Chronic Periodontitis: Diagnosis, Treatment and Medico Legal Challenges
In this article Mr Antony Visocchi, dental surgeon, discusses chronic periodontitis, a common disease and the cause of many claims involving dentists. He explores the condition and the circumstances that can lead to cases of clinical negligence arising.
What is periodontitis?
Periodontal disease is a chronic and life-long inflammatory condition, which affects the majority of the adult population to a varying degree. The condition affects the oral cavity and consists of chronic inflammation (swelling) of the periodontal tissues (gum and bone) caused by the accumulation of dental plaque.
The inflammatory process begins with gingivitis, which is a common and mild form of gum disease. This causes irritation, redness and swelling of the gingiva, the part of the gum around the base of the teeth. It’s important to take gingivitis seriously and treat it promptly. Importantly, gingivitis is a reversible process.
When gingivitis is left untreated, it will worsen over time and impact the integrity of the gums in a serious way. Periodontal disease occurs when plaque from the teeth builds and begins to grow underneath the gum line. Pockets form between the tooth and gum and more plaque gathers in this area due to the area being less accessible with a toothbrush. The plaque, in turn, destroys the bone around the teeth and results in reduced support. Once bone is lost, it does not grow back. This is periodontal disease and is irreversible.
How is Periodontitis Diagnosed?
As part of routine care in general dental practice, a Basic Periodontal Examination (BPE) should form part of clinical examinations and should be completed at least annually. The purpose of these assessments is to provide a simple and rapid screening tool that is used to indicate the level of further examination needed and to provide basic guidance on treatment.
The Basic Periodontal Examination (BPE) was first developed by the British Society of Periodontology in 1986 (BSP). Initially, it was known as the Community Periodontal Index of Treatment Needs (CPITN). Since then there have been four updated versions to the most recent, in 2011. The treatment suggested for the BPE scores are as follows:
0 – No need for periodontal treatment
1 – Oral Hygiene Instruction (OHI)
2 – OHI, removal of plaque retentive factors, including all supra- and subgingival calculus
3 – OHI, Root Surface Debridement (RSD)
4 – OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated
* – OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.
What are the limitations of the BPE scoring system?
It is important to note that the BPE is a very general and crude tool to screen for periodontal status. This is a ‘one-size-fits-all’ tool for quick assessment only.
One of the inherent problems in using the BPE is the poor reproducibility between clinicians as well as by the same clinician on different occasions. Furthermore, the individual clinical judgement of a competent clinician must be incorporated into the overall periodontal care and implementation of the BPE treatment guidance for individual patient needs.
Despite the possibility of irregular and inconsistent scores, the BPE still provides the dentist with a good basis on which to base the assessment and treatment plan. Any repeated scores of 3 and 4 should alert the practitioner to a significant periodontal problem which requires a more focused treatment plan and a maintenance programme.
How is Periodontal Disease Treated?
The key to successful prevention and treatment of periodontal disease is effective oral hygiene. Preventive care, customised to the individual, is also necessary for the patient to maintain healthy gingival tissues, this should include regular professional cleaning and reinforcement of the importance of effective plaque removal. Smoking is a major contributory factor to periodontal disease therefore smoking cessation advice should be provided as necessary
Long-term periodontal assessment and monitoring is the ongoing review of the bone levels which support the tooth. The end result of periodontal disease is that the supporting bone is ‘eaten away’. Once bone loss occurs through periodontal disease, no regrowth will occur. Successful treatment of periodontal disease is indicated by the resolution of the inflammation of the gum tissues to prevent further bone loss.
In addition to clinical examinations, regular radiographic examinations should be undertaken. Best practice includes standard bitewing radiographs every 2 years for a patient with a low risk of caries (decay). As well as assessing the teeth for decay, these radiographs give a very good overview of all the tissues surrounding the back teeth. The tip of the bone surrounding the tooth can usually be seen and the bone level assessed. If this bone is not visible, further radiographs should be taken to investigate the extent of bone loss.
Radiographic investigations will provide an accurate assessment of the levels of bone supporting individual teeth and the amount of periodontal disease that has affected the teeth in the past. This can be a very accurate assessment of previous disease levels, although it does not reflect when the bone loss happened. The assessment of the bone levels can be compared to looking at the rings of trees to calculate their age, in a similar way bone levels are assessed to identify historical damage.
One of the main reasons for periodontal disease being missed or left untreated, is that the condition is relatively painless. Unless pain prompts a patient to seek treatment, it is very much up to the skill of the dental professional to identify, advise, educate and treat periodontal disease. Furthermore, the nature of the disease means there is no end to the treatment or to the patient’s responsibilities at home.
Good periodontal health requires a long-term commitment to prevention and maintenance from both the dental professional and the patient. Associated, exacerbating factors should also be factored into the management programme by the dental professional. These range from poor fillings that have ‘plaque traps’, underlying systemic disease e.g. diabetes, patient dexterity, and some medication e.g. for high blood pressure
How Does Clinical Negligence Arise?
A clinical negligence claim can arise if the treating dentist breaches their duty by failing to examine, investigate, diagnose and treat periodontal disease.
The result of a failure to treat this condition properly can lead to advanced chronic periodontitis, severe bone loss and, ultimately, tooth loss. If teeth are lost due to periodontal disease, the restorative options can be limited or can involve extensive reconstructive treatment (bone grafts) to allow implant placement.
Identifying Clinical Negligence
From a clinical negligence perspective, the bone levels shown on a radiograph can confirm causation and lead to a claim of breach of duty due to undiagnosed and untreated periodontal disease. As periodontal disease is irreversible, the stage at which the diagnosis occurs and when treatment commences is critical to the long-term prognosis of the teeth affected.
Progression of the disease can occur even when it has been identified and treated. Increased bone loss results in more challenging oral hygiene practices for both the patient and the professional. This, in turn, will have a direct effect on the prognosis of the teeth and consequently, needs to be included in any recommendations when damages in tort are assessed.
Case study
Read more about a recent case study involving chronic periodontitis here.
About the Author
Mr Visocchi is a highly skilled dental practitioner who provides expert opinion to the General Dental Council Fitness to Practice Panel in respect of the GDC’s fitness to practice process, as well as being an independent expert for negligence, personal injury and indemnity solicitors. The remainder of his time is split between being a dental practice inspector for NHS Forth Valley, serves on the panel of Expert Advisers for the National Institute of Health & Care Excellence (NICE) Centre for Guidelines and is a clinical lecturer at Aberdeen Institute of Dentistry
Mr Visocchi is available for instruction via Medicolegal Partners. He is able to accept instructions in all aspects of general dental practice including, but not limited to;
- Examination and diagnosis
- Consent
- Emergency care
- Treatment routinely undertaken in general dental practice
- General dental practice regulation & compliance
- Scope of practice
If you have a dental negligence case that you would like to discuss with him, please get in touch. More information about his experience, can be found here.