BDA Advice Sheets

Advicesheet
Ethics in dentistry B1
Advicesheet
Ethics in dentistry B1
contents page
This advice sheet provides detailed, practical advice and information on the
major aspects of ethics in dentistry. The sections are:
The duty of care and professional obligations 6

Professional regulation and registration 6
The patient’s best interests 6
Equal treatment and human rights 6
Professional competence and experience 7
Lifelong learning 7
Clinical audit, peer review and clinical governance 8
Professional indemnity/insurance 8
Revalidation 8
Checklist 9
Consent 9
Key definitions 9
The need for valid consent 10
Obtaining consent 10
Material risks 12
Consent under duress 13
Treatment at the patient’s request 13
Making claims 14
Battery 14
The age of consent 14
Children in care 15
Incompetent patients 15
Where consent is not obtainable 15
Clinical trials, research and lectures 17
Consent forms 18
Checklist 18
Confidentiality 19
What is personal health information 19
Data Protection Act 1998 20
Age of consent to disclosure 20
What information can be disclosed 21
Training and disciplinary procedures 24
Checklist 25
Model confidentiality policy 25
Data protection code of practice 27
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contents page
Dental records 29
Good record keeping practice 30
Storage, retention and disposal 31
Fair processing 32
Subject access 32
Third party access 33
Sale/transfer of records 34
Checklist 35
Patient care 35
Patient communication 35
Agreeing to provide care and treatment 36
Patient choice 37
Treatment planning 37
Health checks 37
Alternative therapies 37
Non-surgical cosmetic procedures 38
Tooth whitening 38
Medical emergencies 38
Misleading patients 38
Maintaining appropriate boundaries 39
Referral fees 39
Missed appointments 39
Debt collection 39
Handling complaints 40
Checklist 41
Professional relationships 41
Professional agreements 41
Duties of a dentist manager 41
Second opinions 42
Raising concerns 42
Specialist practice 43
Veterinary dentistry 43
The death of a dental practitioner 43
Checklist 44
Commercial interests 44
Financial interests 44
Advertising and canvassing 45
Shared arrangements with other health professionals 45
Buying, selling or closing a practice 45
Bodies corporate and limited liability partnerships 46
Practices owned by dental care professionals 47
Promotion of products and services 47
Private dental plans 47
Bankruptcy 48
Checklist 48
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Child protection 48
Types of abuse 48
Practical steps 49
Recording and reporting 50
Child protection policy 51
Criminal record checks 52
Further information 53
Checklist 53
The dental team 53

Vicarious responsibility 53
Dental hygienists and dental therapists 53
Dental technicians and clinical dental technicians 54
Dental nurses 54
Dental receptionists 54
Training 54
Terms and conditions of service 55
Staff management and appraisal 55
Checklist 55
General anaesthesia and sedation 55

General anaesthesia 55
Conscious sedation 56
Conscious sedation in Scotland 58
Alternative techniques 58
Consent 58
Checklist of ethical principles 59
Dentists’ Health Support Programme 61
BDA Benevolent Fund 62
The guidance gives members essential advice on ethical issues that will enable
them to practise safety and in accordance with high standards of professional
conduct and behaviour. The BDA is able to provide ethical advice and support
to members, contact practicesupport@bda.org or telephone 020 7563 4574.
Dentists are facing greater demands from patients, regulators and NHS
commissioners. Cases going before the General Dental Council are rising and
dental negligence claims are also becoming more common. In order to manage
these risks successfully, dentists need to ensure that they understand and keep
up-to-date with changing professional regulations and are fully conversant with
what is expected of them. Use these advice booklets as reference documents
and in conjunction with guidance issued by the General Dental Council
(www.gdc-uk.org).
© BDA March 2009 5

This section gives an overview of the main obligations of a dentist and covers: The dentist’s
Professional regulation and registration duty of care and
The patient’s best interests
Equal treatment and human rights professional
Professional competence and experience
Lifelong learning obligations
Clinical audit, peer review and clinical governance
Professional indemnity/insurance
Revalidation
Checklist
Until recently, dentists had a professional monopoly, being the only individuals Professional regulation
who could carry on the business of dentistry, that is, profit directly from dental and registration
practice. This changed in 2006 with amendments to the Dentists Act and the
opening of the Dental Care Professionals Register. Since then, all GDC
registrants can own dental practices. It is now also possible for non-dentists do
be involved in an incorporated dental practice as long as the majority of
directors of the company are GDC registrants.
Dentistry is a self-regulated profession, which means that the General Dental

Council determines the standards against which dentists are judged. As is the
case with all health care professionals, dentists must retain public trust and
confidence, both as individuals and in the profession as a whole. Complying
with certain fundamental principles, which are the basis of sound ethical
practice, will ensure that dentists continue to maintain their status as respected
professionals:
Acting in the patient's best interests and respecting their dignity and choices
Communicating with patients and listening to their concerns
Obtaining consent to treatment and keeping personal health information
confidential
Complying with the rules and regulations that apply to dentists
Providing patients with the best possible clinical outcomes
Being trustworthy
Keeping their skills and knowledge up-to-date
Co-operating with other members of the dental team and other health
professionals in the interests of patients.
In some circumstances these principles can place great demands on dentists

and this section identifies some of the issues involved. The GDC has a set of
standards guidance booklets with which all registrants must familiarise
themselves. These are available on their website at www.gdc-uk.org.
A dentist must act in the patient’s best interests and provide a high standard of The patient’s best
care and service. Acting in a patient’s best interests can be interpreted widely interests
but includes:
Providing appropriate, necessary care and treatment to a high standard

Not misleading patients
Putting the patient’s needs first
Treating the patient regardless of race, sex, religion, sexual orientation,
social class, medical or dental condition or disability
Providing information that is necessary for the patient to make an informed
choice about care
Providing care in an emergency and out of hours.
© BDA March 2009 6

Complying with these rules can be difficult, particularly where financial
constraints mean that dentists are not always able to spend enough time with
their patients. Communication failures can mean that dentists can inadvertently
mislead patients about the type or quality of care they can expect, and this is a
particular danger in dental advertising. Sometimes, the patient’s and dentist’s
perceptions of what is an acceptable standard of care can differ, for example in
what constitutes a dental emergency.
Equal treatment and The Human Rights Act came into force in October 2000. The Act makes it
human rights unlawful for the human rights of individuals (as defined by the European
Convention) to be infringed by public authorities, which includes NHS
organisations. The effect of the Act is to allow individuals to pursue public
authorities in the UK courts rather than having to go to the European Court.
The Act covers issues such as consent to treatment and physical restraint of
patients.
Professional competence Dentists must not undertake procedures for which they are not competent or do
and experience not have appropriate experience. Asking for help from colleagues or ceasing
treatment and referring a patient to another practitioner can be difficult, but is
always a wise course of action. Inexperienced dentists particularly can
encounter difficulties undertaking complex procedures and, although many
problems are solved during vocational training, sometimes they continue in
practice, resulting in great stress and loss of confidence for the dentist and
potentially harm to patients. Help is available from postgraduate dental deans,
dental schools, General Dental Practice Advisers to PCTs/Health Boards and
professional organisations. Contact the BDA Practice Support on 020 7563
4574 or email: practicesupport@bda.org for further information.
Unsatisfactory treatment or failure to provide treatment without adequate skill

and care can lead to civil cases of negligence, disciplinary proceedings by
PCTs/Health Boards, referral to an NHS Tribunal or allegations before the GDC
of unfitness to practise. Where dentists encounter colleagues in this situation
they have a professional duty to raise their concerns with an appropriate
individual. Dentists’ responsibilities in this regard are discussed on page 42.
Lifelong learning Dentists are expected to undertake continuing postgraduate development

(CPD) by attending relevant courses, reading professional journals and making
use of other educational resources such as videos and CD-ROMs. This activity
will generally ensure that a dentist is kept up to date with changes in clinical
techniques and is able to adapt their practice accordingly, maintaining
professional standards. Individual dentists also benefit in achieving greater
satisfaction from their work, contact with professional colleagues, building a
good professional reputation amongst patients and peers and being able to
prevent and defend complaints.
GDC registration includes participation in its CPD scheme, whereby registrants

are required to undertake a minimum number of hours (250 for dentists, 150 for
DCPs) to show that they are keeping up to date. The GDC also requires all
registrants to undertake CPD in a number of set core subjects: medical
emergencies (ten hours per cycle), disinfection/decontamination (five hours per
cycle), and radiological protection (five hours per cycle). Registrants should
also keep up to date with ethical and legal issues.
Short postgraduate courses are organised by postgraduate dental deans,

specialist dental societies, the BDA, the Faculty of General Dental Practice
(UK) and commercial organisations. Information on courses is available from
the BDA on request.
Dental schools, the Royal Colleges and other bodies also award postgraduate
qualifications. Information on postgraduate courses is available from the BDA's
Education Team.
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Clinical governance is the name for quality assurance within the NHS. An Clinical audit, peer
overall clinical governance system is in place throughout the NHS, but a review and clinical
specific framework has also been developed for dental practice. PCTs are using governance
this framework to assess dental practices locally and to ensure that procedures
are in place to comply with the wealth of legal requirements governing health.
The practice framework is subdivided into twelve distinct areas, ranging from
infection control, radiation, patient safety through child protection, consent,
confidentiality, staff development and patient involvement to clinical audit and
peer review. The BDA has a clinical governance kit which provides all relevant
policies and models to comply with the requirements.
Clinical audit and peer review are an integral part of clinical governance.
Reviewing treatment outcomes either through individual assessment or on a
group basis is fundamental to modern ethical practice. PCTs take varying
approaches to these activities; some require the practices to carry out audit
projects on set subjects, whereas others expect practices to choose their own.
The BDA has an Advice Sheet E10 CPD, clinical governance, audit and peer
review and a number of sample audits on its website.
Dentists must have appropriate professional indemnity/insurance cover to Professional

undertake any form of practice. The cover may be in the form of membership of indemnity/insurance
one of the dental defence organisations or insurance with a company that offers
an appropriate level of cover to protect patients and the dentist.
Currently there are three defence organisations in the UK; some, such as
Dental Protection and the Medical and Dental Defence Union of Scotland, offer
indemnity cover, while the Dental Defence Union offers cover underpinned by
an insurance policy. Indemnity cover is discretionary so that they do not
guarantee to cover claims. Indemnity covers occurrences within the period that
a dentist is a member, even if they are no longer a member when the claim is
made. This is occurrence-based cover.
Medico-legal insurance guarantees to cover the insured up to the limit of the

policy provided that the claim falls within the scope and conditions of the policy
and is within the policy period. The company will cover on a claims-made basis,
that is the dentist will be protected against claims made during the policy period
and matters arising out of the dentist’s clinical relationship with patients
occurring whilst the dentist is insured. If a dentist discontinues a policy and
wishes to be covered for the period of insurance, “run-off” cover must be
purchased.
When choosing appropriate cover, dentists should consider whether the

proposed cover meets their current and future practising needs, will provide
help with proceedings by the General Dental Council as to matters of
professional conduct and health and provides suitable professional support that
is appropriate to their practice. It should be noted that sometimes defence
organisations will terminate the membership of dentists following a GDC case
or will require the member to pay a higher membership fee. For more
information see BDA Advice Note Professional indemnity cover.
The GDC is committed to introducing a system of revalidation, in which Revalidation

registrants will have to demonstrate that they are fit to stay on the register.
There is no definite timescale for this, but plans for pilots are well advanced.
Revalidation will include continuing professional development, but will also look
at other professional achievements and activities of registrants, such as
compliance with clinical governance and further postgraduate qualifications.
These ‘positives’ will be counterbalanced with any ‘negatives’, for example high
numbers of complaints or an appearance before the GDC. It is also expected
that appraisal will play a part. The vast majority of all registrants will be able to
show their fitness to remain registered, but, where there is a case where
© BDA March 2009 8

questions remain, the GDC will be able to take further steps, for example an in-
practice assessment or a full assessment through the National Clinical
Assessment Service (NCAS).
Checklist Always act in a patient’s best interests

be familiar with the GDC’s Standards for dental professionals guidance and
supplementary booklets (Principles of dental team working, Principles of
patient consent, Principles of patient confidentiality, Principles of raising
concerns, Principles of complaints handling, Principles of management
responsibilities, Conducting clinical trials, Responsible prescribing, and Child
protection)
Only undertake procedures for which you have the necessary training,
competence and experience
Undertake continuous postgraduate education and comply with clinical
governance arrangements
Obtain and keep up appropriate professional indemnity/insurance cover.
Consent The law on consent is subject to change and further specific advice should be
obtained from BDA Practice Support on 020 7563 4574 or practicesupport@bda.org.
This section gives general guidance on the dentist’s responsibility to patients to

obtain consent to examination and treatment. It is not intended to be
comprehensive, but it contains sufficient information for dentists to gain a
general understanding of a complex subject. The case law on medical consent
is constantly developing and advice should be sought from the BDA/defence
organisation when particular problems arise.
Key definitions Express consent
A patient gives express consent when he or she indicates orally or in writing

consent to undergo examination or treatment or for personal information to be
processed.
Implied consent
In very limited circumstances consent may be implied. An example is where the

patient indicates agreement to an examination by lying in the dental chair and
opening their mouth. Consent to other types of dental procedures cannot
normally be implied from compliant actions; an open mouth does not
necessarily mean that the patient has understood what the dentist has
proposed to do or the reasons why.
Informed consent
Informed consent requires a full explanation of the nature, purpose and material
risks of the proposed procedures, and the consequences of not having the
treatment, in language that the patient can understand (using an interpreter and
visual aids where necessary). The patient should have the opportunity to
consider the information and ask questions in order to arrive at a balanced
judgement of whether to proceed with the proposed treatment.
Specific consent
Specific consent means that the patient consents expressly to each of the
procedure(s) to be undertaken. An agreement to undertake a course of
treatment without knowing what is to be done is not specific consent. For
example, obtaining a patient’s informed consent to sedation does not mean that
the patient has given specific consent to the treatment that will be carried out.
© BDA March 2009 9

Valid consent
For consent to be valid it must be specific, informed and normally be given by

the patient or a parent or guardian (if the patient is under 16 and is unable to
give informed consent).
A dentist has a legal requirement to obtain the valid consent of the patient to The need for valid
the treatment proposed. Before carrying out an examination or treatment, valid consent
consent must be obtained. For consent to be valid, the patient giving the
consent must be:
1. Competent to give it
2. Adequately informed of the nature of the procedure that is being agreed to
and
3. In a position to give consent freely.
The need to obtain a patient's informed consent arises from the moral
obligation and ethical principle to respect a person's autonomy and right to self-
determination. Any treatment or intentional physical contact with the patient
undertaken without valid consent may amount to assault and a breach of the
patient’s human rights. A court may award damages for assault and the General
Dental Council considers that assault or treatment without consent can amount
to serious professional misconduct. Consent should be regarded as an ongoing
process rather than a specific event and is another instance where effective
communication between dentist and patient is vital. Refer to the GDC’s
guidance in Principles of patient consent (www.gdc-uk.org)
Who can obtain consent? Obtaining consent
Consent for examination and treatment must be obtained by a dentist (normally

the dentist who is undertaking the treatment). In no circumstances should the
obtaining of consent to treatment be delegated to staff, although they may be
extremely helpful in reinforcing the information that has been given.
For treatment undertaken by a dental hygienist or dental therapist, the

prescribing dentist should obtain consent and the treating professional should
check before it is done that the patient is still content for the treatment to be
carried out.
Who is competent?
This is a question of fact in every case and requires that the patient is able to
understand what is involved in the procedure. The patient must be able to (i)
comprehend and retain the relevant information, (ii) believe it, (iii) weigh in the
balance so as to arrive at a choice, and (iv) communicate their decision
(whether by talking, using sign language or any other means).
The patient does not have to make a “mature” or “wise” decision, nor do they
have to achieve the unattainable, such as fully appreciating the consequences
of the decision. The law will not impose unreachable expectations about a
patient’s reasoning powers and experiences. A patient must be able to
understand what is wrong, that it requires treatment and the consequences of
undergoing or declining treatment.
An assessment of whether a patient is able to consent should be carried out

before any dental care or treatment.
© BDA March 2009 10

Express and implied Consent may be express or implied. An example of implied consent for an
consent examination is when a patient makes an appointment and presents for
examination. Consent to other types of dental procedures cannot normally be
implied from compliant actions - only in very limited circumstances consent may
be implied. Express consent may be given orally or in writing. Oral consent
would normally be adequate for routine treatments, such as restorations and
prophylaxis, provided that full records are maintained. Written consent is
necessary in cases of extensive intervention and essential where a general
anaesthetic or conscious sedation is given (see pages 55 and 56).
Specific consent
The precise nature of the treatment to be undertaken must therefore be

explained clearly and in terms that the patient can understand. Asking whether
the patient has understood or whether more information is needed is useful, as
is, where possible, providing supporting written information. Aids such as
radiographs, photographs and models can be helpful in discussions as well as
books such as the BDA’s Pictures for patients portfolio.
Going beyond the consent that has been given
It must not be assumed that, because consent has been obtained for one
procedure, it is implied for an alternative or subsequent treatment that may
become necessary. Consent must therefore be appropriate and the changed
circumstances must be explained to the patient and specific consent sought.
The best interests of the patient are of course paramount and if, while under a
general anaesthetic or sedation, it becomes clear that further treatment of
complications is absolutely necessary, it would be reasonable to proceed,
provided that the dentist is willing to be accountable for his/her actions in the
patient's best interests. Where it is anticipated that this situation is likely to
occur, the dentist should obtain prior consent to treat such problems that might
arise. As soon as the patient is sufficiently recovered to understand, the
treatment actually provided must be fully explained together with the reasons
for undertaking it.
Restricted consent
Sometimes patients will consent to part of a treatment plan but withhold

consent for treatment that may become necessary so that the procedure can be
given further consideration. Such instructions must be fully documented and the
patient’s wishes must be followed.
Informed consent
The dentist should endeavour to assess how much the patient wants and ought
to know about the condition and its treatment. The patient's comprehension is
an essential element in the validity of consent and the onus is on the dentist to
be satisfied that the patient has understood the treatment to be carried out and
the consequences of not having the treatment. Alternative treatments which
may be available and their likely prognosis, any material risks involved in each
option, methods of pain control to be used and any aftercare or precautions
which may be necessary all form a vital part of the explanation leading to full
comprehension and an informed choice by the patient. When all of these
components are present a patient may have been judged to have given
informed consent.

