Periodontal monitoring

Undiagnosed and untreated periodontal disease is one of the fastest growing areas of litigation and complaints in dentistry.

People are living longer, and more people are retaining their teeth into later life. Consequently, the overall potential periodontal risk is rapidly increasing. Most allegations of undiagnosed, untreated and under-treated periodontal disease arise when a patient sees a new dentist for the first time. This may result from the retirement of the patient’s previous dentist, or simply because the dentist has left the practice. Sometimes the patient attends a different dentist in an emergency situation, or following the sale of the practice where they have been treated over many years.

On other occasions, of course, a patient will seek a second opinion because they already have concerns about the treatment being provided for them by their existing dentist.

Allegations

The most common allegation is that the patient was unaware of the presence of periodontal disease, or that the extent and implications of the periodontal problems had not been explained to them. Where there are significant levels of periodontal disease, and one or more teeth have a doubtful or terminal prognosis, the patient may well become very angry, blaming the previous dentist for allowing the periodontal condition to deteriorate under their care. If the condition, along with the treatment options and appropriate advice, is not explained to the patient, the individual may well feel that they have been let down by the professional person they have trusted over many years.

Whether such allegations are made in the form of a complaint, or a claim in negligence, two questions always arise:

• Did the dentist in question properly diagnose, treat and monitor the periodontal disease?
• Did the critical discussions and explanations occur between the dentist and the patient?

It is not unusual for there to be differences of opinion and recollection between the patient, and the dentist, as to what did (or didn’t) happen. As a result, attention often focuses upon the clinical records and what they do (or do not) contain, in order to establish which version of events is better supported by the contemporaneous notes.

Clinical audit

Carry out the following simple audit on the dental records of the next 10 patients that you see either with either moderate or significant levels of periodontal disease. Are there one or more dated entries confirming each of these 16 key landmarks?

1. A written medical history has been taken, and updated at regular intervals. This includes a review of any medication taken by the patient
2. Appropriate screening (for example, BPE score, do the patient’s gums bleed on brushing?) and follow-up investigation (for example, x-rays) has been carried out.
3. A diagnosis of periodontal disease has been made.
4. The patient has been informed of the presence of the disease.
5. The patient has been given specific information regarding the site(s) and severity generally, and in respect of any specific teeth which have an unfavourable prognosis.
6. Some kind of measurement of the site(s) and severity of the disease has been made (this may range from BPE scores, to more detailed probing depth recordings and might include notes of bleeding points, mobility, and pathological changes affecting individual teeth).
7. Known risk factors for periodontal disease (especially smoking) have been checked.
8. Appropriate levels of initial treatment (for example, scaling, root planing) have been carried out, and repeated at suitable intervals.
9. The patient has received suitable advice and instruction regarding oral hygiene, risk factors (for example, on cessation of smoking), to enable the patient to become personally involved in the control of their periodontal disease.
10. The tissue response and the patient’s compliance has been checked for and further measurement/monitoring of the progression of the disease has taken place.
11. The above monitoring has been repeated at appropriate intervals, with any necessary x-rays and other investigations (including questioning the patient as to any areas of bleeding, discomfort, etc).
12. Any failure on the patient’s part in respect of compliance (oral hygiene,risk factors, attendance, for example) has been brought to the patient’s attention, and the importance stressed.
13. Where the periodontal disease is particularly severe, and/or has not responded to the advice and treatment provided, the possibility of a referral for specialist advice, or treatment has been considered and discussed with the patient.
14. If the patient has declined such a referral for any reason, has this been made clear?
15. Any occasion when the patient has failed to attend appointments, or has cancelled appointments at short notice. This includes occasions when the patient agrees to contact the practice to make further appointments, but fails to do so, or when the patient does not respond to reminders or recall letters.
16. Any occasion when the patient has declined the treatment recommended for them (for example, a referral to a dental hygienist, or the provision of treatment to address any occlusal imbalance).

Scoring

Score	Level of detail
0	If the records contain no reference at all to the landmark in question.
1	If the records contain an entry which, while not optimal in terms of its detail, still suggests that the landmark had been identified.
2	If the records contain a specific dated entry, clearly identifying the landmark in question.

This provides a possible (maximum) score of 32 per record card, or 320 for the sample of 10 patients, although not all of the ‘landmarks’ will apply in every case. Where possible, ask a colleague to review your records and repeat the exercise to standardise your approach to the scoring system.

Action and follow-up

Identify any gaps or weaknesses in your record keeping, and involve other team members in these discussions. Set clear objectives for improving your record keeping, preferably enlisting the help of these other members of your team. For example:

• The receptionist routinely checks that there is a recently updated, written medical history.
• The receptionist records every broken and cancelled appointment and understands the importance of this. The dental nurse or assistant provides a backup, ensuring that key conversations, explanations and warnings are always fully recorded.
• The hygienist identifies and fills any gaps in the record keeping (risk factors, oral hygiene instruction, treatment provided, patient non-compliance, etc).

Repeat the exercise above after allowing sufficient time to develop consistent, reproducible routines.

Summary

In many cases, the levels of periodontal disease present in a patient’s mouth are due to factors beyond the dentist’s control, and do not reflect any fault whatsoever on the part of the dentist. However, it is made much easier to demonstrate this fact if the records contain the entries listed above.