Medico-legal in orthodontics
Advertising orthodontic products and techniques to the public
According to BOS advice sheets the advertisements which are often limited and
exaggerated is unacceptable and unethical. It should follow the GDC guidelines.
GUIDANCE ON WRITING PRACTICE LEAFLETS
The Advertising Standards Authority requires all advertisements to be Legal,
Decent, Honest and Truthful.
Orthodontist duty of care
1. Ethical responsibility
protect the life and health of patients
provide good dental care to acceptable standards
respect the autonomy of patients and their right to exercise control of treatment
in addition to the GDC standard
1. Continuing care
The treatment plan at all times is realistic in terms of the patient’s ability to
comply, the time frame is reasonable, and the appliances are comfortable and
sufficiently robust. If treatment has gone beyond the anticipated duration, the
patient must be made fully aware of why and what the likely new timescale will
The removable/functional appliance fitted is user-friendly and that the design is
the most appropriate.
Fixed appliance breakages are not due to archwire design faults or inappropriate
bracket position and that the correct bonding procedure has been used.
Accessory appliances such as headgear or elastics are correctly prescribed;
where there are difficulties, alternatives should be suggested and good
2. Emergency care
3. Care of all member of the public
Management of patient compliance
Cooperation is collaboration or teamwork
Compliance can be defined as obedience and requires a patient to follow
an orthodontist’s instructions.
Record keeping is particularly important particularly in cases of non-
compliance or nonattendance.
Parents of patients under 16 yeas of age should be involved at every level
although where there is difference of opinion it is essential that Fraser
competence* is understood.
Compliance information delivery methods
1. The effective communication of responsibilities to the patient and parent
is an essential part of obtaining informed consent
2. It is necessary to ensure that the message has been properly understood.
3. Explanations do not necessarily have to be provided by the orthodontist.
It can be given by an orthodontic nurse or auxiliary.
4. Visual aids are useful and written leaflets should be given as take-away
The orthodontic patient compliance can be classified into:
1. Passive acceptance – wearing fixed appliances.
2. Exercise of restraint - patients will be asked to
Avoid certain foods and drinks,
Not abuse the appliance
Desist from habits such as biting on pens or sucking thumbs.
3. Active participation - where we ask patients to do things. These include
Maintaining good oral hygiene,
Using fluoride supplements,
Keeping appliances clean and in good order.
Wearing all sorts of removable appliances and adjuncts such as elastic
Reporting problems when they arise,
* Fraser competence, previously called Gillick , is a term originating in England
and is used in medical law to decide whether a child (16 years or younger) is
able to consent to his or her own medical treatment, without the need for
parental permission or knowledge, if and when the child achieves sufficient
understanding and intelligence to understand fully what is proposed It is based
on a decision of the House of Lords by Lord Scarman in the case Fraser v West
Norfolk and Wisbech Area Health Authority .
1. Poor oral hygiene and diet control
Every attempt should be made to discuss the problem openly with the
The efforts made to modify patient behaviour should be clearly recorded
in the clinical notes.
The issue of premature discontinuation should be discussed with the
patient with adequate forewarning and any warnings recorded in the notes.
2. Poor wear of appliances and continued breakages
The orthodontist should be able to demonstrate that efforts have been
made to eliminate the possibility that the breakages or poor wear might be due
to clinical rather than patient related problems
Discontinuation of treatment can be considered.
A careful, clear written record should always be kept of any action taken
or recommendation made. The orthodontist should inform the referring dentist
and, when appropriate, notify either the Primary Care Trust or Health Board.
3. Poor attendance
It is important that every attempt to contact the patient is made.
If the practice operates a policy of charging for failed appointments, it is
essential that this is made clear in any written information provided to all
patients at the start of treatment and explanations that these charges are
permissible within NHS regulations.
The making of further appointments should not be conditional on prior
payment or the settlement of non-attendance charges. The child’s treatment
should continue while debt recovery measures are in progress.
Continued failure to attend would suggest that the patient has effectively
withdrawn consent for the continuance of care. In these circumstances, efforts
should be made to inform the patient that wearing an unsupervised appliance
carries risks for the dentition.
According to the NHS (GDS) regulations on discontinuation of treatment:
A. When both parties agree that treatment should cease, it is not necessary to
inform the Primary Care Trust or Health Board.
