Dr Andrew Walker assesses the risks associated with attempting to prevent oral disease

Learn to:

• Provide preventive advice effectively and how to record this activity
• Assess the patient’s risk of developing future dental disease 
• Obtain consent even for the application of fluoride 
• Understand alternative preventive strategies 
• Consider a holistic approach

Over the last two decades there has been a shift in the management of patients towards prevention rather than cure. The associated refocusing of effort can be found in all fields of healthcare, including dentistry. The dental profession continues to invest time and resources in helping patients to achieve and maintain good oral health, rather than concentrating that investment in the treatment of oral disease. 

The key elements of this approach include not only patient education, but also helping patients implement any advice given. In this sense, preventive medicine and preventive dentistry not only concentrate on the individual, but also look at communities and populations. Synergy can play a role here, if public health measures are aligned with the commissioning of primary care service providers.

As well as education, there are clinical interventions, such as fluoride application and fissure sealants, which can be implemented as part of an overall preventive approach. The provision of preventive dentistry is not restricted to dentists alone, and the whole dental team can be involved including dental therapists, hygienists, dental nurses and dental health educators – as long as it is in their scope of practice. 

From a dentolegal perspective, many cases involve criticism of a clinician’s failure to give primary preventive advice that would avoid the need for subsequent treatment. The resulting allegation is that the patient has suffered harm that could, and should, have been avoided. Even when there is genuine doubt as to whether or not the patient would have acted upon any advice offered, the alleged breach of a clinician’s duty of care often arises from the assertion that the patient was denied opportunity to benefit from an intervention that could have prevented the disease or damage in question. 

The criticisms that a clinician might face broadly fall into one of three categories: 

• The provision of inappropriate advice and/or treatment.
• The provision of treatment (or the decision not to provide treatment) without adequate consent having been obtained.
• The occurrence of problems which may have been prevented if appropriate action had been taken at an earlier stage.

Screening and Risk Assessment

There is now greater emphasis on the benefits of performing a risk assessment on patients, which will allow more targeted and focused healthcare. RAG (Red, Amber, Green) scoring is one example of a risk assessment that has already been adopted by many healthcare systems.¹ 

All dental patients stand to benefit from a preventive intervention; however, the greatest benefits can be achieved by focusing such measures on those patients who present with a higher risk profile. There are many screening tools which can be employed to identify early problems, potential problems and high-risk patients. The two most commonly used examples of these are the Basic Periodontal Examination (BPE)² and bitewing radiographs. Specific guidance on the use of such tools may vary and you should be aware of the standards where you practise and ensure you are acting in the best interests of your patient and within your scope of practice. 

In Australia, the accepted teaching is that appropriate recall intervals be based not on a set interval, but on the original diagnosis, the extent of the disease, the nature of any treatment carried out, patient response to treatment, and the need for long term review and maintenance. As dental caries and periodontal disease are essentially chronic diseases, this means that any treatment plan must account for and manage aetiological risk factors and treatment risks. Any individual treatment plan must include ongoing and long term reassessment and management. Failure to do so may mean inadequate patient care. 

The importance of adequate dental patient records is an important part of patient management.³

ARPANSA outlines the Code of Practice and Safety Guide for radiation protection in Dentistry. The Australian Dental Association has additional guidelines for dental radiography. 

The American Academy of Periodontology and the American Dental Association have extensive articles relating to guidelines and suggested requirements in managing periodontal disease from diagnosis to long-term maintenance. 

Fluoride

There is overwhelming evidence that fluoride has a significant impact on the prevalence of caries. The use of fluoride can take one of two forms: topical application and systemic supplements. The introduction of fluoridated toothpaste is one example of how mass access to fluoride has improved oral health by reducing the incidence of dental caries. 

Other forms of readily available fluoride can be found in varnishes, mouth-rinses and fluoridated additives, such as fluoridated salt. As already mentioned, specific guidance may vary from country to country and each practitioner should check their own local recommendations. This is important, as the information may vary depending on factors such as whether the water supply is fluoridated. 

Regardless of location, the consent process for the patient is a key issue when using fluoride, especially in topical agents. As with many areas of healthcare, there is some controversy surrounding the issue. A small number of research articles, and a commensurately small number of clinicians, have linked fluoride to serious side effects, including cancer, in some instances. Such negative connotations have been reported in the media and, understandably, caused some concern for the general public. 

Whilst the overwhelming body of evidence suggests fluoride is beneficial and safe, when used in the recommended dose, some patients or parents may not wish to have such treatment. Of course, it is their right not to do so and it is critical, if you are undertaking such treatment, that the patient or their parent fully understands what you are proposing, what materials you are using, the intended benefits and any associated risks. 

Dental Protection is not the arbiter of clinical opinion; so when deciding on treatment approaches, each clinician must carefully weigh up the evidence and guidance for themselves and act accordingly. They must also be willing to justify all of these decisions in the event they are challenged at a later date. 

