While cheaper dental treatment overseas continues to be a draw for some patients, we need to set parameters and pathways for dentists faced with situations that are often unfamiliar or challenging.
The emergence of dental tourism
Dental tourism has been an issue for a couple of decades. The first cases I saw of it were people going to Central and Eastern Europe to have treatment done, often implants because it was cheaper. The number of cases were small and quite often the treatment provided was limited.
The ‘Turkey teeth’ phenomenon has really taken off in the last five years. Social media has been an important driver of this. Turkey is not the only destination for the dental tourist but it has become the poster child for it.
Very recently I was invited to join a Facebook group dedicated to clinics in Turkey. Reading the constant posts and looking at the endless photos I have been saddened and shocked. Ear to ear super white, completely fake looking dentitions. There is a minimum 24 zirconium units or all on four or six implants.
Pre-treatment photos often show sound teeth the appearance of which could be dramatically improved with bleaching or simple orthodontic treatment. Some photos reveal significant primary perio and caries issues that require attention before advanced restorative treatment. The post ops all show the same full arch zirconia, often joined together, after the two-visit experience. They have “braved the shave”. It is really sad because people go abroad and say they did their research, but what is occurring online isn’t research, but the blind leading the blind.
The recent BDJ coverage of dental tourism identified the explosion of new clinics in Turkey and the almost non-existent regulation. Concerns were raised by ethical skilled colleagues in Turkey who recognised the destruction of their professional standards, as a result there is complete lack of ethical framework and professional accountability that we take as normal in the UK. Patients clearly have no understanding of this.
The BDA has already worked with the BBC highlighting the risks that come with ‘Turkey teeth’. 1000 dentists responded to our poll - and nearly every one of them are seeing the results. The complications that have arisen, and the hidden follow up costs.
A mystery shopper with good dentition was told not to go for crowns by any of the UK clinics the BBC contacted, no crowns would be advised by 50 clinics in the UK but overseas we saw hard sell for a full mouth zirconia refit. This was on a beautiful smile with an intact dentition. Posts online also reveal coercive tactics, pressure selling, changing costs and lack of proper consent.
I want to be clear patients have an absolute right to want dental cosmetic treatment and it can be positively life changing, but we are ethically required to advise them what is in their best interests and to not provide treatment if we feel it is detrimental. Just like every dentist I encounter these requests on an almost daily basis. When properly explained and discussed with the patient in the vast majority of cases a mutually agreeable and ethical way forward is found.
There are now many minimally invasive options to improve the aesthetics of a smile. In many of the dental tourism cases, if you want something and are prepared to pay for it, then that’s what you will get no matter how damaging it is to your oral health.
Sometimes their own dentist in the UK has even advised the patient against the treatment. If the patient still goes ahead, we cannot be expected to be responsible for cleaning up the fallout.
"I want to be clear patients have an absolute right to want dental cosmetic treatment and it can be positively life changing, but we are ethically required to advise them what is in their best interests and to not provide treatment if we feel it is detrimental."
Factors that cause dental tourism in Northern Ireland
There are three main reasons.
- Patients wanting to have a whiter than white smile that their local dentist will not do for them
- Lack of access to dental care
- Cost.
The cost of dental care in the UK is undoubtedly higher than in many foreign jurisdictions. This reflects the higher costs of actually running a dental practice in a highly regulated ethical environment. However, receiving 24 cheap crowns that you don’t need isn’t value in anyone’s book. Never mind the gross, irreversible, life shortening destruction of the dentition that goes with it.
Lack of access to particularly NHS dental care is a significant issue and maybe is the initial driver for some people. However, it is clear that in many cases the hard sell is then given to get the full restorative make over.
A recent case of a couple, already on holiday in Turkey, deciding to go for a check-up and a clean at a local clinic comes to mind. They both leave with preparation for 28 zirconia units. No temporaries fitted, common practice it appears, and then back a few days later, having been in sensitivity hell to get the one piece upper and lower zirconia blocks fitted. They have been attending their local dentist for over 30 years, on return home they couldn’t explain why they had it done.
Consultations in the UK
Dental tourism is a growing problem even in remote areas. Every few months we have people coming over, mainly from Turkey, to local hotels where they do consults. Then the patients fly out and have the treatment done abroad. These were advertised on Facebook and so on but have changed to individual messaging to avoid scrutiny.
This is a serious problem because legally you cannot do dentistry in a hotel, the Regulation and Quality Improvement Authority (RQIA) have written to hotels and told them they cannot let people do dental examinations there, but this does not seem to deter them. They need to start to take punitive action against any establishment that facilitates this practice of dentistry and again put that out in the public domain.
You also should not be doing dentistry in the UK if you are not GDC registered. Examining patients and providing treatment plans constitutes dentistry and the GDC need to be crystal clear on that. They also need to be clear what action they have taken to deal with this already and how they intend to combat in the future, Informing registered dentists in the UK or having a section on their website simply isn’t sufficient to protect the public. It requires wider publicity and concrete action against the offenders.
The Department of Health need to have very clear guidance on dentists’ obligations to registered patients, who self-refer for advanced restorative treatment, often without their own dentists being aware or indeed against their clear advice. Often these cases, due to the design and quality issues, present significantly increased treatment and maintenance dilemmas. The patients’ responsibility for their own decisions has to be paramount. There cannot be a greyness created that pushes the onus back on to the individual practitioner.
