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Independents' Day

Can I refuse to treat a dental abscess?

Three experts advise

A patient asks you to help with a problem that ought to be seen by a dentist. What should you do?

Dr Justine Hall

Dr Justine Hall: If you are uncertain what you’re treating then refuse

Prescribing for dental problems in primary care is a topic on which GPs are divided. Many feel that prescribing a course of amoxicillin, possibly with metronidazole, is simple enough and helps when dental appointments on the NHS are hard to get, especially if the patient is in pain. Those doctors feel they know that dentists

will almost universally prescribe this course of antibiotics, except in cases of allergy, and the treatment is not hard to replicate.

However, we must remember we are not trained in dentistry, nor do we have the necessary equipment and lighting to see clearly inside a patient’s mouth to establish whether antibiotics are the right approach or whether further intervention such as incision and drainage is needed – or indeed whether another antibiotic may be more appropriate.

A GP would be perfectly within their rights to refuse treatment if they were not sure what they were treating – as long as they signposted the patient to an NHS dentist. A fundamental part of GMC guidelines is only to prescribe within your own competence, no matter how much pressure a patient may exert on you. This has been underlined by recent BMA guidance on treating patients who present with dental problems.

Many surgeries carry a number for their local NHS emergency dental line. Alternatively, the patient can call NHS 111 to find this out. Many LMCs also offer guidance on this to their GPs, but this may differ up and down the country. If in doubt, contact your LMC or indemnity provider for advice.

Dr Justine Hall is a GP in Guildford, Surrey, and planned care clinical lead at NHS Guildford and Waverley CCG

Prof Azeem Majeed

Professor Azeem Majeed: Inform the patient that they need to see a dentist

A study published in 2016 reported that around 600,000 GP consultations annually are for dental problems. The reasons why people present to GPs with dental problems include the poor provision of NHS dental services in many parts of England and the £19.70 charge that some patients have to pay for a dental consultation.

If you decide that your patient may have a dental abscess, assuming there are no red flags (such as signs of spreading infection or sepsis) that would warrant an urgent referral to hospital, the patient should be told that they need to see a dentist. Explain that a dentist is trained to treat dental abscesses but you are not. The dentist has the expertise and equipment needed to assess, carry out suitable investigations (such as dental radiographs), and drain the abscess if this is required. The dentist can also treat any underlying problems, through procedures such as root canal treatment or a tooth extraction, to minimise the risk of the abscess recurring.

You should also explain that issuing an antibiotic is inadvisable for someone with a suspected dental abscess as it won’t address the underlying problem and may mask symptoms, potentially resulting in a worse long-term outcome. Also, it will encourage the development of antimicrobial resistance.

If the patient does not have a regular dentist, tell them they can call NHS 111 or use the NHS Choices website to find out about local services for emergency treatment. It is NHS England and NHS commissioners, not GPs, who are responsible for ensuring the population has access to adequate NHS dental services.

Professor Azeem Majeed is professor of primary care at Imperial College London and a GP in London 

Dr Marika Davies 330pxx330px Online

The medicolegal view: Carry out an adequate assessment before asking the patient to see a dentist

It is clearly more appropriate for a patient with a dental problem to be seen by a dentist. However, patients may sometimes experience difficulties accessing emergency dental services and may present to their GP instead. Refusing to treat a patient in this situation could give rise to a complaint, and you must be able to demonstrate that you have acted appropriately and in the best interests of the patient before recommending they see a dentist.

You should carry out an adequate assessment of the patient to establish the precise nature of their needs. You should be familiar with NICE guidance on the management of dental abscesses in primary care, as well as local guidelines on patients presenting with dental pain. If the patient is in pain you should provide advice and analgesia if necessary.

GMC guidance says you must always recognise and work within the limits of your competence, and refer the patient to another practitioner if necessary. The GMC also says you should prescribe medicines only if you have adequate knowledge of the patient’s health and are satisfied that doing so serves the patient’s needs.

