Dental Mismanagement Claims: Periodontal Disease and Caries Mismanagement

How Does Periodontal Disease develop?

Periodontal disease develops when plaque and bacteria build up on the tooth. When patients attend their dentist for an appointment, the dentist should remove the plaque on the top of the patient’s tooth to assist with the prevention of periodontal disease.

As the bacteria on the tooth growths, the gum becomes red, the plaque on the tooth begins to harden and a rough surface on the tooth develops. The bacteria then works its way down the tooth, leading to bone loss and loss of the tooth.

Smoking, genetics, stress, and tooth grinding have all been found to be contributory factors of periodontal disease.

If periodontal disease is properly managed, it should not result in tooth loss.

Duty of Care

Dentists must do a basic periodontal disease examination (BPE) at every patient check-up. If your dentist fails to undertake a BPE at your appointment, this will constitute a breach of duty of care. The BPE involves using a scoring system of 1 -4 to assess the level of further examination required. The BPE examination involves the dentist using a probe to the gum to assess how far the probe can go into the gum. The deeper the probe into the gum, the higher the patient should score on the BPE assessment.

The British Society of Periodontology Basic Periodontal examination Guidelines indicate that if a patient has a BPE score of 3 or more, the dentist should undertake bitewing radiographs to assess the condition of the patient’s mouth and any signs of tartar on the teeth indicative of periodontal disease. The dentist should also undertake root surface debridement, which involves the dentist using an instrument to remove plaque from the root surface, below the gum line. This eases the redness and swelling of the tooth and will prevent the escalation of periodontal disease. A BPE score of 4 requires the dental practitioner to consider the need for more complex treatment and the need for referral to a specialist.

Examples of Breach of Duty of Care

-          Dentists failing to use the BPE scoring system

-          Dentists using the BPE scoring system, but failing to investigate or consider the need for more complex dental treatment or the need to refer to a specialist in light of a BPE score of 4.

-          Dental practitioners failing to undertake radiographs when patients have a BPE score of 3 or more, resulting in a failure to observe the bone loss that has occurred, indicative of periodontal disease.

-          Dentists failing to offer smoking cessation advice and oral hygiene instructions to patients who have periodontal disease, despite smoking and a failure to maintain proper oral hygiene known to be factors that may exacerbate periodontal disease.

-          Failure to treat BPE scores of 3 or more with root surface debridement.

-          Failure to refer to other specialisms when required.

Causation

In order to bring a successful clinical negligence claim, the client must prove that there has been a breach of duty, and that the breach of duty caused extra pain and suffering, loss and damage over and above that which would have been experienced if the appropriate treatment had been provided.

In the context of periodontal disease claims, an example of a claim may be:

1)      The dentist failed to respond to a score of 3 or more, indicative of periodontal disease. They did not undertake root surface debridement or radiographs despite the signs of periodontal disease.

2)      The claimant’s condition worsened to an extent that they lost a tooth and were in considerable pain as a result.

It is essential that clients demonstrate that there was both a breach of duty and that it had causative effect. Difficulty may arise in proving the causative element of the claim where:

-          The patient was contributorily negligent, meaning that the patient was partially responsible for their injuries. In the context of a periodontal disease, an example of this could be that the patient continued to smoke, or failed to follow the oral hygiene advice provided by their dentist.

-          If, following negligent care which fails to identify or treat periodontal disease, the patient receives the correct treatment but this does not resolve or improve the periodontal disease there may be an issue with establishing causation. This is because, if the first dentist had completed the appropriate treatment, there is no evidence that this would have provided an improved outcome.

Caries Mismanagement Claims

Caries is essentially another name for tooth decay. It is caused by a patient consuming excess sugar, leading to bacteria on the tooth surface which penetrates the pulp, (jelly like centre of the tooth that contains the nerves, the blood vessels and connective tissues). This causes the tooth to become infected, the gums to swell, and is very painful. The pain will eventually stop when the nerve becomes dead. The pain will then resurface in the future as the patient develops an abscess, caused by the bacteria growth. If caries are left untreated it can cause the patient to lose the tooth.

Duty of Care

Dentists have a duty to examine the patient’s teeth properly during examination. This involves probing the tooth, undertaking bitewing radiographs, and assessing the patient’s risk level of developing caries. Dentists should provide advice on diet, encourage patients to use fluoride which prevents tooth decay, and provide oral hygiene instructions.

Breach of Duty

-          Dentists should carry out bitewing radiographs on patients every 2 years as a minimum. If a patient is at high risk of developing caries, it is recommended that radiographs be undertaken every 6 – 12 months. If a patient has caries, it will be clear from the radiographs undertaken by the dentist.

-          Dentists failing to provide advice on diet, where the patient consumes large quantities of sugar and continues to experience tooth decay.

-          The dental practitioner gives the patient a filling to treat the cavity in their tooth caused by caries, but fails to remove the caries bacteria from the tooth. This is often caused by poor local anaesthetic technique – as the dentist drills nearer the patient’s nerve, it becomes painful, and the dentist stops drilling the tooth. The caries bacteria is left behind.

-          Failure to interpret radiographs properly due to artefacts showing up on the radiograph, or the patient moving during the radiograph. This results in caries being missed by the dentist.

Causation

It is for the claimant to prove that the breach of duty by the dentist, in failing to treat, or give proper advice regarding caries lead to them experiencing pain and suffering over and above what would have occurred had the appropriate treatment and advice been given. In the context of caries, the outcome of the negligence will be tooth loss.

If you or anyone you know feels that they may have experienced any of the issues outlined in this article and would like to discuss this, please contact the Clinical Negligence Department on 0800 0374625, a member of our team will be happy to assist.