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Dental tourists: treat, re-treat or do not treat?
Shoukat Ashiti*1 and Catherine Moshkun2
Introduction
Many dentists will be able to relate to the
situation where their patient has travelled
abroad to undergo dental treatment. In some
cases, they will return without complications;
however, how should dentists manage patients
where this treatment has not gone to plan? If
a patient presented with a numb lip following
implant placement abroad, or with implants
of unknown type that have not been restored,
how are we as professionals expected to handle
this? ere are various reasons why patients are
travelling abroad for their healthcare and it is
undoubtedly impacting on dentistry, the NHS
and clinicians, especially when patients return
to the UK requiring remedial work. Dentists
are therefore increasingly faced with dicult
situations where they feel the need to help
these patients, who are oen in pain, or upset
with their new but failing dentition, yet they
do not feel comfortable taking over treatment
that has been started elsewhere.
What is dental tourism?
Medical, or dental tourism, is when patients
travel abroad for the purpose of medical or
dental treatment. In 2010, around 63,000UK
citizens travelled abroad for treatment.1 It has
been reported that the number of Britons going
abroad for treatment has increased signicantly
from 48,000 patients in 2014to 144,000 in
2016.2 Also, it was reported that Medigo, which
was a medical travel platform, had more than
350,000 visits a month by 2016,3 and in 2015,it
was estimated that at least 190,000 patients
were thinking of treatment abroad because of
long NHS waiting lists.4 e estimated value of
the medical tourism market worldwide was 60
billion US dollars in 2006, which increased to
100 billion US dollars in 2012.5 While patients
from developing countries are keen to travel to
the UK to access better quality health services,
UK citizens are now willingly leaving the
high-quality treatment in the UK in pursuit of
cheaper treatment abroad. e majority access
treatment in Asian countries such as India,
Malaysia, ailand and Singapore, and other
Eastern European countries such as Hungary,
Bulgaria and Romania.6,7,8
What are the reasons behind dental
tourism?
According to the media, literature and
websites of overseas dental practices, the main
reasons for medical tourism were classied
into pushing and pulling factors that drive
patients’ decisions for medical tourism; for
example, quality, efficiency and hospital
reputation were considered as pulling factors,
while high-cost treatments, long waiting
lists and lack of availability were the pushing
reasons.9 Additionally, other reasons include
patients travelling abroad for holidays, cultural
reasons, reducing treatment timescale or the
treatment option itself.8,10 It has been reported
that some travel abroad because they do not
Raises clinicians’ awareness of healthcare tourism
and the reasons behind it.
Highlights complications arising for patients from
treatment abroad, and the diculties in treating
these patients and possible clinical and medico -
legal issues dentists may face.
Highlights the impact of m edical tourism on U K
healthcare.
Key points
Abstract
Many UK patients in the search for their perfect smile have now decided to have their dental treatment abroad,
the main reasons being that they believe they can have the same treatment but at a much lower price. With many
overseas clinics oering treatment packages that also include a holiday, dental tourism seems an opportunity not to
be missed. Although not always the case, some treatments unfortunately do not go to plan, often leaving distraught
patients and their apprehensive dentists in a dicult situation. This article will discuss the reasons behind dental
tourism and if the health system has contributed to the increasing demand for dental tourism. We will touch on the
impact dental tourism has had on UK dentistry and if the NHS should be responsible for handling the consequences of
any failed or incomplete dental treatment carried out abroad. It will also put the spotlight on dentists’ responsibilities
and to what extent they should treat these patients, as these cases can leave clinicians in primary and secondary care
in a challenging predicament, not only clinically but also ethically and medico-legally.
1Postgra duate OMFS studen t, Universit y Dental Hospita l
of Manches ter, Higher Cambrid ge Street, M15 6FD,
UK; 2Spe ciality Dentis t, Universit y Dental Hospita l of
Manches ter, Higher Cambridg e Street, M15 6FD, UK.
*Correspondence to: Shoukat Ashiti
Email address: drshoukat@hotmail.com
Refereed Paper.
