The DDU’s Leo Briggs on new implant dentistry guidance…

National standards and best practice guidance on implant dentistry is due out later this year.The initiative by the Faculty of General Dental Practice UK (FGDP(UK)) is welcome because the DDU has seen a rise in the number of implant dentistry claims as the procedure has grown in popularity. Common reasons for claims to be settled include failed treatment, poor assessment and planning, poor fit and nerve damage.
As well as the frequency of claims, compensation in successful implant claims tends to be at the upper end of the scale. This is because of the significant ongoing cost of addressing failed implant treatment, including bone grafts in some cases, as well as the pain and suffering experienced by patients. In some cases settled by the DDU patients have received upwards of £200,000 in compensation.
Of course, implants can fail without negligence on the part of the dental professional – for example, osseointegration may not take place. However, it is important for dental professionals carrying out implant work to:

•  properly risk-assess the patient to ensure their suitability for implants

•  formulate a comprehensive written treatment plan, and

•  obtain valid consent, including warning the patient of potential complications such as nerve damage, post-operative pain, and failure to integrate.

As with any type of treatment, you can reduce the likelihood of a successful negligence claim by following available national guidance. This will include the FGDP’s Standards in Implant Dentistry when it is published in the second half of 2018, as well as existing guidance from the Association of Dental Implantology (ADI)¹.

You can take immediate steps to manage the risks associated with implant dentistry by considering this DDU advice:

•  Ensure implant training courses you attend have formal, structured educational aims and objectives, assessment and certification and meets the FGDP’s current Training Standards in Implant Dentistry² which is endorsed by the GDC. Keep a log of all your training to ensure you are up to date.

•  Obtain and record a detailed patient history and be alert to the complicating factors for implant treatment, such as untreated periodontal disease, immunosuppression and smoking.

•  Base your treatment plan on a thorough evaluation of the patient. The ADI’s implantology guidance includes a section on case selection and treatment planning.

•  Explain the benefits, risks and alternatives (including no treatment) to patients as part of the consent process and record the discussion in the notes. Be careful not to raise unrealistic expectations of what can be achieved and give patients a cooling-off period to consider their decision.

•  Provide a written fee estimate and be sure to warn patients of the cost implications if circumstances change.

•  Always use materials and systems which are supported by robust research. Don’t be swayed by marketing claims for new implant systems unless they have the research to back them up.

•  Explain to patients how to care for their new implant and stress the importance of rigorous oral hygiene and regular dental check-ups.

•  Ensure patients are carefully monitored for symptoms and signs, such as bone loss or inflammation at the implant site.

•  Consider a log of implant patients at your practice to ensure appropriate recall intervals are maintained and that enough time is allocated for appointments.

•  Offer referral to an appropriate specialist in complex cases if you lack the necessary experience or technical competence.

•  If you refer a patient, provide all relevant clinical information, including copies of radiographs, in line with GDC guidance. Ensure colleagues have the information they need, understand what is expected of them, and can easily raise any queries. Responsibility for the patient’s long-term care and the maintenance of implants should be agreed in advance. 

References

1 A Dentist’s Guide to Implantology, Association of Dental Implantology, 2012

http://www.adi.org.uk/profession/dentist_guide/a-dentists-guide-to-implantology.pdf

2 Training standards in implant dentistry 2016, FGDP, November 2016

https://www.fgdp.org.uk/sites/fgdp.org.uk/files/docs/in-practice/fgdp%20implant%20training%20standards%202016.pdf/

In Scotland, new ways to prevent poor oral health, cut oral health inequalities and address the needs of the ageing population have been outlined this week.
The Scottish Government’s new Oral Health Improvement Plan sets out a new preventive system of care to assess patients based on risk, and address the link between deprivation and ill-health. It will see the introduction of personalised care plans which focus on lifestyle choices, for example diet, alcohol and smoking, and how these impact on health.
Among its recommendations, a new scheme is proposed to meet the needs of the ageing population, enabling suitably skilled practitioners to treat people cared for in their own homes, and a Community Challenge Fund of up to £500,000 in 2018/19 will allow organisations to bid for funding to work in deprived communities and support people to practise better oral health. 
Health Secretary Shona Robison launched the plan following extensive consultation with health professionals and the public, and based on the latest clinical evidence.
Ms Robison said: 
“Record numbers of Scots have access to NHS dentists, and as a nation our oral health is improving. But poor oral health is entirely preventable and we need to ensure we do all we can to tackle it, and break the link between oral health and deprivation.
“The Oral Health Improvement Plan will support the profession to spend more time on what they do best – providing excellent care for the patients who need it most. We will continue to work closely with them as the recommendations are implemented. It will ensure people get the personalised care they need, when and where they need it.
“We will reach out beyond dental practices to support communities to find innovative ways to support people lead healthier lives – particularly in deprived areas or among older people.”
Professor Lorna Macpherson, Glasgow University Dental School, said:
“The Oral Health Improvement Plan – with its focus on prevention, community initiatives and ‎services for older people – is exactly the dental public health approach Scotland should be adopting.”
Valerie White, Chair of the Scottish Consultants in Dental Public Health Group, said:
“The publication of the Oral Health Action Plan for Scotland marks an important step in developing a preventive approach within NHS dental services. It also presents an opportunity  to maximise the contribution that dental teams can make to the general health and wellbeing of the population of Scotland.”