During the discussion about proposed treatment, the dentist should not make
assumptions about patients’ views but ask whether they have any concerns
about the proposed treatment or its risks. Engaging in open and helpful
dialogue takes up clinical time but, as well as satisfying a dentist’s ethical and
legal obligations, it increases the quality of care that is provided.
Material risks
In deciding which risks are material and should be explained, a practitioner will
rely on professional judgement, but must warn patients of any substantial or
unusual risks involved and of consequences which may be slight but which
commonly occur. Examples include the possibility of nerve damage in oral
surgery procedures, perforation or instrument breakage in endodontics, and
crown and bridge failures. To what extent risks must be described to patients is
influenced by public and professional expectations and dependent on case law.
Some of the relevant cases in the fields of medical negligence and consent are
described below.
Bolam and Sidaway
In Bolam v Friern Hospital Management Committee (1957) it was held that a

doctor should not be found guilty of professional negligence if a reasonably
competent doctor in a similar position would have acted in the same way and
the actions would have been supported by a responsible body of medical
opinion. This is known as the Bolam test. Applying the Bolam test to dental
consent means that a dentist would not be found guilty of failing to warn a
patient of a material risk if a reasonably competent dentist in similar
circumstances would not have warned of the risk and that decision would have
been supported by a responsible body of dentists.
The Bolam test was affirmed and extended in the Sidaway v Board of
Governors of Bethlem Royal and the Maudsley Hospital case (1985) where the
House of Lords held that a decision on the degree of disclosure of risks that is
best calculated to assist a particular patient to make a rational choice must
primarily be a matter of clinical judgement and that the attention of a patient
should be drawn to any danger which may be special in kind or magnitude, or
special to that patient, with sufficient information being provided to enable the
patient to reach a balanced judgement. In deciding on whether to warn of a
particular risk, the Sidaway judgment held that the health professional must
take account of all of the relevant factors such as the severity of the risk to the
patient and the likelihood of the risk, as well as the patient’s specific need for
the procedure. Where risks could result in grave and adverse consequences to
the patient (referred to in the judgement as substantial risks), the dentist has a
duty to inform the patient of them even if a substantial body of dental opinion
would not have done so.
Increasingly, the legal profession, the public and health care professionals
expect that patients are informed of all of the risks that apply to proposed
treatment, not just those that a responsible body of medical opinion would have
warned them of. While the
Bolam test is still of importance in the UK courts, recent judgments in Ireland

and the UK have challenged it.

Bolitho v City and Hackney Health Authority (1997)
The Bolitho judgment involved the issue of causation in medical negligence and
refined the Bolam test of the practitioner being able to rely on what a
responsible body of medical opinion would have held to be correct. Although
the judgment specifically excluded the issue of disclosure of risks to patients
when obtaining consent, subsequent consent cases have referred to it (see
below).
In the judgment, the Law Lords found that a practitioner who is alleged to have
been negligent by omission could not rely on evidence that a body of medical
opinion would have omitted to act in the same way. In the circumstances that
the claimant and defendant call expert witnesses (as was the case in Bolitho),
reliance could only be placed on opinion that was “sensible” in that it had a
logical basis. Bolitho has been used in the case of Pearce v United Bristol
Health Care NHS Trust (1999).
Pearce v United Bristol Healthcare NHS Trust (1999)
In this case a female patient was not warned of a one or two in a thousand risk
of stillbirth in a delayed delivery. The body of medical opinion brought by the
defendants concluded that the risk was not significant. The Court of Appeal
held that a doctor must take account of all relevant circumstances when
deciding how much information to give, including the patient’s ability to
understand the information and emotional and physical state.
The court held that it was for the court and not for doctors to decide on the
appropriate standard of what should be disclosed to a particular patient about
particular treatment.
It would normally be the legal duty of a doctor to advise the patient of any
significant risks that may affect the judgement of a reasonable patient in making
a decision about treatment. In summary, the court decided that “if there is a
significant risk which would affect the judgement of a reasonable patient, then
in the normal course it is the responsibility of a doctor to inform the patient of
that risk if the information is needed so that the patient can determine for him or
herself as to what course he or she should adopt”. On the facts in this case the
court held that the risk of stillbirth was not significant and it was not proper for
the court to interfere with the clinical judgment of the doctor.
Consent under duress Consent is not valid if it is obtained under duress. The consent must be given
voluntarily and freely. Claims of lack of voluntariness do not, for the most part,
involve brute force or duress. The courts wish to ensure that patients are not
unduly influenced – if it is deemed that patients have not given consent
voluntarily, the consent will not be valid. It has been argued in Court that
consent could never be given voluntarily where
the patient is a prisoner and the doctor was also a prison officer. This argument
was rejected by the Court of Appeal.
Care should be taken in obtaining consent in the presence of third parties,

including family members, that confidential information is not disclosed without
the patient’s prior authorisation and that third parties are not unduly influencing
the patient to consent.
Treatment at the Cases arise where patients ask a dentist to undertake treatment that is not in
patient’s request their best interests and is against the dentist’s clinical judgement, for example,
removal of healthy teeth, crown and bridgework instead of extraction and
dentures or dental implants (where these are not clinically advisable). In these
situations, dentists still have responsibility for the clinical treatment provided
and always to act in the patient’s best interests. Treatment should not be

undertaken if it will cause permanent damage to the dentition or will be of no
clinical or cosmetic benefit. If the treatment fails, the patient may seek damages
for negligence or a refund of treatment costs. In these events it can be difficult
to establish that treatment was undertaken with the required skill and care.
Obtaining a signed statement from the patient instructing the dentist to carry out
the treatment and absolving the dentist from any stated adverse consequences
may not be a valid defence in court or before the General Dental Council.
Finally, dentists should be careful that the claims they make for a particular Making claims
form of treatment can be substantiated and that they do not unrealistically raise
their patients' expectations of the benefits or results of particular treatments. In
dentistry, it is also essential that the patient understands and agrees to the
costs involved and is clear whether treatment is being provided under the
National Health Service or privately (see page 36).
To undertake treatment without the consent of the patient constitutes an assault Battery
on that individual and could render the dentist liable to an action in battery even
if the treatment were not performed negligently. The practitioner would be liable
in battery for failing to obtain consent at all, or failing to ensure that the patient
understood even in broad terms the nature of what was proposed. The fact that
the patient, if asked, would probably have consented to the procedure is no
defence. Even where consent has been sought, the practitioner could still be
liable in negligence for failing to give adequate information as to the risks
involved in the procedure or the possible alternatives. There is also a possibility
of action under the Human Rights Act 1998 where the dentist is providing NHS
care. Further information on the implications of the Act is available from BDA
Practice Support on 020 7563 4574. .
A person who has reached the age of 18 and who has the capacity to reach The age of consent
decisions on their own behalf is a competent adult and can give or withhold
consent. Capacity will necessitate being able to understand, believe and retain
the information provided about treatment and having the ability to weigh up the
information in order to choose whether or not to proceed. No-one else is able to
consent for a competent adult.
The Family Law Reform Act 1969 provides that any person age 16 years or
over and of sound mind may legally give consent to any surgical, medical or
dental treatment. A parent theoretically could lawfully consent to treatment of a
child who is refusing consent, but a parent cannot overrule such a child’s
consent to treatment. Best practice would be to make an application to court
where parents are prepared to consent but a child is capable of understanding
what is involved and is refusing to consent to some major form of treatment.
Children under 16 who are of sufficient maturity and intelligence to understand

fully the nature of the treatment proposed and its ramifications are also entitled
to give consent to treatment. This is known as “Gillick competence” after the
1985 case of Gillick v West Norfolk and Wisbech Area Health Authority where
the Law Lords ruled that a child under 16 was able to consent if he or she
understood the nature of the treatment, its purpose and hazards. It will
ordinarily be for the practitioner to decide whether the child satisfies these
criteria of competence. The ability of a child to understand will depend on the
child’s age, maturity and the proposed treatment. For example, a twelve year-
old child might be able to give consent to a dressing, but may not be able to
consent to an extraction. A parent can lawfully consent to treatment of a “Gillick
competent” child who is refusing consent, but a parent cannot overrule a “Gillick
competent” child’s consent to treatment.

The Children Act 1989 reinforces the right of a child with sufficient
understanding to make an informed choice to refuse to submit to examinations
or treatment. But if a child aged 16 or 17 refuses treatment, this will not
override parental authorisation. Alternatively, where parents refuse treatment
that is in the child’s best interests, a court can be asked to make an order for
the treatment to be carried out lawfully.
More than one person may have parental responsibility for the same child at
the same time. Where more than one person has parental responsibility, each
may act alone and without the other. In the absence of agreement by all those
with parental responsibility, the specific approval of the court must be obtained
if the treatment involves an important decision.
The following have parental responsibility: the child’s father and mother, where
they were married to each other at the time of birth; the child’s mother but not
the father where they were not so married, unless the father acquires parental
responsibility either by order of the court or pursuant to a “parental
responsibility agreement” with the mother; a person appointed as the child’s
guardian and a person in whose favour the court makes a residence order with
respect to the child.
Where a child who is unable to consent is accompanied by an adult relative

without parental responsibility and consent from the parent has not been
obtained, the adult cannot give consent to the treatment. If the parent cannot be
contacted then treatment should only proceed in exceptional circumstances, for
example where the child is in pain and the treatment is undertaken to alleviate it.
In Scotland, the Age of Legal Capacity (Scotland) Act 1991 is specific and
provides that a person under 16 who, in the practitioner's opinion, is capable of
understanding the nature and possible consequences of the procedure or
treatment shall have legal capacity to consent on his or her own behalf to any
surgical, medical or dental procedure or treatment. In Northern Ireland the age
of consent for medical and dental treatment is 16.
Children in care Where a child is taken into local authority care, the local authority may acquire
parental responsibility in addition to the child's natural parents. If the child is in
care, usually the dentist can obtain consent from an authorised representative
of the local authority. Where a major surgical procedure is involved, however,
the consent of the parents would usually be sought as well. In the case of
children under 18 who are wards of court, the consent of the court must be
obtained before any major intervention can take place.
Incompetent patients Incompetent patients are those who, for reasons of mental incapacity or illness,
cannot give informed consent to treatment on the basis of full understanding of
the need for, nature of and consequences of treatment proposed. Not all
mentally ill or incapacitated patients are incompetent. But in the case of minors,
the informed consent of the parent or guardian should be obtained. Full details
of the law regarding consent and mental incapacity is available in a BDA Advice
Note Assessing mental capacity.
Where consent is not Where consent may not be obtainable, for example in cases of incompetent
obtainable adults, unconscious patients or an emergency, the same basic principle applies:
the professional has a duty to make up their own mind and to act in the best
interests of the patient, taking a second opinion where necessary. In cases of
unconscious patients, a practitioner should carry out only that treatment which
is necessary and should await such time as the patient is able to consent
before undertaking further procedures.
Consultation with the next of kin is advisable.

Notes must be made in the patient’s clinical record to explain why consent was
not obtained, to record the second opinion that was given, and include any
other views that were sought.
In the case of both minors and people with mental incapacity, a patient may be
competent to consent to some treatments but not to others. Some patients with
mental illness may be competent to consent at some times and not at others.
The dentist's responsibility with regard to confidentiality should also be borne in
mind in these cases.
Where patients are detained under the Mental Health Act 1983 without their
consent, treatments can be performed without consent if the treatment is for the
“mental disorder” and as such the normal rules for obtaining consent should be
followed for dental treatments. The courts have extended this to allow
treatments to be performed without consent that are unrelated to the mental
disorder but which could cause the patient’s mental health to deteriorate.
Decisions made by the Court of Protection
The Court of Protection is the final arbiter in relation to the legality of decisions
concerning patients who do not have capacity to consent. In addition to
adjudicating in relation to specific, one-off decisions, the Court will have the
power to appoint deputies to assist with continued decision making. Although
health care decisions can be lawfully made without a deputy, they can be useful
where there are disputes over care and treatment
Lasting Power of Attorney
Individuals over the age of 18 who are competent can nominate another person
to make health care decisions on their behalf when they lose the capacity to
make such decisions. The person nominated is known as having a lasting
power of attorney (known as a welfare power of attorney in Scotland).
Independent mental capacity advocates
For incompetent adult patients who lack any form of external support in relation
to serious treatment and there is no-one close to the adult to provide advice or
guidance, including an attorney or deputy, then the services of the Independent
Mental Capacity Advocate can be engaged.
This service will only be available in the case of a single treatment being
proposed where there is a fine balance between its benefits to the patient and
the burdens and risks it is likely to entail, or what is proposed would be likely to
involve serious consequences for the patient.
Advance statements or directives to refuse treatment
People over the age of 18, who are competent, are able to make advance
statements that they refuse a particular type of medical treatment (which will
include dental treatment) if they lose capacity.
If a patient is incapable of consenting, the dentist must ensure that the advance
decision exists and is valid. The advance statement must refer to the particular
treatment in question and should explain the circumstances to which the refusal
applies.
It is only possible to make an advance refusal of medical treatment. A person

cannot make an advance request for treatment.

Clinical trials, research Research should not be carried out on patients without specific consent given
and lectures on the basis of a full understanding and explanation of the research and its
possible effects. Participation of a patient in research must be voluntary and
recorded. The same rules regarding age of consent and capacity to consent
apply in the case of research.
Research protocols should always be submitted to the appropriate Local

Research Ethics Committee and a consent form devised which is specific to the
procedure. Guidance is available from the National Research Ethics Service at
www.nres.npsa.nhs.uk
Where a dentist wishes to use photographs or other images of patients in

clinical lectures, papers, videos or presentations, consent should also be
obtained.
Consent for records-based research
Wherever possible, where research is being undertaken using data taken from
patients’ records, explicit consent must be obtained from the patient. If this is
not possible, because of the cost and time involved, the data must be encoded
or anonymised as early as possible within the data processing. If it is
anticipated that this type of research will be undertaken, then this should form
part of the stated purposes for which data might be disclosed and information
should be included in the practice’s data protection policy (see the BDA
Practice Compendium for a model).
Any research that is carried out must be approved in advance by the Local
Research Ethics Committee/Multi-Centre Research Ethics Committee. The
Medical Research Council has issued guidance on the use of personal
information in research
Consent forms Model consent forms are available for use in general dental practice and the
hospital and community dental services. Signing a form, however detailed and
specific, is no substitute for the communication between dentist and patient that
is the essential component in obtaining valid consent. Forms have a place in
recording consent and in some cases (for example general
anaesthesia/conscious sedation, extensive or expensive treatment) are a
professional requirement.
Salaried services: The Department of Health in England has published a

consent form (available in a number of languages) to be used for medical or
dental investigation, treatment or operation and one to be used for mentally
incapacitated patients). The form emphasises the patient’s right to a full
explanation of the proposed treatment, the right to ask questions and the right
to be accompanied by a relative, friend or nurse. It also states that the patient
may refuse or withdraw consent.
General practice: Copies of treatment plans and estimates may be used to

record consent, provided that they accurately reflect not only that the patient
has agreed to the proposed treatment, but that the necessary explanations
have been given and incorporate a signature. A suggested model form for use
in extensive intervention is given below and is available in the BDA Practice
Compendium.