"The quality of care is commonly poor, with leaking margins, poor emergence profiles, the joining of multiple units and untreated primary perio, caries and endodontic issues."
Treatment abroad
My own experience in Northern Ireland is that when patients go abroad they have huge amounts of dentistry done, often to previously sound teeth. The quality of care is commonly poor, with leaking margins, poor emergence profiles, the joining of multiple units and untreated primary perio, caries and endodontic issues.
The patients are completely unaware of this, they think they look OK and therefore they must be. This has led to many difficult conversations. There is a clock ticking on all dental treatment from the time we do it. Things that control that timeline are the quality of the care, the quality of the patient’s own maintenance, and professional maintenance. When people have unnecessary treatment, they shorten the life of their natural teeth and they are condemned to a future of endless and more invasive dentistry.
The drawbacks of cosmetic dentistry
Natural teeth that have been looked after properly require less care than teeth that have had treatment done to them even when that is treatment is required. Dentists understand that fact and unsurprisingly you will not see a dentist who has “braved the shave” to get the zirconium smile on sound teeth. I strongly suspect that applies to all of our colleagues, even those providing that treatment abroad. A simple check to us all is, would I do this for a loved one?
Complications working with dentistry done abroad
Dentists do feel sympathetic to these patients, and they feel a level of professional obligation, but that has to be balanced with the patients’ own responsibilities. The challenges many of these patients present substantially increase the risks to a dentist of an extremely stressful complaint or having to deal with the GDC or litigation.
The old adage that a good deed rarely goes unpunished rings true. Clear conversations, excellent notes and records might ultimately protect the dentist from sanction but it won’t shield them from the colossal stress generated by any of these sequelae.
Pain
A lot of the tourism cases I see have been referred because the patient is in pain. This can be due to untreated primary disease, pre-existing endodontic issues, new endodontic issues, the failure of endodontic treatment provided, or a combination of all of the above. Temporomandibular disorders are also a common issue due in part to the massive and often very poorly managed occlusal disruption. A number of cases I have seen have developed neuropathic and persistent pain issues. So even if you remove the initial biological cause you don’t cure the pain, and these cases need specialist facial pain management, a service which is not available in my area of Northern Ireland.
The GDC say we have a professional obligation to get patients out of pain, stabilise their condition or offer a care pathway. It is important to deal with these individually. The massive loss of tooth structure and the equally enormous pulpal assault that results from the aggressive treatment often leads to poorly localised severe pulpal issues. This is particularly true in the otherwise sound teeth of young patients.
Identifying the source or indeed sources of pain can be enormously challenging, even for experienced practitioners with substantial postgraduate training. A pharmacological solution, even short term, is not appropriate in these cases and the appropriate operative approach may require multiple interventions to a highly compromised dentition, thus inevitably increasing the level of remaining tooth fragility and core fracture risks.
If you cannot get someone out of pain or stabilise them, you have an obligation to direct them on a pathway to someone who can, but often these pathways do not exist, especially within the NHS. The normal route of referral would be to the dental hospital, but our local dental hospital has told us they will not see patients who have complications from dentistry abroad.
How does a dentist fulfil their GDC obligations in such circumstances? Who is responsible for ensuring that appropriate accessible pathways exist? The Department of Health or the GDC? It certainly isn’t the responsibility of an individual practitioner.
These are commonly complicated and difficult cases to manage, beyond the scope of most general practitioners and certainly not feasible under the NHS. In the absence of appropriate pathways should practitioners be getting involved at any level?
"“Braving the shave” may be quick, but decide in haste and repent at leisure."
What can dentists do to mitigate these challenges?
We should try to persuade patients to concentrate on the health of their teeth and not completely on how they look. A patient’s desire to improve the aesthetics of their teeth is reasonable and common, and we should try and achieve this for our patients in the most minimally invasive way possible. Bleaching, composite bonding, orthodontics and so on give us so many options to fulfil that goal. “Braving the shave” may be quick, but decide in haste and repent at leisure. The short, medium and long term consequences of that approach can be catastrophic, irreversible, and sadly for some patients, life changing.
Also, we should publicly address the misconception that British dentists oppose dental tourism because of lost income on those treatments. The reality is that often a British dentist would advise against the treatment anyway. There are obviously good dentists in some of these countries popular for dental tourism, but patients cannot tell which are the good ones and which are not.
Our policy is that patients need to understand the risks of dental tourism, and they should be protected.
Why is it important that NI Council takes this issue forward on behalf of practitioners in Northern Ireland?
Practitioner obligations and safeguards are issues that lack clarity from the bodies that should be providing clarity, so NI Council has recently written a letter to the Chief Dental Officer about dental tourism.
Dental tourism affects all practitioners in hospitals, practices, and probably to a lesser extent in community services. Dentists at dental hospitals may not agree to see a patient who has had treatment abroad, or they may be put on a waiting list and never get off it. When patients are in pain they cannot wait four or five years.
The waters are muddied on this and there needs to be clarity both for practitioners and patients.
At the moment, the responsibility is being pushed too far onto the practitioner, without adequate guidance and support. The GDC and the Department of Health need to be very clear on our responsibilities, and the pathways available to practitioners.
What are the next steps you would like to see on the issue?
In addition to practical parameters for dentists, we should have a public campaign from the GDC and the Department of Health warning of the risks of going abroad for dentistry. Patients need to know it is dangerous not just because of the immediate risks, but because patients may get themselves into difficulty that they cannot get out of, if dentists in Northern Ireland are unable or unwilling to treat them.