of safe dentistry. The safe of regulatory penalties, legal actions by Article 1 §1024.1.
operation of a dental practice requires all injured parties and restrictions placed 33. Business and Professions Code §1638.
members of the dental team to be aware on dentists’ licenses to practice provide 34. Business and Professions Code §1656.
of the appropriate scope of practice to strong incentives for dentists to fulfill their 35. Business and Professions Code §1646 et seq.
ensure that treatment is performed by obligations to practice safely and protect 36. Business and Professions Code §1647 et seq.
37. Business and Professions Code §1647.110 and
licensed personnel with the proper training their patients and the general public. ■ §1647.118.
and under proper supervision.46 Failure 38. Business and Professions Code §1648.10.
REFERENCES
to do this can lead to patient injuries or 1. Business and Professions Code §1601.2.
39. Business and Professions Code §1670.
sanction of the dentist’s license. To practice 2. 29 Code of Federal Regulations 1910.1030; California
40. Business and Professions Code §1680 (d).
41. Business and Professions Code §1680 (m).
safely, dentists must be aware of proper Code of Regulations Title 8, Subchapter 7, Group 16 Article
42. Business and Professions Code §1680 (t).
actions that may be performed by each 109 §5193.
43. Business and Professions Code §1680 (ab).
staff member and what treatment can 3. 29 Code of Federal Regulations California Code of
44. Business and Professions Code §1680 (ad).
Regulations Title 8, Subchapter 7, Group 16 Article 109
be performed under general supervision §5194.
45. Business and Professions Code §1684.
46. 16 California Code of Regulations Division 10, Chapter 1
(when the dentist is not in the office, but 4. California Code of Regulations Title 8, Subchapter 7, Group Article 1 §1089 to 1090.
pursuant to an agreed plan of treatment) 16 Article 109 §5155.
versus direct supervision (with the dentist 5. California Code of Regulations Title 8, Subchapter 7, Group THE AUTHOR,Steven Barrabee, Esq., can be reached at
16 Article 109 §5217. sbarrabee@professionals-law.com.
present in the office). Knowledge of the
JULY 2 0 1 9 453
QUESTIONS MOST OFTEN ASKED BY SELLERS:
& ASSOCIATES INC.

1. Can I get all cash for the sale of my practice?
2. If I decide to assist the Buyer with financing, how can I be

guaranteed payment of the balance of the sales price?
3. Can I sell my practice and continue to work on a part time basis?
4. How can I most successfully transfer my patients to

the new dentist?
LEE SKARIN
5. What if I have some reservation about a prospective
Buyer of my practice?
6. How can I be certain my Broker will demonstrate

absolute discretion in handling the transaction in all
aspects, including dealing with personnel and patients?
7. What are the tax and legal ramifications when a

dental practice is sold?
QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?
2. Can I afford not to buy a dental practice?
3. What are ALL of the benefits of owning a practice?
4. What kinds of assets will help me qualify

for financing the purchase of a practice?
5. Is it possible to purchase a practice

without a personal cash investment?
6. What kinds of things should a Buyer consider when evaluating a practice?
7. What are the tax consequences for the Buyer when purchasing a practice?
2IÀFHV
Lee Skarin & Associates have been successfully assisting Sellers and Buyers 805.777.7707
of Dental Practices for nearly 30 years in providing the answers to these and other
questions that have been of concern to Dentists. 818.991.6552
Call at anytime for a no obligation response to any or all of your questions
Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461
CA DRE #00863149
emergency medications
Making Dentistry Even Safer:

Understanding the Proper
Choice and Use of
Mark Donaldson, BSP, ACPR, PharmD, and Jason H. Goodchild, DMD
A B S T R A C T It is vital that oral health care practitioners and the entire office team
be vigilant in recognizing signs of patient distress and trained to take appropriate
action when needed. This involves inculcating all staff on a culture of safety that
includes training in the recognition and management of medical emergencies, basic
life support training, mock drills, prescribed individual responsibilities and stocking
of appropriate equipment and emergency medications.
AUTHORS
T
Mark Donaldson, Jason H. Goodchild, he American Dental approximately one emergency per
BSP, ACPR, PharmD, DMD, is a graduate of Association (ADA) defines OHCP per year.3 Another survey by
received his bachelor’s the Dickinson College in
a medical emergency in Malamed reported 13,776 medical
degree from the University Carlisle, Pa. and received
of British Columbia and his dental training at the the dental office as an emergencies by 2,704 OHCPs over the
his Doctorate in Clinical University of Pennsylvania “unexpected event that same time frame, in this case indicating
Pharmacy from the School of Dental Medicine. can include accidental or willful an incidence of two emergencies per
University of Washington. Dr. Goodchild is the bodily injury, central nervous system OHCP per year.4 A study by Laurent
He completed a residency director of clinical affairs
stimulation and depression, respiratory reported an incidence of 2.1 medical
at Canada’s largest tertiary at Premier Dental Products
care facility, Vancouver Company in Plymouth and circulatory disturbances as well emergencies per OHCP per year among
General Hospital, and is the Meeting, Pa., and a clinical as allergic reactions.”1 Although OHCPs in France and Belgium,5
current associate principal professor in the department uncommon, medical emergencies in and two other international studies
of clinical pharmacy of diagnostic sciences at the dental setting can range from found that two-thirds of OHCPs had
performance services the Creighton University
conditions that are not life threatening encountered a medical emergency
for Vizient in Whitefish, School of Dentistry in
Mont. Conflict of Interest Omaha, Neb. to fatal situations and oral health care in the dental setting within the last
Disclosure: None reported. Conflict of Interest professionals (OHCPs) must be capable year.6,7 The most encountered medical
Disclosure: None reported. of recognizing and managing them emergency among these studies was
appropriately.2 In an early survey by syncope, followed by orthostatic
Fast and colleagues, 1,605 respondents hypotension, asthmatic attack,
reported 16,826 emergencies over hypoglycemia, allergy, cardiovascular-
a 10-year period, an average of related emergencies, seizures and stroke.
JULY 2 0 1 9 455
TABLE 1 TABLE 2
Recommended Basic Emergency Equipment 2,15,18 Seven Drugs Comprising the

Minimal Dental Emergency Kit*
Stethoscope and blood pressure monitoring device (appropriate-sized cuffs)
Oxygen delivery system Epinephrine 1:1,000 (injectable)
■ Bag-valve mask device (appropriate sizes) with reservoir and connection to oxygen tank.
Histamine blocker (injectable)
■ Portable oxygen system (E size cylinder) with both nasal hood and full face mask permitting positive
Nitroglycerin (sublingual tablet or aerosol spray)
pressure delivery.
■ Pocket mask (nonrebreathing mask) that allows mouth-to-mask ventilation. Aspirin (oral tablet)
Automated external defibrillator Bronchodilator, β2-adrenergic receptor agonist
(inhaled)
Disposable syringes and needles (e.g., 23 gauge, 1.5-inch needle for epinephrine administration)
Glucose (oral)
Yankauer suction tips and portable handheld suction pump
Aromatic ammonia (inhaled)
Pulse oximeter
* Other sources also commonly include oxygen as an
Glucometer and lancets
emergency drug, together with equipment to deliver it under
Spacer device for inhaled bronchodilator positive pressure for a nonbreathing patient.9,14,16
Adult-sized and child-sized oropharyngeal airways

