Frequently asked questions

11 August 2014

Last updated

Bookmark and Share         

For frequently asked questions about the RiskCredits scheme click here

For frequently asked questions about the Clinical Indemnity Scheme click here

Q. If I hold a practice open day providing free screening for oral cancer and invite members of the general public to come in, would I be responsible for all their dental needs or can I do just an oral cancer screen, essentially a soft tissue examination and oral cancer advice?

The first thing you need to do is to ensure that you manage patient expectations by accurately communicating your intention. It is important that they are informed about the nature and limitations of the cancer assessment. You also need to ensure that members of the public who attend your practice purely for the purposes of an oral cancer assessment are not coerced into becoming patients of the practice, as some of them may have their own dentist.

The importance of good communication with members of the public who attend your open day cannot be overestimated. They should be made fully aware of the nature and limitations of the examination which is to take place both verbally and perhaps more usefully in written form.

Since there are a number of techniques which serve as an adjunct to visual examination, and which may show up an early abnormality, patients therefore should be advised of the scope and limitations of your examination depending on the technique you are proposing to adopt.

Members of the public who agree to an examination of their mouth should be taken through the consent process before they are examined. They should be reminded of the scope and nature of your examination and whether or not you will be carrying out a full examination of their teeth and the gingival tissues.

They should also be made aware at the outset that they may have to provide a medical history as well as a social history which may provide markers for an increased incidence in oral cancer. All this information should be documented in a clinical record for each person you examine. The record should also include personal details such as their name, address, date of birth etc together with the results of your examination.

Any mouth cancer examination form is a key part of a patient record and needs to be retained as part of the record in the usual way. Dental Protection’s advice is to retain dental records for at least ten years and in the case of children, up until three years after the patient’s 21st birthday.

If your examination extends beyond the oral cavity and includes the face and neck you should notes both positive and negative findings. For example, a note should be made whether any lymph nodes were palpable say in the neck, for example.

Your duty of care to each person you examine extends to whatever was agreed to be the nature of your examination - hence the importance of defining any limitations at the outset. It would also be desirable to advise patients of the importance of seeing a dentist on a regular basis especially if they fall into a high risk category.

In the event of you discovering a suspicious lesion then you will need to discuss with the patient how this should be followed up. You should not follow this up with their dentist or doctor without the express consent of the patient, as you will still be bound by a duty of patient confidentiality. However, you should stress the importance of referral to a specialist and the need to involve their doctor and also their current dentist (if they have one).

You initial agreement with the patient might include a confirmation that '…in the event of an abnormality being detected, I would like to be referred appropriately and understand that I will be responsible for the fees associated with any follow-up examination, diagnostic tests or treatment required.'

You may wish to consider following up an urgent referral to ensure that it has been received and that the patient has been seen.

The best way to ensure the smooth running of your open day is to have a system in place at your practice so that members of the public who attend are made fully aware of the full nature and limitations of the screening they are to receive so that expectations can be met.

Q. I am in a Limited Income Concessionary Rate category and the HSE has stated that it does not accept 'partial/limited indemnity'. Do I have partial indemnity?

No!

Members of MPS served by DPL do not have 'partial/limited indemnity'. Those members in a limited income concessionary category are treated no less favourably than other members. Members are entitled to seek assistance in the event of a complaint of claim being made against them and there is no pre-defined financial limit on a member’s indemnity.

Q. I have heard that I need to display information about private patient charges. Is this true and if it is how should I do this?

The Dental Council has issued the Code of Practice relating to Display of Fees in Private Practices

This Code of Practice comes into effect on 1 June 2011 and makes it mandatory for dentists to display private fees in a place where patients can view them before consultation.

The fee notice must be at least A4 size (29.7 x 21cm or 11.7 x 8.3in) and be legible, accurate and up-to-date.

It must be prominently displayed in the practice and must be situated in a place where the patient could reasonably be expected to see the list before the consultation. It is recommended that the fee notice be displayed at any of the following locations:

  • Entrance to the practice
  • Reception area(s)
  • Waiting room(s).

