Dealing with dental emergencies

MANY general medical practices will be familiar with this scenario. A patient turns up 15 minutes before closing time with a throbbing toothache. You usher her into your consulting room for an examination. Her face and gums are swollen and she has a slight temperature. It is clear this is something that a dentist should be dealing with. You check your watch. Do you signpost her to the appropriate services or do you decide to offer treatment right away?

This can be a challenging situation for a GP and one that is on the rise. Figures cited by the British Medical Association (BMA) suggest a typical general practice can expect to see between 30 and 48 patients with dental problems per year.

There are a number of reasons behind the trend. Anxious patients may delay seeking care for dental issues until they are acutely unwell, at which point they will turn to their GP or even A&E service for help. There may also be a lack of awareness over the availability of urgent dental care services in the local area, difficulty in accessing out-of-hours dental care, or concerns over the potential cost of treatment.

Ethical responsibility

In our scenario above, some practices may be tempted to simply send the patient away, telling them to see their dentist because "we don’t treat dental problems". It is true that GPs are not contractually obliged to administer dental care and are also legally restricted (under the Dentists Act 1984) from doing so unless they are dually qualified.

However, they do have an ethical responsibility to offer help in an emergency. This can extend to medical care where the patient requires urgent treatment for pain or an infection.

Always assess

Before making any kind of referral, it is vital to assess the patient to exclude other non-dental conditions. Signposting any patient (particularly one in acute pain or distress) to alternative care services without first evaluating their condition considerably increases the risk of both complaints and negligence claims.

Signpost

Only once you are satisfied the issue is solely dental should you signpost to a dentist, local emergency service or, for serious cases, secondary care. If there is no usual dentist or they are closed, then the local NHS 111 (England), NHS 24 (Scotland), NHS Direct or local dental helplines (Wales) or the Health and Social Care Board (Northern Ireland) should be contacted.

Doctors should also be alert to signs of spreading infection or systemic involvement of a dental infection as this would require an immediate secondary care referral. Signs and symptoms may include diffuse or severe facial swelling, trismus, dysphagia, fever or malaise.

Be mindful of the GMC’s Good Medical Practice guidance which clearly states you must recognise and work within the limits of your competence.

Prescribing

MDDUS often deals with enquiries from doctors faced with dental issues, many of which relate to prescribing and particularly for pain relief and use of antibiotics. When prescribing for patients with dental issues, it is important to remember that you should not supply an NHS prescription unless you are in a position to accept responsibility for that prescribing decision. This includes ensuring the patient’s dentist is aware of the drugs you have prescribed.

Don’t be pressured into giving the patient a medication or treatment if you’re not sure it is in their best interests. The GMC advises 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". Your records should show justification for whatever decision you make and should be clear and accurate.

Key points

• Patients presenting with apparent dental issues should always be examined to ensure there is no medical condition requiring treatment.
• Only treat within the limits of your competence.
• Ensure that you and your practice team have the contact details for local emergency dental services, including urgent secondary care referral pathways.

Further information

• BMA – Patients presenting with possible dental problems tinyurl.com/hf59898

Lindsey Falconer is a risk adviser at MDDUS