Dental Problems in Primary Care

dental problems are best assessed by dental practitioners who are fully trained
recognise your limits
generally speaking an abscess* will need analgesia and a review with a dental practitioner within 24 hours

(*The local LDC have told us that antibiotics are not the correct primary treatment for an abscess although it can be for other dental infections. Mishandled abscess can be complicated by a rapid spread of infection (Ludwig's Angina) which can be fatal.) SDW2008

Whenever a GP prescribes a medication he accepts responsibility for all aspects of that prescription. The GP could well be professionally and legally liable for any adverse consequences if he agreed to undertake ongoing care of a dental condition and the patient suffered harm as a result.

Emergency Treatment

Occasionally dentists refer patients to their GP for antibiotic treatment of a suspected dental abscess, for example. This is an inappropriate referral. The dentist should see the patient in order to make the diagnosis and provide a prescription for any necessary medication.

If the dentist feels unable to prescribe the necessary medication for a serious dental problem, the patient should be referred to a specialist dental practice or to a secondary care consultant. If the prescription is beyond the competence of the dentist, it is definitely not a situation in which the GP should become involved! Only a dentist who is competent to make the initial assessment of the patient should prescribe sophisticated treatment.

Patients should generally not seek emergency treatment from a GP or the Accident and Emergency Department. However, it has been drawn to our attention that NHS Direct sometimes refer patients to the Accident and Emergency Department for dental treatment.

Doctors are trained in medicine and, with very few exceptions, have no dental training and should not therefore be providing dental treatment!

When a patient is registered with a dentist and needs emergency dental care the dental practice should provide that care within a 24-hour period.

If the patient is not registered with a dentist, then the Health Authority should be able to provide a list of practices that can offer such a service.

There is a significant danger in treating cases of dental abscess with antibiotics without appropriate dental treatment. A patient that presents to the GP with a dental abscess should be given analgesia and advised to see a dentist as soon as possible within the next 24 hours. If the patient is not registered with a GP and has difficulty accessing speedy dental treatment, then the PCT or NHS Direct should be able to advise on where such treatment is available locally under the NHS.

If a patient is still unable to access prompt treatment for a dental emergency, or has other cause for complaint about the treatment received, the PCT should be asked to investigate and take the appropriate action.

NHS Prescriptions for Private Dental Patients

From time to time private dental patients seek an NHS prescription for drugs prescribed by the dentist.

There is a dental formulary http://www.drugtariff.com/dental_formulary.htm which specifies the drugs that a dentist may prescribe under the NHS. In general if the patient requires such medications the dentist should prescribe these since he has the professional training to assess the response and the need for any further dental treatment that may arise. Most doctors would not be competent to make a judgement on this aspect of the care of a dental patient.

The dental formulary, however, only restricts the medications that a dentist may prescribe under the NHS. The dentist may therefore prescribe any drug for a private patient using a private prescription. This is probably the best course of action in this situation, provided that the dentist believes he is competent to prescribe the medication safely.

NHS Prescriptions for Drugs not included in the Dental Formulary

The dentist may very occasionally believe that a medication is required that is not included in the dental formulary. In such cases he may not have the necessary medical knowledge to prescribe safely. In this case the dentist may refer the patient to the GP for a prescription. The GP must then decide if he is prepared to write an NHS prescription on the basis of the dentist's recommendation. The dentist should in this case always continue to monitor the dental condition.

A GP should only prescribe for a dental problem if he feels able to accept the responsibility for the ongoing management of the dental condition or can agree to share the continuing dental care with the dentist.

Dentists and Medical Reports

Dentists sometimes discover that their patient suffers from a medical condition which may influence the treatment they are proposing to give. In this event they would generally require medical advice form the GP in order to treat the patient safely. It is not generally necessary for the GP to provide a full medical report, but he or she should provide relevant information by telephone or in a brief written report. It is clearly in the patient's best interests that this clinical information is shared with another health professional, provided of course that the patient has consented to the release of limited medical data for this purpose.

Mental Capacity and Consent to Dental Treatment

No person may provide consent for treatment of another adult and all healthcare professionals, including dentists, must have regard to the Mental Capacity Act Code of Practice

There is always a legal presumption of capacity and in order to give consent a person must be able:

to understand relevant information
to retain that information
to use/weigh it in decision-making process
to communicate decision (speech, sign language or any other means)

If a person is thought to lack capacity a two stage test of capacity should be applied;

is there impaired / disturbed functioning of mind or brain?
is it sufficient that person lacks capacity to make the particular decision?

The dentist may require factual information from the GP regarding any clinical problems likely to impair mental functioning, but the dentist must himself assess the patient's capacity to make the particular decision to consent to the specific proposed treatment at that particular time.

The dentist may make a 'best interests' decision to treat a patient who lacks capacity without obtaining prior consent, but this must always follow the Statutory Checklist and be in line with the guidance given in the Code of Practice. The reasons for the decision should be carefully documented for legal reasons.

Further information;