valid consent provided that the clinician considers him or her to be mature enough to
fully understand the proposed intervention. However, as the understanding required
for different interventions will vary, a child aged less than 16 years may have the
capacity to consent to some interventions but not to others.
Key Point
If a child is considered to be Gillick competent, his or her consent will be valid.
Additional consent by a person with parental responsibility will not be required.
Young people aged 16 or 17 years are entitled to consent to their own dental
treatment and anaesthetic where the treatment offers direct benefit to the individual.
However, the refusal of a competent individual of this age to undergo treatment may
in certain circumstances be over-ridden by either a person who has parental
responsibility or by a Court.
3.3 HISTORY
3.3.0 Introduction
Taking a comprehensive case history is an essential prelude to clinical examination,
diagnosis, and treatment planning. It is also an excellent opportunity for the dentist to
establish a relationship with the child and his or her parent. Generally speaking,
information is best gathered by way of a relaxed conversation with the child and his
or her parent in which the dentist assumes the role of an interested listener rather than
that of an inquisitor. While some clinicians may prefer to employ a proforma to
ensure the completeness of the process, this is less important than the adherence to a
set routine.
A complete case history should consist of:
- personal details;
- presenting complaint(s);
- social history;
- medical history;
- dental history.
Table 3.1 summarizes the key information that should be included under each
heading.
3.3.1 Personal details
A note should be made of the patient's name (including any abbreviated name or
nickname), age, address, and telephone number. Where these details have been
entered in the case notes prior to the appointment they should be verified. Details of
the patient's medical practitioner should also be noted.
3.3.2 Presenting complaint(s)
It is important to ascertain from the child and his or her parent why the visit has been
made or what they are seeking from treatment. It is good practice to ask this question