How to avoid problems in implant placement and/or restoration

How to avoid problems in implant placement and/or restoration

Dental implants are the gold standard to replace missing teeth. For many patients, they provide a more comfortable and well-fitting alternative to dentures and bridgework. Their durability also means they provide a secure anchor for restorations and/or dentures for many years.

The success rate is high, but because implant dentistry can take many months, and involve several invasive procedures as well as high costs for the patient, dentists are at risk of litigation if things go wrong. Not all patients are suitable candidates, and a small percentage of dental implants do fail.

The most common pitfalls that lead to complaints and claims are related to consent, planning and treatment execution. This article looks at how such problems can be avoided.

Gain appropriate training

To perform implant dentistry safely and ethically, dentists must complete further training. Different training routes are available, allowing dentists to provide implant treatment within general practice or to specialise in implant surgery or prosthodontics.

The College of General Dentistry (CGDent) guidance, Training standards in implant dentistry, explains the required training and the standards that must be met by training courses. Note that this guidance is also a reference point for the General Dental Council (GDC) when considering patient complaints about the competence of dentists providing implant treatment.

Following completion of an appropriate training course, dentists are expected to be mentored by an experienced clinician. The complementary Mentoring in Implant Dentistry: Good Practice Guidelines explains the requirements.

Follow GDC standards

Dentists performing implant treatment should follow the GDC’s Standards for the Dental Team, with particular attention to:

Working ‘within their knowledge, skills, professional competence and skills’.

  • Any practitioner without the appropriate training should refer patients requiring implant dentistry to somebody who is trained and competent; this may be a specialist in oral surgery or restorative or prosthodontic treatment.

Communicating effectively with patients and obtaining valid consent.

  • The patient should receive a treatment plan, with sufficient information about the treatment options, benefits, risks, likely prognosis, and costs, in a format that they can understand.
  • Dentists must seek consent for every stage of the implant process, so it is important that they continue to discuss with the patient the progress of ongoing treatment and record this meticulously in the notes.
  • Dentists should also spend time with the patient to ensure they understand and agree to any post-procedure advice (for example, diet, analgesics, and good oral hygiene), since non-adherence to the advice could increase the risk of complications or dissatisfaction.

Work with colleagues in a way that serves the interests of patients.

  • Implant dentistry often involves a multidisciplinary team, so communication between colleagues is fundamental to success. All the involved team members may be liable to some extent if a claim is made.
  • If different practitioners perform the surgical and prosthodontic aspects of implant treatment, they must agree on the treatment plan and document who is responsible for each aspect of treatment.

Keep complete and accurate patient records.

  • Diligent record keeping is essential and helps if problems occur that subsequently lead to complaints or litigation. Maintain a record of all discussions with patients and colleagues regarding dental implant treatment, as well as any imaging, models, and documentation. It is highly recommended to have photographic records as well.

Perform a thorough patient assessment

The initial patient assessment is crucial to identify and record conditions that could complicate treatment. Successful treatment also depends on the patient’s bone to allow osseointegration of the implant which cannot be predicted, thus discussions must be recorded in the notes as well as ensuring the patient has copies of the consent process and all information related to treatment. Any failure to do so could be a cause for litigation if complications occur.

Assessment should include:

  • Relevant health conditions and patient factors that are associated with increased risk of implant failure, including: smoking, diabetes, untreated caries or periodontitis, bruxism, age, chemotherapy or radiotherapy, and therapy with bisphosphonates or corticosteroids. These cases require caution and alternatives to dental implants may be preferable.
  • Bone and soft-tissue condition: deficiencies may need to be addressed before implant surgery. Bone structure determines many aspects of treatment, from selection of the implant design to the surgical approach, type of reconstruction, the need for bone grafts, and the healing time between stages of treatment.
  • Retained roots at the implant site: these usually need to be removed before implant surgery. More complex cases may require invasive surgery under sedation or general anaesthetic, and potential complications include injury to the adjacent teeth, bone or nerves. This makes implant treatment a longer and more complex process, so it is essential to discuss the risks and benefits with the patient.
  • Testing for implant allergy or sensitivity.

