The British Society of Periodontology states that periodontal disease is the sixth most prevalent disease in the world, affecting over half the population of the UK. Dental professionals are imperative in the diagnosis, monitoring and treatment of the disease, but it is the patient who ultimately has the biggest impact on its cause and progression, as a result of their oral hygiene and habits.

One of the most important roles the treating clinician has is therefore making sure a patient is aware of the disease and its consequences, and what steps they need to take in their home dental care to prevent or manage it.

Despite being such a common condition with clear processes for diagnosis and management, claims involving periodontal disease are some of the most complex to investigate, and most expensive to settle.

DDU claims data

Over the period 2009-2023, an average of 58% of claims about periodontal disease that were notified to the DDU needed to be settled. In 2023 that figure was 64%. Every year from 2009-2023, a higher proportion of periodontal claims required settlement than any other type of dental claim we dealt with.

As well as this, every year, the average settlement value of a periodontal disease claim is higher than that of any other type of settled dental claim. In 2023, £2.2 million was paid out in settled claims involving periodontal disease, in both damages and the claimant’s legal costs and disbursements.

In the last few years, the DDU has begun to see a reduction in the number of periodontal disease claims notified, but it is too early to know if it represents a trend. In 2023, periodontal claims made up 5% of total dental claims notified, which is the lowest in the 13 years of data analysed. However, we did settle more periodontal disease claims in 2023 than in each of the preceding five years.

The good news is that if DDU members face a claim, our claims handlers and dento-legal advisers can offer expert support. Because we're staffed by dentists with real-life experience of exactly these sorts of issues, we understand how stressful the process is and the importance of mounting a maintainable defence of your position.

Reasons for claims

Cases involving periodontal disease often arise when a patient has been seen by the same dental professional for a long time - and when that clinician retires or the patient moves to a new practice, they are seen by someone new who assesses the dentition with fresh eyes.

However, we also see many periodontal cases pleaded against a number of different clinicians who the patient has seen for shorter periods of care over decades, often at the same practice. It is most common for these claims to be pleaded against general dental practitioners, but claims are also brought against hygienists, therapists and specialists.

Invariably, the majority of periodontal disease claims centre on the same key allegations of failure to diagnose, monitor, treat and manage the disease in an appropriate and timely manner.

Here are some of the most common recurring features.

• Failure to take BPE scores and diagnostic quality radiographs at appropriate intervals, and act upon the findings.
• Failure to perform pocket charting when necessary.
• Failure to inform the patient of their periodontal condition, explain what it is, the adverse impact on the dentition and consequences if it progresses.
• Failure to record associated factors such as tooth mobility scores, gingival recession, gingival attachment levels, furcation involvement, presence and levels of calculus, bone levels and periapical issues.
• Failure to give advice on oral hygiene, smoking cessation, diet and personal habits
• Failure to advise on and to initiate appropriate and targeted treatment and management in a timely manner.
• Failure to refer to a hygienist and/or a specialist promptly when required, in line with the relevant guidance.

The importance of the patient

It is imperative that a patient understands the importance of their role in preventing the disease from progressing and worsening, and what will happen if it does.

In nearly every claim, the patient alleged they were not aware of the presence or extent of their periodontal disease or what its consequences could be, namely bone loss and tooth loss. It is difficult to defend such allegations if the clinical records do not clearly evidence that a diagnosis was made and the discussions that took place, with appropriate advice given and repeated as often as necessary.

Other types of claims the DDU handles involving periodontal disease arise when treatment has been undertaken in the presence of underlying periodontal disease - for example, providing fixed or removable long- or short-term orthodontics, implants and implant-retained superstructures, or bridgework or dentures when periodontally compromised teeth are involved.

Even veneers and crowns can be compromised by underlying periodontal disease. In these cases, it will be alleged that failure to undertake appropriate pre-treatment assessment and treatment planning, and to discuss the risks with the patient, have led to adverse outcomes.

These can include failure of the treatment or restorations provided, the need for remedial treatment, unwanted tooth movement, and worsening of the periodontal condition with bone loss and tooth loss.

Patients will usually claim for the costs of implants and implant retained bridges and crowns to replace lost teeth. These can be very expensive, particularly if bone grafting is indicated and, dependent on the patient's age, if repeat cycles of the crowns and bridges are required.

However, often a patient is not a suitable candidate for implants if they continue to have active and uncontrolled periodontal disease and poor oral hygiene, as this places them at risk of treatment failure and peri-implantitis.

Minimising risks

To help dental professionals reduce the risk of periodontal claims, the DDU recommends the following points of advice.

• Follow available national guidance to make sure your treatment is evidence-based - for example, the British Society of Periodontology's guidance on the Basic Periodontal Examination (BPE), 6 point pocket charting, radiographs and recall periods.
• Record all your examination findings in the patient's clinical notes, including their BPE scores, radiograph reports, tooth mobility scores, gingival recession, gingival attachment levels, furcation involvement, presence and levels of calculus as well as bone levels.
• Record your diagnosis and recommended treatment.
• Explain to the patient what periodontal disease is, if they are at risk and how they can protect themselves. Emphasise the need for good oral hygiene and more frequent visits to the hygienist, and the importance of stopping smoking. Make a detailed note of the conversation and any information leaflets or other resources provided.

• Record if a patient declines recommended treatment (including radiographs, hygienist appointments and specialist referral), cancels or fails to attend appointments at the advised intervals, or fails to comply with smoking cessation, diet and oral hygiene advice.
• If you decide that the patient's gum disease only requires monitoring and advice, explain this to them and record your discussion and their consent to your treatment plan in the records. Continue to record the periodontal condition, such as pocketing and loss of attachment at each visit and reassess the treatment plan.
• When obtaining consent for periodontal treatment, take time to explain the risks, benefits and alternatives. Make a careful note of what you discussed and the patient's agreement.
• Check the patient's medical history questionnaires and seek further information if needed - for example, about conditions and medications that can impact periodontal disease. Liaise with their medical practitioners if required.
• Review the hygienist's records if possible and liaise with them as necessary if a patient's condition is not stabilising or improving.
• Recognise the limits of your own clinical skills. Be prepared to offer referral to a specialist if the patient's condition does not improve despite treatment.