The involvement of the whole dental team can help to ensure the effective management of these risks.
Some patients present higher levels of potential risk than others. In some cases, this increased risk is self-evident, while in other cases the need for extra vigilance and caution may be less apparent.
Ensuring that every member of the dental team understands where and why these additional risks might exist, is a necessary pre-requisite to being able to take steps to minimise and manage those risks effectively.
A sensible risk management strategy is to identify, at the start of each treatment session, any patients who present a particular risk for one reason or another. Different members of the dental team will have their part to play in minimising this risk, which will vary according to the type of risk involved;
- Medical/systemic problems
- Physical problems
- Communication problems
- Specific risk categories
- Children
- Pregnancy
- The elderly
- General anaesthesia and sedation
- Emergency patients
Medical/systemic problems
It should be possible to identify many patients at risk from the details contained within their medical history. This emphasises the need not only for a comprehensive medical history to form an integral part of the clinical records of every patient, but also for such histories to be kept up-to-date.
Medical conditions impact upon dental care in a variety of ways, either by presenting an inherent risk to the patient's welfare (e.g. uncontrolled diabetics, severe uncontrolled angina or a history of myocardial infarction) or by placing them at risk if certain kinds of dental treatment are provided for them (e.g. patients with a history of rheumatic fever, or functional heart valve problems, or patients with a history of head and neck radiotherapy) or by complicating the provision of treatment in some way or another (e.g. immuno-compromised patients, or patients with a latex allergy).
In many situations, dental treatment might be complicated not by the medical condition itself, but by medication being taken by the patient to treat it (e.g. steroid or anti-coagulant therapy, tricyclic antidepressants or monoamine oxidase inhibitors). In the case of many patients, it is important to realise that the medication they take may not be static in nature; they may well be taking different drugs, at different dosages, from one dental visit to the next. This emphasises the need to update clinical records at regular intervals to reflect the patient's current medication regimen, and also to check this regimen before providing any treatment, or administering any medication, that might be contra-indicated.
Whether the records are held electronically, or in conventional (paper) form, it is important to have a clear means of identifying any patients who might present a special risk because of some aspect of their medical history-“ sometimes referred to as a 'MEDI -ALERT '.
In the case of paper records, this 'MEDI - ALERT' flag (often taking the form of a prominent coloured sticker) should appear on the notes themselves and each relevant sheet thereof - as well as on any outer envelope or retaining folder. Adverse incidents have occurred in the past because important information of this nature has not been carried forward from one sheet of clinical records, to the following sheet(s).
The more people in the team that are trained to recognise and understand the various kinds of MEDI -ALERT , the less likely it becomes that these important details might be overlooked.
Physical problems
Patients with hearing problems and/or visual impairment can present additional challenges for the dental team if the quality of their dental care is to be maintained.
In some locations, clinicians and dental team members with special training in the care of patients with these (and other) disabilities, are available in specialist units, often in facilities that have been suitably modified, where necessary, to maximise the quality of the patient's access and care/treatment experience.
Where such referral units are not readily available, patients with a variety of physical disabilities might seek their treatment in general practice, or elsewhere in primary care.
Additional time, thought and planning is needed to ensure that such patients are not disadvantaged in the overall care they receive. Here again, record systems, appointment systems and the use of 'alert' signals can and should be used to ensure that patients in any of these categories are given the additional time and consideration they need.
Certain other kinds of physical disability can create difficulties in maintaining oral hygiene, placing these patients at risk of caries and periodontal disease.
Carers need to be made aware of the importance of maintaining the oral hygiene of those under their care, and the dental team needs to suggest the best means of achieving this in the circumstances of each individual patient.
Communication problems
In addition to physical disabilities, there is a variety of other barriers to effective communication. For example:
- Language barriers - the patient's first language may not be that which is used routinely by the dental team. Even when communicating with the patient through an interpreter, breakdowns in communication and misunderstandings can still occur.
- Some patients, perhaps because of mental health problems or learning difficulties, may not have the capacity to understand information provided to them, or to interpret the significance and relevance of this information to their own situation.
- The clinician or other members of the dental team may be communicating in the same language as the patient, but the clarity and overall quality of this communication may be poor. In some cases the clinician or other dental team member(s) may be unaware that they are not making themselves clear to the patient.
- Some elderly patients (see below) may forget information given to them, and patients who are extremely nervous may be so distracted by anxiety that they may not really be listening to what is being explained to them. In these cases, advice/information sheets summarising the key points, that can be read by the patient away from the surgery environment, or perhaps explained and emphasised to the patient by others, can be very helpful.
- In all of the above situations, there is a real risk that patients will not be able to make informed and considered decisions regarding treatment that is proposed for them (i.e. the consent process will thereby be defective). Alternatively, the patient may not act upon important pieces of pre-operative or post-operative advice, thereby prejudicing the outcome of treatment or - on occasions - placing them in danger.
Various means are at the disposal of the dental team to overcome these problems;
- having third parties present when important conversations/ discussions are taking place - either to act as an interpreter at the time, or to be able to explain things to patients in their 'home' environment, or to ensure that advice is acted upon, even if not fully understood by the patient.
- The use of visual aids where this might help to overcome a language barrier.
- The use of information/ advice sheets written in various languages (especially relevant if a practice treats a significant number of patients from a community where the native language is not that normally used within the practice).
Wherever there is any doubt as to whether or not the patient has understood and appreciated the significance of information provided for them - especially where this information is of a nature that might influence a patient's decision whether or not to proceed with the treatment in question - it is wiser to postpone treatment rather than to proceed in the absence of a valid consent from the patient.
