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“Expert-driven education”
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The complete guide for

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With 30 SJTs & 30 Professionalism (PML)
and Communication Scenarios with Detailed
Explanations and Tips

First Edition
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Written by Dr. Rajen Nagar, Alaa Guni,
Dr. Dima
Written Mobarak
by Dr. andDr.
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Preyesh Patel
Mobarak,
Mr. Rajen Nagar & Dr. Priyesh Patel
 The complete
professionalism,
guide for
management
DFT interviews
and leadership station (PML) Advice Scenario
and guide1

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2431 Dental Final Year Advert 1.indd 1 19/08/2016 11:04
The Complete Guide for DFT
Interviews
First Edition

“Expert-driven education”
 The Complete Guide for DFT
Interviews
First Edition

Dr. Rajen Nagar BDS

Dr. Alaa Guni BDS (hons)
Dr. Dima Mobarak BDS
Dr. Preyesh Patel BDS

With thanks to

Dr. Alisdair Miller BDS, FFGDP, FFGDP, FDS, FAcadMEd

Professor Nicholas Grey BDS, MDSc, PhD, DRD, MRD, FDSRCSEd, FHEA
Dr. David Whitehouse BDS, PG Cert TLCP
Dr. Kalpesh Prajapat BDS
Dr. Sarah Sacoor BDS

“Expert-driven education”
© 2016 DentaliQ Ltd
DentaliQ
36 Marcia Road
London
SE1 5XF

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise without the prior permission
of the copyright owner.

First published 2016

Printed and bound in the UK

The information contained within this book was obtained by the author from
reliable sources. However, while every effort has been made to ensure its
accuracy, no responsibility for loss, damage or injury occassioned to any
person acting or refraining from action as a result of information contained
herein can be accepted by the publishers or author.

In turn, the views and opinions expressed in this book are those of the authors
and are not a representation of COPDEND. This book is a general guidance for
candidates wishing to undertake the DFT interview however it is not designed
to be a rehearsed method of tackling the scenarios. It is important to answer
the scenarios in your own personal way.

DentaliQ Revision Books and Courses

At DentaliQ, our mission statement is all about making learning simple, easy
and fun whilst being supported by experts in the field of Dentistry. With
DentaliQ, you can learn Dentistry the fun and simple way. Be sure to download
our revision app on the iTunes app store (for iOS) or Google Play (for Android).

For further details, please contact:

www.dentaliq.co.uk [email protected]
CONTENTS
About the authors ..................................................................................... xii
About the contributors ............................................................................. xiv

Chapter 1
An introduction to DFT
An introduction to Dental Foundation Training (DFT) .............. 2
Applying for DFT ................................................................................... 3
Assessment centres and schemes ................................................. 8

Chapter 2
The professionalism, management
& leadership (PML) station

2.1 Theory & advice

PML overview ........................................................................................ 14
PML answer framework ...................................................................... 18
PML scoresheets ................................................................................... 25

2.2 Practice scenarios

PML practice scenarios
1 A father’s influence ..................................................... 29
2 Left alone ....................................................................... 33
3 A difference in opinion ............................................... 37
4 Parental guidance? ...................................................... 41
5 A mother’s influence ................................................... 45
6 Say cheese! ................................................................... 49

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and guide1 Contents

7 Dentist on call ............................................................... 51

8 Oops! .............................................................................. 55
9 Half-time! ........................................................................ 59
10 Nurse feeling worse? .................................................. 63
11 A careless colleague .................................................. 67
12 An irritating injection ................................................... 71
13 An incompetent implantologist? .............................. 75
14 The root of the problem ............................................. 79
15 Naughty nurses ............................................................ 83

Chapter 3
The communication station

3.1 Theory & advice

Introduction ............................................................................................ 88
What is the examiner looking for? .................................................. 90
What is the actor looking for? .......................................................... 92
Communication framework: overview .......................................... 94
Communication framework: detailed breakdown ..................... 95
Gathering information ........................................................................ 98
Clinical examination ............................................................................ 102
Explaining the problem ...................................................................... 103
Closing the session .............................................................................. 107
General add-ins ..................................................................................... 108
Communication marking criteria ..................................................... 110

3.2 Clinical explanations

Dental extraction .................................................................................. 114
Root canal treatment .......................................................................... 116
Composite filling .................................................................................. 118
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Amalgam filling ..................................................................................... 120

Glass ionomer cement ........................................................................ 122
Crown ....................................................................................................... 124
Resin-retained bridge .......................................................................... 126
Cantilever bridge .................................................................................. 128
Denture ..................................................................................................... 130
Copy denture .......................................................................................... 131
Dental implant ........................................................................................ 132
Reline ........................................................................................................ 134
Rebase ...................................................................................................... 136

3.3 Practice scenarios

1 In pain ............................................................................. 141
2 Dry socket ..................................................................... 147
3 A nervous patient ...................................................... 153
4 Treatment options ....................................................... 157
5 Sleepless nights ........................................................... 161
6 Bullying behaviours .................................................... 167
7 Total recall ..................................................................... 171
8 A rude receptionist ..................................................... 175
9 The extraction .............................................................. 179
10 A recurrent issue ......................................................... 183
11 Mercury mouth ............................................................. 189
12 The wisdom tooth ........................................................ 193
13 Positive discrimination ............................................... 197
14 Periodontal advice ...................................................... 201
15 A wrong shade ............................................................. 207

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and leadership station (PML) Advice Scenario
and guide1 Contents

Chapter 4
The situational judgement test (SJT)

4.1 Advice & guide

About the SJT exam ............................................................................ 214
Key facts & important tips ................................................................. 220

4.2 Ranking questions

Questions 1 to 15 .................................................................................. 224

4.3 Ranking answers

Answers 1 to 15 ..................................................................................... 242

4.4 “Best of threes” questions

Questions 1 to 15 .................................................................................. 254

4.5 “Best of threes” answers

Answers 1 to 15 ..................................................................................... 270

Chapter 5
Post-interview guide

Choosing the right DFT practice for you ...................................... 284

Main considerations ............................................................................ 286
Other factors to consider ................................................................... 288
Meet and greet checklist ................................................................... 292

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Chapter 6
Guidelines
NHS dental banding ............................................................................ 296
The complaints protocol .................................................................... 299
Negligence and claims ....................................................................... 305
Maintaining records and patient confidentiality ........................ 308
Data protection and Caldicott principles ...................................... 314
Consent: competence and capacity ............................................... 316
Quality assurance, clinical governance, patient safety and
audits ........................................................................................................ 322
RIDDOR & IR(ME)R ............................................................................... 325
CPD ........................................................................................................... 327
COSHH ..................................................................................................... 329
NICE guidelines: wisdom tooth extractions ................................. 330
Orthodontic referrals ........................................................................... 332
Sedation ................................................................................................... 334
Bisphosphonate therapy .................................................................... 337

xi
 About the authors
Dr. Rajen Nagar

Dr. Rajen Nagar is the Founder and Director of DentaliQ,

and enjoys working with the many talented people
of the team. Having graduated with his BDS from
The University of Manchester, Rajen continued his
professional training in Central London. Following his
studies, he left with several clinical and academic prizes
as well as being ranked as the No. 1 dental student in the UK through the DFT
recruitment interviews.
During University, he was closely involved in educational events, being a
founding member of the British Undergraduate Dental Research Conference
(BUDRC). He has also been a representative for the British Academy of
Cosmetic Dentistry (BACD), which involved helping to organise their corporate
events and national conferences. Rajen aims to pursue a rich and diverse
career in Dentistry and looks forward to the year to come.
Outside of Dentistry, Rajen enjoys playing and teaching the piano and violin,
which has lead to him setting up a classical instrument learning website with
leading musicians across the UK.

Dr. Alaa Guni

Dr. Alaa Guni graduated from Kings College London in

2014 with Honours and several awards including; The
War Memorial Prize 1st Place, Ronald Gains Prosthetics
Prize Cert of Merit and Maurice Wohl General Dental
Practice Prize Cert of Merit. Following a year of work in
General Practice he wanted to further develop his skills
in all aspects of General dentistry and began working as an Associate in Oxford
in mixed NHS/Private practice as well as working with specialists on Saturdays
in a fully private setting. Alaa has a passion for teaching and mentoring the
younger generation of dentists to ensure they are as fully equipped for the
future challenges in the lifelong career of dentistry. Hence, he has lectured at
universities and schools throughout the country, been involved in workshops to
impart his experience and has also written several articles in relation to DFT on
Dentinal Tubules.

xii
 Advice Scenario
and guide1
Dr. Dima Mobarak

Dr. Dima Mobarak is a University of Birmingham

graduate and has completed her dental foundation
training at her first choice scheme: Birmingham City.
She is currently completing her dental core training in
Restorative and Oral Surgery at The University Dental
Hospital of Manchester and aims to go into specialty
training in 2 years. She is passionate about education and is currently a mentor
for younger dental students at her university. Dima has had a lot of experience
in DFT preparation having worked as an event coordinator with Dental Training
Consultants and organised DFT mock interview courses at the Birmingham
and London interview centres. She is heavily involved in dental and non-dental
humanitarian charity work, having set up oral health promotion schemes in local
primary schools and trained junior dental students in her projects.
Dima has an interest in facial aesthetics and adult orthodontics - she has
undertaken a study on Invisalign at Arthur Dugoni School of Dentistry, San
Francisco and was invited to present this at the International Association for
Dental Research Conference 2016 in Seoul, South Korea. She has been a
representative for the British Academy of Cosmetic Dentistry for two years
and has taken part in organising numerous corporate events and national
conferences with them.

Dr. Preyesh Patel

Having studied in Kings College London, Preyesh has

had first hand opportunity to work with several leading
professionals in the field of Dentistry. This has propelled
his desire to produce publications of his own and work
further in this field. Prior to becoming a co-author of this
book, Preyesh had previously delved into many solo
ventures as an individual. He has written a book dedicated to ‘Professionalism,
Management and Leadership’ scenarios, as well as writing articles for Dentinal
Tubules, Dental Update and Teeth Geek. Through this book, Preyesh hopes to
convey his passion for Dentistry while at the same time equipping the reader
with the necessary skills to succeed in this interview process.

xiii
 About the contributors
Professor Nicholas Grey
BDS, MDSc, PhD, DRD, MRD, FDSRCSEd, FHEA

Professor Nick Grey is currently Associate Dean for

Teaching and Learning in the Manchester Dental School
faculty. His main role within the School of Dentistry is in
teaching. His current theme is to explore new models
of the delivery of teaching and learning for Student
Dentists, to enhance their experience. In addition, he is developing novel
ways to engage the student body using a myriad of ways of communication.
Nationally he is an examiner for Royal College of Surgeons and also a member
of their Advisory Board in Restorative Dentistry. He has lectured nationally
and internationally and co-authored one textbook. In 2007 he was awarded
“Teacher of the Year” for his efforts in enhancing the learning experience for
Students. As Head of School he has overseen the building of a State of the
art Clinical Skills Facility and the refurbishment of the main undergraduate
clinical treatment clinic which places Manchester at the forefront of high quality
teaching resources.

Dr. Alasdair Miller

BDS, FFGDP, FFGDP, FDS, FAcadMEd

As an experienced dental practitioner, Alasdair works

very closely with a number of organisations to influence
and shape the landscape of dentistry and education.
In 2014/5 he was the President of the BDA. His past
experience includes acting Programme Director and
Dental Postgraduate Dean for DFT placements as well
as the Programme Director of Bristol University’s BUOLD diploma programme.
Alasdair is the current director of the Lloyd & Whyte Group, the award-winning
and leading insurance brokers to healthcare professionals, and an associate
with Synergy Global Consulting. Alongside these duties, he was also a non-
executive director of various health authorities and companies. He is the
Council member of the MDU, QA inspector for the GDC and External Examiner
for NEBDN. All of these experiences have lead him to develop a passion for
encouraging success in others via executive coaching. When not involved
engaged in these activities he skis, sails and plays his saxaphone, badly!

xiv
 Dr. David Whitehouse
BDS, PG Cert TLCP

Dr. Whitehouse is the practice owner and partner

of Johnson & Whitehouse, Chester. He is an
undergraduate tutor for Liverpool University, a
postgraduate trainer with Mersey Deanery and was
the Dental Clinical Lead for the Western Cheshire
Primary Care Trust. He also is a member of the formative Local Professional
Network. David’s professional interests are general family dentistry, advanced
conservation and surgical dentistry.
Dr. Whitehouse is a member of the British Dental Association, The Society for
the advancement of Anesthesia in Dentistry, the Dental Defence Union and the
European Mentoring and Coaching Council.

xv
 The complete
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guide for
management
DFT interviews
and leadership station (PML) Advice Scenario
and guide1

theyoungdentist.com
is one of the many
resources provided by
Dental Protection to
support you in the early
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• Risk
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resources

• Events

• Publications

For more information about the benefits of membership

visit dentalprotection.org/youngdentists

Careers • Events • Competitions • Top Tips • Work Abroad • Volunteer

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Society Limited (MPS) which is registered in England (No.36142). Both companies use Dental Protection as a trading name
2431:08/16

and have their registered office at 33 Cavendish Square, London W1G 0PS. Dental Protection Limited serves and supports
the dental members of MPS with access to the full range of benefits of membership, which are all discretionary, and set out
in MPS’s Memorandum and Articles of Association. MPS is not an insurance company. Dental Protection® is a registered
trademark of MPS.

2431 Dental Final Year Advert 2.indd 1 18/08/2016 09:11

 Chapter 1
An introduction to DFT

ship

unteer
otection
name
2431:08/16

pports
set out
red
1

18/08/2016 09:11
 The complete
professionalism,
guide for
management
DFT interviews
and leadership station (PML) Advice Scenario
and guide1

An introduction to Dental Foundation Training (DFT)

Dental Foundation Training (DFT) is a curriculum-based training year

that provides a broad clinical experience of NHS dentistry.

The program provides a method of ensuring clinical administrative

competence in newly trained dental graduates in order to work
effectively and to a high standard within NHS general dental practice. It
aims to provide a high standard of training by offering a wide variety of
experiences in dental treatment to underpin further training. The training
year also helps graduates prepare for postgraduate examinations
such MJDF and MFDS as well as careers in Dental Core Training and
specialist posts.

Alongside clinical practice, the DFT year consists of a clear curriculum

of a range of competencies to provide an academic structure to the
training program. This is in the form of weekly study days organised
outside of the dental practice by the deanery, and weekly tutorials given
within the practice by the DFT trainer. In this way, one year is spent in an
approved dental practice within a selected deanery with a trainer who is
an experienced dental practitioner.

On top of providing experience of NHS dentistry, successful completion

of the DFT post grants the trainee a performer number on the NHS
dental list, allowing them to work as an NHS dentist. Dentists may work
within the NHS without undergoing this training year; however, this is
reserved for individuals who can show they have received relevant
experience of NHS dentistry, have training equivalent to DFT or are
exempt from undertaking DFT.

Competition for DFT posts is highly competitive and places are open
to candidates outside of the UK. To be eligible for the DFT year, a full
registration with the GDC with a valid UK work visa with no training
restrictions is required.

2
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Applying for DFT

The recruitment process

All assessments for the DFT post take place within a number of
centralised centres across England, Northern Ireland and Wales.
Applicants are assigned to centres that correspond to the geographical
location of their dental school (see page 24 - Assessment centres).

Stage 1: Applications open

Applications open via the NHS Recruitment website (www.oriel.
nhs.uk/) between August to September. Candidates need to
register their basic details by the given deadline in order to confirm
eligibility and assign a place for interview.

Stage 2: Assessments conducted

Candidates undergo their DFT assessments in regional assessment
centres. The assessments comprise of three core subjects (see
page 21 - Interview format).

Stage 3: Schemes ranked

Following the assessment, candidates can then rank their scheme
preferences from the most to least desirable.

Stage 4: Rank and schemes allocated

Candidates receive their assessment score and rank. Based on this
score, they are assigned their scheme preference. The higher the
rank, the more likely they are to obtain their first choice scheme.

Stage 5: Practice selection

Trainees receive a list of dental practices within their assigned
scheme to rank in order of preference. The higher their rank, the
greater the chance of securing the top choice dental practice.

3
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and leadership station (PML) Advice Scenario
and guide1

However, some schemes carry out a second round of interviews,

whereby the candidate and trainer rank each other and are paired
up accordingly.

Stage 6: Begin your DFT post!

Now that you have been allocated a scheme and a practice with a
trainer, you are now ready to begin your DFT training post and carry
out your first year performing as a graduated dentist! Training posts
usually start on 1st September. However, candidates who secured
one of the March start-date schemes, will begin in March of the
same academic year.

Application statistics

The figures from the table

2015/16
have been taken from the
Places total 976 COPDEND Funnel Report. This
Applicants total 1269 document can be accessed
Applicants eligible 1268 from the following shortened
Applicants invited to interview 1268 URL link: goo.gl/98Ki2U
Applicants interviewed 1189
Offers total 1063
Accepted placement 976
Not accepted placement 87
Not offered a placement 97*

*5 of the 97 candidates not offered a place preferenced

themselves out of a job (i.e. they could have been offered a job
in a scheme, but they chose not to place the scheme on their
preference list). With the number of applicants exceeding places
available, the DFT training post is highly competitive, and cannot
be guaranteed for UK dental graduates. Therefore, preparation is
imperative to secure a post.

4
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Interview format
The DFT assessments comprise of three core elements: a
professionalism station (PML), a communication station and a situational
judgement test (SJT). These are detailed below.

Part 1: Professionalism, management and leadership (PML) station

(10 minutes)
This station assesses a candidate’s ability to think critically, ethically
and morally about a given scenario, relating the scenario to the
GDC standards and giving methods of managing the scenario in
clinical practice. Unlike the communication station, there is no actor
in this station; the candidate discusses their management with
two examiners guided by a number of prompts provided in the
scenario text. The aim of this station is to examine the candidate’s
moral compass and their critical thinking skills to problem solve and
resolve tricky situations that may arise during their DFT training year.

Candidates are given 5 minutes to prepare for the station and 10

minutes to discuss their management with the two examiners. Both
the examiners mark the candidate and collate their scores to form an
average score for the station.

Part 2: Communication station (10 minutes)

The communication station assesses a candidate’s ability to
effectively and successfully communicate with a patient actor
giving a clear plan of action or management in response to the
given clinical scenario. It is essentially an actor-based OSCE station.
Therefore, the aim of this station is to form a judgement of how the
candidate would interact with their patients during their DFT training
year.

Similar to the professionalism station, candidates are given 5

minutes to prepare for the station and 10 minutes to interact with the
patient. Marks for this station are collated and averaged between an

5
 The complete
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and leadership station (PML) Advice Scenario
and guide1

examiner (who has no active involvement in the role play) and the
actor themselves.

Part 3: Situational judgement test (105 minutes)

The situational judgement test (SJT) assesses the candidate’s ability
to correctly judge a given scenario and form rational, ethical and
moral responses. The test consists of two sections: the first is a
ranking exercise, whereby the candidate has to rank five responses
to a given scenario in order of most to least appropriate; the second
part consists of the candidate choosing the best three out of eight
responses to a given scenario that are the most correct when
chosen together. The first and second parts consist of 42 and 12
questions respectively.

Key dates
The key dates for the DFT recruitment cycle vary each year by the
discretion of COPDEND. However, they usually follow the same
guideline dates and months. For the 2016/2017 DFT cycle, the dates are
as shown below.

Activity Date
Applications open 25 August 2016
Applications close 22 September 2016
Interviews commence 21-25 November 2016
Scheme preferencing opens 8 December 2016
Scheme preferencing closes 15 December 2017
Rank and offers given 09 January 2017
Second round offers given 10 July 2017
Placement commences March 2017 and September 2017

The dates from the table above have been taken from the COPDEND website
(http://www.copdend.org).

6
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and guide1

Submitting your application

Applications in England, Wales and Northern Ireland are handled by
the London Deanery Recruitment office and COPDEND. For the latest
information for your DFT recruitment cohort, it is advisable to read the
guidance notes provided by COPDEND on the London Deanery website
at http://www.lpmde.ac.uk.

Applying to Scotland
The application process for Scotland is handled separately from the
London Deanery Recruitment office. Any fifth year dental student may
apply to Scotland regardless of whether they studied in a Scotland-
based dental school or not. Applications for Scotland DFT recruitment
may be made by emailing [email protected]. The
deadline for submission is in early January.

The application process involves submitting an application form with

supporting identification documentation as outlined by the Scotland
recruitment guidelines.

7
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and guide1

Assessment centres and schemes

Assessment centres
DFT assessments take place in centralised locations according to the
geographical location of the candidate’s dental school. The table below
gives the venues of the assessment centres by region and dental school.

Region Venue Dental schools covered

Belfast Ramada Hotel, Shaw’s Bridge, Belfast Queen’s University, Belfast

Birmingham West Bromwich Albion University of Birmingham

University of Sheffield

Bristol Bristol Marriott Hotel, City Centre Bristol University

Cardiff University
Peninsula College of Dentistry

London London Recruitment Events Centre King’s College London

Queen Mary
University of London

Manchester Reebok Stadium, Bolton University of Central Lancashire

University of Liverpool
University of Manchester

Newcastle Newcastle United Football Club Newcastle University

Leeds United Football Club University of Leeds

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and guide1

Schemes across England, Wales and Northern Ireland

The list below provides the schemes available for DFT applicants. They
are always subject to change, either by name of region served. You
can view the latest list of DFT schemes at http://www.lpmde.ac.uk. The
deanery/region is given in bold and the schemes served within it are
given underneath it.

HE East Midlands HE North East

Chesterfield Scheme GPT Scheme
Leicester Scheme North 1 Scheme
Lincoln Scheme North 2 Scheme
Loughborough Scheme South 1 Scheme
Northampton Scheme South 2 Scheme
Nottingham Scheme West Scheme

HE East of England HE North West

Basildon Scheme Blackburn Scheme
Bedford Scheme Lancaster Scheme
Essex Coast Scheme North Manchester Scheme
Ipswich Scheme Pennine Scheme
Norwich Scheme Wythenshawe Scheme
Peterborough Scheme
Welwyn Garden City Scheme HE North West (Mersey)
Aintree Scheme
HE Kent, Surrey & Sussex Chester Scheme
Central Scheme Clatterbridge Scheme
Coastal Scheme Speke Scheme
East Scheme
South Scheme
West Scheme

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HE South West HE Yorkshire and Humber

Bath Scheme East Yorkshire / North Lincolnshire
Bristol Scheme Scheme
Exeter Scheme GPT Scheme
Plymouth Scheme Harrogate Scheme
Salisbury Scheme Sheffield and Doncaster Scheme
Taunton Scheme Wakefield and Dewsbury Scheme
Truro Scheme York Scheme

HE Thames Valley / HE Wessex London Shared Services

Scheme North East Scheme
Berkshire Scheme North Central Scheme
Buckinghamshire / Milton Keynes North West Scheme
Scheme South East Scheme
Oxfordshire Scheme South West Scheme
Portsmouth Scheme
Winchester Scheme Northern Ireland Deanery
North Ireland Scheme
HE West Midlands
City Scheme Wales Deanery
Coventry Scheme East Wales Scheme
Russells Hall Scheme (March start) Glamorgan Scheme
Solihull Scheme North Wales Scheme
Stafford Scheme South Wales Scheme
Telford Scheme South Wales Scheme
Worcester Scheme Port Talbot Scheme

10
This section has been left for you to make notes:
 Chapter 2
.1The professionalism, management
& leadership (PML) station

2.1 Theory & advice

 The complete
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DFT interviews
and leadership station (PML) Theory
Scenario
& advice1

PML overview

Introduction
This guide provides a summary of the management and issues raised in
a variety of dental scenarios with particular reference to professionalism
and leadership. It can serve as a useful reference tool to all dental
professionals, both qualified and currently under training.

The layout used in this guide assists readers in:

• Rapidly identifying key issues involved in each scenario

• Managing each scenario using the recommended pathway

Structure of the station

As the name suggests, the scenarios in this station probe your
understanding and thinking with regards to professionalism,
management and leadership. The scenarios usually deal with ethical
dilemmas and examples will be given in the next pages with which
you can practice. A summary of the practical aspects of the station is
provided below:

• You will be seated outside and have 5 minutes to prepare for the
scenario. In this 5 minute window, you will be given a laminated
A4 card with the scenario written on.
• You will have 10 minutes to discuss the scenario with two
examiners.
• At 8 minutes, a knock on the door will occur indicating you have
two minutes remaining.
• One particular difference between the PML and the
communication scenario is that the PML station is more of a
monologue rather than a dialogue. Once have you practiced
enough, you should be able to speak for around 10 minutes
about the topic presented to you.

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PMLprofessionalism,
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Scenario
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Author’s tip:

The best way to practice the PML station is to get into groups of
three: two examiners and one interviewee. Most of the time there
are two examiners for this station; however this can vary.

What the examiner is looking for

The scoring sheet for the PML station can be seen on page 25. As
shown in the sheet, the criteria that you will be marked on are:

1. Organisation and planning/thoroughness

2. Managing others and team involvement
3. Vigilance and situational awareness
4. Coping with pressure
5. Professional Integrity

Author’s tip:

It is very unlikely the examiners will help you out if you become
stuck when answering. Some examiners probe you and ask you the
questions on the card whilst some allow you to speak freely in a
monologue fashion. Therefore it is imperative you have a system in
your head when answering the question so as not to become stuck.

There is a method to answering the scenario. Most scenarios usually

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& advice1

have several questions that you are expected to answer. These are:

1. What are the issues?

This part tests your ability to recognise the key professional
issues in the scenario. The GDC provides standards for
dentists and the whole dental team which acts as a guide
to safeguard patients’ interests. The examiners expect you
to know all the standards inside out. This question usually
involves going through the GDC standards (see page 18)
as well as the clinical governance issues (see page 20)
that have been breached or may be breached (testing your
understanding of professionalism).

2. What would you do?

This part tests your immediate management, judgement and
leadership skills considering both the patient and your wider
dental team.

3. What could you do?

This part tests your ability to plan ahead. Although it sounds
similar to the previous question, this question asks you to
consider how you could have prevented the scenario from
happening in the first place. i.e. this question could more easily
be understood as ‘What could you have done differently?’.

4. What are the consequences of your actions?

This part tests your understanding of what will happen
following acting on the choices you make in the scenario. You
will want to consider the consequences of your actions on the
patient, the public and the profession.

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The practice scenarios
management and leadership (PML) station Theory
Scenario
& advice1

Author’s tip

Remember to answer the question as if you are a foundation

training dentist, therefore no heroic actions. The examiners are
looking for common sense answers which prove that you are SAFE
and ethical. Leadership does not only mean taking responsibility but
also knowing your limitations and understanding of when to ask for
help!

If you run out of things to say and have gone through everything
you can think of, maybe discussing the consequences of NOT
taking your actions may gain some marks. Silence is deafening in
those last few minutes.

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 The complete
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PML answer framework

In answering the PML scenarios, it is very helpful to follow a clear

framework. In the stress of the day, this will allow you to methodically
think through and consider each aspect of the scenario. This will
ultimately provide you a fail-safe method to ensure that you don’t miss
anything in your answer.

Step 1: what are the issues?

You first need to state the issues that you have identified in the scenario.
The issues are outlined by the 9 GDC Standards for the Dental Team.
These standards are outlined below:

1. Patient’s interests first

2. Communicate effectively with patient
3. Obtain valid consent
4. Maintain and protect patients’ information
5. Have a clear and effective complaints procedure
6. Work with colleagues in a way that is in patients’ best interests
(teamwork)
7. Maintain, develop and work within your professional knowledge
and skills (CPD)
8. Raise concerns if patients are at risk
9. Make sure your personal behaviour maintains patients’
confidence in you and the dental professional

The 9 GDC standards are not only for dentists but also apply to all
dental care professionals registered within the team. Therefore, with
any scenario involving other members of the dental team, you should
ensure that you apply the principles to them too. Technically, dental
receptionists are the only team members to whom the GDC standards
do not apply. However, they should still be adequately trained in key
topics such as confidentiality. This is why it is imperative to read the
booklet on standards thoroughly. It is available as a free download from

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 PMLprofessionalism,
The practice scenarios
management and leadership (PML) station Theory
Scenario
& advice1

the GDC website. In fact, in the GDC book of standards it clearly states:

“6.1.6 As a registered dental professional, you could be held responsible

for the actions of any member of your team who does not have to
register with the GDC (for example, receptionists, practice managers
or laboratory assistants). You should ensure that they are appropriately
trained and competent.”
From GDC Standards for the Dental Team

Author’s tip

Regurgitating the nine principles aimlessly will not only lose marks
but waste a lot of your very limited time.

Remember, most scenarios will not involve all nine principles being
breached. In some scenarios you may only find two or three standards
which are applicable. To obtain marks, you will want to use the PEE
method of explanation. This is described below:

Point
You must state which GDC standard principle was breached - i.e.
“The GDC standards state that confidentiality must be ensured for
all patients”
Evidence
You must state how the issue relates to the scenario - i.e. “In
this scenario, the receptionist gave away the patient’s personal
information to an unauthorised individual”.
Explanation
You must then explain why this is an issue - i.e. “all patients expect
their data to be kept confidential”.

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As well as outlining the GDC principles, is important to consider any

clinical governance issues that may have been raised in the scenario.
Below is a list of the clinical governance issues to consider. The first
letters of each point spell the mnemonic, PACCER PIRATES.

• Patient and public involvement

• Access
• Clinical records
• Child protection and safeguarding
• Emergencies
• Risk management

• Prevention and public health

• Infection control
• Radiography and radiology
• Audit
• Teamwork
• Evidence-based dentistry
• Safety

As well as discussing the issues that are raised in the scenario, it may
also be pertinent to outline the issues that haven’t been raised. This
indicates that you are thinking about the wider picture. Do not spend
time explaining these issues, but just state them - i.e. “there are no
teamworking, safeguarding or organisational issues in this scenario”.

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The practice scenarios
management and leadership (PML) station Theory
Scenario
& advice1

Step 2: What would you do?

Now that you have identified the issues, you now need to consider the
actions that you would take to manage the scenario. You need to order
your management logically and chronologically, as you would do in
practice. Therefore the order of events would be:

1. Immediate management
Stop the problem from continuing
Ensure that the patient is safe
Reassure patient - inform them about went wrong and your plan
to fix it
Ask if patient has any questions
Ensure other patients are safe
Ensure that other patients can be seen to
Delegate team effectively (use receptionist to inform other
patients about possible delays)

Continuity statement: “Once the patient’s needs have been

addressed, I will investigate this matter further.”

2. Investigating the situation further

Is it a recognised risk?
Gather more information.
Has this happened before?
Why has this happened?
How can this be solved? (Delegate to colleagues)
Discuss with trainer/practice manager

Continuity statement: “Once the situation has been investigated, I

will think about what I can do after the situation has resolved/after
the patient has left.”

3. Thinking ahead
Contact defence organisation for advice
Remedial action, refer

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Practice meeting to discuss incident.

How can this be prevented in the future?

Step 3: What could you do?

In Step 2, you discussed how you would manage the situation on a
patient, public and professional level. Now, you need to discuss what
actions you could have taken to prevent this scenario from occurring in
the first place.

1. Before patient:
Check notes
Inform nurse of procedure
Check referral letter or lab card before procedure
Ensure there is a protocol in place (delegate member of team to
the role or change induction procedures)
Book patient in at sensible time

2. During patient:
Correct site surgery
Identify possible complication quickly and seek trainer
Check with team
Check with patient
Check medical history
Check other details about treatment
Check day-list

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The practice scenarios
management and leadership (PML) station Theory
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& advice1

Other considerations
1. Patient safety is paramount: don’t let anything that can harm
the patient continue
2. Address the issues that the patient has: ask questions and
propose a plan
3. Assess the problem: is it an issue of consent, behaviour, crime,
infection, patient treatment?
4. Who to speak to: patient, trainer/educational supervisor, nurse,
programme director, LAT, CQC or the GDC; or social services
5. Resolution: internally, externally, independently, practice
meeting or audit (i.e. complaints)

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Step 4: What are the possible consequences of your actions?

In Step 2, you discussed how you would manage the situation on
a patient, public and professional level. Now, you need to discuss
what actions you could have taken to prevent this scenario from
occurring in the first place. You will need to consider the good and bad
consequences of your actions.

1. Bad consequences. Effect on:

Patient (loss of trust; complaint; breakdown of patient-dentist
relationship necessitating referral)
Colleagues (breakdown in relationship, disciplinary action,
stress)
Public (loss of practice reputation, patient complains to friends)

2. Good consequences. Effect on:

Prevent harm/issue continuing
Patient (gain trust by telling truth; prevent harm or issue
continuing)
Colleagues (patient safety ensured, improvement in skills by
training)
Public (remediate loss of reputation)

24
 The
Dental Foundation Year 1 (Vocational Training)
Professionalism , Management & Leadership Station Score Sheet
Please note: If you mark 0 or 1 for any question you MUST record objective comments & reasons for your decisions

Candidate Name: Candidate Number: PMLprofessionalism,

Criterion 0 / Unsatisfactory 1 / Poor 2 / Satisfactory 3 / Good 4 / Excellent Score

PML scoresheets
practice scenarios

No key issues Few key issues Some key issues Most of the key issues Thorough response.
Organisation mentioned even after mentioned and needed mentioned. Needed mentioned. Little
and planning / prompt prompt some prompting prompting. /4
Comments:
Thoroughness
Attempts to “go it alone” Fails to utilise few Utilises most relevant Uses all team members Demonstrates use of all
Managing others without involving others relevant members of the members of the team to good effect team members to good
team or does so effect
and Team ineffectively /4
involvement Comments:

No clear sense of Little situational Some awareness of the Shows understanding of Clearly understands
priorities or need to set awareness shown situation and the situation and developing situations
Vigilance and them; confused or implications anticipates issues that and anticipates issues
situational jumbled thinking demonstrated may arise /4
awareness Comments:

Evidence of lack of Limited initiative shown Some capacity to work Shows capacity to work Demonstrates the
initiative and resilience & limited resilience to under pressure shows under pressure with capacity to work under
cope with challenging some initiative and good initiative and pressure. Shows
Coping with situation some resilience to cope resilience to cope with excellent initiative and
with challenge challenges. resilience to cope with
pressure
management and leadership (PML) station

challenge.. /4
Comments:

Takes no responsibility Reluctant to take Takes limited Will take responsibility Clearly takes
for own actions. Shows responsibility for own responsibility for own for actions. Shows responsibility for own
no respect for others, actions. Lacks respect actions. Respect for all some respect for all. actions. Clearly
puts patients needs for others. Does not put not demonstrated. Generally puts patient’s demonstrates respect
Professional below own. patients needs first. Confusion over putting needs first. for all. Clearly
Integrity patients needs first. demonstrates the
importance of putting
patient’s needs first. /4
Theory

Comments:

Total Score /20

Scenario

Print Name: Signed: Date:

& advice1

25
26
C

Dental Foundation Training National Selection

Professional, Management & Leadership Station Score Sheet
Please note if you mark 0 or 1 for any question you MUST record objective comments & reasons for your decisions
The complete
professionalism,

Total Score:
guide for

Candidate sticker Assessor sticker

/20
management
DFT interviews

This is an assessment of Professional, Management & Leadership in dealing with a clinical situation.

