BACKGROUND A 46-year-old businessman – Mr T – attends his dental surgery complaining of generalised mouth pain. His last appointment was over two years ago for a check-up and scale/polish and the records show no clinical issues at that time. Dr G undertakes a dental history and reviews Mr T’s completed medical history questionnaire. Dr G notes Mr T smokes over 20 cigarettes per day and is a social drinker. Mr T states that he recently heard on the
radio that amalgam fillings had been banned in Europe due to mercury toxicity. He has numerous large “NHS fillings” in his back teeth and insists that these are poisoning his mouth and causing dental pain. He wants the fillings replaced. Dr G carries out a detailed extra and
intra-oral examination, noting calcified deposits and associated gum disease. A BPE is recorded with a score of 333/333 in each sextant. Appropriate radiographs demonstrate loss of supporting bone, particularly around the front teeth, but do not demonstrate the presence of dental decay. Peri-apical radiographs taken of two teeth (suspected sources of pain) do not reveal any apical disease. The dentist informs Mr T that he has periodontal disease and this is causing his mouth pain. He explains ongoing treatment will be required to prevent eventual tooth loss. Mr T insists that – despite being a
smoker – he has always looked after his teeth, brushing twice a day. He believes the pain is clearly associated with mercury “leeching into his gums”. Dr G explains that there is no evidence in
the clinical literature of any connection between amalgam fillings and gum disease – and no European or UK guidance (that he
is aware of) calling for the removal of old amalgam fillings. The new legislation refers mainly to a general “phase down” in the use of dental amalgam aimed primarily at reducing the release of mercury in the environment. But Mr T is adamant that he wants the old fillings removed and the discussion becomes heated. Dr G again advises regular appropriate
periodontal treatment and asks the patient to make a follow-up appointment for next week but states that he is not prepared to electively remove his fillings. Two days later the practice receives a three-page complaint letter. It cites numerous articles on mercury poisoning found on the internet and accuses the dentist of disregarding Mr T’s concerns and implying that he is ignorant. Dr G phones MDDUS to ask for assistance in dealing with the complaint.
ANALYSIS/OUTCOME Dr G formulates a response letter and this is reviewed by an MDDUS adviser. In the
letter he expresses his regret that Mr T is dissatisfied with the treatment advice and states that he in no way intended to be dismissive of the patient’s concerns. He reminds Mr T that he is free to seek a second opinion on the matter – but restates that the removal of the existing fillings is contrary to his clinical judgment and will not be carried out in the surgery. Mr T does not respond to the letter but
remains a patient at the practice with ongoing treatment of his periodontal condition.
KEY POINTS ●Ensure you engage patients in shared decision making with reasoned two-way discussion. ●Do not feel pressured to carry out treatment against your clinical judgement.
ADVICE SEEKING CLOSURE
BACKGROUND A GP contacts MDDUS in regard to a request from a Mr F seeking access to the medical records of his deceased mother who was a patient at the practice. Mr F wants clarity over certain aspects of his mother’s care leading up to her death.
ANALYSIS/OUTCOME An MDDUS adviser responds by letter stating that there are both statutory regulations and professional guidance in regard to such a disclosure. The Access to Health Records Act 1990
provides certain individuals the right to access the health records of a deceased person, including that patient’s personal
representative (i.e. executor or administrator of the estate). The GP is advised to ascertain whether Mr F is either his mother’s personal representative or can
KEY POINTS ● An executor/administrator will usually be able to access a deceased patient’s medical records if there is no reason to believe the patient would have objected. ● Disclosure to close relatives would usually be appropriate (if the patient would not have objected).
provide consent from that person. The GMC advises that doctors can also
disclose certain details after death “when a partner, close relative or friend asks for information about the circumstances of an adult’s death and you have no reason to believe that the patient would have objected to such a disclosure”. This may be particularly important to help those close to a patient understand and come to terms with the death. The adviser informs the GP that it is at
the discretion of the practice how to proceed – bearing in mind what the patient’s wishes would likely have been and her confidentiality (which still apllies after death).
MDDUS INSIGHT / 19
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