Sir, a patient attended a dental practice in the mid-1990s as a new patient for ongoing care. The long-term risks of inadequate plaque control were consistently stressed by Dentist 1 over a period of ten years during which the poor condition of the gums were noted and shared with the patient on numerous visits. Dentist 2 then saw the patient for three years for ongoing care with similar emphasis on poor gum condition and strategies to rectify this, during which the reality of worsening gum health was shown to the patient with advice as to how to halt this process. Dentist 3 then saw the patient and again stressed the importance of self-help in the control of the worsening periodontal condition. The three clinicians concluded that referral for specialist care without commitment to self-help was inappropriate: 'owning' their decisions as 'gatekeepers'.

Eventually an anterior tooth became mobile causing a problem for the patient who was again seen by Dentist 1 who emphasised plaque control measures but presented the reality of tooth loss.

The patient then attended another practice for a second opinion. Dentist 4 correctly diagnosed advanced periodontal disease but the patient claimed that she had not received any information regarding plaque control at the previous practice. In the absence of historical notes and on Patient A's word, advice was to given to take the case to the Dental Law Company (recorded on patient notes). Dentist 4 referred Patient A to a specialist, Dentist 5, who also presented a full case history demonstrating advanced periodontal disease and a treatment plan that involved costly implant therapy. A legal process began which resulted in settlement out of court without any admissions of fault, as this was the most cost effective pathway. This resulted from the note keeping (although extensive and collaborative with the patient) of Dentists 1, 2 and 3 not conforming to the guidelines issued by the Royal College Faculty of General Dental Practitioners.

Applying guidelines without contextual consideration places the clinician in the position of being a technician conforming to rules without the ability to use professional judgement in individual circumstances. There are many circumstances where the acceptance of periodontal disease is an only option, for example in an individual who is compromised in the ability or willingness to control plaque. This professional judgement should be owned by the clinician and should be measured in terms of the collective outcomes achieved by that clinician. However, collective outcomes for GDPs' judgements are not routinely considered by dental professionals. Compliance with process is valued both by dental professionals and lawyers. Guidelines are therefore important documents in legal situations.

The variance associated with human decisions places the GDP in a difficult position if ownership is taken and then challenged retrospectively based on published guidelines. Has the time come for all dentists and particularly those responsible for the development of guidelines to consider the words of Ayer et al.?1 'Nowadays, people are very aware of their rights and laws involving any wrong done to them. Sometimes people misuse these rights to sue the dentist for wrong reasons also and for no mistake of the dentist.'