You should emphasise the need to seek dental treatment and advise the patient how to access local emergency dental services. Good communication about the reasons for your actions will also help to prevent a complaint.

Dr Marika Davies is a medicolegal adviser at the Medical Protection Society

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Readers' comments (25)

  • Azeem Majeed

    There is also some guidance form the BMA.

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  • There are some problems with the advice given, particularly that of the MPS adviser to 'carry out an adequate assessment'. The only way I can carry out an'adequate assessment' is to employ a dentist and get them to assess there and then - I am clearly not competent to do it myself as I have neither the education, skills, nor equipment to carry out an 'adequate assessment'!
    Advice from respected dental authorities (such as Deans of Dental Schools), is that often proper and best treatment does include drainage, but does NOT include antibiotics. I feel these two aspects are not suficiently attended to by the advisers in the article:- it remains a very difficult area where we cannot avoid excess risks of complaint while NHS expects to have GPs assess these patients for free because it won't pay dentists to do it.

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  • Dr Hall's advice is unfortunate as the BDA does not recommend antibiotics as this can increase risk of abscess formation and they recommend dental assessment.
    David Church's view is correct.

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  • Spuds

    My one and only official complaint was about a woman who phoned and asked me to give her "stronger antibiotics" for her abcess that had formed after a dental extraction. It was a bank holiday and she didnt want to travel to the hospital to see the duty dentist. She said I should see her first to see if there was anything I could do instead because it was more convenient for her.

    My defence union tried to water down my reply letter but I wasn't happy to do that. I felt strongly that this was a dental problem and well beyond my competence to assess. The complaint was thrown out.

    This does seem to be a problem with defence unions though - they will always try and accept some guilt/responsibility and appease the complainant (as per the advice given by Dr Davies above)

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  • Yes Defence bodies are there only to limit their losses really - they have lawyers on their side. Also their CEOs have high salaries to pay.

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  • Defence organisation woolly nonsense again. I can't believe we have to pay such huge sums for such ridiculous advice. We are not dentists. We should not have to assess dental problems, and we should not have to explain why we cannot treat a dental problem. The defence organisations should vigorously defend any complaints made in such circumstances.

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  • Ah ! Im not the only one who feels disgruntled at the ; wishy washy sitting on the fence until anal tone is lost replies, recieved from defence unions. As the ' dental abscess' question was the first and only question I asked of them after which I thought not again!

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  • 3 stars; 2 each for the first two answers, but -1 for the wefty answer. We wouldn't treat a patient's cat, even if it was convenient for them; I know more about cats than teeth.

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  • Can I refuse to treat a gearbox fault?

    Can I refuse to treat an exotic animal?

    Can I refuse to treat a space rocket?

    Look, we are doctors-DO YOU UNDERSTAND??????????????

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  • Appalling comment from the MPS doc. We should not even be assessing the person as we would not be in a position to provide treatment as we do not have the equipment or expertise to make a diagnosis. Dental problems- direct to dentist.

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  • Patients may have difficulty accessing a hairdresser but that does not mean we cut their hair in NHS time.

    How can we properly assess a problem we are not trained to manage?

    This is one area the defence organisations should be truly supporting us to reject- dentists spend 5 years on the head and neck. I would have thought the disparity in expertise is obvious.

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  • putting aside the exactly correct way to treat a simple problem this old chestnut instantly weeds out who should never have been a Dr.
    lets just change the question shall we?
    "An old lady or neighbour asks you to help her change her lightbulb as she is worried about climbing on a stool"
    do we say "f-off' I'm a highly qualified Doctor, i'm far too busy and important to do a simple task like that! call an electrician..." or hide behind some other lame elf and safety excuse annd decline.
    Anyone who has ever suffered with toothache knows how painful this can be, you should obviously use this opportunity to hammer home some helpful advice about brushing teeth and not eating sweets before explaining you are incapable of helping them.
    Special (educated) people like Doctors should have their own secret stash of antibiotics and tramadol for this sort of problem.
    (in case you just just dont care or your thought process is too algorythmically wired and inflexible to notice the correct answer,if you are kind and caring is obvious...)

