Sir, we read with interest the paper by Soheilipour et al. on the views of professionals on the NICE guidelines (CG64) relating to antibiotic prophylaxis for cardiac patients.1

We recently completed a survey of 162 dentists in the West Midlands about their views of NICE CG64.2 We agree that we should treat our patients on a one to one basis and take into account their wishes and needs, as these current NICE guidelines state clearly 'treatment and care should take into account patients' needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment'.3

However, we found that most of the dentists we surveyed were not happy to consider patients' preferences: 90% preferred not to administer antibiotic prophylaxis even if patients insisted that they should be prescribed. Fifty-two percent of the respondents felt that the guidelines from the American Heart Association would better serve their patients' interests.

Soheilipour et al. highlighted an important issue, that guidelines should be seen as recommendations rather than protocols. The majority of the dentists in our study were convinced that deviating from the guidelines may result in litigation and disciplinary proceedings. There appears to be a need for a fundamental debate about the rule of guidelines in determining clinical practice and this situation provides a good example of the dilemma faced by dentists in applying national guidelines to every day clinical practice.

Further we note there is a difference in emphasis given by the two main defence organisations regarding this issue. Dental Protection states that 'Dentists working within an NHS contract are required under the terms of their contract to observe the guidance of NICE when writing prescriptions. Clinicians working privately may not have contractual obligation to follow the guidance, but they would need a very strong justification for choosing not to do so'.4 The Dental Defence Union advises members to be aware of the current guidance, but if they judge it is in the patient's clinical interest not to follow advice contained in national guidelines, they will need to make a careful record of their reasons for doing so. They further advise that if a dentist is later called upon to justify a decision to prescribe or not prescribe a prophylactic antibiotic, he or she would have to be able to establish that they were working in accordance with a reasonable body of dental opinion.5 Thus we wish to draw attention to the question of what constitutes a reasonable body of dental opinion, when compliance appears to be done more out of fear of adverse personal consequences than anything else.