Q Is a radiograph mandatory prior to a routine (non-surgical) dental extraction in order to avoid any potential dento-legal issues?
A MDDUS is not an arbiter of clinical practice and it is not our position to advise in such matters. We will provide access to appropriate advice and legal support in the event of a complaint or claim but the strength of your position would depend upon the extent to which you followed the law, regulatory requirements and authoritative guidelines. Statutory requirements are set out in the Ionising Radiations Regulations 2017 (IRR17) and the Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER17). Dentists can also consult the new second edition of Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment, which is available free of charge on the FGDP (UK) website. Most specifically the guidance states that in deciding whether an individual exposure is justified, appropriate weight must be given to:
- availability and findings of previous radiographs (or dental CBCT images)
- specific objectives of the exposure in relation to the history and examination
- age of the individual (bearing in mind the increased radiosensitivity of children compared to adults)
- total potential diagnostic benefit
- radiation risk
- efficacy, benefits and risk of available alternative techniques having the same objective but involving no, or less, exposure to ionising radiation.
Members can also access Selection Criteria for Dental Radiography which states: "Where there are existing radiographs, these should be referred to before extraction of teeth. There is no convincing evidence to support the need for routine radiography prior to extraction in adults. Nevertheless, in some selected cases, a pre-extraction radiograph would be judicious." Read more.
It is possible that local departmental policies or practice rules may be in place obliging clinicians to take (or not take) radiographs in any given clinical situation and this might impose a contractual requirement for the clinician to behave in a particular way. Clearly any such policies or rules would have to be in line with the generally accepted professional standards. Ultimately it is a matter for individual clinicians to make decisions in the best interests of their patients on a case-by-case basis. GDC Standards for the Dental Team confirms (Standard 1.4.2): “You must provide patients with treatment that is in their best interests, providing appropriate oral health advice and following clinical guidelines relevant to their situation.”
Q One of our nurses has found out that she is pregnant and is worried about working in the practice during the pandemic. She does not have any underlying medical conditions, but has asked if she can work from home. Because of the nature of her role, this is not possible. Are we obliged to keep paying her if she stays at home?
A The UK Government classes pregnant women as clinically vulnerable and it is recommended that they should work from home where possible. Although there is no evidence that pregnant employees are more likely to get coronavirus, they should be especially diligent about social distancing. Under the Management of Health and Safety at Work Regulations, all pregnant employees must be subject to a risk assessment to discuss and eliminate any risk. Where a risk is identified, the employer must take steps to control, reduce or remove it. If the practice is unable to do so, the employee needs to be placed on full pay suspension. It is for the employer to discuss the situation with the employee and establish what her specific concerns are. This should include the role she carries out, the safety measures that the practice has put in place and any personal protective equipment (PPE) she may be required to wear as part of her role. Any logistical issues should also be considered, such as how the employee travels into work and if public transport has to be used. If the specific concerns about working in the practice cannot be resolved, then it should be considered if the employee is able to work from home. Women who are less than 28 weeks pregnant may choose to continue to work in patient-facing roles as long as a risk assessment has been carried out and the necessary precautions have been taken. For women who are more than 28 weeks pregnant, or who have underlying conditions, direct patient-facing contact should be avoided. The British Dental Association (BDA) has issued guidance stating that there is a small risk of those employees participating in aerosol generating procedures (AGPs) contracting Covid-19 from the patient. It suggests that pregnant employees should not participate in these procedures. Guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) also advises that pregnant employees should not see patients face-to-face after 28 weeks. If no other work can be found or the employee is unable to work from home, then they should be placed on paid leave.
Retention of GP17PR forms
Q We have been advised by practitioner services that signed GP17PR forms should be retained for two years and then safely disposed. It was our understanding that the retention period for these forms should be 11 years.
A A two-year retention period is required in the relevant NHS regulations. Therefore, you must retain these forms for two years in order to comply with your NHS terms of service. There are wider dento-legal recommendations in relation to record retention. You are quite correct in your understanding that clinical records should be retained for 11 years since the patient’s last attendance and, in the case of children, for 11 years or until the patient has reached the age of 25. However, most dentists now comply only with the two-year rule in regard to GP17PR forms, as copies can be accessed from NHS payment bodies.
