Ask Dental Protection

The importance of good communication with members of the public who attend your open day cannot be overestimated. They should be made fully aware of the nature and limitations of the examination which is to take place both verbally and perhaps more usefully in written form.

Since there are a number of techniques which serve as an adjunct to visual examination, and which may show up an early abnormality, patients should be advised of the scope and limitations of your examination depending on the technique you are proposing to adopt.

Members of the public who agree to an examination of their mouth should be taken through the consent process before they are examined. They should be reminded of the scope and nature of your examination and whether you will be carrying out a full examination of their teeth and the gingival tissues.

They should also be made aware at the outset that they may have to provide a medical history as well as a social history which may provide markers for an increased incidence in oral cancer. All this information should be documented in a clinical record for each person you examine. The record should also include personal details such as their name, address, date of birth, etc, together with the results of your examination. The records should be retained in the usual way.

If your examination extends beyond the oral cavity and includes the face and neck, you should note both positive and negative findings.

Your duty of care to each person you examine extends to whatever was agreed to be the nature of your examination – hence the importance of defining any limitations at the outset. It would also be desirable to advise patients of the importance of seeing a dentist on a regular basis especially if they fall into a high risk category.

In the event of you discovering a suspicious lesion, you will need to discuss with the patient how this should be followed up. You should not follow this up with their dentist or doctor without the express consent of the patient, as you will still be bound by a duty of patient confidentiality. However, you should stress the importance of referral to a specialist and the need to involve their doctor and also their current dentist (if they have one).

Dental members can save 20% on the two-hour interactive programme on oral cancer that has been produced by Smile-on

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.

According to the General Dental Council's Scope of Practice, a clinical dental technician (CDT) can provide complete dentures directly to a patient. However, patients requiring a partial denture must be seen by a dentist before a CDT can provide treatment, and only then following the issue of a prescription.

All appliances provided by a CDT are done so under private contract and therefore if the patient was in any way dissatisfied, the CDT would be expected to have a suitable process for handling complaints. The Dental Complaints Service is available to the patient. The dentist who provides the treatment plan could be challenged if the treatment plan was considered inappropriate.

You would be entitled to refuse to provide the patient with a prescription if for some reason you felt a particular type of denture would not be in their best interests and could justify such a decision.

In general terms a prescription request such as this can be treated in the same way as a referral for treatment; it is a correspondence between two professionals directly concerned in the provision of dental care to a particular patient. Under these circumstances, the patient’s consent would be implied by the professional relationship.

A prescription request could also be seen as a request by the patient for a treatment plan. Following a full mouth assessment by a dentist, the patient should be provided with a treatment plan. The patient is at liberty to take this treatment plan to any appropriate registered dental professional who can, within the overall limits of the plan and their competence, treat the patient. Therefore, a patient would be entitled to take their treatment plan for a denture to a CDT.

To be seen to be obstructive is likely to attract considerable criticism and possibly invite investigation from the GDC should the matter come to its attention.

Who is responsible for the partial denture design?

This is not an easy question to answer as the GDC’s guidance does not make this clear. One could argue that as the dentist is providing the treatment plan and prescription, he or she should be the person to design the denture. Alternatively one could argue that as the CDT is the clinician making the denture, the design should really fall to them.

In reality, however, it is likely to be a collaboration. The lead would depend on training and expertise. Either way, the records should reflect the discussions and decisions made.

Who is responsible if something subsequently happens to the natural dentition as a result of the design?

The responsibility will probably lie with the dentist who examined the patient and provided the treatment plan in the first place as it would be for them to indicate any areas of concern they might have clinically. The CDT would also be liable as although he or she is not trained specifically to identify caries and periodontal problems, they would be expected to recognise such problems and to raise any relevant concerns before the treatment begins. It would however be quite different if the CDT had not followed the advice of the dentist.

Who is ultimately responsible for the patient?

The ultimate responsibility for any patient’s treatment lies with the clinician who undertook that particular element of the treatment. That does not mean, however, that the dentist (who perhaps only provided the treatment plan) has no responsibility at all.

Can a dentist refuse to provide a treatment plan?

The GDC’s guidance makes it very clear that individual registrants should act together in the best interests of the patient and as a consequence a dentist would have to have a good clinical or ethical reason for failing to provide a treatment plan. If that refusal was simply as a matter of ‘protectionism’, the GDC would not be too impressed.

We recommend you only allow the patient to take away copies of your radiography, retaining the originals yourself. The patient is of course entitled to copies but could be asked to pay for your reasonable charges incurred in producing them.

