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A faulty production line

Altogether now, doctors don’t do teeth

Dr Punam Krishan

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I can’t believe it took seven years as a GP to challenge why, when I am not a dentist, I keep having patients turn up to see me with oral problems.A grumbling irritation I've had for years finally erupted a few weeks ago as I saw my fifth patient of the week attend for toothache.

The role of a GP may be described as ‘expert generalist’ but that doesn’t mean we should expect to be called out to fix a blocked drainpipe. That said, I am confident a GP would probably know more about said plumbing issue than some necrotic looking tooth I barely know the anatomy of.

So it was, I became a little frustrated and did what you do to vent these days, taking to Twitter to tell our dentist colleagues about it. I felt better for about 24 hours, as my dental colleagues were empathetic. They even started a hashtag #doctordentistcollaboration – always the best way to begin policy change.

I didn’t feel comfortable managing something I didn’t have the clinical information for

To my surprise, they fully accepted that there were issues with dental access. I liked the idea of collaborating to better educate the public about using services appropriately. There was also a suggestion that doctors and dentists needed to educate one another about what the different specialties do. It took just one tweet to solve this conundrum – dentists do the mouth, doctors do everything else. The whole exchange was a lot easier than with most health board collaborations.

The storm subsequently calmed down, but was that in patients’ best interests?

Midway through my afternoon surgery today, I saw a patient who was referred by his private dentist to see his GP for painkillers and antibiotics. This dentist had diagnosed a ‘fractured jaw and tooth misalignment’ following trauma, as explained by the patient.

The patient obviously saw my physiology change and apologetically handed me the only letter he was given by this dentist – a beautifully designed glossy invoice. The fee of £225 for a consultation and a CT scan with a follow up appointment the next day for £99 stared at me. At the bottom was his name with, ironically, the title of ‘Dr’ in front of it, followed by an impressive list of qualifications. Unfortunately, Dr. Dentist was unable to prescribe analgesia and antibiotics to his patient for management of a diagnosis he made.

In sheer frustration, I tried to contact this dentist to understand his reasoning for sending a patient to me without any correspondence and without an adequate management plan in place. I wouldn’t diagnose a patient with piles then send them to a podiatrist to sort this out, so why did this dentist think he could dump on a GP like this?

At 4:30pm the dentist had left for the day. I couldn’t get hold of him and now this was my problem. I didn’t feel comfortable managing something I didn’t have clinical information for, but what was I to do? I had a helpless patient in severe pain in front of me. This consultation took me 40 minutes to sort out as I tried to find out the facts.

Despite the general consensus for better collaboration in that Twitter debate, some argued that doctors need more dental education. It takes five years to become a doctor to learn about the human body. It takes five years to become a dentist to learn about the head and neck. I would argue that perhaps the dental faculty needs to incorporate more clinical medicine and pharmacology in its education curriculum so dentists can take responsibility for their own patients and manage them effectively. This seems particularly important given dentists are regularly performing invasive procedures that are highly traumatic, extremely painful and associated with a high risk of serious complications.

I believe a dentist should be able to prescribe diazepam for their anxious patient. They should be able to perform a medication review prior to operating on their patient. They should be able to manage anticoagulants, prescribe antibiotics appropriately and manage the analgesic ladder. None of these issues should be referred to the doctor, especially without correspondence. 

I fully appreciate that there are many exceptionally talented, dedicated and holistic dentists out there who are at the opposite end of this spectrum. I have a lot of respect for their input to healthcare. We should support one another, work together and not dump on one another.

In order to facilitate better patient care then, we should perhaps consider sharing patient ‘key information summaries’ with our dental colleagues, as we do with the out-of-hours service. Furthermore, we need to have collaborative discussions with local dentists to raise the awareness of dental emergencies for both clinicians and the general public so everyone knows who to contact and when. The doctor is not the default setting.

It is time for change.

