Ask Dental Protection

I am an associate working in a small practice. In the past, if a dental nurse was off sick the practice manager (who worked as a dental nurse for many years) would work with me, but she is not registered with the General Dental Council. If the situation arises again, should I refuse to see any patients (and cancel their appointments) in the absence of a registered nurse?

In the event of your registered dental nurse being unwell, anyone standing in for her would either need to be registered with the GDC or in training for a registrable qualification. The GDC’s guidance states that when treating patients you must make sure there is someone else present in the room, preferably a registered team member who is trained to deal with medical emergencies. This might well mean cancelling patients, if for example you are unable to treat your patients safely and effectively without a nurse and a registered agency nurse could not be employed at short notice.

It is sensible to have a contingency plan in place. The law states that it is illegal for a non-registered person to be involved in the actual practise of dentistry and the GDC has been quite clear that to allow a non-registered person to assist in the surgery could lead to an investigation into your fitness to practise.

You can find out more about the indemnity obligations for agency-based dental nurses here:

• Why do I need indemnity cover?
• Do my dentist's own indemnity arrangements cover me?
  
  

Provided the practice’s cross-infection standards are within the normally agreed requirements, there is no reason why your receptionist should be vaccinated.

The vaccination is only required for those clinicians who are likely to come into contact with Hepatitis B and the patients who carry the disease. As such it is usually recommended that only those individuals who work chairside are required to have the vaccination.

If your receptionist is also registered as a dental nurse and helps in the surgery from time to time, vaccination would be mandatory. However, a dedicated receptionist whose work does not involve any clinical activity does not require vaccination.

Given the popularity of Facebook and its usefulness in the promotion of business, many dentists have been somewhat cautious in promoting themselves in this way, perhaps through fear of breaching the General Dental Council’s guidance.

In reality, however, a Facebook page is no different to any web-based advertisement other than the fact that access to the page can be restricted. The contents of the Facebook page must conform to the GDC’s guidance and that of the Advertising Standards Authority; they must be legal, decent, honest and truthful. The contents of the page should not make any statements that cannot be substantiated, or would be regarded as misleading.

It is quite possible to indicate to any patient who wishes to subscribe to the friends list that their name will be displayed on the website and will be visible to other members of the public. Their consent to this disclosure can then be obtained.

For obvious reasons no other personal information should be displayed and certainly no indication of any treatment that has been provided for a patient unless they have provided their specific written consent.

If a practice is considering whether a Facebook page is appropriate, it may wish to give thought to whether it will be possible for a ‘patient’ to use the Facebook page to post adverse comments that can be seen by other friends.

Some disgruntled patients are seeking to use the internet as a forum to post their complaints. Thus if a practice is seeking positive reviews in this way, it may also receive negative comments. The practice may wish to consider how easy it would be to remove such comments. 

With a little care, therefore, the use of a Facebook page to promote the practice should not necessarily cause the GDC any undue concern.

The Department of Health guidance Conscious Sedation in the Provision of Dental Care states in section 15 that for an adult receiving nitrous oxide/oxygen inhalation sedation, the requirement that a responsible adult escort must accompany the patient home is less rigid and each patient must be assessed individually.

 Further into the document, at section 18.2 it advises that adult patients who have received nitrous oxide and oxygen inhalation sedation may leave unaccompanied at the discretion of the sedationist.

It is important to ensure that pre- and post-operative assessments are recorded to support the decision to proceed with treatment and discharge without the presence of an accompanying responsible adult. If you ask your dental nurse or the receptionist to telephone the patient to see that they are safely home and comfortable after their treatment, you should also note their response in the record.

There are some aspects of the provision of dental treatment that the General Dental Council’s Scope of Practicesimply does not cover. Acupuncture would be a good example. In the past the GDC has been a little cautious about its use in dentistry, presumably because it is not quite sure where it fits in. The use of holistic medicine and hypnosis would be other good examples. This lack of clarity from the GDC is not helpful, although it would probably argue that there does have to be a point where the scope of practice has to be at the registrant’s discretion.

If a registrant is to consider using these techniques, they would need to demonstrate that they are competent to do so and have acquired the necessary training. A training course run for DCPs by a UK dental hospital would probably be regarded as appropriate training.
The difficulty would be how you might decide to use this additional skill in the dental surgery. As a hygienist, using acupuncture as some form of relaxation technique would not seem unreasonable. If you intended using acupuncture for the treatment of TMJ dysfunction, this would be quite a different matter. For obvious reasons this type of treatment is a long way outside the scope of practice for a hygienist.

The use of acupuncture for a condition that was unrelated to dentistry would also be unacceptable. Indeed it would be necessary to ensure that a clear distinction was made between this alternative practice and the practice of dentistry. You could not, for example, advertise yourself as being a hygienist and in some way give additional credence to the treatment you provide from your GDC registration. On these occasions you would need to obtain additional indemnity from another provider.

There are overlaps which tend to complicate matters further. It is, for example, the duty of all clinicians to provide advice on smoking cessation and to encourage patients to give up the habit. In the past, acupuncture (rather like hypnosis) has been shown to be quite successful in this respect. It is debatable whether the use of acupuncture in such a way is part of the practise of dentistry, or outside the dental field.

