Teamwise UK. Risk management from Dental Protection for therapists and hygienists

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1 Risk management from Dental Protection for therapists and hygienists Teamwise UK inside issue 14 Events 2 A word from the Director 3 Direct access - defining can do 4 5 Clarifying cannot 6 7 Watch and wait 8 9 Caries control from cradle to grave Local anaesthetic; risks and controversies 13 16

2 2 Dental This award will highlight the efforts Premier practices make to be exemplary in risk practice Symposium management and professionalism; we of the therefore ask that entries are based on at least one of the following criteria: year Entries by 9 September 2013 Dental Protection and schülke are proud to present a brand new award for The dental practice of the year award aims to acknowledge the hard work and commitment that goes into being a great practice With a chance to win 1,500 for your practice, enter our award today and treat the whole team. This award is open to any practice within the UK that believes it stands out from the crowd. Entering is easy; simply let us know why your practice is outstanding in no more than 750 words. Entries can be based on a wide range of topics, for example do you have a new record keeping process that has transformed the way your practice works? Have you implemented new cross infection control procedures that you are proud of? Or do you believe that your practice puts in that additional effort with patients and want to reward the whole team? If your practice goes that extra mile, why not tell us about it. Ethics Professionalism Record keeping Cross infection control Team working Consent Communication Health and safety. To be in with a chance of winning submit your entry online via our website Closing date is 9 September. For further information or if you have any queries regarding the sort of topics for entry please call us on or visit Saturday 23 November 2013 Dental Protection and schülke will also be combining forces to deliver the Premier Symposium, the largest dental risk management event of its kind in the UK. The thirteenth symposium will take place at The Shaw Theatre, Pullman London St Pancras This year s programme includes an outstanding line-up of internationally known speakers including: Professor Tara Renton The difficult extraction: Anticipating and managing complications in oral surgery Howard Lloyd The difficult RCT: Anticipating and managing endodontic complications Professor Andrew Smith Buy one get one free: a) Dental unit water line contamination - the state of play b) Prions and vcjd - where are we, 17 years on? Professor Crispian Scully What do you think you are you looking at? Serpil Djemal Clinical and dento-legal issues in managing traumatic dental injuries in adults You can contact Dental Protection via the website or at any of our offices listed below 33 Cavendish Square, London W1G 0PS T F Victoria House, 2 Victoria Place, Leeds LS11 5AE T F George Street, Edinburgh EH2 2HN T F Dental Protection Limited (registered in England No ) is a wholly owned subsidiary of The Medical Protection Society Limited (MPS) which is registered in England (No.36142). Both companies have their registered office at 33 Cavendish Square, London W1G 0PS Dental Protection Limited serves and supports the dental members of MPS, with access to the full range of benefits of membership which are all discretionary and set out in MPS s Memorandum and Articles of Association. MPS is not an insurance company The event will also include the presentation of the Dental Student of the Year award and the Dental Practice of the Year award. Tickets are 150 for DPL members and 280 for non-members. This event is hugely popular so early booking is advisable. Book a place now [email protected] Telephone Opinions expressed by any named external authors herein remain those of the author and do not necessarily represent the views of Dental Protection. Pictures should not be relied upon as accurate representations of clinical situations Editor [email protected] Dental Protection Limited July 2013 Dental practice of the year Premier Symposium

3 Kevin Lewis A word from the Dental Director As any regular user of binocular loupes will tell you, focusing on near field, the middle distance and the horizon all at the same time is a talent that takes some time to acquire. Here at Dental Protection this is precisely what we need to be doing all day, every day, in order to serve and protect members in the way we would wish to. It is also, I suspect, what you have come to expect from us - and we try very hard not to disappoint Here in the UK the profession is still scrolling frantically up and down the focus range, in order to work out whether direct access allowed by the GDC in its watershed decision taken on 28 March is an immediate issue, a non-issue or one which will take a little while to reveal its full significance. Depending on your individual perspective, it could be any of the above, and we have set out Dental Protection s position very clearly in a briefing document supported by a number of frequently asked questions, and also in an article which appears on page 4. Impact The gatekeeper role always seems to have the capacity to divide opinion in healthcare circles. It happened in medicine and it has happened in dentistry in other parts of the world. The breadth and depth of our experience and understanding of these matters internationally is one of the many advantages that Dental Protection has over other forms of professional indemnity here in the UK, and I hope that our fair, balanced and responsible approach to direct access issues reflects our confidence that we know what we are doing and what we are dealing with. But it is important to understand, and be prepared for how these kinds of external events might impact upon us, the care members provide for their patients and the risks we collectively face. That is why we responded very quickly with a briefing for members. Many of them have commented very favourably on the speed and quality of what we produced. We have also provided many speakers at meetings up and down the country, and are continuing to do so in the months ahead. Direct access is here to stay, just as nurse practitioners have cemented their place in medical primary care in recent years. Whitening As we had predicted at the time, the changes to the tooth whitening legislation that took effect on October 31st last year, raised almost as many questions as the practical solutions that were provided by the Cosmetic Product (Safety) (Amendment) Regulations An unhelpful tide of misinformation circulating within the dental profession some of it clearly initiated by third parties for reasons of commercial selfinterest, and some of it because of a genuine misunderstanding or misinterpretation of the wording of the new regulations brought a flood of enquiries by telephone and . Here again we have needed to add to our original position statement to keep members abreast of developments, while taking advice from Senior Counsel on their behalf and also lobbying a variety of interested parties to deal with the remaining anomalies in which we naturally have a very significant interest. Sharps On 11 May, yet more new legislation in this case, the Health and Safety (Sharp Instruments in Healthcare) Regulations came into force and here again we produced a briefing document ahead of the implementation date with an overview of the changes and some practical advice to assist members, whether or not they have any kind of stake in the ownership and management of the clinical environment in which they work. All of these resources are published on the Dental Protection website as soon as they are produced. You can ensure that you receive them (and any subsequent updates to them) automatically by registering yourself for bulletins. Visit our website and click through to Membership Services from the link at the top of the home page. Standards In June 2013, the GDC approved an updated version of its principal guidance document Standards for the Dental Team, which will come into force at the end of September. It is clearer than ever before those things that you do in your personal and social life outside dentistry, can still attract the attention of the GDC. Here there is very much a level playing field between dentists, hygienists, therapists and indeed, all other dental health professionals and the GDC is currently preparing guidance on the use of social media. This is a fast-moving area that has already caught out several hygienists, therapists and dental nurses, and members are strongly advised to maintain the clearest possible separation between postings that they make and information they share socially, and what they share in any forum where they can be identified as a dental registrant. Ask DPL We have been helping members with an unprecedented number of patient complaints and responding to more calls than ever before to our telephone helpline, on an extraordinarily wide range of subjects. This tells us a lot about the degree of challenge and complexity that now exists in the professional environment here in the UK and demonstrates how DPL is recognised as a source of independent and authoritative advice. Our most recent member satisfaction survey (these happen on an ongoing basis throughout the year) revealed a record level of overall member satisfaction with our responsiveness, the quality of the advice given, and the empathy and understanding shown by the adviser who took the call this is all very gratifying given the huge volume of calls being taken and we are currently piloting yet further enhancements to our telephone helpline service. North of the border Depending upon where in the UK you live and work, you may or may not be aware that there are many important differences between Scotland and the rest of the UK in terms of the frequency (and size) of claims, complaints and other dento-legal challenges. The no-win, no-fee law firms have not operated in Scotland to anything like the same extent, for example. Reflecting this, the subscriptions charged to dentists in Scotland are quite a bit lower than in England. In the interests of fairness we have extended this difference proportionally to include hygienists, therapists and other members. There is a lot of useful information packed within this latest issue of Teamwise UK. Not least of all, we have extracted content from two papers that originally appeared in Dental Update and which provide insight into to the risks associated with aspects of dentistry that are frequently taken for granted; using local anaesthetic and adopting a preventive approach. I do hope that you will read and enjoy it all. Kind regards, Kevin J Lewis BDS LDSRCS FDSRCS(Eng) FFGDP(UK) Dental Director [email protected] 3 Dental Protection - Teamwise UK 14

