Use these 60 selected key concepts to connect clinical findings with justified decisions and clear explanations. They support preparation for the Royal College of Surgeons of England's Licence in Dental Surgery Part 2 at the level of a safe Day One BDS-qualified dentist. Apply the distinctions to patient scenarios, compare reasonable options and recognise when advice or referral is needed.
Communication and shared decisions
1. Present reasonable options before asking for consent
Before seeking a decision, set out the relevant options for that patient, including delaying treatment or doing nothing, with risks and benefits of each, plus details of the proposed treatment and possible costs. Only after this discussion ask the patient to choose, so the decision reflects a genuine comparison rather than agreement to a single recommended course.
Worked example: After assessing a symptomatic molar and identifying the clinically reasonable options, the clinician explains each with its risks, benefits and likely costs, including the effects of delaying treatment or leaving it untreated, then records which option the patient chooses.
Mistake to avoid: Telling the patient that extraction is the only sensible choice and asking her to sign the plan without mentioning alternatives.
Reference: [6]
2. Keep consent valid throughout care
Consent is not a one-off event. At every stage of investigation and treatment you must confirm that agreement still covers what is proposed. If findings alter the plan, explain the new position, including risks, benefits and costs, and obtain fresh valid consent before continuing; earlier agreement does not authorise later, different procedures.
Worked example: Midway through an examination you identify a lesion needing a different intervention than first discussed. You pause, explain the revised proposal with its risks and costs, and wait for the patient to agree before proceeding.
Mistake to avoid: Continuing with a planned filling and then extending to a crown in the same visit because consent was given at the start.
Reference: [6]
3. Match communication to the patient's needs
Identify each patient's communication difficulties and adapt delivery accordingly: avoid jargon and acronyms, arrange interpreters where English is not the first language, and consider support such as sign language companions or induction loops for hearing aid users. Match the method to the actual barrier rather than relying on louder or repeated speech.
Worked example: A deaf patient who wears hearing aids struggles to follow your explanation. You switch on the practice induction loop, speak clearly at normal volume, and offer written summaries to support the discussion.
Mistake to avoid: Shouting the treatment options at a patient whose first language is not English, assuming volume will overcome the language barrier.
Reference: [6]
4. Check understanding through questions and summaries
After giving information, satisfy yourself that the patient has understood it, for example by inviting questions and summarising the main points. Allow enough time for questions and decisions. Remember that a comprehension check supports consent but does not alone establish every requirement for valid consent.
Worked example: Before a referral to a specialist, you ask the patient to describe in her own words why it is happening. She says the specialist will definitely treat the tooth, so you clarify that the specialist will first assess and advise.
Mistake to avoid: Accepting a polite nod during the explanation as proof of understanding and moving straight to obtaining a signature on the plan.
Reference: [6]
5. Include the child in the conversation
Communicate directly with both the child and the parent or carer, involving each of them in discussions and decisions about the child's oral health care rather than speaking only to the adult about the child. Involving the child in this way is distinct from the separate question of who holds legal authority to consent.
Worked example: A parent tells you that toothbrushing at home has become a nightly struggle. Ask the child how brushing feels for them, then agree with both that the parent will supervise and help each evening.
Mistake to avoid: Directing all questions and explanations to the accompanying adult while the child sits ignored throughout the appointment.
Reference: [8]
6. Communicate treatment plan changes in writing
Keep the treatment plan and estimated costs under review throughout care, and when the plan changes, inform the patient immediately and provide an updated written version. The updated written plan supports, but does not replace, discussion with the patient and valid consent before the revised treatment proceeds.
Worked example: During a course of care you find that a planned restoration cannot proceed as first described. Discuss the revised options with the patient, answer questions, and issue an updated written plan reflecting the new proposals and costs.
Mistake to avoid: Handing the patient a revised plan without discussion, or leaving them holding an obsolete written plan after care has changed.
Reference: [6]
Records, teamwork and patient protection
7. Make amendments traceable
Patient records must be contemporaneous, complete, accurate, legible and attributable, recording the name or initials of the treating clinician. When an amendment is needed, the change must be clearly marked up and dated so another reader can recognise that the record was amended. This applies to paper and electronic records; the standard does not prescribe a universal method for preserving original text.
Worked example: You notice that a charting entry names the wrong tooth. Add a clearly dated correction identifying the correct tooth and your initials, leaving the original entry readable so any colleague can see what changed and when.
Mistake to avoid: Overwriting or deleting the original entry so that another clinician cannot tell the record was ever changed.
Reference: [6]
8. Separate care sharing from secondary uses of information
Explain proposed sharing of information with others involved in the patient's healthcare and record in the notes whether permission was given or refused. For teaching, research or photographic uses, explain the purpose, obtain and record consent, use only the minimum information necessary and note that permission can be withdrawn. Permission for one purpose does not cover others.
Worked example: A patient agrees to a referral letter being sent to a specialist about their care. That agreement does not extend to using their clinical photograph in a teaching session, so explain that separate purpose and obtain and record specific permission first.
Mistake to avoid: Reusing clinical information or images for a new purpose simply because the practice already holds the records.
Reference: [6]
9. Recognise indirect identification online
Anonymity depends on the whole information set, not just the absence of a name. Rare occupations, distinctive images, dates or locations can combine to identify a patient indirectly. GDC standards prohibit posting patient information or comments about patients on social networking or blogging sites, and require care that patients cannot be identified in anonymised professional case discussions.
Worked example: A dentist wants to discuss an anonymised trauma case in an online forum. The post would combine a distinctive anterior restoration with the small town on the practice profile, so the dentist withholds the radiograph and shares only a de-identified written summary instead.
