Commentary on: A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract

Key Points

• Details the importance of appropriate management of patients attending emergency out of hours clinics.

• Highlights the continued inappropriate use of antibiotics for treating certain conditions.

• Demonstrates that there exists a poor understanding of clinical and best practice guidelines among some clinicians with respect to the examination and management of emergency patients.

Abstract

Aim To investigate the clinical management of patients attending for emergency dental treatment.

Design A retrospective analysis of clinical record cards.

Method Information was collected from patient record cards concerning the patient's reason for attendance and their management at an emergency dental clinic in South Sefton, Liverpool.

Results Over a nine month period, 1,718 patients attended the clinic; 1,472 record cards were analysed. Over 80% of the patients attending the out of hours (OOH) clinic had pain associated with a localised dental infection or dental abscess. Where a diagnosis was recorded, only 67% of patients received appropriate treatment. Over 50% of patients received antibiotics alone with no other definitive treatment provided. The principal antibiotic prescribed for both adult and child patients was amoxicillin.

Conclusion The current study has highlighted that GDPs working within the OOH services are not adhering to current clinical and best practice guidelines with respect to patient examination, diagnosis, management, in particular the correct prescribing of antibiotics for dental infections, and clinical record keeping.

Commentary

Since the inception of the new contract in April 2006 the responsibility for the provision of out of hours (OOH) emergency dental services (EDS) has been placed firmly in the lap of the PCTs. At the same time, the criteria as to what constitutes an 'emergency' were redefined.

This paper looks at the treatment provided in an OOH EDS clinic on Merseyside over the period April to December 2006. The results were interesting in that about half the attending patients received antibiotic therapy, with the most popular antibiotic prescribed being amoxicillin.

The main reasons for attending the clinic hold no surprises but an analysis of the treatment provided throws up some anomalies. Many patients were just prescribed antibiotics with no further treatment being offered or advised. On numerous occasions the use of antibiotics was inappropriate as the diagnosed complaint would require local treatment such as pulp removal or immediate surgical drainage of the swelling or dressing of a dry socket (localised osteitis) to alleviate the problem.

The unsuitable prescribing of antibiotics requires investigation of the actual reasons why this was the chosen treatment. Was it because of a lack of understanding of the condition and its most efficacious treatment? Or poor understanding of the correct use of antibiotic therapy? Or is it possible that the time pressures are the driving force in the quick fix of issuing a prescription even when this is wholly inappropriate?

On many occasions (57%), antibiotics were prescribed though no diagnosis was recorded which brings to the fore the problem of defending one's actions should they be questioned.

Treatment modalities in the OOH environment are disturbing in their unsuitability. This requires further research to understand the causes and education to initiate change. Some further instruction is required to underpin the guidance from the practice defence organisations, who indemnify us, in relation to the contemporaneous recording of all aspects of the diagnosis and treatment provided with choices offered and discussed together with the reasons for the eventual provision of the treatment.