Question for Short Debate
My Lords, peri-implantitis may seem to be a somewhat obscure matter to debate today, but that is the very reason why I am raising the subject. As a long-retired dentist, I was quite unaware of the condition. I found it most interesting when I heard Professor Nick Donos, head and chair of periodontology and director of research at the UCL Eastman Dental Institute, address an international dental conference on this subject in London last month. I thank him and others who have provided me with valuable material for the discussion tonight.
This is an important and growing health problem and there needs to be an awareness and a degree of understanding of the present position and the growing risks associated with this increasingly popular form of dental treatment. The condition is peri-implantitis. When I attended my first international dental conference in 1955 in Copenhagen, dental implants were a new idea and early cases reported by those dentists present had often failed spectacularly. In some cases, large portions of a jaw were lost in the process, mainly due to the rejection of the foreign body—the dental implant —by the patient’s immune system.
Time moved on and it was found that the metal titanium was accepted by the body. Since then, titanium-rooted dental implants have become widely used in the replacement of missing teeth. Half a million adults have at least one dental implant, according to the latest Adult Dental Health Survey. Studies suggest that one third of these patients will have a milder disease—peri-implant mucositis—which is common and treatable. If undetected or untreated, these red swollen gums can develop into peri-implantitis, which is associated with both inflamed gums and jawbone loss around the implants. As with so many health conditions, smokers have a significantly higher risk of peri-implantitis.
The European Association for Osseointegration emphasises the importance of appropriate patient selection. Most of us would accept that view and, as patients, we would expect to receive sound advice from the appropriately trained dentists performing implant procedures. It is important to indicate for the patient, particularly in complex cases, that implant dentistry should be seen as a multidisciplinary treatment. Within the objectives of the General Dental Council curriculae for dental specialists, it is indicated that periodontology, the treatment of gum conditions, is the specialty in charge for the planning and execution of the surgical component, and prosthodontics is the branch of dentistry that deals with replacement of missing parts with artificial structures and executes the relevant implant superstructures.
Complications of implant therapy, particularly peri-implantitis, are within the objectives of periodontology. Some experts studying the condition of peri-implantitis, a growing problem, believe that there should be formal national registration of implants, national health and private, in the UK. This would probably be the first in Europe, and would enable regulation of the type and quality of the implant-related procedures.
An implant is a titanium screw that is inserted into the jaw under a controlled protocol and, when fused with the bone, forms an artificial tooth root. Their use is growing rapidly in the UK, and although they are costly they are often considered the treatment of choice for replacing missing teeth. They can also be used as a support for a more extensive prosthesis.
When I googled “dental implant”, as a patient often would if they had heard about this treatment, I was disturbed to read the advertisement:
“Get smiling again with our same-day dental implants”.
That is surely what can cause adverse conditions post-treatment and is contrary to all the recommendations from the official dental bodies, which believe the patient must be fully assessed prior to treatment and informed and treated if there is an existing periodontal condition before the implant procedure. It must also be made clear to them that an implant is not a treatment you just have and forget. Regular follow-up visits are required to ensure that a periodontal condition does not develop, first into mucositis, and then progress on to the more serious disease, peri-implantitis, which causes loss of bone supporting the implant and often loss of the implant itself.
Remembering the time when so many women were at serious risk from cheap silicone breast implants and the heavy cost of dealing with unsatisfactory, even dangerous, treatments, including removal or replacement of these, it is particularly important that we are aware that many people seeking dental implants are tempted by cheap offers from abroad. These usually have the great disadvantage that the patient does not have continuing care and may be totally unaware that periodontal follow-up is essential to ensure continuing oral health. These patients certainly need to be clear that care and control of the gums before and following implants are most important.
My noble friend Lord Colwyn sends his regrets that he is unable to be here tonight. He also sends the message, as someone who has done implants himself, that implants should be put only into healthy mouths.