SCENARIO:

QUESTION: 1. GENERAL NOTES:

FOLLOW UP QUESTIONS:
and leadership station (PML)

Criterion 0 1 2 3 4 Score
Managing /4
others and
KEY POINTS: COMMENTS:
Team
involvement
Theory
Scenario
& advice1
 Chapter 2
The professionalism,management
Chapter 2
The
& leadership PMLstation
(PML) station

2.2 Practice scenarios

PML practice scenarios Scenario 1

A father’s influence
A 22-year-old female patient presents in pain. The patient
cannot speak English and she is accompanied by her father
who is the interpreter and dictates treatment.
 The complete guide for DFT interviews Scenario 1

Issues

1. Putting patient interests first - respecting their dignity and choices.

2. Communicating effectively with patients in a way in which they can

understand.

3. Obtaining valid consent - informed, voluntary and the patient is

deemed competent.

Management

1. Arrange for an interpreter. Use an interpreter helpline to respect

the patient’s communication needs and to ensure that the patient is
not discriminated against. Ideally, encourage the patient to bring a
relative or carer with whom they are comfortable with.

2. Obtain valid consent - informed, voluntary and patient is deemed

competent. These terms are described below:

Informed: patient should be aware of the nature of treatment,

alternative options, risks, benefits, success and costs. (encourage
patient to ask questions)

Voluntary: without coercion, some patients (particularly in some

cultures) waver their autonomy. Obtain written evidence if
relinquishing autonomy.

Competence: can the patient understand the information, weigh

up the risks and benefits, retain the information and communicate it
back to you.

3. Document the discussion in obtaining valid consent. Offer the

patient leaflets in an appropriate language, followed by a cooling
period (1-2 weeks) to consider the given treatment options.

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PML practice scenarios Scenario 1

4. Refer the patient for a second opinion where appropriate. Ensure

that the patient is aware of any referral arrangements and that
consent has been sought prior to this.

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PML practice scenarios Scenario 2

Left alone
A 15-year-old child is being treated by you when the mother
attending with the child states that she must go and pick up
another child from school. She tells you to do whatever is
necessary. Once she has gone, you discover that the permanent
tooth you are working on requires an extraction.

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 The complete guide for DFT interviews Scenario 2

Issues

1. Putting patient interests first - respecting their dignity and choices.

2. Communicating effectively with patients in a way in which they can

understand.

3. Obtaining valid consent - informed, voluntary and the patient is

deemed competent.

Management

1. The first and most sensible thing to do would be to phone the

mother to let her know of the situation and ask for her to return to
discuss the treatment. If she is unable to return, you may request to
consent for the procedure over phone if it is absolutely necessary. If
the she does not respond, you should consider options that are the
least invasive and would get the patient out of pain.

2. Is the treatment an emergency? In other words, are you

safeguarding their life or getting them out of severe pain?

3. Do you deem the child Gillick competent - i.e. do they have the
capacity to understand the nature, risks, benefits and alternatives of
the treatment options provided (see page 434 - Consent: capacity
and competence)?

4. Discuss the treatment with the child.

5. Gillick competency is not seen as the first line option for consent.
Ideally, the patient’s mother needs to be made aware of the
treatment. However, where there is disagreement in treatment
options, a Gillick competent child under 16 can consent for their own
treatment.

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PML practice scenarios

6. Call supervisor/indemnity provider for advice.

7. Where possible, you should aim to temporise the tooth and inform
the mother why you didn’t proceed. If the tooth needed to be
extracted, another appointment can be booked with more time to
ensure the tooth is extracted safely and with valid consent. If the
tooth can be saved, it is important that the mother is made aware of
specialist opinion and obtain consent for this process.

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 PML practice scenarios Scenario 3

A difference in opinion
A patient refuses to accept amalgam as a filling material in
a posterior tooth, but you feel it is the best material for that
situation. The patient also wants botox treatment.

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 The complete guide for DFT interviews Scenario 3

Issues

1. Putting patient interests first - respecting their dignity and choices.

2. Communicating effectively with patients in a way in which they can

understand.

3. Obtaining valid consent - informed, voluntary, patient deemed

competent.

4. Maintain, develop and work within your professional knowledge and

skills to provide patients with good quality care.

5. Record keeping - provides a picture of the flow of patient care and

any discussions held with your patients.

6. To regulate quality assurance, it would be advisable to register

with the Comparative Health Knowledge System (CHKS) and the
Independent Health Advisor Service (IHAS) “Treatments you can
trust” (TYCT).

7. Make sure that any advertising complies with the GDC guidance
on ethical advertising. Seek advice from Committee of Advertising
Practice (CAP).

8. Compliance with HTM 07-01 in the safe management of healthcare

waste. For example, amalgam waste should be placed in rigid white
receptacles with a mercury suppressant and the waste should
be sent to permitted waste management facilities that undergo a
mercury recovery process.

9. The dentist must be appropriately trained, indemnified, qualified,

competent and confident to provide botox. You must ensure that
you are completely equipped to perform a task safely.

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 PML practice scenarios Scenario 3

Management

1. Ask why the patient feels so strongly against amalgam, listen to the
patient and give them an opportunity to have a discussion. Treat
the patient with dignity and respect, taking their preferences into
account.

2. If the patient’s felt (perceived) needs are discrepant with a normative

(professionally judged) need, you should ensure that the patient is
well-informed to obtain valid consent. You should discuss the risks
and benefits of all options, costs, prognoses and even religious
considerations - i.e. alcohol based dental materials such as dentine
bonding agents.

3. The practitioner should inform the patient why they feel a certain
material may be better in this given scenario (i.e. the benefits, risks
and prognosis).

4. Provide information in the form of leaflets (i.e. about amalgam), and

consider a cooling period before any treatment plan is finalised.

5. Offer to gain a second opinion by a more senior colleague in the

practice if you feel that you are not willing to do a treatment which
you do not think is clinically necessary.

6. Keep clear, concise and contemporaneous notes of any discussions

held with the patient.

7. Proactive measures: carry out a periodic patient record audit to

identify the level of patient involvement by all clinicians at the
practice and whether consent is sought. This satisfies outcome
2 of the CQC essential standards - to seek consent to care and
treatment. An example of a typical audit cycle is shown on the next
page.

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 The complete guide for DFT interviews

Figure 2.1: An example of a typical audit cycle

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PML practice scenarios Scenario 4

Parental guidance?
Can I see a child under 16 for an examination and provide
treatment if they attend with someone other than their parent
or if they attend on their own?

41
 The complete guide for DFT interviews Scenario 4

Issues

1. Patient safety is paramount.

2. Obtain valid consent - you must ensure that all procedures have
been suitably consented for with a patient that has capacity and is
competent.

3. Gillick competent - do they have the maturity to understand the

nature, risks and benefits and alternatives of the treatment options
provided?

Management

1. Examination requires consent if the child is not Gillick competent

and is under 16.

2. Informed consent is ongoing, obtain consent at each visit - the risks

and benefits may change.

3. Mother has automatic parental responsibility. Check if it is the actual

mother (i.e. biological, adoptive or via court order); just because
the child calls the individual a ‘mother’ doesn’t mean that she is. All
fathers married to the mother with their name on the birth certificate
have automatic parental responsibility, unless removed by a court
order. For more information on consent, see page 434 (Consent:
capacity and competence)

However, an unmarried father may also have parental responsibility

if his name is on the birth certificate, for a child born after 1st
December 2003. Otherwise, before 1st December 2003, the father
must be married to the mother at time of birth or sometime after
to have parental responsibility. Parental responsibility can also be
bestowed or removed via a court order. A dentist should be given
written evidence of this during a dental treatment with an individual

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 PML practice scenarios

claiming parental responsibility.

4. In cases of extensive treatment, it is encouraged to discuss with

parents, as aftercare is usually required and thus needs family
support. The child can consent if Gillick competent, although this
should not be seen as a first line method of consent. If treatment is
an emergency, you may stabilise the patient for their best interest
and safety.

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44
PML practice scenarios Scenario 5

A mother’s influence
A 35-year-old female with a moderate learning disability
attends your surgery for the restoration of a lower molar. She
is accompanied by a carer from the residential accommodation
where she lives. The carer informs you that the patient’s mother
is unhappy with the treatment and will not give her consent for
the restoration of the tooth.

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 The complete guide for DFT interviews Scenario 5

Issues

1. Obtain valid consent - informed, voluntary and the patient is

deemed capable to respect autonomy.

2. Assess patient capacity - can they understand, weigh up and retain

information, and communicate their decision as defined in the
Mental Capacity Act (MCA) 2005.

3. Patient interests - respect their dignity and choices taking their

preferences into account.

Management

1. Assess the patient to determine if they are competent - can they

understand, weigh up, retain information, and communicate their
decision? If you deem them competent and with capacity, you may
consider their consent as final, without the mother’s influence.

2. Emergency treatment can be provided to stabilise the patient to act

in their best interests.

3. Arrange for a face-to-face meeting with the patient’s mother.

Educate the mother verbally as well as using visual aids and leaflets.

4. If the patient is not deemed as competent or with capacity to

consent, a multidisciplinary approach may be required. This would
involve holding a ‘Best Interests Meeting’ involving the patient’s
relative, carer, lasting power of attorney and/or their Independent
Mental Capacity Advocate (IMCA) to devise a treatment plan that
is mutually agreed upon and is ultimately in the patient’s best
interests. It is also important to consider the patient’s past wishes.

5. Call your supervisor in the first instance if unsure how to proceed.

Secondary to this, you may also call your indemnity provider for

46
PML practice scenarios Scenario 5

impartial advice if necessary.

6. Alternatively, you can refer the patient for a second opinion to a

colleague within the practice or to a community dentist in the special
care department. Make the patient aware of the referral pathway.

7. Keep complete, clear, concise and contemporaneous notes on your

methods of assessing capacity and seeking consent as well as
detailing all members involved in the holistic care of the patient.

8. Carry out an audit on patient records to assess the processes of

seeking consent in your practice.

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 The complete guide for DFT interviews

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PML practice scenarios Scenario 6

Say cheese!
A 75-year-old female patient is accompanied by her daughter.
The patient is partially dentate with several teeth missing in
the anterior dentition. The daughter explains that she is getting
married in 3 months time and that she wants her mother to
have teeth to smile at the wedding. The mother is adamant she
does not want dentures.

49
 The complete guide for DFT interviews Scenario 6

Issues

1. Obtain valid consent - informed, voluntary and the patient is

deemed capable to respect autonomy.

2. Assess patient capacity - can they understand, weigh up and retain

information, and communicate their decision as defined in the
Mental Capacity Act (MCA) 2005.

3. Patient interests - respect their dignity and choices taking their

preferences into account.

Management

1. Discuss concerns with the patient ideally alone, and determine their
competence. Obtain informed consent with the patient to discuss
issues with their daughter.

2. Explore the reasons behind not wanting a denture. Is there a history

of a previously bad experience? Has she never worn a denture
before? Is she worried about the appearance? Empathy and open
questioning is important to avoid coming across as coercive or
interrogational.

3. Obtain valid consent - informed, capable and voluntary. Consent

is not valid if gained under coercion. Thus you must not must not
discriminate against the elderly as defined in the Equality Act 2010
and the Disability Discrimination Act 2005.

4. Patient can be provided with leaflets of all treatment options, and

offered a cooling period (1-2 weeks) to consider what treatment
option is best for them, followed by a review appointment to discuss
the proposed course of action.

50
PML practice scenarios Scenario 7

Dentist on call
It is a Monday evening. A patient rings and says that her
12-year-old son has a toothache. Can the mother give her child
antibiotics?

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 The complete guide for DFT interviews Scenario 7

Issues

1. Patient safety is paramount.

2. Work with colleagues in the best interest of patients - you must

be appropriately supported when treating patients unless treating
patients in an out-of-hours emergency. Assess the risk of continuing
treatment on that patient. Ensure there is at least one other member
of staff, even if it is a carer or receptionist, to deal with potential
medical emergencies. There must be arrangements for at least
two members within the working environment to deal with medical
emergencies.

3. Antibiotic prescriptions should be based on current evidence to

provide good quality care - refer to the British National Formulary
(BNF) as well as the Faculty of General Dental Practice (FGDP)
publication on antimicrobial prescription.

Management

1. Explore where the mother got the antibiotics from. Was it prescribed
from her GP specifically for this situation?

2. Instruct mother not to give antibiotics. However, you can give simple
advice over the phone about initial pain management.

3. Explore the pain complaint over the phone to work out the priority
and urgency of treatment. You can decide whether an urgent
referral to A&E is needed or if the patient can be managed with
pain killers and waiting until the following morning to attend for an
emergency appointment at the dental practice.

4. You can offer see the patient yourself via an emergency out-of-
hours appointment with another staff member.

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PML practice scenarios

5. Alternatively, you can refer the patient to an Acute Dental Care

(ADC) department in the local district hospital.

6. Keep clear, contemporaneous, concise and complete notes.

7. To prevent the situation from happening in future, the emphasis is

placed on regular dental attendance and preventative dental care.

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 The complete guide for DFT interviews

54
PML practice scenarios Scenario 8

Oops!
You make an operative error which causes the patient
considerable pain.

55
 The complete guide for DFT interviews Scenario 8

Issues

1. Patient safety is paramount.

2. Competency to perform treatment - are you appropriately trained,

indemnified and qualified?

3. Complaints - ensure that there is a clear and effective complaints

procedure for patient use.

Management

1. Empathise with the patient and apologise to them (“Sorry, I am glad

you brought it to my attention”).

2. Reassure the patient. Discuss what went wrong and what you will do
to make it better.

3. If the matter progressed beyond local resolution, after seeking

your supervisor’s advice, it would be prudent to call your indemnity
provider for advice.

4. Can offer remedial treatment free of charge as a gesture of good

will. Pay for travel costs.

5. Can refer to a specialist - obtain consent and provide relevant

contact details of the professional as well as offering a copy of the
referral letter to the patient. Ensure to follow-up on the referral.

6. Refer to complaints procedures - deal with in-house first, and then

refer to other services if in-house procedure was not successful.

7. Document clear, concise, contemporaneous and complete notes.

8. Fill out an adverse incident form within 24 hours. These forms

56
PML practice scenarios Scenario 8

are used in cases of an incident that has harmed a patient or put

patients at risk of harm. These forms are filed separate to clinical
notes. If these incidents continue, you may be prone to fitness to
practice investigations, depending on their seriousness.

9. Arrange a practice team meeting in view of discussing the issue and

how to prevent it in the future. Any changes should be made visible
in the practice newsletter.

10. Carry out a personal reflection on the situation - complete a

reflection on your electronic personal development portfolio (ePDP).

11. Professional development - attend courses that may show an insight

into the failings and your steps to address them. You can receive
CPD in-house (keep log) or via externally accredited courses.

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 The complete guide for DFT interviews

58
PML practice scenarios Scenario 9

Half-time
You are halfway through a root canal treatment on a patient
who then suddenly decides he no longer wants to continue with
the treatment, saying that he ‘just can’t cope’. He seems very
agitated and says that he is going to just go home and forget
the whole thing.

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 The complete guide for DFT interviews Scenario 9

Issues

1. Informed consent - patient can stop the treatment at any time and
their wishes must be respected. Ensure that the patient is aware of
the risks of stopping treatment and future problems that may arise
as a result. Document your discussion clearly.

2. Patient safety is paramount.

3. Patient interests - respect their dignity and choices.

4. Complaints - ensure that there is a clear and effective complaints

procedure for patient use.

Management

1. Empathise with the patient and apologise to them (“Sorry, I am glad

you brought it to my attention”). Listen to patient regarding why they
cannot cope and discuss accordingly.

2. Reassure the patient and explore their concerns.

• What went wrong?

• What could I do to make you feel better?
• Are you in any pain?
• You are always in control, we can stop at any time.
• Would you like to take a break?

3. They may be temporarily incompetent due to agitation, and

thus may make irrational decisions. Hence, for the patient’s best
interests, encourage temporising the tooth. Otherwise, if left
untreated, the tooth may flare up leading to an abscess and an
associated spread of infection.

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 PML practice scenarios Scenario 9

4. Refer to the complaints procedures - deal with the issue in-house

first, and then refer to other service if in-house procedures are not
successful.

5. If the complaint progressed beyond local resolution, after seeking

your supervisor’s advice, it would be prudent to call your indemnity
provider for advice.

6. Keep clear, concise, complete and contemporaneous notes. This

is particularly important, since if the patient decided to discontinue
treatment without temporisation, the tooth would likely flare up in
the future, causing significant pain and development of the existing
dental infection. Therefore, if the patient then needed the tooth
to be extracted as a result of not temporising, you would not be
held accountable. You would have discussed all these risks of
discontinuing treatment with the patient, and more importantly,
would have written these accounts in your notes.

7. Arrange for definitive treatment

• Continue the treatment yourself

• Refer to a more senior colleague in the practice or an endodontic
specialist - pay for consultation fee as a good will gesture, obtain
valid consent.

8. Carry out a reflection on this eventful situation (i.e. in your ePDP)

9. Arrange a practice team meeting in view of discussing the adverse

incident in order to prevent it from occurring again in the future.

10. Professional development - attend courses that may show an insight

into the failings and your steps to address them. You can receive
CPD in-house (keep log) or via externally accredited courses.

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PML practice scenarios Scenario 10

Nurse feeling worse?

You are halfway through the morning when suddenly your
nurse starts to feel unwell.

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Issues

1. Patient safety is paramount. To protect this, if a member of the team

is deemed unfit to practice, they must not treat patients.

2. Strategic effectiveness - ensuring that a strategy is devised to

ensure all patients are safely treated and ensuring that you work
with colleagues in the best interest of patients.

3. Working with colleagues in the best interest of patients - staff are

appropriately supported when treating patients.

Management

1. Empathise and acknowledge the nurse’s illness. Find out what the
problem is. It may be that a short rest, glucose or some painkillers
may suffice and it may not necessarily be that they need to go
home.

2. If this is not the case, ensure that the nurse is safe and suitably
cared for in the practice whilst you stabilise the patient. Ensure that
there is another chaperone in the clinic - according to the GDC
guidelines, you may carry out dental work unassisted in emergency
situations.

3. Encourage the nurse to see her GP to get time off work if needed.

4. Call your supervisor prior to sending the nurse home - justify in

terms of patient safety and team efficiency.

5. Arrange transport for the nurse to get home safely - this will improve
team relationships.

6. Arrange for a replacement nurse - within the practice or a locum

nurses via an agency.

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7. If no nurse is available, the GDC states that you cannot practice

alone unless in an out-of-hours emergency. Hence, you may need to
cancel all patients in the day. Ensure that you apologise to patients
(written, verbally) and rearrange their appointments or refer patients
to a nearby practice or dental hospital in case of emergency.
However, the GDC Standards 6.2.2 states that “you can practice
alone in exceptional circumstances”. These are unavoidable
circumstances, which are not routine and which could not have
been foreseen. Therefore, this should be taken into consideration,
as it would allow the clinician to prioritise which patients need to be
seen during the day - i.e. emergency dental procedures that cannot
be referred elsewhere.

8. Arrange a practice team meeting in view of discussing how to

manage this situation more efficiently in the future.

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 PML practice scenarios Scenario 11

A careless colleague
A patient attends complaining of pain after previously being
seen by a colleague. You notice in the notes that the patient
should have been treated for a carious lower right first
permanent molar. However, the treatment was not completed
and no follow-up appointment was offered. Your nurse states
that this is not the first time that this has happened with your
colleague.

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Issues

1. Patient safety is paramount.

2. Raising concerns if patients are at risk - duty to patient safety

overrides professional loyalty.

3. Clinical effectiveness of clinician and thus their fitness to practice.

4. Complaints - ensure that there is a clear and effective complaints

procedure for patient use.

Management

1. Apologise for how the patient feels.

2. Listen to the patient, allowing them an opportunity to have a

discussion.

3. Reassure the patient and provide pain relief.

4. Call supervisor or indemnity provider for advice and encourage the

previous colleague to contact their defence organisation.

5. Arrange for definitive treatment:

• Continue the treatment yourself

• Refer the patient to a senior colleague in the practice or a
specialist - pay for consultation fee as a good will gesture and
obtain valid consent for referral.

6. Refer to the practice’s complaints procedures - deal with in-house

procedures first, and then refer to other services if the in-house
procedure was not successful.

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7. Document discussions via complete, clear, concise and

contemporaneous notes.

8. You may wish to include a discussion with the colleague in question

about the situation, and allow them the opportunity to address the
situation. You may not know all the relevant facts, and were not
present when your colleague saw the patient; what the nurse has
said is currently just hearsay.

9. If you are not satisfied with the colleague’s reasons, and feel
that their behaviour may continue to risk patient safety, it may be
necessary to raise the concern with the practice manager.

10. The Public Interest Disclosure Act 1998 will protect employees who
raise genuine concerns.

11. Identify whether the nurse has a gagging clause in her contract for
raising concern and highlight the issue with your supervisor.

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PML practice scenarios Scenario 12

An irritating injection
You are injecting a patient with local anaesthetic when they cry
out in pain and demand to be seen by another dentist.

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Issues

1. Patient safety is paramount.

2. Patient interests - must respect their dignity and choices.

3. Maintain, develop and work within your professional knowledge and

skills - are you appropriately trained to give local anaesthesia?

4. Complaints - ensure that there is a clear and effective complaints

procedure for patient use.

Management

1. Apologise - this is not an admission of liability; an apology can help

defuse a situation.

2. Reassure the patient. Explain why the local anaesthetic may have
been painful. Offer ways that you could make the experience more
tolerable (local anaesthetic creams) or special injection techniques.

3. If this does not calm the patient, you could call your supervisor. Ask
the patient if they are comfortable with you continuing treatment
under supervision - obtain consent.

4. Alternatively, in the unlikely event that there is a complete

breakdown in trust, you could offer to make arrangements to refer
the patient to another dentist within the same practice, another
practice or another hospital.

5. Document complete, clear, concise and contemporaneous notes.

6. It may be worthwhile including a review appointment or a follow-up

appointment/telephone call for the patient to show your continued
care for the patient.

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7. If the issue escalates into a complaint, it may then be appropriate to

call your indemnity provider.

8. Refer to the practice complaints procedures and complaints

coordinator. Log the complaint in the complaint log book, separate
from notes. The flowchart below highlights the stages involved in
the complaints procedure.

9. Arrange a practice team meeting in view of discussing complaints.

Complaints are an opportunity to improve service by finding out
what went wrong and exploring ways to address the issues. Produce
a quarterly report of complaints to include key issues, improvements
and ongoing developments.

10. Reflect upon the eventful situation. Record and report any adverse
drug reaction using yellow card scheme which is monitored by
Medicines and Healthcare products Regulatory Agency (MHRA),
separate to clinical notes.

11. Professional developments - you could consider attending CPD

courses in view of improving your local anaesthetic injection
technique, which can be taught in-house or via externally accredited
providers (keep a log).

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PML practice scenarios Scenario 13

An incompetent implantologist?
You have been qualified for 4 years and attend a weekend
implant course. You are keen to try out your new skills and
when an edentulous patient attends asking for alternatives
to conventional dentures, you decide to provide implants.
Complications occur a few weeks after placement and the
patient complains.

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Issues

1. Patient safety is paramount.

2. Obtaining valid consent - informed, voluntary, patient is deemed

competent.

3. Maintain, develop and work within your professional knowledge

and skills. A weekend course is unlikely to be sufficient enough to
prepare you for all eventualities.

4. Complaints - ensure that there is a clear and effective complaints

procedure for patient use.

Management

1. Apologise to the patient and empathise with their concerns. This is

not an admission of liability, as it can help greatly towards defusing a
difficult situation.

2. What were the complications? Conduct a thorough history, listen

to patient allow them to discuss. The history should also take into
consideration patient related factors that may contribute towards
complications, i.e. smoking, poor oral hygiene, etc.

3. Reassure the patient. Inform them how you will aim to address
and resolve the complications, using a senior or outside referral if
necessary.

4. Call supervisor - ask patient if they are comfortable with you

continuing treatment under supervision- obtain consent. Alter-
natively make arrangements to refer to another dentist within the
same practice, another practice or hospital.

5. Call your indemnity provider for advice if the issue escalates outside

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of local resolution.

6. Are the complications a recognised risk - Bolam risk standard

appreciated by a regulatory body (the British Society of Oral
Implantology). And Montgomery ruling on consent - see page 436.

7. Arrange for definitive treatment.

• May need to offer remedial treatment free of charge or

subsidised in accordance with indemnity provider.
• Alternatively refer to specialist (implantologist) if outside your
competency, make sure patient consent obtained and patient
aware of referral process.

8. Document clear, complete, concise and contemporaneous notes.

9. It may be worthwhile including a review appointment or a follow-up

appointment/telephone call for the patient to show your continued
care for the patient. If the issue escalates into a complaint, it may
then be appropriate to call your indemnity provider.

10. Refer to the practice complaints procedures and complaints

coordinator. Log the complaint in the complaint log book, separate
from the patient’s clinical notes.

11. Arrange practice team meeting in view of discussing complaints.

Complaints are an opportunity to improve service by finding out
what went wrong and exploring ways to address the issues. Produce
a quarterly report of complaints to include key issues, improvements
and ongoing developments.

12. Professional developments - you could consider attending CPD

courses in view of improving your implant technique, which can be
taught in-house or via externally accredited providers (keep a log).

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PML practice scenarios Scenario 14

The root of the problem

Your dental colleague recently extracted the lower first
permanent molar and left a little bit of root behind. One week
later, the patient is now in pain and has complained to the
dental surgery. They are demanding to access and take away
their clinical records.

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Issues

1. Patient safety is paramount.

2. Maintain, develop and work within one’s professional knowledge

and skills - are you appropriately trained and competent?

3. Bolam risk assessment to see if the dentist has reached standard

of care that would be deemed acceptable by a responsible body of
experts to determine negligence.

4. Complaints - ensure that there is a clear and effective complaints

procedure for patient use.

5. Data Protection Act (DPA) 1998 - the patient has a right to access
a copy of their records. However, they are not permitted to take or
remove the original notes from the practice.

Management

1. Apologise to the patient for their pain.

2. Reassure the patient and find out what went wrong. Why was the
root left in the socket? Were they previously informed about this
from their dental clinician. Read the patient’s notes to confirm the
story of events (there may have been a valid reason to leave the
retained root - i.e. in the interim between a referral to a specialist).

3. Call your indemnity provider for advice if the issue escalates outside
of local resolution.

4. Is it a recognised risk - bolam risk standard appreciated by a

regulatory body (British Association of Oral Surgeons).

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5. Arrange for definitive treatment.

• May need to offer remedial treatment free of charge or

subsidised in accordance with your indemnity provider.
• Alternatively, you may refer the patient to a specialist (oral
surgeon) to deal with the failed extraction and pay the
consultation fee as a good will gesture. The specialist oral
surgeon would then determine whether the root should be
extracted and its associated risks and benefits.

6. Document clear, complete, concise and contemporaneous notes.

7. Refer to the complaints procedures - deal with the issue in-house

first, and then refer the patient to other dental services if the in-
house procedure was not successful.

8. If a patient wants to access their clinical records, you must address

this request within 40 days, as patients have right to access their
records under the DPA. If you want to charge a fee, check latest
guidelines from National Information Commissioners Office (NICO).
However, you may wish to consider not charging for a copy of the
records, as this could only serve to inflame the situation. You may
also wish to not charge the patient for the treatment as a gesture of
goodwill.

9. Professional development - attend courses to develop skills in oral

surgery via externally accredited course or in-house.

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PML practice scenarios Scenario 15

Naughty nurses
You arrive at your practice in the early morning to find that
your nurse is giving one of her friend’s a scale and polish. On
questioning the nurse, she states that her friend ‘cannot afford’
NHS treatment and she just wanted to work in the patient’s
‘best interests’ to provide her dental care.

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Issues

1. Patient safety is paramount.

2. Working in the patient’s best interests.

3. Scope of practice - you must only carry out treatment that is within
your scope of practice and that you are appropriately trained,
qualified and indemnified for it.

4. Working with colleagues in the best interest of patients.

5. Raising concerns where patient safety is at risk.

6. Working and acting professionally - theft of practice resources and

abuse of position.

Management

1. Stop the procedure and examine the patient for any potential
damage to their oral tissues - stabilise the patient yourself if
necessary.

2. Utilise the wider team to bring your nurse outside of the room whilst
you speak to the patient, ensure you have a chaperone as you
speak to the patient.

3. Apologise to the patient and explain that they have received

incomplete treatment. Ensure that the patient treatment is complete
as a goodwill gesture.

4. Notify your supervisor about the adverse incident and contact your
indemnity provider for advice regarding the best steps forward to
raise concerns.

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5. Ask advice about escalating concerns appropriately, ensuring not to

spread the news to non-senior colleagues as gossip. This is a very
serious offence, and would be likely to involve a GDC referral.

6. A meeting with the offending nurse should be held with your

employer. The nurse would be explained her scope of practice
(current guidelines - 2013) and her duty to follow them. The
employer should explore her reasons for carrying out this treatment,
offer support, and find out whether other patients have been
affected and review their notes if so. A first-stage warning to the
nurse is in order. Their fitness to practice may also be called into
question.

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 Chapter 3
The communication station

3.1 Theory & advice

 The complete
professionalism,
guide for
management
DFT interviews
and leadership station (PML) Theory
Scenario
& advice1

Introduction

The communication station forms one of the assessments of the DFT

recruitment process. According to the recruitment guide:

“This station will take the form of a role play. A medical role player will
play the part of a patient with a clinical problem. Applicants will be
assessed on their interaction with the ‘patient’. This station will last 10
minutes, and account for 25% of the final score. Applicants will read a
scenario five minutes prior to entering this station.

London Recruitment, Health Education South London (HESL)

You will be seated outside and have 5 minutes to prepare for the
scenario. In this 5 minute window, you will be given a laminated A4 card
with the scenario on. You will have 10 minutes to discuss the scenario
with the actor. After 5 minutes, a knock on the door will occur indicating
you have 2 minutes remaining. The Actor and Examiner will both be
marking you on separate scoring sheets with different mark schemes
(see page 150).

Scenarios can range from:

• Taking a history and reaching a suitable diagnosis

• Discussing treatment options
• Dealing with failures of treatment
• Handling complaints
• Providing bad news

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Author’s tip

The laminated piece of paper may also be found in front of you

inside the room where you will be examined. Ideally it would be
best to read it thoroughly in the preparation area outside and not
rely on re-reading the scenario inside the examination room. It
looks unprofessional and shows a lack of understanding if you keep
referring back to the scenario during the exam whilst engaging the
‘patient’ in conversation. Only look at the scenario in the exam as a
last resort.

Author’s tip

The best way to prepare for the communication station is to get

into groups of three so that one person is the actor, another is
the examiner and the third is the candidate. Try and practice with
colleagues that you are not necessarily close friends with and use
non-dental friends to play the actor if possible, as they are more
likely to pick up on jargon.

Following the scenario, the examiner would provide feedback on

the candidate’s delivery of the technical aspects of the scenario.
The actor would then provide feedback on the candidate’s empathy
and sensitivity in the scenario.

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DFT interviews
and leadership station (PML) Theory
Scenario
& advice1

What is the examiner looking for?

In the communication station you will be assessed by two examiners

(who will average their score) and one actor. The examiners are dental
professionals who have been specifically trained in providing objective
feedback for the DFT recruitment programme. The Examiner score
sheet for the communication scenario can be found on page 150.

There are five different areas that you will be assessed on by the
examiner:

1. Clinical knowledge and expertise

For example: if a candidate says during the scenario that
irreversible pulpitis is an infection of the nerve, it may show a
lack of knowledge, as pulpitis is an inflammation of the nerve,
not infection.

2. Empathy and sensitivity

Life as a dentist involves being empathetic to the patient.
Patients can easily pick up if you care about them or not. Hired
actors even more so!

3. Presentation of clinical options

Ensuring that you prioritise the most important issues for the
patient will provide higher marks. For example, if a patient with
quite poor oral hygiene comes in and one of their veneers has
fallen off, the first priority would be to consider recementing the
veneer in the short term (as this is what the patient came for)
and then discuss possible long-term options that may include
management of their oral hygiene.

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Remember the order clinical treatment options:

I Emergency Treatment
II Prevention
III Stabilisation
IV Restoration (prosthesis)
V Monitoring

4. Understanding evidence-informed practice

A thorough understanding of treatment options and conveying
them to the patient is an important part of any patient
interaction. For example, if a patient asked you about the
options for replacing a missing anterior tooth, and you stated
that you could “do nothing” as the first option, you would look
uninformed. It is advisable to mention the options in a logical
and coherent order.

