Global utilisation of the internet continues to increase at a phenomenal rate, with an estimated 11 new users per second and one million new users per day.1 This continual rise, alongside the more recent rise of social media, has led to a considerable increase in the volume of digital advertising and marketing by dental practices across the United Kingdom (UK). Budd et al.,2 in particular, found that between 2011 and 2014, the number of practices across Wales with a dedicated practice website had almost doubled.

While digital promotion and showcasing of dental services may appear straightforward, it is easy to breach a number of common advertising regulations.3 The General Dental Council (GDC) makes specific reference to advertising in its Standards for the dental team (henceforth referred to as Standards); Standard 1.3.3 states: 'You must make sure that any advertising, promotional material or other information that you produce is accurate and not misleading'.4 In 2012, before the release of Standards, the GDC published its Principles of ethical advertising, detailing how ethical and lawful compliance with their regulations could be attained.5 This was subsequently updated in 2013 with the release of Guidance on advertising and introduced the terms 'must' and 'should', reflecting the prose in the main Standards booklet, as well as introducing new guidance on product endorsement and marketing websites.5,6

All methods of advertising, whether digital or conventional, dental or non-dental, are strictly regulated throughout the UK.7 Advertising in the UK consists of two approaches: self-regulation and co-regulation.8 Self-regulation refers to non-broadcast advertising - that is, all advertising except television (TV) and radio - where the industry help to write the very advertising codes to which they must adhere.9 In addition to this, and akin to dental professionals and their relationship with the GDC, self-regulation sees advertisers fund the very organisation to which they report; this funding comes in the form of an 'arms-length levy'; that is, the enforcing organisation is unaware of who and how much is paid, allowing them to remain impartial and independent.9,10 Co-regulation of TV and radio broadcasting is undertaken by the Advertising and Standards Authority (ASA) who regulate the content of broadcast (and non-broadcast) advertisements, in conjunction with the Broadcast Committee of Advertising Practice (BCAP) who write and maintain the UK Code of Broadcast Advertising.9

Dentistry is considered an essential service in the UK, with the market value of the UK dental sector predicted to reach £7.2 billion in 2019-2020, before the COVID-19 pandemic.11 It can therefore not be surprising that, with 87% of UK adults using the internet daily in 2019, dental practices are keen to promote and advertise their services across websites and social media.12 With around 2,500 GDC-registered prescribers of aesthetic products currently active in the UK and a cosmetic industry worth approximately £3.6 billion per year in the UK alone, dentistry is increasingly considered to exist as a commercial enterprise.13,14,15 A recent scoping review was conducted regarding the relationship between professional and commercial obligations in dentistry. This review highlighted that commercialism, for the most part, has been presented as a 'direct threat' to professional values and patient care in the literature.14,15 The ramifications of advertising aesthetic treatments on dental professionalism, consumerism and commercially driven practice will be discussed later in the article.

Background and objectives

The GDC first published guidance on advertising in their 2001 document Maintaining standards and again in their 2005 document Standards for dental professionals, with specific mention given to the need for justification of the trust placed in us by colleagues, patients and the public, as well as not making any claims which could mislead patients.16,17,18 Historically, however, evidence in the literature indicates that overall practice compliance with advertising regulations is poor, with no significant difference observed in the compliance of a primary or secondary care service.2,17,19,20

In the UK, previous research into implant practice websites, orthodontic practice websites and primary care websites all conclude that, although some aspects of the regulations are followed, very few practices conform to all regulatory requirements.2,17,19,20,21 These studies, although congruent in their findings, did not utilise the same methodology in their assessments of websites.2,17,19,20,21 Even those conducted after the most recent GDC guidance on advertising was published in 2013 did not use the most up-to-date guidance in their methodologies.2,6,17,20,21 Looking further afield, research carried out in Australia in 2017, concerning compliance of dental practice Facebook pages with national healthcare advertising regulations, highlighted poor compliance. The research found that the majority of practices sampled were not conforming to Australian advertising law.22

As patient demand continues to rise, the number of dental practices now providing facial aesthetics treatments has risen alongside it. These treatments typically involve utilisation of prescription-only medications (POMs) such as botulinum toxin injections (for example, Botox) and non-POMs such as dermal fillers.23 The Medicines and Healthcare products Regulatory Agency (MHRA) prohibits advertising of POMs to the general public. Their document The blue guide advises that, regardless of registration as a healthcare professional or not, promotion of a POM to the public is unlawful, whereas promotion of POMs to healthcare providers who can provide or supply the product is permitted.24 Dermal fillers are considered to be a medical device and not a POM; therefore, they do not undergo the same advertising restrictions.

