You thought 2020 was bad? Well, 2021 wasn’t THAT far behind.
© @DentistGoneBadd, GDPUK, 2021
Subcategories from this category:DentistGoneBadd, Simon Thackeray , Tony Jacobs, Guest Contributors, Enamel Prism, James Goolnik, Olympic Dentist, Digital Dentistry, Almodovar, GDC Watch, Eddie Crouch, Challenge DoH, Pramod Subbaraman, Ian Dunn, Alun Rees, The Tooth Counsel
You thought 2020 was bad? Well, 2021 wasn’t THAT far behind.
© @DentistGoneBadd, GDPUK, 2021
Over the past 20 years, I’ve been working within the UK and American Dental Industry to support dental practices growth through a number of different engagement and marketing strategies. However, over the last couple of years, I’ve noticed that something has drastically changed. Suddenly getting new, high-value patients has become increasingly difficult, expensive and confusing. So what’s happened?
A personal opinion, by Michael Watson.
Where I live, on the borders of Essex and Suffolk, has gone from a quiet rural community where dentists just got on with the job of treating their patients to the centre of a movement, Toothless in Suffolk, which aims to go nationwide as Toothless in England.
Two of their aims are to have an NHS dentist for everyone and reforms to the NHS dental contract that will encourage dentists to provide NHS treatments. Both of these will require more associates, who to put it simply are not there.
© Michael Watson, GDPUK Ltd
Throughout 2021, the British Dental Association [BDA] has been at the forefront of moves to tell politicians of the challenges facing dental services across the whole of the UK. It joined with Healthwatch England in calling on the Chancellor to provide vital funding for the recovery and rebuild of services, a move backed by 40 cross-party MPs.
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David Hallsworth, a solicitor at BLM specialising in healthcare claims, discusses a potential surge in future dental claims as a result of thousands of children missing crucial check-ups during the pandemic.
I have seen the soft campaigning in the form of opinion pieces and social media posts by dentists active in various positions in the British Dental Association (BDA) in the weeks and months before the General Dental Council (GDC) announced their new Chair to replace Dr William Moyes who is due to step down soon. The question that forms the title of this piece was running in my mind.
© Pramod Subbaraman, GDPUK Ltd 2021
Once upon a time, as all the stories, good, and bad, start, a dental surgeon would have a chair of some sort in his (almost always his) south facing sitting room and ply his trade. George Bernard Shaw in the 1897 play “You never can tell” describes such a set up in the home of Dr Valentine, a “half crown” dentist. The half crown refers to the standard treatment fee, not his clinical technique.
© Alun Rees, GDPUK Ltd, 2021
For the last 18 months I have been campaigning to get the government to change the policy to stop giving out dried fruit as part of the School Fruit & Vegetable Scheme.
GDPUK news was one of the first places to publish details about Raisin Awareness.
Following on from Marcus Rashford's incredible #EndChildFoodPoverty campaign, Sustain are lobbying for the School Fruit and Vegetable Service to be extended to include Key Stage 2 pupils so that it will reach all primary school children.
Public Health Minister Jo Churchill said to journalists that the School Fruit and Vegetable Scheme will resume as normal in Autumn when all children return to school. While we wait for official confirmation, this is not the end of the campaign for more fruit and veg in schools. The scheme should be expanded to all children in primary school and improved to include higher standard British produce.
Now that Sustain are calling for the expansion, I am asking the dental bodies to add their voices, and suggest that together we can approach the called-for extension as an opportunity to raise dental concerns and make this positive change at the same time. I'm hoping that we can use this to eliminate the dried fruit, if and when the scheme expands.
Sustain are delighted to get dental bodies involved, and have agreed to rewrite the calls to action to include dropping dried fruit from the SFVS scheme, and I have drafted a new version with Nigel Carter. We will also be detailing this in a joint letter to DHSC & Department of Education.
Many dental organisations including BDA, BSPD, OHF, BADN, BSDHT & BADT have offered their support.
In my correspondence with Jo Churchill at DHSC I was informed that their stumbling block is delivery logistics (the reason they say that they cannot swap from dried fruit).
I am currently arranging local vegetable delivery to my village primary school (on those 6 raisin days a year) with the hope of reproducing nationally - to overcome this. I am planning to use the Sustain network of local vegetable growers and sellers to provide the national supply web needed, whilst getting dental practices to link up to primary schools to initially pay for this veg and also long-term to input Oral Health Education.
I know that this can be overcome if we are determined.
I wonder if you, the GDPUK community, would also consider supporting this as a collective and as individuals?
There will be a number of ways you can get involved - look out for specific details of what and how in a series of articles coming out in the dental press, and I will also keep you updated with this blog.
If we can’t change it from the top down, let’s do it from the ground up.
© Jo Dawson, GDPUK Ltd, 2021
Christmas Was February
As a committed Labour Party member it is quite something to be impressed by a Conservative Party Minister and Secretary of State for Health, but I have to say this is precisely the case. The recently published proposals on fluoridation represent a clear intention to act. There’s a lot of talk around reducing inequalities and levelling up but precious little action. This is different, it’s a clear intention to support communities and improve oral health and preventing the consequences of poor health, pain, sleepless nights, extractions, poor self-esteem.
© CWF, GDPUK Ltd, 2021
OK, that’s a poor example of poetry, it is not even poetry but merely a poor attempt at some rhyming to a beat-ish!
© GDPUK Ltd 2021
There is always a risk in asking the question “How can you tell a good dentist?” Some people reading it will take offence, others may feel threatened, a few will read and conclude half way through that there is no point in continuing. Hopefully there will be the persistent ones who will take some time to ponder the question and even come up with an answer or two, if you do please feel free to share.
© Alun Rees, GDPUK Ltd 2021
It is now (February 2021) almost a year since dental practices were first told to stop face to face appointments as part of the response to the COVID19 pandemic during the first UK wide lockdown in March 2020. I clearly recall the Prime Minister’s address to the nation on 23rd March, a day when I should have been in India with my father to celebrate as he turned 80 years old.
© Pramod Subbaraman, GDPUK Ltd, 2021
Last Friday (Feb 5) Health Policy Insight published[i] the draft of the Government's forthcoming White Paper on Health, which was reviewed extensively in the media over the weekend. The main news in it for dentistry was that the paper included proposals to hand over control of water fluoridation to the health secretary and away from local councils. The move was widely welcomed in the profession especially by the CWF network (@network_cwf), the national organisation of dentists supporting water fluoridation.
Andrew (now Lord) Lansley’s 2012 reforms, when he was health secretary, handed control of the measure to local councils, which led, in October 2014, to a decision by Southampton City Council to scrap plans to fluoridate its water. This followed a vigorous campaign by ‘Hampshire Against Fluoridation’ and tentative plans to introduce the measure in other areas such as the North West of England and Hull were quietly dropped. Speaking in the January 14 Commons debate on dental services during Covid-19, health minister Jo Churchill said she was ‘extremely sympathetic’ towards the measure, so we may expect its revival perhaps.
In his report[ii], the late Professor Jimmy Steele said the first priority of any NHS system should be ‘a strong, co-ordinated public health system’, something that has not been possible with it being devolved to individual local councils,
The Lansley approach, which was controversial in the Conservative/LibDem coalition, was to take power away from ministers and put it in the hands of administrators. NHS England was given ‘power without responsibility’ to quote Stanley Baldwin’s description of the press in the inter-war years[iii]. But Ministers were still held accountable to Parliament for the NHS; ‘responsibility without power, the worst of all worlds’ as then Home Secretary David Blunkett, described it in 2002.[iv]
Without going into any detail, the document says there will be ‘enhanced powers of direction for government’ to ensure that ‘those overseeing the health system’ are held to account. For dentistry this could mean that the focus moves from NHS England’s obsession with delivering UDAs to MPs’ demand that anyone who wants to see an NHS dentist can do so - a shift from activity to access.
Secondly the Lansley approach was to promote competition within the service, hence the over-long process of commissioning new services, typically a year or more and, arguably, the botched orthodontic recommissioning exercise.
The pandemic showed, though the commissioning of urgent dental care practices, that the NHS can move rapidly when circumstances demand and so it should be in the future.
In responding to the January 14 debate, health minister, Jo Churchill said that ‘a transformation in dentistry is necessary.’ She continued: “There is a huge opportunity to deliver a greater range of health advice monitoring and support, using dentists and their teams.”
The demise of the Lansley system could give her the opportunity to achieve this.
[ii] NHS dental services in England: An independent review led by Professor Jimmy Steele, June 2009
[iii] ‘power without responsibility – the prerogative of the harlot throughout the ages’, Stanley Baldwin speech on newspaper proprietors March 17, 1931
[iv] Speech by home secretary, David Blunkett to Labour local government and women’s conference Cardiff, February 2002
© Michael Watson, GDPUK Ltd 2021
We are all (well most of us!) now actively involved in prevention and risk assessment.
We stay at home, keep our distance, wash our hands and wear masks. We know some people are at higher risk of serious complications and death from COVID than others, so we shield the elderly and those who are clinically vulnerable, and we require our medics, dentists and care workers to wear PPE and engage in comprehensive disinfection routines to protect them and their patients from the close contact they have to have in their essential work. Our vaccination programmes have initially been targeted at those who, by nature of their inherent risks or lifestyle risk factors, are in most danger.
It is the coming of age of risk assessment and prevention, a time when the public accept that the inconveniences of doing the right thing are essential to ensure a better future.
I strongly believe that NHS dentistry post-COVID will take on this challenge: the one that says prevention comes first, and to prevent you must first to know your susceptibility and what you personally can do to protect your health. Treatment is a fix, not a cure and whilst essential to get patients out of pain, should not be the focus of a modern health service. Advanced restorative treatment on an unhealthy periodontium should not be paid for out of the public purse.
A study has just been published from Qatar on the impact of perio disease on COVID outcomes. Qatar has electronic health records containing medical and dental data (definitely something for the NHS to aspire to!) which facilitated the analysis of confounding factors. To quote the press release here:
The case control study of more than 500 patients with COVID-19 found that those with gum disease were 3.5 times more likely to be admitted to intensive care, 4.5 times more likely to need a ventilator, and almost nine times more likely to die compared to those without gum disease.
Blood markers indicating inflammation in the body were significantly higher in COVID-19 patients who had gum disease compared to those who did not, suggesting that inflammation may explain the raised complication rates.
Professor Mariano Sanz, one of the study’s authors, noted that oral bacteria in patients with periodontitis can be inhaled and infect the lungs, particularly in those using a ventilator.
“The results of the study suggest that the inflammation in the oral cavity may open the door to the coronavirus becoming more violent,” said Professor Lior Shapira, EFP president-elect. “Oral care should be part of the health recommendations to reduce the risk for severe COVID-19 outcomes.”
Causality, which is very difficult to prove, is not claimed here, and as always, whilst confounding factors have been adjusted for, those with perio disease often also have other health issues. Maybe the periodontitis is just a manifestation of a tendency to inflammation, and the COVID response simply results from that. However, the evidence for periodontal disease raising your risk for other systemic diseases is indisputable and growing.
The crunch is this: gum disease is the easy part to deal with: it is not invasive, expensive or harmful. When you can stop the disease in its tracks, why risk COVID complications? Why accept the heightened discomfort and dissatisfaction with your teeth, and the tooth loss that results from periodontitis? Knowing that gum disease is associated with diabetes, CVD, kidney disease, dementia etc, why would the susceptible patient not choose health over bleeding?
Now is the time to talk prevention: to explain to the susceptible periodontal patient how they are more vulnerable than others in the population; to identify and share the lifestyle factors which put them personally at risk of the disease; to explain the potential impacts on their systemic health, and persuade the patient that it is up to them to take the decision to work with you to take charge of their future.
OHI Ltd, UK provider of PreViser and DEPPA technology
© Liz Chapple, GDPUK Ltd, 2021
In this exclusive interview, Laura Hannon shares with readers how the BDA Benevolent Fund has continued to support the profession in times of unprecedented challenges.
© DentistGoneBadd, GDPUK Ltd 2021
Hambley Trading Limited are looking to supply dental professionals, experienced in the delivery of local anaesthesia to patients, example prototypes of the SINCROTM system for them to examine and assess and compare with their current choice of syringe delivery device.
A questionnaire relating to the handling characteristics may be completed and returned electronically which will entitle the respondent to a FREE box of SINCROTM [50 syringes] after the device is launched into the UK dental market.
For a limited number of early respondents there is also the chance to be awarded a £25 Amazon gift voucher, so get your response in quickly.
© Hambley Trading Ltd 2021
There’s little doubt that THE hot topic in the UK media currently, is the delivery of COVID vaccines to the population of the nation: I say the nation, I’m excluding those who think the pandemic is a hoax and that Bill Gates has contaminated the vaccine with microchips that will turn them into that infuriating old Microsoft Word paperclip assistant “Hi, it looks like you are a moronic conspiracy theorist writing anti-vaxxer propaganda, how can I help?”
© @DentistGoneBadd, GDPUK Ltd, 2021.
That opening line from the song “The Living Years” resonates with anyone who has lost a parent, grandparent, teacher or mentor and comes to appreciate that, “we are all prisoners of what our predecessors held dear”.
One of my prepared talks (post-covid bookings are now being taken!) includes me reading a paragraph from one of the required textbooks of my undergraduate years, Immediate and Replacement Dentures. Chapter two, “The patient as a person”, has a section called “The quiet mind”, this starts with a definition of the normal patient which reads, “The normal patient is one in whom the loss of teeth follows previously satisfactory dental treatment”. When presenting, I pause and read it again emphasising loss of teeth, normal and satisfactory.