5. Clinical communication
Jargon should be avoided at all costs and therefore practising
with colleagues is essential. Remember the patient/actor is not a
dentist and therefore does not know what a ‘pulp’ or 3/4 crown
is.

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guide for
management
DFT interviews
and leadership station (PML) Theory
Scenario
& advice1

What the actor is looking for

As well receiving an assessment from the station examiner, you will

also be marked by the patient actor. The marks given by the actor
and examiner have an equal weighting, thus meaning the actor’s
assessment account for 12.5% of the total DFT interview score.

There are five different areas that you will be assessed on by the patient
actor:

1. Empathy and sensitivity

“I’m sorry to hear that you’ve been in pain”
“My aim today is to get you out of pain and to get you a good
night’s rest hopefully”

2. Reassurance/problem solving
Try and come to a resolution with the actor by the end of the
scenario.

3. Information sharing
Give the patient all treatment options. So for a missing space,
ensure you offer everything including implants, despite it not
being available on the NHS.
If you are dealing with a root canal vs extraction scenario,
ensure that the patient is aware that they may require a crown
after the root canal therapy. Patients hate surprises so if you
finished the root canal and then told the patient that they
will need a crown, the patient will not be very happy about
this “hidden cost”. It is always wise to be transparent about
costings and options from the start.

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4. Generic clinical communication/capacity to adapt language

as appropriate to the patient
Do not use jargon.
When you have given the diagnosis to the patient - e.g. a
dental abscess - ensure that you explain what that means: “A
dental abscess is an infection that forms around your tooth as a
result of bacteria”.
Explain all treatments clearly e.g., “A crown is a cap that sits
over your real tooth and protects it”

5. Professional attitude/non-judgemental approach

If you are unsure about something that the patient has asked
you, never say “I don’t know”. The best way to do this is to say
something along the lines of “That’s a very good question. I’ll
check with one of my colleagues and get back to you about
that at the end of the appointment”. This shows that you are
“safe” and that you are professional.

Author’s tip:
When practising, ask your colleagues to video the interview. You
will be amazed to discover what your hands, eyes and voice do
under pressure which you may have never noticed before. Many
celebrities have coaches who video them so that wild gesturing
with the hands or lack of eye contact can be identified and
corrected. Yes, it may be cringe worthy but it will be worth it in the
end!

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DFT interviews
and leadership station (PML) Theory
Scenario
& advice1

Communication framework: overview

The general guide as to how to answer a scenario involves a simple

pathway:

1. Initiate
• Greet the patient
• Confirm their name and date of birth
• Ensure patient comfort
• What would you like to discuss today?

2. Gathering info
• Paraphrase and summarise their responses
• Are you anxious about dental treatment?

3. Clinical examination
• Can I take a look inside your mouth if that’s OK with you?

4. Explanation and planning

• Use visual methods to convey information - X-rays and
hand gestures
• Investigate the patient’s prior knowledge before explaining
something
• Give information in small chunks (‘chunk and check’)
• informed consent - is there anything more you need to
know?
• Do you have any questions so far?
• Are you happy with the choices offered and the plan?

5. Closing the session

• Summarise the patient episode
• Explore what will happen if there is an unexpected outcome
from the agreed treatment
• Schedule a review appointment at the patient’s discretion

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Scenario
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Communication framework: detailed breakdown

When answering a scenario, it is important to follow a logical answer

format, especially when you may be nervous during the interview itself.
Having a structure that you can rely on will help calm your nerves. We
will now go through each step of the communication framework and
explain how to tackle them.

Step 1: Introduce yourself to the patient

Greet the patient. This is possibly the most essential part of the pathway
and unfortunately the most forgotten. A lot of candidates will jump in
and get to the treatment before even saying hello. This is not only rude
but you need to establish who you are and who the patient is as well.

Do not introduce yourself as the “foundation dentist” or “trainee dentist”.

Be confident! If you introduce yourself as the dentist, you’ll feel like the
dentist. Start the conversation with something such as:

“Hi, my name is [Your Name]. I’m one of the dentists at the practice who
will be looking after you today”.

To shake or not to shake?

This has been a longstanding matter of discussion for years. The
actor and examiners will be unlikely to shake your hand, as this may
make certain candidates uncomfortable due to certain religious
and cultural differences. As a general rule of thumb, if an examiner
offers you their hand, then offer yours and ensure you shake
everyone else’s hand in that room. If only the actor offers their hand,
then just shake theirs as it could be part of the scenario. In the PML
scenario it would be wise to only shake their hands if the examiners
offer. If not, then do not force it. The last thing that you need is for
your hand to be rejected before you start.

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Scenario
& advice1

Step 2: Confirm the patient’s name and date of birth

Confirming this information is more than enough. Do not start asking
for address confirmation too - this is over the top and you only have 10
minutes to get through everything! You can then ask how the patient
actor would like to be referred.

Using the patient’s first name

Use the patient’s first name throughout the pathway if possible
- it shows that you are providing a personalised service to your
patients. At the end of the day, you need to remember you are
treating a person, not just a mouth; the actor will also be marking
you on this.

A personal experience from the author

“In my interview, the laminated sheet containing the scenario said
that the patient’s name is Michael which I remembered and had
ingrained into my mind for the period I was waiting outside the
exam room. However, when I entered the room, my smile turned
into horror as the actor in front of me was female. I did not know
whether to carry on with Michael or change it Michelle! I composed
myself quickly, introduced myself, and followed up by asking ‘what
would you like me to address you as?’ Quick thinking saved the day.
You should find that the scenarios have now been made gender
neutral.”

Author’s tip

Don’t forget to smile! It uses up less facial muscles than frowning,

and the opposing person will most likely smile back!

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Scenario
& advice1

Step 3: Reason for attendance

If the scenario is vague, then a simple question like that given below
would be a good start:
‘How can I help you today?’

However some scenarios provide a diagnosis with a history and in this

case, you could say something like:

‘So I understand that you are having trouble with...’

or
‘Am I correct in saying that...?’

In these opening statements, you will be summarising what has already

been given to you in the scenario. Going through the history to gain
the information already provided may be less effective. However, it is
also important not to assume anything. Going through a history may be
necessary to gain further information to that provided in the scenario.
For example, if the history is that of just ‘pain’, then a relevant and
detailed pain history needs to be taken (see below).

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& advice1

Gathering information

It is imperative to take an excellent history of the problem when

speaking to the patient. In doing so, you should allow the patient to
speak fully without interrupting, whilst demonstrating empathy. Due
to the short time restraints, you must keep questions relevant to the
scenario. So when seeing a new patient (most likely an emergency or
trauma case), avoid treating the station like a new patient exam and
focus on gathering information about the issue at hand.

Pain history
One way of gaining a pain history is to remember the acronym,
SOCRATES:

Site Where is the pain?

Onset When did it start?
Character How would you describe the pain?
Radiation Has the pain spread anywhere?
Associations How does it affect your everyday life such
as your work, sleep and eating?
Have you noticed anything else with the
pain? Bleeding or swelling?
Time course How long does the pain last for?
Exacerbating factors Does anything make it better or worse?
Severity On a scale of 1-10 (1 being no pain and
10 being unimaginable pain), how would you
rate the pain?

Several mnemonics can be used

to take a pain history, the most
common is SOCRATES however many
people also use LOCATES (location,
onset, character, association, timing,
exacerbating factors and severity).

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Trauma history
A trauma history is essential to carry out for patients who have
undergone any kind of traumatic injury in the scenario. For example:
an enamel-dentine fracture, jaw fracture, or simply a fall. The most
important sections of a trauma history are to elicit whether the patient
fell unconscious after the injury and where the tooth fragment (if
relevant) is located. Other pieces of information include:

• When did the injury occur? • Headache?

• How did the injury occur? • Fragment present?
• Loss of consciousness? • Were police involved?
• Bleeding/vomiting? • Degree of mouth opening

Medical history
Regarding asking about medical history only three essential questions
need to be asked, as time is valuable:

1. Do you have any medical conditions or are you carrying a

yellow book?
2. Do you take any medications?
3. Are you allergic to anything at all such as penicillin or latex?

If the patient has declared an allergy you may want to say:

“Thank you for letting me know, I will note it down for anyone else that
sees you”

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Potential red card:

Failure to ask about medical history may cause you to FAIL the
station as it shows that you are not a “safe” beginner.

Dental history
Dental history may also be covered. However, it is important to keep
your questions relevant to the scenario, as asking the patient whether
they use a manual or electric toothbrush in a scenario regarding oral
cancer would not be appropriate. Remember, to gain the highest marks,
it would be imperative to recognise, ask about and create a plan to treat
the relevant issues.

Denture history
Common scenarios include patients with an oral disease (i.e.
oral candidiasis) as a result of underlying poor denture hygiene.
Alternatively, they may present with a poorly fitting denture, for which
you need to assess the possible causes. Therefore the following
questions about the denture should be asked.

• What do you not like about the denture?

• How long have you had this denture?
• When was this denture given to you? Immediately after
extraction? Did you have a denture before this?
• Is it affecting your eating, speech or appearance?
• Has anyone else tried to treat this before?
• How do you take care of your denture?

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Periodontal history
You may be faced with a patient with chronic periodontal issues
presenting with loose teeth or/and bleeding gums. They will be
understandably upset and perhaps distressed. Therefore, it is important
to reassure and empathise with the patient whilst assessing the
underlying history of the periodontal condition. This scenario is an
examination favourite, as it is a common area of ligitation, due to a
clinician’s neglect of the patient’s periodontal condition. Therefore, the
patient management must be handled delicately and sensitively without
apportioning blame.

• Do you spit out blood following brushing?

• Have you noticed your teeth becoming loose?
• Do you have a bad taste in your mouth?
• Do you smoke?
• Do you have any other concerns?
• Have you noticed any gum boils or swellings on the gums?
• How do you take care of your mouth and teeth?
From the BSP Guidelines, 2014

Social history
When taking a social history, target your questions to the scenario.

• If the patient is a smoker, alcoholic or at risk of cancer: do you

smoke or drink alcohol? How much?
• If the patient leads a busy lifestyle: what appointment times are
best for you?
• If the patient is elderly: do you have any dependants? Do you
live alone? Does anyone manage your care?
• Traumatic injury or sporty patient: do you play contact sports?

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Clinical examination

Rather than saying “can I take a look inside your mouth?” followed by an
awkward pause as the actor stares at you, it would be more prudent to
state:

“So I have taken a look inside your mouth and these are my findings...”

Special tests
Special tests are vital to select a definitive diagnosis from the various
differential diagnoses suggested from the patient’s history and clinical
examination. In the same way as described above, when discussing
special tests, you would go straight into the results: “So I have taken an
X-ray of your teeth and this is what we can see...”.

In general, it is also prudent to ask for the patient’s consent to have the
special test taken before discussing the results. This would demonstrate
to the examiner that this would be part of your normal clinical
practice.

• Radiographs: ‘I’m going to take an X-ray’ OR ‘I’m going to take a

black and white picture of the inside of your teeth’
• Vitality testing: ‘I will check if the tooth is alive’
• Detailed periodontal chart: ‘I will take more measurements to
assess your gum health’

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Explaining the problem

Now you have gained all the information you need to come to a
definitive diagnosis, you should now explain this diagnosis to the
patient. Ask the patient first whether they would like to know more
about the problem. This gives a good way of involving the actor in the
patient episode, as it is very easy to start on a long discourse without
any involvement from the patient.

When explaining the problem, the following considerations should be

made:

• The name of the diagnosis

• Why is the problem happening? (see ‘Clinical explanations’
section on page 153)
• Prognosis of the problem if no treatment is carried out

As described above, the diagnosis should be stated followed by an

explanation. For example:

“Mr Smith, the tooth has something called reversible pulpitis which
means that the nerve inside the tooth has temporarily become irritated
due to the presence of decay near the nerve of the tooth”

Throughout the scenario, it is very important to ‘chunk and check’

- i.e. breaking the discussion up and regularly asking the patient if
they understand what has been stated so far. This shows that you are
ensuring that you are gaining fully informed consent. For example:

“Has everything been clear so far?”

or
“Do you have any questions for me at this stage?”

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Author’s tip

If you are given a scenario involving a radiograph which is not

given to you in the exam, it’s a good idea to show your palm to the
patient and gesture towards your hand pretending the radiograph
is there. The actor will follow this through. Remember - DO NOT say
radiograph ( jargon). Instead, you could say “an x-ray” or preferably -
“a black and white picture of your teeth”.

Treatment options
The treatment options available to you as a clinician are wide and
varied. For this case, we cannot describe every management scenario in
detail in this section. However, the common scenarios will be described
in the ‘Practice scenarios’ section on page 179.

Firstly, it is important to try and find out what the patient wants to ensure
there that is no confusion. This also shows the examiner that you have
not only understood all the treatment options available, but have also
taken into account the patient’s own preferences.

“We want to make sure you are happy with the treatment. What are you
hoping to achieve today? What are your expectations?”

In providing the treatment options to a patient, you may need to think

about both the short-term and long-term options. Some examples of
short-term treatment options include:

• Extirpation of pulp
• Extraction of tooth
• Restoration of fractured tooth
• Grinding down wisdom tooth and local irrigation
• Provision of antibiotics (if appropriate)

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Some examples of long-term management options include:

• Root canal treatment (with crown)

• Replacement of extracted tooth (denture, bridge, implant)
• Extraction of tooth (following pain management)

When providing treatment options to the patient, you should describe

each option briefly (see ‘Clinical explanations’ section on page 153).
From here, you can identify the patient’s preferences and explore this
option in more detail. Due to the time restraints of the scenario, it is not
expected to describe every treatment option in great detail. It is more
important that full informed consent is obtained for the preferred and
proposed treatment option. Therefore, this exploration and discussion
should include:

• Risks
• Benefits
• Success rate
• Cost (see ‘NHS Banding’ section on page 414)
• How it can fail
• Guarantee
• Consequences of not undergoing treatment
• Your recommended option
• The need for referral or second opinion
• Reasonable alternative options

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Dealing with difficult situations

Do NOT get into an argument about the cost with the patient.
Remember that this is an imaginary scenario where the ideal
factors are there for you to use to your advantage. For example, if
a colleague’s veneer fails off a month following placement and the
patient does not want to pay, you can tell the patient that you will
speak to the colleague and ensure that it will be resolved for the
patient (deflect the argument). Telling the patient that they may have
to pay for the veneer will only infuriate the patient. In fact, all NHS
veneers, crowns and inlays should be guaranteed for 12 months.

If the patient/actor is angry and it seems like you are digging a

bigger hole, simply ask the patient “what would you like me to do
today that would make you happy?” This trick forces the patient to
really tell you what they want.

If the patient asks you, “What would you do if it was your tooth?”,
you could respond with, “That’s a really good question. If a close
relative asked me the same, this is what I would recommend.
However, everyone is different and it is entirely your choice”

There is nothing wrong with providing your honest opinion on

what you would do in their situation. A lot of people confuse that
with trying to influence patients. As long as you provide the risks,
benefits, prognosis (outcome in lay terms), cost and alternative
options (if applicable) and the patient makes a decision on this, then
valid consent is obtained.

In communication scenarios that deal with angry or upset actors,

they may begin to cry during the exam. Do not be put off and take
that as the cue to look concerned and reassure the actor. Have a
clean tissue pack in your pocket and if the patient begins crying,
offer a tissue to the actor!

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It’s very important to try and come to a resolution with the actor.
Ensure that you have come to an agreed management by the end
of the station that both the patient and yourself are happy with.
Finish the scenario on a positive note if possible.

Closing the session

Summarise what the session involved to provide an overview of the

findings in today’s appointment and the agreed management. This is a
chance to confirm all your findings and ensure full understanding by the
patient.

For example:

“So Mr Smith, you came in today with pain in your upper molar tooth.
We did an examination, took an x-ray and determined that you have
reversible pulpitis due to some decay that’s going on. We talked
about treatment options and you have decided to go for a white filling.
Is everything correct so far? Are you happy to go ahead with the
temporary filling now?”

“Do you have any other concerns/Do you have any further questions?”

“It was very nice to meet you, I look forward to viewing your progress.”

[Handshake and smile]

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General add-ins

As well as following the communication framework outlined earlier, it

may be useful to consider some of the following pieces of information in
the clinical management of a patient. They are useful add-ins that would
make you stand out from the crowd.
1. Be empathetic at all times.

2. How is the problem affecting their work, life, eating, sleeping.

3. Pain management: “I understand you’re in pain and I want to get

you out of pain”.

4. Managing an anxious patient - “I’m here for you. You’re in

control”.

5. If discussing their children, ask about their name and show an

interest in their background.

6. Ensure to provide an option for no treatment.

7. I wish I could do that for you, but we have to follow guidelines.

8. Offer to provide information leaflets and a written treatment plan

for the patient to take away.

9. Utilise your trainer/Educational Supervisor (“we have a senior

colleague who can also take a look at you”).

10. In-house referrals:

• Receptionist: for booking appointments
• Hygienist: for treating periodontal conditions
• Nurse: to provide oral hygiene instruction and toothbrushing
instruction

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11. Out-house referral:

• GP
• Hospital
• Specialist

12. Has the patient been drinking alcohol and driving? Arrange for a
taxi or chaperone.

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110
Dental Foundation Training National Selection
DFT Clinical Communication Exercise Score Sheet
Please note if you mark 0 or 1 for any question you MUST record objective comments & reasons for your decisions
Candidate sticker Panel member sticker

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Criterion 0/Unsatisfactory 1/Poor 2/Satisfactory 3/Good 4/Excellent Score

guide for

Clinical knowledge Fails to recognise the Recognises some of the Recognises most of the Reasonable grasp of Clearly identifies all
and expertise issues issues but confused issues the situation relevant issues
Appropriate clinical about others /4

Examiner score sheet

knowledge Comments:
Applies sound
clinical judgement
Empathy and Fails to take patients Takes some issues on Adequate coverage of Coverage of most All issues taken on
management

sensitivity view into account board & partial issues & negotiation issues and negotiation board & full negotiation
Treats others with negotiation of plan of plan /4
understanding Comments:
DFT interviews

Capacity to take in
others perspectives
Communication marking criteria

& priorities
Presentation of Fails to recognise the Recognises some of the Recognises most of the Reasonable grasp of Clearly identifies all
clinical options issues issues but confused issues the situation relevant issues
Prioritisation of about others /4
clinical needs Comments:
Understanding of
clinical risk
management
Understands evidence Does not cover what Covers minimal future Covers what is likely to Covers most Covers everything that
informed practice may happen in the possibilities happen in the future possibilities is likely to happen
Analytical approach future /4
Shows awareness Comments:
of own limitations
and leadership station (PML)

Shows initiative

Clinical Communication not Poor and ineffective Misses out some key Good communication Communicates
communication adequate due to communication issues thoroughly and was
Adapts language language difficulties or excellent
appropriate to over use of jargon /4
patient Comments:
Shows initiative
Uses a non
judgemental
approach
Total Score /20
Theory

Signed: Date:
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Dental Foundation Training National Selection
COMMUNICATION SKILLS- Role player scoring

Date: _______________
Candidate sticker Role Player sticker PMLcommunication

Actor score sheet

practice scenarios
station

0 1 2 3 4 Score
Empathy and Empathy and Good display of
Empathy and sensitivity Empathy and sensitivity
Empathy and Sensitivity sensitivity severely sensitivity empathy and
satisfactory could not be improved
deficient inadequate sensitivity /4
Reassurance and Reassurance and Reassurance and
Reassurance/problem Adequate reassurance Able to reassure and
problem solving problem solving problem solving could not
solving and problem solving problem solve well
inadequate poor be improved /4
Information sharing Excellent information
Poor information Information sharing Good information
Information sharing not adequate due to sharing, could not be
sharing satisfactory sharing
language difficulties improved /4
Generic clinical
communication/Capacity Communication not Poor and Communicates
Misses out some key
to adapt language as adequate due to ineffective Good communication thoroughly and could not
issues
appropriate to the patient language difficulties communication be improved
/4
Appropriate professional
Professional attitudes Did not inspire trust Dentist inspired some Dentist inspired trust Trust and confidence
attitudes/Non judgemental
very deficient or confidence trust and confidence could not be improved
approach /4

Total Score
/20

Global rating: Please indicate with a tick below in the appropriate box for candidate
GREEN AMBER RED
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The communication station

3.2 Clinical explanations

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Dental extraction

This chapter provides various explanations of common clinical

treatments that you may offer as part of your clinical management.

Simple information
• Permanent removal of the whole tooth from the socket
• Cracking sound
• Pressure not pain
• The tooth will be put to sleep but you’ll stay awake

Explanation of surgical approach (if necessary)

• Carried out if the tooth cannot be delivered in one piece.
• A small cut will be made in the gums and some bone drilled in
order to remove the tooth.
• Dissolvable stitches will be placed in the region which would
disappear after about a week.

Benefits
• Removal of pain and source of infection

Risks/drawbacks
• Pain, bleeding, swelling, bruising and infection
• Stitches (if surgical approach)
• Tooth drifting if the new gap is not filled
• Altered sensation
• Opening of maxillary sinus

Alternative options
• Root canal treatment

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Consequences of no treatment
• Continuation of pain and infection (leading to abscess or
swellings).

Cost
• Band 2: £53.90

Options to fill the gap

• Denture, bridge, implant (if over 18) or leave.

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Root canal treatment

Simple information
• A tooth has a hard outer shell that protects the soft inner part.
The soft inner part contains blood vessels and nerves that
keep the tooth alive. Bacteria/germs can spread from the outer
surface of the tooth into the soft inside part affecting the nerves.
We feel this as pain. Over time, this causes the nerve of the
tooth to die.
• As the nerve is infected and dying, we need to remove it and
clean and fill the inside of the root to prevent further infection -
this is called a ‘root canal treatment’.
• It is a skilled and time consuming procedure which may be
spread over 2-3 visits. At the first appointment we can remove
the infected nerve. The tooth is cleaned, shaped and dressed
with medication to allow the tooth to settle. The tooth can then
be permanently filled. Root canal treatment is usually successful,
however, if the infection comes back, the treatment can
sometimes be repeated. You will need a cap (crown) following
the root canal treatment to protect the tooth from breaking.

Success rate
• The overall success rates for primary endodontic treatment,
re-treatment and surgical treatment were 86.02%, 78.2%, and
63.4% respectively after at least four years follow-up (Eleman &
Pretty, 2011).
• However, studies show that survival rates for primary
endodontic treatment can extend up to 98% (Friedman & Mor,
2004)

Benefits
• Keep the tooth
• Removal of decay, pain and source of infection

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Risks and drawbacks

• Chance of failure
• File breakage or perforation
• Increased risk of tooth fracture due to the removal of tooth bulk
and devitality - so the tooth so may need a ‘cap’ (crown).

Consequences of no treatment
• Pain, infection (leading to abscess or swellings) or dental
extraction

Cost & guarantees

• Band 2: £53.90
Band 3: £233.70 (if placing crown too)
• 12 months guarantee*

* Most NHS work (fillings, root fillings, inlays, porcelain veneers or crowns
) is guaranteed for 12 months following treatment, provided the work is
carried out by the same dentist and the original treatment was advised -
i.e. if the dentist advised for the patient to receive a crown and the patient
asked for filling instead then the filling is not guaranteed.

References
Elemam, R. F., & Pretty, I. (2011). Comparison of the Success Rate of End-
odontic Treatment and Implant Treatment. ISRN Dentistry, 2011, pp. 1–8.

Friedman S, Mor C. (2004). The success of endodontic therapy-healing and

functionality. J Calif Dent Assoc, 32(1), pp. 493–503.

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Composite filling

Simple information
• Tooth coloured plastic material to fill holes in teeth in the mouth
• The tooth will be put to sleep but you’ll stay awake (if necessary)

Survival
• Annual survival rate: 95% in high risk patients, compared to 98%
in low risk patients. (Opdam et al., 2014)
• 91.7% at 5 years and 82.2% at 10 years (Opdam et al., 2007)
• It is important to inform the patient that survival rates are
highly variable, and can be dependent on the patient’s own
standard of oral hygiene. In studies for the longevity of posterior
composite resins, survival rates from 55% to 95% over a 5-year
period have been documented. (Hickel & Manhart, 2001)

Benefits
• Removal of decay, pain and source of infection
• Tooth coloured/aesthetic
• Strong and durable
• Restores the bite
• Sticks to tooth and maximum tooth preserved

Risks/drawbacks
• Pulp exposure leading to root canal treatment
• Sensitivity
• Requires good moisture control
• Potential for allergy
• Faster wear
• May leak over time
• Reinfection under filling

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Consequences of no treatment
• Spread of decay
• Pain and infection
• May need root canal treatment or extraction

Cost & guarantees

• Band 2: £53.90
• 12 months guarantee

References
Hickel R, Manhart J. (2001). Longevity of restorations in posterior teeth and
reasons for failure. J Adhes Dent 3(1), pp. 45-64

Opdam, N., Bronkhorst, E., Roeters, J. and Loomans, B. (2007). A

retrospective clinical study on longevity of posterior composite and
amalgam restorations. Dental Materials, 23(1), pp.2-8.

Opdam, N., van de Sande, F., Bronkhorst, E., Cenci, M., Bottenberg, P.,
Pallesen, U., Gaengler, P., Lindberg, A., Huysmans, M. and van Dijken, J.
(2014). Longevity of Posterior Composite Restorations: A Systematic Review
and Meta-analysis. Journal of Dental Research, 93(10), pp.943-949.

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Amalgam filling

Simple information
• Silver-coloured metal material to fill holes in teeth in the mouth
• The tooth will be to sleep but you’ll stay awake (if necessary)

Benefits
• Removal of decay, pain and source of infection
• Durable with good wear properties
• “Amalgam restorations are safe and cost effective” (WHO)

Risks/drawbacks
• Not tooth coloured
• May stain teeth over time
• Requires greater removal of tooth
• May weaken tooth or increase the risk of fracture
• Temporary sensitivity to heat/cold
• Sensitive when contacting with other metals
• Reinfection under filling
• Possible root canal treatment if the decay is deep

Survival
• 5-year: 89.6% (Opdam et al., 2007)
• 10-year: 79.2% (Opdam et al., 2007)
• Annual failure rates range from 0.16% to 2.83% (Bernardo et al.,
2007)

Consequences of no treatment
• Spread of decay, pain and infection
• May need root canal treatment or extraction

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Cost & guarantees

• Band 2: £53.90
• 12 months guarantee

References
Bernardo, M., Luis, H., Martin, M., Leroux, B., Rue, T., Leitão, J. and DeR-
ouen, T. (2007). Survival and reasons for failure of amalgam versus compos-
ite posterior restorations placed in a randomized clinical trial. The Journal
of the American Dental Association, 138(6), pp.775-783.

Opdam, N., Bronkhorst, E., Roeters, J. and Loomans, B. (2007). A

retrospective clinical study on longevity of posterior composite and
amalgam restorations. Dental Materials, 23(1), pp.2-8.

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Glass ionomer cement (GIC)

Simple information
• White-yellow coloured plastic material to fill holes in teeth in the
mouth

Benefits
• Removal of decay, pain and source of infection
• Good appearance
• Releases fluoride
• Bonds to enamel and dentine
• Low risk of post-operative sensitivity
• Excellent choice as an interim filling

Risks/drawbacks
• Not perfectly tooth coloured (yellow tint)
• Less wear-resistant than composite or amalgam

Consequences of no treatment
• Spread of decay, pain and infection
• May need root canal treatment or extraction

Cost & guarantees

• Band 2: £53.90
• 12 months guarantee

Please note:
It is unlikely that you will need to offer such specific filling options to the pa-
tient. These options are likely to be offered as a means of temporisation in
an ‘emergency’ situation, and thus full consent should be obtained for the
final restoration with the information provided for the short-term temporary
restoration. Although other material options exist (i.e. RMGIC, reinforced
zinc oxide eugenols, etc), it is more important to communicate the overall
plan rather than specifics of the treatment, as the examiner is looking for
your ability to solve the issue at hand and put the patient at ease.
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Crown

Simple Information
• A ‘cap’ that fits over a prepared tooth, making it strong and
giving it the shape of a natural tooth.
• The tooth is prepared and an upper and lower mould is taken
which is then sent away to the lab to make the crown. In the
interim period, a temporary crown will be provided between
visits. It may initially feel different although it should feel fine in a
few days once you become used to it. It is like getting used to a
new pair of shoes. Of course when reviewing you, we can make
any adjustments where necessary.

Benefits
• Strengthens heavily broken down tooth and restores function
• Works well at keeping root treated teeth healthy

Risks/drawbacks
• Requires significant tooth tissue removal
• Up to 9% chance that tooth will die (pulpal necrosis) due to the
tooth preparation and, as a result, require a root canal treatment
(Bergenholtz & Nyman, 1984)
• Crown can possibly de-bond and come off
• Metal-ceramic crowns have metal shine-through
• Chance of decay at margins

Survival
• 18-year: 75-80% (De Backer, 2007)

Consequences of no treatment
• Fracture, leading to pain and infection

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Cost & guarantees

• Band 3: £233.70
• 12 months guarantee

References
Bergenholtz G, Nyman S. (1984). Endodontic complications following
periodontal and prosthetic treatment of patients with advanced periodontal
disease. J Periodontol, 55(1), pp. 63-68.

De Backer, H., Van Maele, G., Decock, V., & Van Den Berghe, L. (2007).
Long-term survival of complete crowns, fixed dental prostheses, and
cantilever fixed dental prostheses with posts and cores on root canal-
treated teeth. International Journal of Prosthodontics, 20(3), 229-234.

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Resin-retained bridge

Simple information
• This process involves attaching a false tooth to a neighbouring
tooth via a metal wing. The metal wing will be on the side of your
tooth that is not showing.

Benefits
• Simple preparation with minimal tooth loss
• Minimal chance of tooth death
• Usually don’t need anaesthetic
• Easy to clean

Risks/drawbacks
• Chance of de-bonding
• Metal wing can shine-through
• Not as long lasting as a conventional bridge

Survival
• 5-year: 80. 8% (King et al., 2015)
• 10-year: 80.4% (King et al., 2015)

Consequences of no treatment
• A missing tooth – loss of function, drifting, overerupting,
aesthetics, phonetics and psychology.

Cost & guarantees

• Band 3: £233.70
• No guarantee offered by NHS, but good practice to replace*

*If a bridge were to fail within the first 12 months, this may be due to the
technical and mechanical aspects of the tooth preparation and overlying
bridge. According, to the Office of Fair Trading, it is considered good

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practice to offer a 12-month guarantee for dental work. Therefore, it would

be prudent to re-cement the bridge if appropriate or offer a replacement if
needed to avoid complaint.

References
King, P. A., Foster, L. V., Yates, R. J., Newcombe, R. G., & Garrett, M. J. (2015).
Survival characteristics of 771 resin-retained bridges provided at a UK den-
tal teaching hospital. British dental journal, 218(7), 423-428.

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Cantilever bridge

Simple information
• This process involves replacing the missing space with a false
tooth that is connected to caps that fit over the prepared surface
of neighbouring teeth - in the same way a bridge connects two
points.

Benefits
• Better prognosis when used for replacing back teeth
• Stronger than resin-retained bridges
• Lasts longer than resin-retained bridges

Risks/drawbacks
• More tooth tissue removal
• Greater risk of tooth ‘dying’
• Significantly weakens the teeth that have to be capped
• Chance of debonding

Survival
• 10-year: 81.8% (Zwahlen et al., 2004)

Consequences of no treatment
• A missing tooth – loss of function, drifting, overerupting,
aesthetics, phonetics and psychology.

Cost & guarantees

• Band 3: £233.70
• No guarantee offered by NHS, but good practice to replace* (see
page 166)

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References
Pjetursson, B. E., Tan, K., Lang, N. P., Brägger, U., Egger, M., & Zwahlen, M.
(2004). A systematic review of the survival and complication rates of fixed
partial dentures (FPDs) after an observation period of at least 5 years.
Clinical oral implants research, 15(6), 625-642.

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Denture

Simple information
• A plate which is made up of either acrylic or metal that has a
false tooth attached to it.

Benefits
• Can replace more than one missing tooth
• Minimal/no tooth preparation needed
• Can be easily removed for cleaning
• Metal: thin, conducts heat, better retention
• Acrylic: simple, can add to denture, no metal clasps

Risks/drawbacks
• Does not maintain bone
• Has to be removed
• Metal: requires tooth preparation and a good periodontal
condition
• Acrylic: thick bulk, no heat conduction, higher risk of fracture,
‘gum stripper’

Consequences of no treatment
• Difficulty eating and speaking
• Reduced aesthetics (sunken cheeks and lips)
• Psychological aspects of tooth loss
• Teeth drifting into space

Cost & guarantees

• Band 3: £233.70
• No guarantee offered by NHS, but good practice to offer
adjustments to the denture if necessary (i.e. relines)

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Copy denture

Simple Information
• A replica denture which has the same tooth shape and position
as the previous denture but with a changed fit surface
• Worn areas of the polished denture surface will be restored and
the tooth shade can be altered.

Benefits
• Simpler, quicker and easier procedure than a remake
• Easier adaption to the new copy denture (especially for the
elderly)
• Maintenance of tooth position and height
• Spare denture set

Risks/drawbacks
• Any fault in the old dentures is likely to be repeated
• Less opportunity for customisation available compared to
remaking

Consequences of no treatment
• Continuation of current denture and existing issues (poor fit,
worn surfaces)

Cost & guarantees

• Band 3: £233.70
• No guarantee offered by NHS

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Dental implant

Simple information
• A biocompatible metal screw that is placed into your jaw, onto
which a fixed a crown, bridge or a denture can be fitted.