Valid consent is informed and specific Checklist
Informed consent means that the patient understands the proposed
treatment, its purpose, alternatives, material risks associated with it and the
effect of not having it done
Consent to treatment must be obtained by the dentist treating the patient
Consent may be express (that is given orally or in writing) or implied (by
compliant actions)
Children aged 16 or over may consent to treatment although younger
children who are Gillick competent may also do so
The most important aspect of consent is communication between dentist
and patient. Signing a consent form is of secondary importance although it
is compulsory when general anaesthesia or conscious sedation are
undertaken.
Model consent form for treatment (without sedation)
Name of patient…………………………………………………….
Name of parent or guardian (if applicable)………………………..
Address…………………………………………………………….
1. I hereby consent to undergo (or to ……………………….. undergoing)* the

following dental treatment…………………..………… as explained to me by
Dr/Mr/Mrs/Ms/Miss* (name of treating dentist) …………………… who has
explained the nature of the treatment, its purpose, risks and alternatives to me.
I have been given the opportunity to ask questions. I understand that should
any change in this treatment be required, it will be explained to me and my
specific consent obtained.
Treatment :
2. I understand that the cost of the treatment will be

…………………………………………………
Signature_______________________________ Date__________________
(Patient/parent/guardian)*
I confirm that I have obtained a full medical history and explained to the person
who signed the above form of consent, in terms which in my judgement are
suited to his/her understanding, the nature, purpose, risks and alternatives of
this treatment and that the anaesthetic techniques and usual pain control
procedures have also been explained to him/her.
Signature_________________________________Date__________________
Name____________________________________
(Dental practitioner)
*Delete whichever is inapplicable

4. Maintaining Dentists have a professional and common law duty to keep confidential all
personal information gained about patients in the course of their professional
confidentiality relationship. The patient-dentist relationship is built on the premise that a
patient who gives information to a dentist or member of the dental team is
normally entitled to assume that the information will not be disclosed without
the patient’s consent to anyone for any purposes other than the provision of
health care. This principle is included in the GDC’s Standards for dental
professionals. The Council has also issued specific guidance on confidentiality
in Principles of patient confidentiality (www.gdc-uk.org).
Clinical dental records and other items of personal information are held by
individual dentists and dental practices as well as by health service bodies such
as trusts, private hospitals, dental hospitals and government payment agencies
such as the Business Services Authority Dental Services Division. In general
dental practice, responsibility for disclosing information without patient consent
rests with the patient’s dentist (unless, for NHS contract purposes, the dentist is
a deputy, assistant or an employed performer). In the salaried primary care
dental services, responsibility rests with the particular employing trust, although
the dentist who is treating the patient should be consulted if a request for
disclosure is made.
This section considers:
What is personal health information?

Data Protection Act 1998
Age of consent to disclosure
What information can be disclosed?
Training and disciplinary procedures
Checklist
Model confidentiality policy
Data protection code of practice
Checklist
What is personal health Personal health information is any information relating to the physical or mental
information? health of an individual who can be identified from that information or from other
information which is in the possession, control or held by or on behalf of a
health service body or qualified health professional in connection with the
provision of health care.
In dental practice, personal health information includes:
Clinical notes and medical histories (manual and computerised)

Radiographs and study models
Personal information about the patient or identifiable third parties
Information held in appointment books/systems
Financial payment records/NHS forms relating to the patient daybooks
Receipt books with patients’ names
Exemption status
Video, audio tapes, photographs and other medical illustrations
Information that is held in the dentist’s (or other team members’) minds.
Essentially, the fact that an individual is a patient at the practice is confidential

and cannot, under normal circumstances, be disclosed without the patient’s
consent.
Removal of obvious identifying features from the information may not

necessarily remove the need to maintain confidentiality. The patient’s condition
or circumstances may be very unusual or unique so that disclosure of the
information might make it possible to deduce or speculate on the patient’s
identity.

The 1998 Data Protection Act protects the confidentiality of sensitive personal Data Protection Act 1998
data (which includes information on the data subject’s physical or mental health
or condition) by placing obligations on the data controller (that is the person or
legal entity responsible for the data) only to disclose information to a third party
in prescribed circumstances included in the Act and to keep the data secure.
The Act applies to manual data and data that are processed automatically.
An important requirement of the Act is that data must be processed fairly and
lawfully. Data processing includes the obtaining, holding, use and disclosure of
personal data. Applying the terms used in the Act to dentistry, the patient is the
data subject and the dentist responsible for care is normally the data controller.
Processing includes taking records, submitting claims to the NHS, sending out
recalls, sending work to laboratories and referrals.
Among the information that should be given to the patient is that data will be
shared on a ‘need-to-know’ basis with certain organisations (such as the BSA
DSD/ SDPD/ CSA) in order to provide the patient with appropriate care and
treatment and for the provision of general health services.
Under the Act, information should only be held for the period for which it is
required and for the purposes that have been stated to the data subject. For
example, in dentistry, dentists should not send information to patients about
non-dental business ventures unless they have the patient’s consent to do so.
This also applies to information about financial products such as personal
loans.
The relevant principles of the Data Protection Act must be followed: that is data
must be kept for no longer than is necessary and must be obtained for
specified and lawful purposes. An illustration of this might be when a dental
chart of a missing person is given to the police for the purpose of identifying a
body. If the body is not found to be the patient, the charting should be returned
to the dentist and not kept on file by the police.
If the practice operates an appropriate confidentiality policy (see page 25) and
provides a data protection policy, then it is likely that the requirements of the Act
will be met. BDA Advice Sheet B2 Data protection contains further information
and a model data protection policy, which also appears in the BDA Practice
Compendium.
Patients aged 16 and over can consent to the disclosure of their health records Age of consent to
and can withhold their consent. Mature minors of any age, who understand the disclosure
implications of their decisions, can give or withhold consent to disclose
information. Legal rights to confidentiality depend not just on age but also on
understanding. Thus, a parent does not automatically have the right of access
to a child’s records, even if the child is under 16, and the dentist cannot discuss
the child’s treatment with the parents without the child’s consent. It is for the
dentist to judge whether a child is competent in the circumstances, taking into
account the child’s age, maturity and the consequences of disclosure or failing
to disclose. For detailed advice on consent for minors see page 14.
Questions of consent to disclosure also arise where the patient might be judged
to have a mental impairment that may make them incapable of consenting to
disclosure. In these circumstances the dentist must follow the guidelines for
consent included on page15 , which comply with the Mental Incapacity Act and
associated Code of Practice. BDA Advice Note Assessing mental capacity
available, on the BDA website www.bda.org/advicenotes, provides more
information.

What information can be The legal disclosure of personal health information to third parties can be
disclosed? divided roughly into two particular types of disclosure: those exempt from the
disclosure restrictions of the Data Protection Act (broadly, disclosures that are
in the public interest) and those to which the data subject has consented.
Disclosure with consent
Where a patient gives specific consent to disclose particular information (and

the patient is able to give informed consent - see page 10), the information may
be disclosed in accordance with the consent that has been given. An example
might be the use of an identifiable photograph of the patient in a research
paper or practice advertisement.
The Data Protection Act requires patients to give explicit consent to the
disclosure of information held about them where: the disclosure is not covered
by one of the Act’s exemptions; the patient has not been informed that such
disclosure will occur and has not objected to it; or it cannot otherwise be held to
be in the public interest.
Sharing health information
The most common instance of disclosure in dentistry is the sharing of personal

health information in order to provide health care to the patient. Examples of
the necessary sharing of information in dentistry include:
Referral of a patient to another dentist or NHS Trust for specialist treatment.

Referral letters should give full information about the treatment required and
any information about the patient that the referral dentist needs to know
There is a medical condition that may affect the patient’s ability to undergo a
particular dental procedure safely and the dentist wishes to discuss the best
approach with the patient’s GMP/hospital consultant
The dentist is informed by the patient about changes to their medical
condition after treatment has been carried out and needs to check the
details with the patient’s consultant/GMP
The issuing of a written prescription by the dentist to the DCP
Prescribing work to a dental laboratory.
The premise of these disclosures is that they can only be made to persons who
need to know in order to provide care to the patient. The purposes for which the
disclosure is made should also have been notified to the data subject and the
information must only be used for the purposes for which it has been disclosed.
For example, when responding to a GMP’s request for information about the
oral health status of a particular patient, information would not normally be
given about the patient’s personal circumstances. The consent of the patient
should be obtained. Similarly, if the GDP needs to know about a patient’s
medical condition, which has a bearing on the dental treatment, consent should
be obtained before approaching the doctor. Information given to a GMP would
also normally be given directly to the doctor and not to the receptionist, even
though the receptionist would be covered by confidentiality rules. It is for the
dentist to decide what the third party to whom information is disclosed needs to
know.
Disclosure necessary to provide appropriate care and to ensure that the

NHS is able to function
In order to provide patients with appropriate health care and to ensure that the
NHS can function, personal health data needs to be shared.

Patients should be made aware that information will be sent to a third party
(that is, a payment authority) for the purposes of paying the dentist and
monitoring the quality of care provided by, for example, the dental reference
service. Their consent to such disclosure can be implied if they do not object.
Additional details about the treatment, such as patient records and radiographs,
can also be disclosed to a payment authority. NHS payment authorities (the
Business Services Authority, Scottish Dental Practice Division and the Central
Services Agency) have their own procedures for ensuring that patient
information is kept confidential, as do the private dental schemes.
The need to ensure that the NHS is administered efficiently can sometimes
conflict with the need for patient confidentiality. NHS bodies must have clear
procedures for safeguarding patient confidentiality.
The NHS confidentiality code of practice sets out procedures with which health
service bodies (NHS Trusts, Primary Care Trusts/Health Boards/Local Health
Boards) must comply to ensure patient confidentiality. A copy is available on the
DH England website www.dh.gov.uk.
The guidance includes information on:
Safeguarding NHS information

Complying with the law
Giving information to patients on the purposes for which their data will be
used
Security measures
Subject access
Where and how information about patients may be passed on.
Justified disclosure:
Although information belongs to the patient, there may be circumstances in

which the disclosure of patient information without consent may be justified.
Dentists may be asked or required to disclose personal data about patients
without consent, for reasons such as:
Health research
Health research involving access to patient records in England must be

approved by Local Research Ethics Committees, Details of your local REC is
available from the National Research Ethics Committees’ website
www.nres.npsa.nhs.uk/contacts/find-your-local-rec
In the area of confidentiality, the LREC will wish to be satisfied that:
Arrangements to safeguard confidentiality are satisfactory

The use of identifiable patient information is fully justified
Published research findings will not identify individual patients without their
specific agreement.
Where patients will be involved personally in teaching and research activities,

their specific consent must be obtained. The Medical Research Council
publishes guidelines on confidentiality of personal information - Personal
Information in Medical Research - that emphasises the researcher’s
responsibilities, the obligations on hospitals and practices to ensure that
patients are made aware that their information may be used in research, and to
explain the safeguards that are in place for protecting confidentiality. A copy of
the guidance is available from the MRC website on www.mrc.ac.uk.

Public interest
In limited circumstances, disclosures may also be made in the public interest:
Cases of suspected child abuse (see page 48)

Protection against serious future risks to the health and safety of others
A patient is putting their own health and safety at serious risk
Where the law compels it, for example where a court order is obtained or
Disclosure is necessary by statute. This includes:
Certain Acts of Parliament
Serious injury or dangerous occurrences
Certain infectious diseases (not including HIV)
Normally, dentists who receive a court order are required to disclose

information or face being found guilty of contempt of court. In Gaskin v
Liverpool City Council (1980), however, the Court of Appeal found that
Liverpool City Council should not be required to produce confidential files and
information that had been prepared in the course of caring for the child. This
gives professionals bound by confidentiality rules scope to contest orders to
appear in court and submit records. This sort of situation would not normally
apply to dentists, however.
In order for the data controller (the dentist) to pursue his or her bona-fide
legal rights
Cases involving serious crime or national security
Disclosure without consent at the request of the police investigating a crime is

one of the most difficult decisions that a dentist can be asked to make and each
situation needs to be considered individually having regard to its nature,
seriousness and the harm to the patient or others that might result from the
crime. When in doubt, the dentist should ask the police to produce a court order
for disclosure. It can also be in the Crown Prosecution Service's interests to
obtain a court order to prevent the defendant being able to obtain a ruling that
the evidence had not been correctly obtained and was therefore inadmissible.
Where a court order is not made and the police demand that information about
the patient is supplied, for example a record card or confirmation that the
patient attended on a particular day, the dentist must weigh up the following
factors:
The seriousness of the crime

The potential future danger to the public if a disclosure is not made
The likelihood that the suspect will commit a serious injury to another
person or persons.
Where the crime of murder or rape is involved or the victims are children, most
dentists will provide the necessary information. Normally robbery, assault or
drugs offences would not be sufficient grounds for information to be supplied
without patient consent or a court order. Where a request from the police is
received, advice should be sought from the BDA or a defence organisation/
insurer.
The duty of confidentiality does not preclude reporting to the police a crime to
which the dentist has been a witness or which may have been committed
against the practice, such as robbery or assault or threats to the personal
safety of staff or patients. Where, for example, a full list of patients seen in a
session is given to the police in order to investigate a theft from the practice,
patients should be informed that the information is being disclosed.

Road Traffic Act 1988
Where a dentist is asked by police for the name and address of the driver of a
motor vehicle who may have been injured or committed an offence under the
Act, the information must be provided. Clinical information should not normally
be given.
Prevention of terrorism
Under the provisions of the Terrorism Act 2005 a dentist who has information on
a planned or actual terrorist act must inform the police.
HMRC inquiries
In the course of routine inspections, tax inspectors frequently ask to see and
take away appointment books, day books and patient records. The dentist
should not supply this information unless the patients whose names or other
identifiable details are shown have given specific consent to the disclosure or
the patients’ names have been removed or obscured.
If the inspector has reasonable grounds to suspect that an offence involving

serious fraud has been or will be committed and that evidence will be found on
the dentist’s premises, an order requiring the dentist to produce the information
or a warrant for the inspectors to enter the premises, search and seize them
can be obtained.
Further information is available in BDA Advice Note HMRC access to records

can be obtained from www.bda.org/advicenotes or BDA Practice Support on
020 7563 4574.
Identification of missing and deceased persons
It is not a crime to go missing. Patients can sometimes decide to leave their

families for a period and would expect that their medical/dental records are not
disclosed. Where the police find a body that they reasonably expect is a person
who is a patient of a practice, relevant charts, models or other information can
be handed over for identification purposes. The records should be returned to
the dentist after they have been used and not kept on file for future reference.
Dentists are also often asked for patient charting where the patient has died in
an accident or fire and identification by relatives is not possible or desirable.
Where the police have reasonable grounds to believe that the body is the
patient, the charts may be provided.
Patient fraud
It is a criminal offence for a patient to secure for himself or another, the

evasion, reduction or remission of an NHS charge. Patients may be convicted
of a criminal charge, or may have to pay a penalty of up to five times the fee, or
£100, whichever is the lesser.
Dentists may be involved in giving evidence or providing information for

prosecutions for the fraudulent claiming of NHS fees. This is not a breach of
confidentiality.
Every member of the practice must understand the need for confidentiality and Training and disciplinary
that only the dentist responsible for the care of the patient can make a decision procedures
to disclose information to a third party.

Confidentiality training might be part of a general session on dental ethics or
the main component of a staff meeting. The BDA's Consultancy Service can
provide customised training for a practice or a group of practices. Maintaining
confidentiality should also be part of a practice's conditions of employment and
breach should be grounds for summary dismissal. Practices should also have a
specific confidentiality policy as a condition of employment and a model is
included (see below) and available in the BDA Practice Compendium.
Checklist Personal health information gained in the course of providing care to

patients is confidential and must only be disclosed with the consent of the
patient and in particular circumstances
The Data Protection Act 1998 must be followed regarding the non-disclosure
of personal health information and patients should be given a copy of the
practice’s data protection code of practice
Patients should be asked to consent to the sharing of information with other
health care professionals involved with their care. This disclosure should be
done on a need-to-know basis
Dentists must disclose personal health information about patients when
required by a court order or under the terms of the Terrorism Act or the
Road Traffic Act
Dentists may disclose necessary information about their patients in order to
defend their legal rights
Information about patients may be disclosed to the police in order to identify a
body where there is good reason to believe that the body is that of the patient
Staff should be trained in patient confidentiality and practices should have a
confidentiality policy
Breaches of confidentiality should be included in staff disciplinary
procedures as an offence which would result in summary dismissal.
Model practice Compliance with this policy must be made a condition of employment for all
confidentiality policy staff.
At this practice the need for the strict confidentiality of personal information
about patients is taken very seriously. This document sets out our policy for
maintaining confidentiality and all members of the practice team must comply
with these safeguards as part of their contract of employment/contract for
services with the practice.
The importance of confidentiality
The relationship between dentist and patient is based on the understanding that
any information revealed by the patient to the dentist will not be divulged
without the patient’s consent. Patients have the right to privacy and it is vital
that they give the dentist full information on their state of health to ensure that
treatment is carried out safely. The intensely personal nature of health
information means that many patients would be reluctant to provide the dentist
with information if they were not sure that it would not be passed on. If
confidentiality is breached, the dentist/dental hygienist/dental therapist/dental
nurse/clinical dental technician/orthodontic therapist/dental technician faces
investigation by the General Dental Council and possible erasure,and may also
face legal action by the patient for damages and, for dentists, prosecution for
breach of the 1998 Data Protection Act.
General Dental Council
All staff must follow the General Dental Council’s rules for maintaining patient
confidentiality contained in Standards for dental professionals and Principles of
patient confidentiality.