Mistake to avoid: Assuming that replacing the name with initials or cropping a photograph is enough to make an online case discussion anonymous.
Reference: [6]
10. Define what has actually been delegated
Delegation only works when team members understand their roles and responsibilities, including which decisions and actions have, and have not, been delegated to them. Clear delegation allocates a specific task; it does not expand anyone's scope of practice or establish competence, so the delegated task must remain within the person's registered role and training.
Worked example: A dentist asks a dental nurse to chase an outstanding laboratory report. The dentist explains that the nurse may request it and record the contact, while any clinical decision about the resulting treatment plan stays with the dentist and was not delegated.
Mistake to avoid: Giving an ambiguous instruction such as asking a colleague to deal with a case without defining which decisions and actions were delegated.
Reference: [6]
11. Raise concerns without waiting for proof
Concerns about patient safety must be acted on promptly; a justified concern does not need proof before it is investigated, and if in doubt the concern must be raised. Usually raise concerns locally first, but this may be inappropriate when the manager is the source, and failed or unsuitable local action requires escalation to the appropriate body. The duty overrides personal and professional loyalties.
Worked example: A dentist notices a colleague repeatedly skipping hand hygiene between patients. She raises the specific concern with the practice manager the same day, without waiting for a documented infection, and asks for it to be addressed through the practice reporting procedure.
Mistake to avoid: Withholding a justified safety concern until definite harm or complete proof of a problem has occurred.
Reference: [6]
12. Escalate child welfare concerns according to risk
Where wellbeing concerns arise, act to provide additional support, gather information, keep accurate records, raise the concerns with the child and carers, and monitor progress. If concerns continue or increase, or there is immediate danger or significant harm, follow local child protection procedures and applicable law to make a referral; immediate safety concerns must not wait for a support-and-review cycle.
Worked example: A child attends with bruising that raises concern about immediate safety. Rather than scheduling a routine review, the dentist follows local child protection procedures to make a referral the same day while continuing any urgent dental care the child needs.
Mistake to avoid: Treating every missed appointment as proof of neglect or delaying referral when a child faces immediate danger.
Reference: [8]
13. Assign decontamination responsibilities explicitly
For local decontamination in an England primary care dental practice, HTM 01-05, 2013 edition, requires that all staff involved are suitably trained, that roles and responsibilities are defined and understood by everyone, and that the practice can evidence relevant maintenance and testing duties. One individual may hold several roles, and a service contract does not remove the practice's responsibility for trained operation.
Worked example: In a two-surgery practice, a senior nurse is named in writing as decontamination lead and records daily sterilizer cycle and test results, while an external engineer performs periodic servicing; the practice retains both sets of documentation and ensures all staff know who holds each responsibility.
Mistake to avoid: Treating an equipment service contract as transferring the duty of the practice to train operators and retain testing records.
Reference: [7]
Competence and use of evidence
14. Check all conditions for undertaking treatment
A task may be undertaken only when the clinician is appropriately trained, competent, confident and indemnified, and when it falls within mental and physical capabilities. Confidence alone is insufficient, and qualifications or enthusiasm do not equal competence. Where any of these conditions is not met, the clinician must recognise the limit and refer the patient to an appropriately trained colleague.
Worked example: A dentist returning after an extended career break is asked to remove an impacted third molar. Recognising that current skills and confidence fall short, the dentist refers the patient to a colleague with oral surgery experience and arranges supervised retraining first.
Mistake to avoid: Assuming that holding a qualification or having an available appointment means a dentist is competent to undertake any proposed treatment.
Reference: [6]
15. Justify departures from established guidance
Good quality care must be based on current evidence and authoritative guidance. When departing from established practice and guidance, a clinician should record the reasons and be able to justify the decision; should, unlike must, applies where the duty does not hold in every situation. Unexplained appeals to clinical judgement are not sufficient, and documentation alone does not make a departure safe or justified.
Worked example: A clinical record states a clinician departed from established guidance but gives no explanation. The resolved finding is a missing rationale: the clinician should record the actual reasons and be able to justify the decision; the entry alone does not establish the departure was appropriate.
Mistake to avoid: Recording clinical judgement alone as the reason for departing from guidance without explaining the specific patient factors involved.
Reference: [6]
16. Distinguish evidence certainty from recommendation strength
In GRADE, certainty of evidence describes confidence in the estimated effect of an intervention, while recommendation strength describes how broadly it should guide decisions. A conditional recommendation means different choices will be appropriate for individual patients, whose values and preferences must shape the shared decision. Low or very low certainty limits confidence but does not mean an intervention never works.
Worked example: For a posterior Class II restoration, a guideline conditionally suggests certain materials using very low certainty evidence. The dentist explains that the evidence is limited and that the choice should reflect the values and circumstances of the patient rather than a single proven best option.
Mistake to avoid: Describing a conditional recommendation with very low certainty evidence as conclusively proving one treatment is superior.
Reference: [19]
Population prevention and access to care
17. Translate dietary prevention into specific choices
Dietary prevention for children involves specific, actionable advice rather than general encouragement. Advise limiting sugary foods and drinks, drinking only water or milk between meals, choosing low-sugar snacks, and taking nothing except tap water after night-time brushing, while staying alert to hidden sugars and the acid content of drinks, and tailoring this guidance to the child's dietary and medical context.
Worked example: During a family discussion about a young child's frequent sweetened drinks, agree that only tap water will be offered after evening brushing, and highlight hidden sugars in the squash and the acidity of the fizzy drinks the family currently buys.