B. Where the practitioner wishes to terminate treatment but the patient
wishes to continue, the practitioner should apply to the PCT/HB. The PCT/HB
may wish to investigate the matter by contacting either the practitioner or the
patient or both.
C. In respect of non-payment of money owed, whether for NHS charges or
for charges for broken NHS appointments, a dentist or orthodontist may decline
to continue treatment until any charge payable has been received.
The use and storage of digital images
At present it is difficult to provide clear guidelines concerning the use and
storage of digital images, because advice differs between institutions,
particularly NHS Trusts.
Do I need to get consent for photography?
Permission should always be sought from patients before photographs are
When taking an image of a patient, it must be explained to them why the
image is being taken, the intended use and the arrangements for storage.
The DoH model consent policy (http://www.doh.gov.uk/) states that
A. express consent for photographs is not required where there is no
prospect of the patient being recognised
B. Where it may be possible to identify an individual, written consent is
C. Written consent is also essential for publication of any image.
Photographic levels of consent:
1. for medical record use only
2. for medical record and teaching use
3. for one specific purpose e.g. a publication.
What is the Data Protection Act?
The Data Protection Act (1998) allows individuals to find out what
information is held about them, which will include any digital images.
The data controller must take reasonable steps to guarantee that the data
are safe from unauthorised access, disclosure, tampering or loss.
This will include installing security arrangements such as password
protection, regular backups and ensuring that all individuals who have access to
the images are instructed about the need for confidentiality
What about dental practice and the Data Protection Act?
All dentists in general and specialist practice should be registered with the
Commissioner, even if their practice is not computerised.
What about hospital and community departments?
In most Trusts, clinicians will already be covered by the Trust/University
data registration, provided they comply with the local rules of the Trust.
Trusts treat the storage of data extremely seriously and some now state
that data should not be stored on any portable devices unless it is within an
In some Trusts though, employees, including trainees who copy and store
images for their own purposes, may be considered independent data controllers
and will be required to register with the ICO.
Who owns the copyright?
Anyone who takes a digital image is the owner of that image and therefore owns
the rights to it.
Organisations, such as NHS trusts, might insist on owning the copyright of their
patients’ medical illustrations.
How secure are digital images?
There are several methods of protecting the authenticity of digital images.
These falls into two broad groups: watermarking and digital signature.
The former embeds a pattern within the image that cannot be seen by the eye.
Any alteration of the image in the form of cropping or rotating can therefore be
detected. Digital signatures work in a similar way, but the information is
attached to the image in a user-defined part of the file or an independent file
1. Seek permission prior to taking digital images.
2. Obtain consent in cases in which the patient may be recognised from the
image and record this using an appropriate BOS, Trust or practice consent form.
3. Record in the notes that digital images have been taken.
4. Ensure patients understand why images are being taken, how they are to
be stored and used, especially if they are to be published or placed on a website.
5. Comply with the Data Protection Act – if you work in a Trust, seek
advice from your local Data Protection Officer. If you work in practice, check
that your current registration with the Information Commissioner’s Office
covers digital photography.
6. Make appropriate secure arrangements for storage of images.
7. Ensure the original unaltered image is stored in an uncompressed format
on a secure server.
BOS Advice Sheet On complaints
Causes of allegation in Orthodontics
a. Lack of informed consent,
b. Poor record-keeping,
c. making misleading statements to patients regarding the need for and
efficacy of the planned treatment,
d. Treatment for TMD,
e. carrying out ‘experimental’ treatments without properly informing the
patients of alternatives,
g. Fraud claiming
In order to prove negligence a patient must prove
a legal duty of care
a breach of that duty
resultant loss or damage
Ways of complaint
A. NHS dental treatment
If a patient receives treatment within the NHS a complaint can be dealt
with by the NHS complaints process.
If a patient is unhappy about the way a complaint has been dealt with
under the NHS complaints procedure in England and Wales, they can contact
the Care Quality commission.
B. Private dental treatment
if a patient has a complaint about private dental treatment which has not
been resolved to their satisfaction using the practice’s own complaints process
They can contact the dental complaints Service, set up by the GDC.
This service seeks to provide a mediation service and they have an on-line
system to help patients write a letter of complaint to their dentist/orthodontist.
This is an ‘independent’ dental complaints service.