4 4 Direct access - defining can do As from 1 May 2013 patients have had direct access to dental care professionals working within the limits of their training and scope of practice. This is the first of two articles on the subject in this issue of Trainingmatters UK When placed alongside the simultaneous expansion of the scope of practice for many DCP groups, the potential implications for the delivery of dental care, workforce planning and the balance of resources against demand in the UK are far-reaching, and the changes naturally raise questions about how the various DCP groups will be indemnified in future, given that they may not all be practising in the same way as in the past. Our view Dental Protection welcomed the emphasis that the GDC placed on patient safety and the need for all registrants to work within the limits of their knowledge, training and competence. For many DCPs these changes will have little or no effect upon the work they do every day and where and how they do it. For some, the opportunities that are brought about by direct access will be sufficiently attractive to encourage them to change the way they work. This could be by small incremental steps in some cases and for others it could involve a more dramatic step like branching out and opening their own practice. Dental Protection s experience in other countries leads us to believe that for the overwhelming majority of members, things will change very gradually, and in many respects less dramatically than many people have been predicting. Fairness is one of our fundamental principles when our dental subscriptions are being set. The rates we charge are based on the best available actuarial assessment of the case experience. Just as there are no cross-subsidies from one country to another, and dentists do not subsidise medical claims experience, dentists should not subsidise DCP groups, nor vice versa. Unless and until there is clear evidence that direct access has changed the relative risks to an extent which needs to be reflected in different relative subscriptions, Dental Protection does not intend to over-react. DPL did not exploit the situation when dental nurses and other DCP groups became registered and neither did we do so when hygienists and therapists first had their scope of practice expanded to include local anaesthesia. In both of the above cases we took the view that we were already collecting subscriptions which covered the totality of the risk, and there was no justification for collecting any more. Indeed for dental nurses who required indemnity to practise DPL arranged for their indemnity to be made available at no additional cost through practice schemes such as DPL Xtra. Differential subscriptions In subscription terms we already differentiate between DCPs who work independently, owning and operating their own dental practices, and those who do not. We also have existing arrangements in place to ensure that individual members who - whether dentists or DCPs - have a less favourable claims experience than their colleagues, are paying fairly for their own risk rather than being regularly subsidised by others. If necessary we will adjust our subscription categories and relative rates, once there is clear evidence that it is fair and appropriate to do so. We do not anticipate that this will be any time soon, because a lot will depend on the practical impact of these changes here in the UK and how individuals and a range of other parties (including members of the public) react to them. The true picture will take time to evolve. International experience Drawing from our first-hand experience of various forms of direct access in other countries, we recognise that while some risks will change for the better, there is a potential for other new risks to emerge and for the distribution of risk between dentists and the various DCP groups to change. We will therefore keep this currently fluid situation under close review and work with all members to ensure that they fully understand any new risks that they might be thinking of taking on, and how to manage them effectively. Six of the most frequently asked questions 1) What does direct access mean? It means that patients have been given the option to see a dental care professional (DCP) without having first seen a dentist and without a prescription from a dentist. Since 1 May 2013, dental hygienists and dental therapists have been able to see patients direct. This means that the requirement to carry out certain treatments under prescription from a dentist is removed. Dental nurses and orthodontic therapists can also to see patients direct in certain circumstances. Clinical dental technicians will continue to see patients direct only for the provision and maintenance of full dentures and dental technicians will continue to carry out most of their work to prescription, except repairs. Dentists remain the only members of the dental team who can carry out the full range of dental treatments and prescribe radiographs, local anaesthesia and a full range of prescription only medicines. Direct access - defining can do

5 2) What has the GDC said about patient s having direct access to DCPs and how will the general public be protected Registrants treating patients direct must only do so if appropriately trained, competent and indemnified. They should also ensure that there are adequate onward referral arrangements in place and they must make clear to the patient the extent of their scope of practice and not work beyond it. To ensure patient safety: All registrants must be trained, competent and indemnified for any tasks they undertake. All registrants must continue to work within their scope of practice regardless of these changes. All registrants must continue to follow the GDC s Standards for Dental Professionals*. Dental care professionals do not have to offer direct access and should not be made to offer it. Dental hygienists and dental therapists Dental hygienists and dental therapists can carry out their full scope of practice without prescription and without the patient having to see a dentist first. Dental hygienists and dental therapists must be confident that they have the skills and competences required to treat patients direct before doing so. A period of practice working to a dentist s prescription is a good way for registrants to assess this. Registrants who qualified since 2002 covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything. However, many of these registrants will have addressed this via top-up training, CPD and experience. Those who qualified before 2002, or those who have not applied their skills recently, must review their training and experience to ensure they are competent to undertake all the duties within their scope of practice. Orthodontic therapists Orthodontic therapists should continue to carry out the majority of their work under the prescription of a dentist. Orthodontic therapists can carry out an Index of Orthodontic Treatment Need (IOTN) screening without the patient having to see a dentist first. *The GDC are revising and expanding the current guidance. The new Standards for the Dental Team will be published later in 2013 Dental Protection - Teamwise UK 14 3) Can a hygienist ask the dentist to continue examining patients and prescribing their treatment? Yes. Direct access is available as an option, but in no sense is it compulsory. The staff of each workplace are free to make up their own minds, whether to implement direct access and if so, how and to what extent. Some of them may not want to do so at all. Dental Protection s experience of direct access in other countries is that most of the time, for most practices, very little changed. What it does do, is make life easier for practices that use hygienists and therapists, and remove some of the obstacles to patient access to certain forms of dental care. Whether or not the dentists you work with, will want to continue examining patients for the sole purpose of referring them to you for specified treatment, is a matter for mutual discussion and agreement. One of the major advantages for dentists is that they no longer need to do this, especially in circumstances where they could not receive any NHS remuneration for having done so. 4) Does direct access affect the use of local anaesthesia by hygienists and therapists? The administration of local anaesthetics is governed by the Medicines Act The GDC has no influence over this legislation and it is quite separate from the new direct access regulations. Local anaesthetic is a prescription only medicine (POM) and it may be administered by a dental hygienist or dental therapist either by using: 1) A patient-specific direction (in other words a written prescription for that particular patient) or 2) A patient group direction (PGD). A PGD allows the administration of named medicines in an identified clinical situation without the need for the referring dentist to provide an individual written prescription. The regulations state that the practice should be registered with the CQC (in England) or HIW in Wales and that the PGD is appropriately drawn up and signed by the relevant individuals. Because there are variations in the regional regulations associated with patient group directives, Dental Protection recommends that DCPs should familiarise themselves with the regulations that are applicable in their chosen region (s) of practice. There is currently no provision for PGDs in Scotland. Further information on PGDs is available from It is envisaged that in the near future most practices will have PGDs in place as a matter of routine which should simplify the use of local anaesthetics by DCPs in practice. The legislation requires that each PGD is approved and signed by: a doctor or dentist, as appropriate; a pharmacist; a representative of an appropriate organisation (this will depend on whether the work is provided privately or on an NHS contact. 5) Do DCPs need to inform DPL if they intend to start work without a dentist s prescription or extend the scope of practice? No. It is possible that we may need this information in the future, but we believe that it is premature to go through this exercise now, when members are still getting to grips with what direct access might mean and how the way they practise might change. However, all members are reminded that they must only carry out procedures for which they have been trained and in which they are competent. The extended scope of practise does not circumvent this fundamental requirement. The GDC s Scope of Practice document describes the additional skills that DCPs can acquire in order to extend the scope of their professional skills. 6) As a hygienist or therapist will I start paying more for professional indemnity? Not if you are working the same hours and your position has not changed in terms of whether or not you own and operate a practice of your own, employ staff and/or contract with third parties for the commissioning of services to be provided by others. Our dental subscription rates are reviewed annually, and members are notified of the new subscription level at the time of their renewal. No additional subscription increases are being made as a result of direct access. You can find many more frequently asked questions and answers about direct access on the DPL website. 5

