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Periodontitis in the Dock
In my role as an Expert Witness, I recently attended a course in `courtroom skills`. I watched experienced doctors, consultants and specialists of all sorts being questioned in controlled circumstances by a battle hardened barrister. I watched these nice, affable and knowledgeable people being reduced to jabbering nervous wrecks within a matter of minutes, and then had my turn! Standing up in court is just not fun and is a very levelling experience even when you feel you are in the right. It is sad that litigation involving disgruntled dental patients is increasing and one of the biggest growth areas appears to involve periodontal problems of one form or another. The best way to avoid the whole court experience is to be `perio-aware`!
In general terms, be aware of typical perio-pitfalls. Cases I know that have been raised recently range from issues with single teeth to complete clearances. In more detail, they have involved circumstances such as a crown provided on a lower molar. Unfortunately, a tooth with furcation involvement, which was subsequently lost and where no pre-treatment x-ray had been taken to establish perio-endo health. At the other end of the spectrum, a change of practitioner left a large number of patients being newly diagnosed with advanced chronic periodontal disease and needing multiple extractions, despite being told for years and years that they were healthy. It is so easy to fall into a blinkered approach to periodontal health, because it`s such a person centred disease. It takes persistence to keep talking to individuals about it, but if you stop reminding them of the presence of clinical signs, they`ll take it that the problem has gone away.
Now, that previous paragraph sounds a bit clinical and serious, so let`s stand back a bit. Patients are people, with the weaknesses and failings that we all share. However, we should respect them for being part of the greater extended family we all belong to. One senior practitioner I know applies the `sister test` to everything he does. He asks himself, if it were his sister sitting in the chair, how would he treat her? Another way of avoiding the pitfalls I described is to apply the fundamental principles of governance. Is your treatment open, honest and involving the patient? Is treatment safe, as in not making them worse? Is treatment effective, as in making them better?
To badly misquote someone, periodontal therapy involves three things – information, information, information. We have to diagnose an existing problem and tell the patient, we have to identify risk factors and tell the patient and we have to identify what the patient can do to help themselves and tell them about it. All this means communicating with people in a big way. However, this is about open and honest care. If we don`t pass this information on there is no `informed consent` for anything else we do. Catching early clinical stages helps a lot too. If it`s possible to alter the course of the problem with simple changes to oral hygiene, the possibility of real damage is reduced and so is the possibility of litigation.
This article is not about the clinical aspects or processes, but we do need to be aware of changing patterns in BPE scores for an individual, or of changing risk factors such as diabetes or smoking. If we don`t inform people of all aspects of a clinical problem, the gap in communication can come back and bite us badly. In the same way, if we don`t talk to patients about increased risk of heart disease and reduced general health, we might have to answer for it in the future. By the way, these are all ways that we can also use to market our services too. If we can help patients put the facts together in their head they are more likely to take up the hygienist appointments which are lying empty in the diary. Patient involvement is the biggest part of treating periodontal disease and the best way to avoid facing the rottweiler of a barrister acting on their behalf.
There is also a proviso to all this. Help your defence organisation to help you by keeping good notes. Write everything down. Write down what you say, write down what they say, write down what you see. The biggest cause of an indefensible complaint is a simple lack of notes. We are all told the adage that `if it`s not recorded then it didn`t happen`. This isn`t actually quite true, because you can always stand up in court and say that you remember a particular conversation, or a particular response from a patient, and it is up to the judge to believe you or not. It just makes it a lot more believable if it is written in the notes at the time.
The last aspect of patient involvement in this particular arena is to be aware of when you are failing, or likely to fail due to treatment being out with your skills or knowledge. When you are not sure of a course of action, or if a particular course of action hasn`t realised the expected results, there is a duty of care to refer to a specialist (or special interest) practitioner. By informing a patient that you need help with an issue, you are both being responsible and passing that responsibility on to someone else. The patient may not take up that choice, but they need to be given the opportunity.
Now, is your periodontal treatment safe? On the face of it, this seems a simple question to answer. If you are compliant with infection control procedures, and health and safety issues, then you would have to say it is. However, there is another way of looking at this. Diagnosis and treatment that avoids surgery is a lot safer than treatment that leads to surgery. Good risk management of periodontal problems attempts to follow a path that leads away from surgical intervention, because this increases the risk to the patient. I have seen a complaint broken down into a number of questions, including `Was our client put at potential harm by requiring periodontal surgery?`. This question may not seem fair, but lawyers play dirty sometimes. Early diagnosis, or early referral, means the question will not be asked. Additionally, any extractions due to late diagnosis or treatment will be interpreted as `harm`, and that will be expensive.
Finally, is your treatment effective? The problem here is that patient compliance is an important component of success. We travel full circle back to patient involvement and information, give patients reasons to be successful and record the conversation in the notes. As I described at the beginning, most potential litigation is seeded by undiagnosed disease, so just offering treatment of any sort is really positive, but be `perio-aware` here too. Are you investing your own time in this, or are you able to refer to a hygienist in the practice? Surgical or non-surgical treatment? What are the guidelines for antimicrobials? What are the risk factors to address? Gosh, so many questions. In order to answer them, you need to be pretty up to date in your knowledge. If you are asking yourself these questions, or similar, the chances are you need to be planning a bit of Continued Professional Development in this direction. As mundane as this seems, trust me when I say it is worth it, in order to avoid those perio-pitfalls.
If we respect our patients, and want to do our best for them, we need to address these sorts of basement issues before the more challenging and interesting treatments that we really want to do. Patients quite often want the quick fix treatments, and we also want to provide them if it pleases the patient. Sometimes, though, we get a bit carried away and regret giving in to the temptations. I remember another recent case involving multiple anterior crowns which looked absolutely fantastic; for a while. When the crown margins began to show after only a few months, the patient went to a new practitioner who told them the brutal truth, that this would continue until a healthy gum level had been established. New crowns would be needed, and only then after extensive periodontal treatment. The cost to the first practitioner was considerable, and not just in financial terms. Most cases do not actually go as far as court, but take months or even years to come to an end. Going home after a busy day and then worrying about a complaint is really stressful.
This plea is not about having a `go` at anyone, it is about not ignoring the minor signs and symptoms. Be perio-aware, avoid the potential for cost, worry and possible court action. Make your patients happy, not the lawyers.