Agree a plan for treatment

To maximise the chance of long-term treatment success, and reduce the risk of complaints, dentists should prepare a comprehensive treatment plan based on the patient assessment and treatment goals. This should be in writing and agreed with the patient and any other practitioners involved in their treatment.

The plan should include any pre-implant treatments (such as bone augmentation or treatment of existing oral health conditions), all stages of implant surgery and prosthetic placement, healing times, the design and positioning of the implant and selected prosthesis, and post-procedure care.

Use of imaging and wax-ups can assist the treatment planning and help the patient to understand how the prosthesis will look, giving them a chance to discuss any concerns before treatment starts.

Know how to manage complications

Most dental implants are successful, and many complications are minor and easily treated. For example, patients should be advised how to treat any minor swelling, bruising, pain, and bleeding that may occur in the first few days after treatment.

However, dentists who provide implant treatment must also be appropriately trained to manage less common, but potentially serious complications. These include implant site infection, peri-implantitis, failure of osseointegration, mechanical or technical failures, nerve damage, and sinusitis.

At Dental Defence Society, we offer indemnity packages covering implant dentistry and 24/7 dento-legal support. If you provide dental implant treatments, please contact us to discuss your needs.

How to avoid the dento-legal dangers of short-term orthodontics

How to avoid the dento-legal dangers of short-term orthodontics

Dental patients wanting to straighten their teeth are increasingly choosing short-term orthodontics (STO) to improve their smile. The appeal is that STO usually means using braces or clear aligners to straighten the front 6 or 8 teeth within 4–9 months, in a process considerably less invasive and time-consuming than conventional orthodontic treatment.  

Suitably trained general dental practitioners (GDPs) can provide STO but they need to know the limitations and risks involved. Unfortunately, litigation resulting from STO procedures has increased in recent years. However, GDPs can reduce the risks by staying within the scope of their skills and experience, managing patient expectations, and practising in accordance with guidance from the General Dental Council (GDC) 

Short-term orthodontics: not a ‘quick fix’ for all 

STO can produce satisfying results for certain patients who wish only to align their front teeth, but it is necessary to consider the pros and cons of the different options available, enabling patients to make an informed choice. A wide variety of STO systems are available to suit a range of budgets and treatment scenarios, so dentists need to understand their patients’ wishes and be able to advise them on the most suitable treatments to meet their individual needs.  

Full assessment of a patient’s oral health and dental structures is a fundamental part of treatment planning for STO. Not all issues can be fixed by STO and for some patients, especially those with complex problems, conventional orthodontic treatment will be a more appropriate solution in the long term. Used inappropriately, STO risks creating worse problems that need further costly and time-consuming treatment.  

The importance of managing patient expectations and enabling informed consent 

Patient demand for cosmetic STO may sometimes be based on unrealistic expectations, driven by societal pressures, social media hype and misleading advertising. This makes it especially important for GDPs to communicate directly and effectively with patients to fully engage them, manage their expectations and obtain valid informed consent before and throughout treatment.  

The GDC sets out the full requirements for obtaining valid informed consent, key points including: 

  • Obtain valid consent before starting treatment, explaining all the relevant options and the possible costs.  
  • Although a signature is important, it is the discussions with the patient that determine whether consent is valid. 
  • Make sure that patients (or their representatives) understand the decisions they are being asked to make, and document this. Provide sufficient information in a format that they can understand and consider whether the patient is able to make decisions about their care.  
  • Make sure that the patient’s consent remains valid at each stage of investigation or treatment. The consent process should be part of ongoing communication with the patient. Document specific consent for the procedure during each appointment and for any changes to the planned procedure.  
  • Consent can be withdrawn at any time; in this case, ensure patients understand the risks or consequences and that they are responsible for any resulting problems. 