The reactions of the audience, if I am fortunate enough to have attracted one, is varied, the baby boomers nod and smile in remembrance, Generation “X" shake their heads in disapproval, Millennial (Generation “Y”) are cross and want me de-platformed, Generation “Z” need to be revived after the trauma and demand post-presentation counselling.
Not only do I believe that subdividing groups of people into “Gens” in order to predict their behaviour is akin to astrology for sociologists but it can also prove confusing and futile. There are rarely true generation gaps in a profession like Dentistry where changes are introduced slowly and incrementally. Teaching of undergraduates reflects the previous doctrines filtered through the published research, the experiences of the, as yet, unpublished opinions and the perhaps more dogmatic, heavy hands of department heads.
All this of course is filtered and influenced by that relatively new group, the educationalists, or specialists in education, whose views on the manner of teaching delivery may have a significant bearing on what, how and why knowledge is delivered by whom, where and when.
I was moved to write this piece for two reasons. The first was another in a long line of consultations from dentists who are deeply unhappy in and with their chosen profession. Almost all of them tell me that they felt they were too young, usually 14 to 16, when they made the decision to study dentistry and that their undergraduate training, whilst fine at the science of dentistry, hadn’t prepared them for the reality of life in (UK) dentistry.
My other stimulus was reading David Epstein’s book, “Range”. In it the author examines the virtue of early specialisation with many hours of deliberate training in one field compared with the value of being a generalist.
I am not sure if I have come to any definite conclusions. What I know is that I never wanted to be anything but a dentist and it took me 25 years to accept that I didn’t enjoy being a “wet-fingered”, micro-managing surgeon. With hindsight I can see that I spent too long climbing up the wrong wall, my ladder looked perfect, others were envious of my achievements and success, but it didn’t make me happy, indeed quite the opposite.
A proportion of dental graduates are not suited to the careers available to them and would walk away if they could. Unfortunately the pressure from parents and peers, not forgetting the financial implications, means that leaving is the social equivalent of not turning up for your own wedding. For many who persist this means that further down the road comes a moment where they wake up, unhappy, wondering, “is that all there is?”
Epstein quotes Winston Churchill whose words are used to encourage unhappy, unsuited people to show “grit”, “Never give in”, he said, “never, never, never, never”. What nobody tells you is that he finished the sentence by saying, “except to convictions of honour and good sense.”
What could be done? Could we go down the American route of an honours “Bachelor of Medical Science” degree followed by a three-year dental programme taking 46 weeks per year of proper work? A 21 year old is in a better position to make a career decision than a 17 year old and other pathways are available to those who are unsuited.
Would a better career path in general Dental Practice work? Perhaps a three-year post-grad programme with spells in different independent and corporate practices, NHS, specialist and private with clear transitions, supervision and significant mentoring. Some years ago there was a brave move to start an independent vocational training scheme, which foundered after the intervention of the NHS who were opposed to anything that they could not fully control.
What we have can be inconsistent and does not help everyone. Dentistry is unsure of itself. Is it still a speciality of medicine? Does it want to truly embrace teamwork, if so exactly what model works best? Or is it straddling the divide with one foot rooted in the disease model and the other trying to run away along the road of cosmetics?
Are we failing the next generation? Will more and more unsuited young people be ground beneath the NHS wheels?
You say you just don't see it, He says it's perfect sense,
You just can't get agreement, In this present tense.
© Alun Rees, GDPUK Ltd 2021
Do you remember 2020? That was the year that toilet roll was more sought after than gold and an inadvertent sneeze in a supermarket could get you battered to death by an angry mob armed with batons of sourdough.
© @DentistGoneBadd, GDPUK Ltd, 2020.
I still don’t know how I ended up in dentistry. My own childhood dentist certainly inspired no dental aspirations. The only thing he engendered was a soul-gripping dread whenever I was dragged up City Road, Birmingham, to his terraced house practice. The man had no empathy whatsoever and shouted at me when I gagged on his un-gloved nicotine-stained fingers or what I assumed were child-killing cottonwool rolls.
© @DentistGoneBadd, GDPUK Ltd 2020
“If you think you’re a leader and no one is following you, you’re just out for a walk.” Peter Drucker.
I hesitated before putting finger to keyboard on the subject of leadership. A Google search shows in excess of 2 billion results on the subject. What can I possibly add to that? The answer is to only share my take on the subject, which in spite of all the papers, videos, courses and hot air is still poorly addressed and understood.
Two years ago, in those carefree pre-Covid days, I researched, wrote and presented half a dozen talks on leadership in the hope that I might in some way help to improve things in my nano-field of influence. One of the main points that I made then is that we often look at the wrong people for examples of good leadership. Certainly the procrastination and self-interest shown by politicians and business leaders does little to stimulate recommendation or inspire imitation to those owning, running and working in small businesses.
So what is it leadership? One sidestepping answer to that is, “I’m not really sure but I know it when I see it.” In his landmark book, “Good to Great” Jim Collins expected to find the leaders of successful large companies were “those with high profiles and big personalities who became celebrities”. In reality they were often “self-effacing, quiet, reserved, even shy individuals with a paradoxical blend of personal humility and professional will”.
Dentistry and other professions used to attract large numbers of the latter but I do see growing amounts of attention seekers who appear to believe that success is directly proportional to Instagram posts and can happen almost overnight. Perhaps I am becoming jaded but the retreating tide of 2020 plus the year to come will show just who has been swimming without a suit.
Another regular way of talking about leaders is to compare and contrast them with managers and, until a decade or so ago, I was as guilty of that as the rest. Then it struck me that in the field of small and micro businesses it is impossible to be a good leader without managing; and it is equally impossible to be a manager without leading. Shoving individuals into defined silos doesn’t work, we must all wear different hats to suit circumstances. There are some, but very few, absolutes, there must be overlaps in some areas.
In my experience with successful leaders in dentistry and other small businesses I have found several characteristics that they all share to a certain extent. In many these traits are not instinctive but have been learned by experience and acceptance.
Warren Bennis wrote in, “Becoming a Leader”, “I don’t know if leadership can be taught but I know that it can be learned”. He described “The Cauldron of Leadership” as formative events, critical struggles or serious challenges that force leaders to learn, grow and think differently about themselves. The cauldron theory is fine, but can be traumatic, and you are better off paying attention to what is happening and reflecting and considering what you have learned.
If I have managed to make you think about the boxes that you tick, or not, in your leadership roles then my work is done.
To your success.
© Alun Rees, GDPUK Ltd, 2020
As a kid, I was scared of riding on the pavement. I lived in the middle of Birmingham and there were always beat policeman around. One evening, I cycled back from Scouts. It was quiet and there were few people about. As I reached my home – on a busy main road – I experienced a sudden surge of bravado and chanced cycling across the pavement to my door, when a copper emerged out of nowhere from an off-licence. He gave me a five minute dressing down regarding how I was endangering human life and how I had disgraced my uniform.
© @DentistGoneBadd, GDPUK Ltd, 2020
It was a black day anyway.It had been announced earlier that morning, that Freddie Mercury had died, so I wasn’t particularly bathing my colleagues in the joy-bringing light of my sunny-disposition. I was sitting in my surgery at lunchtime, reading a newspaper (This was the early 90’s, when YouTube was merely a glimmer in Tim Berners-Lee’s eye), when four glum-looking nurses trooped in.
© @DentistGoneBadd, GDPUK Ltd, 2020
Last week, Pfizer and BioNTech announced a breakthrough in the fight against the SARS-CoV-2 virus. Pfizer proclaimed its initial Phase 3 data showed its vaccine is 'more than 90% effective'. The news was hungrily devoured and then regurgitated by the national press in an excited fanfare. The BBC reported Health Secretary Matt Hancock as saying the NHS will be ready from December to roll out the new coronavirus vaccine if it gets approved.
© @DentistGoneBadd, GDPUK Ltd 2020.
Two important ‘documents’ hit the inboxes of dental professionals this week, one was an update on the Standard operative procedure – Transition to recovery from the ODCO and the other was a survey put out by the General Dental Council. One was something you really needed to take in, the other was something you had a choice of participating in, even if it was just for a laugh.
© @DentistGoneBadd, GDPUK Ltd, 2020.
I am thoroughly ashamed. I have struggled to resist seeking solace from psychological props like alcohol or drugs, for many years, but I’ve recently realised that I am, in fact…an addict! I’ve become totally addicted to dental groups on Facebook.
© @DentistGoneBadd, GDPUK Ltd 2020
When UK dentistry restarted back on June 8th after such a long break, I naively thought that it might be a fresh start for the relationship between dental staff and patients. In my mind’s eye, I pictured a beautiful slow-motion reunion between dentist and patient on a beach, against a background of crashing waves, accompanied by a sweeping orchestral soundtrack of music lifted from 1970’s Love Story.
© @DentistGoneBadd, GDPUK Ltd, 2020
Retirement from dentistry isn’t all that it’s cracked up to be. It’s not all waking at ten, eating a big breakfast bowl of Rice Krispies while you listen to PopMaster, taking a leisurely shower, eating lunch and in the afternoon watching the wife working in the garden while you keep an eye on Trump via YouTube.
© DentistGoneBadd, GDPUK Ltd, 2020
There are still dentists and dental care professionals who haven’t returned to work after dentistry resumed in a limited way during the summer. Those dental professionals who have still had no patient contact for months are concerned about the return to work and the change in circumstances in practice. I interviewed one such practitioner.
© @DentistGoneBadd, GDPUK Ltd 2020
Just imagine if the newspapers weren't interested in dental disasters
© @DentistGoneBadd, GDPUK Ltd 2020
For several years it was my honour to be the opening speaker at the annual scientific meeting of the BDA Western Counties Branch, Young Dentist Group (YDG). The challenge for me in, say, 2016 was to try to share some perspective on changes in dentistry. In 2016 it had been 43 years since I embarked on my university studies, rolling that back another 43 years would take us 1930. I wondered what someone from those interwar, great crash and depression, times could have said to me that would have had any relevance to me in my post-qualification years. Eventually I chose to major on the letter “H” and look for similarities rather than changes.
Another “H”, neurosurgeon Henry Marsh, has written one of the best medical autobiographies that I have read. In “Do No Harm: Stories of Life, Death and Brain Surgery” he writes of the cases he has treated successfully and otherwise and the lessons he has learned. He describes his mistakes both surgical and human and the frustrations of his life with an honesty and insight that I can only envy and attempt to imitate.
Back to the YDG where, in my fifteen minutes in the spotlight, I attempted to describe the roles of Humility, Hubris and Humanity in success and failure. My naive younger self believed that the path to success was mostly straight with the occasional glitch of disappointment. Before Dental School I presumed that my skills would grow and develop in a largely logical and linear manner, much like building a wall with Fletton bricks. I hadn’t anticipated the possibility of quantum growth, where I would feel stuck at a level of inadequacy before suddenly acquiring, whatever it took to move up to the next level of competence.
Nor did I realise that there could be levels of competence that I would never, achieve and to which I could not even hope to aspire. Perhaps it was a good thing that I realised, early on, that my own skills and my temperament would always be limited. I could also see that there were those who were naturally, instinctively skilled, even artistic. Journeyman level is honourable enough as long as you have the humility to acknowledge and accept your own limitations and to develop your skills as far as you are able.
There are far more problems in all walks of life caused by hubris. Defined as excessive pride or self-confidence, there can be a natural tendency with new graduates to run before they can walk and pride will come before a fall. With the fall should come learning of limitations, awareness of boundaries and hopefully acknowledgement of what we don’t know.
Henry Marsh describes the “Keynote Speakers” in his subject who, “Clearly had amazing results way beyond anything that I could achieve. People for whom self doubt is never an issue and whose post-op scans never showed a trace of residual tumours.” He then talks about Hubris driving him on, the risks of over confidence and the disasters that arose. I am reminded of the Key Opinion Leaders (KOLs) associated with newer Short Term Orthodontic and other techniques who are paid by companies and make claims and encourage use of one particular system whilst trying to maintain a veneer of independence.
Finally, we reach humanity, which I defined as the quality of being kind, thoughtful, and sympathetic towards others. In our early years this can be an overwhelming urge to help everyone and to treat each case to its limits. Experience should show us our limitations but there are some who do not acknowledge they have any, or are so intent on treating cases that they put the treatment before the patient. Marsh says, “On reflection you only get good at doing the very difficult cases if you get a lot of practice but that means making a lot of mistakes at first and leaving a trail of injured patients behind you. I suspect that you have to be a bit of a psychopath to carry on or at least have a pretty thick skin. If you're a nice doctor you'll probably give up, let nature take its course and stick to the simpler cases."
Perhaps our desire should be to become good surgeons rather than great surgeons. It can be difficult to balance pressure from patients to do something, especially if you have been looking for a case to do. The enthusiasm on the Monday to find a patient who matches the technique learned on Saturday’s course has led many to regret their actions.
Knowing when to treat, and not to treat, or instead to refer is a big skill itself and requires complete detachment from, and yet total compassion for, the patient and what is ultimately in their best interest. Awareness of Humility, Hubris and Humanity may help us to sleep at night.
© Alun Rees, GDPUK Ltd, 2020
This is not a plug for my friend’s laboratory. This an unashamed plug for UK dental laboratories. Because if we don’t support them in some way or another NOW, there won’t be any UK dental technicians left to complain about your lab tills to.
© @DentistGoneBadd, GDPUK Ltd, 2020
Being such a fan of the airway, I resolved at the beginning of my dental training that I was never going to be a butterfingers and compromise a patient’s right to breathe, by accidentally dropping anything down the throat. I was an even bigger fan of the butterfly sponge in the early days of post-qualification.