Viewers of  ITV’s afternoon show Loose Women were convinced singer Stacey Solomon’s veneers were falling out after hearing a strange rattling sound as she chatted on the programme, according to a recent article in The Sun. Read the full scintillating story here.

A new study has revealed that tooth brushing alone is not enough to protect children from tooth decay caused by snacking on sugary foods and drink. The study, published in the Journal of Public Health, looked at nearly 4,000 pre-school children and discovered that snacking habits are the behaviour most strongly associated with dental decay.
Researchers found under-fives who snack throughout the day, compared to eating just at meal times, are far more likely to have signs of dental decay and that relying on tooth brushing alone to prevent it is not enough.
The study authors also identified parental socioeconomic factors, such as education levels, as a more important factor on children’s dental decay than diet or oral hygiene.
Social scientists from the University of Edinburgh and the University of Glasgow used statistical models and survey data to predict dental decay by age 5. They used data collected on diet and oral hygiene from repeated observation of children from ages two to five.
They identified that children who brushed less than once per day, or not at all at age two, had twice the chance of having dental decay at age five compared with children who brushed their teeth twice per day or more often.
Lead researcher Dr Valeria Skafida, of the University of Edinburgh’s School of Social and Political and Sciences says restricting sugar intake is desirable both for broader nutritional reasons and for children’s dental health.
Dr Skafida said: “Even with targeted policies that specifically aim to reduce inequalities in children’s dental decay it remains an ongoing challenge to reduce social patterning in dental health outcomes.”
Study co-author, Dr Stephanie Chambers, of the MRC/CSO Social and Public Health Sciences Unit at University of Glasgow said: “Among children eating sweets or chocolate once a day or more, tooth brushing more often – once or twice a day or more – reduced the likelihood of decay compared with less frequent brushing.”
Dr Nigel Carter, Chief Executive of the Oral Health Foundation, commented: “This research supports messages about snacking being unhealthy; last week it was revealed that 170 children underwent operations in England every day to have rotten teeth removed and this research confirms that snacking on sugary foods and drinks is the key contributing factor.
“It is clear that tooth brushing with a fluoride toothpaste alone is not the magic wand that many people still believe it to be and preventing tooth decay also has to involve changing diet and lifestyle.
“Almost every single one of these operations, and the pain and suffering associated with them, could have been prevented with effective behaviour changes to help protect children’s oral health.
“Snacking throughout the day on sugary foods and drinks means that children’s teeth come under constant attack from acid and can quickly lead to severe problems.
“Children’s snacking should be limited to no more than two a day and unhealthy sugary snacks should be replaced with healthier foods such as fruit and vegetables.  The Change4Life Food Scanner mobile app is a great way of helping to achieve this. Even though a child’s first set of teeth is temporary, the oral health behaviour children learn early on they take into the rest of their lives, so it is vital that they get into good habits as early as possible.”
The research was supported by The British Academy, the Medical Research Council and the Chief Scientist Office of the Scottish Government Health Directorates.

The British Dental Association (BDA) has condemned what it calls ministerial indifference as new statistics show the child tooth decay crisis continues to grow, with 170 multiple extractions performed under general anaesthetic on under-18s in English hospitals every day.

Analysis of official data by the Local Government Association (LGA) shows that 42,911 extractions of multiple teeth in under-18s took place in England in 2016/17, costing the NHS £36.2 million – a 17% increase on the 36,833 procedures in 2012/13. These operations have cost the service £165 million since 2012.

Dentist leaders have lambasted what they call the short-sighted approach of Ministers in England towards tooth decay – which remains the number one reason for hospital admissions among children. They have argued that England is now receiving a second class service, and unlike Wales and Scotland has no dedicated national child oral health programme.

The government’s centrepiece policy Starting Well, aimed at improving oral health outcomes for ‘high risk’ children, has no new funding attached, and is operating in parts of just 13 local authorities in England. Activities in London are thought to cover just three wards in the Borough of Ealing.  

The BDA has insisted that national authorities must provide resources to enable all children in England to benefit. It has long advocated the Scottish programme Childsmile as a potential model for England, a national effort in nurseries and schools with both universal and targeted components that has already reduced the bill for dental treatment costs by £5 million a year. The BDA has also called for a proportion of the sugar levy to be earmarked for oral health initiatives.

BDA Chair Mick Armstrong said:

“These statistics are a badge of dishonour for health ministers, who have failed to confront a wholly preventable disease.

“Tooth decay is the number one reason for child hospital admissions, but communities across England have been left hamstrung without resources or leadership.

“This short-sightedness means just a few thousand children stand to benefit from policies that need to be reaching millions.”

This week the Huffington Post asked the British Society of Paediatric Dentistry (BSPD) and the Oral Health Foundation for tips for parents on how to teach kids about the importance of looking after their teeth, and how to make trips to the dentist less of a chore.