Accepted 27 August 2020
https://doi.org/10.1038/s41415-020-2591-6
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© The Author(s), under exclusive licence to British Dental Association 2021
trust NHS dentists and found some of the
results ‘amateurish’,11 and they nd it dicult
to register with an NHS dentist.12,13 From a
cultural point of view, this was more prevalent
among immigrants. Some Gujaratis who were
born in East Africa travelled to Gujarat for
religious purposes and had treatment at the
same time, whereas other Gujaratis followed
the recommendation of a family member
or a friend when seeking treatment.14 On
the other hand, immigrants in Canada were
seeking treatment in their home country
because of the lack of dental insurance and also
looking for similar culture identity language.15
Interestingly, employment status in Canada has
played an important part in reasons for seeking
dental care abroad, as jobless individuals
cannot have insurance, especially among
females who are facing difficulties finding
a job because of the labour market.15 Some
patients may travel from the UK back to their
home country for treatment, as they feel more
comfortable and at ease in an environment of
their own, and perhaps with a greater trust in
the clinician. ey also may prefer speaking
in their mother language and having family
members around in their home country
during treatment.16 Timescales for treatment
also play a role in inuencing where patients
choose to have their treatment. With dental
implants, for example, although a patient may
be eligible for implant funding on the NHS,
this would involve the patient attending many
appointments, including multidisciplinary
consultations, imaging appointments, surgery
itself and then restorative treatment. If they
cannot aord private treatment in the UK, they
may therefore opt instead for treatment abroad,
where one clinician in a limited number of
appointments can oer everything at a low
price, thus obtaining the final result more
quickly. It could also be that patients requesting
a more controversial treatment option feel the
need to travel abroad as clinicians in the UK
may not feel comfortable in providing this,
both ethically and medico-legally. For example,
patients who do not like the colour or shape
of their own natural teeth and are looking
for a ‘Hollywood smile’ may be in search of
a dentist who will provide extensive indirect
restorations on their otherwise healthy teeth.
Obtaining this kind of treatment may prove to
be increasingly dicult as perhaps UK dentists
are becoming more conservative in their
treatment plans, due to the ever-increasing
problem of ‘defensive dentistry’. Some dentists
will only undertake low-risk procedures in
the hope of not being sued or receiving a
complaint.17 Dental Protection carried out a
survey of 1,000 dentists, which showed 89%
were scared of being sued and 74% argued this
impacted on their clinical practice.18 Increasing
litigation and over-regulation has changed the
perception of UK dentistry, to the extent that,
at the Nobel Biocare Global Symposium, an
American speaker said to a UK dentist that
‘it’s impossible to practise in the UK without
fear of being sued, so fewer risks are taken’.18
erefore, perhaps these dentists would be
reluctant to provide particular treatments
which they felt were risky, thus forcing the
patient to go elsewhere.
Dentistry as a selling product
Many foreign dental practices are enticing
UK patients by advertising an attractive full
package, including dental treatment with a
holiday, ights, accommodation and airport
transfers, for competitive prices. Not only
is this making dental treatment more like
a business product rather than healthcare,
it also seems hard to refuse. Several studies
have looked at patients travelling abroad for
dental treatment and Milosevic claimed it is
likely to increase in popularity due to cheaper
treatment in Eastern Europe, high cost of
private treatment in the UK and limited
availability of NHS dentistry.16,19 As Holden
explains, it is the norm for consumers to decide
what brand of a particular product they want;
however, when it comes to dentistry, the choice
is more complicated.20 us, regardless of a
patient’s reasoning behind travelling for dental
treatment, ultimately, dental patients are now
consumers and can choose where they go and
exactly what treatment theywant.
With the ability of consumerist patients to
now shop around for their dental treatment,
one must consider if this puts a strain on the
professional relationship between dentists and
their patients. As Holden highlighted, once a
patient is seen as a consumer, the ‘clinician-
patient relationship begins to be transformed
into a mere transaction, rather than one driven
by professional duty.’20 Consequently, as both
dentist and patient compete with each other
to achieve the best outcome for themselves
(that is, patients looking for the best possible
treatment at the lowest price and dentists
trying to maximise their prots), ethics and
professionalism fade away.20 Knowing that
the appearance of a patient’s smile is vital, are
dentists using their position to sell treatments
to patients they had not actually attended for?
It is all too easy to see a patient for some basic
llings, but then tell them how easy it would
be to transform their smile with some simple
whitening they can do at home. Are we just
as guilty as those abroad by oering attractive
packages to patients to sell our treatments?
Despite not having the appeal of a holiday
included with the cost of treatment, we too
have now commercialised ourwork.
Problems for patients associated
with dental tourism
No matter how cheap and accessible these
treatments seem to be, they may unfortunately
come at a price, with unexpected complications.
Lunt etal.16 described a patient who travelled
to Hungary for dental implants, which were
unsuccessful, and the patient ultimately had
to spend over £40,000on remedial treatment.16
Equally, patients who have had treatment in
the UK are not always happy with the outcome;
for example, in 2018/2019,the NHS received
14,000 complaints.21 e Dental Complaints
Service reported 2,159 enquiries from patients
wishing to complain about their private dental
treatment in 2018.22 ey also report that 85%
of their complaints are due to what the patient
perceives to be treatment failure.22 However,
it is not easy for patients who had treatment
abroad to complain if things go wrong and
they want to take legal action. ey may face
some diculties; for example, the consent
form they have signed may claim that all legal
proceedings should be in the country where
treatment was undertaken.8 is would involve
the patient having to return to the country,
thus in eect defeating the object of having
treatment abroad to save money. Several papers
have highlighted the diculties patients face if
they want to bring about legal claims abroad.
