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Newsletter dated 4th September 2005... Choice of
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This week
Horizontal hemostat technique
Thinking the Pain Away?
The importance of confidentiality in Record Keeping
MClinDent course staff visit to India
-
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FREE DENTAL CAMP - Mumbai -Sep 5-10,
2005
Manav Seva Kendra is organising a Free Dental Week for
patients suffering from Dental Problems. Dental Specialists will be
available for consultation/check-up/treatment at Shop No 4&5, Amrut Apts,
Bajaj Road, Vile Parle(w). Mumbai 400056, from 5th September to 10th September
2005 from 9.30 AM to 11.00 AM. Patients will be examined on first come
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98201-20186.
Keep this immensely informative website going. My
best wishes for the fabulous job you people are doing to update us on a
variety of subjects pertaining to Dentistry. Dr
Sharad Jhingran - Guwahati(Assam)
|
The opinions and photographs within this
newsletters are not ours. Authors have been credited for the individual
posts where they are. - Photos courtesy of Judy McIntyre -
ROOTS |
This is the horizontal hemostat technique which several of us use here at
UNC as Dr. Rivera has showed it to us here.
Pics are attached.
You can see that you clip/clamp the hemostat onto the rinn (this even works
with non-digital aka conventional films) and then place the hemostat parallel to
the occlusal plane (thanks to the gorgeous Spanish model :) ) and then --
voi-la.
Hope this helps.
PS -- this technique has been extremely helpful with tori, gag
reflexers, all small mouths and other scenarios where simply, the rinn just
won't fit -- esp those 2nd and 3rd molars.:) * Judy McIntyre -
ROOTS
Fear of the dentist is often associated with a fear of pain. Now a new study, testing pain in the jaw, has found that believing a medicine can relieve pain is enough to prompt the brain to soothe it, using natural painkillers
Just thinking that a medicine will relieve pain is enough to
prompt the brain to release its own natural painkillers, and soothe painful
sensations, a new University of Michigan study finds.
The study provides the first direct evidence that the brain’s own pain-fighting chemicals, called endorphins, play a role in the phenomenon known as the placebo effect — and that this response corresponds with a reduction in feelings of pain.
Previous studies at U-M and elsewhere have shown that the brain reacts physically when a person is given a sham pain treatment, which they believe will help them.
But the new study is the first to pinpoint a specific brain chemistry mechanism for a pain-related placebo effect. It may help explain why so many people say they get relief from therapies and remedies with no actual physical benefit. And, it may lead to better use of cognitive, or psychological, therapy for people with chronic pain.
The results will be published in the Journal of Neuroscience by a team from the U-M Molecular and Behavioural Neurosciences Institute (MBNI). The research was funded by the National Institutes of Health.
‘This deals another serious blow to the idea that the placebo effect is a purely psychological, not physical, phenomenon,’ says lead author Jon-Kar Zubieta, M.D., Ph.D., associate professor of psychiatry and radiology at the U-M Medical School and associate research scientist at MBNI. ‘We were able to see that the endorphin system was activated in pain-related areas of the brain, and that activity increased when someone was told they were receiving a medicine to ease their pain. They then reported feeling less pain. The mind-body connection is quite clear.’
The findings are based on sophisticated brain scans from 14 young healthy men who agreed to allow researchers to inject their jaw muscles with a concentrated salt-water solution to cause pain. The injection was made while they were having their brains scanned by a positron emission tomography (PET) scanner. During one scan, they were told they would receive a medicine (in fact, a placebo) that might relieve pain.
Every 15 seconds during the scans, they were asked to rate the intensity of their pain sensations on a scale of 0 to 100, and they gave more detailed first-person ratings after the experiment. The researchers correlated the participants’ ratings with their PET scan images, which were made using a technique that reveals the activity of the brain’s natural painkilling endorphin chemicals, also called endogenous opioids.
Endogenous opioids bind to brain cell receptors called mu-opioid receptors, and stop the transmission of pain signals from one nerve cell to the next. Besides the brain’s own chemicals, drugs such as heroin, morphine, methadone and anaesthetics also act on the mu opioid receptor system to reduce pain.