“All members of the dental team have an ethical and legal duty to keep patient
information confidential. The duty of confidentiality applies to all information
about the patient which is learnt in the professional role. This information must
be kept confidential even after a patient dies”.
If confidentiality is breached by any member of staff, it is the patient’s dentist

who is responsible to the Council. A registered dental care professional whose
act or omission has breached confidentiality may also be called before the
Council.
What is personal information?
In a dental context personal information held by a dentist about a patient

includes:
The patient’s name, current and previous addresses, bank account/credit
card details, telephone number/e-mail address and other means of personal
identification such as his or her physical description
Information that the individual is or has been a patient of the practice or
attended, cancelled or failed to attend an appointment on a certain day
Information concerning the patient’s physical, mental or oral health or
condition
Information about the treatment that is planned, is being or has been
provided
Information about family members and personal circumstances supplied by
the patient or others
The amount that was paid for treatment, the amount owing or the fact that
the patient is a debtor to the practice.
Principles of confidentiality
This practice has adopted the following three principles of confidentiality:
Personal information about a patient:
is confidential in respect of that patient and to those providing the patient

with health care
should only be disclosed to those who would be unable to provide effective
care and treatment without that information (the need-to-know concept) and
such information should not be disclosed to third parties without the consent
of the patient except in certain specific circumstances described in this
policy.
Disclosures to third parties
There are certain restricted circumstances in which a dentist may decide to

disclose information to a third party or may be required to disclose by law.
Responsibility for disclosure rests with the patient’s dentist and under no
circumstances can any other member of staff make a decision to disclose. A
brief summary of the circumstances is given below.
When disclosure is in the public interest
There are certain circumstances where the wider public interest outweighs the
rights of the patient to confidentiality. This might include cases where disclosure
would prevent a serious future risk to the public or assist in the prevention,
detection or prosecution of serious crime. It may also be necessary in instances
where the patient puts their health and safety at serious risk.

If it is necessary to share confidential information, if practical, the patient must
be persuaded to release this information themselves or give their permission for
the information to be released. Failing this, it is advisable to contact the BDA or
your defence organisation before acting.
A court can order patient information to be released without consent. In such

circumstances, only the minimum information should be released to follow the
order.
Before releasing any confidential information in the public interest, it must be

necessary to be prepared to explain and justify the decision and any action
taken.
When disclosure can be made
There are circumstances when personal information can be disclosed:
Where expressly the patient has given consent to the disclosure

Where disclosure is necessary for the purpose of enabling someone else to
provide health care to the patient and the patient has consented to this
sharing of information
Where disclosure is required by statute or is ordered by a court of law
Where disclosure is necessary for a dentist to pursue a bona-fide legal
claim against a patient, when disclosure to a solicitor, court or debt
collecting agency may be necessary.
Disclosure of information necessary in order to provide care and for the

functioning of the NHS
Information may need to be disclosed to third party organisations to ensure the

provision of care and the proper functioning of the NHS. In practical terms this
type of disclosure means:
transmission of claims/information to payment authorities such as the BSA

DSD/SDPD/CSA
in more limited circumstances, disclosure of information to the HA/HB
referral of the patient to another dentist or health care provider such as a
hospital.
Disclosing patient information
If the patient consents to their information being disclosed:
An explanation must be provided about the circumstances in which the

information about them might be shared
The patient must be provided with the opportunity to withhold permission for
disclosure of information
The patient must understand what will be released, the reasons for
releasing it and the likely consequences of releasing the information
The person with whom the information is shared must understand that the
information is confidential.
Data protection code of practice
The Practice’s Data Protection Code of Practice provides the required

procedures to ensure that we comply with the 1998 Data Protection Act. It is a
condition of engagement that everyone at the practice complies with the Code
of Practice.

Access to records
Patients have the right of access to their health records held on paper or on
computer. A request from a patient to see records or for a copy must be
referred to the patient’s dentist. The patient should be given the opportunity of
coming into the practice to discuss the records and will then be given a
photocopy. Care should be taken to ensure that the individual seeking access is
the patient in question and where necessary the practice will seek information
from the patient to confirm identity. The copy of the record must be supplied
within forty days of payment of the fee and receipt of identifying information if
this is requested.
Access may be obtained by making a request in writing and the payment of a

fee for access of up to £10 (for records held on computer) or £50 (for those
held manually or for computer-held records with non-computer radiographs).
We will provide a copy of the record within 40 days of the request and fee
(where payable) and an explanation of your record should you require it.
Note : this paragraph should be edited to relate to the circumstances of the

practice.
Some practices prefer not to make a charge.
If a charge is required, it is for copying and posting the information
only. If a permanent copy of the record is not supplied to a patient, a
fee is not applicable.
The fact that patients have the right of access to their records makes it
essential that information is properly recorded. Records must be
Contemporaneous and dated

Accurate and comprehensive
Signed by the dentist
Neat, legible and written in ink
Strictly necessary for the purpose
Not derogatory
Be such that disclosure to the patient would be unproblematic.
Practical rules
The principles of confidentiality give rise to a number of practice rules that

everyone in the practice must observe:
Records must be kept secure and in a location where it is not possible for
other patients or individuals to read them
Identifiable information about patients should not be discussed with anyone
outside of the practice, including relatives or friends
A school should not be given information about whether a child attended for
an appointment on a particular day. It should be suggested that the child is
asked to obtain the dentist’s signature on his or her appointment card to
signify attendance
Demonstrations of the practice’s administrative/computer systems should
not involve actual patient information
When talking to a patient on the telephone or in person in a public area,
care should be taken that sensitive information is not overheard by other
patients
Do not provide information about a patient’s appointment record to a
patient’s employer without their consent
Messages about a patient’s care should not be left with third parties or on
answering machines. A message to call the practice is all that can be left
Recall cards and other personal information must be sent in an envelope

Disclosure of appointment books, record cards or other information should
not be made to police officers or HMRC officials unless upon the instructions
of the dentist
Patients should not be able to see information contained in appointment
books, day sheets or computer screens
Discussions about patients should not take place in the practice’s public
areas.
Disciplinary action
If, after investigation, a member of staff is found to have breached patient

confidentiality or this policy, he or she shall be liable to summary dismissal in
accordance with the practice’s disciplinary policy. If the staff member is a
registered dental care professional, the General Dental Council will be
informed.
Employees are reminded that all personal data processed at the practice must
by law remain confidential after your employment has terminated. It is an
offence under section 55(1) of the Data Protection Act 1998 knowingly or
recklessly, without the consent of the data controller (name), to obtain or
disclose personal data. If the practice suspects that you have committed such
an offence, it will contact the Information Commissioner and you may be
prosecuted by the Commissioner or by or with the consent of the Director of
Public Prosecutions.
Queries
Queries about confidentiality should be addressed to [ ]. More information is

contained in BDA Advice Sheet B1 Ethics in dentistry which is available for
reference in [ ].
Dental records Good record keeping is central to good dental practice: accurate records are
essential to ensuring that patients receive appropriate and safe treatment.
Clinical records should be viewed as a communication tool, helping anyone
with access to them to understand what was done, when and how.
Dentists are often first judged on the quality of their record keeping and poor
records can sometimes render complaints and claims for damages indefensible.
Unfortunately, inadequate record-keeping systems are very common in dental
practice, often due to time constraints. But dentists must be aware that they are
responsible for the acts and omissions of their staff, including information
documented in the dental record, and it is therefore essential that the following
standards be adhered to:
Consistency of management of the records

Confidentiality
Quality assurance
Access to information through appropriate recording, clear handwriting
That records are made contemporaneously or as nearly contemporaneously
as possible
That care is taken that there is no risk of confusing two patients with the
same or similar names. In such cases, the notes should carry a warning to
check the address or date of birth of the patient at the time of the
consultation to ensure that the correct notes have been selected
That record entries are made only by those people who are authorised to do
so. Generally this would be the dentist, the dental nurse, dental hygienist
and dental therapist, orthodontic therapist, clinical dental technician.

Records must be stored according to the provisions of several Acts of
Parliament. This section summarises the law and good practice and covers:
Good record keeping practice

Storage, retention and disposal
Fair processing
Subject access
Sale/transfer of records
Checklist
It is good practice that all records are: Good record keeping

practice
Factual, consistent and accurate
Legible, written in black ink/ball pen or typed electronically
Dated, with the time and signature
Altered by scoring out with a single line – with the date, time and signature
added
Not abbreviated unless the abbreviations are recorded separately and
periodically updated
Chronological and demonstrating all the events
Identified on each page with the patient’s name, date of birth and unique
number
Secured within the record folder if the record is manual.
A dental record should comprise:
The patient’s personal details (including full name, address, date of birth,
gender and contact telephone numbers/email address)
A comprehensive, up-to-date medical history including alerts, precautions,
current treatment and GP contact information
Dental and periodontal charting
A contemporaneous record of the treatment provided from which the
operating dentist/dental hygienist/dental therapist/clinical dental technician
can be identified
The date, diagnosis and treatment notes each time the patient is seen, with
full details of any particular incidents, episodes or discussions, including
options and advice given
Contemporaneous descriptions of complications or problems
Records of appointments cancelled or not kept
A record of the advice given and consent obtained for treatment including,
where appropriate, consent forms
A record of any unusual incidents, instances where the patient does not
consent to treatment/record keeping
Investigations (printouts from monitoring equipment etc)
Notes of telephone conversations
Computerised records
Handwritten clinical notes (record cards/ envelopes)
Information about the patient's personal circumstances that is relevant to the
dental care
Copies of test results, referral letters and other correspondence
Batch numbers of materials used
Radiographs (named, dated), study models, photographs
A record of drugs prescribed/given (with dosages) together with any adverse
reactions
A reference to any complaints received and action taken (though complaints
records should be stored separately)
X-ray films and other imaging records
Records of estimates and treatment plans and copies of those supplied in
writing

Laboratory orders/work sheets/papers required to comply with medical
devices requirements
Written prescriptions for dental hygienists and dental therapists.
Models
Photographs
All payments made by the patient
All correspondence to and from the patient, or any third party
Other information, for example laboratory instructions, statements and receipts
Videos
Contemporaneous description of problems or complications
Monitoring information, such as BPE scores, tracking oral pathology etc
Findings/diagnosis on radiographs
Drugs and dosages given
Updated list of medications and known allergies
NHS treatment plans
NHS referral letters
NHS orthodontic treatment plans
Where NHS claims are submitted electronically, a signed patient PR form
When compiling records, the purpose for which they are written should be
considered. This includes
Patient safety
Monitoring
Basis for accounts
Probity enquiries
Evaluation of treatment.
Records can be held on paper and on computer. Where written records are
kept, legible handwriting is essential and pencil must not be used. Removing
agents such as Tippex should not be used; alterations, where necessary,
should be made by striking a single line through them. Records should always
be signed and dated with the recorder’s name printed underneath or a central
record of signatures kept at the practice. Accurate dating of entries can greatly
assist with the defence of later claims, ensuring that a claim cannot be made
that the record has been subsequently altered. Abbreviations used should be
uniform throughout the practice so that they can be universally understood.
Computerised record systems must record exactly the same information as

paper records. They must also contain robust audit trails so that subsequent
alterations will be recorded. NHS dental payment agencies issue advice on
requirements for dental systems and, before purchasing a system, dentists
must ensure that the manufacturer complies with the guidance. Further
information on the requirements for dental systems can be obtained by
contacting the Business Services Authority Dental Services Division (for
England and Wales), the Scottish Dental Practice Division (Scotland) and the
Central Services Agency (Northern Ireland).
In view of the fact that patients have the right of access to their records,
derogatory comments about the patient or relatives should be avoided.
Sensitive information (such as a patient’s HIV status or termination of
pregnancy) should only be recorded if it is necessary to ensure that the patient
is treated properly and safely and the patient has consented.
The 1998 Data Protection Act requires that patients are given information about
the processing of their personal data (see page 20).
Storage, retention and Dental records should be stored securely so that they are safe from
disposal unauthorised access, theft, fire, flood and other disasters. This is a requirement
of the 1998 Data Protection Act. Records should not be accessible to patients

or visitors and, when the practice is closed, there should be reasonable
measures in place to ensure their security, for example storage in lockable
cabinets, shelving with a lockable shutter, or be placed in a locked room. Where
records need to be removed from the practice premises, they must not be left in
unattended cars in case of theft.
Ideally, for medico-legal purposes, dental records (including radiographs and

study models) should be retained indefinitely. For the purposes of the
Consumer Protection Act 1987 they should be kept for at least eleven years for
adults, and, for children, for eleven years or up to age 25, whichever is the
longer. Personal representatives can take legal action in respect of a deceased
patient, although in dentistry this is very rare. Records for deceased patients
should therefore be retained for the same period. NHS regulations require
dental records to be retained for only two years (and now six years in Northern
Ireland), but this does not negate the above requirements. There are
commercial companies that offer secure confidential storage facilities for
records and microfiching is also an option.
Disposal of patient records should be by incineration or shredding with

appropriate safeguards for confidentiality during the procedure. Local hospitals
may offer a service either free or for a small charge, and again there are
companies that provide a confidential disposal service. Domestic refuse
services must not be used. Failing to dispose of records without regard to their
confidential nature could lead to action for damages by patients, prosecution by
the Information Commissioner and complaints to the General Dental Council as
well as adverse local publicity.
Special care must be taken with destruction of e-records, which can be

reconstructed from deleted information. Erasing or reformatting computer disks
or personal computers with hard drives which once contained confidential
personal information is not sufficient.
Dentists could be liable to action for damages by patients, be prosecuted by the

Information Commissioner and be reported to the General Dental Council if
they fail to dispose of records without regard to their confidential nature.
The Data Protection Act describes several requirements for data to be Fair processing
processed fairly. These include the obligation to provide information stating:
The identity of the data controller or their nominated representative

The purposes for which the data are intended to be processed
Any further information which is necessary, having regard to the specific
circumstances in which the data are, or are to be, processed to enable
processing in respect of the data to be fair.
The Data Protection Act 1998 gives every living person the right to apply for Subject access
access to their health records This section summarises the procedures for
giving access to patients, but further specific help is available from BDA
Practice Support and BDA Advice Sheet B2 Data Protection.
Request for access
Who can obtain access?
A data subject has the right of access to personal data about him or her. Where
the data subject is a child (that is, someone aged under 16) the data controller
must make a judgement as to whether the child understands the nature of the
request. If so, the data controller should reply to the child, but, if not, the parent
or guardian is entitled to make a request on the child's behalf and to receive the
reply. Parents or guardians should only make such requests in the child’s
interests, not their own. Where the child is capable of making a request for

access but a parent or guardian does so on their behalf, the data controller
should be satisfied that the child has consented to the request for access.
A solicitor or other person may have access on behalf of the data subject if the
data subject has consented in writing to the disclosure.
Any person having a claim arising from a patient’s death may apply and the
data controller may judge what is relevant to a claim. Where the patient has
asked that a note be made on the records that they are not disclosed after
death, disclosure cannot take place without a court order.
How can access be requested?
To obtain access, the data subject must:
Make a request in writing (which may be delivered electronically, that is by

fax or email)
State the name of the applicant and an address for correspondence
Describe the information requested
Pay the prescribed fee
Provide any information that the data controller may reasonably require in
order to satisfy himself as to the identity of the individual and the location of
the information.
Where a request for access to a manual health record is made, the fee for
access and providing a permanent copy of the record is a maximum of £50.
Where access to the health record has already been provided within forty days
of the request for access (and a permanent copy is not supplied) no fee is
payable. This charge includes administration and photocopying costs including
the cost of copying radiographs.
For computer-held records the maximum fee is £10 including photocopying and
administration.
What must be provided?
Within 40 days of the original request, or 40 days from the fee and/or
identification information being provided, the data controller must supply the
data subject with a permanent copy of the requested information unless:
the supply of a copy is not possible

copying would involve disproportionate effort
the data subject consents otherwise.
If a similar request has been made by the same individual within a reasonable
timescale, the data controller is not obliged to accede to the request. The
definition of a reasonable timescale will depend on the nature of the data, its
purpose in processing and the nature of the alteration. The information must be
supplied in an intelligible form and, where it is not intelligible, an explanation
should be given. In dentistry it would be usual for the dentist to offer to provide
an explanation of part or all of the record. The information supplied must be by
reference to the information held on the day the application was received,
subject to any routine processing.
Information about third Where personal data about third parties is part of the record (including being
parties identified as a source) it should be disclosed where:
1. The third party has consented

2. It is reasonable in all the circumstances to supply the information without
consent

3. The information is contained in a health record and the other individual is a
health professional who has compiled or contributed to the health record or
has been involved in the care of the data subject in his capacity as a health
professional (this provision was added in an Order)
In deciding what is reasonable in the circumstances in (2), the data controller

should consider the following circumstances:
Any duty of confidentiality owed to the third party

Whether the third party has refused consent
Any steps taken by the data controller to obtain consent
Whether the individual is capable of giving consent.
The most common instance of information supplied by third parties in dentistry

might be information contained in letters from hospital consultants about a
patient’s medical or dental condition or personal circumstances. This
information should be disclosed to the patient on request except where it is
likely to cause serious harm to the health professional’s physical or mental
health. This exemption is unlikely to be applicable in dentistry, but BDA Practice
Support is happy to advise on individual circumstances. Where appropriate, a
health professional whose identity has been disclosed should be informed that
this has occurred.
There is an exemption to the subject access requirements for health information

if disclosure is likely to cause severe pain or distress to the data subject or
severely affect the mental or physical health of the health care professional.
This provision is also unlikely to be applicable in dental circumstances, but BDA
Practice Support is happy to advise on individual circumstances
Sale of a practice Sale and transfer of

records
Where a dental practice is sold, patient records are normally transferred to the
new owners as part of the goodwill of the practice. Sale agreements should
contain a provision that the purchaser retains the vendor’s records (and those
of any dentists who practised there) for a given period and allows access if
necessary. Subsequent disposal should only be undertaken confidentially.
Ownership of records taken by dentists who are no longer associated with the
practice is generally determined by any agreement between the dentists
concerned or, if there is no agreement, by a court. Difficulties can arise if an
associate moves to a nearby practice and patients wish to follow. Our advice
here is that a patient has the right to choose the practitioner and, in the
interests of patient care, the records, including radiographs, should follow the
patient. Copies should preferably be retained at the practice.
The goodwill relating to the patients of a practice which is closing down may be
sold to another practitioner. In other cases, the retiring dentist should retain the
patient records in case of future complaints or legal action. In cases of death,
the dentist’s personal representative would have custody of the records.
Transfer of records
Generally speaking there is no problem sending patient records to their new

practice at the request of the patient. The practice should retain a copy or
obtain agreement from the new practice that the records will be returned on
request.
Faxing dental records to another practice is permissible provided that the

receiving practice ensures that the fax is secure and out of sight. The practice
should be alerted and their fax number confirmed prior to sending the fax
through.

