Dr Jalpesh Patel, advanced facial aesthetic practitioner and qualified dentist, argues the dental profession should ensure there is greater accountability and transparency in the growing aesthetics sector and a register of practitioners is a good place to start.
Back in 1588, in ‘Love Labours Lost’, Shakespeare wrote ‘Beauty is bought by judgement of the eye’. These days, given that an estimated one million selfies are taken world-wide every day, with the average millennial taking 25,700 of them during their lifetime, the ‘eye’ in question is likely to be your own. That's a lot of self-scrutiny.
Certainly, the demand for aesthetic dentistry and increasingly, facial aesthetic treatments utilising botulinum toxin and dermal fillers has never been greater. Those dentists dental hygienists and therapists who place injections daily have a sound knowledge of facial anatomy and understand the importance of detailed assessment, the consent procedure, infection control and complications management. This means we are well placed to offer and administer aesthetic treatments. For many of us, it is a natural progression to extend services to offer non-surgical cosmetic interventions to patients.
But we have a lot of competition. The demand for fillers and other procedures is filtering down to ever-younger patients, whose self-worth is often defined by likes and followers. Social media, ‘reality’ TV and the rise of celebrity influencers, are all fuelling this. And where there is demand, there is supply. Outside of medically trained professions, this growth is happening without adequate regulation and protection and cut price treatments offered by salons, spas, in homes and hairdressers have further served to trivialise these treatments and this industry.
It has been five years since the Keogh Review, undertaken by Sir Bruch Keogh for the Department of Health, highlighted ‘a person having a non-surgical cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush.’1 On the face of it, little has changed since then.
However, change is starting to happen and I would argue that those involved in these procedures, like myself, can help spearhead the movement. Firstly, we need clear guidelines and educational pathways to ensure that we ourselves are competent to provide these treatments to high standards. Secondly, we need to work together with other medical professions to reduce the risk profile within the facial aesthetic industry. Finally, we need to educate our patients to understand the risks involved with these procedures.
Guidelines and Education
On the back of the Keogh Review, the Department of Health commissioned Health Education England to develop qualification requirements for the delivery of Botulinum Toxin and Dermal Fillers with the aim of improving and standardising the training available to practitioners.
The standards relating to these requirements were subsequently created by the CPSA (Cosmetic Practitioners Standards Authority). The Joint Council for Cosmetic Practitioners (JCCP) currently work alongside the CPSA has been established to provide a recognised vehicle for accrediting and assessing practitioners and training providers in the non-surgical sector, as well as the means for collecting data on the success of procedures and adverse reactions.
The JCCP advises that registered dental practitioners, dental therapists and dental hygienists can undertake injectable toxin and dermal filler treatments and all other JCCP recognised modalities and they will be registered on Part A of the JCCP register. The JCCP also advocates that:
1) Dentists, dental therapists and hygienists should undertake post initial qualifying training level 7 courses in their chosen modality e.g. injectables
2) Dental therapists and hygienists must be under the supervision of an appropriate prescriber whenever carrying out any treatment involving dermal fillers or botulinum toxin
Those dentists, dental hygienists and therapists who place injections daily have a sound knowledge of facial anatomy and understand the importance of detailed assessment, the consent procedure, infection control and complications management.
The JCCP gives dentists and dental hygiensts and therapists access to accredited training providers who ensure there is compliance with the designated standards. It helps the public differentiate between those qualified to practice and those lacking in suitable training and expertise.
As dental registrants, we already benefit from the regulation and framework for training and standards set out by the GDC. Our patients know and are confident we are qualified to treat them as well as ethical in approach and fit to practice. The GDC do not currently have standards or educational frameworks that are specific to facial aesthetics and this provides a grey area in regard to guidance for dentists and DCPs who wish to provide these treatments.
In my view, dentists and DCPs and the GDC should work in partnership, alongside a voluntary regulatory body such as the JCCP and the CPSA, who already have such exacting standards and frameworks in place, to help protect both the practitioner (by differentiating the services we offer from the unsuitable alternatives) and the patient (who will benefit from more informed practice).
Reducing the risk profile in the industry
My practice involves around eight sessions of general and cosmetic dentistry a week, compared to one or two sessions carrying out facial aesthetic treatments. Like many dentists, although my main focus is still dentistry, I really enjoy the aesthetics.
As in dentistry, the patient talks through their concerns, they are clinically assessed and suitable treatment options are then provided whilst highlighting realistic outcomes and possible adverse reactions.
As GDC registrants, we owe it to our patients to ensure that they are fully informed about the procedures that they are about to have. Sir Bruce Keogh referred to the facial aesthetic sector as the ‘wild west.’ A landscape barren of information, with very little in the way of signposting for both practitioner and patient. A review in Clinical, Cosmetic and Investigational Dermatology4 in 2013 stated that all dermal fillers have the potential to cause complications; complications that could be attributed to the volume of the filler administered, the technique of the practitioner or the product itself. Serious complications include vascular occlusion, leading to tissue necrosis and even potential blindness.
It is well known within the industry that there is a lack of reporting of adverse reactions following facial aesethetic treatments. This is partly due the absence of a formal process to report an adverse reaction but also, some practitioners may feel a reluctance to self-report adverse incidents to avoid scrutiny. It's important for us all to encourage openness and transparency if we want to raise safety standards across the sector as it protects both the patient and the practitioner.
Although dermal fillers are due to be regulated in EU member states by May 2020 on the same basis as medical devices, the MHRA has confirmed there are no plans in place to make them prescription only, yet 83% of BMJ members felt they should be.5 It therefore remains our responsibility to have support mechanisms that will improve evidence-based practice. Evidence-based clinical practice forms a large foundation in our mindset and the JCCP encourages this learning culture. Alongside Northgate Public Service, the JCCP, provide the data collection surrounding treatments and adverse incident reporting. They will analyse and evaluate treatments that have led to adverse outcomes and then convey this information to practitioners to help minimise risk and subsequently safeguard patients by allowing a more informed consent process to take place.
Educating our patients
The ready and widespread availability of “botox” and dermal fillers adds to the public's perception that they are safe and the ‘norm.’ Non-surgical cosmetic interventions now account for 90% of market share in an industry estimated to be worth £3.6 billion in the UK.6
Despite this, there is little public understanding of the potential for an adverse effect, especially with the number of non-medically trained injectors, who lack the skills and qualifications to carry out clinical assessments/treatment and are unable to deal with complications should they arise.
As dental registrants we can make a significant contribution to raising standards and, by extension, its reputation. We can help to drive debate, educate the public and bring about much-needed reform. By ensuring there is greater accountability and transparency, we will also make the argument for having treatments in a safe environment, carried out by an appropriately trained professional.
We need to embrace openness and transparency. Data in registries like the JCCP will differentiate our services from the rest of the industry, helping to safeguard patient safety and raise standards and the profile of our sector.
Dr. Jalpesh Patel
BDS (Hons) (Lond) MJDF RCS (Eng) MSc (Aes)
Dr. Jalpesh Patel graduated with honours from King's College London in 2010. He is a member of the Joint Dental Faculties at the Royal College of Surgeons England and has also successfully completed his Masters in Aesthetic Dentistry, at King's College London, graduating with Distinction. He is currently studying towards a Masters in Skin Aging and Aesthetic Medicine at the University of Manchester. He is a member of the Practitioner Register Committee of Joint Council of Cosmetic Practitioners.