Diet and oral hygiene instruction

These are two pivotal, patient-centred issues that are basic to promoting better oral health. Any assessment and advice needs constant re-enforcement, as they can both involve lifestyle changes that are often difficult for patients to implement. 

It is simply not enough to provide patients with information. Clinicians also need to consider how they can help their patients use that information. This might involve looking specifically at the diet and helping the patient identify practical ways in which they can make positive changes. This aspect of care does not need to be performed by the dentist and is an opportunity for the whole dental team to be involved. Hygienists, therapists and oral health educators can all have a role in delivering the educational component of patient care. 

Additional resources

It is well-known that patients can only absorb a small amount of the total information presented to them at any one time in the clinical setting. This is one reason why it is so important to provide continual, positive re-enforcement of the information. One way to enhance the message you want to give is by providing written factsheets. There are many downloadable information sheets, which are published by recognised authorities, and those published by the ADA provide an excellent source of patient education.

Simple conservation

Clinicians will be familiar with the dilemma of having to decide whether or not an early carious lesion can be re-mineralised and reversed, whether it can be kept under observation and reviewed, or whether immediate active intervention is required. With the benefit of hindsight, one can be criticised for any wrong decision. However, it is equally possible to defend a decision which turns out to have been misguided, if it was based on justifiable reasons at the time. This is dependent on an appropriate history, examination and investigations to support the decision are properly recorded in the patient’s clinical notes. 
A particular dilemma exists when treating early pit and fissure lesions, because in addition to the ‘to treat or not to treat’ decision that exists with interproximal or smooth surface lesions, there is the added problem that it is not always easy to detect developing lesions radiographically. 

Transillumination is a useful diagnostic adjunct both for occlusal and interproximal lesions, but here again it is important to record the use of this investigation, and any conclusions reached, in the clinical notes. 

When fissure sealants are recommended as primary preventive procedures (or when sealant restorations are advised in circumstances where any part of an enamel pit or a fissure system is thought to be actively carious), it is important not to give the impression to the patient (or possibly, their parents) that this provides any kind of guarantee of long-term protection against subsequent caries. 

Allegations have been known to be made that fissure sealants were recommended and provided on the assurance by the clinician that the teeth would thereby be protected forever from becoming carious. Any such assurances or guarantees are misplaced, and should be avoided. 

Checking the marginal integrity of fissure sealants, once placed, noting and acting upon any reported sensitivity from the teeth involved and their periodic monitoring by means of radiographs where appropriate, is an important aspect of preventive dentistry. Fissure sealants can, and do, ‘leak’ and they can then obscure the development and progression of caries in the depths of the fissures that they are designed to protect, sometimes leading to extensive caries occurring before the problem is detected. 

Complex conservation

The provision of restorative treatment for patients where caries are not controlled creates the ever-present risk of further caries at the margins of the restorations, or elsewhere in the same tooth. The provision of complex or expensive treatment, when the primary disease has not been controlled, could leave the clinician open to challenge regarding the appropriateness of the treatment plan. This may be a particular issue if there is premature failure of any treatment provided. To mitigate any criticism of the clinician, a careful discussion of all the treatment options is required and should be recorded before treatment starts, together with the reason for the patient’s preferred option if this does not coincide with the recommendations of the clinician. Treatment should not be undertaken unless it is considered to be in the patient’s best interests. 

Some patients are at a higher than average risk of caries or tooth erosion because of impaired salivary function due to systemic disease or medication. In a similar fashion, a patient’s susceptibility to both caries and periodontal disease can be affected by the introduction of fixed or removable prostheses, or orthodontic appliances. Acknowledging these factors, and acting appropriately, is another example of risk assessment and good patient management. 

The provision of treatment without any necessary preventive advice, designed to maximise prospects for success and longevity, can lead to early failure. If this results in the patient being worse off than if the situation had no treatment been provided at all, which is often the case, complaints or claims may ensue. 

Smoking cessation and alcohol use

Scientific research has clearly established smoking as a major risk factor for both periodontal disease and oral cancer; this has changed the standards expected of dental professionals. It is no longer acceptable for clinicians to ignore tobacco use and a failure to inform the patient of the risks it has on their oral health, or failing to advise smoking cessation, could be viewed as a breach of duty. 

All patients should be asked specifically about the nature and extent of any tobacco use habit, including chewing tobacco or other carcinogenic chewing materials such as paan, and they should be made unambiguously aware of the adverse effect that this can have upon their oral and general health. These enquiries, and any necessary follow-up advice, should be repeated at appropriate intervals. It would also be prudent to offer referral to a local professional smoking cessation service. 

Most medical history forms used by dental practitioners also enquire about alcohol use. If it transpires that a clinician had information about the patient’s habits that could impact on their health at a later date, but had not acted upon this information, they may be open to criticism. Although it may be a subject that dental practitioners feel uncomfortable discussing with patients, high alcohol consumption is known to increase the risk of oral cancer. The patient should be made aware of this fact along with the synergistic effect of smoking and alcohol. There is plenty of educational material online that can be used to raise patient awareness. In addition, there are public health campaigns which provide an opportunity to start a conversation with a patient that might otherwise be difficult to initiate.

