Sir, the recent paper by Yusuf, Wright, and Robertson1 has stimulated me to write about our attempts to properly legitimise a fluoride varnish programme.

In the past, when fluoride varnish (FV) trained dental nurses applied Duraphat varnish, they were doing this under the legislation provided within the prescription only medicine (POM) order (1997)2 which permits the administration to human beings of a POM which is not for parenteral administration, without the need for a patient group direction (PGD) or prescription.

In order to improve governance we recently included the FV trained nurses in a PGD so they could more legitimately apply the Duraphat varnish (which is a prescription only medicine).

Writing the Duraphat Varnish PGD highlighted the following issues:

  • Application to patients suffering from asthma is contraindicated. Many training courses substitute the phrase '...hospitalised for severe asthma' although the summary of product characteristics (SPC)3 specifically mentions asthma as a contraindication. Some trainers advise using other varnish products to circumvent this. These products are not presently licensed for caries prevention and therefore cannot legally be substituted for Duraphat varnish

  • Insofar as the Duraphat varnish tube contains latex, and there is a possibility of allergic reactions to other constituents of the varnish, our varnish teams are carrying an emergency kit. This is also required as Resuscitation Council Guidelines state that an emergency kit should be available in all clinical situations. Staff must have appropriate training in the use of the emergency kit, especially recognition and treatment of anaphyaxis. With the number of applications nationwide it may be only a matter of time before a patient suffers a reaction

  • Nurses applying Duraphat varnish must be covered by indemnity as they are undertaking a clinical task

  • As Duraphat varnish contains alcohol, patients and parents must be advised of this, in case they have religious qualms about the procedure. We have included this in the consent procedure.

Digging deeper into the legality of extended duties undertaken by dental care professionals and the use of PGDs raises quite a few similar issues. Whilst therapists working in NHS Trusts are covered by properly written and audited PGDs, what is the situation with open access? Also, perusal of the SPCs for common drugs raises some interesting issues. For example, articaine with adrenaline is contraindicated in diabetics,4 whereas lidocaine with adrenaline is not,5 and this has to be reflected in their PGDs.

Nowadays it is not acceptable to run programmes or promulgate extended duties without due diligence in their design. Our recent experience with Duraphat varnish shows the potential pitfalls even in apparently simple programmes, or am I being too fussy?