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Implants – What’s done is done

“What’s done is done.” (Macbeth) encapsulates that critical aspect of Dental Implant Surgery: it’s not reversible without consequences. This leads us to consider the precautionary steps needed by every dental practitioner prior to surgically placing dental implants.

Presenting Case

A 56 year old female patient presents to you for the first time on recommendation from a friend who mentioned that “my dentist is very good with implants”. She has type 2 diabetes controlled by medication, with a history of periodontal disease. Her presenting condition was:

  • Upper right first molar (tooth #16) lost several years ago from a root fracture
  • The adjacent teeth are unrestored and this is her only missing tooth other than the third molars
  • Her chewing is compromised and would like to have this space restored with an implant.

Case Selection

  1. History of the patient: A comprehensive medical, dental and social history would determine the suitability of the patient. Consultation with the patient’s Medical GP would add further valuable information.
  2. Examination: A thorough extra-oral and intra-oral of the soft and hard tissues inclusive of periodontal health, occlusion and bone volume (Study models and photographs are an integral part of this step).
  3. Investigations: Should be carried out in the form of radiographs, CBCT etc., as required.
  4. Patient Expectations: Assessment of their reasons for seeking treatment, their dental needs and their concept of how to measure a successful outcome.
  5. Diagnosis: Based on the information gathered.
  6. Treatment Planning: Should go beyond the implant and include consideration of the final restorative result, which can then be achieved with provision of a surgical guide.
  7. Treatment Options: Presented to the patient, detailing all available options with associated benefits and risks.
  8. Consent to Treat and Financial Consent: by ensuring that the patient is made fully aware by the treating practitioner of all material risks, alternative treatments, likely outcomes, nature and purpose of the procedure.
  9. Special considerations: Complex dental implant surgery requires detailed communication of possible complications and unexpected sequelae. Discussion should focus on the severity of the complication as well as its probability.

As dental practitioners, if we can evaluate each case with a structured and meticulous protocol, we can generally ensure a predictable outcome. A failure, complication or unsatisfactory outcome with dental implant treatment is usually the result of an error or omission in the preliminary stages of history, examination, investigation, diagnosis, treatment planning and consent.[1]

Are we ready to proceed?

As Dentists, we need to ask ourselves honestly whether we have the necessary skills, experience and adequate post-graduate training prior to placing dental implants. Here are some questions we all need to consider:

  • Have I discussed my case with my mentor or teacher to gain further insight?
  • Am I in contact with experienced clinicians who have years of experience in dental implant surgery that can give me feedback?
  • Do I belong to a study group or an implant team in which I can discuss my case in detail with my peers?
  • What are my limitations with respect to this case?
  • Have I looked critically into my case and made a clever case selection decision?
  • What could go wrong?

The Dental Board of Australia (DBA) Scope of Practice (SOP) for dental practitioners specifies that we must use sound professional judgement to assess our own individual SOP (full range of activities and responsibilities in which we are educated, trained and competent to perform).

Anticipated level of post graduate study and training

Dentists who place dental implants should have acceptable, recognised training over a long period and develop skills from treating simple cases, using the established protocols, prior to progressing to more complex and technically demanding cases.

In Britain, the General Dental Council (GDC) and the Faculty of GDP (UK) have published guidelines on training in implant dentistry for general dental practitioners which requires that a practitioner should have adequate practice in assessment, treatment planning and implant surgery under the guidance of an experienced implant clinician, until they are considered competent.[2]

In Australia, there is no special category for a general dental practitioner who surgically places implants. There might be a need in Australia to inaugurate guidelines similar to GDC (UK), specifically aimed at all clinicians surgically placing dental implants and recognised by the DBA

Preventing poor outcomes

  • Assess, listen and consolidate information.
  • Use a comprehensive treatment plan and list of treatment options.
  • Involve your patient in your choices, communicate and obtain informed consent.
  • Keep comprehensive and accurate records.
  • Embrace protocols that are proven and predictable (don’t take shortcuts).
  • Self-evaluate your skill and experience to deliver the proposed treatment.
  • Above all, refer cases that are too complex.

