Dr Reena Wadia is a specialist periodontist working in London. She has spent years teaching dentists, hygienists and therapists how to handle perio patients in general practice. She also teaches about mitigating the risk of complaints and litigation when it comes to perio and gum disease. Dr Wadia offers more advice and services on her website RW Perio and courses through Perio School.

Have you ever found yourself in a difficult situation when treating a perio patient? Changes are that as a dentist, you have.

In this blog, Dr Wadia breaks down the issue of perio-related litigation and gives practice advice for general dentists. You can also rewatch the webinar that this blog is based on below.

Key takeaways:

• Three-quarters of UK dental litigation relates to perio and implant procedures
• They can investigate any clinician who had treatment responsibility, with reliance on notes
• Most cases relate to patient education, so documenting advice and  follow-up information is key

The problem with perio

Did you know that perio and implant-related procedures account for 44.7% of all dental claims by value? Some claims are more than £100,000. That’s a lot of money!

Perio cases cover extended periods of time, as patients can have problems for decades and across their whole mouths. The cost of treatment can stack up as the disease progresses. The financial and well-being impacts for patients can also be huge.

These cases also often involve more than one clinician. That's why consistent and thorough note-taking by every clinician is important. Every clinician and team member with treatment responsibility for the patient can be investigated as part of a perio claim.

More and more advertorials by lawyers invite patients to sue dentists their gum disease. Patients are also becoming savvier about treatment options.

Perio dental litigation cases have common themes, including a failure to:

• Diagnose
• Refer at an appropriate time
• Explain risk factors
• Explain the consequences of untreated periodontal disease
• Provide adequate treatment

The majority of cases are not down to the physical treatment provided for the patient. These issues relate to the education of the patient about their disease.

Your clinical records are legal documents. In a court case or fitness to practice hearing, they will be relied upon to provide context about what happened at a patient's appointment. We are all too familiar with the adage 'if it's not written in the notes, it didn't happen'.

So, what we as general practitioners can do to avoid a perio case?

Provide an appropriate assessment

Dr Wadia recommends key things that you should be routinely asking your patients about.

Signs of periodontal disease

Bleeding is an obvious sign of some form of periodontal disease. A key tip is to ask your patients if their gums bleed when brushing.

Many patients may assume you are asking about spontaneous brushing. Bleeding whilst brushing is, unfortunately, a normal sign for them. Be specific about what you’re asking them about.

Other things you should be asking about include:

• Mobile or loose teeth
• Bad tastes in the mouth
• Bad breath
• Swelling of the gums

Risk factors for periodontal disease

It is also extremely important to assess and document the following risk factors. You can do this chair-side, or in conjunction with the medical health form patients should be filling out. You need to do this even if the patient is only showing some very mild signs of periodontal disease.

• Diabetes
• Immunodeficiencies
• Pregnancy
• Medications
• Smoking or vaping
• Stress
• Nutrition

[graphic summarising risk factors]

Clinical signs and exams

For clinical exams, supplement all appointments with a BPE score, appropriate 6PPC and radiographs.

A BPE score of 3 in any sextant requires initial periodontal treatment (OHI and scaling). If there is no resolution at the next recall appointment, then carry out a 6PPC in the relevant sextants.

A BPE score of 4 in any sextant requires a full mouth 6PPC.

Dr Wadia's preference is for periapical radiographs. The recommendation is to make sure that the crestal bone is visible in the radiographs. If you capture these on bite-wing radiographs then that would be enough. If not, then you may need to take Posterior-Anterior (PA)s or an Orthopantomography (OPG).

If your patient has implants, they need a 6PPC every check-up (similarly to when you would do a BPE). You can read our blog with Dr Aly Virani to find out more about peri-implant disease management.

Provide an accurate diagnosis

In 2017, a new BSP Periodontal Classification was released. It provides a good framework for documenting a patient's periodontal status.