© @DentistGoneBadd, GDPUK Ltd, 2020.
I don’t know about you, but I don’t believe I’ve ever met a ‘normal’ person working in dentistry.But that begs the question, what IS normal? My definition would be anything or anyone NOT connected in any way, shape, or form, to dentistry.
© DentistGoneBadd, GDPUK Ltd 2020.
I sat down to write something that would show insight or perhaps provoke a response if only to get the reader thinking about their situation and how they might improve it.
Of course I would like to impress or inspire enough for you to pick up the phone and employ my services as a coach and business mentor, but that is secondary.
This column was inspired by the behaviour of several clients. It struck me that the best metaphor was that of swimmers at a pool.
We all start unable to swim, as we know it, with poorly defined strokes and no style. Some are lucky to come from “swimming” families who visit pools routinely, or perhaps have their own pool. Others have parents who are frightened of water, have never learned to swim and avoid aquatic recreation.
We all eventually go through dental school where we are taught a version of the theory and practice of survival in the water. Depending on the school there will be an emphasis on different strokes and skills. After five years we can keep ourselves afloat doing our basic strokes - even if we still have to put the occasional foot on the bottom of the pool for security.
It’s what happens after that interests me; it depends very much on the individual, their attitude to risk, their ambition and luck.
Until VT arrived, new dental paddlers were thrown into the deep end of the pool, the wave machine turned on and, although they swallowed a lot of water, their basic stroke helped them to survive. Confidence grew, widths became lengths, a few strokes under water and duck dives.
With VT a lifeguard was assigned who checked they were still afloat and not dragging anybody under.
Many practiced in different pools until they found one that suited them, and the owner sold them a share, some wanted their own pool and built or bought it.
Some new paddlers throw themselves in not sure if it’s the deep or shallow end.
Fewer still climb to the highest diving board jump in and somehow survive.
Some swimmers become perpetual associates. They never trust the water, are frightened of getting out of their depth, they swim widths and occasionally lengths but always stay within touching distance of the poolside. They move from pool to pool dreaming of the one that is warm enough, the water is calm and they can do whatever style they wish. They want their pool owner to supply designer swimsuits and send them for advanced swimming courses that teach skills, unusable in their home pool.
The 21st century has seen a new phenomenon. The individual who inevitably has the “abs & pecs” gets up on the springboard and bounces up and down a few times with great style and noise. They attract a lot of attention, take a few photos for their Instagram feed and head off without getting their hair wet.
There are nervous types who go on expensive courses on swimming. They listen to everybody, swimmer or not about how to swim best. They read books about how to swim. They walk round the pool, put their foot in to feel the temperature. Eventually they go down the ladder and swim but never, ever go out of their depth.
Some become NHS (National Health Swimmers). They used to enjoy swimming, they felt they had a role in life and swimming was their duty. Nobody told them was that there was a wave machine at the end of the pool, the speed of which was inexorably increasing. As fast as they swim, as hard as they work they don’t make any progress. The depth of the pool is increasing, the flippers, worn for compliance not progress, are getting heavier and make things worse, not better. They’re frightened that if they make it to the side of the pool to leave their swimsuit will have holes in embarrassing places.
Who succeeds? The ones who work hard at being better swimmers, who know about all the strokes and concentrate on the one or two that gives them most happiness. They focus on being smooth swimmers, not fast, making as few ripples as possible. They understand that sometimes the pool can get uncomfortable, the water temperature goes up and down and that to be a successful swimmer you need to be fit and keep practicing.
They know that they don’t know all there is to know but they join a club and work with a coach or mentor they will be helped to improve. They talk to other good and successful swimmers and they learn how to stay afloat.
We learn in pools but we must now swim in the ocean. The riptides are dangerous the currents changing and the water deep and cold. This is no place for social swimmers. Only those who are 100% focussed on being successful swimmers will make it to the next beach.
© Alun Rees, GDPUK Ltd, 2020
A simple guide to General Practice in the 'Post' Covid-19 world
© @DentistGoneBadd, GDPUK Ltd, 2020
General Dental Council - Protecting our income and sometimes the patients.
© @DentistGoneBadd, GDPUK Ltd, 2020
After three months of lockdown in Dentistry how are the nags doing? Nobody quite knows where the finish line is in this race so the bookies aren’t paying out yet a while; but as far as the punters are concerned there are few surprises.
Let’s remind ourselves of the runners and riders. First the two back markers involved in their own race, the dental mediocrity cup, these set off slowly and didn’t seem to want to take part in the race, in fact CeeQuooSee’s jockey went home as soon as the starter waved the flag.
First wearing the camouflage colours and helmet of the Whitehall stud is NashBasher with Sara Hurley on board. Not for the first time this runner is wearing blinkers, which have been adjusted by several committees and has trained on a diet of dogma. The rumour is that this poor creature has never recovered from its owners believing it could be a carthorse, a flat horse and a steeplechaser. In fact since its previous trainer, Barty Cockcroft, had it gelded without an anaesthetic in 2006 it has hardly capable of giving children a ride on the beach at Weston-Super-Mare. Rumour has it the glue factory beckons. A great shame because in its day its predecessors gave sterling service on all tracks and courses, whether the going was hard or soft.
Next up is CeeQuooSee. She is a mare from Compliance out of Paperwork. This is one that promised much when it first came on the scene but has repeatedly failed to deliver. Once again its owners were hoping for a Derby winner but as its sire had only ever delivered milk and its dam was used for dressage it looked pretty, but was ultimately useless. Distinctive coloured silks featuring red boxes and black tick marks. It is notable for travelling with dozens of trainers, advisers and stable maids; it often runs with two jockeys to show diversity and fairness. Loves attending these meetings but rarely performs. Uniquely it trains on a diet of tea and biscuits. Its stable mates, Policy document and Protocol feature in the carriage race that takes place after this meeting.
The third runner is GeeDeeCee. Nobody is completely sure of the parentage of this one, for years its line was full of pedigree and thoroughbreds dominated. Great names from his bloodline include Noble Nairn and Bradlaw’s Barstool. Unfortunately it is rumoured that at some time during the last decade the gene pool was adulterated and the resultant progeny have had less than noble characters. Certainly there have been moves amongst the racing followers to limit its appearances due to its spiteful and aggressive behaviour. It wears a muzzle to prevent biting, and the other jockeys give it a wide berth due to its habit of kicking wildly.
GeeDeeCee is trained and ridden by Billy Moyes who has a chequered past in many sports. He is wearing the characteristic hand made pink silks of its owners, a syndicate from the legal profession. For a horse that has a poor character it wins a lot of races probably due to the dodgy handicapping system. Shows great stamina, nothing seems to discourage it. Due to some arcane rule of the Jockey Club the owners get to keep all prize money but GeeDeeCee’s stable fees and costs are paid from donations from other owners and riders.
The fourth of our horses is Wimpole Wonder. The old joke said that to be a successful Dental Horse you needed the stamina of a shire horse, the speed of a Derby horse and the brains of a rocking horse. Wimpole Wonder was little fancied at the start of the year but has proved itself to be an absolute banker. Owned by the largest syndicate in UK dental history there is now a waiting list to buy a share. For many years it was considered to be a plodder with many detractors but during the current season it has shown to have class and determination. The recent change of trainer is probably a coincidence but the good habits learned at Ward’s stables in Herefordshire have come to the fore since the move to Woodrow’s yard.
Unique in training methods is the collegiate method espoused and led by Mick Strong-arm. Cometh the hour cometh the man. Thankfully he isn’t riding the horse, that duty is taken by Damian Apollonian who has come out of retirement for the race. Distinctive colours of pink and white checks representing healthy gums and teeth, with the prominent shield showing the staff and spirochete.
There were fears that a lot of late entries that tried to claim the BDA’s place in the race, Private Parts, College Boys and Facebook Shouters would have an influence. So far anyway the smart money is on Wimpole Wonder and she’s my tip as the stayer to take the honours in the Dental Covid Sweepstake.
© Alun Rees, GDPUK Ltd 2020
General dental practice appears to have changed forever for both practitioners and patients, ‘post’ COVID-19.
© @DentistGoneBadd, GDPUK Ltd, 2020
The General Dental Council - Our Empathetic Regulator
© DentistGoneBadd, GDPUK Ltd, 2020
The Chief Dental Officer issued advice to all NHS dental practices on Wednesday regarding the ongoing treatment of patients. Whilst these guidelines refer to NHS practices, in reality, all private practices will also want to consider their application.
What this means is that there will be less patients in practices moving forward, which will inevitably mean less work to do. This e-bulletin sets out the various options available to dental practices when considering the impact of COVID-19 on their workforce.
What if a member of staff is unwell?
This is the most straightforward situation. If a member of staff is unwell, they should be sent home immediately. In these circumstances they will be entitled to either the sick pay provisions contained within their contract, or if they are not entitled to contractual sick pay, they will be entitled to statutory sick pay (SSP). The Government have announced, but have not yet put into law, that the SSP will be payable from the first day (normally the 4th) of their absence from work. They should then remain at home for at least 7 days from when their symptoms started.
What if someone in a staff member’s household is ill?
If your staff member lives with someone who becomes unwell, then the government guidelines state that they must stay at home and not leave the house for 14 days.
In these circumstances the staff member is eligible for statutory sick pay even if they are not ill themselves. This was bought into force by the Statutory Sick Pay (General) Coronavirus Amendment) Regulations 2020 on the 13th March 2020.
The Government announced that businesses will be able to claim back any SSP paid from the State. However, the Government will only refund up to two weeks of SSP to businesses with less than 250 employees, albeit this has not yet been put into law
Employers do not need a sick note to claim this money back.
An employee decides not to attend work as they are classed as ‘vulnerable’, do I have to pay them?
The Government’s advice is that staff members should be ‘encouraged’ to work from home wherever possible. If it is possible for phones to be answered remotely, for example, then employees should be paid in the normal way. However, for dental practices this is rarely going to be possible.
Whilst practices may wish to exercise discretion and continue to pay staff, this is not currently a legal requirement. The Government state that staff in these circumstances “should be supported;” they have not said how businesses will be supported in doing so, however. As they are not unwell, or isolating due to contact with a COVID-19 sufferer, they are not entitled to SSP.
However, the dental practice will need to carefully consider their obligations to protect the health and well being of a staff member. It would be considered unfair to dismiss an employee who chooses to self-isolate in these circumstances. A staff member who chooses to self-isolate because they are categorised as vulnerable is likely to be protected against dismissal (and deduction from wages) if they are asked to come into work and refuse to do so because there is a significant risk to their safety.
For those who are not classed at vulnerable, but chose not to attend, dental practices could offer unpaid leave, alternatively a good compromise would be to ask employees to take this as paid holiday.
I am worried about the safety of my staff, should I send them home?
Yes. Employers have a duty under the Health and Safety at Work etc Act 1974 (http://www.legislation.gov.uk/ukpga/1974/37) to protect the health, safety and welfare of their workforce at work, as well as others who may be affected by their operations. Practice owners also have a common law duty to protect their workforce.
If an employee insists on coming to work despite exhibiting symptoms, or that they have been exposed to the virus, and the practice principal orders them to go home, they are technically entitled to full pay during this period as they are willing to work despite their ill health.
My nurse needs to take time off to look after her children as schools are closed, what do I do?
At the time of writing, it is not known whether dental providers are considered key workers, and as such their children will continue to be able to attend school.
An employee may be entitled to time off work if they:
There is no statutory right to paid time off in these circumstances.
I no longer have sufficient work to occupy all of my staff members, what shall I do?
Dental practices who have NHS contracts will have some assistance from the NHS. It being suggested that the global pandemic will be treated as a “Force Majeure” event, meaning neither dental practices nor dentists will be liable for a failure to complete UDAs under the contract. It is also anticipated that the NHS will provide some financial support to contract holders, which should in turn be passed through to Performers.
Unfortunately, there has been no support offered for private dentists or practices in the recent package of measures announced by the Chancellor, save some emergency loans.
This is clearly a significant burden on all practices, and it is unlikely that practices will be able to sustain this for a significant amount of time. If this is unaffordable, dental practices will have to consider the following:
Many people are engaged on Zero Hour contracts within the dental services. If this is a genuine zero hour contract (i.e. there is no obligation upon the employee to do the work, and none on the employer to offer it) then the dental practice can simply not offer hours of work in the coming weeks. However, if staff members are obliged to attend work every week and are given the same, or similar hours every week, then the employee could argue that they have in fact got a guaranteed minimum number of hours through convention, not contract, and are entitled to continue to receive those guaranteed hours. In those circumstances, if notice is given, they must be paid for the same guaranteed hours during the notice period.
These are incredibly difficult times, but when dealing with your workforce, remember to be consistent, be fair, but most of all be safe. We will be providing as much advice and assistance as possible to our dental colleagues over the coming weeks and months. Stay up to date through our dental bulletin and our Facebook and Twitter pages.
Turn the clock back 40 years to the land where Mrs Thatcher was starting to flex her muscles, sharpening her deregulation scythe and readying to privatise any and everything. What changes do I see in Dentistry today? There is one element that dominates professional lives. Nothing to do with their talent, skills or clinical judgement. Even less to do with good working or patient relationships, teams or outcomes that matter.
I am talking about compliance. Defined as “The act of complying with a wish, request, or demand, a synonym is “acquiescence” or “passive assent or agreement without protest”, and a legal definition implies “the abandonment of a right”.