There are three stages of the complaints procedures: -
Stage 1 – The Case Worker:
1. Case workers decide whether an allegation raises an issue the GDC can deal
with and whether the information provided appears to raise a question that
needs to be looked into.
2. If the answer to these questions appears to be ‘yes’, the matter is referred to the
investigating committee (IC).
3. No decision is made at this stage about whether an allegation is true.
Stage 2 – The Investigating Committee :
1. Panel is made up of 5 members: 2 dentists, 2 lay and 1 DCP .
2. The investigating committee considers the allegation, any comments from the
dental professional, and any further comments from the person who made the
3. All parties receive a complete copy of the paperwork.
4. The committee then decides whether to refer the allegation to a practice
committee for a full public inquiry.
If the IC decides there should be an inquiry they can, if necessary, refer the
dental professional to the interim Orders committee (iOc) to consider whether to
impose conditions or interim suspension until the inquiry has been held.
If the IC decides not to refer a dental professional to the practice committee,
they can send them a letter of advice or warning, or take no further action.
Stage 3 – Practice Committees
The practice committees are:
1. Professional conduct committee
2. Professional performance committee
3. Health committee
If allegations are proved, The Committee then decides whether the
registrant is unfit to practise and what action they should take.
The committee can take a number of steps, including imposing conditions
of practice, suspension and erasure. A dental professional has the right of
Child Protection Guideline for Orthodontic Practitioners
All members of the dental team (including orthodontic practitioners) have a
responsibility to recognise and act if child abuse is suspected.
Types of abuse
1. Physical Abuse - may involve hitting, shaking, throwing, poisoning, burning or
scalding, drowning, suffocating or otherwise causing physical harm to a child.
2. Sexual Abuse - involves forcing or enticing a child or young person to take part
in sexual activities, whether or not the child is aware of what is happening.
3. Emotional Abuse - is the persistent emotional ill-treatment of a child such as to
cause severe and persistent adverse effects on the child’s emotional
4. Neglect - is the persistent failure to meet a child’s basic physical and/or
psychological needs, likely to result in a serious impairment of the child’s
health or development.
Signs of Abuse
Being overly affectionate or knowledgeable in a sexual way inappropriate to the
Lack of trust or fear of someone they know
Become worried about outdoor clothing being removed
Extreme reactions, such as depression, suicide attempts.
Regressing to younger behaviour patterns such as thumb sucking
One has to be very cautious as many of these symptoms occur when there is no
sexual abuse present.
Unexplained recurrent injuries or burns
Improbable excuses or refusal to explain injuries
Wearing clothes to cover injuries, even in hot weather
Bald patches on scalp
Fear of physical contact - shrinking back if touched
Fear of suspected abuser being contacted
Continual self-depreciation (‘I’m stupid, ugly, worthless, etc’)
Overreaction to mistakes
Extreme fear of any new situation
Neurotic behaviour (rocking, hair twisting, self-mutilation) •
Poor personal hygiene
Poor state of clothing
Untreated medical and dental problem
Bullying is a particular form of abuse most often inflicted by a child’s peers.
Either direct or indirect bulling such as social isolation.
Boys tend to be more exposed to direct physical bullying than girls.
When bullying is suspected by a treating orthodontist, it is important to
acknowledge the concern with an accompanying parent, and seek reassurance
that the issue has been raised with the school or other appropriate authority.
Management of child abuse
1. Record your concerns as soon as possible begin by documenting all facts: what
you saw, what was said, physical evidence e.g. ‘the mother said this’, ‘the
bruise was here’
2. Record details of any witness
3. The clinician has a duty to assess a child’s capacity to decide whether to consent
to or refuse investigations as long as they are deemed mentally fit to do so.
4. The clinician has a duty to share information with those agencies with a
statutory duty to investigate possible child abuse.
5. Regarding the consent for further investigation:
Child in Need – Parental consent required. Refusal may leave you thinking that
the child is at risk, but NOT always
Child at Risk – Parental consent is NOT required. Informing parents of
concerns and the referral is good practice
Communication is the key to good Patient relations
1. Poor communication involves
2. It considered as a major predisposing factor for patient complain.
3. According to BOS 2010-2011, 40% of the 108 more serious calls were
precipitated by a breakdown in communications either during or after treatment.
