Sir, the risk of oro-antral communication (OAC) arising from maxillary extraction in dental practice is sufficiently remote that neither the symptoms nor signs of fluid and air passing from mouth to nose can be found in post-operative instructions routinely issued in either primary or secondary NHS dental care. However, the risk is not so vanishingly small that patients with OAC or epithelialisation leading to fistula formation (OAF) continue to be referred to dental school oral surgery departments in significant numbers.1

Notwithstanding the recognised OAC risks of advanced age, aberrant anatomy and antral proximity of roots, following lockdown, the transitional return to safe practice carries additional risks for patients of: poor oral hygiene, chronic sinusitis and respiratory-tract infections, coupled with operator risks of skill-fade acquired from inactivity during COVID-19 closure. Undoubtedly, these increase the overall risk for OAC and OAF.

In the absence of post-operative OAC information, a telephone survey requesting post-operative advice from the 18 UK dental school oral surgery departments resulted in:

  • Ten departments categorically refusing to give telephone advice (one refusal took 24 hours)

  • From such refusals, one department transferred the call to an NHS medical advice line that confidently but incorrectly stated there was no communication risk from extraction

  • Eight departments provided advice: four dental nurses (one male) and four female dentists delivered advice that was accurately supportive and reassured: emergency attendance if necessary

  • In contrast to ten cold refusals, the sensitive, warm and empathic responses from those dental nurses and dentists taking their time (an average of eight minutes to respond) were incredibly touching, especially given their ages, range of experiences, qualifications and work pressure

  • For either refusal or advice, there was no variation across the UK nations or London (with its three dental schools).

While both the significance and seriousness of OAC could engage the materiality in Montgomery, consent according to Mulholland is not an abstract exercise; it is formed within a clinical context.2 However, if post-operative instructions fail to document the signs and symptoms of OAC, it may be difficult to prove consent (while actually obtained) was then effectively maintained. From these findings, during the transitional return to NHS dental practice, reliance on communication into the safety net of secondary care cannot be uniformly assured across the UK.

Regrettably, even with such communication failure, there is no regulatory disinclination from the GDC to draw adverse conclusions into the clinical conduct causing communication.

Including an effective means of communication for patients with unambiguous signs and symptoms of OAC in post-operative instructions may reduce complications for the patient and remove the risk of litigation for the practitioner.