These allegations are particularly likely to occur when a patient who has regularly attended the same dental practitioner over many years, for one reason or another, sees a second dentist.
Frequently, this situation arises because the patient moves to another area, or perhaps needs treatment in an emergency whilst away from home or on holiday; on other occasions the dentist retires, or has moved practice, thereby necessitating a change of dentist for the patient.
Inadvertent criticism
Sometimes the second dentist simply describes the periodontal condition in terms that the patient has not heard previously.
Often the cause for the patient's dissatisfaction arises from statements made to the effect that the condition has not appeared overnight.
- 'It must have been present for years'
- 'This is very deep pocketing and a lot of bone has been destroyed'
- 'More teeth might well be lost in the foreseeable future'
Currently there is a level of expectation that tooth loss is avoidable. Certainly many of our patients retain more of their permanent teeth into later life. The loss of teeth in middle or later life, through periodontal disease, is no longer seen as inevitable. There can be strong emotional implications for those patients who associate the loss of teeth with the erosion of their youthful appearance, and with the onset of ageing.
There are several components to the successful defence of cases where the failure to diagnose and treat periodontal disease is alleged.
Risk factors
History
There are many factors in the patient's medical and social history, which are known to be associated with a higher risk of periodontal disease. There are also conditions (e.g. coronary disease and diabetes) where evidence has been growing of a relationship to the extent that periodontal disease should now be considered in the context of a 'marker'.
A written medical history, preferably one which is completed, signed and dated by the patient with specific 'yes' or 'no' answers to specific questions, is the best starting point for a proper assessment of these risk factors. However, the deterioration of a patient's periodontal condition while under the care of the same dentist for many years, sometimes highlights the fact that the patient's medical history and other risk factors have not been assessed or updated regularly -- or indeed, at all.
Smoking, alcohol and stress
Smoking is well recognised as being an important risk factor, and one that should be easy enough to identify. Excessive alcohol consumption and stress are two further risk factors that may be less easily identified. What is important, however, is to act upon any available clues that these factors may be operating.
Sometimes, a patient's current medication (for example, anti-depressants) can be identified more easily than the underlying stress for which it has been prescribed. Other important medical risk factors include diabetes, steroid therapy, and other types of medication known to affect the periodontal tissues, the immune system and salivary function.
In cases of an alleged failure to identify and treat a patient's periodontal disease, it is a frequent finding that there are insufficient records to support the argument that all the known risk factors have been checked for and explored. When they are identified, the record also needs to show that they were discussed with the patient and acted upon. The clinical records should continually reflect an awareness of risk factors, confirming that the clinician has not lost sight of them when monitoring the patient's periodontal health over a period of time; the interplay of these factors being a dynamic one and not static.
The next and most important requirement is the ability to show from the patient's records and radiographs, that any periodontal disease present in their mouth has been identified, recorded and monitored appropriately.
Alongside this, the records should show clearly that the patient has been informed of the nature and extent of their periodontal disease.
If one or more teeth have a doubtful prognosis, then this too, should be explained carefully to the patient in terms appropriate to their level of understanding, and this fact recorded in the notes.
Records
Periodontal records will vary according to the circumstances of each case, but a Basic Periodontal Examination (BPE) using a World Health Organisation graduated periodontal probe, producing a 'score' for each sextant as a screening exercise, is obviously a sensible starting point. Where more extensive breakdown has occurred in individual sites or areas, then a more detailed record of probing depths is indicated at various positions around each tooth, with regular monitoring at suitable intervals to evaluate the progression of any disease process.
A record of bleeding points taken at the time of a periodontal charting of probing depths, is a further useful adjunct to indicate the level and extent of inflammatory changes around the mouth, and when carried out in this way it takes very little additional time.
Plaque scoring, mobility recordings and other indices all have their place, as do records of gingival attachment levels where gingival recession, muco-gingival involvement and furcation lesions form part of the overall periodontal condition.
