Ask Dental Protection

As a registered dental hygienist, I wanted confirmation that I am allowed to administer these drugs in an emergency. Is this also the case for dental nurses?

A medical emergency can occur at any time and every member of staff, not just the registered team members, has a role to play if a patient collapses or if there is any other kind of medical emergency. The General Dental Council advises that all members of staff who might be involved in dealing with a medical emergency should be trained and prepared to deal with such at any time and practise together regularly in a simulated emergency so they know exactly what to do. There should always be arrangements for at least two people available in the practice to deal with a medical emergency when treatment is planned to take place.

Any DCP involved in the management of a patient in an emergency should provide support to the patient working under the direction of the dentist. It is possible that a situation arises where a dental hygienist is working in the practice without a dentist being present. However, it would be expected that in such circumstances the dental hygienist would be accompanied by another member of staff who should be competent in assisting in the event of a medical emergency.

In these circumstances the dental hygienist would need to make a clinical decision based on their own knowledge and competence on how to deal with the emergency. A hygienist would be expected to be competent in maintaining a patient’s airway and administering oxygen and to give directions if necessary to the nurse or receptionist to make a call to the paramedics. Whether or not a hygienist administers any form of drug therapy will depend on whether they are in a position to make a diagnosis and have the competence and experience in administering these drugs.

Normally a dental nurse will have had sufficient training to be able to assist a dentist or dental hygienist in the event of an emergency and it is obviously incumbent on the practice owner to ensure that all members of staff have regular training in CPR.

However, if the dental nurse has had previous training and experience in CPR and was the only person available to deal with a medical emergency, then as long as the nurse is working within their area of competence and expertise it would be difficult to criticise that nurse if they were genuinely acting in the patient’s best interests when no one else was available.

The Resuscitation Council guidelines contain detailed information about basic and advanced life support for adults, paediatrics and the newborn. Also included are guidelines for the use of Automated External Defibrillators and other related topics.

The General Dental Council’s advice indicates that however a clinician is being promoted, either inside or outside of the practice, the wording of that promotional material must be legal, decent, honest and truthful. Business cards would be regarded as promotional material and therefore must comply.

Assuming that your Diploma in Dental Hygiene has been registered with the GDC, you are entitled to use the shortened version of this diploma on your business cards. Similarly, if you have any additional advanced qualifications (BA, BSc, etc.), these may be included too. However, you need to be careful not to potentially mislead patients by including details of qualifications that are unrelated to dentistry.

It would also be advisable to indicate that you are a dental hygienist as part of your job title, simply to avoid any misunderstanding.

It is every General Dental Council registrant’s duty to ensure they are competent and have received adequate training for the tasks they are to perform. Dental nurses certainly do need to be trained in sedation to be involved in its administration, and all team members need to be fully up to date with their resuscitation skills to deal with emergencies. It would be expected these skills would include elements of the immediate life support protocols relevant to the age group of patients being treated.

It would be expected the GDC would refer registrants to the Intercollegiate Advisory Committee on Sedation in Dentistry report on April 2015 and says it is important that all registrants intending to be involved with the provision of sedation are conversant with this. The Standards report makes reference to suitable monitoring. Another source of relevant information would be the Resuscitation Council.

Registrants can subscribe to regular email updates via the GDC website. In this way it is possible to keep abreast of all developments at the Council.

It is desirable to tell patients what your complaints procedures are, in simple terms, either in your practice leaflet or (if appropriate) in a separate leaflet given to all new patients and available in the practice (perhaps in the waiting or reception areas). The same information can also be displayed on the website or as poster in the waiting room. The important thing is to display details of the practice complaints process where it can be seen by patients, so that they do not have to ask for a copy.

The details of the leaflet may vary from practice to practice according to manpower and other resources but the GDC requires that it:

• is clearly written in plain language and is available in other formats if needed;
• is easy for patients to understand and follow;
• provides information on other independent organisations that patients can contact to raise concerns;

In describing the complaints process it would be helpful to show that it:

• allows you to deal with complaints promptly and efficiently;
• allows you to investigate complaints in a full and fair way;
• explains the possible outcomes;
• allows information that can be used to improve services to pass back to your practice management or equivalent; and
• respects patients’ confidentiality. 

The GDC has very sensibly adopted the term ‘valid consent’ which helps to avoid the incorrect perception that giving patients information (‘informed consent’) is sufficient to achieve a proper, valid consent. It isn’t.

Valid consent is much wider than simply providing information, and it comprises a number of considerations, the most significant of which are briefly summarised below.

• First you must determine that your patient has capacity to consent to treatment. ‘Capacity’ means the ability to use and understand information to make a decision.
• Even when you apply the 'capacity' test and you consider the patient isn’t capable of consent then you may still be able to treat the patient provided that you act with their best interests in mind. If they are under 16, you will either need to involve parent(s) or assess whether the child’s capacity to consent can be considered as ‘Gillick’ competent.
• Your next consideration is to establish what your patients wish to know about treatment, as well as telling them what you think they need to know. You should always respect your patients’ autonomy, it is their right to decide what happens to their body and they may decline your advice.
• What would a reasonable person expect to be told about the proposed treatment? What facts are important and relevant to this specific patient? (What risks might be specific to this planned procedure)?
• You may want to discuss why you think a proposed treatment is necessary; the risks and benefits of the proposed treatment; what might happen if the treatment is not carried out; and other forms of treatment, their risks and benefits, and whether or not you consider the treatment is appropriate.
• Do I need to provide any information for the patient in writing? Has the patient expressed a wish to have written information for consideration before they consent? (Remember consent is viewed as an ongoing process and not just about a signature on a consent form).
• Does the patient understand what treatment they have agreed to, and why? Have they been given an opportunity to have any concerns discussed, and/or have their questions answered?
• Does the patient understand the costs involved, including the potential future costs, in the event of any possible complications?
• Does the patient want or need time to consider these options, or to discuss your proposals with someone else? Can you/should you offer to assist in arranging a second opinion?

