How patient consent can help build trust and confidence

Supporting professionalism and learning

We want to regulate in a way which promotes learning over fear, supporting dental professionals to continuously demonstrate professionalism, rather than driving behaviours through the threat of fitness to practise. Our role is to give clear, easy to use guidance that supports dental professionals to show good judgement and professional behaviour in providing good oral healthcare for patients and the public.   

This blog, how patient consent can help build trust and confidence, is part of a series to support your learning and encourage good practice and continuous improvement to achieve positive patient outcomes.

We all understand the need for patient consent in dentistry. Not only is it a legal requirement, but essential for building patient trust and confidence. As a member of the dental team, you are expected to know how to obtain and record valid consent. That being said, failure to obtain valid consent continues to feature in our investigations. For instance, over the past few years, amongst cases presented at the Dental Professionals Hearings Service, not obtaining valid consent and not documenting consent have collectively featured in around 3-4% of all considerations. These figures may indeed be higher, as issues relating to consent often emerge as an investigation progresses. This underpins the importance of obtaining valid consent, as a process that helps patients to understand their treatment options, any risks or benefits, and the costs involved¹.

In this blog, I am going to explore some of the issues around consent, what can be learned from the cases we see and share my insights from my role as a GDC clinical adviser, starting with a reminder about what we mean by valid consent.

Informing patients for valid consent

Valid consent for dental exams is implied when patients are informed, and they then voluntarily sit on the dental chair and open their mouth. For other procedures, express consent (spoken or written) is required. The exception to this is when acute attention is needed to prevent serious harm or the loss of life.

When informing patients (or their representatives) remember to:

• provide complete and clear information, in a way they can understand
• give adequate information for a reasonable person in their position
• avoid making any assumptions
• use everyday words and avoid jargon or improper terminology
• answer any questions they might have in full.    

The person you are informing must have the capacity to understand and retain the information (be that only for a period that is long enough for them to weigh it up), make informed choices and communicate their decision. You can assume that all adult patients have the capacity to consent, unless it has been determined that they lack capacity, in which case you should document your decision and the justification.  

Valid consent must be voluntary and can be withheld or withdrawn at any time. Recording these discussions is crucial. Check in with your patient at each stage of treatment to make sure that their consent remains valid.

Obtaining informed consent requires informing patients about all clinically relevant treatment options and the material risks². Let’s explore these requirements using some examples and provide some further guidance on recording consent.

Setting out clinically relevant treatment options

Relevant treatment options should be identified and appropriately appraised, without confusing patients with irrelevant choices. Giving too much information can confuse and overwhelm patients, which can result in deferred or declined treatment and sometimes avoidable disease progression, or other adverse impacts on oral health.

The following are real examples of treatment options, which were highly unlikely to be relevant, and therefore, presented unnecessarily:

• root canal treatment at an asymptomatic, well-supported premolar tooth with a moderate sized carious (decay) lesion which was not in close proximity to the dental pulp chamber (space in a tooth that contains the pulp tissues which includes nerves, blood vessels and connective tissues)
• the suggestion of invasive, multiple full-coverage crown restorations for a patient with an otherwise healthy, minimally restored dentition, seeking only a tooth colour change.

You can recommend treatment options. This may not be well understood or may be understandably avoided when it is impossible to accurately predict the treatment outcome. Nevertheless, treatment options and any recommendation should be presented in a logical, accurate and balanced manner, and where possible, based on current evidence and authoritative guidance.

Consider what a reasonable person would expect to know before deciding to proceed with treatment, as poor communication is often the root-cause of dental complaints and concerns. The use of visual aids can be helpful for some people, and on occasion, I have seen drawings included in the patient records, which may prove to be supportive.

Delegating consent and your responsibilities

Obtaining consent can be delegated to qualified individuals who understand the patient's history. However, the treating clinician remains responsible for ensuring valid consent has been given, before treatment begins.