The Committee of Advertising Practice (CAP) published new guidance, jointly with the MHRA, on 9 January 2020 regarding advertising of botulinum toxin injections on websites and social media.25 The guidance advised that targeted enforcement action will be taken after Friday, 31 January 2020 should websites, paid-for ads, non-paid-for marketing posts and any influencer marketing be found to advertise or directly reference Botox or other POMs.25 While this included hashtags and phrases like 'anti-wrinkle injections', which could be interpreted as an indirect reference to Botox or a similar POM, the ASA did state that there are occasions where this may be allowed. Failure to comply with these regulations could involve referral to the MHRA or a relevant professional regulatory body such as the GDC.25 The dento-legal challenges of advertising and use of social media by dental care professionals have been previously explored in the literature, emphasising that although websites and social media are excellent networking and communication tools, they must be used properly and in line with the appropriate guidance.26

Despite the announcement of this new enforcement notice, advertising of POMs has been illegal in the UK since 1994 under the Medicines (Advertising) Regulations 1994.27 The Human Medicines Regulations 2012, specifically Part 14, is now the relevant legislation in the UK regarding advertising of POMs.28 Nichols and Halsall19 found that, in 2011, 25% of practices in their 150-practice sample were openly advertising Botox directly or via indirect references such as 'muscle freezing injections' and concluded that practitioners may be knowingly or unknowingly breaking the law when advertising such treatments.

This area of research focuses on the UK Code of Non-broadcast Advertising and Direct & Promotional Marketing (CAP Code), which covers the marketing and sales promotions of non-TV and non-radio advertisements.29 We aim to investigate the advertising of botulinum toxin injections and POMs on dental practice websites and social media in accordance with CAP Code Regulation 12.12 and the ASA guidance on POM advertising.30

The aims and objectives of this study were: to assess compliance of dental practices across North East England and North Cumbria (NENC) with the GDC Guidance on advertising; to assess compliance of dental practices across NENC with ASA guidance and CAP Code 12.12 - prohibition of marketing of prescription-only medicines/treatments to the public; to increase awareness of the regulations surrounding advertising on internet and social media for dental providers; and to provide checklists for dental practices and dental professionals to safeguard their own compliance with GDC and ASA-CAP advertising regulations.

Materials and methods

All sites providing dental care in England must be registered with the Care Quality Commission (CQC).31 Dental practices were identified from the publicly available database on the CQC website which is updated on a weekly basis ( The database dated 18 April 2020 produced a list of 11,062 practices.

Development of our practice list involved limiting this catalogue to premises categorised as providing dental treatment located in NENC. This region was chosen as all three members of the research team have current and/or prior knowledge of the geographic locale. Nomenclature of territorial units for statistics (NUTS) codes for the North East were used to identify practices in our catchment and included postcodes NE, DH, SR, DL, TS and CA (Carlisle postcodes, encompassing North Cumbria).31,32 This left a list of 512 premises providing dental care. Seventy-two of the 512 practices had a duplicate entry on the CQC practice list and were subsequently removed, leaving a sample of 450 practices. A web-based Google search for the respective dental practice websites and a Facebook and Instagram search for dental practices (either directly or through a social media link on the website) was performed. Facebook and Instagram were chosen as they have been consistently shown to be the two biggest social media platforms for user interactivity and return on investment.33

The first section involved assessing adherence to the 2013 GDC document Guidance on advertising for each practice (Box 1).6 Secondly, compliance against ASA guidance and CAP Code 12.12 was validated against a checklist created from available ASA-CAP online resources, for each practice website and social media page.30 As the recent enforcement notice became enforceable from 31 January 2020, data from practice websites, Facebook pages and Instagram accounts were considered from 1 February 2020 to 19 April 2020. The criteria to be met for aesthetic advertising for the practice website, Facebook page or Instagram account are shown in Box 2.

