Mind the Gap!

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. 


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


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


New oral health improvement plan launched in Scotland

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.”

TV viewers convinced celeb’s veneers are falling out

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.

New study flags up behaviours most strongly associated with tooth decay

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.

Child decay stats ‘badge of dishonour’ for ministers, says BDA

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.”

‘Go to dentist and get fined £100’ reports BBC

In a story also covered by the broadsheet newspapers, the BBC reports that over 40,000 dental patients a year in England – many of them vulnerable – are getting fines of £100 from an automated system that erroneously tells them they are not entitled to free treatment. Click here for the full story. 

Initiative to tackle problems with A&E dental attendance launched

A new initiative from the Oral Health Foundation to assess and tackle problems with the way that dental emergencies are handled by A&E departments in the United Kingdom held its first meeting last week (Monday 9 October) at the Royal College of Emergency Medicine.

The first meeting of the new Dental Review of Emergency Attendances Multi Stakeholder (D.R.E.A.M.S) Group aimed to explore the issue of patients with dental problems who go to hospital emergency departments rather than dental practices.

It is estimated that patients that seek free dental care at hospitals could be costing around £18 million each year and this remains an issue that has been vastly underestimated by the NHS.1

The meeting marked the beginning of an unprecedented initiative aiming to improve the care of patients with dental emergencies across the UK.

The Chair of the group, Dr Chet Trivedy, Consultant in Emergency Medicine and Trustee of the Oral Health Foundation, explained the need for the D.R.E.A.M.S Group and what he hopes it can achieve.

Dr Trivedy said: “Thousands of people go to A&E each year with a dental problem, however, the issue is that many doctors aren’t trained in dentistry and are likely to have limited experience and resources to help these patients.

“Many dental issues, such as having a tooth knocked out, bleeding from an extraction or even toothache, would be much better managed by a dentist or dental specialist but this is not always available 24/7 so we need to support our medical colleagues in A&E to manage some time critical emergencies.

“The D.R.E.A.M.S Group enables a broad range of stakeholders to come together to see how we can collectively tackle this problem and find realistic solutions which will hopefully improve the care and management of these situations.”

Dr Nigel Carter OBE, CEO of the Oral Health Foundation, also spoke of the importance of the D.R.E.A.M.S Group.

Dr Carter said: “It’s crucial that our outcomes help lead to effective interventions which ensure patients get the treatment they desperately need in an appropriate setting and from appropriately skilled staff.

“We hope to not only find solutions suitable for the NHS and their A&E departments but also find ways to better educate the public about the best action to take when they have a dental emergency.”

The D.R.E.A.M.S Group meeting took place on the 50th anniversary of the inception of emergency medicine, preceding a host of events and activities around the UK to mark the occasion.

Dr Trivedy added: “I feel very privileged, as an Emergency Medicine consultant and dentist, to be here at the Royal College of Emergency Medicine headquarters in London and to be holding the first D.R.E.A.M.S Group meeting during this week of celebration.

“This is an extremely complex issue, which is why it is so important to have so many different stakeholders present during these meetings.”

Representatives taking part in the first meeting of D.R.E.A.M.S Group included the Oral Health Foundation, Public Health England, Department of Health, Royal College of Emergency Medicine, British Dental Association, NHS England and the General Dental Council.

“Every group has an opinion, we want to extend the reach of the campaign beyond the dental and medical professions because that will allow us to gain more perspectives on such an emotive topic,” said Dr Trivedy. 

“I would like to say a huge thank you to all the excellent groups and individuals who were present today because it allows us to bring together our expertise and make a huge step towards building cost-effective and sustainable frameworks to manage dental emergencies in the future.”

Other members who took part in the session included the Faculty of Dental Surgery, British Society of Paediatric Dentistry, Royal College of Nursing, British Association of Dental Nurses and NHS Islington CCG.

To find more information about the D.R.E.A.M.S Group and their aims or to get involved in the group, contact Kerry Geldart, Director of Operations at the Oral Health Foundation on 01788 539 781 or email kerry@dentalhealth.org.

ORE should open doors, not merely lead to closed ones


BARRY COCKCROFT says the system needs to be encouraging rather than hindering dental professionals from overseas…

WHEN I was working in government circles I became aware of an often used phrase: “individual cases are not a good basis for policy change”. I came to understand that this was true. As an obviousl example, the fact that, very occasionally, people became trapped in a car by their seatbelt does not mean that compulsory seat-belt wearing would not save thousands of lives and many more serious injuries.

There are, though, occasions when individual cases, clearly, cogently explained, can indicate a significant need for legislative, system or policy change.

I recently had the pleasure of listening to a young dentist who, for personal reasons that are not relevant to the topic, had come to the UK from Egypt and wished to continue her career here.

As the British Dental Association recently pointed out, there is now a widespread difficulty in recruiting dentists to work in general practice and you would think that there would be an enthusiasm to engage and support clinicians who have come from the EU or beyond to contribute to our healthcare, develop their own careers and be able to support themselves and their families.

The NHS has a statutory duty to commission sufficient dental services to meet the needs of those seeking care. This duty is in essence delegated to those who hold NHS contracts, who might reasonably expect some support from the appropriate public bodies, in this case Health Education England and NHS England.