4. Research consistently shows that over 60% of all patients’ complaints do not
involve operator error but are made because their expectations of a good level
of service have not been met.(Krause 2006)
5. Therefore in order to manage and reduce the risk of dissatisfied patients, good
communication skills are an essential part of everyday practice, not only from
the orthodontist but from all members of the orthodontic team.
6. The responsibility of the orthodontist regarding the communication with the
patient involve discussing:
benefit of treatment
the necessity to treat
risks of treatment options
risks of no treatment
limitations and expectations
Consent in orthodontics
Consent to treatment is essentially a process, not a signature. This process is the
communication of key information to the patient about the proposed treatment
and the patient’s response in terms of an informed decision whether or not to
Who can give consent?
Patients can only give consent if they are competent to make the decision.
Adults(above 18 years) and young people aged 16 or 17 are presumed to be
competent to give consent for themselves
Patients fewer than 16 who understand fully what is involved in the proposed
procedure can also give consent.
Legally a person with parental responsibility can give consent if the child
refuses. This would generally be unwise in an orthodontic context as the success
of treatment is very dependent on the co-operation of the child.
A competent child can in principle consent without the agreement of the
parents, but as parental support is also a key factor in the success of treatment,
every effort should be made to reach consensus.
Although an unaccompanied child may be competent to give consent, it is wise
to encourage the child to involve the parents if at all possible, and to give the
parents an opportunity to discuss the treatment with the clinician.
For a child under 16 who does not have sufficient understanding to give
informed consent, consent is required from a person with parental
In England and Wales, if the parents of a child are married to each other at the
time of the birth, or if they have jointly adopted a child, then they both have
parental responsibility. Parents do not lose parental responsibility if they
divorce, and this applies to both the resident and the non-resident parent.
This is not automatically the case for unmarried parents. According to current
law, a mother always has parental responsibility for her child. A father,
however, has this responsibility only if he is married to the mother when the
child is born or has acquired legal responsibility for his child through one of
these three routes:
A. . (from 1 December 2003) by jointly registering the birth of the child with the
B. . by a parental responsibility agreement with the mother
C. . by a parental responsibility order, made by a court
Living with the mother, even for a long time, does not give a father parental
responsibility and if the parents are not married, parental responsibility does not
always pass to the natural father if the mother dies.
When a child is adopted, the adoptive parents are the child’s legal parents and
automatically acquire parental responsibility.
Foster parents rarely have parental responsibility.
A guardian appointed by a court will also acquire parental responsibility.
People looking after the child such as child-minders, grandparents or
schoolteachers do not automatically have parental responsibility, but parents can
authorise them to make medical decisions for the child. Many schools, for
example, seek explicit agreement in advance from parents that teachers may
consent to any treatment that becomes necessary whilst the children are in their
In the case of patients with mental incapacity, the parents can consent for a
minor, but not for adults. In the latter instance the clinician has to make a
judgement as to whether the treatment is in the patient’s best interests; the views
of relatives should be taken into account but they cannot give consent. It is
important not to underestimate the competence of patients with a degree of
mental incapacity to give valid consent;
Types of consents
A. Consent to examination.
Orthodontic examinations are commonly carried out on the basis of implied
B. Consent to treatment.
In seeking consent in orthodontics the following factors need to be addressed:
1. Patient commitment: in terms of
the possibility of time out from school or employment,
oral hygiene requirements,
appliances and post-treatment retention.
The need to continue regular visits to the family dentist
2. Benefits of treatment: in terms of
other areas (as appropriate to the case)
3. Limitations of treatment: Patients should be clear about what the treatment will
and will not achieve, particularly if the treatment objectives are limited.
4. Risks of treatment: including
The possibility of relapse.
5. Multidisciplinary treatments: The patient must be given sufficient information
at the outset to be able to consent to both the orthodontic treatment and the
associated procedure before either treatment is started.
6. Treatment options
7. Retention: Patients should be informed, before the start of treatment, that
wearing retainers is generally considered an essential part of treatment. They
should also be aware of the type of retainers to be used, the length of time they
will need to wear them and the period of supervision provided. The nature of
any charges associated with a patient’s long term retention requirements should
be explained to them.
