Dental Hygienists & Therapists : Should they also be offering Botox to the public?

Posted on 19/03/2013 at 11:19:04 | by Lorna Jackson

Working within the Aesthetic industry for a decade now there has been one debate which rumbles on and on; just who should be permitted, both legally and ethically, to administer botulinum toxin brands, such as Botox® to the general public?

In the past we have looked at various healthcare and non-medical specialities entering this lucrative marketplace with the help of training course companies and medical indemnity insurers facilitahttp://www.consultingroom.com/blog/363/dental-hygienists-&-therapists-:-should-they-also-be-offering-botox-to-the-publicting their business models, including Beauty Therapists and Podiatrists, and now the latest rise in involvement seems to be from Dental Hygienists and Dental Therapists.

As a prescription only medicine, there are of course regulations in place in terms of the provision of the product itself. Botulinum Toxin, including brands such as Botox, Azzalure, Xeomin, Bocouture and Dysport, must be prescribed on an individual patient basis following a face-to-face consultation (remote prescribing is no longer permitted by the GMC, GDC or NMC) by a Doctor, Dentist or Nurse Independent Prescriber (NIP), deemed by the MHRA to be ‘an appropriate practitioner’. Subsequently the administration of the product can be handed over to another person using a set of instructions known as a ‘direction to administer’, thus in the words of the MHRA the other person is ‘acting in accordance with the directions of an appropriate practitioner’. In most cases this is a non-prescribing Nurse, however increasingly more professions are setting themselves up as ‘Aesthetic Practitioners’ and using prescribing services to facilitate their business model of offering this service to the public.

One major insurer within the cosmetic industry, Hamilton Fraser has chosen to side with cosmetic injectable manufacturers and general industry sentiment and is currently not insuring Beauty Therapists, Podiatrists or Dental Hygienists and Therapists for the provision of botulinum toxin services; yet they find themselves under increasing pressure to insure the dental practitioners to do so.

Back in January 2008, Hamilton Fraser did launch a provision of sorts for Dental Hygienists and Therapists but this would not have allowed them to practice independently of a dentist; in a press release at the time they stated;

“Hamilton Fraser Insurance can now provide insurance for dental hygienists and dental therapists undertaking botulinum toxin and hyaluronic acid dermal fillers. Providing certain criteria is met by applicants, including evidence of GDC membership and successful completion of either the 2 year Diploma in Dental Hygiene & Therapy or 3 year BSc in Oral Health Science, it will be possible to arrange cover. Applicants will only be considered by Hamilton Fraser under a ‘practice’ policy where a fully qualified dentist is already insured for the treatments and the work performed by the hygienist or therapist is under the guidance of the dentist.”

Speaking more recently, Hamilton Fraser  told us that they are often confronted and told that other companies are prepared to insure Dental Hygienists and Therapists to provide toxin services, so why aren’t they? In light of this and the fact that their underwriters are also more than willing to provide cover, they find themselves in a situation of reconsidering their current stance on providing medical indemnity to Dental Hygienists and Therapists for botulinum toxins. A watch this space situation...

Dental Protection, the largest medical protection society for the dental industry also do not currently indemnify Dental Hygienists or Therapists for toxin services, yet this stance could also change in the future. They stated in April 2012;

“Currently the Scope of Practice of a hygienist and therapist as published by the GDC does not include Non-Surgical Cosmetic Treatments (NSCT). In addition the Quality Mark registration being made available to dentists by the Independent Health Advisory Services (IHAS) is not yet available to them. However we can foresee that this situation may change in the future and Dental Protection would then be able to offer indemnity to a hygienist or therapist member who is trained and competent at NSCT provided they are in the correct membership category.”

A full position statement from Dental Protection is available here.

Despite these two companies currently not making medical indemnity provisions for Dental Hygienists and Therapists, at least three companies are known to be prepared to offer such cover. As brokers, the attitudes seem to be that if they can find an underwriter to accept the risk then they will insure.

Ron Myers, Consulting Room Director noted; “I fail to understand why any insurance provider would insure any speciality that the brand owner in our market place would not recognise as being an appropriate person to use their products. (Insurers do ask applicants for product brand names used). The thing is that none of the brokers or underwriters seem to be having this dialogue with the manufacturers of these products.”

The General Dental Council (GDC) is the organisation which regulates dental professionals in the United Kingdom. All dentists, dental nurses, dental technicians, clinical dental technicians, dental hygienists, dental therapists and orthodontic therapists must be registered with them to work in the UK. They refer to all their members simply as ‘registrants’ and refuse to differentiate between each specialism or produce different guidance pertinent to one type of dental practitioner over another. They said in a position statement on non-surgical cosmetic procedures that;

“Registrants choosing to offer Botox® or other nonsurgical cosmetic procedures should note that the General Dental Council expects the same high standards of them, whatever the type of treatment they are carrying out.

In particular, registrants must ensure that they only work within their knowledge and professional competence, adhere to the Council’s standards at all times, and be prepared to back up the decisions they make.

They must also ensure that they have appropriate indemnity cover in place. Careful thought also needs to be given to maintaining professional standards in relation to advertising these services.

The full ‘Standards for dental professionals’ and ‘Scope of Practice’ documents can be found on the GDC’s website.”

From this statement, we can therefore deduce that the GDC does not have an issue with Dental Hygienists and Therapists offering Botox® to the public as long as they are insured and feel that they can justify their decision to do so if questioned.

