Missed opportunity to diagnose stage three periodontitis
15. Ms L had an appointment on 2 February 2022 where the Practice took some BPE scores (a screening tool to assess a patient’s periodontal status) and recorded her as being at low risk of periodontitis but having early onset gingivitis. It referred her to a specialist for restoration on her teeth.
16. Ms L says when she saw the specialist (Dr M) in June 2022, they diagnosed her as having stage three periodontitis. She does not understand how the Practice missed this despite her attending all her appointments. She feels its failure to diagnose her gum disease at an earlier stage led to a steep decline in her oral health.
17. We asked adviser A whether it was possible Ms L may have developed stage three periodontitis between 4 February and 29 June 2022. They explained it was possible because there are many factors (alcohol, diet, poor plaque control, and so on) that may accelerate the disease. So, it is not possible to say how quickly the disease may develop. They also confirmed there are no studies to suggest how quickly gum disease may progress because there are so many variable factors that affect this.
18. When we looked at Ms L’s dental notes, we could see the Practice regularly did check-ups and BPE screening every year (typically multiple times a year) since 2015. Adviser B said this is in line with standard protocol as dentists should do this screening during routine examinations. The only exceptions we could see were in 2020 and 2021 due to COVID-19 restrictions. The Practice initially recorded her as being high risk of periodontitis in October 2015, but this score steadily declined over the years. The records show the Practice also gave Ms L dietary and oral hygiene advice over the years, as recommended by NHS England on how to take care of your teeth and gums.
19. But there was something missing from the Practice’s monitoring of Ms L’s oral health. Adviser B says a patient should have X-rays every six months to two years. This is view is supported by guidance from NHS Inform. Broadly, the more problems the person has, more often they need X-rays. The Practice regularly took X-rays until 2017 when it stopped and did none again until after Ms L had seen the second specialist. In line with the national guidance, she should have had further X-rays at least in 2019 and 2022.
20. We do not know what further X-rays would have shown. They may have shown bone loss, but they may not have.
21. The evidence shows the Practice partly screened and monitored Ms L’s gum health and risk of periodontitis as it should have. There was a gap in this during the COVID-19 pandemic, which was sadly unavoidable. But the Practice should have done X-rays, at least in 2019 and 2022. It did not, so we have found a failing here.
22. At this point, we need to share some further detail our investigation has shown. Stage three periodontitis is advanced gum disease leading to severe damage to the gums and supporting bone. Adviser B explained how clinicians should reach this diagnosis. They explained BPE scoring alone is subjective and may vary depending on the clinician as it includes pressure point checks.
23. The BSP guidance says clinicians should make a diagnosis of stage three periodontitis by comparing X-rays to assess the level of bone loss. Adviser B said Dr M’s records show they did not do X-rays and did a non-radiographic assessment. The adviser said this means the diagnosis is speculative.
24. We know the Practice did two sets of X-rays, in 2017 and 2023. Unfortunately, it has not been able to provide copies of the 2017 X-rays to do a comparison. We spoke to Ms L about this and asked if she has any further evidence from more recent specialist dental treatment confirms this diagnosis, but she does not. The Trust’s actions are not in the scope of our detailed investigation, so we cannot comment on how it reached its diagnosis. But it is important to set out we cannot say the diagnosis is confirmed.
25. Based on the available evidence, we cannot say the failure to do X-rays meant the Practice missed an early diagnosis of periodontitis. As we set out above, we cannot know what they would have shown. So, we cannot say they would have changed anything the Practice did. We also cannot be certain the diagnosis of stage three periodontitis is right. But we understand why having a diagnosis of significant gum disease so soon after her last appointment at the Practice caused Ms L to question what it did. The lack of X-rays means she will never know if it could have done more for her before she saw the specialists.
26. We have found failings here as the Practice has not yet acknowledged the failure to include regular X-rays in its monitoring of Ms L’s oral health.
Monitoring and specialist recommendations
27. Regardless of the diagnosis, the specialists gave the Practice clear instructions on the care Ms L needed, which the Practice accepted. So, we have looked at what it did for her.