Magill forceps
It is important to note that this Algorithms and mnemonics exist It is also important to recognize that
manuscript is specifically for adult patients to describe a series of actions that if dialing 911 alone is not adequate
and is not fully applicable to the pediatric properly followed can improve outcomes emergency treatment. Additionally,
patient. Some of the medications listed during emergencies. For example, the using a cellphone to call EMS may
may be for adults who are accompanying American Heart Association’s Chain of actually delay treatment. If the call
the patient and have no indications Survival is intended to describe actions is made near a highway, it could be
for pediatric use. It is the choice of the that can decrease mortality during routed to a central call station that
practitioner to carry these medications if sudden cardiac arrest.12 Roberson and then must contact local EMS, costing
the practice only treats pediatric patients. Rothman describe Six Links to Survival precious minutes in the rescue of the
In 2017, a white paper by Sangrik for when preparing for medical emergencies compromised patient. Depending on
the American Academy of Dental Boards in the dental office: doctor training, the practice location and the amount
hypothesized that “medical emergencies staff training, medical emergency plan, of time required for help to arrive, the
during dental treatment are increasing emergency drug kit, proper equipment PABCD and Six Links to Survival
in frequency, intensity and diversity” and mock drills.13 Most important, must be used.8,14,16 When a medical
for reasons such as an aging and more the PABCD mnemonic describes the emergency arises, OHCPs need to not
medically complex patient population, critical factors of patient management only be familiar with the medications
more invasive dental treatment when urgencies or emergencies arise they have available in their emergency
and an increasing trend of in-office in a dental patient prior to a definitive kit but know how to use them safely and
sedation.8 Although medical emergency diagnosis: P = positioning, A = airway, correctly. The purpose of all emergency
preparedness involves factors such as B = breathing, C = circulation and D care is rescue or the ability to stabilize
equipment, drugs, training and teamwork, = considering definitive treatment, and maintain the patient until additional
the most important aspect involves a differential diagnosis, drugs or help and potential transport arrives.
culture of safety within the dental office. defibrillation.14,15 In his article on In 2013, the California Dental
The OHCP must inculcate and require pediatric medical emergencies, Rothman Association posted an online article
that everyone in the office follow basic describes an additional P for prevention titled “Emergency kit basics for
steps for safely treating dental patients in his mnemonic PPABCD, perhaps dental practices.”17 The article lists
including the collection of accurate and the most important component to the basic equipment that dental
up-to-date medical and pharmacological improving safety in the dental office. offices should stock for patient and
history information, baseline vital Management of medical emergencies employee medical emergencies;
statistics, consideration of the American in the dental office includes all the additional items are listed in TA B L E
Society of Anesthesiologists Physical strategies discussed thus far, but at 1 .2,16–19 The drugs that at a minimum
Status Classification (last amended in its core involves early activation of should be included in the emergency
2014) and possible airway compromise.9–11 emergency medical services (EMS/911). kit are listed in TA B L E 2 .2,14,16,17
456 J U LY 2 01 9
Patient safety is the primary concern. to ensure that the kit is adequately glucose and aromatic ammonia.2,16,19
This article reviews the proper use and stocked with medication and excipients Other sources also commonly
delivery of the essential emergency and to monitor and replace medications include oxygen as an emergency
medications included in a basic drug before their shelf life expires. drug together with the equipment to
emergency kit that should be in every Whether the kit is purchased deliver it under positive pressure for
dental office, while providing new preassembled or created by collecting a nonbreathing patient using a self-
information and challenging historical the individual parts, a drug emergency inflating bag-valve-mask system.9,15,17
dogma around the value of certain kit should only include medications for The decision to include these
products (i.e., ammonia inhalants and which the OHCP has knowledge and medications is primarily based on
autoinjectors). It is important to note has had training to fully understand how the historical findings of the most
that individual specialties (e.g., oral and when to deliver the medication common medical emergencies
surgeons, pediatric dentists) and offices safely.14 However, according to the experienced as described above. Even
that provide sedation may require Sangrik white paper, when dental board if dental offices stock these agents,
additional drugs (e.g., reversal agents) executive directors or equivalents were however, given the low overall
and advanced airway management incidence of medical emergencies,
equipment as well as additional individuals may have limited
training such as pediatric advanced experience accessing and delivering
life support or advanced cardiac life these medications appropriately.
support and health care basic life
A drug emergency kit This results in a significant challenge
support.9,16 OHCPs should also review should only include because many of these medications
and be compliant with the applicable medications for which require additional knowledge or
regulations in their specific area of the OHCP has knowledge manipulations to administer them
practice and in their individual states. safely and effectively, and in an
and has had training. emergency situation some critical
The Minimal Dental Emergency Kit steps may be unintentionally missed
Medical emergency kits for the and result in further patient harm.
dental office can be purchased as a
preassembled kit (often including the asked if their board required dental Epinephrine 1:1,000 (injectable)
needed excipients) or the individual offices to stock emergency medications, Epinephrine is an endogenous
drugs and equipment can be purchased only six responded that the basic seven catecholamine that stimulates both
separately and stored together in an medications were required (one state’s α- and β-adrenergic receptors and is
emergency box. There are advantages dental board responded that the seven the single most important injectable
and disadvantages to each solution. medications were only recommended drug in the emergency kit.16 It is the
The commercially available kits usually and another responded that a first aid drug of choice for treating respiratory
come with a concierge service that kit chosen by the OHCP was required and cardiovascular manifestations of
will monitor drug expiry dates and but no specific drugs were outlined). acute, accelerated allergic reactions.
automatically send new medication Only 38 of 53 dental boards from Epinephrine causes bronchodilation
when needed. However, they are often 50 states, the District of Columbia, and increased systemic vascular
expensive and contain more equipment Puerto Rico and the U.S. Virgin resistance, arterial blood pressure,
and additional medications than Islands responded to the survey.8 heart rate, myocardial contractility and
what is listed in TABLES 1 and 2 . Cost Regardless, there is consonance myocardial and cerebral blood flow when
notwithstanding, having only the most among many dental experts that administered in resuscitative dosages.5,20
important equipment and medications the minimal dental emergency kit For treatment of life-threatening signs
can prevent confusion and inadvertent should be composed of at least seven and symptoms of an acute allergic
errors during an emergency. Kits medicines: epinephrine, an injectable reaction, the clinician must administer
assembled piecemeal can be more cost- antihistamine, nitroglycerin, aspirin, epinephrine immediately, injecting the
effective, but the onus is on the OHCP a β2-adrenergic receptor agonist, drug intramuscularly (0.3mg [0.3mL]
JULY 2 0 1 9 457
of a 1:1,000 epinephrine solution for adult and two pediatric autoinjectors end is actually where the needle comes
adults or 0.15mg [0.15mL] of a 1:1,000 if they treat both of these patient out. Every year there are multiple reports
epinephrine solution for pediatric populations. Alternatively, ampules or of these accidental self-injections in the
patients). A second dose should be multidose vials of epinephrine may be primary literature, to include a meta-
administered within five to 15 minutes of stocked, which have a longer shelf life analysis on this topic, bringing the safety of
the initial dose because of the short half- and are relatively inexpensive. Training this dosage formulation into question.33–35
life of epinephrine (two minutes) and is needed in opening the ampules or For all of these reasons, it may be safer, less
in the absence of clinical improvement. multidose vials and drawing up the expensive and more efficacious to stock
Epinephrine is also indicated for the epinephrine into an appropriately epinephrine 1:1,000 in the ampule or vial
treatment of acute asthmatic attacks that sized syringe. If the dental office formulation for an intramuscular injection
are unrelieved by β2-adrenergic receptor proximity to emergency medical help utilizing the appropriate-length needle.
agonists such as albuterol.21 In either is more than 10 minutes, it has been
case and regardless if symptoms improve, further suggested that three of each Histamine blocker (injectable)
emergency medical services (911) must autoinjector may be advisable.23 Histamine blockers are indicated for
be activated and the patient should patients with mild or delayed-onset allergic
have immediate medical follow-up. reactions to reverse the actions of histamine
Epinephrine is available in ampules by occupying H1-receptor sites on the
and vials as well as in preloaded syringes Given the very short half-life effector cells.36 Diphenhydramine is the most
or autoinjectors for immediate use.22,23 of epinephrine, most dental common representative of this general drug
Caution should be exercised with class and is typically administered as a 50 mg
offices should stock two
autoinjectors, however, because there intramuscular (deltoid) injection followed by
is a growing body of evidence that the adult and two pediatric 25 to 50 mg orally every three to four hours
currently supplied needle length may autoinjectors if they treat both for up to three days after such a reaction.15 It
be too short to be effective in larger of these patient populations. is important to note that oral antihistamines
patients.24,25 With the geometric rise are not emergency medications and in most
in the prevalence of Type 2 diabetes cases the OHCP should not provide them
combined with the associated increase in to the patient. If a patient has an allergic,
obesity rates, several studies have shown While autoinjector formulations have histaminic reaction in which an injectable
that the standardly equipped, 28-gauge, been designed for both the nonhealth histamine blocker is administered in the
1.5 cm (0.5 inch) needle may be care professional and the trained health dental office, the patient should follow
inadequate to deposit epinephrine into care worker to inject, the delivery up with a physician immediately. In the
the rich capillary bed beneath the vastus mechanism is not entirely intuitive and emergency department or urgent care
lateralis muscle in order for systemic has led to inadvertent lacerations and clinic, the physician will determine whether
epinephrine levels to rise fast enough self-injections.28–32 Once removed from additional treatment with glucocorticoids
and high enough to save the patient’s the plastic case, the instructions are to or oral antihistamines is indicated, but
life.24,25 A 1.6 cm (0.63 inch), 2.5 cm first remove the cap that is covering a neither of these drugs should be considered
(1 inch) and 2.5–3.8 cm (1–1.15 inch) hole. Intuitively, the hole appears to be part of the minimal dental emergency kit.
needle has been suggested as being more where the needle must come out while the
appropriate for infants, children and opposite end of the autoinjector has the Nitroglycerin (sublingual tablet or
adults and large adults, respectively.24–26 appearance of a button given its distinctly aerosol spray)
Much has been published recently different color and over which you would Nitroglycerin for the dental office
about the exorbitant price increases of naturally place your thumb in order to is available as sublingual tablets or
the autoinjector, which may dissuade administer the injection. Unfortunately, translingual sprays.16 Nitroglycerin is the
some practitioners from stocking the because of this poor design, during a treatment of choice for the patient with
appropriate number of devices.27 Given stressful event such as a life-threatening angina who may experience acute chest
the very short half-life of epinephrine, medical emergency, autoinjector self- pain. It acts primarily by dilating systemic
most dental offices should stock two injections still occur because the button venous and arterial vascular beds,
458 J U LY 2 01 9
relaxing vascular smooth muscle, which and females, with a history of angina The aerosol spray of nitroglycerin also
leads to a reduction in venous return need to confirm phosphodiesterase has some unique manipulation required
and systemic vascular resistance. These inhibitor usage prior to nitroglycerin prior to effective administration. Once
actions of reestablishing the balance administration because these drugs are the product is removed from the box and
between oxygen demand and oxygen used to treat pulmonary hypertension the cap is taken off, the actuator should
supply in the coronary circulation result and not just erectile dysfunction. be pressed several times to ensure a mist
in the elimination of the chest pain. The If the patient experiencing anginal of medication is being delivered prior
clinician should be prepared to administer pain has brought their own oral tablets to administration. This dosage form is a
one tablet or metered dose spray (0.4 and does not receive relief after two pump that requires priming, especially
mg) if the patient does not bring his or doses, the OHCP could administer their if it is not used frequently. Without
her own nitroglycerin to self-administer. own nitroglycerin as the third dose prior priming the pump, the OHCP is simply
This dose can be repeated twice at to considering a 911 call. Nitroglycerin delivering air; after three attempts at
five-minute intervals for a total of three tablets are hygroscopic and should be reversing the anginal pain, a potentially
doses and relief should occur within one replaced with a fresh supply within unnecessary call to 911 could have
to two minutes. If the discomfort is not been avoided simply by ensuring the
relieved after three doses of nitroglycerin, patient received active medication.
the OHCP must consider a diagnosis If the patient has never received
of evolving myocardial infarction The clinician should be a diagnosis of angina pectoris and
discussed below. Regardless, there are prepared to administer one develops symptoms of a possible acute
some very important considerations in myocardial infarction, such as chest
tablet or metered dose spray
administering nitroglycerin to patients pain or chest pressure, or if the anginal
whether the sublingual tablet or (0.4 mg) if the patient does pain does not respond to three doses
translingual spray is going to be used. not bring his or her own of nitroglycerin as indicated in the
Before administering nitroglycerin nitroglycerin to self-administer. angina patient, the clinician should
to a patient suspected of experiencing call 911 and administer aspirin.
anginal pain potentially brought on by
the stress of the dental procedure, the Aspirin (oral tablet)
OHCP must confirm that the patient 30 days once opened. Many patients Acetylsalicylic acid (ASA, aspirin)
has not received a phosphodiesterase exceed this shelf-life and subsequently tablets reduce the risk of death from
inhibitor within the last 24 to 48 hours the potency and efficacy of their a myocardial infarction (MI) when
(i.e., 24 hours for sildenafil [Viagra, nitroglycerin tablets decreases. If the administered as nonenteric, noncoated
Revatio] and vardenafil [Levitra] and third dose of the medication from the formulations of 162–325 mg. (This was
48 hours for tadalafil [Cialis]).37–40 OHCP’s fresh supply resolves the angina confirmed by the 1988 landmark trial
These medications are also potent pain, the patient should be counseled Second International Study of Infarct
vasodilators and the combination can to replenish their prescription with a Survival (ISIS-2) in which more than
result in a life-threatening precipitous fresh supply of medication after the 17,000 patients were enrolled. According
reduction in blood pressure.37,41 If conclusion of the dental appointment. to the study, the group receiving
the patient has had one of these As an I-C recommendation*, the current aspirin showed a 23% reduction in
medications recently, the prudent American College of Cardiology and cardiovascular mortality in five weeks.43)
OHCP should call 911 and the patient American Heart Association guidelines In the case of a suspected MI, the OHCP
should be taken to the emergency room; do recommend a call to 911 if no relief should first call 911 to initiate the
nitroglycerin should not be administered of chest pain or related symptomatology emergency response team, followed by
by the OHCP. It is also important is achieved after even just one dose of PABCD, which for a conscious patient
to remember that all patients, males nitroglycerine (sublingual or spray).42 primarily includes positioning and
*Medical evidence used in developing recommendations in these guidelines classifies an I-C recommendation as having evidence or general agreement that a specific procedure or treatment is useful
and effective; procedure or treatment should be performed or administered (“I”). The weight of the evidence is then ranked according to the aggregate source or sources of that data, with “C” being
the lowest weighting: C (lowest): The primary basis for the recommendation is a consensus of expert opinion, case studies or accepted standard of care.
JULY 2 0 1 9 459
TABLE 3
Signs and Symptoms of