Dr Reena Wadia's 6 steps make this process very straightforward:

Type of disease (Periodontitis)

• Extent
• Generalised (>30% of sites)
• Localised (<30% of sites)
• Molar-incisor pattern

Staging (from the worst affected site)

• I - <2mm attachment loss from CEJ)
• II - Coronal third
• III - Mid third of root
• IV - Apical Third of root

Grading

• A - % Bone loss is less than the patient's age
• B - % Bone loss is similar to the patient’s age
• C - % Bone loss is higher than the patient's age

Current Status

• Stable - <10% bleeding and no pockets over 4mm
• Unstable - Pockets over 5mm present
• In remission - Bleeding over 10% with no deep pockets

Risk factor profile

• Uncontrolled diabetes
• Smoking

Using the above flow, your diagnostic statement might look something like this:

Generalised Periodontitis, Stage 3, Grade B, Unstable, Smoking 15 a day

Provide a clear explanation

It can often seem like an afterthought, but explaining to your patient what you have seen in their examinations is vital.

Sharing your observations about their dental and medical health and how it relates to their oral hygiene needs can be a matter or life or death.

In one sad case, a patient developed an intracranial abscess, secondary to an oral abscess. Their dentist of 20 years diagnosed periodontal disease from radiographs. Yet there was no clear communication of the findings to the patient or in their notes.

The patient had attended many times over the years, but the dentist never recorded any given advice about their periodontitis. The judge ruled that poor record keeping and lack of information given to the patient about their condition.

The patient, a smoker, said they would have quit if the link between smoking and periodontal disease been made clear to them.

To avoid this, make sure you explain information appropriately. We understand the importance of this, which is why we’ve built patient letters into Kiroku.

Below, Reena gives some suggested wording for how you can explain common questions to your patients. Consider using models or images, as some patients will take in information better when they have something to look at.

What is periodontitis?

“Your tooth (holding pen) is held in place by bone (fist holding the pen). Around the bone, you have your gums (second hand). Normally, the gums are tight and hold everything together.

In gum disease, bacteria start to attach to your teeth. Your gums don't like it and start bleeding. This opens up spaces which start forming between your gums and your teeth.

These spaces are called 'pockets'. Once these form, bacteria can go inside and hit the bone and start dissolving the bone away.”

What are the consequences of not treating periodontitis?

“If this is not treated, the tooth will slowly start becoming loose and eventually, you may end up with tooth loss.”

How severe is my disease?

Explain to the patient which teeth can be saved or lost and which teeth have a 'guarded' prognosis.

The patient needs to have a clear idea about how many (if any) teeth you are expecting them to lose. Explain what their eventual outcome might look like (natural teeth, dentures, dental implant placement, etc).

What does the treatment involve?

Discuss oral health advice and home care, interdental brushing and risk factor management. Also, explain the risks and benefits of periodontal treatment.

Provide appropriate treatment and referral

The specific treatment pathways and protocols are beyond the scope of this post. It goes without saying that the treatment of a patient's periodontal needs must be of an appropriate standard.

This is especially important before starting complex or cosmetic treatments that may compromise the patient's periodontal state. This includes a descriptive referral to a hygienist if you are delegating the treatment and having good practice protocols.

The BSP guidelines outline when and what treatments need to be considered and when it is appropriate to offer a referral to a specialist. You don’t want your patient to find out after failed treatment that they had the option to see a specialist.

Creating appropriate records

Sadly, it is likely that at some point in your career, you will have to defend yourself in a lawsuit or GDC hearing.

This can occur if a different dentist has caused an issue with a patient but you have seen or treated them at any point in their past. In this event, it is crucial that you have documented your discussions with your patient well.

A good set of patient records will be your ticket to get out of the situation with limited stress.

Dr Wadia has worked with Kiroku to build in guidance and workflows into our periodontal templates. This makes it an easy process for you to start taking better notes, and minimise the risk of litigation.

