Dental Care Professionals can, and should, be involved in preventive care, explains Dr Andrew Walker, Dentolegal Consultant at Dental Protection.
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 such as fluoride application. Whichever way it is delivered, prevention is an ideal area for the whole dental team to be involved in. 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.
With the introduction of Direct Access, some dental care professionals have the option of working independently. For those that choose to work in this way it can bring exciting opportunities and benefits. It does, however, mean they take ultimate responsibility for the patient’s care, and it follows they will be responsible for ensuring appropriate preventive care has been provided.
For others who are working under prescription, it is still important to be aware of the implications and requirements of the preventive strategy. The records of a nurse providing oral health education, for example, may prove extremely helpful for other colleagues who may be faced with a professional challenge. They can also highlight areas where they feel the patient needs extra support from other members of the team. In this context, a hygienist or therapist providing periodontal care under prescription would still be expected to raise concerns with the dentist if they felt the treatment plan may need amending or was not improving the situation.
Whatever the scenario, for any care to be provided effectively, there will need to be excellent teamwork and communication between colleagues.
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 such measures on those 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 commonly used 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. In the UK, the NICE guidelines1 should be used to determine appropriate recall intervals and the College of Dentistry have produced ‘Standards Books’ for other areas of practice. One of these publications, Selection Criteria for Dental Radiography2, is one of the leading texts on indications for radiographic investigation. For information on the BPE, UK colleagues should be aware of the up-to-date guidance from the British Society of Periodontology.3
There is overwhelming evidence that fluoride has a strong impact on the prevalence of caries. 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 caries.
Other forms of readily available fluoride can be found in varnishes, mouth-rinses and fluoridated additives, such as fluoridated salt. As above, specific guidance may vary from country to country and each practitioner should source their own local recommendations. This is important, as the information may depend on factors such as whether the water supply is fluoridated. In the UK, the Department of Health publication 'Delivering better oral health: an evidence-based toolkit for prevention'4 is a valuable source of information.
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 general public.
Whilst 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 such treatment. Of course, it is their right to do so and it is critical if you are undertaking such treatment that the patient/parent fully understands what you are proposing, what materials you are using, and 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 of these decisions in the event they are challenged at a later date.
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 the 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 of the information. One way to enhance the message you want to 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 that may be available that you can direct your patients to.
Complex dental care
When a patient is undergoing complex treatment, a dental care 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 OH, a question may be asked why a hygienist or therapist 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 upon their oral and general health. These enquiries, and any necessary follow-up advice, should be repeated at appropriate intervals. It would also be prudent to offer referral to a local professional smoking cessation service.
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 at a later date, but had not acted upon 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 fact 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 in the records. It is therefore critical the records accurately reflect advice, warnings and treatment given.
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:
a) Who gave the advice
b) What form the advice took (for example, whether verbal or supplemented by advice sheets or visual aids of any kind)
c) How the patient responded to the advice
It is particularly important to note instances where a patient appears apathetic or disinterested in preventive advice being offered to them, or when the patient indicates that they are unlikely to follow such advice e.g. smoking cessation. 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 also 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 subsequently repeated for reasons that 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. If these techniques are demonstrated to the patient (e.g. on a model, or in the patient’s own mouth) and/or if the patient is encouraged to practice the techniques(s) under the supervision and guidance. Vague entries such as “OHI” are better than nothing at all, 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 that are 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 who is involved in the provision of 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 the 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 the areas of 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.
1Oral and dental health. National Institute for Health and Care Excellence
2Selection Criteria for Dental Radiography. College of General Dentistry
3Basic Periodontal Examination (BPE) - The British Society of Periodontology
4Delivering better oral health: an evidence-based toolkit for prevention (2021) Department of Health