If the patient records are being emailed, the patient must consent to their
medical records being transferred in this way. It would also be wise to check
that the email address is that of the intended recipient.
Checklist Dental records must be full, contemporaneous, accurate and legible

Records must be retained for at least eleven years and, for children, up to
age 25 or eleven years, whichever is the longer
Patients have the right of access to their manual and computerised records
and to receive a copy
Patients are entitled to a copy of their manual records including radiographs
on payment of a fee of up to £50
Clinical records that are held on computer must have appropriate audit trails
and safeguards to ensure that the record cannot be altered or otherwise
tampered with
Records should be kept securely and safeguarded against accidental
destruction or theft
Computer screens and manual files should not be available to third parties
Practices should have a Data Protection Policy (see BDA Advice Sheet B2
Data Protection or the BDA Practice Compendium) which should be given to
patients.
Patient care This section is about the type of care dentists provide for patients, as well as
the way that care is delivered. Dentists are able to provide care and treatment
that they are competent to provide. They are also able to provide care that is
not dental care but, if they do so, they must ensure that the care is lawful, they
are properly trained to provide it and they have suitable indemnity.
The section covers
Patient communication
Agreeing to provide care and treatment
Patient choice
Treatment planning
Health checks
Alternative therapies
Non-surgical cosmetic procedures
Tooth whitening
Medical emergencies
Misleading patients
Maintaining appropriate boundaries
Referral fees
Missed appointments
Debt collection
Handling complaints
Checklist
Patient communication Effective, clear communication with patients is essential in modern dental
practice. Most patient complaints have at their foundation breakdowns in
communication. The ability to talk and listen to patients is a major factor in
building a successful practice. There are many aids to good communication
available and the BDA Practice Compendium provides a range of advisory
material, model forms, letters and leaflets. Courses are organised by the BDA,
primary care organisations, postgraduate centres, private dental plans and
other training providers which can be very helpful for dentists and the practice
team.

Relations between dental teams and patients should always be friendly and
patients must always be treated politely. Patients should be put at ease and
made to feel that they are active partners in their care. At all times, patients’
dignity must be maintained. Dental staff must be accessible and prepared to
answer patients’ questions clearly, accurately and promptly. Dentists are
responsible for the acts and omissions of members of the dental team that they
lead or supervise and must ensure that they are well trained. Registered dental
care professionals are also responsible for their own acts and omissions.
There are points in the dentist/patient relationship where good communication

by dentist and practice team becomes particularly important in avoiding
complaints and allegations of misconduct. This section considers some of these
areas and includes some useful aids.
Many difficulties and complaints are caused by patients being unclear about the Agreeing to provide care
basis on which they have been accepted for treatment. It is the dentist’s and treatment
responsibility to ensure that this basis is understood at the time of the initial
appointment. In England and Wales it is not possible to examine a patient to
make a decision on whether or not NHS care should be offered. It is possible to
do this in Scotland and Northern Ireland and is not unethical, provided that the
patient is clear at the time of booking that it is a screening appointment and the
cost (if any) of the individual consultation is given.
Patients must be given full information about treatment to be carried out and
the nature of the contract with the dentist, whether NHS or private. It is
important that cost indications are given at the outset and that any necessary
changes to treatment plans or estimates are fully explained and agreed to by
the patient. One way of ensuring that the basis of the contract is unequivocal is
to give new patients a suitably worded welcome letter or include the information
in a practice leaflet. Where new patients are being accepted under NHS
regulations, dentists are required to provide an acceptance form
(FP17DC/GP17DC/HSA45). This form is useful in that it includes a written
treatment plan and cost estimate, as well as the option of recording any
treatment that has been agreed privately. The BDA has a range of advice
sheets on NHS rules and regulations that are listed at the end of this section.
Cases sometimes arise where patients realise that care has not been carried
out under the NHS only when they wish to make a complaint or query the
amount that they have been charged. Intentionally misleading patients might
constitute fraud or give rise to a fitness to practise investigation by the GDC.
Patients have the right of free choice of dental practitioner and to change their
dentist if they wish. The dentist also has the right not to accept patients for
treatment provided that there is no unlawful discrimination. In Standards for
dental professionals, the GDC states that patients must not be refused
treatment or otherwise discriminated against on the following grounds:
Sex, age, race, ethnic origin, nationality, special needs or disability

Sexuality, health, lifestyle, beliefs or any other irrelevant consideration.
GDS regulations in England and Wales also provide that patients cannot be
discriminated against on the grounds of their dental or medical condition.
There is no obligation to provide reasons for a decision not to accept or to

cease to provide NHS care (provided that NHS regulations regarding notice are
complied with), but it is good practice to do so. Generally, dentists should seek
to maintain a continuing professional relationship with their patients.

Where a patient is referred to another practitioner for specific items of
treatment, the terms on which the patient is being accepted for that treatment
should be made clear – whether NHS or private – and the probable cost. Both
the referring and the second dentist in these cases have an equal responsibility
to ensure that the arrangements are acceptable to the patient. The patient
should not find that what they thought was an NHS referral as part of the same
course of treatment turns out to be a private arrangement at a cost they had
not expected (see also page 36).
Patient choice Patients must be treated as individuals who have the right to make choices
about their care. This includes who will provide that care. Dentists are
sometimes consulted by patients who were treated by them at a former practice
where they were engaged as employed dentists or associates. If the dentist is
prevented from treating the patient by a contractual obligation to the former
practice owner, this should be explained to the patient.
Considerable problems can face departing assistants or associates when

questioned by patients about their future plans. The departing general dental
practitioner has a professional commitment to complete or arrange for
completion of any treatment commenced. Except in exceptional circumstances,
it would be unacceptable for a dentist to connive in any arrangement whereby a
patient makes an appointment believing it to be with the former dentist only to
find on arrival that it is with another, perhaps unknown, practitioner. The precise
details of the arrangements for leaving should be left for agreement between
the parties involved according to their contractual arrangements but it must be
remembered that the dentist who performs the treatment has the responsibility
for the best interests and dental care of his or her patients.
Treatment planning Patients must first be seen by a registered dentist who is responsible for
providing a full mouth assessment of the patient. The only exception is
edentulous patients who can be seen first by a registered clinical dental
technician for the provision of full dentures. The dentist can either provide a full
treatment plan or an outline treatment plan according to the needs of the
patient. The treatment plan should include:
Recall intervals for the patient to be seen by a member of the team

The date of the next full mouth assessment
A referral to another dentist or another dental care professional.
A dentist can ask the other team member to set the recall intervals. Until the
date of the next full mouth assessment, a patient can take the treatment plan to
another registered dental care professional to provide the treatment. The
second dental professional can then carry out the plan and are able to make
recommendations to the patient within the scope of the plan, for example to
suggest that a local anaesthetic is used.
Health checks Many patients attend their dentist more regularly than they do their doctor.
Dentists may offer patients the opportunity, if they wish, to have other simple
physiological measurements such as measuring blood pressure or cholestoral
levels. Such services can enhance the service available to patients and
demonstrate a caring, preventive approach. Provided that the dentist is properly
trained to undertake the tests and patients are given appropriate information on
the results, such tests can be undertaken and a reasonable charge made.
Dentists are responsible for the accuracy of the results and the advice and
information provided.
Alternative therapies Dentists may offer their patients treatment using alternative methods of
anxiety/pain control including hypnosis, reflexology and aromatherapy. Patients
must be informed of the cost of the additional treatments in advance. Dentists
should check that they have appropriate indemnity/insurance cover.

In these cases, dentists are responsible for the treatment that is undertaken
and must not make any misleading claims about the treatment or its outcomes.
Care that is provided must be based on available up-to-date evidence and
reliable guidance. This makes the use of unproven or controversial techniques
unwise outside of clinical trials or research that have ethics committee approval.
The General Dental Council has issued guidance on alternative therapies.

Some alternative therapies can have a legitimate use in dental treatment, such
as hypnosis used to help an anxious patient. However, the Council is
concerned that registrants should not use their standing as a dental
professional to offer alternative therapies such as acupuncture or pain relief
which are not provided to a patient as part of their dental treatment, for example
hypnosis for smoking cessation or acupuncture for the relief of non-dental pain.
This is the case even if a registrant is trained and registered as an alternative
therapist.
The Council is of the view that alternative/complementary therapies that are not
provided in conjunction with, or linked to, a patient’s dental treatment must be
provided separately to a registrant’s practice of dentistry. The practice of
alternative therapies must be advertised or otherwise publicised separately to a
registrant’s practice of dentistry.
Care should be taken when providing for cosmetic reasons treatment to Non-surgical cosmetic
patients that does not constitute the practice of dentistry, for example dermal procedures
fillers or Botox. Dentists are responsible for the treatment that they provide and
must ensure that they have appropriate indemnity/insurance cover. It is
essential that they have the appropriate skills and training to undertake the
procedure. The word Botox is copyright and cannot be used in advertisements.
The GDC requires only dentists, dental hygienists and dental therapists (if
trained and competent) to undertake tooth whitening.
Tooth whitening is covered by the Cosmetics Products (Safety) Regulations Tooth whitening
which control the amount of hydrogen peroxide they are able to contain. This is
subject to change, so for the latest information, see the BDA website.
Prosecution of a dentist who exceeds the maximum allowable dose is the

responsibility of local Trading Standards Departments rather than the General
Dental Council. But if a dentist is prosecuted, the fact would be reported to the
GDC who would consider it under their fitness to practise procedures. Also, if a
dentist was using whitening products in a way that compromised professional
standards, this would be investigated by the GDC.
Whenever dental care is planned to take place, there should normally be at Medical emergencies
least two registered dental professionals trained to deal with medical
emergencies available in the room. There may be circumstances where this is
not possible, where out-of-hours emergency care is being provided or care on a
domiciliary basis. In this case there must be an assessment of the risks of
continuing treatment.
Dental teams should be trained to ensure each member knows exactly what to
do in the event of patient collapse or other emergency and practise regularly in
a simulated emergency situation.
Dentists must not mislead their patients. It is all too easy inadvertently to Misleading patients
mislead by failing to communicate properly or by statements in practice
literature or other advertising material which the patient misunderstands.
Information provided must be accurate and truthful and must not make claims
that cannot be substantiated, for example relating to the quality, longevity or
cost of treatment.

The BDA is happy to check draft advertisements, leaflets and other literature to
ensure that they don’t mislead. Having an outsider look at a draft often enables
inadvertent errors to be avoided.
Further guidance in relation to the provision of NHS and private care is

contained in BDA Advice Sheets A4 Private practice made simple and E13 A
guide to GDS regulations in Northern Ireland, E14 Guide to GDS regulations in
Scotland and E11 Guide to GDS/PDS regulations in England and Wales.
Maintaining appropriate It is important to maintain appropriate boundaries between dentists and

boundaries patients. This is in terms of personal relationships and friendships with patients.
It is not appropriate for a dentist to enter into a personal relationship with a
patient. Further information is available in the publication Clear sexual
boundaries between healthcare professionals and patients: responsibilities of
healthcare professionals available on the website of the Council for Healthcare
Regulatory Excellence – www.chre.org.uk.
Referral fees Dentists should not enter into arrangements whereby, unknown to the patient,
fees for treatment are split between two dentists to encourage referral of certain
patients for particular forms of treatment, for example. A dentist should not ask
for, or receive, money gifts or hospitality in return for referring patients.
Missed appointments A reasonable charge may be made to private patients who fail to attend an
appointment or cancel without reasonable notice. Patients should be aware in
advance of any cancellation charges that may be levied, and commonly such
information is contained in the practice's information leaflet or an appointment
card. If patients are not aware that there is a cancellation charge in advance, it
is unlikely that a dentist would be able to pursue a patient successfully in court
for non-payment. In England and Wales, charges for missed NHS appointments
may not be made. They are still permitted under NHS arrangements in
Scotland and Northern Ireland.
Exempt NHS patient cannot be asked to pay a refundable deposit in case an

appointment is broken.
Debt collection As a last resort, dentists may pursue patients for debts in the civil courts, or
employ debt collectors. Prior to taking such action, however, the practice should
make every effort to recover debts by sending suitably worded written
reminders.
A dentist is not obliged to embark on or continue with a course of treatment if

an NHS patient is in debt to the practice. Where such a patient attends in pain
or with another dental emergency, however, the dentist must provide
emergency care and then may, if appropriate, deregister the patient in Scotland
and Northern Ireland or refuse to provide another course of treatment in
England and Wales. Information about de-registration is contained in BDA
Advice Sheets E11 Guide to GDS/PDS in England and Wales, E13 A Guide to
GDS regulations in Northern Ireland and E14 Guide to the GDS in Scotland.
It is a breach of the dentist's duty of confidentiality to disclose lists of debtors to

third parties, other than to recover the debt. Lists of patients with debts to local
practices should not be compiled or circulated.

Dentists are required under GDS/PDS regulations and by the GDC to have in Handling complaints
place a procedure to handle complaints from patients swiftly and satisfactorily.
Both NHS and private patients may complain to the practice about the
treatment or service that they have received and have their complaint
considered by their dentist and, if necessary, action taken. Most complaints
arise from a breakdown in communication and many patients are happy with an
apology and/or a refund. Sometimes the patient wants a sincere commitment
by the practice that the matter will be put right in order to avoid the situation
occurring to another patient. Where damage is alleged to have been caused,
the patient may refer the matter to court rather than using the complaints
procedure or take legal action after the complaint has been made to the
practice.
There is a formal complaints service for private patients provided by the Dental
Complaints Service, funded by the GDC but independent of it. The Dental
Complaints Service assists private dental patients and dental professionals to
resolve complaints about private dental services. It would be very wise to co-
operate with the service to help resolve the complaint quickly and without
escalation to the courts or the GDC. For more information visit
www.dentalcomplaints.org.uk.
Further information on dealing with complaints is contained in BDA Advice

Sheet B10 Handling complaints and B11 Private Practice Complaints.
Patients must be treated fairly and reasonably and not misled about the
treatment they will receive, the contractual basis on which it is provided or Checklist
its cost
Dentists are free to accept or not accept patients but non-acceptance must
not amount to discrimination
Patients should have freedom of choice of dentist
Where an associate leaves a practice, his or her patients should be informed
Ownership of dental records depends on the agreement between associate
and practice owner
Patients must see a dentist first to undertake a full mouth assessment and a
treatment plan, the only exception being edentulous patients who require full
dentures who may be seen by a clinical dental technician
Where planned treatment is taking place, there should be two people in the
room who are trained in medical emergencies
Dentists may pursue bad debts using debt collecting agencies or the courts
but must not circulate lists of debtors to other practices
Dentists should not refer patients to colleagues in return for a fee
Dental practices should have a complaints procedure. Where treatment is
offered that does not amount to dental treatment, the dentist must have
appropriate indemnity cover and be fully trained and competent to provide
the treatment
Where dentists offer patients treatment under private dental plans, the scope
of care to be provided by the plans should be clear and its terms should not
interfere with the contract and relationship between dentist and patient
Full and clear communication with patients is vital to successful practice
Patients should not be misled as to the arrangements under which they are
being treated or its cost
Dentists may offer patients alternative therapies as part of their treatment,
provided that any additional cost is made clear at the outset
Care must be evidence based and unproven techniques should only be
used as part of clinical trials or research.

