Madam DentistGoneBadd looks to the future.
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!
It's a Question of Taste - (Practice Ownership - Love it or Hate it).
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.
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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
They sell tooth whitening kits on the Internet. You can even buy temporary crown kits from the web. Guess what you can buy now? Brace Yourself - DIY Orthodontics Via Webcam By ADentistGoneBadd
Believe it or not, it’s just over ten years since the CQC came into being.
I know! It doesn’t seem five minutes since the CQC burst into existence. Sometimes it seems like it’s been hanging over dentistry forever - like the extended impact winter that wiped the dinosaurs out after that postulated asteroid crash-landed without warning – which was a bit like the CQC itself really.
In England, the CQC is the independent regulator for the quality and safety of care, although to many practitioners, it’s more regarded as a major irritant – another regulatory body to which you have to kowtow, pay an exorbitant fee and produce a forest’s worth of paperwork.
I vaguely remember that the CQC landed on dentistry’s doorstep in about 2011. I was a practice owner in those days and I remember only too clearly, spending most of my spare time writing policies to fulfil forthcoming CQC requirements and being too busy to notice I could have just downloaded them from the internet.
I didn’t have any direct contact with the CQC until I had to go down to one of the organisation’s regional headquarters in the Midlands, for the registered manager’s interview, sometime in 2012. I seem to remember then having to go again a few months later, when the bizarre individual who was about to buy my practice had to have his registered manager’s interview and we had to tell the CQC how we were going to effect the ownership changeover. Naively, I had thought he would simply give me the dosh, and I would skip over the horizon, happily whistling the ABBA hit, Money Money Money. But no, the CQC wanted to make it more complicated and we had to outline our contingency plans for provision of treatment if the practice was consumed by a flood or a volcano. I thought I’d made that clear at my first interview – canoes and a Dyson.
I finalised my practice sale in 2013 so I’ve had no real exposure to CQC fees since, but I seem to remember a registration fee of £1500 or thereabouts. I had a quick Google this morning and there nowadays seems to be a complicated formula for working out how much dental practices have to pay in fees, based on the number of chairs the practice has, and if you are insane enough to work at more than one site.
I remember that there was a lot of resentment among dental practice owners around
2011-2012 at the introduction of the CQC to the dental field. Many questioned the need for yet another authority to oversee the profession. We’d already got the Health and Safety Executive, the Primary Health Care Trusts (as they were then) and the General Dental Council. Did we REALLY need another?
Yes. We certainly did.
Over the 19 years I had my practice, I had only a couple of informal routine visits from an NHS dental practice advisor. Near the introduction of CQC registration, I had a visit from the area infection control coordinator (until that point I didn’t know such a person existed) to ensure we were complying with HTM-01-05. As it happened, we weren’t - a sink in the decontamination room was in the wrong place and we had to move it to comply with the rules. Apart from that, there was no real oversight of the practice. In most of my ownership days, we still had the random checks from the RDO where the Dental Practice Board would choose a few patients for inspection at the local correction facility (as I liked to call the community dental clinic), but that was it. What went on in your practice was very much your own affair. Nobody randomly checked to see if you were boiling the instruments properly in new saucepans, or diligently spraying the reusable patient bibs with Febreze.
As it happened (and it was probably more luck than judgement), apart from a few bits of paperwork we needed to spruce up, we were pretty near compliant before the CQC came-a-calling. But having worked in a number of practices as an associate before I bought my own place, I can attest that there were a lot of places that would have really struggled to come up to basic CQC expectations, let alone those required by the CQC.
I will describe ONE such practice that I worked at.
It was 1990 and I’d been qualified a couple of years. I joined an old established practice on the Cotswolds border as an associate. The practice had five surgeries and was manned by a husband and wife who were the owners, a long-term associate, a hygienist and moi. The bosses had taken over from two very old school and respected dentists, one of whom appeared to have been grandfathered on to the dental register from his primary job as a barber and blood-letter.
