The GDC's Standards for the dental team sets out the core ethical principles of dental practice which dental registrants are required to uphold when providing dental care. This guidance document sets out patients' expectations in relation to their dental care, the standards to which dental registrants must or should adhere to ensure these expectations are met, and guidance to help registrants meet the standards.

It is recognised that there can often be legitimate differences in clinical opinion and approach to treatment between dental professionals. However, it is sometimes difficult for a dental registrant to reconcile this with their ethical principles when discussing care that has been recommended by a colleague and which the registrant considers is not in a patient's best interest. This issue was the subject of the scenario below.

The scene

A member contacted the DDU advice line about a patient who was intent on undergoing extensive cosmetic treatment (the provision of multiple crowns) outside the UK, in order to improve the appearance and alignment of his teeth.

The patient had obtained a treatment plan and quotes from both a UK and an overseas provider for their intended treatment. He had then attended the member to discuss this and to enquire to what extent, if any, this treatment could be provided under NHS regulations.

After a discussion and clinical assessment of the patient, the member reviewed the patient's recent radiographs, which had been taken in preparation for the intended treatment. The patient was to attend for a further discussion following the radiograph review.

The member thought that the proposed treatment was not in the patient's best interests and may be detrimental to his oral health, having the potential to give rise to harm and long-term ongoing treatment needs. The member was concerned about how to communicate his views and concerns to the patient and what future obligation he might have to meet the possible remedial treatment needs of the patient.

GDC Standards

Principle One reminds us that patients 'expect to be listened to and have their preferences and concerns taken into account.'

Standard 1.1.1 states:

• You must discuss treatment options with patients and listen carefully to what they say. Give them the opportunity to have a discussion and to ask questions.

Standard 1.4.2 states:

• You must provide patients with treatment that is in their best interests, providing appropriate oral health advice and following clinical guidelines relevant to their situation. You may need to balance their oral health needs with their desired outcomes.
• If their desired outcome is not achievable or is not in the best interests of their oral health, you must explain the risks, benefits and likely outcomes to help them to make a decision.

Standard 2.2 states:

• You must recognise and promote patient's rights to and responsibilities for making decisions about their health priorities and care.

During his initial discussion with the patient, the member had listened to the patient's views and intentions regarding the appearance of his teeth.

The member's clinical examination and radiographic review had concluded that the extensive treatment may provide the cosmetic benefit the patient sought. However, he considered that the need for multiple extensive tooth preparation would pose an unacceptable risk to the patient's oral health in terms of possible pulpal pathology and potential need for root canal treatment or extractions.

DDU advice

The dento-legal adviser reassured the member that he was perfectly entitled to decline to offer treatment that he considered not to be in the patient's best interests, and that it was appropriate for him to explain this to the patient in understandable lay terms.

Dentistry is best provided in an atmosphere of mutual trust and confidence. If, following the member's clear advice, the patient was intent on pursuing significant invasive treatment entirely opposed to that advice, then arguably in this particular case the professional relationship between the dentist and the patient may have been undermined to a degree which could prevent the member providing further care. It would not therefore be unreasonable to forewarn the patient of this.

The member was advised to make comprehensive records of his discussion with the patient, including the potential risks to the patient's oral health and the ongoing professional relationship.

Key points

• Patients' autonomy means they are free to reject the advice or treatment you offer, but not that you are obliged to offer inappropriate treatment if a patient demands it.
• Don't provide treatment you consider to be contrary to a patient's best interests.
• Carefully explain your advice in lay terms, and offer a second opinion where appropriate.
• Carefully document all advice and discussions.