[Cosmetic injectables in dental practice: legal aspects in the Netherlands]. / Cosmetische injectables in de tandheelkundige praktijk: juridische aspecten in Nederland.

A recent survey indicates 49% of this journal's subscribers endorse the administration of cosmetic injectables by properly trained dentists. Given the surging demand for cosmetic treatments, it's essential to establish clear guidelines and conventions defining the roles of the various healthcare professionals in various situations. There is, however, considerable discussion still and from a legal standpoint, the role of dentists within cosmetic medicine remains ambiguous. Under the Dutch Individual Healthcare Professions Act (Wet BIG), dentists are authorized to administer cosmetic injectables exclusively for dental purposes. However, based on the content of current dental training, one might argue that dentists' authorization could be extended to include facial injectable treatments in the entire face, in future. Presently, it is prudent for general practice dentists to abstain from cosmetic procedures with cosmetic injectables without a specific (aesthetic) dental objective.

[Consent for treatment: a results or a reasonable endeavours agreement? Two alternatives with significant practical differences to dentists]. / De behandelingsovereenkomst: een resultaats- of een inspannings­verbintenis? Twee alternatieven met grote praktische verschillen voor de tandarts.

The character of a consent for treatment is not a mere hobby for lawyers; it also has consequences in daily practicein the Netherlands, particularly if it concerns questions of who should prove what in proceedings. In general, consent agreements can be divided into an obligation to achieve results and an obligation to use reasonable endeavours. In oral healthcare, there is usually a question of an obligation to use reasonable endeavours, in which professional standards must play a leading role in the behaviour of the dentist; and here there have been a number of recent developments, such as an increase in the number of (clinical) guidelines and the acceptance of wish fulfilling medicine, under strict conditions. It is concluded that recent developments in the dentist's requirement to provide evidence in proceedings have definitely not made things simpler.

[Series: Education and the dentist in 2025. Harmonisation of dental curricula in a European and Dutch perspective]. / Serie: Onderwijs en de tandarts anno 2025. Harmonisatie van de opleidingen tandheelkunde in Europees en Nederlands perspectief.

Coinciding with an increasing tendency of professionals to cross national borders, there is also an increasing need to harmonise curricula. In dentistry in Europe, this tendency is undiminished. By defining international curriculum requirements for dentists, international harmonisation can be strengthened. In the Netherlands, too, harmonisation with European standards has taken place in establishing final achievement levels for dentistry curricula, as defined in a national framework. In a working environment where oral health professionals are confronted with rapid change, for example, in the division of responsibilities, future caregivers should have an optimal educational preparation for their competences, skills and expertise.

[Wish fulfilling medicine and wish fulfilling dentistry: legal aspects]. / Wensgeneeskunde en wenstandheelkunde: juridische aspecten.

Wish fulfilling medicine (human enhancement (therapy)) concerns medical treatment without a direct medical need. In traditional medicine, a classical triad applies: 1. after investigation symptoms of illness lead to 2. a diagnosis, followed by 3. a proposal for treatment by the health care provider. In wish fulfilling medicine, the emphasis lies on patient's wishes. Wish fulfilling medicine concerns medical treatment, often at the request of the patient, and should be distinguished from shared decision-making,a form of communication seeking to meet the preferences of the patient and to actively involve the patient in his treatment. In the Netherlands, in accordance with the Healthcare Quality, Complaints and Disputes Act, health care providers have to offer good care at a good level, which is safe, effective, efficient and client-orientated, offered in a timely fashion and geared to the real needs of the client. Good care has to meet professional standards. In this way, fulfilling patients' wishes for treatment without a medical need can be restricted by law.

[The image of general practitioners compared to that of dentists in the Netherlands]. / Imago van huisartsen versus tandartsen in Nederland.

The image of the professions of family doctor and dentist in the Netherlands was investigated by means of a questionnaire distributed online and in four cities. In total, 270 questionnaires were analysed. The dentist was seen more as a businessman, a solo performer for whom the interests of the patient were less highly prioritised, who,was less communicative, more associated with pain, more distant, less open to dialogue and could be trusted less than the general practitioner. Respondents also felt less safe at the dentist's office than at the general practitioner's. On average, respondents rated the general practitioner significantly higher than the dentist. Dentists scored significantly lower than general practitioners on eleven of the twelve statements. The score of the profession dentist was not significantly different from that of general practitioner in only one category, professionalism. These results indicate that the image of the dental profession is worse than that of the general practitioner.