Professional Dentists' relationships with other practitioners can be problematic and lead to
stress and patient complaints. As with all aspects of dental practice, most
relationships problems can be avoided by good communication. This section looks at some
of the most common situations in which difficulties arise:
Professional agreements
Duties of a dentist manager
Second opinions
Poor performance
Specialist practice
Veterinary dentistry
The death of a dental practitioner
Checklist
Professional agreements It is essential for both dentists and their patients that dentists practising together
enter into reasonable arrangements that are confirmed in a comprehensive
written agreement. This is particularly important for practitioners entering
general dental practice for the first time. Terms of such agreements should not
place any undue pressure on an associate or assistant to reach an
unreasonable target since this may compromise patient care. Agreements
should guarantee clinical freedom for dentists, provide for adequate chairside
support, suitable facilities and contain full financial arrangements. The BDA
provides advice sheets for members on performer agreements, assistantships,
associateships, locumships and partnerships, all of which contain model
agreements. BDA Practice Support can look at draft agreements and advise in
the case of disputes. A conciliation and mediation service is also offered where
both parties agree to its use, avoiding costly litigation. Contact
practicesupport@bda.org or telephone 020 7563 4574.
Most written agreements contain restrictive clauses preventing one party from
practising within the vicinity of the practice for a defined time period after the
end of the arrangement and from soliciting or treating former patients. The
terms of these clauses must be reasonable and reflect such factors as the
location of the practice, the number of local dentists, patient catchment area
and other relevant aspects. Restrictive clauses must not operate to the
detriment of patients on termination and should only aim to prevent unfair
competition, not competition itself.
Courts do not automatically uphold restrictive covenants and either party has
the option of asking a court to rule whether a particular clause is reasonable. If
it is judged unfair, it will be struck out without a more reasonable term being
substituted.
Duties of a dentist An increasing amount of dental care is provided by large dental corporations
manager and large practice chains. Dentists can be placed in management positions
where they have little control over organisational management or decision-
making. Dentists also manage dental services within the NHS, direct a dental
company or own a dental practice, which gives them management duties and
responsibilities.
In their management activities, dentists must put their responsibilities to patients

before responsibilities to themselves, colleagues, the organisation or business.
In their business and commercial dealings they must be open and honest as
well as generally acting honestly and fairly in their professional lives.
For any dentist in a management or leadership position, any concerns about

the organisation’s decisions or activities that may be putting patients at risk
must be raised with colleagues. If no action is taken or the matter is ignored,
contact the GDC.

The GDC guidance document ‘Guidance on principles of management
responsibility’ contains further information on dentists’ management
responsibilities (www.gdc-uk.org).
Patients increasingly seek the reassurance of a second opinion about treatment Second opinions
that has been undertaken or proposed. This happens particularly where they
are not satisfied with the treatment already undertaken or where the proposed
treatment is expensive or extensive. A dentist who is asked by a patient for a
referral for a second opinion is obliged to accede to the request as part of
respecting patient choice and at patient’s best interests.
Clinical dental opinions vary widely and dentists often have very different
treatment philosophies. In some cases dentists may conclude that the
treatment provided has been of very poor quality or treatment proposed is
either unnecessary or insufficient. The dentist then has a responsibility to give
an accurate clinical opinion to the patient and might wish to discuss the
treatment of the previous dentist with a senior colleague.
Where a second opinion is given, the patient should be told of the consultation
charge before an appointment is made. In all cases, the dentist must put the
patient's best interests first, rather than professional loyalties.
Dentists are sometimes faced with a colleague who they believe is putting Raising concerns
patients at risk because of their health, behaviour or professional performance.
In these cases, the GDC guidance document Principles of raising concerns
must be followed. The guidance places a professional responsibility on dentists
and dental care professionals in this situation to raise concerns if patients may
be at risk. Further guidance is also available in BDA Advice Sheet B12
Handling underperformance.
There are two stages for raising concerns, locally and then centrally. If a dentist
becomes concerned by the behaviour, health or professional performance of a
colleague that does not pose an immediate risk to public safety, then they
should raise the matter with the appropriate local authority.
First, talk to the dentist/DCP directly to try to persuade them to seek

appropriate professional help
If the dentist is self-employed the designated person within the local primary
care organisation should be informed.
If the dentist concerned is in a salaried position, the employing authority’s
procedures for handling such cases should be followed.
If alcohol or drug dependence is suspected, contact the Dentists’ Health

Support Programme (which is a confidential service) for advice (see page 61).
If the case appears to be serious or a local referral has been made and no
action has been taken, speak to the General Dental Council. Action should be
taken if the dentist is in any doubt. The dentist should be kept informed of the
action taken to deal with concerned that have been raised. Dentists have a
responsibility to ensure that people they employ or manage are encouraged to
raise concerns and are protected if they do so.
BDA Practice Support will advise on appropriate local contacts.

Specialist practice Treatment on referral
Dentists have a professional duty to refer a patient to a colleague where

treatment is required that is beyond their clinical capabilities. Responsibility for
making an appropriate referral rests with the referring dentist and particular
care must be taken when referring for treatment under general anaesthesia or
sedation. It is not acceptable to refer a patient for financial reasons alone or the
need to meet targets.
Where the patient is treated by a second dentist on referral, responsibility for

the treatment provided and for providing for emergency care in connection with
that treatment lies with the second dentist. The referring dentist remains
responsible for the general care of the patient and related emergency cover.
The second (referral) dentist must endeavour to complete any treatment that
has been started, but, if this is not possible, the patient will normally return to
the first dentist who must make another suitable referral.
Specialist lists
Only dentists who have been admitted to one of the specialist lists held by the
General Dental Council may use the title “specialist” or claim or imply specialist
expertise. This applies to information for patients as well as other professional
colleagues. A practice wholly or mainly devoted to a particular type of dental
treatment can be advertised as such.
Patients must not be misled about the practice, or that the treatment is provided
by specialists, if the dentists practising on the premises are not on the
appropriate GDC specialist list.
Veterinary dentistry Dentists may provide dental treatment to animals provided that it is for health
rather than cosmetic reasons and that it is done under the direct personal
supervision of a vet who is present throughout.
The death of a dental Arrangements must be made for the immediate continuing care of patients a
practitioner general dental practitioner who dies, particularly those undergoing treatment. If
the dentist was providing NHS care, the primary care organisation should be
contacted for help and advice. Patients should be notified and told of the
arrangements that have been made for booked appointments. The dentist’s
widow/widower/personal representative may carry on the business of dentistry,
that is own the practice (engaging dentists to provide care) for a period of up to
three years after the dentist’s death. Where the dentist is in partnership, the
partnership agreement should make arrangements for what happens to the
business on the death of a partner. The practice owner must make
arrangements for the care of the patients if the dentist is an
associate/assistant/performer. If the dentist is a contract holder in England or
Wales, the PCO should be contacted immediately to ensure that the contract
continues.
Dentists will often leave instructions with their will on what their next of kin
should do in the event of their death. Sometimes single-handed practitioners
will have previously agreed with a local dental colleague to help out in the initial
stages to help the practice continue.
Detailed help and advice is contained in BDA Advice Sheet B4 What to do

when a dental practitioner dies.

A patient request for a referral for a second opinion must be acceded to Checklist
Agreements between dentists must always be written down. The BDA is
happy to comment on drafts
Openness and honesty is necessary in business dealings and financial and
other targets must not be set so that the quality of care is at risk
Patients’ interests must be put before those of the dentist, his colleagues,
organisation or business
Where a patient is referred to another practitioner, a comprehensive referral
letter should be sent
Where a patient has been referred, the second dentist should undertake the
treatment that is set out except where it is not in accordance with his or her
clinical judgement. In this case the matter should be discussed with the
referring dentist.
Specialist expertise must not be claimed unless the dentist is on a GDC
specialist list.
Dental practices must operate using sound business methods to ensure that Commercial
sufficient income is generated to facilitate a high standard of care and treatment
for patients. Commercial business methods can be at variance with caring interests
professional practice and in certain areas dentists must be careful about
breaching ethical rules.
This section covers
Financial interests
Advertising and canvassing
Shared arrangements with other health professionals
Buying, selling or closing a practice
Bodies corporate and limited liability partnerships
Practices owned by dental care professionals
Promotion of products and services
Private dental plans
Bankruptcy
Checklist
Dentists must not put their own financial interests above the interests of their Financial interests
patients. This is a specific requirement of NHS contracts in England and Wales.
Financial interests can come into play, particularly where NHS care is provided,
and it is important that dentist’s treatment decisions are not influenced by
associated costs or NHS targets.
Financial interests may have an influence on treatment planning and making

NHS recommendations to patients. One question that professionals in general
practice in England and Wales need to ask themselves on occasions is “Would
I recommend this course of treatment if the patient was paying privately?” If the
answer is no, then their care may be being influenced by their own financial
situation. If a dentist finds that they are unable to provide a good standard of
care while working under a particular contractual situation, then alternatives
should be considered.
A patient must be given full information about the various appropriate treatment
options and be able to make an informed and free choice.
Dentists must have full clinical freedom to provide the most appropriate
treatment in the best interests of the patient and to a high standard. Dentists
should not practise in circumstances where recommended standards of health
and safety and infection control are not achieved.

Advertising and The general professional rules set out in Standards for dental professionals
canvassing apply to the way that dentists are able to advertise and market their practices.
Best practice in dental advertising and marketing is discussed fully in BDA
Advice Sheet A6 Marketing your practice. Dental advertising must comply with
the Advertising Standards Authority’s Code of advertising practice
(www.cap.org.uk).
In summary, dentists should not:
Claim to specialise unless they are on a GDC specialist list

Say or imply anything that is untrue or misleading, particularly regarding the
services or treatment that are available from the practice
Make a claim that is not capable of substantiation
Use the courtesy title Dr in advertising or promotional material
Be associated with any publicity or advertising material that is likely to bring
the profession into disrepute.
Advertisements should contain the name of at least one dentist normally in

attendance at the practice.
Methods of practice promotion are varied and can include open days,
circulation of leaflets to surrounding houses and businesses, sponsoring local
sports teams, giving dental health education talks to interested groups.
Marketing to the public via unsolicited telephone calls or house to house
canvassing should not be undertaken.
Dentists sometimes instruct advertising agencies or marketing companies to

prepare advertising or publicity material for them which may not comply with
GDC standards. The BDA is happy to check draft advertisements or other
publicity material. Contact BDA Practice Support.
Shared arrangements Dentists may share practice premises with other health professionals. Common
with other health arrangements involve rental agreements with chiropodists, physiotherapists or
professionals being part of a health centre with general medical practitioners.
Where premises are shared, care should be taken that dental records are not
accessible to third parties and that drugs and other hazardous substances are
kept secure when the dental practice is not in use. Separate entrances and
telephone numbers are not necessary, but patients should not be made to feel
that they should be consulting other practitioners within the building.
Buying, selling or closing There are ethical considerations to be taken into account when a practice
a practice changes ownership to ensure that patients, dentists and staff are not misled.
Advice on all aspects of practice sale and purchase is contained in BDA Advice
Sheet A2 Buying and selling a practice.
Informing patients
Patients (NHS and private) should be informed when a practice is sold, a

dentist leaves or a practice closes down. NHS regulations in Scotland and
Northern Ireland require patients to be given three months' written notice of a
dentist ceasing to provide NHS dental care at the practice. There is no such
requirement in England and Wales. It is not acceptable for patients to make an
appointment only to find on arrival that the dentist they have been seeing for
some time has left the practice (provided that the departure was known to the
practice at the time). In answer to questions about the whereabouts of the
dentist, it is important to avoid untruthful statements.

On leaving a practice, every effort should be made to complete outstanding
treatment or arrange for its completion. In rare cases, patients have discovered
that a practice has suddenly closed and that they are left in pain or in the
middle of treatment, with no means of contacting the dentist. This situation has
led to the dentist facing a fitness to practise investigation by the GDC.
The names of dentists no longer providing dental care at a practice should be

removed from signs, professional plates and practice literature to avoid
misleading patients, or suitable wording should be added to make it clear that
the dentist is no longer at the practice. Such wording should only remain for a
reasonable period.
Informing dentists
Dentists practising at the premises should be given adequate notice of a

practice sale to ensure that, if they decide to cease to work at the practice, their
patients can be informed and treatment may be completed.
Informing staff
Dental staff should be informed at an early stage if a practice is being sold. As

well as being a matter of good management, it ensures that patients are given
accurate responses to questions and staff anxiety about the future (which can
lead to a lowering of standards) is minimised.
Most employees have some employment protection when a business is sold

and further detailed advice is available from BDA Practice Support.
Provided they meet certain conditions, companies can carry on the business of Bodies corporate and
dentistry. "Carrying on the business" is generally taken to mean directly limited liability
receiving money from patients in respect of dental services. Companies must partnerships
have a majority of directors who are GDC registrants and can be bought and
sold. There must always be one more registered dental professional director
than the total number of lay members: for example two registered dentists to
one lay person or one registered dentist, one registered dental nurse and one
lay person. A growing number of companies operate a large number of
practices and large companies operating in other fields of healthcare have
entered the dental market.
Dentists who are directors of dental bodies corporate are liable for the actions
of the company, which must conform to GDC rules. The individual dentists who
are employed or engaged by them are also responsible to the GDC for
providing proper standards of care and treatment, ensuring safe practice and all
other aspects of professional conduct.
Contracts of employment or engagement provided by companies should be

considered carefully and advice taken from the BDA on their terms. Dentists
working for a company are still responsible for matters of professional conduct
and for ensuring that they observe the guidance in Standards for dental
professionals.
A company’s commercial interests must not influence the dentist’s clinical

relationship with patients and the company must not compromise clinical
freedom.
Dentists must ensure that they do not enter into employment or engagement
with corporate bodies that do not comply with the legal requirements for dental
corporates. To do so may lead to fitness to practise proceedings.
Because of the restrictions on carrying on the business of dentistry by lay

people, explained above, dentists cannot take persons who are not GDC
registrants (such as wives, husbands or business people) into partnership

without operating a corporate body. The only involvement non-dental corporates
can have in the operation of a practice is to provide services to the practice
such as premises, staff, equipment and management. The contract with the
company must not contain a charging structure linked to turnover or profits, in
order to avoid the company being held to be receiving money from patients.
Further information is contained in BDA advice Sheet B9 Running a practice as

a company or limited liability partnership.
Practices owned by Registered dental care professionals (dental hygienists, dental therapists,
dental care professionals dental technicians, dental nurses, clinical dental technicians and orthodontic
therapists) may carry on the business of dentistry. Where a practice is owned
by a DCP, a dentist must be engaged to see patients and provide treatment
plans. The only exception is if patients are edentulous and care is provided by a
clinical dental technician or the practice only provides care to patients who have
a written treatment plan from a dentist and the DCP is providing care in
accordance with the plan.
Promotion of products Advertising for appropriate products or services may be included in patient
and services information leaflets and newsletters, provided that the products are not in
conflict with health care. By accepting payment or sponsorship, the dentist
should not have a conflict of interest which might jeopardise the professional
relationship with patients.
As well as advertising, dentists are sometimes approached to enter into

commercial arrangements with third parties. Financial incentives may not be
accepted from third parties in return for promoting to patients specific dental
products, the uptake of insurance or enrolment in a particular scheme for the
provision of dental care.
Patient lists must not be sold or given to third parties without consent. BDA
Advice sheet B2 Data protection gives further information on third party access
to patient data.
Dentists occasionally become involved in outside business ventures that involve

selling products and services to the public. Great care should be taken when
attempting to sell non-dental products to patients. Patients have trust and
confidence in the dental profession and when attending a practice do not
expect to be sold other products unrelated to dentistry. If purchases are made,
dentists must ensure that they are aware of their liability under consumer
protection legislation and of the possibility of a complaint if the patient feels that
misleading statements have been made.
Private dental plans Many dental practices offer their patients the opportunity to pay for their private
dental care by joining a private plan. The plans may be either capitation
schemes or insurance schemes. Some dental corporates offer their own
insurance plans and a growing number of dental practices operate their own in-
house schemes. In-house capitation schemes should have appropriate
insurance cover to avoid contravening insurance law.
When giving information to patients about private dental plans, dentists should
not mislead about the cost of the schemes or the scope of the cover that is
offered. Patients should have the option of paying for their private care on an
item-of-service basis if they wish. Care should also be taken to ensure that
legal requirements regarding consumer credit licensing and the provision of
insurance are met. Further advice is available from BDA Practice Support.

Private dental plans should have no effect on a dentist’s clinical freedom and
should not interfere with the relationship between dentist and patient. Many of
the larger plans require practices to adhere to particular standards and
membership can be beneficial to a practice in terms of raising the quality of
service given to patients.
Further information on private dental schemes is available in BDA Advice Note

Private dental plans.
Bankruptcy does not prevent a dentist continuing to practise and registration is Bankruptcy
unaffected, provided that there is no attendant question of fitness to practise. A
dentist who is no longer able to run a business may take up an employed
position, either within the salaried services or as an assistant/employed
performer in general dental practice. Dentists in financial difficulties should
contact BDA Practice Support for advice.
Advertising material must not be misleading Checklist

Dentists cannot lend their names to specific products or services
Only companies with a majority of GDC registrant directors may carry on the
business of dentistry, that is own a dental practice
Dentists employed/engaged by companies must follow the same ethical and
legal rules as other general dental practitioners
Where dentists offer patients treatment under private dental plans, the
scope of care to be provided by the plans should be clear and its terms
should not interfere with the contract and relationship between dentist and
patient
Bankrupt dentists may continue in clinical practice
Lay people cannot enter into partnerships to own dental practices.
Members of the dental team are in a position where they may observe the Child
signs of child abuse or neglect or hear something that causes them concern
about a child. The dental team has an ethical responsibility to find out about protection
local procedures for child protection and to follow them if a child is or might be
at risk of abuse or neglect (Standards for dental professionals, GDC 2005).
There is also a responsibility to ensure that children are not at risk from
members of the profession. This section covers:
Types of abuse
Practical steps
Recording and reporting
Child protection policy
Criminal record checks
Further information
Checklist
The dental team is not responsible for making a diagnosis of child abuse or Types of abuse
neglect, just for sharing concerns appropriately. Abuse and neglect are
described in four categories:
Physical abuse may involve hitting, shaking, throwing, poisoning, burning or

scalding, drowning, suffocating or otherwise causing physical harm to a child. It
may also be caused by a parent or carer fabricating the symptoms of, or
deliberately causing, illness in a child. Orofacial trauma occurs in at least 50
per cent of children diagnosed with physical abuse – and a child with one injury
may have further injuries that are not visible.