Last month I accused the GDC being a sledgehammer used to crack nuts. This time I am levelling my sights at another organisation better known by its TLA (three letter acronym), the newer kid on the block, the Care Quality Commission. Set up in 2009 with the intention of “regulating and inspecting health and social care services in England” it has rarely if ever been seen as an ally by those who it “governs or directs according to rule”.
It was parachuted into dentistry with little consultation, minimal clarity and maximal condescension. This is not an unusual occurrence for matters relating to dentistry, long considered the awkward mob by government and much of the rest of medicine. “Necessary when you need them but resented for their freedom” was how a Whitehall Mandarin patient of mine who commuted every morning from Peterborough to London having served his time in the Department of Health described Dentistry.
The CQC’s stated role is to provide people with “safe, effective and high-quality care, and to encourage them to improve”, yet without inspection of clinical standards how can they judge “care” properly?
This statement from their website, says much that is wrong with the CQC.
We inspect 10% of dentists in England each year. You can use our inspection reports to help you understand the quality of care. We do not rate dentist services but we do highlight if a service is meeting the standard of care we would expect.
It was always bad fit, the wrong solution to the wrong problem, a knee jerk reaction to medical tragedies, particularly the Shipman affair; it started badly when its disgraced first Chief Executive was forced to resign.
The fundamental problem (like the GDC in many ways) is that of it being a compliance-based programme where rules of conduct are put in place. Penalties, which can be severe, are waiting for anyone who is seen to be out of step from the norm. The rules are obeyed in order to avoid the repercussions, hence (like the GDC) fear becomes the driving factor.
The dental businesses are not judged on their moral compass, rather on a right or wrong tick box which, too often, is administered and delivered by individuals who, may be for the most part well meaning, but have little or no clear idea of 21st century dentistry.
How could this be improved? I know I have spent too much time in Ireland because the answer once again is, “You wouldn’t want to start from here”. The CQC is a massive bureaucracy little suited to examining dental practices and the systems for Dentistry should be clearly different from that for Care Homes and Hospitals.
Rewarding aspirational practice, understanding the real differences between good, less good and bad practices plus properly evaluating what is meant to be truly well run. I would like to see fewer “inspections” with all the connotations of confrontation and clipboards they bring. Instead there should be far more conversation, communication and encouragement to reach not just the basic but higher standards ethically, culturally and clinically.
Of course now we come to the elephant in the room. The NHS; committed to getting more bangs for its, ever diminishing and inadequate buck, to being in control of all things health related from education through research and education. It ensures the blame for bad news is always as far distant from the top as possible.
Dental businesses are for the most part separate entities, even large corporates serve different communities with different people. The quality of care (it’s about quality of care) cannot be measured by an “inspection” of an off-the-peg compliance system once a decade.
There must be clarity about what is expected, better two-way communications and some obvious effort to regain the shattered goodwill of a profession which feels compliance has been used as a weapon to control it rather than to improve patient care.
Dentists look at the CQC and how it deals with what they know then despair about the rest of the Health and Social framework where out-dated inspection methods are used to address the wrong problems.
© Alun Rees, GDPUK Ltd, 2020
We all, I would like to think, got into this profession for the reason of trying to help others and improve the health and wellbeing of patients. If we were in it solely for the money, there are plenty of other professions that can give the financial rewards without the types of stress that we face on a daily basis from all aspects of our wonderful profession.
Before I continue, I should note that yes of course we all need to make a living and there is nothing wrong with wanting to earn more. That is not my concern here, but more that I am worried that we are starting to see our patients as customers, and therefore trying to sell them a product rather than provide a health service.
A recent dental conference I attended had a stand hosting a lecture titled ‘How to earn an extra £100,000 a year through facial aesthetics’. Now my issue here is nothing to do with facial aesthetics at all, it could just as easily be swapped with dental implants, short term ortho, smile design or whatever aspect of dentistry one may be more interested in. For me, it’s more the headline like that got me thinking - are we becoming ever more financially driven and could this lead to us ‘selling’ patients treatments or rather a product they may not necessarily want or more importantly need. We are all part of the health care sector but are we making dentistry into an industry more than ever and forgetting that it’s actually a profession? I’ve even heard of undergraduates taking external courses on ‘how to sell private dentistry’ when they haven’t even passed their licence to cut exam yet so if that is the motivation from such an early stage, is there cause for concern?
There is already a misconception by members of the public that dentists are there to take patients money, so this made me think that we could be adding fuel to the fire.
This is not aimed at people wanting to be a successful practitioner and earn a good living or run a profitable practice, it’s a general concern about our profession losing its way a little bit and putting profits above patients.
We have all seen those cases on social media whereby unbelievably invasive dentistry has been carried out at both a financial and biological cost to patients, when really a much more conservative treatment plan would achieve just as good if not better results. I’m sure many of us have looked at those cases and thought that clearly there has been a financial objective here as why would a well-informed patient actually consent to some of these treatments.
That’s not to say that patients don’t have the right to elect to do these types of treatments and of course maintaining patient autonomy is key. However, with the continuing role and influence of societies’ obsession with achieving the perfect aesthetic (in many aspects not just dentistry), are we being lured into this type of dentistry by the financial gain and compromising our moral obligations to our patients? Is the ‘Love Island effect’ or the role of ‘social media influencers’ (not just celebrities but even dentists these days too) starting to influence us as dentists, not just our patients?
© GDPUK Ltd 2020.
I’m not, by nature, a hoarder.
I chuck stuff out on a pretty regular basis and the only inanimate possessions I would risk my life to save in the event of fire or flood would be my treasured MacBook, iPad and iPhone – in short, anything with an Apple logo on it.
So, I suffered gargantuan cognitive dissonance the other day when I came across my massive folder of CPD certificates collected over thirty years in practice, in the loft. Why do I still keep it?
I’d been up in the loft because the gas engineer who installed our gas supply and heating system earlier in the year had been sent back by the safety people to fix all the bits he’d not done properly in the first place and after he’d gone I was just checking he’d not carried out some sort of ‘dirty protest’ as revenge for being called back to our house.
To say the gas engineer was a little ‘frosty’ on the morning he arrived, was an understatement. When I saw him finally pull up on the road after a five-day wait, I went out with a cheery wave as he sat in his van, and started to back my car out of the drive to allow him to park closer to the house. He’d parked halfway across the drive and it was a bit tight getting out and I noted that I was quite close to him as I swung backwards. My car radio was quite loud as I reversed, but I was focussed on getting out of the engineer’s way and parked on the road. As I got out of my car, he was inspecting the front of his van. My “Morning Bill” was greeted by “Did you know you’d just hit the van?” I didn’t, but when I had a look, there was no denying it. There was no dent in his bumper, but there was a clear and undeniable smear of Peugeot 107 red on his immaculately matte black rubberised fender. If he HAD carried out a dirty protest, I would have understood.
Anyway, back to my CPD folder. I must have buried it up there a year ago, on retirement, though I don’t remember doing it. The folder lay under the bed for thirty years and it had about seventy elastic bands around it for fear that a valuable certificate proving I’d been on a day course on the use of Wizard Wedges in 1991 might inadvertently slip out from the pile of loose certificates on top.
For about a billionth of a nanosecond I actually thought about throwing the folder out, until I came to what passes for my senses and asked myself “But what if the GDC asks to see it retrospectively?” Yes I know, bizarre thought – why would they? But I was always a dentist scared of not only his own shadow, but the shadow of a hostile dental litigation lawyer carrying a sharpened writ. In my head I could visualise a scenario where the GDC demanded to see my CPD folder, realised I’d not followed the rules and retrospectively declared my career null and void. In consequence, every procedure I had ever carried out I’d done illegally and I’d be jailed for being a fraudulent dentist.
Torn, I realised that I needed guidance and so I went to my ‘go-to’ default advisor – Twitter of course. I asked whether I should: a) destroy the CPD records, b) destroy them, laughing or c) keep them in the loft. The results of my survey were closer than I anticipated. Fifty-five percent of participants thought I should destroy them with a maniacal laugh, but a surprising forty percent thought I should keep them in the loft. One Twitter wag, Rebecca Cox questioned my commitment to CPD. She said “One folder…in 25 years?” Fair point. Anyway, the loft it is, forever, until we find another house with another inaccessible loft, but hopefully, safe gas pipes.
I was sort of reassured that forty percent of the people surveyed erred on the side of caution and I was comforted by a Tweet from a dentist I follow, Adrian Walley, who said:
“This is sad, but 35 years qualified and I still have all my undergraduate files and coursework in a box in the loft. Every time I go to throw them out, I can’t quite bring myself to do it; all that work and if nothing else, (it) proves how neat my handwriting used to be!”
This Tweet struck a chord for my other confession is that I too have all my undergraduate notes still in the loft, sitting on piles of books ranging from Gray’s Anatomy to a worthless book written by one of my dental professors on restorative dentistry that seemed to have been aimed at dental students with ADHD.
I WILL admit that keeping my undergraduate notes is pretty much pointless. I also admitted on Twitter a few days ago that I used to write extensive notes during lectures. I’d then go back to my room and during the evening, write my notes up neater and add bits from textbooks. I always felt more comfortable with a fine black felt-tip pen and with every test we had during the course, I’d go back to my notes and highlight them in fluorescent pink or green. When we came to finals, I opened my files one day to find that the writing was unreadable, the black felt-tip having dissolved in the washes of fluorescent felt-tip. I was inconsolable, and for a while, hysterical. My fellow finalists found it pant-wettingly funny.
Despite all that, I still can’t throw the notes folder out. I’m really not sure why. I don’t know whether the CPD folder and the notes represent all that time invested and all that agony endured in order to qualify as a dentist and then keep the ball in the air. I suppose they’ll stay there till the ceiling starts to sag with the weight of them plus the folders we’re keeping for the kids for some obscure reason, from their ‘A’ level days, nigh on 15 years or so ago.
But flicking through the CPD folder made me think about the whole Continuing Professional Development thing and how it’s developed since the days that I qualified and how I may have had a lucky escape retiring when I did, before Enhanced CPD really kicked in.
Back in the late eighties, we didn’t have CPD, we had Section 63 courses. I don’t recall having to declare the fact that I’d done a course to the GDC but I do vaguely have this feeling that someone was watching my course activity. After every course, you had to collect a certificate and a form which you submitted to the local Family Practitioner’s Committee. In those days (I was reminded by someone I follow on Twitter) you could claim your car-parking fees back at least, but I don’t recall having to didn’t have to fill in a feedback form.
In those days you didn’t even have to stay the full day. They were simpler, more naïve times. You could go to the course in the morning, sign in, pick up your certificate and your Section 63 expenses claim form and slip out at the first coffee break, being home for lunch or grabbing a swift half at pub before you caught the bus to catch the second session of the cricket (Birmingham Dental School is VERY close to Warwickshire’s Edgbaston ground). Not that I ever did that of course.
When Section 63 courses were about, the UDA system wasn’t, and there seemed to be more time and less financial pressure to attend courses. If you went on a day-long course, although you knew you weren’t earning any money, you didn’t feel you were effectively going to LOSE money by risking not hitting targets. Consequently, courses seemed to be well attended and filled with the sort of people you would cross the M25 on foot in order to avoid.
Some of the most excruciatingly irritating dentists on the planet I encountered at Section 63 courses. There was one lecturer who I had to take my hat off to, just for keeping his cool. The course was in London and was on ‘Endodontics in Practice.’ There was a little chap sitting down the front and he must have had the lecturer bitterly regretting his rash words: “Feel free to ask questions as we go along.” When the lecturer said: “I can’t emphasise this enough, you MUST irrigate with hypochlorite,” the audience member asked “So do you ALWAYS irrigate with hypochorite?” When the speaker said “It’s critical to use rubber-dam to stand any chance of success,” the irritant asked “So do you think it’s important to use rubber-dam to be successful?” When the speaker emphasised the importance of recapitulation, the annoying dentist asked “So you’d recommend recapitulation then?” And on and on. By the end of the day, the rest of the audience had had enough and every time the hand went up, there were murderous murmurings all over the lecture hall. I can almost guarantee you have met this bloke at a CPD meeting at some point in your professional life.
When the GDC officially threw its their hat in the ring and CPD came in with its implied threat of erasure if you didn’t take an apple for your teacher, all the fun seemed to go out of practice awaydays. Courses were suddenly geared towards meeting legislative requirements and you’d be really struggling to find a course that DIDN’T involve cross-infection control or compliance. I missed courses with titles like ‘Fun With Mercury’ and ‘Who Needs A Perio Probe?’
The prospect of the new 100 hours verifiable CPD in five years target didn’t particularly bother me. Apart from my last year in practice, I usually far exceeded requirements. That may surprise some. I was fascinated by the science behind dentistry, it was just the idea of being in the same building as patients that I hated.
When it came to non-verifiable CPD declarations to the GDC at the end of the year, my attitude was a little more ‘relaxed.’ I mean, I did quite a lot of journal reading, but I can’t say that I scrupulously logged my hours, so when it came to putting in a non-verifiable figure to the GDC it had the accuracy you’d normally associate with Oliver Reed telling his GP how many units he drank per week.
My difficulties with enhanced CPD would have been associated with the production of a Personal Development Plan. Every PDP I’ve ever been asked to produce in the past has basically identified endodontics as my weakness and all my CPD would have been directed towards attending endless courses on RCT until I finally found the Holy Grail – a course that that said hypochlorite and rubber dam was totally unnecessary.
I would imagine the pursuit of UDA’s and economic viability has led to an increase in the number of practitioner’s carrying out a lot of CPD online. I have no quantitative evidence for that assumption other than I was often asked while I was practising which organisations provided the cheapest online CPD content.
