Dental Tourism: Home and Away

This article looks at the many aspects that need to be addressed for patients considering undergoing dental treatment abroad.

Patients are always on the lookout for the best deal possible, and getting value for money is considerably more important during this recession. For some, this can mean going abroad to obtain  the dental treatment they want at a price to fit their budget. In patients who have had treatment overseas, I've seen huge posterior composites, endodontically treated third molars, lengthy "suspension" bridges and full mouth implant restorations. While treatment like this pushes the boundaries of conventional dentistry, sometimes to its limits, it still works. But despite this, challenges remain to both the dentist and the patient.

Over the years, a multitude of press articles have been written on this topic. There is even a Wikipedia page! Just a quick search on Google reveals how much really is on offer and many companies will entice a prospective patient with incentives and the attraction of a holiday in the sun. Locations range from Eastern Europe to India to Central and South America to the Far East. It is marketed as a win win situation.

In our multicultural society, we're beginning to see more and more of this from patients who have emigrated to the UK and patients who have gone down the dental tourist road. For the patients from abroad, to them it's their normal treatment. But for those travelling overseas to undergo treatment  it can offer huge savings. There appear to be hundreds of dedicated companies that have been set up to offer this as an all-inclusive service. Some even have treatment planning clinics set up in the UK before patients get anywhere near a plane. It's almost like buying a package holiday. It sounds so simple: pick a clinic and destination, pay for flights, hotel, treatment and spending money, get over there, have the preps done, work on your tan for a week whilst waiting for the lab, have the work cemented and then get the flight back. The whole process probably takes up to two weeks to complete from start to finish and before you know it you've arrived back home with a smile to be proud of. Some claim there is an added bonus too and that the treatment can be carried out at faster timescales and fewer visits. It sounds too good to be true.

The surgeries are portrayed as very modern and appear to be beautifully kitted out with all the latest equipment. The material costs are virtually the same, especially in a custom lab. Yet all this must cost money, so how is it possible to offer the same treatments at slashed prices? At the heart of the debate lies the argument of quality variances with some perceiving the cheaper costs being the result of lower standards. Yet without concrete evidence, there's no way to actually prove that this is definitely the case. As for the internet reviews, these are far more positive than negative. Is that down to biased printing or is it really how the patient felt about their experience? It's hard to find a negative review and for good reason: it would be bad for business. For any patient who goes to research the subject, their view could be tainted. But we can't stop our patients from pursuing this route.

What happens if your patient does decide to go abroad? There's a lot to consider before, during and after their treatment. Does their country of choice have regulatory bodies that maintain their standards? Are the dentists suitably trained and then appropriately qualified in any necessary specialities? What experience do these dentists have? Are reliable references available? There are also legal issues for anything that might go wrong. If something happens during your treatment, is this covered by the patients travel insurance? What are your legal rights as a foreign patient? What about consent? Informed consent relies on a full understanding between both parties. Does this really occur in patients where there may be difficulties in the language barrier? What happens in differences of opinion between the dentist providing the treatment plan and the dentist who carries out the work?

It doesn't stop there though. Once the patient reaches home, who will  maintain and care for all the advanced work? What guarantees are offered by the clinic and dentist that carry out the treatment? Are there any clauses to these guarantees such as the necessity to attend regular reviews at their clinic? Who will cover the travel costs if you have to go to these reviews or if there is a problem? Is there an adequate complaints procedure? What happens when something fails or if there is a dental emergency? Will the patient's own dentist be competent enough to resolve any problems? Is the patients' dentist able to get a copy of the records to see exactly what treatment has been provided and the materials, components and techniques used? Are the records written in English and are they comprehensible? Are the records of sufficient quality and detail?