8. Photographs: The purpose and possible future use of the photographs must be
clearly explained to the person, before their consent is sought to take the
9. Reaffirming consent. Where there has been a lengthy delay between the initial
consultation and the start of treatment (as for example when a patient has been
on a treatment waiting list), the patient’s views or circumstances may have
changed, or treatment techniques may have evolved. Reaffirmation of consent is
10.Withdrawal of consent: Consent to treatment can be withdrawn at any time,
even in the middle of a course of orthodontic treatment. If a patient indicates a
wish to terminate treatment, advice should be given to the patient on any likely
adverse consequences of a premature termination. If the patient continues to
request termination, the operator is obliged to comply and must remove any
C. Consent to continuation of treatment.
The fact that a patient continues to attend for treatment in the normal way can
be regarded as implied consent for its continuation.
D. Consent for a change of plan.
The patient should be fully informed of the circumstances and continuation of
Written or Verbal Consent?
There is no legal requirement for consent to be written.
Written confirmation of consent may be thought to offer a more satisfactory
defence in the case of subsequent litigation
The GMC recommends that written consent is obtained in cases where:
1. The treatment or procedure is complex, or involves significant risks and/or side-
2. There may be significant consequences for the patient’s employment, social or
3. The treatment is part of a research programme
4. Procedures in orthodontics where written consent is particularly desirable are
joint treatments that involve surgery or complex restorative work. For other
procedures clinicians will need to take account of local policy and the perceived
needs of the case.
The NHS Litigation Authority has recently issued an alert regarding changes to
the law on informed consent. A recent decision by the House of Lords in the
case of Chester–v- Afshar (2004) has had the effect of significantly extending
clinicians’ liabilities in cases where less than full consent is obtained. Although
the judgement of this case applies only to English courts as precedent, it will
have significant effects generally. Miss Chester suffered repeated episodes of
low back pain and an MRI scan revealed evidence of disc protrusions.
Following injections and conservative treatment she was referred to Mr Afshar,
a consultant neurosurgeon. He advised that three intervertebral discs should be
removed surgically. Miss Chester gave consent to the operation, which then
went ahead. Cauda equina syndrome (CES) is a well-recognised risk of such
surgery and occurs in 1-2% of cases. Despite the patient’s operation being
carried out extremely competently, this risk materialised and she ended up with
Miss Chester sued Mr Afshar claiming that he had failed to warn her of the
potential risk.Because Mr Afshar had no evidence to the contrary, the court
accepted Miss Chester’s allegation and liability was established. The surgeon
argued that his failure to warn the patient was irrelevant to the outcome because
Miss Chester could not state that, given appropriate warnings, she would not
have proceeded with the operation.
The guidance of the GDC remains the most appropriate, legally enforceable,
framework within which to operate. The key features are:
1. Putting patients’ interests first and acting to protect them
2. Respecting patients’ dignity and choices
3. Protecting patients’ confidential information
4. Co-operating with other members of the dental team and other
healthcare colleagues in the interests of the patients
5. Maintaining your professional knowledge and competence
6. Being trustworthy
Do patients have a right to a second opinion?
Answer All patients have a right to second opinions at any stage during
assessment, diagnosis,whilst in treatment or at the end of their orthodontic
Second opinions can be provided
a) Before treatment to confirm a diagnosis and treatment plan.
b) D uring treatment to assess the progress of treatment and to allay any fears
that the patient may have.
c) After treatment to confirm that the outcome is consistent with good practice
and to discuss any long term issues.
Procedure for the practitioner who provided the first opinion
When a patient requests a second opinion, a practitioner should:
1. Write to the patient acknowledging their wish.
2. Write to their general dental practitioner pointing out that the patient has
asked for a second opinion.
3. Agree to send any appropriate records to the practitioner identified to provide
the second opinion.
Procedure for the practitioner providing the second opinion
Once a second opinion has been given, the practitioner should:
1. Send a report to the patient.
2. Send a report to the referring practitioner.
3. Send a report to the current orthodontist
4. Suggest, if considered necessary, that if the patient’s continuing orthodontic
care is to be provided by the first orthodontist then the treatment plan is either:
revised if necessary before treatment commences, or
re-evaluated if necessary during treatment, or
Arrangements are made for the patient to undergo the treatment with another
5. Return any records to the patient’s general dental practitioner or referring
practitioner as appropriate.
