Sir, I read with interest the first instalment of what promises to be an interesting and useful series (BDJ 2006; 200: 661–665). In this first paper the authors have put forward a coherent, well supported and persuasive argument for the biological and clinical benefits of the provision of implants over conventional treatment strategies.

The concern I wished to raise, however, relates to the omission of an important component from the authors' discussion; namely economics. At no point in this paper are the cost implications discussed. I do not doubt the authors' argument that implants provide a better solution. The problem is that there is no mention that for many, these benefits may be financially unobtainable.

I do not suggest that the paper 'degenerate' into a NICE cost/benefit analysis, but where a significant change in clinical practice is being advocated a mention would seem sensible.

A defence union (or more importantly the GDC) would not consider valid consent to have been obtained for a treatment strategy without a discussion and estimate of the cost. I understand that many authors work in a secondary or tertiary care environment where patients may not contribute financially toward the cost of their treatment, or treat patients already self selected to be able to pay (on referral in specialist private practice). But this does not exonerate them discussing the financial implications of their clinical recommendations on the rest of us. Articles published in the BDJ are after all, mainly read by those working in primary care, dealing with patients for whom this is a very real concern.

Indeed the most regularly cited barriers to dental care by patients are access, anxiety, fear of pain and cost. I seem to recall that the patient consultation documents published prior to the Government's recent changes contained many responses criticising the cost of NHS fees even for exams and identifying them as a significant barrier to care. I think that the treatment being advocated here may be a bit more expensive than that!

Where expert opinion advocates a change in clinical practice, whether it concerns the viability of routine use of implants, the single use of endodontic files or another issue, experts have a responsibility not to do so in a financial vacuum.

Primary care does not expect the secondary and tertiary sectors to have all the answers, except on clinical issues that is (only joking), though it would be nice. We tend to be realistic. But it would be likely to facilitate a reduction in potential resistance to change if the side putting forward the idea identified problems with its implementation. This can only result in a more informed discussion from all parties and the correct identification of barriers to change at an earlier stage of the process.

I look forward to the next article with interest.