Access and affordability of dental care can be problematic for some in the Australian community. Therefore, dental tourism is increasingly becoming more attractive to some patients due to decreased expense, increased convenience and immediacy of treatment. However, there are significant issues for both clinician and patient in regards to dental tourism. Lack of accountability and regulation are the main issues and this is particularly evident when complications occur. This paper presents five cases where complications have arisen in the setting of dental tourism.
Access to affordable dental care can be a significant problem for some in the Australian community. Increasingly, some patients have been turning to treatment overseas as an option rather than accessing routine dental care in Australia. There are some benefits for accessing dental care outside Australia. These include increased affordability, speedy completion of treatment plans, convenience of treatment, combination of treatment with some leisure activity or visiting family and avoidance of public waiting lists. The affordability factor is a significant issue as a procedure may be performed at a far lower financial cost compared to the amount that a patient would otherwise spend in Australia.1,2 This affordability has been made even more attractive by a recent strong Australian dollar as compared to other currencies and the ease and affordability of overseas travel. Improvements in the standard of care overseas may also play a role.2,3
Medical or dental tourism is a term that describes seeking medical or dental treatment in another country.1,3 The necessity for travel may be the sole or primary motivation for medical or dental treatment sought. The internet and internet advertising may also be an important source for accessing and researching treatment possibilities overseas.
However, there are significant disadvantages to dental tourism. The main issue for patients undertaking dental tourism is accountability. Accountability implies the professional, moral, legal and ethical duty of the practitioner regarding the outcome of treatment. Once a patient leaves the country that they have undergone treatment in, it may be difficult to address accountability, even if the patient returns to that country. If complications occur, review and management by the practitioner who provided treatment is almost impossible. Patients are often not covered by insurance companies and are unable to seek compensation. Therefore, clinicians in their home country may be warranted with managing complications and giving second opinions. There has been a reluctance by local practitioners to provide remedial treatment, however they are obliged to make a diagnosis and provide treatment.4,5 Other disadvantages may include differences in training and risk of nosocomial infections, particularly those that are blood-borne.
Implant dentistry is now part of routine dental care which is practised by both generalist and specialist alike. It could be considered as the gold standard of care for the management of the partially or fully edentate patient. However, the cost of implant treatment as a treatment option can be prohibitive and this can be the justification for seeking dental tourism. Complications related to dental implants may be related to the patient, implant or prosthetic components and these complications are seen by oral and maxillofacial surgeons in both hospital and outpatient settings. Little has been documented in the literature regarding dental tourism, particularly in reference to dental implant treatment. The aim of this paper was to document a series of cases with suboptimal outcomes related to dental implant placement in the setting of dental tourism that have presented to the Department of Oral and Maxillofacial Surgery at both the Royal Melbourne Hospital and Royal Dental Hospital of Melbourne.
A 60-year-old Australian man with poorly controlled type 2 diabetes had three dental implants placed in the posterior right mandible in sites 45, 46 and 47 (Fig 1a) whilst on holiday. Ten days later in Australia, he presented to the emergency department of the Royal Melbourne Hospital with a large, tender and hard facial swelling in the right submandibular region and progressive odynophagia. He was administered IV antibiotics (amoxicillin and metronidazole), fasted and taken to theatre for surgical drainage. The patient required an awake fibre-optic intubation as computerized tomography (CT) scanning of his head and neck taken preoperatively demonstrated a narrowing of the trachea as a result of his infection. Once the patient was prepared and draped, extraoral incision and drainage of the right submandibular, buccal and lingual spaces with insertion of a penrose drain into the right neck was performed. The amount of oedema and swelling required that the patient remain intubated in the intensive care unit (ICU) (Fig 1b). The patient was closely monitored under the shared care of oral and maxillofacial surgery, ICU and endocrinology departments. The following day, the patient developed a marked increase in the amount of submandibular swelling. A repeat CT scan exhibited almost complete occlusion of the patient’s airway with marked oedema of the parapharyngeal and retropharyngeal spaces (Fig 1c). The patient was taken to theatre for urgent redrainage and redebridement of his fascial spaces, and IV antibiotics were continued as advised by the infectious diseases unit. The patient made a slow but steady recovery with the aid of IV antibiotics and strict control of his diabetes. The patient remained in hospital for a total of eight weeks.
A 58-year-old female was referred to the Department of Oral and Maxillofacial Surgery at the Royal Dental Hospital of Melbourne complaining of pain and swelling associated with both maxillary and mandibular implant supported prostheses. The patient had been unhappy with her conventional full upper and lower dentures due to retention problems. The implant supported prostheses were delivered six months earlier, whilst visiting family in the patient’s country of origin (Fig 2a). The patient reported that the implants were placed in one day, and the final porcelain–metal fixed prostheses were fitted one week later.
On examination, both maxillary and mandibular implant supported prostheses were mobile and painful. Radiographic examination revealed non-conventional screw implants had been placed, with six screw-type implants in the maxilla and a further eight screw-type implants in the mandible. All of the implants had significant peri-implant radiolucencies.
Treatment required urgent removal of all maxillary and mandibular implant supported prostheses under general anaesthesia (Fig 2b). The implant surfaces, when removed, appeared to have a green crust which was not removable and resembled copper corrosion. Her postoperative course was unremarkable and she reverted to her old complete set of dentures whilst awaiting consultation at the multidisciplinary implant treatment planning clinic at the Royal Dental Hospital of Melbourne.