Holistic care

The following concepts encapsulate the idea of considering all aspects for patient care and there may be other areas of concern where the dental team may be able to implement a preventive strategy. Such areas include, but are not limited to: 

• Dry mouth – there may be many reasons why patients have a lack of saliva and this can predispose them to a high caries rate. If this is recognised early, appropriate management can help reduce the impact of the condition.
• Acid erosion – this is a growing problem, especially in younger adults and teenagers. The restoration of severely affected teeth can also present a difficult challenge for the dentist. Again, early detection and prevention can prevent a lifetime of difficult problems for both the patient and dentist.
• Oral sex and the risk of HPV – although a sensitive subject, it still falls within the remit of dental care. It may not always be appropriate to directly ask or discuss this with patients and so it can be useful to use other forms of communication. Factsheets and posters subtly displayed in the practice can inform patients without causing embarrassment and offer them the opportunity to ask further questions if they so desire.

Record Keeping

As with all complaints and claims, your clinical records are your best line of defence. Therefore, it is critical that they accurately reflect advice, warnings and treatment given. 
Detailed records should be kept of all occasions when preventive advice is given to patients, or parents. It should be clear from any such entries: 

• who gave the advice
• what form the advice took (for example, whether verbal or supplemented by advice sheets or visual aids of any kind)
• how the patient responded to the advice.

It is particularly important to note instances where a patient appears apathetic or disinterested in the preventive advice being offered to them, or when the patient indicates that they are unlikely to follow such advice. Here, any entries should be sufficient to demonstrate that the patient was appropriately warned of the likely consequences of not acting upon the advice given. 

It is sometimes conceded on a patient’s behalf, especially when confronted with good contemporaneous records, that certain advice was indeed given, but then argued that it had been given in such a way as to attach no great importance to the advice. 

When the advice given to a patient is likely to have a direct bearing upon their 
future oral health (or general health), it is advisable to ensure that the record entry properly reflects any emphasis given to the advice and also that the subject was re-explored with the patient at subsequent visits. If a preventive message is important enough to give to a patient, it follows that it is important enough to reinforce at regular intervals. 

A patient who may not be receptive to the advice on one occasion may well be more receptive to the same advice when it is subsequently repeated, often for reasons of which the clinician may never be aware. 

In the case of oral hygiene instruction, it is helpful if records provide sufficient detail of any specific preventive techniques that the patient is advised to use. If these techniques are demonstrated to the patient (for example,  on a model, or in the patient’s own mouth) and/or if the patient is encouraged to practise the technique(s) under the supervision and guidance of a dentist, hygienist or therapist, then this similarly needs to be described clearly in the clinical notes. Vague entries such as ‘OHI’ are better than nothing at all, but are still of relatively limited value in confirming precisely what advice was given. 

Similarly, a note should be made of any educational material, videos, leaflets or advice sheets that are given to patients (or parents) to supplement any preventive advice given verbally. Additional resources, such as clinical photographs and study models can help demonstrate not only the clinical situation, for example at first presentation, but can demonstrate appropriate monitoring and education.

Summary

Any member of the dental team who is involved in the provision of dental care, advice and treatment to patients, whether to specific patients or more generally, needs to be aware of current thinking in the field of preventive dentistry and to take steps to keep their knowledge and skills up-to-date. Preventive dentistry needs to be seen as an integral part of the care provided for all patients, rather than being reserved for specific patients in specific situations. This is reflected in The Dental Board’s Code of Conduct, which states that healthcare professionals should encourage “patients or clients to take interest in, and responsibility for, the management of their health and supporting them in this”. 

Communication and documentation are key aspects to successful practice. For the right messages to be given and received, communication is essential, not only between the clinician and the patients, but also between all the members of the dental team. Advice is more likely to be acted upon if communicated effectively; consideration should be given to how, when, where and by whom this advice is given, and also to the need for training and personal development of the dental team in the areas of behavioural psychology and communication skills. 

When the team has worked hard on promoting oral health and providing high quality preventive dentistry, this should be reflected in the clinical records with excellent documentation. The critical aspect of record keeping is that a third party needs to be able to read and understand the records and subsequently know exactly what has happened, and when. 

When there is nothing abnormal to be seen with the oral tissues and a fee is charged for achieving this highly desirable condition, a clear record of how this was achieved is the only way of proving that the outcome was due to professional nurture (a chargeable activity) and not a gift from nature (no charge).

Resources

1. Asimakopoulou K, Rhodes G et al. Risk communication in the dental practice. British Dental Journal Vol 220 No. 2 Jan 2016. Department of Health. Dental Contract Reform: prototypes. Overview document 2015

2. Council of the British Society of Periodontology. Basic Periodontal Examination (BPE). British Society of Periodontology 2016

3. Guidelines are available at Dental Board of Australia