The practice was set in a grand Georgian terraced house, and once you went above the surgeries on the first floor, it appeared that the last vacuum cleaner ever to be used on the 2nd and 3rd floors, was the Batty-Fang Carpet Beater 1900. I never saw those floors during my interview, and neither did I see my surgery. When I turned up for the interview, my surgery was in use by the hygienist (apparently) and I couldn’t see into it, the door being solid wood. When I arrived for my first day of work, my surgery was decorated in the style of a 1940’s London Underground station lavatory. Every square inch of the walls, ceiling and floor were tiled in a faded turquoise and the pipes for the aspirator and services lay on top of the floor, presenting a tripping hazard to anyone entering the room. I found out later in the day that the practice was supposed to be haunted. The legend went that the house was originally owned by a well-to-do family and the man of the house had an affair with the housemaid, who I shall call ‘Flora.’ When it all went pear-shaped and Flora became pregnant and was shamed, she hung herself in my surgery (which was the kitchen originally – the fireplace was still in the one wall). Her feet would have dangled over the reclining headrest. It’s another story, but my associate colleague heard Flora singing late one night on the top floor, and truly I saw an outline of her brushing her hair through a window, one dark winter’s afternoon.
After a week I could stand no more. I discovered that Tanya the hygienist only worked in the practice two days a week and although not spectacular, it at least had an acceptable, if dirty wall-covering. I asked if I could swap rooms and poor Tanya found herself in the lavatory. She never thanked me. I asked the practice owners if I could decorate the room myself and at my expense. The bosses agreed. I did it in a nice bright pink and I put some decorative borders up. The husband came in first thing on the Monday after I had decorated, put his head around the door and said without a hint of humour: “It looks like a bleeding tart’s boudoir in here.”
Unfortunately, the equipment was as old as the building and the delivery unit was the size of a modest Buckingham Palace fridge and it was about as manoeuvrable as trying to get a Dalek up the stairs. It had polyoxybenzylmethylenglycolanhydride (Bakelite) control switches and buttons and piping that had been repaired by shortening so often, when you moved the drills in a patient’s mouth, the unit was dragged with it. In the two years I was there, I never saw an engineer come in to service the equipment (not that the spare parts were still made for the units). I’m sure it would never have come through a thorough PAT test with flying or even submerged colours. My unit had a dodgy connection with the handpieces and every now and then there would be an explosion of air and what remained of the air-tubing would fly off and snake wildly about the room like a twerking cobra. I point blank refused to have anything to do with fiddling about with the equipment and so my nurse would go and fetch the husband. I REALLY want to name him, but I can’t, so I’ll call him Boris. Anyway, Boris would invariably come with a pair of scissors in his hand and a cannister of sturdy floss, and tie the tubing back on to the handpiece coupling until the perished rubber broke again.
Fortunately, the CQC also ensure premises are safe and up to the mark these days. Boris’s place wasn’t. I doubt that the electrics of the practice had been checked since Thomas Edison was a lad. One day I was doing a full denture try in. I had just given a deaf lady a mirror so she could have a good look and the small, white, straight set up. There was suddenly a loud bang and a flash from behind her. A Bakelite electrical socket (without anything plugged in) had just exploded with no provocation. I jumped and my nurse shrieked, but the patient just sat there wondering if the shade was maybe a little bit dark. She even carried on looking intensely at the denture while Boris ran into the room behind her with a fire extinguisher and started spraying powder all over the place. I can’t remember off hand if the socket was ever dealt with afterwards. We were probably told never to use it again.
One of the worst incidents that happened at this place and inspired me to look for a job elsewhere was when I was treating a patient and Boris’s nurse flew in and said “Can you give Mr Aguecheek a hand…NOW!”
I went into the lavatory-surgery to find Boris was struggling to keep a child anaesthetised. “Just pop the E out for me” he shouted. I went cold but did it. I hadn’t realised until that point that he was doing child general anaesthetics acting as operator and anaesthetist. I knew for a fact that his nurse wasn’t trained at all, being a newby. I rarely lost my temper, but told him as soon as the opportunity arose, that he was never to involve me in GA’s again.
But that probably wasn’t the worst of it. Oh no. I discovered while I was working my notice, that Boris and his wife Priscilla didn’t dispose of sharps through a clinical waste company. He apparently used to box them up and dispose of them just as the local tip was shutting and it was getting dark. I found that out from one of the receptionists as I was having a chat between patients. I had only just muttered “That is absolutely disgusting” to turn round to find Priscilla was standing behind me. Well it WAS disgusting and again, I told them that I would have to report them to the local Family Practitioner’s Committee (as it was then) if I witnessed them doing it again.