I have encountered cases where consent and payment for elective minimally invasive procedures, like composite bonding at multiple teeth has been obtained by others but not confirmed by the treating clinician. As the treating clinician, you should check that your patient has fully understood common risks for treatments procedures. For instance, for composite bonding these may include (but not limited to) chipping, staining, de-bonding, sensitivity, the perception of bulk, potentially unwanted changes to the bite, and loss of lustre, as well as the longer-term maintenance requirements. 

Minimally invasive treatment should not be confused with non-invasive treatment. The risks of treatment failure, the potential consequences and longer-term care needs, especially for more complex treatment plans, must be properly explained. Proceeding without this can create vulnerabilities.  

Discussing the material risks and benefits

Before treatment begins, you should discuss with your patient:

• the benefits of treatment
• any appropriate alternative options, and
• the material risks.

Material risks are those considered significant to a reasonable person in your patient’s position or, those known to be significant to the specific patient. Patients need to be made aware of the material risks and understand their implications. Options may be weighed against no treatment, although for some clinical presentations, the option of no treatment may be irrelevant and doesn’t need to be recorded.

Commonly identified risks and specific material risks should be discussed. For example, a discussion about the risks of the irreversible loss of tooth tissue and pulp tissue death following a full coverage crown preparation at a vital, non-root canal treated tooth would usually be expected. However, the risk of lisping, following the fitting of a set of upper front crowns, may be of material importance to someone employed as a public speaker.

This process shouldn’t be confused with providing an exhaustive list of risks, such as those from administering local anaesthesia for a routine restoration, which is not usually a material risk. You will only deter patients from proceeding with care. However, where there is a known prior complication, such as a history of Bell’s palsy, from a dental local anaesthetic, when planning on using an inferior dental block technique to numb the lower jaw, some discussion would be expected.

You are unlikely to be criticised for not recording risks for simple, routine, minimally invasive procedures like a scale and polish, especially with a history of prior provision and no adverse outcomes or risk factors. However, we do hear from patients treated in mixed practice settings, who say they were not offered a routine, clinically indicated, scale and polish on the NHS, but instead given the sole option of private dental hygiene treatment. It is important to not mislead patients into believing that treatments available on the NHS, can only be provided privately.

Being sensitive to your patient’s individual needs and values is important. Patients have raised issues about not being informed of the use of dental materials that may contain animal derived ingredients, and similarly, some patients may object to the use of bone augmentation materials containing bovine bone. 

The importance of recording consent

Record keeping often now includes the use of pre-populated templates, copy-paste methods and support from other members of the dental team. These records must be properly verified in a timely manner by the treating clinician. However, these records can be written in a concise way.

Accurate records are vital for mitigating allegations of failure to obtain consent. Poor use of record keeping templates or copy-paste notes, can invite errors, for example, I have seen cases where oro-antral communication was incorrectly recorded as a risk for the extraction of a canine tooth in the lower jaw. Records should capture your patient's understanding of the information you have provided.

With the potential for AI tools to support clinical decision-making and to include the attainment of consent, it is important to have a clear understanding of how these and other automated tools work and their limitations. Ultimately, the treating clinician is responsible for ensuring compliance and appropriate decision making; it would be improper to blame shortfalls on tools such as AI. I have encountered examples of over-reliance on tools for caries diagnosis, resulting in gross over-prescription, as well as inaccurate (or absent) clinical records following the use of voice-capture tools where the clinician was not aware until a concern was raised.

Not having an accurate record of consent can result in challenging fact-finding later, particularly when relying on a (busy) clinician's recollection versus a patient's conflicting account. In such cases, there is the possibility that the patient's version of events could be favoured, especially if further time has elapsed. Encourage your patients to ask questions and invite them to repeat the information provided to confirm their understanding. Keep documentation.

Fees, written treatment plans and consent forms

Disputes about treatment costs, terms of care i.e. NHS or private, and treatment guarantees often leads to complaints or concerns being raised. Clear communication is essential. Provide timely written treatment plans, keep copies and clarify NHS/private terms. Written treatment plans should include key information and be signed.

