It is time for the government to redouble its efforts to prosecute illegal teeth whitening providers. This is in light of the recent English Department of Health review of cosmetic practice published on April 24th 2013 which was highly critical of some of the standards in the cosmetic medicine industry. The report is entitled the “Review of the Regulation of Cosmetic Interventions”.

In 2012 there was a successful prosecution and jailing of an illegal teeth whitening trader. Barrington Armstrong-Thorpe was given a 16 month jail sentence by a judge at Chelmsford Crown Court for illegally selling teeth whitening products.

We are living in austere times and many people are looking at ways of maximising or supplementing their income. It is easy to go on to the internet where you can find lots of companies offering franchise opportunities for teeth whitening or sales opportunities for teeth whitening products and on the surface this can seem like a perfectly legitimate way of making extra money. In the case of Mr Armstrong Thorpe it was deemed to be illegal and I am therefore pleased that the law has finally caught up with him. The government needs to move to the next level following its review of cosmetic practice and aggressively and actively prosecute illegal tooth whitening traders.

There has been a lot of guidance recently about teeth whitening which should hopefully give some clarity around the whole situation. Firstly the General Dental Council (GDC), the organisation which regulates dental professionals and is responsible for protecting the UK public clearly states that applying materials to teeth and carrying out procedures that are supposed to improve the appearance of teeth and also giving clinical advice about these matters is actually the practice of dentistry. The GDC state that this should only be undertaken by dentists or dental hygienists/therapists working to a dentist’s prescription. I support the GDC in its view that the carrying out of dentistry by individuals not registered with them is a criminal offence. This is not about dentists having a monopoly it is about the protection of the public. Good teeth whitening is not just about price. It is about safety, standards and quality.

The most recent important piece of legislation from the government is the Cosmetic Product (Safety) (Amendment) Regulations 2012. A link to the document is here. This came into force on 31st October 2012. From 31 October 2012 the government has basically fallen into line with a directive issued by the EU.

This means that:

1.    Products containing more than 0.1% hydrogen peroxide cannot be provided direct to the consumers or public.

2.    Products containing between 0.1% and 6% hydrogen peroxide can only be sold to dental practitioners.

3.    These products can only be made available to patients following an examination – by definition that would be a clinical procedure which would have to be undertaken by a dentist. The first session of whitening treatment should be provided by a dentist, or by a hygienist or therapist under supervision of a dentist after which they can be provided to the patient to complete the cycle of use.

4.    Products containing between 0.1% and 6% hydrogen peroxide should not be used on under 18s.

5.    Products containing over 6% hydrogen peroxide are illegal to use.

Some dentists as an alternative to hydrogen peroxide are using carbamide peroxide and 6% hydrogen peroxide equates to just over 16% of carbamide peroxide.

Many so-called teeth whitening clinics are using products such as chlorine dioxide and sodium perborate. These are not appropriate products for teeth whitening and have strong and serious question marks around safety attached to them. So with so-called teeth whitening clinics, what we are effectively talking about a group of people who are not only illegally practising dentistry, but also selling products that are dangerous for health to a public that is unsuspecting and is looking for what they think is a cheap bargain. Why on earth would people want to compromise their health in this way by using organisations and companies that are providing a service that does not fall within any recognised framework of regulation or scrutiny?

I and my team at Langley Dental Practice, Middleton, Manchester have been offering safe, effective and legal teeth whitening for over 10 years with superb results. I am very critical of the misleading advertising tactics that some of the franchising teeth whitening companies are using to scare patients away from dental practices. The so-called cosmetic teeth whitening companies try and put forward the myth of greedy dentists ripping off the public claiming that we want to charge anything between £350 and £700 for whitening. Here at Langley Dental Practice we start our teeth whitening prices at just £199 for both upper and lower teeth and this includes a full detailed consultation with an experienced British educated, qualified and trained dentist, somebody who is skilled in the art and science of looking after your teeth – not a “cosmetic technician” or “beauty therapist” or even worse somebody working out of the back of a van who comes to your home.

