Would you recommend a career in Dentistry to a member of your family?

At the moment, probably not!

Why so?

Because its rotten! Beset by problems.

And yet dentistry should be a great career and should be more attractive now than it used to be, with technical advances like implants and digital dentistry.

So what’s gone wrong?

Lots has gone wrong, but much of it relates to how we interact with each other. We buy our practices and they become the focus of almost all our professional attention. That’s understandable as running a practice is demanding, but:

• We start to lose contact with our peers
• We start to see our peers as competitors rather than colleagues
• We’re so busy with the practice and our personal commitments that we forget to take an interest in and support our representative bodies
• When we’re not happy, we hope someone else will fix it
• The representative bodies have so little support they become ‘toothless’ (sorry!)
• The terms get worse, we get more apathetic and more focused on our own problems
• The vicious cycle repeats

In the immortal words of Bob the Builder ‘Can we fix it, yes we can’.

• To restore our profession to good health we must change the way we see each other. We must rediscover the friendships of our university years and connect with our colleagues. We must support each other as fellow professionals doing a difficult and demanding job.
• We must look beyond our own worlds and take in the bigger picture
• We must each take responsibility for the health of our profession
• We must support our representative bodies
• We must rediscover our pride and our self-confidence as a profession
• We must unite

SDPO seeks to unite Scottish practice owners, the key stakeholders in Scottish Dentistry.

This should be a powerful group with strong representation, and we believe this should include legal support. With your support we can tackle the issues facing our profession.

We are reasonable people and will make reasonable demands, but we will challenge behaviour that we think harms the interests of our members and the public that we serve.

We spend our working lives restoring things. Please support us in restoring our profession to good health.

Dentistry should be a career that you would recommend to your kids.

There are very few countries in the world where one would get reliable and standardised dental treatment at a low cost or even free like NHS dentistry. From the point of view of affordability, it cannot get better for the patient seeking care from a dental professional. By default, everyone has access albeit not advanced. Scotland is in such a unique position and it is time we start appreciating this great health benefit around us. Most economic indicators across the globe show a widening gap between rich and poor and this service provision goes a long way.

Of course, when such a niche service is provided by the State it is argued that State cannot cater to the ever increasing demand for advancement of science and technology in dentistry but risks being a very basic service. Is that fair? Many a times I wonder why do such discussions not happen when a NHS Trust invests on a ultra-modern MRI scanner costing millions? Business case is always there. Is successful dentistry not important for health and well-being of the society? Dentistry isn’t just a cosmetic tooth replacement program, it is an essential commodity to provide a decent quality of life in the society and pays for itself. As simple as it sounds, I wish policy makers were thinking on these lines.

It is important we remind ourselves of the law of diminishing value in economics. The law states that once you become used to a value or benefit, if not reminded of the value on a regular basis, the original high-perceived value diminishes. You can see this law at work all the time in the world around you. It seems perfectly plausible that when something is given free or at a price next to nothing, it is not perceived as being good. Patients rightly think it is their right.  Imagine the sweat and hard work for that difficult surgical extraction of a root treated lower molar. Neither the State nor the patient in general appreciate it. The same procedure carried out privately at a much higher price is seen as excellent, outstanding, great value for money and so on.

Corona virus pandemic has opened up new challenges and we have all heard from time to time ….there is no more money in the pot….. Of course, priorities of health care providers has changed dramatically.

Speaking on the basis of social welfare, NHS dentistry is indeed a great service that State delivers, as long as it is robust and comprehensive. However, we need to ask the question why despite pumping in millions, Oral Health in Scotland is one of the worst in Western Europe? Is it worth spending that money on preventative dentistry and let the individual take responsibility for oral health? Many of us think NHS dentistry must provide basic pain management and emergency treatment to the needy. Rest of the services must occur in an independent patient funded manner.

What is the need of the hour? Should we as professionals start advising patient to move away from NHS dentistry as it isn’t possible to deliver the service at the costs agreed by the State? (considering the massive upward increase in costs of delivering dental services and ever increasing regulatory scrutiny) Or should we appraise Scottish Government and policy makers that pumping in additional funding will drive the oral health and quality of life upwards?  The ultimate issue here is how we can adequately fund the service and expect good outcomes?

What will happen to a patient who cannot afford and need additional treatment? Imagine the letter you received from a Hospital Consultant asking you to provide 6 posterior composite build ups to be changed to full coverage crowns down the line to manage tooth surface loss or even a chrome denture where practitioners have to pay the cost out of their pocket? Worst when the denture needs remade within a short span of time!

