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UK dentists who place and restore implants are expected to follow the training pathways recommended by the General Dental Council and the Faculty of General Dental Practice (UK). When more than one clinician is involved in providing implant treatment, it is important that there is the ‘team leader’ with overall responsibility for the treatment, and that both clinicians can work together, complementing each other’s skills.

Implants can and do fail, and the criteria for reimbursing or compensating the patient depend on many factors, such as the discussion during the consent process, the standard of care and the length of time the implant was viable. Other factors such as patient co-operation and subsequent treatment by the referring general dental practitioner may also be relevant. Any subsequent failure might involve both the original placement of the implant as well as the restorative element.

Ideally there should be a good working relationship and close liaison between the two clinicians involved, on the understanding that one will be placing the implant and the other placing the restoration. To obtain patient consent there may need to be separate input from the clinician placing the implant as well as the clinician placing the restoration. Once the patient has given their consent, the treatment can be carried out. It would be prudent to advise the patient that the success of implants, like any other aspect of clinical dentistry, cannot always be guaranteed.

When it comes to the apportionment of responsibility (including fees), this is something which should be discussed and decided between the clinicians involved, without the patient being involved or indeed compromised.

I fitted a set of dentures which the patient says are hideous and demands that I refund his money. However, he will not return the dentures so I can examine them, saying they belong to him. I am happy to refund the money but would like my work returned.

Generally speaking, the ownership of any item of dental treatment passes to the patient at the time the appliance is fitted. This is, however, not always at the same time as the treatment is completed.

It follows that during the various stages of denture construction, the denture itself still belongs to the clinician. Once it is fitted, however, the patient then owns that denture, irrespective of whether or not a fee has been paid.

If the patient is unhappy with the dentures and the clinician decides to refund the fees, there is no absolute right to demand the denture should be returned in lieu of the refunded fee.

A patient who is unhappy with a denture for whatever reason would probably argue that the denture was not ‘fit for purpose’ as defined under contract law. As such the patient may ask for either a replacement item or their money back. On the basis that any replacement is unlikely to satisfy the patient (particularly if they have high expectations), the best option may be to refund the money.

It is a simple matter to suggest to the patient that if they return the denture to the practice a full refund will be made. Most patients are happy to return the dentures as they are apparently of little use.

However, if the patient insists they wish to keep the denture, a demand for its return could create an obstacle to the resolution of the patient's complaint. From a pragmatic perspective, whilst you may wish to ask for the dentures to be returned, if the patient remains unwilling to do so you may wish to refund the fees in any event.

The concept of consent arises when a patient seeks advice, care and treatment from a dentist and that dentist carries out an examination of the patient and provides them with details of the treatment required together with the options, benefits and risks as well as the cost of that treatment. This is an on-going conversation that is picked up at every stage of the treatment being provided.

Most dental procedures are carried out without the need for written consent but it is important that a record is made (either by the dentist or dental nurse) of the conversation during which the patient gave their consent.

When seeing a patient for a dental examination there is likely to be implied consent that the patient wishes the dentist to look in their mouth and therefore opens it to facilitate this. When carrying out more invasive treatment such as taking radiographs and providing fillings, the dentist should obtain the express consent of the patient for each procedure.

Certainly when carrying out fillings patients should be informed of the various options which are available to them, the costs of the treatment as well as the risks of not having a particular treatment carried out.

In the UK, consent only needs to be obtained in a written form signed by the patient, when the treatment is being provided under general anaesthetic or sedation.

Some employers make it a contractual obligation to obtain the patient’s signature on a consent form for a variety of procedures as well as anaesthesia. The employee has an obligation to respond to the terms of their contract. Indeed in complex cases it is a sensible precaution to have some form of written consent. This would apply to treatment plans for extensive restorative work or for patients undergoing treatment which could pose a significant risk, such as the removal of a lower wisdom tooth.

The signature on a consent form does not automatically imply the patient has provided their consent to the treatment. All it means is that the patient has signed their name and may not in fact have understood the treatment which the dentist had discussed with them.

The best way of ensuring consent has been obtained is to check with the patient if they fully appreciate the details of what has been discussed and to make good notes within the clinical records of both the discussion and the patient’s response.

Read our region-specific advice booklets on consent in the UK

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.

There is a view that working casts and models from routine crown and bridge work could be given to the patient for safe keeping and a note made in the dental records that this has been done. If they are presented to the patient in a protective model box, they are more likely to look after them and bring them back if required.

