Periodontal disease claims: evidential pitfalls in BPE recording and referral timing

Clinical context: BPE as a screening tool

The Basic Periodontal Examination (BPE) is a screening tool used in UK general dental practice to identify patients who may require further periodontal assessment. It employs a WHO probe to record the highest score in each sextant, ranging from 0 to 4, with an asterisk indicating furcation involvement or other complexity. While BPE is widely adopted, its limitations must be recognised in medico-legal contexts.

BPE scores do not quantify attachment loss, recession, or mobility. A score of 3 in a sextant indicates pocketing of 3.5 to 5.5 mm, but does not distinguish between true periodontal pockets and false pockets caused by gingival enlargement. A score of 4 indicates pocketing of 6 mm or more, which may reflect advanced disease or anatomical variation. The asterisk code signals complexity but does not specify the nature or severity of furcation involvement.

Guidance from the British Society of Periodontology and Implant Dentistry (BSP) recommends full periodontal charting, including six-point probing depths, bleeding on probing, recession, mobility, and furcation assessment, when BPE scores of 3 or 4 are recorded. Failure to progress from BPE to full charting may be relevant to allegations of breach of duty where disease progression is alleged.

Legal relevance: breach of duty and causation

To establish breach of duty in a periodontal claim, the claimant must demonstrate that the defendant dentist failed to meet the standard of a reasonably competent general dental practitioner. This is assessed with reference to Bolam v Friern Hospital Management Committee [1957] and Bolitho v City and Hackney Health Authority [1998]. The court will consider whether the dentist acted in accordance with a responsible body of dental opinion, and whether that body of opinion is logically defensible.

Common allegations in periodontal claims include:

• Failure to record BPE at appropriate intervals
• Failure to progress from BPE to full periodontal charting when indicated
• Failure to refer to a periodontist in a timely manner
• Failure to provide appropriate periodontal treatment in primary care
• Failure to monitor disease progression adequately

Causation in periodontal claims requires the claimant to show, on the balance of probabilities, that the breach of duty caused or materially contributed to the loss of teeth or other harm. This involves expert evidence addressing the natural history of untreated periodontal disease, the likely progression had the breach not occurred, and the impact of confounding factors such as smoking, diabetes, or poor oral hygiene. The Barnett v Chelsea and Kensington HMC [1969] test applies: but for the breach, would the harm have been avoided?

Where periodontal disease was present but unmonitored, expert opinion may address whether earlier intervention could have preserved the dentition. This assessment involves the rate of bone loss, the pattern of disease, and the response to treatment in comparable cases. Radiographic evidence is pivotal, as it provides objective data on bone levels over time.

Common evidential pitfalls

Over-reliance on BPE scores

BPE scores are often central to periodontal claims, but their limitations are frequently overlooked. A score of 3 or 4 does not necessarily indicate periodontal disease requiring specialist referral, as such scores may reflect gingival enlargement, anatomical variation, or operator error in probing technique. Expert evidence must distinguish between true and false pockets and assess whether the dentist acted appropriately given the clinical presentation.

BPE does not monitor disease progression. A stable BPE score over time does not indicate stable disease, as attachment loss may occur without an increase in pocket depth. Expert opinion may address whether the dentist should have progressed to full periodontal charting to monitor disease accurately.

Delayed referral to a periodontist

The timing of referral to a periodontist is a frequent issue in periodontal claims. Guidance recommends referral for patients with BPE scores of 4 in any sextant, or scores of 3 with additional risk factors such as smoking, diabetes, or poor oral hygiene. However, the decision to refer must be individualised, considering the patient’s overall risk profile, response to initial treatment, and the dentist’s competence in managing periodontal disease.

Expert opinion may address whether the delay in referral caused or materially contributed to the loss of teeth. This involves assessing the likely outcome had referral occurred earlier and whether the periodontist would have recommended treatment that could have preserved the dentition. The expert must also consider the patient’s compliance with treatment and oral hygiene, as these factors influence periodontal outcomes.