Mistake to avoid: Telling a family simply to eat healthily, without exploring their actual dietary habits or agreeing specific changes such as the timing of sweetened drinks.
Reference: [8]
18. Coordinate practice and community prevention
Standard prevention means 5% sodium fluoride varnish twice yearly for children aged two and over; enhanced prevention for increased caries risk means four applications yearly, some possibly via community programmes, so coordinate provision across services. Before applying, assess colophony risk, including hospitalisation for severe asthma or allergy within the last 12 months and sticking-plaster allergy, and consider a UK-licensed colophony-free varnish or age-appropriate alternatives.
Worked example: An increased-risk five-year-old needs four varnish applications; two came via a community programme, leaving two to arrange. Screening finds sticking-plaster allergy but no hospitalisation for severe asthma or allergy in the last 12 months, so the dentist chooses a UK-licensed colophony-free varnish for the remainder.
Mistake to avoid: Omitting community-delivered applications when planning the enhanced schedule, or applying a colophony-containing varnish without first assessing the stated asthma and sticking-plaster allergy cautions.
Reference: [8]
19. Treat accessibility as a component of appropriate care
Dental patients should receive reasonable adjustments for disabilities and communication needs suited to each individual, and the professional standards include expectations such as providing an induction loop for patients who wear hearing aids. Applying an identical process for every patient can leave avoidable barriers unaddressed. This concept does not establish detailed statutory requirements, so select adjustments according to the individual patient.
Worked example: A patient with restricted mobility finds transferring to the dental chair difficult and tiring. Explore which adjustments would suit this individual, such as extra appointment time or support from a companion, and verify the chosen arrangements meet the patient's needs rather than applying a standard routine to everyone.
Mistake to avoid: Describing the service as accessible because every patient receives the same written leaflet, without making individual reasonable adjustments.
Reference: [6]
20. Use the child's local referral service and maintain continuity
For a child living outside the practice's usual locality, referral should be directed to the service local to the child, which may not be the customary provider, with all relevant information included and local pathways followed. Referral does not end the practice's responsibility for care: continue providing dental care and take appropriate action to meet urgent clinical needs while the referral is arranged.
Worked example: A family from a distant area attends for a child with extensive caries. Identify the service local to the child, send a referral containing the relevant information, provide prevention and arrange relief of pain or infection as needed while referral proceeds, and continue the child's dental care rather than assuming the referral transfers ongoing responsibility.
Mistake to avoid: Automatically referring every child to the practice's customary provider or assuming that referral transfers responsibility for the child's ongoing dental care.
Reference: [8]
21. Match preventive support to family circumstances
Before advising a family, evaluate whether they can realistically carry out brushing, dietary and attendance routines, and adapt the preventive plan to their circumstances. When practical obstacles persist, involve suitable community or health professionals such as health visitors or school nurses for multidisciplinary support. This supportive route differs from a child protection referral, which follows a separate pathway when welfare concerns arise.
Worked example: A grandmother caring for her grandson understands toothbrushing advice but works night shifts and cannot supervise morning brushing. The dentist reshapes the plan around evening supervision, arranges a brushing chart, and asks the health visitor to reinforce routines during home visits.
Mistake to avoid: Repeating identical brushing instructions at every visit while overlooking the shift patterns, workload or family circumstances that prevent the family from following them.
Reference: [8]
22. Connect antimicrobial decisions with population harm
Antibiotics must only be prescribed when clinically indicated, because unnecessary courses can encourage drug resistance and may increase the risk of Clostridioides difficile-associated disease. Prescribe with particular caution for vulnerable patients, those with previous C. difficile infection, and those with prolonged or repeated antibiotic exposure, while never withholding antibiotics when treatment is genuinely indicated.
Worked example: A fit adult with dental pain asks for a precautionary antibiotic. Assessment finds no spreading infection, systemic involvement or other indication, so the dentist declines the prescription, explains resistance and C. difficile risks, and advises optimal analgesia with safety netting.
Mistake to avoid: Prescribing an antibiotic purely to reassure a worried patient, without recognising that unnecessary courses encourage resistance and raise C. difficile risk.
Reference: [16]
Childhood caries and preventive care
23. Plan for both dentitions
When planning caries care for a child, prioritise preventing disease in the permanent dentition while managing primary teeth so they can exfoliate without pain or infection and with minimal treatment-induced anxiety. These prevention priorities never justify delaying relief of existing pain or infection, which remains an immediate priority.
Worked example: An eight-year-old presents with a painful primary molar and newly erupted first permanent molars. The dentist arranges prompt relief of the symptomatic tooth, then builds the plan around sealing and varnishing the permanent molars alongside prevention for the remaining primary teeth.
Mistake to avoid: Concentrating solely on restoring primary teeth while overlooking the newly erupted permanent molars, or postponing relief of existing pain because prevention takes planning priority.
Reference: [8]
24. Assess lesion activity rather than relying on colour
SDCEP advises assuming every carious lesion is active until there is evidence of arrest. Assess activity clinically, considering appearance, texture and patient factors, and use appropriately selected radiographs to judge progression over time. A single image cannot establish longitudinal change, so colour or absence of pain alone never justifies labelling a lesion arrested.
Worked example: A teenage patient has a dark pit on a permanent molar recorded without any activity assessment. At the next visit the dentist dries and examines the tooth clinically, reviews previous bitewings taken for appropriate clinical reasons, and plans management according to the findings.
Mistake to avoid: Equating a dark appearance or the absence of symptoms with established inactivity, thereby recording a lesion as arrested without any clinical assessment of activity.