Hypoglycemia
Feeling shaky
Being nervous or anxious
administering aspirin. The aspirin should Bronchodilator, β2-adrenergic receptor
be chewed and swallowed. Timing is agonist (inhaled) Sweating
very important because many of these The most common β2-adrenergic Chills
patients lose consciousness, in which receptor agonist used to treat acute Clamminess
case oral aspirin cannot be administered bronchospasm that may be experienced
and therefore the antiplatelet benefit during an asthmatic attack or Mood swings
of aspirin will not be received. Patients anaphylaxis is albuterol administered Irritability
should be kept comfortable until medical via inhalation.16 Albuterol relaxes
Impatience
help arrives and OHCPs should be bronchial smooth muscles and
prepared to provide cardiopulmonary inhibits chemical mediators released Confusion
resuscitation (CPR) if required. during hypersensitivity reactions. Increased heart rate
Monitoring the patient’s vital signs Unlike other β2-adrenergic receptor
Feeling light-headed or dizzy
during this critical period is also advised. agonists, albuterol is an excellent
Historically, the American Heart choice because it is associated with Hunger
Association, educational videos, fewer cardiovascular adverse effects Nausea
universities and websites have commonly than other bronchodilators.51,52 In the
used a mnemonic for morphine, oxygen, case of a patient experiencing acute Pallor
nitrates and aspirin (MONA) to refer to asthma in the dental office, possibly Feeling sleepy
the adjuvant treatment used for the in response to the stress of the dental
Feeling weak
management of a suspected MI. Recent procedure, it is important for the
scientific data now refute this strategy OHCP to be prepared by having the Having no energy
and MONA should be viewed as an patient with a history of asthma bring Blurred/impaired vision
obsolete teaching and learning aid.44 in their own rescue inhaler or to have
Headache
Morphine is associated with delayed the office inhaler close by. The inhaler
activity of platelet inhibitor drugs in has three parts: a cap covering the Coordination problems
patients presenting with ST-elevation mouthpiece, the canister of aerosolized Clumsiness
myocardial infarction (STEMI).45,46 In medication and the boot (a plastic
Seizures
2017, the Determination of the Role of case in which the canister resides).
Oxygen in Suspected Acute Myocardial The challenge with inhalers is Tingling or numbness in lips, tongue or cheeks
Infarction (DETO2X-AMI) trial twofold once the mouthpiece cap
enrolled acute coronary syndrome is removed: The canister needs
patients with an oxygen saturation of to be shaken several times prior Once the cap over the mouthpiece is
≥ 90% to receive oxygen supplementation to administration; if the patient removed and the canister is shaken,
versus inhalation of ambient air.47 There is unable to self-administer the the mouthpiece easily attaches to
was no statistically significant difference medication, the OHCP needs to one end of the spacer device. Spacers
in one-year, all-cause mortality observed coordinate actuation of the canister come in different shapes and sizes,
between groups and supplemental with the patient’s inhalation while but the technology is essentially the
oxygen is no longer a class IA their lips are held tightly around same allowing for the actuation of
recommendation in managing patients the mouthpiece. Given the typical the canister to deliver medication
with a suspected MI.48 Regarding dose in this situation is four to eight that is confined in the chamber of
nitrates, randomized-controlled trials inhalations every 20 minutes for up the spacer until the patient inhales
have shown that their use in suspected to four hours then every one to four through the one-way valve at the other
MI could not provide a benefit in terms hours as needed, the correct delivery end of the spacer. This removes the
of improved mortality or adverse of this medication is very difficult need to coordinate actuation of the
cardiovascular outcomes.49,50 Only aspirin during a stressful situation.53 In this device with the patient’s inhalation
has been shown to offer a consistent case, it may be advisable for OHCPs and makes the delivery of medication
benefit in this patient population. to also have a spacer device on hand. easier and more effective.54
460 J U LY 2 01 9
Glucose (oral) minutes, the blood glucose should be tested irritant, especially because no drugs are
Hypoglycemia is one of the most again; additional glucose may be needed typically needed to manage syncope.
common medical emergencies given the if it is still below 70 mg/dL or if symptoms The use of aromatic ammonia during
increasing prevalence of diabetes in the of hypoglycemia persist. This treatment suspected syncope can worsen the
general population. The Centers for Disease algorithm is typically described as the 15-15 condition of a patient by potentially
Control and Prevention predicted in 2010 rule.59,60 If the diabetic patient should lose causing airway edema or infection,
that as many as 1 in 3 U.S. adults could consciousness, it is important to remember triggering acute asthma and increasing
have diabetes by 2050.55 More recently, the that nothing should be administered orally intracranial pressure.62 According
National Health and Nutrition Examination to an unconscious patient. If available, an to the Material Safety Data Sheet
Survey (NHANES) data have predicted that intramuscular injection of glucagon can (MSDS), inhaled ammonia can cause a
50% of the U.S. population will have either be administered to treat an unconscious “burning pain in the mouth and throat,
prediabetes or diabetes by the year 2050.56 diabetic patient suffering from severe constriction of the throat and coughing
Hypoglycemia is defined as an episode hypoglycemia. If glucagon is not available, followed by nausea, vomiting or diarrhea
of abnormally low plasma glucose levels 911 should be called immediately.59 when inhaled.”63 Physical positioning
(usually occurring when a patient’s of the patient followed by assessment
blood glucose drops below 70 mg/dL) of the airway, breathing and circulation
with associated symptoms that resolve may be more advised with activation of
with administration of oral glucose and If the diabetic patient EMS/911 also being a consideration.9,16
restoration of euglycemia. Historically, should lose consciousness,
the treatment of choice was sugar in the
it is important to remember Conclusions
form of cake frosting or orange juice, but All dental offices must have a basic
more recently the American Diabetes that nothing should be medical emergency kit stocked with
Association has advocated for the administered orally to an equipment and medications appropriate
oral delivery of a nondiet, carbonated unconscious patient. to the age and population that the office
beverage.57,58 The carbonation helps to treats. The contents of this kit must be
open both the esophageal and gastric able to address common urgencies and
sphincters allowing the liquid sugar quick emergencies that may arise as a part of
access to the small intestine where it is Aromatic Ammonia (inhaled) dental treatment or occur concurrently
rapidly absorbed to reverse this condition. An example of an emergency and randomly. It is vital that the entire
OHCPs should have a high index of medication that some OHCPs may team be vigilant in recognizing signs
suspicion in known diabetics who typically currently be required to have available of patient distress and trained to take
come to the office just before lunch or as are smelling salts (ammonia inhalants) appropriate action when needed. Office
the last appointment of the day. The signs for the management of syncope. preparedness involves inculcating all
and symptoms of hypoglycemia are listed The use of ammonia inhalants is members of the office on a culture of safety
in TABLE 3 .58 For these reasons, OHCPs controversial due to the lack of safety that includes training in the recognition
may benefit from having a glucometer in and efficacy in addressing the underlying and management of medical emergencies,
the office to accurately assess the glucose pathophysiology of the syncope.61 basic life support training, mock drills,
status of patients because many of these Regardless, ammonia inhalants remain prescribed individual responsibilities
symptoms may simply mimic a well- part of many medical emergency kits in and stocking of appropriate equipment
sedated or even nervous patient. Using a dental offices. The continued inclusion and emergency medications. Whether
glucometer, an accurate assessment can of aromatic ammonia in dental office the basic medical emergency kit is
be made within 30 seconds. If the blood medical emergency kits is an example commercially prepared or assembled
glucose is lower than 70 mg/dL, the patient of historical dogma that is changing in piecemeal, the seven medications
should be administered 15 g of glucose clinical and regulatory practice, and discussed in this article plus oxygen
(e.g., 4 ounces of a nondiet carbonated indeed there is a strong patient safety capable of being delivered under positive
beverage or juice, three glucose tablets argument to be made for not exposing pressure must be available. Additionally,
and one serving of glucose gel). After 15 patients to this nonspecific respiratory OHCPs must always verify state dental
JULY 2 0 1 9 461
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SV141.032018.7. 10.1016/j.ajem.2013.09.001. Epub 2013 Oct 4. the phosphodiesterase 5 inhibitors: Focus on alpha-blocker
8. Sangrik LJ. Medical emergency preparedness in dentistry: 25. Song TT, Nelson MR, Chang JH, Engler RJ, Chowdhury interactions. Am J Cardiol 2005;96(12B):42M–46M.
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Dentistry-Sangrik-2017.pdf. Accessed Oct. 15, 2018. length: What is the ideal length? Curr Opin Allergy CIRCULATIONAHA.110.944603.
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of the American College of Cardiology/American Heart 10.1136/bmj.k648. 60. How To Treat Hypoglycemia. The National Diabetes
Association Task Force on Practice Guidelines. J Am Coll 55. Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson Education Initiative. www.ndei.org/uploadedFiles/Common/
Cardiol 2014;64(24):e139–e228. doi: 10.1016/j. DF. Projection of the year 2050 burden of diabetes in the U.S. NDEI/Home/Whats_New/How-To-Treat-Hypoglycemia.pdf.
jacc.2014.09.017. Epub 2014 Sep 23. adult population: Dynamic modeling of incidence, mortality Accessed Dec. 12, 2018.
42. Pollack CV Jr., Braunwald E. 2007 update to the ACC/ and prediabetes prevalence. Popul Health Metr 2010 Oct 61. Bledsoe BE. This procedure stinks: The hazards of ammonia
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Med 2008;51(5):591–606. 1988–2012. JAMA 2015 Sep 8;314(10):1021–9. doi: 63. Ammonia inhalant solution material safety data sheet.
43. [No authors listed]. Second International Study of Infarct 10.1001/jama.2015.10029. www.safety.vanderbilt.edu/msds/products/ammonia-inhalant-
Survival Collaborative Group. Lancet 1988;2(8607):349–60. 57. Villani M, de Courten B, Zoungas S. Emergency treatment solution.pdf. Accessed Oct. 14, 2018.
44. de Alencar Neto JN. Morphine, oxygen, nitrates and of hypoglycaemia: A guideline and evidence review.
mortality reducing pharmacological treatment for acute Diabet Med 2017 Sep;34(9):1205-1211. doi: 10.1111/ THE CORRESPONDING AUTHOR, Mark Donaldson, BSP, ACPR,
coronary syndrome: An evidence-based review. Cureus dme.13379. Epub 2017 Jun 29. PharmD, can be reached at drmarkdonaldson@gmail.com.
2018;10(1):e2114. doi: 10.7759/cureus.2114. 58. American Diabetes Association. Low Blood Glucose
45. Hobl EL, Stimpfl T, Ebner J, Schoergenhofer C, Derhaschnig (Hypoglycemia). professional.diabetes.org/pel/low-blood-
U, Sunder-Plassmann R, Jilma-Stohlawetz P, Mannhalter glucose-hypoglycemia-english. Accessed Oct. 14, 2018.
C, Posch M, Jilma B. Morphine decreases clopidogrel 59. American Diabetes Association. Hypoglycemia. www.
concentrations and effects: A randomized, double-blind,
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46. Meine TJ, Roe MT, Chen AY, et al. Association of
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NEJMoa1706222
48. Milan M, Perman SM. Out of Hospital Cardiac Arrest:
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s40138-016-0118-x. Epub 2016 Nov 3.
49. [No authors listed]. GISSI-3: Effects of lisinopril and
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50. [No authors listed]. ISIS-4: A randomised factorial trial
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Comparative safety of inhaled medications in patients with
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mixed treatment comparison meta-analysis of randomised
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53. National Asthma Education and Prevention Program.
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JULY 2 0 1 9 463
Specializing in selling and appraising dental practices for over 40 years!
LOS ANGELES COUNTY LADERA RANCH— Beau ful GP in premier LA JOLLA—Beau ful GP with 17 yrs of goodwill
shopping center. Has 11 eq ops. Grossed near the beach. Has 4 eq ops in 1,100 sq
CENTURY CITY—GP in 11 story prof med bldg. $1.9M in 2018. Property ID 5262. condo suite. Grossed approx. $335K in 2018.
Has 5 eq in a 1,955 sq . Grossed approx. State of the art prac ce. Property ID #5271.
ORANGE— Turn-Key GP in small shopping
$715K. Buyer’s net of $149K. Property ID
center on a major heavy traffic street. Has 3 eq OCEANSIDE— Established in 1990 with 4 eq
4509.
ops in a 1,800 sq suite. Proj. approx. $164K ops in a one story busy shopping center. PPO
CULVER CITY— GP w/ 60 yrs of goodwill to for 2018. Property ID # 5253.
and Cash Only. Grossed approx. $560K in
offers is located in 2 story free standing bldg.
ORANGE—(Turn-Key) General prac ce located 2018. Property ID #5267.
Averaging 30 new pa ent/mo. Grossed $365K
in med/dent building. Has 4 eq operatories.
in 2018. Property ID #5283.
Reasonable rent. Grossed approx. $165K IN RANCHO BERNARDO—With 23 yrs of goodwill
DIAMOND BAR— Beau ful GP w/ 6 eq ops in 2018. Great opportunity for a full me den st. this GP grossed approx. $841K in 2018. Net of
a 2 story building. Grossed approx. $434K in Property ID 5277. $328K. Has 4 eq ops. Prorperty ID 5280.
2018. Long term lease. Property ID #5279.
SANTA ANA— GP W/ 3 eq ops and 1 plmb not
SAN DIEGO—Turn key prac ce with 3 eq ops
DUARTE— GP established in1964 located in a eq in 4 story med bldg. Property ID 5113.
and 1 plumbed not eq on an approx. 1,815 sq
2 story mixed bldg. Grossed approx. $404K in
STANTON— Turn-Key GP in a single story suite. PPO and Cash only. Grossed approx.
2018. PPO & Cash Only. Property ID #5183.
corner strip mall. PPO and Cash only! Has 2 $325K in 2018. Property ID # 5274.
ENCINO— GP with 40 years of goodwill in eq ops in 797 sq suite. Grossed approx.
SORRENTO VALLEY– Located in premier shop-
pres gious 12 story med/prof. building. Has 4 $237K in 2018. Property # 5260.
ping place with convenient freeway access.
eq ops and 1 plumbed not eq. Grossed ap- YORBA LINDA— GP established in 1987 con- Established in 1992. Has 3 eq ops and 3
prox. $309K in 2018. Property ID #5263. sists of 4 eq ops in a 1,150 sq suite. PPO & plumbed not eq ops room for expansion on an
Cash Only. Grossed approx. $658K in 2018. approximate 2,400 sq suites (2). Grossed
GRANDA HILLS— With 50 yrs of goodwill this Property # 5258. approx. $486K in 2018. Property ID #5272.
general prac ce grossed approx. $328K in
RIVERSIDE &
2018. Low overhead. Property #5276.
SAN BERNARDINO COUNTIES
LONG BEACH —GP w/ 35 yrs goodwill. Has 3 SAN DIEGO COUNTY
eq ops in a 1,698 sq suite. Grossed $336K in RANCHO MIRAGE— Beau ful Fee for service
CARLSBAD— This beau ful prac ce has over 22
2018. Property ID #5282. General / Implant prac ce located in free
yrs of goodwill. Has 4 eq ops in a 1,800 sq
suite. Fee for service office. ProjecƟng approx. standing building. Has 4 eq ops. Established in
LYNWOOD— GP in single story busy shopping 2000. Grossed $1M in 2018. Property ID
$440K for 2018. Property ID # 5256.
center. Absentee owner. Grossed approx. #5284.
$610K in 2018. Property ID #5264. CHULA VISTA (Turn-Key) —Well laid out prac-
ce in a 2 story med/dent building. Has 3 eq TEMECULA—Absentee owner GP with 2 GP
ROWLAND HEIGHTS— Estab. in 2009, this GP operatories and 1 plumbed not eq. On a ap-
Associates. Has 4 eq ops in busy shopping
is located in a 1 story free standing bldg. prox. 1,400 sq suite. Grossed approximately
$588K in 2018. Great poten al for a full me center. Grossed approx. $327K in 2018. Prop-
Grossed $772K in 2018. Property ID 5278. erty ID 5259.
den st. Property ID #5273.
ORANGE COUNTY EL CAJON - GP + Real State. Consists of 5 eq LA QUINTA— Well established GP with over 8
ops and equipped with 3D Sirona CBCT Digital X years of goodwill. This modern designed prac-
ANAHEIM— GP located in 2 story building w/
-ray. Grossing over $1M in the past 10 years. ce has 8 eq ops. On a the busiest major inter-
heavy traffic flow. Has 8 eq ops. Grossed ap-
Property ID # 5265.
prox. $754K in 2018. Property ID #5255. sec on. ProjecƟng approx. $1.5M for 2018.
ESCONDIDO— Turn-Key GP in single free stand- Property ID #5130.
IRVINE (GP / Specialty) In premier shopping
ing building w/ 8 parking spaces. Seller is the
center. Established in 2012. Spacious opera-
landlord. Has 4 eq ops in an approx. 2,400 sq
tories. Grossed approx. $847K in 2018. Proper-
office. Grossed approx. $312K in 2018. Proper-
ty ID #5230.
ty ID #5275.
Visit our Website and Social Media pages for

