It’s the Tortoise and the Hare all over again…

Boota Singh Ubhi, Principal of Birmingham Periodontal & Implant Centre (BPI Dental), Specialist Periodontist and implant dentist, shares a long-term referral case that highlights some important lessons.

The patient was initially referred to us for full arch reconstruction with guided surgery in 2006. She presented with failing upper bridgework, which was partially implant-retained. There were multiple problems including failed apicoectomies, fractured roots, and the two anterior implants were failing as well (Figures 1-3).

The treatment options discussed with the patient were to either do nothing for as long as possible or to replace all existing restorations and implants. As the patient was keen to find a solution sooner rather than later, she chose the latter option.

A full clinical assessment was conducted with radiographs (Figures 4-5) and photographs. The only good tooth remaining was the upper right canine, but other than that the natural upper dentition had a hopeless prognosis and was unrestorable. A very large lesion was detected on the UL5, the UL3 was 

apicoectomised and both the anterior implants were positioned very poorly, which had affected the smile aesthetics with a midline shift to the left. These implants had been placed about 13 years previously, so they featured very old designs. 

Initial treatment and surgical planning 

The treatment process was explained to the patient and informed consent obtained to proceed. The existing implants were removed (Figure 6), as were the few remaining natural teeth. As poor bone quantity had been identified in the assessment radiographs, bone augmentation was indicated if we were to place new implants with a good level of primary stability. The procedure was performed at this time around the implant site to preserve the sockets and in the upper left quadrant. This was left to heal for about six months, during which time the patient was provided with a removable temporary denture.

After this healing time period, the patient returned to the practice for a follow-up CT scan and wax-up, which was used for the guided planning process of the implant placement. The ideal implant positioning, angulation, length and width were determined using Simplant software.

Surgical treatment

On the day of surgery, mid-crestal and midline reliving incisions were made (Figure 7) and a full thickness mucosal flap was retracted back. A bone-supported guide was used (Figure 8) to place six Astra Tech dental implants (Figure 9), which at that time enabled the guided planning process with Simplant software. The flap was closed and sutured (Figure 10). Six multi-unit abutments were then placed (Figure 11) in preparation for the new screw-retained bridge. The post-operative X-ray demonstrated good positioning of the implants, which were all parallel to each other (Figure 12). The bridgework was fabricated (porcelain fused to Cresco gold framework), once again utilising compatible products. Due to the effective angulation of the implants, there was no need to angle the screw channels and we achieved a very passive fit for the bridgework. In this time, two implants were placed in the LL5 and LL6 areas, which were restored with two splintered crowns (Figure 13). The lower right bridgework was left alone despite the distal cantilever, as it was causing no problems at all.

Several try-ins of the upper bridge were conducted with the patient in order to achieve the right aesthetics. Once the patient was happy, she went on her way.

Review

After about a year – during which time the patient saw her routine dental team for check-ups and general care – she returned to our practice for her annual clinical review, involving X-rays and full six-point pocket charts on every tooth and implant. The restorations still looked great (Figures 14-17) and the patient reported no issues.

Images show the result at one year review.

The patient continued to frequent her routine practice to ensure on-going maintenance of the dental implants and restorations and to help optimise her oral health. She also had access to our dental hygienist at BPI Dental on a yearly basis to support this maintenance programme. Around 10 years after we performed the surgical treatment, we were lucky enough to see the patient again and, as shown in the photos, the restorations still looked great (Figures 18-20). There had been very little soft tissue change and the aesthetics were fantastic, so the patient was still delighted with the final outcome.

Images show the result at ten year review.

Discussion

This case highlights a few important aspects worthy of note. First, we don’t always need to rush treatment – this case required treatment over several months and the final outcome was highly appreciated by the patient. Secondly, dental implants placed in the right positions will facilitate long-term soft tissue and hard tissue stability for durable outcomes.

As in all dental implant cases, the presented case emphasised the importance of excellent maintenance by the patient – only by attending on-going review appointments and adhering to strict hygiene routines at home can patients enjoy long-lasting results. Finally, this case demonstrates the superior aesthetics of porcelain both in the short- and long-term – I don’t think it can really be bettered and therefore it would remain my gold standard restoration material wherever possible.

For more information on the referral service available from BPI Dental, visit www.bpidental.co.uk, call 0121 427 3210 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

Author biography:

Boota graduated in 1992 and later gained an MSc in Periodontology from Liverpool University. He became a lecturer at the University and passed his Membership in Restorative Dentistry form the Royal College of Surgeons of England in 2000 to become a registered Specialist in Periodontology. Since then, Boota has lectured at universities and educational events in the field of periodontics, dental implantology and bone / soft tissue augmentation, running his own implant training programme for colleagues as well. He is also an active member of the British Society of Periodontology, the Association of Dental Implantology and the American Academy of Periodontology.

Keeping an eye on the GDC by Victoria Holden.

My next concern relates to conflicts of interests and, again, I have raised these with the GDC and I remain concerned hence I am ‘going public’. 