Because the endorphin system naturally tries to quell pain whenever it occurs, the researchers slowly increased the amount of concentrated salt water being injected in the muscle as the scans continued, in order to keep the participants’ rating of their pain within the same point range throughout the experiment. The placebo, a small amount of hydrating solution, was then given intravenously every four minutes.
As the researchers alerted participants that the placebo was coming, and injected the placebo dose, the amount of additional concentrated salt water needed to maintain participants’ pain over time increased — indicating a reduction in pain sensitivity that the subjects were not aware of. In other words, thinking they were getting a pain drug actually allowed the participants to tolerate even more pain-inducing concentrated salt water than before.
After each scan, the researchers asked the participants more questions about their mood, emotions and other aspects of how they felt during the scans. There were significant differences between post-scan ratings given by participants after the scan in which they received the placebo, and after the scan during which they received the jaw injection alone.
Nine of the participants were classified as “high placebo responders” because they had more than a 20 percent difference between pain and placebo scans in their average pain ratings per volume of salt water infused — in other words, the placebo effect was strong. The other five were classified as ‘low placebo responders’.
These subjective ratings are consistent with previous findings, Zubieta notes. But the simultaneous imaging of the participants’ endogenous pain-reducing opioid systems sheds new light on why the placebo effect occurs.
The imaging method used in the study involves tiny doses of a medicine called carfentanil that is attached to a short-lived radioactive form of carbon, which releases subatomic particles known as positrons. These positrons are detected with the PET scanner, which acts like a photographic camera to capture those particles. It then determines exactly which part of the brain they originated from, and how many of them are coming from each brain region. The researchers also made MRI scans of the participants’ brains, which they cross-registered with the PET scans to give accurate information on exactly which brain regions were active.
Because carfentanil competes with the brain’s natural endogenous opioid painkillers for space on nerve cell receptors, the PET scans can be used to see how active the opioid system and mu-opioid receptors are. The stronger the positron signal from a particular brain region, the less active the mu opioid system, and vice versa.
All of the participants showed an increase in the activation of their mu opioid endorphin system after they were told that the ‘medicine’ was coming and the placebo was given. The most pronounced differences were seen in four areas of the brain known to be involved in complex responses to, and processing of, pain: the left dorsolateral prefrontal cortex, the pregenual rostral right anterior cingulate, the right anterior insular cortex and the left nucleus accumbens.
When the researchers correlated the mu opioid activity changes with the participants’ own ratings of their pain and emotions, they also observed that the placebo-induced activation of the opioid system was correlated with various elements of the experience of pain.
For example, activity in the dorsolateral prefrontal cortex was associated with the expectation of pain relief reported by the volunteers. In other areas, that activation was associated with relief of the intensity of pain, how unpleasant it was, or even how the individuals felt emotionally during the pain experience.
Because the new study was done only in healthy men between the ages of 20 and 30, further research will be needed to determine whether the effect occurs in women and in people with various illnesses. The power of placebos to ease pain symptoms has been well-documented in many groups of subjects and illnesses, but the researchers started with healthy young males to rule out the impact of chronic pain, mood disorders and hormone variations, which can also affect the endorphin system.
In addition to Zubieta, the research team included MBNI members Joshua Bueller, Lisa Jackson, David Scott and Janyun Xu; radiology professor Robert Koeppe, Ph.D.; Thomas Nichols, Ph.D., an assistant professor of biostatistics in the U-M School of Public Health; and Christian Stohler, formerly of the U-M School of Dentistry and now at the University of Maryland School of Dentistry.
Reference: The Journal of Neuroscience, August 24, 2005, Vol. 25, No. 34
The study provides the first direct evidence that the brain’s own pain-fighting chemicals, called endorphins, play a role in the phenomenon known as the placebo effect — and that this response corresponds with a reduction in feelings of pain.
Previous studies at U-M and elsewhere have shown that the brain reacts physically when a person is given a sham pain treatment, which they believe will help them.
But the new study is the first to pinpoint a specific brain chemistry mechanism for a pain-related placebo effect. It may help explain why so many people say they get relief from therapies and remedies with no actual physical benefit. And, it may lead to better use of cognitive, or psychological, therapy for people with chronic pain.