Inadequate radiographic assessment

Radiographs are essential for assessing bone loss in periodontal disease. Guidance recommends bitewing radiographs for patients with BPE scores of 0 to 2, and vertical bitewings or periapical radiographs for patients with scores of 3 or 4. Panoramic radiographs are not suitable for assessing periodontal bone loss due to limited resolution.

Expert evidence may address whether the dentist breached their duty by failing to take radiographs at appropriate intervals or by failing to interpret them accurately. The expert must assess the extent of bone loss, the pattern of disease, and the likely rate of progression. This requires comparison of serial radiographs, where available, to determine whether bone loss occurred gradually or rapidly.

Consent and communication

Informed consent is critical in periodontal claims. The dentist must explain the nature and severity of the periodontal disease, the treatment options, the risks and benefits of each option, and the likely outcome if treatment is not undertaken. This discussion must be documented in the clinical records, as required by the General Dental Council (GDC) Standards for the Dental Team.

Expert opinion may address whether the dentist provided sufficient information to enable the patient to make an informed decision. The expert must consider whether the patient was given the opportunity to ask questions and whether their concerns were addressed appropriately.

The role of the expert witness

The selection of an expert witness with substantial experience in periodontology is critical in periodontal claims. The expert must be familiar with the standards expected in primary dental care and be able to provide an independent opinion on breach of duty and causation.

The expert’s role is to assist the court in understanding the clinical issues. This requires a detailed review of the clinical records, radiographs, and any other relevant evidence. The expert must consider the patient’s medical and dental history, as well as any confounding factors that may have influenced the outcome.

Under CPR Part 35, the expert’s overriding duty is to the court, not to the instructing party. The expert must provide an objective, unbiased opinion. The expert’s report must comply with CPR 35.10, including a statement of the expert’s qualifications, the substance of all material instructions, and the facts and assumptions on which the opinion is based.

Where a single joint expert is appointed under CPR 35.7, the expert must provide an independent opinion to the court and comply with the court’s directions regarding the format and content of the report. The expert may respond to written questions under CPR 35.6.

Where two or more experts are instructed, they may be required to discuss the case and produce a joint statement under CPR 35.12. This statement must identify the issues on which the experts agree and disagree, and the reasons for any disagreement. The experts must not be influenced by the parties’ solicitors and must not be pressured to change their opinions.

Practical guidance for instructing solicitors

For solicitors instructing an expert witness in a periodontal claim, the following steps are recommended:

1. Obtain all relevant clinical records, including dental charts, radiographs, referral letters, and correspondence. Ensure the records are complete and legible.
2. Identify the key issues in the case, such as the adequacy of BPE recording, the timing of referral, or the appropriateness of treatment.
3. Select an appropriate expert witness with substantial experience in periodontology and familiarity with the standards expected in primary dental care.
4. Provide clear, focused instructions to the expert, outlining the issues to be addressed and the questions to be answered.
5. Consider the need for additional evidence, such as radiographs, photographs, or models, to support the expert’s assessment.
6. Review the expert’s report carefully, ensuring it complies with CPR Part 35 and addresses all relevant issues. If necessary, pose written questions to the expert under CPR 35.6 to clarify any points of uncertainty.

In cases involving a single joint expert, solicitors must ensure that the expert is instructed in accordance with CPR 35.8 and that the expert’s independence is respected. The expert must not be pressured to favour one party over another.

Where two or more experts are instructed, solicitors must facilitate discussions between experts under CPR 35.12 and ensure that the joint statement is prepared in a timely manner.

Conclusion

Periodontal disease claims present evidential challenges, particularly around BPE recording and the timing of specialist referral. For instructing solicitors, identifying the key clinical and legal issues is essential to building a robust case. Expert evidence from a dentist with substantial experience in periodontology can provide the court with the specialist insight needed to assess breach of duty and causation accurately. By focusing on the adequacy of records, the appropriateness of treatment, and the impact of any delays, solicitors can ensure that the expert’s report addresses the critical questions in the case.