Waiting list management
Where government and/or purchaser targets allow, waiting lists for orthodontic
care can be managed using one of two methods:
1. New patient waiting lists
A new patient is seen for a consultation when an opportunity for treatment
• This has the advantage of being able to offer immediate treatment to any
patient who is eligible and willing to receive care. However, in this system,
referred cases go to a waiting list without examination risking the late diagnosis
of potentially harmful conditions not identified in the referral and the delayed
delivery of growth dependant procedures. In addition, there may be a delayed
decision as to whether the severity of the malocclusion merits NHS orthodontic
2. Treatment waiting lists
This system offers a consultation soon after receipt of the referral and allows:
• Reassurance if treatment is not, or not immediately, indicated and when
coupled ith appropriate advice may fulfill the requirements of the 18 week wait
from referral to treatment
• Identification and immediate management of potentially harmful problems
• Immediate referral to a more appropriate provider if required
• Identification of those in greatest need of treatment
• Explanation of the proposed treatment plan
• Explanation of any further waiting time for treatment
THE DUTIES AND RESPONSIBILITIES OF EXPERT WITNESSES
Why are such expert witnesses necessary?
In cases of alleged negligence, as courts have no expert clinical knowledge
themselves, there is a need to be able to objectively assess the skill of a clinician
against what is reasonable clinical practice. For this reason the courts will hear
expert evidence for the claimant and the defendant.
The criteria of the report and Duty to the court
1. The report should indicate whether the defendant met an appropriate standard of
care (taking all the circumstances into account) and if there was a failure to
meet such a standard, did this failure cause the injury to the claimant, i.e.
2. The expert is not being asked if he or she would have diagnosed/treated the
patient in the same way, but to indicate if the diagnosis/treatment is reasonable.
3. If there is a range of approaches to a particular set of clinical circumstances,
then this should be indicated in the report.
4. If any literature is quoted it should be that relevant at the time the alleged
negligence took place.
Changes in the Civil Procedure Rules, following recommendations by Lord
Woolf when he was Master of the Rolls, were introduced on the 26th April
1999. These include:
1. Reducing the number of expert witnesses.
2. Increasing reliance on a single joint expert witness
3. Encouraging parties to an action to settle as early as possible to reduce the costs
of litigation by allowing either side to make an offer to prevent the case
Orthodontic records collection and management
Why are good clinical records important?
1. For effective and efficient orthodontic practice
2. important means of communication
3. For responding to complaints
4. For improving standards of patient care and Auditing
What constitutes the clinical record?
1. Handwritten notes
2. Computerised records
3. Correspondence between health professionals
4. Correspondence from the patient (not relating to complaints)
5. Radiographs and other imaging records
6. Laboratory or radiography reports
7. Photographs, videos and other recordings
8. Orthodontic study models
9. Statements concerning custom-made devices provided under the Medical
10.Regulations i.e. laboratory sheets
Writing good clinical records
Notes should include:
1. Reason for referral.
2. Patient’s presenting complaint.
3. History (dental, medical and social).
4. Details of the orthodontic examination.
5. Description of radiographic findings and the results of special tests.
6. Orthodontic diagnosis in clear, easily understood terms.
7. Record of the level of treatment need e.g. IOTN.
8. Treatment aims and options for treatment.
9. Treatment plan (it should be clear from the notes how you arrived at this plan).
10.Details of discussions with the patient and information given, including details
of risks and benefits of particular treatments.
11.Details of any consent that the patient or guardian has given.
12.Details of treatment undertaken.
13.Details of any mishaps or complications.
14.Appropriate outcome records.
Access to clinical records
Unless patients specify otherwise, there is usually no problem in sharing
information with other health professionals involved in the patient’s current
care. However, it may be a good idea to tell patients that you will do so.
Under the terms of the Data Protection Act (1998), any patient has a right to
access or view their medical records within 40 days of a written request.
It is your professional duty to respect the confidentiality of all information you
hold on a patient. You may be asked to disclose a patient’s records to certain
individuals orauthorities e.g. relatives and carers, social services, police,
solicitors, the courts. Except inexceptional circumstances, always seek the
patient’s consent to disclose any informationabout them to others. For consent
to disclosure of records to be valid, the patient mustunderstand: to whom the
information will be disclosed, what information will be disclosed,the purpose of
disclosure, the significant foreseeable consequences and that relevant
information cannot be withheld except in exceptional circumstances.
You should respect the wishes of a patient who has not given permission to
disclosureunless this can be justified to be in the public interest.
Altering clinical records
If a mistake is discovered, an additional note should be added as a correction.
Notes should never be erased, overwritten or inked out.