Benefits
• Gold standard to replacing a missing tooth
• Avoids any need to prepare adjacent teeth
• High success rate
• Provides stable denture or bridge

Risks/drawbacks
• Expensive
• Invasive surgery and risk with that (infection, pain, swelling,
bruising, bleeding, nerve injury)
• Proximity to maxillary sinus
• Long treatment time
• Adequate bone levels

Survival
• Annual failure rate: 0.82% (Lang et al., 2012)
• 2-year survival rate: 98.4% (Lang et al., 2012)
• 10-year survival rate: >90% (Albrektsson et al., 1986)

Consequences of no treatment
• Other options may be available to replace the space such as a
bridge, denture or leaving the gap untreated.

Cost
• Private - £1500-2000
• Not normally available on NHS

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References

Albrektsson, T., Zarb, G., Worthington, P., & Eriksson, A. R. (1986). The long-
term efficacy of currently used dental implants: a review and proposed
criteria of success. Int J Oral Maxillofac Implants, 1(1), 11-25.

Lang, N. P., Pun, L., Lau, K. Y., Li, K. Y., & Wong, M. (2012). A systematic
review on survival and success rates of implants placed immediately into
fresh extraction sockets after at least 1 year. Clinical Oral Implants Research,
23(s5), 39-66.

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Reline

Simple Information
• A lining applied to the acrylic fit surface of the denture to fill
voids, adjust the retention of the denture or to improve the
condition of the denture-bearing area. It can be done at the
chairside with either a soft or hard material.

Benefits
• Simple and quick procedure
• Can provide immediate relief
• Patient does not have to go without denture
• Relatively cheap (compared to sending to a lab)
• Reline material can be medicated for cases of denture
stomatitis (oral thrush)

Risks/drawbacks
• Not a long-term solution
• Not as robust as a rebase
• Require time in chairside for material to set

Survival
• Temporary soft (therapeutic) reline: a patient would wear this
for up two weeks to resolve local inflammation, but the reline
is unexpected to last longer than a few months.
• Soft reline: one to two years before the next soft reline would
be recommended (gold standard reline option)
• Hard reline: up to two years before next hard reline
appointment is recommended

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Consequences of no treatment
• Continuation of existing issue: poor retention or stability; or
denture stomatitis

Cost
• Band 2: £53.90

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Rebase

Simple Information
• A procedure whereby the acrylic fit surface of the denture is
removed and completely replaced with new acrylic in the dental
laboratory.

Benefits
• More robust than a reline
• More long-term
• Simple procedure

Risks/drawbacks
• Patient has to go without denture
• Not as suitable for cases of denture stomatitis (oral thrush)
• More expensive than reline

Consequences of no treatment
• Continuation of existing issue: poor retention or stability; or
denture stomatitis

Cost
• Band 2: £53.90

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The communication station

3.3 Practice scenarios

DISCLAIMER
The following scenarios constitute example situations that may
occur in practice and common scenarios that may be examined
during the DFT recruitment process. Unlike the PML stations, you
will have a patient actor in the scenario to work with. Therefore, the
suggested scenario responses should be considered as part of the
holistic patient management with respect to the patient actor and
the questions or discussions that are brought up.

While it would be good practice to ensure that the majority of points

mentioned in the scenario are discussed, it is also important to
allow time to answer the patient actor’s specific questions.

Following a rigid or formulaic approach to this scenario would result

in a low score from the patient actor and a poor understanding
of the meaning of ‘communication’ as a means of working with a
patient rather than ‘tick-boxing’ the scenario.
 The comminication
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In pain
A 25-year-old patient attends your surgery with a painful
upper back tooth that is affecting their sleep. The patient is
an irregular attender who has had three teeth extracted in the
past five years. He smokes, is fit and well, and has average oral
hygiene. He is a builder and finds it difficult to take time off for
appointments. Discuss the management with the patient.

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Issues

This scenario revolves around the candidate’s ability to assess the

clinical information provided to formulate a logical treatment plan that
meets the patient’s desires and expectations. It is important to realise
that the patient is attending for an emergency appointment and so it is
critical to address the short-term and immediate options for resolving
the pain. Following this, the longer-term options for restoration at a later
appointment could be considered and consent for both aspects sought.

The candidate will be marked on their ability to communicate

empathetically with the patient, whilst presenting the clinical information
in a coherent, logical and understandable manner, and taking into
consideration the patient’s time commitments to attend appointments.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

apologise to the patient for their upset.

Author’s tip: Do not say you are a trainee or DFT. You have a BDS
degree which makes you a fully qualified dentist. If the patient
specifically asks if you are a trainee, you must be honest and
comply.

2. Carry out a pain history and a medical history. A thorough pain

history is required to reach a diagnosis. The helpful acronym,
SOCRATES, may be used to acquire this (see page 138 for an
example).

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Author’s tip: In this emergency scenario some history has been

given but not all. Some candidates panic and make the mistake of
jumping in after a few questions on history to treatment options. The
management order of a patient should always follow: history, exam,
investigations, diagnosis and treatment.

3. Apologise for the patient’s pain: “I understand that the pain is clearly
bothering you. I am sorry to hear about this.”

Author’s Tip: Apologising for the pain the patient is having does not
mean you acknowledge it is your fault at all; it shows that you care
about the patient’s feelings.

4. Offer patient to provide more information.

Example: I’ve heard a little bit about your problem, Is there anything
else that I should know?

5. Carry out a brief dental history and social history. As this is an

emergency appointment, the focus is getting the patient out of pain.
State the importance of regular visits. Identify work-life commitments
for dental treatment. Provide smoking cessation advice - you could
suggest that “you are 4-times more likely to stop smoking if you
seek professional support rather than cutting down on your own”.

6. Conduct a clinical examination and take special investigations:

Example: to find out the cause of pain, it is important for us to take
some X-rays and check if the nerve of the tooth is still alive (vitality
tests). Is this OK?

7. Provide the diagnosis and explanation to the patient for irreversible

pulpitis.
Example: On looking at your teeth and the X-rays, I can see a dark
shadow just at side of your tooth. Now this could mean that there
are bugs which have travelled through the top of your tooth into the
nerve and has led to irreversible damage and inflammation.”

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8. Provide the short-term treatment options. Short-term options would

involve resolving the pain by either removing the nerve of the tooth
(pulp extirpation) or tooth extraction. Find out whether the patient
would like to keep the tooth or extract the tooth.

Author’s tip: if the patient would like to extract the tooth, this may
be due to their severe pain and a decision that they would not
normally make otherwise if they were in their right mind. Therefore,
it would be wise to make clear that the pain can be resolved in the
same way whilst still keeping the tooth - ‘if we can get rid of the
pain and still keep the tooth, would you like this?’.

If the patient would still like to have the tooth extracted, you
would then be advised to discuss the long-term implications for
this decision such as the patient eventually requiring a tooth
replacement, or if no replacement is sought, the possibility of the
nearby teeth drifting into the newly edentulous space.

If the patient is still happy with extracting the tooth, you should
then proceed down this line of discussion for the scenario, as the
examiner most probably would like you to discuss these options
with the patient.

9. Provide the long-term treatment options. Provide each option with a

brief description. Options would include either providing a full root
canal treatment (with a crown), carrying out a dental extraction (and
replacing the space with a bridge, denture, implant or leaving the
space untreated) or just leaving and monitoring the tooth. You may
also provide a recommended option if the patient asks or seems
unsure.

10. Identify time commitments: Is the treatment plan lengthy? What

times/days are best for the patient? Liaise with reception. Does the
patient intend to travel abroad anytime soon?

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Author’s tip: From the scenario text, one of the patient’s concerns
is about finding time off from work. Remembering this problem and
asking about it ensures higher marks and can make the difference
for the rankings. If the patient is unlikely to attend for multiple
appointments as required and is unwilling to make alternative
arrangements, options for extraction and replacement may be
considered. However, the patient should be aware that future
appointments would be required if it is desired to replace the
missing tooth space.

11. On identifying the patient preference, you can then provide more
detail about the chosen option (i.e. a root canal procedure with a
crown) to gain valid consent for carrying out the procedure. Provide
information on the risks, benefits, alternative treatment options,
costs, prognosis, any treatment guarantees and whether the
treatment can be provided under the NHS or private only. Check
patient understanding throughout the explanations.

12. Summarise the plan and check patient understanding. Ask the
patient if they have any questions and offer to commence the initial
stages of treatment today (if appropriate) or offer farewell.

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Scenario

Dry socket
A 20-year-old patient complains of a deep throbbing pain in the
lower left quadrant alongside a bad taste and a bad-smelling
breath. Clinical examination reveals a dry socket where the
lower left third permanent molar was extracted five days ago by
your colleague who now is on annual leave abroad. The patient
is also concerned about the lower left lip, which is still ‘tingly’
and feels ‘strange’. Please take a history, discuss your findings
and outline your management.

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Issues

In this scenario, the candidate will be expected to carry out a full

history of the patient’s pain alongside relevant clinical investigations
whilst empathising with the patient for their discomfort. It is important
to identify risk factors for the dry socket such as smoking, and whether
the patient has been following post-operative advice following the
extraction.

Once the candidate has gained the necessary information, they will be
expected to formulate an appropriate treatment plan as an emergency
for the patient during the appointment to relieve their pain as well as
providing advice to prevent the recurrence of the dry socket.

In the principles of teamworking, it is also important to not place

any blame on your dental colleague regarding the lip numbness or
dry socket. As such, the candidate will be expected to consider the
wider dental team to address the patient’s concerns regarding the
lip numbness (Oral and Maxillofacial Surgery Department of a local
hospital) and referring the patient back to the original dental colleague
when they return from their holidays.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

apologise to the patient for their upset.

2. Carry out a pain history (SOCRATES) and a medical history.

Author’s tip: If you have a female patient, be sure to ask about

whether they are taking the contraceptive pill, as this is a known
risk factor for dry socket.

3. Dental history: Have you ever had a tooth extracted before? Did you
ever get these symptoms following a tooth extraction before?

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Author’s tip: Patients with a history of dry socket are more prone to
it in the future.

4. Social history: Do you smoke? How long did you wait following the
procedure before you smoked again? How many units of alcohol do
you drink per week?

5. Clinical examination: Ask the patient if you can take a look at their
teeth. You will not be expected to carry out an examination during
the scenario.

6. Special investigations. Look at pre-operative radiograph to see the

proximity of the roots to the ID nerve.
Example: In order to find out the cause of pain, it is important for us
to take some x-rays.

Author’s tip: Generally radiographs are not taken for dry socket.
However, the patient is complaining of numbness too, so an OPG
can be used to aid diagnosis.

7. Provide the diagnosis to the patient - explain dry socket.

Example: following an extraction, the socket from which the tooth
was removed develops a blood clot to protect the bone underneath.
What may happen is that sometimes this clot may dislodge or
dissolve, exposing the underlying bone to air, water or food. This
can lead to pain. There may be an increased risk of developing this
if you smoke, had a wisdom tooth extracted, had a complicated
extraction, are currently using the contraceptive pill, have suffered
from previous dry sockets, if you rinse and split on the first day after
the extraction and the older you are.

8. Manage the potential of complaints. If the patient complains that

the previous dentist was at fault, it is important to calm the situation
and state that you cannot comment on the other dentist’s work, as
you would not have been there. However, reassure the patient that

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you will do everything to get them out of pain today, as this is the
patient’s main reason for attending today.

Author’s tip: if the patient still wishes to go ahead and complain,

it would be worthwhile considering a second opinion (Educational
Supervisor). For local resolution, it would be wise to inform the
patient that they should return to see the dentist when they return
from holiday to discuss the issue with them. To avoid sounding
blunt, you could offer to call the patient when the dentist returns, as
well as liaising with the receptionist to book a suitable appointment
time with the dentist. If the patient is still unhappy, you may then
need to consider the formal complaint procedure and explaining
this to the patient - a patient pushing you into this situation would
indicate that the scenario is also aiming to test your knowledge of
the complaints procedure.

9. Provide the treatment plan to the patient. The treatment protocol is

provided below:

• Numb the area

• Irrigate the socket with saline water
• Pack the open socket with antiseptic dressing to promote
healing.
• Take over the counter painkillers to ease the discomfort.
• Inform the patient to monitor the numbness of their lip and
return to the practice if it doesn’t resolve in a couple of weeks
(for a referral).
• Instruct the patient to not bite on their lip, or drink anything too
hot as there may be irreversible damage to that area.

Author’s tip: Ask the patient if they have been warned regarding
temporary or permanent numbness.

10. Summarise the treatment plan to the patient and emphasise that the

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aim is to get them out of pain. “I can do the emergency treatment for
you today to get you out of pain. How do you feel about this?”

11. Check the patient’s understanding, ask if they have any questions
and offer to commence the initial stages of treatment today.

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Scenario

A nervous patient
A very nervous 20-year-old patient attends the clinic for a
dental examination. They are upset, shaky and confides in the
receptionist that they are absolutely terrified of dentists. This is
the first time the patient has attended a dental apppointment
since they were a child. The patient is not in any pain.

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Issues

This scenario is all about managing dental anxiety. The candidate will
be marked on their ability to come across as caring, empathetic and
understanding to reassure and relax the patient. The candidate will
also be assessed on their ability to use exploratory questions to gain
important information about the cause of and reasons for the patient’s
anxiety.

Using this information, the candidate will be able to offer practical

methods to relieve the patient’s anxiety. The aim of this scenario is
for the patient to be sufficiently reassured and for their anxiety to be
managed so an initial dental examination can commence.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

apologise to the patient for their situation.

2. Explore and manage the patient’s anxiety. To do this, it is important

to ask exploratory questions to investigate the cause of the anxiety
to consider methods that you could employ during the patient’s
treatment to help them relax.

• Do you have any general concerns?

• What is it in particular about going to the dentist that makes you
feel nervous?
• When was the last time you visited the dentist?
• Was there anything about that visit that you didn’t enjoy?
• Is there anything that we can do to help you relax more?
• Do you have any other questions or concerns?

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3. Discuss options of sedation with the patient as well as reiterating

that all invasive procedures will take place with the patient
completely numb. See page 452 for more details regarding dental
sedation.
Example: If you are feeling nervous about dental treatment, we can
help you relax via methods of sedation. Would you like to know
more? This can be in form of gas or a sedative which will make
you slightly drowsy and you won’t notice what is going on. For any
procedure you will be nice and numb in that area anyway.

Author’s tip: It is important to first explore why the patient is anxious.

If it was due to a previous terrible experience then explain how your
procedure will be different (explaining each step, use of numbing
cream, you can raise your left hand whenever you want to stop and
we can take a break, etc).

4. Discuss that there are many methods of managing the patient’s

anxiety. This can involve acclimatisation, tell-show-do, stop signals,
noise-cancelling headphones, watching TV during the treatment,
numbing creams, special local anaesthetic pens, inhalation sedation,
intravenous sedation or even a referral to a specialist. Explain
each of these methods. Ask the patient if they have any questions
throughout.

5. Highlight the importance of regular dental visits in an empathetic

and understanding tone.
Example: I fully appreciate that a dental setting can be quite a
nervous experience for you. However, it is better that we see you
more regularly so that we can aim towards preventing certain
diseases occurring so that in the future you may not need treatment
such as fillings, extractions or root treatments.

6. Check the patient’s understanding, ask if they have any questions

and offer to commence just the dental check-up today to acclimatise
the patient, and no other treatment

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Communication practice scenarios Scenario 41
Scenario

Treatment options
A 58-year-old fit and well patient attends in pain with an apical
abscess related to a lower molar which had a gold crown placed
12 years ago. The patient is a regular attender with good oral
hygiene and a full dentition. The patient wishes to discuss their
treatment options with you, including costs.

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Issues

This scenario involves the candidate communicating clearly and

empathetically with the patient to ascertain the necessary clinical
information to formulate a clear and coherent treatment plan. The
candidate will be expected to explain the cause behind the abscess in
layman’s terms as well as suggesting a range of options for the patient
to consider, with the patient’s preference in mind, to gain full and valid
consent. The candidate will be marked on their ability to carry out the
above and address any concerns or potential complaints the patient
may have.

Example of management

1. Introduction, identify concerns, reassure immediately and apologise

to the patient for their situation.

2. Carry out a pain history (SOCRATES), medical history and brief

dental history.

3. Carry out a clinical examination and special investigation

Example: In order to find out the cause of pain it is important for us
to take a look at your teeth, to take some ‘X-rays’ and check if the
nerve of the tooth is still alive (vitality tests). Have you had these
checks done before? Am I OK to do this?

4. Explain the clinical findings. Inform the patient of the cause of the
abscess.
Example: On looking at the ‘X-rays’ (use hand to explain the
radiograph), can you see the dark shadow just at the root of your
tooth. Now what it means is that the germs have travelled from the
top of your tooth into the nerve and progressed through the root,
eventually leading to pus forming. This can happen if germs get into
the junction between the crown and the tooth.

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5. Check the patient’s understanding and allow them to ask questions.

6. Deal with any potential complaints. If the patient is unhappy with the
longevity of the crown, it would be worthwhile mentioning that the
mean life of gold crowns is typically around 15 years, so it is quite
close to the expected timeline. Praise the patient for maintaining
the crown for so long, to dispell negativity, and empathise with their
concerns.

7. Offer the short-term treatment options. The main priority is to get the
patient out of pain. Offer to drain the abscess and dress the tooth,
or to extract the tooth. Offer a brief description of each option in
layman’s terms to assess the patient’s preferences.

Author’s tip: due to the gold crown, orthograde access should be

made in the first instance to the apical abscess via the root canal
system. In some cases of an expensive crown, retrograde access
may be made, but this should be done by an endodontic specialist.
In the interest of tooth preservation, if the patient wants to have the
tooth extracted, it would be prudent to mention that the pain can be
stopped and they can keep the tooth - ‘If I can get you out of pain
today whilst saving the tooth would you be interested?’.

8. Offer the long-term treatment options. Assess whether the patient

would like to save the tooth vs having it extracted.

9. If the patient chooses to save the tooth: Explain the root canal
procedure for cases with abscesses. As an initial guide, the basic
template is given below. More detailed treatment explanations can
be found on page 153.

Simple information: If you would like to save the tooth, our initial
management would be to drain the abscess to remove all the pus
and give the tooth some breathing space. What we could then do
is to remove the infected nerve from the tooth, for the initial stages

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of a root treatment. This is done by making a hole in the crown, and

dressing the inside with a medication which would help settle the
pain, although this is only a temporary measure to get you out pain.
Check understanding.
Additional information: After a root canal treatment of the tooth,
the tooth will require a cap to provide extra support and strength
which will require another couple visits, as a dead tooth is more
brittle. Check understanding.
Risks: There may be a chance that the infection can recur, although
the treatment can be repeated. For this treatment we use fine files,
which may break inside the root. There may even be accidental
spillage of chemicals used to clean the inside of the roots into your
mouth. However, all precautions will be taken to avoid these risks.
Cost: Band 3 NHS: £233.70 (including crown)

10. If the patient chooses to extract the tooth: Explain the extraction
procedure and the fact that a prosthetic tooth replacement will be
needed if the patient wishes to have the edentulous space closed.
This would involve describing and explaining restorative options
such as a denture, bridge or implant and gaining informed valid
consent to proceed.

11. Summarise the treatment plan to the patient and emphasise that
the aim is to get the patient out of pain today (short-term) and work
on the long-term options at the next appointment. “I can do the
emergency treatment for you today. How do you feel about this?”

12. Check patient understanding, ask if they have any questions and
offer to commence the initial stages of treatment today.

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Scenario

Sleepless nights
A 40-year-old new patient attended your surgery two days ago
presenting with discomfort in the upper left and upper right
region. You identified a deep carious upper left first premolar
on which you performed a vitality test (vital), conducted
radiographs (no periapical radiolucency) and dressed. Today
this tooth is painful and disturbing sleep. The patient struggles
to be able to take time off from work and is is angry that he has
to return again for treatment.

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Issues

This scenario involves the candidate communicating with the patient to

explain the reasons for the original decay and the recurrent pain - most
likely irreversible pulpitis. The candidate will be assessed on ther ability
to calmly manage the patient, especially when faced with claims of
‘negligence’ or ‘incompetent’ work, claims based purely on the fact that
the pain has reoccurred. As such, the candidate will also be expected to
know about the complaints procedure as well as how to utilise the wider
dental team to support their clinical management of the scenario.

The candidate will be marked on their ability to empathise with the

patient throughout the scenario whilst explaining the clinical reasons
behind the pain and the methods by which the pain will be resolved as
well as the long-term treatment options for the tooth. The candidate will
score particularly highly if they can offer solutions for the patient that
work around their busy schedule.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

apologise to the patient for their situation.

2. Carry out a pain history (SOCRATES) and medical history.

3. Carry out a clinical examination. Gain consent for examining the

patient’s mouth and performing vitality tests. Radiographs may be
taken, but would be unlikely to demonstrate any significant change
since the last set taken two days ago.

4. Explain the findings to the patient. Discuss the reasons behind

the original decay, what you did to remove the decay and why the
patient is now in pain. Check patient understanding throughout.
Example: On looking at your teeth and the X-rays, I can see a dark
shadow just at side of your tooth. Now this could mean that there

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are bugs which have travelled through the top of your tooth into the
nerve and has led to irreversible damage and inflammation.
When the tooth was previously treated, the decay was originally
very deep. There were areas of decay overlying the nerve of the
tooth - the pulp. If I removed this decay, we would need to enter the
nerve of the tooth and perform a root canal procedure. As a result,
I wanted to be more conservative to leave an area of less infected
tooth, as evidence shows that these areas can sometimes reheal
if they aren’t too infected. This is to prevent entering the pulp, and
therefore requiring a root canal procedure. However, the decay was
too deep and looks like it could not reheal, and so we will need to
go ahead with a root canal treatment as originally planned.

5. Deal with any potential complaints. Empathise with the patient and
reassure them that your aim is to get them out of pain.

Author’s tip: If the patient claims that you are at fault, it is important
to stay calm and discuss that you were doing what you thought
would be best at the time. It is hoped that you also consented the
patient for the ‘indirect pulp cap’, and would have discussed the
potential of a post-operative flare up/recurrent infection. However,
rather than arguing with the patient, it is more important to continue
to empathise with the patient and reassure them that your number
one priority is to get them out of pain today.

6. Re-emphasise the issue at hand is to get the patient out of pain.

Check the patient’s understanding, offer to repeat information,
provide further details or ask if they have any questions.

7. Provide the short-term treatment options. Short-term treatment

options centre around resolving the patient’s pain. This can be done
by either choosing to save the tooth (by pulp extirpation, root canal
and crown) or extract it (and consider options to replace the space)
Example: in terms of treatment, it will simply fall into two main
categories: we can try and save the tooth or extract it. Both options
will get you out of pain. What would you like?“
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Author’s tip: In these types of high-pressured scenarios, with a

patient who is clearly angry and time-pressured, they may state
they do not have enough time for a root canal treatment and crown
procedure (which would take at least two further appointments
before the patient has a final crown restoration). Therefore, rather
than just pointing the patient to have an extraction, the examiner is
looking for the candidate to consider the patient’s busy schedule:
asking about their work rota; days or times they are off; offer
saturday appointments; if the patient has to travel far, you could
refer them to a sister/affililate practice; ask the patient what will
make attending appointments easier. Making these considerations
will score highly in the scenario.

8. Once the patient preference is identified (save vs extract), explain

the order of the chosen treatment to the patient. If saving the tooth,
explain the basic process of a root canal treatment (and crown) in
layman’s terms (see page 156). Or if extracting the tooth, explain the
steps for a dental extraction, making the patient aware that they will
need to consider prosthetic options to replace the tooth space (i.e. a
denture, bridge or implant).

9. Once the short- and long-term options have been provisionally

decided, it would then be prudent to provide more detail about the
chosen option to ensure valid consent. Summarise the treatment
plan to the patient and emphasise that the aim is to get the patient
out of pain today (short-term) and to work on the long-term options
at the next appointment. “I can do the emergency treatment for you
today. How do you feel about this?”

Author’s tip: In the interest of tooth preservation, if the patient

wants to have the tooth extracted, it would be prudent to mention
that the pain can be stopped and they can keep the tooth - ‘If I
can get you out of pain today whilst saving the tooth would you be
interested?’.

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10. Check the patient’s understanding, ask if they have any questions
and offer to commence the initial stages of treatment today.

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Scenario

Bullying behaviours
You see a 12-year-old patient for a dental examination. You find
that they are very thin and appear very tired. The patient does
not speak much and appears depressed. You enquire about
the patient’s diet and lifestyle and they reveal they only have
one to two portions of fruit and vegetables each day along with
vigorous daily exercise. Medical history indicates no acid reflux
problems. You come to the conclusion that she may be anorexic
and you suggest the diagnosis to her. She breaks down in tears
and, between sobs, admits that she does not eat as she should
because of bullying.

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Overview

This scenario is highly sensitive and requires you to empathise with the
young patient and support her through this very emotional time. As a
result, it is crucial to create an environment in which the patient feels
that they can share their concerns with you without judgement. In these
very delicate situations, it is important to not steer the conversation, but
allow the patient to speak out about their illness. You will be marked on
your ability to communicate, empathise and offer practical, thoughtful
and considerate advice as a dental professional in balance with your
duties to raise concerns and safeguard the welfare of the child patient.

Example of management

1. Introduce yourself, identify concerns, reassure immediately,

empathise and support the patient. Explore further concerns too.
Example: First of all, I’d just like to say just how brave I think you are
for telling me this. Please do not consider yourself alone, there are
many support groups out there that can help you. Do you have any
general concerns? Do you feel stressed out?

2. Offer support and practical advice. Offer leaflets, contact details to

helplines as well as opening the forum to discussing the issue with
the patient’s GP and legal guardians.
Example: Once again, I appreciate you may feel that one way that
you can deal with stress is through this, but what if I give you some
leaflets and support helplines for you to take a look at and maybe
you can find another strategy for dealing with stress? Have you
considered speaking to your parents or GP about this? They will be
able to support you in other aspects of healthcare to this.

Authors tip : If the patient does not want you to speak to their
parents, explore the reasons why.

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3. Once concerns are identified and initial management is sought,

inform patient of the next steps to ensure their safety.
Example: Although I cannot promise that I will not inform authorities,
if I do, I will notify you. They are there to help you. I want to make
sure you feel well again and are receiving the best possible care.

Author’s tip: Authorities include social services and the school that
the patient attends. As a dental professional, you have an obligation
to raise concerns and put the patient’s interest first, especially
because this issue concerns a minor who you may not deem as
competent or with capacity to decline the authorities being notified.

4. Offer options for immediate treatment and an appropriate referral.

Example: What we can offer you in terms of immediate treatment
is to go through a diet sheet of what a healthy balanced diet would
entail. However, I would like to refer you to your GP who will be able
to help you as best as possible for this.

5. Reiterate support to the patient, summarise the plan and open for
questions from the patient.
Example: I am really proud that you have come to me today and we
have discussed this. We will support you through this and this will
get better. Are you happy to go ahead with receiving help (referral to
authorities and informing parents)? Do you have any questions that
you would like me to answer for you?

6. Say goodbye to the patient in an empathetic manner

Example: Thank you for coming in today. How are you getting
home? Let me show you out of the practice and we can get a taxi for
you (if parent not available). [Give tissues, offer for the patient to wait
with another free member of staff in a room to calm down before
leaving to the public waiting room to provide a sense of dignity]

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Scenario

Total recall
A 31-year-old patient who was previously seen for a 6-month
recall is now told they now just need to attend for an
appointment every 12 months. The patient is unhappy with this
and feels that they are being neglected and not valued as a
patient by the practice.

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Issues

This scenario focuses on your ability to explore patient concerns and

successfully manage potential patient complaints. The patient upset
has been brought about as a direct result of patient misunderstanding
regarding the recall intervals. As a result, it can be resolved with a
simple explanation of the recall guidelines in a non-patronising manner
whilst empathising with the patient and identifying any further concerns
that they may have. You will be marked on your ability to resolve the
patient’s concerns, show empathy and put the patient at ease regarding
their dental care.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

apologise to the patient for their situation.

2. Explain the concept behind recalls to the patient. The following

points have been included as a pointer for statements to include in
your discussions with the patient.

• Recalls are no longer a “one-size fits all” principle.

• The NHS suggest a recall period that is specific to your dental
health to identify your risk of needing dental treatment.
• Some patients may be recalled in 6 months (high risk), others in
24 months (low risk)
• The dentist will recommend a recall period after assessing your
dental health, by taking into consideration factors such as decay,
gum health, family history, social history and medical history.
• At this appointment, the dentist works out the chance of
developing dental infections within certain periods of time. And
based on this, they decide your recall period from anywhere
between 6 months, 12 months, 18 months to 24 months.
• This decision is all evidence-based. A report produced by dental
experts published by the National Institute of Health and Clinical

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Excellence said that science couldn’t find a reason to stick to a

fixed interval of six months.
• Having a longer recall period therefore means that you are
doing an excellent job of taking care of your mouth so we won’t
need to see you now for another year.
• Your recall interval will be reviewed at every visit and over time
the recommendation can change in any direction.
• This is to also ensure that you aren’t overpaying for dental
treatment checkups each year when you don’t need them,
saving you money.
• If you develop any pain, you can still always come into the
practice at any time and the dentist will see you.
• If you don’t understand anything about your recall interval
please discuss with us.

Author’s tip: praising the patient ensures you bring them onto your
side.

3. Check the patient’s understanding, if they are happy and ask if they
have any questions and offer your farewell.

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Scenario

A rude receptionist
A patient has come in for a second appointment with you for a
dental filling looking visibly upset. During the first appointment,
she was told that you were running late. The patient refused to
wait any longer and so they choose to rebook the appointment
for a later date.

When the arrived into the dental practice for their second
appointment, they stated that the receptionist was very rude
to them and did not apologise for the issues caused by the last
visit.

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Issues

This scenario revolves around managing the patient’s complaint by

speaking and apologising to the patient as well as discussing the issue
with your receptionist to prevent a similar incident from occuring again.
You will be marked on your ability to empathise with the patient to
resolve their complaint to restore their confidence to commence dental
treatment in a positive environment.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

apologise to the patient for their situation.
Example: I am very sorry for causing you to have to rearrange the
appointment and the way you were treated. We always want to put
you first as our patient.

2. Empathise with the patient to resolve their concerns

Example: It sounds like you’re feeling a bit frustrated and were
waiting for a lot longer than you expected. We’re all busy people
and nobody wants to be sat around waiting. I can appreciate this
issue completely. I want to give you immediate attention, and when
I hear that you have had to be waiting for a long time, I do feel very
disappointed.

3. Give the reasons for the delay, especially if the patient is still not
satisfied with your apology and empathetic understanding.
Example: I was attending to an emergency, and unfortunately, these
cases are out of my control. Taking care of each patient, like I would
for yourself, is of the highest priority. I had no idea how long I would
be and it is OK to feel upset.

4. Clarify that patient is happy with response. Explain the reasons for
the delay further if needed.
Example: How do you feel? I’m sorry to hear that you’re unhappy

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about being kept waiting. Of course we don’t intend for this to

happen. However, one of the few reasons that you may be kept
waiting in this clinic is that sometimes a patient might find it
difficult to undergo a particular procedure. So naturally if they were
experiencing considerable discomfort we’d extend our consultation
time to ensure they have a more comfortable experience. Naturally
we’d extend the same courtesy to you too.

5. Manage any potential complaint against the receptionist. Use the

patient’s comments to help guide your management.
Example: I apologise for the way that the receptionist spoke to you.
I will be speaking to the receptionist about this and will ensure it
never happens to you again. Is there anything you would like me to
discuss with the receptionist in particular?

6. Check the patient’s understanding, that they are happy, ask if they
have any questions and offer your farewell.
Example: Is there anything I can do to make you happy today? Do
you have any questions? Would you be happy to commence the
treatment for the dental filling today? Great, let’s get started.

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Scenario

The extraction
A 26-year-old patient attends your surgery in pain. The lower
right first premolar is decayed without pulpal involvement,
and can be restored with a filling. The patient wants the tooth
extracted. How would you deal with this situation?

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Issues

This scenario revolves around your ability to discuss different treatment

decisions with the patient with an appropriate level of detail. You
will be marked on your ability to communicate clearly whilst putting
the patient’s preferences and best interests into consideration when
coming to a finalised treatment decision.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

identify the aims of the appointment for the patient.

2. Carry out a pain history (SOCRATES), medical history and dental

history.

3. Request to carry out a clinical examination and explain findings.

Check the patient’s understanding throughout the discussions.
Example: Do you mind if I take a look at your teeth and take some
X-rays? On looking at your teeth and the X-rays, I can see a dark
shadow just at side of your tooth. This could be due to bugs that
have travelled through the top of your tooth into the bulk of the
tooth (called the dentine), leading decay.

4. Re-emphasise the issue and aims after explaining the diagnosis

Example: However, our main priority is to get you out of pain.

5. Identify initial patient preference for treatment to guide

conversation.
Example: In terms of treatment, the tooth is restorable, so we can
remove the decay and place a filling.

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Authors tip: Just because the patient wants something, it is within

your right to refuse if you believe it is not in their interest at the time.
The question states that the tooth is restorable; but not an actual
diagnosis so all reasonable restorative options should be explored.
If you feel that the patient is being unreasonable to extract the
tooth when it could be easily restored more conservatively with
a filling, this will guide your conversation in the later part to focus
more attention onto these aspects to educate the patient. Asking
the patient - If we could get you out of pain and save the tooth still,
would you like this? - may make the patient reconsider a decision
to extract the tooth. However, you should do all you can do get the
patient out of pain.

6. Explain restoring the tooth with a filling or carrying out a root canal
treatment if there is extensive decay
Example: the treatment that you undertake falls into a spectrum of
more conservative to more invasive. The least invasive option would
be to carry out a filling procedure. Would you like me to explain
this? (see explanation of clinical treatments on page 153). Do you
understand this so far? In some cases, the decay can extend into the
nerve of the tooth, which may require me to carry out a root canal
treatment to clean out the nerve of the tooth (see page 156).

