The coronavirus outbreak has been an anxious and challenging time in dental practice. Health concerns, financial pressures and the need to adapt to wholesale changes in working arrangements have caused real anguish, but dental professionals have always sought to act in the best interests of patients.

If you need evidence of this, consider the reasons that dental members sought advice from the DDU. During the height of the pandemic, we saw a 130% increase in dental professionals visiting our website for guidance on matters such as remote consultations and telephone triage.

We also opened more than 500 case files between the start of lockdown in March and the end of the year. Nearly all were members seeking advice with an aspect of patient care so they could pre-empt problems, rather than requesting help with patient complaints.

The DDU has reviewed these files and found that:

• 92% of files concerned general dental practice - the remainder were private dental specialties, community and hospital dentistry
• the types of dental professional to feature most commonly were dentists (72%), dental therapists and hygienists (18%) and specialists (5%)
• 91% were requests for advice while 9% were patient complaints.

Advice files

These were the eight most common issues raised in the DDU's advice files. Some files included more than one theme.

• Returning to practice - 38%
• COVID-secure measures - 34%
• Indemnity requirements - 20%
• Staffing and the dental team - 13%
• Provision of urgent/emergency care - 7%
• Remote consultations - 4%
• Patient consent - 3%
• Communication - 2%

The most common theme in the DDU's advice files was the safe transition to practice after dental practices were given the greenlight to resume routine treatment in early summer. Inevitably there was considerable overlap between these cases and requests for advice from dentists and dental care professionals on COVID-secure measures to limit the risk of transmission to staff, patients and their families. These included concerns about appropriate PPE and social distancing rules, for example, a dental professional sought advice on whether they could carry out essential periodontal treatment if they wore suitable PPE.

Indemnity

Professional indemnity was an issue that came up relatively frequently in the files, including provision for staff. Some wanted to know whether they would be indemnified for telephone triage work or if they were redeployed. Others wanted to know if they could rely on DDU indemnity if they were unable to follow best practice guidelines because of staff shortages.

We were able to reassure them that, while we would advise members to be aware of and follow current guidance from a responsible body of opinion, members practising in good faith can seek our assistance, including access to indemnity, in the usual way, whatever their clinical decisions when caring for patients during the pandemic. As has always been the case, we do not make access to indemnity conditional upon adopting a particular treatment modality or safety precaution.

Staffing issues

With many practice staff furloughed, redeployed or shielding, it was no surprise that staffing and employment issues were relatively common. These included several requests for advice on variations to associate contracts through the DDU's checking service including remuneration and notice periods. Other concerns raised included working without a nurse, and whether pregnant staff could continue to work.

During lockdown itself, there were plenty of queries about the dento-legal considerations of remote consultations. These included the potential limitations of giving telephone advice to a patient without access to their records and when it was acceptable to prescribe remotely, particularly antibiotics.

Obtaining valid consent and effective communication has been more challenging during the pandemic for several reasons, from the lack of non-verbal signals during telephone consultations, to the difficulties of making yourself clearly understood while wearing PPE. Members sought advice on how to overcome these difficulties, and also how best to communicate with patients about COVID-security measures such as pre-appointment questionnaires.

Complaints

It was common to find several issues raised at one time in complaints files, so there is some overlap in the number of cases under each theme. The five most common themes are listed below.

• Treatment availability - 55%
• Dissatisfaction with treatment - 40%
• Issues around fees and patient requests for refunds - 23%
• Communication/attitude - 23%
• COVID-secure measures (infection control, PPE and face masks) - 14%

Delays

The most common issue in the complaints files we reviewed was the lack of access to dental care and treatment. Delays and cancellations caused first by the shutdown of dental practices and then by the limitations on patient numbers led some patients to take their frustrations out on their practice.

For example, one practice received a complaint from a patient who was unhappy with the delay in being fitted with veneers and was seeking a refund. Another complaint concerned the delay before the patient was able to have an infected tooth extracted at an urgent dental care centre.

Patient satisfaction

Another common theme which was typical of pre-pandemic times was patients' dissatisfaction with an aspect of the treatment they had received. This included a patient who was unhappy with their orthodontic treatment and wanted this to be addressed during the pandemic and another who alleged a delay in diagnosing periodontal disease.

Unsurprisingly, there was a clear overlap between these and complaints about fees and requests for refunds, such as the patient who was unhappy at paying for a 'faulty crown'. Other complaints in this category included patients who wanted a refund or compensation for treatment delays or incomplete treatment.

Communication

Finally, there were complaints alleging poor communication and rudeness. Several concerned patients who felt they had not been properly informed about delays, cancellations and arrangements for urgent care during lockdown. A handful disputed the way practices implemented COVID-secure measures, including some patients who were unhappy that they had been asked to wear a mask.

Most patients have been understanding about the unavoidable compromises in dental provision during the pandemic, but practices still had to respond to a significant number of complaints. Unfortunately, it is also possible that the likelihood of complaints and claims will increase as patients experience the detrimental consequences of treatment delays, or become frustrated by the continued restrictions on routine dental practice. This risk can best be mitigated with pro-active and consistent communication, which will help to manage patient expectations.

With the UK's vaccination programme well underway, there is hope that it won't be long before the pandemic recedes. However, it is likely to be some time before dental practice is back to normal and dental professionals may encounter further unexpected dento-legal challenges.

We advise members to call our helpline if they are unsure how to proceed. Not only can we provide reassurance and advice, but we will be able to share any learning points with fellow dental professionals.