Non-surgical cosmetic interventions are increasingly sought by patients, and whilst procedures such as injectable dermal fillers and neurotoxins were once mainly used to rejuvenate the maturing face, such interventions are now also in demand by younger clients seeking to modify their appearance to conform to a popular aesthetic norm.
It is quite common to find unregulated providers offering such services, along with a range of other cosmetic interventions such as lasers and light therapies, micro needling, chemical peels and hair restoration.
Promoting patient safety
Any procedure which pierces the skin poses a potential infection risk, and a range of other adverse reactions can occur, including bruising, haematoma, allergic reaction, anaphylactic shock, vascular occlusion, necrosis and blindness.
Despite the potential risks of significant harm, a recent IPSOS mori survey commissioned by the General Dental Council revealed a high level of public confidence in the provision of injectable cosmetic procedures by unregulated providers such as beauty therapists. The same survey revealed that 20% would complain to/ask for advice from the General Dental Council if something went wrong when receiving Botox injections for cosmetic reasons at a dental practice.
Following the government commissioned Keogh review of the regulation of cosmetic interventions in 2013, Health Education England (HEE) developed standards and a qualification framework to address practitioner failings, to improve public protection and to mitigate risks that might occur as the result of harmful aesthetic practice. This framework sets out recommendations on the level of training considered appropriate for delivery of a range of cosmetic procedures.
Joint Council for Cosmetic Practitioners (JCCP)
The HEE standards were transferred to the Joint Council for Cosmetic Practitioners (JCCP) by HEE in 2018. The JCCP is a not-for-profit UK charitable body charged with the responsibility of voluntary 'self-regulation' of the non-surgical aesthetic sector in the four UK countries.
The JCCP holds a register of accredited practitioners and approved education and training programmes. JCCP have a memorandum of understanding with the General Dental Council, a fitness to practice procedure and a cross reporting mechanism in the event that concerns are raised about a practitioner. Registration with the JCCP is voluntary.
Save Face holds a national register of accredited practitioners who provide non-surgical cosmetic treatments. The register is accredited by Professional Standards Authority (PSA) and is recognised by the government, the Department of Health, NHS England and Care Quality Commission.
Despite the efforts of these organisations to promote patient safety, non-registrant providers of cosmetic injectables remain relatively free from regulation and educational standards vary widely.
Cosmetic Practice Standards Authority (CPSA)
The CPSA is an expert group of specialists with patient/public representation, committed to safeguarding people who undergo non-surgical cosmetic treatment (such as fillers, skin rejuvenation, lasers and botulinum toxin injections) and hair restoration surgery.
Prescription only medicines (POM)
Dentists are the only member of the dental team who have prescribing rights, and might be asked to prescribe a POM that will be administered by someone else.
Anyone who prescribes a POM for administration to a patient by a third party must also be appropriately trained and competent in its use, and should carry out a full medical history and clinical assessment of the patient's suitability for intended the procedure before providing the prescription.
In England, a change in the law means that it is now a criminal offence to administer botulinum toxin or a subcutaneous, submucous or intradermal injection or filler for cosmetic reasons to a person under the age of 18.
Permission to go ahead with treatment cannot be provided by someone with parental responsibility for the child. It is also an offence to book appointments or make arrangements to provide treatment to anyone under the age of 18 in England.
Despite this change in England, a report by the Royal Society for Public Health (RSPH) recently highlighted inconsistencies in the way cosmetic practices are regulated across the four nations.
Legislation is expected to be passed in Wales and Scotland in the near future.
It is illegal to provide neurotoxins such as botulinum toxin and fillers to patients under 18. Cosmetic premises only need to register with the local authority, but there are no powers to refuse registration.
The Regulation and Quality Improvement Authority (RQIA) regulates clinics providing laser or intense pulsed light cosmetic treatments. However, those carrying out treatments such as botulinum toxin or dermal fillers are not required to register with RQIA. Cosmetic premises only need to register with the local authority, but there are no powers to refuse registration.
From 1 April 2017, all clinics offering non-surgical treatment were required to be registered with Healthcare Improvement Scotland (HIS). A government consultation in 2020 sought views on introducing a licensing regime for cosmetic treatments but no regulatory framework has yet been introduced.
A national licensing scheme is currently being implemented, but excludes some higher risk procedures such as botulinum toxins and dermal fillers.
Registrants are expected to only carry out a task or type of treatment if appropriately trained, competent, confident and indemnified. GDC Standard 7.2.1 states, "You must be sure that you have undertaken training which is appropriate for you and equips you with the appropriate knowledge and skills to perform a task safely."
Standards and guidance
Wherever a registrant practices, GDC guidance and standards apply in the usual way. In delivering non-surgical cosmetic interventions it is important to observe and comply with laws and guidance on advertising, consent, confidentiality, record keeping, data protection, infection prevention and disposal of clinical waste, complaints handling and the management of medical emergencies.
The Committee of Advertising Practice (CAP) rule (12.12) states, "Prescription-only medicines or prescription-only medical treatments may not be advertised to the public".
The Human Medicines Regulations (2012) prohibit the publishing of an "advertisement that is likely to lead to the use of a prescription only medicine", as laid out in Chapter 2, Advertising to the public, 284 (1).
An enforcement notice compiled by CAP (2020) draws upon policies written in both the Human Medicines Regulations 2012 (HMRs) and Rule 12.12 of the CAP Code which make very clear that the advertisement of Botulinum Toxin and its trademarks towards the public is prohibited and that enforcement action will be taken for any breaches of the guidelines on social media and failure to rectify them.
Registrants are advised to take care not to directly or indirectly promote botulinum toxin injections to UK consumers.
There are also specific rules around the advertising of prescription only medicines (POMs). For more information, read our article on POMs in the DDU journal.
Wherever a registrant practices, GDC guidance and standards apply in the usual way.
The All-Party Parliamentary Group (APPG) on beauty, aesthetics and wellbeing was established in May 2019 to champion the British beauty, aesthetics and wellbeing industry in parliament.
The APPG launched an inquiry into aesthetic non-surgical cosmetic treatments to investigate how standards for undertaking and advertising treatments should be improved to protect public safety, and made recommendations in a report published in June 2021.
This urges the government to consider the recommendations and to take action to improve the landscape surrounding aesthetic non-surgical cosmetic treatments for the benefit of the industry and public safety. In 2021, The JCCP also published a Ten Point Plan for Safer Regulation in the Aesthetic Sector.
We advise all members who carry out these procedures to keep abreast of this fast-changing situation.
Click here for more on how we can offer support and indemnity to dentists who are suitably trained.
B.Ch.d (Hons) MSc, PG Cert Medical Education, PG. Cert Medical Aesthetics, SFHEA.
Jo qualified from Leeds Dental Institute in 1991 and spent 16 years providing general dental services in the UK and Australia. She has worked in private and NHS practice as well as in the Community Dental Services. Jo is a senior fellow of the Higher Education Academy and has held several teaching posts in Yorkshire and more recently in Hampshire, where among other roles she worked as Associate Head (Education) at the University of Portsmouth Dental Academy. Jo joined the DDU as a telephone adviser in 2020 and began working as a dento-legal adviser in 2021.
See more by Jo-Anne Taylor