Data were collected by the research team (CD, JJ, SW) and analysed using Microsoft Excel (Microsoft Office Professional Plus 2016, Version: 16.0.4993.1001). Formal calibration of the data collectors was carried out before data collection by using a sample of ten practice websites and social media pages with inter- and intra-rater reliability standardised between the research team. One area was re-calibrated post-hoc when a discrepancy was discovered in the interpretation of the date a website was last updated versus the copyright date of the website when no update date was present.


Of the 450 dental practices sampled, 84.7% (n = 381) had a website, 72.7% (n = 327) had a Facebook page and 34% (n = 153) had an Instagram account. One hundred percent (n = 381) of the practice websites included the name of the practice (Fig. 1). GDC Standard 2.3.10 implies that, as a practitioner, you should make sure patients have the details they need to allow them to contact you by their preferred method.4 Interestingly, 0.8% (n = 3) of practice websites did not include the practice address and 4.5% (n = 17) did not include a phone number (Table 1). A much higher number of practices failed to include a contact e-mail address; 44.9% (n = 168).

Fig. 1
figure 1

Percentage of dental practice websites compliant with GDC Guidance on advertising criteria

Table 1 Dental practice websites compliant with GDC Guidance on advertising criteria

A similar level of practices included GDC numbers for all registered dental professionals (78.2%; n = 298) as well as their professional qualification (69.6%; n = 265); however, compliance regarding providing information of the country of the qualification was poor with 419 of 450 (91.8%) practices not providing details. In addition, a similar level of practices provided both their local complaints procedures (55.9%; n = 213) and details of whom to contact if patients are unsatisfied with the management of the complaint (50.4%; n = 192). A large number of practices clearly stated that the practice provided NHS treatment, private treatment or a mixture of both (84.0%; n = 320).

It was positive to see that a large cohort of practices did not compare their practitioners' skills or qualifications to others (97.4%; n = 371) and correctly used the term 'specialist' (94.0%; n = 358) where appropriate; however, these results are lower than the 2014 study completed by Budd et al.,1 which found 100% compliance. It is also useful to highlight a number of practices (83.2%; n = 317) avoided the use of memberships or honorary degrees (for example, FHEA) in their registrants' profiles.

GDC guidance stipulates that information must be current and website details must be updated regularly.6 Although this cannot be directly assessed, only around a quarter of practice websites (26.2%; n = 100) provided a date to denote when the website was last updated and so we could not be sure any of the other information on the remaining 73.8% (n = 281) of websites was accurate and current. Again, this may lead to confusion for patients.

A total of seven (1.8%) practice websites were compliant with all criteria. This was mainly as a result of neglecting to verify the country from which the primary dental qualification was derived. This is far lower than previous studies have demonstrated.2,7,17,19,20,21 The findings perhaps reflect under-informing rather than misinforming; nevertheless, GDC Standard 1.3.3 implies that advertising material must be accurate and not misleading and therefore not achieving 100% compliance is still not acceptable.4

The second section of data collection considered the ethical advertising of botulinum toxin injections and/or other POMs on practice websites, Facebook pages and Instagram accounts. Of the 450 practices included in the original sample, a total of 148 (38.8%) websites, 51 (13.4%) Facebook pages and 41 (10.8%) Instagram accounts mentioned or offered skin treatments and were subsequently analysed.

When comparing overall data from the three sources, Instagram accounts and practice websites were more compliant in avoiding direct advertising of POMs (Table 2). Overall, 77.0% (n = 114) of websites and 75.6% (n = 31) of Instagram accounts avoided mentioning Botox and/or other POMs on the landing page compared to 31.4% (n = 16) of Facebook accounts. Similarly, 87.2% (n = 129) of websites and 63.4% (n = 26) of Instagram accounts avoided direct POM promotion using before and after images pertaining to the use of Botox or other POMs, compared to 29.4% (n = 15) of Facebook pages. All three sources were particularly poor at avoiding the indirect promotion of POMs (Fig. 2); 19.6% (n = 29) of practice websites, 17.6% (n = 9) of Facebook pages and 12.2% (n = 5) of Instagram accounts. Reference to 'anti-wrinkle injections' alongside a price that relates to a POM can be seen as an ad for that POM; practice websites were almost twice as compliant (60.8%; n = 90) with this criterion compared to Facebook pages (33.3%; n = 17) and Instagram accounts (31.7%; n = 13).