Moving on to the question of the treatment of periodontal disease, the basic ingredients are the removal of calculus and other local factors, and patient education about the nature of periodontal disease, and the importance of associated risk factors and the demonstration of oral hygiene/plaque control measures appropriate to each individual case. It is important to record each of these aspects in as much detail as possible.
One of the hallmarks of cases involving allegations of untreated periodontal disease is the patient's assertion that the nature of the disease process has never really been explained, nor has any specific advice or treatment been given to deal with the periodontal disease itself.
Comprehensive dental records are the surest way of deflecting any such allegations, and members are strongly encouraged to pay particular attention to their record keeping in cases where periodontal disease is present.
Bone loss
Where bone loss has occurred, and/or problems have been identified in specific sites, it is prudent to monitor bone levels and periapical status radiographically at appropriate intervals.
Changes in the periodontal ligaments should be carefully evaluated, to identify possible development of furcation or periapical problems, and the possibility of perio-endo communication should always be borne in mind. Teeth at risk should be regularly checked for vitality and this fact duly recorded in the notes.
Referrals
After initial periodontal treatment - or in some cases, from the outset - it may become clear that specialist advice or treatment would be in the patient's best interests.
Record carefully any discussions with the patient along these lines, and always keep copies of all referral correspondence and replies. Bear in mind that in cases of severe periodontal disease, it is much easier for patients to allege, after the event, that they would have preferred a referral for specialist care. Similarly, one should remain aware of the perils of any delay in a referral, where promptness is clearly indicated. One of the problems here is the relatively small number of specialist periodontists.
Overall treatment plan
Another important aspect of periodontal care is its relationship to other kinds of treatment within the broader context of treatment planning.
Particular care should be taken in the assessment of periodontal health prior to the provision of veneers, crowns, bridges or any other complex restorative work. The premature failure of any such work, which follows upon an inadequate preoperative assessment of the periodontal support, invites the allegation of a failure in the dentist's duty of care to ensure the appropriateness of the treatment proposed or carried out. Other allegations of negligence often relate to shortfalls in the consent process, and dentists undertaking treatment of this nature should take care to explain the prognosis, and discuss possible treatment alternatives, as well as the advantages and limitations of each in turn, and record these discussions carefully in the patient's notes.
Consent
Very often, a patient reaches a 'crossroads' in their dental life, and here the importance of the consent process cannot be over stressed. Any patient who embarks upon extensive restorative work specifically in order to avoid tooth loss, will be understandably disappointed if the premature failure of this treatment and any subsequent tooth loss, is attributed to an inadequate assessment and management of their periodontal situation.
A natural extension of this consideration is the well-documented relationship between periodontal disease and the prognosis for osseointegrated implants, either when placed in areas where bone quality has been compromised by long standing periodontal disease leading to the loss of the teeth in question, or when implants are placed in situations where periodontal disease remains present elsewhere in the mouth. This is certainly an area where specialist advice would be a pre-requisite, and an active consideration of the many dento-legal risks would be prudent before embarking on any such treatment.
Despite best efforts
An important consideration in periodontal cases is, of course, the fact that the dentist has usually not directly caused the periodontal disease.
Sometimes, periodontal disease progresses despite a dentist's best efforts, rather than because of any act or omission on the dentist's part. For this reason, good baseline records of the periodontal condition at the time when the patient first attends can be very helpful in defining a starting point over which the dentist had no control at all.
What is then important is how well any periodontal condition is managed by the dentist whilst caring for the patient.
Some patients decline, or fail to attend visits for scalings or other periodontal care, and it is important to note this fact in the patient's record card, just as it is important to record any lack of co-operation in oral hygiene, or resistance/apathy towards treatment generally. In many cases, this helps to demonstrate that the periodontal disease has arisen or progressed because of failings on the part of the patient, rather than the dentist.
With our patients living longer, and retaining more of their teeth into later life, periodontal problems are likely to present an ever-increasing challenge for dentists in the years ahead, both clinically and dento-legally.