Dental surgeon Dr. Ravinder Varaich has prepared more than 1,000 medical reports in personal injury and clinical negligence cases as a dental expert witness over a career spanning more than 20 years.
In this article, she explores the significance of expert reports in dental injury cases, providing detailed insights into the required documentation and strategies for conducting a thorough assessment.
Furthermore, she examines breaches of duty in periodontal disease management, focusing on pre-treatment assessments, treatment protocols and patient responsibilities.
Dental personal injury claims
In personal injury claims involving dental injuries, the quality of the expert report can significantly influence the outcome of the case. Personal injury claims typically require a report from a dental expert witness when injury to a tooth or the temporomandibular joint (jaw joint) is caused by an accident for which the claimant is not at fault. These dental injuries often coincide with other injuries, with symptoms ranging from jaw pain to tooth fracture or loss.
How to obtain the best report from a dental expert – advice for instructing solicitors
Providing relevant documents – providing the expert with all relevant documents before the claimant’s appointment enables the expert to be better prepared and ask more direct questions during the consultation. This also allows any discrepancies to be addressed during the claimant’s interview.
For example, if there was a delay of six months before seeking a dental appointment despite severe toothache, the reasons for the delay can be discussed.
Detailed letter of instruction – a detailed letter of instruction should give brief details of the accident and injuries sustained, including specifics of the dental injuries. Any missing records should be noted, so the expert can determine whether they are essential prior to the appointment.
Relevant medical reports – medical reports can provide additional details on the injuries and symptoms, ensuring a comprehensive understanding of the claimant’s condition.
Pre-accident dental records – these records enable the expert to comment on the pre-accident state of the teeth. It is important to request x-rays and photographs with proper labelling and dating.
Hospital and GP records – these should be included if the dental injuries were reported during hospital or GP visits. However, irrelevant records can add bulk and incur additional reading time and fees.
Post-accident dental records – including emergency care records, treatment estimates, x-rays and photographs can provide crucial information about the claimant’s dental condition following the accident.
Case example
A 27-year-old male was cycling to work at around 7am when a car turned into a side road, cutting in front of him. He attempted to stop but was thrown over the handlebars, landing face-first on the car bonnet.
His upper right incisor came out at the scene of the accident and a pedestrian passing by noticed the tooth on the ground. The pedestrian picked it up, placed it in his water bottle and handed it to the paramedics at the site.
Additionally, he had fractured biting edges on the neighbouring teeth, specifically the two left incisors. Approximately two months later, the claimant reported that these two fractured left incisor teeth had turned grey.
At the hospital, an oral surgeon reimplanted the knocked-out tooth and splinted the adjacent teeth. Despite treatment, the reimplanted tooth shifted position overnight. He required sutures on his lower lip due to teeth digging into it, resulting in scarring and tingling sensations.
The claimant experienced dental pain for months, managed initially by a GP who also removed lip sutures. His regular dentist couldn’t see him promptly, so he visited an emergency dentist who removed the splint and referred him to a private dentist. His teeth’s appearance significantly affected his social life and work performance, particularly in a client-facing role, causing financial strain.
The impact on his life was profound, causing him to miss social events and affecting his confidence at work. He awaits the outcome of his claim before proceeding with further dental treatment.
The detailed account provided forms the basis for the expert’s assessment and investigation, supported by a photographic diary and additional guidance provided to the claimant.
So what records are required?
For a comprehensive expert report, the following records should be requested:
- Ambulance records
- Hospital records, particularly the oral surgeon’s records and dental x-rays
- GP records
- Pre-accident dental records
- Emergency dental clinic records
- Records from the new private practice close to home
- Records from the specialist practice where further treatment was sought
- Records from the implant dentist consulted for future treatment
- The claimant’s photographic diary
What would the expert report comprise?
- Summary of the case – a concise overview of the incident and injuries sustained.
- Summary of the conclusions – the expert’s findings and opinions based on the investigation.
- Statement of instructions – including specific questions from the instructing party.
- Investigation of the facts – reviewing medical and dental records, particularly the pre-accident condition of the teeth.
- Claimant interview – details from the photographic diary and the impact on the claimant’s life.
- Claimant dental examination – examination and special tests of the relevant teeth.
- Expert’s opinion – assessment of the pre-accident condition, current state and prognosis.
- Advice on additional expert reports – recommendations for further specialist evaluations if necessary.
How to record the effects of the accident
Providing claimants with clear instructions on recording the effects of the accident can significantly enhance the quality of the expert report. An advice sheet should include:
- Photographic documentation of injuries and their progression.
- A diary of pain relief taken and other symptoms.
