Cosmetic & Adjunctive Procedures

Preamble

A cosmetic procedure is one which is carried out, even in the absence of pathology, for the primary purpose of altering a patient's appearance. It might involve the teeth, the intra-oral tissues, the lips, the face and neck, and/or the bony structures of the head and neck.

Some of these procedures (for example, orthognathic surgery and orthodontics) are well recognised as forming a central part of the relevant specialties, but increasingly the distinctions are becoming blurred.

An adjunctive procedure is a cosmetic procedure which is carried out as an adjunct to and/or alongside other dental procedures of a non-cosmetic nature. For example, a patient might receive treatment involving botulinum toxin or dermal fillers, alongside conventional complete dentures.

Scope of Practice - Current position

There has been some heated recent debate in the dental profession regarding whether or not certain cosmetic and adjunctive procedures represent ‘the practise of dentistry‘:

(a) when carried out by a registered dentist.
(b) when carried out by another dental registrant (for example, hygienists, therapists and dental nurses).
(c) when carried out by any person who is not registered with the GDC (it is a criminal offence for any such person to carry out the practise of dentistry).

The GDC has a jurisdiction to investigate any complaint or other information received regarding a dental registrant, irrespective of whether or not it relates to the practise of dentistry. All dental registrants are required to maintain ‘adequate and appropriate‘ professional indemnity for their dental professional activities, but a ‘grey area‘ has existed in respect of whether this requirement for indemnity extends to those activities which the GDC has deemed not to represent ‘the practise of dentistry ‘.

To address this ‘grey area‘, the GDC is supporting the ‘shared regulation' approach developed by the Independent Healthcare Advisory Services (IHAS), incorporating a third party registration scheme managed by CHKS on behalf of IHAS. Initially, only registered doctors, dentists and (adult) medical nurses will be able to register with CHKS under the IHAS scheme, which includes a quality assurance framework covering training, standards, the facilities from which these services will be provided and a programme whereby these facilities can be independently inspected and accredited. Registration with IHAS/CHKS will not be compulsory, but will be strongly encouraged in addition to GDC registration. It is hoped that the existence of the IHAS Quality Mark will, once established, guide and assist consumers in their choice of provider for these procedures. Details of the IHAS Registration scheme appear on their website. A new dedicated site for the Quality Mark will also be launched. Click here to register your interest in receiving further information from IHAS.

Fortunately, Dental Protection can approach this subject with a great deal of flexibility because the scope of its discretion is (unlike insurance policies) very wide. Each situation can be viewed on its individual merits, and Dental Protection's approach can evolve as new techniques appear and attitudes change.

Defined cosmetic procedures

As a result of this flexibility, Dental Protection has announced that with effect from 1st April 2010, the use of injectable, cosmetic procedures including botulinum toxin and non-permanent dermal fillers in the face (but excluding the neck) can be indemnified (subject to certain conditions) at no additional cost and without having to take out any separate cover from a third party insurer.

The procedure must be carried out by a dentist who is registered with CHKS/IHAS and who holds the IHAS Quality Mark standard throughout the membership year. In certain full time membership categories for those who graduated four or more years previously, it is generally possible to include up to 10 hours a week (500 hours per year max) of these procedures at no additional cost. Full details including options for more than 500 hours/year of these procedures and any exceptions in particular categories are provided in the relevant subscription booklet.

DCPs

A second complication arises in relation to registered DCPs. All dental registrants are required to practise within the limits of their training, skills and physical ability (the so-called ‘competency-based approach‘) and the GDC no longer publishes definitive lists of permitted procedures for each group of DCP, as it had done in the past. Instead it publishes lists of procedures that each group of DCPs could ‘normally ‘ undertake, supplemented by a second list of procedures that might also be carried out after appropriate training had been completed - but neither list is intended to be comprehensive or exhaustive. The question then arises of the extent to which these groups of DCP, if suitably trained, can carry out cosmetic and adjunctive procedures, especially those that may not be recognised as part of the practise of dentistry.

Dental Protection believes that the present uncertainties and inconsistencies are unhelpful, particularly if it results in a situation where a patient cannot be compensated for a cosmetic or adjunctive procedure that results in a successful claim against a dental healthcare professional. In the first instance the IHAS-CHKS third party registration scheme is not being extended to dental hygienists, therapists and other DCPs although IHAS has committed itself to reviewing the situation regularly.

The risks

Dental Protection believes that dental healthcare professionals are better placed, in many respects, than many other potential providers to carry out these procedures safely and successfully, not least because of their particular range of background knowledge and training, the standards of infection control, and their ability to manage a medical emergency. The safety and welfare of patients should be the overriding consideration, and the patient's right to choose what treatment they wish to receive, when, and from whom, is fundamental to patient autonomy.

However, Dental Protection also recognises that many of these procedures present additional risks either because they are inherent in the procedures themselves, or because of a clinician's relative unfamiliarity with them, when compared to ‘traditional‘ dental procedures, or sometimes because the patients who present themselves for such treatment are not typical of the population as a whole. In particular, they may well have different levels of expectation, or in terms of their willingness to accept a sub-optimal aesthetic outcome. Some of these patients may present with a true body dysmorphic disorder (BDD) which the clinician may or may not recognise. In all ‘cosmetic‘cases the consent process is crucially important, yet it is sometimes fraught with potential difficulties.

Bearing all of this in mind, Dental Protection has adopted what it believes to be the most responsible position, which is to facilitate the indemnification of dental registrants to specified cosmetic and adjunctive procedures, subject to the individual having obtained suitable training for the procedure(s) in question. Dental Protection believes that it is in the interests of both healthcare professionals and patients that this indemnity should be occurrence-based, as opposed to many of the stand-alone
claims-made insurance policies which are offered by commercial insurers for this purpose. There are many ways in which a claims-made insurance policy might not respond to a claim relating to these procedures, leaving a healthcare professional potentially unindemnified and a patient potentially uncompensated. See ‘Making Sense of Professional Indemnity ‘.

This might be the case even when the clinician has purchased an insurance policy which is in place at the time of treating a patient.

Dental Protection also believes that it is far preferable for all of a registrant's indemnity to be available from a single source, to avoid a situation where s/he is indemnified for part of the patient's treatment, but not for another part. Other potential nightmare scenarios include two or more separate firms of solicitors (and/or barristers) being involved in a negligence claim, or a GDC hearing, for different aspects of treatment provided to the same patient (perhaps even on the same day). Under the terms of some insurance policies, this ‘double‘ indemnity can also invalidate the insurance contract.

Categories, definitions & subscription rates

As from April 1st 2010, new arrangements allow ‘defined cosmetic procedures‘ (see relevant paragraph above for details of what this means) to be carried out in defined circumstances with no additional subscriptions being payable.

Members wishing to carry out these procedures in other circumstances (eg when not additionally registered under the IHAS scheme) and certain other procedures can choose between four membership grades/categories (DC1, DC2, DC3, DC4) which have been established for this purpose. All the normal benefits of full (DFU) membership are included within the categories/rates shown, but are extended to include the various cosmetic/adjunctive procedures.

Members who are on the Specialist List/Register in Oral or Maxillofacial surgery who are already in one of our many maxillofacial categories may be able to include some of the specified cosmetic/adjunctive procedures within their current subscription. Please contact the membership helpline for guidance on 0845 7187 187.

Updated 17 February 2010