6 6 Easing the pain Shaun Howe Clarifying cannot Although much has been written about direct access, the exact duties that dental hygienists and dental therapists can and cannot provide may seem a little confusing. Shaun Howe is one of DPL s local advisers as well as a dental hygienist. He explains things that are not currently permitted by the GDC s recent announcement Cannot Despite the fanfare accorded to the announcement about direct access (DA), it must be remembered that dental hygienists and dental therapists (DH&T) can still only work within their scope of practice. To stray out of scope may lead to an enquiry by the GDC should a concern ever be raised. With the sole exception of tooth whitening, the GDC has made it clear that a DH&T can now undertake the whole of their scope of practise, without the need for a prescription from a registered dentist. The GDC has also sought to clarify the other areas that are listed in the current scope of practice document 1. It is slightly ironic that for many years, some hygienists and therapists worked in the absence of any valid prescription, which effectively created direct access by proxy. With the publication of the new guidance, the status quo for many has been maintained so they can now operate as many had done for years but also relax in the knowledge that what they were doing is now entirely legal. Injectable local anaesthetics currently require a prescription from a registered dentist. That said, a DH&T may seek to put a Patient Group Direction (PGD) in place which may be used to facilitate the use of injectable local anaesthetics without the dentist providing an individual prescription for each patient and allows the DH&T to use their discretion when deciding which agent to use. It is interesting to note that the peripatetic dental hygienist and dental therapist will require a separate PGD for each place of work (unless they happen to be employed by a single provider). There are also regional variations England: All practices (NHS and private) may use PGDs for all groups of patients. Wales: All NHS practices and those private practices where individual dentists are registered with the Health Inspectorate Wales may use PGDs for all groups of patients. Northern Ireland: All NHS practices and those private practices registered with the Regulation and Quality Improvement Authority may use PGDs for all groups of patients. Scotland: All NHS practices. There is currently no provision for the use of PGDs in private practice in Scotland until practices are required to register with Health Improvement Scotland. Dilemma 1 Could a DH&T working under DA use injectable local anaesthetic in the absence of a prescription (or PGD) if it was deemed in the best interests of the patient? The short answer is no; it is unlikely that regardless of the situation that any defence could be used that would justify the use of a POM in the absence of a valid prescription as this is primary legislation 2 that dictates it. In the picture Currently, the Ionising Radiation (Medical Exposure) Regulations (IRMER) and other legislation recognises dentists as being the only member of the dental team trained as prescribers for the purposes of radiography; a hygienist or therapist, provided they are trained, is currently only recognised as an operator and as such, may not prescribe radiographs. This may present some real issues for those working independently of their dentist colleagues, because a full assessment of the patient, may require radiographs in order for this to be completed. The independent dental hygienist or therapist may need to strike up a working relationship with a local dentist that will allow the necessary radiograph(s) to be taken. It is worth noting that the GDC has expressed the opinion that the prescription of radiographs is a skill which may be developed by hygienists and therapists despite it currently being contradicted by IRMER. Until the regulations change to accommodate this particular GDC opinion, hygienist and therapist members are advised to follow the existing guidance within IRMER. 1 This guidance is under review and we await the publication of new Standards for the Dental Team when approved by the GDC 2 Medicines Act 1968 Clarifying cannot

7 Dilemma 2 Can a dental hygienist/dental therapist working in an independent practice refer patients to the local hospital for radiographs? On the face of it, this might seem like a solution for those working independently yet it is hard to imagine that any hospital (or other healthcare provider) would accept such a request because the DH&T is acting as a prescriber in this situation. The radiographer at the hospital (or other provider) is regarded as an operator rather than a prescriber in their own right. Whilst it may seem to be the same as asking a dentist colleague to prescribe and take radiographs, unfortunately, it is very different. A whiter smile? Tooth whitening is within the scope of the DH&T but, the Cosmetic Product (Safety) (Amendment) Regulations 2012 require that the first application of gel is carried out in the surgery and that when performed by DH&T, it must be directly supervised by a registered dentist. DPL and the BDA jointly sought counsel's opinion on the legal interpretation of direct supervision for tooth whitening. Counsel s view was that direct supervision by a dentist almost certainly requires the registered dentist to be on the premises. When it comes to tooth whitening, it means that a registered dentist must be on the premises during the first episode of treatment. The DH&T can go so far yet has to stop at the final hurdle. Can or cannot? For tooth whitening, can a hygienist or therapist: discuss whitening, the benefits, drawbacks, side effects, cost and expectations? Yes provide explanations, gaining valid consent? Yes take pre-treatment photographs and shade? Yes take impressions for the provision of trays? Yes try in trays ensuring a comfortable fit? Yes demonstrate the application of gel, explaining about spillages and excessive use? Yes provide the first episode of treatment (without a GDP on the premises)? No Prevention is better than cure The use of fluorides, whether as a varnish or paste, is well accepted for the prevention of caries, but they can also be used to treat sensitivity. This presents a real ethical dilemma for the DH&T as the most common of these medicines can be found in the British National Formulary (BNF) and are POMs designed for caries prophylaxis and may be prescribed or on a PGD (like local anaesthetic). However, there are other manufacturers of high concentration fluoride varnishes for use in patients with sensitive teeth, whose products do not currently appear in either the BNF or MIMMs. This does beg the question: Can a DH&T use these unlisted high concentration fluorides without a prescription or in the absence of a PGD? The answer must be no because they would have a similar potential risk to those products which have already licensed as prescription only. If a product is licensed as a POM it needs to be prescribed. If, on the other hand, a product is not licensed as a POM (Sensodyne toothpaste for example) it can be recommended. The fluoride content would be of such a low concentration that the risks would not require it to be listed as prescription only. There are other varnishes which do not contain fluoride at all (eg. Gluma) and therefore do not require a prescription. Want to look younger? The GDC has intimated that the DH&T may be able to use botulinum toxin and dermal fillers under certain circumstances. Whilst Dental Protection accepts that many hygienists and therapists are well placed to undertake such treatments, until the use of this agent is recognised by the GDC as an acceptable extension to the present scope, indemnity for such procedures is not available within the dental membership categories offered to any DCPs. If you are considering providing such treatments is strongly advised to speak to Dental Protection in the first instance. Hindsight is a wonderful thing The GDC have been quite explicit in suggesting that there is no experience requirement for those wishing to provide direct access or to practise independently; it does however make the suggestion that those who are newly qualified should consider a period of supervised practice so that they can be sure their skills are fully secured before embarking on a journey alone. It is incumbent on any registrant, regardless of experience, to ensure their skills and knowledge are up to date and appropriate to the treatment they want to provide to patients. If in doubt The introduction of direct access presents new challenges for the DH&T and also for those practices that are taking full advantage of direct access. There will need to be some changes in the legislation in all regions of the United Kingdom before the full potential is achieved. Meanwhile, you should ensure that you are compliant with current requirements, Don t be afraid to contact Dental Protection for definitive advice if you are in any doubt on any issue regarding direct access. 7 Dental Protection - Teamwise UK 14