Table 2 Compliance of practice websites, Facebook pages and Instagram accounts with ASA-CAP criteria on advertising prescription-only medicines (POMs)
Fig. 2
figure 2

Percentage of dental practice websites, Facebook pages and Instagram accounts compliant with each of the ASA-CAP advertising criteria for prescription-only medicines

A high number of websites (93.9%; n = 139), Facebook pages (92.2%; n = 47) and Instagram accounts (100%; n = 41) avoided the use of the title 'specialist' or 'specialising in' facial aesthetics or a POM such as Botox.

Overall, practice websites were more compliant to the ASA-CAP POM criteria. Websites had the highest compliance in six of the eight criteria, falling short in avoiding the use of inappropriate titles (such as 'specialist') and in avoiding references to treating medical conditions in a way that could indicate the promotion of a POM; for example, in treating hyperhidrosis. In addition, 27.0% (n = 40) of websites indicated the use of a POM for excessive sweating, compared with 9.8% (n = 5; n = 4) of Instagram accounts and Facebook pages.

The ASA stipulates it must be clear that you are promoting the consultation and not the treatment; that is, that a discussion of various treatment options will take place and a product won't be sold or administered if a customer is not deemed suitable. All Instagram accounts (100%; n = 41) failed to provide a statement to the effect that a 'consultation is required' or 'treatment may not be suitable for all'. Facebook accounts and practice websites also had a comparable low level of compliance with this at 7.8% (n = 4) and 24.3% (n = 36), respectively.


This is the first study in the UK to assess compliance of dental practice websites and their associated social media against published advertising guidelines on POMs including botulinum toxin injections and associated brand names such as Botox/Vistabel, Dysport/Azzalure, Xeomin/Bocouture and Aqualyx.25 Rule 12.12 of the CAP Code enforceable by the ASA directly states: 'Prescription-only medicines or prescription-only medical treatments may not be advertised to the public.'30 This is further compounded in chapter two of the Human Medicines Regulations 2012 which prohibits the publishing of an 'advertisement that is likely to lead to the use of a prescription-only medicine'.28 There is no ambiguity; it simply isn't allowed. Yet, in NENC, only 4.1% (n = 6) of practice websites and 5.9% (n = 3) of practice Facebook pages were compliant. Of the 41 practice Instagram accounts found to be advertising facial aesthetics, none were compliant.

Targeted enforcement action on social media by the ASA has now been in place since 31 January 2020.25 While the ASA compliance team are largely focused on posts from this point onwards, it should be noted that if posts pre-dating 31 January are immediately visible on a social media landing page and contain reference to a POM, these should be amended, or the ASA may take action.25 Social media was chosen as an area of specific target as this is where most breaches of Rule 12.12 have been observed.25 The enforcement notice, however, does not just specifically apply to social media; it also applies to websites, posters, leaflets, newspaper ads and magazine ads.25 Repeated infringements of the CAP Code can invoke a referral to the MHRA or even a professional regulatory body such as the GDC, which may result in a fitness to practise investigation.6,25

Zahra et al.,34 in a recent GDC-commissioned report, found that of all fitness to practise cases reviewed by the GDC between 2013 and 2016, 1.1% (182/16,461) involved cases of alleged advertising misconduct, a drop from the 10.8% observed in 2009-2010, before publication of the initial advertising guidance.21 Advertising cases were more common among dental care professionals and were found least likely to go beyond the 'assessment' stage of a fitness to practise investigation. Notably, however, if they did progress past the assessment stage, they were linked with an increased likelihood of case closure with a sanction (OR - 8.17). This gives credence to the hypothesis made by Nichols and Halsall19 in that, with a low risk of prosecution, the potential for increased revenue gain outweighs advertising risk. The GDC may take grievance with this as it contravenes Standard 1.7.1 in which patients can expect their interests to come before those of any personal, financial or other gain, for ourselves, our colleagues or businesses.4,35

The GDC asserts that you must ensure patients are not misled by using titles which could imply specialist status, such as 'facial aesthetic specialist' or 'specialising in facial aesthetics'. It was encouraging to see that a high number of websites (93.9%; n = 139), Facebook pages (92.2%; n = 47) and Instagram accounts (100%; n = 41) avoided the use of the title 'specialist' or 'specialising in'. The authors contend this is most likely as a direct result of an awareness of the related GDC guidance, but not necessarily the associated CAP Code.

