The state of our children's teeth came under the spotlight in 2015. Amid concerns about diet and education, experts agreed that regular visits to the dentist from an early age are an important factor in preventing childhood tooth decay.
Visiting the dentist can be an anxious time for children and their parents, but for dental professionals it represents a great opportunity. By making the experience positive and unthreatening, it's possible to encourage regular attendance and identify oral health problems early.
Good communication is the foundation of any good relationship with patients. But it is also in the interests of dental professionals to understand their ethical obligations when treating young people. Understanding the dento-legal issues which could arise should help ensure they don't later become a cause for mistrust and conflict.
Capacity and consent
At what age can children give valid consent?
Children in England, Wales, Scotland and Northern Ireland are deemed legally capable of giving consent for dental treatment at 16.
Children under 16 can also give valid consent, depending on their maturity and the nature of the decision. To meet the criteria for Gillick competence a patient must understand the nature of the proposed treatment, its consequences and the alternatives, be able to retain that information, use it to make a decision and communicate that decision.
For young children and those who are not judged competent, you need to get authority for treatment you believe is in the patient's best interest.
Who can give authority for treatment on a child's behalf?
In the first instance, seek consent from someone with legal parental responsibility. This will usually be the child's birth mother, or father provided they were married to the mother at the time of birth of the child. Divorce or marital separation doesn't affect parental responsibility.
Unmarried fathers have automatic parental responsibility if their name is on the birth certificate of a child born after 15 April 2002 (Northern Ireland), 1 December 2003 (England and Wales) or 4 May 2006 (Scotland).
Parental responsibility can also be held by adoptive parents, those appointed as a legal guardians, those given a residence order or the local authority if the child is subject to a care order. It can also be acquired or removed by a court order.
What if a child is accompanied by a grandparent or child minder?
If you're unable to contact an adult with legal parental responsibility, your overriding consideration should be the best interests of the child. Take into account the nature and possible risks of the proposed treatment, the consequences to the child if untreated and the urgency. If a child is in pain and temporary solution isn't possible, don't delay emergency treatment that is in their best interests. Whatever your decision, note the details of any discussion in the patient's clinical records.
Should we treat a struggling child?
In theory, necessary treatment can be provided with parental authority. Even a competent young patient doesn't have an absolute right to refuse treatment if it's in their best interest.
But from a practical and ethical standpoint, it's almost never a good idea to impose treatment or restrain a patient because of the repercussions for the patient's trust and wellbeing, as well as damaging their trust in the dental profession. If the patient can't be persuaded to cooperate and you believe the treatment is needed to safeguard their health, consider a referral to a specialist paediatric dentist who would be better placed to manage the situation.
If a teenage patient fails to comply with treatment, can we inform their parents?
As young patients get older, their trust often relies upon you respecting their autonomy and right to privacy. In most cases, a patient mature enough to attend on their own and consent to treatment should also be independent enough to manage their own dental health.
If you're concerned a patient's behaviour is compromising their health or jeopardising the chances of a positive treatment outcome, discuss this directly with them. Take the opportunity to ask for their permission to involve their parents, especially if they're being asked to foot the bill. However, it would be difficult to justify disclosing information about treatment without consent, and doing so could prove counterproductive.
How can I advise parents about their children's sugar intake without causing offence?
Some parents may still not be aware of the impact of snacking and fruit drinks on their children's teeth. Sensitive questioning about diet and lifestyle can help you draw up an appropriate treatment plan and provide relevant advice.
However, there is risk that parents will be deterred from bringing their child to see a dental professional if they feel your questioning is intrusive, critical or persistent, so good communication skills are essential. Explain the relevance of your questions and pay attention to your tone and body language to help parents feel at ease.
If a parent appears defensive it may be better to wait for another opportunity - you could provide specific dietary advice as part of treatment aftercare when the parent may be more receptive. If you have concerns about the child's welfare, consider involving other professionals through the Care Assessment Framework.
Confidentiality and records
An estranged husband wants access to their child's records. Should we comply?
Much depends on the child's age and whether the father has legal parental responsibility.
If the patient is over 16 or capable of understanding the significance of disclosure of their records, you should respect their confidentiality and only disclose records with their consent.
If the child lacks capacity to make the decision and you believe it's in their best interests, you can allow someone with legal parental responsibility to access a child's records. If you're in doubt about the father's status, you could ask to see a copy of the child's birth certificate and/or the parents' marriage certificate, or a letter from the person's solicitor confirming their parental responsibility.
There's no obligation to seek consent from the other parent but it may be wise to make sure they're aware of the request and that you take into account any objection they may make.
If I'm worried about a young patient's health, can I tell their parents?
You could be justified in disclosing concerns about the patient's welfare or safety, but again, you should usually discuss this with the patient first. If they refuse permission and you think the disclosure is in their best interest, you can share information with their parents or another professional without consent. You would usually be expected to tell the patient of your intention (unless this is not practicable) and should record your decision-making.
Can we confirm a patient's attendance with their school?
You should not give out information without the permission of the patient (if they have capacity) or someone with parental authority. It's generally up to schools to confirm that a child has booked or attended a dental appointment with someone who has legal parental responsibility for the child rather than getting the information from the practice.
How long should we retain a child's records?
As an absolute minimum, NHS and private clinical records for children should be kept for 11 years after the last entry, or until they reach the age of 25, whichever is longer.
If you are sued, records could be critical to your defence. It's not unknown for a claim to be received many years after the original treatment. If a patient was a child at the time of treatment - that is, they were under 18 - they have until they are 21 to make a claim, as long as they're aware before that date that a cause of action exists. If they are justifiably unaware of a cause of action, a claim could be made later.
A rotten state of affairs?
The image of British teeth has been largely restored in recent years but children's oral health remains a significant cause for disquiet among dental experts and health campaigners. In 2015, their concerns received widespread media attention following two new reports highlighting significant disparities in the incidence of dental decay.
In January, the Royal College of Surgeons (RCS) Faculty of Dental Surgery published The State of Children's Oral Health in England which included the revelation that tooth decay was the most common single reason for children aged five to be admitted to hospital, some for multiple extractions under anaesthetic. The RCS made a series of recommendations to address the problem, calling on the government to introduce a national oral health programme, explore ways to reduce sugar consumption and ensure timely access to specialist paediatric dental services for children with advanced decay.
In March 2015, the latest Children's Dental Health Survey was released by the Health and Social Care Information Centre (HSCIC), assessing the prevalence of oral health problems in England, Wales and Northern Ireland in 2013. Published every 10 years, the latest survey found that 46% of 15-year-olds and 34% of 12-year olds had experience of tooth decay, although this was an improvement on 2003 when the figures were 56% and 43% respectively. Children from lower income families were far more likely to have oral disease: 26% of 15-year olds eligible for free school meals had severe or extensive decay, compared with 12% of 15-year olds who were not eligible for free school meals.
These insights matter because they help raise awareness of the environmental factors contributing to poor oral health in younger patients, encouraging the ‘holistic and preventative approach to patient care' now expected of dental professionals by the GDC.
They also emphasise the positive role that dental professionals already play in improving children's oral health. Encouragingly, the Children's Dental Health Survey reported that 81% of 12-year olds and 82% of 15-year olds said they had attended the dentist for a check-up. This is supported by the HSCIC's latest dental statistics for England which showed that eight million children were seen by an NHS dentist in the 24 month period to 30 June 2015. Young patients were also more likely to receive Band 1 course of treatment.