The results will be published in the Journal of Neuroscience by a team from the U-M Molecular and Behavioural Neurosciences Institute (MBNI). The research was funded by the National Institutes of Health.
‘This deals another serious blow to the idea that the placebo effect is a purely psychological, not physical, phenomenon,’ says lead author Jon-Kar Zubieta, M.D., Ph.D., associate professor of psychiatry and radiology at the U-M Medical School and associate research scientist at MBNI. ‘We were able to see that the endorphin system was activated in pain-related areas of the brain, and that activity increased when someone was told they were receiving a medicine to ease their pain. They then reported feeling less pain. The mind-body connection is quite clear.’
The findings are based on sophisticated brain scans from 14 young healthy men who agreed to allow researchers to inject their jaw muscles with a concentrated salt-water solution to cause pain. The injection was made while they were having their brains scanned by a positron emission tomography (PET) scanner. During one scan, they were told they would receive a medicine (in fact, a placebo) that might relieve pain.
Every 15 seconds during the scans, they were asked to rate the intensity of their pain sensations on a scale of 0 to 100, and they gave more detailed first-person ratings after the experiment. The researchers correlated the participants’ ratings with their PET scan images, which were made using a technique that reveals the activity of the brain’s natural painkilling endorphin chemicals, also called endogenous opioids.
Endogenous opioids bind to brain cell receptors called mu-opioid receptors, and stop the transmission of pain signals from one nerve cell to the next. Besides the brain’s own chemicals, drugs such as heroin, morphine, methadone and anaesthetics also act on the mu opioid receptor system to reduce pain.
Because the endorphin system naturally tries to quell pain whenever it occurs, the researchers slowly increased the amount of concentrated salt water being injected in the muscle as the scans continued, in order to keep the participants’ rating of their pain within the same point range throughout the experiment. The placebo, a small amount of hydrating solution, was then given intravenously every four minutes.
As the researchers alerted participants that the placebo was coming, and injected the placebo dose, the amount of additional concentrated salt water needed to maintain participants’ pain over time increased — indicating a reduction in pain sensitivity that the subjects were not aware of. In other words, thinking they were getting a pain drug actually allowed the participants to tolerate even more pain-inducing concentrated salt water than before.
After each scan, the researchers asked the participants more questions about their mood, emotions and other aspects of how they felt during the scans. There were significant differences between post-scan ratings given by participants after the scan in which they received the placebo, and after the scan during which they received the jaw injection alone.
Nine of the participants were classified as “high placebo responders” because they had more than a 20 percent difference between pain and placebo scans in their average pain ratings per volume of salt water infused — in other words, the placebo effect was strong. The other five were classified as ‘low placebo responders’.
These subjective ratings are consistent with previous findings, Zubieta notes. But the simultaneous imaging of the participants’ endogenous pain-reducing opioid systems sheds new light on why the placebo effect occurs.
The imaging method used in the study involves tiny doses of a medicine called carfentanil that is attached to a short-lived radioactive form of carbon, which releases subatomic particles known as positrons. These positrons are detected with the PET scanner, which acts like a photographic camera to capture those particles. It then determines exactly which part of the brain they originated from, and how many of them are coming from each brain region. The researchers also made MRI scans of the participants’ brains, which they cross-registered with the PET scans to give accurate information on exactly which brain regions were active.
Because carfentanil competes with the brain’s natural endogenous opioid painkillers for space on nerve cell receptors, the PET scans can be used to see how active the opioid system and mu-opioid receptors are. The stronger the positron signal from a particular brain region, the less active the mu opioid system, and vice versa.
All of the participants showed an increase in the activation of their mu opioid endorphin system after they were told that the ‘medicine’ was coming and the placebo was given. The most pronounced differences were seen in four areas of the brain known to be involved in complex responses to, and processing of, pain: the left dorsolateral prefrontal cortex, the pregenual rostral right anterior cingulate, the right anterior insular cortex and the left nucleus accumbens.
When the researchers correlated the mu opioid activity changes with the participants’ own ratings of their pain and emotions, they also observed that the placebo-induced activation of the opioid system was correlated with various elements of the experience of pain.