Dentists with websites must also display fees in a similar format.

The fees displayed must be accurate, transparent and inclusive of all costs.

Dentists must display a single fee only for the following treatments:

  • Examination, diagnosis and treatment plan
  • Hygiene treatment (hygienist) - per visit
  • Hygiene treatment (dentist) - per visit
  • X-rays - small
  • X-rays - large (OPG)
  • Prescription

Dentists must display fees for the following treatments and these may be displayed in the form of a range of fees. If displaying a range of fees both the minimum and maximum fee must be shown. It is not permitted to set a minimum price only for any treatment:

  • Advanced gum treatment
  • Restorations - white (composite resin)
  • restorations - Silver (amalgam)
  • acrylic-based dentures
  • Metal-based dentures
  • Root canal treatment
  • Routine extraction
  • Surgical extraction
  • Core/post preparation
  • Crowns

Further information and advice is available here

Q. Do I need any additional indemnity when I am supervising a younger colleague who has just started to undertake the prosthetics associated with the implants that I have placed for his patients?

Dental Protection looks upon a mentoring role as squarely part of one's professional activity, and consequently it falls under the scope of the professional indemnity provided to members of this organisation. No additional subscriptions are payable by the mentor (unless the member in question has opted for membership in a non-clinical category which excludes any involvement in the treatment of patients. This would not be considered sufficient to provide indemnity for any work carried out in a mentoring capacity).

Each individual practitioner has a duty of care to each and every patient in whose treatment they are involved. This duty of care has an ethical as well as a legal dimension and reflecting this fact, one should start from the premise that such a duty of care exists, even when one is not treating the patient personally.

Thus, while a mentor's relationship with any colleague they are mentoring will be self-evident, one should not lose sight of the more subtle and indirect relationship with any patients involved under the care of the mentee, and in relation to whom the mentor might be providing advice.

Read our full Position Statement on Mentoring here

Q. Is it advisable for a dentist to apologise if a patient experiences pain after treatment?

An apology is not an admission of guilt but is simply an expression of regret. For example, ‘I am sorry you had so much pain after the extraction'. This does not mean that the dentist has done anything wrong but is more an expression of sympathy / empathy and an understanding of the difficulty the patient faced. An apology coupled with an explanation can provide reassurance to a complainant and is often all the patient is looking for.

It is particularly important where a patient has been avoidably harmed; the lack of an apology in these situations is one of the many reasons why patients take complaints further.

Members might like to explore this further by downloading Dental Advice Booklet on Handling Complaints here

Q. I employ an associate who regularly leaves his patient in the surgery with the dental nurse whilst goes outside to get fresh air or to get something to eat. The nurses are unhappy about him doing this particularly after giving an injection. Is this professional behaviour?

It is not uncommon for some dentists to administer local anaesthetic to a patient and then send them into the waiting room (where they may not be supervised or observed) whilst waiting for the local anaesthetic to take effect. Similarly some dentists work between two surgeries and may leave the patient in the chair either alone or with a dental nurse.

There are a couple of potential problems which could arise as a result of this type of practice.

From a clinical point of view any patient may have an immediate or delayed reaction to the local anaesthetic and it is obviously important that the dentist is alerted and that if the patient is accompanied by a dental nurse, the nurse is able to at least start to deal with an adverse clinical scenario. The other issue at stake is whether the dental nurse’s position could possibly be compromised because there was not a third party to act as a chaperone.

The Dental Council’s ethical guidance strongly recommends that dentists have a third person present in the surgery and this could be interpreted to encompass the supervision of a patient after the administration of local anaesthetic.

The main concern here is why this dentist appears to be acting in this way on a reasonably regular basis. From a practice management point of view you may wish to set protocols within your practice to ensure patients are provided with a high standard of service and care and you therefore may wish to advise your associate that you would wish him to sit with the patient unless there were other acceptable reasons for leaving the surgery. You may need to take further advice if he fails to comply with your wishes.

