Dr Tariq Drabu Affair Around Whitening Update

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?

Tariq Drabu Dentist Affairs Around Cosmetic Practice

The time has come for better and effective regulation of non surgical cosmetic treatments such as Botox and dermal fillers. This follows the publication of a report published on 24 April by the Department of Health in England. The report is entitled the "Review of the Regulation of Cosmetic Interventions". The Department of Health reporting group was asked to review regulation in the cosmetic interventions sector following the PIP breast implant scandal which revealed serious lapses in product quality, after care and record keeping. I was astounded to read that the report also draws attention to widespread use of misleading advertising, inappropriate marketing and unsafe practices right across the sector. The report points highlights that cosmetic interventions are a booming business in the UK, worth £2.3 billion in 2010, and estimated to rise to £3.6 billion by 2015. They can either be surgical – such as face-lifts, tummy tucks and breast implants – or non-surgical – typically dermal fillers, Botox or the use of laser or intense pulsed light (IPL). These latter account for nine out of ten procedures and 75% of the market value.

The report authors were surprised to discover that non-surgical interventions, which can have major and irreversible adverse impacts on health and wellbeing, are almost entirely unregulated. The report highlights that a person having a non-surgical cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush. This type of finding points to an industry that is out of control with no regulatory input where everybody and anybody with minimal training can set themselves up to provide services. The industry is glamourised by the media who fail to discriminate between legitimately trained and ethical practitioners with a scientific background and operators who are just cashing in.

As a concerned, responsible and ethical practitioner I support the key recommendations of the report namely:

• 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.

We have looked at the regulation of these procedures. If you are working in an unregulated environment where you do not have to worry about hygiene, safety, inspections and regulations you will be able to provide this procedure at a cheap cost. There are no issues of training or continuing professional development or education involved. In this way you are putting your health at risk and those people who administer these treatments they are a danger to the public and must be stopped. I am not saying that doctors and dentists provide these treatments cheaper. However at least you know that you will be treated in a safe, clean, hygienic environment to the highest standards by a professional whose job is to put your safety above all else. I continue to support the position that only trained doctors, dentists and nurses should provide nonsurgical cosmetic treatments.

I and my team at Langley Dental Practice, Middleton, Manchester have been offering treatments such wrinkle smoothing and dermal fillers for almost 10 years with excellent results. We also offer tooth whitening administered by UK trained and qualified dentists from only £199. Currently non-surgical procedures such as laser treatments or injectables can be administered by people with no healthcare qualifications whatsoever. I was quite astounded when I read that you do not need to be medically trained to administer these types of procedure. Regulation of these procedures is important and I hope that the government will act swiftly and decisively.

Tariq Drabu Dental Foundation Training 2013 Funding

I recently gave my 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/40302

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. 

Dr Tariq Drabu Affairs Around Update Cross Infection Guidance

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.

Our job as responsible professional dentists is to ensure the highest standards of care for our patients. This is in all aspects of treatment including decontamination and infection-control. However these needs have to be balanced with the requirements of running a frontline busy primary-care dental practice within in many cases a high street setting. We are not able to send our instruments to a central reprocessing centre for them to be sterilised like hospitals do. The original HTM 0105 document was found to be extremely difficult to work with and had a poor evidence-base and was criticised from many quarters of the profession for its poor evidence base. From the outset many dentists were of the opinion that it was technically flawed and over cumbersome and placed far too much burden on process rather than outcome. The British Dental Association was at the forefront of lobbying for change and I am pleased to say that it has been successful in reversing many of the somewhat burdensome items of the original document.

The most important and significant change to the document is the extension to the shelf life of wrapped instruments from either 21 or 60 days to a maximum of one year. As things stood we were going through cycles where we were repeatedly sterilising and autoclaving instruments that were not being used on a regular basis purely because of either 21 or 60 day deadline. Interestingly enough, prior to the revision there were different deadlines for England Scotland Wales and Northern Ireland. The twelve-month deadline is a very sensible and logical proposal and helps in the efficient running of dental practices without compromising patient safety. Another very important change is the fact that unwrapped instruments in a clinical area can now be stored for one day and if they are in a nonclinical area they can be stored for one week unwrapped. A non clinical area has been defined as either a clean area of the practice decontamination room or a clinical area not in current use. Another important change is the removal of the obligatory requirement to have two separate sinks in a decontamination area in order to wash and rinse instruments. Manual washing scrubbing and rinsing can be done with one sink with a removable bowl that is contained within the sink just for the purpose of holding instruments for watching and rinsing.