Nearly 43,000 children and teenagers in England and Wales had hospital operations to remove teeth last year, NHS figures show.

According to the Huffington Post, Councillor Izzi Seccombe, chairman of the Local Government Association’s (LGA) Community Wellbeing Board, said the figures show we have an oral health crisis” and called for money raised from the sugar tax to be invested in “innovative oral health education so that parents and children understand the impact of sugar on teeth and the importance of a good oral hygiene regime”.

“Untreated dental care remains one of the most prevalent diseases affecting children and young people’s ability to speak, eat, play and socialise,” she added.

“These figures also highlight how regular check-ups at a dentist can help prevent tooth decay and the need for hospital treatment.”

Here are the tips:

1. Take them on a few visits before it’s their turn

A clinical director of Revive Dental Care and trustee of the Oral Health Foundation, Dr Ben Atkins said: “Getting younger kids to join you or an older sibling on a trip to the dentist is a good way of getting them used to the sights and sounds of a dentist’s room and understand there is nothing to worry about.

“Start them early, take them to the dentist before their first teeth even start to appear,” he explained.

“As soon as they are born, at my practice, we welcome babies, because then by the time they need to jump on the chair they have visited two or three times and the hardest decision is which sticker to take home.”

2. Start them early

Claire Stevens, BSPD president, told the Huffington Post about the Dental Check by One campaign, introduced to raise parental awareness of the importance of taking young children to the dentist when their first teeth come through.

“If you can start your child going to the dentist early, then as they grow up, they are not anxious – it’s a positive experience,” she explained.

3. Act as a role model

“Much of children’s anxiety comes from their parents or carers,” explained Dr Atkins. “Try to ensure you do not pass this on to the kids by avoiding speaking about bad experiences.”

One way to do this is for parents to also book an appointment themselves directly ahead of their child’s, so they can see that there is nothing to be afraid of. However, if parents are very nervous then they should be advised to have their appointment on a different day, so nerves can be treated separately.

4. Explain exactly what happens

A child may not remember his/her last appointment.

Fear of the unknown can make the whole experience seem even more daunting.

“Speak through with them exactly what will happen during their dental visit so they know what to expect,” Dr Atkins said.

5. Ensure they are comforted and rewarded

“Let them take something to comfort them, a favourite toy or book or even music can help calm them,” said Dr Atkins.

“Also after the appointment, rewards do work too, but make sure it is not sweets, – a special trip after or a new book can motivate them.”

6. Give them the option of where to sit

“The big dentist’s chair (especially when a child is so little) can seem incredibly scary, so don’t worry if the first few times they don’t make it on there alone,” parents are advised.

“Letting them sit on your lap is a great way to comfort them,” said Dr Atkins. “I find giving the patient the option: ‘Where would you like to sit, on daddy’s knee or on the chair on your own?’

“This gives the child control, and visiting the dentist is all about control, if the child feels that they are in control then a visit to the dentist can feel like a breeze.”

7. Make the experience fun

Claire Stevens commented that as a child grows older, they can climb onto the chair themselves and try to enjoy the experience of the “big chair”.

“A lot of children enjoy the fun of the moving chair going up and down,” she said. “That’s how I get my patients to feel at home in my surgery.”

The BDA is advising dentists in England, Scotland and Wales, that new regulations came into force on 1 January 2018, which means dentists using x-ray generators must register with the Health and Safety Executive.

IRR17 will replace IRR99 and the BDA advises that most of the regulations remain unchanged.

However, IRR17 introduces a three-point risk-based system of regulatory control – “notification” (for low-level risk activities), “registration” (for the operation of radiation generators) and “consent” (for the highest risks).

General dental practitioners use x-ray generators, so they will be required to apply in the “register” category (Level 2).

The regulations in Northern Ireland are currently under consultation and we will update members on this when any changes are announced.

What you need to do
We have been advised that the legal person (who is responsible for enforcing the H&S at Work Act in the practice) will need to register with the Health and Safety Executive (HSE) during January 2018 and apply before 5 February 2018.

We understand there will be an administration charge of £25 to register.
You will need to apply even if you have previously notified HSE that you work with ionising radiation.
We have been assured that the online registration system will be a series of yes/no questions, and we understand this will be similar to the existing process.
We have been told to expect more detailed guidance notes for medicine and dentistry in May 2018.

The current legal requirement
The current legal requirement under IRR99 is for dental practices to appoint an RPA and this requirement remains the same under the IRR17, and that is the appointed person to go to for advice on how a practice updates their radiation protection file.

FAQs

We understand that:
For general dental practices, it is registration (rather than notify or consent), unless it refers to new premises and the HSE has not notified previously.
The fee is a one-off £25 payment.
The person responsible for the provision of dentistry as the practice has to register – it does not involve associates having to register, as they are deemed to be “employed” for these purposes
If the practice is part of a wider organisation, the overall owning body will be the one responsible for registering.
If the entity registering has more than one practice, it will still be £25 only – it is not a “per practice” fee.
Entities with more than one site will need to state how many sites are involved and the number of employees (including include self-employed dentists and all other staff).

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