From Dental Protection’s point of view, provided you are using acupuncture as part of dental treatment, there is no particular difficulty accessing indemnity as a benefit of dental membership. This may change in the future if the GDC should decide it falls outside the scope of practice for a hygienist.

Any DCP members finding themselves in a similar situation are invited to contact Dental Protection for advice during office hours on 0845 608 4000.

You could be criticised if you did not undertake ‘due diligence’ to satisfy yourself that the credentials, training and qualifications of the company’s employees’ opinions and recommendations were appropriate. Did you, for example, check if their name appeared on the orthodontic specialist register?

The answer also depends upon whether or not the case(s) was suitable to be treated with aligners, or whether another orthodontic treatment approach might have been more appropriate. Further questions arise as to whether or not you considered (or discussed with the patient) these other treatment options, or perhaps different aligner techniques, and how well you documented these conversations in the clinical records, correspondence, etc. It may even be asked whether a specialist opinion should have been obtained.

If it is subsequently alleged that your case assessment and/or treatment plan was negligent from a clinical perspective, this situation would be no different to any other orthodontic claim and would be managed as such. If it is argued that you could or should have known it was unwise to proceed with the use of this particular aligner system, much would depend upon when you started the treatment and whether or not you did so after rumours started circulating about the viability of the company in question.

If you had sought and received reassurances in this latter regard, and were able to demonstrate them through records that you have retained, this may well be sufficient to deal with any challenge raised on that basis.

Read our briefing document on this and associated aligner issues here [internal to position statement].

 

Dentists may be instructed as experts in relation to two separate types of cases. Most dentists commence carrying out expert work in personal injury cases where the claimant is often the victim of some type of accident. The expert is normally asked to examine the claimant and to provide a report on the claimant’s current condition and prognosis. In providing such a report, the expert is expected to be able to advise the court on what injuries were specifically caused by the accident. 

The other type of report which experts carry out, and which Dental Protection frequently commissions, are on causation and liability. These are provided in cases of medical and dental negligence when the expert is asked to provide an opinion on whether they believe the clinician has acted in a way which would be considered acceptable by a reasonable body of similar clinicians, and if not what harm if any has flowed from the treatment in question.

There are various courses available, details of which will be available online or from the Law Society in London. Dental Protection has an advice booklet on providing expert reports and second opinions which is available here

It has come to light that a dental nurse colleague has failed to renew her registration with the GDC, but is still working clinically. How should this situation be managed by the practice principal? In the meantime, is my registration compromised if she continues to assist me in the surgery?

 
Clinical members of the dental team must either be on the GDC register or engaged in a course of training that leads to registration. The only exception to this rule would be where a dental nurse was waiting to start a training course for which s/he has registered. Clearly in the situation outlined here, the dental nurse meets neither of those criteria and s/he would then be vulnerable to an allegation of the illegal practise of dentistry.

From the practice’s point of view, it should either suspend the dental nurse or move him or her to other non-clinical duties (reception, administration, etc.) until such time as they have been able to contact the GDC and their name once again appears on the DCP register. This usually takes a few days from the receipt of the re-application – provided there are no other significant circumstances.

Allowing an unregistered dental nurse to continue working in a clinical setting would leave the dentist or hygienist open to criticism at the GDC.

In reality both the dental nurse concerned and the practice should never have allowed the situation to occur in the first place. The GDC offers all registrants the facility of paying their registration fee by Direct Debit. It is advisable for a practice to keep a copy of every registrant’s current certificate of registration and also details of professional indemnity. The file of both documents can then be reviewed on a yearly basis.

I'm aware that in NHS general practice I can prescribe from the list in the Dental Practitioners’ Formulary, in a hospital setting I can prescribe any drug in the British National Formulary(BNF). What are the regulations with private prescriptions?

A dentist’s right as a professional to prescribe medication is laid out in the Medicines Act. As you have already pointed out, to prescribe medication within the NHS in general dental practice there are NHS prescription forms and dentists are restricted to prescribing from the Dental Practitioners’ Formulary (DPF), the list of which appears at the back of the British National Formulary (BNF)

In general terms you may be right that you can prescribe any drug in the BNF in a hospital setting. However, usually in a hospital environment, prescribed medication is dispensed from the hospital pharmacy under the local rules of the hospital and under the umbrella of a consultant who may be medically trained and is responsible for patient care.

If a private patient requires a prescription in general practice, dentists are not permitted to provide an NHS prescription form; they are required to write a private prescription. Privately, there are no limitations on the type or dose of medicines you choose to prescribe. However, you should be aware of the ethical obligations as laid down by the General Dental Council in its Standards document.

Dentists are required to be trustworthy and to treat patients within their best interests. In addition, the GDC’s guidance details the obligations for dentists to prescribe responsibly and in the best interests of patients.

Drugs not included in the DPF list should only be prescribed if there is a genuine dental need which can be fully justified. If there is any question over the genuine dental need for a prescription, it would be advisable to liaise with the patient’s medical practitioner.

It would be viewed as inappropriate and unacceptable to prescribe medications for personal use (self-prescribing). It could also be viewed as inappropriate to prescribe medications for close friends or family. Pharmacists do have an obligation to raise any concerns they have if they consider prescriptions to be inappropriate.

Dental Protection’s risk management module 36, Drugs and Prescribing, is available from our Prism educational platform

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, it would be reasonable to accept that situation but always to ensure the drugs are in date and adequate for emergency purposes.