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Risk factors


27 August 2014
A clinician’s specialised knowledge of the aetiology of various oral and dental conditions places him, or her, in a position of significant advantage relative to most patients.

That said, the role of oral hygiene in various dental conditions, and the role of diet in caries are, in broad terms at least, well known to most patients, even if they choose not to alter their habits in order to control the disease process. Lack of engagement by the patient, whatever the cause, can place the clinician at risk if it could be implied that the disease has progressed without the patient having been warned of the consequences and given information on how to prevent that from happening.

The role of smoking in periodontal disease, oral cancer, delayed wound healing and other conditions may be less obvious to most patients. In addition, bruxism, thumb/finger sucking, and other parafunctional habits can contribute to orthodontic problems, restorative failures and other situations that can sometimes provide a diagnostic challenge for the most experienced of clinicians.

Communication

Part of a clinician’s duty of care is to recognise these and other risk factors and to explain their significance to patients in terms that they can understand, in the hope that by removing or minimising the relevant risk factors, the patients’ future oral and dental health can be protected or improved.

If you fail to give a patient (or in the case of a child, a parent) sufficient information at an appropriate time about relevant risk factors it might be thought that you denied them an opportunity to take remedial action in order to avoid the occurrence, or a deterioration of a condition. Whether or not the patient would have acted upon your advice is a quite separate issue - and an important one - but if the information, explanation and advice is not given at all and a problem results or a clinical situation deteriorates, the clinician will be left arguing from a position of relative weakness. If you are aware of a risk factor, make sure that the patient is aware of it too.

The words used during an explanation can also be relevant, because the purpose of the exercise is not simply to impart the information, but to try to ensure that it is also understood. Whenever possible, the patient must understand the likely consequences of not following the advice that is being given, in the context of the condition that is being discussed.

Follow-up

It is important to check that the patient has acted upon your earlier advice. If they have not done so, repeating the advice can help to convey the necessary emphasis, so the patient is more likely to appreciate the fact that this is specific, relevant and important personalised advice about his or her current and future oral health, and not simply general information. It is important to ensure that the clinical records are sufficient to demonstrate:

  • The nature of the condition in question.
  • What risk factors were identified?
  • When they were explained to the patient, and in what terms.
  • What (specific) advice was given to the patient regarding each of the identified risk factors?
  • Who gave the initial advice (and any following advice), and when?
  • What (if any) questions were asked by the patient, and how they were answered?
  • What (if any) written or other material was given to the patient, to supplement any one-to-one advice?
  • What efforts were made, and when, to follow up the initial provision of the advice, and to check whether or not the patient had acted upon it?
Unwilling patients

When a patient has been told about one or more risk factors, but nevertheless appears to have taken no steps to address them, it is important that the clinician should try to ascertain whether this is simply a case of an unwillingness to follow the advice, or alternatively, it is because the patient has not yet understood the significance of the advice, or its importance and relevance to their own oral condition.

The fact that this particular check has taken place should similarly be recorded in the clinical notes.

Where appropriate, these messages should be reinforced. If this can be done by several members of the team the effect may well be synergistic. A second person might communicate the information in a way which allows the patient to attach greater significance to it.

Clinical audit

Review a random selection of approximately 25 clinical records of patients with the same type of dental/oral disease - such as a high caries rate, or significant periodontal disease, or one of the other problems described in this article.

  • Define the risk factors that you would like to see identified, when treating patients of the kind you have selected. ‘Score’ the 25 records for the presence or absence of these ‘markers’, perhaps on a scale of 1 - 5 where:
  1. Indicates that the records contain no reference to the risk factor having been identified or discussed.
  2. Indicates that the records suggest that the risk factor was identified, but not that it was discussed with the patient.
  3. Indicates that the records contain a confirmation that the risk factor was both identified, and discussed with the patient.
  4. Indicates that the records contain a confirmation that the risk factor was both identified, and discussed with the patient. The record contains details of precisely what was discussed.
  5. As in (4) above, except that the records provide evidence that the initial discussion was then followed up.
  • Repeat the above exercise, for a different oral/dental condition, or a different set of risk factors, and select a different group of approximately 25 clinical records for review.
  • Use the exercise as a basis for a discussion involving the whole dental team, to stress the importance of making patients aware of risk factors which affect their dental and oral health, and also to emphasise the importance of maintaining comprehensive and up-to-date records of the information provided, and any subsequent discussions. Use every appropriate member of your team to ensure that this is done consistently.
  • Repeat the process after allowing a suitable period of time to elapse, and compare your scores.
Practical tip
Because it may not always be possible, or convenient, to review a particular number of records in each instance, convert your ‘scores’ into a percentage, remembering to note the size of the sample in each case.

The maximum score will always be 4, so in a sample of, for example, 17 records, a score of 43 out of a possible total of 68 will be 58%. This makes it easier to compare the scores of different clinicians or of the same clinician at different moments in time.
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