Reference: [8]
25. Choose primary-tooth management by expected consequences
For a carious primary tooth, choose the least invasive feasible strategy, weighing time to exfoliation, lesion site and extent, risk of pain or infection, presence of infection, tooth structure preservation, number of teeth affected and avoidance of treatment-induced anxiety. Least invasive never means leaving disease unmanaged; infection or pulpal involvement changes the available options, and caries or infection must not be left unmanaged.
Worked example: An active advanced proximal lesion in a primary molar years from exfoliation. Assessment finds no pain, no infection signs, and bitewing radiographs show clear separation between lesion and pulp; the child accepts care, so selective caries removal is among the preferred options.
Mistake to avoid: Choosing management from cavity size and expected shedding alone, without assessing lesion activity, extent, site and whether infection is present.
Reference: [8]
26. Distinguish selected primary-tooth pulpitis from abscess
SDCEP conditionally recommends, based on moderate-certainty evidence, considering pulpotomy for a child in pain with pulpitis in a vital primary tooth showing irreversible symptoms when there is no evidence of dental abscess. This preserves the tooth and may avoid extraction, but suitability depends on cooperation, consent and operator competence, and it is an option-selection concept rather than a procedural technique.
Worked example: A cooperative child presents with pain from a vital primary molar showing irreversible pulpitis symptoms, and examination and radiographs reveal no abscess. Pulpotomy is considered among appropriate options alongside other factors, rather than assuming extraction is the only course, and the family is involved in the decision.
Mistake to avoid: Applying the pulpotomy recommendation to a non-vital primary tooth or one with an abscess, where different management applies.
Reference: [8]
27. Recognise infection in a primary tooth
Abscess, sinus, inter-radicular radiolucency or non-physiological mobility can indicate infection in a primary tooth, requiring an appropriate management plan such as extraction or, in certain circumstances, referral for pulpectomy. Local measures to bring infection under control may be appropriate in some cases, but infection must not be left unattended simply because the tooth will eventually be shed.
Worked example: A primary molar shows a sinus tract and inter-radicular radiolucency on radiographic assessment. Rather than waiting for natural exfoliation, the dentist discusses options with the parent and plans management of the infection, which may involve extraction or referral for pulpectomy depending on the findings.
Mistake to avoid: Dismissing an infected primary tooth from consideration because it will eventually be shed naturally anyway.
Reference: [8]
28. Choose sealant material according to eruption and cooperation
Resin-based fissure sealants are the first choice of material for permanent molars. Glass ionomer has specific roles: on fully erupted teeth where the child is uncooperative, and as a temporary sealant on partially erupted first and second permanent molars under enhanced prevention. Reassess when eruption and cooperation permit the intended definitive approach, since a temporary sealant does not remove the need for review.
Worked example: An increased-risk child has a partially erupted first permanent molar that cannot yet be properly isolated. A temporary glass ionomer sealant is considered, with the plan to reassess as eruption progresses and place the intended definitive sealant when eruption and cooperation allow.
Mistake to avoid: Placing a temporary glass ionomer sealant and then failing to reassess the tooth as eruption and cooperation improve.
Reference: [8]
29. Use recall to reassess prevention and lesion control
Set each child's recall interval according to individual caries risk and oral health needs, since no universal interval applies. At every review, reassess brushing and diet, check sealants for wear or leakage, monitor lesions managed by prevention alone, and judge whether caries control is working; if control is ineffective, reconsider the plan and create a new care plan rather than repeating an unchanged strategy.
Worked example: A seven-year-old on enhanced prevention returns for review; a bitewing shows the prevention-managed approximal lesion has clearly progressed and a molar sealant is leaking. Reassess caries risk, repair the sealant and reconsider management options instead of simply repeating the previous preventive plan unchanged.
Mistake to avoid: Treating recall as a routine inspection without evaluating whether the chosen preventive strategy is actually controlling the child's caries.
Reference: [8]
Periodontal assessment and management
30. Distinguish attachment loss from pocket depth alone
Periodontitis is characterised by interdental clinical attachment loss at two or more nonadjacent teeth, typically with pockets of four millimetres or more and/or obvious interdental recession, and bone loss visible radiographically. This summary describes characteristic findings only; complete diagnosis, staging and grading require separate classification guidance. Assess attachment levels, recession and radiographic bone loss together, because probing depth measurements alone give an incomplete picture.
Worked example: An adult patient shows obvious interdental recession with attachment loss, yet deepest pocket readings are only four millimetres and radiographs confirm interdental bone loss. Record and interpret the attachment and bone findings as characteristic of periodontitis rather than dismissing disease because pocket depths appear modest.
Mistake to avoid: Ruling out periodontal disease solely because no very deep pocket was recorded during the examination.
Reference: [9]
31. Explain periodontal treatment as a continuing partnership
Explain that periodontitis is multifactorial and that successful control depends on both the patient's self-care and in-surgery interventions, forming a partnership requiring lifelong commitment. Where applicable, offer smoking cessation advice and support for controlling diabetes, but never promise that changing any single risk factor guarantees disease stability; both contributions matter together over the long term.
Worked example: A patient with periodontitis believes professional instrumentation alone will secure stability and plans to reduce daily plaque control. Explain that management is a partnership in which self-care and in-surgery treatment each contribute, reinforce smoking cessation support where relevant, and agree long-term shared goals together.
Mistake to avoid: Presenting periodontal treatment as a one-off cleaning that permanently removes the patient's future disease risk.