The dental implant industry is growing rapidly each year and there is substantial pressure from dental implant suppliers encouraging clinicians to place dental implants even if they have minimum experience and knowledge. Don’t fall into that trap! Excellent planning and execution of a dental implant case can still result in complications and an unexpected outcome, but if the protocols followed are proven and predictable, the outcome is supported by evidence of accepted clinical practice.

A further important perspective: Guild Insurance’s Annual Review based on a five year analysis of dental claims made, established that of 850 claims incurred by 230 practitioners, one procedure contributed greater and more frequent claims (based on the number of insureds conducting this procedure)  than any other, and that is “Insertion of Endosseous Implants (not including restorative procedures)”[3]. Surgical placement of dental implants has a higher claims cost than any other procedure, as demonstrated by the diagram below provided by Guild Insurance:

Dentists who surgically place dental implants need to assure themselves that they have the necessary training and competency which you can’t attain through a weekend course: it takes long periods of study, education and practice. If you don’t commit to these criteria then you can anticipate future patient problems, conflicts and high insurance risk, none of which you can easily cotrol.

Key Statement

…. if we can evaluate each case with a structured and meticulous protocol, we can generally ensure a predictable outcome.

Key Point

  1. Training + Practice = Competency
  2. Case Selection is Critical
  3. Ensure well informed consent inclusive of all relevant warnings.

 

by:  Dr. Sumanthi Mani, NSW Peer Advisor, Advisory Services

 

[1] Rees J. Medicolegal implications of dental implant therapy. Prim Dent J. 2013 Apr; 2(2):34-8
[2] Palmer, R.M: Risk management in clinical practice. Part 9. Dental implants: BDJ 209: No10
[3] Guild Insurance Limited (May 2016) Renewal Information

Managing patient expectations


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It’s well recognised that patients don’t necessarily complain simply based on their clinical outcome. Most dentists will have heard of or seen situations where a patient has experienced an outcome which wasn’t ideal yet wasn’t particularly poor, however the patient has been quite annoyed with the outcome and has lodged a complaint.  On the other hand, there are many cases of patients who have experienced quite poor outcomes yet have chosen to not complain.

There are many reasons why the above may occur, some which are easier to identify than others. All patients are different and human behaviour isn’t always predictable.  Good communication and the relationship between the patient and dentist will greatly influence the likelihood of a complaint.  One other very important factor is the expectations of patients.

Patient expectations

Many patients will go into dental appointments with some level of expectation regarding their likely outcome. They may have a very clear and detailed outcome in mind or it may be more broad and open.  Most importantly, some of these expectations will be realistic, however others won’t be.

Unrealistic patient expectations pose very real challenges for dentists. If a patient undergoes treatment which they have unrealistic expectations about, it’s unlikely those expectations are going to be met simply due to them being unrealistic.  If a patient’s expectations haven’t been met, it’s likely the patient is going to be unhappy or dissatisfied with the treatment.  Those unhappy and dissatisfied patients are the ones more likely to complain about the treatment and expect further corrective treatment or compensation.  It’s therefore vital that dentists do all they can to help the patient fully understand treatment and the likely and possible treatment outcomes before treatment begins.

Creating realistic expectations

A key step in making sure a patient has realistic outcomes regarding treatment is to have an open and honest conversation with them. This will not only provide the patient with further information about their treatment, but will also give the dentist a clearer understanding of the patient’s expectations.  A dentist’s clinical skills are vital to what they do, however effective communication goes a long way in providing positive outcomes.

To assist a patient to have realistic expectations, dentists must ensure they explain the treatment and outcomes using simple, clear terms. Technical clinical language should be avoided as many patients won’t understand this.  Dentists should also consider how they tailor their language and the information for each individual patient.  For example, a person with language or literacy challenges may need information presented in a more detailed manner than other patients.  Dentists should also consider using diagrams, pictures or models to assist with understanding where appropriate.

When discussing treatment with a patient, it’s important that dentists don’t make assumptions about what the patient will or won’t understand. It’s easy for dentists to become so familiar with what they do and know that they sometimes forget how foreign that knowledge can be to other people.  Patients will have varying degrees of knowledge and experience regarding dental treatment.  Therefore, what they understand about their treatment will also vary.

