New techniques, new materials and perhaps more importantly, a shift in treatment philosophies in recent years has led to a greater emphasis upon minimally interventive, preventive approaches to the management of the early carious lesion. In some key respects new technology has helped, and in other respects it has hindered, this process. In a dento-legal sense, the most likely allegation would be that the clinician failed to recognise, act upon and appropriately manage the small or early carious lesion and as a result it was allowed to develop, causing pain and suffering together with the cost and inconvenience of more extensive (and more expensive) treatment. To head off any such challenge, the clinician needs appropriate baseline records confirming:
- The site of the lesion
- Its extent and appearance
- The fact that the patient had been told about the lesion and that it was being kept under review, and what actions the patient should adopt to assist the process
Unlike the charting of missing teeth, existing restorations, and carious cavities requiring treatment, there is no universally recognised protocol for recording the minimal ‘white spot’ lesion, de-calcified enamel, or the slightly larger lesion where remineralisation or arrest of the lesion might still be possible. Perhaps because of this, very few types of computer software intended for dental practices have been designed in a way that allows the clinical team to distinguish between lesions that require direct intervention, and restorative treatment, and those lesions that are being approached in a minimally interventive, preventive fashion. This presents the clinical team with the challenge of finding a way to review and audit this information, using whatever recording systems they have at their disposal, and whether these are in paper or electronic format. In addition to a ‘charting’ of some kind, certain other baseline records and investigations might be considered:
For many kinds of early lesion (eg. smooth surface and some pit/fissure lesions) this will be of little help, and even where inter-proximal lesions are being monitored, the image quality of bitewings, for example, needs to be very high if radiographs are to be of any real use or value. They may at least help the clinician to identify the point at which more active and extensive treatment is required, and this helps to deal with the allegation of ‘supervised neglect’. The clinician should record the findings from any radiographs, within the clinical notes.
Digital photography has transformed the ease with which a visual record can be kept of the appearance of the lesion. This is particularly helpful in monitoring changes in the size, opacity and colour of an early carious lesion.
High intensity, fibre-optic light sources can provide a safe and effective alternative to radiographs, especially when monitoring inter-proximal lesions, and in some instances even pit/fissure lesions.
Various kinds of testing systems have been advocated, to assist the clinician in deciding whether or not a lesion is active. Dento-legally the ‘false positive’ result has the potential to cause more problems than the ‘false negative’. Once the decision to intervene and restore has been made, there is no way back, while the ‘missed’ diagnosis can still be made by means of a combination of other diagnostic techniques, before any serious lasting harm has been caused.
An important aspect to bear in mind when adopting a ‘watch and wait’ approach, and giving preventive care a chance to work. Consent is the need to keep the patient fully aware of what you are doing, and why. Explanations and discussions with the patient (or in the case of children, with their parents) should be confirmed in as much detail as possible, in a dated entry in the clinical notes. If there are any particular (eg. medical) factors which suggest the appropriateness of a less interventive, less radical and more cautious approach, these should be similarly discussed with the patient and clearly recorded in the notes.
There is a world of difference between doing nothing at all, and doing nothing that the patient can recognise as representing active dental care and treatment – especially if most of the treatment rationale relies upon things that the patient needs to do (or stop doing) themselves. Included here might be oral hygiene and plaque control, modification of dietary factors, or the use of fluoride in one form or another.
But nor is providing the patient with advice in any (or all) of the above respects, on a single occasion, likely to be sufficient to satisfy a clinician’s duty of care. Equally important when managing the early carious lesion is the need to review the position at appropriate intervals both in terms of assessing the clinical situation itself, and also the patient’s adherence to the recommended strategies for eliminating any risk factors that might have led to the lesion(s) in the first place.
Here again, the clinical records need to be sufficient to demonstrate that this formal review took place. The more objective and structured this review seems to have been, the more compelling the argument that the clinician really was taking appropriate steps to control the patient’s disease and maintain their oral health.
Patients at risk
Some patients are at particular risk of caries, perhaps by virtue of a medical condition or medication which affects their salivary function, or which creates repeated episodes of low intra-oral pH. The records should be organised in such a way as to provide a clear ‘alert’ for the dental team, whether the records are being held in paper or electronic form. Regular screening for early carious lesions becomes all the more important because of the increased risk of a rapid progression of these lesions in ‘at risk’ patients. The patient should be recalled and reviewed at intervals which are commensurate to their level of risk, and the records should make it clear that the patient has been made aware of any recommendation as to the timing of their next periodic review.
- Select a sample of 10 to 20 record cards of patients with a higher than average caries experience.
- Devise a scoring system. You might consider the use of a scoring system such as the following:
| Standard of records
|Recorded/updated regularly to a high standard
|Recorded/updated periodically to a reasonable standard
|Recorded/updated rarely, or not at all
- Create a protocol, setting out what you aim to record, how it is to be done and make sure your whole dental team is aware of this and why it is being done.
- Decide on the criteria for assessment. For example:
- Charting the site of any early carious lesion.
- Recording the size and extent of an early carious lesion.
- Recording the appearance of an early carious lesion.
- Identifying and recording any relevant risk factors.
- Providing/recommending any relevant preventive care, advice and treatment.
- Carrying out and reporting upon any relevant investigations.
- Reviewing the situation at appropriate intervals.
- Creating and maintaining an appropriate ‘alert’ system.
- Recording discussions with the patient and any explanations given.
- Identify areas for improvement, plan/implement any necessary changes and repeat the exercise after a suitable interval.