[The use of scientific journals and professional periodicals by Dutch dental students]. / Gebruik van wetenschappelijke tijdschriften en vakbladen door tandheelkundestudenten in Nederland.

In the present study, the extent to which dental students in Amsterdam, Groningen and Nijmegen consult scientific journals and professional periodicals was explored by means of a digital questionnaire. 333 dental students (20% response rate) participated in this study, 69% of whom had experience in conducting scientific research. 65% of the students had a subscription to a dental journal. Of the Dutch-language dental journals, the 'Nederlands Tijdschrift voor Tandheelkunde' [Netherlands Journal for Dentistry] and the 'Nederlands Tandartsenblad' [Dutch Dentists' Journal] are frequently consulted journals. International publications are consulted especially by masters students, although less frequently than Dutch dental journals. The study revealed that 77% of the students consider it important that attention is paid to the development of scientific skills early in the dental curriculum in order to adequately prepare students to select and interpret publications.

[Wish fulfilling medicine and wish fulfilling dentistry: -medical-ethical aspects]. / Wensgeneeskunde en wenstandheel­kunde: medisch-ethische aspecten.

Wish fulfilling medicine comprises medical procedures applied without a direct medical need. In such procedures, the medical-ethical principles can come under pressure: the autonomy of the patient, when wishes originate from social pressure; beneficence when the (underlying) aim and consequences are unclear; and 'doing no harm', when that appears to be impossible. The principle of justice, too, could come under threat when especially those with a privileged socio-economic background can take advantage of wish fulfilling medicine. Regardless of whether it concerns wish fulfilling medicine or conventional medicine, respect for human dignity and the individual integrity of the patient continue to be paramount. In care ethics and moral ethics, the qualities necessary in a proper caregiver are emphasised, such as caring, compassion, commitment, honesty and personal dedication. Wish fulfilling medicine is the subject of significant ethical debate. Important aspects arising from this debate are that the risks of harm should be limited, human dignity and integrity should be respected, people should genuinely be helped and the principle of justice should be upheld.

[Wish fulfilling medicine and wish fulfilling dentistry: what does this mean?] / Wensgeneeskunde en wens­tandheelkunde: wat wordt ermee bedoeld?

Wish fulfilling medicine refers to medical procedures applied without a direct medical need. In wish fulfilling medicine, the wish of the patient is dominant, but wish fulfilling medicine is also promoted indirectly by healthcare providers, (pharmaceutical) companies and healthcare insurers. Wish fulfilling medicine often concerns the enhancement of appearance or performance; therefore, wish fulfilling medicine is also referred to as (human) enhancement (therapy). The line between traditional and wish fulfilling medicine is vague: the border between illness and health, normal and abnormal functioning is not sharply defined and is relative to time and place. In the Netherlands, wish fulfilling medicine is not covered in the basic package provided by healthcare insurers and is paid for by the patients themselves. However, 'pay yourself' is not a decisive criterion for wish fulfilling medicine. With new biotechnological developments the domain of wish fulfilling medicine is expanding. Some dental treatments can be considered as wish fulfilling dentistry, for example in the context of cosmetic dentistry, orthodontics, or dental implantology. Although wish fulfilling medical treatments do not cure disease, they can promote health.

[The new law concerning complaints in practice]. / Het nieuwe klachtrecht in de praktijk.

Most patients who file a formal complaint against a dentist do so by way of the law concerning complaints. In 2017 the law concerning complaints was changed radically, with the intention of making the law easier for the patient to make use of and providing the patient with a financial settlement. This article considers the extent to which the possibility of being compensated has had the effect of encouraging patients to file claims in the case of the Royal Dutch Dental Association (KNMT), the complaints service with which most dentists are associated. The article also considers whether the new law has made the process of filing a complaint more readily accessible. Finally, if the law of complaints has become more appealing for patients to make use of, one could imagine that fewer cases would find their way to the disciplinary board. For that reason, the number of disciplinary complaints in 2017 is compared to the number for 2016.

[Health care plan: a treatment as a piece of a puzzle. Considerations with respect to judgement of the Central Disciplinary Board for Health Care]. / Zorgplan: een behandeling als deel van een puzzel. Beschouwing op uitspraak Centraal Tuchtcollege voor de Gezondheidszorg.

When faced with the question whether a particular treatment is indicated, dentists have to ask themselves to what extent it fits within a health care goal. If it does not, then the indication is usually rejected because it is in conflict with professional standards. Dentists who nevertheless consider such an indication have to bear the responsibility to make clear to the patient not only the general risks of a certain treatment but also the additional risks associated with the hazardous indication.