When a patient attends a dental clinic and requests a particular form of treatment, this is an occasion when a dentist should be especially mindful of the patient’s expected outcome. When a patient has requested a form of treatment, the patient has clearly formed a decision around what treatment they need to get the outcome they desire.  What they’re requesting and expecting may be reasonable and realistic, however in some cases it may not be.  When presented with this situation, dentists need to be sure they don’t rush into providing the patient with the requested treatment.  As with all patients, there needs to be a thorough assessment and diagnosis process.  Then the patient is to be provided with their treatment options, as well as the risks and benefits of those options.  There may be treatment options which are more suitable for that patient which the patient isn’t aware of.  The patient also needs to be made aware of the likely treatment outcomes for each of those treatment options.

The dentist needs to be sure the patient has all required information before consenting to treatment and this includes understanding the likely outcomes. A patient requesting particular treatment doesn’t alter this required process.  And dentists need to remember that they’re always responsible for the treatment they’ve provided, regardless of whether it was requested by a patient.

In summary…

Dentists should be doing all they realistically can to improve the outcomes for their patients and reduce the likelihood of poor outcomes and complaints. An important step in this process is making sure patients have realistic expectations regarding treatment outcomes.  Dentists have a very important role in using their clinical knowledge in conjunction with practical terminology to assist patients to develop realistic expectations.  Dentists need to remember this is of great benefit to both themselves and their patients.

 

Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them. This article contains information of a general nature only, and is not intended to constitute the provision of advice.

 

 

What would happen if you can’t operate your business?

The threat of storms and fire are obvious threats to any business; however it’s often the seemingly harmless incidents which can severely affect a business’s operations. Events such as prolonged unforeseen power outages, burst water pipes or a sewage leak can all wreak havoc on your business.

However, there are ways you can attempt to minimise the effects of interruptions to your business.

1. Identify ways in which your business may be vulnerable to an interruption.
> For example, conduct regular building inspections and ensure preventative maintenance programs are in place.

2. Develop a critical tasks checklist to follow in the event of a major disruption.
> Include items such as diverting phones, photographing damage, securing stock and other assets.

3. Maintain a list of critical contacts to call when an interruption events occurs.
> Include staff, landlords, contractors, security providers, local council, suppliers and details of your insurance provider.
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4. Produce an essential items kit of things you might need in an emergency.
> A site map of your premises showing the location of electrical switchboards, hot water service, water and gas shut-off valves and emergency exits.
> Instructions for restoring IT systems and hardware.
> Instructions for accessing updates from key government agencies such as CFA, SES, Bureau of Meteorology.
> Emergency provisions such as a torch, mobile phone charger, and a battery operated radio.
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5. Maintain an accurate list of current assets.
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6. Regularly back-up electronic records and ensure a copy is securely stored offsite.
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7. If an event does occur, record evidence of any damage before beginning the clean-up.+++
If you would like information on how Business Interruption cover can help you, simply contact your ADA state branch or visit guildinsurance.com.au

DOWNLOAD AS PDF

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Are you sure it couldn’t happen to you?

Below are common scenarios many dentists believe will never happen to them. But claims reported to Guild Insurance tell a different story. These scenarios do happen; often causing considerable distress to the dentists involved.

Case example 1

A patient telephoned her dentist after-hours to report persistent pain and swelling post procedure. The dentist took the call on his mobile phone while driving home from work. He clearly recalls advising the woman to return to the practice the following day if her symptoms hadn’t settled. However, he didn’t make any record of their conversation. As the woman didn’t return the next day, he assumed her symptoms had subsided. Yet she was subsequently hospitalised with a systemic infection and later claimed the dentist was negligent in failing to diagnose her condition and provide adequate post procedure care. She denied he’d told her to return to the practice the following day if her symptoms had not subsided.

Case example 2

An endodontic file broke during root canal treatment, and a small fragment remained in the root. The dentist decided to leave the fragment and complete the filling as it was unlikely to be problematic. Unfortunately, he didn’t think it necessary to tell the patient.  The woman subsequently lodged a formal complaint 18 months later when another dentist pointed out on x-ray the “broken instrument lodged in her tooth”. She claimed the dentist had “deliberately tried to cover-up his shoddy work”.

