CONSENT FOR SIMPLE DENTAL IMPLANT TREATMENT: MATCHING PRACTICE WITH THEORY ANDREW TOY, NILESH SHAH, NIGEL ROSENBAUM, Dr REG DENNICK

Introduction The purpose of this research project was to assist dentists in providing a modernday consent process for simple dental implants. This article reports on the action research conducted with 30 dentists of various levels of dental implant experience. The research combines analysis of their experiences with social theory and expert opinion to provide a guide to the process of consent required in the modern world.

paternalistic approach to patient care. The simple ‘dentist knows best’ stance has evolved into a more complex interaction. It requires the dentist to include the concepts of authority, capacity/competence, and voluntariness in their consent procedures, as well as simply providing information.3 The consent process is now described as a trusting, professional relationship in which the dentist respects the autonomy of the patient and gives them the means to make an appropriate choice.

The evolving nature of consent

Material risk

Sociological developments have led to significant changes in the professional relationship between dentist and patient. In 2005, Rees Jones reported that, in general, there has been a ‘collapse of trust’ between doctor and patient.1 The dentist should no longer assume that their patient will automatically accept whatever is ‘best’ for them. In 1988, Dolly (reported by Haug), described a theory of ‘De-professionalisation’, as: “The drive towards consumption and client-centred care, better informed clients – what many doctors now refer to as internet-positive patients – are examples of challenges to the cultural legitimacy of medicine captured in the phrase the ‘revolt of the client’.” 2 AUTHORS

Andrew Toy BDS MFGDP(UK) MMedSci (Clinical Education) General dental practitioner, 34 Maxwell Drive, Loughborough Nilesh Shah BDS MFGDP(UK) MMedSci (Implantology) General dental practitioner, 34 Maxwell Drive, Loughborough Nigel Rosenbaum BDS MFGDP(UK) MMedSci (Implantology) MRDRCS(Eng) Specialist prosthodontist, one80dental, Sheffield Dr Reg Dennick PhD Assistant director of Medical Education at The Medical School, The University of Nottingham, Nottingham

It’s not only the patients that are questioning the professionals’ status. Changes in the regulatory bodies such as the General Dental Council (GDC) to include a majority of lay members demonstrates that the professionals are no longer ‘trusted’ to police themselves. According to Jones, these changes are a result of the ‘paternalistic culture of the medical profession, a sense of a lack of engagement with patient rights and growing calls for patient involvement in decision-making’.1 Dentists will now have to respond to greater demands from the regulatory bodies who do not accept a

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The legal sense of acceptable consent has matched these social changes. Before the 1990s, the legal test was based on asking what a ‘responsible dentist’ would do in the circumstances; the present position now asks what a ‘reasonable patient’ would do if they understood the risks involved. Not all risks have to be identified and described, just those that are most relevant to the patient – known as the ‘material risks’.

Shared decision-making Shared decision-making is the second element in the modern world of consent. Where there are options for treatment (which is always the case when considering dental implants), then the decision on which option is best is no longer made by the dentist. The dentist has a responsibility to work in partnership with the patient to enable them to make an informed decision. This principle is demonstrated in the GDC’s guidance on consent, which states: ‘Recognise and promote patients’ responsibility for making decisions about their bodies, their priorities and their care, making sure you do not take any steps without patients’ consent (permission).’4

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CONSENT FOR SIMPLE DENTAL IMPLANT TREATMENT: MATCHING PRACTICE WITH THEORY

The key principles of this document are: • Informed consent – the patient has enough information to make a decision. • Voluntary decision-making – the patient has made the decision. • Ability – the patient has the ability to make an informed decision. The patient’s ability to make a decision (also referred to as their capacity) is discussed in the Department of Health’s Reference guide to consent for examination or treatment. It states: ‘For consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question.’ It is essential the patient can: ‘understand the information given to them that is relevant to the decision...retain that information long enough to be able to make the decision.’ 5

The principles of adult education If a patient is to have the ‘capacity’ to share in the decision-making, then they will have to move from a position of ignorance of their clinical situation and treatment options to one of sufficient knowledge and understanding to make a decision. That is, the patient has to ‘learn’ some things about their condition and the options available. In order to truly share the decision-making with the patient, the authors would argue that the implant dentist should take the patient through an appropriate process of education. It is important to note that an education process is not simply the provision of information to the patient. Patients will have to learn and gain an understanding of their situation. In short, an education process, according to Cotton, involves:6 1 Establishing rapport. 2 Establishing prior learning. 3 Providing the right information, in the right form at the right time. 4 Allowing time for reflection. 5 Evaluating understanding. Redefining consent in educational terms