8 8 Watch and wait Avoiding problems when keeping things under review There are many situations in clinical dentistry where it is much more sensible to keep a watching eye on things and wait to see how they develop, than to take a decision to intervene immediately in some way. This article highlights the dento-legal risks inherent in the more cautious approach, even when it would generally be regarded as the treatment approach of choice Whether one is keeping an eye on an unusual appearance of the oral mucosa, or monitoring the effect of some form of initial or provisional treatment, or waiting to see if symptoms settle down, or perhaps waiting for some antibiotics or other medication to take effect, the four keys to managing the potential risks of a watch and wait approach are: Communication - keeping the patient informed of what you are doing and why Record keeping - keeping good records at every stage of the review and monitoring process Defining responsibilities - ensuring that the patient understands not only what you expect of them during the review process (for example, the need for the patient to return at agreed intervals to allow the situation to be monitored, or to take prescribed medication, or to carry out some form of homecare) but also the possible consequences of any failure on their part to follow your recommendations Proactivity - not only in terms of staying in control of events, but avoiding any possible perception that you were simply sitting on your hands, doing nothing and allow yourself and the patient to be overtaken by events as a result. The care and reassurance trap The natural inclination of most clinicians is to do their best to reassure patients and to avoid alarming them unnecessarily. Occasionally this caring approach can come back to bite us when a patient argues that they had not realised the potential seriousness of a situation because the clinician had seemed so untroubled and relaxed when suggesting that the patient needed to return for a review appointment. The patient may assert that this absence of any sense of importance or urgency had led them to attach less significance to the review appointment, and resulted in their failure to attend. Not all review appointments have the same significance, of course - some of them being central to a treatment plan and the responsible management of a patient s condition, while others are more of a professional courtesy in terms of managing the patient and their concerns/peace of mind as opposed to managing the condition itself. For critical review appointments of the former type, the clinician s options include: Using a specially designed appointment card as a vehicle for communicating to the patient the importance of attending the appointment, and/or emphasising the risks or disadvantages of postponing it beyond the intended time interval. Sending a reminder to the patient 48 hours before the appointment (or on the day). This can be done by letter, phone, or text message with due regard for the need for information security/confidentiality and ideally after agreeing with the patient their preferred means of communication. Whatever means of communication is chosen, it is important to keep a record of the fact that the patient was sent this reminder of their review appointment. This important step is often overlooked, leaving the clinician with the less persuasive defence that this is what they would normally have done even though they cannot demonstrate that they did so on a particular occasion, for a particular patient. Here it will be evident that electronic methods of communication can help to create a more complete audit trail. Proactivity This can take many forms, but is best illustrated by the difference between arranging a future appointment for the specific purpose of reviewing something, on the one hand, or simply inviting the patient to contact you if they have any further problems. Both have their place in certain situations, but the less formal (second) approach may not be sufficient or appropriate if the focus of your review is some form of oral pathology and you are considering whether or not it is necessary to refer the patient for a specialist opinion, in case it is something significant or potentially serious. Watch and wait. Avoiding problems when keeping things under review

9 Investigations These need to be appropriate to the speed at which a patient s condition is likely to progress. At one extreme, a simple expedient such as taking a patient s temperature can be a very useful and responsive indicator in the case of monitoring the patient s response to an acute infection, while at the other extreme radiographs are relatively slow to reflect developing conditions such as periapical infection/inflammation. On the other hand, radiographs may be an excellent means of monitoring caries development or bone loss in periodontal disease or around implant fixtures - just as study casts may be an entirely sensible adjunct for monitoring tooth surface less from erosion, abrasion and attrition - because all of these conditions are progressing more slowly anyway. Situations can change with alarming speed in children, and with the elderly and the medically compromised, and these situations require particular vigilance and attentiveness. Records It becomes more difficult to argue that you are effectively monitoring a situation if you have no means of comparing the presenting situation from one occasion to another. For that reason it is important not just to manage the clinical situation appropriately, but to track your findings and the steps that you are taking, by means of appropriate records. This serves the dual purpose of helping you to monitor the situation, while also protecting yourself against possible dento-legal challenges. In many cases it is sufficient to describe the evolving clinical situation in plain text, together with details of what you and the patient have said and what you have decided to do and why. Unfortunately, many clinicians tend to omit many of the most important details, perhaps because they feel confident that they will remember why they are arranging to see the patient again, and what the presenting situation was at the previous visit. This may even be the case, but this does not help the process of convincing third parties that you had the situation under control, especially when this assessment arises some months or years later when things have gone badly wrong. Despite the convenience of digital photography and the widespread use of electronic records, it is perhaps surprising that digital photographic images are not used more widely to capture the visual appearance of clinical conditions and thereby facilitate the quality of the monitoring process. This is a lost opportunity where advances in technology can help to make clinical practice safer. There are many conditions where a visual record adds significantly to the quality and substance of the notes. Dental Protection - Teamwise UK 14 The second practitioner Every clinician will recognise the importance of knowing the full story and background before reaching a diagnosis. Most of us will have encountered a new patient, with a presenting condition and story that makes no sense to us at all, but in many cases it would all seem a lot more logical if we were in possession of a little more information and background. This can create some dilemmas and concerns that some find difficult to resolve: the previous treating dentist may be a colleague in the same practice, or even the previous owner of the practice. Or it may be someone you know nothing about. Any of these situations can create challenges. In such instances it can be helpful to talk things through with one of DPL s dento-legal advisers in the first instance. There is a fundamental difference, for example, between an isolated incident when one is mystified by treatment provided (or not provided) by a patient s previous dentist, and the scale of concerns that arise when a succession of patients previously under the care of the same dentist, present a picture of widespread under-treatment or an approach to patient care that would not be supported by a reasonable and responsible body of professional opinion. You may personally disagree with the approach taken by a previous dentist, but that is not the same thing at all. Taking a different scenario, we have all been faced with a clinical picture that is unclear, and we quite properly adopt a cautious step-wise approach rather than jumping in with both feet. But when a second dentist sees the patient 24 hours later, everything can look a lot clearer and the correct diagnosis is glaringly obvious. Reaching the wrong diagnosis (or no definitive diagnosis at all) for the right reasons, having carried out an appropriate assessment of the presenting condition, is entirely defensible if the records are sufficient to show that you took all reasonable and necessary steps and reached a conclusion which was entirely acceptable under the circumstances at the time. Delays The crucial question that arises from a dento-legal perspective is that of how long it is reasonable to watch and wait ; because the allegation that is waiting to ensnare us is that our failure to act upon a patient s condition in a timely fashion has resulted in a worse outcome for the patient. It is the combination of our failure to discharge our duty of care, and some kind of harm suffered by the patient as a result of this, that creates the exposure to a finding of clinical negligence. Sometimes the alleged breach of our duty of care is that we have failed to do something which might have given the patient a better outcome. At one extreme this may be a shortening of a period of pain, discomfort or other kind of suffering even by a day or two while in the case of a missed diagnosis of oral pathology the consequences for the patient can be much more devastating. In between, cases of untreated or under-treated periodontal disease will often result in an allegation that teeth that must now be extracted might have been saved if earlier and better treatment had been carried out. Some of these situations invite a consideration of whether or not it would have been more appropriate to have referred the patient to a specialist or more experienced colleague and if so, at what stage? Flowing from this, a second question will sometimes arise of what difference this is likely to have made (in some cases it can reasonably be argued that the outcome would have been materially the same). It may even be that you discussed a possible referral with the patient, and the patient declined. Here again, the quality of your clinical records can make all the difference to your ability to demonstrate your effective management of the patient s overall care. It is always a lot easier to make these judgements with the benefit of hindsight, of course, and a full and detailed clinical record of what the actual situation was at a particular moment in time, is invaluable when third parties such as courts and tribunals apply the evidential test of the balance of probabilities. When we leave a vacuum in which presumptions rather than facts can flourish, we leave ourselves more exposed to challenge. Situations can change with alarming speed in children, and with the elderly and the medically compromised, and these situations require particular vigilance and attentiveness 9