GDPs providing STO need to make sure that patients understand the limitations of treatment and accept their own role in the treatment contract to gain the best outcomes and avoid damage to their dentition; for example, the need for good oral hygiene, regular attendance at appointments, and requirement for life-long use of retainers to prevent relapse. 

Patients should be aware that:  

  • Teeth will not move rapidly, due to the need for remodelling of supporting tissues. The speed depends on biological factors and may vary from the manufacturer’s claims.  
  • Orthodontic treatment is associated with a risk of adverse effects and complications, including periodontal damage, pain, root resorption, tooth devitalization, temporomandibular disorder, caries, speech problems and enamel damage.  
  • Underlying oral health conditions may impact on the overall success of alignment. 

At the American Association of Orthodontists 2017 Annual Session, Dr Laurance Jerrold, a specialist in dental risk-management education, presented template forms containing a comprehensive list of considerations for obtaining informed consent; although developed for a US audience, UK GDPs may also find this a useful resource for further reading. 

Dento-legal concerns with direct-to-consumer short-term orthodontics 

As patient demand has grown, some companies have started to provide direct-to-consumer treatments, so-called ‘DIY orthodontics’. Patients often consider using such services because they offer attractive prices without the need for multiple dental appointments.  

Dentists may be asked to confirm suitability of a patient for direct-to-consumer treatment, sometimes remotely. However, to reduce the risk of dento-legal issues, it is wise for dentists to avoid commenting on the specific STO appliance; instead, they could explain to the patient why it is important to discuss the treatment options and potential risks with a qualified, registered dental practitioner. 

Dentists have a responsibility to adhere to the GDC’s guidance and Standards for the Dental Team. In May 2021, the GDC issued an updated statement on direct-to-consumer orthodontics. Crucially, this makes it clear that: 

  • Such services can only be performed by GDC-registered dentists and dental care professionals.  
  • Full assessment of the patient’s oral health is needed to form clinical judgements about any proposed orthodontic treatments. “At present, there is no effective substitute for a physical, clinical examination as the foundation for that assessment.”  
  • The responsibility for a clinical judgement lies with the prescribing dentist. 

The GDC also provides the following resources: 

Indemnify against risk in STO 

The GDC states: “Dental professionals also need to ensure that they are appropriately indemnified. Those who do not comply with the Standards for the Dental Team, indemnity requirements and authoritative clinical guidance put patient safety, and their registration, at risk.”  

GDPs can minimise the risk of problems if they perform STO within the scope of their own expertise and obtain valid informed consent, discussing with the patient all the treatment options, including referral to an orthodontist, as well as the risks, limitations and a realistic timeframe.  

As always, treating dentists should keep detailed patient records and note the reasons for any deviation from established practice and guidance. In the event of litigation, this documentation can provide evidence of informed consent and appropriate management of treatment. 

Please contact Dental Defence Society for expert advice if you face a complaint or claim or if you have any questions about indemnity requirements for STO. 

Avoiding the pitfalls in composite bonding

Avoiding the pitfalls in composite bonding

Composite bonding can be a highly effective way to perform minor cosmetic adjustments such as repairing, reshaping or recolouring teeth. Thin layers of adhesive resin material are attached to the tooth and sculpted to achieve the desired shape and appearance.

The technique is popular with patients as it is a less invasive, more affordable alternative to veneers that can provide a natural-looking improvement to the appearance of their smile. The fact that the procedure can often be done in one appointment also makes it ideal for busy patients.

A major advantage of composite bonding is that repair is usually straightforward. This contrasts with ceramic veneers and crowns, which can be difficult or impossible to repair.

When used appropriately, cosmetic bonding can have excellent aesthetic outcomes, but it has some limitations and disadvantages, which could be the cause of complaints. Dentists should be aware of the following pitfalls and how to avoid them.

Inadequately informed patients

Careful patient assessment and honest discussion about the treatment options is essential to obtain valid patient consent before composite bonding. Complaints and litigation are more likely if the patient does not understand and accept the limitations and possible adverse effects prior to the procedure.