Reference: [9]
32. Sequence supragingival and subgingival periodontal care
For patients with diagnosed periodontitis, Step 1 addresses self-care, modifiable risks, supragingival plaque and calculus, and correction of local plaque-retentive factors. Assess the response before Step 2, which provides subgingival professional mechanical plaque removal at sites of four millimetres or deeper where deposits are present or bleeding is detected. Appointment numbers, anaesthesia and instruments depend on disease extent, patient preference and operator skill.
Worked example: After Step 1 therapy, a five-millimetre site on an upper molar bleeds on probing and subgingival calculus is detected. When planning Step 2, include this site for subgingival professional mechanical plaque removal, choosing appointment length and anaesthesia according to disease extent and the patient's preference.
Mistake to avoid: Ignoring plaque-retentive restoration margins while focusing exclusively on deeper subgingival instrumentation during the early steps of periodontal therapy.
Reference: [9]
33. Explain tissue changes after periodontal treatment
After subgingival instrumentation, patients may experience some discomfort and tooth sensitivity in the immediate period, and clinicians should warn them in advance. As pocketing and gingival swelling reduce with stabilisation, smooth-surface recession or interdental spaces, sometimes called black triangles, can become more noticeable. These are possible responses rather than inevitable outcomes, and any unexpected or persistent symptoms still require clinical assessment.
Worked example: A patient telephones two days after root surface instrumentation reporting sensitive teeth and a visible gap between the front teeth. The dentist explains these possible tissue responses as inflammation settles, checks plaque control, and arranges a review to assess the findings.
Mistake to avoid: Promising patients that successful periodontal therapy will leave the gingival appearance unchanged, leaving them unprepared for possible recession or interdental spaces.
Reference: [9]
34. Separate residual disease from supportive maintenance
Reassessment after initial cause-related therapy determines whether residual disease remains. Where diseased sites persist, further management may involve additional non-surgical or surgical treatment or onward referral for specialist care, depending on findings and discussion with the patient. Once active treatment is complete, maintenance care aims to preserve stability and detect recurrence; it does not replace addressing unresolved disease.
Worked example: At reassessment, several molar sites still bleed and probe deeply after initial cause-related therapy. The dentist discusses options with the patient, including further instrumentation, surgical access or specialist referral, before any maintenance schedule is agreed.
Mistake to avoid: Placing a patient with persisting deep bleeding pockets directly into routine maintenance and deferring any discussion about further active treatment options.
Reference: [9]
Endodontic assessment and referral
35. Build an endodontic diagnosis from converging findings
Making an endodontic diagnosis is a process: collect information from the patient verbally, conduct a clinical examination, carry out special tests, then assimilate the facts to determine the problem. The initial discussion is only the first stage, so the clinician must not prejudge the condition purely from the opening account of symptoms.
Worked example: A patient insists her pain comes from a lower left molar. The dentist does not prejudge, instead examining adjacent teeth and restorations, performing pulp and percussion tests, and reaching the diagnosis only after assimilating all the findings.
Mistake to avoid: Beginning root canal treatment on the tooth the patient nominated, relying on the presenting history alone without examination or special tests.
Reference: [10]
36. Record control teeth and imaging assessments
Pulp testing records should include the results for control teeth as well as the suspect tooth, so comparisons remain interpretable later. Any imaging must be clinically justified, and both the justification and a written report of the findings should be recorded clearly in the notes. A bare statement that a test was positive, or that a radiograph exists, leaves the diagnostic evidence incomplete.
Worked example: A note records only cold test positive. The clinician supplements it with the teeth tested, the responses of the suspect tooth and adjacent control teeth, and a written radiographic report stating why the image was justified and what it showed.
Mistake to avoid: Recording that a periapical radiograph was taken without documenting the clinical justification for it or a report of its findings.
Reference: [10]
37. Make an endodontic referral diagnostically useful
A referral is diagnostically useful when it equips the receiving clinician to assess and triage the case. It should state the presenting problem and histories, examination and special test findings, restorability where assessable, diagnostically acceptable relevant radiographs, a provisional diagnosis, previous failed attempts, and the case-difficulty justification for referral. Difficulty scores inform but do not replace judgement, and the recipient still independently reassesses the patient.
Worked example: A dentist asked to retreat a molar containing a separated instrument refers the patient with the complaint history, special test findings, an acceptable periapical radiograph, a provisional diagnosis and the difficulty justification, expecting the specialist to reassess independently.
Mistake to avoid: Sending a letter that requests root canal treatment without histories, examination findings, radiographs, a diagnosis or difficulty justification, leaving the recipient unable to assess it.
Reference: [10]
Restoration and removable prostheses
38. Distinguish selective, non-selective and stepwise removal
These terms describe how far carious tissue is removed and whether re-entry is planned. Selective removal stops at soft or firm dentine, non-selective removal continues to hard dentine, and stepwise removal places a temporary restoration before re-entry months later. The ADA panel conditionally favours selective removal, with very low certainty, for specified moderate or advanced lesions in vital, non-endodontically treated permanent teeth restored without pulp therapy.
Worked example: In a vital permanent molar with a moderate lesion restored without pulp therapy, the clinician removes carious tissue to firm dentine and places the final restoration at one visit with no re-entry planned, which is selective removal.
Mistake to avoid: Calling a single-visit excavation stopped at soft dentine, with no temporary restoration or planned re-entry, stepwise removal rather than selective removal.
Reference: [19]
39. Include isolation and curing feasibility in material selection
Material selection must match achievable placement conditions. The ADA guide notes GIC options may be preferable when tooth isolation cannot be achieved, for patients with special healthcare needs or lacking predictable access to care, and conventional GIC may be preferable when light-curing is not feasible. Scope it to the guide's relevant recommendations for vital permanent teeth without pulp therapy; US guidance, not UK regulatory authority.