Specific risk categories
(1) Children
Children who are not, by virtue of their age and/ or capacity to understand information about treatment proposed for them, able to give a valid consent to treatment, should only be treated in the presence of someone who is legally able to give consent on their behalf.
Care needs to be taken when children are accompanied by temporary carers (including teachers, parents of school friends, relatives etc) who do not have the legal authority to give a valid consent on behalf of the child. In certain situations (this varies from jurisdiction to jurisdiction) there are specific restrictions on parental responsibility in situations where a child's natural parents have become divorced or separated; this determines who can and cannot give a valid consent to treatment on a child's behalf.
If in doubt, it is safer to postpone treatment or to provide the minimum of treatment if this is required in the child's best interests, limiting any intervention to reversible treatment wherever possible.
Children receiving local anaesthetic injections (especially when this is for the first time) need to be warned against cheek/ lip/tongue biting and this risk should also be stressed to those who will be responsible for supervising the child in the period following treatment.
To minimise risk from this source, the use of minimal doses of appropriate local anaesthetic solutions and of vasoconstrictor, will shorten the duration of any anaesthesia and thereby minimise the risks involved.
Children present additional complications when medication is being prescribed and administered, in terms of the range of suitable drugs, the appropriate dosages to be given, and the route of administration.
Children in pain, or with acute infections, need to be handled with great care and caution, especially in the case of very young children. Deteriorating situations need to be monitored very closely as a child's condition can change very quickly.
A separate module in this series (Module 19 - Treating Children) provides further information.
(2) Pregnancy
Most of the additional risk when treating pregnant women, relates to risks to the unborn child.
The special need to avoid ionising radiation (especially during the first trimester) highlights the need to identify any patient who might be pregnant, even at the very earliest stages of pregnancy.
This can be done by appropriate information and questioning before undertaking any treatment where a patient's pregnancy might be relevant.
Various kinds of medication are contraindicated at different stages in a pregnancy. For example, metronidazole should be avoided in the first trimester, and also after birth if the mother is breastfeeding.
Tetracyclines and benzodiazepines, on the other hand, should be avoided during the second and third trimesters, close to the delivery date, and again, if the mother is breastfeeding the child.
(3) The elderly
When prescribing medication for the elderly, drug dosages normally need to be adjusted to a significantly lower level.
Where renal or hepatic function is impaired, special considerations apply.
Elderly patients are particularly likely to experience postural hypotension when brought back to the upright position after lying down (e.g. in a dental chair).
The longer the patient has been in a supine position, the greater the likelihood of this complication occurring. Dental nurses and other members of the dental team should ensure that such patients are closely observed until they feel entirely recovered.
Some elderly patients may be forgetful and confused and this can impact upon their compliance in taking necessary medication, or acting upon pre-operative or post-operative advice.
Wherever practicable, the involvement of a responsible third party, carer or family member can help to ensure that any recommended action is taken as required.
Elderly patients may suffer from a range of conditions (arthritis, cervical spondylosis, muscle weakness) etc, which when combined with any visual impairment and other problems, may compromise their ability to maintain adequate oral hygiene.
The use of alternative methods of oral hygiene may usefully be suggested and explained by members of the dental team.
(4) General anaesthesia and sedation
Patients receiving treatment under general anaesthesia are at particular risk because of the loss of their normal protective reflexes while anaesthetised, and also during the recovery period. The length of this period varies according to the drug(s) administered. Patients should be closely and personally supervised by trained and experienced staff throughout this period, until they are sufficiently recovered to be able to leave the premises.
Patients who have received general anaesthesia or sedation, should always be accompanied home by a responsible (named) adult, to whom the need for careful postoperative supervision has been explained in advance.
Patients should be warned not to operate any machinery, or to have control over any kind of vehicle, for an appropriate period after the administration of any general anaesthetic or sedative agent.
Patients need to be made aware that the effect of the drug(s) may continue, even after they initially feel 'normal'. The need for caution should be stressed and backed-up by written advice sheets that are explained to the patient well before the procedure (i.e. not immediately before, and on the day of the procedure, as any such information is unlikely to be retained and acted upon).
(5) Emergency patients
One category of patient that can present a less obvious risk, is the emergency patient who is attending the practice for the first time.
Although the patient may present with an immediate, pressing and sometimes very obvious need, and the dental team might often be accommodating them in an already-busy schedule creating time pressures, it is important to approach their care in the same meticulous fashion as would apply for any patient being seen for the first time.
A detailed medical history is an obvious first step, but where the answer to any question is not clear, or is incomplete, one should avoid any temptation to make assumptions, or to proceed with treatment without taking steps to clarify or confirm the information provided.
Few dental situations are life-threatening, and however insistent the patient, one should not feel pressurised into providing treatment if it would be wiser to postpone the treatment or to carry out only minimal 'first aid' treatment in the first instance, while further and more reliable information is being obtained.
The same principle applies in respect of any investigations that one would normally carry out; the fact that a patient has attended as an emergency, and/or that the time available to treat the patient is limited, is no justification for cutting corners.
Even with a patient who is well known to the clinician involved, the shortage of time that sometimes exists in an emergency situation can lead to deficiencies in the quality of the consent process; as a result, treatment decisions can be taken which, if later found to be unsuccessful or ill-advised, invite the allegation on the part of the patient that they would not have agreed to the treatment had they been properly warned of the likely (or possible) outcome.
Summary
Patients can present additional complications or risks for a variety of reasons. Every member of the dental team needs to understand the nature and implications of these risks, and to appreciate the part they can personally play in minimising them.
In addition to staff awareness and training, practice systems should be designed to identify, manage and protect patients at risk. It is particularly important that these systems should be designed to identify potential risk at the earliest possible opportunity, and also be flexible enough to respond promptly when a patient's risk changes for any reason.