Richard III was king for a relatively short 26 months before his untimely and violent death at the Battle of Bosworth. However, analysis of his bones and teeth have shown that becoming king brought about a dramatic change in lifestyle, although was it worth it? From an upbringing in an affluent but moderate family life he was suddenly eating and drinking at banquets on a huge scale. His bone structure showed the sudden addition of fresh fish and birds such as swan, crane, heron and egret to his diet. Add to this a sudden upward swing in alcohol consumption that would have taken him over the 21 units we mature adults restrict ourselves to (don’t you?). Most dramatic though are the images of his teeth which are caked with hard calculus and with a degree of bone loss quite advanced for a thirty three year old.
So this means the royal surgeons were not encouraging their leader to clean his teeth at bedtime! Let’s not fall into the same dilemma and instead do our best to stimulate good oral hygiene in our patients. As an Expert Witness I am seeing case after case where periodontal care has been sidelined and made the practitioner vulnerable to complaint.
Good guidance
As we come under all sorts of pressures in the clinical day it is easy to concentrate on the reparative nature of dentistry and the demand from UDA targets. However, the expectation is that there is no difference in the standard of care given under private or NHS contract. The same procedures, time and treatment regimes are applicable. Guidance for what is expected can be found from a number of sources, but the best and most universal is that issued by the The British Society of Periodontology.
I don’t intend this to become a lesson in periodontology, so log onto their website and check the current guidelines and standards for care. Now, see how this sort of treatment is led by the Quality Compliance Systems ‘Treatment Policy and Procedure’.
Safe and effective treatment
We need to assist patients in achieving the level of oral health they are capable of supporting, by providing appropriate, safe, evidence-based treatment that reflects their needs, preferences and diversity. The General Dental Council expect us to support a Person-centred approach to care. The Care Quality Commission expect us to ensure that treatment plans are developed in partnership with patients following discussion of all possible options, including their outcomes, risks, benefits and costs.
We are expected to make an initial periodontal assessment and then record BPE (Basic Periodontal Examination) as prescribed by the guidelines, and ask about lifestyle and medical factors affecting periodontal risk. Where risk is high, further, more detailed examination is recorded and any x-rays taken as required.
The more information a patient receives about their condition and causes, the better choices they make. Informed consent is not valid unless the diagnosis is explained. As periodontal treatment can be difficult and prolonged, sometimes a patient refuses an option. The choice should be respected and recorded after explaining the implications and giving the patient time to consider the choices.
Treatment planning must include provision of information on preventative care following active treatment, to prevent further problems and enable patients to manage their own oral health. In the case of periodontal care this is the most important part, as the responsibility for gum health is passed back to the patient. Oral Hygiene Instruction should be tailored to the individual and not just generic in nature.
Treatment planning should be based on safe, effective, evidence-based treatment. So this is where careful consideration of the guidelines is important. Where BPE scores are `3` or more, RSD (Root Surface Debridement) is called for. This procedure is almost certain to require local anaesthetic and take place over several visits. Where periodontal disease is extensive or advanced then consideration should be given to referral to a specialist when you are not sure if treatment is within your capability.
When treatment is to be carried out by more than one professional, either because of the need to refer outside the practice to a specialist or within the practice to someone like a hygienist, the referral should be made within a reasonable time to avoid any delay. A referral should include all the relevant information and be made by a safe and secure means which protects the patient’s confidentiality. A lead clinician should be named and responsible for coordinating all aspects of treatment.
Keep safe!
Protect yourself and keep safe:
- Check the current guidelines on treatment
- Work through the QCS Treatment Policy and Procedure
- Talk everything through with the patient and be sure that they understand the implications of treatment or not having treatment
- Refer inside the practice if a fellow professional, like a hygienist, can do the treatment
- Refer outside the practice if you feel treatment is outwith your skill-set
- Write everything down
We should not pressurise patients into taking one option or another, however, it is possible to highlight a preferred option. Other options include ‘do nothing’ and are valid as long as the implications are explained in a way that patients will understand. As the success of periodontal treatment is reliant on patient cooperation, this has to be explained especially as ‘do nothing’ will probably lead to tooth loss.
Follow these basic rules and help the patient to help themselves. Richard III never lived long enough to lose his teeth, but it was only a short time away. I`m sure that poor advice from the royal surgeons would not have been tolerated. Our patients deserve the same level of commitment as any king or queen!
