Estimated read time: 6 mins
The rising risk of litigation relating to periodontitis has prompted a number of recent queries to Dental Protection, from members keen to ensure they are in the best position to prevent a claim for compensation, or to defend a claim should one arise.
In our experience, periodontal claims tend to focus on particular themes. In no particular order, these can broadly be categorised as allegations regarding:
a failure to diagnose the disease
an underestimation of the extent of disease
a failure to follow recognised treatment protocols
a failure to communicate how treatment is progressing.
These issues are often compounded when there are multiple clinicians involved over a long period of time and/or the clinical records lack sufficient detail.
The question of which indices must be recorded in order to defend a claim doesn’t have a simple answer. It is also important to highlight that Dental Protection is not the arbiter of clinical opinion. We can signpost members to appropriate professional guidelines and standards, but it is not our role to set these standards nor advise members how they treat their patients. In turn, it would be inappropriate to suggest which indices can legitimately be left out.
Nevertheless, we can still offer risk management advice based on our experience of managing complaints and claims.
Periodontitis is different from other aspects of restorative dentistry in the fact that it is a long-term disease, and good outcomes are arguably more reliant on patient engagement than treatment by the clinician. Not every poor treatment outcome is caused by clinician error or negligence. The assessment of a claim will therefore revolve around assessing whether the overall, long-term standard of care provided was of a reasonable standard. This is as opposed to what happened during individual appointments. There is therefore a clear difference to, for example, the provision of a root canal treatment.
When you look to assess the overall, long-term standard of care, the specific details of what indices were recorded (and when) and what treatment was provided may therefore vary between individual patients. A simple example of this would be to distinguish between engaged and motivated patients compared with those who are not complying with, for example, oral hygiene advice. The treatment records and discussions could legitimately contain different information in each case.
There are recognised guidelines and pathways that can assist the clinician in what treatment protocols should be followed in various situations. But guidelines are not rules. There is always scope for the clinician to use their professional judgment and perhaps deviate slightly from such guidelines. In these situations, the clinician should be able to justify their decision making with a clear rationale documented in the records.
When making such decisions, it is worth reflecting on why you may (or may not) be recording certain periodontal indices. In a fully engaged and motivated patient you are hoping the treatment you provide will result in a good clinical outcome. It is then hoped this will be maintained in the long term. The periodontal indices you choose to record are to objectively assess this, and the change in parameters will influence what happens next: further treatment, referral or some form of maintenance, for example.
In other words, we would advise you think about which periodontal indices you need for patient management and future decision making, rather than which periodontal indices you need to defend a claim for compensation. If the patient management is appropriate, that is the first step in defending any claim.
As a final point, it is sensible to discuss the importance of good patient communication. Many problems we assist members with arise when this breaks down. A common allegation in periodontal claims is that the patient was unaware they had periodontitis, or that the situation was deteriorating. When considering this from a risk management perspective, it is clear that one way to help protect your professional position is to ensure the patient is fully aware of their current status. The records should reflect any appointment-specific, and patient-specific, conversations and advice. This may include, for example, information about whether initial treatment has been successful or whether, in a long-term maintenance patient, there has been a relapse. Further to that, the records should then detail what treatment options have been offered which may include referral to a specialist.
We all recognise the treatment of periodontitis is challenging in general practice and poor outcomes are not always the fault of the dentist. Unfortunately, when there is a poor outcome, there is the potential for the patient to complain. Nevertheless, there are a few basic steps that you can take to guard against this:
It is important to screen for periodontitis
Once diagnosed, follow recognised guidance for treating the disease
The periodontal status can fluctuate between stable and unstable, so ensure you can appropriately monitor treatment outcomes and the effectiveness of any maintenance
It can be reasonable to deviate from professional guidelines, but you should be able to justify why this may be
Ensure the patient is regularly updated on their current periodontal status
Ensure the clinical records clearly reflect all of the above