You have obviously made the patient aware of the potential problems associated with seeking treatment abroad, especially the provision of follow-up care which may be necessary should the treatment not go according to plan. You cannot be held responsible for the outcome of another practitioner's work.

All communications sent to your patients should be enclosed in an envelope to protect confidentiality. This applies to all correspondence in connection with treatment as well as recalls.

Announcements that are not patient-specific – for example a practice open day or the opening of a new practice – can be sent on a postcard.

Postal charge increases will clearly encourage more dentists and practice managers to seek permission from patients to send out appointment reminders by text or email.

Owing to the confidential nature of dental records, it is best practice to receive verbal or written consent from the patient and this can be documented. Radiographs can be copied and handed to the patient or posted by secure delivery. A reasonable copying charge could be applied, and it would be best practice to inform the patient of this beforehand. Digital images can be shared more readily than images taken on film and the copying charge can be reduced accordingly. Remember, care should always be taken when transmitting images digitally to ensure, for example, that emails and attachments are properly encrypted.

Ethically you have a duty to ensure that the patient’s interests are put before your own. Certainly in the case of a dental emergency you are likely to be criticised for declining to treat a person on the grounds of their poor personal hygiene.

There may be an underlying reason why this patient has body odour. It may be related to health issues (including mental health), genetic conditions or some learning difficulty. There is always the risk that a decision to decline treatment could be seen as discriminatory.

The General Dental Council guidance warns registrants not to discriminate against patients on the grounds of their health. The NHS contract also prohibits discrimination on health grounds. If this is the underlying cause of the body odour, you could be exposed to a challenge both legally and by your regulatory body if you declined to provide treatment.

However, if the smell is impacting on your ability to treat your patient in their best interests, you might wish to tackle the situation in a different way.

You could discuss the body odour with your patient so that he has the opportunity to try to address this and seek medical support should this be necessary.

Although it might be a somewhat difficult conversation, you could explain that the smell was sufficiently intrusive that it was distracting your concentration. Reduced concentration would naturally not be in his interests.

You should document the discussion so that, should a subsequent challenge arise, you would be in a position to demonstrate you had taken all reasonable steps before considering declining to continue treatment.

All dental nurses in the UK need to be either in training, on a waiting list to undergo training, or be fully qualified and registered with the General Dental Council. As such, this is a protected title and the tasks of a dental nurse can only be carried out either by a registered dental nurse, a registered hygienist or dental therapist, or a registered dentist.

If the overseas dentist is to work as a locum dental nurse, he or she would first need to be registered with the GDC as a dentist or dental nurse. If the prospective dental nurse was able to obtain appropriate registration with the GDC or demonstrate that he or she was ‘in training’, you would be able to consider offering him or her the role of a dental nurse.

Before allowing the individual to carry out dental nursing duties, you need to ensure they have had the appropriate immunisations, including Hepatitis B. Without satisfactory immunisation, you would be vulnerable to action under health and safety laws, as well as a potential civil claim from the dental nurse were he or she to contract Hepatitis B.

Discover more about the flexibility of our dental membership for DCPs

A dental nurse, whether qualified and registered or a trainee, working in a clinical setting should not only be Hepatitis B vaccinated but must have clear proof of antibody titre to confirm that he or she is appropriately protected from the virus.

The reasons for this are twofold:

1. The individual must be protected (to protect themselves and their partner/family)
2. Without vaccination, the dental nurse runs the risk of becoming infected with hepatitis which could then put patients at risk, which would be entirely contrary to the General Dental Council’s ethical guidance

Anybody working with you chairside must be able to demonstrate that their Hepatitis B immunisation has been completed and that they have the required antibody titre. If this is not the case, they should not be assisting you in the dental surgery. You should discuss an alternative solution (perhaps agency staff) with the practice manager.

The General Dental Council considers that this skill is over and above the skills that would be expected upon qualification when a dental nurse first registers.

Nurses who wish to undertake training in dental sedation must therefore be fully qualified and registered with the GDC. The National Examining Board for Dental Nurses certificate in dental sedation nursing is probably the easiest route to follow. However, there is nothing to stop you training your nurses in-house if you cover equivalent course content, although it is very important that the training you give is appropriately planned and executed and thoroughly logged with clear aims and objectives and educational outcomes, plus case numbers. Essentially you would be reproducing an external course, but there is nothing to stop you doing this.

One caveat to remember when delivering in-house training is that you would still be required to have an appropriately trained person present while the trainee is undergoing training at the chairside.

There might also be some difficulty in finding an appropriate number of patients to undergo this treatment and to co-ordinate their appointments to coincide with the availability of an appropriately trained assistant while the training of the dental nurse is taking place.