DCT - Scenario #1

You are a DCT working in a busy multi-surgery dental practice. Your patient, A West, a
49-year-old, attends your surgery in pain. They take warfarin regularly and have done
so for years. Other than that, they are relatively fit and well and have no known
allergies. On clinical examination, the upper left first premolar has a large, deep
carious lesion close to the pulpal region and could be restored. The patient is keen to
have the tooth extracted because of the severe pain it is causing them. As they are on
warfarin, they had their INR recorded two days ago, showing a result of 3.0.

Please discuss the diagnosis and treatment to the patient and any questions or concerns
they may have.

Answer/Guidance
Questions the candidate should ask the patient:
• What has your pain been like? When did it start? Where does it hurt?
• Do you know what I mean by that diagnosis? Shall I explain?
• What would you be most comfortable doing? How can we help?
• Do you understand your treatment options? Do you understand how we could save the
tooth? Do you know what root canal is?
• Have you had any dental treatments in the past?
• What do you understand about your medical history and taking warfarin?

Plain-speaking phrases the candidate should use:

• You have a large, decayed tooth.
• The decay is sitting on your nerve. The nerve is irritated and damaged.
• Your -ray shows..
• We could remove the tooth (rather than saying "extract" the tooth).
• The root canal involves filling the root (rather than saying "killing the nerve").
• The tooth will be dead.
• Warfarin causes bleeding to occur.

The treatment and options:

To get full marks the candidate should consider and communicate the following clinical
options. All options and risks should be discussed with the patient with their needs in mind. It
is important that they make it very clear that the choice of treatment is entirely up to the
patient.

Short-term option
Acute pain management - The candidate must demonstrate insight into pain relief, e.g., local
anesthesia or extirpation

Long-term options
Do nothing
• Risks - Pain and issues in the future.
Root canal treatment, with or without a crown
• Risks - A complex procedure, cuspal coverage, cost of time and money.
• Benefits - Natural tooth is saved, bone is retained, there is no gap in your teeth.

Extraction, with or without gap replacement

• Risks - Extraction means the natural tooth is removed, leaving a gap. Warfarin causes
bleeding. An INR result of below 4.0 means extraction is an acceptable option, but bleeding
is always a possibility that might require sutures, haemostatic agent or post- operative
instructions.
• Benefits - Patient will no longer be in pain, the procedure is less time-consuming, and there
is less risk of issues in the future.
• Further discussion - Gaps can be filled with dentures, bridges, and implants.

Note: Antibiotics are not an option. There is no clinical justification as there is no

lymphadenopathy or pyrexia. Further investigations and aspects to consider

The candidate should explain the meaning of and reasoning for these options:
• Radiographs, vitality, TTP tests.
• Vitality tests: electric pulp tests, ethyl chloride.
• Referral to oral surgery or OMFS.
• BNF reference.
DCT - Scenario #2

You are a DCT working in a busy multi-surgery dental practice. T Duffy has been
booked at the end of your Thursday diary as an emergency. They are a very pleasant
person, currently under the care of an associate at the practice. They arrive with a
debonded single anterior veneer, which was placed last week. They would like you to
rebond it as they have a wedding to attend on Saturday evening. You try to place the
veneer without any luck, noticing that the fit is extremely poor and additionally the
shape, contour and colour are not consistent with the patient's natural teeth. They tell
you that they were not consulted regarding the shade. You can see the start of
gingivitis around the tooth in question.

Please discuss the diagnosis and treatment to the patient and any questions or concerns
they may have.

Answer/Guidance
Questions and phrases the candidate should say to the patient:
• I am sorry you are unhappy with the treatment.
• I will follow up with the associate.
• I will coordinate with the team and help as best we can.
• What I can see today is... (the fit, the colour)
• Ideally what would you like to happen?
• We will take some photos.

Plain-speaking phrases the candidate should use:

• A veneer is like a false nail.
• Contacting the laboratory means speaking to a dental technician.
• The shade of the veneer refers to the colour.
• Taking impressions means getting a mould of the teeth.

The treatment
To get full marks the candidate should consider and communicate the following treatment. All
options should be discussed with the patient with their needs in mind,

Apology and reassurance

• Let the patient explain the history.
• Reassure them that a plan will be put in place.
• Apologise for the grievance.
• Advise that treatments can be complicated, and things are not always right first time.
• Nevertheless, the team will do their best-look ahead at what can be done.

