Andrew Walker, dentolegal consultant at Dental Protection, looks at whether the disruption caused by COVID-19 will heighten the risks around periodontal disease
Over recent years there has been a lot of concern across the profession in relation to litigation and periodontal disease, and indeed it is one of the areas of dentistry that members are often challenged about.
More recently, members have contacted the Dental Protection advice line worried about whether the current pandemic situation may put them at further risk of a periodontal claim for compensation. A particular issue that some members have wanted to talk through is when they are unable to use ultrasonic scalers and have been required to undertake periodontal treatment with hand instruments.
As has been discussed on many occasions, this is an unprecedented situation. As such, it is very difficult to predict with any degree of certainty what the impact will be on, for example, future claims compensation. That being said, it is worth considering a few relevant points in relation to periodontal claims for compensation.
Hand instrumentation is effective
In the first instance, it is helpful to remind ourselves that the evidence in the periodontal literature does say that hand instrumentation and powered instrumentation can be equally effective. This is also mentioned on the British Society of Periodontology (BSP) website. It is therefore not inappropriate to provide periodontal treatment with hand instruments.
However, it is also accepted that clinicians only maintain skills that they use. The BSP website also goes on to state:
“…. Clinical experience indicates that non-AGP management of periodontal diseases, whilst being effective, requires hand instrumentation carried out to a high standard. This may take more time than the equivalent use of powered scalers and can be technically challenging in some circumstances.”
It is quite possible that there are some dentists, hygienists or therapists who do not use hand instruments regularly, or simply prefer powered instrumentation. In this regard, as well as ensuring efficiency of treatment, it is equally important to ensure that you are using an instrument safely. If anyone is concerned about using hand instruments, then the first thing that could be done would be to see whether there is any CPD or revision available to update knowledge and skills. Again, professional societies are a useful point of reference and the BSP has produced helpful webinars on this very topic.
Educating patients on their own role
In relation to potential claims, there are perhaps several points that should be reviewed. Firstly, if we again reference BSP recommendations, there is a suggested phased approach to periodontal treatment. The first of these is motivating and supporting patients to obtain and maintain successful removal of the supragingival dental plaque biofilm, as well as controlling risk factors for the disease. In other words, this can be viewed as patient education and motivation.
If we are going to enter a phase where professional intervention is potentially or possibly harder, it may afford a bit of a refocus on the patient’s role in managing their own disease. This in itself can have many benefits, and good documentation of any further advice provided to the patient can be vital if a claim is brought.
In relation to any claim, it is often the case that the records and patient need to be reviewed by an independent expert witness. One of the roles of the expert is to comment on the standard of care provided. In relation to the standard of clinical treatment, this is meant to be compared against that of their peers, or what would be expected of a reasonable dentist, hygienist or therapist. In this situation, it may be hoped that an independent expert would acknowledge and take into consideration that, during this current situation we are all facing, periodontal care may be a little different.
Perio is a longer-term issue
While we don’t know how long this period of uncertainty will last, we can hope that it is a relatively short period in a lifetime of periodontal need. Moving on from that, it is worth remembering that all periodontal patients should have regular and careful assessment and reassessment. In most of the periodontal claims seen by Dental Protection, the claim relates to care over a long period of time, where the periodontal condition has deteriorated over many years. Therefore, if you are concerned about any deterioration that you feel has occurred, communicate this with the patient and talk through the potential options.
The above point is perhaps the most important message, and it is essentially the same principle as before COVID-19. Your duty is to provide a reasonable standard of care for the time the treatment was undertaken and offer referral if, after that, you are still concerned. This may be for a variety of reasons, such as you feel you have reached the limit of what you can offer, or you feel the patient is still not stable despite your best efforts. In some cases, you may also be of the opinion an early referral to a local specialist may be a reasonable option for the patient. Again, as in any time, when you do have these discussions, and when difficult clinical decisions need to be made, good documentation in the clinical records is paramount.
For dentolegal advice relating to this or any other topic, please call our advice line on 0800 561 1010 or email firstname.lastname@example.org