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Ask Dental Protection

We receive hundreds of enquires every week, and we publish some of the frequently asked questions on this page. These may not always provide the complete answer in your own situation, and members are invited to contact us for specific advice.
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  • Q
    The practice owner has told me to economise the use of local anaesthetic by using it only in those cases where the patient will be in extreme pain. How can I decide what I should do?
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    09 June 2015

    The practice owner has told me not to use local anaesthetic routinely for fillings and has asked me to economise by using it only in those cases where the patient will be in extreme pain. How can I decide what I should do?

    Most patients have an expectation that their dentistry will either be pain-free or that any pain will be managed effectively. Therefore, the provision of a local anaesthetic for a given procedure will initially involve a discussion with the patient about the nature of the procedure being contemplated and what they may expect.

    This is an issue of consent. As a clinician, you should not impose your views and provide treatment without local anaesthetic simply because you have considered the matter (as requested by the practice owner) and concluded that the procedure will not be painful and does not require local anaesthetic. It is incumbent upon clinicians to respect patient autonomy and an individual’s right to make decisions about their treatment and this would extend to a decision about local anaesthetic. 

    In any case, the patient’s medical history initially needs to be checked and updated before considering the type of local anaesthetic to be administered.

    Our advice booklet on consent is available here 

  • 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?
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    11 December 2014
    Whilst a signature of a dental nurse indicates his or 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.

  • Q
    Where can I find additional information to help explain these changes to patients?
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    02 December 2014

    See the British National Formulary (BNF) website or the NICE website. 

  • Q
    Will I still be able to prescribe antibiotic cover on an NHS prescription?
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    02 December 2014

    Yes you will, in the sense that the drug will still be included in the DPF. But this alone does not of course mean that this justifies its use for any NHS patient – this is still a clinical decision, which needs to be made for each individual patient, in the light of current best practice.

    Even when the use of antibiotic cover is clinically indicated under current guidelines, you should not use an NHS prescription to order antibiotics if the treatment in question is being provided privately.

  • Q
    Five years ago, I took over a patient from a retiring colleague.
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    02 December 2014
    His records make reference to a mild heart murmur and because of this I have always insisted that the patient had antibiotic cover whenever I treated him. He has always made it very clear that he was taking the antibiotics under protest, pointing out that the previous dentist had never felt it to be necessary. I am worried about how he will react if I now tell him that he quite possibly never needed antibiotic cover in the first place. What should I do?

    The important thing is to be open and honest with your patient, rather than ducking the issue. Your patient will certainly not be happy if you continue treating him with antibiotic cover and he later finds out from other sources that the NICE guidance was published some time earlier, but you chose to ignore it. You should explain that you were only acting in what you genuinely believed to be his best interests, following the expert guidance that existed at the time.

    Explain that this guidance has now changed in the light of new scientific evidence – tell him about the present difficulty of having two authoritative sources of advice saying different things. He may simply be delighted at the prospect of not having to take antibiotics for his future dental care – but in any event you have a duty to share what you know with him, and a failure to do so could leave you at risk anyway.

    This question does, however, raise a separate issue – the patient‟s records state that he has a mild heart murmur – but it seems that you „inherited‟ these records from the previous dentist. How much do you really know yourself about the nature and significance of this murmur? And what steps have you taken to find out more?

  • Q
    My self-employed sessional hygienist is not prepared to treat a patient without antibiotic cover
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    02 December 2014
    even though the NICE guidelines suggest that he no longer needs to be considered ‘at risk’ of infective endocarditis. Can I insist that she follows my instruction to adhere to the new (NICE) guidance? And who would then be ultimately responsible if we did follow NICE, and something went wrong?

    As GDC-registered clinicians, you and your hygienist each have your own separate duty of the care to the patient. You could both be named as defendants in a civil (clinical negligence) claim and are each separately accountable to the GDC for your own acts and omissions. However, as the treating dentist you are ultimately responsible for directing and overseeing the patient‟s treatment and ensuring that the patient is treated safely and to an acceptable standard. You would be accountable and almost certainly, have a degree of vicarious liability for any failure in that responsibility - even if the hygienist was self employed. If the hygienist were an employee your vicarious liability would be inescapable. If the patient was treated without antibiotic cover, and later did suffer from infective endocarditis (IE), both you and the hygienist would have a good argument that in respect of your failure to provide antibiotic cover, you cannot have been be negligent since you were jointly following a reasonable body of opinion.