Explanation of clinical examination results

• Explain findings step-by-step.
• Explain shade and fit.
The next steps
• Discuss treatment options with patient Temporary veneer or direct composite veneer.
• Offer to contact technician and ask for a quick turnaround. No guarantee but shows
awareness and caring.
• Provide patient with appropriate OHI.
• Reassure patient that you will liaise with associate dentist, speak to reception or PM to
organise treatment visits, and arrange a follow-up phone call or review.
DCT - Scenario #3

You are a DCT working in a busy multi-surgery dental practice. Your patient is Andy
Ackerman who is a teacher at a local school. Your colleague examined them last week
where Andy complained of a broken- down tooth causing a throbbing ache in the
upper right jaw keeping them up all night. The patient reported that painkillers did not
help relieve the pain and had no other symptoms. A radiograph was taken at the initial
visit as there was obvious cavitation of the tooth and caries deep within the coronal
region. The radiograph showed mesio-occlusal caries into the pulpal complex with
associated periapical pathology. The caries extended subgingivally. The tooth was
deemed unrestorable and extracted on this visit. The patient is fit and well, has
otherwise a complete and intact permanent dentition with no other carious lesions or
restorations but has signs of significant gingival inflammation, and a greyish,
non-healing socket around the extraction site. You suspect a dry socket. Andy has
attended today in pain, a week after the extraction. After taking a radiograph today
you notice a small root is retained within the socket.

Please discuss your findings and proposals for treatment with Andy Ackerman and answer
any questions of concerns he may have.

Answer/Guidance

Facts:
• URQ Pain - analgesia not helping, waking up at night
• Radiograph shows caries MO into pulp with PAP
• Subgingival caries
• Extracted
• No MH
• Dry Socket
• Retained root in socket

Introduce/Initiate
Good morning, I am….. One of the dentists and I will be seeing you today. Before we begin
can I confirm your full name, medical history.

Exploring patient issues:

• "I believe my colleague saw you last week to take a tooth out - can you explain what
occurred?"
• "What do you know about the treatment you had last visit?"
• "What is the pain you are experiencing like?"
• "What have you been doing to alleviate pain?"
• "This is what I have found today.

Actor Questions:
• "Why am I in pain?"
• "Did something go wrong at the last visit?"
• "What did the X-ray show?"
• "How much is today going to cost?"
• "What can be done to get me out of pain?"
• "What is a dry socket?"
• "How did I get the dry socket?"
• "Was it the dentist's fault that the root got
stuck?"
• "How will the root come out?"
• "Does the root have to come out?"
• "Is the root removal traumatic?"
• "How much will that cost?"
• "What are the risks and benefits of taking or leaving the root?"
• "What is the sinus risk?"

Empathy:
• "I can understand that you may feel aggrieved..."
• "Do you understand thus far?"
• "Is there anything I can clarify?"
• "I am sorry to hear you were unaware of those risks.

Assurance and Planning:

• "I would like to move forward by alleviating your pain…
• Local anaesthesia if necessary
• Syringe saline to flush debris from socket
• Place Alvogyl for reintroduction of clot formation
• Post-operative instructions: no spitting, rinsing, analgesia “...and planning for the future”
• Referral to specialist; may be complex, shows competence and understanding limits
• Root removal risks: surgical procedure, potential sinus risk
• Leaving: could erupt naturally (unlikely), pain/infection may occur

Explanation and planning;

• Investigate the patient's knowledge prior to explaining the procedure
• "How much detail would you like me to go into, a lot or a little?"
• Use visual methods to convey information radiographs, hand gestures and check
understanding by 'chunk and checking'
• "Do you have any questions thus far?"
• "Just so we are clear that you fully understand could you please provide me a quick
summary of what was discussed today?

Closing the session:

• Summarise of the patients queries and plan going forward
• Asking if any further questions are necessary
• Explore what will happen if there are any unexpected outcomes from the agreement.
DCT - Scenario #4

S Thorpe is 43-year-old patient who has previously seen a colleague of yours for
aesthetic treatment. They are at the practice and are waiting to see you today for their
general dental examination. While in the waiting room they flick through some
practice material and find their 'before and after! treatment photos in the practice
promotion material. They enter your room visibly distraught and want to know why
their personal treatment is being displayed when they had not given consent for this.
You go through their notes and find no consent form agreeing to photos being used
for promotional material or educational purposes.

1. What are the issues?

2. What could you do?
3. What would you do?
4. What are the implications of your action?

Answer/Guidance
The outcomes
• The candidate should explain how they would manage this situation and the potential
outcomes.
• Candidates who break this into short-term and long-term management and future
development should be highly commended

Short-term
• Check notes to confirm no verbal or written consent has been documented.
• Apologise to the patient.
• Remove the material with their information on immediately.
• Ask patient if anything can be done to improve the situation.
• Offer a gesture of good will, e.g., free hygiene for the appointment.
• Reassure patient that it will be investigated further.
• Make a note in the significant event log.