For example, activity in the dorsolateral prefrontal cortex was associated with the expectation of pain relief reported by the volunteers. In other areas, that activation was associated with relief of the intensity of pain, how unpleasant it was, or even how the individuals felt emotionally during the pain experience.
Because the new study was done only in healthy men between the ages of 20 and 30, further research will be needed to determine whether the effect occurs in women and in people with various illnesses. The power of placebos to ease pain symptoms has been well-documented in many groups of subjects and illnesses, but the researchers started with healthy young males to rule out the impact of chronic pain, mood disorders and hormone variations, which can also affect the endorphin system.
In addition to Zubieta, the research team included MBNI members Joshua Bueller, Lisa Jackson, David Scott and Janyun Xu; radiology professor Robert Koeppe, Ph.D.; Thomas Nichols, Ph.D., an assistant professor of biostatistics in the U-M School of Public Health; and Christian Stohler, formerly of the U-M School of Dentistry and now at the University of Maryland School of Dentistry.
Reference: The Journal of Neuroscience, August 24, 2005, Vol. 25, No. 34
The
importance of confidentiality in Record Keeping
When working in a well-established, friendly
practice with long-term patients, who feel more like friends, it is easy to let
professional relationships slip. However, one of the most fundamental principles
of dental ethics is that whatever information passes between the dentist and
patient in the course of a professional relationship is secret. This should be
straightforward enough, were it not for the fact that we are human…
The information that a practice holds about its patients should be protected to safeguard the patient and the practice. In most cases improper disclosures are unintentional, but a breach in a patient’s confidentiality could render a dentist liable to a charge of serious professional misconduct. Consideration for the patient, their family and friends must be a top priority within professional relationships. With the busy schedules that most surgeries work to, errors can occur and scenarios similar to the one outlined below can easily happen. Let me introduce you to John, the apprentice dental technician who has recently started his training.
It is the end of a busy working day and John has arrived to collect work for the laboratory where he works. He pops behind the reception desk to collect his box as June, the receptionist, is busy cashing up. Beside the box he notices a record card left out. He is drawn to it because of two red stickers, one displaying an account outstanding and the other a medical note. He recognises the patient’s name as that of a close friend. He also notices HIV+ noted in the medical box. Try as he might on his way home, he cannot stop thinking about it. It was amazing that his very close friend had not shared this information with him, or did he in fact know himself? Consumed with torment he goes home to confide with his fiancée. The following day, she tells the cleaner at work (after all the cleaner doesn’t know the people she is talking about, so that’s OK.) However, after relaying the story to her friend, the cleaner realises that she does know the person because of a connection with her daughter. And so the chain goes on. Consider the repercussions involved from a chance sighting.
In this case the record card should have been filed away and the medical notes kept inside the patient’s folder, with no mention of HIV or any ‘sensitive’ medical history on the cover, which could bear a note to ‘see medical history’.
The topic of confidentiality is one that must be treated with respect, ensuring maximum protection to the patient. The General Dental Council (GDC) publication Maintaining Standards (2001), states that:
’The dentist/patient relationship is founded on trust and a dentist should not disclose to a third party any information about a patient acquired in a professional capacity without the permission of the patient. A dentist must also be aware that the duty of confidentiality extends to other members of the dental team.’
Within dental practice there are many areas to look at so that the risk of disclosure can be minimised. Consider a patient entering a practice and track him / her through a potential visit.
Mrs Jones has arrived in reception for her appointment. She is very nervous and acutely aware of the people and noises around her. Trying to immerse herself in her newspaper she notices two staff members talking and starts to worry that they are talking about her. She pauses to listen and to her relief hears they are discussing Mary Smith, the previous patient. Apparently she had fallen pregnant and, as her wedding is due to take place in five months, she will have to have her lovely new wedding dress remade to fit her. Eventually Mrs Jones is called to a surgery over the loudspeaker. She wanders along the corridor not quite remembering which door it is. Glancing through the open doors as she goes she sees her neighbour - looking most odd without her teeth. Eventually, she arrives at the surgery. The dental nurse Helen helps to make her comfortable as the dentist is engrossed in a phone call. He concludes his call and greets his patient, but before treating her, asks Helen to flick up Mr George Hall’s records so he can make a quick medical note which Mr Hall’s doctor has just given him. Mrs Jones watches the ‘new technology’ on the screen in front of her. How clever it all is nowadays.