Suffice to say, they also ignored employment laws. A trainee nurse who had gotten fed up with £2.40 per hour they paid, handed in her notice. At the end of the first week of her fortnight’s notice, they withheld her wages, only giving them to her after the rest of the nurses and I, threatened to strike. After I put my own notice in, I found two of my monthly payments were delayed and Boris used to sneak out of the practice so he didn’t have to see me. He worked on the first floor and I was told by his nurse that he daily tiptoed down the stairs quietly so I wasn’t aware he was leaving. One morning, I finished early and waited for him. I flew out and ran at him, catching him halfway up the stairs. I’m not a big bloke, but when I get angry, I can make myself big. When he came back from lunch, he gave me two cheques.
The thing that was interesting here, and it accounts for the fact that I am not impressed by people on committees is that both Boris and Priscilla were ‘upstanding’ members of the local dental community. Both were big in the British Dental Association locally, and both had been LDC members, yet they operated like that.
So do we need the CQC?
Yes we do. The pally pally relationship they must have had with the local dental practice advisor obviously didn’t address major problems with their practice. In these days where we are all faced with a torrent of potential litigation every day, at least complying with the high standards set by the CQC reduces risks marginally and prevents inadvertent swamping by an avalanche.
But it all turned out okay in the end for Boris and Priscilla.
They both dead now.
Have you ever regretted a decision? Have you ever leapt at a chance only to end up slipping on a banana skin? That pretty much describes my dental career. "Do I Get Another Go?" Rethinking A Dental Career After Retirement By @DentistGoneBadd
It's the summer, and soon you'll all be inundated with patients wanting their teeth fixed before they smile nicely for the border control people. Brace Yourselves, People - The Holidays Are Coming. By @DentistGoneBadd
NHS hospital doctors are understandably concerned about refusing treatment if overseas patients can't pay. But is it that hard to deny patients treatment?
I'll Do Anything For Teeth But I Won't Do That)
If your patients feel more confident using a bit of glue on your superb denture, do you despair? Well you shouldn't. It's all cool according to a new white paper.
Meeting A Sticky End
Why Dental Fixatives Are No Longer Taboo
Domiciliary dental care was in the news the other day — or rather a lack of it. Hopefully there may be some discussion now on adequate funding for treating the housebound. "Sorry. Don't Do House Visits"
I was initially quite scathing of the Tory Leadership selection process, but when I looked back critically at the way that I chose members of practice staff, I thought better of it. "You'll Do" How NOT To Choose Practice Staff By @DentistGoneBadd
The poet Philip Larkin wrote words to the effect of "They mess you up, your mum and dad." They may very well do, but I think dental school has exactly the same effect on dentists.
Dental School. The Worst Days Of My Life
Sometimes, keeping quiet is the best way to remain diplomatic in dentistry. There are various ways of stopping yourself from putting your foot in your mouth. Here is my favourite.
Stock Up With Lip Balm
When Biting Your Lip Is The Best Policy
Patients do some strange things, but so do dental product manufacturers sometimes. They're as bad as each other in my book. You're putting WHAT In Your Mouth? (Some DIY Dental Tips) By @DentistGoneBadd
The Definitive Guide To
Writing Referral Letters
Let’s start with the essentials. Referral letters should contain the basics; name, sex (if any – I don’t like to ask really), date of birth and reason for returning….oh sorry, that’s sending a parcel back to Amazon. Long gone are the days of “Please see and treat,” so try and give the specialist you are referring to, a bit of a clue as to the reason for your referral. Throw in a couple of vague differential diagnoses if you can, just to demonstrate you aren’t completely gormless, with proper medical terms like ‘epidermolysis bullosa’ or ‘squishy lump.’ It’s probably best not to refer a patient just because you don’t like the look of them, tempting though it is.
If you are worried about a lump, it’s best to send to a consultant lumpologist. But beware, some specialisms do cross over and consultants can get a bit elbowy and will fight over interesting lesions. I once witnessed a near fist-fight between an oral medic and an oral surgery registrar – both convinced they could write a paper about it. Every time, make sure you are referring to the most appropriate department. One department will treat a lesion with a spray and ineffective mouthwash, while another will cut it out and put an implant in its place.