Worked example: For a vital permanent tooth covered by a relevant guide recommendation, where the light-cure unit has failed and isolation is unreliable, the clinician plans a conventional GIC restoration because its placement requirements can genuinely be met that day.
Mistake to avoid: Choosing a resin composite solely for appearance while ignoring that the required isolation and light-curing cannot be reliably delivered in the planned circumstances.
Reference: [19]
40. Separate denture support from stability
Support is the foundation of teeth and soft tissue on which a prosthesis rests; stability is resistance to displacement under functional, horizontal and rotational stresses. For distal-extension removable partial dentures the two are related but distinct: foundation contact provides support, while stability depends on the overall quality of adaptation to the supporting teeth and tissues and must be assessed separately.
Worked example: In a delivery record for a distal-extension partial denture, the clinician notes that the prosthesis rests on its abutment teeth and residual ridge, and separately records visible sideways movement during function, distinguishing the supporting foundation from resistance to displacement.
Mistake to avoid: Recording a denture as stable merely because it rests on its foundation, without testing resistance to functional, horizontal and rotational displacement.
Reference: [13]
41. Interpret distal-extension rotation clinically
In a distal-extension RPD, finger pressure on the distal-most base tests vertical stability: lifting of the anterior indirect retainer indicates rotation about the terminal abutment. This finding does not identify a single cause; it may reflect poor tissue adaptation, inherent tissue compressibility, or both, so framework relationships and denture-base coverage and adaptation must both be assessed in the mouth.
Worked example: While delivering a new mandibular free-end partial denture, a dentist presses the distal extension base and observes the anterior rest lift, then assesses framework fit and base adaptation to the supporting tissues before accepting the delivery.
Mistake to avoid: Treating a framework that fits the master cast as proof of vertical stability in the mouth without testing tissue adaptation under load.
Reference: [13]
42. Compare direct and laboratory hard reline materials
The 2011 JCDA article describes laboratory-processed relines as stronger, denser and more completely cured than direct chairside materials, which offer same-visit convenience but are generally less hard, more porous, less colour stable and less completely polymerised, so residual monomer may potentially irritate the oral mucosa. These are that article's material-class comparisons; current products require their own instructions and applicable comparative evidence.
Worked example: A patient asks for a loose distal-extension base to be corrected at one visit. The dentist explains the 2011 article's comparison of material classes, noting chairside convenience against possible incomplete polymerisation, and checks the chosen product's current instructions without claiming established comparative superiority.
Mistake to avoid: Presenting chairside and laboratory hard relines as equivalent simply because both produce a hard reline, ignoring the 2011 article's described differences in cure and strength.
Reference: [13]
The developing dentition
43. Distinguish dental age from eruption asymmetry
Dental age may differ widely from chronological age, so a generalised delay in eruption can be unremarkable and may require only review. However, a change in the normal eruption sequence or an asymmetrical pattern between matching sides may indicate an abnormality and warrants further clinical assessment, with imaging used only where clinically justified.
Worked example: A child presents with both lower central incisors erupting later than typical guide ages. Because the delay is generalised and symmetrical, the clinician reviews development and medical history rather than assuming pathology, reserving radiographic investigation for findings that justify it.
Mistake to avoid: Declaring an eruption abnormality solely because tooth eruption falls outside published age guides for the child's chronological age.
Reference: [12]
44. Recognise specific delayed upper-incisor patterns
An upper incisor's eruption is considered delayed enough to investigate when the contralateral tooth erupted more than six months earlier, when the lower incisors erupted more than a year earlier, or when the sequence deviates significantly, such as a lateral incisor appearing before the central. These findings trigger assessment but are not proof of a specific obstruction or an automatic indication for extraction.
Worked example: At a routine review, an upper lateral incisor has erupted while the adjacent central incisor remains unerupted well beyond the expected interval. The dentist records the sequence deviation as an investigation trigger and assesses the unerupted central clinically, arranging imaging only where the findings justify it.
Mistake to avoid: Reassuring a patient repeatedly about an unerupted upper incisor without assessing a persistent asymmetry or an abnormal eruption sequence.
Reference: [12]
45. Monitor maxillary canine position early
Palpate canines routinely from age nine because the maxillary canine most often strays during late mixed dentition. Ectopic canines are frequently unilateral, so asymmetry in palpability is a warning sign. Absent palpability is a concern prompting clinical and justified radiographic assessment, not a diagnosis on its own. When ectopia is suspected, seek appropriate orthodontic assessment early, since later detection reduces chances of successful interception.
Worked example: At a routine check-up of a ten-year-old, the right maxillary canine bulge is palpable buccally but the left is not. You record the asymmetry, take a justified radiograph, and refer for orthodontic advice about possible ectopia.
Mistake to avoid: Deferring canine palpation until all permanent teeth have erupted, which delays detection of ectopic canines and narrows interceptive options.
Reference: [12]
46. Use parallax as a geometric localisation method
Parallax uses two appropriately selected views with a known tube shift, such as horizontal parallax with paired periapicals, which research suggests is more reliable than vertical parallax. When the ectopic canine image moves in the same direction as the tube shift relative to adjacent teeth, this relationship indicates palatal displacement. It is a geometric localisation method, not a justification for extra exposures.
Worked example: A child with a suspected ectopic canine has two periapical views taken with a documented horizontal tube shift. The canine image moves with the tube relative to the lateral incisor root, so the relationship is interpreted as palatal displacement.