At the end of the day the treating dentist will be responsible for the care of their patient and should the patient develop an adverse reaction while the dentist was not present then that dentist would have to provide a cogent reason why he believed it was in the patient’s best interests to leave them with the dental nurse. The training and experience of the dental nurse will also have a bearing on any decision made by the dentist. If a dental nurse feels that the patient could be at risk because of their own particular level of experience, then it is very responsible act to have brought this to your attention.

Q. I refund the patient's fees, am I admitting liability and risking a future claim?

There is often a degree of hesitation before any dentist proposes this course of action. Admitting to yourself that a particular treatment didn't achieve exactly what was intended can take a moment to accept. However there is a common misconception that giving a refund to a patient should be avoided because it implies there has been a problem. However in certain circumstances where the patient is disappointed with the look or the comfort of the final result (eg dentures that the patient cannot wear or the degree of whiteness achieved with bleaching) dentists can give the patient a refund. This can often resolve difficult situations and avoid further hassle. Provided the refund is given with a clear indication, preferably in writing, that it is ‘a gesture of goodwill with no admission of liability' it is unlikely to increase the risk of any further action and does not provide any additional grounds on which the patient might base a claim.

Members might like to explore this further by downloading Dental Advice Booklet on Handling Complaints here

Q. I've received a letter from a solicitor proposing action against me; what should I do?

Statistically speaking most dentists will receive at least one such letter in their working life. This does not mean that standards in dentistry are falling! Rather it means that patients are becoming more litigious and it is relatively easy for a patient to seek and obtain legal advice.

Dental Protection is aware that certain firms of solicitors have recently been approaching our members directly; even after having been advised that we are acting on behalf the dentist concerned, and demanding that the original clinical records should be supplied direct to the firm in question, often within a very short time scale.

Members should immediately contact Dental Protection for advice if this happens and we will take up the communication on your behalf with the solicitors concerned. You should resist the temptation to contact the patient or to provide the patient's solicitors with an explanation or the patient records. Instead you should send a short acknowledgement to the solicitors confirming that their correspondence has been passed on to Dental Protection.

 When writing to Dental Protection, you are asked to provide the following details:

  • Your full name, address, qualifications and current daytime and evening phone numbers. Include fax and email address if relevant,€ and indicate any preference you have regarding how, when and where we should communicate with you, bearing in mind any confidentiality considerations. 
  • Your MPS membership number (you will find this on your membership certificate). 
  • The name, age, gender and occupation (if known) of the patient. 
  • The full names of any other clinicians involved, so that they can be accurately identified. 
  • The date(s) and details of your personal involvement in dealing with the patient - symptoms, signs, investigations and treatments, as a plain factual narrative. 
  • The original records with the authors of entries identified. If the records supplied are not those which were made at the time in question, or if any entries have been added or amended more recently, it is important to make this clear to Dental Protection when you send them to us. 
  • It is often very helpful if an accurate transcript of the records is provided, visit- by visit, to explain any entries on the record card which are unclear for any reason. 
  • Any radiographs, photographs, study models, or other parts of the overall record which are relevant to the case.
  • Due care should be taken to ensure the safe transit and security of these valuable records, when sending them to Dental Protection. We will acknowledge safe receipt of such records.
  • Please provide your written consent to the disclosure of copies of the records.
  • The correspondence from the solicitors

In order to protect your position our solicitors will contact the patient's solicitors confirming our interest on your behalf. From that point onwards the patient's solicitors should correspond directly with Dental Protection and you should receive nothing further directly from them. However, if you receive any further correspondence from them, do please let us know.

The patient's solicitors may take some time to investigate the claim. We will keep you updated as to any developments and you may also contact Dental Protection for an update when you wish.