Jenny Collard, Policy Manager at the GDC told us “The reference to registrants in our statement does include hygienists and therapists and you are correct in your understanding that they are able to carry out Botox® as long as they are trained, competent and appropriately indemnified and as you quite rightly point out, the initial prescription would need to be provided by a dentist. We do not set out what ‘trained and competent’ means; it is up to the individual registrant to decide whether they are trained and competent and whether they would be able to justify any decision they make if challenged.”

When we asked if there was any issue with Hygienists or Therapists offering these services under their professional titles if the treatments are not part of the GDC’s Scope of Practice, Jenny told us;

“As far as the promotion of Botox® and other services, registrants need to make sure that they do not mislead the public and they should also ensure that they adhere to the principles set out in our guidance on ethical advertising.Whether an individual wishes to advertise their cosmetic injectable services as a hygienist/therapist or as an ‘aesthetic practitioner’ is up to them, we would just want to ensure that patients are not misled and we often recommend that registrants speak to their indemnity provider for further advice on this issue.”

Yet, Sally Simpson, Immediate Past-President of the British Society of Hygiene & Therapy (BSDHT), formerly the  British Dental Hygienists' Association, who represent the interests of Dental Hygienists and Therapists explained that “...because it is not within our permitted GDC Scope of Practice, if we wanted to provide non-surgical cosmetic procedures, such as Botox®, it would not be permitted under our professional title as ‘Dental Hygienist’ or ‘Dental Therapist’.”

This highlights a clear difference in opinions on the matter.

So who is providing the training? Well one company who has been in the industry since 2006 is KT Training in Wiltshire. They have set up a dedicated website aimed at recruiting Dental Hygienists and Therapists for Botox and dermal filler training - http://dentalhygieniststraining.co.uk.

Their website states; “KT provide a range of training courses for dentists and dental hygienists including botox training and dermal fillers courses. The training courses are structured to provide theory and practical treatment time with the procedures to ensure an excellent level of confidence for each course attendee. Dental hygienists can be trained with botox or dermal fillers and should practice medical aesthetics within the guidance of GDC.”

KT Training is not alone, Medics Direct also offer training but do make minor stipulations and state that, “Dental Hygienists who have a prescriber to work with following the courses are also accepted.”

Examples of practicing Dental Hygienists include Aesthetic Rejuvenation in Hull run by Dental Therapist Amy Hill, who ‘has after running a successful mobile aesthetic service now launched her own clinic’.

Her website seems to ooze experience and qualifications and no doubt is exactly what the GDC means when it says “the GDC expects the same high standards of them”. In describing her skills, it says;

“Amy has worked alongside top ENT and Plastic Surgeons in maxillo facial theatres where she has assisted in facial reconstructions whilst experiencing all aspects of restorative surgery. Keen to ensure she is up-to-date with all the latest techniques she has attended conferences all over the UK and has also undergone training at numerous hospitals as well as Harley Street & Buckinghamshire Aesthetic Training Centres where she has gained various qualifications. Due to Amy's extensive dental and maxillo facial background she has a deep understanding of facial anatomy such as facial nerves, facial muscles and skeletal structure which is paramount when undertaking the treatments available.”

This may well be so, and we are not here to judge Amy’s skills, (we did contact her for comment, with no success); but is a Dental Therapist adequately qualified and able to deal with any medical emergencies or possible adverse reactions such as anaphylaxis which could occur? Many medical professionals would firmly state, no.

Regulation of this arena, aside from the regulations governing the prescribing of toxins, is voluntary.  The Independent Healthcare Advisory Services (IHAS) was set the task by government to create and oversee a self-regulatory scheme, now known as the Treatments You Can Trust (TYCT) Register of Cosmetic Injectable Providers. This register, open to doctors, nurses and dentists to join and demonstrate their best practice and qualifications when it comes to the provision of botulinum toxin and dermal fillers services has come under increasing pressure and lobbying since launch, from parties such as Beauty Therapists who feel that their exclusion from the register is unwarranted. More recently Dental Hygienists have started writing to board members of the TYCT Governance Board to lobby for inclusion on the register also.

With a government review currently underway, lead by Sir Bruce Keogh, which is looking at the regulation of both dermal fillers as medical devices and the issues of just who should and shouldn’t be providing ‘cosmetic interventions’, this topic could not be more hotly debated than at present.

Sally Taber, Head of TYCT said; “TYCT adheres to the high standards it has always set and firmly believes that only appropriately trained Doctors, Dentists and Registered Nurses should be administering cosmetic injectables. The TYCT Governance Group was pleased that the Royal College of Surgeons recently endorsed this statement. TYCT also believes that Registered Nurses working independently should be Nurse Prescribers otherwise as the European Standard draft states should work under supervision.”

There are those who argue that this whole situation has a simple solution – if the suppliers of the products don’t support the use of them by Beauty Therapists, Podiatrists, Dental Hygienists, Dental Therapists and other Allied Healthcare Professionals or non-medics then nor should the training companies who offer courses in their administration or the insurance providers who facilitate their ability to practice on the public post training course qualification. Yet, whilst there is money to be made by all parties, it comes down to business and where there is no law to actually stop their decision to train or insure, then others may simply feel aggrieved and decide that they want to milk that cash cow as well. Without some form of obligatory code of practice, mandatory or statutory regulation more and more groups will be permitted to provide cosmetic injectables to a largely, unknowing general public as there will be plenty of companies willing to ‘help’ them along the way.

We await the outcome of the Keogh review to see what recommendations may come about and be acted upon by government.