- Records of time off work and adjustments required upon return.
- Notes on changes in work performance and income.
- Daily records of the impact on daily duties and social life.
- Documentation of missed events and financial losses.
Clinical negligence – Periodontal disease cases
Aetiology of periodontal disease
Periodontitis is a chronic inflammatory disease of bacterial origin that affects the supporting tissues around the teeth. The disease is initiated by plaque accumulation, and the host’s immune response to the bacterial challenge leads to periodontal tissue destruction. Various factors such as smoking, diabetes and genetic predisposition influence the disease’s severity.
The 2009 UK Adult Dental Health Survey indicates that 37% of the adult population suffers from moderate periodontal disease, while 8% suffer from severe periodontitis.
Breaches of duty
Dentists are expected to screen, diagnose and manage periodontal disease. Failures in these areas constitute a breach of duty. Any negligence case is generally split into pre-treatment assessment and consent, treatment and aftercare
Pre-treatment assessment and consent
Using a periodontal screening tool like the BPE score is the minimum standard. Failing to perform this basic screening is a breach of duty. An appropriate diagnosis must be established, including discussions of findings with the patient to ensure valid consent.
Accurate records, including BPE scores, pocket measurements and radiographs, are essential. Failing to perform these tasks accurately constitutes a breach.
Treatment
Treatment must follow established guidelines. Inaccurate BPE scores and failure to perform indicated treatments like root surface debridement are breaches of duty.
Aftercare
Follow-up intervals should be appropriate based on the patient’s condition. Failure to provide proper aftercare, such as post-treatment pocket measurements, constitutes a breach of duty.
Patient factors
Patients also have responsibilities, such as adhering to oral hygiene advice, attending recall appointments and managing their general health. Non-compliance can impact the progression of periodontal disease and the success of treatment.
Sample periodontal disease case
Mrs A, a 42-year-old woman, has been with the same dental practice for 20 years. She recently experienced bad breath, bleeding gums and teeth drifting. A long-time smoker (20 cigarettes a day since age 15) with poorly controlled diabetes, she was previously diagnosed with gingivitis and advised to improve her brushing and flossing.
Shocked by a new dentist’s diagnosis of severe bone loss, she was distressed to learn she might lose her teeth within five years, fearing the impact on her singing and saxophone playing. Determined to avoid dentures, she quit smoking, enhanced her oral hygiene and now visits the hygienist every three months, showing significant improvement in her condition. However, some teeth are beyond saving, and she is considering a negligence case against her previous dentist.
Brief breaches of duty
Pre-treatment assessment and consent
There were significant deficiencies in the pre-treatment assessment and consent process. According to BSP guidelines, there was inadequate screening for periodontal disease, as evidenced by inaccurate BPE scores, inconsistent pocket measurements and a lack of necessary radiographs to fully assess bone levels. Additionally, bleeding on probing was not recorded after 2018, contrary to guidelines. The records failed to accurately reflect bone loss observed in radiographs and these findings were not communicated to the patient, violating General Dental Council and FGDP guidelines.
Despite evident bone loss, the diagnosis of gingivitis persisted, overlooking the presence of periodontal disease from 2018 onward, contrary to BSP guidelines. The management of the patient’s risk factors for periodontal disease was insufficient, with oral hygiene instructions lacking tailored advice on techniques such as toothbrushing, flossing and using interdental brushes.
The assessment also neglected genetic factors, like the patient’s family history of early tooth loss, and omitted discussions on smoking cessation and the role of smoking and diabetes in periodontal disease development. Furthermore, despite the patient’s age and the extent of bone loss, there was a failure to consider referral to a specialist for further evaluation and treatment.
While records indicate that risks and benefits were discussed and consent obtained, the repetitive nature of entries suggests templated documentation, casting doubt on whether these crucial conversations actually took place. Considering the above failures and as the patient was not appropriately screened and diagnosed, the consent is not valid.
Treatment
Considering the breaches of duty regarding the accuracy of the BPE scores, the scale and polishing treatment did not adhere to BSP guidelines. Specifically, there were failures to record periodontal pocket measurements and to perform root surface debridement.
Aftercare
Considering the bone loss, risk factors and presence of periodontal disease, a recall interval of six months is not appropriate. Additionally, there was a failure to perform post-treatment pocket measurements.
Learning points
Navigating the complexities of dental negligence cases demands meticulous attention to detail from both practitioners and legal professionals alike. By adhering to best practices in documentation, diagnosis and treatment, dental experts can strengthen their defence against claims while ensuring the highest standards of patient care.
Proactive measures in periodontal disease management not only safeguard practitioners but also promote trust and accountability within the dental profession.