7. If the patient chooses to extract the tooth: Explain that the tooth is
restorable, and it is not your recommended option. Extraction of the
tooth is not a reasonable option unless the tooth is unrestorable. If
the patient is being difficult and requesting an extraction, you should
state that the procedure is not in their best interest and that you will
seek a second opinion.

8. Identify the preferred treatment option and provide more detailed

information around this to ensure informed consent. Ask if the
patient has any questions.
Example: What would you like to go ahead with? Do you have any
questions? Would you like me to explain anything again or in more

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detail?

9. Summarise the treatment plan to the patient, emphasise that the aim
is to get the patient out of pain and offer to commence treatment.
Example: Great, so let’s go ahead with [insert chosen treatment
option]. We can commence treatment today to get you out of pain
today if you like?

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Scenario

A recurrent issue
A 42-year-old patient attends complaining of a broken amalgam
filling that was carried out by another dentist two years ago.
The dentist who originally treated the patient has since left the
practice. Radiographs show caries underneath the filling but the
patient is not in any pain. The tooth is restorable. Outline what
you will do.

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Issues

This scenario involves communicating and empathising with the patient

to explain the clinical issues of the broken filling and necessity to repair
or replace the filling, or consider extraction. The candidate should
explain the reasons behind the broken filling, ensuring not to blame the
previous dentist, even if probed by the patient. The candidate will be
marked on their ability to explain the clinical treatment options to the
patient in a clear, coordinated and concise manner. They will also be
assessed on their teamworking abilities to professionally manage any
complaints the patient may have and resentment the patient may feel
towards the previous dentist.

Example of management

1. Introduce yourself, confirm patient details, identify concerns,

reassure immediately and identify the aims of the appointment for
the patient.

2. Explore the patient’s complaints regarding the broken filling. Ask

exploratory questions to gain further information (i.e. what, when,
how).
Example: I’ve heard a little bit about your condition regarding the
broken filling. Would you like to tell me a little more about it? I
understand that you are not in any pain. However, are the sharp
edges of the filling or tooth causing any discomfort? When did you
notice that the filling was broken? How did the filling break?

3. Carry out a clinical examination. Ask to examine the patient’s teeth,

take radiographs as well as performing vitality tests to assess the
tooth’s status.
Example: In order to better visualise the health status of your teeth,
I need to take a look inside your mouth and take some x-rays and
work out if the tooth if still alive. Is that OK with you?

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4. Explain the clinical findings. Discuss about the broken filling and
how you can see that there is decay underneath the broken filling
on the radiograph. Reassure the patient that this is treatable and
they are not in pain.
Example: On examining your teeth, I can see that the filling is
broken. From the X-ray images, there appears to be a dark shadow
just underneath your broken filling. Now what this could mean is that
the bugs have travelled from the top of your tooth and through the
filling. The bugs have a potential to irritate the nerve of the tooth
and cause pain if left untreated. However, it is good that you are not
in any pain right now, and this issue can be prevented if I treat the
tooth.

5. Check patient understanding, and provide the opportunity for the

patient to ask any questions about the findings and your diagnosis.
Reiterate the aim of the appointment today. Be prepared for the
patient to complain about the previous dentist.
Example: Do you understand everything or have any questions so
far? Our main priority is try to restore the tooth and replace the filling
if possible. Would you like this?

Author’s tip: if the patient is angry about the situation, you should
empathise with their concerns whilst ensuring that you do not say
anything that might indicate the previous dentist may be at fault.
This will score you high marks. Statements like ‘I am sorry, I cannot
comment on the previous dentist, as I wasn’t there’, will quell the
patient. All fillings are guaranteed under the NHS for 1 year from
placement. Since the filling has broken 2 years from placement, it
isn’t covered under guarantee. However, in this made-up scenario,
you can always calm a patient down by saying you can speak to the
principal to find out if the treatment can be provided free of charge.
Asking what the patient would like as a resolution is also a good
tip to resolving a potentially difficult complaint scenario. Following
attempts at local resolution, if the patient still wants to go ahead
with a complaint, the formal practice complaints procedure should
then be explained.
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6. Provide the overview of treatment options to restore the tooth.

Treatment options revolve around either restoring the tooth or
extracting it.
Example: in terms of treatment, it will simply fall into two main
categories - to save the tooth or extract it. What would you like?

7. Restoration: Provide a basic description of the spectrum of

treatments available if the patient chooses to restore the tooth. This
would involve either providing an amalgam filling, composite filling
or an inlay/onlay. If the decay is extensive, a crown may be required,
as well as a root canal treatment if the decay extends into the nerve
of the tooth.

Amalgam: a silver coloured metal filling.

Composite: tooth coloured filling.
Inlay: can either be made of metal or a tooth coloured material.
They are designed in a lab after moulds have been taken of your
mouth.
Root canal treatment: a procedure to remove the infected nerve of
the tooth, followed by cleaning and filling the inside of the root to
prevent further infection. A root canal treatment may be necessary
if the nerve is exposed during the removal of decay and the old
filling (further explanation on page 156).
Crown: a cap that fits over a prepared tooth, making it strong and
giving it the shape of a natural tooth. It can be made of a variety of
different materials such as ceramic or metal.

8. Extraction: Provide a basic description of the spectrum of treatments

available to restore the tooth space if the patient chooses to extract
the tooth, as well as a description of the extraction procedure itself.
This would involve either providing a denture, bridge or implant to
restore the missing gap.

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Author’s tip: in the interest of the principles of conservative

dentistry, it would be prudent to recommend the patient to restore
the tooth initially before considering options to extract the tooth.

You should emphasise the irreversible nature of such a decision

and that the tooth is ‘restorable’ (as described in the scenario text).
However, if the tooth was stated to be ‘non-restorable’, the situation
would be rather different; the treatment protocol would typically
revolve around first stabilising the tooth to remove infection if the
patient was in pain. This may involve either removing gross decay
and restoring with an interim restorative material before making
a decision to extract the tooth, or proceeding with an extraction
straight away.

It is always prudent to state that you can gain a second opinion from
a more senior colleague in these high-pressured situations to put
the patient at ease. Following stabilisation of the tooth, you may
even offer to refer the patient to a specialist if they are convinced
that they want to keep the tooth. It is important to remember that
whilst you wish to make treatment decisions that are in the patient’s
best interests, it is just as important not to force treatment decisions
on them - doing so would not be regarded as gaining valid consent.

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Scenario

Mercury mouth
A patient comes to you with a newspaper article that describes
mercury fillings as ‘poisonous’. The patient wants you to take all
their amalgam fillings out and change them to ‘white fillings’.

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Issues

This scenario involves you educating and communicating with the

patient in an encouraging and non-patronising manner. You will be
marked on your ability to identify and alleviate the specific patient
concerns as well as rationalising the evidence-based safe use of
mercury in amalgam fillings. As a result, you will formulate a plan to
continue their dental care in a safe and evidence-based manner with
the patient happy to keep their sound existing amalgam restorations.

Example of management

1. Introduce yourself, confirm patient details, identify concerns,

reassure immediately and identify the aims of the appointment for
the patient.

2. Open a discussion about the patient’s fears and any other issues
(i.e. aesthetics)

Explore issues: what is it that worries you about amalgam fillings?

What are your biggest concerns?

Current evidence: according to the Medicine and Healthcare

Regulatory Agency (MHRA), the safety of amalgam has been
reviewed nationally and internationally over the last ten years and it
has been concluded that amalgam is safe to use. At present, dental
amalgam provides a high quality and effective restoration with
many of the current alternatives not as effective (MHRA 2012).

Furthermore, according to a study conducted by Berglund (1990),

the intra-oral vapour levels of mercury were measured in patients
with a significant number of amalgam fillings (at least nine amalgam
restorations) over a 24-hour period. The vapour released amounted
to just 1% of the threshold limit value set by the World Health
Organisation.

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Risk management: current advice is that it may be prudent not to

remove or place amalgam restorations during pregnancy where
clinically reasonable, although there is not evidence to show that it
is harmful. Removing amalgam produces a lot of vapour which may
be inhaled, although in practice we ensure patient safety by using
effective suctioning systems. Mercury vapour may be released from
amalgam during placement and removal, and not whilst it is set.
Therefore, removing amalgam would be more detrimental to health
rather than leaving them in a set state.

Supporting reasons to remove: there are a few cases of allergy

and hypersensitivity; in these cases, alternatives should then be
used. If the fillings are compromised in either structure of underlying
decay, it may then be necessary to remove the amalgam, and if
clinically indicated, you could replace the filling with a ‘white filling’
(composite) alternative. This decision would be made as part of a
wider clinical examination.

Summary: it is best to leave things as they are for the present

situation and replace the fillings when indicated (i.e. infection) with
composite.

Author’s tip: It would be easy to dismiss the newspaper article that

the patient brought. However, patients would much prefer it if you
take them seriously. Saying that you will read up on their concern
and investigate it further while also stating current evidence would
surely be better to keep the patient on your side. Offering to bring
in another more senior dentist for a second opinion may also
alleviate the patient’s concerns if needed. If the patient presses for
composite fillings (i.e. for compromised amalgam fillings), it may be
worthwhile clarifying that they may incur private fees if not seen as
a necessary option under the NHS.

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3. Check the patient’s understanding, that they are happy to continue

their dental examination and care under yourself, ask if they have
any questions and offer your farewell.

References

Berglund, A. (1990). Estimation by a 24-hour Study of the Daily Dose of

Intra-oral Mercury Vapor Inhaled after Release from Dental Amalgam.
Journal of Dental Research, 69(10), pp.1646-1651.

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Scenario

The wisdom tooth

A 21-year-old fit and healthy male patient attends your practice
with pericoronitis. He is suffering from pain relating to his
upper left wisdom tooth. This is the first episode of pain in the
wisdom tooth. He requests for the upper left wisdom tooth to
be extracted. Take a history, the necessary investigations to
ascertain a clinical treatment decision and obtain valid consent.

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Issues

This scenario revolves around information gathering and explanation

of relevant treatment decisions in accordance with the NICE Guidelines
regarding the extraction of wisdom teeth. You will be marked on your
ability to communicate with the patient empathetically whilst exploring
the treatment options for the short- and long-term. You should come to
an agreed management with either yourself or another senior colleague
to help resolve the patient’s pain during this appointment.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

identify the aims of the appointment for the patient.

2. Carry out a pain history (SOCRATES), dental history, medical history

and social history.

3. Carry out a clinical examination, special tests and radiographs.

Example: In order to find out the cause of pain it is important for me
to take a look at the teeth and take some X-rays as well as to check
if the nerve of the tooth is still alive (vitality tests). Have you had
these tests before? Do you mind if I take a look at your teeth and
carry these out?

4. Explain the clinical findings, the cause of the pericoronitis infection

and wider issues regarding the wisdom tooth. Describe the
expected symptoms and expected duration of infection following
interventional treatment.
Example: On looking at your teeth, I can see that the wisdom tooth
is only partially erupted into the mouth and has a flap of inflamed
and swollen gums over the biting surface of the tooth. As a result,
when we bite down on the gum, it can cause cuts which are painful.
These cuts can become infected, especially because food can get
trapped easily in the back of the teeth between the gum flap and

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the tooth. On looking at the X-rays, we can see that the wisdom
tooth is lacking space to come out in the mouth. Often we find that
there isn’t enough room in your mouth for wisdom teeth. When
this happens, your wisdom teeth are said to be Impacted. This can
happen both in a forward direction and a backward direction.

5. Check patient understanding.

Example: Do you understand everything so far? Would you like
me to explain anything else, or in further detail? Do you have any
questions so far?

6. Provide treatment options. As this is the patient’s first case of

non-severe pericoronitis, the NICE Guidelines recommend that
preventative measures should be employed first. Unless the patient
presents with a severe episode of pericoronitis, it would not be
suitable to extract the tooth. However, it should be noted that the
NICE Guidelines are guidelines only, and not fixed rules. So it is
up to the dentist’s discretion to decide an appropriate treatment.
Examples of treatments offered are provided in the box below.

Hygiene instruction: Ensure that you maintain excellent oral

hygiene by brushing the flap of gum, the wisdom teeth and the
space in between - all to prevent food and bacteria accumulation. It
is also good practice to floss daily and, if desired, mouth rinsing at a
different time to brushing.
Irrigation: We can use special scalers to help flush out any food and
bacterial debris between the tooth and gums.
Warm salty rinses: Alongside brushing, you can carry out gargles
with warm water with salt added to it. This helps to prevent any
infection in the area.
Grinding down of the opposing cusps: This procedure involves
drilling the cusps down slightly to help prevent excessive biting
between the opposing teeth and the gum flaps.

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Antibiotics: If the patient shows signs of systemic infection,

antibiotics should be considered. Alongside good oral hygiene, the
infection should resolve in one week.

Operculectomy: In some cases, if the inflamed flap of gum tissue

does not resolve, it may be removed surgically via a simple
procedure whereby it is cut off whilst the gums are put to sleep.

7. Check patient understanding and carry out consent for chosen

treatment options. Provide details for what may happen if the tooth
has a flare-up again and is not amenable to the initial management
methods provided above. This may warrant an indication for dental
extraction.

8. Summarise the treatment plan to the patient and emphasise that the
aim is to get the patient out of pain. Ask if the patient has any further
questions. Offer farewell.

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Positive discrimination
A HIV positive male comes into the surgery and is very upset,
as he has noticed some clinical notes on the counter of the
reception with a large red sticker on it marked with a ‘positive’
symbol. The patient is also very concerned as he only received
a 20-minute appointment for his periodontal treatment and
feels discriminated against. The patient wishes to make a
complaint and wants to know what you are going to do about it.

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Issues

This scenario revolves around communicating with the patient to

empathise with their concerns and apologise for the way they have
been treated to resolve their complaint. The scenario relies on
the fact that each patient should be treated fairly, equally, without
prejudice and in their best interests. There are also issues of patient
confidentiality, managing complaints, working with colleagues such as
your receptionist effectively and education around treating HIV-positive
patients. You will be marked on your ability to completely resolve the
patient’s complaint by explaining the situation calmly and how you will
prevent these issues from happening in future, as well as ensuring the
continuity of their care in an environment that they feel respected.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

identify the aims of the appointment for the patient.

2. Apologise immediately for the situation and reiterate the importance

of the patient being treated in their best interests.
Example: I am sorry if the doctor has made you uncomfortable. He’s
truly an excellent dentist and cares very much about providing you
with the best care.

3. Offer to mediate the issue.

Example: Would you like me to talk to him privately at some point
about how he could help patients feel more welcome in the
practice?

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4. Address each issue presented by the patient - the red sticker.

Indicate that the sticker is for office use only for the patient’s best
interests and safety. Also, address the issue of patient confidentiality
and that you will educate the reception staff about storing patient
notes in locked cabinets away from plain view.
Example: The reason why a red sticker was placed on your notes
is to make other practitioners aware of a medical condition, as they
may be able to check for a deteriorating condition and thus act to
preserve your safety. We take the same precautions for everyone
here when treating. Some treatments that we may do may affect
your health and we want to make sure your health and safety is our
number one priority. However I can reassure you that we will ensure
henceforth that notes are not in frank view of other patients. We will
ensure that when not in use, notes are locked away in cabinets.

5. Address each issue presented by the patient - the ‘20 minute

periodontal treatment.
Example: How did you feel about the quality of care you received?
Usually 20 minutes is all that is required for periodontal treatment.
In some cases, patients require more time if their gum health is
particularly worse.

6. Check the patient’s understanding, that they are happy to continue

their dental examination and care under yourself, ask if they have
any questions and offer your farewell.

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Periodontal advice
A 50-year-old patient attends your practice complaining of
‘wobbly teeth’. The patient is a chronic smoker and you identify
that they are suffering from severe chronic periodontitis. The
patient wishes to find out how to preserve their teeth.

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Issues

This scenario revolves around explaining the diagnosis of chronic

periodontitis to the patient in a sensitive manner whilst exploring the
treatment options to prevent further bone resorption and tooth loss.
There is also a focus on exploring the patient’s attitudes towards their
dental health and their motivation to quit smoking. You will be marked
on your ability to sensitively and empathetically discuss the diagnosis
with the patient without blaming your colleagues to eventually agree
and consent on a proposed treatment plan.

Example of management

1. Introduce yourself, identify concerns, reassure immediately and

identify the aims of the appointment for the patient.

2. Carry out a dental history (with a focus on their periodontal history

and dental motivation) and medical history.

3. Carry out a clinical examination, special tests and radiographs.

Example: In order to look into the issue, it is important for me to take
a look at the teeth, probe your gums and take some X-rays as well
as checking if the nerve of the tooth is still alive (vitality tests). Do
you mind if I take a look at your teeth and carry these tests out?

4. Explain the clinical findings to the patient in layman’s terms.

Example: After taking a look inside your mouth, I can see that you
have something called gum disease. Have you ever been told about
gum disease and what it is? Gum disease is caused by bacteria
which live in your mouth. The bacteria stick to your teeth and irritate
the gums by making them bleed. The disease may destroy your
gums and bone which support your teeth. The infection itself is
completely reversible, but unfortunately the loss of bone is not. We
can talk about ways of managing the wobbly teeth today and how to
prevent more teeth becoming wobbly.

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Author’s tip: Using props is a great way of explaining to a patient

conditions that affect their oral health. If the patient is still failing to
understand the concept of bone loss, it may be helpful to explain
via a demonstration to describe and compare the state of tooth
mobility in healthy bone vs resorbed bone: (1) hold a pen tightly (to
represent healthy bone) and ask the patient ‘can you wobble the
pen?’; (2) next, hold the pen loosely (to represent resorbed bone)
and ask the patient ‘can you wobble the pen?’. From this simple
analogy, the patient should notice that is it is much easier to wobble
the pen from the loose hand than the gripped hand.

5. Ask the patient what they would ideally like from today’s
appointment to identify an appropriate focus for the discussion of
treatment options.

6. Address the patient’s smoking habits and carry out smoking

cessation advice.

• Have you ever throught about quitting smoking?

• Have you ever tried to stop and how was that?
• How does smoking fit into your life?
• Is smoking a big part of your social life?
• What else do you like about smoking?
• Have you noticed any negative aspects of smoking?
• On a scale of 1-10, where 1 is you cant stop at all and 10 is really
confident you can quit if you tried, where do you fit?

Motivate the patient to quit smoking: the good news is just by

stopping you can reverse some of the negative effects that smoking
is having on your gum health and will help towards preserving
your teeth. Smoking affects healing and so gum treatment will
work better if you don’t smoke. I would be more than happy to
provide you with information where you can obtain extra support
about quitting. Where do you think we should go from here? I really
appreciate you talking to me about this today.

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7. Discuss the treatment options with the patient. The different options
are provided below:

Oral hygiene instruction: Teaching you the best way to clean your
teeth and gums to remove bacteria. By brushing, flossing, using
interdental brushes and mouthrinses.
Gross clean: We will remove tartar from your gum line by scaling.
Explain the terms tartar/calculus to the patient.
Deep clean: We may also need to remove bacteria and tartar
from below the gum line by scaling. If this is uncomfortable, we
can give you an injection to make the gums numb. The treatment
will take place over a number of appointments and we may need
to integrate your care with other members of our team such as
hygienists
Review: Your response to the treatment will be monitored at a
future date where further treatment may be needed.
Further treatment: On reviewing, we may find that scaling isn’t
effective in removing all the bacteria and tartar and thus we may
need to carry out gum surgery. This would be carried out by a
specialist, who I would have to refer you to, and they would expect
you to have quit smoking beforehand too .

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8. Gain valid consent for the periodontal treatment by explaining its

benefits, risks, related consequences of no treatment, prognosis and
associated costs.

Benefits: your gums will become healthier allowing you to keep

your teeth for longer. The redness and swelling will reduce,
soreness will reduce, teeth may feel firmer after time and breath will
feel fresher.
Risks/drawbacks: your gums may feel sore after scaling but should
feel better after a few days. Your teeth may feel sensitive to hot,
cold or sweet but this usually decreases within a few weeks. You
may need to use a special tooth paste. Gums tend to shrink as they
heal so teeth may tend to appear longer.
Consequences of no treatment: the result of not having treatment
may mean that your gums become worse resulting in pain and loss
of teeth.
Prognosis: A good prognosis is largely dependant you maintaining
excellent oral hygiene. However, some teeth may have a poor
chance of surviving even after treatment due to the amount of
bone loss and thus may need to be extracted. Of course in that
case if you are happy for that to occur, you will be given options of
restoring this space with dentures, bridges or implants if clinically
justified.

9. Reiterate the plan and that success is based on patient compliance.

They must be motivated to maintain excellent oral hygiene.
Example: Oral hygiene instruction, scaling and deep cleaning
(subgingival scaling) with review. How do you feel about this?

10. If you feel as though we can achieve you goals when would you like
for us to start.

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11. Check the patient’s understanding, that they are happy to continue
their dental examination and care under yourself, ask if they have
any questions and offer to commence the treatment today.

Author’s tip: If the patient states the previous dentist has not told
them this before, explain that periodontal disease can occur at any
time and does not follow a simple time line. Whether it was there
before or not you do not know. Explain that the patient can always
discuss their history with previous dentist but at this moment it is
important to treat the condition.

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A wrong shade
A patient is upset about the shade of a metal-ceramic crown
(UR1) that you fitted 1 week ago, as it does not match the shade
of the rest of his teeth. He is requesting that you correct it.

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Issues

This scenario revolves around managing patient expectations

and resolving potential complaints when they arise. It relies on an
empathetic tone to understand the patient’s concerns and offering
options to resolve the issue of the poor shade match of the crown. You
will be marked on your ability to communicate in an understanding
manner with the patient to apologise and formulate a plan to rectify the
issue. You should wish resolve any potential disputes in the practice
during the appointment and finishing off the scenario with an agreed
and consented plan that the patient is happy with.

Example of management

1. Introduce yourself, identify concerns, reassure immediately,

apologise and identify the aims of the appointment for the patient.

• You seem really upset

• Listen attentively to their concerns
• As a dentist, your smile is very important to me.
• What would you like out of today’s appointment?
• Apologise to the patient: I am very sorry that the shade isn’t
what you were expecting.
• Thank you for sharing your feelings with me, I want to make
sure you are completely happy with your treatment

I am really sorry that you are unhappy with the colour of the crown.
I will talk to the lab and investigate what went wrong. Is it just the
colour or is there something else (symmetry, shape, etc). It is very
difficult to match the exact shade of a front tooth crown, but we can
always try again for you. What would you like me to do that would
make you happy today?

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Author’s tip: If the patient says they want to make a complaint then
let them know of the complaints procedure. Many candidates offer
the complaints procedure too quickly before trying to solve the
problem. Remember that the GDC advises local resolution when
possible.

2. Carry out a dental history (simply to check that they are not in any
other pain) and medical history.

3. Discuss the treatment options with the patient. In this scenario,

the only option would be to remove and replace the crown. The
description of the clinical treatment is provided below, and should
be discussed with the patient to gain valid consent.

Nature: We can remove the existing crown, and replace it with one
that matches your expectations. This process will involve cutting the
crown into pieces, adjusting the preparation and taking mould and
shade to be sent to the lab.
Benefits: You will receive a crown that matches your expectations.
Risks/drawbacks: On removing the crown, the tooth may fracture
and damage the pulp and therefore requiring root treatment.
Prognosis: Although I cannot give you a guaranteed lifespan of the
filling, what I can tell you is that ways in which you can promote its
longevity, i.e. ensuring good oral hygiene in the area.

Author’s tip: Offer the patient to visit the lab so they can take a
shade match of the tooth, or even better ask the lab technician
to come to the practice to take the shade for the patient’s
convenience.

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4. Reiterate the plan and that the aim is to make a new crown with a
new shade.

5. Check the patient’s understanding, ask if they have any questions

and offer to commence the treatment today (removing the crown,
taking new impressions and placing a temporary crown).

Author’s tip: Never get into an argument of cost with the patient. If
they are still unhappy with the crown and you have tried everything,
offer the money back and arrange to find another dentist for the
patient to continue their care. This is an acting scenario where
losing the imaginary fee for a crown is acceptable rather than
having a full blown argument!
In practice, the management depends on the case. Metal-ceramic
crowns usually match poorly, due to the metal substructure. This
may have already been consented for and needs to be explained
to the patient again. In practice, replacement of the crown is quite
extreme, as the crown would have been tried in first before fitting
- therefore it is unlikely that the crown would be so much worse as
the crown that had been trialled in the fitting appointment.

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The situational judgement
test (SJT)

4.1 Advice & guide

 The complete
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and guide1

About the SJT exam

Format of the SJT exam

You will need to answer 56 questions in 105 minutes (averaging 1.8
minutes per question). The SJT counts as 50% of your final score. The
SJT test will provide questions in two possible formats:

Format 1 - ranking: A scenario is given whereby the candidate has

to rank the five available options from most to least appropriate.
Marks are available if you make a mistake. The marking method for
this format is given on page 307.

Format 2 - multiple choice: For multiple choice scoring scenarios

you will be given a number of options from which the candidate
is required to pick the three best choices that work effectively
together.

What does the SJT exam test?

In an SJT, candidates are presented with a set of hypothetical and
relevant scenarios that may occur during your career and asked to make
judgements on what the best options would be to take. The scenarios
do not test your clinical knowledge or skills but ethical understanding
of the right thing to do in these situations. The GDC standards are the
professional attributes that you will be expected to uphold.

The GDC set dental professionals specific standards and domains that
they should abide by in their professional practice. The SJT exam is
designed around these five domains which can be summarised as
follows on the following page.

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Committment to professionalism
• Is punctual, reliable and accountable
• Takes responsibility for own actions and owns up to mistakes
• Takes responsibility for own health and well-being
• Demonstrates commitment, enthusiasm and responsibility
towards the role of being a dentist
• Is reliable, trustworthy and honest
• Challenges the behaviour or knowledge of others where
appropriate
• Demonstrates awareness of ethical issues, including
confidentiality

Coping with pressure

• Remains calm and in control of situations
• Manages uncertainty and ambiguity
• Effectively deals with outcomes of mistakes and decisions
• Exhibits flexibility/adaptability when dealing with changing
circumstance or issues
• Employs effective coping mechanisms and seeks support for
dealing with stress or emotions
• Deals appropriately with confrontational and difficult situations
• Demonstrates good judgement under pressure
• Does not give up easily

Effective Communication
• Listens effectively
• Ensures surroundings are appropriate when communicating
• Understands, uses & responds to non-verbal cues
• Uses jargon-free and sensitive language
• Communicates information (verbal and written) clearly and
concisely with relevant information
• Asks appropriate questions and is available to answer questions
• Adapts the content and delivery of information to the needs of

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the intended situation and audience

• Checks patient’s and relative’s understanding
• Reflects information to clarify own understanding
• Is diplomatic yet assertive where necessary

Effective teamwork
• Understands the roles, skills and responsiblities of others within
the team
• Utilises the most appropriate person for a task or situation
• Is aware of own role/responsibilities within team
• Builds rapport, establishes relationships and provide support
and advice to other team members
• Seeks, values and respects other people’s opinions and
contributions
• Delegates and shares tasks effectively
• Identifies when others are in difficulty or are struggling
• Is able to take direction and adapt their role within the team (i.e.
being team leader)
• Makes others aware of own workload

Patient focus
• Shows respect and gains trust from patients
• Makes oneself available to patients whilst maintaining
professional boundaries
• Respects the differing needs, values and beliefs of patients
• Works jointly with the patient to put them at the centre of care
• Shows interest, compassion and empathy towards patients
• Is willing to spend time with patients/relatives to build a rapport
• Is polite, courteous and reassuring to patients whilst working in
an open and transparent manner
• Provides reassurance to patients
• Maintains patient’s safety at all times

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How is the SJT exam written?

The SJT exam is written by a mixture of dental clinicians, dento-legal
experts and psychologists. The answers are decided by a consensus
from a panel of experts. The bank of questions are then quality-
assessed by another independent panel of experts, whereby they take
the exam to assess whether the same responses are found across the
expert group. The results are then screened for concordance, as it is
assumed that the experts in their field should all come to the same
answer responses. The questions that demonstrate disagreement
between the experts are either removed from the bank or re-assessed,
evaluated and improved upon.

It is important to note that in comparison to other knowledge-based

exams, such as OSCEs or MCQs, SJTs sometimes may not have a
definitive correct answer as it assesses your judgement and NOT
knowledge. Because differences between certain answer options
can be very subtle, there may be some answers that a candidate may
disagree with. Therefore, we have provided an explanation of the
answers in this book, so you can understand the thought-process of
answering an SJT question.

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How is the SJT exam marked?

The SJT exam is a written paper. Therefore, it is not a computer-based
test. The candidate provides their answer responses by scoring boxes
on an Optical Mark Recognition (OMR) answer page (see image below).
These papers are marked by a machine, which analyses the exact area
of the box that you have marked with a HB pencil. For this reason, it is
important to keep your answers neat and accurate, as smudges outside
of the box may negate your answer. The SJT questions are divided
across two different question formats (ranking and multiple choice). The
number of marks assigned to each question format vary. The details for
each are provided in the next section.

Figure 1: The score sheet, showing

the penciled-in boxes and ranking
for options A to E. In this answer, the
options have been ranked from most
to least appropriate as: DABEC.

Ranking questions
A scenario is given with five different answer options, each worth a
maximum of 4 marks, if correctly ranked. Therefore, each ranking
question carries a maximum total of 20 available marks. Marks are still
available if you make a mistake.

Correct answers are given 4 marks, but an answer that is one place
away from its ideal ranking position would still get 3 marks (see the
worked example in the table on the next page). Therefore, in these

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types of questions, it is important to put an answer down even if you

are not sure. Otherwise, by not answering the question, you may be
forfeiting all 20 marks. Below is a table that demonstrates the method of
scoring for these types of questions.

Ideal Rank 1st choice 2nd choice 3rd choice 4th choice 5th choice
A 4 3 2 1 0
B 3 4 3 2 1
C 2 3 4 3 2
D 1 2 3 4 3
E 0 1 2 3 4

Let’s imagine the above table applied to a question whereby the ideal
ranking order was ABCDE. Let’s say you answered ACDBE. Looking at
the table, this would score you 16 marks (4 + 3 + 3 + 2 + 4).

Multiple choice questions

For each correct answer (out of three), 4 marks will be awarded.
Therefore, if all three options are chosen correctly 12 marks will be
given. If no correct answer is chosen in that question, then 0 marks will
be gained. There is no negative marking.

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Key facts & important tips

When answering SJTs, there are various standards and pieces of

information that you should be aware of to inform your decisions. This
book contains various guidelines that are essential for the candidate to
be aware of before the day (see guidelines section on page 413). For
SJTs, the main guldelines you should be aware of include:

• Confidentiality
• Consent
• Capacity

Approach to answering ranking questions

• The candidate is given a booket containing the questions and

a separate answer sheet. Read the scenarios carefully and
underline key points from the scenario in the question booklet.
• Pick the first and last choice as these are the most obvious for
the ranking scenarios
• From there, order the other three remaining options
• Review your answers, place them onto the answering sheet and
move onto the next question

Approach to answering multiple choice questions

• Read the scenario carefully

• Rule out incorrect options by placing a cross next to the option
in the question booklet
• Pick three answers from the remaining viable choices that are
the best for the scenario when chosen together and place them
into the answer sheet

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Potential pitfalls

• Not knowing how DFT dentists act in situations

• Thinking there is a rule book
• Following advice and examples rigidly

General advice

• Read the scenario carefully and assume nothing. Sometimes

you would like more information from the scenario to answer
the question better, but stick to what is given and answer
accordingly.
• Your DFT trainer is called the Educational Supervisor (ES) who
oversees your progress in practice. Above the Educational
Supervisor is the Training Program Director (TPD), who oversees
the ESs in the area and who organises your study days.
• You will be pushed for time so ensure you have finished
answering all questions before the exam ends
• Read each choice carefully and ensure you understand the
differences between each choice (some are very similar)
• Answer the ranking questions in full. Do not leave a choice blank
as that will score 0 marks.
• Do not overthink the answers as that may lead to wrong
decisions. Only take a second look at the scenarios once you
have finished all the questions
• For multiple choice questions, selecting more than 3 answers
will lead to no marks for the whole question.
• Answer the questions as if you are a DFT dentist nothing more
or less.
• Although some authorities say you cannot revise or prepare
for such exams, the authors would disagree. The more SJT

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questions that are done, the more the candidate is used to

thinking about the rationale of the questions and in a given
time limit. However, it should be noted that no two SJTs will be
exactly the same, and so answers should not be ‘learnt’, but only
the rationale should be taken as an educational resource.
• Practice as many SJTs as possible. Some medical questions are
very similar to dental scenarios and they can also be used for
practice. Check out http://sjt.foundationprogramme.nhs.uk/ for
free SJT medical practice. The layout of the questions are very
similar to what you will find in the dental exam.
• Ensure you place your answer into the answer sheet. Time
is short in these exams and it is found that those who do not
answer all the SJT questions are the ones with the lowest
rankings as each non-answered question gains no marks.
You can always rub out your answer and change it later on, as
answers are scored in pencil.
• If the scenario answer ideally should be ABCDE and the
candidate answers correctly in that order then full marks of
20/20 will be given. If however the candidate chose to answer
BACDE then total marks would be 18/20 losing only 2 marks.
Marks are still gained.
• For the multiple choice questions, it does not matter in which
order you pick the three options.
• Place a question mark on the scenario on the booklet if you are
unsure of the answer so that you can come back to it later on if
time permits.

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4.2 Ranking questions

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Question
Question1 1

You have started your new DFT job in the new dental practice.
Things are going well but you notice that your nurse, an
experienced dental nurse, is not cleaning properly between
patients.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Ignore it and hope things get better.