Q. Is it reasonable to take an extra x-ray just for the record?

Clinicians sometimes feel that in order to protect themselves dento-legally it would be useful to have an x-ray ‘just in case'. This situation might arise after fitting a post crown or a bridge - the objective being to ensure the post angulation was correct or the marginal fit of the bridge was accurate. Orthodontists sometimes take a range of radiographs mid-treatment and again post-operatively to assess the angulation of teeth as well as checking for any root resorption following fixed appliance therapy. Hygienists have been known to take x-rays simply to check they have removed all the subgingival calculus following periodontal therapy.

Radiography is of course an invaluable tool for the clinician, providing information that is impossible to obtain by clinical examination alone. It is important however, when deciding to take a radiograph that a risk to benefit assessment is also made. Every radiograph presents a radiation risk and any exposure of a patient to that risk must be offset against a reasonable clinical benefit. No patient should be exposed to an additional dose of radiation (and the associated risk) as part of a course of dental treatment, unless there is likely to be benefit in terms of improved management for that patient.

Q. I have received a letter from the Dental Council advising me that my name has been removed from the Dental Council register for non-payment of my annual retention fee. I have been working without realising that my registration had lapsed and I have now requested a restoration form - is it ok to continue working in the meantime?

Carrying out the practise of dentistry or the business of dentistry when one's name is not included in the Dental Council Register would be considered to be the illegal practice of dentistry under the provisions of the Dentists Act 1985. It is also a criminal offence. The purpose of having a Register is to reassure members of the public that the names of dentists and DCPs who appear in the Register are not only qualified but are also regulated by the Dental Council.

It is imperative that, until your name has been restored to the Dentists Register, you do not carry out either the practise of dentistry or the business of dentistry.

In addition to this, you need to be aware that whilst your name is not included in the Dentists Register, you cannot be indemnified. However, should a claim should arise in relation to the advice and treatment that you provided during the time when you were practising without being registered you may apply to Dental Protection for assistance. Dental Protection is a mutual organisation which means that it has the discretion to offer you assistance if it considers there to be extenuating circumstances which contributed to your situation. However, this would need approval from the Board of Directors.

In the meantime you should ensure that you have made the appropriate arrangements for the care of your patients. It is also important that you take all steps to have your name restored to the Dentists Register as soon as possible. This is not an automatic process and the application form requires you to enclose a letter setting out the reason why you were working as a dentist during the time you were not registered with the Dental Council. You should contact Dental Protection for assistance in relation to this.

The Dental Council is not interested in any arguments about change of address or delayed cheques. It takes the view that the onus is on the registrant to ensure that their registration is continuous. It is also the registrant's responsibility to check that their application for renewal has actually been processed. Being unaware of lapsed registration is no excuse in the eyes of the Dental Council and the law.

Q. I undertake domiciliary visits as part of my job and I wondered if it is necessary for me to carry the same emergency drugs that I keep in the surgery. Would I need to do this if I was visiting a nursing home with its own supply of emergency drugs?

When carrying out home visits for patients, you should make every effort to ensure that the patient will not be disadvantaged by having treatment carried out in an environment which is not a normal dental practice.

Consequently, you should always carry emergency drugs and oxygen etc. If visiting a nursing home that has its own drugs and portable oxygen, then it would be reasonable to accept that situation but always to ensure that the drugs are in date and adequate for emergency purposes.

Q. Can I withdraw from treating a patient?

Sometimes, for a variety of reasons, you may decide that you need to withdraw from a patient’s treatment, or suggest that they seek further treatment elsewhere. You may find it difficult or impossible to treat the patient or something may have happened as a result of which you are simply not prepared to continue treating the patient. This has the potential to create a dangerous flash point and it needs to be sensitively managed.

Try never to lose your temper with a ‘challenging’ patient. Keep your cool and remain professional at all times, however difficult it might be on occasions.

If you are finding it difficult to treat the patient safely and to an acceptable standard, consider referring the patient to a suitably experienced colleague.