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  • Dr Brigg.....I fail to see how this "weeds out who should never have been a Dr"..... I would not assess or treat a dental problem because I am not a dentist.... I would still describe myself as a kind, caring Dr.
    This is not about health & safety concerns, being "inflexible" or about being a "highly qualified Doctor" or "far too busy and important" .....but about NOT being qualified as a dentist.

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  • Dr Brigg, suggest you change the analogy, from change lightbulb to rewire house. Now do you see? Treating dental problems is not like changing a lightbulb, as it requires years of experience and training to be competent.

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  • unbelievably lame , but predictable responses!
    are you seriously telling me that if you were stuck on a desert island with bad toothache and a swollen jaw, but also happened to have a supply of suitable antibiotics and analgesia, you would not know what to do??!
    treating a dental abscess/infection is no different from any other infection. go back to basic principles.
    the 4 years of dental training are mainly spent on learning to do fillings bridges and restorative dentistry ,and orthodontics etc.(something i would not attempt)
    they also spend time learning a bit of medecine, ent and preventive health care.
    most would do a pretty good job of CPR.
    I could go on (and on), but its time some of us Drs took a hard look in the mirror and asked themselves if they are trying to help the patient or themselves...

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  • ps. it IS a lightbulb and not a rewire, that would be dental implants

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  • |Peter Brigg | GP Partner/Principal|29 Jan 2017 9:37am

    putting aside the exactly correct way to treat a simple problem this old chestnut instantly weeds out who should never have been a Dr.

    And there we have it - everything which is wrong with general practice in one sentence. The fact that we are such a divided profession that standing up for what we should and shouldn't be doing brings out accusations of being unsuitable for the role. No wonder the GPC has a hard time - how can anyone lead a bunch of GPs who have no self respect or self worth.

    Peter Brigg - no-one is saying we can't prescribe antibiotics or analgesia. We are saying there are other more suitably trained professionals to do it so we should be optimising access to them, not propping up their failure of service delivery.

    And no - I wouldn't change the old lady's light bulb when her perfectly capable son is living round the corner from her but she doesn't wish to bother him.

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  • MPS advice horrible, just ghastly. The two doctors have it spot on, Just say no, not trained, not indemnified, not my problem.

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  • What would a dentist do, or be advised to do, if a patient consulted them with chest pain?
    Would they be expected to carry out an 'adequate assessment' or would they simply refer on?

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  • If a patient turns up at an appointment I wouldn't turn him away before examining his mouth. What if he actually has a tumour?. It would look bad if the dentist referred him after a Gp refused to see him

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  • Mps know the rules
    Get a complaint and see

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  • Mps know the rules
    Get a complaint and see who you need
    It can't that long to be a dentist ...seems possible in a year
    My dentist scratches X-ray drill fill bill ...large

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  • As Dr Brigg blithely appears ignore is that sometimes the problem is not as simple as a well meaning, untrained amateur might think. Thus giving well meaning - but utterly inappropriate - treatment will do more harm than good. More people get morbidity / mortality from overly (and inappropriately)confident doctors than from any other cause.

    The examples given to back up this poorly thought through position are hilarious - what one would do with no recourse to expert assessment is always going to be different to what one will do when experts are available.

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  • I think we all want to help, the problem is what happens when it's not a simple toothache. If we miss osteonecrosis of the jaw or even worse a tumour, it's the GP who gets hung out to dry despite the fact we are not adequately trained in this area and don't have good access to appropriate investigations like OPGs. How on earth are we supposed to 'carry out an adequate assessment,' as the MDOs glibly remind us when we don't have the right skills? The solution to all this is for the NHS to provide good quality acute dental services rather than continual cuts to services. Then we can stop arguing with each other about who does what.

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