Q. When an NHS patient requests me to use a tooth-coloured material in their posterior teeth, must I comply with this request instead of using amalgam?
It is only natural that many discerning members of the public might wish to have the most cosmetic treatment that is available to them. For others the key issue is not cosmetic but their wish to avoid the use of amalgam in their teeth because of their concerns about he health issues that have been raised over the safety of using mercury in dental amalgam.
While the mercury debate proceeds without any definitive evidence to support its withdrawal from use, the evidence base for the use of composite as the most clinically appropriate restorative material in certain well defined clinical situations continues to grow. Taking things a step further, The Chief Dental Officer in the June 2009 CDO Update states that ‘the appropriate restorative material for a small single surface caries lesion is a composite restoration, and that is what the NHS would expect people to provide in these circumstances'.
While it could be argued that the ‘expectations of the NHS' are defined by the regulations themselves and the associated contractual undertakings, not by ad-hoc statements and interpretations such as this, it remains a fact that a practitioner must be able to justify their clinical decisions as to the materials used.
Obtaining a patient's consent to the provision of an amalgam filling in the mistaken belief that a composite restoration cannot be provided (eg. within the NHS) or obtaining the patient's consent to the private provision of a composite, would in both cases undermine the validity of the consent obtained because the patient would have been misled.
The GDC expects all registrants to keep up-to-date with current best practice and to apply this knowledge ethically At all times, a dentist should act in a patient's best interests and it might therefore be argued that to restrict the use of composite resin to private fee-paying patients, when the current GDS regulations place no restrictions on the use of composite within the GDS contract in England and Wales, is unethical.
The current GDS contract does not extend to purely cosmetic treatments, however, and any patient who requests the replacement of existing, unsightly but clinically sound, amalgam restorations should not expect to receive this treatment as part of a course of NHS treatment.
On the other hand, the clinician faced with the challenge of restoring primary carious lesions would be expected to offer a patient contemporary evidence-based treatment and this now includes the use of composite resin in posterior teeth as part of a course of NHS treatment.
Ultimately, any decision to use composite (or any alternative material) as a posterior restorative boils down to individual clinical judgment. However, to restrict its use to private patients only, when the GDS Regulations permit its use within NHS care, would leave a dentist in a vulnerable position.
When making that decision the clinician might find it useful to consider the following quote from a Department of Health document (7 October 2005)
Gateway Reference 5584.
Treatment offered under the NHS should be necessary to improve oral health and should be long lasting.
Treatment given for either cosmetic reasons, or reasons other than oral health improvement, should not be provided on the NHS.