iConsentu now integrates with leading dental technology Dentally.

My name is Julian Perry, I’m a dentist; I always say I’ve been a dentist for about 140 years but that’s probably not true. I’ve been in corporate dentistry for 35 years. So I’ve worked with all the major groups of being a chief executive, a clinical director, a director of mergers and acquisitions, group commercial director – so it’s been an interesting career.

Throughout all that time, my world has been entirely focused on dental implants and throughout all of my career I’ve run an implant practice. In the last 10 years, I’ve taken a big role in medico-legal negligence and litigation. I spend quite a lot of time looking at patterns of litigation, as well as subjects we’ll talk about today, which are things like consent and how they’ve changed over the last sort of 10 to 15 years, and what my views are on what consent should look like today.

If we looked back at the last 10 years, in terms of litigation in the dental industry, what do you think the major hallmarks have been? 

Patient expectation: we’ve become a more consumer driven society. It’s not a good thing or a bad thing; it’s just a change in society. What you’ve got is now people purchasing services. The customer tends to look and say “Well, I’m buying that filling, or that crown, I expect, X, Y, and Z.” The profession has been very slow to adapt to that. Around 10 to 15 years ago, dentists didn’t really much bother with written consent, or it was just implied. The patient turned up, so you could argue, “Well the patient turned up, therefore, they consented.”

Then it went through a transitional period of people writing consent forms, and that in itself has its own challenges because a written form only is relevant providing you can demonstrate that you had valid consent. Valid consent is where you have to demonstrate that the patient had sufficient knowledge to be able to sign the piece of paper in the first place. 

How has the transition from written consent to digital consent impacted the field of dentistry, particularly in terms of patient understanding and satisfaction?

There were many cases about 8 or 9 years ago where written consent, both in medical and dental, were thrown out by the courts, because it couldn’t be demonstrated that the patient understood what they signed. So, that’s a transition, and as we move forward now, the number of complaints against dentists is probably 10 times what they were 10 years ago. They don’t all litigate; in fact litigations are about the same level. But dissatisfaction from patients, from lack of understanding has gone up, certainly tenfold. 

I work for a dental indemnity company called Densura, and we’ve probably seen a tenfold increase in the last 5 years in inquiries about patient dissatisfaction from our dentists. I think part of the thing is that, as we move into the digital age, it’s my very firm view that dentists need to be embracing digital consent in a way that is simple to apply to the patient, it’s simple for the practice to manage, but makes sure that you achieve that all important, valid consent.

How do dentists feel at the moment about these kinds of cases, and about the legal side of dentistry in general?

Stressed. I talk to a lot of dentists and have probably worked with a good 5,000 dentists in different groups. I was at a meeting over in Marbella where there were 55 corporate dental groups there, and the common theme throughout is that they express their concern that the dentists that work for them are fearful on a regular basis that they’re going to be complained about or litigated. So the levels of stress are very high. I mean, it’s worth noting that dentistry as a profession, has the second highest suicide rate.

With the advancements of technology and the training involved, would you say standards of dentistry have improved?

Dentistry has changed phenomenally. In the last 8 or so years, everything from technology, intra-oral scanning, three-dimensional radiography, to the work that the Care Quality Commission do. Issues like safeguarding, and making sure the workplace is safe, making sure people are respected and the values are respected has changed. The standards are much higher today than they were, even 10 years ago. Technology is also great. I mean the world of digital now with digital scanning, digital manufacturing; it means the quality of the work that can be fitted is much better than it was when it was all analog 20 years ago.

As a medico-legal advisor, when have you seen cases being thrown out even though consent does seem to have been obtained?

When the consent doesn’t match the patient’s expectation. For example, my world is implant dentistry. If I say to somebody, “I want you to sign a consent form saying that you’re having a dental implant, you understand the risks and the benefits and you consent to the procedure,” that’s not valid consent. 

How has the expectation of providing detailed information about risks, benefits, and warranties in dental procedures evolved in recent years?

What is now expected by the courts is that you cover things like longevity and warranty. Almost no dentist 5 years ago would say to a patient that was having a crown, “this crown will last 12 months.” The guarantee is 12 months or the guarantee is 3 years, and quite often when you look and talk to patients who have a problem with the crown 10 years later, they feel perfectly justified and say, “you made this 10 years ago, it’s broken, make me another.”

Then the dentist says, “it’s not warranted.” Then they say, “you never told me about any warranty or guarantee.” You have a disconnect where dentists know what they think they’re offering, but if it’s not articulated well enough to the patient, then the courts will look at it and say you didn’t explain to a level that met the patient’s requirement of understanding. 

Is there a specific area of dentistry you’ve seen where litigation is highest?

One of the biggest areas of litigation is gum disease, because gum disease takes 20 to 30 years to develop. In that time that patient might have seen 3, 4, 5, 6, different dentists. If a dentist is halfway through a patient’s life cycle and the patient comes in and they’ve already got gum disease, the dentist doesn’t record the fact they’ve got gum disease. They simply say, “You need to see a hygienist twice a year and you’ll be fine.” 

I’ve had cases where I have to go back 10 to 15 years, and 8 or 9 dentists, because the courts want to find out who was the person right at the beginning who didn’t tell the patient they had a problem, and why all the other dentists did not tell the patient they had a problem. It sets up a chain reaction which is difficult to unpick really.

What do you think about iConsentu, and how important is it for the future of dentists practice?

iConsentu is a brilliant concept. [Dr Biju Krishnan] understands the challenges, because he works in practices with patients on a regular basis.

Can you explain how digital consent, particularly using iConsentu, enhances communication with patients compared to traditional consent methods?

One of the beauties of digital consent is that it is easy to communicate it to a patient. You also have a digital audit trail, so you can evidence that you actually sent the information through to the patient. iConsentu works really well. It says “You’re choosing to have this type of procedure, here’s the advantages and the disadvantages.” 

It’s clever because it shows the patients video animations; a picture is worth a thousand words. The patient can get a total understanding of the procedure. Also, it requires the patient, having watched the video, to answer some questions, which demonstrates that they understood what they saw on the video. That’s really important, because it’s difficult for the patient to say they didn’t understand it, when they’ve answered a multiple choice question at the end. 

Right at the very end, it makes the point about being very specific to the patient, that to proceed with treatment, they require valid consent. If you click on the little “valid consent,” it says what valid consent is.  If the patient can’t agree with that, then the dentist doesn’t proceed with treatment. So it’s a safeguard both from the patient’s point of view, and from the practices point of view. I think it’s extremely clever. 

It’s about demonstrating that you’ve done everything you can to make sure the patient is correctly informed about the procedure, understands the implications, the warranties, the guarantees, the cost, the risks and the benefits.