Referral dilemmas with root canal treatment

NHS England is trying to clear up the confusion over when and how to refer patients to specialists, John Makin says.

If performed to a good standard, the success rate of root canal procedures is 90%, according to the British Endodontic Society. In most cases, GDPs have the skills and training to do this.

However, root canal treatment demands a higher level of technical skill than many other dental restorations, especially when encountering factors such as curved roots. Little wonder that root canal treatment (RCT) is a common source of patient complaints and featured in over 100 claims notified by DDU members in 2017 alone.

Given the risks, it is important that practitioners are able to recognise their technical limits and refer patients to a specialist where appropriate. After all, the GDC says: ‘If you are not confident to provide treatment you must refer the patient to an appropriately trained colleague.’

Unfortunately, GDPs can face pressure from commissioning bodies, who generally expect GDPs to carry out root canal treatment as a band two treatment under their contract, and from patients, who would prefer to have the procedure carried out by their own dentist or have an expectation that any referral be made under NHS arrangements.

Dentists can face a real dilemma as some patients will raise a complaint on the basis that a referral has been offered (in other words that they are being denied treatment that the practice should provide), others (normally when complications have occurred) that they ought to have been referred and were not.

Guides for commissioning

NHS England is in the process of producing a series of guides for commissioning dental specialities, including endodontics, which will: ‘Describe what is expected of providers of dental services at each level of care complexity in terms of clinical competence, procedural complexity, modifying patient factors, and equipment or environment requirements.’ Greater clarity would be welcome, provided the guidance recognises dental professionals’ ethical duty to know their limitations and refer if it is in the patient’s best interests.

In the meantime, I would advise dentists to contact their NHS regional team to find out about the NHS specialist endodontic provision in their particular area and the referral protocol. To avoid the risk of allegations of having mislead patients, it is important not to make assumptions about the availability of funding for NHS specialists and to be able to provide accurate up-to-date advice to patients.

As with every procedure, root canal treatment patients are generally less likely to make a complaint or claim if they believe they have been fully informed about their treatment options.

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