Missed periodontitis: lessons from negligence claims

Failure to diagnose or appropriately manage periodontitis remains one of the most common and highest value categories of dental negligence claims encountered in legal practice.

In this article, Sabrina Mahmood, associate at Keoghs LLP, explores the key legal issues that frequently arise in such claims and outlines practical risk management strategies for dental practitioners.

Why periodontitis claims?

The British Society of Periodontal Disease and Implant Dentistry (BSP) describes periodontitis as ‘one of the most widespread diseases in the world’. Against that backdrop, it is unsurprising that claims in this area are increasingly common. The condition often presents with subtle clinical signs, which may not be immediately apparent without a thorough periodontal assessment. This can create particular challenges in the busy, time-pressured environment of general practice, where many of these claims arise.

Common allegations include inadequate assessment and treatment planning, the provision of inappropriate or suboptimal therapy, insufficient patient communication regarding aetiology and risk factors (including smoking and oral hygiene), and a failure to make timely and appropriate referrals. Another level of complexity is that these claims often involve multiple practitioners as they can span extensive time periods, usually anywhere between five to 25 years.

Below we set out some of the key risk factors in more detail and consider practical steps that can be taken to mitigate these risks in everyday practice.

Risk factor one: assessment and treatment planning

Effective assessment and treatment planning can be a great way to ensure that many of the key risk areas are minimised. What we often see in legal claims are missing/regular BPE scores and where scores are three or higher, in-depth periodontal charting has been omitted, contravening the recommendations by the BSP (2019).

Another common issue is the failure to take radiographs at appropriate intervals. Radiographic assessment is often essential in identifying early bone loss and periodontal disease, particularly where clinical signs are not readily visible to the naked eye.

It is important to clearly document in the clinical records when radiographs are due, and to record any instances where a patient declines them, including the reasons for doing so. This provides important protection in the event of a later allegation that radiographs were not taken when clinically indicated. Patients may decline radiographs for a variety of reasons, including concerns relating to health or pregnancy, dental anxiety or phobia, concerns about radiation exposure, as well as general cost considerations given that they may incur an additional expense.

Finally, a clear discussion and documentation of the appropriate recall period will be important as patients with periodontal disease often need to be seen more frequently to help manage their disease, and allegations can arise where recall periods are too long.

Risk factor two: suitable treatment and onward referral

Many patients can be managed within the general dental setting with non-surgical therapy carried out by the dentist or hygienist at regular intervals. A common allegation is that appropriate therapy with non-surgical root surface debridement (RSD) has not been provided, and where treatment has been provided, it has been inadequate due to a failure to undertake subgingival debridement or supragingival plaque removal.

From experience, where a practitioner considers that a scale and polish is the most appropriate course of treatment, it is helpful for the clinical records to clearly set out both the decision taken and the reasoning behind it. In addition, where RSD has been carried out, this should be clearly documented including whether sub/supra gingival scaling has been undertaken.

An effective early treatment plan can help to ensure that appropriate therapy is provided, and where practitioners in the general dental practice setting feel that the patient’s needs are more complex or that surgical therapy is required, onward referral should be discussed and documented within the records. Failure to provide suitable referrals is another area where negligence allegations are common. Where periodontal disease is advanced, unresponsive to treatment, or beyond the practitioner’s scope, referral to a specialist should be discussed, offered and documented clearly in the records.

Risk factor three: oral hygiene and smoking

On nearly every periodontal claim, we see allegations that appropriate oral hygiene and tooth brushing advice was not provided, nor was smoking cessation discussed with the patient. Often, practitioners will notify us that they have discussed this but not documented it within the records.

Recent experience suggests that allegations in this area have become increasingly sophisticated. As patients have greater access to information, it is now commonly alleged that the aetiology of periodontal disease was not adequately explained, preventing patients from understanding how the condition develops and how factors such as poor oral hygiene and smoking may contribute to its progression.

Many smokers further allege that, had they been properly informed of the detrimental impact smoking can have on periodontal health and bone levels, they would have ceased smoking. In practice, we frequently see such allegations advanced even where smoking cessation advice has already been provided in primary care settings, often with limited evidence of patient engagement or compliance. In a number of cases, claimants have continued to smoke or use electronic cigarettes, even where they have subsequently received specialist periodontal input.

Financial implications

Legal costs in periodontal disease claims can escalate quickly. Independent expert evidence is often required, not only from a general dental perspective, but also from specialist periodontal and restorative experts. In addition, there is frequently a need for a detailed review of dental records, including both historic records and those from the index period. This is necessary to identify any pre‑existing disease, assess compliance with oral hygiene and smoking cessation advice over time, and consider whether gaps in attendance may have contributed to the outcome in question.

Claimants commonly allege that multiple teeth have been lost, or that tooth loss has been significantly accelerated, as a result of the alleged negligence. Claims often include the cost of extensive remedial treatment, including implants and complex restorative work, which can substantially increase the value of a claim. Defence experts will typically examine whether the proposed treatment is clinically appropriate and achievable, particularly where a patient’s oral hygiene remains poor.

In practice, many patients are not suitable candidates for the treatment claimed unless and until meaningful improvements in periodontal health are demonstrated, although there are cases where patients do engage positively and achieve sufficient improvement to proceed with restorative care.

Periodontitis treatment planning

From a risk management perspective, the most critical factor in limiting financial exposure is robust treatment planning supported by clear, documented discussions with the patient. Clinical records should demonstrate not only that an appropriate periodontal assessment was undertaken, but that the diagnosis, treatment options, risks, and prognosis were fully discussed and understood. Records should also reflect ongoing review and monitoring, including patient compliance or a lack of compliance with oral hygiene and smoking cessation advice. Where patients fail to attend, decline recommended treatment, or do not adhere to advice given, this must also be clearly and consistently documented.

From an indemnity perspective, early notification to insurers is critical where concerns arise regarding the management or progression of periodontal disease. Early involvement allows insurers to provide timely guidance, secure relevant records, and obtain early expert input which can support a robust defence of the allegations or otherwise inform an appropriate resolution strategy. This proactive approach can significantly reduce overall claims spend and improve prospects of a successful defence as well as preserving important evidence.

Summary and practical takeaways

Periodontal disease claims can involve scrutiny of many aspects of clinical care. However, practitioners can take reassurance from the fact that many of the associated risks can be mitigated through thorough assessment, clear and structured treatment planning, and well‑documented contemporaneous records of discussions and decision‑making.

While the financial exposure arising from periodontal disease claims can be significant, early notification to insurers plays a critical role in effective claims management. Prompt engagement allows for timely advice, early evidential review, and a more proactive approach to limiting both liability and overall claims costs.

If you have any questions or would like advice on dental negligence matters, please contact Louise Jackson, Keoghs partner and England and Wales regional lead for healthcare and sport, or Sabrina Mahmood, Keoghs senior associate and dental claims specialist in healthcare and sport.

For robust dental indemnity cover, contact Densura.

References

This article is sponsored by Densura.