The scene

A DDU member saw a patient in their early twenties for the first time for an examination, having taken over their care from another clinician who had treated the patient at the same practice over the previous year. The DDU member treated the patient over the next two years.

The patient then saw another dentist at the same practice, who diagnosed periodontal disease and advised that treatment was needed to stabilise the condition.

The claim

The DDU member received a claim alleging a failure to diagnose and treat the patient's periodontal disease. Assisting the member in responding to the claim, the DDU obtained a detailed clinical report from the member and instructed an expert in periodontics to comment on breach of duty, causation, condition and prognosis.

The expert was not supportive on breach of duty and causation. They confirmed that based on the available clinical and radiographic information, the patient was suffering from aggressive periodontitis.

The expert noted that at the initial appointment with the DDU member, the patient's oral hygiene was recorded as fair and the periodontal risk as low. The member diagnosed generalised gingivitis, had given oral hygiene instruction, including the use of dental floss and interdental brushes, and provided with a scale and polish.

The member completed a second dental examination around six months after first seeing the patient, recording BPE scores of 2, 1, 2/2, 1, 2. During the period of care, the patient was not diagnosed with any significant periodontal issues.

Expert opinion

The DDU expert concluded that based on the available records, the patient was suffering from aggressive periodontitis, which was not diagnosed. The appropriate treatment would have been referral to a specialist for further management, but this did not take place and the DDU member managed the patient's periodontal condition based upon BPE scores that were recorded in the two years during which they saw the patient.

The periodontal treatment provided to the patient by the DDU member was appropriate, based upon the BPE scores recorded. However, on the balance of probabilities, these scores underestimated the patient's periodontal status, as evidenced by bitewing radiographs taken during the period of treatment - the degree of interproximal bone loss around the patient's posterior teeth would not be commensurate with the BPE score of 2 recorded by the member.

In terms of breaches of duty, the DDU expert identified the following:

• the member failed to show an awareness of the patient's established periodontal condition
• the DDU member under-estimated the patient's periodontal condition when completing the BPEs
• bite-wing radiographs showed clear evidence of vertical bony defects around the patient's posterior teeth, which on the balance of probabilities would not correspond to the recorded BPE score.

The DDU expert concluded that the member should have been aware that such bone loss in a young adult is very unusual and indicative of a diagnosis of aggressive periodontitis.

The expert also stated there were breaches of duty in relation to the management of the patient's periodontal condition; their aggressive periodontitis should have been recognised when they first saw the member, and they should have been referred to a specialist.

Conclusions and outcome

After concluding its investigations and consulting with the member about how to proceed, the DDU started negotiations in order to reach an amicable settlement of the patient's claim.

Based on the expert evidence, the DDU argued that despite the vulnerabilities that were identified in relation to breach of duty, future periodontal maintenance treatment would have been required in any event due to the chronic and progressive nature of periodontal disease.

The DDU's expert had stated that the ongoing periodontal maintenance therapy required by the patient would have been needed regardless. This was based on a diagnosis of localised aggressive periodontitis and the patient's high susceptibility to periodontal breakdown.

The DDU also argued that even if the patient had received adequate treatment from the member, they would still have required ongoing periodontal therapy because of their inherent susceptibility to periodontal disease. The main issues were that early intervention could have stabilised the condition.

The patient also claimed damages for future losses, but the DDU argued successfully that based on the treatment duration and the chronic and progressive nature of the disease, there was no evidence that there would be any future loss of teeth due to the identified breaches of duty.

The claim was eventually settled for over £5,000 in damages. The patient was compensated for the general worsening of their periodontal condition but not for any future losses, as there was no evidence to support a claim for this.

DDU advice

This case highlights the importance of diagnosing more aggressive forms of periodontal disease early with a thorough periodontal exam and referring a patient to a specialist for further management in order to stabilise the periodontal condition.

The statistics show that more aggressive forms of periodontitis affects approximately 1 in every 1,000 patients, who suffer more rapid attachment loss. This type of disease might be localised or generalised.

The disease is often characterised by vertical bone defects on radiographs (although not necessarily in all cases) and there may be little plaque or calculus present.

Successful management of the disease is challenging especially if diagnosed at advanced stages of the disease. An extensive range of treatment modalities is available which can be employed with varying success rates.

Tissue destruction in patients who suffer from aggressive forms of periodontitis is not always directly related to bacterial deposits. If a patient is referred to a specialist for further management of the condition, surgical and non-surgical techniques can be applied in the treatment of the disease.