And of course, online CPD has opened up the opportunity for taking shortcuts to attaining verifiable hours. I knew one practitioner who never read the content of the course, but ticked the multiple choices as he thought fit and repeat until he hit the 80% pass score required for his certificate - it took him way less time than spending the two hours the course providers reckon he needed to complete the course, and failing that, he’d photograph each page of text and then go to the test at the end. If he didn’t know the answers, he’d scroll through the pictures till he found the bit he wanted and ticked the box with confidence.
Another well-known CPD website apparently counted up the time you spent online answering questions and issued certificates logging the hours spent on each subject. One ingenious practitioner I know discovered an App for his computer called a ‘Mouse-Clicker.’ You could set the App so that it clicked automatically every few seconds. This registered with the website that you were still active on the page and he could go off down the pub while he was automatically logging verifiable hours without breaking sweat.
I say! That’s not quite cricket!
© @DentistGoneBadd, GDPUK Ltd, 2020
Happy 2020 to Dr Moyes and colleagues.
I hesitated before putting finger to keyboard on this topic, it’s too easy, and a real barn door isn’t it? In fact I wrote, rewrote, and finally binned, one piece and started again.
Here are some New Year wishes for the General Dental Council. They make demands and enforce what they say are patients’ expectations of the Dental profession; surely this should not be a one-way street?
Empathy. If there is one quality that is essential in any successful relationship it is empathy or “The ability to understand and share the feelings of another”. I have looked back through the last decade of the GDC and seen little evidence that they have made any concerted effort to either understand or share the feelings of the tens of thousands of people on their register. Lip service from the occasional survey perhaps, worded in such a way to avoid exploring the real fears of day-to-day clinical practice.
Context. All practices are different, all patients are different. There cannot be one rule for all. Yet it seems we are reaching a point where any treatment that is less than “ideal” is unacceptable and therefore negligent. I was able to convert my practice away from a reliance on the NHS in the early 90s. When I reached my personal ceiling and sold it I then did locums in different sorts of places and had my eyes opened. In some places the practice of dentistry is like working in a war zone with a shifting population, all with different wants, needs, expectations and budgets.
In the same way with the massive shift towards corporate and chain practices there can be pressures on, but little support for, younger dentists. When shareholder value, rather than patient care, becomes part of a company’s ethos the clinician is often caught in the middle between bean counters and patient expectations. It can take years to build an appropriate trusting relationship with a patient yet pressure to “produce” can put unrealistic and unfair expectations on clinicians.
Engagement. When was the last time any of the staff actually listened and responded face to face with a group of dentists and their teams about what the future has planned for them? The current (Corporate) Strategy is so full of “corporate speak” that any message is hidden behind paragraphs like this one, “Key to fulfilling our statutory responsibilities is ensuring that our resources are allocated to reflect our priorities and that opportunities to improve the efficiency and effectiveness of our operations are taken promptly. Much has been achieved in this respect, but there is more to do and we are actively pursuing further opportunities.”
Humility. Dr Moyes could learn a lesson or two from the Chief Dental Officers who put themselves in the (metaphorical) firing line at conferences and speak… and appear to listen. They have learned from the mistakes of predecessors, the GDC shows no such humility. This aspect is damning.
Leadership. The morale of many dentists, especially young dentists, in the UK is at an all time low, there is clearly a disconnect between what their expectations are and what the reality is that they encounter. The only body that has control over both education and daily dentistry wherever it is practiced is the GDC.
Brexit and more. It is clear from the cases that come before the GDC that many overseas graduates are not prepared for practice in the UK. The responsibility for that falls on the shoulders of the GDC. Or are they under such pressure to keep the dental lights on and the dental queues at bay that things could are fudged?
Blame game. Reports of meetings from official and unofficial sources say that the usual excuse for any lack of action is “it would take government intervention” which translates into “we don’t have the will”.
It is clear that large, unrealistic contracts, [like the famous cross infection control case in Nottingham] have been awarded, the profession has known that, why hasn’t the GDC taken steps to ensure things are running well and the mistakes remedied? Or would that be the clip-boarding, tick-boxers of the CQC’s responsibility?
Finally. I challenge you to grasp one simple nettle, just the one, only one. Allow registrants to pay their registration fees monthly by direct debit. It is one element that typifies the lack of listening, the lack of will to take action and the inability to appear to be anything other than a Dickensian schoolmaster who knows only wrong in others.
Happy New Year to you and to all who pay the fees that you collect, spend and keep in reserve. I wish you all the very best for 2020.
© Alun Rees, GDPUK Ltd 2020
I won’t pretend for a second that the news stories breaking around dentistry in 2019 came up to the standard of those surrounding the world of politics. We didn’t have the dental equivalent of a Prime Minister resigning, the new one willingly calling a general election and that Prime Minister’s Pinky and Perky twin across the water being impeached. But it wasn’t completely without drama. The GDC, in particular, being the gift that keeps on giving.
The Daily Mail carried on its tradition of providing cheap and easy to read non-verifiable CPD, by highlighting the results of a Cochrane Review which found there was no clinical difference between patients receiving regular scheduled scaling and polishing against those not having a ‘scrape and brush-up’ (not the Mail’s term, my patient Mrs Cholmondsley of Milton-on-the Truss’s term for what our hygienist did to earn a living). The Dundee meta-analysis of two studies involving 1711 patients found that there was no difference in the two groups with regard to the development of early signs of gum disease. There was a noticeable difference in terms of calculus build up but the researchers didn’t think the build-up was significant although it was remarked that they didn’t know whether this build-up was more important to the patient or the dentist. As a dentist I always worried about munge building up around the gum margins, and fortunately Professor Damien Walmsley agreed with me. I also worried about stories like these in the general press, just in case people like Matt Hancock inadvertently see them while searching for their latest polling figures. It hasn’t happened yet, but just you wait for the government to reduce the number of scales NHS patients are allowed per year, with a concomitant reduction in fees.
Meanwhile also in January and in the same vein, the Journal of Clinical Periodontology published the results of a study which revealed that pregnant women are one and a half times more likely to go into labour prematurely, if they have gum disease. So here’s an idea – why not ensure pregnant women have closer periodontal supervision during parturiency by carrying out regular scale and polishes…oh!
But if the dental profession has less work to do because we ARE banned from doing scales, that will hopefully neutralise the effects of the inevitable reduction in EU trained dentists leaving the UK as a result of Brexit. The General Dental Council presented evidence that up to a third of EU qualified dentists on the dental register may quit UK dentistry after Brexit because of…Brexit and its associated uncertainties. Some of the EU-trained dentists also cited the difficulties of working under the NHS and dental regulation as reasons for leaving. I think these Europeans have their heads screwed on. Who could blame them for shunning a system which pays them a piddling amount for one filling and exactly the same amount for half a dozen fillings. Brexit means Brexit. Exploitation means exploitation.
Also in January, the British Dental Journal published a large-scale study of 2,000 practitioners which showed that almost half of dentists admitted that job stresses were exceeding their ability to cope. The study found that the most stressful aspects of their work was related to regulation and fear of litigation from their patients. It probably doesn’t help the mood of GDP’s that they’re being told that some of their ministrations are pointless (see above), that at some point a litigation lawyer might blame them for premature births and their workload is going to increase in 2020 when Manuel and Helmut escape back to the mainland.
February saw the revelation that practitioners were more likely to be struck off the GDC register if they didn’t have any legal representation at hearings. A Freedom of Information request to the GDC by Dental Protection showed that nearly two thirds of dentists who were erased from the dental register didn’t have a legal advocate speaking on their behalf. My first thought about that story was “What kind of fruitcake would go to the GDC without legal representation?” Having been a career-long member of one of the original ‘big two’ professional indemnity organisations, the thought never entered my head that such representation may be denied. But apparently, that’s not the case. Even though they often offer cheaper ‘cover’ to dentists, there are defence organisation or insurers who may decline assistance to dentists in personal conduct matters. You pays your money and you takes your choice. I personally preferred to pay a not insignificant amount per month in the hopes that if I got into trouble I would get Rumpole defending me rather than rely on my own inane ramblings that come out more like Elmer Fudd than Perry Mason.
Big news this month was that ‘British Teeth’ helped win an Oscar. Rami Malek won an Academy Award for his role as Freddie Mercury in Bohemian Rhapsody wearing prosthetic teeth made by dental technician Chris Lyons for British-based Fangs FX. Much to the mild annoyance of British dentists, Americans often use the denigratory term ‘British Teeth’ to describe not only our teeth, but British dentistry. Just a slight snag – Freddie was born in Zanzibar to Parsi parents. So they were more like Persian Pearlies than our pride and joy.
Birmingham University hit the dental headlines with its new dental model that reproduces the feel and ‘behaviour’ of real gums and the tongue. As well as helping to teach students how to examine the mouth safely and check for disease, the models reproduce the ‘feel’ experienced when checking pocket depths. In my opinion, this must be a welcome and invaluable teaching aid. The first time most dentists had to check for pocket depths was on a patient. Nobody can tell you how it feels to use a pocket probe or how much pressure to place on the tip. This probably explains the squeamishness of a lot of dentists trained up to now, in tackling pocket depths. You simply didn’t know when to stop pressing – wait until the patient’s eyes rolled back into their sockets or simply sobbed and/or threatened litigation.
I warned you about this back in January. In April, the RAINDROP study carried out by the University of Newcastle proposed that ‘routine’ scaling and polishing of teeth should be stopped from the dental budget since the money would be better off being spent elsewhere. I personally felt this was poppycock. Since many NHS scalings, I would suggest, are completed on a Band 1 treatment with an examination, how is money going to be saved? The Nash gets a bargain out of dentists anyway for this service and money-saving will only be executed by cutting the fee for an examination I reckon. I repeat. I told you back in January and you wouldn’t listen, would you?
The GDC was seeking views on its consultation for its strategy for 2020-2 – “Working with the dental team for public safety and confidence.” GDC chair Bill Moyes boldly claimed that the overall decrease in GDC expenditure pointed to a significant reduction in the dentist’s Annual Retention Fee. My advice on that is – don’t hold your breath. Highly unlikely. I bet you believe in the tooth fairy as well, don’t you?
The Government’s Migration Advisory Committee announced that dentists would not be on the Shortage Occupation List, despite the BDA’s evidence that 63% of dental practices are experiencing difficulties in recruiting dentists and the GDC’s findings that a third of EU graduates may leave the UK in the next five years. A significant number of currently registered dentists are also thought to be considering retirement in the next few year – for ‘considering retirement,’ read ‘running for the exit like their backsides are on fire.’ One suggestion to alleviate the operator shortage problem – get a UK trained dental therapist before everyone catches on.
Thankfully, I never came close, but it was always something else to worry about. July saw NHS England and NHS Improvement (nope, I’d never heard of it either, I’ll need to Google it later) agreed to remove wrong-site blocks as a ‘never event.’ The British Dental Association had long argued that administration of wrong site blocks didn’t meet the threshold of a never-event. Although inconvenient to the patient and incredibly embarrassing for the dentist or student, giving a patient a dribble on the wrong side, is hardly likely to kill.
Removing the wrong teeth is considered a never-event and I would suggest that allowing your dog to bite a practice inspector really ought to be on the list. Dentist Aileen Hopkins was erased by the GDC after one of the three dogs she kept at the surgery bit an inspector. The dentist had 57 complaints about safety and hygiene also considered, but the dentist apparently thought the GDC was being a bit “nit-picky.”
Journalists know August as ‘the silly season,’ the time of year when people are on holiday and Parliament and public bodies uproot and go to the Algarve. Hence, not a lot happens during August, which meant the The London Evening Standard reported on the UK’s first ‘healthy’ supermarket which was launched in Central London. In essence, the store was giving greater visibility to healthy foods such as fruit and vegetables and less shelf space to foods like chocolate, crisps and sugary drinks. And that was it really. Laudable though it is, it didn’t really press any journalistic buttons. Nobody was bitten by a dog and no one was brought in front of a disciplinary body for stacking M&M’s in front of the Monster Munch.
The British Orthodontic Society and Oral Health Foundation announced plans for a national campaign to warn patients about the risks of internet-based/DIY orthodontics. GDPUK had warned earlier in the year that patients are being prescribed courses of adult orthodontics without seeing a qualified dentist face-to-face or having a full clinical examination. Although one of the companies involved in providing internet-based ortho offers ‘scanning’ in various centres throughout the UK, you CAN have a traditional impression taken – providing you take it yourself. Curious, I approached an online advisor at Smile Direct Club for further information. Just don’t try the following if you are keen on hanging on to your registration.
Bad news for parents of teething children, hoping for restful nights. The British Dental Association revealed that 9 of the 14 teeth products licenced for use in the UK could have potentially harmful side effects. The nine products contained either sucrose, alcohol and or/lidocaine and there is apparently little evidence that the products are effective in reducing teething pain. Where does that leave dentists when confronted with a red-eyed, half-lidded mum begging for advice on how to relieve teething pain? My guidance for the desperate parents would still be alcohol. Forget the child, just drink the alcohol.
But great news for dentists. Early in October, the GDC announced the new levels of ARF fees set for the next three years, ‘barring any unforeseen exceptional circumstances.’ The new level for dentists is £680 and £114 for dental care professionals. Two thoughts: a) why did they bring reduced fees in after I retired? b) what does the GDC define as ‘unforeseen and exceptional circumstances?” There’s still three months to go. Don’t bank on it yet!
Also in October, Medical News Today reported on a study linking periodontal disease with hypertension. This didn’t surprise me. Patients with perio often caused my blood pressure to rise.