Dr Punam Krishan is a GP in Glasgow


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Readers' comments (9)

  • Oh PK, but Doctors DO do teeth!
    All registered General Dental practitioners in GB are entitle to use the title 'Doctor'.
    And all registered dental practitioners in GB are allowed to give prescriptions for analgesia and antibiotics too! - see BNF section 'Dental prescribing formulary'.
    Any reasonable GDP would know that a case like yours should be sent to hospital Maxillofacial service for further treatment, not a GP, and would also follow GDC guidelines for acceptable communication and handover of care. The circumstances reported suggest that this was not the case here, and they should no longer be registered to see patients (dental or otherwise).
    I am pleased to hear you had support from dentists. We also find we get on well with our local actual Dentists. We get less good referrals from local dental receptionists, who seem to think every patient wanting a dental assessment should first have antibiotics from a GP before seeing a GDP!
    We also have one local health board dentist who seems to think all patients need a written referral from a GP to see a Dentist, but our LMC have had words with that one!

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  • Had a patient who's dentist told him he cannot prescribe antibiotics for people who are allergic to penicillin, because he only knows about amoxicillin. I though the dentist was at least being honest, but still it is not acceptable to be a dentist and not know about the treatments needed to adequately look after teeth.

    Sent hime back with a little note and my old copy of the BNF.

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  • It’s my understanding that at least one of the defence organisations-mine- has reminded its members that they do not cover us for dental care and my surgery has therefore required that we clearly respond to any requests for dental care by saying we are not allowed to practice in nhs without insurance and therefore can’t continue a dental consult.surrprisingly not had any negative reactions so far.

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  • Fractured jaw - A&E
    saved you 40 mins

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  • doctordog.

    Giving antibiotics for a presumed tooth abscess will usually give temporary respite from pain and often result in the person not attending the dentist.
    We then run into the potential risks of inadequate treatment of the infection and the person going on to develop osteomyelitis in the skull /jaw or worse.
    Ultimately you have not served the patient well and left yourself open to possible litigation.

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  • the abdication of responsibility by this private dentist should surely result in a letter to the GDC from yourself. This is at a minimum unsafe practice and failure to hand over correctly and should result in some form of investigation. I bet this isn't the first time said dentist did this. A few letters to the GDC would soon sort it out and stop the unsafe dumping of work.

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  • Okay let’s go a bit historical! At the dawn of time (!) when I was a student at a London Medical School we did 3 months on a dental firm where each of us were required to perform at least 12 dental extractions with patients admittedly under GA! We learned a lot about dentistry during that time and this helped our future knowledge.
    As far as anatomy was concerned during preclinical time we had six students per body and strangely even dissected head and neck! In those days we couldn’t go onto clinical firms unless we passed 2nd. MB exam and had full knowledge of anatomy etc.
    How times have changed where we seem to take less responsibility for fear of litigation and have apparent less generalised knowledge despite seemingly being able to do more.I am so glad that I’m not a student now!

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  • All good suggestions above. I think that a complaint or letter to the dentist would be called for here. The only way to stop this dentist dumping work is to make the alternative (dumping work and then getting a complaint) worse!

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  • AlanAlmond

    Medico legal risk. That’s what changed from times gone by. That’s why we pay ever increasing danger money to insurance companies who employ lawyers at great cost to ponder the rights and wrongs of our actions at their own self enriching snail pace. It’s legal parasitism. Yes dentists should see dental issues, yes this dentist was wrong. Perhaps theur are fewer cases of osteomyelitis as a result of inappropriate GP dental care as a result, but I bet this is far out weighed by the harm done by delays in treatment as patients scramble to see the appropriate clinician. But the lawyers can’t sue a patient for their inability to get an appointment with a dentist can they, or their stupidity in booking to see a GP instead. I would suggest the overall global outcome has not been improved by the rise in medico legal risk, even if the occasional case of osteomyelitis of the jaw has been prevented.

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