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means by which to defend an allegation of periodontal neglect. Remember that any decision to take X-rays, the technique used and the accompanying quality assurance should be informed by the relevant statutes and best practice guidelines. If history and examination show the patient is periodontally fi t


and exercises good home care, then little more is required. Where disease is observed or where the patient’s habits predispose to its onset, appropriate management should be discussed.


Informed consent No intervention can begin without valid consent. However, since patients are often relatively unconcerned by a disease whose progress is generally slow and which causes relatively little discomfort, securing their agreement to recommended treatment can be problematic. Therefore, the consenting process must involve not only a description of procedures, potential complications, alternative approaches and costs, but also clear advice as to the risks of non-compliance. Patients must understand that, while the rate at which supporting tissues deteriorate can be unpredictable, in most instances loss of dentition will be the ultimate end-point. Hopefully the fully informed patient will be keen to cooperate but, if having understood this advice, the competent patient withholds consent then treatment cannot proceed.


Sound advice Active treatment must be complemented by home care advice. Flossing, brushing and smoking cessation instruction are essential components of achieving periodontal health and must be tailored to the patient’s individual needs. Getting patients to fl oss or interdental brush in all quadrants daily is a particularly hard sell. I’ve heard all the excuses (“fl ossing pulls my fi llings out” is a favourite), so it is important to be gently persistent.


Finally, treatment… The next stage is to treat the patient’s periodontal disease. This involves skills which are beyond the scope of this article and which


will be refi ned through experience and further education but it is important to bear in mind the chronic nature of periodontitis when treatment is being planned. Unless the management of a cooperative, conscientious patient has resolved and stabilised the periodontal condition, then periodontal therapy tends to be a continuous and repetitive process.


If it’s not recorded, it didn’t happen It is my experience that the onset of advanced periodontitis is often accompanied by selective amnesia. Non-compliant patients who fi nally realise that their dentition is irreparably compromised rarely recall their own failings, focusing instead on any lack of care and attention on the part of their dentist. In such circumstances, a complaint or claim of negligence is likely. The pathogenesis of periodontal disease tends to dictate that these allegations will emerge many years down the line so defence relies heavily on what is contained in clinical notes. These should always record the vital facets of each appointment, such as examination fi ndings, consent and treatment outcomes. When dealing with periodontal problems, details of preventive advice and the patient acceptance and implementation of that advice should also be included. If it is evident from the records that the patient failed to cooperate with sound clinical advice then a lengthy dispute (and many months of stress) can be more easily avoided. Perhaps due to the relatively subtle nature of periodontal disease, this aspect of clinical practice presents particular challenges. Motivating patients to attend for treatment and to maintain the subsequent improvements through scrupulous home care can be an uphill task. Where patients cannot be persuaded, it may take many years for the presence of periodontal disease to become apparent. By this time, the situation can be dire. Therefore, the implementation of appropriate and well- documented preventive education and periodontal treatment must form an integral part of every patient’s care.


Doug Hamilton is a dental adviser at MDDUS


BUT THE GUMS WILL NEED TO COME OUT…


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