Case example 3

A patient presented in pain with a deeply carious 37. He refused RCT, preferring extraction. The roots of the 37 were in close proximity to the inferior alveolar nerve. The tooth had a hot pulp and local anaesthesia was given both as a block and as infiltration, as anaethesia proved difficult. The extraction was challenging, but ultimately successful. However, the patient experienced ongoing numbness to his lips and chin. He successfully argued that had he known there was a risk of nerve damage he wouldn’t have agreed to the extraction. He said he’d always assumed extraction was the “simplest and best option”, and the dentist “hadn’t made any mention of nerves, let alone nerve damage”. While the dentist was adamant she’d warned the patient of the risks, there was no mention of it in the clinical record.

Case example 4

A new patient elected to have tooth 36 extracted, rather than try endodontic treatment. Periapical radiographs revealed bulbous roots and as such, the dentist warned the extraction might be difficult and referral to an oral surgeon may ultimately be needed. Unfortunately, the crown did fracture during extraction and the roots were subsequently removed without incident by an oral surgeon. The patient seemed satisfied with the outcome and no further contact was had. However, a year later the dentist received a solicitor’s letter alleging he’d been negligent in using prolonged and excessive force when extracting the tooth, and that he should have referred the man to an oral surgeon from the outset. The man successfully argued that the dentist’s actions had aggravated his previously undiagnosed TMJ condition.

Case example 5

A patient with a fear of dental procedures was prescribed Temazepam 10mg and instructed to take a dose one hour before his appointment. However, the dentist didn’t think to warn him that because the drug is a sedative, he should have someone else drive him to and from his appointment. Don’t assume patients will automatically know what you think is obvious or common sense!

Case example 6

A patient complained about the quality of veneers performed to teeth 11 and 21. At the heart of her complaint was that she “would never have agreed to veneers” had she known they “were not going to be the same size and feel as her natural teeth”. Expert opinion was subsequently critical of the quality of the dentist’s work, along with inadequate dental records and informed consent. It was near impossible to defend the dentist’s actions as she’d recorded next to nothing in the clinical record.

It may be tempting to view these cases as unfair criticism of dentists who “haven’t done much wrong”. But that’s rather short-sighted. Community expectations are driving higher standards of practice for all health professionals, dentists included. And at the same time, dentistry is becoming more complex and financially challenging. So unfortunately, those not willing to embrace necessary changes in practice are more likely to face an uncertain future.

When a patient does make a complaint against you, they’re really saying, “I came to see you and I ended up worse off”. That someone could end up “worse off” after a trip to the dentist never crosses the minds of most people. They just expect that with your credentials and expertise, you’ll be able to fix any problem. So when things don’t go according to plan, they often say, “I’d never have agreed to that treatment had I known that could have happened”.

It’s also tempting to underestimate the impact claims can have on the dentists involved. Not only may they feel hard done by, but their reputation and livelihood can be damaged too. Some people take to social media to broadcast their dissatisfaction, while every year hundreds of others make formal complaints to regulatory authorities like the Dental Board of Australia. And of course, many patients also seek financial compensation from the dentist for what they believe is sub-standard treatment.

Top 10 learnings from claims

It may surprise you to know, thousands of dental claims reported to Guild Insurance highlight the same recurring themes year after year. While there are no surprises in the top 10 learnings, it seems many dentists are still reluctant to heed the warnings. Don’t fall into the trap of thinking it couldn’t happen to you.

  1. Poor communication undoubtedly tops the list.

Our claims clearly show that if dentists don’t manage patient expectations from the outset, they significantly increase their risk of serious complaints.

Don’t assume that what’s clear or obvious to you is understood by your patients. You’ll often need to explain the same information more than once throughout the course of treatment.

  1. Informed consent to treatment runs a close second.

What’s an acceptable risk to one person may be completely unacceptable to another. And it’s the dentist’s responsibility to ensure each patient has the right information to make an informed decision about their treatment and associated costs. Avoid the temptation to assume you know what the patient considers to be reasonable or acceptable. And don’t simply ask someone if they understand, as in many cases they’ll say yes even if they don’t! Ask them to tell you what they’ve understood from the discussion.