Emotional abuse is the persistent emotional maltreatment causing severe and
persistent adverse effects on the child’s emotional development. It may involve
conveying to children that they are worthless or unloved, inadequate, or valued
only insofar as they meet the needs of the other person. It may feature:
Age or developmentally inappropriate expectations being imposed on

children
Interactions that are beyond the child’s developmental capability
Overprotection and limitation of exploration and learning
Preventing the child participating in normal social interaction
Seeing or hearing the ill-treatment of another
Causing children frequently to feel frightened or in danger
Exploitation or corruption of children.
Sexual abuse involves forcing or enticing a child or young person to take part
in sexual activities, whether or not the child is aware of what is happening. The
activities may involve physical contact, including penetrative (for example rape,
buggery) or non-penetrative acts. They may include non-contact activities, such
as involving children in looking at, or in the production of, pornographic material
or watching sexual activities, or encouraging children to behave in sexually
inappropriate ways.
Neglect is the persistent failure to meet the child’s basic physical and/or
psychological needs, likely to result in the serious impairment of the child’s
health or development. It may occur in pregnancy as a result of maternal
substance abuse. Once a child is born, neglect may involve a parent or carer:
Failing to provide adequate food and clothing, shelter

Failing to protect a child from physical and emotional harm or danger
Failure to ensure adequate supervision
Failure to ensure access to appropriate medical care or treatment
Neglect of, or unresponsiveness to, a child’s basic emotional needs.
Practical steps If you are worried about a child – practical steps
It is uncommon for dentists to see patients with signs of child abuse and,
generally, dentists are not in a position to assess all the factors involved. But
where you have concerns about a child who may have been abused and there
is no satisfactory explanation, prompt action is important.
Ask yourself:
Could the injury have been caused accidentally? If so, how?

Does the explanation for the injury fit the age and clinical findings?
If the explanation of the cause is consistent with the injury, is this itself within
the normally acceptable limits of behaviour?
If there has been any delay in seeking advice, are there good reasons for
this?
Does the story of the accident vary?
Observe:
The relationship between the parent/carer and child

The child’s reaction to other people
The child’s reaction to dental examinations
Any comments made by the child or parent/carer that give concern about
the child’s upbringing or lifestyle.

Discuss your concerns with an appropriate colleague or someone you can trust.
If you remain concerned, informal advice could be sought first from your local
social services without disclosing the child’s name. This will help you decide
whether you should make a formal referral – by telephone so that you can
directly discuss your concerns.
Seek permission to refer
It is good practice to explain your concerns to the child and parents, informing
them of your intention to refer and seek their consent – being open and honest
from the start, results in better outcomes for the children. Don’t discuss your
concerns with the parents where
The discussion might put the child at greater risk

The discussion would impede a police investigation or social work enquiry
Sexual abuse by a family member, or organised or multiple abuse is
suspected
Fabricated or induced illness is suspected
Parents or carers are being violent or abusive and discussion would place
you or others at risk
It is not possible to contact parents or carers without causing undue delay in
making the referral.
Where there is serious physical injury arising from suspected abuse:
Refer the child to the nearest hospital Accident and Emergency Department
with the consent of the person having parental responsibility or care of the
child
Advise the A&E Department in advance (by telephone) that the patient is
coming
If consent is not obtained, the Duty Social Worker at the local Social
Services Department or the police should be told of the suspected abuse by
telephone so that the necessary action can be taken to safeguard the
welfare of the child
A telephone referral to Social Services must be confirmed in writing within
48 hours, repeating all relevant facts of the case and an explicit statement of
why you are concerned. The telephone discussion should be clearly
documented – who said what, what decisions were made and the agreed
unambiguous action plan.
Where less serious injury is recorded or there is concern for the physical or
emotional well-being of the child, discuss the appropriate reporting procedures
and your concerns with a senior local colleague, such as a hospital consultant,
dental adviser or consultant in Dental Public Health or contact the health
professional for child protection at the local primary care organisation (PCO).
Reports should be restricted to Recording and reporting
The nature of the injury

Facts to support the possibility that the injuries are suspicious.
Attendance of the referring dentist may be required by the Social Services

Department at a case conference or if there is a court hearing, so
comprehensive written records of the injury and its history (as reported) must
be kept together with clinical photographs.

Child protection policy A suitable child protection policy for a dental practice should affirm the
practice’s commitment to protecting children from harm and should explain how
this will be achieved. A policy by itself is not enough, however. Safeguarding
children also involves:
Listening to children
Providing information for children
Providing a safe and child-friendly environment
Having other relevant policies and procedures in place
Listening to children
Create an environment in which children know their concerns will be listened to

and taken seriously. You can communicate this to children by:
Asking for their views when discussing dental treatment options, seeking
their consent to dental treatment in addition to parental consent
Involving them when you ask patients for feedback about your practice
Listening carefully and taking them seriously if they make a disclosure of
abuse
Providing information to children
To support children and families, you can provide information about:
Local services providing advice or activities

Sources of help in times of crisis, for example, NSPCC Child Protection
Helpline, NPCC Kids Zone website, Childline, Samaritans
Providing a safe and child-friendly environment
Taking steps to ensure that areas where children are seen are welcoming
and secure with facilities for play
Considering whether young people would wish to be seen alone or
accompanied by their parents
Ensuring that staff never put themselves in vulnerable situations by seeing
young people without a chaperone
Ensuring that your practice has safe recruitment procedures in place
Other relevant policies and procedures
Clinical governance policies that you already have in place will contribute to
your practice being effective in safeguarding children. Relevant policies and
procedures include:
Safe staff recruitment procedures –

Making potential job applicants aware of your child protection policy
Checking gaps in employment history
Requesting proof of identity
Taking up references
Complaints procedure so that children or parents attending your practice
can raise any concerns about the actions of your staff that may put children
at risk of harm
Public interest disclosure policy (underperformance policy) so that staff can
raise concerns if practice procedures or action of other staff members puts
children at risk of harm
Code of conduct for staff clarifying the conduct necessary for ethical
practice, particularly related to maintaining appropriate boundaries in
relationships with children and young people (including a statement that staff
members will be chaperoned when attending unaccompanied children, for
example).

To increase patient safety, all new recruits into the NHS must undergo criminal Criminal record checks
record checks.
The existence of a criminal conviction does not of itself prevent anyone from
working in the NHS and information should considered in the light of all relevant
circumstances including the nature of the offence and the relevance of the
offence to the work involved. Obtaining a disclosure for practice staff in private
practice is regarded as good practice.
England and Wales
Dentists working under a GDS contract or PDS agreement in England and

Wales must ensure that staff with direct patient contact undergoes criminal
records checks. This includes, for example, dental nurses and receptionists but
not cleaners that work out of hours. Dentists are checked automatically on entry
to a Primary Care Organisation performers list. The Criminal Records Bureau
(CRB) undertakes the criminal records checks.
There are two types of disclosure – standard and enhanced. Standard

disclosures allow disclosure of criminal convictions (spent or unspent),
cautions, reprimands, warnings and bind-overs. Enhanced disclosures allow the
additional disclosure of information held by local police forces. The employing
dentist decides whether an enhanced disclosure is needed, although a
standard disclosure is usually sufficient for employees. The relevant paperwork
can usually be obtained from the local Primary Care Organisation. Many PCOs
do not charge for this service, but where one is made it should only reflect the
charge made by the CRB.
CRB checks can be undertaken by other organisations listed on the CRB

website. Being commercial, these organisations will charge a fee for providing
this service.
Scotland
Disclosure Scotland is a voluntary body established within the Scottish Criminal

Record Office (SCRO) to issue disclosure certificates. Its aim is to enhance
public safety and help employers and voluntary organisations in Scotland to
make safer recruitment decisions.
The bureau is responsible for issuing three levels of disclosure – basic,

standard and enhanced. It draws on three sources of information – the SCRO
database, the Police National Computer (PNC) and, where appropriate, local
police force records.
Basic disclosures show details of all unspent convictions and are available to
anyone. Standard disclosures are available for occupations whose duties
involve, for example, regular contact with children and young people under the
age of 18, vulnerable adults and professional groups in health. They contain
details of all convictions on record, whether spent or unspent under the
Rehabilitation of Offenders Act, so minor convictions, no matter when they
occurred, will be included. The highest level, enhanced disclosures, may also
contain non conviction information held locally by the police. The prospective
employer should decide which level of disclosure to apply for.
Requests for standard and enhanced disclosures must be countersigned by a

registered body, such as a Health Board.

Further information Child protection and the dental team
www.cpdt.org.uk
Criminal Records Bureau

(England and Wales)
Tel: 0870 909 0844
www.crb.gov.uk
Disclosure Scotland
Tel: 0870 609 6006 or email
info@disclosurescotland.co.uk
www.disclosurescotland.co.uk
Checklist Ensure the dental team in trained in child protection procedures

Have a child protection policy
Record and report cases
Undertake criminal record checks
The dental Dentists have to place great reliance on members of their dental team to
ensure that they comply with ethical and legal requirements. This section gives
team some practical ways in which dentists can ensure that their teams meet the
required standards.
Vicarious responsibility
Dental hygienists and dental therapists
Dental technicians and clinical dental technicians
Dental nurses
Dental receptionists
Training
Terms and conditions of service
Staff management and appraisal
Checklist
Vicarious responsibility Dentists are vicariously responsible for the acts and omissions of their
unregistered staff. This includes dentists working as assistants, locums and
associates who, although they may not be the employer of the staff, are
responsible for the delegation of tasks to them and for the outcomes of their
actions on patients. Both dentists and registered DCPs may be held
responsible by the General Dental Council and NHS contractors will be
responsible for the acts and omissions of all dental professionals they engage.
Dental hygienists and The General Dental Council has published a Scope of practice for each group
dental therapists of DCPs giving the tasks that they can undertake, providing they have
appropriate training. See the GDC’s website at www.gdc-uk.org.
The dentist is responsible for checking the GDC registration of dental hygienists
and dental therapists and must ensure that they work within their competence.
Failure to do so may lead to a charge of covering the illegal practice of
dentistry, as well as fitness to practise proceedings against the DCP.
Dental hygienists may work without a dentist being on the premises. Hygienists
and therapists work within the treatment plan provided by the dentist stating the
treatment to be provided, the date of the next full mouth assessment and recall
intervals at which the patient should be seen. The dentist can ask the dental
hygienist or dental therapist to decide the recall intervals where appropriate.
Dental therapists can work in all spheres of dental practice.

Dental hygienists and dental therapists should have their own indemnity cover
to protect them in the case of proceedings by the GDC and action by a patient.
Dental defence organisations accept dental hygienists and dental therapists into
membership.
Dental technicians have to be registered with the GDC or be in formal training. Dental technicians and
Dental technicians do not work with patients, that is take impressions, or fit or clinical dental
adjust dentures. technicians
Clinical dental technicians are able to fit dentures to patients if instructed to do

so by a dentist, but they cannot work without such a prescription. They are,
however, permitted to provide full sets of dentures to edentulous patients
without prescription. There is currently no training course available in the UK for
dental technicians to become CDTs, but a number of UK dental technicians
studied denturism at a Canadian college and, for such graduates, the FGDP
has set up a conversion course. After passing this course, these individuals can
register with the GDC as CDTs.
If a patient prefers to be referred to a local CDT, dentists should cooperate as

far as possible. We suggest that the CDT’s registration is checked and that
dentists should get to know their local CDT so that a working relationship can
be built up. There is no compulsion on a dentist to refer a patient to a particular
CDT, but dentists should respond to the patient or CDT in a courteous and
timely way and act in the patient’s best interests, respecting their preferences
as far as possible. Ensure that a full mouth examination has been undertaken
and that the patient has given informed consent for the referral and/or treatment
plan.
CDTs must follow the GDC’s Standards for dental professionals and the Clinical
Dental Technicians Association also has a code of conduct for its members
which can been seen at
www.cdta.org.uk/index.php?option=com_content&task=view&id=47&Itemid=69.
Dental nurses must be registered with the GDC or enrolled on an approved Dental nurses
training course. They do not treat patients, but assist the dentist in the surgery.
It is possible for dental nurses to undertake further training, for example in
taking radiographs or in providing oral health education. They must ensure that
they work within their competence. Clinical responsibility for their work remains
with the dentist but the nurse may also be held accountable by the GDC. The
National Examining Board for Dental Nurses accredits courses and provides
certificates both for the primary qualification (national certificate or NVQ/SVQ 3
in dental nursing) and for the additional qualifications.
Dental receptionists do not work in the surgery. Since registration for dental Dental receptionists
nurses became mandatory, receptionists cannot be asked to cover surgery
duties in the event of absence of a dental nurse unless he/she is registered. A
dentist asking the receptionist to do so would be subject to fitness-to-practise
procedures.
It is essential that all members of the dental team are adequately trained, Training
registered and competent to perform their required duties. Once trained, skills
and knowledge must be kept up-to-date.
Dental nurses must be qualified and registered or in training towards a

qualification. Courses for dental practice managers and dental receptionists are
also available. All DCP groups have their own professional associations that
provide courses, information and journals to their members. All registered DCPs
are subject to mandatory CPD requirements. Postgraduate deaneries invite
DCPs to appropriate courses and are also establishing programmes designed
especially for them.

Dental employers have a responsibility to allow their employees time off to
attend appropriate training courses and to pay for or contribute to the cost of
such training. Many practices attend courses as a team or arrange in-house
training sessions.
Terms and conditions of Dental employers are obliged to comply with employment legislation covering
service conditions of employment, the minimum wage, dismissal, redundancy and
discrimination. Detailed advice on employment legislation is contained in a
series of BDA advice sheets and personal assistance is available from advisers
in BDA Practice Support (practicesupport@bda.org; telephone 020 7563 4574.
Dentists must take particular care to avoid breaching discrimination law since
an adverse employment tribunal decision will lead to details of the case being
passed to the GDC. Practices should have in place an equal opportunities
policy that provides a procedure to deal with allegations of discrimination and
sexual harassment.
Dentists can find it difficult to compete in the local labour market for competent
staff because of constraints in NHS funding. Careful thought should be given to
pay and benefits packages to ensure that staff turnover is minimised and the
quality of care and service to patients remains high.
Staff management and A good staff appraisal scheme can help to deal with poor performance, reward
appraisal good performance and increase motivation. The BDA provides a
comprehensive guide to appraisal, available in the BDA Practice Compendium.
Dental undergraduates receive little or no staff management training, although

these issues are covered in the vocational training year. Communicating with
and motivating staff are skills that are learned in practice. Providing a high
standard of care and service to patients requires good management and
administration by dentists and courses are available. The BDA also has a large
amount of management information for use in dental practice. Contact the
BDA's Information Centre and Professional and Advisory Services and use the
BDA Practice Compendium. Also consider taking part in the BDA MasterClass
management training programme.
Checklist Dentists should ensure that their staff are properly trained and qualified to
undertake the tasks that have been delegated to them
Dentists are responsible for the acts and omissions of their staff
Dentists must comply with employment legislation
Training in the management of staff is important for dentists
All dental care professionals must be registered with the GDC or enrolled on
an approved training course
Dental practices should follow a comprehensive equal opportunities policy.
General There are stringent requirements for the provision of general anaesthesia and
conscious sedation in dentistry. GDC requirements are contained in the annex
anaesthesia and to Standards for dental professionals.
conscious sedation General anaesthesia, a procedure which is never without risk, should be
avoided wherever possible. It must only be provided within a hospital setting
General anaesthesia which has critical care facilities. This means it cannot be provided within
primary care. General anaesthesia may only be given by someone who is:
on the specialist register of the General Medical Council as an anaesthetist

a trainee working under supervision as part of a Royal College of
Anaesthetists’ approved training programme, or

a non-consultant career-grade anaesthetist with an NHS appointment under
the supervision of a named consultant anaesthetist, who must be a member
of the same NHS anaesthetic department where the non-consultant career-
grade anaesthetist is employed.
The anaesthetist should be supported by a health professional who is

specifically trained and experienced in the necessary skills to help monitor the
patient’s condition and to assist in an emergency.
For settings which do provide general anaesthesia the recommendations set Conscious sedation
out in the Department of Health (England) publication A Conscious Decision – a
review of the use of general anaesthesia and conscious sedation in primary
dental care (July 2000) and associated letters of advice from Chief Dental
Officers in England, Northern Ireland, Scotland and Wales must be adopted.
The Department of Health’s (England) guidance document Conscious sedation

in the provision of dental care was published in 2003 and lays down specific
recommendations for all practitioners providing conscious sedation in general
dental practice, community and hospital settings. It is a Standing Dental
Advisory Committee (SDAC) report of an expert group on sedation for dentistry
and is endorsed by the GDC’s Standards for dental professionals.
It underlines:
1. The importance of the referring dentist and the sedationist considering

alternative methods of pain and anxiety control and discussing these with
the patient before deciding that conscious sedation is appropriate
2. The need for both theoretical and practical training, continuing updating and
clinical audit for the whole dental team is stressed as part of the clinical
governance framework for ensuring the delivery of a high quality service,
and
3. The necessity of having the appropriate equipment and drugs and ensuring
that the equipment is properly maintained.
The executive summary of the report is given below, but all practitioners and
dental care professionals who offer sedation services are advised to make
themselves aware of the full contents of the report. This is available from the
BDA or Department of Health website.
Executive summary – Conscious sedation in the provision of dental care

Department of Health (England)
The effective management of pain and anxiety is of paramount importance

for patients requiring dental care and Conscious Sedation is a fundamental
component of this.
Competently provided Conscious Sedation is safe, valuable and effective.
It is absolutely essential that a wide margin of safety be maintained between
Conscious Sedation and the unconscious state of general anaesthesia.
Conscious Sedation must under no circumstances be interpreted as light
general anaesthesia.
A high level of competence based on a solid foundation of theoretical and
practical supervised training, progressive updating of skills and continuing
experience is the key to safe practice.
Education and training must ensure that ALL members of the dental team
providing treatment under Conscious Sedation have received appropriate
supervised theoretical, practical and clinical training.
Training in the management of complications in addition to regularly
rehearsed proficiency in life support techniques is essential for all clinical
staff. Retention and improvement of knowledge and skills relies upon regular
updating.