Mrs Jones has her treatment and then confides to the dentist that she and her husband are moving back to Wales. Could he possibly recommend a dentist? Helen, the dental nurse, makes a note on the whiteboard of Mrs Jones’ details and reassures her they will look into it and contact her. Just as Mrs Jones leaves she asks at reception for the outstanding balance on her husband’s account so she can settle the account before moving. Then she leaves to meet her friend for coffee. Joan, her friend, was really interested to hear all about Mary Smith being pregnant as she was friendly with Mary’s mother. She must ring her when she gets home. It was also interesting to learn that Mrs Jones’ next door neighbour had dentures - you would never be able to tell…
Mrs Jones had quite a visit. She has learned a little more information than ‘scale and polish required’. The information she heard in the reception area was private to that patient.
She should not have been able to see another patient receiving treatment without that patient’s permission. She was witness to another patient’s private records on the computer screen.
Her own details should not have been written in view of others unless she had agreed to it.
The receptionist should not have disclosed any information about the patient’s husband without his consent. There seems to be a common theme.
It is easy to see how breaches of confidentiality can occur when meeting a number of different members of the dental team. It is so easy for hygienists to pop into a dentist’s surgery to discuss the patient they have just seen who will be seeing the dentist next, while the dentist’s previous patient is still in the chair. The previous patient may be supine and watching a DVD or seemingly occupied taking a rinse or meditating through an impression. Hygienists and dentists must not hold such discussions assuming the patient in the chair is not listening. It is Murphy’s Law that they will know the patient who is being discussed.
The most important aspect of patient confidentiality is consent. The golden rule is that the secrets belong to the patient and not the dentist. Therefore, it is only permissible for a dentist or members of staff to disclose the information when the patient’s consent has been given.
There will be many reasons why a dentist is asked to disclose information about a patient.
In all but a very small minority of occasions the patient must first give their full consent to such disclosure. Children absent from school or employees from their work may give a visit to the dentist as an explanation. The dentist concerned must have their consent before confirming or denying that the claimed appointment has been attended. Dental records can be and are requested by solicitors, Inland Revenue, police or relatives. In all these cases the patient’s permission, preferably in writing, must be obtained before the records are released. There have been cases where a child’s parents are not living together and the estranged parent has requested information from the dentist regarding the child’s high caries rate to use to support a case that the other parent is unfit. The dentists concerned have no right to release the information unless proper authority is obtained.
In the case of a missing or deceased person, a breach of confidentiality by, for example, giving the police a copy of their dental records to help identification, can be justified in order to minimise distress caused to relatives at such a distressing time.
On occasion a patient, perhaps very ill, may be brought in for treatment by a relative or nurse. In such circumstances it would be totally reasonable to discuss the patient’s treatment with the accompanying person, especially if the accompanying person is involved in their care.
It is possible that a dentist may have information of a serious nature about a patient. Whilst having a duty of confidentiality to the patient, the dentist also has a duty to society and in some cases this may outweigh the duty to the patient. One such occasion arose when a dentist was contacted by the police following a report of attempted child abduction in the doorway leading to his waiting room. The police requested the details of all the patients who had visited the practice that morning and, due to the serious nature of the incident, the breach of confidentiality was merited.
A related issue concerns patient consent. Consent forms should be completed for a wide variety of treatments. These may be produced on headed practice paper with clear information regarding the treatments proposed along with any risks, drawbacks or limitations. However, to make consent valid it is essential that the patient concerned has fully understood all the information and the costs involved.
Furthermore, accurate entries must be made in the patient’s records, clearly showing that all required pre-treatment steps have been taken and notes of all agreements and explanations documented. The responsibility for the patient’s records is ultimately the dentist’s, although in most cases a PCD may be recording the data. Excellent training is required to make sure that staff are aware and competent to carry out this important job.