10 10 Edwina Kidd Caries control from cradle to grave The management of caries is a classic exercise in risk management. Patients do not all present the same risk: different tooth surfaces do not all present the same risk: many intrinsic and extrinsic factors affect the risk of caries arising and progressing. Because of this, the caries risk in the same individual patient may vary significantly over time. Clinicians make assessments of these risks all day, every day and make clinical decisions based upon them Although caries has been around for a long time, our understanding of the disease has evolved enormously in the last years and so has current thinking about the most appropriate way to manage caries in different situations The dento-legal issues have been evolving in parallel with these developments, some clinicians being criticised for failing to recognise the risk factors in a particular patient or for failing to diagnose carious lesions at a sufficiently early stage. Some have found themselves criticised for being too quick to intervene, others for not intervening sufficiently, or approriately, or quickly enough, or for failing to provide preventive advice. This is proving to be a dynamic field with the accepted treatment approaches and the risks continually changing This article has been extracted from an original paper by Edwina Kidd, BDS, FDS RCS(Eng), PhD, DSc, Emerita Professor of Cariology, King s College London, UK. A complete version of the text was published in Dental Update 2010; Volume 37: Readers are invited to consider the text in conjunction with the previous article (Watch and wait) on page 8. Caries control from cradle to grave Dental caries: the concept of a controllable process Dental caries is a ubiquitous, natural process that occurs in the biofilm. The formation and metabolism of the biofilm cannot be prevented, but disease progression can be controlled so that the symptom of the process, the caries lesion, never forms. The progression of established lesions can also be controlled so that they do not progress further. The important factors in caries control are: Plaque control; Use of fluoride; Dietary modification. Combinations of the above can prevent the formation of visible lesions and transform an active caries lesion into an arrested lesion. This control is just as much treatment of the caries process as placing a filling. Indeed, fillings are a part of plaque control. They make holes in teeth accessible for cleaning. How to assess current caries activity and caries risk status The most reliable evidence of caries activity and caries risk status is the presence of active caries lesions, cavitated and/or noncavitated. The history of recent caries activity, the number of new/filled lesions in the past 2 3 years, is also important. The following should be noted on clinical examination: How many lesions are present? Where are they? Multiple active lesions in areas of rapid salivary flow (lower incisors, buccal surfaces of molars) which would indicate high caries activity; Visible plaque and gingivitis indicating poor oral hygiene. What constitutes high caries activity? This is a relative judgement related to the caries activity of the population. As a rule of thumb, a yearly increment of two or more lesions would indicate a high rate of lesion activity and progression. Why is it important to assess caries activity? This information is relevant to the following: All patients should be advised to clean teeth twice daily with a fluoride-containing toothpaste, but some non-operative treatments for the individual patient (eg diet analysis and advice) should be focused on those with high caries activity. Dentists must identify which risk factors are relevant to the particular patient in order to ensure logical management. Dental treatment involves recall and reassessment. The caries activity and risk status is relevant to the recall interval. The patient needs to know his/her activity and risk status so that he/she can take appropriate action to reduce the rate of lesion progression and be aware of the appropriate recall interval. Identifying biological risk factors It is important to identify relevant risk factors because it may be possible to help the patient to modify these and thus slow down disease progression. Protective factors are also relevant because these can be introduced if not present. Many of these factors are best identified by taking a careful history from the patient, while others become obvious when the mouth is examined. Possible risk factors include: Medical history, particularly medications and systemic diseases causing dry mouth; Parents and/or siblings with active caries; Frequent sugar-containing snacks or drinks; Poor oral hygiene; Gingivitis (indicates poor oral hygiene); Erupting molars; Deep pits and fissures; Existing restorations and the need for them to be replaced; Low salivary flow. Of all these risk factors, the medical history may be particularly important because many systemic diseases and medications cause a dry mouth. Persistent dry mouth is likely to result in new and recurrent dental caries and it can be difficult to prevent this. All the patient s medications should be checked in a suitable formulary or pharmacopaeia. A dry mouth is noted in the formulary as a side-effect to the medication, where appropriate. Similarly, all illnesses should be checked in a suitable text where the dental relevance is explained 1. Relevant protective factors are: Good oral hygiene with assistance if required; Fluoridated water; Fluoridated toothpaste; Fluoride varnish applied by dental professional; Fissures sealed; Use of sugar-free chewing gum to stimulate saliva if salivary flow low. Social risk factors Social factors can have an overriding influence on health and disease and the lifestyle changes that a patient can or will make. However, the professional must be very careful not to jump to unwarranted conclusions. To give an example, dental caries is concentrated in socially deprived people, but not all socially deprived people will present with lesions.

