Fluoride has become another political hot potato in recent times. Given the difficulties in Southampton it seems unlikely that any new water fluoridation schemes are likely to be started any time soon if at all. As dental professionals we recognise the value in the use of fluoride as a mechanism of reducing the risk of decay. We have been fortunate that we have been armed with other forms of fluoride such as high concentration fluoride toothpastes and fluoride varnish. These are both still considered prescription only medications and as such require prescription from an appropriate prescriber, which in most cases is a dentist. Dental hygienists and therapists can in certain circumstances issue these fluoride preparations operating under a patient group directive or specific directive. Dental nurses can only apply fluoride varnish under the prescription of a dentist provided they have had the appropriate training.
Increasingly general medical practitioners are facing pressure from patients and sometimes other professionals to prescribe fluoride based medications. There are lots of reasons this could happen, it may be because patients do not want to visit a dentist or possibly because they are facing some other form of access difficulty, for example, patients who are not eligible for NHS charge exemption may avoid visiting a dentist for an examination before being prescribed a high concentration fluoride; or it may be that patients are housebound or living in a care home where ‘home visiting’ dental provision is poor.
So you may wonder why this is generating such debate and whether a problem exists? At first glance it may be easy to assume that there is no problem with a GMP issuing a prescription for a high fluoride medication. Superficially some may even believe that because a dental nurse can be trained to apply fluoride varnish then surely a GMP should be allowed to prescribe it; some may even argue that the beneficial effects of fluoride outweigh the risks of prescribing errors. The issue comes down to who is permitted to prescribe prescription only medication and the circumstances in which such a prescription can be issued as well as the continuing care requirements.
At present ‘prescription only medications’ can only be prescribed by those people with prescribing rights, these are usually doctors and dentists. When making the decision to prescribe that doctor or dentist has to operate within their sphere of competence and be able to assess the clinical need of the patient to determine whether or not a particular medication is justified. In the case of high concentration fluoride this would typically involve an examination of the mouth, diagnostic tests and some baseline measures with an individual plan for ongoing monitoring and assessment. In fact some indemnity organisations websites suggest preference for a further mouth assessment before issuing repeat prescription for high concentration fluorides. With population based fluoride varnish schemes, that prescribing decision is usually taken by a dental public health specialist operating within their sphere of competence. This is different to making individual prescribing decisions in a clinical setting.
It is difficult to understand how GMPs would be able to undertake an examination of the mouth, and make baseline measurements before issuing a prescription. It would be very hard to argue that the issue of a prescription for fluoride could be considered a medical emergency and such an argument may fall flat. The professional regulators have a duty to protect the public and it’s for this reason they issue guidance to their registrants about exercising
their prescribing rights, understandably they take safety seriously. This is not an issue about ‘doctors’ practising
dentistry but is an issue about appropriate use of prescribing rights in relation to prescription only medication.
In my view, whilst the prescription of fluoride seems simple on the surface there are more complex underlying
prescribing issues that need to be considered. Whilst high concentration fluorides are prescription only medicines then any prescriptions need to be issued with the same diligence as any other medication. NHS England needs to address the underlying reasons that are driving patients to their GMPs and help improve the access to dentistry for these patient groups.