Errors should be scored with a single line and the corrected entry written
alongside, dated and signed.
Retention of the dental records
Defence organisations however, recommend that ideally all recordsshould be
There is a conflicting demand between the destruction ofrecords, which is
irreversible and the continued storage of records, which is expensive.
Record should be kept for 11 years for adults.For children 11 years or up to
their 25th birthday, whichever is the longer. X-Ray films should be kept for 7
Orthodontic transfer cases
To help in patient transfer these guidance notes are subdivided into three:
1. Transferring a patient
Finding a new orthodontist
The transfer method: When transferring a patient, sufficient information
should be forwarded to the neworthodontist to enable treatment to continue with
the minimum of disruption. A suggested minimum data set is outlined on the
BOS Case Transfer Form and should include a set of duplicate records where
appropriate. You should keep the original records until after the transfer has
Prior to the transfer: Try to ensure all the appliances are in good order and
that the oral hygiene is as satisfactory as possible. It is advisable to take up to
date records, such as study models and photographs, just prior to transfer to the
new orthodontist. Both the patient and parents should be advised that the
accepting orthodontist will have full authority to treat the case in a manner that
they feel is best for the patient.
2. Accepting a transfer
Once you have received a referral letter and records consider the following:
If you are unable to accept the transfer, or following examination feel unable to
do so, let the referring orthodontist know as soon as possible. If possible try to
secure the services of another competent orthodontist in your area.
Following a review of the diagnostic data, inform the patient and/or parents of
the procedures necessary to achieve a successful treatment outcome and
particularly anyfee schedule where relevant, then the patient should be
welcomed into the practice as quickly as possible.
Sometimes patients under treatment arrive without being referred. In such cases
it is prudent to write to the original orthodontist to request the necessary transfer
information, as outlined in the BOS Case Transfer Form, along with a set of
duplicate records, in order to avoid unnecessary confusion.
It is advisable to get up to date records, such as study models and photographs,
before continuing the orthodontic treatment.
Orthodontic extractions risk management guidelines
The purpose of this guideline is to minimise the chances of a mistake being
made when the patient is referred for the extractions to be carried out.
1. A request should be made in writing.
2. It should include the name, address and date of birth of the patient, a brief
outline of the proposed treatment, its timing, any relevant medical history and
the extractions needed.
3. It is preferable to identify the extractions by at least two different methods.
4. The identification of erupted supplemental or supernumerary teeth poses
particular problems. There is no generally accepted method of notation, which
provides for unambiguous identification and a simple description in words is
recommended e.g. "the more distal of the two upper left lateral incisors".
5. The teeth listed for extraction in the letter must be checked directly against the
patient record, which should always be to hand when the letter is signed.
6. If as occasionally happens a dentist telephones the practice/ department needing
to know urgently which teeth are to be removed, verbal instructions should be
avoided wherever possible and the information sent out in a signed and dated
extraction letter faxed to the practice.
7. If a fax is not possible, it is essential to speak directly to the dentist and not via a
third party such as a dental nurse or receptionist. The information must be read
out from the notes and not from a copy letter (which may contain uncorrected
errors). The information should be repeated back for checking. A follow up
extraction letter should always be sent to the practice for confirmation.
8. If the dentist carrying out the extractions questions the choice of teeth for
removal, an offer should be made to see the patient again in order to confirm or
modify the treatment plan before the extractions are performed.
Breaches of Confidence
Even though strict adherence to the principles of confidentiality should be
observed at all times, there are some extreme cases where a breach of
confidence can be justified.
1. Research and teaching
Audit is an essential and mandatory part of clinical governance. However,
where possible,patient consent should be obtained or data anonymised.
3. Court Order
4. Police Request
The police are not automatically entitled to access to personal patient data
unless they produce a court order. The clinician must satisfy him or herself that
there is a definite public interest, justification and document it clearly in the
patients’ notes. If in doubt, legal advice should be sought.
5. Risk of Harm/Public Interest
Where there is risk of serious harm to an individual(s), for example, the spread
of a serious disease or child abuse, a breach may be warranted. Each case
should be assessed on its’ own merits and legal advice sought and the breach
should be limited to the minimum necessary.
It is permissible to liaise with other healthcare professionals involved in a
patient’s care without explicit consent, but where possible it is advisable to
ensure that the patient is content with the disclosure.