Face covering required
Q We require patients to wear face coverings in the waiting areas of our practice. What can we do if a patient refuses?
A This is a difficult situation. First, it is important to explore why the patient is refusing to comply and if there is any valid reason, perhaps including a medical condition. Some patients may not fully appreciate why a face covering is required. Should the patient persist in refusing, consult latest guidance from the NHS and governmental departments of health and undertake a risk assessment to judge what would be reasonable in the circumstances. Remember that you have a professional obligation to make the care of the patient your first concern. A decision to deny care in such circumstances would need to be sufficiently justified and you could be criticised for any global policy to deny care to patients refusing to wear face coverings. Practice policies should build in flexibility to consider the particular circumstances of individual patients.
Q A patient has asked to buy whitening gel though he has not had bleaching providing by the practice. Can we offer this for sale?
A Only dental practitioners can buy tooth whitening products releasing between 0.1 per cent and 6 per cent hydrogen peroxide under the relevant regulations. Selling whitening gel to a member of the public not undergoing bleaching treatment may be regarded as a breach of the regulations. Before being provided with any tooth whitening product, patients should first be examined by a dentist. This should involve a careful assessment of the case and an appropriate consenting discussion (covering the risks and benefits, together with the costs of the proposed treatment). The first bleach treatment should be conducted with the assistance of the dentist or under the dentist’s direct supervision. Following this initial visit, the tooth whitening product can be provided to the patient so that the bleaching cycle can be completed at home.
An anonymous letter
Q Our practice manager has received an anonymous letter alleging that one of our patients is faking dental pain for the purposes of prescription fraud. How should we handle the situation?
A Such communications should be treated as hearsay and dealt with using great caution in the first instance. You may wish to bring the letter to the attention of relevant staff so that it can be considered when the patient next attends. However, the practice should not treat the concerns raised as a matter of fact. Consider discussing the letter with the patient to obtain his or her response but be careful not to discriminate against the patient in any way on the basis of the letter, as it may be malicious. Note that such letters should not be stored in the patient’s dental records.
Flexible working request
Q We have a receptionist returning from maternity leave. She has hinted that her current hours will not be suitable on her return to work, given her childcare needs. We are a small practice with only three administrative staff. Are we obligated to change her working hours?
A The employee has the right to return only to the hours that she left, but she can submit a flexible working request. Flexible working regulations allow employees to request a more flexible working pattern but in a manner compatible with business efficiency. A flexible working application may cover such aspects as hours of work and times or place of work, and employees can request a range of different working arrangements, including part-time working, flexi time, job-sharing and working from home. To be eligible to apply, an employee must have worked for the practice for at least 26 weeks and not made a previous application in the last 12 months. A meeting to discuss the request should be arranged and the employee has the right to be accompanied by a work colleague. In assessing a flexible working request, you should consider the benefits both to the employee and the practice and weigh these against possible adverse impacts. An employer can refuse a request for flexible working for a number of reasons, including the burden of additional costs, any detrimental effect on the ability to meet patient demands, an inability to reorganise work amongst staff or recruit additional staff, and possible compromised practice quality and performance. All requests, including any appeals, must be considered and decided on within a period of three months from first receipt of the request but this period can be extended in agreement with the employee. Ensure that all such requests are dealt with fairly and consistently, but the practice is not obliged to alter working hours.
Q What is our legal obligation in regard to compassionate leave for staff? A nurse in our practice has been off work for four weeks having suffered a bereavement.
A There is no statutory compassionate leave entitlement under current UK law. However, the Employment Act 1996 does specify that employees can take time off with the death of a dependant. Acas advises that anyone classed as an employee has the right to time off if a dependant has died, including a partner, parent or someone else who relied on them. An employee having lost a child under the age of 18 or a stillborn baby after 24 weeks of pregnancy has the right (since April 2020) to two weeks paid parental bereavement leave. Otherwise there is no legal obligation for bereavement leave to be paid, although some employers do so. You should check the contract of employment and your workplace policy. The law also does not stipulate how much time can be taken off if a dependant dies but simply says the amount should be “reasonable”. Read more from Acas.