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Diagnosis and treatment planning

  • Q
    Can a dental hygienist or therapist undertake examinations and provide treatment for NHS patients under my dentist’s performer number?
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    11 May 2016

    When new guidance is introduced this can produce a period of uncertainty for registrants, as they seek to understand how the changes may affect their practice.

    Under direct access it is possible for dental hygienists and therapists to see a patient for treatment that would be within your normal scope of practice without first obtaining a prescription from a dentist. But, certain treatment, for example the use of local anaesthetic and tooth whitening, will still require a dentist’s prescription.

    The procedures that you can provide under direct access have to be interpreted with reference to the existing guidance. GDC’s Guidance Scope of Practice is still current and this document specifies that hygienists / therapists cannot diagnose disease.  Therefore, it is not currently within your scope of practice to see patients on either an NHS or private basis to perform check-ups or examinations, regardless of the circumstances. It follows from this that at the moment you cannot provide check-ups for patients under your dentist’s performer number.

    Click here to read our briefing document on Direct Access.

    The GDC has also produced a statement in relation to direct access together with frequently asked questions and you may wish to review this information.

  • Q
    A new patient has registered with our NHS practice and has requested that she remains with the hygienist at her old private practice. Can I refuse or do I have to agree to the patient’s wish?
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    11 August 2015
    It is clearly easier to look after a patient’s care when all the practitioners are located at the same address.

    However, there is no legal reason why you should not allow the patient to see her existing hygienist and indeed prescribe to a hygienist at another practice if you can satisfy yourself that the hygienist works in a way which is acceptable to you and they will co-operate with you in the patient’s overall treatment plan.

    It is possible that the patient has an issue with the dentist who was treating her at the old practice. Your prescriptions to the hygienist at the old practice could be criticised by the dentist there and of course that would be in nobody’s interest.

    It might be a good idea for you to write a gentle letter to the patient explaining why you would prefer the hygienist at your practice to carry out the treatment in accordance with your established team approach.

  • 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.

    Find out about the benefits of Dental Protection Xtra, our practice rewards programme that takes a team approach to dentistry and offers risk management education for all team members. Practices subscribing to Dental Protection Xtra receive a range of free and discounted risk management material from Dental Protection and leading providers such as Croner and schülke. Since the purpose is to lower your risk, team members in a practice which subscribes to Dental Protection Xtra will receive free or discounted individual membership.
  • Q
    How will direct access affect the role of an orthodontic therapist?
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    11 May 2016

    1. Does the new Direct Access Guidance affect whether an Orthodontic Therapist needs to work under the supervision of an orthodontist?

    The GDC guidance on direct access relates to whether DCP’s can work without a patient initially being seen by a dentist and a prescription provided.  The guidance does not make any reference as to whether orthodontic therapists should be supervised when working and, as previously, orthodontic therapists are perfectly entitled to work without a dentist on the premises. The decision as to when an orthodontic therapist can work  without a dentist being present is, to a large extent, a matter of personal choice depending upon treatment being provided, competency and experience. 

    2. By allowing direct access to orthodontic therapists does this mean that they can provide Index of Orthodontic Treatment Need (IOTN) screening in private dental practice or only as part a public health initiative?

    The Direct Access Guidance introduces the option for orthodontic therapists to carry out IOTN screening, without a prescription from a dentist, subject to having completed appropriate training but it also refers to this being as part of a structured public health programme. 

    The GDC has now clarified that orthodontic therapists can carry out IOTN screening direct to patients (should a practice chose to organise their service in such a way) or as part of a structured public health programme. The intention of the recommendation to Council was for the task itself – that orthodontic therapists can undertake IOTN screening without the patient having to see a dentist first. The GDC’s website has been altered to include this clarification.

    3. Will my membership subscription increase if I expand my role to undertake IOTN screening?

    Not if you continue to work the same hours and your position has not changed in terms of whether or not you own and operate a practice of your own, employ staff and/or contract with third parties for the commissioning of services to be provided by others.  Our dental subscription rates are reviewed annually, and members are notified of the new subscription at the time of their membership subscription renewal.  No additional subscription increases are being made as a result of direct access.

     4. What training do I need to undertake before I am able to undertake IOTN screening?

    The GDC guidance stresses the need for orthodontic therapists to be trained and competent to undertake IOTN.  They have advised that training can either be undertaken through an accredited course, or can be carried out in-house.   When accredited external training is not undertaken, any in-house training taken should be carefully documented, noting the dates it was undertaken and what the training involved at each stage.  Additionally, irrespective of whether initial training is external or in-house, it would be appropriate to keep a log of a number of cases initially on which IOTN scoring was reviewed by another experienced colleague to demonstrate competency.

    As IOTN scores may form the basis on which a patient may, or may not, be accepted for orthodontic care; where an IOTN score is borderline, it may be sensible to seek a second opinion, irrespective of the amount of training or experience of undertaking IOTN scoring.