The word 'guidance', by definition, does not imply an obligation; guidance simply aims to illustrate a suggested best practice. It is noteworthy then that, in line with the roll-out of Standards in 2013,4 the GDC updated their advertising guidance to include the terms 'must' and 'should' where they state that when 'must' is used, the duty is compulsory, making it more of a requirement than a suggestion.6

Advertising, in its most basic form, is often tasked with the promotion and selling of goods and services. While the scope of this research was chiefly aimed at assessing compliance against published advertising guidance, the relevance of the findings needs to be discussed in the wider context of how they relate to the cultural and social milieu of dentistry, specifically, consumerism and cosmetic dentistry.15,36 Commercial advertising practices, especially those advertising facial aesthetic treatments, have the potential to damage the 'social contract' between the profession and the patient, when our perception of what is considered the 'social norm' is shifting.36

Instagram, where we found no compliance with advertising regulations of POMs for aesthetic treatments, is a key area of focus with regards to the use of before and after photographs. In cosmetic dentistry, we have witnessed a paradigm shift as the promotion of perfectly straight white teeth has become synonymous with having good oral health.36 With facial aesthetic treatments now so readily accessible in the dental setting, are we beginning to see a shift in the social norm of how a patient views their facial profile outside the oral environment? Once patients have reached their ideal dental aesthetic, they move on to consider the surrounding structures and how these can be adapted to complete their entire 'cosmetic picture'.37 The commonality that exists between facial aesthetics and cosmetic dentistry is the age-old argument of 'need vs want' - cosmetic treatment is seldom needed by a patient; it is self-perceived by the patient of having an improved effect on their quality of life.38,39,40

Dental practice is becoming a more consumer and commercially orientated practice, as dentistry becomes more elective in its provision of facial aesthetic treatments. Consumerism and the consumer response to inappropriate advertising of facial aesthetic treatments make the public vulnerable to unrealistic representations of the social norm by setting patient expectations too high.36,40,41

How then can the business of dentistry reconcile itself as a healthcare practice? Dentists currently find themselves in a precarious tripartite relationship between consumerism, duty of care and professionalism. Due to the very nature of the dental practice environment, a person can exist as a mixture of patient, client or consumer; for example, having dental trauma management as a 'patient', whitening your teeth aesthetically as a 'client' and buying interdental aids at the desk on your way out as a 'consumer'. With regards to advertising, we have an ethical, moral and social duty to appropriately advertise our services, especially regarding the 'medicalisation of beauty and the body' and the effect advertising of aesthetic procedures has on body image and body confidence.42 As the profession continues an upward trajectory towards increased provision of aesthetic treatments, we need to collaborate and understand a patient's needs and wants. This should be achieved without creating an idealised version of a 'need' from unrealistic and coercive advertising on websites and social media, thereby enabling maintenance of the delicate balance between consumerism and professionalism.15

The GDC Guidance on advertising, as with previous literature, remains a document with poor compliance, with some domains better adhered to than others. Areas of good compliance such as practice name, address and telephone number were ≥95% compliant, directly comparable to that in the available literature.2,7,17,19,20,21 Budd et al.2 found an increase in compliance in Wales between 2011 and 2014 with regards to the availability of a practice e-mail address; this, however, was not the same story in NENC, with only around half of practices (55.1%; n = 210) having their e-mail address available on their website. It must be noted, however, that in most circumstances where an e-mail address was not given, a white-space 'contact us' electronic form was in place.