B. Tell her forcefully she is doing a poor job and must improve.

C. Have an honest discussion with her about what she is missing.

D. Tell the practice manager that she should be sacked, as the nurse
should know better and is just being idle.

E. Approach the practice manager and ask them to talk to the nurse.

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Question
Question22

A patient returns to the practice complaining that the denture

you made three months ago is ‘rubbish and doesn’t fit anymore’,
demanding a new denture and their money back. Upon checking
the notes you see that you made an immediate denture for the
patient after removing their remaining upper arch dentition, and
gave an explanation that a new denture may be necessary in a few
months, at a new charge.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Refuse to see the patient, telling reception that they know it was
only a temporary denture.

B. Offer the patient a refund and advise them to seek a new dentist if
they are unhappy.

C. Apologise to the patient and tell them you are sorry they are
unhappy. Explain to the patient again that this was an immediate
denture and they were always likely to need a new one, as you had
previously stated.

D. Tell the patient that’s the way it is, you do not make the rules.

E. Ask your Educational Supervisor for help.

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Question 3

You are performing a root canal treatment (RCT) on a patient when

you realise that a file has separated.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Inform the patient, explain that this was one of the risks you
mentioned previously and now you can complete RCT leaving the
remains of the file in place.

B. Inform the patient, apologise and offer an extraction, a referral to an

endodontic specialist or to complete the RCT yourself.

C. Carry on with the RCT as if nothing has happened, as you are fairly
sure that you can obtain a reasonable result.

D. Call your Educational Supervisor for advice.

E. Tell the patient the procedure has failed and extract the tooth.

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Question 4

You are seeing a 9-year-old boy who has toothache. It is January

2nd.

You see from the notes that his father rang the practice on
Christmas Eve to make the child an appointment because he
was in pain. The receptionist noted the father was offered an
appointment to attend the practice and to ‘sit and wait’ for
treatment as there were no free appointments. The father said he
was not prepared to ‘waste his time’ and would bring the child in
after Christmas.
His mother and father accompany the child. The father appears
to be drunk. The child has a persistent cough and looks generally
unwell. The child has several carious deciduous teeth with early
caries in all the 6s.
You notice the child has bruising around both wrists. When you say
the child looks very unwell the father becomes quite aggressive
and tells you to get on with treating the toothache. The mother
tells the father to ‘calm down and let the dentist do their job’.
You treat the immediate toothache.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Get the family out of the practice as quickly as possible, and ask
they see a senior dentist for any future treatment. This family could
cause problems and are beyond your ability to manage.

B. Discuss the issue with your Educational Supervisor after the family
have left.

C. Ring social services as soon as the family leaves to report child

abuse.

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D. Ask the parents how the child got the bruising around his wrists.

E. You need not do anything further, as you have fulfilled your duty as a
dentist.

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Question 5

You are the sole dentist in the practice today. Your only nurse
rings in ill at 8.45am. The one other person in the practice is the
receptionist who does not have training in medical emergencies.
The receptionist manages to cancel all the patients except for your
first booked patient; this patient is in the waiting room and booked
for an examination and scale & polish.

There is also a patient, who was due to come back for a root
canal treatment, who has attended with an acute abscess, a large
swelling and is in considerable pain.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Tell the receptionist you cannot see either patient.

B. Talk to the patients yourself explaining you are not allowed to see
them without a nurse.

C. Treat the patient who was due for exam and scale & polish but send
the patient with swelling away as they are more likely to have
complications.

D. Treat the patient with the acute abscess and ask the patient who
was booked for an examination to rebook

E. Treat both patients but omit any reference to treating them alone
and without a suitably trained second medical professional.

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Question 6

You are two months into your role as a Foundation Dentist.

A patient that your colleague treated returns to the practice
appalled by the treatment that they have been provided. As your
colleague is away you are asked to see this patient. What is your
management?

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Kindly sit the patient down and explain to them that you are unable
to deal with this issue, and refer the patient to the practice manager.

B. Give the patient the complaints procedure and tell them that the
Dentist who saw them will deal with the issue.

C. Sit the patient down and talk through their concerns.

D. Agree with the patient and file a complaint to the GDC.

E. Speak to your Educational Supervisor about the patient’s complaint

to address the issue together.

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Question 7

You are becoming concerned that you are not receiving as much
clinical support as your peers in other practices. Your Educational
Supervisor has only been coming in two days per week for the past
month and you find that you have been lacking behind in tutorials.
You have found out that your Educational Supervisor has bought a
new practice and this is consuming their time.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Report your Educational Supervisor to the GDC.

B. Approach your Training Program Director with a complaint about

your Educational Supervisor.

C. Speak to the practice manager about your concerns.

D. Trust your Educational Supervisor to arrange more time with you.

E. Keep quiet, as if you make a complaint, you will find it difficult to

work and this may compromise your chances of another job after
this year.

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Question 8

You are seeing a new patient, a 7-year-old girl and her mother for
an initial treatment plan. On the first encounter, you notice the child
has a large bruise behind her ear and a pungent odor from her
clothes. The mother says she fell at school in the playground.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Contact the Local Child Safeguarding Board.

B. Speak to your Educational Supervisor before continuing as you

suspect a safeguarding issue.

C. Document your findings and investigate for further injuries.

D. Carry on with the treatment plan, ignoring the issues, as you know
that it will be an easy treatment plan for you to complete.

E. Explain to the mother that these injuries could not be done in a

playground and ask more questions for how this injury occurred.

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Question 9

You are due to arrive in work in 20 minutes. However, you hear

on the radio there has been a large road traffic accident causing a
1-hour delay on the road you take to work.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Text your colleague to let him know that there has been delays, and
ask him to see your morning patients.

B. Phone your receptionist and inform them that you are on your way.

C. Contact your Educational Supervisor, explaining your situation and

ask for their advice, as you will be late if you drive.

D. Attempt to go in but avoid calling in as your Educational Supervisor

will already know you will be stuck In traffic.

E. Phone in sick, pretending you are ill, as you will be late if you go in
now.

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Question 10

You have been out drinking, and return to your house at 5.00 AM
feeling very rough. Your senior colleague calls you at 6.30 AM on
your booked day off to ask for a favour. They want you to come
in, as the other associate has phoned in ill. They say you will get
double the pay, as the patients are private.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Agree to the offer, as you spent a lot last night and could do with the
extra income.

B. Agree to come in but only for the afternoon clinic, as you need time
to rest.

C. Empathise with your colleague, but tell them you have drank a lot
and you feel it would not be wise to come in today.

D. Sympathise with your colleague but make up that you have things
on for the day.

E. Ignore the phone, as you know it’s your colleague who has asked
you for favours before.

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Question 11

Over the past few weeks you have notice that one of the practice
nurses has been acting very promiscuously around you, and you
feel this behaviour is becoming noticeable to the patients.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Report the nurse to the practice manager as their behaviour is out of

order.

B. Speak to your Educational Supervisor about their behaviour and

seek advice.

C. Tell the nurse that her actions are inappropriate and they should
stop whilst in front of the patient.

D. Dismiss the actions until the end of the day when you are alone
together.

E. Report the nurse to the CQC.

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Question 12

You are out one evening in your local town and on the way home
you notice a fellow foundation dentist getting into a brawl with a
local. You intervene and diffuse the situation. He tells you not to tell
anyone, as they don’t want to tarnish their reputation.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Speak to the fellow foundation dentist about the issue and see if
they think it is a problem.

B. Ignore what happened as it is most likely the other person who

started it.

C. Seek support from your defence union regarding this issue.

D. Discuss this incident with your colleague’s Educational Supervisor.

E. Advise your colleague to visit the Practitioner’s Advice and Support

Service.

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Question 13

You have been informed that this Friday is the study day at the
local hospital, but you have accidentally booked a morning day of
patients. What is your management?

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Give the study day a miss to treat the morning patients yourself.

B. Go to the study day but make sure you pass your patient list to a
colleague.

C. Go to the study day, as you know the patients usually do not attend
on Fridays.

D. Seek help from your Educational Supervisor.

E. Prioritise the morning list and ask if a colleague can see the urgent
cases only.

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Question 14

You have been falling behind with writing your e-Portfolio, so you
decide to take photos of the patient case notes on your phone. On
the arriving at home, you realise that you have left your phone on
the train.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Accept that your phone has gone missing and return to the practice
early tomorrow morning to complete the e-Portfolio using the
computer notes.

B. Inform your colleague and ask for their advice.

C. Seek help from your indemnity provider.

D. Contact the train company to see if the phone has been returned.

E. Seek advice from your Educational Supervisor.

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Question 15

You have been noticing that your nurse has been arriving late
to the practice for the past three weeks. This has put additional
pressure on your appointment times and has also meant that your
patients feel as though their treatments are being rushed.

Rank the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate):

A. Wait until you finish your last patient to speak to your nurse to
confront her about your feelings.

B. Discuss the issue with your Educational Supervisor to seek advice

on how to manage the situation.

C. Ask all the associates for advice during your lunch break whilst in
the staff room.

D. Report the nurse to the CQC as their behaviour is not ‘safe’ for the
patient.

E. Speak to the nurse to find out why this may be the case and offer
support to help improve their punctuality.

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4.3 Ranking answers

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1. CEBDA
This question assesses your ability to manage team relations whilst
prioritising patient safety by following appropriate clinical guidelines
and protocol.
(A) The situation cannot be ignored due to the risk to patient
safety, therefore this ranks last. (C) There may be a genuine reason
that the nurse is not performing as well as she should be, including
personal circumstances that may be distracting her from her work.
Therefore, starting out with an honest discussion is best. (E) The
next most appropriate action would be to talk the manager, although
the nurse will know it was you, and may think you went behind
her back. However, it deals with the matter in a structured and
formal environment. (B) Speaking to her forcefully addresses the
issue but is a poor way to communicate initially, and may lead to a
breakdown in relationship. (D) Telling the practice manager that the
nurse should be given an official warning on the basis of laziness
is unprofessional and not within your remit, as you have not fully
understood or explored the problem to come to that conclusion.
Furthermore, this action does not address the concern directly, as it
does not allow a process for the nurse to understand and improve
upon her clinical practice. However, you are raising the issue to be
investigated which is why it ranks higher than option A.

2. CEBAD
This question assesses your ability to manage patient complaints in
an empathetic and understanding manner to maintain an adequate
patient-dentist relationship.
(C) In the event of a complaint it is always good to apologise for
the patient’s distress, this is not an admission of wrongdoing. This
can calm an angry patient and gives you a simple opportunity to
discuss the issue sensibly. (E) Following this, seeking advice from
your Educational Supervisor will be the next sensible step if the
patient is not quelled by an apology. (B) If they are still unsatisfied
with the responses given, a refund can be the next step as a
goodwill gesture as well as arranging continuity of care in the case
of a breakdown in professional patient-dentist relationship. Neither
(A) or (D) is a sensible option as they will likely lead to a formal

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complaint, and so are ranked last; option (D) is worse than (A) as it
is a direct action against the patient and is more likely to result in a
complaint than a correspondence via the receptionist.

3. BDAEC
This question assesses your ability to own up to when something
has gone wrong (duty of candour) and communicating to the patient
an ammended plan to continue their care.
(B) You must inform the patient of any adverse event in the first
instance. (D) Before making the decision to leave the file in place
and complete the RCT, it would be pragmatic to seek the advice of
your Educational Supervisor as a second opinion, as the ideal option
would be to remove the file or refer to a specialist. Option B ranks
higher than D, as you are informing the patient of the issue first
before seeking advice about management. (A) Following the advice
of your Educational Supervisor, you may then go ahead to continue
the root canal treatment, leaving the file in place. (E) Extracting the
tooth without discussing the other options is not classed as valid
consent, as is considered a last resort option. (C) Ignoring the issue
and not informing the patient is highly unprofessional and dishonest;
it goes against clinical judgement and protocol. This would likely
result in a complaint and potential law suit, and would be looked at
highly unfavourably by a GDC panel if brought into question.

4. BDCAE
This is a complex case with a major element of child safeguarding.
You should treat the immediate toothache. You have an implicit
safeguarding duty to the child.
(B) As you are a Foundation Dentist lacking experience, seeking
advice from your Educational Supervisor about how to proceed first
is a sensible option. (D) You probably suspect the aggressive father
of child abuse but may not want to precipitate an incident in the
surgery. However, you have a right to ask how the bruising occurred,
as bruising around both wrists is unlikely to be accidental but may
not have been caused by the family. You should also consider
the history of not obtaining treatment for the child at the earliest
convenience. (C) If your Educational Supervisor does not follow up

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the case you should take it further, at first within the practice, but
then with Social services if nothing is done.
It is important to remember that ‘Members of the dental team are
not responsible for making a diagnosis of child abuse or neglect, just
for sharing concerns appropriately. (Child Protection and the Dental
Team, Harris, Sidebotham, Welbury et al (2006)). If you consider
the parents are an immediate danger to the child, you could make
a case for ringing Social Services immediately. Not involving the
family in a referral to Social Services is only allowed if the family is of
immediate and significant threat to the child. However, an immediate
discussion with your Educational Supervisor still keeps this option
open. (A) Removing the family from your care is unprofessional, as
you have a duty to care for your patients and provide appropriate
referrals. However, this option ranks higher than (E), as you are
referring to a senior dentist, rather than just opting to avoid the
situation and do nothing.

5. DBACE
GDC guidelines state you should always have a second person
trained in medical emergencies present when treating patients,
except if under exceptional circumstances. However, they also say
that there is no substitute for a trained professional using their own
judgment. In this case you have to balance the risks to the patients
against the benefit or necessity for treatment. They also state to
“always act in the patient’s best interest”.
(D) The patient for the examination is not going to suffer any
harm from rebooking the appointment. However, the patient
with the acute abscess is in extreme pain, and may suffer further
complications from an unchecked swelling. Treating the abscessed
tooth (i.e. open drainage) is only likely to help the patient. (B) The
next best option is to inform the patients that you cannot treat
them yourself. (A) Informing the patients yourself is preferred over
asking the receptionist to inform them on your behalf, as the dentist
would be better placed explaining the exact situation and medical
risks associated with carrying out treatment alone. (C) The patient
with the acute abscess is in higher need than the patient that
requires a scale and polish, and so this ranks lower. (E) Purposefully

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omitting details in medical records directly contravenes the GDC

standards and would be highly unprofessional and indicate serious
malpractice.

6. CEABD
This question assesses your ability to manage complaints effectively
and address the concerns of the patient in all instances whilst
respecting and working with colleagues in a way that does not put
the profession in disrepute.
(C) Talking with the patient allows you to explore the patient’s
concerns and therefore determine your management. (E) As you
are only two months into the job, speaking with your Educational
Supervisor regarding this issue would be prudent; therefore, it is the
second best option. (A) Saying that you are unable to deal with the
issue suggests you cannot do anything about this situation. As you
are passing the responsibility to the practice manager, there is little
management shown here and you are unable to help the patient.
As a Foundation Dentist, you are expected to be able to deal with
complaints effectively and not dismiss them as option (A) suggests.
(B) Giving the complaints procedure in the first instance provokes
the issue further, as complaints should first be dealt with locally;
simply handing the complaints procedure shows little management
and efforts for arranging a resolution. The patient would much prefer
you to explore their concerns. (D) You should never assume that the
fault is due to your dental colleague, or speak about colleagues to
patients in a way that would bring the profession into disrepute. The
GDC should only be contacted once a serious issue has been noted.

7. BCDEA
This question assesses your ability to work with colleagues in a
way that puts patient interests first whilst ensuring that you are
being assertive in following the correct order of hierarchy in raising
concerns.
Educational Supervisors are required by contract to attend
a minimum of three days a week within the training practice.
(B) Therefore, it is worth approaching your Training Programme
Director (TPD) regarding this. A TPD is an individual who regulates

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the Educational Supervisor within the LETB (Local Education and

Training Board). (C) Speaking to the practice manager would be the
second best option, as you are raising your concern. However (B)
ranks higher than (C), as the Training Programme Director has the
authority to enforce change. (D) Since the Educational Supervisor
has bought a new practice and that this has been an on-going
issue for several months, it would be prudent to speak to someone
about this matter sooner rather than later, and as such option (E) is
less preferable than option (D). You must put your patient’s interest
first and if you have no one senior to you for support, there is a
potential risk of harm to patients if your Educational Supervisor is not
present. (A) Calling the GDC would be most inappropriate and would
seriously hinder your working relationships, as this is an issue that
should be dealt with locally; adopting the correct hierarchy of raising
concerns is essential.

8. CBEAD
This question assesses your ability to communicate effectively and
utilise the wider team to ensure that you safeguard patients and
protect them from potential harm.
(C) In any safeguarding scenario it is important to document
clear, accurate and contemporaneous notes, with the help of
diagrams such as a face map form, if necessary. Although these
factors are highly suggestive of a neglect issue, it would be
wise to speak to a senior colleague to confirm your findings
usually following the local protocol of the practice. (B) Here, your
Educational Supervisor would be appropriate. (E) Although you
should aim to find out more about any injuries and listen to the child
and the parent individually to see if the stories coincide, it would be
inappropriate to ask provoking or leading questions. (A) Contacting
the Local Child Safeguarding Board (LCSB) should be done once
you have discussed the issue with a senior colleague and you have
gained permission from the parent/individual with PR. (D) In some
instances, this may not be possible, for example in instances where
discussing your concerns may endanger the victim further. You
should always put the patient first, as there is an overriding duty of
care to this patient; bypassing this issue for your own financial gain

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would be unethical.

9. BCEAD
This question assesses your ability to communicate with colleagues
in an honest and strategic mannger to manage and prioritise
unexpected situations to ensure patient care.
(B) Your receptionist is able to control your appointment book
and will be available front-of-house to deal with patients that arrive
in your absence. They can explain the situation to patients and
possibly organise for your patients to be seen by another colleague
if they are available. (C) Contacting your Educational Supervisor in
this circumstance would be beneficial to seek advice. But, for them
to arrange for the other patients to be seen to, the Educational
Supervisor would most likely end up delegating this task to your
receptionist. Therefore, this option ranks second. (A) Although
you are doing something to resolve the issue, putting additional
pressure on your colleague who is already busy with their patients
is not a wise move. (A) Despite being dishonest, you are not putting
undue pressure on your colleague and risking patient safety. There
is no guarantee your colleague will see this text either, therefore this
is a worse option. (D) Not informing your colleagues of the situation
ranks lask, as this is highly unprofessional and shows a severe
lack of organisation. This option places your colleagues in a very
stressful position to manage your patient lists when it is too late and
would likely lead to a breakdown in team relations.

10. CDEBA
This question assesses your ability to understand one’s limitations to
communicate decisions that prioritise patient care whilst managing
team relations.
(C) Being honest with your colleagues is a way to build trust and
rapport. Despite it being an inconvenience, you are also putting
patient interest first. (D) Although you are being dishonest, you
have informed the colleague that you are unable go to work due
to plans, therefore protecting the patient from risks caused by your
health. (E) Although you are ignoring the phone call, this option is
more appropriate than (B), as you are avoiding to treat patients in an

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unfit state, therefore putting patients interest first. (B) Even though
you are just treating patients for an afternoon, this is still highly
unprofessional. (A) Agreeing to treat patients for the entire day is
less appropriate, as you are in an unfit state (heavily intoxicated and
suffering from a lack of sleep) and you are a risk to patients.

11. BADCE
This question assesses your ability to communicate effectively
with your colleagues to highlight your concerns about professional
practice.
(B) In this situation, you ought to understand that this behaviour
is unprofessional and the nurse needs to change her attitude. It is
prudent to speak to your Educational Supervisor in this instance
as they are in a position of authority to address the situation.
(A) Reporting the issue to the practice manager is the next most
appropriate person to raise your concerns with. (D) Although you
are doing something, you are leaving the issue to lie for the day,
therefore delaying the process to stop their behaviour. (C) However,
letting the situation rest until the end of the day is more appropriate
than confronting the nurse in front of the patient, as this would
aggravate the situation and appear unprofessional. (E) Reporting the
nurse to the CQC is the most inappropriate option, as actions should
be resolved at a local level before reaching this stage.

12. AECDB
This question assesses your ability to communicate sensitively with
your colleague to ensure that they behave in a way that maintains
confidence in the dental profession as a whole.
(A) speaking to your colleague about the issue allows you
to take a caring and non-judgemental approach to explore their
concerns. (E) The Practitioner’s Advice and Support Service
(PASS) offers impartial help and advice to dentists who may have
psychological or health issues or difficulties out of work (C) Your
defence union would not be able to directly help you, as the
service is more designed for managing litigation cases between a
dentist and patient. (D) It would be unwise to immediately share this
concern with your colleague’s Educational Supervisor, as this is a

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confidential and isolated matter. if this becomes a repeated incident

that your colleague is unwilling to address, you may then reason
escalating your concerns to your colleague’s Educational Supervisor.
(B) Ignoring the issue is the worst option, as you have turned a blind
eye and assumed that your colleague has nothing to do with the
incident. This is a professionalism issue.

13. EDBAC
This question assesses your ability to prioritise your training
expectations with patient care whilst communicating with your
colleagues to manage team relations.
(E) By prioritising the morning list, you are actively using you
initiative; and by asking your colleague to see the urgent cases
only, you are putting patient interests first. (D) Seeking help from
the Educational Supervisor is advisable in these cases. However,
they are likely to ask you do what you have done already in (E). (B)
Despite going to the mandatory study day, this option ranks lower
than option (E), as you are offloading your entire patient day list onto
your colleague. (A) Although you are missing the study day to see
patients, you are missing a mandatory activity which can prohibit
you from completing DF year successfully. (C) Although you aim to
attend the study day, you did not assign your patient list to anyone,
and therefore have breached your duty to care for patients.

14. DCEBA
This question assesses your ability to prioritise patient confidentiality
whilst communicating with relevant individuals to address the
situation.
(D) Immediate action is required to prevent the confidential
information from being disclosed, so aim to find the phone. (C)
Seeking help from your indemnity provider may be better than
option (E), as they should be able to provide you with more specific
advice than your Educational Supervisor. (B) Seeking help from your
colleague will be less useful than your Educational Supervisor, as
they are less experienced. (A) This is the least appropriate option,
as you have actively ignored the fact that you have lost patient
identifiable information – a serious breach of the NHS code of

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confidentiality.

15. EBACD
This question assesses your ability to communicate empathetically
with your nurse and other colleagues to ensure patient care is
prioritised whilst maintaining team relations.
(E) initially speaking to the nurse to understand the issue may
highlight a reasonable excuse for their lateness. This can then be
managed by the wider team (i.e. the practice manager could adjust
their rota patterns). (B) Discussing the issue with your Educational
Supervisor is the next most appropriate option, as they will be in
a position to determine the most suitable management due to
experience and knowledge of staff history. (A) Addressing the issue
sooner is better, however confronting the nurse is not constructive.
(C) You should avoid discussing these matters openly with non-
senior colleagues to respect confidential information, and avoid
internal gossip. (E) Contacting the CQC would be highly unnecessary
as you would aim to settle this at a local level.

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Question 1

You are three months into your dental foundation training job and
begin experiencing lower back pain. Your GP has prescribed a
strong pain killer which you have been persistently taking over the
last week. You begin noticing increasing tiredness and drowsiness
throughout clinical hours.

Choose the THREE most appropriate actions to take in this situation.

A. Mention this to your Educational Supervisor.

B. Consider taking time off work.

C. Write yourself a prescription for an alternative pain killer.

D. Ensure you get enough sleep each night.

E. Discuss with your GP the side effects from the pain killer and
request an alternative.

F. Do not mention the pain killer, pain or tiredness to anyone.

G. Fill out a Yellow Card to report an adverse drug reaction.

H. Increase appointment times to reduce over straining oneself in the

working day.

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Question 2

You are about to start an extraction of a lower molar tooth on

a patient. After explaining the nature of the procedure to the
patient, you ask your nurse to prepare the anaesthetic syringe and
extraction forceps. The nurse snaps at you unexpectedly in front of
the patient and says, ‘Prepare it yourself!’. This is the first occasion
that the nurse has reacted in an aggressive manner.

Choose the THREE most appropriate actions to take in this situation.

A. Arrange a meeting with the nurse to discuss her actions and working
relationships after the patient has left.

B. Complain to the GDC regarding her actions.

C. Discuss this incident with your Educational Supervisor.

D. Prepare any necessary instruments required for this particular

treatment yourself on this occasion.

E. Immediately reply back to the nurse that her behaviour is

inappropriate.

F. Immediately take the nurse outside of the surgery and inform her
that you will only carry out the procedure if she apologises to you.

G. Discuss this issue with other nurses at the practice.

H. Request that a new nurse assists you for future appointments.

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Question 3

An elderly man presents to you in pain, complaining of a swelling

under his jaw. He is convinced that he has oral cancer. However, on
intra-oral, extra-oral and radiographic examination you are certain
that it is simply a dento-alveolar abscess with associated swelling
related to the lower first permanent molar. You have advised an
initial course of antibiotics, after which the patient will be reviewed
for definitive treatment.

Choose the THREE most appropriate actions to take in this situation.

A. Prescribe an initial course of antibiotics, after which the patient will

be reviewed for definitive treatment.

B. Send the patient home without treatment.

C. Tell the patient that there is something wrong with them and that
they may have cancer.

D. Refer the patient to the hospital for further investigation.

E. Inform the patient of the diagnosis and provide reassurance that it is

not sinister.

F. Refer the patient to a periodontologist.

G. Prescribe a course of anxiolytic medication to help in the

management of the patient’s cancer-related anxiety.

H. Proceed to anaesthetise and extract the lower left first permanent

molar.

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Question 4

You overhear your nurses making fun of how a patient looks. Other
patients can hear the conversation.

Choose the THREE most appropriate actions to take in this situation.

A. Draw the nurses away from the patients that are present and
privately inform them of their actions.

B. Complete a critical incident form.

C. Tell the nurses that you will raise the issue with practice manager if
this occurs again.

D. Firmly tell the nurses to stop the discussion there and then.

E. Raise the matter with the practice manager.

F. Apologise to the patients that are present and reassure them that
this will not happen again.

G. Join in the conversation as to avoid confrontation.

H. inform the patient of the specific remarks made about them and
assess whether they heard them.

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Question 5

You notice that an associate at your practice has come to work

smelling of alcohol. She presents with slurring of speech and
disorganised motor coordination. This is the first occasion that you
have seen her like this.

Choose the THREE most appropriate actions to take in this situation.

A. Inform the associate that she smells of alcohol and inform her to go
home.

B. Inform your colleague of your concerns and offer any help.

C. Report the incident to your practice manager immediately.

D. Give the associate some breath mints to disguise the smell.

E. Carry out a CAGE questionnaire to ascertain if the colleague is an

alcoholic.

F. Complete a critical incident form.

G. Report the associate to the GDC.

H. Seek advice from your Training Programme Director.

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Question 6

You prescribe a patient who presents with a dento-alveolar abscess

with a course of amoxicillin. You receive a phone call from the local
pharmacy explaining that the patient is allergic to the drug.

Choose the THREE most appropriate actions to take in this situation.

A. Complete a critical incident form.

B. Document the mistake in the patient records only.

C. Ask the pharmacist to change the prescription to metronidazole,

which is the first line drug to treat dento-alveolar abscesses for
patients allergic to amoxicillin, according to FGDP guidelines on
antimicrobial prescription.

D. Check the medical history of the patient again and re-write a more
suitable prescription with an alternative antibiotic.

E. Apologise to the patient for causing them an allergic reaction.

F. Write the incident in your personal reflective journal.

G. Inform the pharmacist that the ‘allergy’ is merely a normal side effect
and to prescribe the amoxicillin as normal.

H. Call your Educational Supervisor to ask for advice.

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Question 7

A patient at your practice shows signs of affection to you and

constantly makes remarks of a sexual nature when you are treating
her. She also gives you her phone number. This is the first time that
you have seen this patient.

Choose the THREE most appropriate actions to take in this situation.

A. Take the patient’s number.

B. Reciprocate with sexual remarks as you do not want to upset the

patient.

C. Inform the patient that you must maintain appropriate boundaries as

their dentist.

D. Inform your practice manager of the patient’s behaviour.

E. Refuse to accept her number.

F. Refuse to accept her number but add her as a contact on a popular

social media website after work.

G. Remove the patient from your list and discontinue her dental care.

H. Report the patient to the community police for sexual harassment.

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Question 8

You notice that an associate at your practice constantly appears

tired. Although no patients are affected, you are concerned that
she may make a mistake that may compromise patient safety.

Choose the THREE most appropriate actions to take in this situation.

A. Express your concern to the associate regarding their tiredness and

the risk to patient safety.

B. Offer to discuss the issue in a meeting with your Educational

Supervisor and associate, offering to see some of the associate’s
patients.

C. Inform the associate that if the issue doesn’t resolve, you will have
to address the concern to the practice manager and escalate if
necessary.

D. Contact occupational health regarding the associate’s behaviour

and potential medical implications.

E. Encourage the associate to speak to the practice manager to figure

out a solution to the issue.

F. Report the associate to the GDC for patient negligence.

G. Make the associate a cup of strong coffee each morning as a

gesture of support.

H. Do nothing as this is not your concern and no patients are affected.

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Question 9

A patient’s medical history shows that they have a history of heroin

abuse. On checking the medical history again, the patient would
like that area deleted from the notes to avoid compromising her
medical insurance.

Choose the THREE most appropriate actions to take in this situation.

A. Actively inform the insurance company about her previous heroin

addiction.

B. Explain to the patient that you can only delete non-factual

information.

C. Inform the patient that you may have to breach confidentiality but
the patient will be informed first.

D. Comply with the patient’s request and delete the information.

E. Inform the patient that you have a duty of patient confidentiality to

maintain and that information can only be given in specific situations.

F. Inform the patient that you have no choice but to divulge information
if requested by the insurance company.

G. Inform the patient that you have deleted the information but keep
the notes unchanged regardless.

H. State to the patient that they have no right to demand such requests.

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Question 10

While you are changing into your tunic in the staff changing
facilities, you notice a bag falling out of an associate’s locker. On
inspection, you notice that the bag contains illicit drugs. This is the
first time that this has happened.

Choose the THREE most appropriate actions to take in this situation.

A. Discuss the incident with your Educational Supervisor.

B. Advise the associate concerned to seek professional help.

C. Speak to the associate concerned about what you have seen to

understand the situation.

D. Inform the police regarding the possession of illegal substances.

E. Inform the GDC regarding the possession of illegal substances.

F. Advise the associate to dispose of all illicit drugs before they get
caught again.

G. Put the drugs in the bin and avoid mentioning the isolated incident
to your colleague.

H. Discuss the incident with your other colleagues to work out if the
associate may have a drug addiction issue.

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Question 11

You have become increasingly aware that one of the DFT

colleagues at your practice has a poor sense of hygiene; he has
dirty clothes, an untidy appearance and a foul smell.

Choose the THREE most appropriate actions to take in this situation.

A. Kindly ask your Educational Supervisor to have a word with your

colleague as you don’t feel confident to approach them yourself.

B. Speak to other nurses at the practice about your concerns and

create a signed petition to encourage the DFT to improve their
personal hygiene.

C. Seek help from indemnifier.

D. Inform the CQC.

E. Inform the GDC.

F. Speak to him in private, respecting the issue and provide help to

deal with any issues.

G. Ask the practice manager to speak to him.

H. Tell your colleague everyone has noticed and he should consider

moving deanary.

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Question 12

Your nurse is getting angry with you as your are slower than the
previous DFT. This means you are working into some lunchtimes
and they are getting very agitated.

Choose the THREE most appropriate actions to take in this situation.

A. Demand a new nurse.

B. Inform the nurse of your work rate capacity and agree to a pace
suited to the both of you.

C. Seek advice from your indemnifier.

D. Report your nurse to the BDA.

E. Speak to your receptionist to rearrange the appointment times to

maximize your efficiency.

F. Seek help from your trainer as to how to improve your efficiency.

G. Ignore your nurse as her duty is to support you throughout all

procedures despite their length.

H. Offer for the nurse to leave during lunchtime so she can have a
break whilst you continue to see patients.

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Question 13

As you are just about to bring in your routine review patient, a

young gentleman collapses in the waiting room. The receptionist
mentions that the patient was very stressed whilst waiting for the
appointment in the waiting area, and that they have not eaten.

Choose the THREE most appropriate actions to take in this situation.

A. Ignore this situation as the reception team are capable of handling

this situation.

B. Ensure the young gentleman is safe before you treat your next
patient.

C. Call 999 immediately.

D. Apologise to your current patient and see to this situation at hand

before treating your patient.

E. Aim to place the patient in supine position.

F. Immediately commence CPR.

G. Give intramuscular adrenaline.

H. Give buccal adrenaline.

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Question 14

You are just about to fit a partial denture but you realise it is a poor
shade match and you incorrectly wrote the shade number

Choose the THREE most appropriate actions to take in this situation.

A. Apologise to the patient but fit the denture as you need the UDAs

B. Apologise to the patient and encourage them to accept the

dentures, as you know the lab bills will be high to adjust the shade.

C. Explain the reason for the mistake and offer to replace the dentures
for the patient, apologising for the inconvenience.

D. Hope that the patient does not notice and fit the dentures
immediately.

E. Allow the patient to try the dentures in and explain what has
happened.

F. Offer for the patient to take the dentures home as a trial, explaining
why the mistake has occurred.

G. Blame the mistake on the lab, as you do not want the patient to
loose confidence in you.

H. Claim that the patient chose the wrong shade for their teeth.

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Question 15

You are due to perform your first root canal treatment in practice,
but your nurse informs you that there is no rubber dam. The patient
is not in any pain today.

Choose the THREE most appropriate actions to take in this situation.

A. Go ahead and perform the root canal treatment carefully, ensuring

that the nurse uses a high volume aspirator.

B. Report your Educational Supervisor to the GDC.

C. Inform the patient and proceed to extract the tooth instead.

D. Seek help from your indemnity provider.

E. Aim to locate a rubber dam sheet in your practice or a neighbouring

practice.

