Demand for aesthetic dentistry is increasing, but it's important to be aware of the potential pitfalls of this form of treatment - especially since it might be provided on an elective basis rather than to treat a dental disease.
Dental professionals are forever trying to balance the demands and expectations of patients against continuing to provide treatment in those patients' best interests, as based on their clinical judgement. And we have assisted a number of DDU members who called our advice line saying they feel under pressure to carry out treatment in line with a patient's online search, or as shown on a social media platform.
Unfortunately it can be difficult to manage the expectations of a patient who has decided that composite edge bonding or a smile makeover is for them, against careful treatment planning and consideration of other treatment options that might be more appropriate.
In such circumstances, communication is key. Although elective aesthetic treatment can be transformative, patients must be able to understand the risks and complications and have sufficient time to fully consider their options before proceeding with treatment.
A member called our dento-legal helpline for advice about a tooth whitening request from a 17-year old patient. The member was aware that under the law patients must be 18 or over, but the patient involved had a discoloured non-vital front tooth and the member was considering agreeing to carry out non-vital bleaching as a conservative treatment option.
The DDU's dento-legal adviser empathised with the member and advised that although the GDC makes an exception for whitening the teeth of under 18s when used "wholly for the purpose of treating or preventing disease", the DDU cannot currently see any circumstance where this might be the case.
Our advice is that there are no exceptions to the rule, and all patients must be aged 18 years or over. The member decided to discuss the treatment plan further with the patient and to advise reconsideration of this form of treatment when the patient was 18.
Limited treatment orthodontics
Changes in the way dental care has been made available has widened and diversified many forms of remote treatment, including orthodontics. Although patients may associate these innovations with lower costs and greater ease of access, they may be unaware of the risks involved.
The GDC is aware of the increase in patients taking a DIY approach to aesthetic improvements in their smile and have updated advice available on their website, which itself was welcomed by the British Orthodontic Society.
The GDC has alerted patients to the necessity of being able to speak to the dentist offering this form of treatment, so they can be sure the treatment is appropriate for them and to enable the patient to give their consent.
Suitability and training
Patients might ask you for a report on their dental fitness and confirmation of their suitability for remote orthodontic treatment. If you are not aware of a named registrant offering this service, our advice would be to decline on the basis you wouldn't know who would be providing the patient's treatment.
As its recent statement says, the GDC expects that "Patients must know the full name of the dental professional responsible for their treatment and be able to make direct contact with that person."
We would also advise not to involve yourself in treatment being carried out in circumstances likely to be contrary to the GDC's position, which states that "In line with current authoritative clinical guidance, and orthodontic training, clinical judgements about the suitability of a proposed course of orthodontic treatment must be based on a full assessment of the patient's oral health. At present, there is no effective substitute for a physical, clinical examination as the foundation for that assessment."
Depending on their level of training, a general dental practitioner may not have sufficient training or knowledge to involve themselves in the orthodontic treatment of the patient and having identified treatment need it would be more appropriate to offer a referral to a suitably qualified and trusted colleague for advice and an opinion.
In the circumstances that a member is satisfied that the patient will be treated by a named appropriately trained and competent clinician, it may be legitimate for the dentist to charge for their time in providing the exam and/or report.
A DDU member received a complaint from a patient who had undergone limited orthodontic treatment. The patient was unhappy with the positioning of one tooth despite the member's very best efforts over an extended treatment time, involving additional costs to the member in the provision of extra aligners and the associated increased surgery time.
This can be a frustrating situation, especially because our member felt that the patient had been fully informed of the limitations of this form of treatment at the outset.
The member spoke to a DDU dento-legal adviser, and they discussed the various ways to respond. These included an explanation as to why the treatment provided had been appropriate and an apology for any misunderstanding, and that a gesture of goodwill could be offered if the member felt this to be appropriate - although this is not mandatory.
Sadly this situation is not unusual. Before agreeing to provide limited treatment orthodontics, it's often worth spending time setting out a realistic outcome and common complications with the patient, in order to manage their expectations.
This can be helpful in avoiding a complaint from a patient when the treatment has been completed. Detailed records of conversations and discussions as relevant to the individual case can be more helpful than generic information forms which patients may sign without fully understanding their content.
In a previous journal article, we pointed out that the GDC acknowledges that advertising and marketing material can be helpful to patients when making informed choices about their dental care - but that overtly or potentially misleading information could attract negative attention from patients and increase the risk of complaints.
We recommend reading the article in full, but some useful links from it include:
In another issue, we also advised on unlawful advertising of botulinum toxin injections on social media, after the ASA stepped up its enforcement around adverts for prescription only medicines - including botulinum toxin in early 2020 and issued a warning aimed at tackling the unlawful advertising of botulinum toxin injections on social media.
- ASA requirements state that all advertisements must be legal, decent, honest and truthful. They must not mislead, harm or offend.
- The ASA has the power to remove any advert that they feel is unsuitable and refer persistent offenders who advertise inappropriately to other bodies, such as Trading Standards.
- The ASA's guidance warns that the organisation will now be taking "targeted enforcement action using monitoring technology to automatically find problem posts for removal."
Dr Sarah Ide
Sarah Ide is one of the dento-legal advisers at the DDU. She qualified in 1992 from Guys and worked there as a house officer before entering general practice as a VT. Sarah worked in independent and private general practice for 25 years and completed an MSc in Aesthetic dentistry at King's. She's been working at the DDU for over six years, initially combining this work with general practice, and now working here full time.
See more by Dr Sarah Ide