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provides the dentist with a well-researched almost step-by-step guide to the process they need to employ in practice. It is likely that many dentists will believe that stages 1-4 are commonly known and practised – there is nothing new here. However, the authors of this paper believe that the introduction of evaluation (stage 5 of the education process) could provide a significant improvement in the quality and consistency of consent provided by implant dentists. The authors have found no previous reference to evaluating patients’ understanding in respect to consent, so this would appear to be a novel idea. How are the modern implant dentists equipping themselves for these changes in the social world? They now have to ensure that their high standard of ‘hard’ clinical skills are accompanied by an equally high standard of ‘soft’ consultation skills if they are to successfully match the expectations of patients, regulators, the courts and their peers. Has the training and practice of providing dental implants advanced to match the evolving nature of the consent process?

The research In the aim to facilitate an improvement in the provision of consent for dental implants, the authors conducted a research inquiry using a grant of £5,000 from the Association of Dental Implantology (ADI), a large UK special interest group. The authors who made up the research team were Nigel Rosenbaum and Nilesh Shah – two dentists experienced in the provision of dental implants, Andrew Toy – a dentist with experience of practicebased research, and Dr Reg Dennick – a medical educationalist. The inquiry took place between May 2007 and April 2009.

Methodology The team’s research aims were not only to describe what is happening, but to also provide practitioners with some direction to improve their practice. For this reason, Elliots’ action research methodology was

adopted,7 providing a structure to help, as Lomax put it, ‘close the gap between the ideal and reality’.8 The team’s research plan was as follows: 1 Seek ethical approval. 2 Literature search to identify key themes associated with the consent process for dental implant treatment. 3 Recruit implant dentists into the study and gather demographic data. 4 Devise a patient questionnaire to assess the efficacy of the consent process conducted by the participating dentists. 5 Distribute and collect patient questionnaires (phase 1 data gathering). 6 Analyse and interpret data from patient questionnaires to identify ‘stronger’ and ‘weaker’ consent processes. Match with dentists’ demographic details to identify a list for in-depth semi-structured interviews (phase 2 of data gathering). 7 Conduct semi-structured telephone interviews with the phase 2 dentists, using themes identified in the literature search. 8 Final analysis and interpretation of all available data.

Reflexivity The dental members of the research team strongly believe in the importance of applying the modern principles of consent to their practice. Consequently, analysis and discussion of the data will be influenced by their firmly held opinions on the issue. As with all qualitative research, outright objectivity in conclusions are impossible to obtain. However, the authors believe that their conclusions are validated by triangulating against those reported in the literature search. Rosenbaum and Shah have undertaken formal implant training to Masters level, and are involved with the teaching and examination of implant dentists in an academic setting.

Ethical issues Ethical advice was sought from Hilary Tulloch, business support coordinator at the National Research Ethics Service, who classified the research as ‘service

P R I M A R Y D E N TA L J O U R N A L

TA B L E 1

PATIENT QUESTIONNAIRE Answer as many questions as you can. Please use block capitals. 1

Write down the options for replacing your tooth/teeth given to you by your dentist (other than a dental implant).

11 Have you been given information about dental implants from the practice? (Tick all that apply).

a

a

Poster?

b

b

c

c

d e 2 3

4

YES

NO

Leaflet/Brochure/Booklet?

YES

NO

Personal letter?

YES

NO

d

Email?

YES

NO

e

Website?

YES

NO

Have you been informed of the likely cost? NO YES

f

CD-Rom?

YES

NO

g

DVD?

YES

NO

Did you discuss the possible need for future replacement of your implant? YES NO

h

Discussion with the dentist?

YES

NO

i

Discussion with a team member?

YES

NO

j

Discussion with another patient?

YES

NO

What are the risks, complications, problems or side effects of implant therapy?

k

Models of implants?

YES

NO

l

Slideshow/video?