When I first took over Langley Dental Practice in 1998 it was a very rundown building in a poor state that I knew in a few years would not be fit for purpose. Therefore when I redesigned Langley Dental Practice back in 2005 I knew that further and tighter and more stringent cross infection rules and regulations would be coming. Therefore from the outset I incorporated dedicated built-in cross infection areas into the design of the building. We have always been praised when the practice has been inspection expected whether by the local health trust or by the North West deanery or by the Care Quality Commission (CQC). We regularly audit our cross infection procedures and policies and the latest guidance from Department of Health has now amended the requirements from 3 monthly audits to 6 monthly audits.

The government and the dental profession need to work together to ensure progress and ways forward for the best treatment for our patients. Logic and common sense need to prevail over rigid fixed and intransigent positions. I am really pleased that the government has demonstrated that it is able to listen to the genuine concerns of the dental profession and take them on board in order to promote the highest standards of care and also the efficient running of dental practices.

Tariq Drabu Dentist Funding Rise Disappoints

The Department of Health in England have recently announced that will award NHS general dental practitioners in England an uplift on their funding of just 1.5 per cent for the year 2013/14.

We are not just dentists we are also responsible members of society and we realise that public finances are tight. As dentists we understand that difficult choices have to be made but we also have to look at our ever increasing cost base in the face of a static income stream from the NHS. Water, gas and electricity for example are amongst the items that have increased way beyond the level of inflation over the past two years. There is also an increased burden and cost implication of tighter and more stringent regulation from bodies such as the Care Quality Commission (CQC). These increasing expenses eat in to our cost base and therefore will eventually have a direct impact on patient care.

This month sees the biggest shake up in health care in England since 1948 and it is a time of major uncertainty for dentists. Local arrangements, whereby dentistry was commissioned by Primary Care Trusts, have been abolished and replaced by arrangements with the National Commissioning Board based in Leeds and London. At the moment, we do not know which personnel we are dealing with and what their remit is. Allied to that, we face the prospect of a new dental contract in 2015 about which few details are as yet known except that it is to be based on capitation, registration and quality. There is no detail about how this contract is to be delivered and by whom.

NHS dental charges have gone up for the three bands of treatment. A band 1 has gone up from £17.50 to £18.00, a band 2 from £48.00 to £49.00 and a band 3 from £209 to £214. Dentists act as unpaid tax collectors for the government and if patients don’t pay we end up holding the bad debt. This is a very unfair state of affairs and one which is not replicated in any other aspect of direct health care.

I am proud to come from a family who have worked and served the NHS since the 1950s. In 1998, when I bought Langley Dental Practice it was a very run down premises but I bought it because I wanted to make a difference to people’s lives. In 2005, the practice underwent a total rebuild and refurbishment - a project that took 6 months. Support for this expansion came from local MP Jim Dobbin and the then Minister at the Department of Health Rosie Winterton MP, both of whom personally visited the practice to show support. I invested more than £350,000 to secure the rebuild and improve dental services for the residents of Middleton. The practice more than tripled in size and expanded from 2 to 4 chairs. High tech dedicated cross infection areas and modern brand new dental equipment were installed. When the practice reopened in October 2005 it was featured in both local and national press and on TV. Our patient base has expanded from 1500 back in 1998 to nearly 20000 now.

I am also wary of the further stipulations and conditions put forward by the Department of Health (DoH) around future contract management which lack detail. The DoH have announced that dentists will be expected to continue to work closely with the them and the NHS Commissioning Board to prepare for moves to a national contract based on capitation, quality and registration; there is also mention of a further move to fully computerised practice systems and a nationally consistent approach to contract management. The package mentions changes to the way the NHS will manage dental contracts at the end of the 13/14 financial year and new ways to ensure more appropriate patterns of referral between dentists both within primary care and to acute services. There is no detail about these measures as yet and we need to see what is being proposed. Our aim as dentists should be to do the best for our patients and be able to work with a contract that puts oral health at the front of the agenda and delivers a workable quality based system of remuneration. I hope that these changes can lead to this.