Oral surgery referrals are probably the most common type made. It’s not quite clear why this should be. Fewer dentists get into trouble over oral surgery than perio neglect or root-treatments. I think that oral surgery is probably all a bit too gooey for a lot of dentals and the anticipation of complications is overthought. Because oral surgery departments are absolutely swamped, you have to make a convincing case. Warfarin patients are no longer a bar to treatment in practice, so throw in ‘difficult access’ and ‘a history of difficult extractions’ for good measure. ‘Proximity to the antrum’ doesn’t often wash. Since many oral surgery departments insist on you supplying a supporting radiograph, they can justifiably throw out the referral and tell you where to stick your jpeg when they realise it’s a lower molar you are talking about.
These are probably a little more clear-cut, if you completely ignore IOTN, which I did. I doubt very much if it’s done now, but the acronym ‘FLK’ (Funny Looking Kid) in the margins of the old paper files, acted as a reminder to refer to the orthodontist once the overcrowding started to hurt your aesthetic sensibilities. I find FLK’s generally DO get orthodontic treatment, so providing they are reasonably competent with toothbrushing, and generally look as if they’re using the hairy end, send that referral. Again, don’t just ask to ‘see and treat’. Throw in ‘well-motivated,’ ‘optimal oral hygiene’ and ‘very stroppy mother’ to emphasise the need for action. Chuck in a couple of measurements if you can, and try and crowbar in a stab at a ‘division’ to show to the orthodontist you’ve given it some careful consideration.
This type of referral is usually done in panic five minutes after you have just unexpectedly lost a BPE probe down a previously scoring ‘1,’ so do try and keep the panic out of your letter. Make it sound like you’ve been closely monitoring things for a considerable period of time and really emphasise that when you first saw the patient, most of the damage was already done. ‘Despite my oral hygiene instruction’ also shows that you have been caring, but don’t get too down about having to refer and being condemned by the periodontist. The specialist will probably only see the patient for twenty minutes max anyway, and will never see them again, immediately throwing the patient into the ‘Pit of Hygienists.’
Endodontic referrals are becoming incredibly popular and you are highly unlikely to get one rejected, since they are often made to private specialists. Don’t bother trying to refer to your local dental hospital. The sun will have died well before your patient gets to the top of the list. Besides, dental hospital endodontists are exceptionally picky about what they treat. My local dental hospital won’t treat any tooth beyond a first molar. They aren’t that clear why, though I suspect it’s because trying to get to a seven is a bit ‘too fiddly.’ Failure in endodontics is a growing area of litigation and if you are an NHS dentist in particular, don’t risk ANY root-treatment – refer. You can throw a lot of information into your referral letter – sclerosis, unusual anatomy or “There’s a prominent squiddly-do on my radiograph” – but it doesn’t matter. These are endodontists. They have to pay for swanky microscopes and German Sportwagen. They’ll accept anything.
See Endodontic Referrals. Patients think they are the same thing anyway.
Tricky. Prosthetics specialists are a dying species. Their natural habitat in the 60’s and 70’s was gummy, but since forestation with teeth, the need for them has diminished. The few prosthetists left, tend to pack together at dental schools, desperately attempting to procure close relationships with implantologists, borne out of their innate instinct to survive. Having said all that, I have had more referrals rejected by prosthetics specialists than any other type. To be absolutely honest with you, whatever you say in your referral to a denture specialist, they’ll write back with “We would recommend extending the flanges and see no reason why this cannot be carried out in practice. Now leave me alone. I need to bury my nuts for the winter.” Good luck.
This is where you send all of your ‘challenging’ patients, or those that take an hour to do an enamel-only incisal edge composite on. Terms you should include in your letter are ‘wriggly,’ ‘anxious,’ ‘fearful,’ ‘phobic’ and ‘gagger,’ though be careful you don’t end up making it sound like a Facebook advert for happy hour at the local S&M Club. Make it absolutely clear that this patient needs sedation. Forget about suggesting GA. The clinicians at these emporia don’t stop talking about the risk of death from the time the patient enters the place having found it after previously mistakenly walking into the adjacent STD Clinic. If your local clinics have their own referral forms and it gives you the option to have the patient back if they refuse sedation, tick ‘NO!!!’
Quite a few restorative specialists lurk in dental schools, but despite this, they try not to have anything to do with teeth. There is only one important, indeed, CRITICAL sentence you need to include in your referral letter, and that is: “I am ALREADY monitoring the diet and wear.”
You will normally refer to the oral medicine specialists as a means of backing up your diagnosis, which is almost certainly, atypical facial pain/burning mouth syndrome. Often, you would save a lot of time by giving a nightguard or benzydamine hydrochloride rather than wasting your time on a referral letter.