The use of patients’ photographs in practice newsletters or advertising will also require consent and even that innocent thank-you letter displayed in reception will need the patient’s permission. Radiographs with patients’ names displayed, record cards and other documents showing any information, no matter how trivial it seems, can all be deemed a breach of that patient’s confidentiality. It is important to consider what level of confidentiality is needed in the surgery and exactly what information the dentist and team members need to know. Different team members will need different levels. For example, unless he or she is in the habit of packing cotton wool rolls around outgoing laboratory work, a dental technician will not have the slightest interest in the medical note of a patient’s allergy to cotton wool, but a hygienist will of course need to know before tucking them into the sulcus.
It is important that how information is documented and the most secure way of storing or filing it. The reception area is often the most vulnerable for accidental disclosure due to the high volume of people who may be there at any one time. Others include surgeries and a number of other locations.
Suggestions for Minimising Risks of Accidental Disclosure
1. Reception Areas:
The information that a practice holds about its patients should be protected to safeguard the patient and the practice. In most cases improper disclosures are unintentional, but a breach in a patient’s confidentiality could render a dentist liable to a charge of serious professional misconduct. Consideration for the patient, their family and friends must be a top priority within professional relationships. With the busy schedules that most surgeries work to, errors can occur and scenarios similar to the one outlined below can easily happen. Let me introduce you to John, the apprentice dental technician who has recently started his training.
It is the end of a busy working day and John has arrived to collect work for the laboratory where he works. He pops behind the reception desk to collect his box as June, the receptionist, is busy cashing up. Beside the box he notices a record card left out. He is drawn to it because of two red stickers, one displaying an account outstanding and the other a medical note. He recognises the patient’s name as that of a close friend. He also notices HIV+ noted in the medical box. Try as he might on his way home, he cannot stop thinking about it. It was amazing that his very close friend had not shared this information with him, or did he in fact know himself? Consumed with torment he goes home to confide with his fiancée. The following day, she tells the cleaner at work (after all the cleaner doesn’t know the people she is talking about, so that’s OK.) However, after relaying the story to her friend, the cleaner realises that she does know the person because of a connection with her daughter. And so the chain goes on. Consider the repercussions involved from a chance sighting.
In this case the record card should have been filed away and the medical notes kept inside the patient’s folder, with no mention of HIV or any ‘sensitive’ medical history on the cover, which could bear a note to ‘see medical history’.
The topic of confidentiality is one that must be treated with respect, ensuring maximum protection to the patient. The General Dental Council (GDC) publication Maintaining Standards (2001), states that:
’The dentist/patient relationship is founded on trust and a dentist should not disclose to a third party any information about a patient acquired in a professional capacity without the permission of the patient. A dentist must also be aware that the duty of confidentiality extends to other members of the dental team.’
Within dental practice there are many areas to look at so that the risk of disclosure can be minimised. Consider a patient entering a practice and track him / her through a potential visit.
Mrs Jones has arrived in reception for her appointment. She is very nervous and acutely aware of the people and noises around her. Trying to immerse herself in her newspaper she notices two staff members talking and starts to worry that they are talking about her. She pauses to listen and to her relief hears they are discussing Mary Smith, the previous patient. Apparently she had fallen pregnant and, as her wedding is due to take place in five months, she will have to have her lovely new wedding dress remade to fit her. Eventually Mrs Jones is called to a surgery over the loudspeaker. She wanders along the corridor not quite remembering which door it is. Glancing through the open doors as she goes she sees her neighbour - looking most odd without her teeth. Eventually, she arrives at the surgery. The dental nurse Helen helps to make her comfortable as the dentist is engrossed in a phone call. He concludes his call and greets his patient, but before treating her, asks Helen to flick up Mr George Hall’s records so he can make a quick medical note which Mr Hall’s doctor has just given him. Mrs Jones watches the ‘new technology’ on the screen in front of her. How clever it all is nowadays.
Mrs Jones has her treatment and then confides to the dentist that she and her husband are moving back to Wales. Could he possibly recommend a dentist? Helen, the dental nurse, makes a note on the whiteboard of Mrs Jones’ details and reassures her they will look into it and contact her. Just as Mrs Jones leaves she asks at reception for the outstanding balance on her husband’s account so she can settle the account before moving. Then she leaves to meet her friend for coffee. Joan, her friend, was really interested to hear all about Mary Smith being pregnant as she was friendly with Mary’s mother. She must ring her when she gets home. It was also interesting to learn that Mrs Jones’ next door neighbour had dentures - you would never be able to tell…
Mrs Jones had quite a visit. She has learned a little more information than ‘scale and polish required’. The information she heard in the reception area was private to that patient.