Operating chairs and patient trolleys must be capable of being placed in the
headdown tilt position and equipment for resuscitation from respiratory and
cardiac arrest must be readily available.
Dedicated purpose-designed machines for inhalational sedation should be
used.
It is essential to ensure that hypoxic mixtures cannot be delivered.
There should be adequate active scavenging of waste gases.
All equipment for the administration of intravenous sedation including
appropriate antagonist drugs must be available in the treatment area and
appropriately maintained.
Supplemental oxygen delivered under intermittent positive pressure together
with back up must be immediately available.
It is important to ensure that each exposure to Conscious Sedation is
justified. Careful and thorough assessment of the patient ensures that
correct decisions are made regarding the planning of treatment.
A thorough medical, dental and social history should be taken and recorded
prior to each course of treatment for every patient.
There are few absolute contraindications for Conscious Sedation however
special care is required in the assessment and treatment of children and
elderly patients.
Patients must receive careful instructions and written valid consent must be
obtained.
Fasting for Conscious Sedation is not normally required however some
authorities recommend the same fasting requirements as for general
anaesthesia.
Recovery from sedation is a progressive step-down from completion of
treatment through to discharge. A member of the dental team must
supervise and monitor the patient throughout this period.
The decision to discharge a patient into the care of the escort following any
type of sedation must be the responsibility of the sedationist.
The patient and escort should be provided with details of potential
complications, aftercare and adequate information regarding emergency
contact.
The three standard techniques of inhalation, oral and intravenous sedation
employed in dentistry are effective and adequate for the vast majority of
patients.
The simplest technique to match the requirements should be used.
The only currently recommended technique for inhalation sedation is a
titrated dose of nitrous oxide with oxygen and it is absolutely essential to
ensure that a hypoxic mixture cannot be administered.
The standard technique for intravenous sedation is the use of a titrated
dose of a single drug; for example the current use of a benzodiazepine.
Oral premedication with an effective low dose of a sedative agent may be
prescribed.
No single technique will be successful for all patients.
All drugs and all syringes in use in the treatment area must be clearly
labelled and each drug should be given according to accepted
recommendations.
Stringent clinical monitoring during the procedure is of particular importance
and all members of the clinical team must be capable of undertaking this.
Conscious Sedation for children must only be undertaken by teams which
have adequate training and experience.
Nitrous oxide / oxygen should be the first choice for paediatric dental
patients.
Intravenous sedation for children is only appropriate in a minority of cases.
The management of any complication including loss of consciousness
requires the whole dental team to be aware of the risks, appropriately
trained and fully equipped. It is vitally important for the whole team to be
prepared and regularly rehearsed.

Attention must be given to risk awareness, risk control and risk containment.
Evidence of active participation in continuing professional development
(CPD) and personal clinical audit is an essential feature of clinical
governance.
The Scottish Dental Clinical Effectiveness Programme has produced specific Conscious sedation in
guidance on the provision of sedation in Scotland. Conscious sedation in Scotland
dentistry – dental clinical guidance was published in May 2006 and evolved
from the report by the English Department of Health summarised above.
A full copy of the Scottish guidance is available at:
www.scottishdental.org/cep/guidance/dentalsedation.htm
In August 2007 the Royal College of Surgeons of England - Faculty of Dental Alternative techniques
Surgery and the Royal College of Anaesthetists produced new additional
guidance encompassing the use of alternative conscious sedation techniques.
‘Standards for Conscious Sedation in Dentistry: Alternative Techniques - A
Report from the Standing Committee on Sedation for Dentistry’ can be
accessed at www.rcseng.ac.uk/fds/docs/SCSDAT%202007.pdf
Alternative techniques include:
Any form of conscious sedation for patients under the age of 12 years* other
than nitrous oxide/oxygen inhalation sedation
Benzodiazepine + any other intravenous agent for example: opioid, propofol,
ketamine
Propofol either alone or with any other agent for example: benzodiazepine,
opioid, ketamine
Inhalational sedation using any agent other than nitrous oxide / oxygen
alone
Combined (non-sequential) routes for example: intravenous + inhalational
agent (except for the use of nitrous oxide/oxygen during cannulation)
*It is recognised that the physical and mental development of individuals varies
and may not necessarily correlate with the chronological age.
A dentist has a legal obligation to obtain the valid and voluntary consent of the Consent
patient to the treatment proposed. The nature of the treatment to be undertaken
must therefore be explained clearly and in terms that the patient can
understand. The patient’s comprehension is an essential element in the validity
of consent and the onus is on the dentist to satisfy him or herself that the
patient has understood the treatment to be carried out. Alternative treatments
and methods of pain control which may be available, any material risks involved
in each option and any aftercare or precautions which may be necessary form a
vital part of the explanation leading to full patient comprehension. The patient
must have the opportunity to ask questions and make a choice free from
pressure.
The duties of the referring dentist
It is important that the referring dentist, as well as the treating dentist, obtains
the patient’s agreement to the referral following a thorough and clear
explanation of the risks involved and the alternative methods available.

Checklist of Dentists’ duties include
ethical Obligations to patients
principles Always to act in a patient’s best interests and put those interests before their
own or those of any colleague, organisation or business
Respect a patient’s dignity and choices
Treat patients politely and with respect
Only undertake procedures for which they have the necessary training
competence and experience
Obtain and keep up appropriate professional indemnity/insurance cover
Obtain valid consent that is informed and specific
Confidential personal information about patients must only be disclosed with
the consent of the patient and in particular circumstances
Respect a patient’s human rights
Comply with the Data Protection Act 1998 and give patients a copy of the
practice’s data protection code of practice
Not provide excessive or unnecessary treatment
Maintain appropriate professional boundaries
Patients must be treated fairly and reasonably and not misled about the
treatment they will receive, the contractual basis on which it is provided or
its cost
Where dentists offer patients treatment under private dental plans, the
scope of care to be provided by the plans should be clear and their terms
should not interfere with the contract and relationship between dentist and
patient
Where a patient makes a complaint, try to resolve it using the practice
complaints procedure
Not discriminate on the grounds of sex, race, religion, gender reassignment
or disability
Refer a patient for further advice and treatment if it transpires that the task
in hand is beyond the dentist’s own skills or experience
Not intimidate child patients and only use physical restraint in the most
exceptional circumstances
Arrange for the completion of treatment when leaving a practice
Train staff in patient confidentiality and use a comprehensive practice
confidentiality policy
Include breaches of confidentiality in staff disciplinary procedures as an
offence which would result in summary dismissal.
Professional practice
Notify the GDC promptly of any change in registered address or practising

name
Registration with the GDC must be renewed every year and a dentist must
ensure that dental care professionals whom they engage are registered
Read communications from the General Dental Council promptly and retain
GDC guidance for reference
Undertake the required amounts of continuing postgraduate education,
together with clinical audit and peer review
Comply with ASA advertising guidelines
Comply with current health and safety legislation and infection control
procedures
Have a registered DCP who is trained in emergency procedures in the room
when a patient is being treated
Promote oral health among patients
Only provide or refer a patient for general anaesthesia where there is no
suitable alternative
Ensure that where a patient receives either general anaesthesia and
sedation, GDC rules are followed

Ensure that the dental team is regularly trained in resuscitation techniques
Keep comprehensive clinical records for at least eleven years after
treatment has finished or for children up to age 25, whichever is the longer
Not refer patients to colleagues in return for a fee
Where treatment is offered that does not amount to dental treatment, the
dentist must have appropriate indemnity cover and be fully trained and
competent to provide the treatment
Ensure that staff are properly trained and qualified to undertake the tasks
that have been delegated to them
Are responsible for the acts and omissions of staff
Where a patient is referred to another practitioner a comprehensive referral
letter should be sent.
Patients have the right

To a high standard of dental care
To a free choice of general dental practitioner
To a prompt referral for a second opinion where this is necessary or the
patient has requested it
To change dentist
To be fully informed of the treatment that is necessary, alternatives and
material risks as well as the nature of the contract (NHS/private) and the
cost of treatment
To a written treatment plan and estimate where a new course of NHS
treatment is planned or expensive or extensive treatment is required
To be provided with an itemised bill on request
To be notified of the terms (NHS/private) and the probable cost of specific
items of treatment if referred to another practitioner
To have a complaint dealt with sympathetically and promptly by the practice
in the first instance
To be informed in writing if they are ceasing to be entitled to NHS dental
care at the practice
To access to information held about them
If offered alternative therapies as part of their treatment, to know at the
outset any additional cost.
Professional relationships
Agreements between dentists must always be written down. The BDA is

happy to comment on drafts
Transfer of dental records depends on the agreement between associate
and practice owner and the wishes of the patient
Dentists must act in a professional manner towards colleagues
Where a professional colleague, because of poor performance, health or
other unprofessional conduct may be putting patients at risk a dentist has a
duty to raise a concern with an appropriate body to protect patients
Not to place young colleagues under pressure to achieve target earnings
which may compromise their clinical standards and put pressure on them
not to act in their patients’ best interests
Where a patient has been referred, undertake the treatment that is set out in
the referral letter, except where it is not in accordance with the treating
dentist’s clinical judgement. In this case the matter should be discussed with
the referring dentist.
Legal responsibilities
Comply with employment legislation

Follow a comprehensive equal opportunities policy and not discriminate on
the grounds of sex, race, disability, religion or gender reassignment
If practising within the NHS comply with the terms of their contract

Keep up to date with his responsibilities under a wide range of relevant
legislation including:
Data Protection Act 1998
Health and Safety at Work Act 1975
Ionising Radiations Regulations 1998
Dentists Act 1984 (as amended)
Medicines Act 1988
Misuse of Drugs Act 1971
Employment Rights Act 1996
Disability Discrimination Act 1998
Working Time Regulations 1998
Supply of Goods and Services Act 1982
Consumer Credit Act 1974
Consumer Protection Act 1987
Medical devices regulations
Human Rights Act 1998.
Dentists’ Established in April 1986 as the Sick Dentist Scheme, the Dentists’ Health
Support Programme is designed to help the dentist who is in need of – but not
Health Support seeking - medical attention and whose condition is considered to compromise
well-being, the safety and welfare of patients and the reputation of the
Programme profession. It is designed both to protect patients and to help dentists who may
be at risk of formal complaint to the GDC. Whilst the majority of cases are
alcohol/drug related, this is not always the case.
The Dentists’ Health Support Programme can be contacted by calling the

helpline number below. This line can be used by any dentist who has a problem
or by someone (a colleague, staff, family member or a friend) who knows a
dentist who might have a problem. The scheme is entirely confidential and
callers are assured that their identity will not be disclosed to the dentist at any
time. The caller will be put in contact with a Regional Referee in the appropriate
geographical area or with the Co-ordinator of the Programme.
Regional Referees are usually retired or semi-retired dentists who are trained
and willing to make time to help colleagues in trouble. The Regional Referee
will contact a Special Referee and help establish whether there is a problem.
Special Referees are recovered alcohol/drug addicts who have received
specialised training.
The Referees discuss and investigate the case in a careful and confidential
manner. If necessary, the sick dentist will be visited by both referees who will
discuss the problem, offer help and, with the dentist’s agreement, make suitable
arrangements for the provision of treatment and such other help as is
necessary. The key role of the Regional Referee is to provide practical help and
advice in dealing with practice problems and support for the family - both very
important. The management of the practice may have deteriorated and the
dentist may have to be absent from the practice and from home while receiving
treatment.
If you know of a dentist who might be helped by the Dentists’ Health Support
Programme, call the following confidential number, which is also widely
advertised in the dental press. Names and addresses of Regional Referees
may also be available from GDPC representatives and LDC Secretaries.
Tel: 01327 262 823

Who does the Fund help? BDA
The Fund cares for all dentists in the UK and their families at times of need, not Benevolent
just members of the Association. Dentistry is a stressful profession, and some
people find it difficult to cope with the pressures, suffering mental or physical Fund
breakdown. Others retire in apparently comfortable circumstances, but find after
twenty or thirty years that their savings and pensions have dwindles
considerably. People of all ages are cared for, whenever need arises.
How does it help?
The Fund helps many people every year, supplementing their income or paying
the occasional bill they cannot manage. Grants help people replace items such
as washing machines, beds and refrigerators, and pay for television licences.
The Fund enables people to enjoy life, gives a Christmas grant to every
beneficiary and occasionally pays for holidays. Some people only need help in
the short term, and may be offered a loan (usually interest-free) to see them
through the difficult time. The valuable team of visitors provides friendship and
support for those who require it.
Many deserving cases do not come to the Fund’s attention. If you know of
someone you think could benefit from the Fund's assistance, please encourage
him or her to contact the Fund's Welfare Manager, Mrs Sally Atkinson. Her
address is 64 Wimpole Street, London W1G 8YS, telephone number:
020 7486 4994 (24 hour answerphone) and email: dentistshelp@btconnect.com.
Every enquiry is considered in absolute confidence.
Can I help the Fund?
Yes! You can help in many ways. You can give money regularly to the Fund
through a tax-efficient covenant system. You can leave a bequest to the Fund in
your will. You can also tell colleagues and their families about the work of the
Fund, particularly when you think its help might be needed.
The Fund is truly grateful for the generous support received from members of
the profession as, without it, it could not continue its work.

British Dental Association
l 64 Wimpole Street l London W1G 8YS l Tel: 020 7563 4563 l Fax: 020 7487 5232
l E-mail: enquiries@bda.org l www.bda.org l© BDA March 2009

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The duty of care and professional obligations 6

© BDA March 2009 3

© BDA March 2009 4

The dental team 53

General anaesthesia and sedation 55

Checklist of ethical principles 59

Dentists’ Health Support Programme 61

BDA Benevolent Fund 62

© BDA March 2009 5

Dentistry is a self-regulated profession, which means that the General Dental

In some circumstances these principles can place great demands on dentists

Providing appropriate, necessary care and treatment to a high standard

© BDA March 2009 6

Unsatisfactory treatment or failure to provide treatment without adequate skill

Lifelong learning Dentists are expected to undertake continuing postgraduate development

GDC registration includes participation in its CPD scheme, whereby registrants

Short postgraduate courses are organised by postgraduate dental deans,

© BDA March 2009 7

Dentists must have appropriate professional indemnity/insurance cover to Professional

Medico-legal insurance guarantees to cover the insured up to the limit of the

When choosing appropriate cover, dentists should consider whether the

The GDC is committed to introducing a system of revalidation, in which Revalidation

© BDA March 2009 8

Checklist Always act in a patient’s best interests

This section gives general guidance on the dentist’s responsibility to patients to

Key definitions Express consent

A patient gives express consent when he or she indicates orally or in writing

In very limited circumstances consent may be implied. An example is where the

© BDA March 2009 9

For consent to be valid it must be specific, informed and normally be given by

Who can obtain consent? Obtaining consent

Consent for examination and treatment must be obtained by a dentist (normally

For treatment undertaken by a dental hygienist or dental therapist, the

An assessment of whether a patient is able to consent should be carried out

© BDA March 2009 10

The precise nature of the treatment to be undertaken must therefore be

Going beyond the consent that has been given

Sometimes patients will consent to part of a treatment plan but withhold

© BDA March 2009 11

Bolam and Sidaway

In Bolam v Friern Hospital Management Committee (1957) it was held that a

Bolam test is still of importance in the UK courts, recent judgments in Ireland

© BDA March 2009 12

Pearce v United Bristol Healthcare NHS Trust (1999)

Care should be taken in obtaining consent in the presence of third parties,

© BDA March 2009 13

Children under 16 who are of sufficient maturity and intelligence to understand

© BDA March 2009 14

Where a child who is unable to consent is accompanied by an adult relative

Consultation with the next of kin is advisable.

© BDA March 2009 15

Decisions made by the Court of Protection

Lasting Power of Attorney

Independent mental capacity advocates

Advance statements or directives to refuse treatment

It is only possible to make an advance refusal of medical treatment. A person

© BDA March 2009 16

Research protocols should always be submitted to the appropriate Local

Where a dentist wishes to use photographs or other images of patients in

Consent for records-based research

Salaried services: The Department of Health in England has published a

General practice: Copies of treatment plans and estimates may be used to