Need a dentist, then why ask a doctor?

A COMMON dilemma faced by GP practices in the busy holiday season is whether to treat patients who present with dental problems. The BMA has found that a typical GP practice can see up to 30 to 48 dental problems in a year.

There are a number of reasons behind this. Anxious patients may delay seeking care for dental issues until they are acutely unwell, at which point they will turn to their GP or A&E services 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.

Dental backlog

The Covid-19 pandemic has also led to a backlog in dental services due to previous restrictions preventing routine dental check-ups and some specific treatments. This has inevitably led to some patients suffering longer than usual with dental problems and confusion over who to contact for emergency treatment.

A typical scenario might involve a patient who contacts a medical practice complaining of an oral abscess. MDDUS dealt with one such case where a patient with a gum abscess was informed by a GP receptionist that the practice “does not deal with dental problems”. He later attended A&E, having developed a temperature and vomiting; the abscess had resulted in a spread of systemic infection. The patient later complained and demanded an explanation why the practice “refused” to see him earlier in the day.

Some medical practices may be tempted to simply send such patients away. 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, doctors do have an ethical responsibility to offer help in an emergency.

Certainly it would be inadvisable to have a blanket policy that all dental-related issues should be signposted to a dentist or dental hospital without a clinical assessment by a healthcare professional. Oral infections can spread rapidly and dental pain may in some cases be an indicator of a serious underlying medical problem.

Signposting

Only when the clinician is satisfied that the issue is solely dental should the patient be signposted to a dentist, local emergency service or (for serious cases) secondary care. If there is no usual dentist or they are closed, then the patient should be advised to contact NHS 111 (England), NHS 24 (Scotland), NHS Direct or local dental helplines (Wales) or the Health and Social Care Board (Northern Ireland). It is also good practice to ensure that staff have the contact details for local emergency dental services, including urgent secondary care referral pathways.

The majority of GP practices will utilise well-established signposting processes (for example, see the Care Navigation Toolkit). NHS England recently demonstrated the success of this by sharing a case study from a practice in South Warwickshire, in which trained staff working to a standard operating procedure managed to free up around 80 inappropriate GP appointments each week by effectively signposting patients to services more appropriate for their symptoms.

Prescribing and GMC guidance

MDDUS enquiries from doctors faced with dental issues often relate to prescribing, particularly for pain relief and antibiotics. It is important to remember that a doctor should not prescribe medication unless in a position to do so safely in line with the GMC guidance Good practice in prescribing and managing medicines and devices, as they will be responsible for any complications arising from the prescription. This will also include ensuring the patient’s dentist is aware of any medication prescribed.

Don't be pressured into giving the patient a medication or treatment if it is not clearly in their best interests. The GMC advises that in providing clinical care: "you must prescribe medicine or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the medicine or treatment serve the patient’s needs". Clinical records should state the justification for the decisions made and should be clear and accurate.

Remote consultations

Remote consultations remain the default position for many GP practices currently, but it is good practice for doctors to maintain a low threshold for requesting patients to attend for face-to-face review if a physical examination might be required. This is just as important for patients contacting the practice with oral symptoms. Doctors should clearly document the reasoning behind any decision not to review a patient in person, as well as any advice given in regard to ongoing care and safety netting. This is important to ensure continuity of care and also, should the need arise at a later date, to explain or defend clinical decision-making in the event of a complaint or claim.

Conclusion

Now that dental services are again able to provide a broader range of treatment options, General Dental Council (GDC) advice to the public is: “If you have an urgent dental care need, or need advice about your personal oral health needs, you should contact your dental practice in the first instance”.

However, medical practices will still have patients seeking advice for oral care. The GMC states in Good medical practice: “You must recognise and work within the limits of your competence”. This would include only treating a patient when confident that “the drugs or treatment serve the patient’s needs”. Otherwise refer the patient to the appropriate service and clearly record that decision and the advice given.

Key points

• Patients contacting general practice with apparent dental issues should be triaged/assessed to ensure there is no medical condition requiring attention.
• Only treat within the limits of your competence.
• Ensure the practice team has contact details for local emergency dental services, including urgent secondary care referral pathways.
• Understand local arrangements for patients not registered with a dentist and out-of-hours dental care.

Kay Louise Grant, risk adviser, MDDUS