Sir, I write in response to the letter written by Professor Wayne Richards published in the BDJ (2014; 216: 376–377). Professor Richards raises issues which are worthy of further debate and discussion within the profession, especially with regards to those who provide reports as expert witnesses to the court. I hope that many who read that example felt the same as me in failing to understand what about the dentists' actions were so wrong as to result in an out-of-court settlement for the patient concerned.

In the example given by Professor Richards, the patient involved is reported to have been given preventive advice regarding her periodontal disease but had not acted upon this. This has resulted in the patient not being referred onwards for specialist treatment. I feel that this course of action as portrayed in the example, with an emphasis upon prevention, is reasonable and as Professor Richards states, the dentists were 'owning' their decisions as 'gatekeepers'. The guidelines produced by the FGDP regarding record keeping state that BPE scores of 3 and 4 require full pocket charting to be taken in the appropriate areas. Whilst this guidance makes sense, I fail to understand why not following this guidance, providing BPEs, prevention and treatment as appropriate has been carried out, constitutes a breach of duty. Even if a breach of duty is ascertained, I feel it would be very difficult to claim causation based solely upon a clinician not undertaking full pocket charting.

The guidelines that are produced by the various clinical authorities, such as the FGDP, British Society of Periodontology etc should be seen as exactly that: guidelines. When assessing cases for liability and causation, experts should try to convey to their instructing parties that not all deviations from guidelines are breaches and even if they are seen as so, many small breaches, such as the example given above, do not constitute grounds for the finding of causation.

We are all too aware of the burden of litigation within dental practice in this country. It is lamentable that litigation, whilst helping to protect patient rights, has such a detrimental effect upon morale and the potential to encourage defensive practice. The use of guidelines in such a strict and inflexible way is not conducive to providing the best for our patients. If the expert witness community and the legal profession insist upon this approach, to quote Lord Denning, 'initiative would be stifled and confidence shaken'. Some might argue we are already quite far down this path.