'I am a practice principal, and the dental hygienist who works for us has recently asked me to write prescriptions for botulinum toxin. She intends to provide this treatment to some of our patients and to patients at another practice where she works part-time. I have no training in the use of botulinum toxin, but our hygienist has been on a course.

She has also asked me about prescribing local anaesthetics and antibiotics for patients she is seeing under Direct Access at our and the other practice. This would all be without my seeing the patients at all. What are my responsibilities and am I liable if something goes wrong?'

Prescribing

Botulinum toxin, local anaesthetics and antibiotics are all prescription only medicines (POMs) and a registered dentist is the only member of the dental team with prescribing rights. The GDC's guidance on prescribing, which includes guidance on remote prescribing, states you must only prescribe medicines to meet the identified dental needs of your patients. It also states you should only use remote means to prescribe medicines for dental patients if there is no other viable option and it is in their best interests.

Accordingly, the prescriber should not only assess the individual patient, but also be trained in the use of the particular POM in order to assess the patient's suitability for the treatment. In the example scenario given above, both practitioners might be at risk of justifiable criticism if the hygienist were to administer botulinum toxin prescribed remotely by the principal, or prescribed directly by the principal without up-to-date training and experience to assess whether the patient is suitable for the treatment, particularly if that resulted in the patient suffering some avoidable harm.

Indemnity and advertising

If you intend to provide botulinum toxin for your patients you need to be indemnified for it - DDU members can contact us here for more information. Indemnity for a limited amount of facial cosmetic work is normally available without any additional subscription, subject to appropriate training.

Whilst the GDC permits registered dental hygienists and dental therapists to administer botulinum toxin and injectable cosmetic medicinal compounds, the DDU does not offer indemnity for this work to its dental hygienist and therapist members, who must therefore source their indemnity elsewhere for these particular procedures.

If the practice principal in our scenario intended to allow the hygienist to provide botulinum toxin treatment in the practice, they should check that the hygienist has adequate and appropriate indemnity for the work, and make regular checks thereafter to ensure that this indemnity is maintained. Regular checks on indemnity and registration of DCPs and dentists working in your practice are prudent in any event.

The Medicines (Advertising) Regulations 1994 mean it's illegal to advertise or promote a POM to the public, and as such you cannot use the word 'Botox' (a registered trademark) or the words 'botulinum toxin' in an advert or on a practice website or information leaflet. You may though refer to 'facial cosmetic treatment' or 'anti-wrinkle treatment', or similar.

Examinations and assessment

The FGDP's Antimicrobial Prescribing in Dentistry makes clear that patients should routinely be examined clinically by the prescriber before being prescribed antibiotics, or any other POM. Save for Patient Group Directions, which cannot be used for antibiotics, a dental hygienist can only administer or dispense a POM to a patient with a valid prescription from a dentist.

Without an examination, a dentist cannot adequately determine the patient's clinical condition and decide whether antibiotics are appropriate, and, if so, which antibiotic should be prescribed, in what dose and for what duration.

The GDC's Scope of Practice for dental hygienists does not include the assessment of patients with acute infections for the remote prescription of antibiotics by a dentist. A dental hygienist seeing a patient with an acute infection has an obligation to refer the patient to a dentist promptly, whether the patient is being treated on referral from a dentist or under Direct Access. The GDC's guidance on Direct Access requires the hygienist to have a clearly established path of referral to a dentist for patients needing to be seen by a dentist.

With regard to local anaesthetics, the GDC's Scope of Practice permits a dental hygienist to administer infiltration and inferior dental block analgesia, but because local anaesthetics are POMs and dental hygienists do not have prescribing rights, they need either a valid Patient Group Direction or a patient specific direction from a dentist who has examined the patient.

A patient specific direction requires a dentist to record - usually in the patient's clinical records - the local anaesthetic to be administered, the treatment for which it is to be used, the dose or maximum dose, and the route(s) to be used (ie, infiltration and/or inferior dental block).

Referring again to the example scenario, both the practice principal and the dental hygienist involved would be vulnerable to criticism were it to come to the attention of the GDC or the NHS authorities that the practice principal was routinely prescribing remotely for patients being treated by the dental hygienist. The same applies if a patient were to make a claim for negligence alleging they had suffered avoidable harm as a result of inappropriate prescribing, or a dispensing error by the hygienist. There are strict requirements on the dispensing of antibiotics from practice stocks.

GDC registrants have a professional and common law duty to act in patients' best interests and to comply with GDC guidance and current accepted practice as would be supported by a responsible body of dental opinion (such as the FGDP guidance). So too does the dental hygienist involved in our example.

In this type of situation, the DDU would strongly advise not participating in the proposed arrangements, save in exceptional circumstances where there is no alternative and it is in the individual patient's best interest.