Having been taken to task myself by Counsel once over an issue of a conflict of interest during a Fitness to Practise hearing, I fully appreciate that expert witnesses and FtP panel members must be, or at least be seen to be, ‘whiter than white’.  That is, of course, subject to the phrase not being in anyway offensive to any sectors of society as it certainly isn’t intended to be, or otherwise inappropriately bringing the profession into disrepute, in which case I mean ‘holier than thou’.  Or do I? Truthfully I’m not sure what I can and can’t say these days.

The GDC also seem to grasp the impact that conflict of interests may have on the disciplinary processes, as they have a document titled ‘Managing Interests Policy for Council members and Associates’. In this document it says:

So it all sounds like, on paper at least, the GDC takes the issue of conflicts of interests very seriously indeed.   And it is with reference to conflicts of interests and the Pate case that I am writing this blog.

There has already been plenty written on the GDC v Pate case elsewhere.  On Dentistry online their 4 most popular links refer to the proverbial ‘FtP case of the year’. 

At the time I started writing Mr Hill was winning with over 9,000 views.  Coming up fast at the back with a late article on the subject was Mr Anis with a tidy 4000 views of his re-iteration of the points Mr Hill makes, but it feels with more insistent tone that negative Islamic comment equates to hate speech.   Mr Rees and Mr Watson also give opinions on the subject and there are some excellent arguments made in all these pieces, including within the comments.

Much is made of the fact that the Met Police said that no crime had been committed by Mr Pate and that this means nothing in terms of FtP.  Actually, I would have to concur.  But the problem is that the Chief Constable of the Met did not simply say ‘no crime committed here, everyone move on’.  What he appears to have said as I read it, is that what was said wasn’t that bad.  The police letter, which is not mentioned in the determination, but I shall add it here for transparency, says:

Interesting. Controversial views, and at times unpleasant to the majority, but certainly not criminal, offensive or even religiously offensive says the Chief Constable of the Met.  And, there are well-known individuals saying the same things.  Not an entirely helpful letter for the GDC’s case, which presumably explains why it is not referred to the determination.  The transcript does refer to the letter, but these are not publically available and only available to the parties directly involved in the proceedings.  Well, correction; they are available to the public, at a cost of approximately £250 per hearing day as I found out recently from an FOI. 

Anyway, I am side-tracking.  Back to the conflicts issue.  Further to the complaint, and the Met letter, the hearing progressed with an unrepresented Mr Pate, as non-clinical issues fell outside of his defence indemnifiers remit as it has been reported. Having read the transcript, the need for representation at these hearings is clear.  Many of the arguments and points Mr Pate put forwards would have been better made, and no doubt have carried more weight if made by Counsel. ‘Stories of the Law’ by the Secret Barrister who explains how self-representing people frustrate the hell out of everyone else in any kind of legal or quasi-legal hearing.  So the GDC got a great opportunity to make the point that registrants should tone it down, or better still, completely shut up on social media by securing a four-month suspension of Mr Pate. 

Chair of the FtP panel, Mr Adair Richards was soon after noted to have listed the General Dental Council as a previous client when tweeting about his new training and consultancy company website earlier in the year:

Indeed, the GDC are right in their warnings that social media can be hazardous. 

Unfortunately, the level of trust in our regulator appears to be so low that registrants are now at the point of scrutinising the background and motives of associated individuals. Here, it appears that we have an FtP panel member who has been paid by the GDC to provide training and consultancy to the GDC.  A Freedom of Information request was submitted to request Mr Richards declaration of conflicts and other information about his previous business relationship with the GDC, of which nothing was apparently declared.

I was told that Mr Richards ‘made an error’ on his website, and as if by magic, one week later the website had been altered to remove the GDC from the previous list of clients.  I’ll be honest, and say I am not sure that I buy this is an ‘error’.  FtP panel members go through rigorous testing of their critical thinking skills.  They are not unintelligent people.  To make an error implies that Mr Richards either misunderstood that his role on the FtP panel was somehow an extension of his consultancy services, or perhaps that he was completely unaware that the website copywriter had listed the GDC as a client.  The other possibility that crosses my mind is that it could have been a ‘deliberate error’, made with the intention to mislead potential future clients into thinking the company had trained or consulted with the GDC.  Either way, it does not look good.   The Managing Interests Policy document tells me that these are the possible interests, of which I pick at the very least a ‘perception of a conflict’:

As a result of this error/lie on the website, which seems to have been swept under a rug in Wimpole Street, I also perceive that Mr Richards could be in breach of the Nolan Principles listed in appendix 2:

I think it is great that Mr Hill came online to explain why the GDC took the Pate case so seriously, and highlighting why protecting public confidence in the profession is so important.

However, I can’t help thinking that the large number of dissenting registrants would be more respectful of the Pate hearing outcome were it not for the issues that I have exposed here and in my previous blogs.  It is not just the registrants that are responsible for public confidence: the GDC also have a major role to play.  If registrants do not have confidence in the regulator and those associated with them to act professionally and properly this can only lead to damaged public confidence at the end of the day. 

Next time, I will be looking at Prejudicial Interests, and delving a bit further into the Pate case.

In the meantime, if you have been affected by any of the issues raised in my blogs, do not worry.  You could waste 15 minutes of your life that you will never get back by sharing feedback about our regulator with the Professional Standards Authority here.

 Image credit - Best Picko ; under CC licence - modified.

For Part One of this blog - click here.