As dentists, we want to spend our time discussing the disease with our patients. It’s no longer good enough to only have quick conversations due to time restraints. Especially if you still then spend hours writing up your notes.

Templates and stock text can be useful for making things more efficient in your practice. Your notes will stand up to scrutiny if they contain relevant information about your treatment.

To do this efficiently, you need a system that allows personalised notes with minimal effort.

Key phrases to include in your notes

These are Dr Wadia’s key phrases to include in your notes, where relevant.

About Periodontitis:

• “Patient advised that they are at risk of developing periodontitis”
• “Patient advised of mild/moderate/severe periodontal disease”
• “Patient warned of tooth mobility and tooth loss related to periodontal disease”
• “Patient advised that oral hygiene is not adequate to support formal periodontal therapy.
• "Patient advised to improve plaque levels to support periodontal therapy”
• “Discussed referral to periodontal specialist”

Oral Health Information:

• "Patient advised to start brushing twice daily"
• "Patient advised to change to an electric rechargeable toothbrush as these are more effective plaque reduction, discussed brushing technique"
• “Patient shown how to use interdental brushes properly and advised sizes yellow and red”

Risk Factors

• “Patient advised of smoking-related to periodontal disease – increases the risk for the condition and poorer response to therapy”
• "Explained we are unsure of the impacts on oral health but would advise vaping cessation"
• "Patient advised that stress is a risk factor for periodontal diseases"
• "Patient advised of the risks of diabetes – explained it increases susceptibility and severity of periodontal disease. Explained that if diabetes control is suboptimal then this will impact the success of perio treatment and maintenance of the results"
• "Patient advised that pregnancy is a risk factor for periodontal diseases"

Although every line may be relevant to some patients, most individuals won't need these in their notes. With Kiroku, your notes can be fully customised to your patients. You can add key phrases from our snippets functionality too.

The key to having good records that hold up is making sure everything is tailored. So if a patient doesn't smoke and never has, you don't want to write about smoking cessation advice. Similarly, a non-diabetic patient doesn't need documented advice on maintaining good diabetic control.

We’ve built these key phrases from Dr Wadia into the GDP Periodontal Examination Kiroku template.

When you use it, you’ll realise that the discussion section will begin to auto-populate. This will be based on the patient's individual clinical circumstances.

This means that:

• You can actually spend time talking to your patients
• Your notes are comprehensive
• They contain relevant information
• They can act as a reminder for you to discuss certain points
• You will start your next appointment on time

Dr Wadia's Kiroku template also allows you to enter all the clinical findings recommended in her webinar!

Kiroku users can download the GDP Periodontal Examination template from our template library.

Not using Kiroku yet? Not a problem. You can sign up for our free trial in a matter of minutes and start using Reena’s template immediately.

Common periodontal litigation questions from patients

A dentist failed to diagnose periodontal disease, but they have since retired. Can you sue a retired dentist?

By law, all dentists must be registered with the General Dental Council (GDC). They must also have appropriate indemnity and insurance arrangements in place. This allows patients to seek any compensation they may be entitled to.

Even after a dentist retires they will still be responsible for the treatment which was carried out when they were practising as a dentist.

How much compensation could I get for a gum disease dental negligence claim?

As with most dental negligence claims, the amount of compensation that you may receive if your dentist has failed to accurately diagnose or treat gum disease will depend on the circumstances of your specific case.

Factors taken into consideration will include:

• The severity of your gum disease diagnosis
• The delay in accurately diagnosing gum disease
• The short and long-term implications of the failure to diagnose

Implications may include financial issues for further treatment and physical, psychological and emotional trauma caused by negligence.

Is there a time limit for making a gum disease claim?

In the majority of cases, you have three years from the date of your last dental appointment to claim for gum disease compensation. However, there are some exceptions to this rule.

Speak to a solicitor as soon as you realise you have suffered an injury. This will allow you to determine your next steps and whether you are eligible to make a claim.

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