Mistake to avoid: Applying the same-direction rule when the tube shift direction or reference structures are unknown, which makes the localisation relationship meaningless.
Reference: [12]
47. Assess developmental consequences before extractions
Where crowding is present, early loss of primary teeth permits mesial molar drift and reduces arch space. Under that crowded condition, losing a second primary molar causes more space loss than losing a first primary molar, and space loss is always greater in the upper arch. Poor-prognosis first permanent molar extraction timing should be specialist-informed, since molar extraction does little to relieve anterior crowding.
Worked example: A child with a crowded dentition loses a second primary molar prematurely. Because crowding is present, you anticipate greater space loss than would follow loss of a first primary molar, monitor the arch, and seek specialist advice before planning any first permanent molar extraction.
Mistake to avoid: Stating the upper-versus-lower and second-versus-first space-loss comparisons as universal rules without attaching them to the presence of crowding.
Reference: [12]
Third molar assessment and imaging
48. Include temporomandibular disorders in the pain assessment
Preauricular pain in a patient with an impacted third molar may originate from a temporomandibular disorder rather than pericoronitis, and the RCS guide warns this can lead to incorrect diagnosis and unnecessary surgery. The preoperative examination should therefore include temporomandibular joint assessment as part of the differential diagnosis before any surgical decision.
Worked example: A patient reports pain near the ear and has an impacted lower third molar. Before attributing the pain to pericoronitis, you examine the temporomandibular joints and other extraoral findings, and discuss the differential diagnosis with the patient before any surgical decision.
Mistake to avoid: Attributing preauricular pain to an impacted third molar without assessing the temporomandibular joints, risking an incorrect diagnosis and inappropriate surgery.
Reference: [11]
49. Select panoramic imaging for a clinical decision
After taking a history and examining the patient, panoramic radiography is indicated for third molar assessment when surgical intervention is genuinely being considered. This is condition-specific imaging guidance, so current radiation legislation and local procedures must also be followed. Routine screening of unerupted third molars is discouraged, since imaging alone does not justify exposure.
Worked example: A young adult has recurrent pericoronitis affecting a lower third molar and further episodes are likely, so removal is a genuine management option. Following clinical assessment, a panoramic radiograph is selected to inform the surgical decision rather than exposing routinely.
Mistake to avoid: Requesting a panoramic radiograph simply because an unerupted third molar is present, without any clinical indication that surgery is being considered.
Reference: [11]
50. Reserve third molar CBCT for a management question
The RCS 2020 third molar guideline advises against routine CBCT for third molar assessment. Its own assessment of the evidence was that CBCT has no effect on outcome while dose and cost are higher. Where conventional imaging shows a close nerve-canal relationship, CBCT may be useful when additional findings would alter management; this selective-use recommendation is open, so weigh radiation exposure and imaging expertise.
Worked example: Conventional radiographs show a close relationship between a lower third molar and the inferior dental nerve canal. Before requesting CBCT, the clinician identifies a specific management question that additional imaging could answer; where no such decision exists, the guideline does not support the scan.
Mistake to avoid: Requesting CBCT for a clearer picture without identifying any management decision that the additional findings could change.
Reference: [11]
51. Assess systemic factors that may compromise healing
Third molar planning must account for medical factors that may compromise healing, including diabetes mellitus, chronic renal disease, hepatic disease, haematological disorders, malnutrition including eating disorders, and immunosuppression. A condition's presence requires individual assessment rather than an automatic contraindication or medication change, and relevant advice should be sought where indicated.
Worked example: A patient with diabetes is considering third molar surgery. The assessment records diabetes as a factor that may compromise healing, and the clinician seeks advice from the patient's medical team before the management plan is agreed together.
Mistake to avoid: Planning third molar surgery from the radiograph alone while overlooking medical history and systemic conditions that may compromise healing.
Reference: [11]
Bleeding risk and medical context
52. Classify the procedure's bleeding risk by extent
For patients taking anticoagulants or antiplatelet drugs, bleeding risk is categorised by the extent and invasiveness of the procedure, not the drug alone. Simple extractions of one to three teeth with restricted wound size are low risk, while complex or adjacent extractions causing a large wound, or more than three extractions at once, carry relatively higher risk. The categories are guides with overlap.
Worked example: An anticoagulated patient needs one straightforward extraction with a restricted wound, categorised as low risk. A different patient needing four adjacent extractions producing a large wound falls into the higher-risk category, so the plan reflects the extent of surgery rather than the medication alone.
Mistake to avoid: Calling every procedure high risk simply because the patient takes an anticoagulant, instead of judging the extent and invasiveness of the planned treatment.
Reference: [15]
53. Clarify medication uncertainty with the prescriber
When a patient cannot give reliable details about anticoagulant or antiplatelet therapy, or a relevant medical condition, the bleeding risk cannot be assessed accurately. Contacting the prescribing clinician, who may be a haematologist or cardiologist rather than the general medical practitioner, before treatment planning allows invasive care to proceed safely, with interim non-invasive pain relief used where needed.
Worked example: A patient attending for a surgical extraction says her antithrombotic drug was recently changed by the hospital and she cannot recall its name. The dentist contacts the cardiology team to confirm the regimen before finalising the invasive treatment plan.
Mistake to avoid: Guessing the unknown medication regimen, or advising the patient to pause anticoagulant tablets independently to make the extraction simpler.
Reference: [15]
54. Include access to help in bleeding-risk planning
For patients in remote or rural locations, reaching urgent care after a bleeding complication can take longer, so the individual circumstances deserve explicit consideration. Limiting the initial treatment area, staging treatment, applying haemostatic measures and extending post-operative monitoring before discharge can reduce consequences, while the attitude to risk and its consequences is discussed with the patient.