11 Categorising caries activity and risk status 2 On the basis of the history and examination, the patient may be allocated to one of the following caries activity status and caries risk status: Caries inactive/caries controlled (green); no active lesions and no history of recurrent restorations. Caries active but all relevant risk factors can potentially be changed, such as plaque control, fluoride, diet (orange); presence of active lesions and a yearly increment of more than two new, or progressing or filled, lesions in the preceding 2 3 years. Caries control may be achieved by changing risk factors. Caries active but some risk factors cannot be changed (such as some dry mouths and some medications) or caries risk factors cannot be identified (red); this category will always be high risk although it may still be possible to control caries by maximal control of risk factors. The dentist may wish to colour code this risk status with green, orange and red stickers inserted in the notes. The aim is to help the patient change the risk factors. What caries control factors are available? We will now concentrate on the various non-operative treatments that control caries. Plaque control; Use of fluoride; Dietary modification; Saliva stimulation or replacement for those with a dry mouth. Plaque control Caries lesions form as a result of the metabolic events in dental plaque. Thus plaque control is the logical cornerstone of non-operative treatment. Teeth should be brushed with a fluoride-containing toothpaste. The brushing interferes with the growth and ecology of the biofilm and fluoride application retards lesion progression. The preventive action of toothbrushing can be maximized if the following principles are followed 3 : Brushing should start as soon as the first deciduous tooth erupts; Brush twice daily, last thing at night and at one other time each day; Children under 3 years should use a toothpaste containing no less than 1000 ppm fluoride; Children under 3 years are likely to swallow toothpaste and this may cause fluorosis. To prevent this they should use only a smear of paste and not be allowed to eat or lick toothpaste from the tube; From 3 years onwards, family fluoride toothpaste ( ppm fluoride) is indicated; Children between 3 and 6 years should use no more than a pea-sized amount of toothpaste in order to prevent fluorosis if paste is swallowed; Children need to be helped and supervised by an adult when brushing; The occlusal surface of erupting molars should be individually brushed with the brush coming in at right angles to the arch; Adults with multiple lesions and/or a dry mouth should be prescribed a high fluoride paste (2800 or 5000 ppm fluoride); Dependant adults should be helped with tooth cleaning; Rinsing with lots of water after brushing should be discouraged; spit, don t rinse, is the relevant advice. Oral hygiene instruction Instruction should be general to the whole mouth and site specific to the particular lesion. The following may be helpful with respect to toothbrushing: The patient should attend each appointment with their brush and toothpaste; The dental health professional should check the toothpaste for fluoride content; Disclose the mouth so that the plaque can be clearly seen by the patient; Can the patient (or parent/carer) remove the plaque or should the technique/brush be altered? Is thorough brushing in the surgery causing gingival bleeding. If so, does the patient realize this indicates gingivitis caused by dental plaque? If active lesions are present, is the patient aware where they are and able to remove disclosed plaque from them? Where active approximal lesions are present, either in the enamel or on the root surface, an interdental cleaning aid will be needed. In young patients, lesions are best cleaned with floss, whereas interdental brushes are preferred for cleaning larger interdental spaces following gingival recession. The following may be helpful with respect to interdental cleaning: Advice must be site-specific; Examining the tape or brush after use may show the plaque that has been removed and this can be a useful motivating factor; A special holder for the floss or brush may help the patient; If the gingivae bleed, the relevance of this should be explained to the patient. If bleeding persists for days after effective cleaning is instituted, this may indicate a cavity is present that prevents the patient removing the plaque from the hole. A restoration is needed to restore tooth integrity. Use of fluoride Fluoride works by delaying lesion progression. Vehicles for fluoride include: Water; Toothpaste; Mouthwash; Professionally applied high concentration varnishes. In caries active patients, it is essential to intensify the fluoride therapy until the situation is under control. This could be achieved by intensive use of fluoride toothpaste, fluoridecontaining mouthwashes or operator-applied topical applications. The choice of vehicle is not crucial, but it must be combined with improvement in oral hygiene. It is very important that the patient accepts the mode of treatment and complies with advice. Water fluoridation Be aware of the fluoride content of the water where your patients live. Toothpaste Fluoride toothpaste is cheap, requires minimal patient co-operation and enhances the patient s appreciation of his/her essential role in caries control. Fluoride mouthwashes These can be prescribed for patients aged 8 years and above, for daily or weekly use. Below 8 years, they are not advised because there is a risk of swallowing sufficient mouthwash to cause fluorosis in the developing dentition. The rinse should be in addition to twice-daily brushing with toothpaste containing at least 1350 ppm fluoride. Rinses require patient compliance. They should be used at a different time from toothbrushing to maximize the topical effect. Daily rinse 0.05% NaF; Weekly rinse 0.2% NaF. 11

12 12 Caries control from cradle to grave The indications for mouthwash are: Patients over 8 years with high caries activity; Patients with orthodontic appliances which inevitably encourage plaque accumulation and therefore predispose to caries lesions; Patients with a dry mouth; Patients developing root caries. In these patients a weekly concentration mouthwash may be advised for daily use. Professionally applied fluoride varnish The fluoride concentration of the varnish is high, 22,600 ppm F or 2.2%F. Systematic reviews of research have shown that fluoride varnish application by dental care professionals reduces the caries increment in the deciduous dentition by 33% and by 46% in the permanent dentition. These are impressive reductions in caries, but the dental professional should be aware that: Professional application must be repeated at 3 or 6 monthly intervals to be effective and this is inevitably costly; The emphasis switches to the care being by the professional rather than by the patient; The concentration of fluoride is high and this means the varnish is potentially toxic (the child could vomit) to the small, and therefore light, child if the varnish is swallowed. The maximum dose advised for use in the primary dentition is 0.25 ml and in the mixed dentition is 0.5. The varnish should be applied to isolated, clean, dry teeth. An ideal time to apply varnish is therefore when the teeth are being examined for caries lesions because, to detect caries lesions, the teeth must be isolated, clean and dry. Once the charting is complete, it takes only seconds to apply varnish to fissures, over contact points, cervical margins buccally and lingually and exposed root surfaces. Dietary modification The evidence that the frequency and amount of sugar consumption is linked to caries is irrefutable. Thus emphasis on diet in caries control would seem logical. Unfortunately, the evidence that it is possible to modify people s diets is lacking! Since the advent of fluoride, the emphasis in caries control has shifted from diet to oral hygiene with a fluoridecontaining toothpaste. Reducing the amount and frequency of sugary food intake can reduce dental caries and could help weight control. All health professionals have a responsibility to give advice on diet, in the same way that we have a responsibility to give advice on smoking. The consensus recommendations to prevent dental caries are: Reduce frequency and amount of sugars; keep sugars to mealtimes; Limit consumption of foods and drinks with added sugars to four times per day. Most sugars are in processed and manufactured foods and drinks such as: Sugar and chocolate confectionery; Cakes and biscuits; Buns, pastries, fruit pies; Sponge puddings and other puddings; Table sugar; Sugared breakfast cereals; Jams, preserves, honey; Ice cream; Fruit in syrup; Fresh fruit juices; Sugared soft drinks; Sugared, milk-based beverages; Sugar-containing alcoholic drinks; Dried fruits; Syrups and sweet sauces. Dietary advice for dental patients No change in diet should be advised for the caries inactive patient, but the dentist should make the patient aware of how an adverse change in diet and/or salivary flow could pose a problem, especially if oral hygiene is poor. All our patients should be aware of the link between sugar and caries. With the caries active patient a fuller investigation of the diet may be warranted. Advice is based on the diet sheet. Be aware that this technique is time-consuming and therefore expensive. When the diet sheet is returned, the sugar attacks should be highlighted. This gives the clinician the opportunity to explain the Stephan curve and the importance of decreasing the frequency of sugar intake. The following may be useful in giving advice: Try to get the patient to suggest changes as this helps the patient to select realistic goals and it allows the dental care professional to check whether the relationship between sugar intake and caries has been understood; A list of safe snacks and drinks will be useful to help the patient choose alternatives to sugar; Record the negotiated changes in the notes and on paper for the patient to take away and ponder on at leisure; Aim to confine sugar to mealtimes; Check main meals are adequate; Follow up with enquiries about progress at the next appointment. Salivary stimulation or replacement for those with a dry mouth Controlling caries when the mouth is dry is very difficult. The approach should be: Immaculate oral hygiene; Prescribe a high fluoride toothpaste (5,000 ppm F); Prescribe a fluoride mouthwash; Apply fluoride varnish to lesions every 3 months; Ask the patient to keep a diet sheet and try to minimize sugar intake; Be aware that the patient needs to moisten his/her mouth frequently and plain water is safe; Recall the patient every 3 months; Saliva may be stimulated by chewing a xylitol-containing chewing gum, provided there is sufficient glandular activity; In cases of Sjögren s syndrome or postradiotherapy to head and neck, a saliva substitute may be required; Check any anti-fungal agent does not contain sugar. The role of operative dentistry in caries control The role of operative dentistry in caries control is to facilitate plaque control. Tooth restoration also sends the caries process back to the tooth surface potentially to start again if the factors which determined the caries activity in the first place are not controlled. This dental game of Snakes and Ladders gives the patient time to establish new habits. Tooth restoration also restores: Appearance; Form; Function. It arrests the progression of the lesion towards the pulp and therefore prevents the onset of pulpitis with its attendant pain. 1 References Scully C, Cawson RA. Medical Problems in Dentistry 6th edn. Edinburgh: Churchill Livingstone, Kidd EAM, Nyvad B, Espelid I. Caries prevention for the individual patient. In: Dental Caries. Fejerskov O, Kidd EAM, eds. Munksgaard: Blackwell, 2008: pp Department of Health and the British Society for the Study of Community Dentistry. Delivering Better Oral Health. An Evidence-Based Toolkit for Prevention 2nd edn, Gateway Ref: 8504 Caries control from cradle to grave

