The scene

A dental core trainee had started working for the Community Dental Service and was asked to treat a very anxious patient who had been referred for several fillings under sedation.

Soon after starting the procedure, the trainee noticed a molar with an exposed nerve which meant they needed to revise the treatment plan that the patient had previously consented to. The trainee was unable to decide whether to treat the tooth straight away or wait until the patient could give informed consent.

DDU advice

The patient had already been judged to have capacity to make an informed decision about the proposed treatment under sedation and given her advanced written consent, in line with the GDC Standards. (Para 3.1.6, Standards for the Dental Team)

However, consent should be thought of as a process rather than a one-off event because the clinical situation can easily change. In para 3.3.5, the GDC specifically states: “If you think that you need to change a patient’s agreed treatment or the estimated cost, you must obtain your patient’s consent to the changes and document that you have done so.”

However, for her consent to be valid, she would need to understand the information relevant to the decision, be able to retain this and weigh it up as part of her decision-making process and be able to communicate their decision.

Although the patient didn’t have the necessary capacity while under sedation and when recovering from sedation, the trainee knew that this was only temporary. Section 4 (3) of the Mental Capacity Act 2010 requires healthcare professionals to consider whether a patient is likely to regain capacity to make a particular decision and whether the decision can be delayed.

Performing an irreversible procedure while the patient was unable to consent could destroy her trust, especially as she already suffers from dental anxiety. However, by applying a dressing to protect the tooth, the trainee would not restrict the patient’s options and give her the opportunity to consider the options so she could decide for herself.

Whatever they decided to do, the trainee needed to be able to justify this and should keep careful records of what took place.

What happened next

The trainee decided to dress the tooth and complete the rest of the treatment plan. They arranged time to talk with the patient to explain before they left the surgery and then a further appointment to talk about the next steps.

The patient was grateful that the decision hadn’t been taken out of her hands while she was sedated as she wanted to be involved, despite her anxiety. After talking through the risks and benefits of root canal treatment and extraction, she opted for an extraction which was carried out under sedation at a later appointment.

Further reading on conscious sedation

Although you may have received some training in conscious sedation at dental school, you will need to complete additional postgraduate training and gain clinical experience to administer conscious sedation independently and practise in a suitable setting.

For now, it’s a good idea to familiarise yourself with the key standards and guidance on this subject:

Standards for Conscious Sedation in the provision of Dental Care, Faculty of Dental Surgery at the Royal College of Surgeons of England

Dental mythbuster 10: Safe and effective conscious sedation, The Care Quality Commission

Conscious sedation in dentistry, NHS Education for Scotland

This is a fictionalised case compiled from actual DDU case files.

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Conscious sedation and consent

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