More concerning was the revelation that overseas dentists are being allowed to register as dental therapists by the General Dental Council, without any practical examination of their clinical skills. Normally, dentists qualifying outside the EU have to take the Overseas Registration Examination (ORE) or the Licentiate In Dental Surgery. An investigation by GDPUK.com revealed that there is a high failure rate in the practical element of the ORE and yet overseas dentists are being allowed to register and carry out operative restorative procedures on patients, with no further checks on their skills. The GDC is apparently convinced that its checking of the dental syllabus of these dentists is ‘robust’ and yet apparently NOT robust enough if they want to work as dentists.
At the end of October, the GDC was again in the headlines, when it was revealed that the regulatory body withheld evidence from its own Professional Conduct Committee (PCC) which resulted in the erroneous reinstatement of a fraudulent dentist to the dental register. Justice Julian Knowles criticised the GDC in a High Court hearing brought against the GDC and the dentist, by the Professional Standards Authority. He said the GDC had committed a ‘serious procedural irregularity’ in withholding evidence from the PCC. The evidence was withheld following its late submission to the dentist’s legal counsel because it had been mislaid by a GDC solicitor.
The GDC was probably feeling hunted by now, much like their registrants. It was early in the month that the Daily Telegraph revealed that the GDC had spent over £17,000 on hiring private investigators to ‘investigate’ registrants. BDA chair Mick Armstrong described the GDC’s investigatory method as ‘entrapment.’ One case involved private eyes attempting to induce a clinical dental technician to provide treatment without a dental examination by a dentist, by claiming she was too unwell to go to see a dentist for an examination. This revelation just made me feel slightly grubby. I mean, the GDC is supposed to be setting the profession’s standards and all they are interested in is in putting on a heavily stained Columbo mac.
It appears that the GDC only scares legitimate dental professionals. GDPUK.com ran a story that a Derby man who was fined for illegal teeth whitening in 2017 has been caught doing it again. A Derbyshire Live reporter set up a sting operation to catch Colin Vernall attempting to sell his whitening wares again. He told the reporter although he wasn’t registered with the ‘dental council,’ he did do a course. Mr Vernall, who prefers to be called ‘Vern’ Collins (sounds legit) is still taking money for his whitening service despite the £7,000 fine he received as a result of a court case brought by Derby City Council Trading Standards officers. When the reporter revealed his identity, Vern said: “Teeth whitening has changed and it’s self-administered, I simply supply the equipment and you place the tray and products in your mouth yourself.” Thus abrogating all responsibility presumably. He added “I'm simply renting you the light to accelerate the procedure.” When it was obvious the reporter wasn’t going to use his services, Vern said: “I just got a taxi up here, it has cost me a tenner to get here as well.” Vern has gone ‘mobile’ since his £7,000 run in with Trading Standards.
As I write during the hiatus between Christmas and New Year’s Eve, the GDC hasn’t yet found any ‘unforeseen exceptional circumstances’ which will destroy our dream of having to pay a mere £680 quid a year to have our names placed on an internet list.
But there’s still two working days, so don’t spend the savings yet.
© @DentistGoneBadd, GDPUK Ltd 2019
If the BDA did not exist…It would need to be invented.
I was encouraged as a student not only to join the BDA but also to join in. I have served in several roles at Section and Branch and, even as a non-clinician, I still read and enjoy the BDJ.
I remain, an advocate and a critic of the BDA. I am often reminded of the “What have the Romans ever done” sketch from The Life of Brian when dentists ask, “What has the BDA ever done for me?”. They often continue, “Why don’t they…?” the questions being the old chestnuts, “Sort out the GDC/CQC/Department of Health” or “get some action like the BMA does”. The same individuals usually disappear when you ask them to do something for themselves or others.
So what is the BDA’s role, how could it change and what benefit would that bring? The cliche goes, “You wouldn’t want to start from here”, but here is where we are.
The BDA’s mission statement is: “to promote the interests of members, advance the science, arts and ethics of dentistry and improve the nation’s oral health.”
Let’s accept that and start there.
A new organisation is a non-starter, it has been tried with little success, why reinvent the wheel? It could be a broader church, D stands for Dental not Dentist. Many successful sections actively welcome all team members to their meetings, we work in the same places and, if we want to truly embrace team working, why not?
An individual’s perception is their reality. The BDA is composed largely of people who work in general practice and, rightly or wrongly, they see the BDA through the lens of their silo. Their interests are different from one working in the community, academia or the hospital services. The main challenge is making sure that you are profitable, dentists like all small business owners run the risk of bankruptcy and ruin if they don’t get their maths right. Many practices run on very small margins of profitably, are undercapitalised and work from hand to mouth. More like corner shops than other professional businesses.
For many this has worsened since the imposition of the 2006 contract for which I most definitely do not blame the BDA. The then CDO did a whitewash job and the contract is deeply flawed, underfunded and bad for everyone.
Dentistry is a very stressful occupation. It can be a lonely place; being a medical professional has pressures upon it, having to make immediate decisions with patients that are awake and where you have finite time to complete procedures produces even more pressure.
Being the owner and main producer of a small business is lonely too. Many dentists are poor leaders and have problems separating management from leadership.
The stress of working under the NHS system plus an aggressive GDC is showing itself in rising numbers becoming burnt out and dissatisfied with their lot. In my role as a business consultant I meet many people at their wits end, not knowing which way to turn.
The BDA should be far more active in encouraging dentists to move away from a reliance on the NHS. In the past many elected representatives choose to be reliant on the NHS, have businesses that cope with the system and are so close to retirement they do not want to make changes. Change is happening there at last.
Through the sections and branches the BDA is responsible for large amounts of CPD provision yet there seems to be little cross communication. Some sections shine like beacons, others hardly flicker. Newer CPD providers have adopted different ways to be more attractive to a changing audience and the BDA has been slow to embrace the change.
One of the advantages of local face to face meetings is the provision of “fellowship”. Traditionally the opportunity to share experiences in a non-confrontational way with senior and junior colleagues provides a great way to let off steam, to unwind to share and gain support.
The annual conference was an excellent source of CPD and a hub around which the Dental World rotated, yet latterly struggled for an identity and was eventually subsumed by The Dentistry Show. I know that decision was hard to make and to take.
The BDA has clearly listened to criticism and there is far more comment and reaction about dentistry in the news. We also see and hear about disagreements, the profession has a mouthpiece with an opinion.
The press office needs to be ahead of the game more often and on more topics. For this to work there needs to be more dentists willing to stand up and speak up locally.
I would like the BDA to take a long hard look at what the scenery of UK dentistry should look like in a decade’s time, to examine other systems and drive change. The only opportunity we have of being ahead of repeated government intervention is by inventing our own future. What will things be like under headings of personnel, science, economics and social? How will that be reflected in the BDA’s advice to members? What decisions do practices and individuals need to take now for the world of 2030 and beyond?
Some years ago I had to explain to a member that as section secretary I had little or no way of making direct representation, and he would have to approach the LDC or his GDSC rep. His reply, “You’re the “face" of my Trades Union, I have no idea who the other people are, they never come to our meetings and the LDC people are all 100% NHS why can’t you do something?” I felt useless.
The route of feedback from practices to “HQ” remains poor, the communication needs to be improved and to be seen to be improved. Members don’t know who their representatives are or what they do. Clarity is required.
Dentists - if you want someone to represent you then get off your backside, find them, tell them exactly what you want and demand feedback, otherwise there is a large chance that you won’t get it! Don’t ask what your BDA can do for you, ask what you can do for your profession.
BDA - make it easier to contact representatives. Ensure your offer is of interest and relevance to all members. Keep the messages simpler, don’t presume everyone knows everything, continue the website improvement and keep reinventing yourself.
© Alun Rees, GDPUK Ltd, 2019
(An Interview With A Former Member)
The General Dental Council’s work in disciplinary matters is sometimes not fully understood by dental practitioners. The revelations over the past few weeks that the GDC is registering overseas dentists as dental therapists without a thorough check of their practical abilities, that they withheld evidence which resulted in a fraudulent dentist being restored to the dental register, and that they have used private detectives to entrap registrants, has opened the GDC’s registration and disciplinary processes to close scrutiny. These recent stories on the GDC suggest those disciplinary processes to be more mysterious than ever.
GDPUK has been fortunate in being given the opportunity to speak frankly with a recent ex-member of the GDC’s Fitness To Practice panel, which helps determine the professional fate of over 112,000 registrants.
Peter is a clinician with over 28 years of experience in dentistry. He is currently working full-time in private and NHS practice. We have been asked not to reveal his identity.
It sounds like a lot of hard work. What made you want to serve with the GDC?
Serve? An interesting terminology there. The GDC has the statutory function of regulating the profession and whilst to many it seems odd, I wanted to be a part of this. Someone has to do it. I thought it might as well be me. You can stand on the outside and criticise, or you can be on the inside and see how the machine really works
Briefly, what were your duties on the committee on which you served? What is the makeup of the committee on which you served?
I sat on the Fitness To Practise panel and as a consequence, you sat on all the statutory committees. They are independent of the GDC – which is a challenging concept, given the GDC writes the committee guidance. On the FTP panel, you read, listen to and evaluate evidence presented. The civil legal standard is used so you find evidence on ‘the balance of probability.’ I personally believe it should revert back to the criminal standard. Beyond reasonable doubt stops charismatic barristers winning you over.
What training do committee members get?
It really isn't as intense as it should be. There is far too much concentration on ‘soft skills,’ such as communication and people skills, rather than legal understanding. I often felt it lacked any real depth. That said, the whole selection process is (allegedly) designed to select individuals that are able to carry out the workload. I personally doubt that, and feel the recruitment process is biased since the GDC seeks to ensure diversity. That aim is incredibly important since the profession is diverse, yet there is a part of me that is convinced that the recruitment process is flawed for this very reason
What sort of cases did you hear?
I heard cases involving all classes of registrant. They were, in broad terms, clinical or criminal. In addition to this there are health cases. Some were easy, some were extremely challenging due to the nature of the allegations.
Did you feel the cases brought before you were justified?
Ah, well, that’s a very difficult question to answer. In some cases yes, in others, no. When a dental professional is convicted of paedophilia then there's no discussion, but when a registrant is in front of a committee with a huge list of allegations that were clearly gained after the original index complaint, then it becomes difficult to clear the mind. The committee can only hear the evidence presented to it (alongside the allegations) yet I personally struggled with the concept. Indeed, in some cases (more than ever should have been) the original index complaint never even made it into the hearing. This conflicts with my personal sense of justice. The GDC managing to amass a long list of allegations based on its investigation was, and remains, of concern to me.
There are some criticisms that caseworkers can be over zealous when preparing ‘charges’ against registrants. Are these justified?
My personal issue with the caseworkers is that they lack any real knowledge of the profession. It can be reasonably argued that they don't need it to just list allegations, but this argument is fundamentally flawed as their inability to understand what is important and relevant is only dictated by guidelines they work to. The system is evolving with dental professionals now involved, but it is currently still lacking serious input
Do you think the makeup of committee’s is balanced and makes for a ‘just’ system?
Committees have to contain various elements in order to make them work. Prior to 2003 the ‘old school tie network’ led to many cases that were serious, failing the patients. There was a time when committees sat with five members. Nowadays, because of cost-cutting, it is invariably three. (The cost per day, per person plus expenses, is considerable). A three-person committee is unbalanced. It comprises one Lay, one dentist and one Dental Care Professional (DCP). One strong individual can influence the other two in my personal experience and a dominant influence means the case will fall their way. It's inadvertent "bullying" and this is why there is a focus on soft skills in the training process. Reverting to the criminal standard would eliminate this bias and mean that an individual’s influence would be more difficult to exert. It's either that or revert to ensuring committees sit with five members. One strong personality has to try much harder to convince four other members of his view.
Do you feel that decision making is hampered by Lay people?
No. The Lay perspective is very important BUT this must be balanced. I have already suggested that a strong personality can influence a committee. The Lay person is potentially the most at risk yet, again, a five-person committee would reduce this bias.
Quite often, registrants complain that they can also face ‘dishonesty’ charges in addition to the main charge – why are these added?
The dishonesty allegation actually tends to be a "collection" of allegations. It seems to arise from (again) expert evidence where the report writer may suggest that a "thing" couldn't have happened. It tends to be termed ‘inappropriate,’ ‘misleading’ or ‘dishonest.’
This to me seems to be a ‘get you one way or another’ allegation. They are usually listed as individual allegations that seem almost a snare. The GDC has to work to the remit the Professional Standards Authority decides and that overarching organisation seems to take great store in allegations that demonstrate dishonesty. Apparently, it is extremely difficult to remediate someone one who is dishonest. I'll let people make their own minds up on that aspect, but will say, to err is human.
Do you feel registrants are treated fairly in the FTP process?
Yes. Whilst to many from the outside it seems a draconian process, as a tribunal it has to follow English law. It is a quasi-judicial committee and it relies on expert input. As a committee member, you are not party to the build-up of a case but as a process, it is probably far too protracted for the comfort of a registrant.
Is it justified or necessary to go outside the index complaint and delve into all aspects of a dentist’s practice?
In my opinion, no. Now, if there was a very obvious risk to patients then certainly. But one complaint of a seemingly simple problem seems to lead to an escalation of the issues by ‘investigating’ the individual. I personally believe that if the index complaint falls away then the investigation should be stopped. This is not a criminal court. It has no powers other than to stop someone practising dentistry. But, and this is where I struggle, many employers may ask if you have ever been subject to an investigation. It won't appear on any criminal record but you would have to declare it - potentially ruining someone's future prospects because they failed to record someone's smoking habits.
