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Guidelines on prescribing

20 July 2018
A new patient (Mr T) attended a new practice for an initial examination and an OPG radiograph was taken. The dentist informed Mr T that this x-ray had shown deep decay under a crown 16, and that the prognosis of 46 was also very poor because of considerable decay. Treatment options for both teeth were discussed and well documented in the clinical records, and Mr T decided to have both teeth extracted.

The upper tooth was extracted uneventfully, but unfortunately Mr T returned as an emergency with a dry socket. The socket was irrigated and packed. 

Mr T was allergic to penicillin and was already taking a course of metronidazole tablets, which had been prescribed by a medical practitioner whom he had visited a few days earlier. Because Mr T remained in considerable pain, the dentist decided to prescribe a further course of antibiotics, clindamycin.

Unfortunately the patient, who had a long standing history of irritable bowel syndrome, went on to develop pseudomembranous colitis and an overgrowth of clostridium difficile, resulting in severe abdominal pain, nausea and diarrhoea. He was hospitalised and needed to undergo complicated and unpleasant medical treatment.

Six months later, the dentist received a letter from solicitors acting on behalf of Mr T, requesting a copy of the patient records. This was followed by a letter of claim, alleging negligence on the part of the dentist. It was accompanied by an expert report that pointed out that the patient notes were “very sparse” and recorded no clinical reasons why the prescription of the additional antibiotics was necessary.

In addition, the national guidelines for this jurisdiction advised that the antibiotic prescribed was not regarded as being the third choice antibiotic for the treatment of dental infections; the guidelines in that jurisdiction suggested clarithromycin as the alternative antibiotic of choice. The expert concluded that the dentist had failed in his duty of care to the patient. The adverse outcome in this case could have been avoided if current guidelines had been followed.

The allegations were found to be indefensible and the case was settled for a modest amount.

Learning points
There is a legal and ethical obligation for all practitioners to comply with contemporary standards of care:

  • Provide justification in the notes for all treatment undertaken.
  • Ensure that the medical history is current and up to date.
  • Consider fully the patient’s past medical history.
  • Follow evidence-based guidelines on prescribing in the jurisdiction in which you practise.
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These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
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