GPs may find themselves presented with patients with dental pain in a variety of situations, so how should we manage such requests?
Dr Rachel Birch from MPS presents a roundup of useful advice for an all too regular clinical presentation.
Dr L was working at a walk-in centre over a busy bank holiday weekend. On the Saturday morning Miss C attended and told her she had a troublesome dental abscess. She said that the dentist had told her to attend her GP for antibiotics if it recurred.
Dr L told Miss C that a GP was not the best person to treat dental infections. She advised Miss C to contact her dentist straight away. Miss C told her she had telephoned her dental surgery but had just got a message saying the surgery was closed. She told Dr L she was in a lot of pain.
This scenario is not uncommon. Patients who present with dental problems are clearly more appropriately seen by dentists. However, patients may sometimes experience problems accessing emergency dental services and present to doctors instead.
The GMC advises doctors to recognise and work within the limits of their competence. If doctors assess, diagnose or treat patients they must:
- Adequately assess the patient’s conditions taking account of their history, their views and values, and where necessary examine the patient
- Promptly provide or arrange suitable advice, investigations or treatment where necessary
- Refer a patient to another practitioner if necessary
- The GMC prescribing guidance advises doctors “should prescribe medicines only if you have adequate knowledge of the patient’s health and you are satisfied that they serve the patient’s needs”.
NICE offers clinical guidance on the management of dental abscesses in primary medical care. This was developed in collaboration with the Faculty of General Dental Practice and the British Society of Antimicrobial Chemotherapy. It advises:
- Doctors should emphasize the need to seek dental treatment as soon as possible and advise the patient when and where to seek urgent dental intervention.
- In the absence of immediate dental attention, doctors should provide appropriate advice regarding self-care and the use of analgesia.
- Generally, antibiotics are not indicated for healthy individuals when there no signs of spreading infection. However, there may be situations when an antibiotic should be prescribed, such as for individuals at high risk of infection or when there are signs of severe infection.
- There may also be situations when the patient should be admitted to the dental or maxillofacial team.
It highlights that all people with a dental abscess should have definitive treatment provided by a dental practitioner.
The BMJ published a clinical review in 2015. It emphasised that dental infection is a common and potentially life-threatening condition and that dental abscesses require surgical treatment. It stated:
- Prompt dental surgery should be arranged rather than prescribing unnecessary antibiotics
- Antibiotics are inappropriate in the absence of signs of spreading infection or systemic upset
- Patients presenting with signs of sepsis, facial swelling, trismus or dysphagia should be reviewed by a dental or maxillofacial surgeon without delay.
What should Dr L do?
The key emphasis in all the above guidance is regarding an adequate assessment of the patient so that the precise nature of the patient’s care needs is established. Dr L could be criticised if she didn’t assess the patient first before recommending the patient sees a dentist.
- Dr L should assess the patient, taking an adequate history and undertaking an appropriate examination of the patient’s mouth, vital observations, face and local lymph nodes.
- If the patient is in pain, Dr L should act in the patient’s best interests and provide advice, and a prescription, if necessary for analgesia.
- Dr L should consider if antibiotics are indicated, and if not, explain to the patient why she is not prescribing them.
- Consideration should be given as to whether emergency admission is necessary and, if so, Dr L should arrange this.
- Dr L may wish to refer to patient to the local emergency dental service since she has had problems accessing her own dentist.
- It is important for Dr L to be familiar with local Out of Hours guidelines regarding patients presenting with dental pain.
If Dr L is involved in a subsequent complaint from Miss C, she should request assistance from her medical defence organisation in the usual way. However, by taking time to assess Miss C, provide analgesia and explain and arrange the necessary treatment, Dr L will be able to demonstrate that she has acted appropriately and in the best interests of the patient.
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