PracƟce Photos and Videos
youtube.com/mycpsteam faceboook.com/mycpsteam
CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM

Phone: (800) 697-5656 CA BRE #00283209
RM Matters C D A J O U R N A L , V O L 4 7 , Nº 7
Avoid Medication-Related Tragedies With

Comprehensive Health History Forms
TDIC Risk Management Staff
T
ake two of these and call me in the previous health history could not be “The patient’s signature serves
morning. That may have been located after the practice transitioned as evidence that the information
sage advice a generation ago, but to a digital record-keeping system. is current and the patient’s health
today, dispensing medication Senior Risk Management Analyst was discussed,” Solaiman said.
requires much more scrutiny. Taiba Solaiman said this tragic case is a Health history forms should contain
Americans are taking more prescription reminder that a patient (or a patient’s questions about over-the-counter
drugs than ever before, meaning health parent if the patient is a minor) should medications, prescribed medications and
professionals, including dentists, must review, update and sign a health history supplements, among others. TDIC provides
use extra precaution when dispensing form at every appointment. Dentists sample health history forms in English and
and prescribing routine medications should then review the form prior Spanish at tdicinsurance.com/sampleforms.
as part of an overall treatment plan. to treatment. If the form is missing, Dentists should verify the information
The Dentists Insurance Company a new form should be filled out and in the patient’s chart by speaking to
reminds dentists that the greatest ally in signed prior to initiating treatment. the patient directly. Often, patients
preventing negative drug interactions,
allergic reactions or other adverse effects
is a patient’s health history form. An
accurate, up-to-date, comprehensive
health history gives dental practitioners
the data they need to make informed
treatment recommendations — including
those that incorporate medication or
prescription-strength dental products.
Unfortunately, incomplete, outdated
or missing health history forms can lead
to tragedy. In one case reported to TDIC’s answers
Risk Management Advice Line, an 11-year-
old patient died after suffering an allergic
reaction to a prescription-only toothpaste
dispensed by the dentist. The patient had
come in for a routine exam and teeth
cleaning. The dentist noticed the presence
of extensive decay throughout her mouth,
so he dispensed a prescription-strength From one-on-one risk management advice by phone
toothpaste to use at home. Two days later,
to informed consent forms to expert-led seminars,
the dentist learned the patient had suffered
from anaphylactic shock and died. we’re here to help you practice with confidence.
The patient’s medical doctor alleged We are The Dentists Insurance Company.
that the milk-based proteins in the
toothpaste contributed to the patient’s
Learn more at tdicinsurance.com/rm
death, as she had a lactose allergy.
However, her parents had not disclosed ®
the lactose allergy to the dentist at the Protecting dentists. It’s all we do.
800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783
time of the appointment. The patient
had not been seen in five years and her
JULY 2 0 1 9 465
JULY 2019 RM MAT TERS
don’t recognize the link between overall Typically, pharmacists advise ■ If it has been two to three
health and oral health nor do they recall patients of the possible side effects years since treatment, consider
every medication they take, especially and contraindication of medications. asking the patient to complete
if they haven’t been seen recently. The In-office dispensing takes the a new health history.
following questions should be asked when pharmacist out of the review process. ■ Obtain a new health history on
updating a patient’s health history form: Before prescribing or dispensing any minor patients once they turn 18.
■ Have you sought care from medication, dentists should review ■ Attach new forms to the old
other health care providers a patient’s current medications and health history. Do not discard
since our last visit? existing medical conditions. They the previous health history.
■ Have you visited the emergency should review health history with the ■ Every two years, check with
room or been hospitalized patient to identify known allergies your local dental society or
since our last visit? and to avoid contraindications. This professional liability carrier for any
■ Have you begun, discontinued or review process and discussion should required changes to the form.
changed the dosage of medications then be documented and included in Although adverse reactions to
(prescribed or over-the-counter)? the patient’s record. Dentists should medication and dental products can and
A complete health history reveals not rely on patients to determine do happen, there are preventive measures
crucial information about health whether they are allergic to a drug or to take to limit their occurrence. The
conditions and medications that could a derivative of a drug. Rather, they most effective way to keep patients safe
affect dental treatment. It could also alert should refer to the Prescribers’ Digital is by keeping thorough health history
a dentist that dental treatment could References at pdr.net or consult with forms and holding open, face-to-face
affect a patient’s health condition. the patient’s treating physician to ensure conversations with patients. Doing so
Additionally, staff should immediately appropriate medications are prescribed. gives dental practitioners the information
inform the dentist of any changes to a “The more time you take to research they need to make the right treatment
patient’s health. Attention to a patient’s medication, the less likely you will be decision based on individual need. ■
medical and dental condition shows called upon to defend your prescribing
concern for their well-being and thus decisions and protect yourself from TDIC’s Risk Management Advice Line
strengthens patient confidence in a allegations of negligence,” Solaiman said. is a benefit of CDA membership. If you need
dental practice’s treatment ability. Clear guidelines on dispensing to schedule a confidential consultation with
If dentists are dispensing medication, should be established and staff should be an experienced risk management analyst,
it’s essential they are familiar with the educated on these guidelines. Dentists visit tdicinsurance.com/RMconsult or call
medications (and products) they are should also use caution not to dispense 800.733.0633.
dispensing and know the interactions, or prescribe medications beyond
side effects and contraindications of their scope of practice and instead
each. Patients may not always be aware consult with the patient’s physician.
of the ingredients contained in dental In addition, TDIC recommends
products (such as milk proteins in a adhering to the following health
toothpaste), so the onus is on the dentist history guidelines:
to educate them. For example, some ■ If a patient is not certain about his
dental products, such as prophy paste and or her medications, ask the patient
fluoride gel, contain gluten and may cause to bring all medications to the
a reaction to gluten-sensitive patients. dental appointment. Document
“Dentists should take dispensing all medications, including dosage
and prescribing medication seriously,” and associated health conditions.
Solaiman said. “Adverse reactions ■ Ensure that the form is legible
can and do occur and even something and writing is not crowding
as seemingly benign as toothpaste into the margins. Attach an
can have a devastating outcome.” additional form if necessary.
466 J U LY 2 01 9
V CARROLL &COMPANY
“Matching the Right Dentist to the Right Practice”
4359 SANTA CRUZ GP offering 30+ years of goodwill within 4331 SAN FRANCISCO GP Downtown SF practice in gorgeous,
walking distance to the beach! Located in a well-established, remodeled 1,300 office with panoramic views. Suite includes 4 fully
attractive, single story professional building complex w/ample equipped ops, reception area, business office, private office, staff
parking, good visibility and easy access. 2 doctor days/week, 2 LD area. Beautiful, modern cabinetry
lounge, lab area, and sterilization
SO
hygiene days/week, 380 active patients with approx. 10 new and equipment. 1,600 active patients with 15-20 new patients/mo.
patients/mo. 3 fully equipped ops in 850 sq. ft. Average GR $250K Owner/doctor works 3 days/wk with 5 hygiene days/wk. Average
with Average adj net of $135K. Asking price $150K. gross receipts $738K with average adj. net of $305K. Asking
$495K.
4351 SONOMA COUNTY GP & BUILDING Offering 70+ years of
goodwill. Beautiful modern facility with 3 fully-equipped ops and 4358 SAN MATEO GP Unique opportunity to own a downtown
digital x-ray. Equipment is in pristine condition, most purchased in San Mateo GP surrounded by a variety of retail, restaurant, service
2016-2018. Dental suite has lots of natural light with views looking and specialty shops generating significant foot traffic and daily
into a courtyard and garden. 2018 Gross Receipts $600K+ with 4 business draw. 1,498 square foot facility with 4 ops, reception area,
doctor days/week and 4 hygiene days/week. 700+ active patients, business office, private office, staff lounge, lab area, sterilization area,
all fee-for-service. Seller owns the building, it is available for bathroom, storage & dedicated parking spaces. Family oriented
purchase. Asking $305K for practice, $425K for building. Owner/ practice with an emphasis on Restorative care. Average annual
doctor willing to help for smooth transition. Gross Receipts $400K+.
4338 PENINSULA PROSTHODONTIC PRACTICE Preeminent 4336 SAN BRUNO GP Legacy practice centrally located in a
45 year Prosthodontic practice located in mid peninsula combined commercial & residential neighborhood, convenient to
neighborhood. State-of-the-art 1,242 square foot facility with 5 highways 101, 280, and 380 and close to the BART station.
operatories. Seller willing to help in the transition. Outstanding Elegant, remodeled 1,463 sq.LDft. office with 5 fully-equipped ops. &
referral sources. Average Gross Receipts $1.3M with 4 doctor-days SOaverage Gross Receipts $922K+. 1,000
digital radiography. 5 year
per week. Asking $884K. active patients with an average of 10 new patients per month. Asking
$661K.
4256 SANTA CRUZ COUNTY GP Seller moving out-of-state and
offering 33 years of goodwill. Wonderful location on major 4216 SIERRA NEVADA FOOTHILLS 23 year practice located in
thoroughfare in a charming beach G the heart of the Sierra Nevada foothills in modern building close to
N DINcommunity close to wineries and
the water. Tranquil and modern,
PE beautifully appointed, 5 op facility. downtown area. 1,024 square foot office with 4 fully- equipped ops.,
Approx. 1,300 active patients (all fee-for-service). Seller will help for upgraded major equipment and digital radiography. Average Gross
smooth transition. Asking $180K. Receipts $890K+ with 56% average overhead. Asking price for
practice $604K. Seller is offering real estate for sale to the buyer of
4343 CAPITOLA GP Ample 3,000 sq.ft. faciltiy w/5 fully-equipped his practice.
operatories,. Terrific opportunity to own the facility and well-
established community practice with quality and seasoned staff. 4262 MOUNTAIN VIEW GP Desirable 1,700 square foot
Average Gross Receipts $870K+. Asking $643K. Mountain View location. 5 fully equipped operatories. Average Gross
Receipts $886K+ with 4 doctor days and 6 hygiene days. Practice
4261 CAPITOLA GP Retiring doctor offering an established with an emphasis on Restorative Gand Preventative care. Seller
practice in professional office complex built around a garden setting.
DIaNskilled
Nfor
retiring. Great opportunity dentist to take over a 35 year
LD foot facility with 4 fully-equipped P E
Beautiful and modern 1,465 SOsquare practice with seasoned staff and loyal patient base. Asking $619K.
operatories. Average gross $743K+ with 3 doctor days and 6
hygiene days per week. Approximately 1,800 active patients. Asking COMING SOON: SF GP, Santa Clara GP, Napa County GP &
$562K. Monterey County GP
4355 SAN FRANCISCO ENDO Endodontic practice in signature

building with wealth of referral sources. State-of-the-Art, modern,
1,027 square foot office with 2 fully equipped ops. Well established, Carroll & Company
seller with sterling reputation willing to help for smooth transition. 2055 Woodside Road, Suite 160
Redwood City, CA 94061
4233 SAN FRANCISCO GP Seller offering 26+ year general BRE #00777682
practice in SF Financial district. Ground floor office with high volume
LD
foot traffic. Approx. 1,200 sq.Oft. facility with 4 fully-equipped ops.
S
$930K+ avg. annual GR. Seller willing to help for a smooth transition. Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll
carroll.company dental@carrollandco.info (650) 362-7004 (650) 362-7007