I welcome the fact that there is now greater clarity around the issue of teeth whitening and also that illegal teeth whiteners are now being prosecuted. The government review of cosmetic practice should be a wake up call for all those concerned about illegal and poor practice whether in medicine or dentistry. Everybody is looking for value for money these days but why put a price on your health and take unnecessary risks?

• The scope of the EU Medical Devices Directive should be extended to include all cosmetic implants including dermal fillers, UK legislation should be introduced to enact the changes sooner. Legislation should be introduced to classify fillers as a prescription-only medical device.
• All those performing cosmetic interventions must be registered.
• The Health Education England’s (HEE’s) mandate should include the development of appropriate accredited qualifications for providers of non-surgical interventions and it should determine accreditation requirements for the various professional groups. This work should be completed in 2013.
• Surgical providers should provide both the person undergoing a procedure and their GP with proper records.
• A breast implant registry should be established within the next 12 months and extended to other cosmetic devices as soon as possible, to provide better monitoring of patient outcomes and device safety.

Regrettably for some people nonsurgical cosmetic treatment is not seen as a medical procedure. This has led to events such as Botox parties where non-qualified non-trained members of the public can inject other members of the public with a drug and a chemical with no regulation, license or inspection. This is a situation that has to be stopped and cannot continue for safety of the public. This is not about cost and any arguments that are put forward to advance that are missing the point. This is simply about public safety.

Recently I gave full backing to an e-petition on the HM Government website launched to guarantee funding or places for all new graduate foundation dentists. The details of the petition which already has over 3000 signatures can be seen here. http://epetitions.direct.gov.uk/petitions/4030

All new dental graduates are supposed to be given a training place in a practice in the first year after graduation. In fact a few years ago in response to a shortage of NHS dentists, the government created an additional 77 new dental places by opening two new dental schools, UCLAN and Peninsula. However last year 35 new graduate dentists ended up without a training place job. I cannot imagine how desperately demoralising and shattering this experience must have been for these new graduate dentists. 

In 2005 the Chief Dental Officer giving evidence to the Public Accounts Committee of the House of Commons stated that it cost the taxpayer around £250,000 to train each student dentist. That was seven years ago. Last year we had 35 dentists unfunded. If you add that all up in today’s money, that makes a figure of £9 million wasted last year with 35 unemployed dental graduates – a frightening sum. On top of that these students are leaving universities with levels of debt approaching £50,000. If last year’s state of affairs is duplicated it will be heartbreaking for new graduate dentists and a waste of time and money for the taxpayer. Because completion of Dental Foundation Training is a prerequisite for newly-qualified dentists wishing to provide NHS care, these individuals will be disqualified from caring for NHS patients.That surely cannot make sense.

Here at Langley Dental Practice we have been a training practice for seven of the past eight years. It is one of the most rewarding experiences that we get in dentistry to watch and train a new graduate and see them mature over a 12 month period of training and mentoring into a competent caring associate able to practice independently. I feel that by signing this petition I am showing that what has happened this year is unacceptable because the government has squandered taxpayers’ money and betrayed those who have strived hard to pursue a career providing NHS dental care. 

I was a nominated finalist in the Dental Defence Union “Trainer of the Year” award in 2007 for my efforts in training and mentoring newly qualified dentists. Trying to find your first job in the run up to your final dental examinations must be an extremely stressful experience. To go through a difficult complicated application procedure and rigorous interview process, only not to be allocated a place must be extremely demoralising and distressing. To make matters worse we now have a large influx of new European Union graduates where the economy has hit a downturn who do not even have to do foundation training yet some of them have actually got places on the foundation training scheme.

We know that the government has to make cutbacks and that we live in an era where difficult choices have to be made. However it is a crazy state of affairs that the NHS invests £250,000 in training a new dentist only for that dentist not to be able to find a job within the NHS. I support this e-petition for full funding for foundation dental places and I urge the government to make sufficient funds available for all dental foundation training places as a matter of priority.