In some of the cases we see, written treatment plans are often either not supplied, provided after care has been commenced or not retained. Patients frequently cite treatment plans when raising issues about complex care, which sometimes only list fees.

Occasionally, the treatment prognosis will be guarded. It is crucial that your patient understands that it is not always possible to predict the treatment outcome, and the consequences of premature failure of the proposed treatment. In one case, fillings were done at teeth with guarded prognostic outcomes, with the prognosis only becoming clear to the patient when they made a complaint. Unfortunately, written treatment plans were not supplied and there was no clear documentation of discussions about prognosis and guarantees.

Signed written treatment plans and signed consent forms support the attainment of consent, but a signature or consent form alone is insufficient. Conversely, the absence of a treatment plan does not imply failure to obtain consent but remember that costs must be discussed and documented in the patient's clinical notes. Altering a signed treatment plan can result in questions about integrity.

Written consent is required for treatments involving conscious sedation or general anaesthesia, and the process must include appropriate discussions and documentation. Written consent is also advisable if you want to use photographs outside of the patient record.

The prognosis of the treatment and ‘cooling off periods’

Discussing the likely prognosis, guarantees, duration, and any exclusions of a treatment is important. However, treatments including (but not limited to) the rehabilitation of tooth wear have limited long-term data on restoration survival, and new dental materials and techniques are continually emerging, which can sometimes make it highly challenging to offer a likely prognosis.

This issue commonly arises when providing:

• immediate replacement dentures (fitted at the time of extraction), and
• the placement of deeper fillings (closer to the pulp chamber).

In the case of immediate replacement dentures, the post-extraction tissue changes accompanying the healing process may subsequently result in an ill-fitting appliance, necessitating remedial treatment, which could include making a new denture. For deeper fillings, root canal treatment may be required, if the pulp tissue responds adversely to the intervention. Accurately predicting the need and extent of any remedial care in either scenario is not always possible, but you should properly inform patients, from the outset, when there is a realistic risk of an adverse outcome. The need for further treatment and the accompanying costs should not come as a surprise.

Some patients report being given the impression that routine treatments like crown or onlay restorations provided on the same day as the initial examination would offer a ‘permanent solution,’ or last for at least 25 years. This and similar situations can arise from inadequate or rushed consent processes, or where the patient has not had enough time to consider the information or ask questions. Of course, some patients can make informed choices, without the need for more time.

You can help avoid any issues by offering a cooling-off period. These can be particularly important for some patients, especially for those with more complex or elective treatment plans. You should also confirm consent immediately before treatment, as it can be withdrawn at any time.

Where to go if you want to know more

Careful and effective communication helps to avoid many of the issues raised by patients relating to consent. Patients (or their representatives) must be properly informed about the risks and benefits of all reasonable treatment options - before treatment begins.

You must have documentation supporting the attainment of consent. It can be crucial if concerns are raised, and it will help clinical advisers and others to understand exactly what has happened. Your documentation should:

• reflect the patient's understanding of their options, and
• confirm they have made an informed choice.

Remember the importance of recognising and promoting patient rights, their role in making decisions about their health, and to act in their best interests.

You may find this additional information helpful:

• Standards for the dental team | Principle 3: Obtain valid consent
• CQC | Dental mythbuster 23: Consent to dental treatment
• SDCEP Practice Support Manual | Obtaining consent for a dental examination and treatment

Find out more on a related topic, dental record keeping.

References:

1. GDC, Unlocking the potential of GDC fitness to practice data, April 2024
2. The Lancet, How Montgomery is reconfiguring consent in the UK, Volume 392, Issue 10142 p102-104, July 2018

This blog is part of a series by Shamir Mehta, please read his other blogs:  

Clear aligner treatment: What can we learn from complaints and concerns? 

Dental record keeping: what is professional, reasonable and in the interest of patients?