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Regulatory Compliance C D A J O U R N A L , V O L 4 7 , Nº 7
Security Incident Response Procedures

CDA Practice Support
I
ncidents of ransomware and email Assess the security incident. Each
phishing have significantly increased incident should be assessed in terms of
in the last two years, according to Regulators require and risk and impact in order to determine
regulators and industry analysts,1 security experts urge next steps. At a minimum, a low-risk,
and U.S. Department of Health no-impact incident such as a single
and Human Services Office for Civil
HIPAA-covered entities, failed access attempt simply would be
Rights investigations have identified such as dental practices, documented. However, if the number
misconfigured information systems as a to have written procedures of failed access attempts is much higher
cause of some data breaches.2 In order for detecting and responding than usual, then the risk level increases
to limit the impact of cyberthreats and and further investigation and other steps
for emergency preparedness, regulators to security incidents. would be warranted. An example of an
require and security experts urge impactful incident would be ransomware
HIPAA-covered entities, such as dental infecting an information system with
practices, to have written procedures no viable data backup. With a loss of
for detecting and responding to security ■ Compromised user accounts, access to ePHI, the security incident
incidents. A “security incident,” as it for example, staff sharing the would be assessed to be a breach that the
relates to electronic protected health same password to the practice dental practice would have to report.
information, is defined as “the attempted management system. Identify who must be notified about the
or successful unauthorized access, use, All staff should be trained to identify incident. The security officer will bring
disclosure, modification or destruction of security incidents, such as phishing in or consult with individuals as needed.
information or interference with system attempts and slow computer processing, Many security incidents may require
operations in an information system.” and to report them as soon as possible to evaluation by a professional IT support
Security incidents include the dental practice security officer. The person or company. A dental practice
but are not limited to: security officer must also ensure the dental should retain a professional IT support
■ Theft, attempted theft or practice has a procedure to regularly person or company in order to assist
loss of a server or device with review information system activity in the practice in both preventing security
electronic protected health order to detect other security incidents. incidents and responding to them. Local
information (ePHI). Information systems can be configured law enforcement and/or the FBI should be
■ Unauthorized use of or access to to automatically generate certain reports contacted if there appears to be criminal
the dental practice information such as access, software updates and system activity, for example, with the theft of a
system, software or data, for errors. Client/server networks offer more server or laptop or the use of ransomware. If
example, failure to terminate the controls than a network of computers. a dental practice has cyber coverage and it
account of a former employee. There is no recommendation for the scope is clear that data was lost or stolen through
■ Unauthorized or accidental and frequency of reviewing such reports so hacking or ransomware, the insurance
disclosure of ePHI, for example, a dentist can determine their own level of carrier should be contacted. A breach of
email with an incorrect address. vigilance. A dentist may want to review ePHI requires notification of patients, the
■ Attempts, failed or successful, some reports, such as failed login attempts Office for Civil Rights (OCR), the state
to access the dental practice or business associate access, more often than attorney general and possibly local media,
information system, software or others. The dental practice’s IT advisor and the security officer should work with
data without authorization. can be consulted for recommendations on the dental practice’s privacy officer to
■ Virus or malware infection/attack, scope and frequency of review. All security complete appropriate breach notification
for example, a phishing email. incidents should be logged, even if a security procedures. Breaches of information of
■ Denial-of-service attack. incident is assessed not to be a breach. 500 or more individuals must be reported
■ Unauthorized access to area The security officer is responsible for to those affected and to the OCR within
where the server and other initiating the dental practice’s response to 60 days of discovering the breach, even if
computer hardware are located. such incidents. The security officer must: the incident continues to be investigated.
JULY 2 0 1 9 469
J U L Y 2 0 1 9 R E G U L ATO RY C O M P L I A N C E
Contain, eradicate and recover. The procedures, if any, to prevent repeat com/news/hacking-and-it-incidents-causing-bigger-breaches-
healthcare; Phishing, negligent insiders leave healthcare
security officer will work with the occurrence of the incident. Examples vulnerable, HIMSS says, HealthITSecurity.com, Feb. 11, 2019,
individuals identified above to limit of actions that may be taken include healthitsecurity.com/news/phishing-negligent-insiders-leave-
the impact of the security incident and disciplining one or more employees healthcare-vulnerable-himss-says.
2. OCR concludes all-time record year for HIPAA enforcement
to recover ePHI to the extent possible. or terminating their employment, with $3 million Cottage Health Settlement, Feb. 7, 2019,
Examples of actions that may be taken changing data backup protocol and press release, www.hhs.gov/about/news/2019/02/07/
include checking backups to ensure upgrading equipment and software. ■ ocr-concludes-all-time-record-year-for-hipaa-enforcement-with-3-
million-cottage-health-settlement.html.
they are free from virus or malware and REFERENCES
taking a server offline and replacing it. 1. Breakfast and breaches: HIPAA and cyber risk management
Review post-incident procedures. Once readiness, recovery and requirements. Expert panel discussion Regulatory Compliance appears monthly and
with Illinois OCR investigators, Feb. 28, 2019, webinar;
the immediate needs of managing a Phishing, employee error still putting data at risk, but in-house features resources about laws that impact dental
security incident are finished, the security detection is improving, HealthcareITNews.com, April 9, 2019, practices. Visit cda.org/practicesupport for more
officer should work with the individuals www.healthcareitnews.com/news/phishing-employee-error- than 600 practice support resources, including
still-putting-data-risk-house-detection-improving; Hacking
identified above to assess how and why and IT incidents causing bigger breaches in health care, practice management, employment practices,
the incident occurred and to identify HealthcareITNews.com, Feb. 26, 2019, www.healthcareitnews. dental benefits plans and regulatory compliance.
REFER A SHARE THE BENEFITS OF MEMBERSHIP.