Dr Tariq Drabu Affair Around Dental Access

The latest set of statistical figures produced by the NHS which show an overall increase in NHS dental access but still have some numbers that prompt concern. 
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.
However, looking at it from another angle, it shows that the 29.7 million figure is an increase of 135,000 patients on the previous quarter and a rise of 265,000 on the same quarter in 2011-12. The total number of patients seen has increased each quarter since its lowest point in June 2008. In December 2009 the number exceeded the March 2006 baseline, when the current dental contract was introduced. So overall the news is positive in terms of raw numbers, however there remains a massive amount of work to be done to get a larger proportion of the population to access NHS dentistry.
It is disappointing to note that the number of children seen by an NHS dentist is equal to the March 2006 base figure of 7.8 million; however what is of more concern is that the percentage of children seen (69.0 per cent) is below the 2006 base figure (70.7 per cent). When the coalition government came to power in May 2010 they promised to make the dental health of children a priority and I seems that they have not been able to deliver on this. Child dental health is important.
Here in North Manchester, we practice in an area of high social deprivation and poor dental health. In terms of tooth decay levels, our local health trusts are in the bottom 20 out of all 300 health trusts in the whole country. Figures from the Department of Health show that areas like ours have children's tooth decay rates that are eight times worse than the best areas in the country. As such, we need prompt and proactive public health measures such as water fluoridation in order to improve the dental health of the population, especially children. A comparable area like South Birmingham, which is in the bottom third for social deprivation but which has fluoride in the water, is in the top third of areas with the lowest levels of tooth decay. So, when we compare like for like we can see that fluoride does work.
The amount of treatment appears being undertaken appears to be less There were an estimated 9.9 million Courses of Treatment (CoTs) in the second quarter of 2012/13, a decrease of 118 thousand (1.2 per cent) on the same period in 2011/12. All treatment bands saw a decrease in the second quarter of 2012/13 compared with the same quarter in 2011/12. These figures may indicate an increasing move towards prevention.
I find it both sad and amusing that an MP from the Labour Party, which abolished dental registration in 2006, who has dentistry as his brief, has actually tabled a parliamentary question asking about the number of registered dental patients. This just shows a woeful and inadequate level of understanding.
There are lies, damned lies and statistics. It is easy to look at headline figures, but any set of statistics need deeper analysis and reflection. They can be viewed from many angles and seized upon by people with different agenda to satisfy their political needs. The good news is that more patients are being seen but the figures are a mixed bag.

Tariq Drabu Affair on Public Health and Flouride

Recent dental news revealed that in Wales more than four in 10 children are suffering tooth decay by the age of just five, according to figures released today by the Welsh Government. These worrying figures came to light last month just as the Government launched its National Oral Health plan, which aims to tackle dental problems in children. Tooth decay is a preventable disease and it is a well known fact that getting fluoride in to contact with teeth will have a positive effect on dental health. The best ways of doing this is by Fluoridation of the public water supply.

With the abolition of Primary Care Trusts responsible for local health provision after 1st April these current NHS reorganisations may lead to moves towards public water fluoridation being missed and in some cases abandoned, leading to a deterioration in the dental health of the population, especially children.

Last year there was confusion surrounding the proposed fluoridation of water in Southampton. In early 2012, the South of England Strategic Health Authority, which is due to be abolished in April 2013, insisted that fluoridation was due to go ahead in Southampton. However, from April 2013 the decision for fluoridation was to be passed to the local council. The council itself has already voted against the measure. The current understanding is that now, in a move that makes matters even more confusing, Southampton city council will await the outcome of a government consultation before deciding if they will consult residents on whether the fluoridation scheme should go ahead or be stopped. If the Southampton situation is reproduced all over the country where nobody knows what is going on then we are heading for a complete and utter mess. The current state of affairs is ambiguous, uncertain and muddled and it must be reviewed.

We practice here in North Manchester, which is an area of high social deprivation and poor dental health. In terms of tooth decay levels, our local health trusts are in the bottom 20 out of all 300 health trusts in the whole country. Figures from the Department of Health show that areas like ours have children's tooth decay rates that are eight times worse than the best areas in the country. Therefore we need prompt and proactive public health measures such as water fluoridation in order to improve the dental health of the population, especially children. A comparable area like South Birmingham, which is in the bottom third for social deprivation but which has fluoride in the water, is in the top third of areas with the lowest levels of tooth decay. So, when we compare like for like we can see that fluoride does work.

Back in 2010 after the election the Coalition government in its flagship "Programme for Government" document said not only that it would introduce a new NHS dentistry contract but more importantly it talked about an additional focus on the oral health of schoolchildren. The new contract is making ground but the dental public health of children is falling by the wayside and the confusion surrounding fluoridation will only make matters worse.

We need a strong lead from government to get fluoridation back on the agenda. The government talks a lot about reducing health inequalities. It needs to show that it is serious. It can show that it is serious by pushing forward with a programme of water Fluoridation.