A revised HTM0105 document on cross infection was released at the end of March. The revised document was released by the English Department of Health with very little fanfare and publicity. The very low-key launch of this document is in stark contrast to the original launch of HTM 0105 which was launched in a blaze of publicity in 2008.

There are very many dentists out there at the frontline who are not actually even aware that this document has been released. I emailed five of my colleagues forwarding them the link and none of them had even got the slightest idea that these major changes were coming through. When the original document was released in 2008 there was a massive amount of publicity given to it and it was supposed to be the new way forward for dentists in promoting the highest standards of cross infection control and decontamination. However the profession as a whole was very concerned about the very weak and poor evidence base that supported some of the recommendations. Many of the recommendations were put forward in response to concerns about CJD and many of these concerns have now been demonstrated to be perhaps a little unrealistic. It is pleasing to see that both ministers and civil servants have actually listened to and taken on board the serious and justified concerns of the dental profession and amended the document.

The most recent report from the NHS is the latest in a series of quarterly reports published by the NHS that brings together information on NHS dental activity in England up to the second quarter of 2012/13 and also provides information on the number of patients seen by an NHS dentist, up to the third quarter of 2012/13. One of the key headline figures is that a total of 29.7 million patients were seen in the 24 month period ending December 2012, an increase of 1.5 million on the March 2006 baseline date when the last dental contract was introduced. However although this may seem like a large number if one looks a little deeper one can see that this represents 56.0 per cent of the population compared with the March 2006 figure of 55.8 per cent. This is a very small increase.

I write today to remind colleagues of the need to maintain high quality up to date dental records which in turn will promote high quality referrals and minimise the risk to patients from inaccurate and confusing referrals. Good quality record keeping promotes high standards of communication between colleagues.

I am prompted to do this following the incident reported this month where a patient who suffered four years of agony after a procedure to remove a tooth has accepted £50,000 compensation. Rehana Musa, 72, sued dentist Dr Piotr Pietruszczak after he failed to consult her medical history before pulling out her wisdom tooth in 2008. This led to severe complications due to the wound not healing and indeed Mrs Musa had to have part of her lower jaw removed.

As dentists and responsible health professionals we must do whatever we can to minimise human error and mistakes when we treat patients. Good accurate record keeping is important. Inaccurate and poor record keeping can and indeed does lead to devastating errors.

I am the lead clinician on the Heywood Middleton and Rochdale CATS service, an innovative scheme designed to deliver specialist dental services within a primary care environment and have been leading on this service for the past 8 years. I get referrals from all over the borough of Rochdale from colleagues asking me to undertake surgical procedures on their patients. I have noticed an increasing incidence of poor quality, and inaccurate referrals. Some of them are illegible, some have the wrong tooth to be extracted, say lower left instead of lower right. Often the medical history is incomplete. A complete and accurate medical history is vital bearing in mind the events suffered by Mrs Musa.

Many times pre-operative diagnostic tests such as x-rays of the tooth in question have not been done which sometimes makes me wonder how a referring dentist can have assessed the tooth as being suitable for surgery. On occasions up to 40% of the referrals that I receive are deficient in some way and have to be rejected and returned to the referring practitioner.

In order to improve the quality of record keeping and thereby minimise errors I would always advise the following six key points:

1. Dental records must be easily legible if handwritten and they must be contemporaneous – i.e. they must be written at the time not some hours or days later when one’s memory can cloud recollection of events.

2. Dental records must be of a consistent standard and must state facts and not opinion and must be accurate.

3. Paper records must be kept securely together and have the patient’s name and date of birth on each page.

4. Records must be arranged in chronological order – so one event logically follows another.

5. Records must be regularly audited and benchmarked against recognised national quality standards. I would recommend doing this every quarter.