In Malaysia and Singapore, for example, it is
completely given for clinicians to judge the
quality of care and decide if there was a breach
of duty.23 It has been reported by a Malaysian
hospital that ‘it never has been required to
pay for a wrongful death, or negligence suit’,23
thus making it dicult for patients abroad to
prove malpractice.23 In India, although cases
can be brought, it has been reported that 95%
of cases are unsuccessful.16 is could be due
to the deciency of complaint procedures, as
has been found by the Indian Health Ministry
and the World Bank study.24 It has also been
reported by a consumer advocacy group
‘that patients claiming damages for medical
74 BRITISH DENTAL JOURNAL | VOLUME 230 NO. 2 | JANUARY 22 2021
OPINION
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negligence are often unable to prove their
allegations because doctors are unwilling to
testify against other doctors.’24 Equally, it is
dicult for patients to claim compensation in
the UK because patients have to prove that the
clinician breached their duty of care and that
this breach of duty led to harm.25 erefore,
these difficulties for the patient having to
prove negligence means they oen receive no
compensation.25
Also, the patient may not have the
opportunity to report poor practice to a dental
regulator because the country where they
received treatment may not have professional
regulators like in the UK.8,26 ese patients
would lose financially on the initial cost
of their treatment, but if they return with
complications such as infections, nerve injuries
or failed restorations, they also potentially face
further costs in paying for complex remedial
treatment.7,27,28 e GDC29 and NHS30 advise
patients to be careful when deciding about
travelling for their treatment, as not every
regulator has the same standards as the GDC
or GMC. e GDC will not have the authority
to get involved with foreign clinicians who are
not registered withit.29
When considering medico-legal issues,
another challenge is that of language and
the consent process. If there is a language
barrier between the dentist and patient, it
makes discussing treatment options, risks
and benets extremely dicult, so arguably,
fully informed consent may not be obtained,31
which may have ramications if the patient
ever needed to take legalaction.
Furthermore, these patients may face
diculties in that the dentist abroad may not
accept responsibility for ongoing care. e
clinics abroad may tell the patients they have
been discharged from their care following
treatment. Alternatively, they may oer the
patient further treatment; however, this may
include the costs of ights and accommodation.
If patients seek help from a UK dentist, they
may struggle to find someone who feels
competent to address their concerns. ey may
visit a primary dental care provider who may
nd that the complications are beyond their
skillset and outside their scope of practice,
therefore referring the patient to secondary
care or a private specialist. Although in both
cases, dentists are obliged to act ethically and
not breach their duty of care, it raises the
question of what treatments we should oer
and which treatments UK dentists would be
happy to provide.
Who is responsible?
As a minimum, whether NHS or private,
dentists should address any acute problems,
such as pain or infection.32 However, one must
consider who should pick up the tab for any
remedial work required.
If a patient were to attend with failing
implants, perhaps removal may be acceptable
on the NHS, but surely not their replacement.
Imagine the situation where a patient has had
several implants placed abroad, but they have
not been restored; would any dentist try to
restore these for the patient? If a dentist in the
UK accepted to restore them and they later fail,
who is responsible? If no dentist was willing
to restore them, could we really justify the
surgical risk of removing them and starting the
treatment again if the unrestored implants did
not appear to be failing? It could be that we do
not even recognise the implant system that has
been used, even if we were willing to restore
them. Even if the patient signed a disclaimer
accepting that failure is a possibility, it would
be dicult to prove whether the implant itself
or the restoration is the reason for failure.
Does the dentist’s fear of litigation lead to the
patient ending up in a half-treated dicult
predicament?
e lack of guidelines on managing these
patients puts clinicians in a dilemma both
ethically and medico-legally. The study of
Jeevan etal.33 in 2011 demonstrated the impact
medical tourism is having on plastic surgery
units in the UK; it highlighted the need for
guidance for NHS clinicians when faced with
patients who have suered complications from
treatment undertaken abroad and has pushed
the Department of Health to state clinicians’
duties towards such patients.33 The NHS
has stated that health providers should only
address emergencies for such patients, but
should not carry out any elective treatments.33
One must also consider if the NHS has
a duty to educate the public and to what
extent patients should take responsibility
for themselves. However, as Hanefeld et al.1
quite rightly point out, the UK does not have
any guidelines or regulations about patients
choosing to have their treatment abroad1 and it
is unlikely to happen because of the complexity
of governing medical tourism. Furthermore,
Beland and Zarzeczny highlighted that
medical tourism has many stakeholders and
factors with competing interests, thus making
its regulation challenging.34 erefore, how
can clinicians be expected to advise patients
about treatment abroad while they do not have
the information themselves? Consequently, it
could be argued that the lack of regulation and
information is making patients vulnerable. If
patients had treatment abroad and it went
wrong, are they victims because we could not
better advise them? Alternatively, if we were
able to warn them of any potential problems,
but they ignored our advice, surely then they
would be responsible for their own decisions.