Do you feel lay members fully understand the seriousness of their decisions on the registrant?
That's extremely difficult to answer. I have worked with some outstanding people and a few challenging individuals. One thing they have to learn is that, the consequence of a previous decision needs to be put aside by committee members. You can't let previous decisions regarding a registrant influence your decision. An example would be a registrant convicted of fraud in criminal court, but you are not convinced they were as guilty as the court found them. You must take it at face value. As a committee member you can't hide behind a previous verdict and you can only base decisions on the facts presented.
I think it is important to remember that some Lay members are, in essence, professional committee members and may sit on several tribunals and be extremely competent in what they do. That has a flip side, because a ‘professional’ Lay person then ceases to be truly ‘Lay.’
Did you ever feel that you your views were disregarded or overruled by the GDC or other members of the committee?
Yes. But that isn't always a negative. The whole point of having a minimum of three people sitting is so that a majority decision can be made. Your opinion will be heard but not necessarily agreed on. The GDC never influenced my decisions other than the published guidance (which is a separate question).
Do you think the GDC is currently fit for purpose with regard to disciplinary matters?
It is very easy to be critical and I think we are no different to our nursing/medical colleagues regarding professional regulation. By that I mean as long as there is a process whereby a professional’s conduct is questioned then no one will be happy. I have already raised some points regarding this. I do find it very bizarre that committees sit and hear evidence even though a registrant has said they are not going to attend/engage and indeed, are no longer working within dentistry. I once asked the GDC about the costs of a case, in 2009. A three-day hearing for a dental nurse who was never going to attend (she had actually written in saying they could ‘stick’ dental nursing), yet the committee sat and suspended her for 9 months. It cost in excess of £50k to hear this. I never followed up the individual after the period of suspension ended. When this happens (another area that is far too common) then no, it isn't fit for purpose. That was (at the time) the equivalent of the ARF of 50 dentists.
There is another area that makes me question the ability of the GDC to consider itself fit for purpose. This relates to the whole world of eggshells that is inclusivity and diversity.
The drive for diversity and inclusion is extremely noble and proper but shouldn't be a reason to put people in to the role that are essentially carried by more illuminated individuals on panels. The drive to hit inclusivity targets has skewed recruitment into the role rather than ensuring individuals have the ability and capacity to deal with the huge amount of information they are fed"
Do you think the source of complaints has changed over the years? Are there more fellow registrants reporting on their colleagues as ‘whistleblowers?’ If so, what do you feel their motivations are. Could you estimate the proportion of patient-generated complaints vs dental professional-generated complaints vs those brought by health authorities?
I despise the term "whistleblower" but I do genuinely think that motives vary. They go from genuine concerns, to vexatious ex-employees, to other motivations. There was a time when it wasn't the done thing to criticise another individual’s work. I don't necessarily think this is right but I do think there seems to have been a drop in professional discretion. Simply criticising some previous work for personal gain is shocking.
A committee isn't there to judge whether a complaint is based on that, but you get some that come through and you know that the motivation was all wrong. Vexatious ex-employees should be simply filtered out. Part of the problem is that if someone decides to raise concerns then invariably mud is slung from one side to the other. This leads to bizarre accusations that damage everyone involved.
I think genuine concerns regarding safety of patients is important but those involved in the very early stages of a complaint should be more robust in filtering. When a legal firm is the initiator of a complaint then surely alarm bells relating to a litigation process should be sounding in the GDC s ears.
Do you believe that radical changes are necessary in the GDC? If so, what?
I'm not sure there is a need for radical change. Perhaps what is really needed is consistency. If you look at the turnover of staff at all levels then you realise there is a distinct lack of consistency in the executive function of the regulator. That can only lead to confusion over time.
It's a bit like Chinese whispers I guess. Over time, interpretation of the way things SHOULD be done, is diluted. That said, I am still puzzled why any dental professional would contact the GDC for advice on any matter other than their ARF. The shake-up maybe needs the GDC to again tell dental professionals they do not give advice. Go on, give them a call and ask for advice on something and they give it... especially interpretation of guidance. The only folk you should contact are your indemnity company
Despite the GDC’s stated intentions to reform their disciplinary processes, do you feel they will effect change?
I think change will be forced upon them. I think this is a little similar to something I've already said, without consistency then change will just be a hand grenade that will just cause mayhem. It also depends on what reforms they actually can make. What us registrants want would be very different to what they are allowed to do. The Professional Standards Authority is not blameless in all this. They (the PSA) have instilled a sense of fear in the executive function of the GDC by essentially threatening judicial reviews when it disagrees with a committee’s decision. They are the watchmen watching the watchmen. If they don't like something then they choose to challenge it. Change must happen top down, not bottom up
The GDC has recently been criticised for:
What are your views on these recent controversies, if any?
The GDC should really hang its head in shame over certain aspects of these three areas.
I have read online discussions regarding all of these and have (unsurprisingly) formed an opinion on all three.
With regard to the registration story I read, it suggested that the GDC see no risk from registering overseas trained dentists as dentists despite the fact they may have failed aspects of the normal route of entry on to the register as a dentist. ‘Shocking’ is my only response. How long will it be before such an individual is in front of a committee? Will the committee have the kahunas to criticise the GDC for this? (Committees can criticise the GDC, I once sat on a case where we did and, as was stated in the determination, we would have awarded costs against the GDC if we had the power).
I sat on several cases where private investigators were used. I was always extremely uncomfortable with this process but was assured it was perfectly legitimate to attempt to get a professional to offer something they're not allowed to do. It feels wrong...very wrong and should be stopped and indeed, in cases where this evidence was used, I feel the cases should be re-sat without this evidence.
I'm no lawyer but withholding evidence is surely a miscarriage of justice? Remember it works both ways. In the case that has been highlighted, it has been demonstrated that all is not well at the GDC. Withholding evidence to prevent a hold (adjournment or postponement) is damaging to all parties involved. It's interesting how the GDC has been extremely quiet in not responding to enquiries in this and other areas. That is worrying because stonewalling only increases suspicion.
Do you believe the GDC uses the ARF money effectively?
I have never analysed the GDC accounts although there are many that do. I think there may have been some mismanagement many years ago which left the GDC in a predicament. That aside, the ARF is, for all registrants, far too high. A dental nurse whose skill set is not comparable to that of a general nurse, pays far more yet is probably paid less - shocking and the hike up for dentists was shocking. The GDC is not ostentatious (any more) when providing lunch or accommodation so those outside the organisation that criticise this should be careful. The attempt to reduce costs is noble, but perhaps not severe enough.
Do you believe that it is difficult for individuals to effect change from within? Does the government need to take a role in regulation?
The GDC is attempting to reform but as an outsider it is easy to criticise. That aside, they really only have themselves to blame given that they choose not to answer enquiries and using underhand methods to gather evidence instils no confidence. They perhaps need to be open about their dealings with ministers and health ministry officials and about how they have to engage in order to ensure that the guidance they give reflects the changing nature of dentistry.
Endless consultations seem to only attract a certain type of individual to respond and they will never get a balanced response because that nineteen year-old dental nurse who works from 8 to 8 for £9 per hour just couldn't give a toss. And when she is called in front of a regulator that she isn't aware of other than they want money off her annually, she will just go and do something else if called before a committee. Who wants that stress when you feel like you're the bottom of the pile and getting paid peanuts? You are understandably not going to care. That is possibly where the GDC could easily reform. Look at how it manages dental nurses and dental technicians.
Employees and ex-employees often describe the atmosphere within the GDC as ‘toxic.’ What is your view?
I wasn't an employee. No FTP member is, so my fleeting visits to the various GDC locations would not give me an opportunity to assess the working environment adequately. But I do take websites that people post these comments on, with a pinch of salt. A vexatious ex-employee may put toxic postings on just to be mischievous or air a grudge.
Why did you give up your role with the GDC?
I realised that I had "done my bit" it is very easy to stagnate in the role. I think I intimated earlier, that there are essentially professional committee members. They're not all Lay. Whilst it is important to have a broad church on committees it is somewhat bizarre that academics and non-clinical registrants are making decisions about care standards in an aggressive UDA system or on private practitioners just trying to earn a living.
Now you are no longer involved with the GDC, do you have any views on the current state of regulation and the ‘fear’ that is said to be gripping the UK’s dental professionals?
Neglect, fraud and certain things need addressing for sure but sanctioning an individual for a speeding offence really pushes the remit. The GDC says these committees as not punishing individuals but I beg to differ. Suspend an individual for a year and you have denied them their income. These sanctions are punitive in even the simplest form. It was becoming, and continues to be, farcical – leading to protracted hearings for trivial matters that should be dealt with locally.
Back to the subject of reform, the GDC perhaps should engage an ombudsman in more cases to decide what the complainant REALLY wants. If it is retribution or just a matter of "where there's blame there’s a claim" then that doesn't protect the public. Look at the length of determinations for even trivial matters, amazing. The Professional Standards Authority forced that. No, I don't want to be a part of that anymore.
With regard to the culture of fear that has developed in dentistry over recent years - the professional indemnity companies are not playing ball either. Their fees are extortionate yet they have the audacity to criticise the GDC. In 28 years, I have had to contact my indemnification company just once. I wasn't impressed.
I actually believe the indemnity companies are mostly to blame for the culture of fear. Their courses are toxic and full of fear. “If you don't do X or Y then the GDC will have a case.” Having watched many, many cases I can hand on heart say, I often shook my head at the really useless arguments they would instruct the barristers to present. They use ‘expert’ evidence to counter GDC evidence rather than peer to peer evidence. The experts are invariably academics or specialists that are way out of touch with the pressures of general dental practice. There is a massive disparity there.
Finally, I would sometimes find the hypocrisy at the GDC amazing. The biggest example that STILL irks me to this day is in the Maintaining Standards document pre-2006. It clearly stated that “a dentist must not work to a target driven standard.”
Because of the new UDA-based contract, the GDC had to make sure that particular passage wasn’t included in the guidance following the introduction of the new contract.
And the GDC is independent of Government interference you say?
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Dentistry is tough, I have written that phrase as an opening to several pieces in the past. Things haven’t got any easier, in fact quite the opposite. There is a crisis of confidence in many young, and not so young, dentists.
© Alun Rees, GDPUK Ltd, 2019
>A High Court Judge has criticised the General Dental Council’s Professional Conduct procedures after highlighting a “serious procedural irregularity” which allowed a fraudulent dentist to be restored to the dental register.
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The Charity helps dental students, dentists and their families when they face hardship, supporting those who do not have the funds to pay for some of the normal things in life, ranging from contributions towards food and daily living costs, funds to improve the quality of life for those retired due to ill health, to more specific needs like paying someone’s annual retention fee or indemnity, to help them get back on their feet and into the profession.
For many years Hull LDC stayed away from the national conference of Local Dental Committees (LDCs). Our preconception was that whilst the Conference might be good for networking, it punched below its weight. We were wrong.
LDC Conference is a fantastic forum, which provides the opportunity to debate Motions, to come to a consensus and to influence policy. In 2017 we saw the light and we decided to table a motion suggesting that we should solicit the support of Local Authorities for water fluoridation as part of Starting Well (SW) Programmes in relevant areas. We were basically “dipping our toes” in the (fluoridated) water. After all, SW is about investing in programmes targeted at the 13 worst areas for child dental health in England where need is greatest, including our “back yard” - Hull.
The result of this motion was that it was supported by Conference – but not unanimously.
We’ve learned a lot along the way – including the importance of making the motion clearer which would have helped to avoid the voting result. Some delegates wanted CWF included as a short-term strategy!
The LDC also started to use the letters pages of the excellent BDJ to get their messages across. In response to a letter from Paul Connett of Fluoride Action Network1 Hull LDC2 highlighted the lack of credible evidence for his points that fluoride at 1ppm is chemophobic, neurotoxic and toxic as well as the emotionally charged language. This letter exchange was two and half years ago and similar “tactics” remain the thrust of the Fluoride Action Network3,4 position on CWF.
In 2018 we decided to build on the first motion and call for funding reform for CWF- because Councils simply don’t have the resources to implement schemes following years of central government budget cuts. This is also fair because as the motion explains, the majority of the return on investment5 falls to NHSE.
This time the motion was unanimously supported and the BDA picked up the baton:
The successful motion reflected the support for CWF at the sharp end of Primary Dental Care and created opportunities for the BDA to take forward issues generated by LDCs. Conference motions are effective and with support from the LDC community and BDA leadership, the momentum for change is building. This is huge credit to LDCs whose members work at the coalface and who over three years have supported CWF motions again and again.
The letter the BDA refers to was sent to Simon Stevens. It called for the reallocation of the recurrent costs of CWF schemes from Councils to the NHS. Interestingly, this concept was further developed in this year’s Prevention Green Paper where it was suggested that we need to look for ways of removing barriers to CWF. Councils should be encouraged to come forward and seek cost-sharing partnerships6.
In 2019 Hull LDC built on both of the previous motions to ask conference to support those local authorities moving forward with CWF.
Once again Conference supported the motion 100%.
At the beginning of 2019 Hull LDC began to work with the British Fluoridation Society and the BDA to form the National CWF Network. This alliance now has a large membership of dental organisations and a growing membership outside dentistry including the National Children’s Bureau (NCB). The partnership with the NCB is especially powerful, as this organisation exists to support change in society and deliver better childhood.