F. Rearrange the patient’s treatment if there is no rubber dam available.

G. Discuss your concern with your practice manager.

H. Carry out the root canal treatment but use sterile saline instead of
hypochlorite.

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1. ABE
This question assesses your ability to balance, manage and prioritise
personal health with patient care and safety.
(A) It is evident that the pain killers are affecting your ability to
function and potentially compromising patient safety. It is therefore
important to inform your Educational Supervisor who has the
ultimate responsibility for patient care under their practice. Once
equipped with this knowledge, your DFT Educational Supervisor can
help provide a possible solution. (B) Although this option doesn’t
resolve the underlying issue, it can provide time for rest, identifying
source of problem and ensuring patient safety until you are fit to
practice. (E) Going back to your GP to seek an alternative pain killer
which is more suitable, can potentially allow you to carry on working
with reduced pain and not experience the negative side effects of
tiredness.
(C) It would be unethical to self-prescribe. (D) Whilst it is
important that you are appropriately rested each day, it is unlikely
to combat the underlying issue of lower back pain. (F) This is
inappropriate as you cannot obtain any help or advice to resolve the
problem. (G) While filling out a Yellow Card may be helpful for other
practiitoners, doing so will not solve the issue at hand. On top of
this, the drug may already be known to cause the experienced side
effects, and so a Yellow Card will do little to address this issue. (H)
Increasing appointment times is not a practical response, as it only
masks the central issue of the drug side effects. The tiredness does
not seem to be related to the intensity of clinical treatment and so
the drowsiness will still be experienced through the day regardless
of treatment times.

2. ACD
This question assesses your ability to maintain good working
relationships with your staff in a way that maintains a high quality of
patient care.
(A) Since this is the first time you nurse has spoken to you in this
way, it would be wise to discuss the incident with the nurse after
the patient has left. Furthermore, waiting some time allows for her
emotions to cool, as she may have been stressed at that particular

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point. (C) It would be appropriate to discuss this incident with your

Educational Supervisor, as he may be able to provide advice on
handling the situation. (D) In this heated situation, it is important not
to argue back, but rather the prepare instruments yourself as patient
care is paramount.
(E) It would be equally inappropriate for you to reply back and
create an uncomfortable atmosphere for the patient. (F) This options
ignores the patient’s interests; either way the extraction still needs
to be carried out. Taking the nurse out of the surgery and leaving
the patient alone in the chair is also unprofessional. (G) Discussing
the issue with other non-senior colleagues would be considered
unprofessional, as it may be misconstrued as gossip, thus
undermining professional relationships. (H) Requesting a new nurse
is a dramatic response to the event, considering that this is the first
occasion that the nurse has reacted in an aggressive manner.

3. ADE
This question assesses your ability to manage patient concerns
whilst demonstrating clinical effectiveness in diagnosing and
treating the patient’s infection.
(A) According to the FGDP guidelines on antibiotic prescription,
amoxicillin is the first line drug for dento-alveolar abscesses.
(D) Seeing another dentist at a hospital setting will confirm your
diagnosis if it is correct and give the patient further reassurance.
This option also provides the potential for further investigations to
be carried out if necessary. It may well be that an ultrasound or MRI
may be required for soft tissue swellings. (E) If you are certain of the
diagnosis, the patient does not need to be referred and can simply
be managed locally. It is essential to reassure the patient.
(B) Sending the patient home does not address the acute pain.
(C) If you are unsure of a diagnosis, it is better to refer to a specialist
to make a definitive diagnosis before giving a potentially incorrect
diagnosis that would only inflame the situation. (F) There is no
indication in this scenario to refer the patient to a periodontologist,
as the text gives no indication of inadequate or complex periodontal
health. (G) It would be inappropriate to prescribe anti-anxiety
medications to a patient without full assessment in conjunction with

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either the patient’s GP or a psychiatrist. (H) Attempts to anaesthetise

the lower left first permanent molar would be likely to fail, due to
the low pH of the abscessed fluid associated with the swelling..
Furthermore, no discussion of treatment options have been given
either (i.e. RCT vs XLA), and so valid consent has not yet been
obtained.

4. AEF
This question assesses your ability to manage team relations whilst
ensuring patient integrity and respect.
(A) This option allows the nurses to be informed of their
inappropriate behaviour at a site away from patients, therefore not
embarrassing them. (E) The practice manager needs to be informed
in order to take appropriate actions and prevent this from happening
again. (F) It is important to reassure patients that actions are being
taken to address this issue.
(B) This option is too formal, especially when there are more
effective short-term methods of handling the situation. (C) This
may give the nurses an opportunity to behave in this manner
again. It is important to address this issue immediately to restore
patient’s trust in the dental team. (D) Although this option will stop
the conversation, it will also embarrass the nurses in front of other
patients. (G) Joining in the conversation would be deemed highly
unprofessional and does not act to solve the issue, only propagate
it. (H) Solely asking the patient if they heard what was spoken about
them does not resolve the situation, and would only risk worsening
the situation, in the case the patient was never aware of the
comments made in the first place.

5. ABC
This question assesses your ability to manage team relations whilst
ensuring patient safety in a timely and sensitive manner.
(A) The associate’s clinical judgement will be impaired; she
should be sent home to ensure patient safety. (B) Offering help
to the associate will foster a supportive environment to help aid
in amending her ways. (C) It would be appropriate to inform your
practice manager of the incident. This issue would need to be

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addressed appropriately in a formal manner when the associate is

sober, as fitness to practice is called into question.
(D) This will only mask the underlying problem where patient
safety will still be at risk. (E) The associate would need to go a
designated clinic where this can be diagnosed. This is not within the
remit of your role. (F) There is no need to complete a critical incident
form at the moment considering the colleague has not even seen
a single patient. (G) Considering this is the associate’s first alcohol-
related incident, this issue should be resolved at the local level first.
(H) Whilst seeking advice from your TPD is a pragmatic action, it
would not usually elicit a fast response. Patient safety will potentially
be compromised if the associate is not managed immediately.
Therefore, more local management (i.e. discussing with your
practice manager or Educational Supervisor) is desired to ensure
patient safety and effective management.

6. ADF
This question assesses your ability to manage interdisciplinary care
whilst guarding patient safety, managing patient complaints and
learning from reflective practice.
(A) This is a mistake that could have seriously affected the
patient and hence should be recorded in the critical incident form.
This will allow members of the dental team to reflect on why this
has occurred and highlight any potential flaws in recording patient
allergies. (D) Confirm the medical history and prescribe alternative
antibiotics. (F) A reflective journal is important to record any mistakes
and learn from it.
(B) This will not be as effective as recording the mistake in a
critical incident form, where members of the team can learn from it.
(C) Although this option is the most convenient, it is your mistake
and you are liable for it. It is not the pharmacist’s role to make any
adjustments to your prescriptions. Therefore, you should correct the
mistake by rewriting the prescription with an alternative antibiotic for
the patient to collect. (E) This is not necessary at this stage since no
medication was actually issued to the patient yet to elicit an allergic
reaction. (G) Although the allergy may be self-reported and an over-
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it is not your place to make such an overriding decision to continue

to prescribe the drug. Therefore, a worst-case allergy is assumed
and an alternative medication should be sought. Doing otherwise
would be potentially dangerous and an act of potential negligence.
(H) Calling your Educational Supervisor for advice may be helpful.
However, the pharmacist is best trained to give you advice specific
to the patient, and your Educational Supervisor would only likely
refer you back to speaking to the pharmacist or looking towards the
FGDP guidelines on antimicrobial prescriptions.

7. CDE
This question assesses your ability to act in a way that maintains
patient and public confidence in yourself and in the profession as a
whole, whilst sensitively managing the patient.
(C) It is important to make the patient aware at an early stage
of your responsibilities, duties and what is deemed appropriate.
(D) Informing your practice manager will ensure that someone else
is aware of the situation and that you have taken the necessary
steps to escalate your concerns. (E) Refusing to accept the patient’s
number aims to avoid encouraging this behaviour from the patient.
(A) Taking the patient’s number would only encourage
the patient to continue behaving in the same way and act
inappropriately towards you. (B) Reciprocating her behaviour
with sexual remarks is highly inappropriate, as you must not
take advantage of your position as a dental professional in your
relationships with patients. (F) Accepting a patient as a contact on
the popular social media site is still unprofessional considering the
circumstances. (G) Removing the patient from your list is a dramatic
response to the isolated incident. The GDC state that a dentist
may discontinue the care of a patient if there is a breakdown in the
professional patient-dentist relationship. However, they must ensure
that the patient is suitably referred to another appropriately qualified
dentist to continue their dental care. (H) Reporting the patient to
the police is again a dramatic response and would not serve well
for your personal or practice’s reputation. It is best to manage and
resolve this situation at a local level.

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8. ABE
This question assesses your ability to sensitively manage
professional relationships whilst prioritising patient safety.
(A) Make the associate aware that their tiredness could have
an implication on patient safety. (B) If you feel comfortable, you
can take on some of her cases. This will reduce the workload for
the associate and add to your experience. (E) It is better for the
associate to discuss the issue with the practice manager directly.
(C) This option is abrupt and harsh and does not offer to take
into account her circumstances or explore her issues. (D) It is not
your place to contact occupational health; this is a decision that
should be taken by the associate or the practice manager. (F) This
action would be highly inappropriate, as the issue should be first
resolved at the local level and no patients seemed to be affected at
this stage. (G) Making a cup of strong coffee may seem helpful, but
it does not solve the core reason of your colleague’s tiredness. It is
therefore more supportive to explore the reasons of the tiredness,
rather than masking it. (H) Doing nothing is not desirable, as it does
little to support the professional relationship that you have with your
colleagues, and it may vicariously compromise patient safety if the
colleague’s tiredness is left unnoticed and unsupported.

9. BCE
This question assess your ability to keep accurate and
contemporanous medical notes whilst guarding patient
confidentiality and managing patient expectations.
(B) It is important that the patient is aware that despite keeping
the information in their records, it can only be provided to insurance
companies under certain circumstances. (C) It is important that the
patient is aware that prior to you divulging any information, they
will be notified prior to it. (E) Unless the patient has consented, you
will not be able to give any information. However, if information
is requested without the patient’s consent (i.e. via a court order),
you will have to provide any relevant records - see page 426 on
‘Maintaining patient records and data protection’.
(A) Actively informing the insurance company of the heroin
addiction without the patient’s consent is not appropriate, as it

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would be in breach of patient confidentiality. (D) Complying with

the patient’s request to delete the information is not appropriate,
as you may be complicit to insurance fraud. (F) Divulging
information to insurance companies is only appropriate under
certain circumstances - e.g. a court order via an insurance company
requesting the patient’s information. (G) Lying that you have deleted
the relevant information is dishonest and does not address the
issue of informing the patient of the importance of keeping accurate
medical records. (H) Although correct in content, the response itself
may come across as rather harsh and abrupt, risking a potential
complaint against yourself.

10. ABC
This question assesses your ability to raise concerns appropriately
in the clinical environment to protect patient safety whilst managing
professional relationships effectively and sensitively.
(A) It is important to raise awareness of the issue with your
Educational Supervisor who may have more experience in handling
such situations. (B) This option demonstrates that you are showing
support to your fellow colleagues. (C) Addressing the situation with
the associate in question is the most logical first step to take.
(D) Informing the police about the possession of the illegal drugs
is premature and abrupt. This is a decision for the practice manager
to make after further local investigation has occurred. (E) In the same
way, informing the GDC about the possession of the illegal drugs
is also premature at the moment, but may be necessary if patient
safety is at risk. (F) Disposing of the drugs is better than using the
drugs. However, this action would appear as attempting to cover
up the incident without addressing the issue at hand. (G) Avoiding
the issue is highly inappropriate, as it is important to raise concerns
at work when patient safety may potentially be compromised. (H)
Discussing the issue with non-senior staff is inappropriate as they
do not have the power to escalate the issue further than your
Educational Supervisor or practice manager can, and it encourages
gossip.
11. AFG
This question assesses your ability to communicate with colleagues

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in a way that is understanding and with integrity whilst ensuring

patient interests are put first.
(A) The Educational Supervisor is the most appropriate person
to contact, especially if you don’t feel confident to talk to your
colleague about the issue. (F) If you are confident enough to discuss
this personal issue, speaking and exploring the concern in a non-
judgemental way is wise. (G) Your practice manager would be
another member to seek advice from for this personal issue.
(B) Discussing the issue with other non-senior staff is
unprofessional and would appear as gossip. Proceeding to get
other colleagues to sign a petition seriously denigrates the DFT’s
dignity and privacy and would appear extremely unprofessional. (C)
Indemnity providers are involved in matters of legal/clinical disputes.
Therefore, it is not necessary to inform them. (D) The CQC would
be very inappropriate unless the colleague has placed the patient
in immediate danger. (E) Although professional etiquette should be
maintained, issues should always be first dealt with at local level;
thus reporting to the GDC would be a very inappropriate option,
and serve to seriously harm team relations. (H) Telling the colleague
he should move deanery is hurtful and bordering on bullying; you
should be acting to help not hinder your colleague.

12. BEF
This question assesses your ability to work effectively with
colleagues to address their concerns to ensure effective time
management whilst understanding one’s own practice limitations.
(B) Sharing your thoughts and seeking a shared work pace can
help the nurse manage time and help you to achieve targets. (E)
Speaking to the receptionist who is responsible for your patient
bookings can help to ensure that you are not overbooked so
you can have time to treat patients accordingly. (F) Seeking help
from your Educational Supervisor to improve your work rate in a
pragmatic manner is key to development and shows self-appraisal.
(A) Demanding a new nurse is not resolving the underlying
issues. Therefore, this would be inappropriate and highly
unreasonable. (C) Although your indemnity provider could help
provide impartial advice, they are mainly involved in matters

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concerning legal disputes with your patients. (D) Reporting the

nurse to the BDA is a very premature and inappropriate action.
Furthermore, the BDA do not handle staff complaints and would not
be able to offer in the matter. (G) Ignoring your nurse is not resolving
the issues; also this shows poor teamwork, communicate and
management skills. Although it is important for the nurse to respect
that sometimes you may overrun, it is important that something is
done to ensure that your nurse is aware of this and you are taking
steps to prevent overrunning in future. (H) Offering for the nurse
to leave for her lunch break may seem like a helpful suggestion to
calm the nurse. However, you must treat patients with appropriate
support and with a chaperone. Treating patients alone in this case
would be unsafe and unprofessional.

13. BDE
This question assesses your ability to manage and prioritise medical
emergencies in a stressful and high-pressured environment, whilst
employing strategic effectivess with your wider dental team to put
patient interests first.
(B) Seek to the young gentleman as the first priority, as this is
a medical emergency. Here, you have a duty to protect patients.
(D) You will need to prioritise the patient in need, which will be the
patient who has collapsed. As a result, you will need to manage
your patient by apologising to them. (E) Although you do not have
a definitive diagnosis, it is likely to be vasovagal syncope. Thus, a
supine position would encourage blood flow to the brain.
(A) Ignoring the situation is most unprofessional, as you are
medically trained to handle this situation and have a duty of care
towards protecting your patients. (C) Calling 999 immediately may
be inappropriate, as the likely diagnosis is a syncope; this can
be managed initially with local measures. (F) CPR would be the
incorrect treatment for a syncope. (G) Intramuscular adrenaline
would only be needed for anaphylaxis. (H) Buccal adrenaline would
be given for status epilepticus.

14. CEF
This question assesses your ability to communicate with the patient

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to discuss their concerns whilst demonstrating your duty of candour

to own up to one’s mistakes.
(C) Being open and honest is a core principle as a dentist. Thus,
apologising for your mistakes is vital. (E) In some instances, the
patient may accept the fault as long as you are honest about why
it occurred and what the consequences of the mistake might be.
(F) Offering the patient the dentures to take home as a trial, whilst
explaining the issue is a good option to gain the patient’s trust.
(A) this would be unprofessional, as you are placing financial
gain before patient interest. (B) Again, although you are apologising
to the patient, you are still placing interest on payment rather than
the patient’s dental care. (D) Hoping that the patient will not notice
the issue would be a very poor choice, as you must be clear and
open with any mistakes. (G) It would be poor etiquette to blame
others, especially the lab who have not caused the fault here. (H)
The patient is not to be blamed, as this was your mistake. Doing so
will only antagonise the situation, as the patient will still be unhappy
with the shade by the end of the argument.

15. EFG
This question assesses your ability to work within one’s knowledge
and skills to ensure that patient’s interests are put first whilst in a
pressured environment. You will be expected to think about ways to
manage the issue, as root canal treatments without protection from
a rubber is unsafe and unacceptable.
(E) Aiming to locate a rubber dam may place you in a difficult
circumstance, but a root canal treatment cannot take place without
it. (F) If you are unable to find a rubber dam kit, it would then be
prudent to rearrange the treatment to protect the patient from harm.
(G) Discussing your concern with the practice manager who orders
in stock would be appropriate.
(A) High volume aspiration would be required as well as a rubber
dam; using an aspirator is not sufficient to prevent contamination
of the tooth. Further to this, an aspirator may not catch any files
if they were to be lost in the mouth, risking patient aspiration. (B)
Reporting your Educational Supervisor to the GDC would be highly
inappropriate and show a serious lack of insight into the escalation

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process - the next stage of escalation after your Educational

Supervisor would be your Training Program Director. (C) Opting to
extract the tooth simply because a root canal treatment cannot take
place is highly unprofessional and unsafe. Your fitness to practice
will be called into question. (H) This would be completely incorrect
as a rubber dam is always needed during a root canal procedure
alongside hypochlorite. (D) Seeking help from your indemnity
provider may be helpful if action at a local level does not resolve this
issue.

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Choosing the right DFT practice for you

Disclaimer
As a recent graduate, the author writes this advice in the hope that it
would be useful for the current final year dental student cohort who are
preparing to undergo their meet and greet. This section is based on the
author’s experience, recommendations and personal opinion. Therefore,
it should be taken into account as an adjuct to the current resources
provided by COPDEND.

Introduction
Following allocation scheme preference and ranking score, you will
be offered the opportunity to rank the practices within your scheme. In
ranking the practices, there are two methods of practice allocation:

1. Candidate ranking: The student ranks their practice

preferences. Your place in a practice is based on the national
ranking obtained from your national recruitment interview (well
done for getting through that!).
2. Mutual ranking: Both the student and the trainer rank their
preferences and then the allocations are made. Also, in some
schemes, an up-to-date CV is required.

The first type of allocation (candidate ranking) is more common than the
mutual ranking. The day will be quite tiring, so have questions prepared.
A checklist is provided in this section to help you.

Although every scheme (and every practice) is different, it would be

sincerely advised that you should be prepared for the day. This is
because some schemes ask you to choose the preferred practices on
the same day. Generally, the day will consist of you effectively having a
mini-interview or chat with each of the trainers one after another.

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The reasons for preparation are:

1. To utilise the available information prior to the meet and greet to

have a ranking in your mind of which practices suit you. Making
this decision takes time and effort and trying to do it on the day
without a prior idea can lead to the wrong decision.
2. You will make a better impression and impress trainers if you
have information about their practice or their careers. It shows
that you’re willing to put in some effort.
3. It will be a lot less stressful on the day as you only have to
confirm the information regarding the practices you prepared for.

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Main considerations

Before discussing each factor in any detail, the two most significant
factors are:

The trainer

Author’s experience: “It was interesting that after my meet and

greet I could tell which trainer I would get on with and which I may
have difficulty building rapport after 5 minutes of chatting. Now
obviously you cannot know a person really well in that short of a
time but ‘first impressions’ certainly count. Not getting on with your
trainer would be a nightmare of a year and i would suggest this to
be the number one factor with utmost importance.”

Distance to and from home

This is important for those who plan to live at home and have picked a
scheme with that in mind. With many students in debt, DFT is certainly a
time to save money and plan ahead. However, ignore this if you chose a
scheme far away from home.

For both factors, it is highly recommended to carry out your own

research before the meet and greet. This will allow you to have an idea
of the practices that you would like to be a part of for your DFT year.
This includes:

• Talking to current DFTs in the scheme is invaluable and you

should certainly make use of them if you know any. If not, do
not worry as most schemes on the day will have the DFT dentist
available to answer any of your questions in the meet and greet.
• Googling the practices you know about and identifying the staff.
Do they even have a website in this modern age?

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• Visiting the practice is probably the best idea but rarely done.
See how the receptionist greets you and how staff treat you as a
person. DFT will shape you into the dentist that you will be, and
being part of an ethical and caring practice will limit complaints
and prevent bad habits creeping in.

Note that you may be able to answer some of the considerations given
in the next section via the same methods above before asking the
trainer on the meet and greet. This will save you time during the meet
and greet - you already have limited time to know your trainer as well as
asking the questions that are important to you.

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Other factors to consider

Location

• City centre or rural: A practice in the centre of any major city will
certainly have many patients which will provide you with great
clinical experience as well as a variety of places to eat at lunch
time. On the other hand, rural areas tend to have (generally) loyal
patients who are less likely to FTA or DNA.
• Parking: For those who drive cars, it would be ideal to identify if
parking is available. Those who drive cars know the annoyance
of trying to find a parking space during rush hour; not a great
start to the day.
• Transport: For those who do not drive to work, find out how
close the practice is to the nearest station or bus stop and
consider the total time needed for travel.

The nurse

• This factor is often overlooked but again is in the author’s top 5

for importance.
• Is the nurse qualified?
• Has she worked with DFTs before?
• WiIl you be working with the same nurse?

The surgery room

An ideal surgery should be of a good size and have windows. There is
very little worse for you and the patient than working in a four-walled
cage with no room to move. Also, the number of surgeries available is
an important consideration; a five-surgery practice is usually a sign that
the practice is going to be very busy.

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The equipment

• Are the notes hand-written or computerised? it would be better

to be in a computerised system; in the long-term, more practices
are being computerised so familiarisation with dental software is
invaluable.
• Is Protaper available to use?
• Is the dental laboratory on-site, local or foreign?
• Are intraoral DSLR camera available for case photos?
• Are you able to order equipment yourself such as burs?

Associates/specialists
Will there be other associates to provide clinical help. Sometimes the
trainer can be busy and another opinion is always valuable.

Patients

• How many patients did the previous DFT see on average?

• Are you in control of your appointment times?
• Is the local area high-need? The greater the need, the greater
the experience.

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The trainer

• Experience: Does the trainer have any post-graduate degrees

or special interests? This may be useful if you are interested in
gaining further experience in that field.
• Commitments: Will the trainer always be there when you need
him/her.
• Communication: A dentist that appears friendly and reassuring
in the first 5 minutes is a good sign. The greatest learning
experience for the author was not clinical skills (which all DFTs
want) but communication skills.
• Teaching style: Every dentist learns differently. Learning styles
can be divided into four different categories. An analogy of
the learning styles as applied to the ‘construction of a desk’ is
given below:

1. Theorist: Those who like to read the whole manual and

background information before attempting to construct it.
2. Pragmatist: Those who would read the manual and
construct it simultaneously following each step.
3. Activist: Forget the manual and give it a go.
4. Reflector: Those who ponder their past mistakes in
constructing the desk and attempt to correct it for the
future.

Not everyone will be in the same category and some will feel they
are in two or more of those categories. The important thing is
working out your style of learning and what style of teaching will
compliment it. For example, if you feel that you are an activist, you
won’t learn much by being given slideshow presentations every
day.

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• Number of trainers: Not every practice will accomodate for

just one trainee. Some practices take on two trainees. In other
practices you can get two trainers for one trainee.

There are pros and cons for having one trainer or two trainers, each
of which will be listed below:

1 trainer to 1 trainee

Positives
You will be spending almost every day other than the study
day with the trainer so make sure you get on with them.
Consistency with teaching is obtained with one trainer, so
there will be minimal confusion on treatment planning and
procedures.

Negatives
If you do not get along it becomes very awkward

2 trainers to 1 trainee:

Positives
Hear different opinions and ways of dealing with patients and
procedures - this is certainly a positive as you can learn so
much more.
Different trainers have different specialties or interests they
are passionate about which further enhance your learning
experience.

Negatives
It can be confusing when hearing different opinions

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Meet and greet checklist

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Dental NHS Banding

Dental treatment is categorised into 4 bands of prices by the NHS. The

band prices and included treatments are given below. These prices
change every April so ensure you are up to date by viewing the NHS
Choices Website. Prices correct from April 2016.

Band 1 dental treatment: £19.70 (1 UDA)

• A clinical examination, assessment and report

• An orthodontic assessment and report
• Advice, diagnosing and planning of your treatment
• X-rays
• Moulds of your teeth – for example, to see how your teeth bite
together
• Taking coloured photographs
• Advice on preventing future problems, such as diet advice and
cleaning instructions
• Applying sealants or fluoride preparations to the surfaces of your
teeth
• A scale and polish
• Marginal correction of fillings
• Taking a sample of cells or tissue from your mouth to examine
(pathological examination)
• Adjusting false teeth (dentures) or orthodontic appliances, such
as braces
• Treating sensitive cementum (the tissue that covers the root of a
tooth)

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Band 2 dental treatment: £53.90 (3 UDAs)

• All band 1 treatment

• Non-surgical treatment of periodontitis (a severe form of gum
disease) – such as root planing (cleaning bacteria from the roots
of your teeth) or deep scaling and a polish
• Surgical treatment of periodontitis – such as removing some
gum tissue (gingivectomy)
• Free gingival grafts – when healthy tissue from the roof of your
mouth is attached to your teeth where the root is exposed
• Fillings
• Sealant restorations – when sealant is used to fill a small hole
and seal any grooves in your teeth
• Root canal treatment (endodontics)
• Pulpotomy – removing dental pulp (the soft tissue at the centre
of a tooth)
• Apicectomy – removing the tip of the root of a tooth
• Transplanting teeth
• Removing teeth (extraction)
• Oral surgery – such as removing a cyst
• Soft tissue surgery to the mouth or lips
• Frenectomy, frenoplasty or frenotomy – surgery to the folds of
tissue that connect your tongue, lips and cheeks to your jaw
bone
• Relining and rebasing dentures
• Adding to your dentures – such as adding a clasp or a tooth
• Splinting loose teeth – for example, after an accident or due to
periodontitis; this doesn’t include laboratory-made splints
• Bite-raising appliances (similar to a mouth guard) – for example,
to correct your jaw alignment; this doesn’t include laboratory-
made appliances

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Band 3 dental treatment: £233.70 (12 UDAs)

• All band 1 and band 2 treatment

• Veneers and palatal veneers – new surfaces for the front or back
of a tooth
• Inlays, and onlays – used to restore damaged teeth
• Crowns – a type of cap that completely covers your real tooth
• Bridges – a fixed replacement for a missing tooth or teeth
• Dentures
• Orthodontic treatment and appliances such as braces
• other custom-made appliances, not including sports guards.
• Treatments such as veneers and braces are only available on the
NHS if there’s a clinical need for them (not for cosmetic reasons).

Band 4 dental treatment: £19.70 (1.2 UDAs)

• Urgent treatment only such as:

• Pain management
• Extirpation
• Extraction
• Temporary restoration of fracture
• Wisdom tooth temporary treatments

Taken from NHS Choices

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The complaints protocol

Overview
These guidelines are correct for 2015/16.There are two main causes
of complaints; either a patient is dissatisfied with their service or there
has been a failure to meet their needs and expectations. The factors
that contribute to a raised complaint include the clinician’s attitude,
time-keeping, standards, costs and unclear NHS/private treatment. The
patient will expect an outcome that involves or all of the following: an
explanation, assurance, apology, remedial treatment, ex-gratia payment
or a goodwill gesture. Avoiding a complaint is best served by adopting
clear communication into your working practice whilst informing patients
about all issues that may arise during their treatment.

There are two tracks for following-up a formal complaint, depending on

whether the complaint concerns private or NHS treatment.
NHS complaints involve a two-stage complaints procedure, where local
resolution is sought first before escalating to the Parliamentary and
Health Service Ombudsman. Private complaints escalate directly to the
Dental Complaints Service (DCS).

It is vital to learn from each complaint (and even general feedback) to

improve service quality and prevent the reoccurence of the original
complaint from another patient. Following a complaint, it is considered
good practice to have a ‘significant event meeting’ to:

• Discuss in detail
• Analyse issue to inform changes
• Share action with dental team to avoid repeat

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The complaints policy

The in-house complaints procedure should be displayed in the practice
and all team members should be familiar with the policy.
There should also be a dedicated Complaints Manager who is
accessible to the public to ensure compliance to the complaints
procedure. The Complaints Manager signs all complaint responses,
analyses all complaints to improve service and take steps to reduce the
risk of complaints being raised.

Handling a verbal complaint

If you resolve a verbal complaint within 24 hours then they are not
logged as an official complaint. Therefore, a fast response turnaround
is essential in the practice. It is recommended to speak directly with the
patient to resolve their issue. If this is not possible (if other patients are
waiting), you should arrange a later appointment. Patients should not
be directed to make a complaint written. The complaints manager will
provide the patient with a written record of the complaints process. This
complaint log would be recorded in the practice but not included in the
annual report.

Official complaints are sent to the local commissioning group. These

logs contain information on the nature of the complaint, the manner
in which it was handled, the resultant improvements to service (if
appliable) and whether the complaints received were well-founded and
required referral to the Parliamentary and Health Service Ombudsman.

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The local resolution complaints procedure

The local resolution complaint procedure is the practice’s in-house
complaints policy. The following points describe the typical order of
events in managing a complaint via local resolution.

• Apologise to the patient

• Aim to resolve the patient’s complaint within 24 hours before it
progresses to a formal complaint.
• Involve the relevant team members to resolve the complaint
(receptionist for administrative issues and the dentist for clinical
issues)
• Arrange a face-to-face meeting with the patient to discuss,
plan or confirm investigation into their issue. This should be
conducted in combinationg with your Educational Supervisor or
another consillator. A separate individual should also take notes
during this meeting. Identify what outcome the patient wants.
Encourage the patient to speak openly, and inform them that
their concerns will be confidential and not prejudice their care.
• Inform patient of the complaints procedure and where they
can get advice (CAB, local patient group, NHS England, HS
ombudsman)
• If the complaint cannot be resolved within 24 hours, provide a
written acknowledgement of the patient’s complaint in 3 working
days. The acknowledgement should be carefully worded in a
professional, measured and sympathetic tone.
• Provide a resolution within at least 10 days (or provide updates
every 10 days whilst a resolution is being sought).
• In this time, the relevant team members should make a thorough
investigation into the complaint.
• Arrange another meeting with the patient before sending the
resolution letter to discuss the findings of your investigations.
• Speak to your dental defence organisation
• The resolution letter should be sent First Class and marked
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patient to confirm receipt.

• Keep a written record of the entire complaint process separate to
the patient’s clinical records

A written record of the local resolution should contain:

• Full chronology of all events and relevant information (either

stated as normal practice or from your notes)
• Whether the patient was seen alone or accompanied
• Identifying yourself and writing in first person
• Response to each concern
• Explanation of investigation
• Conclusion reached
• Area for remedial action (to prevent re-occurrence)
• Proposed action: offer of redress, change of dentist, redoing
work or refund (the offer is made as a gesture of goodwill, not as
an admission of liability)
• Explain right to escalate complaint to Ombudsman if still
dissatisfied (within 12 months)

Ombudsman Complaint Procedure:

The Ombudsman complaints procedure forms the second stage
of a complaint regarding NHS treatment. The Ombudsman has the
discretion to investigate cases based on their merit. The office can ask
for all documents and witnesses. They may obtain expert advice with
specialist assessors for clinical judgement. A draft report is first given
to the complainant and dental professional with the final report then
sent to all parties, including the Secretary of State and published on
Ombudsman’s website.

The Ombudsman cannot enforce recommendation but they can inform

NHS England who will consider the contractual compliance issues
at the next annual review. It is therefore recommended to adopt the
recommendations that the Ombudsman suggest.

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The Parliamentary and Health Service Ombudsman works to serve

patients under six key principles in ‘Principles of Good Complaint
Handling’. These are: “get it right, customer focused, open, fairly/
proportionately, put things right and continuous improvement”

Private Complaints
Like NHS complaints, private complaints should first be managed via
local resolution. If unsuccessful, the complaint is then referred to the
Dental Complaints Service (DCS) - a fully independent agency set up
and funded by GDC.

The DCS resolves complaints impartially, fairly and transparently. They

are strongly in favour of local resolution - the DCS refers almost 75% of
all complaints back to the practice. Complaints to the DCS are usually
resolved within 7-10 days; however this can be longer if a panel are
involved. The formal resolution involves a panel hearing with three
trained volunteers (one lay person and two dental professionals)

GDC Complaints Procedure

When complaints are referred to the GDC, they follow the following
schedule of events. The entire GDC complaints procedure can take
up to 15 months for a full resolution. However, the case can be fast-
tracked to an “interim orders committee” if it is necessary to make
an order affecting an individual’s registration for the protection of the
public. A complaint may be referred to three different case committee
departments, depending on the nature of the complaint - conduct,
performance and health

1. The complaint is first triaged - takes up to 10 days

2. Once triaged, the complaint is assessed and investigated - takes
up to 6 months
3. The complaint is then referred to an appropriate practice
committee who then review the case - takes up to 9 months

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Key points

• Resolve complaints within 24 hours to avoid an official log

• Acknowledge all formal complaints within 3 working days via a
written letter
• Provide a resolution within 10 working days, or an update to the
complaint progress every 10 days
• Complaints to secondary independant agencies should be made
12 months within receipt of the official resolution letter.
• Those aged 16 or over or under 16 (who are competent) can
make complaints
• An individual can nominate a representative (relative or solicitor)
to make a complaint on their behalf
• If complaint is on behalf of someone who lacks capacity, the
practice needs to ensure the complainant is acting in patient’s
best interest.