A dentist should assess the patient, carefully examining the teeth and gums to determine whether composite bonding is suitable. They should also explore whether the patient has psychological issues or unrealistic expectations about cosmetic dentistry. Such issues could make a subsequent complaint more likely, so extra care is warranted.

Patients should be fully informed of the pros and cons of different treatment options and advised on the most appropriate procedure to achieve the desired result. The cost of treatment should be explained, including the long-term costs of maintenance and replacement. They should be forewarned about the need to avoid chipping or staining the composite material to prolong its life.

Inappropriate treatment

Cosmetic bonding is not suitable for everyone. It is less durable and stain-resistant than porcelain veneers and crowns and may be inappropriate for some patients. For those with heavily-restored teeth, bruxism, extreme discolouration or extensive damage to teeth, other treatments may be preferable.

Patients with periodontal disease and caries will require treatment before composite bonding. Others may first need to undergo orthodontic procedures.

Patients should also be advised that tooth whitening is best done before composite bonding since it will only alter the colour of natural teeth and not the composite material. Following whitening, it is advisable to wait several weeks before applying composite bonding, to ensure a stable bond is achieved.

Failed composite bond

Being less durable than porcelain restorations, the composite material may occasionally fall off or become damaged. Dentists can help to create a robust bond and avoid premature failure by:

  • Isolating the tooth with a rubber dam to prevent interference by moisture
  • Preparing the tooth correctly before applying the composite
  • Carefully choosing the composite
  • Following the directions for use to achieve the required quality and depth of resin
  • Using material systems with high-quality products from reputable manufacturers
  • Polishing to create a smooth surface.

Patients should be advised about the need for ongoing maintenance and asked to return for a review of the bonding if they feel any sharp edges or a change in bite.

Suboptimal appearance

If the composite material does not match the patient’s natural teeth in shade or opacity, or if it is not shaped correctly, the aesthetic outcome may be poor. Training is necessary to help dentists develop skills in choosing, applying and sculpting the layers of composite bonding.

Sensitivity

Composite bonding is generally well-tolerated, and any sensitivity should be short-lived. However, patients should be advised to contact the dentist if any sensitivity continues.

Staining

Composite bonding is susceptible to staining by tobacco, foods and drinks, especially tea, coffee, and red wine. The patient should be informed about this risk prior to treatment and advised about the durability of the restoration based on their habits. They should also receive advice on good aftercare, including brushing, flossing, and avoiding foods and drinks that could stain. The dentist can also help to prevent staining by polishing the bonding to form a very smooth surface.

Inadequate documentation

As always, accurate records should be made of the assessment, planning and treatment processes. In the event of a subsequent claim, these may be useful as medico-legal evidence to support the dentist’s case. Keeping photographic records pre- and post-bonding is also important as objective evidence.

Diagnostic wax-ups may form a useful part of treatment planning and would also be valuable evidence if a claim was made. They can be used to plan and guide placement of the composite and to show the patient the expected outcome. Providing this additional clarity about the extent of treatment may help to achieve patient satisfaction and avoid complaints.

If you have received a complaint or experienced any incident related to composite bonding, please contact Dental Defence Society for expert advice as soon as possible.

Avoiding the pitfalls in facial aesthetics

Avoiding the pitfalls in facial aesthetics

Rapid growth in demand for facial aesthetics treatments, such as botulinum toxin injections and dermal fillers, has led a rising number of dental practitioners to offer these services. With the UK non-surgical cosmetic industry currently worth over £3 billion, expanding into this field to complement traditional dental services can offer a commercial boost to many practices.

Dentists are well placed to provide these treatments safely and effectively, given their extensive training, technical skills and Care Quality Commission (CQC)-registered premises. However, complications leading to complaints and claims can occur, so it is essential to be aware of the dento-legal issues and to maintain appropriate indemnity cover.

Key regulations

Facial aesthetics is a largely unregulated field. Anyone can administer non-surgical cosmetic treatments and many untrained practitioners are marketing these at attractive prices. The ease of access raises concerns about patient safety, and dental practitioners have a role to play in helping patients to make safer choices when seeking facial aesthetic treatments.