  1. Claims reported to Guild Insurance make a compelling case for improving dental records. Hundreds of cases every year are extremely difficult to defend because the dentist’s records are so poor. The patient and the dentist often have different recollections of what happened, so in the absence of good records, the patient’s views tend to hold sway.No prizes for guessing this one … yes, dental records!

Yet our claims experience also shows that a dentist’s version of events is more likely to be accepted, if they can demonstrate that good record keeping is part of their usual practice. Not just for the patient in question, but for all patients.

  1. Don’t be tempted to perform procedures unless you can demonstrate the requisite training, skills and experience.

When sub-optimal outcomes occur, the quality and appropriateness of the treatment is frequently called into question. Importantly, you’ll be judged against what the dental profession considers appropriate standards of practice and training.

Therefore, it’s imperative that you keep pace with changes in dentistry and seek supervision when needed. It’s surprising how many dentists we meet who are not fully aware of their professional obligations.

  1. Similarly, resist the temptation to embark on overly ambitious treatment plans.

Take the time to think through the pros and cons of each possible treatment and your level of expertise in delivering what the patient expects. Many claims reported to Guild Insurance focus on allegations of poor quality treatment, where the patient seeks reimbursement of not only the initial treatment costs, but the cost of replacement or corrective treatment too.

Consider referring the patient to a specialist where appropriate, and carefully explain the difference between what you can offer and what a specialist can do. Likewise, weigh up the risks of adopting new techniques or equipment – don’t be blinded by commercial opportunities.

  1. Don’t be pushed into doing things against your better judgement.

There’s a common misconception that if a patient insists on a course of treatment, despite being warned against it, the dentist can’t be held accountable for poor outcomes. For instance, a patient may insist on treatment without undergoing the preferred radiographs. But don’t be fooled, as a registered dentist you’ll still be held accountable for the care you provide, even if the patient pressured you into it.

  1. Likewise, don’t be coerced into providing complex care during initial or ‘emergency’ appointments.

It’s important to carefully explain to patients what can and can’t be done during these appointments. Written material for them to take home also helps emphasize the need to return for a follow up appointment to further assess their oral health and agree a plan of care.

  1. Don’t agree to treat patients under The Child Dental Benefits Schedule (or any other program) without fully understanding your obligations first.

As dentists well know from the CDDS, there can be serious consequences for non-compliance. An updated guide for helping dentists to understand their responsibilities is available via the Department of Health website.

  1. Resist the temptation to make off the cuff comments to patients about the treatment they’ve received from another dentist.

Check your facts first! It’s possible the clinical situation you’re seeing is different to what the other dentist faced. Where possible, contact the dentist involved, or the ADA, to discuss your concerns before sharing them with the patient.

  1. Don’t rely on social media to inform your clinical decision making.

Much of this content is unchecked and unregulated. It’s always preferable to participate in recognised CPD and make use of the formal networks promoted by the ADA and special interest groups.

Furthermore, when making any posts on social media, carefully consider how your comments may be perceived by your colleagues, patients and regulatory authorities. Despite the often casual nature of social media, the rules of professional practice still apply.

Finally, seek regular feedback from your patients and staff about their experiences in your practice. They may see opportunities for improvement that you don’t!

For more information, please contact your ADA state branch or Guild Insurance on 1800 810 213.

Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them.

Advertising pitfalls in the modern era of dental practice

Advertising for dentists has become a recurring issue given the legislative considerations and the logistical problems in meeting these. All dentists are familiar with “old fashioned” avenues of advertising, but the emergence of new forms of social media and avenues to advertise has trapped many members into promotions which, unwittingly in many cases, cause them to breach the DBA standards.

In particular, many members have been approached by web based advertising companies having no regard or responsibility for protection of health professionals compliance with regulatory requirements. In many cases dentists are not in control of the material which is published. Social media or “limited deal” sites have been increasingly breaching DBA standards and CROs have been alerting members of these breaches. In a number of cases the corporation for whom members work, or their employers have placed the advertisements. In other instances the dentist may have bought a “package” and left it up to the media company to design the advertising.