  • Q
    What happens when the patient’s cardiologist insists that in spite of NICE guidance, antibiotic cover must still be provided?
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    02 December 2014

    Each clinician has his/her own separate duty of care to the patient. An opinion expressed by the patient's cardiologist (or orthopaedic surgeon, or GP) is a valid consideration as part of the overall mix of information, but it is not in itself definitive. You should certainly not rely upon a second-hand (hearsay) account of what the cardiologist may or may not have said to the patient.

    Unquestioningly following an opinion from a single clinician, even if this has been confirmed in writing, when it clearly conflicts with guidelines issued by an authoritative body, is inadvisable and may be difficult to defend. This conflict of opinion is something that needs to be discussed with the clinician concerned, and also with the patient, as part of a proper consent process.

    If you do not believe that you should be prescribing antibiotics in the specific circumstances of an individual patient, then you should not do so. Explain your decision to the patient and keep a full contemporaneous (ie. made at the time) record of this conversation in the patient‟s clinical notes.

  • Q
    I have concerns that following the NICE guidance on antibiotic prophylaxis for endocarditis is no longer appropriate
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    02 December 2014
    and that it may be harmful not to provide antibiotic cover – should NICE still be followed?

    The NICE guidance on antibiotic prophylaxis is still current and represents the most up to date approach based upon the weight of available evidence. There is a recent study which suggests that rates of infective endocarditis have risen in recent years but it is unclear as to what the cause of this is.

    Following on from the research paper, NICE is to review the present guidance to establish if there would be any justification for updating the current recommendations on the basis of the findings from the study. In the meantime, the advice from NICE is that the guidance remains unchanged.  

  • Q
    I've just started in a new practice that is owned by a dentist who belongs to a different defence organisation. He told me I need to join his organisation because my dental nurse will not have access to indemnity when I'm supervising her. Is that true?
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    02 December 2014

    No, it certainly isn't true. A dental member who is working in general or specialist dental practice could be held to be vicariously liable for the negligent acts and omissions of a dental nurse working under their direction and supervision even if they are not the actual employer of the dental nurse.

    Reflecting this, your membership already covers your potential vicarious liability for any dental nurse who is working under your direction and supervision. What makes our approach different from that of other defence organisations, however, is that we offer several additional categories of membership in which an employer/practice owner can provide access to indemnity up to five dental nurses or dental technicians employed by them, in respect of negligence claims, whether or not they are working with them or directing/supervising them at the time of an adverse incident. We believe this flexible approach is fairer to practice owners, associates and dental nurses alike.

  • Q
    Are there any limitations in the role of a treatment co-ordinator if the individual is not registered with the General Dental Council?
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    01 December 2014

    Some practitioners use the services of a treatment co-ordinator to provide the patient with information about their treatment and to answer their questions, although it would still be for the dentist and treating clinician to obtain consent rather than another member of the team. For obvious reasons, the treatment co-ordinator would not be in a position to provide any clinical advice.

    The role of the co-ordinator can sometimes be helpful in showing patients information about various treatment options which have already been discussed with the dentist. A treatment co-ordinator usually has more time to spend with the patient and some patients are more inclined to ask questions of a treatment co-ordinator than they are to ask questions of the dentist. However, there may be other patients who do not want to discuss any aspects of their possible treatment with anyone other than the dentist.

    If a patient brings a civil claim in negligence, a lack of detailed contemporaneous records of the consent process may mean a claim that could otherwise be defended has to be settled.

    Any practitioner planning to use a treatment co-ordinator will need to work closely with them to ensure there is no potential for miscommunication or misunderstanding and that everyone is aware that the ultimate responsibility for taking the patient appropriately through the consent process lies with the treating practitioner.

    Click here to see the benefits of DPL Xtra – an indemnity programme designed to protect the whole practice.