Key regulations to be aware of are:

  • Botulinum toxin is available by prescription only. It can be administered by appropriately-trained dentists, dental hygienists and dental therapists (not by dental nurses), but a dentist must always assess the patient and provide the prescription. Dermal fillers are classed as devices and do not need a prescription.
  • Since 1 October 2021 it has been illegal to administer botulinum toxin or a dermal filler for cosmetic purposes to under 18s. Dental practitioners must always verify age prior to booking and performing the procedure.

Reduce the risks: be trained, competent and indemnified

To protect patients from harm and dental professionals from litigation, the General Dental Council (GDC) provides guidance:

“If you choose to offer Botox or other non-surgical cosmetic procedures the GDC expects the same high standards of you, whatever the type of treatment you are carrying out. In particular, you will need to ensure that you only work within your knowledge and professional competence, adhere to the Council’s standards at all times, and be prepared to back up the decisions you make.”

“You need to also ensure that you have appropriate indemnity cover. Careful thought also needs to be given to maintaining professional standards in relation to advertising these services.”

Dental professionals providing facial aesthetic treatments should meet the qualification requirements set by Health Education England. Accredited training providers can be found through the Joint Council for Cosmetic Practitioners (JCCP) ‘Register of Approved Education and Training Providers’.

Patients can identify suitably-qualified practitioners by searching voluntary, Professional Standards Authority (PSA)-accredited registers such as those provided by JCCP and SaveFace. Dental professionals are allowed to enter these registers with a Level 7 qualification in aesthetic medicine.

Work in the best interest of patients

The GDC expects dental professionals to communicate effectively with their patients, obtain valid consent, and work with colleagues in the best interest of patients.

The process of obtaining valid consent is especially important when patients seek non-surgical cosmetic treatment. They may have high expectations and any dissatisfaction with the outcome could trigger a complaint if the patient has not been fully informed about the range of possible outcomes and potential risks and costs.

Patient assessment is also crucial. Dentists should be vigilant for signs of psychological vulnerabilities that indicate a need for caution in providing cosmetic treatment, and decline treatment if it is not clinically appropriate and in the patient’s best interest.

Be prepared for complications

Facial aesthetic treatments can have good results when performed by a trained health professional but there is always a risk of side effects and complications. Fortunately, patients can be confident that registered dental professionals are trained to avoid, recognise and manage any adverse effects.

As always, documentation of patient assessments, treatment plans and follow-up care is crucial in case something goes wrong and the patient makes a complaint. At discharge, patients should be given details of who to contact if there is a problem.

Marketing facial aesthetic services

It is imperative that any marketing is done responsibly, to enhance patient trust and avoid falling foul of GDC rules on advertising. Since compliance with those rules is often poor, practitioners may need to enhance their knowledge in this area. All advertising and promotional material must be accurate, not misleading, and backed up with facts; promotional tactics should be avoided that could prompt patients to make an ill-considered decision. Importantly, prescription-only medicines, including botulinum toxin, cannot be advertised directly to the general public.

However, in a market where unregistered, sometimes rogue, practitioners are advertising cut-price treatments, appropriately-trained and registered dental professionals can offer patients a safer choice, with the skills to provide ethical facial aesthetic treatment in a well-equipped environment.

If you offer facial aesthetic treatments, or plan to in the future, please keep us informed at Dental Defence Society so that we can make sure you have appropriate indemnity cover.

Updated SDCEP guidance on dental management of patients taking anticoagulants and antiplatelets

Updated SDCEP guidance on dental management of patients taking anticoagulants and antiplatelets

In March 2022, the Scottish Dental Clinical Effectiveness Programme (SDCEP) published the second edition of its guidance on the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs.

This guidance is principally aimed at dentists, hygienists and therapists in primary care dental practice. It provides recommendations about the assessment of bleeding risk, treatment planning and management of patients who have been prescribed anticoagulants and antiplatelet drugs.

