EACH summer as schools break for the holidays, MDDUS tends to see an increase in the number of calls from doctors requesting advice about how to deal with patients seeking appointments to discuss dental problems.
A common explanation for this increase is an apparent shortage of emergency dental appointments, often with patients needing analgesia or antibiotics – but other examples include patients requesting the GP to “have a look at a tooth the dentist wants removed to see whether he’s right” or “my dentist has given me a private prescription but it’s going to be really expensive – can you write me an NHS one please”. One patient told his GP: “my dentist has suggested I ask you for a prescription for Prozac as she thinks it might help my anxiety”.
Turning patients away
One recent call to our advice line related to a patient complaint at being sent away from the practice by a receptionist because he had requested an appointment for what he described as “maybe an abscess” on his gum. The receptionist told him that the doctors “don’t see patients with dental problems” and that he should phone his dentist instead. The patient stated that he had been unable to get a dental appointment but the receptionist still refused to offer a GP appointment. Later the patient attended A&E as he subsequently started vomiting and developed a temperature. He was treated for a dental abscess which had resulted in a spread of infection. He now wanted an explanation why the GP would not examine and treat him at the practice earlier that day.
There are risks associated with doctors treating patients who have asked for help with dental problems; however, it is important that reception staff do not turn patients away just because it may be a dental problem – particularly where the patient has been unable to get a dental appointment and further when they need pain relief, treatment or advice. There is always the possibility that there may be an associated medical problem and a doctor should undertake reasonable enquiries to ascertain the nature of the patient’s condition. Once it is clear that the issue is dental, advice can then be given on how to access local emergency dental services.
A question of competence
In deciding how to handle such cases it is essential to remember that dental treatment is not covered as part of the GP contract and that dentists are best qualified to deal with dental problems. All UK patients should be able to access emergency dental appointments locally, and referring the patient to these is likely to be in the patient’s best interests.
Patients cannot always be relied on to provide an accurate history of their dental treatment and this, along with a lack of knowledge or expertise, may mean that a doctor is not able to offer a diagnosis or understand fully the complications which could arise from treatment. This may mean a doctor straying outside their area of competence.
GMC guidance states that in providing clinical care: “you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs”.
Should a doctor decide that it is reasonable in the circumstances (and in the patient’s best interests) to offer treatment in a dental case – perhaps with analgesia or antibiotics – they are responsible for the outcome of that decision and any follow-up required. GMC prescribing guidance states that: “if a patient asks for a treatment that the doctor considers would not be of overall benefit to them, the doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient, they do not have to provide the treatment. But they should explain their reasons to the patient, and explain any other options that are available, including the option to seek a second opinion.”
In all circumstances the patient must be informed that dental advice should be sought as soon as possible and this advice should be clearly documented within the patient’s medical record.
For doctors: GP staff should understand arrangements for obtaining emergency dental treatment within their local area so that they can easily pass information on to patients. When a patient is asking to be seen, ensure a clinician decides whether examination is appropriate. If the decision is made to provide treatment, inform the patient that they should seek a dental appointment as soon as possible and ensure you keep adequate records of your history-taking, examination, decisionmaking, the treatment you provide and instructions to the patient.
For dentists: During holiday periods, when there may be a reduction in appointment availability, dentists should ensure that emergency appointments are available to patients and that the instructions on how to access out-of-hours emergency treatment are prominently displayed.
Liz Price is a senior risk adviser at MDDUS