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Industry Insights

Berger: Work Comp Dental Injuries: Pre-Existing vs. Job-Related

  • National

A causality dilemma can be summed up as, “Which came first, the chicken or the egg?” In dental workers' compensation terms, which came first, the injury or the bad teeth?

It is very common for a dentist to tell a patient who has been involved in an accident with dental trauma that he or she needs to have other dental needs taken care of as well as the resulting teeth affected by the accident. In some cases, it may be recommended to treat other teeth not related to the accident before the accident-related teeth are fixed. Why?

I have lectured around the country to workers' compensation nurses and adjusters, and the most common question I get goes something like this: “Why does my client need to have fillings and a deep cleaning before the dentist can fix the tooth that was injured in the worker's accident?”

According to the American Dental Association and all accredited dental schools, dentists are doctors who specialize in oral health, and their responsibilities include:

  • Diagnosing oral diseases.
  • Promoting oral health and disease prevention.
  • Creating treatment plans to maintain or restore the oral health of their patients.
  • Interpreting X-rays and diagnostic tests.
  • Performing surgical procedures on the teeth, bone and soft tissues of the oral cavity.

The first three bullet points sum up the foundation for why some dental treatment cannot be completed until other treatments have been completed.

Commonly followed guide to treating patients

Stage 1:

  • Eliminate pain or abscess.
  • Address emergency concerns.
  • Initial scaling and root planning.
  • Caries control.
  • Home care instruction.

Stage 2:

  • Splint therapy.
  • Equilibration.
  • Referrals to specialists.
  • Provisional restorations.

Stage 3:

  • Restore mandibular anteriors.
  • Restore maxillary anteriors.
  • Restore posterior teeth.

Important: If a tooth is chipped, needs to be pulled or if other treatment needs are not severe, I can and will get the patient out of pain and as close to pre-accident status as possible. This is considered treating the chief concern. 

Chief concerns are almost always a Stage 1 treatment. Make sure the doctor treats the chief concern and only the chief concern, if possible. Be aware that it is not always possible to give the final desired result until other things have been completed.

I’ll give you an example of a patient coming to see me following a work-related fall that fractured two front teeth. I will create a very common story that is a perfect depiction of the dentist doing his job to the best of his ability, which creates a situation where the patient must tackle a few costly procedures before the dentist can treat/restore two front teeth.

Bob the Builder has not been to the dentist in four years, and the last time he went for an exam he was diagnosed with chronic moderate periodontal disease — the loss of the bone holding the teeth — usually due to poor oral health resulting from poor oral hygiene.

Bob was also told he had four cavities on back teeth, and one of them was quite large and should be addressed soon to prevent an infection, and to prevent the loss of the tooth.

Bob doesn’t come back for treatment of the periodontal disease because, as he stated, “The cost of a deep cleaning is too expensive and it is unnecessary, and I am not doing the fillings because two years ago my last dentist told me I didn’t have any cavities and there is no way four just popped up in my mouth.”

This is very common for me to hear even after showing patients the evidence in their X-rays and through photos.

Bob comes back to see me after a trip-and-fall accident at work, and needs his two front teeth removed and implants put in to restore what will become two missing teeth.

The dentist writes up a report and states that the two front teeth need to be removed and implants should replace them. However, the patient needs fillings completed first, as well as a deep cleaning.

Here is where the questions start stacking up. Some questions may include, but are not limited to:

  1. Does the patient need implants or a partial denture? If he had periodontal disease that means the patient's teeth may have been loose prior to the accident. If so, why do I have to replace them with sturdy implants if the natural teeth weren’t sturdy to begin with?
  2. Why can’t the dentist remove the teeth and place the implants without the patient getting the deep cleaning, the fillings and a non-related tooth pulled? Wait, a tooth pulled? Yes, remember that one tooth that Bob was told had a large cavity four years ago? It got worse, as do all cavities. Who pays for the “non-related” deep cleaning, the cavities and the extraction? What if the patient is responsible for those fees but can’t afford it? Can he still have the workers' compensation pay for the implants? Will the dentist even put the implants in without the other issues resolved?

Let’s go back to the responsibility of a dentist. My job is to diagnose oral disease and treat it to promote oral health, and prevent disease. I did that for the patient and have identified that he has three oral diseases: decay, periodontal disease and now an infection requiring the removal of a tooth.

The decay and periodontal disease have both increased in severity in the four years since I saw the patient last. Now the patient has one tooth that is rotting severely and needs urgent treatment because of an infection at the base of it dripping pus into his mouth.

If you were the doctor, knowing that your patient has an active infection that could lead to death, three teeth that will get to that point soon, and an active disease that is making his teeth looser every day, would you put two pretty implants in to patch up the problem, letting him walk away with a life-threatening situation and teeth that may all fall out in the next 20 years?

In dentistry, doing work out of order can be considered negligence, malpractice and unethical. It is my duty to make sure the patient treats the cavities, treats the disease and removes the infected tooth.

After all of that has been completed and paid for, I need to assess if he is making progress toward better oral health. Then the dentist can replace those two missing teeth with implants. (Don’t forget the three stages you read earlier. Stage 1 needs to be completed before Stage 3).

The next time you are told your patient needs to have other work completed before the work on the teeth you are paying for, think of Bob. Think of Bob’s health — not just fixing one problem and moving on.

I do believe it is Bob’s responsibility to pay for the dental work he needs before the workers' compensation portion is completed. That is his disease and was not related to the accident. There are things I can do as the dentist to give Bob a temporary fix while he fixes the other problems.

There are also things I can do to help Bob get his implants sooner, which will help you close the case more quickly. What I can’t do is harm the patient by doing things backwards just because Bob wants it done the way he wants it done or because the nurse/adjuster wants it done a certain way.

This is a fictional story but it is a common story. All too often we find that many dentists are not familiar with managing a work comp dental claim and, unfortunately, not all dentists do the right thing for the right reason. Because of that it is recommended when encountering a work-related dental injury to partner with industry experts who specializes in the management of work comp dental claims.

Injured workers are channeled to an appropriate dental specialist who understands work comp, resulting in treatment plans that are solely related to the work injury. The end result: Injured workers receive appropriate and cost-effective treatment with early maximum medical improvement.

Dr. Jacob Berger is a dental adviser for EZ Dental Care, which provides dental claim management and provider network services for the workers’ compensation industry.

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