She should not have been able to see another patient receiving treatment without that patient’s permission. She was witness to another patient’s private records on the computer screen.
Her own details should not have been written in view of others unless she had agreed to it.
The receptionist should not have disclosed any information about the patient’s husband without his consent. There seems to be a common theme.
It is easy to see how breaches of confidentiality can occur when meeting a number of different members of the dental team. It is so easy for hygienists to pop into a dentist’s surgery to discuss the patient they have just seen who will be seeing the dentist next, while the dentist’s previous patient is still in the chair. The previous patient may be supine and watching a DVD or seemingly occupied taking a rinse or meditating through an impression. Hygienists and dentists must not hold such discussions assuming the patient in the chair is not listening. It is Murphy’s Law that they will know the patient who is being discussed.
The most important aspect of patient confidentiality is consent. The golden rule is that the secrets belong to the patient and not the dentist. Therefore, it is only permissible for a dentist or members of staff to disclose the information when the patient’s consent has been given.
There will be many reasons why a dentist is asked to disclose information about a patient.
In all but a very small minority of occasions the patient must first give their full consent to such disclosure. Children absent from school or employees from their work may give a visit to the dentist as an explanation. The dentist concerned must have their consent before confirming or denying that the claimed appointment has been attended. Dental records can be and are requested by solicitors, Inland Revenue, police or relatives. In all these cases the patient’s permission, preferably in writing, must be obtained before the records are released. There have been cases where a child’s parents are not living together and the estranged parent has requested information from the dentist regarding the child’s high caries rate to use to support a case that the other parent is unfit. The dentists concerned have no right to release the information unless proper authority is obtained.
In the case of a missing or deceased person, a breach of confidentiality by, for example, giving the police a copy of their dental records to help identification, can be justified in order to minimise distress caused to relatives at such a distressing time.
On occasion a patient, perhaps very ill, may be brought in for treatment by a relative or nurse. In such circumstances it would be totally reasonable to discuss the patient’s treatment with the accompanying person, especially if the accompanying person is involved in their care.
It is possible that a dentist may have information of a serious nature about a patient. Whilst having a duty of confidentiality to the patient, the dentist also has a duty to society and in some cases this may outweigh the duty to the patient. One such occasion arose when a dentist was contacted by the police following a report of attempted child abduction in the doorway leading to his waiting room. The police requested the details of all the patients who had visited the practice that morning and, due to the serious nature of the incident, the breach of confidentiality was merited.
A related issue concerns patient consent. Consent forms should be completed for a wide variety of treatments. These may be produced on headed practice paper with clear information regarding the treatments proposed along with any risks, drawbacks or limitations. However, to make consent valid it is essential that the patient concerned has fully understood all the information and the costs involved.
Furthermore, accurate entries must be made in the patient’s records, clearly showing that all required pre-treatment steps have been taken and notes of all agreements and explanations documented. The responsibility for the patient’s records is ultimately the dentist’s, although in most cases a PCD may be recording the data. Excellent training is required to make sure that staff are aware and competent to carry out this important job.
The use of patients’ photographs in practice newsletters or advertising will also require consent and even that innocent thank-you letter displayed in reception will need the patient’s permission. Radiographs with patients’ names displayed, record cards and other documents showing any information, no matter how trivial it seems, can all be deemed a breach of that patient’s confidentiality. It is important to consider what level of confidentiality is needed in the surgery and exactly what information the dentist and team members need to know. Different team members will need different levels. For example, unless he or she is in the habit of packing cotton wool rolls around outgoing laboratory work, a dental technician will not have the slightest interest in the medical note of a patient’s allergy to cotton wool, but a hygienist will of course need to know before tucking them into the sulcus.