6. Medical histories must be checked and updated every time a patient visits the practice and any changes noted down immediately.

Ultimately we are responsible for the care of a patient who is putting their trust in our hands. We must do whatever we can to earn and keep that trust. Good, accurate record keeping is an important step along this pathway of trust. Poor quality and inaccurate record keeping can lead to lead to a confusing state of affairs for patients and disastrous consequences.

Last week marked six months since my appointment as oral surgery specialist to the prestigious University of Lancashire (UCLan) Dental Clinic in Preston. The University of Central Lancashire has created a £1.3m state-of-the art dental clinic at its Preston city campus, which is providing much-needed services for local people as well as staff and students. The clinic has four general dental surgeries; an oral surgery suite (two surgeries and recovery room) and a 10-chair training suite and will be fully equipped to meet both treatment and teaching requirements. UCLan is one of the few universities in the country, other than specialist dedicated medical centres, to have such facilities on site.

I lead the specialist oral surgery services at the UCLan Dental Clinic. I am registered with the General Dental Council as a specialist in Oral Surgery and have responsibility for providing not only treatment to patients but also teaching dentists. Between 2001 and 2009 I was a senior teaching fellow in oral and maxillofacial surgery at Manchester Dental Hospital where I was responsible for the teaching, lecturing and supervision of dentists on the University of Manchester’s Masters program in oral and maxillofacial surgery. Currently I am the clinical Lead for the NHS Heywood, Middleton and Rochdale dental CATS services which since 2010 have been providing specialist oral services out of primary dental practices at Langley Dental Practice, Middleton, Manchester and The Phoenix Centre Heywood.

As a teacher and educator I have over the past decade taught and mentored over 500 dentists in oral surgery at postgraduate level and have lectured and taught on the subject at regional and national meetings. Recently I was selected as a tutor on the Faculty of General Practice Certificate in Minor Oral Surgery course at the Royal College of Surgeons of England in London for the second year in a row.

In terms of UCLan it has been a very exciting and progressive six months. We started out in September 2012 from scratch with no patient base. Over these six months we have built up a steady cohort of patients who are coming to see us both from within the University campus and from outside based on our reputation and recommendation. My position as a specialist oral surgeon means that I get to see some of the more advanced, difficult and complicated cases that are either referred from amongst my own colleagues or from outside from fellow practitioners. I am also involved in teaching  dentists at postgraduate level who are undertaking the Masters programme in oral surgery at UCLan.

I have been very excited to be able to work with my first cohort of postgraduates and it has been a very stimulating and interesting experience. They are keen, enthusiastic and very impressed with the high tech, modern teaching facilities that we have here at the clinic. My job is to guide and supervise them whilst they are performing complex cases in oral surgery. I oversee them and am also responsible for their assessment. Teaching and training at this level is so important if we are to create the next generation of specialist practitioners who will take the profession forward.

We need to ensure that general dentists are given enough training to allow them to confidently complete minor oral surgery procedures in practice. It  is not just completing the cases that is important – it is the ability to assess what they can and cannot manage in terms of treatment that also determines their competence and ability. Knowing ones limitations is an important part of being a caring, competent and reflective practitioner. Whilst many dentists put themselves forward to study implant based hands on courses many of them are not confident in soft and hard tissue management including extractions and surgical removal of roots. The rigours of a Masters programme is a rewarding challenge for those dentists who are seeking to gain experience and a formal university level qualification in oral surgery in practice whilst still being able to continue to work.

In terms of dentistry UCLan is one of the most progressive and forward thinking institutions in the country. The clinic itself is one of the most exciting and groundbreaking dental ventures of the past 12 months. The staff who work there are of the highest quality and well respected in their specialist fields. I am confident that the next six months will see a widening of our patient base and an increase in the uptake of oral surgery services. So far it has been a wonderful first six months and I am looking forward to helping this clinic go from strength to strength.

