Periodontal disease is widespread and as much a threat to patients' oral health as tooth decay but the DDU continues to receive claims alleging failure to diagnose or treat the condition properly. Periodontist and DDU dento-legal adviser Leo Briggs analyses the latest statistics and provides risk management advice.
Around 45% of the adult dentate population in England, Wales and Northern Ireland have periodontal pocketing exceeding 4mm and just under 10% have advanced periodontal disease which can eventually lead to tooth loss.
Dental professionals have a critical role in monitoring their patients' gum health at each check-up, and in diagnosing periodontal disease and advising those who are at risk. In the minority of cases where this does not happen, the dental professional is increasingly vulnerable to a negligence claim and even a GDC investigation.
We analysed the reasons for, and outcome of, 170 claims involving periodontal disease that were closed between 2008 and 2012. Of these, we settled 126 (74%) on behalf of members and paid out over £2.8m in compensation and a similar amount in legal fees. In 25 cases, the dental professional also faced a formal complaint and in five cases, their fitness to practise was investigated by the GDC. The remaining 44 claims were discontinued by the claimant.
The number of settled claims rose from 21 in 2008 to 30 in 2012, reflecting the increase in claims overall during this period. However, there has also been a rise of nearly 50% in the average compensation payout each year, from £21,425 in 2008 to £31,607 in 2012.
The largest damages award was £170,000 for failure to diagnose and treat periodontal disease leading to bone and tooth loss. In this case, in addition to general damages for pain, suffering and special damages to pay for remedial treatment, the patient was also entitled to significant compensation for their loss of earnings as they were unable to pursue their chosen career.
Failure to diagnose and treat periodontal disease
This was by far the most common allegation to feature in our analysis, representing three-quarters of settled claims. The average compensation awarded in these cases was £25,600, slightly higher than for other claims.
Such claims are especially difficult to defend if there is no indication in the records that the dentist has carried out a periodontal assessment during examinations. Many of the patients reported bone and tooth loss as a result of undiagnosed periodontal disease and the subsequent failure of costly dental work such as implants and crowns. Their compensation would have covered this, as well as the ongoing cost of treatment to stabilise their condition, such as additional visits to the hygienist and specialist periodontal treatment.
In 14 cases, periodontal disease was diagnosed but the dental professional was accused of not managing the condition properly or failing to make a suitable referral, sometimes over several years. Often, the patients only discovered there was a serious problem when they changed dentist. This left the dental professionals involved open to an allegation of supervised neglect, particularly if they failed to record a treatment plan, any discussions with the patient about the advice given and their ongoing monitoring of the patient's condition.
A small number of cases reflected a breakdown in communication between dentist and patient. Most allegations centred on whether the periodontal treatment provided had been 'unnecessary', implying that the patient believed they had not been fully informed about the treatment, its risks, benefits and possible alternatives, and had therefore not given proper consent.
Risk management advice
Incomplete or inaccurate records were a common theme in settled periodontal claims. In some cases, this simply made it more difficult for the dental professionals concerned to monitor the patient's progress and meant they could not appreciate a marked deterioration. However, failure to record relevant details of the treatment plan and the advice given would also make it significantly more difficult to challenge the patient’s version of events.
The DDU offers the following risk management advice to help dental professionals reduce the risk of a successful claim relating to periodontal disease.
- Follow available national guidance to ensure your treatment plan is evidence-based, e.g. the British Society of Periodontology's guidance on the Basic Periodontal Examination (BPE) is recommended by the Faculty of Dental Surgery.
- Record all your examination findings in the patient’s clinical notes, including their BPE scores and your assessment of their periodontal health. Make a note of factors such as the presence of plaque, calculus and gingival bleeding that may make them susceptible to periodontitis and in need of closer examination at future appointments.
- Explain to the patient if they are at risk of periodontal disease and how they can protect themselves, e.g. information about the link between diabetes and periodontitis, the need for good oral hygiene and more frequent visits to the hygienist, the importance of smoking cessation etc. Make a note of the conversation.
- If you decide that the patient's gum disease only requires monitoring and advice at this stage, you should still explain this to them and record your discussion and their consent to your treatment plan in the records. Ensure you have a system in place to record periodontal pocketing and loss of attachment at each visit.
- When obtaining consent for periodontal treatment, take time to explain the risks, benefits and alternatives. Make a careful note of what you discussed and their agreement in the clinical records.
- If the patient fails to respond to treatment, including a failure to carry out adequate plaque control despite repeated oral hygiene instruction, make a note of this in the records, along with the explanations given to the patient regarding the consequences.
- Recognise the limits of your own clinical skills. Be prepared to offer referral to a specialist if the patient's condition does not improve despite treatment.
This article originally appeared in the printed version of the DDU Journal March 2014 entitled "Probing deeper".
This guidance was correct at publication 02/03/2014. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.