An article on the GDC website could either be some useful advice among many for registrants to learn from, or a binding edict that they cannot go against. As Peter Ingle argues, the concern is that we don’t know which it is
‘Heavy is the Head: Complaints about dental crowns – sharing insights and learning’ is a recently posted blog on the GDC website by Dr Shamir B. Mehta, the regulator’s lead clinical adviser. There is nothing wrong with either what Dr Mehta writes, or the fact that he is offering his thoughts on the issue.
Dr Mehta is no lightweight, being a dental practice owner and holding a range of academic positions, as well as his role at the GDC. He has a wealth of knowledge and experience in this topic that most registrants can only aspire to. In his blog he provides a lucid and reasonable run through some of the pitfalls involved in crown provision. Inevitably, in a short piece he offers general principles, which he also illustrates with some examples from cases that have come to his attention.
Experienced registrants will have acquired their knowledge from a variety of sources, and have arrived at their own personal interpretation. They will have been exposed to the views and teaching of experienced and highly qualified colleagues, who do not always agree. As professionals they must then decide how best to use that knowledge. This is a useful source, among many others.
Therefore, it is no fault of Dr Mehta’s that experienced professionals may find anomalies that are contrary to the general principles within that blog. One small example was raised on the GDPUK forum. Dr Mehta includes a good periapical radiograph as an essential pre-treatment part of the assessment for a crown, citing an FtP case where one of the roots was not shown, with unfortunate consequences both for the patient and dentist.
A forum reader asked about the case of a non-root treated tooth that reacted to cold, which would confirm its vitality. Consider the case of an otherwise sound molar which would benefit from a crown, that responds to thermal and electrical testing. A clinical examination and recent bitewing do not raise concerns about periodontal issues or caries. A periapical is not taken, on the basis of limited justification for the exposure, and a crown is provided.
Subsequently there is an unconnected issue from the same course of treatment and the GDC review the records. We know from past experience that notes are extensively examined beyond the primary issue, and charge sheets are often enthusiastically bulked up. A case examiner spots the lack of a periapical X-ray taken immediately before a crown was prepared.
Optional in theory?
And here is where the problem lies. Because this is a blog that has been published on the GDC website, written by its clinical adviser. But could Dr Mehta’s general principles come to be treated as requirements in practice, whatever their formal status?
Since ‘Crowning Glory’ Dr Mehta has contributed a further blog item aimed at early career dental professionals. It begins: ‘We want to regulate in a way which promotes learning over fear, supporting dental professionals to continuously demonstrate professionalism, rather than driving behaviours through the threat of fitness to practise. Our role is to give clear, easy-to-use guidance that supports dental professionals to show good judgement and professional behaviour in providing good oral healthcare for patients and the public.’
Note the use of the word ‘guidance’ and compare this with its use in the new Standards. The blurring between standards, guidance and supporting material may not be intentional, but the boundaries are already becoming cloudy.
The blogs on the GDC website refer to their contents as guidance. As the GDC moves to update its Standards, it has continued to insist that the new category of supporting materials will not be used in FtP proceedings. At least, an undertaking to this effect was given during one of the webinars about the new Standards. However, it was given by one of the Standards development team who is not involved with FtP.
Gold-plated
Given the lack of trust that many registrants have in the GDC and the understandably risk averse nature of most of the indemnifiers, there is a non-negligible chance that we will see the contents of such blogs become non-negotiable.
In the above example, therefore, when the dentist finds themselves in front of the practice committee, the registrant may finding themselves having to say ‘yes’ when asked the question of whether they went against guidance. Explaining why this deviation was in the patient’s interests is much more nuanced. The dentist’s defence will have to convince a GDC curated and trained committee, following a GDC process, that on this occasion robotically following the same organisations guidance was not the only way to properly care for the patient.
That is not all. We cannot be confident that future guidance will come from colleagues as experienced, or independently minded as Dr Mehta. There is abundant evidence of past guidance becoming ‘gold plated’ and practice becoming ever more restrictive, ‘just to be on the safe side.’
This represents a grave threat to both clinical freedom and professionalism. The old joke about showing a patient’s record to three dentists, and then getting eight treatment plans reflected a profession that sometimes placed individualism above reflection. A dental profession homogenised by their regulators’ guidance is unlikely to be much of an improvement. Or much of a profession.