Now Where DID I Put That Enthusiasm?

My favourite writer of the moment is David Sedaris, The New Yorker humourist and author.  If you ever really want to wean yourself off YouTube and Netflix and get back into the habit of reading, start with David Sedaris.  You won’t regret it.

Last year, David got into trouble when asked his opinion of Donald Trump at an event in Washington D.C.

"I would like to build a time machine," Sedaris said. "I would like to go back in time and smother him in his crib."

Death threats soon followed, which the author said he didn't take seriously.

I was often asked over the years: “What on earth made you want to go into a job where you’re staring into people’s mouths all day?”

Now that was a question, I often asked myself – since about 1984 if I’m honest – and it’s one I wrestled with almost daily until exactly December 31^st, 2018 – the day I retired from dentistry. I wrote on Twitter recently, that if I could time travel, I’d go back to the 80’s and stop the development of the Maryland Bridge. I think one glance at the look of despair in my face would have stopped the project in its tracks.  On reflection, the best use of a time machine would have been to travel back to about 1978 and throttle myself before the daft idea of becoming a dentist entered my spongy little head.

My inspiration to go into dentistry was the dentist I met in in the late 70’s. I’d just moved to an evening newspaper in the Midlands and my late wife recommended I went to her dentist, having bravely confessed to her that I was, and always had been,  a little jellyfish in the dental chair. I was never scared of drilling, needles or pain, but I was a top-notch gagger.  As soon as any instrument touched my tongue, I’d be off.  Bitewings were a nightmare and cotton-wool rolls were the marshmallows of  Beelzebub. I once went to a dentist near Birmingham as an emergency, with pain from my LL6.  I explained that I was an enthusiastic puker and he said to his nurse “His nibs is a gagger, so keep your pipes out the way.”  She did and his Ledermix lining lasted right up until about 1998.

At dental school, I once admitted that I gagged easily and the prosthetics lecturer selected me to demonstrate his infallible technique for taking impressions on gaggers.  The episode ended with me halfway across the clinic dragging the imp out of my mouth, with the red-faced (angry) prosthetics lecturer having to select another victim in order to save face by demonstrating his technique worked.  His method mainly involved screaming in the patient’s face to breath through their nose.

My new dentist was brilliant, taking the time to explain procedures and the need for them before he commenced and it was the nearest I’d ever been to receiving an actual treatment plan.  Even more brilliant was the fact that he not only used topical anaesthetic gels before he used local, but he also treated me with Relative Analgesia (RA).  The latter, literally changed my life.  I think it was while I was under the RA that I must have had something akin to a religious conversion and decided to become a dentist.  Many years later, I went to a Medical and Dental Hypnosis Society lecture one Sunday morning and the presenter described RA as “Hypnosis in a bottle.” It certainly was.  From those first experiences with my new dentist, I was hooked on the idea of becoming a dentist, despite the fact that at that point, my school qualifications amounted to nothing more than a glorified certificate of attendance. 

Getting the right qualifications seemed almost an insurmountable challenge until I had a lecture from my younger brother, who told me not to be so pathetic and get on with it. He had similarly had a poor secondary modern school education and had left school with CSE’s, but had recently begun taking ‘A’ levels in order to study theology at university.

After been given a metaphorical booting by my late bro’, I commenced three years of part-time evening study for ‘A’ levels and a couple of required ‘O’ levels, and after an awful lot of toadying around dental school registrars, I found myself at dental school being humiliated by a prosthetics lecturer with a retching fetish.

Now, I wasn’t the most brilliant of students, but I think I was hardworking and exceptionally eager. On Wednesday afternoons when we were given afternoons off to pursue funny shaped leather balls or develop our macramé skills, I quietly used to volunteer for sessions in the emergency department or oral surgery extraction clinics.

So where did that enthusiasm go, and what caused its depletion? I think it was chiefly the emergence of the Big Brother mentality in the authorities, that finally killed my passion for dentistry.

Not that it bothered me particularly, but pretty much when I qualified, I got the impression that dentistry was low down in the medical world pecking order. Dentists seemed to be almost despised by the GDC. During the 90’s the “Call Me Doctor” campaign was rumbling on and I found it insulting in the extreme that the GDC found it necessary to instruct dentists not to imply they were medically qualified if they used the title, pretty much used worldwide by the dental profession. Dentists qualify with a surgical degree anyway, so the use of the titles Mr, Mrs or Miss, are those that medics strive for when they are pursuing surgical qualifications. The fact that our own regulator deemed it necessary to warn us not to overuse our new courtesy title, did dampen my enthusiasm a tad, seeing it almost as a warning not to act above my station. The fact that medics use the same courtesy title didn’t seem to factor in.

I don’t suppose for a second that I am the only dentist to have lost drive and enthusiasm early on in a career, particularly nowadays with increased litigation and the hurdles of increasing guidelines and mountains of paperwork piling up on a daily basis.

In the 90’s, fair enough, we were aware that the GDC lurked in the undergrowth, but private litigation was almost unheard of (at least it wasn’t a daily topic of conversation) and Section 63 courses were pretty much left up to you to attend if you fancied it. They even used to pay your parking and travel and out of pocket expenses if you asked nicely.

Notes could be written as “Exam. NTR.” and nobody minded, not even the RDO or local Dental Practice Advisor from the FPC.

If I could go back in time and locate where I lost my enthusiasm, I’d be flummoxed as to where on the Tardis time dial, I’d set the ‘best before’ date.

There are so many points since the late eighties where dental spirits have been crushed – generally, not just mine. When I started, we had a pretty straightforward payment system where you got paid for what you did. Yes, the fees per item were set at a pretty low rate – I seem to recall £6.80 for an occlusal amalgam – but there was no upper limit and if you worked hard, you could make a reasonable living.