I am pleased to report that once again I have again been selected as a tutor on the Faculty of General Practice Certificate in Minor Oral Surgery course at the Royal College of Surgeons of England in London. This will be the second year in a row that I has been selected as a tutor on this prestigious course. This is on top of being the oral surgery clinical lead for the NHS Heywood Middleton and Rochdale CATS scheme which is an innovative, pioneering referral based scheme designed to bring specialist oral and dental surgical care closer to communities in Middleton, Heywood and Rochdale in Greater Manchester, as well as the staff specialist in oral surgery at the UCLAN dental clinic in Preston. I have a passionate commitment to dental postgraduate education having been a trainer for vocational trainees (new dental graduates) between 2005 and 2009 and having taught on the Masters programme in oral surgery at Manchester and now at UCLAN.

I am thrilled and honoured to be working with the Faculty of General Practice at the Royal College of Surgeons once again. The certificate course in oral surgery is a superb hands on way for general dental practitioners to increase their confidence and experience in minor oral surgery. The fundamental aim of this course is to provide the dentists with an opportunity to complete multiple “hands on” oral surgery cases supervised by a specialist oral surgeon within a primary care setting or specialist minor oral surgery clinic. The theoretical part is delivered at the Royal College of Surgeons in London and the practical sessions are delivered regionally by tutors. Last year after a competitive selection process I was delighted to be selected as a tutor and I am even more thrilled to be selected again as a tutor for the new cohort of dentists who have commenced this month on this year long course.

We need to ensure that general dentists are given enough training to allow them to confidently complete minor oral surgery procedures in practice. It  is not just completing the cases that is important – it is the ability to assess what they can and cannot manage in terms of treatment that also determines their competence and ability. Knowing ones limitations is an important part of being a caring, competent and reflective practitioner. Whilst many dentists put themselves forward to study implant based hands on courses many of them are not confident in soft and hard tissue management including extractions and surgical removal of roots. There aren’t many courses out there that provide the chance for the busy general dental practitioner to gain experience in carrying out hands on minor oral surgery in practice whilst still being able to continue to work. Dental schools are no longer sending out qualified dentists – they are sending “safe beginners” in to the world. The surgical removal of teeth has been identified as one of the areas that newly qualified dentists feel least prepared for after their university training has been completed. Unfortunately the effect of this is that many minor oral surgery cases which could be seen in practice are referred to hospital secondary care facilities which takes away valuable resources that perhaps could have been treated in the primary care sector. The dental schools have abdicated their responsibility for producing skilled practical dentists and they argue that the world has changed from the past say 25 plus years ago when I qualified. However although the world has changed dentists are still hands on people who need to deliver practical hands on care. Regrettably nobody at either dental schools or anywhere else amongst the powers that be are willing to listen – they continue to agree amongst themselves that all is well. Yet those of us that come across new dental graduates see a different picture. To speak out against this self perpetuating elite is indeed heresy.

The Faculty of General Dental Practice at the Royal College of Surgeons is a very prestigious organisation. It was formed over 20 years ago as the academic home for general dental practitioners and aims to improve the standard of care delivered to patients through standard setting, postgraduate training and assessment, education and research. To be working with such an auspicious body on one of their courses is indeed an honour

I welcome the latest UN Treaty which seeks to reduce mercury pollution. It is called the Minamata Convention and will be adopted later this year in Japan. It is named in memory of the victims of mercury poisoning from industrial pollution that occurred when residents of the Minamata Bay ingested contaminated fish and shellfish in the 1950s. The treaty will require nations to phase down the use of mercury containing dental amalgam fillingsover an appropriate time period relevant to each country’s national requirements.

• National governments to set the pace of the phase down according to local domestic requirements.

• There should be a focus on public health programmes designed to reduce the incidence of dental disease.

• Using non mercury based filling materials should be encouraged and research into such materials should be encouraged.

• Best practice measures should be used to minimise the load from waste dental amalgam.