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EARN dental supplies through tdsc.com.
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SS required dues. Total rewards possible per calendar year are limited to
$500 in gift cards from ADA and $500 in value from CDA.
470 J U LY 2 01 9
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of practicing in Lakeport is ability to step back in time when life was less hectic. PRACTICE #1 Unique opportunity for Ambitious Successor. Roll up
Decompress and have more time for yourself. Practice has 44-year foundation. sleeves and improve performance in absentee-owned practice. 30,000 charts,
Beautiful 6-op facility with high-end technology, inhouse fabrication center and 100 new patients/month. Work four 10-hour days. Net $800,000.
completely networked. 2018 collected $956,000 with Profits of $360,000. PRACTICE #2 Grossing $1,500,000 and Nets $500,000. Great location.
Building is optional purchase. Full Price $350,000. Take to $2,000,000.
6162 REDDING Great alternative to practicing in uber-competitive markets
DSO can acquire both practices and increase Net by $1,000,000.
located in ultra-expensive housing communities. Strong foundation as evidenced
by 1,500+ patients and growing Hygiene Schedule which is now 8-days a week. ALTA LOMA Great Shopping Center, 5-Ops, will do $1 Million.
Charges in 2018 totaled $709,800 - down from 2017 which realized $779,000. BAKERSFIELD Union Practice with building. Grosses $650,000.
(2018 experienced a hiccup due to the Carr Fire in July.) Owner works 3.5 day BAKERSFIELD AREA Grosses $40,000/month. 1,800 sq.ft. building
week and takes 9-weeks off. Simple “bread & butter” practice with all specialty $330,000.
work referred. Seller previously owned a very busy Group Practice in expensive CAPISTRANO BEACH Low overhead. Grosses $200,000 16 hours/week.
beach community in Orange County. Comparing the two, he prefers his Redding By taking Denti-Cal, increase to $500,000. Will net $250,000 with Denti-Cal.
practice. 2,000 sq.ft. suite leases for $2,296/month and enjoys River views. Full Full Price $165,000.
Price $190,000. DIAMOND BAR Fantastic Shopping Center Location. 5-ops. Full Price
6160 SAN FRANCISCO’S 450 SUTTER 12th floor with unencumbered views $150,000
of Downtown. Upgraded office, technology and delivery systems. PPO practice
GLENDALE / BURBANK Absentee owned. Absolutely gorgeous free
collected $270,000 part-time due to Owner’s East Bay practice.
standing building. Real estate also available. Grosses $840,000. 5 Ops.
6159 WOODLAND 3-day practice perfect for first practice, or acquisition by $300,000 in recent upgrades. Full Price $750,000
nearby DDS as can be relocated. Collections in 2018 totaled $518,000. 3-days of
Hygiene. 4-ops in well-designed office. Quality patients. Full Price $250,000. HEMET Super Bargain. Assume mortgage. 3,500 sq.ft. building. 5-ops.
Absentee owned. Full price $65,000.
6158 FORTUNA Relaxed lifestyle in Humboldt County’s Banana Belt. Adjacent
to Ferndale. Perfect for Dentist seeking small town living. 2018 Collected INLAND EMPIRE Union Practice can do $1,000,000. Averages 50 new
$395,000. $156,000 in Profits. 6-weeks off. Lots referred. Full Price $75,000. patients per month. Low rent.
6157 SACRAMENTO’S ELK GROVE AREA 2018 collected $909,000 on INLAND EMPIRE Alongside freeway, high identity location.
Owner’s 3-day week. Successor can immediately increase to 4-days as practice is $10,000/month HMO income. 7-ops, low rent. Grosses $500,000. Should be
rich in patients. 25+ new patients per month. 5-ops, digital Pan, strong Recall, doing $1,000,000. Full Price $485,000.
great staff. Want to be busy and make a “no-risk” acquisition? Then investigate IRVINE GP with small children will sell and work back or share with
this opportunity. Dentist. Grosses $1 Million.
6156 SANTA ROSA Sited on Sonoma Highway near Oakmont. Strong LA HABRA Large mall. 6-ops. Female DDS does not want to own, will
foundation evidenced by 4-days of Hygiene. Well-designed 5-op office. 2018 work back. Needs marketing. 1,600 sq.ft. Full Price $270,000.
collected $730,000. Over $200,000 invested in equipment and technology. Full ORANGE COUNTY BEACH CITY Buyer will do $1.5 Million first year.
Price $325,000. Special circumstances makes this a Super Purchase. 1,800 sq.ft., 4-ops, Cone
6155 LAKEPORT - “SOLD” 5-days of Hygiene. 2018 collected $825,000. Beam. Rent only $3,600. Seller will work back 1+ year. HMO checks shall
Lakeside location and nicely equipped. Seller happily looks forward to pay rent. This is a fantastic buy! Full Price $850,000.
retirement. Full Price $225,000. ORANGE COUNTY – THREE PRACTICES All High Identity, all
6152 SAN RAFAEL - “SOLD” Across the street from Marin Academy. 2018 grossing near or over $1,000,000 – all First Cabin.
collected $520,000. Stand-alone building optional purchase. Nearby DDS who
PALM SPRINGS AREA 8-Ops, Gross $1,000,000+ with Specialists.
desires their own building should vertically integrate their practice here and have
Bargain.
an instant $1+ Million practice in a superior location.
6151 MODESTO - “SOLD” Located on north end of Coffee Road where REDLANDS Established 25-years, 5-Ops. Did $600,000 in past. Needs
new development is occurring. Attractive 3-op office. 2018 collected $408,000 hands on Owner.
on 2-day week. Did $700,000+ in 2016 when Owner was full time with $240,000 SAN GABRIEL / PASADENA Seller lost Lease. Grossing $1,400,000.
in Profits. Seller will work back 2+ years. 10 days of Hygiene/Week.
6150 HAYWARD - “SOLD” Strong Dental DNA. Well-designed 5-op office. SAN GABRIEL PEDO Losing Lease. 35-years. 3,500-to-5,000 families.
Digital radiography and computers. 2018 trending $850,000+. 5-days of SANTA CLARITA Location, Location, Location. 2,600 sq.ft., 10-Ops. 3
hygiene. Full Price $200,000. Tenant Dentist will pay rent free to Buyer. 50-to-70,000 auto pass per day
6147 SAN FRANCISCO BAY AREA - “OUT-OF-NETWORK” - “SOLD” $250,000
2018 collected $2.2 Million. Hygiene produced $1+ Million. $700,000+ in SANTA CLARITA Shopping center. Share 5-ops. Full Price $50,000
profits. Unique in so many ways! Seller available for long transition. VENTURA Established 20-years. $10,000/month HMO. Grossing
6143 BERKELEY’S ALTA BATES VILLAGE - “SOLD” 3-day week $1,800,000.
collected $540,000 in 2018. 4-days of Hygiene. Housed in its own building on WEST COVINA Absentee owned. Grosses $650,000. Beautiful 3-op office.
Webster Street.
Your Life’s Work
Comes Down To BAY AREA BAY AREA CONTINUED
This Decision AC-886 SAN FRANCISCO (Facility): Unsurpassed visi- CC-927 SAN RAFAEL: Build the practice of your dreams
bility & location! Potential here is limitless! 850 sf w/ by increasing this 2-day work week! 800 sf w/ 3 ops
3 ops $85k $199k
What separates us from
AC-989 SAN FRANCISCO (Facility): Busy Retail Shop- CC-960 SONOMA: Great location in one-of-a-kind
other brokerage firms? ping Plaza w/ major anchor tenants! 3 ops $125k setting! 950 sf w/ 3 ops. $385k/ Real Estate $350k
AG-871 SAN FRANCISCO: Seller Motivated! 600 sf w/ CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops
estern PracƟce Sales is locally 2 ops Price Reduced $65k near downtown and Old Town Novato. $195K
ned by denƟsts and has been AG-944 SAN FRANCISCO: 980 sf w/ 3 ops $595k (Real Estate $215k)
oudly serving denƟsts in AG-945 SOUTH SAN FRANCISCO: Be a part of this CC-1017 VACAVILLE: Maximize your work days and
vibrant, diverse population. 1800 sf w/ 4 ops $495k watch your production increase! ~ 1500 sf w/ 4 ops
ifornia for over 45 years. Our AG-990 SAN FRANCISCO: Build the practice of your $125k
rsonal aƩenƟon to our sellers dreams! 850 sf w/ 3 ops $228k CG-616 NAPA COUNTY: State-of-the-Art office!
d reputaƟon of integrity and AG-993 WEST PORTAL AREA: Desirable area w/ easy ~850 sf w/ 2 Ops. Seller Motivated $250k
nesty has made us Northern commute to downtown San Francisco. 1000sf w/ 3 CG-995 VALLEJO: Live, play and practice here where
ops $450k your lifestyle can’t be beat! 2035 sf w/ 7 ops
ifornia’s Preferred Dental AG-994 SAN FRANCISCO: Highly profitable with net $1.175M
acƟce Broker. profit over $400k! 850 sf w/ 3 Ops $825K CN-911 SANTA ROSA: “Quality Care & Patient well-
AN-947 DALY CITY: Seller Motivated! Great curb being FIRST”. 2250 sf w/4 ops + 1add’l. $545k
appeal and visibility! 1500sf w/ 4 ops. $375k DC-984 SUNNYVALE: Near Apple, Google & Mi-