Endorsed by the Royal Colleges, and the College of General Dentistry, the guidance aims to promote the safe and effective provision of oral health care for this group of patients.

Updated recommendations from SDCEP

Dental practitioners will be aware of the risk of bleeding complications when they perform invasive dental procedures in patients taking anticoagulants or antiplatelet drugs. This updated guidance from SDCEP provides clear and practical advice to enable dental teams to manage this group of patients within primary care.

First published in 2015, the guidance aims to encourage a consistent and evidence-based approach to the dental management of patients taking these medications. The 2022 update incorporates current evidence to support the clinical practice recommendations. It was developed by a multidisciplinary group using SDCEP’s NICE-accredited methodology.

The Full Guidance is available from the SDCEP website.

Topics covered

The guidance includes recommendations about:

  • Assessment of bleeding risk from dental treatment: Dental practitioners can refer to the guidance, which includes a table categorising dental procedures according to low or high risk of post-operative bleeding complications.
  • Medical history: This should include questions about the patient’s use of medications, including anticoagulants or antiplatelet drugs, as well as medical conditions and bleeding history. The guidance advises delaying non-urgent, invasive procedures where possible for patients receiving time-limited anticoagulant or antiplatelet drugs. The full guidance also provides advice about the management of patients with other relevant medical complications, including when to consult with the patient’s prescribing clinician, specialist or GP.
  • Treatment planning: For all patients taking anticoagulants or antiplatelet drugs who require dental treatment likely to cause bleeding, general advice is given regarding treatment planning to avoid complications, and provision of pre-treatment and post-treatment instructions to the patient.
  • Management according to the type of anticoagulant or antiplatelet drug: Further advice is provided, specific for patients taking direct oral anticoagulants (DOACs), vitamin K antagonists such as warfarin, injectable anticoagulants (low molecular weight heparins), antiplatelet drugs, or a combination of anticoagulants/antiplatelet drugs.

Following a full review of the original 2015 guidance, many of the recommendations remain unchanged in this update. However, Steven Johnston, Senior Dental Officer, NHS Orkney, and Chair of the group that developed the updated guidance, commented:

“Prescribing of anticoagulants and antiplatelet drugs has increased since publication of the first edition of the guidance and dental practitioners are increasingly likely to encounter patients taking them, particularly the Direct Oral Anticoagulants or DOACs.”

“The second edition of the guidance provides up-to-date recommendations to continue to help clinicians manage dental care for these patients and includes the newer DOAC edoxaban and expanded advice about the low molecular weight heparins.”

Environmental considerations

This edition of the guidance is also the first SDCEP document to consider the potential environmental impact of its recommendations. The advice offered to support implementation of environmentally sustainable oral health is intended to minimise patient travel, a significant contributor to a dental practice’s carbon footprint:

  • Confirm medical history in advance in case of changes that lead to postponement.
  • Consult with the patient’s prescribing clinician, specialist or medical practitioner in advance, if required.
  • Provide pre- and post-treatment patient instructions.
  • Suture and pack at the time of treatment to avoid reattendance for postoperative bleeding.

Implementation and supporting resources

Reassuringly, a recent study by Woolcombe et al, looking at the implementation of the 2015 guidance, concluded that the recommendations were safe to follow – among a cohort of 98 patients who underwent 119 dentoalveolar procedures, none experienced major haemorrhage.

Yet, absolute compliance with the recommendations was achieved in less than half of cases. This suggests that dental staff need additional education and support to fully implement the guidance.

Helpfully, SDCEP provides supporting tools to assist with the implementation of the 2022 guidance:

Dental practitioners have a responsibility to make decisions appropriate for the individual patient, with the consent of the patient. Where significant departures from this guidance are deemed necessary, the SDCEP guidance advises that “the reasons for this, are documented in the patient’s clinical record”.

If you require dento-legal advice about the management of patients taking anticoagulants or antiplatelet drugs, please contact Dental Defence Society for expert support.

