1. Never treat a stranger. Work hard to build a good rapport with your patients, as patients are less likely to sue people they like. “It isn’t necessary, then, to know much about how a surgeon operates in order to know his likelihood of being sued. What you need to understand is the relationship between that doctor and his patients” – M Gladwell (Blink, the power of thinking without thinking).
2. The progress of periodontal disease can be stopped at any level by adequate periodontal treatment and optimal patient cooperation. The first step is making a thorough diagnosis. Without this you cannot have any discussions on prognosis or the suggested treatment plan. To diagnose you must probe. Probing is essential for every new patient or recall visit. Be aware of the current BPE guidelines and record as well as review your findings every visit. It can help to examine as though you’ve never seen the patient before at every recall visit – you are then less likely to miss anything. When examining radiographs, look out for early warning signs of interdental bone loss – aggressive periodontitis cases can progress rapidly.

3. Make an assessment of risk for every patient. Practice based software such as the PreVisor Risk Analysis can also help with this. Provide a tooth-by-tooth prognosis in complex cases. It’s always worth giving teeth with a periodontally guarded prognosis a chance as you may be surprised as to how long they survive. Remember that prognosis can also change following reassessment.

4. Interestingly, the effects of providing periodontal disease risk information to patients has been shown to improve psychological outcomes – in a recent study patients saw periodontal treatment as more effective, were more confident in their ability to follow a periodontal treatment regime and reported higher intentions of adhering to periodontal disease instructions when provided with risk information (Asimakopoulou et al 2015).

5. When gaining consent ensure the patient understands what is wrong, the consequences of no action, alternative reasonable options, material risks, likely duration outcome and prognosis especially when their contribution is important. Costs and funding should always be discussed at the outset. Consent is a process and ideally should be written. It’s useful to note any specific fears or concerns raised by the patient. According to the recent Montgomery ruling we must warn the patient about any conceivable risk and let the patient decide what level of risk they are prepared to undergo. It is not for the doctor to decide on medical grounds what he thinks the patient should be told notwithstanding the risk of a serious outcome may be very small. There are 3 exceptions to this rule: when the patient states he does not want to know; when disclosure of risk would be detrimental to the patient’s health or when the patient is unconscious or otherwise unable to make a decision.

6. Good record keeping is key to defending any claims. Records should be contemporaneous and include warning and options. If it isn’t written down, it didn’t happen.

7. If you face a difficult patient who is not complying, it sometimes helps to write them a letter explaining the importance of treatment, risks of not complying and reassuring them you are there to help when they are ready.

8. Ensure you are aware of the criteria of when to refer patients for more complex cases. These have been outlined by the BSP: https://www.bsperio.org.uk/publications/downloads/28_143801_parameters_of_care.pdf

9. Be familiar with the GDC standards (2014) that outline the 9 principles of care including putting patients first, communicating effectively, obtaining valid consent, working with colleagues in a way that is in patient’s best interest, maintaining and developing your professional skills.

10. Everyone in general practice is obliged to provide a standard of care appropriate to a reasonably competent qualified dental professional. A breach of that duty may occur through failure to examine properly, failure to provide the appropriate treatment, or failure to follow up or advise appropriately. If that causes the patient to suffer damage/harm e.g. they lose a tooth due to undiagnosed periodontal disease, this is termed as negligence and can lead to legal action. Your Duty of Care remains the same whether you are working on the NHS or privately.
    
11. Neglience claims can be brought 3 years from the patients “date of knowledge” NOT the date of negligence. So claims can be made be many years later. The number of failure to diagnose periodontitis cases is increasing. According to Dental Protection, the number of claims received in respect of patients treated before 1999 more than doubled between 2010 and 2015. A periodontal claim today relating to alleged mistreatment over 25 years might cost as much as £100,000. Assuming costs increase by 7% pa, a periodontal claim reported in 2042 relating to a treatment started in 2017 could exceed £0.5M!

12. Remember, any complaint to the GDC will lead to the GDC investigating all records – so periodontal claims can arise from initially non-periodontal complaints. It can take 18-22 months for a case to run it’s course and so is a very draining process. Ensure you are supported by the right people and always follow the advice provided by your indemnity organisation.

Periodontology