ge in consent


respective endocarditis guidelines. Contrary to NICE, the ESC maintains that prescription of prophylactic antibiotics for high-risk patients is the safer approach. It is important to acknowledge that a causal link has not been


established between the withdrawal of cover since 2008 and the apparent rise in IE cases. Nevertheless, the question is begged whether, in the new era of patient autonomy heralded by Montgomery, both sides of the debate should be discussed with this patient. Remember that the law, as it now stands, places the dentist “…under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment”. Te all-important test of materiality is “…whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk”. It does seem quite reasonable to presume that a patient with a


previous episode of endocarditis may attach significance to the view of the ESC. So, there may be some dentists, possibly emboldened by the sentiments conveyed in Montgomery, who


“ There may be plenty for the dentist to explain … prior to carrying out a seemingly routine extraction”


feel compelled to offer the choice of antibiotic cover to our hypothetical patient. Doubtless, this would be based upon well-informed reflection and would be the result of factual, neutral and very well-recorded advice. Before I remove my toe from these very troubled waters,


please let me emphasise that MDDUS is not endorsing the provision of prophylactic antibiotics. Whilst slavish adherence to best practice guidelines is not mandatory, members must be aware that NICE remains a voice of authority and refuge lies within its parameters.


More routine risks Tankfully, most patients are not at risk of IE, so there is no need to consider antibiotic cover. However, the loss of this particular tooth might well lead to reduction in function, denture retention or aesthetics. Tese problems might be remediable, but only by means of treatments such as bridgework or an implant, both of which involve their own risks not to mention significant cost. Having been so advised, the patient may well decide that conservative options, though possibly less durable or predictable, are worth exploring. Of course, the patient is always entitled to refuse or delay treatment. So, there may be plenty for the dentist to explain and for the


patient to consider prior to carrying out a seemingly routine extraction.


SUMMER 2016


No risks? Moving further down the excitement scale, it may be that the cause of the presenting symptoms was simply cervical sensitivity. No need for extractions or endodontics: this problem might be treatable by means of something as mundane as topical fluoride application. Surely, little in the way of warnings is needed? Perhaps not – but this does open the door to a related cautionary tale involving younger patients. I had a call from a member recently who had been engaged by


his area team to visit a local primary school with a view to applying fluoride varnish. A letter was sent to each parent in advance which contained very limited information but did ask if their child suffered from asthma, and, if so, the severity. Tese forms were reviewed and fluoride was not applied to the dentition of any children with a history of severe asthma. Later and following discussion on a well-known parenting


forum, a number of complaints were received at the school. In summary, some parents completing the consenting form did not realise that there were a variety of possible adverse reactions to the varnish. Te dentist’s approach (based largely upon guidance from his


area team) was not without logic. Fluoride application represents an efficient means of reducing dental disease. Complications are very rare with, arguably, the only serious outcome being exacerbation of severe asthma. Nevertheless, it must be remembered that the physicians’ “…


advisory role cannot be regarded as solely an exercise of medical skill without leaving out of account the patient’s [or their ‘legal proxies’] entitlement to decide on the risks to her health which she is willing to run”. Unsurprisingly, many parents attached significance to the


possibility, however slight, that the application of fluoride varnish could have led to unpleasant side effects, such as gastric disturbance or allergic reaction. Had they been given the full picture, as they should have been, consent may have been withheld.


Securing reliable consent If the treatment of choice is obvious, even the most fastidious dental practitioner may be tempted to offer advice which is incomplete or slightly skewed. Tis is not done to actively mislead patients. Instead, it is generally the result of a mental calculation, based upon extensive expert knowledge, which is designed to offer the most helpful and digestible amount of advice in a reasonably time-efficient manner. Yet this approach fails to recognise that different facets of


planned treatment will have significance for different patients. Information which might appear to be irrelevant or superfluous to the practitioner may be very important to a patient undergoing treatment. Terefore, discussion is almost always needed in order to secure consent upon which dentists can subsequently rely.


n Doug Hamilton is a dental adviser at MDDUS 19


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