Early advice pays dividends in long-standing periodontal claim

Dentolegal Consultant Dr Simrit Ryatt discusses a case that presented 20 years after the initial treatment.

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Dental Protection’s indemnity allows you to request assistance for incidents that arise at any time during your membership, no matter when the complaint is made or when a claim arises. The value of this protection was highlighted in a recent case, where a patient made allegations against a dentist over treatment that took place 20 years ago.

Case history

Dr T had recently been contacted by a firm of solicitors acting on behalf of Patient B. The firm alleged that Dr T had failed to diagnose and treat the patient’s periodontal disease 20 years earlier. This was of particular concern to Dr T, as he felt his record keeping between 2004 and 2007 lacked detail and was not as thorough as his recent records. Patient B’s claim involved a number of dentists over a 20-year period, and Dr T was the first of those dentists alleged to have been negligent.

Dr T had a recent positive experience with a similar claim related to treatment he had provided three years ago. Dental Protection had successfully defended the allegations of ‘failing to diagnose and appropriately treat periodontal disease’ for Patient ‘A’. The claim was easily defended, as Dr T provided the appropriate treatment, and this had been clearly reflected in his clinical records.

To elaborate, Dr T was able to demonstrate he had appropriately examined and assessed Patient A. Dr T had provided screening, by undertaking a Basic Periodontal Examination (BPE). When two BPEs scoring 3 were found, he undertook six-point pocket charting (6PPC). Accompanying bitewing radiographs (BWs) included all crestal bone and captured generalised bone loss. Dr T made a diagnosis of periodontal disease, provided a periodontal risk assessment and produced a targeted treatment plan for Dr A to attend every three months to have 6PPC and non-surgical periodontal therapy (NSPT).

The treatment plan also highlighted that further investigations would be undertaken if necessary. Patient A had no underlying medical issues or risk factors, such as smoking or a family history predisposing to periodontitis. Dr T explained in detail the importance of oral hygiene and the need for continued periodontal treatment with reviews.

Patient A had suffered a close family bereavement and understandably missed some key appointments during this period. Compliance with good oral hygiene had also slipped, which led to a rapid deterioration of the periodontal disease.

In defending Dr T’s case, Dental Protection was able to demonstrate that his care was more than reasonable, as the detail in his clinical records supported how he provided his treatment.

Having reviewed Patient B’s clinical records, Dr T noted there was no mention in his notes of a clear diagnosis, or a ‘targeted’ treatment plan, other than a signed treatment plan that included ‘periodontal treatment’. There were also allegations of inaccurate screening, that no monitoring had been provided, and that the patient should have been referred for specialist care. As all these points had been raised in the claim for compensation, Dr T contacted Dental Protection and raised his concerns about the comparative lack of detail in his clinical records from 2004 to 2007, compared to his current records.

Dr T had always completed a BPE and Patient B scored 3 in a couple of sextants on a few occasions. But during the period of 2004 to 2007, no 6PPC had been provided. The bitewing radiographs captured sufficient detail to support the accuracy of his BPE in each course of treatment (COT). The COTs always included oral hygiene instructions, diet advice, and scale and polishes were provided. Patient B was a smoker, and the records demonstrated that ‘smoking cessation’ advice had been provided.

The dentolegal consultant reassured Dr T that his clinical records in 2004 to 2007 would be compared to the standard of record keeping that prevailed at that time. Through the years, the classification of periodontal disease has evolved, with different key features and terminology. Therefore, periodontal care in recent cases would be compared to current standards, such as the ‘British Society of Periodontology and Implant Dentistry (BSP) Implementation of the 2017 Classification of Periodontal Diseases and Conditions’. It would be unreasonable to apply the current standards of care on past cases. Nevertheless, even historic cases should demonstrate that patients were aware they had periodontal disease and were given appropriate care.

Although there was no specific diagnosis made regarding Patient B, his signed treatment plans clearly outlined that he was due to embark on ‘periodontal treatment’, which suggested he must have had some knowledge that he had periodontal disease. Similarly, the patient was not presented with a formal targeted treatment plan, and initial periodontal therapy and a review after three months with localised 6PCC was not always provided. The chinks in Dr T’s armour were evident.

Nonetheless, it could be demonstrated that Dr T provided regular interventions involving subgingival and supragingival debridement in the form of his scale and polish. Lastly, having reviewed the sequence of BWs, there appeared to be little, if any, deterioration in Patient B’s periodontal disease over the timeframe Dr T was responsible for his care. Therefore, even though there was a breach of duty related to Dr T not providing a targeted treatment plan, crucially, no clinical causal link could be found.

It transpired that Patient B’s periodontal condition had worsened in recent years, when other dentists were involved in the treatment, and tied into a period around COVID-19 when Patient B did not see any dentists.

Dr T was relieved to learn that Dental Protection had managed to successfully defend his claim against Patient B. The matter was resolved using Dental Protection’s experienced in-house team of dentists and legal experts.

Learning points