Long-term
• Discuss this with the associate - Inform them of patient complaint.
• Discuss with practice manager or practice principal.
• Make sure this promotional material is completely removed and that all other photos have
appropriate consent.
• Bring it up at a team meeting - Raise issues of confidentiality, GDPR, consent and
complaints.
• Encourage team to review consent and carry out audit.

Future development
• Update ePDP accordingly.
• Undertake targeted CPD in this area.
The candidate should also address the potential implications of ignoring the issues:
• A possible complaint from the patient.
• Breakdown in the relationship between patient and dentist.
• Loss of faith in the profession.
DCT - Scenario #5

R Shelby is a patient who has been seeing a fellow associate at your practice. They
have attended today in pain and have been booked into your diary. When you open
their records, you notice there are no notes at all for the last five visits with your
colleague. The patient has presented today with pain from a root treated UL6 that was
completed several visits ago, and which is due to be crowned. There are no
radiographs available or any medical history updates. After taking routine
radiographs you notice the root treatment is 3mm short, poorly condensed, and one
canal has been missed. The tooth has a large periapical radiolucency.

1. What are the issues?

2. What could you do?
3. What would you do?
4. What are the implications of your action?

Answer/Guidance
The outcomes
• The candidate should explain how they would manage this situation and the potential
outcomes.
• Candidates who break this into short-term and long-term management and future
development should be highly commended.

Short-term
• Inform the patient of the findings - duty of candour.
• Explain the diagnosis of a failed RCT.
• Discuss the short-term treatment options - XLA versus antibiotics, with discussion of
justification.
• Discuss the long-term treatment options - Redo RCT versus XLA, with or without
replacement.
• Follow up with a phone call to patient, or review appointment.
• Ensure all notes are up to date.

Long-term
• Discuss this with the associate - Find out why there are no notes or radiographs.
• Discuss with practice manager or practice principal
• Bring it up at a team meeting - Raise issues of record-keeping, complaints, clinical
governance.
• Consider a significant event analysis
• Encourage team to review record-keeping and carry out audit.

Future development
• Update ePDP accordingly.
• Undertake targeted CPD in this area.
The candidate should also address the potential implications of ignoring the issues:
• A possible complaint from the patient.
• Breakdown in the relationship between patient and dentist.
• Loss of faith in the profession.
• NHS England and GDC involvement especially over failure to keep accurate
contemporaneous records.
DCT - Scenario #6

You are a DCT working in an Oral and Maxillofacial Surgery department at a busy
District General Hospital. A Jones is a patient who has attended for his biopsy results
for a red patch on his right buccal mucosa. The biopsy results indicate an area of mild
dysplasia with fungal involvement. They suggest antifungals and review. Mr Jones is
a longstanding smoker of 30 years, smoking 15/day. He also consumes around 30
units of alcohol a week.

Explain the diagnosis and potential management with Mr Jones.

Answer/Guidance
Facts:
• You are a DCT
• There is mild dysplasia with a fungal infection
• Review has been suggested
• Active smoker
• Drinking above the recommended limit

Introduce/Initiate
• Good morning, I am … and I'll be looking after you today. Before we begin can I confirm
your full name, medical history.
• Has everything been okay since the last appointment?

Explain the results to the patient:

• "The sample we took from the inside of your right cheek shows the presence of abnormal
cells"
• "Your mouth is made up of lots of cells and these range from healthy all the way to badly
damaged and cancerous. In between, we have a large spectrum where the cells are slightly
abnormal and you fall in this range"
• "This does not mean you have cancer. However, it means you are at an increased risk of
cancer"
• "The biopsy has also found the presence of a fungal infection that we need to look at
treating for you and seeing you for a review"
• "It's important we manage the risk factors to minimise the risk of problems. Normally, we do
not need to remove anymore tissue in this situation but we need to monitor you closely

Ensure that the patient has plenty of time to ask questions and you give them time and
space to process what you're saying.

Actor Questions:
• "Do I have cancer?"
• "Do I need to have more treatment?"
• "Why has this happened?"
• "Will it go away?"
• "What are the chances of it turning to cancer?"
• "How did this happen?"
• "What else can you do for me?"
• "What are the risks?"

Empathy:
• "I can understand that this may be a lot for you to take..."
• "Do you understand thus far?"
• "Is there anything I can clarify?"