The introduction of the General Data Protection Regulation (GDPR) in 2018 has seen a marginal decline in the volume of daily 'spam' e-mails being received.43 Practices may nonetheless still have considerable reluctance to place their e-mail address on the practice website to avoid unwarranted spam e-mails. The GDC's stance on this is clear; the e-mail address must be included. The 'contact us' forms used by a substantial amount of practices are insecure and the GDC has not yet included encryption as part of its advertising guidance.44 Transport Layer Security (TLS) encryption is the primary means of protecting network communications over the internet and the authors suggest that this should be incorporated into the next guidance update to ensure any forms filled out on a practice website are fully secure.45

This is the first study to show that, although marginal, practices can be fully compliant with GDC advertising guidance. Corporate practices were better in some domains (for example, country of qualification) and poorer in others (for example, e-mail address of the practice), when compared to independent practices. There were no significant trends observed with regards to whether practices providing private and NHS treatment were more likely to have a website, than those solely providing NHS dentistry. Eighty-four percent (n = 320) of practices were clear on the types of treatment they offered; whether NHS treatment, private treatment or a mixture of both.

Checklists used in the healthcare setting can not only increase patient safety but also promote process improvement at the same time.46 Checklists have most merit in processes that are simple, easy to follow and consistent, much akin to their use in aviation.47 The GDC issued an advertising checklist to complement their advertising guidance in which they lay out general questions to ask about yourself, the practice and website content.48 The authors are of the assumption that registrant knowledge of this checklist is low and are in agreement with Addy et al.7 that perhaps few practitioners or web design firms are aware of the GDC advertising guidance, and as such, are inadvertently non-compliant.

Each GDC registrant is responsible for the content or information that appears about them on practice websites and social media.2 Furthermore, it is the responsibility of each individual registrant to ensure that specific information is available when they are mentioned on a practice website. The authors agree with previous literature that increased awareness about this little-known fact is required.2,7,17,19,20,21,26

To this end, we have created three simple, logical and easy-to-follow checklists and summary examples that should put both individuals and practices on the road to compliance with the GDC and CAP Code of advertising (Appendices 1, 2 and 3). These checklists cover: the information individuals should cross-check website compliance with (Appendix 1); practice information that should be available on websites (Appendix 2); and facial aesthetics information, including POMs available on websites and social media (Appendix 3). The checklists could similarly be utilised by the considerable number of practices which employ third-party web design companies to run their websites and social media accounts, as well as by facial aesthetic trainers to give to their delegates, ensuring guideline compliance from the outset.

Hoppenbrouwer35 advises that the guidance should be interpreted as being 'circumstance-specific', with erring on the side of caution to ensure compliance recommended. The British Dental Association (BDA) advises that, if you have difficulty complying with guidance, you should seek advice from your indemnity provider.49 It is hoped that these checklists will go a long way to not only help improve the quality of information available to the public, but also to help dental professionals ensure they comply with their ethical and legal obligations on promoting their services.7 This will, however, require the GDC, ASA, defence unions and bodies such as the BDA to regularly publish reminders regarding adherence, to make more registrants aware of the guidance.

Overall, despite some domains of GDC advertising compliance remaining low, the profession continues to move forward in its aims to fully meet the standards laid down by our governing body, with overall compliance finally being met in this study, although at a relatively low rate.17 This study provides a baseline for future comparison with regards to compliance against the CAP Code for POM advertising of aesthetic treatments. The findings from this study indicate that there is a generally poor level of compliance with the advertising guidance of botulinum toxin injections and other POMs. Websites generally provided a better overall level of compliance than Facebook pages and Instagram accounts.


Compliance with the most up-to-date advertising guidelines from the GDC and ASA is varied and better on websites than social media. Despite the existence of easily accessible guidance, it remains to be seen why 100% compliance has not been reached. A lack of registrant knowledge surrounding the scope of guidance available has most likely resulted in inadvertent non-compliance. Some domains of the guidance are better adhered to than others. Easy-to-follow checklists should enable registrants and third-party web designers to advertise the appropriate information in order to remain compliant. Regularly published guidance reminders by appropriate bodies should lead to increased registrant compliance. This paper serves as a baseline going forward for adherence to guidance on facial aesthetics advertising and the findings should be generalisable to the rest of the UK.