May 31, 2021

UK Dental Regulator acts on Direct to Consumer Orthodontics.

I have posted a lot about Direct to Consumer Orthodontics.  In one of my posts, I discussed the role of the dental regulator in this form of treatment.  I was also critical of the amount of time that the UK Dental Regulator was taking to address this problem. I am pleased to see that they have produced some useful documents on their approach.

You can find these documents here.

Dentists and orthodontists are concerned about the risk to the patient of DTCO. These companies seem to be flourishing in many countries.  The specialist societies are working on providing information for patients on this treatment.  However, the regulatory bodies are now making progress on highlighting issues.  The UK Dental Regulator (the General Dental Council) has recently produced three related documents. I am going to highlight the main points of each one.

GDC Statement on ‘direct-to-consumer orthodontic treatment

This first document outlines their overall viewpoint; they direct this to dentists and other dental care professionals.  They make the following points.

  • Any innovation should not compromise patient safety measures.
  • Anyone who is not registered and practices dentistry could be prosecuted.
  • Face-to-face interaction or a physical clinical assessment is necessary to ensure patient safety.
  • The responsibility for treatment rests with the treating dentist.
  • Direct interaction between the patient and dentist is essential. Patients must be able to make contact with the treating dentist. They must know the full name of the treating professional.
Direct-to-consumer orthodontics: information to support professional judgement

In this second document, they outline in more detail the GDC standards that are relevant to dentists who are involved in DTCO.  These are:

  • There is no authoritative clinical guidance that supports a remote substitute for a physical clinical examination. Any dentist proposing to deviate from established practice and advice in this way must record and be able to justify their decision.
  • ‘You must communicate effectively with patients – listen to them, give them time to consider information and take their individual views and communication needs into account.’
  • Make sure that there is an effective complaints procedure readily available for patients to use and follow that procedure at all times.’
Aligners or braces sent directly to your home.

They also produced advice for patients who are seeking DTCO. I thought that the main points of this were:

  • Without seeing you in person, the dentist might not have all the information they need about your oral health.
  • To give valid, informed consent, you need to have been given all the information about what the treatment involves.
  • Knowing the name of the person treating you is very important as the dentist who prescribes your aligners or braces is responsible for all your treatment.
What do I think?

Firstly, I think that the GDC has taken a disappointingly long time to issue these guidelines. I discussed the role of the regulator in DTCO in a blog post in August 2016.  If you want to reread this, you will see that I raised all the issues that the GDC has mentioned in its guidance in the last section.  I cannot understand how or why this has taken nearly four years to address.

Nevertheless, I do think that the guidance is good. The GDC have written it clearly, and they have provided good information for the prospective patients.  It is also important to see that they have mentioned that they will prosecute unregistered providers.  They have also used their Standards to warn UK based dentists/Dental Care Professionals that their licence is at risk if they work with one of these companies.

However, there is one massive hole in this process. This problem is the role of the “treating” dentist based outside the UK. The General Dental Council has no jurisdiction outside the UK.  As a result, there is a role for the specialist/dental societies in pointing this out to prospective patients.

We are now in a position to see the action that the GDC takes when we report a company for illegal practice etc.  So let’s get reporting!

Finally, I am not sure whether the other dental regulators throughout the World have addressed this problem.  Does anyone want to add this information in the comments?

 

 

Have your say!

  1. Avatar

    Finally an advantage to working in such a heavily regulated profession.
    Lets see if it sticks and how long it takes.
    Watching with interest.

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    As I kept reading, I felt a huge relief and pride of this action by your General Dental Council! Well done!! I hope this encourages the same posture from Dental Councils in other countries such as mine.

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    Good to see your persistent and well-worded efforts, have yielded results, although with a bit of delay. This should be a trend-setter for regulators in other countries as well. Slowly the companies might retreat or involve orthodontists more actively, throughout the treatment.
    Congratulations, Kevin. It’s indeed a great service to the whole profession. Thanks.

    • Avatar

      Thanks for the comments. I am sure that my blogs did not make a difference here. The British Orthodontic Society and the British Dental Association (the dentists trade union) did a great job in lobbying the GDC.

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    Hi Kevin.
    I’m pleased to see the GDC have finally taken a step in the right direction with these statements. They should be commended, even if there has been a disappointedly long delay before they responded.
    Regrettably, the national dental regulator here in Australia has refused to address the obvious patient safety issues of DTCO. This is despite multiple lobbying attempts from the Australian Society of Orthodontists (ASO) dating back to 2018 (before these products even appeared in our market).
    Evidently our health regulator requires multiple reported cases of adverse outcomes from DTCO *in this country* before the will take any action. Unfortunately this is a cumbersome and slow process that most affected patients choose not to follow, especially if they manage to get their money back from the DTC provider – so reporting is low.
    In other words, there needs to be actual hard evidence of the people being hurt in Australia before the health regulator will step in and only the worst affected are likely to lodge a notification.
    Our regulator is 100% reactive, 0% proactive on this issue. It’s quite unbelievable.
    It would be tantamount to the Australian aviation regulator ignoring the fact that a certain type of aeroplane has regularly fallen out of the sky in other countries but waiting for an actual crash of the same aeroplane to occur in Australia before they investigate and take any action. Thankfully this is not how they operate!
    This regulatory inaction on DTCO means that inevitably there will be collateral damage to naive, unsuspecting punters who have been misled by the deceptive advertising of these companies. That’s the saddest part.
    As best as we can, the ASO has been using our resources to educate the Australian public about the dangers on DTCO and the importance of seeing a specialist orthodontist for any type of orthodontic care. See orthodonticsaustralia.org.au and our social channels.
    Unfortunately the annual budget for the ASO’s public education program is miniscule compared the marketing budgets of the DTCO companies so it’s difficult to shift the dial. We’ll keep trying though.
    Warm regards
    Howard Holmes, President ASO

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    That really is good news! Let’s hope the GDC actually applies it.

