Increasingly, preventive dentistry is recognised for its contribution within the much wider context of health promotion
In the past, preventive dentistry was looked upon as an aspect of dentistry which was based upon dental health education (primarily oral hygiene instruction and dietary counselling), the use of fluoride both topically and systemically, and specific techniques such as fissure sealants.
Unlike many aspects of dental care and treatment, the provision of preventive dentistry is not restricted to dentists alone, nor even to dental therapists and dental hygienists. Dental health educators and other team members may also provide information and advice to patients that fall within the ambit of preventive dentistry.
Dento-legal problems in preventive dentistry tend to be of three kinds:
- The provision of inappropriate advice and/or treatment.
- The provision of treatment (or the decision not to provide treatment), without an adequate consent having been obtained from the patient.
- The failure to provide advice and/or warnings which might have prevented a patient from suffering some kind of harm or disadvantage.
Preventive advice and treatment
One area of preventive dentistry that has led to allegations of inappropriate advice/treatment is the recommendation of fluoride supplements. The purpose of recommending fluoride supplements - usually in the form of tablets, capsules or drops, but occasionally in the form of fluoride-containing drinks - is to adjust a child's daily fluoride intake to an optimal level (within safe margins to avoid any adverse side effects). This safe level will always be somewhat empirical, as it depends upon the baseline fluoride intake that a child might otherwise be receiving through drinking water (which might contain natural or added fluoride), drinks such as tea (some varieties of which contain significant amounts of fluoride) and through other sources. There is also evidence to suggest that some children (especially small children) might ingest surprising amounts of fluoride from inadvertently swallowing fluoridecontaining toothpaste while brushing their teeth.
When all these possible sources of fluoride are combined, the additional supplementation of a child's diet by means of their regular intake of fluoride drops, tablets etc can easily raise the overall fluoride intake to levels where fluorosis might start to appear.
Where this results in mild opacities and other slight blemishes, it may be of no great significance, but where more extensive or severe discolouration or surface defects occur, the resulting aesthetic disfigurement (and possible cost of any treatment required to rectify it) may cause the appropriateness of previously recommended fluoride supplements to be called into question.
Alternatively, the failure of whoever recommended the fluoride supplement, to establish possible alternative sources of systemic fluoride, and the likely fluoride intake from such sources, might be criticised.
Ultimately, the dentist will be held responsible for advice given by other members of the dental team, to or for patients who are under their care. Hygienists and therapists can, however, also be held separately responsible for their own acts and omissions, being registered healthcare professionals in their own right. The dentist will be expected to ensure that those giving advice to patients (or parents) are adequately trained and competent to give such advice.
Treatment decisions
Clinicians will be familiar with the dilemma of having to decide whether or not an early carious lesion can be re-mineralised and reversed, whether it can be kept under observation and reviewed, or whether immediate active intervention is required. With the benefit of hindsight, one can be criticised for any wrong decision, of course, but it is equally possible to defend a decision which turns out to have been misguided, if it is taken for justifiable reasons at the time, and an appropriate history, examination and investigations to support the decision, are properly recorded in the patient's clinical notes. (Module 14 in this series, 'Undertreatment and Supervised Neglect' provides useful advice in this respect).
A particular dilemma exists when treating early pit and fissure lesions, because in addition to the 'to treat or not to treat' decision that exists with interproximal or smooth surface lesions, there is the added problem that it is not always easy to detect developing lesions radiographically.
Transillumination is a useful diagnostic adjunct both for occlusal and interproximal lesions, but here again it is important to record the use of this investigation and of any conclusions reached, in the clinical notes.
When fissure sealants are recommended as primary preventive procedures, or when sealant restorations are advised in circumstances where any part of a pit of fissure system is thought to be actively carious, it is important not to give the impression to the patient (or more likely, their parent(s) given the likely age of many of the patients concerned) that this provides any kind of guarantee of long-term protection against subsequent caries.
Allegations have been known to be made that fissure sealants were recommended and provided on the assurance by the clinician that the teeth would thereby be protected for ever from becoming carious. Any such assurances or guarantees are misplaced, and should be avoided.
Checking the marginal integrity of fissure sealants, once placed, noting and acting upon any reported sensitivity from the teeth involved, and their periodic monitoring by means of radiographs where appropriate, is an important aspect of preventive dentistry.
Fissure sealants can and do 'leak' and they can then obscure the development and progression of caries in the depths of the fissures that they are designed to protect, sometimes leading to extensive caries occurring before the problem is detected.
The provision of dietary advice and counselling is an obvious element of preventive dentistry where caries is concerned, but also (less obviously, perhaps) to prevent tooth tissue loss through erosion, or accelerated tooth tissue loss when abrasion and attrition are additional contributory factors.
