the secondary care service provider, especially where sedation and general
anaesthesia are involved. Many health trusts and other employing authorities are
increasingly demanding that written consent is obtained for all procedures. This is
especially difficult now as the lower age of consent is no longer specifically limited.
The sole criterion is whether or not the patient is 'able to understand' the procedures
and their implications. If so, the patient is considered 'competent' and the child may
give (or refuse) consent. It is usual to arrive at a consensus view among parents, child,
and dental surgeon. A sufficiently informative entry should be placed in the patient's
case records. As a pragmatic rule the age of 16 years still acts as a guide. But if a
procedure is proposed and a child under 16 years says 'no' then consent has been
refused. Fortunately, in paediatric dentistry the prospect of a life-saving operation is
rare so a refusal of consent can be managed by a change in the procedure or by
establishing a temporal respite. The current advice from the protection societies is that
written consent must be obtained for a course of treatment. The plan of treatment
proposed must indicate the nature and extent of the treatment and the approximate
number of times that local anaesthesia and/or sedation is to be used. There is no need
to obtain written consent for each separate time that sedation is used. If the plan of
treatment changes and along with it the frequency or nature of sedation, then it is
prudent to obtain written consent for the change. The greater risks associated with
general anaesthesia require specific written consent for each and every occasion that
treatment is carried out under general anaesthesia. Examples of suitably worded forms
are available from the Medical Defence Societies.
Key Points
- A conference that involves both the parent and child helps to gain informed consent:
-discuss the dental problems;
-discuss the treatment options/alternatives;
-agree the treatment plan. - Write-up in the case record.
- Obtain written (signed) consent
4.4 SYSTEMIC PAIN CONTROL
Children may need pain control for 'toothache' for a day or two before the removal of
carious teeth. Often, the teeth are also abscessed so that it is necessary to combine
antibiotic therapy with analgesia to obtain optimum pain relief. Additionally,
analgesia is required postoperatively usually after dento-alveolar surgery.
The most common method of administration is by mouth. Small children, and some
recalcitrant adolescents, refuse to take tablets so liquid preparations are needed. If
other methods of administration, such as intramuscular or intravenous, are required
then these injections should be administered by clinical staff experienced with these
special techniques. Rectal administration is increasingly common as absorption from
the rectal mucosa is rapid. If such a route of administration is to be used, specific
consent must be obtained. It should be remembered that the dose for children of
different ages needs to be carefully estimated to avoid the risk of an overdose
(dangerous) or of an underdose (ineffective). The parents must be advised that all
drugs must be stored in a safe place, in a child-proof container. Bathroom cabinets or
kitchen cabinets are the safest places as they are out of reach and out of sight of small
children. Specific advice on prescribing for children can be obtained from a local