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    In the US, I often hear complaints about the perceived lack of action against SDC. However, I think that this is misguided because state dental societies and boards, national organizations, and even individual practitioners are taking aggressive action against Smile Direct Club. If you go to Google Scholar – US, then select Case Law and continue your search by entering Smile Direct Club. I think that you may find this an eye-opener. Do not confuse lack of change with lack of action. It is evident that SDC is very agile legally with an outstanding national law firm to defend their business model. According to their required public financial disclosures, they have set aside tens of millions of dollars for current and potential legal actions. These proceedings can go on for years, effectively thwarting the authority of dental regulatory bodies. In the interim, SDC operates in their usual manner, which gives their organization the opportunity to refine and improve. Perhaps a future blog discussion(s) on other strategies to deal with SDC recognizing that they will be a permanent fixture?

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    There’s probably no doubt that SDC type braces, without much clinical input, will be prone to problems in some cases. The elephant on the room here though appears to be cost. Prospective patients will be swayed by the cost of private treatment. It looks like the cost of SDC in the uk is about the cost of a course of nhs braces. This will still be high enough to have little effect on the nhs provision (being free) but is significantly less than most charge for private treatment. This price varies over the country and I don’t know what the average is but it won’t be the same as the nhs fee. It’s a market isn’t it and SDC is one of those Dominic Cummings type disruptor thingys. It will either be prohibited and normal service will be resumed or it will force down the price of braces generally I expect.

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    Hopefully you don’t find out that any of your GDC Board Members are secretly paid consultants for the DTC Aligner companies as we found it in America with the AAO. Our AAO Board directly lobbied against these companies in public, while these same Board members in secrete were being paid as consultants by Smile Direct Club. The AAO president put out a letter to all members stating there was not a conflict of interest because those Board Members resigned their positions with SDC. Why they weren’t asked to step down from their AAO Board positions is a mystery to me.
    I would encourage you to write a blog about this hypocrisy. At lease us KOL’s are open about our ‘conflict of interests’ and don’t try to hide it.
    I’m more than happy to provide the letter from the AAO president if you would like it.

    • Avatar

      The members of the General Dental Council are independently appointed and include 50% laypeople. Their conflicts of interest are clearly stated on the GDC website. Only one is an orthodontist. They all are signed up to abide by the Uks seven principles of public life.

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        Here’s the AAO Letter. Sounds like a much different situation than ours in the US thankfully for all of you. Always nice when you can trust the people that are protecting your interests and profession.

        Recently, information came to the attention of the AAO indicating that members of certain AAO committees or councils might have some ownership and/or employment role with a provider of direct-to-consumer orthodontic treatment. In particular, AAO members expressed their concern that such a relationship, if it in fact existed, might create a con!ict of interest between those individuals’ association with such company and their council or committee roles for the AAO.
        The AAO took these concerns seriously, as it does in any situation where a potential con!ict of interest is alleged. Under the AAO’s Con!ict of Interest policy, “A con!ict of interest exists when an individual has a direct or indirect (i.e., bene”ciary) interest or relationship, “nancial or otherwise, that may con!ict or be inconsistent with the individual’s duties or exercise of independent judgment with respect to the Association.” Certainly, the AAO considers a signi!cant role (ownership or employment) with a company whose teledentistry practice or treatment is
        not in accordance with the AAO’s
        not in accordance with the AAO’s Current Teledentistry Parameters to be a con”ict of interest with positions of service on its councils and committees.
        The AAO’s Policy of Con!ict of Interest provides a number of potential options to address a con!ict of interest. These range from simple disclosure to the full board or council/committee, to recusal from pertinent discussions or votes, to removal from the council/committee position. Each alleged con”ict of interest must be assessed individually, under the particular circumstances regarding the relationship giving rise to the con”ict, as well as the AAO role or position that is a#ected. As you can appreciate, the AAO cannot and would not react to any allegation of a con!ict of interest prematurely, but must act carefully and deliberately in order to (a) ensure that all information concerning the alleged con!ict is accurate, and (b) provide all necessary due process in considering a response, including providing the allegedly involved individual appropriate opportunity to respond and provide information.
        The AAO has followed these considerations in responding to the present situation. Information, including that provided by the individuals involved, indicates that the alleged relationship no longer exists. The information gathered further indicates that the nature of the alleged relationship was limited, such that there was no undue in!uence on any decision taken by the relevant council or committee.

        The AAO takes very seriously its role in protecting the health and safety of orthodontic patients. This includes ensuring that AAO members serving on councils or committees are una#ected by any potential con!ict of interest that could hinder their role in protecting patient health and safety, including through abuses of teledentistry and similar treatment models. You can rest assured, as an AAO member, that the AAO will take any allegation of such a con!ict of interest very seriously, while at the same time, acting in a manner to carefully comply with AAO policies and procedures as well as protect the due process and other rights of the AAO member involved.
        Sincerely,
        Christopher A. Roberts, DDS, MS President, American Association of Orthodontists

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