    Click here to read Our briefing document on Direct Access.

  • Q
    I have just completed the Invisalign certification course and want to start treating patients in my surgery. Does my dental membership cover this?
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    27 August 2014
    A normal DFU/DFN dentist grade subscription with Dental Protection provides access to indemnity for all aspects of general dental practice, including the use of techniques such as Invisalign. There is therefore no need for you to obtain any additional indemnity or limit the type of treatment you provide in this respect. Your membership certificate displays your current subscription grade.

    For details of UK membership categories, click here

  • Q
    I work part-time in two practices as a dental hygienist and therapist. I have always assumed my employer is ultimately liable for the work I carry out if one or both of us gets sued.
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    11 May 2016

    Is that no longer the case now, and what happens in the other practice where I work two sessions a week on a self-employed basis?

    In some circumstances your employer can be held to be vicariously liable for any negligent acts and omissions on your part. That remains the case even if patients see you without first seeing a dentist, and even if a dentist is completely unaware of the treatment you are providing for a patient. While this does not prevent a patient suing you too (i.e. naming you personally as a defendant to the claim), it is likely that a patient would direct a claim to your employer in the first instance.

    The situation in the other practice, where you are working on a self-employed basis, could well be different as it is likely that the practice would disclaim any liability for your actions, in particular where treatment was carried out without input from another clinician. If you choose to carry out treatment in the absence of any direction from a registered dentist, you are solely responsible for your own acts and omissions.

    Click here to read our briefing document on direct access.

  • Q
    I'm a hygienist. If a GDP refers a patient to me and then leaves our practice, is the referral still valid? Or should a currently employed dentist rewrite the referral?
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    30 June 2015

    The referral from the GDP is still valid in this situation providing there has not been an unduly large time lag between the referral being written and the patient being seen by you.

    At the time of creating the original referral, the patient would have been examined and the GDP would have made a referral on the basis of those clinical findings. Those clinical findings and any associated tests and investigations form part of the patient’s clinical record and this does not automatically leave the practice when the dentist in question moves on.

    There may, in rare circumstances, be a wide variation between what is written in the original referral and what the new dentist considers should be written. However, care plans are not set in stone and can be modified. A simple discussion (documented within the notes) between the hygienist and the new dentist should be sufficient to ensure continuity and appropriateness of care.

    It is important to remember that the patient is at the centre of the process and their consent is required for any changes which may arise in respect of the originally planned treatment.

  • Q
    Is an aspirating technique essential for administering local anaesthetic as an inferior dental block?
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    17 July 2014
    In general terms, it is good practice to use an aspirating technique, especially for inferior dental block analgesia, if not for all local anaesthetics.

    If you believe that aspirating is a part of the acceptable technique for ID blocks, then you should ensure you use an aspirating syringe. If you are working in somebody else’s practice, you should ask whoever supplies your equipment if they would make aspirating syringes and suitable cartridges of local anaesthetic available.

    If you are not provided with these tools, then you would have to make a decision as to whether you could continue to work in a setting where it is not possible to treat patients in a manner you consider to be correct.

  • Q
    Is it okay for me to use an online radiograph interpretation service?
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    08 September 2015

    As with any other referral, it is the responsibility of the referring dentist to establish the suitability of the person/service to whom/which the referral is made. Even though teledentistry relies on digital files being exchanged between colleagues, the principle is the same. It is important for you to know who will be responsible for interpreting the patient’s records, as well as establishing that they are registered and what qualifications they have to provide this service.

    To protect the patient, it is also important to know that the distant colleague is suitably indemnified. Dental Protection recommends that members should contact us first if they are considering using a teledentistry service situated outside the UK.

    In addition, Dental Protection recommends that:

    • All patients are made fully aware of the involvement of any other named person(s) in their care and treatment, through teledentistry, and also that they properly understand any constraints, limitations or risks introduced as a result
    • You establish written protocols between yourself and any other clinician/organisation with whom/which you have any kind of teledentistry relationship. These protocols should specify the parameters of the relationship, the role and responsibility of each party, the arrangements in place for data protection, and quality assurance
    Read our position statement on Teledentistry
  • Q
    Our NHS practice has a ‘policy’ which says that the hygienist will only see patients on a private basis. Is this acceptable now?
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    18 September 2014

    Looking at this principle together with standards 1.7.2, 1.7.3 and 1.7.4 there appears to be very little room for doubt. Patients must be given a real choice, and a practice cannot hide behind a ‘policy’.

    If the practice uses the services of a hygienist, the practice may give the NHS patient an option of seeing the hygienist privately. However, if the patient does not want to have the treatment privately, then under the terms of NHS contract, there is an obligation to provide all necessary treatment on the NHS.