Never part company with a patient in anger. If for any reason you do decide that you cannot continue treating the patient, make it clear that you are withdrawing from the treatment in the patient’s best interests, not your own.

The Dental Council ethic guidance states a dentist who accepts a patient for treatment has a responsibility to complete the course of treatment necessary to render the patient dentally fit. If, for some reason, the professional relationship between a dentist and patient breaks down during the course of treatment the dentist should refer the patient to a colleague to have the course of treatment completed.

Make the necessary referral arrangements, keep the patient informed, and resist the temptation to insert any ‘one liners’ in the correspondence or in the clinical records, or worse still in any direct communication you have with the patient. Never give the impression that you are being arrogant, dismissive or petulant when deciding to end your relationship with a ‘challenging’ patient. A few ill-chosen words spoken in the heat of the moment can result in months or years of subsequent repercussions if you end up being sued or facing a complaint to the Dental Council or other agencies.

Q. Is there any legal obligation to take photographs of the patient’s teeth prior to undertaking bleaching?

Generally speaking, photographs provide an extremely useful record of the clinical situation. Not only do they show the shape, size and position of various teeth, but they also record the patient’s clinical condition, gingival status, oral hygiene etc. What photographs are not good at, however, is reproducing the precise colour of the teeth and therefore they cannot be relied upon for shade matching. Many dentists find it useful to take a photograph of the teeth, prior to undertaking bleaching as it does allow them to produce a ‘before and after’ comparison. This often helps the patient realise just how much the colour of the teeth has improved during the bleaching treatment.

For a more precise colour record you could include the relevant shade guide tab alongside the teeth both before and after treatment to demonstrate that a change in colour has occurred. However, because of the variables in creating and viewing the image, the result should be interpreted with caution.

There is no legal requirement to take a photograph prior to starting a bleaching procedure, but since they can provide a useful addition to the clinical records they are to be encouraged. The photographs should be stored within the clinical record (on paper or in a digital format on the computer) along with details of the patient’s name, date of image and an indication of what it shows (for example, John Doe; pre-bleaching; 17/07/2010). Click here to see our position statement on tooth whitening note to BDE - this is currently being checked.

Q. I am a practice owner who is taking time off from the practice to undergo an episode of elective surgery which will stop me working for the partnership for several months. I have arranged a locum to treat patients in my absence but I wanted to ask;

a) I am responsible for the treatment provided by the locum?

b) Will my inability to work affect the cost of my Dental Protection membership?

You are not responsible for the standard of work undertaken by your locum. Every dentist is responsible for their own acts and omissions and they should be indemnified accordingly. You should therefore take a moment to ensure that your locum is suitably indemnified

Your indemnity with DPL does not cover any claim in negligence which might be made against your locum. Your locum must have his own indemnity which should cover him for all acts and omissions whilst he is working at your practice. Some dentists decide for whatever reason not to become members of a defence organisation but take out an individual insurance policy. If this is the case with your locum it is important to ensure that suitable arrangements for ‘run-off cover’ will be in place, if and when he stops paying his insurance premium, if say he retires from practice.

Because you are a practice owner you will be required to maintain full indemnity throughout your current DPL subscription. This will provide you with protection in your role as a partner in a practice should any claims be made against the practice (say due to a breach of health and safety or infection control) even when you are not working on the premises. It is not uncommon for some dentists to administer local anaesthetic to a patient and then send them into the waiting room (where they may not be supervised or observed) whilst waiting for the local anaesthetic to take effect. Similarly some dentists work between two surgeries and may leave the patient in the chair either alone or with a dental nurse.

There are a couple of potential problems which could arise as a result of this type of practice.

From a clinical point of view any patient may have an immediate or delayed reaction to the local anaesthetic and it is obviously important that the dentist is alerted and that if the patient is accompanied by a dental nurse, the nurse is able to at least start to deal with an adverse clinical scenario. The other issue at stake is whether the dental nurse’s position could possibly be compromised because there was not a third party to act as a chaperone.

