GP practices

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Patients presenting with possible dental problems

This guidance informs GPs of their obligations to patients either requesting emergency dental treatment or asking for an NHS prescription for drugs recommended by private or NHS dentists. It is aimed at all GP’s including out of hours practitioners.

The number of patients seeking dental advice from GPs is increasing. A recent study in Wales found a typical general practice can expect to see between 30-48 patients with dental problems a year. The BDA estimates that this costs the NHS £26 million per year. A potential driver that may be pushing patients from dental services to GPs may be the NHS dental charge.

GPs and practice teams should make themselves aware of in hours and out-of-hours dental services available locally to manage urgent and emergency dental conditions. This may include NHS Choices, NHS 111, local dental access centres and local NHS dentists. This information should be available from local commissioning and planning bodies. Local arrangements for advice and treatment of urgent and emergency dental conditions vary between areas and different service providers may be responsible for the provision of in-hours and out-of-hours urgent/emergency dental care.

 

  • Emergency dental services

    General dental practitioners have an ethical responsibility to provide reasonable access to advice and emergency treatment for their patients, including those who are seen under a private contract. A dentist’s immediate responsibility for in-hours urgent dental care applies to patients who are currently undergoing or have recently completed a course of dental treatment with them. However, dentists are not available to see patients 24 hours a day.

    NHS commissioning and planning bodies are responsible for the provision of out-of-hours dental care. Most provide emergency out-of-hours dental treatment for patients. Commissioning and planning bodies may also buy in-hours open access urgent sessions from dental practices.

    The General Dental Council’s principles are that dental professionals are responsible for putting patient’s interests first and that they must cooperate with other members of the dental team and other healthcare colleagues. Therefore, dentists have an ethical responsibility to make appropriate arrangements for access to emergency treatment outside of normal hours and make sure that such arrangements are known to patients for example, information around the out of hours care available in that area. Despite this, many patients will contact their GP when they require emergency dental treatment.

    GPs should not attempt to manage a condition requiring dental skills unless they have the appropriate training and expertise. Both the civil courts and the GMC require doctors to have appropriate skills for any treatment they offer.

    Even in cases where the patient is not ‘registered’ with a dentist, and the GP is unable to contact a local emergency dental service, the treatment of dental problems is not the responsibility of GPs. In such circumstances, the patient should be advised to contact local urgent or emergency dental services, or in severe circumstances the nearest accident and emergency department.

    If GPs choose to treat a patient themselves such treatment would be provided under general medical services and the level of skill and degree of care the GP would be expected to exercise is that of a general medical practitioner. The determination of a complaint against a GP would take this into account.

    GPs should also be aware of the following legal and contractual obligations1:

    • Before refusing to treat a patient asking for emergency dental treatment, a GP must ascertain that the condition requires only dental treatment. Primary care teams must put themselves in a position to judge the nature of the patient's condition by undertaking reasonable enquiries and where appropriate a clinical assessment.
    • Having established an apparent dental problem, GPs or practice teams should signpost to a dentist or local emergency service or if they feel necessary refer a patient for any further assessment and treatment, to secondary care.
    • Everyone in the practice team must do their best to ensure the patient doesn’t need the attention of a GP when signposting.
    • If the patient has no usual dentist, or there is no response from the usual dentist, the patient should contact the local NHS 111 (England), NHS 24 (Scotland), NHS Direct or local dental helplines (Wales) or the Health and Social Care Board (Northern Ireland).
    • Patients presenting with signs of spreading infection or systemic involvement of a dental infection should be referred immediately to secondary care for appropriate surgical management. Signs and symptoms of this may include, diffuse or severe facial swelling, trismus, dysphagia, fever or malaise.

    1. The GP’s obligation to refer is set out in regulation 15(4)(b) [Essential services] of the GMS Regulations and in schedule 5, part 1, paragraph 1 of the National Health Service (Personal Medical Services Agreements) Regulations 2004.

     

  • Acute dental conditions

    Many dental problems arise as a consequence of tooth decay or gum disease. Clinical guidelines recommend that the first-line treatment for acute dental conditions should be an operative intervention, such as extraction or root canal treatment. Acute dental abscesses respond well to local surgical treatment and for patients presenting with bleeding and trauma early diagnosis and referral to a dentist is advised. However antibiotics are not recommended for the treatment of many acute dental conditions and should only be prescribed in patients exhibiting signs of local or systemic spread or for those who are moderately or severely immunocompromised.

     

  • Oral cancer / pathology / medicine

    Patients who smoke, use smokeless tobacco and consume excessive alcohol are at high risk of oral cancer. Human Papilloma Virus (HPV) infection is also a risk factor for oro-pharyngeal cancers. Many patients visit GP practices with co-morbidities associated with smoking and alcohol abuse but do not visit the dentist for regular check-ups. Current advice is for all adults, including those without any natural teeth, to have an oral health risk-assessment and full examination at least once every 24 months and more frequently if required.

    Many patients may present to GP surgeries with oral pathologies including suspected oral cancers. GP surgeries must be aware of the local arrangements in place for the urgent referral pathway for suspected oral cancer cases. A patient who sees a GP or another member of the practice clinical team with a non-suspicious oral pathology should also be advised to see a dentist for full examination as soon as possible.

     

  • Oral health and general health

    Many general health conditions (e.g. diabetes, stress, organ transplantation, stroke, chemotherapy etc.) and/or drugs can cause oral health problems. These patients should be advised to see a dentist for examination and management/treatment as required.

    In many occasions, complications such as infections as a result of untreated tooth decay and/or gum disease can be prevented through a full dental examination and treatment before starting medical treatment or undergoing surgery e.g. IV bisphosphonate, chemotherapy and any treatment/surgery that suppresses a patient’s immune system.

     

  • Prescribing

    Dentists are obliged to issue NHS prescriptions to NHS patients where required. They also have a duty of care to issue private prescriptions to private patients.

    If, after seeing a dentist, a patient asks their GP for an NHS prescription, the GP should make a reasonable investigation into the patient’s condition and accept responsibility for that aspect of a patient's condition before issuing an NHS prescription (paragraph 39 of the NHS (GMS Contracts) Regulations 2004 at annex 1). GPs should be cautious about accepting a patient’s understanding of dental advice and, although they may take a dentist's advice into consideration, GPs should satisfy themselves that what they prescribe is appropriate to the patient's condition.

    If a patient asks a GP to supply an NHS prescription the GP must refuse unless they are sure they are able to accept sole responsibility for that prescribing decision (see health circular EL(91)127 at annex 2). If a legitimate need for an NHS prescription cannot be established, under paragraph 39(1) of contractual terms (see annex 1), it should not be provided.

    This guidance applies to patients seeking an NHS prescription following the issue of a private prescription, or recommendation of a drug, by a dentist.

     

  • Recommendations for local arrangements

    LMCs and Local Dental Committees (LDCs) should establish a working partnership. This would enable GPs to raise local problems with their LMC, which could then liaise with the LDC to discuss and make appropriate plans to manage the problems. If good LMC-LDC relations are established, the LDC can be apprised of any difficulties with emergency arrangements.

     

  • References cited in this guidance