Providing preventive care to patients requires the skills and experience of the whole dental team, including dental healthcare professionals.
There have been many exciting developments in dentistry over the last two decades. Along with new technologies, materials, and techniques, there has also been an emphasis on utilising the skills of the whole dental team. Another shift has been the focus towards prevention rather than cure, and this is a particular area where the whole dental team can work together in a positive way.
Clearly, a key aspect of prevention is patient education, but it also includes helping patients implement any advice given, and clinical intervention like fluoride application. Whichever way it is delivered, prevention is an ideal area for the whole dental team to be involved. Whether working independently under a direct access arrangement, or working under prescription, dental care professionals can, and should, be involved in preventive care.
From a dentolegal perspective, many cases involve criticism about the lack of preventive advice. One example may be an allegation that the lack of appropriate advice has resulted in the patient requiring treatment that could have been avoided, or at least reduced in severity. This can be frustrating for the clinician when there is genuine doubt as to whether the patient would have acted upon the advice if given, but it is nevertheless easy for a patient’s solicitor to make the point about the loss of opportunity.
Screening and risk assessment
There is now greater emphasis on the benefits of performing a risk assessment on patients, which will allow more targeted and focused healthcare. All dental patients stand to benefit from a preventive intervention. However, the greatest benefits can be achieved by focusing these measures on patients who present with a higher risk profile. There are many screening tools which can be employed to identify early problems, potential problems, and high-risk patients. Perhaps the two most common examples of these are the Basic Periodontal Examination (BPE) and bitewing radiographs.
Specific guidance on the use of such tools may vary and you should be aware of the standards where you practise.
There is overwhelming evidence that fluoride has a strong impact on the prevalence of cavities. The use of fluoride can take one of two forms: topical application and systemic supplements. The introduction of fluoridated toothpaste is one example of how mass access to fluoride has improved oral health by reducing the incidence of dental cavities.
Other forms of readily available fluoride can be found in varnishes, mouth-rinses, and fluoridated additives, such as fluoridated salt.
Whatever the location, the consent process for the patient is a key issue when using fluoride. As with many areas of healthcare, there is some controversy surrounding the issue. Such negative connotations have been picked up by the media and, understandably, caused some concern for the public.
While the overwhelming body of evidence suggests fluoride is beneficial and safe when used in the recommended doses, some patients, or parents, may not wish to have this treatment. It is critical if you are undertaking fluoride treatment that the patient, or parent, fully understands what you are proposing, what materials you are using, the intended benefits, and any associated risks. The risks of not accepting the treatment should equally be discussed.
Dental Protection is not the arbiter of clinical opinion, and so when deciding on treatment approaches, each clinician must carefully weigh up the evidence and guidance for themselves and act accordingly. They must also be willing to justify all these decisions in the event they are challenged later.
Diet and oral hygiene instruction
These are two pivotal, patient-centred issues that are basic to promoting better oral health. Any assessment and advice will need constant re-enforcement, as they can both involve lifestyle changes that are often difficult for patients to implement.
It is often not enough to provide patients with information. Clinicians also need to consider how they can help their patients use that information. This might involve looking specifically at diet and helping the patient identify practical ways in which they can make positive changes.
It is well known that patients can only absorb a small amount of the total information presented to them in a clinical setting. This is one reason why it is so important to provide continual, positive re-enforcement. One way to enhance the message you give, is by providing written factsheets. There are many downloadable information sheets, which are published by recognised authorities, and are fantastic ways of educating the patient. There are also other e-resources you can direct your patients to.
Complex dental care
When a patient is undergoing complex treatment, a dental healthcare professional may be involved in delivering aspects of care. An example may be providing periodontal treatment to a patient prior to conventional bridgework or implants.
When complications or failure arise following the provision of complex or expensive treatment, it is not uncommon for patients to complain or attempt to claim compensation. Naturally, it is the responsibility of the treating clinician to ensure the provision of the bridge or implant is appropriate. Nevertheless, if a patient was clearly not suitable, had unstable periodontitis, or consistently poor oral hygiene, a question may be asked why a hygienist involved in preparing the patient for this did not bring any concerns to the dentist. It is therefore possible they could be involved, to some extent, with the potential claim.