The provision of restorative treatment for patients where caries is not controlled carries the ever-present risk of further caries at the margins of the restorations, or elsewhere in the same tooth. The provision of complex or expensive treatment without stressing to the patient the likely consequences of continuing whatever dietary pattern had led to the original caries, leaves a clinician vulnerable to the allegation that the patient could and should have been made aware of the likelihood of the premature failure of the restorations, unless the relevant dietary advice was acted upon. This presupposes, of course, that such advice was given at all and if so, that its importance was sufficiently stressed and reinforced.
A similar example of the provision of treatment without the proper preventive advice which is necessary for its success arises when a patient suffers a traumatic fracture of an anterior tooth following a sports injury.
Providing treatment to repair the tooth fracture, without advising the patient as to the need to protect the restoration and remaining tooth tissue from further similar damage, by using a mouth guard/sports protector of an appropriate design and construction, leaves the clinician vulnerable to criticism if any further traumatic injury is suffered by the patient as a result.
Some patients are at a higher than average risk of caries or tooth erosion because of impaired salivary function - either in terms of salivary quality, or quantity: either can be affected by systemic disease or medication.
In such cases, the use of topical fluoride applications in the form of gel, solutions or rinses might be appropriate. The failure to suggest or implement any such logical and relatively simple preventive steps can be difficult to defend.
A patient's susceptibility to both caries and periodontal disease can also be made greater by the introduction of any kind of appliance that makes the maintenance of effective oral hygiene more difficult. Included here are various fixed and removable restorations in the field of prosthodontics, and also orthodontic appliances (both fixed and removable).
It is obvious from the above that the dental team needs to remain alert to the need for the specific provision of preventive advice and treatment in a variety of clinical situations; the provision of treatment without any necessary preventive advice to maximise its prospects for success and longevity, often leaves the patient worse off than if the treatment had never been provided at all. Upon being provided with any such appliances, it is important that any appropriate advice is given to the patient (and parents, where applicable) regarding the proper cleaning and maintenance of the appliance.
Preventive advice
In many cases, the criticism of a clinician's actions is one of the failure to give primary preventive advice to avoid the need for treatment. The resulting allegation is that the patient has suffered harm that could and should have been avoidable. Even when there is genuine doubt as to whether or not the patient would have acted upon the advice, if given, the alleged breach of a clinician's duty of care is often one of having denied the patient the opportunity to have prevented the disease or damage in question.
Rampant caries in young children is one such example, especially when caused by inappropriate use of feeding bottles, or coated 'dummies'/'comforters'. It has been argued that any member of the dental team who is involved in treating a patient who is known to have a young child, has a duty to the child to give the parent(s) appropriate preventive advice.
Unless and until the clinician has been asked to examine the child, or to advise the parent(s) regarding the child's dental health, the law may not recognise that such a duty exists. It may therefore be difficult to demonstrate that the failure to provide the preventive advice amounts to negligence on the part of the clinician - however desirable it might have been for the advice to have been offered.
Preventive dentistry is an area where the provision of oral hygiene instruction, together with specific advice regarding the discontinuance of other activities (e.g. smoking) which is known to increase the risk of periodontal disease and its development, is an integral part of treatment. It would be reasonable to ask why such advice had not been offered, if a patient were subsequently found to be suffering from advanced periodontal disease.
Smoking cessation
The established base of evidence indicating that smoking is a major risk factor in the development of both periodontal disease and oral cancer, has brought smoking cessation advice into the mainstream of preventive advice given in the dental environment.
All patients should be asked specifically about the nature and extent of any smoking habit, 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.
Record keeping
Detailed records should be kept of all occasions when preventive advice is given to patients. 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 be sufficient to demonstrate that the patient was appropriately warned of the likely consequences of not acting upon the advice given.
It is sometimes conceded on a patient's behalf, especially when confronted with good contemporaneous record card entries, that certain advice was indeed given, but then argued that it had been given in such a way as to attach no great importance to the advice.
Where such advice is likely to have a direct bearing upon the patient's future oral health (or general health), it is advisable to ensure that the record card 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 the advice on one occasion may well be more receptive to the same advice on a subsequent occasion, often for reasons of which the clinician may never become aware.
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 study 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 of a dentist/ hygienist/therapist or dental health educator, then this similarly needs to be described clearly in the clinical notes.
Similarly, a note should be made of any leaflets or advice sheets that are given to patients (or parents) to supplement any preventive advice given verbally.
All of the above helps to demonstrate the time and effort taken by members of the dental team to communicate preventive advice to a patient, and to ensure that the patient has understood and is capable of acting upon the advice given.
Summary
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.
Recording the provision of preventive advice is as important as recording the details of treatment provided, and rather than being deterred by a patient who appears to be unreceptive to such advice when first offered, members of the dental team should be prepared to repeat and reinforce the advice, where necessary, and to record the fact that this has been done.
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.