Periodontal classification and the increasing risk of litigation

Periodontal classification and the increasing risk of litigation

Unfortunately, claims alleging failure to diagnose and treat periodontal disease top the list of legal action against dental professionals. Those subject to such litigation may find it a highly stressful experience, especially if it leads to investigation by the General Dental Council (GDC). Cases commonly involve multiple dental staff who treated a patient over several years, and many take a year or more to resolve. Settlement frequently involves large sums – over £25,000 in most cases, and often more than £100,000.

To avoid future claims related to periodontal diseases, dental professionals must follow relevant guidelines, communicate their findings with patients, and keep detailed records. Defence against such a claim is much more difficult if the patient’s records do not document relevant examinations, investigations and diagnoses, as well as advice and treatment.

UK classification of periodontal disease

Regular screening and early diagnosis are essential for managing periodontal disease and preventing tooth loss, with its consequent disabilities and health impacts. Importantly, periodontal disease can be asymptomatic even in advanced cases and is only identified by dental professionals.

To support clinicians in recognising and diagnosing the condition in general dental practice, a new international classification system for periodontal disease was agreed at the 2017 World Workshop. This was subsequently adapted and adopted for use in the UK by the British Society of Periodontology and Implant Dentistry (BSP).

UK dental professionals should refer to BSP’s UK Implementation, which classifies periodontal disease into stages based on severity (I, II, III or IV) and grades based on disease susceptibility (A, B or C).

As explained in the UK implementation of European S3-level treatment guidelines for stage I-III periodontitis, the clinical pathway for diagnosis of periodontitis includes 4 steps:

  1. Basic periodontal examination (BPE) screen (see BSP’s BPE guideline and Simplified BPE guideline for under 18s)
  2. Provisional diagnosis
  3. Further investigations (radiographs and detailed probing charts)
  4. Diagnostic statement. This includes: definitive diagnosis; extent (localised or generalised); stage and grade; current status (stable/unstable); and risk factors.

A BSP decision-making flowchart is available to help practitioners implement the classification.

Why clinical negligence cases arise

A substantial number of complaints, claims and even referrals to the GDC arise because of allegations that the treating dental professional(s) failed to examine, investigate, diagnose or properly treat periodontal disease. The usual three-year limitation period may not apply if a patient can demonstrate that they only recently learned of their condition.

Successful claims often hinge upon insufficient documentation. Even if the treating dental professional argues that they did assess, treat and inform the patient correctly, they will find it difficult to support that argument if the patient’s clinical records do not show a complete and accurate record.

Since the consequences of undiagnosed or improperly managed periodontitis may be serious, compensation pay-outs are often highly costly, including damages for pain and suffering, loss of teeth and damage to the jawbone, remedial treatment costs as well as loss of earnings. Dental professionals should be aware of the risk and protect themselves from future litigation.

Reduce the risk of damaging litigation for periodontal disease

Follow guidelines: Dental professionals can reduce the risk of being subject to a claim or complaint for failure to diagnose and treat periodontal disease by following the BSP guidelines on classification and treatment.

Perform regular screening: The BSP Parameters of Care statement emphasises that oral healthcare professionals have a responsibility to screen patients regularly for periodontal and peri-implant disease, using appropriate clinical investigations to aid diagnosis and formulation of a treatment plan.

Seek specialist help if required: Patients with periodontal diseases may be referred according to BSP guidelines for a specialist opinion to assist with patient management.

Communicate well: The BSP statement also stresses the importance of good communication between clinicians and patients. Following every assessment, dental professionals should take time to explain their findings to the patient and discuss all reasonable treatment options, obtaining informed consent where necessary.

Make detailed records: All periodontal assessments and findings should be recorded in a patient’s clinical records, along with details of any discussions with the patient. Even if the treatment plan requires only monitoring and oral hygiene instructions, notes of the discussion and advice given, as well as any follow-up, should be as detailed as possible. An article in BDJ Team provides some useful phrases to include in templates, which should always be personalised (Wadia R, D’Cruz L. Avoiding the pitfalls of dento-legal issues. BDJ Team 2018;5:18091).

Provide written information: Wadia and D’Cruz also suggest using written information leaflets, and if a patient is non-compliant, then it may help to write them a letter explaining the importance of treatment. Ensure these actions are recorded in the patient’s notes.

Manage complaints proactively: Any complaints should be handled quickly and proactively to limit the damage.

At Dental Defence Society, our dento-legal experts can provide timely advice about dealing with complaints and claims regarding periodontal disease. Please contact us for 24/7 support as soon as a case arises.