DPL Feature

Perio and the pandemic: a cause for concern?

BY ANDREW WALKER & COLM HARNEY

DENTOLEGAL CONSULTANTS

Will the disruption caused by COVID-19 heighten the risks around periodontal disease? In recent years, the dental profession has been concerned about litigation in relation to periodontal disease. More recently, members have contacted the Dental Protection advice line, worried about whether the current pandemic situation may put them at further risk of a periodontal claim for compensation. A particular issue that some members have wanted to discuss is the need to undertake periodontal treatment with hand instruments, when they are unable to use ultrasonic scalers. The Covid-19 pandemic has given rise to many unprecedented situations. As such, it is difficult to predict with any degree of certainty what the impact will be on, for example, future claims compensation. Although, it is worth considering the following points in relation to periodontal claims for compensation.

Hand instrumentation is effective

In the first instance, we should bear in mind the evidence in the periodontal literature, which does say that hand instrumentation and powered instrumentation can be equally effective. This is also mentioned on the British Society of Periodontology (BSP) website. It is therefore appropriate to consider providing periodontal treatment with hand instruments when required. However, it is also accepted that clinicians only maintain the skills they use. The BSP website also goes on to state:

“…. Clinical experience indicates that non-AGP management of periodontal diseases, whilst being effective, requires hand instrumentation carried out to a high standard. This may take more time than the equivalent use of powered scalers and can be technically challenging in some circumstances.” It is quite possible that there are some dentists, hygienists or therapists who do not use hand instruments regularly, or simply prefer powered instrumentation. In this regard, as well as ensuring efficiency of treatment, it is equally important to ensure that you are using an instrument safely. If you are concerned about using hand instruments, the first thing that can be done is to see whether there is any CPD or revision available to update your knowledge and skills. Again, professional societies are a useful point of reference and the BSP has produced helpful webinars on this very topic.

Educating patients on their own role

In relation to potential claims, there are several points that should be reviewed. Firstly, if many periodontal treatments are planned with a phased approach. The first of these is motivating and supporting patients to obtain and maintain successful removal of the supragingival dental plaque biofilm, as well as controlling risk factors for the disease. In other words, this can be viewed as patient education and motivation. If entering a phase where professional intervention is potentially or possibly harder, it may call for a refocus on the patient’s role in managing their own disease. This in itself can have many benefits, and good documentation of any further advice provided to the patient can be vital if a claim is brought. In relation to any claim, it is often the case that the records and patient need to be reviewed by an independent expert witness. One of the roles of the expert is to comment on the standard of care provided. In relation to the standard of clinical treatment, this is meant to be compared against that of one’s peers, or what would be expected of a reasonable dentist, hygienist, or oral health therapist. In this situation, it would be hoped that an independent expert would acknowledge and take into consideration that, during the current situation we are all facing, periodontal care may be a little different.

Perio is a longer-term issue

While we don’t know how long this period of uncertainty will last, we can hope that it is a relatively short period in a lifetime of periodontal need. Moving on from this, it is worth remembering that all periodontal patients should have regular and careful assessment and reassessment. In most of the periodontal claims seen by Dental Protection, the claim relates to care over a long period of time, where the periodontal condition has deteriorated over many years. Therefore, if you are concerned about any deterioration that you feel has occurred, communicate this with the patient and talk through the potential options. The above point is perhaps the most important message, and it is essentially the same principle as before COVID-19. Your duty is to provide a reasonable standard of care for the time the treatment was undertaken and offer referral if, after that, you are still concerned. This may be for a variety of reasons, such as you feel you have reached the limit of what you can offer, or you feel the patient is still not stable despite your best efforts. In some cases, you may also be of the opinion an early referral to a local specialist may be a reasonable option for the patient. Again, as in any time, when you do have these discussions, and when difficult clinical decisions need to be made, good documentation in the clinical records is paramount.

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