Although the outcome for this particular dentist was ultimately very positive and inspiring in the way she demonstrated personal commitment and determination to achieve her goals, the way the system had placed hurdles in her way was deeply disturbing.

All dentists coming into the UK from outside the EU have first to pass the Overseas Registration Examination (ORE) in order to gain registration. This young dentist, with appropriate training and experience, was able to pass the ORE swiftly. You might think that that would open doors – but the initial story was one of doors being slammed in her face.

In order to work in the NHS she had to acquire a performer list number, which, in her situation, required her to undertake a period of supervised practice in an approved practice by an approved mentor. There are people approved as mentors but getting funding and approval arranged is unacceptably variable between regions and can be very difficult. After much searching in her case, it initially proved impossible.

Undeterred (though I suspect more downhearted than she is now prepared to admit) and showing amazing persistence this dentist decided to take up a post as a trainee dental nurse in order to stay close to her chosen profession and to be available if an opportunity arose.

Perhaps fortuitously, the practice where she started working as a dental nurse had a dentist who was suitable to be a mentor. I was surprised to hear that mentors charge the dentist in order to provide them with this help and that the fees charged are different for EU graduates and those who have taken the ORE route. Unfortunately most dentists in the latter situation may for obvious reasons find it difficult to raise the funds to pay for a mentoring service.

Although this is not just about funding, when one looks at the cost of a traditional dental education – from entering dental school to completing Foundation Training – it is hard to understand why HEE and NHS England are not more supportive of ‘outsiders’.

Having successfully completed her mentorship the dentist from Egypt now has a performer list number, has moved practices and is working full time, providing services to patients, developing herself as a clinician and supporting herself.

When I was Chief Dental Officer we worked with the GDC in order to tackle the unacceptable waiting lists for taking the ORE as there were several hundred dentists in this situation, qualified (some highly qualified) and capable of contributing to healthcare in this country but unable to do so because of administrative issues.

This, though, is not only a service capacity issue! As a civilised society we should be supporting clinicians in this situation, not putting unnecessary barriers in their way.

Passing the ORE should open doors to the future – not merely open a corridor that leads to further closed doors! 


New support materials for enhanced CPD available

The General Dental Council (GDC) has published a series of guidance documents and templates for dental professionals, ahead of the launch of enhanced continued professional development (ECPD) next year.

ECPD is the first step in a longer-term reform of CPD to move to a system based on quality of CPD activity rather than quantity. ECPD will empower professionals to embark on life-long learning, which can be embedded into their practice. Patients will also benefit from being treated by dental professionals with up to date knowledge and skills. The chang es include the introduction of a personal development plan (PDP) for each member of the dental team. This is a tool that professionals can use to support their CPD and aid further development, whilst also recording the details of CPD activity with corresponding learning outcomes. There are also changes to the number of hours that dental professionals must complete during a cycle and a new requirement to make an annual declaration of the number of CPD hours completed each year. The changes will take place in January 2018 for dentists and in August 2018 for dental care professionals.

The new support materials, which are available on the GDC website include:

  • ECPD Guidance for Professionals – this publication outlines the new ECPD requirements and aims to answer any questions dental professionals may have about ECPD.
  • ECPD Guidance for CPD Providers – this publication outlines the new requirements and any changes required by providers to ensure the standards for CPD to be met.
  • PDP template – a blank PDP template is available for dental professionals to use, if they wish.
  • PDP examples – there are seven PDP examples available, featuring different members of the dental team, to help ensure all dental professionals understand what content is required for their PDP.
  • Activity log template – a blank activity log template is available for dental professionals to use, if they wish.
  • Activity log examples – there are three activity log examples available, which aim to ensure professionals understand what is required when recording their CPD. Please note the examples do not demonstrate a full activity log, but give examples of how professionals may record their activity and reflection.

Matthew Hill, Executive Director, Strategy, at the General Dental Council, said: “This is the first step towards a much more meaningful approach to professional development, one that gives dentists and DCPs the responsibility they have told us they want. How far we go on this journey will depend on how well the professions seize the opportunity on offer. I encourage the whole profession to embrace this first step and work with us to take the next ones.”

There is also an Enhanced CPD transition tool available online, which is designed to help dental professionals who are mid-CPD cycle to understand the requirements.

‘Antibiotic Apocalypse’ – front line staff need government to step up, says BDA

The British Dental Association (BDA) has responded to warnings from the Chief Medical Officer, Professor Sally Davies, of a post-antibiotic apocalypse, calling on government to step in and help front line NHS staff deliver an effective response.  

The Association has led the debate on antimicrobial resistance in dentistry in the UK, engaging with the CMO and other leaders across the human and animal health professions, and has expressed concern that huge patient pressures and the lack of funded emergency treatment time will stifle crucial progress. 

Dentists in England and Wales have faced significant challenges engaging with this agenda owing to contracts focused exclusively on hitting tough activity measures.

BDA Health and Science Chair Russ Ladwa said:

“This is the century’s defining health challenge, but health professionals are still bearing brunt of patient pressure, lacking both adequate time and resources. Time-consuming treatment will struggle to compete with prescribing until government recognises and responds to the challenges front line staff are facing.”