When I tabled this Question for Short Debate, I had seen nothing in the press on the subject. I was pleasantly surprised to see that on 14 July the Daily Telegraph had a very informative article on peri-implantitis titled “The ‘Time Bomb’ in Dental Implants” about a patient, age 52, who had four teeth implanted at a cost of £13,000 in 2002. Three months ago this patient felt a lump on her lower jaw, near one implant. She went to have this checked, and it responded to antibiotics, but the X-ray showed that the bone supporting the implant was receding, and the diagnosis was peri-implantitis.
Ten years ago this disease was almost unknown, but it is now a serious possible consequence of implantation, particularly when the implant patient has not continued to have regular periodontal checks, with treatment if necessary, following an implant. Some studies suggest that one-third of implant patients will be infected, and because jawbone loss is silent and invisible, people do not realise that they are at risk. Early warning signs are red, swollen gums and bleeding, which is often apparent when tooth-brushing; smoking seems to aggravate the situation, and significantly more smokers develop peri-implantitis.
The Faculty of Dental Surgery at the Royal College of Surgeons points out that long-term assessment and maintenance need to be assured if this threat to stability of the implant is to be prevented. It believes that the General Dental Council should introduce minimum standards of education and training for complex dental treatment, such as implants, to ensure patients are treated by a qualified professional. It supports the view that the General Dental Council should include peri-implant assessment and maintenance in the undergraduate curriculum. Too often the practitioner who inserts the implant does not provide long-term support for the patient, discharging them back to their general dental practitioner.
Periodontal disease has been associated with diabetes, cardiovascular disease and pneumonia. Some people speculate that an increase of bacteria in the body may aggravate these conditions but it is not considered to cause them. Professor Donos says:
“The main challenge is for the patients suffering from periodontal disease who represent a significant proportion of the population. As you know, due to the silent nature of the disease, it does not always provide ‘pain’ as a symptom for the patient”.
“I think it is important for the public to be informed that even though implants are successful and offer great functional and aesthetic solutions in terms of replacing missing teeth, appropriate patient selection is required”—
as my noble friend Lord Colwyn said—
“control of periodontal disease before and after implant placement is essential and all risk factors need to be controlled through regular follow up according to the susceptibility profile of the patient”.
In my experience, pain is the thing that brings many patients into the dental surgery. I cannot end this dental discussion without mentioning the report this week that 26,000 children in England aged between five and nine have been hospitalised to have multiple tooth extractions in 2013-14, which is nearly 500 children a week, at a huge cost to the NHS and a great disturbance and upset for the children and their families. However, that is a debate for another time: I flag it up here for the Minister.
Tonight, I hope that patients who want and should have dental implants will benefit from understanding the importance of dealing with periodontal conditions before and after treatment. I look forward to a positive response from the Minister and to his assurance that his department will create public awareness of this condition.
My Lords, the noble Baroness, Lady Gardner of Parkes, is one of our most active Members and I am sure we all owe her a great debt in bringing this matter to our attention tonight. I declare an interest as a member of the Faculty of Dental Surgery at the Royal College of Surgeons. Last Friday, I attended a celebration of the 50th anniversary of the fluoridation of the water supply in Birmingham. Will the noble Earl join me in congratulating the great city of Birmingham on this achievement? It is interesting that, when one looks at health outcomes, Birmingham is often towards the lower end of the table, but it is way up in the top 10 in oral health. Whatever one’s views on fluoridation—and I also declare my presidency of the British Fluoridation Society—there is no question that it has had a very positive impact in Birmingham and the West Midlands in terms of the number of children who have to go into hospital because of oral issues, which was a point raised by the noble Baroness.
As the noble Baroness said, the use of dental implants has grown rapidly across the UK in the last few years. That has been very welcome to many patients but we know that, on the other hand, alongside this rise, the General Dental Council has seen an increasing number of complaints, particularly regarding the lack of informed consent for treatment, damage to the tissue and bone surrounding the implant, and failures. The noble Baroness was very explicit about some of the health issues that can arise. I have looked very carefully at the briefing provided by the Faculty of Dental Surgery at the Royal College of Surgeons. It makes four points that I will put to the noble Earl, alongside the questions raised by the noble Baroness.