Assurance and Planning:

"I would like to discuss some risk factors that we need to manage..."
• Discussion of smoking cessation and the impact of smoking. May signpost to stop smoking
services
• Discussion of the alcohol intake and the recommended levels

“…and planning for the future”

• Prescription of antifungals and then arranging a review
• Setting a recall period for this patient

Explanation and planning;

• Investigate the patient's knowledge prior to explaining the procedure
• "How much detail would you like me to go into, a lot or a little?"
• Use visual methods to convey information - hand gestures and check understanding by
'chunk and checking'
• "Do you have any questions thus far?"
• "Just so we are clear that you fully understand, could you please provide me a quick
summary of what was discussed today?

You are a DCT and can advise the patient that you may need to get a senior colleague to
help.

Closing the session:

• Summarise of the patients queries and plan going forward
• Asking if any further questions are necessary
• Explore what will happen if there are any unexpected outcomes from the agreement.
DCT - Scenario #7

You are a Core Dentist working in practice. Ashley attends today due to pain from her
upper right first molar. The pain is constant and throbbing in nature. Ashley is taking
regular pain relief to manage this. You assess the tooth clinically and then take a
radiograph. The radiograph demonstrates a separated instrument in the mesio-buccal
canal. You check the patient's notes and notice that your colleague started root canal
treatment on this tooth 2 weeks ago. Although the separated instrument is
documented, the patient states that she was told all the treatment had gone well.

1. What are the issues?

2. What could you do?
3. What would you do?
4. What are the implications of your action?

Answer/Guidance
The outcomes
• The candidate should explain how they would manage this situation and the potential
outcomes.
• Candidates who break this into short-term and long-term management and future
development should be highly commended.
• Always carry out an introduction and confirmation of the patient's details.

Short-term
• Inform the patient of the findings - duty of candour.
• Explain the presence of a separated instrument.
• Apologise that this may not have been discussed with the patient.
• Discuss the short-term treatment options - XLA versus access and dress, with discussion
of justification.
• Discuss the long-term treatment options - Continue RCT, refer to specialist versus XLA,
with or without replacement. Explain the risks of leaving the separated instrument.
• Follow up with a phone call to patient, or review appointment.
• Ensure all notes are up to date.

Long-term
• Discuss this with the colleague - Find out why the patient was not made aware of the
separated instrument.
• Discuss with practice manager or practice principal if necessary
• Bring it up at a team meeting - Raise issues of record-keeping, complaints, clinical
governance.
• Encourage team to review record-keeping and carry out audit.

Future development
• Update ePDP accordingly.
• Undertake targeted CPD in this area.
The candidate should also address the potential implications of ignoring the issues:
• A possible complaint from the patient.
• Breakdown in the relationship between patient and dentist.
• Loss of faith in the profession.
• NHS England and GDC involvement especially over failure to keep accurate
contemporaneous records.
DCT - Scenario #8

Gillian has attended for a routine check-up. On carrying out a soft tissue examination,
you remove her upper denture and find that her palate is bright red. She states she
has never had any symptoms. She is medically fit and well and has no allergies. Her
social history is unremarkable.

Discuss your findings with Gillian.

Answer/Guidance
Facts:
• She is asymptomatic
• There is a bright red appearance to her palate
• She wears a denture

Introduce Initiate
Before we carry on, can I just confirm you medical history? Do you smoke or drink any
alcohol?

Denture history needed

• "How long have you had your denture?"
• "How do you look after your denture?"
• "Do you keep your denture out at night?"

Explain the findings to the patient:

• "Based on what I have seen today Gillian, it appears as though you have a fungal infection
under your denture"
• "It is nothing to worry about particularly but it's something we should manage"
• "This usually happens when the denture isn't being cleaned as effectively as it should be or
it is being kept in whilst you're sleeping"

Ensure that the patient has plenty of time to ask questions and you give them time and
space to process what you're saying.

Actor Questions:
• "Do I have cancer?"
• "Do I need to have treatment?"
• "What does the treatment involve?"
• "Do I need a new denture?"
• "Will this infection spread elsewhere?"
• "How did this happen?"
• "Why has no one told me this before?"
• "What are the risks of leaving it as it is?"
Empathy:
• "I can understand that this may be a lot for you to take..
• "Do you understand thus far?"
• "Is there anything I can clarify?"

Assurance and Planning:

"I would like to discuss how we manage the infection for you..."
• Discussion of denture hygiene instructions for the patient
• Discussion of the potential need for antifungals

"…and planning for the future"

• May require a new denture in the long-term