Case Management Case Management FailuresFailures

What is a Case Management FailureWhat is a Case Management Failure?

A diagnostic error leading to an incorrect diagnosis Pulp pathology

NeuralgiaDiagnostic 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

What factors might predict case What factors might predict case management failuremanagement failure

• Subjective complaints

• Behavioral factors

• Examination findings

What factors might predict case What factors might predict case management failuremanagement failure

• Subjective complaints– Unusual (non-dental) description of pain– Description of concomitant dysesthesia,

paresthesia, or anesthesia– Aggravating factors not typically associated

with dental pathology (e.g. pain increased by placement of makeup or shaving)

– Nonanatomic distribution

What factors might predict case What factors might predict case management failuremanagement failure

• Behavioral factors– Excessive treatment seeking– Obvious medication abuse (e.g. too much knowledge re

drugs, allergy(s) to non-narcotic medications, etc)– Excessive pain behavior – Pain persisting in spite of reasonable prior treatment or

multiple procedures– The presence of two or more co-morbid pain problems– A history of two or more kinds of physical or sexual

trauma preceding development of chronic pain, especially in men

Gender differences in associations Gender differences in associations between trauma history and adjustment between trauma history and adjustment

among chronic pain patientsamong chronic pain patientsSpertus 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

What factors might predict case What factors might predict case management failuremanagement failure

• Examination findings– Inadequate examination of the patient– Lack of objective evidence of disease from

imaging– Lack of positive examination findings– Questionable or conflicting examination findings – Ignoring positive examination findings

potentially reflecting the possibility of a non-dental cause of the patient’s pain

67 Year Old Female67 Year Old Female• 6 years pre-evaluation developed adult onset

chicken pox (2 weeks with resolution)• Post above, began to notice a funny sensation

between teeth – “felt like stuff in mouth”• Unusual coating sensation enveloped mouth and

then localized with greater intensity to the right mandible

• Root canal on right mandibular molar• Left mandible with increasing sensation

67 Year Old Female67 Year Old Female• Root canal of left mandibular tooth• Continued symptoms• Extraction of left mandibular teeth• Continued sensation of a coating in mouth and a

feeling of something between the teeth• Scraping of tongue biopsy by Oral Pathologist:

Diagnosis - Herpes with treatment• Diagnosis of candidiasis with treatment• ENT evaluation with 9 months of topical treatment

Cardinal Findings Suggestive of Cardinal Findings Suggestive of a Non-Dental Diagnosisa Non-Dental Diagnosis

• Pain is electrical or shock like and paroxysmal with pain free intervals not associated with intra-oral cold or heat application

• Pain is associated with feeling ill or visual change• There is concomitant nausea, vomiting, light or

noise sensitivity• Pain is aggravated by light touch of the external

skin or is provoked by swallowing • Pain is associated with memory loss, loss of skills,

or motor activity abnormality

Cardinal Findings Suggestive of Cardinal Findings Suggestive of a Non-Dental Diagnosisa Non-Dental Diagnosis

• Facial pain is not shut off with a peripheral block• There is history (symptoms) suggestive of systemic

disease (e.g. URI, sinus abnormality, cardiac disease, etc)

• Severe facial pain stops when the patient sleeps• Pain crosses the midline or the radiation pattern is

bizarre • Pain is provoked by palpation of neck or jaw muscles• Pain migrates after appropriate treatment (to adjacent

teeth)

Reasons for Case Management Reasons for Case Management (Treatment) Success(Treatment) Success

• Placebo

• Doctor-patient interaction

• Cyclic-fluctuation of the disease

• Spontaneous remission

• Therapeutic effect

• Therapeutic effect of intervention not appreciated by clinician

Reasons for Treatment Reasons for Treatment SuccessSuccess

• Clinician bias

• Chance

• Misinterpretation of information gathered from patient

• Absence of or inappropriate outcome variables

Dental pathology

Neurophysiology / Pain mechanisms

Systemic pathology Psychological Abnormality

Behavioral Issues

Peripheral Central Sympathetic

Learning and memory

Age and Gender Effects