Your teeth are fine... but the gums will need to come out

MANY of the commonest dental conditions, such as pulpitis or an apical infection, are usually accompanied by pain and/or swelling. Sufferers will therefore tend to arrive at your practice knowing that something in the tooth department is very wrong. As a result, the need for treatment is often anticipated and easily accepted. Once symptoms have been relieved, these patients are often grateful and amenable to having other diseased teeth restored or extracted. They may even pay their bill!

Periodontitis, however, tends to be more insidious. Often the only obvious marker is bleeding gingivae, about which many patients seem to be remarkably relaxed. Since it rarely causes the overt symptoms which are usually associated with dental disease, convincing patients that treatment is required can be difficult. Initial scepticism may be heightened by the fact that patients rarely perceive tangible post-treatment benefit. On the contrary, newly scaled teeth can feel ‘rough’ and sensitive.

Once these concerns have been addressed, the beleaguered practitioner often has to remind the patient that the periodontal treatment must be repeated (and paid for) periodically. Thus, persuading patients to undergo appropriate hygiene and maintenance phase treatment can be difficult even for experienced dentists who have been able to develop a trusting relationship with their patients. For the more recent graduate, faced with an overbearing and cynical patient, it can be a particularly daunting prospect.

The temptation in such situations can be to avoid confrontation by ‘deferring’ discussion of prevention and treatment of periodontal disease, secure in the knowledge that it may take many years for the resulting problems to manifest themselves.

Informing patients

Regardless of circumstances, failure to inform patients of clinical findings is unethical and may lead to serious censure. However, the ramifications for the patient’s dentition of supervised neglect can vary. For example, if caries are left untreated then the patient may return with both pain and awkward questions. Yet the resulting symptoms and loss of coronal tissue can often be remedied by a variety of restorative techniques, perhaps preceded by endodontics. Even where this is not feasible or unwanted, the resulting loss tends to be limited to the involved tooth.

Untreated periodontal disease, on the other hand, is often very difficult to stabilise and impossible to reverse. Furthermore, it is liable to affect a number of teeth, if not entire arches. Explaining this to a disgruntled patient who has “never heard of gum disease” can be very challenging. However, keeping schtum until these patients eventually return with irreparably mobile (and perhaps expensively restored) teeth is a recipe for complete disaster. As always, honesty and patience are the best tactics.

Build from the ground up

Maintenance of the supporting tissues must underpin the care of all dentulous patients. This philosophy starts with a comprehensive history which includes questions regarding home care regimens, previous periodontal treatment need and smoking. The subsequent examination will include visualisation of the soft tissues accompanied, at appropriate intervals, by pocket chartings.

All findings must be recorded in the clinical notes – this will assist treatment and help defend any future allegation of negligence. It is also essential when certain items of service in the Scottish Statement of Dental Remuneration are being claimed. This said, the inclusion of a basic periodontal examination (BPE) or six-point charting must not become a defensive or ‘tick-box’ exercise. These chartings must be carried out methodically to reflect the clinical picture and provide an accurate and credible basis for treatment.

Once the soft tissue examination is complete, radiographs may be required to assess the extent of periodontal bone loss. These films can be an exceptionally useful diagnostic tool. Furthermore, although X-rays should not be taken for purely dento-legal reasons, they also provide a definitive record of the patient’s presenting condition which can be another extremely useful means by which to defend an allegation of periodontal neglect. Remember that any decision to take X-rays, the technique used and the accompanying quality assurance should be informed by the relevant statutes and best practice guidelines.

If history and examination show the patient is periodontally fit and exercises good home care, then little more is required. Where disease is observed or where the patient’s habits predispose to its onset, appropriate management should be discussed.

Informed consent

No intervention can begin without valid consent. However, since patients are often relatively unconcerned by a disease whose progress is generally slow and which causes relatively little discomfort, securing their agreement to recommended treatment can be problematic. Therefore, the consenting process must involve not only a description of procedures, potential complications, alternative approaches and costs, but also clear advice as to the risks of non-compliance.

Patients must understand that, while the rate at which supporting tissues deteriorate can be unpredictable, in most instances loss of dentition will be the ultimate end-point. Hopefully the fully informed patient will be keen to cooperate but, if having understood this advice, the competent patient withholds consent then treatment cannot proceed.

Sound advice

Active treatment must be complemented by home care advice. Flossing, brushing and smoking cessation instruction are essential components of achieving periodontal health and must be tailored to the patient’s individual needs. Getting patients to floss or interdental brush in all quadrants daily is a particularly hard sell. I’ve heard all the excuses (“flossing pulls my fillings out” is a favourite), so it is important to be gently persistent.

Finally, treatment…

The next stage is to treat the patient’s periodontal disease. This involves skills which are beyond the scope of this article and which will be refined through experience and further education but it is important to bear in mind the chronic nature of periodontitis when treatment is being planned. Unless the management of a cooperative, conscientious patient has resolved and stabilised the periodontal condition, then periodontal therapy tends to be a continuous and repetitive process.

If it’s not recorded, it didn’t happen

It is my experience that the onset of advanced periodontitis is often accompanied by selective amnesia. Non-compliant patients who finally realise that their dentition is irreparably compromised rarely recall their own failings, focusing instead on any lack of care and attention on the part of their dentist. In such circumstances, a complaint or claim of negligence is likely.

The pathogenesis of periodontal disease tends to dictate that these allegations will emerge many years down the line so defence relies heavily on what is contained in clinical notes. These should always record the vital facets of each appointment, such as examination findings, consent and treatment outcomes. When dealing with periodontal problems, details of preventive advice and the patient acceptance and implementation of that advice should also be included. If it is evident from the records that the patient failed to cooperate with sound clinical advice then a lengthy dispute (and many months of stress) can be more easily avoided.

Perhaps due to the relatively subtle nature of periodontal disease, this aspect of clinical practice presents particular challenges. Motivating patients to attend for treatment and to maintain the subsequent improvements through scrupulous home care can be an uphill task. Where patients cannot be persuaded, it may take many years for the presence of periodontal disease to become apparent. By this time, the situation can be dire. Therefore, the implementation of appropriate and well-documented preventive education and periodontal treatment must form an integral part of every patient’s care.

Doug Hamilton is a dental adviser at MDDUS