Essentially, the briefing says that it is very important for patients to be given adequate information about the risks and alternative options for treatment. Secondly, patients should be aware that periodontal and peri-implant checks are essential to ensure that problems are detected early. The stability of the implant is threatened by diseases such as the one mentioned by the noble Baroness. I do not dare attempt to repeat its name, although I believe that the noble Earl, Lord Howe, is perhaps braver than me on that. However, this is why checks are essential.
Thirdly, the GDC should consider ensuring that peri-implant assessment and maintenance is part of the normal undergraduate course. Fourthly, I would like to mention the Law Commission draft Bill. We are not to see the Bill, but it contains proposals to give regulators the power to annotate their registrar and indicate specialisms or other qualifications. Given that we are not going to have the Bill—I know that there will be some Section 60 orders—perhaps I could make a plea that this might be considered if a dental order is to be brought forward.
Finally, I refer to a very interesting note I received from the Faculty of General Dental Practice about the standards of training in implant dentistry. This is available from a wide variety of providers in the UK, including universities, royal colleges and hospitals. These standards have been developed to ensure patient safety and protection, and I understand that they also serve as a reference point for the GDC in consideration of patient complaints. The only question I wanted to put to the noble Earl about this is that, although this seems to be absolutely fine, how can we ensure that more dental teams take up these training opportunities?
Clearly, we have a good system where standards are very much developed. The providers have to provide training in line with those standards, and the General Dental Council is there to follow up complaints when there are indications that dentists are not practising according to those standards. I wonder whether the noble Earl thinks that there is an issue of some dental practitioners not doing that, which then has an impact on their provision of clinical services.
My Lords, before I respond to the particular points raised by my noble friend on the issues to which she drew our attention, I begin by paying tribute to the way she has consistently championed the commitment of members of her profession to improving the oral health of the population and the quality of dental care provided in this country.
The oral health of the nation has been transformed since the creation of the NHS in 1948, and the rate of improvement has picked up pace since the introduction and widespread use of fluoride toothpaste in the late 1960s and early 1970s, and the growing awareness of the need for good oral hygiene.
The coalition made two key commitments in relation to dentistry in 2010: to increase access to NHS dentistry and to improve oral health by reforming the NHS dental contractual system. We are making solid progress on that reform. As noble Lords know, there is currently an engagement exercise aimed at dentists and the wider dental community. As part of this I took part last month in a web chat, and I was encouraged by the positive—though, of course, rightly robust—questioning and debate from those dentists who took part.
However, we are not waiting for this more fundamental reform before starting to tackle access and oral health. We are already making progress on delivering on those commitments. The people of this country appreciate the ability to access dental care when it is needed, and the number of people seeing a dentist under the NHS since May 2010 has increased by 1.5 million. We are also committed to working with our partners, including those in the profession, to improve the oral health of the population—with a particular focus on children. The latest epidemiological data published by Public Health England demonstrates that progress is being made. Like the noble Lord, Lord Hunt, I follow with interest the decisions being taken locally about fluoridation of water.
These decisions are best taken locally and the arrangements we made under the Health and Social Care Act 2012 are intended to increase democratic legitimacy of decisions on fluoridation; I am pleased that the noble Lord attended the 50th anniversary of the city of Birmingham’s fluoridation scheme. Dental caries continues to affect a sizeable proportion of the population and is a common cause of children being admitted to hospital, as my noble friend mentioned, for the removal of decayed teeth. Public Health England recently published a health monitoring report which showed lower rates of tooth decay and hospital admission in fluoridated areas compared to non-fluoridated areas. In March, Public Health England published guidance for local authorities on improving oral health for children and young people. That guidance advises on the range of measures, including water fluoridation, that local authorities might consider as part of their oral health improvement strategies.
One of the real drivers of this improvement in oral health has been the greater appreciation by the public of the value and importance of both good oral health and acceptable appearance. With this value now placed on oral health has come significant technological development, and again the dental profession must be congratulated on the way it has researched and developed new techniques and procedures to improve oral health and functionality; the use of implants, which my noble friend focused on, is a case in point. We recognise that inequalities still exist and my officials are working with colleagues in Public Health England, NHS England and local authorities to tackle those inequalities; nevertheless, the overall trend is positive.