    The GDC recognises that patients expect their interests to be put before financial gain and business need. Since the GDC’s function is to protect the patient it is likely to take dim view of those who do not meet patient expectations. ‘You must always put your patient’s interests before any financial, personal or other gain’ 1.7.1

    The NHS does accept that patients may choose a private option - for example if in the opinion of the dentist, the treatment is not clinically necessary and the patient is insistent on having this done or simply because the patient preferred to have the treatment provided privately.

    If a private charge is to be made for scaling and polishing, the mixing rules must be adhered to - with an FP17 DC form signed to confirm the choice made by the patient. In those circumstances, there is no cause for concern.

  • Q
    What does ‘Direct Access’ mean?
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    11 May 2015

    Direct Access means patients have been given the option to see a dental care professional (DCP) without having first seen a dentist and without a prescription from a dentist. From 1 May 2013, dental hygienists and dental therapists have been able to see patients directly. This means the requirement to carry out certain treatments under prescription from a dentist is removed.

    Dental nurses and orthodontic therapists are also able to see patients directly in certain circumstances. Clinical dental technicians can see patients directly only for the provision and maintenance of full dentures, and dental technicians continue to carry out most of their work to prescription, except repairs.

    Only dentists can carry out a full range of dental treatments and prescribe local anaesthesia and the full range of prescription-only medicines.

    Click here to read our briefing document on Direct Access.

  • Q
    What does taking a ‘holistic approach’ mean?
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    18 September 2014

    It means that when assuming responsibility for the care of a patient, a registrant must be mindful of the impact that any decision taken about oral health may have on the general health of the patient. Taken simply it means that no decision about an individual item or items or treatment can be made without considering the wider implications for the patient.

    This standard (1.4) is particularly relevant when patients seek one off cosmetic treatments that have limited or no therapeutic benefits. It also means that when seeing a patient on referral for an item of treatment, an overview of the oral health of the patient should be taken and the treatment plan discussed in that context, rather than in isolation.

  • Q
    What has the GDC said about patients having direct access to DCPs and how will the general public be protected?
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    11 May 2016

    The GDC has stated that the new arrangements have been made with patient safety as an up-most priority. Registrants treating patients directly must only do so if appropriately trained, competent and with adequate indemnity or insurance arrangements in place. They should also ensure that there are adequate onward referral arrangements in place and they must make clear to the patient the extent of their scope of practice and not work beyond it.

    It should be remembered that to ensure patient safety:

    • All registrants must be trained, competent and indemnified for any tasks they undertake
    • All registrants must continue to work within their scope of practice regardless of these changes
    • All registrants must continue to follow the GDC’s Standards for Dental Professionals
    • Dental care professionals do not have to offer direct access and should not be made to offer it

    Dental hygienists and dental therapists

    Dental hygienists and dental therapists can carry out their full scope of practice without prescription and without the patient having to see a dentist first. They must be confident that they have the skills and competences required to treat patients directly before doing so. A period of practice working to a dentist’s prescription is a good way for registrants to assess this.

    Registrants who qualified after 2002 covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything. However, many of these registrants will have addressed this via top-up training, CPD and experience. Those who qualified before 2002, or who have not applied their skills recently, must review their training and experience to ensure they are competent to undertake all the duties within their scope of practice.

    Dental nurses

    Dental nurses can participate in preventive programmes without the patient having to see a dentist first.

    Orthodontic therapists

    Orthodontic therapists can continue to carry out the majority of their work under the prescription of a dentist and can carry out Index of Orthodontic Treatment Need (IOTN) screening without the patient having to see a dentist first.

    Clinical dental technicians

    Clinical dental technicians can continue to see patients directly for the provision and maintenance of full dentures only and should otherwise carry out their other work on the prescription of a dentist. However, the GDC stated that with the potential for further training for CDTs this decision could be reviewed.

    Dental technicians

    The work of a dental technician (other than repairs) should continue to be carried out on the prescription of a dentist. There has been no change to their Scope of Practice.

    More detailed guidance on the implications for individual DCP registrant categories is provided on the GDC website (Guidance on Direct Access).

    Click here to read our briefing document on Direct Access.

  • Q
    When an orthodontist refers a patient back to me to extract healthy teeth as part of their treatment plan, can I decline and ask them to carry out the extractions themselves?
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    25 August 2015

    Removing teeth for orthodontic purposes is very much part of what a referring dentist would be expected to do. Whether it is fair or not, the patient’s own dentist would normally be expected to provide any extractions requested within an orthodontic treatment plan.

    It may well be that you have a colleague who would be happy to carry out the extractions on your behalf. To expect the patient to see another practitioner simply because you are refusing to provide this service may be considered an inconvenience and could possibly even stretch to being a breach of contract if the extractions were associated with NHS treatment.

    To withdraw from providing a particular form of routine treatment may not be considered reasonable and in any of your patients’ best interests. Extractions would be considered part of mainstream dentistry and you should not decline to provide this element of treatment that is also in the best interests of the patient you originally referred.

    If you are uncertain about the reason for the extractions, you may wish to clarify this with the orthodontist.