Paediatric Dental Claims: Radiographic and Record-Keeping Pitfalls in Caries Management and Safeguarding

In paediatric dental claims, the evidential landscape is frequently shaped by two critical domains: radiographic justification and contemporaneous records. Solicitors instructing dental expert witnesses in clinical negligence, CICA, or regulatory proceedings must scrutinise these areas with particular care, as deficiencies here often determine whether breach of duty and causation can be established. This article examines the principal pitfalls in caries management, radiographic practice, and safeguarding documentation, and outlines the role of the specialist dental expert witness in addressing them.

Clinical Context: Caries Management in Children

Caries in primary and mixed dentition presents distinct diagnostic and management challenges. Current NICE guidance on dental recall intervals and caries prevention emphasises early detection, risk assessment, and minimally invasive interventions. The Faculty of General Dental Practice and College of General Dentistry provide further frameworks for behaviour management, radiographic selection criteria, and the use of fluoride varnish.

In medico-legal practice, expert witnesses frequently encounter cases where the following clinical decisions are scrutinised:

• Whether bitewing radiographs were justified and timely, given the child’s caries risk;
• The adequacy of caries diagnosis, particularly in approximal surfaces where visual inspection alone is unreliable;
• The choice between preventive, restorative, or extraction pathways, and whether alternatives were considered;
• The decision to proceed under general anaesthesia, including the documentation of risks and alternatives;
• Safeguarding concerns arising from repeated failed appointments or untreated disease.

Each of these decisions must be supported by records that demonstrate compliance with applicable professional standards.

Radiographic Justification in Children: Legal and Clinical Considerations

The Ionising Radiation (Medical Exposure) Regulations 2017 impose a legal duty to justify every radiographic exposure. In paediatric cases, this duty is heightened by the increased radiosensitivity of developing tissues and the need to minimise cumulative lifetime dose. GDC Standards for the Dental Team state that radiographs must be clinically justified, and the justification documented in the patient’s records.

Common radiographic pitfalls in paediatric dental claims include:

• Failure to justify bitewing radiographs: The absence of a documented caries risk assessment, or a record of why radiographs were deemed necessary, may lead to a finding of breach. Expert witnesses must assess whether the clinical indications (e.g., visible plaque, previous caries experience, high sugar diet) were sufficient to justify the exposure.
• Over-reliance on visual inspection: Approximal caries in primary molars is frequently undetectable without bitewing radiographs. Failure to take radiographs where clinically indicated may constitute a breach of duty, particularly if subsequent disease progression leads to pulp involvement or extraction.
• Inadequate radiographic technique: Poorly positioned radiographs, or those with overlapping contacts, may fail to reveal early carious lesions. Expert witnesses must evaluate whether the radiographs were of diagnostic quality, and whether any deficiencies were recognised and acted upon.
• Failure to repeat radiographs at appropriate intervals: Current guidance suggests bitewing radiographs should be repeated at 6- to 12-month intervals in high-risk children. Failure to do so may result in undetected disease progression, affecting causation arguments in claims for avoidable extractions or pulp therapy.

In Bolam v Friern Hospital Management Committee [1957], the court established that a clinician is not negligent if they act in accordance with a practice accepted as proper by a responsible body of dental opinion. However, in Bolitho v City and Hackney Health Authority [1998], the House of Lords clarified that the court may reject a body of opinion if it is not logically defensible. Expert witnesses must therefore assess whether the radiographic practice in question was both common and reasonable, given the clinical circumstances.

Record-Keeping: The Evidential Foundation of Paediatric Dental Claims

Records are the primary source of evidence in dental claims. GDC Standards for the Dental Team require that records be accurate, legible, and made at the time of the event or as soon as possible afterwards. In paediatric cases, the following record-keeping deficiencies are frequently encountered:

• Incomplete caries risk assessment: The absence of a documented risk assessment (e.g., diet, fluoride exposure, oral hygiene) may undermine the justification for radiographic exposure or preventive interventions.
• Lack of detail in treatment planning: Records should demonstrate that alternative management options (e.g., preventive care, fissure sealants, restorations, or extractions) were considered and discussed with the parent or guardian. Failure to document this process may suggest inadequate consent or a lack of individualised care.
• Safeguarding concerns: Repeated failed appointments, untreated disease, or signs of neglect (e.g., poor oral hygiene, untreated caries in multiple quadrants) may trigger a safeguarding referral. The absence of documentation regarding safeguarding concerns, or the rationale for not making a referral, can be particularly damaging in claims involving CICA or regulatory proceedings.
• Behaviour management: In children with dental anxiety or special needs, records should detail the behaviour management techniques employed (e.g., tell-show-do, inhalation sedation, or referral for general anaesthesia). Failure to document these discussions may suggest a lack of informed consent or a breach of duty in managing the child’s welfare.