Our extensive buyer AN-1011 SAN FRANCISCO Facility: Don’t pass up this crosoft. 965 sf & 3 ops $185k
database remarkable opportunity! Perfect for Specialists! 604 DG-862 MID-PENINSULA: Rare gem with up to 7 oper-
allows us to offer you… sf w/ 2 ops $65k atories in the Bay Area!! 2274 sf w/ 6ops + 1 add’l.
BC-741 DANVILLE (FACILITY): Move in Ready! ~ $475k
Better Exposure 1600 sf w/ 3 ops. PRICED TO SELL! $10k DG-936 SUNNYVALE: Opportunity of a lifetime! ~1000
BC-926 ANTIOCH: Long established, well respected sf w/ 3 ops. $495K
Better Fit office. 1866 sf w/ 5 ops $495k DG-978 PALO ALTO: Imagine the possibilities with
BC-949 ALBANY: Desirable commercial/residential the newly opened Amazon corporate office near-
Better Price! area. Medical Prof Bldg w/ good frontage. 3200sf by! $455k
w/ 4 ops $695k Real Estate: $1.8 DG-986 CAMPBELL: The ideal opportunity to prac-
BC-1010 ANTIOCH: Amazing Opportunity in Health tice in this community! 988 sf w/ 3 ops $325k
Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l DG-1006 MONTEREY AREA: This practice is one which
$250k every dentist aspires to! 3400sf w/ 8 ops $1.395M
BC-1015 SAN RAMON Facility: Fantastic location, DG-1009 MONTEREY BAY AREA: Don’t hesitate!
beautiful buildouts and well equipped, move in 1150sf w/ 4 ops $725K
ready office! $200k DG-1014 MONTEREY: Don’t miss your opportunity
BG-925 HAYWARD: Profits close to $900K per to live and practice in beautiful Monterey! 11125 sf
year! ~ 1930 sf w/ 6 ops $1.15M w/ 4 Ops. $875k
BG-981 BERKELEY: Long established, family- DN-898 SAN JOSE: Built-out 2015 w/ location, visibil-
oriented practice. 1100 sf w/ 3 Ops $345k/ Real ity, convenience in mind! 2,204 sf w/4ops + 2 add’l.
Estate Available $499k $500k
BN-891 PINOLE: This seller is ready to retire, & DN-937 SAN JOSE: This opportunity is waiting for
looking for someone to continue the legacy! 1300 your talent & skills! 2210 sf w/ 4 Ops + 2 add’l. $500k
sf w/3 ops. $350k DN-928 CASTRO VALLEY: Continue the tradition of
BN-943 MARTINEZ: Opportunities like this only delivering quality dental care! 883 sf w/ 3 Ops.
comes along every great once in a while. 1520sf w/ 4 $275k
ops +1 add’l.. $450k DN-1004 REDWOOD CITY: On Track to Exceed
all or email today for a free BN-952 BERKELEY: Step into this quality practice and $800k in Revenues for Current Fiscal Year! 1,150 sf
copy of Dr Giroux’s book you’ll know you belong here! ~ 835 sf w/ 3 Ops. w/ 4ops. $545k
Reduced Price $375k DN-1003 PLEASANTON Facility: This amazing turn-
CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 key facility is an excellent opportunity! 1,000 sf w/
Top Ten Issues for ops 640 sf Collections $433k in 2017 $275k 3ops. $75k
Dentists Contemplating
Retirement in Ten
Years or Less 800.641.4179 WPS@SUCCEED.NET
Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD
NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED
EC-1005 YOLO CO: Highly Successful w/ Great Reputation in the Communi- HN-991 PLACERVILLE: Quality, conservaƟve and compassionate pracƟce! Will
ty! 1239 sf w/ 3 fully equipped ops $720k consider work back. 1,654 + 473 sf w 5 ops. $675k
EG-910 MIDTOWN SACRAMENTO: Unlimited Potential! ~ 1107 sf w/ 2 ops
+ 1 add’l. $210k/ Real Estate $395k CENTRAL VALLEY & SOUTHERN CALIFORNIA
EG-965 SOUTH AUBURN VICINITY: The ideal opportunity to practice in this
community! ~1100 sf w/ 4 Ops.. $350k IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k
EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample park- IG-832 OAKHURST: 2048 sf w/3 ops + 1 add’l. $235k/ Real Estate 375k
ing in garage! ~1527 sf w/ 5 Ops. $550k IG-881 TURLOCK: ~3500 sf w/ 10 Ops (shared). $360k
EG-1012 EAST SACRAMENTO: A practice like this one does not come availa- IG-1007 GREATER MODESTO AREA: Combines a quality learning environment
ble very often! ~ 2900 sf w/ 8 ops. $2.5M with relaxed rural living. 3000sf w/ 6 ops. $645k
EG-1016 LINCOLN: Look no further than this growing community to spring- IN-764 STOCKTON: 5,000 sf w/10 ops. $220k
board into your success! 1800 sf w/ 4 Ops $595k IN-917 MERCED AREA: Well established practice with a stable, loyal patient
EN-976 SACRAMENTO: Philosophy to treat patients like family & listen to base! 1300 sf w/ 3 Ops. Reduced! $295k
their needs. 1750sf w/5ops. $595k JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified
FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $3 350k for DDS w. intention to Buy In! 3,000 sf w/ 6 ops $350k
the Practice & $400k for the Real Estate JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k
FC-962 HEALDSBURG: Known as 1 of top 10 small cities in the US! Amazing KL-909 SAN DIEGO: Remarkable Opportunity. Long established in vibrant
practice w/ 1200 sf & 3 ops. Beautifully landscaped professional plaza $180k North Park. 2400 sf w/ 5 ops & 2 Pedo chairs $810k
FG-841 ARCATA: Great demographics w/ very little competition! 1114 sf w/3 KG-921 SANTA MARIA: Live and practice in this desirable collegiate coastal
ops Reduced Price: $200k/ Real Estate Available community! 930 sf w/ 3 ops Seller Motivated $285k
FN-961 EUREKA: Where the quality of life can’t be beat! 1400sf w. 4 ops. KL-955 SAN DIEGO: Just Listed! Well established & centrally located in 1st
$395k/ Real Estate Available $395k! floor suite w/easy freeway access. Adjacent vacant suite available for
FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS prac- expansion. $225k
tice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available
GN-953 CHICO: Established for 55 years and the seller is passing their good- SPECIALTY PRACTICES
will on to you! 1067sf w/ 3ops. $315k
GN-924 TEHAMA COUNTY: Don’t miss this ideal opportunity! 3000 sf w/ 6 BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like
ops. Practice $495k / Real Estate $455k well-oiled machine! 3 ops $295k
GN-988 YUBA CITY: Excellent Merger Opportunity! Location and Lifestyle! BG-843 WALNUT CREEK Perio: Great gross and profit for only 2 ½ days per
1,600 sf w/ 3 ops.. $100k week! 1085 sf w/ 4 ops $390k
HG-815 TRUCKEE AREA: Busy, productive practice with 3 days of hygiene! BN-998 WALNUT CREEK/SAN RAMON AREA Ortho: Looking for your dream
1000 sf w/ 3 ops $165k/ Real Estate $437k OrthodonƟc pracƟce! 1450 sf w/ 5 Open bays/Chairs. $1.150M
HG-851 SO LAKE TAHOE: Projected Revenue on track to do just under $700k DC-835 TRI-VALLEY Perio: Collections over $1.2M. 2,100 sf $800k
this year! 2100 sf w/ 5 ops $425k DN-908 SAN JOSE Pedo: Amazing Location! Providing affordable pediatric
HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighbor- dentistry to families! 3600 sf w/ 4ops + 3 add’l. $175k
hood! ~1250 sf w/ 3 ops. Reduced Price $195k/Real Estate Available DN-959 APTOS Perio: Highly successful at this proven location! 1350sf w/
HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by 4op. Reduced $675k / Real Estate Available $650k
increasing office hours! 750 sf w/ 2 ops $65k EG-903 CARMICHAEL Oral Surgery: Gross receipts were over $1.1 million in
HN-740 SHASTA CO: Beautiful mountain community, well-established prac- 2017! Stable patient base won’t be affected by transition! 2282 sf w/ 5 ops
tice, exceptional long-term staff. 2400 sf w/5 ops + 1 add’l. $475k/ Real Amazingly Priced: $450k
Estate $350k GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more
HN-773 SUTTER CREEK: Qualified & credentialed Seller willing to show you than $1M in revenues this year! 4300 sf w/ 5 ops. Reduced $650k
how! 1536 sf w/4 ops + 1 add’l Only $95k! Real Estate Available! JG-757 VISALIA Perio: 9 Hygiene days per week, this practice is a rare
HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 ops gem! ~ 2,000 sf w/ 5 ops Steal at $335k
Reduced Price: $265k
We are a proud member of: * Western Practice Sales is a member of
HG-934 GRASS VALLEY: Just imagine living and practicing here! ~1200 sf w/ 3 American Dental Sales (ADS Transitions),
Ops $225k/Real Estate $190k a nationally recognized organization of
dental practice brokers throughout the
HN-941 GOLD COUNTRY/CALAVERAS CO: This is the right practice for you! United States. ADS members have a
2,300sf w/2 ops + 3 add’l. $175k strategic alliance & combined marketing
efforts with other practice brokerage
HN-999 CALAVERAS Co. (Facility/Real Estate): 1,500 sf w/ 2 equipped Ops + 1 firms, financial companies & lending
fully plumbed & 3 parƟally plumbed. $500k organizations. All ADS companies are
independently owned and operated.
“ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM

