If a patient reviews the displayed fees then he or she will have some idea of treatment costs. However most patients would have little or no idea of, for example, the number and type of radiographs required, or the differences between the various types of restorations.  
As well as the requirement to display fees in private practice, the Dental Council Code of Practice: Professional Behaviour and Ethical Conduct states that you must:

• provide an estimate of the cost of treatment options
• get your patient’s agreement before the treatment commences.

It also recommends that you give an estimate of costs in advance and in writing. If the estimate needs to be revised as treatment progresses, you should give a full explanation of the revised costs as early as possible.

The display of fees assists the patient with general information prior to the clinician providing specific information in relation to their specific course of treatment. This avoids any unexpected fees and should assist the clinician in collecting the fees in a timely fashion.

In practical terms it is good policy to take a full medical history every time a patient is examined and the use of a medical history form provides an excellent way of recording this information.

It is important, however, that the patient is not left to complete the medical history form; whoever is carrying out the examination should go through all the questions with the patient to ensure they fully understand them or indeed can actually read.

Such questioning should obviously be carried out in a manner that ensures patient confidentiality. If a practice wishes to become paperless, the medical history form can be scanned onto the computer. The hard copies should then be be shredded or incinerated.

When a patient attends for an appointment as part of a course of treatment, it is always worth checking to ensure they have not started on any medication or have suffered any relevant illnesses since their last visit. Some practices encourage patients to volunteer such information by placing a sign in the waiting room requesting patients to inform their dentist of these types of changes.

Taking a full medical history at each examination can be onerous, but it is certainly worthwhile both to protect the patient and the dentist’s own position. Having a written record of the patient’s medical history, signed by the patient, often affords protection to the dentist – particularly if an allegation is made that he or she had not taken the patient’s medical history into consideration when carrying out treatment, which subsequently resulted in the patient being avoidably harmed.

It is impossible for any professional person to stop every complaint from arising. It is better to adopt a positive state of mind and accept that occasionally you will get a sub-optimal result or that for a variety of reasons (some beyond your control) that the patient is disappointed or unhappy with something that happened during their visit.

By encouraging patients to express themselves as they leave the treatment area you can often get them to tell you what could have been done better from their perspective.

There are many ways of identifying dissatisfaction:

• Prominently displaying your complaints procedure so that patients don’t have to ask for it and encouraging them to share any negative views with appropriate staff
• Train all staff to identify the ‘body language’ associated with dissatisfaction. The aim is to encourage patients to tell you if they have a problem, before they tell someone else
• Comment or feedback cards - usually only completed by patients who are particularly displeased or delighted with service. It is, of course, helpful to collect positive feedback as well as negative and neutral feedback

By handling this issue at a local level it may be possible to contain the issue and prevent it from escalating out of your control. It can also help to avoid the dissatisfied patient from bottling up a store of complaints.

Dental Protection’s Handling Complaints advice booklet offers lots more guidance on this subject. It can be found in the Risk Management section of the website.

Although the nature of this patient’s medical condition is not described, some patients trawl the internet seeking a remedy for what they consider to be an untreatable chronic condition.

Historically, amalgam has been considered to be a safe restoration although there have been developments of global plans to control mercury pollution that could see amalgam being phased out over the next few years.

When deciding how to respond, you obviously have to advise her on what is considered current best practice and to offer her treatment which would be considered to be in her best interests.

There would clearly be a dilemma for the patient if there was no improvement whatsoever in her medical condition after you removed the tooth. Even if you did insist on this patient signing a disclaimer, it would be of little help should she decide to make a claim in negligence against you unless there was a cogent reason for you acceding to her request. You could also be asked to justify the reason for the extraction if an adverse incident occurred when extracting the tooth.

You may wish to consider obtaining a second opinion from a Specialist in Oral Medicine or Oral Surgery, and if necessary with the patient’s permission, to liaise with her general medical practitioner before carrying out any irreversible treatment. It may also be worth discussing your concerns with this patient on the efficacy of the treatment she suggests and perhaps trying to persuade her to have the amalgam removed (which in itself can be a source of morbidity), and to restore the tooth on a temporary or semi-permanent basis to see whether it does have any effect on her underlying medical condition.

Further information is available in Dental Protection’s Risk Management Module on Amalgam-free Practice.