The Dental Council’s ethical guidance strongly recommends that dentists have a third person present in the surgery and this could be interpreted to encompass the supervision of a patient after the administration of local anaesthetic.

The main concern here is why this dentist appears to be acting in this way on a reasonably regular basis. From a practice management point of view you may wish to set protocols within your practice to ensure patients are provided with a high standard of service and care and you therefore may wish to advise your associate that you would wish him to sit with the patient unless there were other acceptable reasons for leaving the surgery. You may need to take further advice if he fails to comply with your wishes.

At the end of the day the treating dentist will be responsible for the care of their patient and should the patient develop an adverse reaction while the dentist was not present then that dentist would have to provide a cogent reason why he believed it was in the patient’s best interests to leave them with the dental nurse. The training and experience of the dental nurse will also have a bearing on any decision made by the dentist. If a dental nurse feels that the patient could be at risk because of their own particular level of experience, then it is very responsible act to have brought this to your attention.

Q. I asked to see a certificate of indemnity from a new dentist that I want to employ. The dentist in question showed me a broker’s certificate for a policy backed by Lloyds but which had an excess of €5,000 for each claim. Is this valid?

Several brokers and agents offer insurance policies that are backed by Lloyds. This is acceptable but attention should be paid to the €5000 excess on each claim.

You might want to consider the best way of ensuring how a patient would receive the full amount of any award if a claim should ever arise. Perhaps you should ask the associate to deposit €5,000 in a trust account as a contingency measure?

You might also want to consider why this dentist is not with one of the usual indemnifiers. It is not inconceivable that the associate had conditions applied or had possibly been refused by a previous insurer.

Although the every dentist is responsible for their own acts and omissions, if the associate subsequently leaves the practice it is possible that that any complaint about a former associate may become the vicarious responsibility of the practice. In this situation the associate will need to purchase ‘tail-cover' from the insurer to indemnify against any cases that may come to light after they have left your practice. Unlike the occurrence-based indemnity offered by Dental Protection, claims-made insurance only pays out whilst the policy is in force. Once the contract of insurance providing indemnity has lapsed no payout will be made against a claim unless additional retrospective tail-cover has been purchased.

Most claims arise some years after the treatment was provided. Unless the associate has occurrence-based indemnity, such as that offered by Dental Protection, the practice owner needs to protect themselves against any vicarious liability by ensuring that suitable arrangements have been put in place for any period that the associate works for you.

In conclusion, the policy you describe is a valid type of insurance. However, practice owners should consider their own potential vulnerability and ensure that associates have appropriate arrangements in place.

Q. I am asking my nurse to write up the notes in the patients' clinical records. Does she need to sign every entry on the record card?

Whilst a signature of a dental nurse indicates her presence on that particular day, it does not necessarily have to be an actual signature; it could just be a note of his or her name.

A signature itself does not necessarily indicate the original source of the information to which it relates because the records entered by the nurse will have been dictated by the dentist and s/he alone will be responsible for verifying the accuracy of what is written.

To sum up then, there is no reason why the name of the nurse should not be recorded on the clinical records, but there is no necessity for there to be a definitive signature.

Record keeping can be a team effort and what is required is an appropriately detailed record. The Dental Council's ethical guidance refers to adequate and accurate records of all matters relating to their treatment of patients.

Dental Protection Limited (registered in England No. 2374160) is a wholly owned subsidiary of The Medical Protection Society Limited (MPS) which is registered in England (No.36142). Both companies have their registered office at 33 Cavendish Square, London W1G 0PS.

 

‘DPL membership’, ‘DPL member’, ‘Dental Member’ and ‘Dental Protection member’ refer to a dental member of MPS. Dental Protection Limited serves and supports the dental members of MPS, with access to the full range of benefits of membership which are all discretionary and set out in MPS’s Memorandum and Articles of Association. MPS is not an insurance company. 

 

This site uses cookies. By continuing to browse the site you are agreeing to our use of cookies. Find out more