My noble friend pointed out that smokers are more at risk of peri-implantitis. Public Health England’s Smoke-free and Smiling guidance supports dentists to make brief interventions to help patients who want to stop or cut down to access dedicated stop-smoking services. Dental surgery is a key opportunity to get across brief messages of issues that have implications for oral health—and in this case, of course, the patient’s wider health.
Dental implants can be used in a range of situations. They can play a key role in reconstruction, post-trauma or major surgery. They can sometimes be used, as my noble friend mentioned, as a support for a more extensive prosthesis following surgery for head and neck cancer, and can also be used to retain restorations in the mouth where teeth are missing. I know that the vast majority of cases where implants have been used to replace missing teeth have historically been provided in the independent sector, outside the auspices of the NHS. There are, of course, many other treatment options to be considered, including bridges or dentures, depending on the individual clinical circumstances.
The NHS has a duty to commission services which are both clinically appropriate and cost effective and it is important when discussing the replacement of missing teeth that all those options are discussed. We also need to be aware, as my noble friend mentioned, that some patients choose to travel abroad to have implants fitted because the initial treatment might be available abroad at a lower cost. The General Dental Council has good guidance available on its website for members of the public considering travelling abroad for dental treatment. It is important that people travelling abroad for this sort of treatment understand that, without the ongoing clinical care and support that this type of treatment requires, what looks like a low-cost option initially might ultimately turn out to be high-cost—both financially and from a health outcome perspective.
I am aware that NHS England is providing a series of commissioning guides to give clarity to commissioners and clinicians when discussing treatment options with patients. For dentistry, four such guides are in development, focused on specific areas of dental care. One of these is a restorative commissioning guide and the appropriate use of implants is, I understand, included as part of that work. As my noble friend quite rightly mentioned, appropriate post-placement care is vital if these restorations are to be successful in the long term.
There has been a significant increase in the placement of intra-oral implants in the last 20 years and, although the immediate result can be instantly impressive, it is vital that patients receive good aftercare, including the periodontal checks my noble friend referred to and instruction on how to maintain a healthy interface between the implants and natural tissue. Indeed, in the third edition of Delivering Better Oral Health: An Evidence-Based Toolkit for Prevention, published recently by Public Health England, there is a section on peri-implant health which focuses on these very issues. This provides detailed guidance for clinicians on what they should do at each visit for patients who have had implant treatment. We would expect clinicians to carry out procedures only where oral health is good enough to support the treatment being provided—the point made by our noble friend Lord Colwyn, who cannot unfortunately be with us—and to provide aftercare advice to patients, including advice on self-care and the need for regular check-ups.
However, we know that there is more to do. My noble friend will also, I hope, be pleased to hear that my officials and the Chief Dental Officer have already recognised the issue she raises as a potential area for growing concern. A UK-wide working group, which includes representation from the dental faculties, has been established. Chaired by the Chief Dental Officer, it will look at developing clear and consistent cross-system guidance relating to treatment planning prior to the placement of implants, the education and training required by the clinicians—a point raised by the noble Lord, Lord Hunt—and best practice for aftercare, as referred to by my noble friend. It will also look at how appropriate, easily understood information can be made available to members of the public considering this form of treatment. I am pleased that this group has been set up and understand that it met for the first time earlier this month.
I hope that my noble friend is reassured by the fact that we have already recognised this as an area where public awareness needs raising and that we are taking action to address this. At the end of her excellent speech, my noble friend mentioned the recent data regarding the admission of young children for the administration of a general anaesthetic for removal of teeth. This is unacceptable as dental caries is a preventable disease which can be almost eliminated by the combination of good diet and correct tooth-brushing, backed up by regular examination by a dentist. NHS England is working with colleagues within and outside the profession to educate and inform the parents of these young children so that they are not subject to this extremely unpleasant experience at such an early age.
Committee adjourned at 8.12 pm.