It makes complete sense not to waste money and time on expensive treatment that would have poor outcomes and therefore within NHS dentistry a scaling down of disease centred approach and bringing it in line with a preventative model sounds attractive. Any high value treatment can be an opt in by patient rather than provided by default could be one perspective, while retaining access to dentistry for essential treatment and maintenance of oral health?

This reminds me of my mentor and a trusted surgeon who used to say…….. you don’t need teeth to survive, so no major emphasis is needed on saving them……but then I would say ……would anyone imagine stepping out without their full compliment of teeth in this day and age? Let the patient decide what is needed.

A great many years ago, at a lunch break at a meeting at the Royal College of Surgeons in Edinburgh, I was discussing the disabled access initiative with an elderly dentist. He told me that many decades previously, dental practices were forced to locate above street level. This was due to 2 factors. 

1. Dentists want to locate where greatest footfall is - commonly on shopping streets.
2. Planning regulations prevented dental practices opening at street level on shopping streets. 

For these reasons, dental practices were found up closes and usually above shops. 

Successive generations of dentists have therefore bought existing practices and then converted, relocated or closed them as the modern approach of accessibility and street-level advertising to the exterior has come into vogue.

But…..and here's the rub. Much of this modernisation forced onto practices due to changes in governmental and health  legislation, was financed by practice owners - often over 2 or more generations. Sure, some minor grants may have been available to some from time- two-time, but no permanent pot of ring-fenced central funding available to all at any time.

The same can be said for many other grant initiatives 

• Extra handpieces in the early 1990s to allow for autoclaving 
• Creation of LDUs 
• Funding for initial purchase of washer disinfectors 
• Purchase of computers, peripherals and practice management software.

I'm sure you can think of more.

The essential thing is a complete lack of recurrent expenditure and a piecemeal patchwork of temporary grants instead.

For example 

• Handpieces eventually need replaced, and the ones bought in the 1990s were certainly not marked as being compatible with washer disinfectors. (WDs were not commonly found in dental practices) 
• WDs bought over 10 years ago are now worn out and need replaced. (Who funds the replacements; and indeed who funds the required maintenance and running costs?) 
• Computers need replaced or upgraded and recurrent expenditure spirals upwards with no additional funding from NHS treatment provision. 

I am absolutely certain that all this must be playing a part in detailed discussions between the BDA/ SDPC and the Scottish Government.

Now consider this.

In the 1970s our general medical colleagues were relocated - some would say "forced" -  into medical centres from the comfort of their individual surgeries. Over the last 20 - 30 years many practices have been incorporated into medical centres. Indeed, in Dumfries over a decade ago, a purpose-built dental centre was built at a cost of £4.2 million, with multiple surgeries.

It is not inconceivable that the Government would like to keep a check on the dental budget and one of the ways it could do this is by medium to long-term planning. Their way of thinking may be along the lines of what they did for general medical practice and gather clusters of GDPs together under the roofs of primary care centres and kit out multiple surgeries with cabinetry, equipment and materials. All bought from lowest bidders.

Existing practices in older buildings would be forced to move or see their assets reduce over time as new graduates take up position in these NHS centres. (No doubt branded as "centres of excellence" or similar).

For the NHS, this would be a kind of dental Eutopia. Acceptance of lowest bidders for provision of buildings, cabinetry, x-ray units, small equipment, materials, sundries, delivery units and maintenance contracts would mean financial control (the current distribution and insistence on use of just one type of FFP3 mask might be testing the water). Meanwhile, a new means of remuneration (currently under discussion) would give greater control over dentists.

For dentists and particularly existing practice owners, all this would be a kind of hellish dental dystopia. Existing practice values would depreciate over time as continued rising costs (due to continued lack of economies of scale) and the lure of patients to NHS centres. By the economics of using the lowest bidders, continual breakdowns of everything from handpieces to computer hard and software will be more frequent and take longer to fix. (Bear in mind that the lowest bidder will have fewer call- handlers and engineers to reduce costs and afford to be lowest bidder). There will be little room to buy and use materials and equipment of choice. Indeed, by forcing dentists into group practices, there would be endless group meetings to negotiate among the group about capital expenditure on new materials and techniques. Nobody will agree with each having their own particular favourite and a "well it works in my hands" mentality. 

For patients, for whom dental services are designed, there would be a lack of choice. All NHS practices will look and feel the same. The equipment breakdowns will mean many cancelled appointments and the lack of ability for practitioners to keep up to date and immediately buy in the newest equipment or materials will mean a gradual erosion of provision of modern dentistry.