The other challenge posed is the foreign patient  who is now in your dental chair. It's a test of our communication skills and to some extent, risk aversion too. It can be difficult to break the news that the treatment they would prefer to have would be a poor long term option or is just not viable. Even if it looks like something with a very slim chance of success it still has to be within your level of competency and skill. And if it's not going to be sustained by your patient, is it really worth it? Why are  patients so desperate to hold on to a grossly carious third molar or always have tooth coloured restorations? You and I both know that they are not paramount to dental function. But it's down to patient perception. For them, they can't lose a tooth or something that doesn't match. It's up to you to offer the correct treatment and to make sure that you are not coerced into doing something you're not comfortable with.

You have to choose your words wisely. Does the patient understand their treatment options? Are they fully aware of the risks? Have you gained informed consent? Do they realise the sequelae in the event of a complication and how this may potentially have to be dealt with? With all these questions, it's akin to being grilled by an inquisitive child. And for good reason too. Some questions are ones that the patient needs to ask themselves, others that the dentist needs to ask the patient to get as much information about the situation as possible, and the remainder need to be addressed by both. It's an exhaustive list which can't be simply glossed over. At the very least they need to be put forward to the patient to show that their dental well-being is in our best interests.

However, the worst question of all is one that your patient asks back - "what would you do?" I dread hearing those four words, not just for the above discussion, but for every discussion about treatment options. No two clinical situations are the same and in 99% of cases I've never experienced first-hand the treatment I'm proposing to the patient. I've always tried to squirm out of answering the question by saying it's my job to explain the options but the patient's job to make a decision, which it is. We can advise and suggest the best options and make recommendations, but it's still up to the patient to make the final choice and for us to then respect and honour that choice.

All the paperwork, record keeping, patient options and discussions you have to provide may seem like a pain. But this is the minimum legal requirement. Clear treatment plans, written estimates, informed and signed consent, contemporaneous records - this is all stuff that's drilled into us as undergraduates to avoid any unnecessary hassle, stress or conflict once qualified. All dentists are regulated by the GDC, who "aim to: protect patients; promote confidence in dental professionals and; be at the forefront of healthcare regulation". It's their job. There's nowhere to hide from them. The GDC Standards Guidance document isn't handed out just for the sake of it. It's there to remind us of our duty of care and obligation towards patients. It is essentially a conditional document detailing our professional responsibilities and "set standards of dental practice and conduct". They also write the syllabus for dental schools too, to make sure that students leave with the right clinical abilities, academic knowledge and ethical and professional ethos.

Mentoring, training and support is available throughout a dentist's career. There's a myriad of postgraduate training before embarking on a speciality and the presentation of a CCT or CCST to show you've reached the required skill level and competency in that speciality. Logbooks, personal development plans, CPD and revalidation provide further evidence  that our standards and knowledge is kept up to date. It's a lot of effort for practice owners to sift through all the paperwork to make sure their practices are worthy of the seal of approval. Not just that, but any changes have to be paid for by the practice owners which can result in a  high cost to the budget. But this also provides continuity, ensuring that practices are of similar setup and standard. By getting practices to operate as close to a uniform blueprint as possible, hopefully uniform standards can be maintained.

My own personal dentist graduated from Sweden, and I have the utmost faith and confidence in him. He has been my dentist for close to two decades, before I even had thoughts of wanting to be a dentist. I always wanted to have some sort of career in healthcare, and it was him that made me choose to be a dentist. I go back and see him because of the trust I have in him and the relationship we have built. Even with my paranoid dental moments, if he says everything is ok, then I trust that everything is ok. That's exactly how it should be. We are general practitioners in a niche speciality. And just like with a medical GP, patients want trust, continuity and a professional relationship. That's what we need to aim to build. So, what would I do? Well I wouldn't go overseas for my treatment. It's not because I'm scared of a poor outcome or worried about the skills of an overseas dentist. It's partly because of the way our profession is regulated, the continual reinforcement that prevention is better than cure, and the maintenance after treatment. But mostly, it's because I trust my dentist with my teeth, and that's really all that it comes down to.

Hussein Hassanali