The Regulator

The DBA has set and polices the standards, and a recent publication (Fact sheet) on the AHPRA website states:

“For the first year of the scheme the Boards’ approach to advertising matters has been largely educational, by helping practitioners understand the law and the new requirements set down in each Board’s standards.

The National Boards will now take a more structured approach to addressing concerns about advertising. This will include a series of warnings to the practitioner, initially reminding them of their obligations in relation to advertising, and ultimately possible prosecution for non-compliance with the Board’s standards.”

Members are reminded that guidelines are published by DBA and failure to comply can result in a finding of unprofessional conduct. The 2010-2011 AHPRA Annual Report gives details about the classification of notifications received and notes that, as they have not acted to prosecute but have given some leeway in the matter of advertising, it is not represented in the current report. However ADA Branches are aware of a large number of breaches that have been reported, and in the interests of helping members to reduce their liabilities, the ADAVB has taken action to highlight these issues to members via newsletter items and personal contact when social media and other advertising breaches are found.

Section 133 of the National Law states that

‘a person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that —

(a) is false, misleading or deceptive or is likely to be misleading or deceptive; or

(b) offers a gift, discount, or other inducement to attract a person to use the service or the business, unless the advertisement also sets out the terms and conditions of the offer; or

(c) uses testimonials or purported testimonials about the service or business; or

(d) creates an unreasonable expectation of beneficial treatment; or

(e) directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services.’

Practitioners are held responsible for the style and content of all advertising material associated with the provision of their goods and services. Practitioners may not delegate accountability for ensuring the accuracy of advertising and compliance with these guidelines to an administrator, manager, director, media or advertising agency, or other unregistered person. In addition AHPRA has the right to pursue owners or unregistered persons with regard to advertising breaches.

Social media makes life more difficult

It may seem to many dentists that AHPRA would be better pursuing disciplinary matters other than advertising. But the rationale behind the standards is that dentists are health care providers and so are able to advertise health services within the guidelines. Unfortunately some practitioners are advertising services not considered a health service, and outside the DBA guidelines. In addition a number of dentists have come to grief over the past two years in connection with social media rather than established forms of advertising. There have been a number of media commentaries recently highlighting the need for organizations to develop a social media policy to regulate the use of these forms of communication in the workplace. AHPRA is aware of the need to update the standards to address these issues and it published “Common Advertising Breaches by Dental Practitioners” in March 2012, with a number of clear examples of breaches.

Unacceptable advertising via daily deals

Daily Deals, Living Social, All the Deals, DealFetch, Jumponit, DealWatch, Smarter Daily Deal and

Groupon style discount offers and similar advertisers have been attracting dental practices to offer their services via their online facilities, and the ADAVB has been asked whether in our view these are compliant with advertising guidelines promulgated by the Dental Board of Australia (DBA).

Those guidelines state:

To comply with s. 133 of the National Law and these guidelines, advertising of services must not:

… contain price information that is inexact, or fails to specify any conditions or variables to

an advertised price (see Section 6.5, ‘Advertising of price information’), or offers timelimited discounts or inducements

Many of the advertisements for dental services that we have seen using these daily deals or specials involve time limited discounts, and so they would not comply with the DBA’s advertising guidelines.

If your advertisement includes words like “PROMOTIONAL VALUE EXPIRES ON [date]”, then your advertisement may be in breach of the DBA advertising guidelines.

Reports have also been received of some practices handing out flyers either in shopping centres orin the street, offering time limited discounts or special deals. These too would be in breach of the DBA guidelines.

In addition to advertising concerns, the use of social media such as Facebook has also led to substantiated complaints about misuse of private information and even notifications about inappropriate relationships and behavior of some health professionals. All members are urged to be cautious with use of these media with respect to patient information and identification. SMS messages have also been used as evidence in complaint cases.

At this stage all ADA Branches and GIL would urge practitioners to familiarize themselves with the requirements but accessing the following resources. Unfortunately the ADA Branch staff cannot “sign off” on any advertising material as it is outside their area of expertise and indemnity to do so. They can provide members with some limited advertising advice if contacted but may also suggest that you seek your own legal advice to ensure compliance with the registration standards.

Practitioners intending to advertise should make themselves familiar with