It is one thing providing consultation rooms for general medical practitioners in the 1970s (desk, examination bench and prescription pad). It is an entirely different matter to provide treatment rooms for general dental practitioners. It is far more complex. Surely too complex for non-dental politicians and civil servants to get their heads around.

If you think all this seems a bit far-fetched, consider this: 

The BDA/ SDPC has responsibility of negotiating dental matters with the Scottish Government. The BDA acts in the interests of the profession AND  the public. It does not act solely in the interests of dental practices or dentists. 

If the Scottish Government wanted changes as described above, it would not want to get involved in discussions with dental practice owners, despite them currently providing the buildings, facilities and manpower for the overwhelming majority of NHS dental treatment. 

Perhaps this is one reason it hasn't engaged with practice owners and continues to engage solely with SDPC, at times imposing its unilateral will.

My late father-in-law used to say "if you can't think of a reason, think of this", as he rubbed thumb against his first 2 fingers to signify money and greed. If you can't think of a reason for the recent actions of SG towards dentistry, bear this in mind!

Well it’s that time of year. The schools have been back for a couple of weeks and usually after 2-3 weeks the bugs, which the kids/ children/ pupils/ students (I’ve lost track of what is the accepted terminology) have been carefully nurturing, start spreading between them and into surrounding communities. Then, come the October holiday and the onset of colder weather, more serious flus are spread –largely by the same route.*

Those in society, who are classed as “vulnerable”, are eligible for flu vaccinations for the most likely forms of flu virus to be circulating, while there may be some innate immunity conferred on the remainder due to circulating antibodies which have been created from past exposure to previous similar viruses.

Of course, with the present Covid-19 pandemic, anyone who has a temperature, new persistent cough, or loss of taste or smell is encouraged to self-isolate and seek a test. But a common cold can cause the same symptoms.

The upshot is that there will be a rash of late cancellations or FTAs at dental practices which are likely to be more numerous than usual for the time of year –not great when we are all trying to catch up with private or maintenance plan patients and appointment slots are at a premium. Of course it is the same from our side. If a clinical member of staff has a child sent home from school, that member of staff will need to self-quarantine until a negative test or positive test (entailing at least a week of being away from the practice and disruption to the appointment book). Add to the mix the complexities of fallow time, urgent NHS AGPs, and the possible reintroduction of all NHS AGPs in the coming months, the organization of appointment books becomes ever more challenging.

Now, more than ever, it is important to keep a list of patients who are able to come in at the drop of a hat to fill appropriate slots vacated by children and others who develop a bit of a sniffle and don’t want to risk spreading it in case its Covid -19. Our pre-visit screening will aid this and continuing financial support from the NHS will help with those late cancelation appointment spaces which cannot be filled.

But that’s not the end of the story. There is some research to show that about 40% of those who test positive for Covid–19 are asymptomatic or are not particularly ill. This is increasingly thought to be due, in part, to at least a partial immunity from antibodies produced in response to exposure to similar viruses.

Coronavirus Pandemic Update 102 with Dr Seheult

So it may be that over the years, children returning to school after a holiday period, not only spread bugs around the community, but also help in creating a protective antibody response to more virulent strains of bacteria or viruses for the future.

This then begs the question:

Are school pupils friend or foe to the when it comes to spread of infections?

(* other routes of spread are available)

A box of masks showing the original expiry date

Most of us have worn masks at dental school. We were used to them, although they were uncomfortable to wear for prolonged periods. We were only aware of paper-types and certainly unaware of the differences between various grades of masks/respirators/hoods which could be worn. Indeed, in Scotland until the outbreak of Covid-19, masks were not thought necessary as long as visors were worn.

At the start of the pandemic, face masks of all sorts became difficult to source. This was especially so in Scotland, with most supply companies reserving them for practices in other parts of the UK, where wearing masks had always been a requirement.

We have since learned a whole new vocabulary FRSM, FFP2, FFP3, N95Stealth, Full Face respirators, 3M 1863 and 3M 1863+ have become widespread terms in dental social media, where only ear loop or tied masks were only ever subjects of debate before.

3M 1863 facemask

The current arguments over out-of-date masks will no doubt rumble on for years and the legalities will no doubt be a bone of contention. It is pointless to go over this in detail here. However, the elephant in the room has not really been touched on (yet). That is 2 questions:

1. Why the NHS had a stockpile of FFP3 masks, which are thought to have been ordered during the threat of previous pandemics which were not deployed in March and April when the country was told of a shortage and care homes, hospitals and dental practices were unable to find any?
2. Why incoming new stocks were deployed rather than using up the older stock of masks? It is, after all, normal business practice to employ proper stock rotation; using oldest stock first (last in, first out) to avoid waste and expense.