YES

NO

YES

NO

a

m Case studies?

b

n

Other (please specify)

c d e 5

Do you know the name(s) of the dentist(s) providing treatment? YES NO

12 Have you had a written estimate? YES NO

6

Has your dentist discussed the length and number of appointments? NO YES

13 Have you had written details of potential benefits? YES NO

7

Describe the process of having a dental implant/implants

a

14 Have you had written details of possible complications? YES NO 15 Have you had all your questions answered by the practice team? NO YES

b c

16 Have you had enough time to consider the proposed implant and any alternatives before starting treatment? YES NO

d e 8

Do you know what could happen if you do not have this treatment? NO YES

9

Has the dentist discussed with you what happens if the implant fails? NO YES

10 What additional maintenance will be required for your implant restoration?

17 Are you happy with the consent process? NO YES 18 Please give reasons for your answer:

19 Any other comments? (continue overleaf if necessary)

a b c d e

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Please post this in the Freepost envelope provided. Thank you for taking the time and trouble to complete this questionnaire. You have helped to improve care for implant patients of the future.

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CONSENT FOR SIMPLE DENTAL IMPLANT TREATMENT: MATCHING PRACTICE WITH THEORY

development’. A submission to an ethics committee was therefore not required. Data was collected from patients and dentists. Care was taken to ensure that participation in the study would not adversely affect patient care, nor harm the participating dentists’ professional reputation.

from 30 to 59 years old. 15 reported they had received ‘formal’, peer-assessed implant training in the form of diploma or master’s degree; the rest reported ‘informal’ training ranging from individual study days to longer dayrelease courses and mentoring relationships.

Literature search

The number of implants placed since the start of their implant service varied from two to 3,500. Most of the participants had placed between 150–500 implants, and one dentist was only involved in restoration of implants. Twenty of the participants accepted referrals from colleagues. All reported using proprietary leaflets from bodies such as the ADI and implant manufacturers, while 17 reported use of their own literature. Models and photos were commonly used as audio-visual aids. Four used implant computer software of some form to assist the consent process.

A literature search was conducted by Shah and Rosenbaum. Data was gathered from recently published research using the PubMed database, as well as the opinions of respected individuals within the field. The literature was evaluated and a selection made to establish the key principles of modern consent – what may be described as the ‘theory’ of modern consent.9,10,11,12 These were used to inform the next two stages of the research – the creation of the patient questionnaire and the semistructured interviews with dentists – and the aim was to map the ‘theory’ of the modern implant consent process with the ‘practice’ as reported by the participating dentists.

Recruiting participants Recruiting participants to the study proved to be one of the most challenging aspects of the whole project. The original intention was to gather demographic data for at least 100 implant dentists. Following this, 30 dentists would be selected to take part in phase 1 data gathering (patient questionnaire). The recruitment campaign consisted of an email to all ADI members along with personal requests to colleagues by Rosenbaum and Shah during their meetings with implant dentists. However, as only 30 dentists responded to the request to complete the demographic spreadsheet, all respondents were used for this part of the study. The list of 30, however, did exhibit a wide range of experience within the criteria recorded. Most participants practiced in the UK with two in the Republic of Ireland and one in the Republic of South Africa. Ages ranged

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Patient questionnaire The research group’s original intention for phase 1 of the data gathering was to evaluate the success of the participating dentists consent process by assessing their patient’s knowledge of the key aspects of their impending implant treatment. It was hoped that this would help evaluate the performance of the participating dentists (in terms of consent) to inform the second research phase (interviews with the dentists). The 19 questions (see Table 1) covered as many aspects of consent for a simple implant treatment as possible, with room for the patient’s opinions or additional information. There was a need to keep the questionnaire as short as possible, whilst ensuring that nothing significant was omitted. Rosenbaum and Shah piloted the questionnaire on over 20 of their own patients, leading to some modification before it was released. It was during this piloting phase that the research group experienced a ‘crystallisation’ of their thinking and the questionnaire became more significant than originally intended.

Distribution and collection of patient questionnaires Ten questionnaires and freepost envelopes were posted to each of the 30 participating dentists, along with the practice protocol document. Five dentists had no returns, most had between three and five returns, and one star performer managed to achieve 23. The total number of returns was 93.

Analysis and interpretation of questionnaire data; creation of interview list Whilst the response rate was disappointing, it was never intended to use the patient questionnaire data for statistical analysis during this project. The patient questionnaire was only designed to add ‘richness’ to the data held on our participating dentists. The very small numbers of returns for some of the dentists means that only very tentative conclusions were derived from the data. The data received did demonstrate some variation in reporting of the consent process by patients and it was possible to use it with limited success to identify ‘stronger’ and ‘weaker’ consent processes. A ‘stronger’ response was regarded as a high proportion of questions correctly completed; with particular importance placed on questions related to the risk and complications, opportunity to ask questions and written material. Purposeful sampling of the demographic data was used to create a data set of implant dentists with a wide range of experience, and a variety of training and qualifications. This was matched with apparent strength or weakness of their consent process where possible (as indicated by the patient questionnaire data). The three dental members of the research team selected 15 participants from the original group of participants for part two of the data gathering, which consisted of semi-structured telephone interviews. Nine of the participants responded to the request for telephone interviews, which were conducted between August and December 2008.