[The allocation of tasks and responsibilities in oral healthcare: basic terms]. / Toedeling van taken en verantwoordelijkheden in de mondzorg: kernbegrippen.

Oral healthcare is to an ever-larger extent delivered by a team or network. Members of such a network often seem to be unsure about the rules that govern the distribution of tasks. The Individual Healthcare Professions Act (Dutch: Wet BIG) in which this distribution is defined, makes use of very specific terms. Clarity concerning these terms is a prerequisite to be able to reflect, in a subsequent contribution, on the realisation of the prerequisites that are applicable to working in a team or network.

[Medicines and oral healthcare 3. Insurance coverage and qualification to prescribe]. / Medicamenten en mondzorg 3. Vergoeding en bevoegdheid tot voorschrijven.

On the advice of the National Health Care Institute in the Netherlands and the institute's Board of Scientific Advisors, the minister of Health, Welfare and Sport decides whether a certain drug will or will not be included in the list of drugs covered by the basic health insurance plan mandated for all Dutch citizens. In making this decision emphasis is placed on the therapeutic value of that particular drug compared to that of the standard drug for that disorder, the impact that the inclusion of the drug would have on the budget and the drug's cost-effectiveness. In the case of disorders that do not respond or respond insufficiently to the standard treatment, however, one comes up against the limitations of this system and in some cases a necessary treatment is not reimbursed. With respect to prescribing medications, dentists are qualified to prescribe, provided they are enrolled in the so-called BIG register [that recognises the qualifications of healthcare professionals in the Netherlands]. Dental hygienists, by contrast, are not qualified to prescribe and have to limit themselves to at most recommending over-the-counter medicines. In prescribing medicines, dentists are of course limited to those about which they have comprehensive knowledge and sufficient experience. If a dentist wants to prescibe a drug that is outside his or her own experience, then he or she should consult with an oral and maxillofacial surgeon, general practitioner or medical specialist to determine whether the medication can be prescribed and if so, by whom.

[Evidence-based clinical guidelines in dental practice 5. Guidelines: professional autonomy and right of self-determination]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 5. Richtlijnen: professionele autonomie en zelfbeschikkingsrecht.

Judges up to and including the Law Lords (Supreme Court) and the Central Disciplinary Tribunal for Healthcare in the Netherlands do not consider guidelines to be optional. This offers security to patients and dental care professionals. But a field of tension can exist between, on the one hand, a patient's right of self-determination and the dental care workers professional autonomy and, on the other, a guideline. This field of tension can be resolved by first limited testing of the acceptability of the goal of care desired by the patient, taking into consideration at the same time professional autonomy; and, subsequently, by selecting the most effective treatment for achieving this goal of care on the basis of 'evidence'. With respect to the current definition of guidelines for clinical practice, this means that patients and healthcare workers explicitly acknowledge that they have been able to agree on a goal of care that deviates from the ideal. In this way, a judicially responsible balance is achieved between the right of self-determination and professional autonomy, on the one hand, and, on the other, the desire for evidence-based treatment and a limitation on unaccountable variation in treatment and transparency of care.

[Authority and division of responsibility: inventory of pressure points in dental care]. / Bevoegdheden en taakverdeling: inventarisatie van knelpunten in de mondzorg.

For patient safety and public trust in dental care it is essential that the patient can trust the person who is providing him with care. It is increasingly common for dental care to be provided by non-dentists. The regulations governing this practice are contained in the Individual Healthcare Professions Act. A recent evaluation of this legislation revealed that those affected are not generally aware of the conditions under which non-dentists are permitted to carry out tasks in dental care or that they are unsure how these requirements have to be put into practice. It is a matter of concern that this knowledge, by comparison with a previous study, has hardly increased and in some cases has actually decreased.

[The dentists' image. Is history repeating itself?]. / Het imago van de tandarts. Herhaalt de geschiedenis zich?

Each generation likes to see itself as unique and thinks that the conditions under which people live and work are also unique. This position does not, for the most part, apply to dentists. Two questions which are now under discussion were also under discussion in the past. In the first case, this has to do with whether dentistry should be seen especially as a profession in which skill and competence are central, or as a medical discipline in which science (too) is central. The second question which was posed in the past as it is now is whether the dentist is seen especially as a salesman, albeit as a healthcare provider. Both questions are of the greatest significance for the image of dentists and also perhaps indirectly for the future of the professional group. Indeed, the answer to these questions has determined in the past as well as now the image of dentists and the degree to which the government has believed that dentists could be replaced by less highly educated non-dentists. For that reason, a clear answer to these questions ought to be formulated. It is possible that the answers given to these same questions in the past will be helpful in formulating answers now.

