Dental Case Management Failures


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This lecture, presented to the University of Washington Dental School and a King County Dental Society group

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  • Accumulating research suggests that chronic pain patients may have a higher prevalence of sexual and physical abuse than normal Few studies assessing correlation between abuse history, pain severity, and disability….those available with inconsistent findings. No studies looking specifically at orofacial pain with respect to the above parameters In this study pain intensity and disability was not apparently associated with abuse history in either men or women Limitations included small sample size, retrospective nature of history taking/ absence of corroborative evidence, etc
  • Dental Case Management Failures

    1. 1. Case Management Failures
    2. 2. What is a Case Management Failure ? A diagnostic error leading to an incorrect diagnosis Pulp pathology Neuralgia Diagnostic errors leading to inappropriate treatment Root canal therapy Temporal Arteritis, cardiac disease Treatment that is inappropriate to the diagnosis Reversible pulpitis Antibiotic without evidence of infection
    3. 3. What factors might predict case management failure <ul><li>Subjective complaints </li></ul><ul><li>Behavioral factors </li></ul><ul><li>Examination findings </li></ul>
    4. 4. What factors might predict case management failure <ul><li>Subjective complaints </li></ul><ul><ul><li>Unusual (non-dental) description of pain </li></ul></ul><ul><ul><li>Description of concomitant dysesthesia, paresthesia, or anesthesia </li></ul></ul><ul><ul><li>Aggravating factors not typically associated with dental pathology (e.g. pain increased by placement of makeup or shaving) </li></ul></ul><ul><ul><li>Nonanatomic distribution </li></ul></ul>
    5. 5. What factors might predict case management failure <ul><li>Behavioral factors </li></ul><ul><ul><li>Excessive treatment seeking </li></ul></ul><ul><ul><li>Obvious medication abuse (e.g. too much knowledge re drugs, allergy(s) to non-narcotic medications, etc) </li></ul></ul><ul><ul><li>Excessive pain behavior </li></ul></ul><ul><ul><li>Pain persisting in spite of reasonable prior treatment or multiple procedures </li></ul></ul><ul><ul><li>The presence of two or more co-morbid pain problems </li></ul></ul><ul><ul><li>A history of two or more kinds of physical or sexual trauma preceding development of chronic pain, especially in men </li></ul></ul>
    6. 6. Gender differences in associations between trauma history and adjustment among chronic pain patients Spertus I, et al; Pain 82 (1999):97-102 N = 73 chronic pain patients (51% female, 60% lower back) Measures: questionnaires for trauma, stress, MPI, Beck depression, West Haven-Yale Multidimensional Pain Inventory Discussion: trauma history may effect men and women differently and men may experience a specific pattern of difficulties. Men experiencing trauma with higher levels of anxiety, symptoms of depression and general emotional distress than men without such history
    7. 7. What factors might predict case management failure <ul><li>Examination findings </li></ul><ul><ul><li>Inadequate examination of the patient </li></ul></ul><ul><ul><li>Lack of objective evidence of disease from imaging </li></ul></ul><ul><ul><li>Lack of positive examination findings </li></ul></ul><ul><ul><li>Questionable or conflicting examination findings </li></ul></ul><ul><ul><li>Ignoring positive examination findings potentially reflecting the possibility of a non-dental cause of the patient’s pain </li></ul></ul>
    8. 8. 67 Year Old Female <ul><li>6 years pre-evaluation developed adult onset chicken pox (2 weeks with resolution) </li></ul><ul><li>Post above, began to notice a funny sensation between teeth – “felt like stuff in mouth” </li></ul><ul><li>Unusual coating sensation enveloped mouth and then localized with greater intensity to the right mandible </li></ul><ul><li>Root canal on right mandibular molar </li></ul><ul><li>Left mandible with increasing sensation </li></ul>
    9. 9. 67 Year Old Female <ul><li>Root canal of left mandibular tooth </li></ul><ul><li>Continued symptoms </li></ul><ul><li>Extraction of left mandibular teeth </li></ul><ul><li>Continued sensation of a coating in mouth and a feeling of something between the teeth </li></ul><ul><li>Scraping of tongue biopsy by Oral Pathologist: Diagnosis - Herpes with treatment </li></ul><ul><li>Diagnosis of candidiasis with treatment </li></ul><ul><li>ENT evaluation with 9 months of topical treatment </li></ul>
    10. 10. Cardinal Findings Suggestive of a Non-Dental Diagnosis <ul><li>Pain is electrical or shock like and paroxysmal with pain free intervals not associated with intra-oral cold or heat application </li></ul><ul><li>Pain is associated with feeling ill or visual change </li></ul><ul><li>There is concomitant nausea, vomiting, light or noise sensitivity </li></ul><ul><li>Pain is aggravated by light touch of the external skin or is provoked by swallowing </li></ul><ul><li>Pain is associated with memory loss, loss of skills, or motor activity abnormality </li></ul>
    11. 11. Cardinal Findings Suggestive of a Non-Dental Diagnosis <ul><li>Facial pain is not shut off with a peripheral block </li></ul><ul><li>There is history (symptoms) suggestive of systemic disease (e.g. URI, sinus abnormality, cardiac disease, etc) </li></ul><ul><li>Severe facial pain stops when the patient sleeps </li></ul><ul><li>Pain crosses the midline or the radiation pattern is bizarre </li></ul><ul><li>Pain is provoked by palpation of neck or jaw muscles </li></ul><ul><li>Pain migrates after appropriate treatment (to adjacent teeth) </li></ul>
    12. 12. Reasons for Case Management (Treatment) Success <ul><li>Placebo </li></ul><ul><li>Doctor-patient interaction </li></ul><ul><li>Cyclic-fluctuation of the disease </li></ul><ul><li>Spontaneous remission </li></ul><ul><li>Therapeutic effect </li></ul><ul><li>Therapeutic effect of intervention not appreciated by clinician </li></ul>
    13. 13. Reasons for Treatment Success <ul><li>Clinician bias </li></ul><ul><li>Chance </li></ul><ul><li>Misinterpretation of information gathered from patient </li></ul><ul><li>Absence of or inappropriate outcome variables </li></ul>
    14. 14. Dental pathology Neurophysiology / Pain mechanisms Systemic pathology Psychological Abnormality Behavioral Issues Peripheral Central Sympathetic Learning and memory Age and Gender Effects