Smoking cessation and alcohol use
The scientific research clearly establishing smoking as a major risk factor for both periodontal disease and oral cancer has changed the standards expected of dental professionals. It is no longer acceptable for clinicians to ignore tobacco use and a failure to inform the patient of the risks it has on their oral health, or failing to advise smoking cessation, could be viewed as a breach of duty.
All patients should be asked specifically about the nature and extent of any tobacco use habit, including chewing tobacco or the use of paan, and they should be made unambiguously aware of the adverse effect that this can have on their oral and general health. These enquiries, and any necessary follow-up advice, should be repeated at appropriate intervals. It would also be appropriate to offer smoking cessation advice and encouragement.
Most medical history forms used by the dental profession also enquire about alcohol use. If it transpires that a clinician had information about the patient’s habits that could impact on their health later, but had not acted on this information, they may be open to criticism. Although it may be a subject that dental professionals feel uncomfortable discussing with patients, high alcohol consumption is known to increase the risk of oral cancer. The patient should be made aware of this along with the synergistic effect of smoking and alcohol. There is plenty of educational material online that can be used to raise patient awareness. In addition, there are public health campaigns which provide an opportunity to start a conversation with a patient that might otherwise be difficult to initiate.
As with all complaints and claims, your clinical records are your best line of defence. It can be particularly frustrating for a clinician when they feel they have provided correct advice, but in hindsight can see that this is not sufficiently documented. It is therefore critical the records accurately reflect advice, warnings, and treatment.
Detailed records should be kept of all occasions when preventive advice is given to patients, or parents. It should be clear from any such entries:
• who gave the advice
• what form the advice took, for example, whether it was verbal, and/or supplemented by advice sheets or visual aids of any kind
• how the patient responded to the advice.
It is particularly important to note instances where a patient appears apathetic or disinterested in the preventive advice, or when the patient indicates that they are unlikely to follow such advice. Here, any entries should clearly demonstrate that the patient was appropriately warned of the likely consequences of not acting upon the advice given.
When the advice given to a patient is likely to have a direct bearing upon their future oral health, or general health, it is advisable to ensure that the record entry properly reflects any emphasis given to the advice and that the subject was re-explored with the patient at subsequent visits. If a preventive message is important enough to give to a patient, it follows that it is important enough to reinforce at regular intervals. A patient who may not be receptive to the advice on one occasion may well be more receptive to the same advice when it is repeated for reasons the clinician may be unaware of.
In the case of oral hygiene instruction, it is helpful if records provide sufficient detail of any specific preventive techniques that the patient is advised to use. This includes if the techniques are demonstrated to the patient, for example on a model, or in the patient’s own mouth, and/or if the patient is encouraged to practice the techniques under supervision and guidance. Vague entries such as “OHI” are better than nothing but are still of relatively limited value in confirming precisely what advice was given.
Similarly, a note should be made of any educational material, videos, leaflets, or advice sheets given to patients, or parents, to supplement any preventive advice given verbally. Additional resources, such as clinical photographs and study models can help demonstrate, not only the clinical situation, for example at first presentation, but can demonstrate appropriate monitoring and education.
Any member of the dental team involved in providing dental care, advice and treatment to patients, whether to specific patients or more generally, needs to be aware of current thinking in the field of preventive dentistry and to take steps to keep their knowledge and skills up to date. Preventive dentistry needs to be seen as an integral part of the care provided for all patients, rather than being reserved for specific patients in specific situations.
Communication and documentation are key aspects to successful practice. For the right messages to be given and received, communication is essential, not only between the clinician and the patients, but also between all members of the dental team. Advice is more likely to be acted upon if communicated effectively. Consideration should be given to how, when, where and by whom this advice is given, and also to the need for training and personal development of the dental team in behavioural psychology and communication skills.
When the team has worked hard on promoting oral health and providing high quality preventative dentistry, this should be reflected in the clinical records with excellent documentation. The critical aspect of record keeping is that a third party needs to be able to read and understand the records and subsequently know exactly what has happened, and when.