Impact of dental tourism on the NHS
Treating these patients on the NHS does not
mean one treatment appointment only. ey
may need several treatments and then follow-
ups, which leads to no extra cost to the patient;
however, some argue this is abusing the system.
Patients may rely on the NHS as they know
they can access it for free when they are back
in the UK.33 Another concern has been raised
as NHS resources are limited, so should they
be being used on patients who have arguably
sustained complications from procedures that
UK clinicians would think avoidable if the
treatment had been performed in the UK? It
has been estimated by a cohort study over three
years that the cost to the NHS for remedial
treatment aer cosmetic surgery abroad was an
average of £6,360per patient and ranged from
£114to £57,968.35 Arguably, the harm from this
cosmetic surgery or dental treatment abroad is
self-inicted, so raises the question if valuable
NHS resources be used for this purpose.
However, it could be dicult to enforce this,
as equally, the same could be said about, for
example, injuries from extreme sports; these
are self-inicted, yet the NHS pays for the
treatment. Perhaps patients should be expected
to subsidise their treatment costs or take out
insurance that covers such complications.
Impact on UK dentistry
The increase of dental tourism has had a
significant impact on UK dentistry. The
founder of the UK cosmetic dentistry cost
and clinic comparison website, Eoin Holohan,
explains that dental tourism has created a
competitive atmosphere that led to a noticeable
drop in prices, especially dental implants that
have been available for about £995in the UK.36
is raises the question of how these implants
are being oered at such a reduced rate, and
we must consider if treatment standards and
quality are being compromised in order to do
this. For example, a study in Australia recorded
BRITISH DENTAL JOURNAL | VOLUME 230 NO. 2 | JANUARY 22 2021 75
OPINION
© The Author(s), under exclusive licence to British Dental Association 2021
that one of the reasons for dental implant
failures that have been placed abroad were the
implants themselves. ‘e implant surfaces,
when removed, appeared to have a green
crust which was not removable and resembled
copper corrosion’,37 which had caused infection
and full removal of the placed implants.37 us,
for UK dentists to lower their prices, do we
have to use products of lower quality or with
less supporting clinical evidence, or are we
having to cut corners? Some overseas countries
do not have as rigorous cross-infection control
procedures, and they have dierent sterilisation
and hygiene processes, which result in fewer
expenses for the clinic but can reduce the cost
of treatment.37
Alternatively, are these clinics abroad able
to provide cheaper treatments because they
have more business? Perhaps their advertising
regulations are not as stringent as in the UK,
meaning a UK dentist can never compete
with an overseas clinic when it comes to
advertising. The Advertising Standards
Authority (ASA) in the UK is responsible for
monitoring and managing any inappropriate
advertising deemed as ‘misleading, harmful
or oensive’.16 eir scope includes websites,
paid advertisements and social media, but
is limited to advertisements in the UK. e
ASA has previously ruled against some
cosmetic surgery adverts, claiming they are
‘irresponsible and misleading’.16 Aer going
through many overseas dental practice websites
on the internet, it is easy to nd many examples
of what is prohibited in the UK. e GDC
document Guidance on advertising clearly
states dentists’ duties to accurately market
their treatments without any misleading
statements. It emphasises the importance of
ensuring patients are aware they may not be
suitable for all treatment options and results
advertised might not be the same forthem.38
Conclusion
It is easy to see why patients are driven to
seek dental treatment abroad. Dentistry is
becoming increasingly consumer-driven
around the world, including the UK, meaning
patients will look around for the best deal.
However, perhaps they travel oblivious to
the potential consequences should things
go wrong. When patients attend requiring
remedial work, from an NHS point of view,
we must consider which patients should take
priority and assess how these limited resources
should be allocated. From a dentist’s point of
view, the risk of litigation will always be a
deciding factor as to whether they should
carry out any remedial work, rather than just
alleviating acute problems. More research
is required to identify if dental tourism has
the same financial impact on the NHS as
failed cosmetic surgery done abroad, as well
as collecting data on failure rates of overseas
treatments in comparison to UK treatments
and more accurate information on the cost
of remedial dental treatment. We also need
clearer guidelines on what dentists should oer
these patients. It might be useful to introduce
insurance schemes to cover any complications
if treatment abroad goes wrong. However, not
all treatment performed abroad goes wrong
and, although somewhat controversial, it could
be that foreign treatments might not actually
be as bad as wethink.
Conict of interest
e authors declare they have no conicting interests.
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