12 • Clinical risk


MDDUS dental adviser Doug Hamilton highlights some common clinical pitfalls in periodontics from a dento-legal perspective


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ANY of the commonest dental conditions, such as pulpitis or an apical infection, are usually accompanied by pain and/or swelling. Suff erers will therefore tend to arrive at your practice knowing that something in the tooth department is very wrong. As a result, the need for treatment is often


anticipated and easily accepted. Once symptoms have been relieved, these patients are often grateful and amenable to having other diseased teeth restored or extracted. They may even pay their bill! Periodontitis, however, tends to be more insidious. Often the


only obvious marker is bleeding gingivae, about which many patients seem to be remarkably relaxed. Since it rarely causes the overt symptoms which are usually associated with dental disease, convincing patients that treatment is required can be diffi cult. Initial scepticism may be heightened by the fact that patients rarely perceive tangible post-treatment benefi t. On the contrary, newly scaled teeth can feel ‘rough’ and sensitive. Once these concerns have been addressed, the beleaguered


practitioner often has to remind the patient that the periodontal treatment must be repeated (and paid for) periodically. Thus, persuading patients to undergo appropriate hygiene and maintenance phase treatment can be diffi cult even for experienced dentists who have been able to develop a trusting relationship with their patients. For the more recent graduate, faced with an overbearing and cynical patient, it can be a particularly daunting prospect. The temptation in such situations can be to avoid


confrontation by ‘deferring’ discussion of prevention and treatment of periodontal disease, secure in the knowledge that it may take many years for the resulting problems to manifest themselves.


Informing patients Regardless of circumstances, failure to inform patients of clinical fi ndings is unethical and may lead to serious censure. However, the ramifi cations for the patient’s dentition of supervised neglect


can vary. For example, if caries are left untreated then the patient may return with both pain and awkward questions. Yet the resulting symptoms and loss of coronal tissue can often be remedied by a variety of restorative techniques, perhaps preceded by endodontics. Even where this is not feasible or unwanted, the resulting loss tends to be limited to the involved tooth. Untreated periodontal disease, on the other hand, is often very


diffi cult to stabilise and impossible to reverse. Furthermore, it is liable to aff ect a number of teeth, if not entire arches. Explaining this to a disgruntled patient who has “never heard of gum disease” can be very challenging. However, keeping schtum until these patients eventually return with irreparably mobile (and perhaps expensively restored) teeth is a recipe for complete disaster. As always, honesty and patience are the best tactics.


Build from the ground up Maintenance of the supporting tissues must underpin the care of all dentulous patients. This philosophy starts with a comprehensive history which includes questions regarding home care regimens, previous periodontal treatment need and smoking. The subsequent examination will include visualisation of the soft tissues accompanied, at appropriate intervals, by pocket chartings. All fi ndings must be recorded in the clinical notes – this will


assist treatment and help defend any future allegation of negligence. It is also essential when certain items of service in the Scottish Statement of Dental Remuneration are being claimed. This said, the inclusion of a basic periodontal examination (BPE) or six-point charting must not become a defensive or ‘tick-box’ exercise. These chartings must be carried out methodically to refl ect the clinical picture and provide an accurate and credible basis for treatment. Once the soft tissue examination is complete, radiographs may


be required to assess the extent of periodontal bone loss. These fi lms can be an exceptionally useful diagnostic tool. Furthermore, although X-rays should not be taken for purely dento-legal reasons, they also provide a defi nitive record of the patient’s presenting condition which can be another extremely useful


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