While this approach can relieve an acute storage problem, the fact remains that the clinician loses control over what could prove to be a critically important part of the total record.

Off-site storage is another solution but the problem with using alternative locations – apart from any cost involved – is that retrieval may take time, even when the contents of the containers are accurately indexed. 

Commercial storage is available both for paper records and x-rays, artefacts such as working casts and study models as well as electronically stored data. Remember that it is important to always comply with the legal requirements for retaining and/or disposing of records in whichever jurisdictions you work.

If you are leaving an existing business arrangement in a practice and continuing to work reasonably close to the practice you have just left (subject to any contractual terms precluding this), it is quite likely that some of the existing patients will want to come to you for their ongoing dental care. In that case it may be possible to arrange with the original practice owner to forward the records for those patients who wish to continue treatment with you.

Working from the original set of records would be in the patient’s best interests; it avoids the need to undertake new radiographs and also allows the clinician to monitor care and to review their historical treatment more accurately.

Situations also arise whereby an assistant dentist may leave a practice and wish to take the patient records with them. While there is no statutory basis for it, it is the view of Dental Protection that unless agreed otherwise the records are owned by the practice. However, any departing practitioner should be given reasonable access to the records if required in the future, which would allow them to respond to any concerns later raised by patients. To avoid grounds for dispute on the departure of a practitioner, it is again recommended that reference to the ownership of records be made at the outset in a written contract between the practice owner and associate dentist.

Clinicians sometimes feel that in order to protect themselves dento-legally it would be useful to have an x-ray ‘just in case’. Orthodontists sometimes take a range of radiographs mid-treatment and again post-operatively. Hygienists have been known to take x-rays simply to check they have removed all the subgingival calculus following periodontal therapy.

It is important when deciding to take a radiograph that a risk-to-benefit assessment is made. Every radiograph presents a radiation risk and any exposure of a patient to that risk must be offset against a reasonable clinical benefit. No patient should be exposed to an additional dose of radiation (and the associated risk) as part of a course of dental treatment unless there is likely to be a benefit in terms of improved management for that patient.

Sometimes, for a variety of reasons, you may decide you need to withdraw from a patient’s treatment, or suggest they seek further treatment elsewhere. This has the potential to create a problem and it needs to be sensitively managed.

Try never to lose your temper with a patient. Keep your cool and remain professional at all times, however testing it might be on occasions. If you are finding it difficult to treat the patient safely and to an acceptable standard, consider referring the patient to a suitably experienced colleague.

You must never part company with a patient in anger. If for any reason you decide you cannot continue treating the patient, make it clear that you are withdrawing from the treatment in the patient’s best interests, not your own. Make the necessary referral arrangements, keep the patient informed and resist the temptation to insert any ‘one liners’ in the correspondence or in the clinical records, or worse still in any direct communication you have with the patient.

Never give the impression that you are being arrogant, dismissive or petulant when deciding to end your relationship with a ‘challenging’ patient. A few ill-chosen words spoken in the heat of the moment can result in months or years of subsequent repercussions if you end up being sued or facing a complaint to the GDC or other agencies.

When a patient reports a persistent loss of sensation, the clinician needs to be sympathetic to their concerns residual numbness could lead to a distrust of future dental treatment and a real fear of a similar problem arising again.

Management usually involves counselling and medication for any pain. In addition the patient needs to be reassured and given realistic expectations of recovery. Referral to a suitable oral surgery facility for assessment is also desirable. An explanation of why they were not warned of this complication may also be required.

 The risk of damage can be reduced if the clinician can:

• Avoid multiple blocks where possible.
• Avoid using high concentration local anaesthetic for ID blocks (for example, use 2% Lidocaine as standard).

Always document any unusual patient reaction during local analgesic blocks (such as sharp pain or an electrical shock-like sensation) and contact Dental Protection for advice if the patient’s loss of sensation persists and the patient has made a complaint as a result.

Clinicians remain legally accountable for any treatment which they have provided regardless of whether or not they have left the practice where a patient was seen. Similarly, other clinicians who have been involved in the patient's care subsequently are accountable for their treatment. The dental records are fundamental in determining what treatment each dentist has provided and on what date. Only then can it be decided to what extent, if any, your own treatment for this particular patient might have contributed to the problem.