So we also began to learn that forming wider alliances off the back of campaigning for CWF could be powerful and effective. Working with partners or campaigning with fellowship is the way forward. The LDC national conference is a great organisation and an effective platform for change - it just took Hull LDC a while to work this out. So over time campaigning with fortitude has grown in to campaigning with fellowship.
1). Water fluoridation :Is fluoride chemophobic? P. Connett
2). Water fluoridation: It really is this simple: Hull LDC
3). Fluoride Action Network
5). Return on investment of oral health improvement programmes for 0-5 year olds
6). Advancing our health: prevention in the 2020s
April 1st 2035. On her 40th birthday Alice was taking stock of her career and professional life. Her initial dislike of working as a dentist for GleamDent had mellowed, she was still there, and life was good. The dental arm of a European health corporate had treated her well and she had responded by being a good employee. Her early days of ersatz self-employment had been swept away in John McDonnell’s first coalition budget.
The job had privileges including free health care, crèche and kindergarten facilities at work for her two children and six weeks paid holiday a year. In addition the profit sharing scheme allowed all employees to purchase shares in the company and provided bonuses related to personal performance and length of service.
The deep economic depression in the wake of the exit from the EU had a profound effect. Many universities failed financially and tertiary education was re-structured. Vocational degrees were reimagined and medicine, veterinary science and dentistry became graduate entry, usually via the new modular medical science degree.
Teaching in dentistry took place through an apprentice like system at one of the four English dental schools each of which was associated with a corporate body. Students, or dental cadets, were taught theory “in block” and practiced in outreach clinics. The cadets received their education, accommodation and a stipend in return for their commitment to the career structure for 10 years after graduation.
Experiments with on-line delivery of all teaching at undergrad and postgrad levels had failed when it was seen that isolation and lack of personal contact contributed to mental health problems. Psychometric assessments became as important as practical evaluations before prospective students were admitted to the course.
The financial crash led to the creation of a new National Health Care system, run mostly by large groups and funded by clear and compulsory insurance cover. All practices were effectively privatised and during the last decade the, quaint, old style of practice based in converted houses had nearly disappeared. They were replaced either by stand alone new builds in office blocks or, more often, in “Hurley centres” alongside medical colleagues with the onus fixed on “putting the mouth back in the body”.
Some of Alice’s friends were exceptions. These “Artisan Dentists” had solitary practices where they worked with only a nurse and some even did their own laboratory work. Alice herself had relied on digital technology for all her restorative work for a dozen years.
These Artisan outliers were not able to sign up to any of the main health insurers and depended upon on direct payments from patients. Like many of her colleagues Alice had been suspicious of their approach but after spending a few hours with an old friend had found the personal attitude interesting but not attractive.
Every GleamDent treatment pod was well equipped. Magnification was standard, the lighting excellent and state of the art patient distraction systems, long proved to be essential to obtain relaxation and co-operation were a huge improvement on local anaesthetic alone.
In the early days Alice, like many others, was uncomfortable to find that direct feeds from her loupes, in-surgery cameras and monitors meant that all clinical and non-clinical procedures were recorded. Feedback from the sensors measuring Blood Pressure, pulse and cranial activity, of dentist and patient was also monitored. It was easier to defend the increasingly rare allegations of poor treatment, and operator quality could be assessed and constructive feedback given. Plus, reflective practice in such a practical subject was easier when one could see one’s own work and reactions.
Since 2030 much of the adversarial legal system had been taken over by Artificial Intelligence, this removed the need for involvement of the discredited General Dental Council.
Vaccinations against caries and aggressive forms of periodontal disease plus genetic intervention had resulted in 95% of people being bacterial disease free, with ideal jaw and teeth relationships.
However there was a TSL (tooth surface loss) “epidemic”, due to people living on a 90% plant and fruit based diet. The consequences were that many people needed extensive reconstructions during their lifetime. These were mostly performed, like implants and orthodontics, by dental robots, using computerised treatment plans and 4-D printer generated restorations.
Alice found that these cases fulfilling and challenging. The rest of the time she spent supervising via the in-surgery monitors and mentoring junior colleagues whether they are therapists, dentists or students.
Would she choose dentistry for her children? She already had, thus earning herself a share of the GleamDent finder’s bursary.
© Alun Rees, GDPUK Ltd, 2019
Like many dentists I know, I absolutely love new gadgets and innovations in dentistry. I was therefore excited when the Daily Mail headline proclaimed “The End Of Dental Fillings” the other day. Of course, it isn’t. I couldn’t accurately estimate how many times I’ve read “The End Of Dental Fillings” or “The End Of The Dental Drill” over the years, only to have my hopes crushed by scientific reality and human trials.
Professor Damien Walmsley squished my hopes like a bug when he projected that the in vitro growth of an enamel-like material by researchers at Zhejiang University’s School of Medicine wouldn’t be ready for practical use for “ten to twenty years.” Drat! I’m still waiting for a fully-formed Boots own home tooth-growing kit promised by researchers back in the early 1980’s.
This latest breakthrough does sound exciting though. I won’t bore you with the details but the Chinese scientists found that a material composed of calcium phosphate ion clusters could be used to produce a precursor layer to induce the epitaxial crystal growth of enamel apatite. This then mimics the biomineralization crystalline-amorphous frontier of the hard tissue developed in nature. They also found the CPIC-caused epitaxial growth recovered the enamel strength, with H and E values of 3.84 ± 0.20 GPa and 87.26 ± 3.73 GPa, respectively. I was staggered. Oops. I bored you.
I’m such a sucker for gadgets of any description, I once couldn’t help buying them. Years ago, the practice manager of my own practice banned me from going to Dental Showcase for my own financial safety. I seem to recall that was triggered by me coming back from a show with my arms full of boxes of disposable spring-loaded BPE probes, which I never ever used. Just last night I was glued to the Apple iPhone launch event, salivating, more like drooling over a phone that looks identical to the one in my pocket except the new one has three knobbly bits on the back.
I think I can say that during my career I kept fully abreast of new developments and never feared embracing a piece of kit with a warning beep built in. I don’t know if that was a good thing or a bad thing, a total waste of money, or just plain scary.
I was lucky enough to be given the opportunity after about four years post-qualification, to work with the dentist who first inspired me to become a dentist. My dentist and his partner were two forward thinking professionals who were constantly on expensive courses and they picked up hundreds of tips which they imparted to me and the other associate, as well as spend thousands on bits of kit which they occasionally let us use.
One day, the senior partner appeared at my side, wearing a pleading face, despite the fact he was about to give me the opportunity to try out his latest purchase. The new addition to the practice’s armamentarium was a crown removal system, which I believe is still available. I can’t remember the name of the product, but I can say it was incredibly effective - maybe TOO effective for my liking. After giving me quick instruction on how to use the device, I suddenly found a consultant medical surgeon in my chair, one of my boss’s best private patients.
The ‘device’ was basically a cube of what looked like solidified Rowntrees jelly. You may have come across the material – I don’t want to teach my grandmother to suck eggs (to be honest it was the only way my grandmother could eat eggs because I made her dentures) - but it was a very hard material and had to be softened in hot water. After it reached a nice pliable consistency, the material was placed by the crown and surrounding teeth on the occlusal surfaces and the patient was then instructed to bite down and hold it. The idea was that you let the material cool and once it was set, the patient opened the mouth violently. The desired result was a detached crown in the set jelly.
I could detect that the crown in this particular patient (an upper right 4) was very slightly wobbly but just as I placed the material, I realised that the unrestored UR3 and UR5 were also slightly wobbly. My blood ran cold. I was already committed and I braced myself for the embarrassment of having a consultant surgeon let out a blood-curdling scream as his teeth were ripped out without local anaesthetic, and the trial of having to replant them back into the sockets. Mercifully, only the crown became detached and I marched the patient back downstairs to the private part of the practice. Afterwards, my senior male colleague said “Phew, close call. Well done, my dear.”
It was while I was at this practice that I was also introduced to a miracle product.
The bane of any dentist’s life, in addition to all the other banes, is failed anaesthesia. Particularly miserable, is the inferior dental block, especially when you have a patient who doesn’t like needles. My two bosses came back from a course one Monday and announced that all our blocky worries were about to be over. Ten days or so later, the other associate and me were introduced to something called Lido-Hyal. The drug was administered in a dental syringe the same as anaesthetic and it worked by virtue of it containing hyaluronidase. The enzyme facilitated permeability within the tissues so the anaesthetic could penetrate easily to where it was needed. I can’t honestly recall which way round I administered it, but I think I probably gave the local first, followed by the Lido-Hyal. Even the most resistant patients in the practice succumbed to deep pulpal anaesthesia within a couple of minutes and it seemed worries about local failure was banished forever. The only contraindication was that you couldn’t use if there was any suspected infection around for fear of spreading it deeper into the tissues.
I pretty much used Lido exclusively for ID blocks and it never let me down. The problem with Lido was that it wasn’t licenced in the UK and it had to be imported from Switzerland. When I moved to my own practice in the early 90’s, I found that I couldn’t live without it, although I used it rarely. I had probably about three shipments until one day I received a caution from Her Majesty’s Customs and Excise henchmen, who issued a stern warning and a demand for the import tax I’d apparently been wilfully avoiding. I hadn’t, I was just someone who hadn’t previously imported anything in his life and was also a completely incompetent businessman. That put me off, as did an off-the-cuff remark from my associate who reckoned that using Lido would dissolve patient’s condyles. It never did, but it planted the fake news seed and that was enough for me. I never used it again, for fear of turning local patients into drooling, rubber-jawed yokels.
Before my bosses discovered Lido, one of them experimented with intra-osseous anaesthesia. He reckoned it was great for ‘hot’ pulps and avoided the post-op dribbling associated with ID blocks. I never tried the technique myself, the demonstration patient being enough for me. I think the system I saw being used isn’t available any longer, but it involved using a hollow trephining drill to sink a hole in the cortical bone that went through the cancellous bone of the alveolus. The outer part of the trephining drill was left in situ and the local was administered through the hollow tube. My boss reckoned the procedure was less painful than delivering an ID block, but I saw the patient squirm when he numbed the intra septal gingivae and saw the patient slowly wriggle down the chair when his cortical plate was being drilled. I’m sure it works perfectly well in the right hands but it turned my stomach, and apparently his. The system was in a cupboard gathering dust within what seemed a fortnight.
An innovation that I DID think might change my professional life, was jet anaesthesia. I was an early adopter, grabbing jet anaesthesia enthusiastically, with both hands. You needed to use both hands because if you didn’t, the retort was like that I would imagine you’d experience from an AK-47. The patients loved the idea of no needles, but they didn’t like the thud and kick-back from the unit, despite the ineffective rubbery cushion on the end. I found the unit difficult to use, particularly getting the large business end flat against the buccal bone of the upper molar areas. The main problem was although it got the soft tissues numb, it rarely got the pulp numb enough to work on the tooth. Most patients ended up screaming for ‘the proper needle.’ Having read a couple of papers on the modern units, it would seem they are pretty ineffective, though I would be first to admit it could have been operator error in my case.
I was also one of the first customers for surgical loupes with built in fibre-optic lights. These particular units were built in the USA and cost a packet. They were wonderful, but… In those days the light generating unit was a box which to my recall was about the same size as a small fridge which sat on the work surface behind me. The loupes were connected to the light unit by a reasonably lengthy fibre-optic cable and to be fair, it allowed quite a bit of free movement – except if an idiot was wearing the loupes. One day a patient asked me a question during treatment. I couldn’t make out what he was saying and I pulled my mask off and moved to face him so I could lip read as well, forgetting I was still tethered. Fortunately, that act didn’t pull the light unit off the work surface because my nurse dived on it, but my loupes were pulled off and they smashed on the floor. After a couple of weeks on their holidays in the USA, they returned as new. The kind suppliers repaired them free of charge. About two months later, they took a flight to the States again – pretty much the same reason. This time there was a modest charge with an accompanying note asking me if I would like a representative from the company to come and give me a free demonstration on how to use the loupes. I thanked them, but politely refused their offer. My motto over the years seems to have inadvertently been, ‘Once bitten, twice bitten,’ so when my loupes, which I adored, finally hit the deck again, I gave up on them. Eventually I found a local optician who gave me decent magnification in prescription specs, which served me well till I retired.
There were quite a few gadgets I DID resist over the years. Lasers were one of the innovations I shunned. I knew of a good practitioner locally who had spent a lot of money on one and shelved it within a month, advertising for it sale in a dental journal for nearly a year before the ad disappeared. I had heard he failed to shift it.
The early Cerec machines I also dismissed, though mainly on the grounds of cost. In my opinion, the results I saw when they first came out had all the aesthetic beauty of a toilet bowl created by Armitage Shanks. I’d call the shades available in the early days as ‘Comfort Station White.’
Ozone healing was the other ‘breakthrough’ I pretty much ignored. It was promoted originally as being effective way of treating early caries, particularly in pits and fissures. Being old-fashioned, I preferred to witness that I’d dealt effectively with the caries and regarded ozone treatment as snake oil. I note that it’s not currently recommended for the treatment of decay, by NICE.
As for ‘breakthroughs’ like the elimination of filling and drilling, I am a sceptic. Back in the 80’s, at the welcome address by the Dean of my dental school, he told us that caries would be eliminated in the developed world within ten year and that our futures lay in the ‘Third World.’ It was a pretty dour introduction to dental school. I note we are still waiting for the caries vaccine he promised.
I’ve just noticed a tiny chip in the back of my mobile. I think I need a new phone. The iPhone 11 looks nice.
Negative reviews can be upsetting. Could the answer be an App? "We'll Be With You In Ten Minutes Mate" Should We Adopt The Uber Model? By @DentistGoneBadd
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