13 John G Meechan Local anaesthesia: risks and controversies John G Meechan, BSc, BDS, PhD, FDS RCS(Edin), RCS RCPS(Glasg) is Senior Lecturer in Oral Surgery at Newcastle University. He has worked in general practice in Scotland and Wales, held hospital positions in Glasgow and Newcastle, and University positions in Vancouver and Newcastle. He chairs the dental injection systems working group of the International Standards Organisation. John is the recipient of a Distinguished Scientist Award from the International Association for Dental Research and holds a King James IV Professorship from the Royal College of Surgeons of Edinburgh 13 It is said that familiarity breeds contempt, and such is the central position of local anaesthesia in the life and routine of the dental clinician, that it is easy to lose sight of the fact that one is using one or more drugs as part of a range of procedures that have the potential to cause avoidable harm to patients Cases of nerve damage arising from the administration of local anaesthesia are not common, but they do arise with sufficient (and increasing) regularity, so that a few words of risk management advice to our members may be helpful. Less commonly, other complications arise from the use of local anaesthetics and until you encounter them at first hand, they may seem to be somewhat remote and theoretical risks. As rare as some of these complications may be, they have still resulted in some serious and costly cases so an awareness of how to keep these risks to a minimum has a value of its own in any event John Meechan was one of the invited speakers at the Premier Symposium (2007) in London, and he delivered an oustanding presentation based heavily upon the attached paper which had been published in Dental Update magazine. We are most grateful to George Warman Publications Ltd, the publishers of Dental Update, for their permission to reproduce this article Local anaesthetics are the most commonly administered drugs in dental practice. They have an amazing safety record. Most side-effects are minor and reversible. 1 Nevertheless, some serious unwanted outcomes may ensue after the intra-oral injection of a local anaesthetic. This paper describes such effects and suggests strategies to minimise these events. Unwanted effects Unwanted effects may occur as the result of the following: Injecting an inappropriate solution Injecting too much solution Injecting into the wrong site Bad luck. Each of these will be considered. The most serious adverse effects are central nervous system problems as a result of overdose or intra-arterial injection and long-standing nerve problems after regional block anaesthesia. Table1 Recommended doses for the solutions used in dental practice in the United Kingdom Injecting an inappropriate solution The only absolute contra-indication to the use of a local anaesthetic in an individual is allergy to that solution. Allergic reactions to amide local anaesthetics are very rare indeed. 2 All of the injectable local anaesthetics used in the United Kingdom are amides. Allergy to esters is more common. The only ester local anaesthetics commonly used are the topical agents benzocaine and amethocaine. The other agent that may cause an allergic reaction during injection of a dental local anaesthetic is latex, which is used in the manufacture of some cartridges. Fortunately, latex-free cartridges, such as Septanest (articaine with adrenaline, Septodont, Kent, UK) and more recently manufactured Citanest (prilocaine with octapressin, Dentsply, Surrey, UK) are available. If a dentist is unsure as to the status of a cartridge, the manufacturer should be contacted as some older cartridges may not be latex-free. If a patient gives a history suspicious of an allergic reaction, such as the development of a rash or breathing difficulties, they should be referred for allergy testing to determine if an allergy exists and also to establish a suitable alternative drug. Some patients seem to have a genuine supersensitive reaction to adrenalinecontaining local anaesthetics and experience tachycardias after injection. If a patient reports this, it is wise to avoid the use of an adrenaline-containing solution. Local Maximum dose Amount (mg) Amount (mg) Amount (mg) anaesthetic (mg/kg) in 1/10 in 1/10 in 1/10 1.8ml cartridge 2.0ml cartridge 2.2ml cartridge 2% lidocaine % mepivacaine % mepivacaine % prilocaine % prilocaine % articaine Values in bold show where 1/10th of a cartridge is greater than the recommended maximum dose per kilo. The ceiling doses approximate to those for a 70kg subject Dental Protection - Teamwise UK 14

14 14 Local anaesthesia: risks and controversies Injecting too much solution Overdose of local anaesthetics leading to toxicity is possible. This is particularly the case in children as the toxic dose is weight related. Table 1 gives recommended maximum doses for the solutions used in dental practice in the United Kingdom and also shows how much is in 1/10th of a cartridge of each solution. A guideline of 1/10th of a cartridge per kilogram is a useful rule of thumb as a maximum dose. The organ that usually suffers during a local anaesthetic overdose is the brain. Central nervous system tissue is more susceptible to the actions of local anaesthetics than peripheral sensory nerves. The early signs of toxicity are excitability as the inhibitory actions of the brain are the first to be depressed. This is followed by signs of central nervous depression that can lead to unconsciousness. If very large doses are administered, death can ensue because of respiratory depression. It must be remembered that the effects of different local anaesthetics are cumulative. It is therefore not possible to change to another local anaesthetic after the maximum dose of one has been given. So, the 1/10th of a cartridge per kilo guideline is useful to determine the safe maximum dose when different solutions are combined. Injecting in an inappropriate site There are three sites of injection that can cause problems. These are: Intra-arterial Intravenous Intraneural. Intra-arterial injection Injection of local anaesthetic solution into an artery is not as common as deposition intravenously. Contact with an artery may produce discomfort as the artery may go into spasm and a localised area of blanching may be noted. The main problems with intraarterial injection are delivery of local anaesthetic solution directly into the central nervous system or interfering with special senses. Sight can be affected. Double vision may occur if the orbital muscles are affected and permanent loss of sight has been reported. 3 This latter effect may occur as a result of occlusion of the retinal artery or introduction of emboli into the ophthalmic artery. Hearing loss following local anaesthesia may occur either as a result of CNS toxicity or ischaemia of the cochlea following intravascular injection. 4 The most dramatic effect on the central nervous system is hemiparesis of the body. This may be the result of reverse carotid flow of solution. 5 In this scenario, local anaesthetic is injected into a branch of the external carotid artery and, if excess force is employed, solution travels against arterial flow to reach the carotid bifurcation where some is then redirected to the brain via the internal carotid artery. This is illustrated in Figure 1. Figure 1 The mechanism of reverse carotid flow. Injection under strong pressure into a branch of the external carotid artery can cause some local anaesthetic solution to flow to the carotid bifurcation, where a portion can be redirected to the brain via the internal carotid artery Intravenous injection Injection of solution into a vein is a real possibility during the administration of intraoral local anaesthesia. An indication as to the likelihood can be gauged by examining studies that have investigated the number of positive aspirates during intra-oral local anaesthesia. In some studies, positive aspirates have been obtained in over 20% of inferior alveolar nerve blocks. 6-8 The danger of intravenous injection is the production of systemic effects caused by the local anaesthetic or vasoconstrictor, such as adrenaline. These include CNS toxicity and effects on the heart, such as tachycardias and arrhythmias. Intraneural injection Injection into a nerve trunk can cause damage, both as the result of needle trauma, and by physical and perhaps chemical damage resulting from the dispersal of solution into the nerve bundle. This can lead to: Long-term anaesthesia (lack of sensation); Paraesthesia (altered sensation such as pins and needles ); Dysaesthesia (pain). Unfortunately, dysaesthesia is more likely following local anaesthesia than surgery. 9 Brain Syringe Common carotid Local anaesthesia: risks and controversies