28. In June 2022 Dr M gave extensive recommendations, such as plaque and bleeding scores and oral hygiene advice, root surface debridement (RSD, which is removal of plaque from below the gumline) with local anaesthetic and regular monitoring. In October 2023, Dr S reviewed Ms L. They noted her gum health had much improved but there was still excess plaque present. Dr S recommended X-rays, more plaque and bleeding scores, continued hygiene appointments for plaque control, a soft guard and a dietary assessment with advice.
29. Ms L complains other than one RSD the Practice did not follow the specialists’ recommendations. The Practice left her feeling it was not proactive in her care. This has left her concerned over her dental health as gum disease is not curable, but it is manageable with the right treatment.
30. In response to Ms L’s complaint, the Practice said she had a scale and polish on 5 August 2022. The dentist discussed Dr M’s recommendations with Ms L and agreed on a treatment plan. This included three monthly hygiene appointments.
31. The Practice explained it did not think Ms L was managing her plaque well at home so it would not do more RSD until she was able to reduce her plaque build-up, as clinical input alone would not stabilise her condition.
32. From Ms L’s dental records, we can see the Practice did an X-ray, hygienist appointments, gave dietary and gum disease prevention advice and did one RSD in line with the specialists’ recommendations. The Practice also offered Ms L a soft guard, but she did not respond to this in an appointment or when it offered this again as part of the complaints process.
33. BSP guidance on effective management of periodontitis says after effective active periodontal therapy patients should follow a specific supportive periodontal therapy such as RSD two to four times a year. The Practice should tailor the frequency of these sessions to a patient’s risk. When we look at the records, we could see in some appointments there was a note to showing excess plaque was present.
34. We asked adviser B whether it was right for the Practice to not offer further RSD. They said if a clinician feels a patient’s oral hygiene is not being maintained well at home they can make this decision in line with normal operating practice. They confirmed successful treatment in periodontitis patients is primarily down to how well they maintain their dental hygiene at home as this accounts for around 80% of the necessary treatment plan. While guidance suggests when a patient has periodontitis, they will have that diagnosis for life, clinicians still need to do BPE scoring to monitor its progression. If a person has periodontitis, they may still have low BPE scores which means the disease is not active and does not require active treatment.
35. This view supports that despite receiving this diagnosis, Ms L may not need active treatment if she manages the condition well at home. The onus on oral care lies primarily with Ms L and the Practice is not obliged to repeat this treatment if it felt she was not maintaining her oral hygiene.
36. So, we have looked at how the Practice supported Ms L with her oral hygiene and monitored her, in line with Dr M and Dr S’s recommendations and BSP guidance. This was particularly important if Ms L’s poor plaque control is the reason it had not fulfilled some of the specialists’ recommendations.
37. On 5 August 2022 the Practice did a scale and polish and agreed a treatment plan that Ms L should have a hygienist appointment every three months. From the records she had further scale and polish on 2 December 2022, then 17 April and 26 September 2023.
38. We could see there were delays between the agreed hygiene appointments, including five months between her appointments on 17 April and 26 September 2023. The records show Ms L attended hygienist appointments but there were limited records (no plaque or bleeding scores) to show how well the Practice was checking the effectiveness of the treatments.
39. We asked adviser A whether the Practice had sufficiently monitored Ms L despite not taking plaque or bleeding scores. They said disease progression cannot be monitored accurately without contemporaneous clinical records. They explained failure to follow these recommendations would not make gum disease worse, but adequate monitoring would increase the chances of stabilising Ms L’s condition.
40. When we weigh up the evidence the records and the accounts from Ms L and the Practice, we have found it did most of the recommendations and got some things right, but it also got some things wrong. Mainly it did not fully comply with its treatment plan and missed monitoring recommendations that would have helped in managing and responding to the progression of Ms L’s gum disease.
41. We cannot say there was a clinical impact of this because the periodontitis diagnosis is not clear. But Ms L says the Practice left her feeling it was not proactive in her care and her gum disease has not been adequately managed. We think the Practice’s failings contributed to this emotional impact.
42. The Practice has acknowledged to us it did not do the plaque and bleeding scores. But it only briefly acknowledged this to Ms L as part of the complaints process. It did not offer an explanation as to why this did not happen. It did not acknowledge a failure to meet the agreed oral hygiene element of the treatment plan.