Although not part of the consent process, you should also ask yourself whether you have made accurate records that are sufficient to demonstrate (or reconstruct) all the key communications between the patient and me?

A full exploration of the subject of consent can be found in the dental advice booklet on consent that can be downloaded from the publications section of the website.

It is every General Dental Council registrant’s duty to ensure they are competent and have received adequate training for the tasks they are to perform. The GDC expects registrants to follow appropriate guidelines, in this case the Report of the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) entitled Standards for Conscious Sedation and the Provision of Dental Care 2015

• You should take the time necessary to really understand the new standards and how you will implement them in your provision of sedation services. In particular you need to consider whether you and your sedation nurses comply with the standards in terms of you being regarded as suitable as a sedation practitioner. This may mean exploring the transitional arrangements section.
• You and your team will need to demonstrate either ILS training or a course which trains the essential components of ILS relevant to sedation dentistry. This training needs to be relevant to the age of the patients you will be treating. If you treat children under the age of 12, compliance with the equivalent to PILS would be expected.
• You will need to provide sedation cases on a regular basis. No minimum limit is set but you need to consider whether you complete enough cases to maintain your skills and be able to comply with the standards.
• Your nurse does not need to hold the NEBDN certificate but will be expected to demonstrate adequate training and experience
• You need to complete regular audits of your sedation activity to demonstrate your commitment to improving the service you offer. As yet there are no "off the peg audits" to use, and you would be expected to tailor yours to your particular style of practice.

It may be helpful to bear in mind the Standards have already undergone several modifications without notice so please ensure that you keep updated of any changes.

If you require further advice, please contact us

The provider holding the provider contract should write and tell the patient that the practice will not tolerate rudeness or aggression from any patient. You may also feel there has been a breakdown in the relationship between yourself and the patient. If you feel it is not right to continue treating the patient, you should say you are ceasing to do so.

If you have completed the patient’s treatment, then this is relatively simple to achieve and you should tell your staff not to book the patient in again. However, if you are halfway through a course, you should bear in mind what the patient’s current situation is, and you may wish to offer 30 days’ emergency treatment, perhaps provided by someone else in your practice, but tell the patient they should seek out another dentist as quickly as possible. You should also provide the patient with a list of any outstanding treatment.

Obtain a list of all the locally contracting dentists from the same NHS Authority that issued your contract in order to offer the patient a list of telephone numbers in order to make alternative arrangements.

Aggression and violence from patients is not tolerated by the NHS.

The Faculty of General Dental Practice (UK) offers a comprehensive range of useful resources and guidelines pertinent to best practice in areas of clinical dentistry, the workplace and equipment.

The Health and Safety (First Aid) Regulations 1981 require all business premises to provide adequate and appropriate equipment, facilities and personnel to enable first aid to be given to employees if they are injured or become ill at work. There is a separate requirement in any dental setting in the UK to ensure that appropriate CPR and medical emergency training has been undertaken by all registered dental professionals as well as other practice staff. The GDC recommends that registrants should undertake training about medical emergencies every year.

In order to comply with the Regulations, the practice must first be assessed as to whether it is a low, medium or high risk environment. A dental practice would probably be assessed as medium risk, bearing in mind the training associated with the roles of the employees.

The minimum first-aid provision on any work site is:

• A suitably stocked first aid box
• An appointed person to take charge of first aid arrangements

An appointed person is someone who is chosen to:

• Take charge when someone is injured or falls ill, including calling an ambulance if required
• Look after the first aid equipment, e.g. re-stocking the first aid box

However, this role is separate, and over and above, to the requirement for all the staff to participate in regular training for medical emergencies including CPR. 

For dental practices assessed as medium risk and employing fewer than 20 people there should be a minimum of one appointed person. If there are more than 20, or the practice is assessed as hazardous, then a first-aider should be appointed.

A first-aider is someone who has undergone a training course in administering first aid at work and holds a current first aid at work certificate, and will need to participate in regular training for medical emergencies including CPR.

These requirements in terms of risk and numbers of employees are suggestions only and not definitive legal requirements. It would be desirable in any event for at least one practice member to have first-aider training, but the qualified first-aider does not need to be on the premises at all times and there is no recommendation to have one for a business with fewer than 20 employees.

The administration of local anaesthetics is governed by The Human Medicine Regulations. The GDC has no influence over this legislation and it is quite separate from the new direct access regulations.

Prescription-only medicines (for example local anaesthetics) may be administered by a dental hygienist or dental therapist either by using:

1. A patient-specific direction (in other words a written prescription for that particular patient) or

2. A patient group direction (PGD)

A PGD allows the administration of named medicines in an identified clinical situation without the need for the referring dentist to provide an individual written prescription. The regulations state that the practice should be registered with the Care Quality Commission (in England) or HIW in Wales and that the PGD is appropriately drawn up and signed by the relevant individuals. Due to there being variations in the regional regulations associated with patient group directives, we recommend that DCPs should familiarise themselves with the regulations that are applicable in their chosen region(s) of practice.

Further information on PGDs is available from gov.uk and NHS Education for Scotland.

Read our briefing document on Direct Access.