P R I M A R Y D E N TA L J O U R N A L

The interviews The aim of this part of the study was to gather data on a wide variety of opinions and practices of implant dentists. Variety of data enabled the research team to identify any issues that had not previously been raised in the study. Collecting contrasting viewpoints and practices also helped the research team gain a greater understanding of the context of providing consent in implant practice. This was essential if the research is to assist dentists in improving their consent process. Telephone interviews were conducted using a semi-structured format, based on a guide supplied to the participants several weeks beforehand. The suggested questions were designed to help the practitioners to describe and justify the implant consent process they use. The interview was conducted by Andrew Toy, who had experience of this form of data gathering. Toy conducted the interviews using Skype telephone software, enabling a digital recording to be made on his computer for reference later. Questions asked were:

The ‘experts’ have told us what good consent is. But how do you deliver it in practice? Describe the process of consent in your practice When does it start/finish? How long does it take? Where does it happen? By whom? What techniques/tools do you use? How easy do you find it? Where did you get your training in consent? How do you know the patient understands everything? Have you had any significant events because of your consent process?

Each interview took no longer than 45 minutes. Brief notes were also made at the time of the interview, the key points of which were checked for accuracy with the interviewee at the end of the session. Toy made a more complete report shortly after each interview. The major themes arising from the interviews were noted

and this helped modify subsequent interviews. Importance was placed on identifying the important aspects of each individual dentist’s practice, rather than aiming for a more consistent but rigid inquiry. The results of the interviews were then distributed to the research team and discussed via phone and email. Further revisions were made during several drafts of this report, which included more expert opinions.

Data analysis and discussion The difficulty experienced in recruiting sufficient dentists into this study is not uncommon in practice-based research. The participating dentists were clearly a self-selecting group who probably had a keen interest in providing good quality consent procedures in their own practices. In addition, the act of becoming involved in the study may also have changed their practice for the better (sometimes referred to as the ‘Hawthorne effect’).13 Therefore, the authors do not draw any conclusions about the quality of consent process being delivered in UK dental implant practices at the time of the study.

The patient questionnaire outcome The patient questionnaire was designed to add to the qualitative dataset and no attempt was made to analyse it statistically. It was useful to gather some insights into patients’ experience of the implant consent process – either through some of the comments made, or, indeed, by the lack of answers to some of the questions. For instance, in response to question 4 (‘What are the risks…?), one patient had written, ‘I didn’t know there were any? I shall be contacting my dentist to discuss this’. It would be easy to conclude that this dentist failed to mention risks and complications. However, the research team believe this is unlikely to be the case in this select group of implant dentists. Instead it is likely that the patient has not understood or recalled this part of the consultation. Just because the message has been given through discussion or in writing, does not necessarily mean it has been received by the patient. It has to be admitted that the true value of the questionnaire to the consent process did not become apparent until it

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was piloted by the implant members of the research team. It was initially seen as a way of providing patient-centred data on the performance of the participating dentists. However, when considering how to enhance the educational aspects of consent, it was obvious that the team had also developed a way of evaluating the patients’ knowledge and understanding of their treatment. For the implant dentists on the research team, the questionnaire has become an integral and extremely valuable addition to their consent process. The authors believe this tool will significantly enhance the quality of the consent process in three ways: 1 The patient and dentist review the key elements of the treatment using a series of questions. This evaluation of the patient’s understanding allows the dentist to further clarify the issues and immediately fill gaps in the patient’s knowledge. 2 Providing dentists with feedback on the efficacy of their consent process (a type of running audit). 3 Creating a useful written record of the patient’s level of understanding at the time of consenting to implant surgery. The team believe there is no reason why such a tool could not be modified for use in a wide range of elective medical situations.