A healthy 64-year-old male was visiting family whilst overseas. He visited a dentist who performed an examination and recommended the placement of seven mandibular dental implants. The patient agreed to have the implants placed with the intention to have the prosthetic restoration in Australia. The deciding factor was that the overseas dentist was able to provide treatment the following day. Seven implants were placed in the mandible in sites 32, 35, 36, 42, 45, 46 and 47 (Fig 3a). Once back in Australia, two months after placement of the implants, the patient presented to a local dentist, reporting pain and paraesthesia of the distribution of the left mental nerve. The patient was referred to a prosthodontist who decided five of the seven implants were not restorable. Cone beam CT revealed impingement of the left inferior alveolar nerve by a fixture (Fig 3b). The 35 fixture had also been inserted into the apical root of the 34 tooth which had become non-vital. The patient was then referred to an oral and maxillofacial surgeon. Upon examination, the gingiva associated with the implants was inflamed and pus drained from the area with significant mobility of the fixtures. Five mandibular implants were removed, as well as the iatrogenically devitalized 34 tooth (Fig 3c) under local anaesthesia. The implant sites were then debrided of remaining granulation tissue and pus. The implant sites healed uneventfully but some residual paraesthesia of the left lip still exists. The patient is under long-term follow-up.
A 71-year-old edentulous male had ongoing problems retaining his lower denture due to a flat mandibular ridge and shallow sulci. The patient could not afford an implant retained prosthesis at the time and therefore sought full mouth rehabilitation with dental implants in his country of origin.
Four months after placement of the implant supported prostheses, the patient presented to the Royal Dental Hospital of Melbourne with debonded fixtures 33–43 and loose 33 and 31 implant abutments (Fig 4a). These were recemented provisionally by a prosthodontist. Two months later, the maxillary unit prosthesis also failed. It was noted that the reason for failure of the unit was deficient anterior support (in regions 13–22) (Fig 4b). Several of the maxillary implants had been placed in a buccal orientation relative to the maxillary arch (Fig 4c). The patient is now awaiting multidisciplinary implant treatment planning.
This case demonstrates communication and logistic difficulties that can occur for patients electing to have placement of dental implants overseas. A 24-year-old Australian woman, with congenitally missing maxillary lateral incisors and canines (Fig 5a), elected to have dental implants placed whilst overseas as she was dissatisfied with her maxillary partial denture. The patient had four dental implants placed (sites 12, 13, 22, 23) (Fig 5b). Her aim was to reduce the overall cost of her dental implant rehabilitation, which was to be completed in Australia. Upon return to Australia, the patient presented to her local dentist for restoration of the maxillary implants. From the OPG examination it was unclear what system of implants were used. The dentist she had seen overseas refused to disclose the implant system used to the local Australian dentist on the grounds that the implants had not been paid for, although the patient disputed this and had evidence of a receipt.
The modern success rates for non-complicated dental implants is approximately 93% to 98% at five years,6,7 generally depending on the number of stages of surgery, surgical training and the timing of loading. A number of factors can influence implant failure, including patient factors, such as poorly controlled diabetes as in case 1; implant related factors, such as the implants placed in case 2; and restorative factors as in case 4. Case 5 was also interesting as it demonstrated a failure in communication.
Failure in implant dentistry does occur, in Australia and overseas. Clinician training can also be quite variable where in Australia it may range from company sponsored courses over a period of days to periodontal or full oral and maxillofacial surgical training, including undergraduate training in dentistry and medicine. However, the benefit for the patient who does not travel overseas for treatment comes from multiple levels of accountability. It is the regulation of dentistry which allows this accountability to be available to protect the patient. These levels include various state and now federal legislation, state and federal dental boards, the Australian Dental Association (ADA), both state and federal, and compulsory clinician indemnity. In this way, if a complication does occur, there are a number of mechanisms for the patient to be followed up and managed in an appropriate fashion. If the management of such complications are suboptimal, then opportunity exists through the dental boards, the ADA and the legal system to claim recompense. This may be quite difficult to undertake for treatment carried out overseas and it is this lack of accountability which is the main issue facing Australians and dental tourism.
Regulation can also be an issue affecting different countries in their practice of dentistry. This can also affect the materials used in the treatment of patients. This issue is particularly important in regards to sterilization and hygiene processes, and the risk of cross-contamination and nosocomial infections as some overseas countries may have a higher prevalence of specific infectious agents and poor cross-infection control.1,4 Regulation is also important in defining the minimum training requirements for dentists and their scope of practice.
These cases of complications related to implant dentistry treatment illustrate some of the issues that dental tourists may experience when seeking dental implant treatment overseas. Although the patients ranged in socio-economic status, a common motive for treatment overseas was to save on cost. Some of the patients were visiting their country of origin. However, two of the patients (cases 1 and 5) were not. It is important for clinicians to educate and advocate to their patients regarding the costs of treatment, particularly in relation to dental tourism. The costs of dentistry are not only related to the costs of service and running a practice, but for the provision of safe and effective dentistry where the clinician is accountable for the planning, quality and outcomes of treatment.