In Montgomery v Lanarkshire Health Board [2015], the Supreme Court emphasised the duty to ensure that patients (or their parents) are aware of material risks and reasonable alternatives. In paediatric dentistry, this duty extends to discussions about radiographic exposure, the risks of untreated caries, and the benefits and drawbacks of different treatment modalities. Expert witnesses must assess whether the records demonstrate compliance with this duty.

Safeguarding Referrals: Legal and Ethical Obligations

Dental professionals have a statutory duty under the Children Act 1989 (s. 17 and s. 47) and the Children Act 2004 (s. 11) to safeguard and promote the welfare of children. The GDC Standards for the Dental Team reinforce this obligation, requiring clinicians to raise concerns if they believe a child is at risk of harm. In medico-legal practice, expert witnesses frequently encounter cases where safeguarding concerns were either not recognised or not acted upon.

Key safeguarding pitfalls in paediatric dental claims include:

• Failure to recognise signs of neglect: Untreated caries, poor oral hygiene, or repeated failed appointments may indicate neglect. Expert witnesses must assess whether the clinical presentation warranted a safeguarding referral, and whether the failure to make such a referral constitutes a breach of duty.
• Inadequate documentation of concerns: Where safeguarding concerns are identified, records should detail the observations, the discussions with the parent or guardian, and the rationale for any referral or decision not to refer. The absence of such documentation may suggest a lack of insight or a failure to act in the child’s best interests.
• Delay in making a referral: Prolonged untreated disease, particularly where it results in pain, infection, or hospitalisation, may give rise to causation arguments. Expert witnesses must evaluate whether the delay in making a safeguarding referral contributed to the harm suffered.

In regulatory proceedings before the General Dental Council, safeguarding failures are often treated as serious misconduct, particularly where they result in harm to the child. Expert witnesses must therefore assess whether the clinician’s actions (or inactions) fell below the standard expected of a reasonably competent dentist, and whether any deficiencies were remediable.

The Role of the Dental Expert Witness in Paediatric Claims

Paediatric dental claims require expert assessment from a dentist with substantial experience in children’s dentistry. The expert witness must address the following key questions:

• Breach of duty: Did the clinician’s radiographic practice, caries management, and record-keeping comply with applicable professional standards? Were safeguarding concerns appropriately identified and acted upon?
• Causation: Did any breach of duty result in the harm alleged? For example, did a failure to take bitewing radiographs lead to undetected caries progression, resulting in avoidable pulp therapy or extraction?
• Condition and prognosis: What is the long-term impact of the alleged negligence on the child’s dental health? This may include the need for future orthodontic treatment, prosthetic rehabilitation, or ongoing preventive care.
• Quantum: What are the future dental care needs arising from the alleged negligence? This may include the cost of restorative treatment, orthodontics, or specialist paediatric care.

In cases involving safeguarding concerns, the expert witness may also assess whether the clinician’s actions (or inactions) amounted to a breach of their statutory duty to protect the child from harm. This assessment must be grounded in the clinical evidence, the records, and the applicable legal and professional standards.

Where radiographic evidence is central to the claim, the expert witness must evaluate the quality of the radiographs, the justification for their use, and whether any deficiencies were recognised and addressed. In some cases, it may be necessary to instruct a specialist in dental and maxillofacial radiology to provide a second opinion on the radiographic findings.

Practical Guidance for Solicitors

Solicitors instructing dental expert witnesses in paediatric claims should consider the following steps to strengthen their case:

• Obtain complete dental records: This includes clinical notes, radiographs, referral letters, and any safeguarding documentation. Incomplete records may suggest a breach of duty or a lack of transparency.
• Identify the correct discipline: Paediatric dental claims require expert assessment from a dentist with substantial experience in children’s dentistry. Where radiographic evidence is disputed, a specialist in dental and maxillofacial radiology may also be required.
• Pose clear questions to the expert: The expert’s report should address breach of duty, causation, condition and prognosis, and quantum. Specific questions about radiographic justification, safeguarding referrals, and the adequacy of record-keeping will help focus the expert’s assessment.
• Consider the timing of instruction: Early instruction of an expert witness can help identify evidential gaps, guide further disclosure requests, and inform case strategy.
• Assess the need for a joint expert: In some cases, a single joint expert may be appropriate to address issues of breach and causation. However, where the case involves complex radiographic evidence or safeguarding concerns, separate experts may be necessary.

In cases involving CICA claims, the expert witness may be asked to provide a condition and prognosis report detailing the long-term impact of the alleged negligence. This report should be tailored to the specific requirements of the CICA scheme, including the assessment of future care needs and the potential for permanent disability.

Conclusion

Paediatric dental claims often turn on the adequacy of radiographic justification, records, and safeguarding documentation. Solicitors must ensure their expert witness is appropriately matched to the clinical issues in question, and that the expert’s report addresses the key legal and evidential challenges. Specialist dental assessment from an experienced expert witness, matched to the correct discipline, can be pivotal in such cases.