What’s happening in practice? The following commentary is based on semi-structured telephone interviews that took place with the nine selected dentists. The interviews were designed to enable the practitioner to fully describe what they did to obtain consent, and why they did it. A number of themes were identified with direct quotes from some of the dentists to illustrate. Theme 1 – The importance of consent All dentists reported that they took the issue of consent very seriously, which was not a surprise as they were all willing participants in a research study on consent. They all offered the observation that the consent process often took longer than the procedure itself. This demonstrates their understanding that there is a lot more to providing dental implants than just screwing metal into bone. However, there was some variation in what they regarded as a correct consent process.

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CONSENT FOR SIMPLE DENTAL IMPLANT TREATMENT: MATCHING PRACTICE WITH THEORY

TA B L E 2

PROFESSIONAL POSITIONS ADOPTED BY DENTISTS DURING THE CONSENT PROCESS Dentist knows best

Shared decision-making – Basic

Shared decision-making – Advanced

Uses a fairly rigid preoperative consent process and expectations of patient.

Consent process is more flexible (will probably put in extra pre-operative visits if the patient does not appear to understand what’s going to happen, for instance).

In addition to ‘basic’ examples in column 2:

A very didactic approach emphasises the provision of a lot of information using literature, models, photos etc. Every patient receives an extensive, standardised letter of closely typed information. There is no attempt to personalise the information so that the content is appropriate and in a form that the patient will easily understand (reading age, use of diagrams, for instance). Takes a defensive approach to the consent process.

Emphasises use of non-verbal clues and active listening to improve understanding of the patient’s situation. Agenda is still fairly dentist centred, though as there is only a rudimentary effort to improve the patient’s ability to make an informed decision. Provides personalised written treatment plan outlining key aspects discussed with the patient during the consent process.

The dentist may be spending a lot of time on the consent process but is ineffective in helping the patient understand the options and risks before making an informed decision.

Theme 2 – Professional position On studying the data, it emerged that the dentists occupied one of three professional positions: 1 Dentist knows best 2 Shared decision-making – Basic 3 Shared decision-making – Advanced. The nature of these positions is described in Table 2, ‘Professional positions adopted by dentists during the consent process’. From some, it was possible to determine an old fashioned, paternalistic, ‘dentist knows best approach’; that is, a consent process primarily focused on giving information that the dentist deemed significant to the patient. Here it was evident that there was a lot of information supply going on, but with little reference to the patient’s context or ability to assimilate it. There was also a sense of

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‘defensive’ practice, where the consent process is designed to protect the practitioner rather than help the patient (see Dentist knows best in Table 2, column one). Others seemed to have embraced the notion of shared decision-making to some extent. They had made clear efforts to discover what was important to the patient and get some sense of their social context (that is ‘get to know their patient’). However, they made few positive efforts to enhance the ability of patients to understand their treatment and become truly involved in the decision-making. This stance is summarised in column two of Table 3: ‘Shared decision-making – Basic’. Some implant dentists went a step further than this and demonstrated an appreciation of the twin principles of material risk and shared decision-

Provides simple pre-visit information on implants and other options. This helps improve the patient’s understanding and enables them to ask questions about aspects that concern them most. Extensive and systematic efforts are made to fully understand the patient’s clinical needs and expectations and also their social setting. Use of nonverbal clues and active listening. This allows the dentist to ensure that the appropriate level of risk in the procedure is highlighted to the patient. Dentist sees themselves in partnership with the patient, helping them to make the best possible decision from a range of options.

making. This group understood the patient would also need to undergo a coherent education process about all aspects of their treatment and the alternatives (including doing nothing). This would enable the patient to ask questions pertinent to their own situation, and therefore participate in a shared decision-making process. Data from these dentists is outlined in column three of Table 2: ‘Shared decision-making – Advanced’. Perhaps not surprisingly, the ‘Shared decision-making – Advanced’ approach emerged from interviews of generally more experienced implant dentists. A few admitted they had developed their consent process as a result of some hard lessons along the way. The main elements or themes demonstrated by these ‘advanced’ dentists can be summarised as follows (dentists’ comments provided in italics):

P R I M A R Y D E N TA L J O U R N A L

Theme 3 – Early provision of background information • (the information)...helps them find out what they need. • ...allows patient to think about the issues. Theme 4 – Getting to know the patient • What the patient expects and what we can deliver may be completely different, especially in complex cases. Therefore it is essential that we find out what they expect. • I study them carefully, watch everything they do and listen to everything they say. Theme 5 – Provide the right information • It’s difficult with patients with learning difficulties – presence of a spouse or partner is essential. • You have to be adaptable: a standard consent form is of limited use, an individual letter is time-consuming but necessary. I think the patient values the individualised letter over the standardised. Theme 6 – Check understanding • I gauge their understanding by the quality of the questions they are asking. • The patient has to understand their problem and their journey. • You obtain consent when the patient understands, not when they sign a piece of paper.

