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The periodontal paradox

05 June 2020

Dr Alasdair McKelvie and Dr Andrew Walker, dentolegal consultants at Dental Protection, advise on controlling risk when it comes to identifying and managing periodontal disease

For most patients, periodontal disease and associated tooth loss are largely preventable with good oral hygiene. There are many factors that increase the probability of a patient developing periodontal disease, and both smoking and diabetes are among the most frequently recognised risk factors seen in clinical practice. Early diagnosis, patient-specific targeted treatment, behavioural management and the transfer of responsibility for the outcome to the patient can, in the most part, prevent further periodontal breakdown and reward the patient with teeth for life.

Sounds simple doesn’t it? The patient takes charge of the outcome for 360 days of the year. For the other five days of the year you as the clinician accept responsibility for monitoring progress, adapting the targeted treatment plan to the changing clinical presentation and reinforcing the behavioural changes that the patient needs to implement and comply with if they want a successful outcome.

Surprisingly, something that should be straightforward has become more complex. Patients have a right to oral health yet a combination of factors, including but not limited to the systems we work in and the way we record information, has led to a significant increase in the number of patients looking to sue their dentist for the avoidable loss of teeth. The allegations are straightforward enough:

    • You failed to screen my mouth for periodontal disease

    • You failed to diagnose periodontal disease

    • You failed to provide a targeted treatment plan to manage my condition

    • You failed to tell me I had periodontal disease

    • You did not explain the increased risk of tooth loss due to my smoking habit and advise me to stop

    • You failed to monitor the deterioration in my periodontal health and refer me to a specialist

    • Even if you had not failed with any of the above six, you nevertheless failed to maintain a suitable record

If your patient is able to prove, on the balance of probability, that the loss of teeth from periodontal disease is your fault and flows from your poor management, the patient will not only be compensated for the loss of those teeth but will seek to have them replaced with implants and not removable dentures. Implants may not actually be appropriate treatment if the patient still has active periodontal disease.

The literature also suggests that patients who are susceptible to periodontal disease are also more likely to develop peri-implantitis. In many jurisdictions it is incredibly difficult to successfully argue that implants are not suitable compensation for teeth lost due to poorly managed periodontal care. We are completely reliant on the expert evidence we obtain to provide pragmatic and fair resolution of the claims. It cannot be in the interests of a patient to receive compensation in the form of treatment they will struggle to maintain and, even if they do, provision of this treatment may well carry a significant risk of failure in these patients.

Within professional circles there is a feeling that this is wrong. Dentists don’t cause periodontal disease and the loss of teeth is almost always caused by the patient’s inability to maintain good oral hygiene and reduce or eliminate those risk factors that they can control. Yet the paradox is that a condition that is so basic in its management and control can end up with the most expensive and complex claims for compensation. So what can you do to take control and play your part in improving periodontal health, reducing indemnity costs and placing responsibility for the outcome in the patient’s hands?

Steps to good periodontal management

    • Implement, undertake, and record a recognised periodontal screening protocol for all your patients with teeth. The basic periodontal examination (BPE) developed by the British Society of Periodontology is used worldwide. It does not, in itself, provide a diagnosis of periodontal disease but indicates where further investigation of periodontal tissues is required. All too often there is insufficient information in a record to show the periodontal condition you inherited when the patient came for the first time.

    • Once a periodontal condition has been identified, tell the patient. There is a reason for their bleeding gums and involve them in the collaboration to address the problem. Agree an appropriate targeted treatment plan. Helpfully the BPE comes with guidance on the correct treatment protocol you should follow; it’s a bit like checklist dentistry but the protocols are evidence-based and considered good practice, against which your conduct can be evaluated by the courts and regulators.

    • If the patient declines the treatment you recommend or fails to comply with your advice and instructions then you need to explain the consequences – and make a clear note of this in the treatment records.

    • If the patient smokes tell them to quit. Help them to quit and explain what will happen if they continue to smoke. Check and record their compliance with your advice every time you see the patient.

    • Using the clinical protocols attached to the BPE, monitor the patients’ response to treatment and their ability to manage their own dental destiny. If the clinical condition is deteriorating then you must tell them, adjust the plan, and record the key information.

    • Never be tempted to record a BPE score that underscores the periodontal condition. Take appropriate radiographs at the right time and carry out six-point periodontal charting in accordance with the protocol.

    • Always make sure the patient owns the outcome. They can only do this if the periodontal condition has been accurately diagnosed, correct treatment provided, response to treatment measured, and sufficient information exchanged about the prognosis and how the patient can influence the prognosis.

Our experience in handling claims highlights how much easier it is for patients suing their dentist to prove on balance what was not done by the dentist. The existence of screening and treatment protocols developed to help and direct clinical management also helps the patient and their claim when the protocols have not been followed or recorded accurately in the records.

Appropriate diagnosis and primary care management of periodontal diseases should actually be quite straightforward, as should the transfer of risk for the outcome to the patient, yet these basics are often ignored. On the other hand, the consequences for your patient can be life-changing if they are deprived of the opportunity to take control of their own destiny.