[Dentistry and healthcare legislation 11. The dentist and the civil law judge: claims]. / Tandheelkunde en gezondheidsrecht 11. De tandarts en de civiele rechter: claims.

In contrast to the law governing complaints and to disciplinary law, a civil law judge can sentence dentists to the restoration of all damages to patients. For this to happen, there has to be evidence of damage, responsibility and a causal connection. For the assumption of responsibility as well as a causal connection, an important question is whether a dentist has violated a relevant guideline or protocol. Moreover, dentists are not only responsible for their own mistakes, but also, in principle, for those of their employees. Depending on the situation, dentists can also be held accountable for the mistakes of a dentist who is working in their practice on a self-employed basis. Dutch dentists do not yet have to fear American situations', because damages awarded in The Netherlands are still relatively low.

[Dentistry and healthcare legislation 9. The dentist and the disciplinary court case]. / Tandheelkunde en gezondheidsrecht 9. De tandarts en de tuchtrechtprocedure.

Disciplinary law can be seen as an element in the system that protects the quality of dental care and in that way helps to maintain the high level of trust which the public has in the profession. A disciplinary court case is regarded by dentists as very taxing. This is in part a result of unfamiliarity with the procedure. The procedure is also feared because of the publicity it attracts. The publicity is partly inherent in the goal of the disciplinary law. To some extent the publicity seems to be taking on the character of 'trial by media'. Questions can be raised with respect to this latter development, regarding, for example, the use of anonymity by journalists; the impact of publication, which is partially dependent on other news-worthy events; and the impact of the publication of reprimands versus the most severe sanction.

[Dentistry and healthcare legislation 10. The law governing complaints: readily accessible filing procedures]. / Tandheelkunde en gezondheidsrecht. 10. De Wet klachtrecht: laagdrempelig klagen.

The law promises patients a readily accessible means of filing complaints. Healthcare providers are therefore required to adopt regulations governing complaints which satisfy a number of conditions. Most dentists choose to adopt the regulations which have been established by their professional organization. In addition to handling complaints, there is also a provision for mediation, which is often used by patients. Mediation appears, then, to be a successful provision. Many complaints have their origin in insufficient knowledge of healthcare legislation and patients' rights legislation. This demonstrates that more attention should be given to these subjects in educational programmes and programmes in continuing education. The present law governing complaints is expected to be replaced this year by a new, more comprehensive law in which considerable attention will be devoted to the quality of care as well as to complaints. It seems likely, however, that the new law governing complaints will damage the effective manner in which patients' complaints are dealt with in dentistry today.

[Dentistry and healthcare legislation 8. Registration and termination of registration of patients: the disciplinary judge determines the norm]. / Tandheelkunde en gezondheidsrecht 8. In- en uitschrijven van patiënten: de tuchtrechter stelt de norm.

The extent of the responsibility to provide care which a dentist bears depends on whether a patient is registered with the dentist's practice. A dentist has the freedom not to register a patient with his practice, provided he does not violate the anti-discrimination laws or a cooperative professional agreement which the dentist has signed. No conditions are applied if a patient wishes to withdraw his registration, or a registration is withdrawn by mutual agreement. If a dentist wishes to terminate the treatment agreement unilaterally, this can only be done if serious reasons for doing so can be identified. The reasons for termination which will be accepted by disciplinary boards as serious depend very much on the conditions of the specific case. In cases of the unilateral termination of a treatment agreement on the part of a dentist, given the serious reasons for doing so, it is usually necessary for a dentist to take into consideration various requirements for careful conduct.

[Treatment of a patient with psychogenic non-epileptic seizures]. / Behandeling van een patiënt met psychogene pseudo-epileptische aanvallen.

A 36-year old man is referred to a centre for special dental care due to problems with treatability in the general dental practice and a deteriorated oral state. His behaviour is unpredictable due to the possible development of sudden changes in the patient's consciousness which are accompanied by severe aggression. The patient suffers from a conversion disorder, a serious mental disorder which expresses itself in his case with the occurrence of psychogenic non-epileptic seizures. The patient fears that dental treatment will provoke a seizure and that he will react aggressively to his surroundings. He therefore requests that he undergoes dental treatment using general anaesthesia and patient fixation measures. This case study provides an example for the discussion of the problems and the rights of patients with severe mental disorders and the use of measures of physical restraint in dentistry.