Theme 8 – Training for consent In addition to the themes, opinions were sought from the participants on the training they had received in consent. There was a very wide variation (to be expected as this group was purposively sampled) and the most thorough training was reported by members who had recently finished a diploma or master’s degree. Other courses did not appear to take the issue so seriously. A number of the more experienced practitioners, who started their implant training before formal courses were so prevalent, cited the value of sitting with mentors and also the hard lessons learnt from making some mistakes.

Conclusions A study of the literature reveals a major social shift from the simple ‘dentist knows best’ position to the vastly more complex world of identifying material risk and shared decision-making. The expectations of patients and authorities are rising, whilst the number of dentists seeking to provide implants is growing rapidly. The conclusions to be drawn from this form of research are necessarily tentative. The generalisability of the conclusions of this study has not been established.

1

2

3

Scambler G. Sociology as Applied to Medicine, 5th ed. Edinburgh: Saunders; 2005. p.248-49. Haug M. A re-examination of the hypothesis of physician deprofessionalization. Millbank Quarterly. 1988;66(2): p48-56. Rattan R, Tiernan J. Risk Management in General Dental Practice. London: Quintessence; 2004. p63, 70-72.

4

5

6

7

Through descriptions of practice, the study has highlighted how some implant dentists operate at an advanced level according to the principle of shared decision-making with their patients. The study has also suggested the additional application of adult learning theory to the consent process, with the introduction of a novel evaluation tool at the final stage. This has the potential to significantly enhance the consent process to the benefit of both patients and professionals, in the authors’ opinion. This tool is yet to be significantly tested, and its efficacy is a topic for another study. There is also potential to apply the tool to other high risk areas of dentistry, such as cosmetic treatments. The authors hope that this research will help to close the gap between the theory and practice of high quality implant consent and improve the professional standards of practitioners providing dental implants.

ACKNOWLEDGEMENTS

Theme 7 – Be flexible, but systematic • I have a personal checklist to ensure all of the relevant issues have been discussed during the pre-treatment visits, before I proceed with treatment. • I have some audiovisual software that records what information has been accessed for that particular patient, when it was accessed, etc.

REFERENCES

However, the reader will be able to assess their own practice and compare it with the experiences reported here. The validity of the authors’ opinions may be measured by the degree to which the reader recognises themselves in one of the three categories described.

This study was funded by a £5,000 grant from the Association of Dental Implantology, which also provided valuable assistance with promoting the involvement of their members in the study. The participating dentists played a vital role in the project for very little reward. The authors wish to thank them for taking the time and trouble to comply with our demands. The dentists were: C Allen, S Barter, L Bernstein, B Bokma, J Buglass, J Burgess, W Ditchfield, R Gatenby, M Goddard, K Hallgren, M Haswell, Z Hathiari, P Hunjan, R Lee Kin, I MacArthur, D Murphy, A Muthukrishnan, S Nelson, A Nesbitt, N Olsen, D Owakee, C Oxley, M Robotham, P Scull.

General Dental Council. Principles of Consent. London: General Dental Council; 2005. p.1-5 Department of Health. Reference guide to Consent for Examination or Treatment, 2nd ed. London: Department of Health; 2009. p.9. Cotton J. Theory of Learning: an introduction. London: Kogan Page; 1995. Elliott J. Action Research for Educational Change. Bucks: OU Press; 1991.

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Lomax P, Jones C. Developing Primary Schools through Action Research. London: Hyde Publications; 1993. 9 Brands WG. The standard for the duty to inform patients about risks: from the responsible dentist to the reasonable patient. Br Dent J. 2006; 201(4):207-10. 10 Dental Protection. Risk management module 10: Implants. London: Dental Protection Ltd Publications; 2003.

11 Givol N, et al. Risk management aspects of implant dentistry. Int J Oral Maxillofac Implants. 2002; 17(2):258-62. 12 Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med. 2004;140(1):54-9. 13 Jones SRG. Was there a Hawthorne effect? The American Journal of Sociology. 1992; 98(3):451-68.

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Consent for simple dental implant treatment: matching practice with theory.

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