15 Bad luck As well as the problems produced by intravascular injection mentioned above, it is possible to penetrate both sides of a blood vessel, especially during deep injections such as inferior alveolar nerve blocks. This may cause bleeding. If this affects a muscle such as the medial pterygoid, then post injection trismus may ensue. There is nothing that can be done to prevent such a complication when regional blocks are administered. It is possible to contact a nerve either in the approach or withdrawal from the site of anaesthetic deposition. The patient may often react when this happens and, if this is noted, then solution should not be deposited at that site. Nevertheless, the fact that nerves can be traumatised by the needle means that such a possibility can occur even when technique and equipment are excellent and, like the penetration of blood vessels mentioned above, this is probably an unavoidable consequence of regional block techniques. It has been estimated that every dentist will have one patient who suffers permanent damage to a nerve following an inferior alveolar nerve block and that there is no means of prevention. 10 Strategies to reduce complications Reducing toxicity The suggestion of using the guideline of 1/10th cartridge per kilo as a rough guide to the maximum dose was mentioned earlier. As shown in Table 1, this is not an absolute rule but it is a helpful approximation, especially when using combinations of different local anaesthetics in the same patient. Reducing systemic effects A good medical history, including a comprehensive drug history, must be taken to avoid systemic effects such as an allergic reaction, drug interaction, or unwanted effect of adrenaline. The best way to avoid injecting into a blood vessel is to use an aspirating syringe system. The use of non-aspirating syringes cannot be supported. Reducing CNS effects In order to avoid injecting into an artery that supplies the CNS, an aspirating syringe system should be used. Aspirating systems are not infallible and can fail in a number of ways. These include equipment defects. However, even with properly functioning equipment, it is possible that aspiration may not be successful. A possible scenario is illustrated in Figure 2, which demonstrates blockage of the needle by the vessel wall preventing aspiration. As this is a possibility, a slow injection technique should be employed as this will prevent retrograde flow of solution. Dental Protection - Teamwise UK 14 Reducing nerve injury The best way to prevent nerve injury is to avoid regional block injections. If a regional block, such as an inferior dental nerve block injection, is given then note must be made of any electric shock type sensation the patient may feel. If this occurs, no solution should be injected at that point but the needle should be moved a few millimetres away before injecting. 11 It is perhaps surprising to note that intraneural injection does not always produce pain and does not always cause nerve injury. 12 Around 8% of inferior alveolar nerve blocks produce an electric shock type sensation and it has been suggested that 15% of this group experience long-lasting altered sensation of varied duration.13 It has been noted, however, that 57% of patients suffering from prolonged altered sensation did not experience electric shock at the time of injection. 10 It has been suggested that any problem caused by needle trauma should recover within two weeks of injection in around 80% of patients. 14 Another point worth noting is that slow injection is helpful in reducing damage to the nerve. It has been demonstrated that nerve damage is more common when local anaesthetics are injected under pressure. 15 Similarly, it has been suggested that, if pressure is required to inject, then this could be a sign of intraneural injection. 16 If such an increase in pressure is felt during injection, it is wise to reposition the needle. Figure 2 a) Aspiration occurs when the tip of the needle is in a blood vessel b) Aspiration may fail if the needle is blocked by the wall of the blood vessel a There are a number of other advantages to injecting slowly. There is less discomfort to the patient during infiltration and regional block injections. 17,18 In addition, slow injection has been shown to increase the efficacy of inferior alveolar nerve blocks. 18 Furthermore, it is reasonable to suppose that slow injection will reduce systemic effects as adverse effects may be noted before large doses are administered. It is also probable, as mentioned above, that slow injection should minimise the possibility of reverse carotid flow. Thus there is little to argue against slow injection. A rate of 30 seconds per ml of solution is recommended. Whether or not the choice of solution, particularly with respect to anaesthetic concentration, affects the chances of nerve damage is an area of controversy. The concentration of the local anaesthetic is certainly related to the survival of nerves in vitro; the higher the concentration the lower the cell survival. 19 There are reports that nerve damage is more common after the 20, 21 use of 4% compared to 2% solutions, however, some dispute the scientific design of those studies. 22 Malamed, 23 quoting the European Pharmacovigilance Committee, states that there is no contra-indication to the use of the more concentrated solutions for regional block anaesthesia. Blood vessel Needle Syringe b 15

16 Local anaesthesia: risks and controversies The nerve that is usually damaged during inferior alveolar nerve block injections is the lingual nerve. This accounts for 70% of the damage. 10 One suggestion is that this is more likely the result of trauma, and that over-reporting of such injuries happens when a new drug formulation, such as 4% articaine, is introduced. There is another explanation why the lingual nerve is more likely to suffer damage. This relates to its structure. At the region of the lingula the lingual nerve is composed of very few fascicles and, in some individuals, it is unifascicular at this point. 9 This is unlike the inferior alveolar nerve, which is multifascicular in this region. This structural difference may explain why the lingual nerve is more susceptible than the inferior alveolar nerve to injection damage. An important question is: should the more concentrated local anaesthetic solutions, such as 4% articaine, be used for inferior alveolar nerve blocks? The incidence of iatrogenic nerve damage after inferior alveolar nerve blocks is about 1:500,000, so the risk is low. If there are advantages to the use of the more concentrated solutions for inferior alveolar nerve blocks, then the benefit probably outweighs any risk of nerve damage. Although 4% articaine has been shown to be more effective than 2% lidocaine in mandibular infiltration anaesthesia, 24, 25 there is no published evidence that the former is more effective during inferior alveolar nerve block injections. Until such benefit is proven, there appears to be no advantage in using the more concentrated solutions for such a technique. As mentioned above, it is the painful dysaesthesia that can result from injection damage. Another unfortunate aspect is that damage resulting from injection is less amenable to surgical repair than surgical damage. The only way to ensure that nerve damage is not produced is to avoid regional block injections. There are many other techniques, such as intraligamentary and intra-osseous injection, that can be used as alternatives. These, however, have their complications, such as damage to the periodontium. There has been resurgence in interest in infiltration anaesthesia in the mandible as a consequence of the introduction of 4% articaine. A couple of recent studies 26, 27 have suggested that infiltration of 4% articaine in the mandibular molar region can obtain anaesthesia of the lower first molar that is as effective as an inferior dental block. Thus it is ironic that 4% articaine, the drug that has caused such controversy concerning nerve damage, may be helpful in preventing this complication. Conclusion In conclusion, the best way to avoid problems is to take (and take heed of) a good medical history, use an aspirating syringe, limit the use of regional block anaesthesia and inject the appropriate solution slowly. Dental Update publishes 60 clinical peer-reviewed papers per year - written by clinicians for clinicians. 10% discount for dental members on every full subscription to Dental Update. This offers you 10 issues of the journal in print or by APP download plus full access an online archive of all papers dating back to Visit to apply online. Quote your membership number to obtain discount. References 1 Daublander M, Muller R, Lipp MDW. The incidence of complications associated with local anesthesia in dentistry. Anesth Prog 1997; 44: Finucane BT. Allergies to local anesthetics the real truth. Can J Anesth 2003; 50: Rishira B, Epstein JB, Fine D, Nabi S, Wade NK. Permanent vision loss in one eye following administration of local anesthesia for a dental extraction. Int J Oral Maxillofac Surg 2005; 34: Tan TS, Shoeb M, Winter S, Frampton MC. 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