Worked example: A farmer needing multiple extractions lives two hours from the nearest dental hospital with limited out-of-hours help. The dentist stages the extractions over separate visits, uses careful haemostatic measures, and keeps the patient under extended observation before discharge.
Mistake to avoid: Applying an identical discharge routine to every patient without asking whether they could obtain urgent help if bleeding developed.
Reference: [15]
Infection and medical emergencies
55. Use antibiotics as an adjunct when indicated
Local measures come first in managing dental bacterial infections, for example draining pus by extraction or through root canals, while avoiding attempts to drain cellulitis-type swelling. Antibiotics are considered alongside these measures where infection is spreading, systemic involvement is present, or the patient faces a high complication risk, such as immunocompromise or uncontrolled diabetes.
Worked example: A patient with a dental abscess develops facial swelling spreading beyond the alveolus with fever and malaise. The dentist drains pus at the tooth, prescribes an antibiotic as an adjunct after checking guidance and interactions, records the reasons, and gives safety-netting advice.
Mistake to avoid: Issuing an antibiotic prescription alone for a draining abscess while omitting the local source management that the infection actually needs.
Reference: [16]
56. Separate inflammatory pain from an antibiotic indication
Pain from irreversible pulpitis or a dry socket arises primarily from inflammation, so antibiotics should not be prescribed to manage that pain. Appropriate analgesia and local measures address it instead. The clinician should still assess whether a separate infection indication or raised complication risk exists before concluding antibiotics are unnecessary.
Worked example: A patient with severe pain from diagnosed irreversible pulpitis believes antibiotics will work faster. Assessment finds no separate infection indication or raised complication risk, so the dentist does not prescribe for pain alone, arranges appropriate urgent dental care, and recommends suitable analgesia with safety-netting advice.
Mistake to avoid: Treating severe or worsening dental pain as an antibiotic indication instead of delivering definitive local care and analgesia.
Reference: [16]
57. Recognise infection red flags requiring emergency transfer
Dental infections can spread into fascial spaces and threaten the airway. Red flags include significant trismus, floor-of-mouth swelling, breathing or swallowing difficulty, rapidly spreading cellulitis and deep or high-risk fascial space involvement, requiring emergency hospital transfer. If airway compromise is present, for example Ludwig's angina or sepsis, call 999 and provide necessary emergency care. Record the diagnosis and any assessments performed without delaying transfer.
Worked example: A patient with a dental abscess develops floor-of-mouth swelling and breathing difficulty, indicating airway compromise. The dentist calls 999, provides necessary emergency care and arranges emergency hospital transfer, recording the diagnosis and vital signs already taken without delaying the ambulance.
Mistake to avoid: Prescribing antibiotics and booking routine follow-up for a patient whose floor-of-mouth swelling and breathing difficulty signal airway compromise.
Reference: [16]
58. Recognise adult cardiac arrest using the 2025 sequence
The 2025 adult basic life support guidance asks rescuers to check safety and responsiveness, call 999 immediately for an unresponsive person, and then assess breathing. Unresponsiveness combined with abnormal breathing, including agonal gasping or panting, means cardiac arrest should be presumed and CPR started at once. The call handler can help if recognition is uncertain.
Worked example: During a busy clinic morning, a middle-aged man collapses in the waiting room and is unresponsive with slow, laboured breathing. A team member calls 999 on speakerphone, and colleagues begin chest compressions immediately, treating the abnormal breathing pattern as presumed cardiac arrest.
Mistake to avoid: Watching for several minutes to confirm that gasping breaths are truly abnormal before placing the emergency call.
Reference: [17]
59. Use the AED promptly with clear contact precautions
Attach an AED as soon as one reaches the scene, applying pads to bare skin in the positions shown and continuing compressions while a second rescuer attaches them. Nobody should touch the person during rhythm analysis or shock delivery. Whether a shock is given or the device advises none, restart chest compressions immediately and keep following the prompts.
Worked example: A practice AED is brought to a collapsed patient and pads are attached while compressions continue. The device analyses the rhythm and announces that no shock is advised, so the team resumes compressions at once and keeps responding to each spoken prompt.
Mistake to avoid: Stopping resuscitation efforts because the AED announced that no shock was advised for the current rhythm.
Reference: [17]
60. Recognise airway signs of anaphylaxis and escalate
Anaphylaxis can present with marked laryngeal oedema and bronchospasm, producing stridor, wheeze, tachycardia and a raised respiratory rate. A rash is not required before escalating. When these airway features appear after a suspected exposure, treat the situation as a medical emergency, assess the patient and call an ambulance for urgent transfer to hospital.
Worked example: Shortly after a drug is administered, a patient develops inspiratory stridor and audible wheeze without any skin changes. The team recognises these airway signs as possible anaphylaxis, positions and assesses the patient, and calls an ambulance for emergency hospital transfer.
Mistake to avoid: Delaying escalation until a visible rash appears despite the patient having stridor and wheeze after exposure.
Reference: [18]
Sources
- RCS England
- RCS England
- RCS England
- RCS England
- GDC
- GDC
- Department of Health
- SDCEP
- SDCEP
- British Endodontic Society
- Royal College of Surgeons of England
- British Orthodontic Society
- JCDA
- Public Health England and FGDP(UK)
- SDCEP
- SDCEP Drug Prescribing for Dentistry
- Resuscitation Council UK
- SDCEP Drug Prescribing for Dentistry
- ADA