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Negligence & Claims

Overview
Negligence is regarded as a failure to take proper care over a patient,
their treatment or any aspects of their care that was trusted to you.
Proving a claim of negligence relies on a four-fold test. All four elements
have to be satisfied. The first letter of each element spells DBCD, which
may be helpful to remember the relevant aspects. In resolving a claim of
negligence, informal resolution is initially encouraged to avoid lengthy
legal disputes.

• Duty: there is a duty of care placed on the professional

• Breach: the duty of care has been breached by acting or failing
to act in a certain way
• Causation: there is a causal link between the breach and harm
done
• Damage: injury occurred as a direct result of the breach

Timeframes

• A claim can be made within 3 years of the date of the incident or

knowledge of the incident occuring;
• Or until the patient turns 21 if the occurence happened when the
patient was under 18.
• There is no time limit for making a claim for adults without
capacity.
• The court has discretion to allow claims to be made outside of
the normal time limit

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The Bolam and Sidaway test

The Bolam test assesses whether the same standard of care would
have been carried out by a responsible body of dentally qualified
profesionals. If this is found, the concerned individual may be disproved
of negligence. The test will no longer apply to the issue of consent,
although it will continue to be used more widely in cases involving other
alleged acts of negligence. More recently, the Montgomory ruling is
being used in the issues of consent (see page 436)

In the Sidaway test, the dentist has a duty to inform the patient of all
“common” and “serious” risks of a procedure. The dentist has a duty to
provide the patient with sufficient information so that they can reach a
balanced judgement.

Informal resolution (before court) procotol

1. Claimant’s solicitor requests the patient’s clinical records

2. GDP notifies defence organisation
3. Defence organisation gives clinical records to the claimant’s
solicitor
4. Claimant’s solicitor writes a medical report with an expert
witness
5. Claim ends or goes ahead
6. A formal letter of claim is sent to the GDP
7. Defence has 4 months to investigate the claim letter
8. Formal letter of response to claimant’s solicitor is sent for
consideration

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Formal resolution (to courts) protocol

If the patient or solicitor is unhappy with the resolution offered by the
GDP during the ‘informaiton resolution’ stages, they can escalate their
claim for a formal resolution via an independant court decision.

1. Claim form (for court) presented to defence within 4 months

of issue, alongside the particulars of claim (contains detailed
information about the claim)
2. Claim acknowledged by defence within 14 days
3. Full defence statement served 28 days after claim is received.
A court extension may be granted if more time is needed. The
defence statement includes:
• The statement of truth (signed)
• Disclosure statement (all documents are provided)
• Witness statement (account of events)

Court role

• Allocates the claim to small-claims, fast-track or multi-track

• Organises the case management conference (with each party’s
solicitor)
• Arranges the date of exchange of evidence. This involves a
simultaneous exchange of witness statement & expert reports
between the defendant’s and claimant’s soliciitors
• Arranges a trial date
• It is up to the judge to decide if standard of care is acceptable

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Maintaining records and data protection

Overview
Maintaining patient confidentiality is an essential requirement of
professional practice. So much so, it forms of the key principles of the
GDC. Under the Data Protection Act 1998, you have a professional,
legal and contractual responsibility to protect patients’ right to
confidentiality. There should be clauses in employment contracts and
induction programmes for staff about patient confidentiality. These
rules apply to all members of dental team and any information about
the patient. The following points form the overarching principles of
maintaining patient confidentiality.

• Patients have a right to expect that you will not disclose any
personal information, unless they consent.
• When patients give consent for disclosure you must make sure
they understand why you are disclosing the information and
exactly what will be disclosed. You must inform them of the likely
consequences.
• You must ensure that information about patients does not get
disclosed without consent to third parties, except in exceptional
circumstances (i.e. where the safety of the patient or others
would be jeopardised).
• If you have to disclose confidential information you should
release as little information as possible for the purpose and you
must be prepared to justify your decision (see page 432 - Data
protection and Caldicott principles).
• You must make sure that those to whom you disclose
confidential information, understand that it is told to them in
confidence which they must respect.
• When discussing cases with fellow colleagues, avoid using
names or other identifying information wherever possible.

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Gaining access to records

Patient’s have a legal right to view their confidential medical records.
They cannot however take the original records (if paper based). If
requested, you are therefore obliged to produce a paper copy of
the records. A nominal administrative fee can be charged to print
out a patient’s medical records (according to guidance provided
by Information Commissioner’s Office). There are various legalities
governing access to patient’s records:

Access to Medical Reports Act: allows patients to see reports about

them
Access to Health Records Act 1990: allows access to records of
deceased patients

Accessing deceased records: records are confidential even after the

patient dies. Authority is provided from the patient representative, the
executor of the person’s will or the next-of-kin. Anyone with a claim
arising out of the patient’s death may be entitled.

Maintaining and archiving records

In maintaining records, the following points should be considered:

• Store, send and receive records securely

• Store and send securely with passwords and encryption
• Only available to those with authorised access
• Not in public sight (unauthorised access)
• Keep back-up copies

Adult records should be arhived for 2 years (minimum) according to the

NHS contract, but recommended for 11 years. Children’s records should
be archived for 11 years, or until the age of 25 (whichever is longest).

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Guidelines to releasing confidential information

Consent to disclosure is only valid if the patient understands the full
aspects of the disclosure (i.e. the ‘who’, ‘what’, ‘how’ and ‘why’) as well
as the consequences of releasing the information and their legal rights.
You should obtain consent to disclose ideally in writing. if oral consent
is given, this should be documented in the notes. In releasing the
information, you should follow the 7 Caldicott principles (see page 432).
You must also respect the patient’s refusal to release information, unless
there is an overiding public interest (see next page).

Children’s confidential records

Adults with parental responsibility can consent for disclosure of
information of children under 16 who are not Gillick competent. The
overiding consideration is ‘what is in the child’s best interest?’. These
rights are governed by the Childrens Act 1989 and Adoption and
Children Act 2002. However, it would be unusual to have a competent
child refuse disclosure against a person with parental responsibility.

Patients with mental health concerns

Like giving consent in normal situations, patients with a learning
disability or mental disorder may still have capacity to consent or
refuse, even those detained under the Mental Health Act 1983. Their
competence and capacity should be judged for the specific situaiton
of information disclosure to decide whether valid consent has been
obtained.

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When can you release confidential information without consent?

If the patient refuses to consent for their confidential information to be
released, you can release it in the following exceptional circumstances
without consent:

• If it is in someone/public’s best interests (if their safety is at risk

or if the information needs to be used in detecting serious crime)
• If ordered by a court/statutory duty (only release minimum
information)
• If a patient is at risk of harm/abuse, inform social services or
police (if in immediate danger)

It is important to persuade the patient as best as possible to release the

information with written consent. If they still refuse, you should call your
defence union before releasing information to ensure legal compliance.
You should consider harm to the patient or patient-dentist relationship
by releasing the information. Through the entire process, you should
also ocument, explain and justify all of your decision and actions.

Disclosing to third parties

Confidential patient information may be disclosed to third parties in
other situations, either with or without the patient’s consent.

• Relatives and carers: with consent, unless in the patient’s best

interest.
• Other healthcare workers: with consent
NHS bodies: with consent, for audits
• GDC: for fitness to practice procedures, with consent
• CQC: have legal powers to request
• Insurance: submitting reports to employers or insurers, with
consent (patient sees report beforehand and what has been
included)
• Social services: with consent, unless in the patient’s best
interest

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• Police: you have no right to release information, even if the

police come with a search warrant or production order from
court. Only if the patient or public are at risk of significant harm
(Road Traffic Act 1988 and Terrorism Act 2000).
• Solicitor: with consent, unless with court order
• Court, tribunals and coroners: have legal powers to access
deceased patient’s records,
• Inland revenue: have legal powers to obtain information, under
the Finance Act 2008
• Practice audits: information should be anonymised

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Data protection & Caldicott principles

Overview
The Data Protection Act 1998 regulates personal data (defined as:
‘related to living person that can be identified from data’). A breach in
Data Protection legislation can lead to civil or criminal prosecution.The
difference between a civil and criminal prosecution is described below:

Civil: redress of wrongs by compelling compensation or restitution;

by a private party
Criminal: by custodial or non-custodial punishment; by government

The Data Protection principles are as follows:

1. Used fairly and lawfully

2. Used for limited and specifically stated purposes and lawful
purposes only
3. Used in a way that is adequate, relevant and not excessive
4. accurate
5. Kept for no longer than is absolutely necessary
6. Handled according to people’s data protection rights
7. Kept safe and secure
8. Not transferred outside the European Economic Area without
adequate protection

Extracted from The Data Protection Act 1998 (https://www.gov.uk/data-

protection/the-data-protection-act; accessed on 20th June 2016)

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Caldicott Principles
The Caldicott principles review the way patient information is dealt
with and how the NHS handles and protects patient information. The 7
Caldicott Principles are provided below. The key term of each point is
also placed in bold.

1. Justify the purpose of using confidential information

2. Do not use patient identifiable information unless it is
absolutely necessary
3. Release the minimum information required
4. Access to confidential information should be on a need-to-know
basis
5. People who have access to information know their responsibility
6. Understand and comply with the law
7. The duty to share information is equally as important as the
duty to protect information

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Consent: competence and capacity

Overview
In gaining valid consent, it is essential to ensure that the patient is
competent and has capacity. Valid consent is crucial in dental practice,
and brings with it a number of issues in relation to both adults and
children whilst complying with the relevant medical legalities. The
process of consent is therefore broken down in this section.

Competence
The term competence refers to the degree of mental soundness that is
necessary to make decisions about a specific issue or treatment/action.
A competent adult is regarded as a person aged 18 or over who has
the capacity to make their own decisions. Everyone must be assumed
to be competent unless proven otherwise. The competence threshold
varies for treatment proposed and complexity of decision - a patient can
be competent to consent for a history and exam, but not for a dental
extraction.

Capacity
According to the Mental Capacity Act 2005, capacity concerns an
individual’s ability to understand, retain, evaluate and communicate an
informed decision about their treatment. A patient’s capacity may also
fluctuate over time. This can be due to a number of factors such as pain,
medications, drugs, panic or shock.

Managing an incompetent adult

Dealing with an incompetent adult in general practice is rare. The
incompetent patient may appoint a Lasting Power of Attorney (LPA) to
make decisions regarding consent on their behalf. Therefore, another
adult (LPA) can authorise or reject treatments on the patient’s behalf.
However, the LPA cannot demand specific treatments outside of
reasonable clinical practice. During this process, you will need to decide

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what is in the patient’s best interest, and not just the patient’s dental
condition. As a result, you should take into consideration the following
factors:

• Values and preference when competent

• Beliefs and values
• Psychological health and quality of life (QoL)
• Age, relationships and emotional development
• Consequences of imposing proposed treatment
• Consequences if untreated

If there is no LPA appointed, you should seek a decision from an

Independent Mental Capacity Advocate (IMCA). In cases where a
patient under 16 lacks capacity to authorise treatment, think in patient’s
best interest, and consider the views of the individual with parental
responsibility or nominated decision-maker

Principles of gaining valid consent

The GDC set specific standards in gaining valid consent for the dental
professional. These are outlined below:

• All treatment options

• Risks and benefits
• Why the treatment is necessary
• Prognosis and consequences if treatment is not carried out
• NHS or private treatment
• The cost of the consultation and treatment
• Any guarantees offered

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There are three domains to gaining valid consent: (1) the consent should
be informed and (2) voluntary, and (3) the patient should have the
ability to consent. Duress, such as coercion or influence from relatives,
can invalidate consent. The following points highlight the main issues
surrounding valid consent.

• Consent should be gained before the treatment or investigation

by a trained and knowledgeable individual.
• A patient signature is of lesser significance to quality of
explanation. Written consent does not carry more legal weight
than verbal consent (it just shows that there is proof of consent).
• If consent is gained by an untrained individual, the actual
clinician needs to verify before treatment that it is an informed
decision
• Consent is a process not a one-off event. The patient may give
their consent and then withdraw it at any time, unless their
capacity is impaired at that moment (i.e. during treatment under
sedation). In these cases, it is important to consider what is in the
patient’s best interests at the time. You should provide a cooling-
off period to think over decision.
• Involve other team members in the consent process if
appropriate (i.e. if previously cared for by another dentist or
dental care professional)
• Clarify the level of consent provided. Did the patient consent for
all or part of the treatment plan.

Montgomery judgement on consent

There has been a recent major change to the way consent needs to
be obtained between a clinician and the patient. In March 2015, the
Supreme Court passed judgement that doctors must now ensure that
patients are aware of all reasonable risks associated with a treatment,
and of reasonable available alternatives. Gaining consent in this way
is not about ensuring you cover every conceivable risk; it focuses the
process of consent on having a meaningful and clear discussion.
This is a significant change to the Bolam test, which asks whether a
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doctor’s conduct would be supported by a responsible body of medical

opinion. This test will no longer apply to the issue of consent, although
it will continue to be used more widely in cases involving other alleged
acts of negligence. (Medical Protection, 2015)

Consenting for children

The term ‘child’ applies to those aged up to 18 years old. All people
aged 16 or over are presumed to have capacity unless shown otherwise.
Valid consent from a Gillick competent child over 16 to carry out a
recommended procedure cannot be overridden by refusal from an
individual with parental responsibility. However, refusal of consent of
Gillick competent child over 16 may be overridden by an individual
with parental responsibility. If the parent and patient both do not want
treatment, the court can override their decision.

Author’s tip: it is highly unlikely that you will be able to convince a

non-compliant child to undergo treatment against their will. They will
not stay still and will be likely to cause more harm. Therefore, it is
up the clinician to decide whether carrying out treatment during that
appointment is in the patient’s best interests. In cases of difficulty, a
referral to a paediatric/community dentist may be appropriate.

Deciding who has parental responsibility is not always a simple process.

Some more complex cases are highlighted below.

Adoptive parents: adoptive parents have parental responsibility.

However, during the adoptive transfer process, the social services
have acting parental responsibility.

Separated/divorced parents: they continue to have parental

responibility unless removed by a court ruling. It is not needed
to gain consent from both parents with parental responsibility. In
exceptional circumstances, you can seek a court order to carry out
treatment without parental responsibility under Section 8 of the
Children’s Act 1989.
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Biological mothers: All mothers have parental responsibility unless

it has been removed by a court. In these cases, the council may
place the child into a number of types of care orders to continue
their care and welfare. These are detailed below:
• Care order: relative, foster carer or a children’s home has full
parental responsibility
• Full care order: social services have full parental responsibility
• Interim care order: both the social services and parents have
parental responsibility. The social services can override the
parent’s decisions in the interest of the child’s welfare. This
would involve the medical consultant, dentist, patient and legal
guardian.

Biological fathers: Under the Children’s Act 1989, if the father is

not on the birth certificate, they never had PR, even if they are
married (as it may just be the step-dad). A father has PR if he is on
birth certificate AND if they are married after 2003. An unmarried
father will only have parental responsibility for a child born after
1st December 2003 in England and Wales. No PR exists for an
unmarried father before 1st December 2003 unless the following
conditions are met:
• The mother and father were married at time of conception,
birth or sometime after.
• A PR agreement has been granted from a High Court.

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Special situations

• An underaged mother: carry out emergency treatment, involve

the social services and share information with the GP.
• Emergencies: carry out the minimum and least invasive
treatment required to get the child out of pain
• Polygamy: only the first marriage is counted for (multiple
marriages without divorce may occur abroad)
Sperm donor: has no PR; an infertile man has PR if he is on the
birth certificate
• Civil partner: both mothers get PR as they are on the birth
certificate; if the two mothers are not civil partners, the non-
biological mother can adopt the child.
• Surrogates (for gay men): Surrogate mother has full right unless
child is adopted

The Mental Capacity Act 2005

The Mental Capacity Act 2005 is a code of practice that gives
guidance to people who care for people who can’t make decisions for
themselves. It outlines the good practice to follow when you act or make
decisions on behalf of people who can’t act or make those decisions for
themselves.

1. An individual is assumed to have capacity unless established

otherwise.
2. A person is not to be treated as unable to make a decision
unless all practicable steps to help him to do so have been taken
without success.
3. An unwise decision does not constitute a lack of capacity.
4. Consent on behalf of a person who lacks capacity must be done
in their best interests.
5. Action taken should be as least restrictive of the person’s rights
and freedom

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Quality assurance, clinical governance, patient safety and audits

Quality assurance
Quality assurance refers to the processes that maintain and improve
standards of patient care. Evidence of effective quality assurance is
required by the NHS General Dental Services contracts. The criteria
for effective quality assurance addresses the quality, safety and
effectiveness of care as well as the response to needs and quality of
leadership. In ensuring quality assurance, there should be a culture
for open communication, education, learning from one’s mistakes and
sharing good practice

Clinical governance
Quality assurance is required to ensure effective procedures and
policies for the 12 themes of Clinical Governance for the dental practice.
Clinical governance comprises of:

1. Infection control
2. Safeguarding and raising concerns
3. Dental radiography
4. Safety of patients, staff and the public
5. Evidence-based treatment
6. Data protection
7. Employment law
8. Accessible care
9. Complaints
10. Raising concerns
11. Clinical audits

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Patient safety
To further ensure patient safety within the practice, risk management
should be adopted into the culture of the workplace. Risk management
involves a 5-stage process, detailed below.

1. Identify areas of risk from patient safety incidents

2. Assess their frequency and severity
3. Eliminate the possible risks - ‘risk containment processes’
4. Reduce the effects of risk that can’t be eliminated
5. Carry out regular audits to evaluate risk-reduction processes

All adverse adverse events should be reported to the National

Reporting and Learning System of NHS England. An adverse event, is an
event that had or could have harmed patients. You also have a statutory
duty to notify CQC of serious injury or death.

When analysing your adverse events, it may be effective to carry out a

Significant Event Audit (SEA). These audits invovle reviewing an incident
using structured root-cause analysis - applying ‘why’, ‘what’ and ‘why’
questions - to identify lessons learnt and action points to be made to
improve service. The designated person agrees an implementation plan
with staff and prioritises the changes required with a project leader with
timescales for completion.

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Audits and peer review

Audits are central to quality assurance and best practice to improve
patient care. They encourage the philosophy of critical thinking with
structured analysis. A typical audit involves identifying following aspects:

1. Identify the problem

2. Set a standard
3. Collect data
4. Compare data with the set standard
5. Implement changes
6. Re-audit

Peer reviews may also be carried out to assess current working

practices and improve quality of service. Issues are discussed within a
peer review group, typically consisting of 4-8 GDPs. In these meetings,
individuals review issues and share their exeriences to identify areas
that can be changed. Action plans for further improvements can then be
made as a result of the meeting.

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RIDDOR & IR(ME)R

RIDDOR
RIDDOR stands for ‘Reporting Injuries, Diseases and Dangerous
Occurrences Regulations’. Reportable incidents are categorised as:

• Death
• Accidents in which an employee suffers a specific injury and is
unable to work for >7 days.
• Accidental resulting in hospital treatment or missing work.
• Employee contracting a work-related disease or being exposed
to carcinogens.
• Specified dangerous occurrences that have the potential to do
significant harm.
• Must report ASAP or within 10 days.
• Must keep record for 3 years.

IR(ME)R
IR(ME)R stands for ‘Ionising Radiation (Medical Exposure) Regulations’.
The regulations are enforceable as criminal law under the Health and
Safety at Work Act 1972. The legistration prevents harm by misuse and
sets a minimum standard.

An internal audit can be carried out in practice, and external inspections

can be enforced by the Healthcare Commission (HCC). In reporting
concerns, employers are required to investigate issues when an incident
has occurred. An example of a possible incident would include a human
error that causes exposure that is ‘much greater than intended’. They
should report the incident to their employer and the employer should
report the Authority (Healthcare Commission). A notification should be
sent to the IR(ME)R officer with acknowledgement and an initial triage
by the IR(ME)R lead inspector is carried out to determine a reactive
inspection

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Guidelines for practice can be found in the practice ‘Local Rules’

document, which contains each staff’s role in radiological protection. It
is important to note that responsibilities cannot be delegated, but tasks
can be. The roles of the staff in IR(ME)R fall into:

• Referrer: provides clinical info to allow justification

• Practitioner: responsible to justify exposure (weighing up potential
benefit against detriment)
• Operator: carries out the exposure (doesn’t have to be a
registered HC professional)
• Radiation Protection Advisor: provides independant advice on
complying with the IR(ME)R

The employer has a statutory duty to: create written radiological

procedures, train staff and keep records for inspection and make clear
people’s legal responsibility in exposure. There are three principles
for radiological protection which include:

• Optimisation: targeted rays, safe equipment and quality

assurance
• Justification: objectives, benefits, detriments and alternatives
• Dose Limits: ensure a dose that is ‘as low as reasonably
achievable’ (ALARA)

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CPD

Overview
CPD stands for ‘Continuing Professional Development’. The aim of
CPD is to maintain and update one’s skill, knowledge and professional
behaviour via a variety of educational sources. CPD helps to improve
the level of care you are providing for your patients and ensures that
the public’s trust in dental services is maintained. CPD can be gained via
lectures, seminars, courses or individual study.

What are the requirements?

Dentists: you must carry out 250 hours of CPD every five years. At
least 75 of these hours need to be ‘verifiable’ (certified) CPD. Your
CPD cycle begins on 1st January after you register.

Dental Care Professionals: You must carry out at least 150 hours
of CPD every five years. At least 50 of these hours need to be
‘verifiable’ (certified) CPD. Your CPD cycle begins on the next 1st
August after you register.

CPD is split into core and non-core topics. Core CPD topics and their
recommended quota (from the GDC) are provided below:

• Medical Emergencies: 10 hours

• Disinfection and decontamination: 5 hours
• Radiography and radiation protection: 5 hours (dental
technicians can do these 5 hours in materials and equipment
instead)

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Your CPD record

You must keep a record of all your CPD activity for 5 years after the end
of your CPD cycle and provide this as evidence. You may be asked to
provide the evidence as part of an audit. The CPD provider must include
the following information in the evidence they give you:

• Concise educational aims and objectives

• Clear anticipated outcomes
• Quality controls

For more information, see ‘Continuing Professional Development’

guidance booklet on gdc-uk.org

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COSHH

COSHH stands for ‘Control of Substances that are Hazardous to Health’.

Such substances include:

• Chemicals
• Products containing chemicals
• Fumes
• Dusts
• Vapours
• Mists
• Nanotechnology
• Gases and asphyxiating gases and
• Biological agents (germs)
• Germs that cause diseases such as leptospirosis or legionnaires
disease and germs used in laboratories.

You need to adequately control exposure to materials in your practice

that could lead to ill health of patients and staff. This means:

• Identifying which harmful substances could be present in the

workplace
• Looking at how staff could be exposed to the substances and be
harmed
• Assessing what measures you currently have in place to prevent
this harm and deciding whether you are doing enough
• Ensuring all workers receive the correct information, instruction
and are properly trained
• In appropriate cases, providing health surveillance

The risk of harm needs to be ‘as low as reasonably practicable’, which

means: all control measures are in good working order; exposures are
below the Workplace Exposure Limit; exposure to harmful substances
that can cause cancer, asthma or genetic damage is reduced to the
lowest level possible.

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NICE guidelines: wisdom tooth extractions

Overview
NICE has recommended that impacted wisdom teeth that are free from
disease (healthy) should not be operated on. There are two reasons for
this

1. There is no reliable research to suggest that this practice

benefits patients
2. Patients who do have healthy wisdom teeth removed are being
exposed to the risks of surgery. These can include, nerve
damage, damage to other teeth, infection, bleeding, and, rarely,
death. Also, after surgery to remove wisdom teeth, patients may
have swelling, pain and be unable to open their mouth fully.

Patients who have impacted wisdom teeth that are not causing
problems should visit their dentist for their usual check-ups.
Only patients who have diseased wisdom teeth, or other problems with
their mouth, should have their wisdom teeth removed. Your dentist or
oral surgeon will be aware of the sort of disease or condition which
would require you to have surgery. Examples include untreatable tooth
decay, abscesses, cysts or tumours, disease of the tissues around the
tooth or where the tooth is in the way of other surgery (see indications
for removal below).

Indications for wisdom tooth removal

There is good reason to remove impacted third molars when they are
associated with the following pathological changes:

1. Overt or previous history of infection including pericoronitis

2. Unrestorable caries
3. Non-treatable pulpal and/or periapical pathology
4. Cellulitis, abscess and osteomyelitis
5. Periodontal disease

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6. Orthodontic abnormalities
7. Facilitation of restorative treatment including provision of
prosthesis
8. Internal/external resorption of tooth or adjacent teeth
9. Pain directly related to a third molar (either severe or second
episode of pain following initial management)
10. Tooth in line of bony fracture or impeding trauma management
11. Fracture of tooth
12. Disease of follicle including cyst/tumour
13. Tooth impeding orthognathic surgery or reconstructive jaw
surgery
14. Tooth involved in field of tumour resection

Factors affecting risk of surgery

1. Presence/absence or underlying systemic disease that my

interfere with normal healing
2. Anatomical position of tooth
3. Root morphology
4. Local anatomical relationships
5. Status of adjacent teeth
6. Other conditions leading to limited access to oral cavity
7. Patient cooperation
8. Bulk of supporting bone in maxilla/mandible
9. Increased or significantly reduced bone density
10. Ankylosis
11. Presence of acute/chronic infection
12. Presence of associated disease or pathology
13. Presence of other local bone/soft tissue disease
14. Presence of associated fracture of maxilla/mandible
15. History of TMD
16. Availability of appropriately trained clinicians speaking the same
language

Taken from NICE guidelines - ‘Guidance on the Extraction of Wisdom

Teeth’ 2000
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Orthodontic referrals

Overview
GDC Standards say that dentists are capable of “prescribing and
providing fixed orthodontic treatment” provided they have had the
training, are competent and possess the correct indemnity. However,
most dentists will refer cases to an orthodontist. It is important to
understand what should be referred as unnecessary referrals contribute
to long waiting lists for orthodontic treatment.

The British Orthodontic Society (BOS) have set out guidelines on what
can be referred - this is called the Index of Orthodontic Treatment Need
(IOTN). It has two main components.

Dental health component (DHC): this records the worst occlusal

feature of the malocculsion. See below
Aesthetic component (AC): 10 colour photographs are supplied to
GDP with 10 being the teeth most in need of treatment

To quality for NHS treatment, the patient should have a minimum DHC
and AC of 3 and 6 respectively. Orthodontists working in primary care
can only provide orthodontic treatment for under 18s. Adults with severe
malocclusions may be eligible for orthodontic treatment in the Hospital
Orthodontic Service (secondary care).

A general dentist’s role

As a dentist, you must be competent and able to carry out an
orthodontic assessment to determine which patients can qualify for
orthodontic treatment on the NHS. If a patient does not qualify for NHS
treatment (minimum DHC 3 and AC 6), you must always advise them
of other options that they have - even private orthodontics as many
patients are willing to pay for this. Patients who do not qualify are also
entitled to seek a second opinion via PALS (Patient Advice and Liaison
Service)

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Patients with poor oral hygiene and caries must be treated first by
their GDP and given oral hygiene advice. They must then be reviewed
and demonstrate that their brushing has improved and that they
are motivate. They must be able to look after their teeth adequately
because orthodontic brackets are plaque retentive and you can
increase their risk of periodontal disease and caries if you do not select
the correct patients.

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DFT interviews
and leadership station (PML) Guidelines
Scenario 1

Sedation

Sedation can be used as a technique to reduce or eliminate a patient’s

dental anxiety. Two types of sedation exist in the main dental setting:
inhalation sedation (IHS) and intravenous sedation (IVS).

IHS indications

• Passed examination (blood pressure, IO)

• Anxious
• Complex treatment
• Medical history - patients who are allergic to benzodiazepine,
cardiovascular disease, respiratory conditions
• Patients with strong gag reflexes
• To avoid GA
• Needle phobia

IHS contraindications

• ASA classification III or IV

Severe anxiety
• COPD/Tuberculosis
• Pregnancy
• Alcoholic
• Poor patient cooperation
• Claustrophobia
• Inability to breathe through the nose - URTI will lead to mouth
breathing
• Psychiatric disease - requires consultation with patient’s doctor

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IVS indications

• Anxiety
• Gagging
• Complex procedures

IVS contraindications and cautions

• Benzodiazepine allergy/addiction
• Medical conditions such as: significant cardiovascular pathology,
hepatic or renal disease, gross obesity, pregnancy, myasthenia
gravis, needle phobias
• Patient will require an escort home and care for 24 hours - this
may be difficult for patients who have children

Sedation assessment

• Reason for referral: Anxiety, gagging, failed LA, fainting, surgical

procedure, special needs, medically compromised
• Patient complaint: current and past symptoms. Take a pain
history.
• Medical history: with ASA classification (sedation in the dental
practice should be limited to ASA I and II only; refer ASA III and
ASA IV to the hospital)
• Dental history: past treatment experience, attendance profile,
motivation, expectations, pain/anxiety history
• Anxiety history: what are they anxious about? Intensity
• Social history: smoking, alcohol, recreational drugs,
employment, transportation, children, is there an escort/
childcare available?
• Psychological history: medication, control, precipitating factors
• Drug history: interactions between sedative drugs and
prescribed/self prescribed drugs
• Examination: soft tissues, oral hygiene, caries rate, charting, BPE

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• Investigations: radiographs and vitality tests

• Diagnosis
• Treatment plan: dental plan (any nasty procedures may require
sedation), pain and anxiety control
• Consent
• Vital signs: blood pressure, pulse, weight and height

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Bisphosphonate therapy

Overview
Bisphosphonates act to reduce bone resorption by hindering the
formation, recruitment and function of osteoclasts. They are typically
used in the management of osteoporosis and in non-malignant and
malignant conditions. In this way, they delay the onset of disease or
treatment complications (i.e. pathological bone fractures and bone pain).

Examples of bisphosphonate drugs include alendronic acid, zolendronic

acid, etidronate disodium and ibandronic acid. Examples of relevant
conditions include (non-malignant) osteoporosis, Paget’s disease,
osteogenesis imperfecta, fibrous dysplasia, hyperparathyroidism, cystic
fibrosis; and (malignant) malignant melanoma, breast cancer, prostate
cancer, bony metastatic lesions.

It should be noted that MRONJ (medicine-related osteonecrosis of the

jaw) has since replaced the term BRONJ, as other medications have
been linked to osteonecrosis of the jaw. However, BRONJ has been
identified below.

BRONJ

• BRONJ stands for ‘bisphosphonate-related osteonecrosis of the

jaw’.
• As bisphosphonates reduce bone turnover and bone blood
supply, this may lead to death of the bone in some cases,
termed osteonecrosis.
• BRONJ is defined as necrotic bone in the maxilla or mandible
that has persisted for more than 8 weeks in patients taking
bisphosphonates and where there has been NO history of
radiation therapy.
• BRONJ is an extremely rare condition that occurs in 1 in 100,000
patients who undergo an extraction.
• Symptoms: delayed healing following a dental extraction or
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DFT interviews
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Scenario 1

other oral surgery, pain, soft tissue infection and swelling,

numbness, paraesthesia or exposed bone.
• BRONJ lesions are currently not treated in primary care and
suspected cases should be referred.

Clinical considerations
Before commencement of bisphosphonate therapy, the focus is to
ensure stabilisation and prevention advice. This would involve:

• Remedial dental work

• Reducing periodontal/dental infection
• Remove teeth of poor prognosis as this avoids the patient
undergoing a dental extraction later during their bisphosphonate
therapy
• Adjust poorly fitting denture (mucosal trauma)

During bisphosponate therapy, you can routinely treat the patient for
non-invasive procedures such as scale and polishes, simple restorations
and radiological review. You should avoid extractions, root planing,
complex restorations, implants or any other procedures that may require
significant healing of the jaw tissues.

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Assessing patient risk

High risk: Previous BRONJ diagnosis, bisphosphonates for

malignant/non-malignant condition affecting bone, systemic
steroids, radio/chemotherapy, intravenous bisphosphonates.

Low risk: Bisphosphonates used in prevention of osteoporosis or if

the patient has a history of previous use, oral bisphosphonates.

Advise BRONJ risk for informed consent. Ensure that the patient does
not stop taking their medicine as the drugs persist in tissues for years
following bisphosphonates (record this advice). The management of a
patient at a risk of BRONJ varies according to their risk.

Low risk management: perform extractions as atraumatically as

possible. Avoid creating flaps and achieve good haemostasis.
Simple extractions can be carried out in primary care. The
consideration for specialist care is the same as for a patient who is
not on a bisphosphonate. Review healing at 4 weeks. If the site fails
to heal within 4-6 weeks, refer to an oral surgeon/hospital.

High risk management: contact specialist for opinion on treatment

in primary care or referral. Include full details of MH and DH.

339
 DO
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The Complete Guide for DFT Interviews
First edition

Essential preparation for your DFT interviews

The Complete Guide for DFT Interviews is a comprehensive and expert-
lead resource on the entire DFT recruitment process from application to
accepting your DFT training post at your chosen dental practice.

Preparation for DFT recruitment can be a confusing, stressful and uncertain

time. We aim for the reader of this book to be as fully informed and reassured
of the processes involved. With 30 SJTs and 30 fully detailed and rationaled
scenarios across Communication and PML (Professionalism, Leadership and
Management) stations, this book will be a useful resource for those wishing
to prepare as fully as possible for their upcoming DFT interviews.

“ A well written, detailed and excellently laid out document that should be very
useful for students preparing for DFT recruitment for England, Wales and
Northern Ireland. It could also be of use to students to enhance their skills with
patients.
Dr. Alisdair Miller (BDS, FFGDP, FFGDP, FDS, FAcadMEd), Past
Postgraduate Dental Dean (Southwest).

This book is an excellent resource for students preparing for their Dental
Foundation Training interviews. This will certainly be something for you to
keep following final year with its helpful communication tips and research.
Previous DFT Dentist

A very impressive piece of work considering the experience of the authors.

Dentolegal Advisor, Dental Protection
“
“Expert-driven education”
DentaliQ, London, SW1Y 6QY