New NHS contract discussions

New NHS contract discussions

The British Dental Association (BDA) and others have long been calling for ambitious reform of NHS dental contracts. The pandemic has added urgency to the situation. With a huge backlog of patients requiring care and NHS dental practices struggling to meet activity targets, a new approach is needed to secure the future of NHS dentistry.

In England, the current contract system, based on units of dental activity (UDA), is widely criticised. The inflexibility of the contracts limits profitability when running costs are escalating and the system fails to address problems of staff retention, patient access and oral health inequality. Although some preliminary changes appear imminent in England, dentists will have to wait longer for a full overhaul of the system.

Progress is mixed across the other UK nations but a fully reformed contract has yet to be introduced anywhere. There are fears that continuing delays in reform may drive more dentists to leave NHS practice altogether.

Current status of NHS contract reform in England

In England, the process of reforming NHS dental contracts began in 2011, after the Steele Review (2009) recommended changes to improve access, continuity of care and focus on prevention. Since then, over 100 dental practices have participated in the Dental Contract Reform Programme to pilot test new ways of delivering NHS dentistry. However, it proved difficult to satisfy all stakeholders. Initial pilots increased satisfaction among dentists and patients but led to declines in access and activity. Later pilots designed to address these issues left dentists unhappy as profitability fell.

The programme was ended on 31 March 2022 and prototype contracts have now reverted to the standard contract based on UDA targets.

Although the outcomes and experiences of practices involved in pilot testing will inform the ongoing process to reform the contract, the BDA stated “It is profoundly disappointing that the prototype approach was abandoned in this way”.

Practices that participated in prototype testing are offered guidance and support from NHS Business Services Authority. However, the BDA has expressed concern that these practices could be financially disadvantaged and that the support provided is too limited.

The route to future contract reform

The complex process of reforming the dental contract in England continues with a new phase, begun in the summer of 2021. An advisory group reviewed the various contracting approaches with the aim of developing new proposals that will work for all stakeholders: clinicians, practices and NHS England.

NHS England and NHS Improvement have stated that to be viable,  contract reform should meet the following aims:

  1. Be designed with the support of dentists
  2. Improve oral health outcomes
  3. Increase incentives for preventive dentistry and prioritise evidence-based care for high needs patients
  4. Improve access to NHS care, addressing inequalities
  5. Demonstrate that patients are not driven to pay privately for previously commissioned NHS dental care
  6. Be affordable within NHS resources.

The BDA is currently holding confidential discussions with NHS England, focusing on:

  • Quick wins: “rapid, modest and marginal changes to existing national contractual arrangements”. Initial changes were expected to be announced in April 2022. In recent weeks, Minister Maria Caulfield MP assured colleagues in the House of Commons that she would announce some short-term contractual changes shortly.
  • Long-term contract reform, with focus on care for high-needs patients, urgent care, fairness in rewarding dental activity, skill mix and teamwork, prevention, and making dental professionals feel valued within the NHS.

Long-term, the BDA is in favour of a capitation-based payment system that would support dentists to deliver prevention-focused care. However, dentists are likely to have to wait a considerable time for the roll out of any such system. The concern is that further delay may push more frustrated dentists to move from NHS practice into private practice.

Contract reform restarted in Wales

In Wales, dentists were informed in March that they could join a ‘test and modify’ reform programme if they chose to adopt a contract variation from 1 April 2022. The alternative choice was a return to UDA contract arrangements.

Under the variation, the UDA element is reduced and the balance of the contract can be met by performance against new metrics (fluoride varnish, new patient target, mandatory services to existing patients, recall intervals). This is viewed as the restart of the reform process, which will help to shape the future NHS contract for Wales.

Elsewhere in the UK, limited headway has been made. Contract discussions are underway in Northern Ireland but in Scotland, there is disappointment at the lack of progress.

If you need advice regarding NHS contracts, please do not hesitate to contact us at Dental Defence Society. Our advisers are available 24/7 to offer expert support.