These guidelines result from the work of a panel whose remit was to :
The guidelines cover the collection and recording of information which enables a diagnosis to be made, a treatment plan to be drawn up, or, sometimes, a referral decision to be made. Each clinical discipline has its own record-keeping issues which the guidance introduces but does not detail. Further guidelines may be developed on specific record-keeping issues by topic. The present guidelines are purley concerned with the foundation examination and associated record- keeping-the elements common to all first patient-dentist encounters.
In accordance with normal terminology, this document constitutes a ‘national guideline’, a broad statement relating to an optimal level of care relevant to all sectors of primary care dentistry. It is acceptable (indeed it is encouraged) for it to be modified to take account of the particular needs of practices or sectors, in the form of a ‘local guideline’. See appendix 1: selected definitions
An appropriate clinical examination coupled with accurate recording of findings is essential to all good clinical practice. It is clear therefore that this topic should be an early Part of the Faculty of General Dental Practitioners (UK)’s programme of guideline development. The need for such guidance is highlighted also by concern to identify the optimal frequency of recall examinations. The Faculty’s hope is that these guidelines will make a significant contribution, in this case by ensuring that recall interval and treatment-planning decisions are made on the basis of good patient-specific information.
At present, there is probably wide variation between practitioners in clinical examination practice, dental and medical history-taking, and recording generally. There is a need to reduce inappropriate variation and minimize:
The FGDP(UK) hopes that clinicians will review current practices against these guidelines and consider making changes, if necessary, better to ensure the delivery of appropriate treatment.
Guidelines are systematically developed statements designed to assist the clinician and patient in making decisions about appropriate healthcare for specific clinical situations. They are not intended to be rigid constraint on clinical practice, but rather a description of general good practice against which the needs of the inh4idual patient can be considered. They are intended to help practitioners assimilate, evaluate and implement the ever-increasing amount of evidence and opinion on how dentistry should properly be practiced.
There is wide acceptance in medicine and dentistry that diagnostic and laboratory tests, clinical decisions and clinical practice should be as ‘evidence-based’ as possible. That is, they should be founded on the basis of rigorous scientific evidence. As resources are scarce, effort should not be wasted and patients should not have to undergo pointless processes.
The evidence-based approach is not without problems, however. There is a lack of high-quality research evidence in a number of clinical fields and the topic of this guidance is a prime example. Where there is a large evidence base the FGDP(UK) guideline programme follows the SIGN (Scottish Intercollegiate Guidelines Network) approach to methodology, which grades evidence for strength, giving the strongest guidance where the evidence is strongest and the risk of bias weakest. Where the evidence base is weakest. Where the evidence base is weaker the approach has to be more pragmatic.
In some areas there is a gap in the evidence base and a lack of high-quality research studies in the literature. Many of these areas merit future research. In the interim, good practice guidelines can help clinicians identify and adopt current best practice. They are based on Export opinion and consultation with specialist groups and as such they are graded as ‘D’ in terms of the SIGN hierarchy of evidence, but still have significant value to improve the quality of patient care (see appendix 2: understanding the guidelines).
Guidelines must be soon as useful and suitable aids to provisions of care by their target group and, ideally, act as catalysts to discussions at practice local level.
In order to establish whether the national and local guidelines have had a beneficial effect, it is important that practitioners audit appropriate topics related to the guidelines. Suggestions of possible audit topics are set out in section seven.
The first edition of these guidelines was developed when there was a comparatively weak scientific basis for making recommendations. Much of the available evidence of good practice was recommended by recognised authorities. Although systematic review were being undertaken in the field the are still limitations to the evidence currently available. As with other guidelines it is recommended that a review is undertaken in three year’time.
However, it is important to appreciate that grade D recommendations have considerable merit as indicators of current best practice and are worthy of consideration by all clinicians seeking to deliver high-quality care for their patients. Goods patient histories, examinations and records assist with quality assurance, audit and research. In addition, they benefit not only the patient but also the practitioner because clear documentation acts as a reference or note of the status quo and is invaluable in cases of query, complaint or litigation.
References are indicated within the text. Where relevant literature could not be identified for review, the authors have attempted to provide recommendations based on ‘good practice’/expert opinion following consultation with specialist societies.
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