It is important that how information is documented and the most secure way of storing or filing it. The reception area is often the most vulnerable for accidental disclosure due to the high volume of people who may be there at any one time. Others include surgeries and a number of other locations.
Suggestions for Minimising Risks of Accidental Disclosure
1. Reception Areas:
2. Surgeries:
Collect patients one at a time for an appointment, even if they have come with a partner or another member of the family who also has an appointment. Many patients will suggest that they come to the surgery together and this may be appropriate. However, it is their decision and they should always be asked whether or not they wish to be seen separately or not, as some patients like to keep their dental affairs totally private and even their nearest and dearest have no idea what treatment or costs they have incurred.
3. Other areas:
If a patient’s records are removed from the practice (maybe for the dentist to complete paperwork at home), great care must be taken that they are kept private and in a secure container.
The above list is far from comprehensive and there are many other ways to reduce the risk of unfortunate disclosures. A practice meeting would be an ideal place for all the members of the dental team to become involved in setting up the rules of confidentiality for their practice.
Further Reading On Confidentiality
Matthews JBR. Risk Management in Dentistry. Oxford: Wright, an imprint of Butterworth-Heinemann, 1995:121-24.
Lee RG. Confidentiality and Medical Records. In Dyer C, editor. Doctors, Patients and the Law. Oxford: Blackwell Scientific Press, 1992:29-43.
MClinDent course staff visit to India
Dear colleague
I have arranged two seminars for prospective students who are
interested to apply for the Masters in Clinical Dentistry
(Prosthodontics). The seminars will give the chance for us to meet and
I will be able to address questions relating to this distance learning
programme. You will be able to receive application forms and specific
information regarding this MClinDent course you will have the
opportunity to ask any questions.
This is also an opportunity to bring along your original qualification
certificates (as well as a photocopy of these documents) and have them
signed and verified by myself there and then. The signed copy can be
used to speed up the application procedure and it is sent to the
University when you apply for a place, together with the application
form.
The venues will be:
Wednesday 7th September 2005 at 7pm
Taj Residency Hotel
41/3 M G Road
Bangalore 560001.
OR
Saturday 10th September 2005 at 7pm
Taj Mahal Hotel
Number One, Mansingh Road
New Delhi. 110011
Places are limited, so I would request that you indicate your interest
and choice of venue by return e mail.
Yours Sincerely
Dr Subir Banerji
Postgraduate Tutor & Consultant
MClinDent (Prosthodontics)
Distance Learning
----------------------
Unit of Distance Education
Guy's, King's and St Thomas' School of Dentistry
King's College London
Denmark Hill Campus
Caldecot Road
Fourth Floor, Rooms 433-435
London SE5 9RW
UK
Email: m.clindent@kcl.ac.uk
Tel +44 (0) 20 7346 3597
Fax +44 (0) 20 7346 3496
I have arranged two seminars for prospective students who are
interested to apply for the Masters in Clinical Dentistry
(Prosthodontics). The seminars will give the chance for us to meet and
I will be able to address questions relating to this distance learning
programme. You will be able to receive application forms and specific
information regarding this MClinDent course you will have the
opportunity to ask any questions.
This is also an opportunity to bring along your original qualification
certificates (as well as a photocopy of these documents) and have them
signed and verified by myself there and then. The signed copy can be
used to speed up the application procedure and it is sent to the
University when you apply for a place, together with the application
form.
The venues will be:
Wednesday 7th September 2005 at 7pm
Taj Residency Hotel
41/3 M G Road
Bangalore 560001.
OR
Saturday 10th September 2005 at 7pm
Taj Mahal Hotel
Number One, Mansingh Road
New Delhi. 110011
Places are limited, so I would request that you indicate your interest
and choice of venue by return e mail.
Yours Sincerely
Dr Subir Banerji
Postgraduate Tutor & Consultant
MClinDent (Prosthodontics)
Distance Learning
----------------------
Unit of Distance Education
Guy's, King's and St Thomas' School of Dentistry
King's College London
Denmark Hill Campus
Caldecot Road
Fourth Floor, Rooms 433-435
London SE5 9RW
UK
Email: m.clindent@kcl.ac.uk
Tel +44 (0) 20 7346 3597
Fax +44 (0) 20 7346 3496
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