Tech Trends C D A J O U R N A L , V O L 4 7 , Nº 7
A look into the latest dental and

general technology on the market
Anker PowerCore Fusion, 5000mAH mobilePDR (Free, PDR Network)

($25, Anker) Many dental offices have traditionally used a physical copy of The
Whether traveling for business or pleasure, consolidation of Physician’s Desk Reference (PDR) as a tool to look up and compare
baggage is a welcomed thing. Mobile devices themselves take drug information and interactions in the medical assessment of
the place of many devices (e.g., computers, GPSs, cameras and patients prior to dental treatment. The final hardcover edition was
phones to name a few) and are must-have items for travelers. printed in 2017. The PDR continues to be updated online weekly
Keeping these devices powered becomes paramount, which is and can be referenced either on the web or through the mobilePDR
why mobile charging stations, accessible wall outlets and power app, available for iOS or Android devices.
bank (or external mobile device batteries) vending machines have
MobilePDR requires an account registration, which is free for all U.S.
become ubiquitous at major travel hubs. Still, a portable battery
health care professionals. Once logged in, users are welcomed with
remains essential for those moments when none of these modern
a simple home screen containing an entry field where providers can
conveniences are accessible. The Anker PowerCore Fusion, a two-
search for drugs by brand or generic name or pharmacologic class.
in-one wall charger and power bank, is a product made for
Selecting a drug from the list displays its comprehensive information
the modern traveler.
sorted by pertinent categories. Users can tap on the “Compare”
Anker is a China-based company founded in 2011, and it has button on any drug to add it to a selection list. Users can
attained worldwide reach by being one of the first major mobile subsequently tap “View Comparison” to see information between
device peripheral companies to embrace Amazon. Introduced in two or more selected drugs side by side by swiping left or right
2017, the PowerCore Fusion is one of Amazon’s most popular between drugs. Comparison lists can be saved for future use. An
products because of its compact versatility and simplicity. Despite Interaction Checker is included, where users can add two or more
being only slightly thicker than a deck of cards, this device drugs and find possible contraindications based on minor, moderate
has two USB ports and a flip-out wall plug. On its own, the or major severity. Another useful feature when patients do not know
PowerCore Fusion acts as a power bank that has enough energy what drug they are taking is Pill ID, where providers can search for
to fully charge any mobile phone or halfway charge any tablet. a drug based on its imprint, shape, color and score qualities. Any
Plug it into the wall and not only will it replenish its own battery, drug can be saved for frequent reference on the home screen via
it will also pass the charge on to two devices plugged into it. A the Share Sheets button.
blue LED light indicates the PowerCore’s own battery levels and
With its reputation as a trusted drug reference for health care
Anker’s MultiProtect system automatically protects devices (and
providers, mobilePDR is a simple implementation of this useful
itself) from damaging power surges. The entire device has one
product for mobile devices. Featuring its simple search and quick
button to check the battery, making it extremely user-friendly.
cross-referencing features, this tool will help equip providers in dental
Having a two-in-one gadget that serves all the mobile device
offices with the information they need to make important health
power needs is a great boon to travelers, and at its price point
assessments for their patients prior to dental treatment.
makes it a must-have for anyone on the go.
— Hubert Chan, DDS
— Alexander Lee, DMD
Would you like to write about technology?

Dentists interested in contributing to this section should contact
Andrea LaMattina, CDE, at andrea.lamattina@cda.org.
474 J U LY 2 01 9
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Journa

Built to serve members of organized dentistry,

SHOP ONLINE AND

421 The Editor/Decorum

469 Regulatory Compliance/Security Incident

474 Tech Trends 425

431 Safety: It’s Not Exciting but Sure Is Necessary

433 Introducing Safety in Dentistry: Perspectives and Directions

439 Checklists as Tools for Improving Patient Safety in Dentistry

Free postings. published by the Editorial Production Manuscript

Copyright 2019 by the California Dental Association. All rights reserved.

MEMBER The Journal welcomes letters

By sending the letter, the author certifies that

...so you’re not fair game.

Choose a specialized protection plan designed

You get game-changing coverage made easy.

Professional Liability Insurance & Risk Resource Services

F E AT U R E D E N D O R S E D P R O G R A M Minimize risks and increase performance. Automate workflows for

HR for Health offers human resources solutions designed for

Multiple Fee Schedules

What a mess! A crown for this patient can be billed at

New Oral Appliance Helps Sleep Apnea

Study Links Mother’s Health to Oral Health of Children

Microscopic Robots Remove Dental Plaque

Study Explains How a Pathogen Causes Hospital Infections

Safety: It’s Not Exciting

Introducing Safety in Dentistry:

FIGURE 2 . Adverse event (AE) types.

Adverse Events Identified in the EHR Through the Use of Triggers

FIGURE 3 . Breakdown of causes. Total 100

A B S T R A C T Safety is not a permanent state of affairs — we relentlessly need to work

Content/construct validity testing Discussion of results

■ Recommendations for improvement

(Leading to version 2) Finalized checklist

FIGURE 1. Schematic for checklist development.

1. Focus the checklist task

FIGURE 2 . Checklists Development Checklist (CDC) as itemized by Stuﬄebeam.32

Endorsements Evaluation (continuous)

FIGURE 3 . Proposed schematic for checklist implementation.

PRACTICE Practice Management

Exceptional protection from people who understand your profession.

The Cost of Not Practicing

A B S T R A C T The unsafe practice of dentistry can cause injures to patients,

& ASSOCIATES INC.

2. If I decide to assist the Buyer with financing, how can I be

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to

6. How can I be certain my Broker will demonstrate

7. What are the tax and legal ramifications when a

QUESTIONS MOST OFTEN ASKED BY BUYERS:

2. Can I afford not to buy a dental practice?

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify

5. Is it possible to purchase a practice

6. What kinds of things should a Buyer consider when evaluating a practice?

Making Dentistry Even Safer:

Recommended Basic Emergency Equipment 2,15,18 Seven Drugs Comprising the

Adult-sized and child-sized oropharyngeal airways

Signs and Symptoms of