Then the NHS gave us a 10% pay cut and introduced capitation and continuing care payments and introduced prior approval, where you had to submit a case for your complex treatment plans (although to call it a ‘treatment plan’ was a bit of a stretch – you didn’t have to introduce BPE readings or perio assessments). If the Dental Reference Service turned you down, you could appeal. I did once, on a patient’s behalf, and found myself in front of two local practitioner’s – one a good lad who went on to become a dental practice adviser and another, a blithering idiot who once lost a hand file in a right bronchus after neither using a rubber dam or at the very least tying a bit of floss to it. They turned me down. I wanted to do three crowns at the time, something I could have done many years later when the NHS said to dentists “Yeah. Do what you want! It’s your money you’re using.” It was at this point that I began to get the feeling that dentists were not being trusted and were being monitored more closely for wrongdoing. Again, a crushing blow to my enthusiasm.

With the introduction of the capitation contract, we found ourselves having to organise local rotas for emergency cover, sweetened only by getting a £50 fee for ‘opening’ the practice. Again, dentists started finding themselves scrutinised for claiming opening fees and I know of a couple of practitioners who had to prove the time that they opened their practices after cross-checks made with patients. It was the beginning of Big Brother.

In 2002, the General Dental Council introduced lifelong learning and formalised it as Continuing Professional Development. While it didn’t really affect my attendance pattern at courses, it introduced a sort of “We’re watching you” vibe and I started to get the feeling that as a profession we were being monitored a little more closely. Even worse was the feeling that they had introduced the measure as a result of the trial and tale of the serial killer Harold Shipman, the general medical practitioner convicted for the killing of 15 patients in 1999. I read at the time that CPD measures had been introduced in direct response to the Shipman story, as if extra studying is going to stop a killing spree. I’d also heard that Shipman had been an avid attender of postgraduate courses anyway, so bang went that theory.

Gradually, after the dawning of the 21^st century, dental litigation became the big growth industry in dentistry and this expanded as dental innovation grew, giving more meat for the litigators to feed off.

I felt that the compulsory registration of dental nurses and dental technicians by the GDC in 2008 increased the fear factor in dentistry, again, delivering to the ambulance-chasers and the GDC, more victims to chew off. I feel it was around this time that dentistry really started to become a pit of fear, with dentists now becoming more concerned about putting a foot wrong.

Then of course, UDA’s. I’ll say no more.

It was around the time of the introduction of the Care Quality Commission in 2011 that I witnessed a marked reduction in enthusiasm coming from colleagues. I also witnessed more dentists looking at pension plans and contributions and assessing if they could extricate themselves from the profession earlier than planned.

It was around this time that the dentist who was willing to ‘have-a-go’ entered a terminal decline and dentists were more inclined to refer than risk being sued or reported to the GDC. It didn’t help that dental litigation firms were increasing their public profiles around this time, with radio advertising being pushed down patient’s throats even while dentists were pushing endo files down patient’s throats. My enthusiasm plummeted to the depths at this time.

The obsession and imposition of evidence-based dentistry I felt, crushed on-the-spot innovation in the surgery. Deviation from the ‘norm’ to help patients out became a thing of the past, with dentists (and me in particular) reluctant to try something slightly out of the norm, to help patients out.

I remember in the 80’s, a dear friend of mine and former boss, confiding in me. He admitted that sometime in the 70’s a well-to-do patient of his had a tooth that had lost a post-crown, but the root was damaged and there was no way a conventional post would have any chance of retaining a crown. One day he had a brainwave and saw a screw had fallen out of the practice’s patient toilet door. The size was perfect. He autoclaved it and placed it in the root, prepped a core on it and it was still working by 1992 when he retired. Nowadays of course, he’d have been slaughtered at the GDC if anything had gone awry.

Similarly, a few years ago, a long-time patient of mine flattened an upper lateral while playing rugby.  The tooth was sclerosed and he had no symptoms.  The radiograph of the root showed no sign of anything untoward.  The teeth either side of the root, albeit a bit wonky from crowding, were untouched by a dentist or the caries worm.  The fracture was well below the gum and was not really post-crownable.  The only option was to remove the root and plan a Maryland, or refer for implants.  It was a lot of information to place on the patient in one go and anyway since he was a teacher at a local comprehensive school, he wanted to fill the gap ASAP.  Since the adjacent upper central was rotated and favourable, I built out the labial surface of the tooth with composite and used the bulk of the composite to swing a pontic off it, since I didn’t have any carbon-reinforced fibres to hand.  It looked great, but I warned the patient it wouldn’t last and we’d have to think again at his next exam.  Fifteen years on (I bump into him occasionally) and the codged-up job is still there. These days, with vulture-litigators and the evidence-based crew beating the drum, I wouldn’t even have attempted it.

I spoke to an ex-colleague of mine yesterday. She has been crushed by not being able to work properly for months – she was caught in the government’s last-minute 14-day self-isolation restriction placed on travellers returning from Spain. She was saying that she had similarly had her enthusiasm dampened since moving to the UK. Spanish restrictions and regulations surrounding dentistry are few, and she finds the guidelines and regulations in the UK stifle her innovation. And before you say, you’ll have to forgive her, she’s from Barcelona (she is), she has a master’s degree in restorative dentistry and I once watched spellbound one afternoon when she did six composite veneers on someone with tetracycline staining. You couldn’t tell they weren’t natural teeth without loupes.

And don’t get me started on patients. Patient expectations rose to insurmountable heights over the last decade and I have little doubt that the images of aesthetic perfection presented by social media influencers combined with the implanted idea that you could get big payouts if your dentist didn’t deliver the goods, has put dentists and dental professionals in an almost impossible position.

And with the whole coronavirus business, I’m amazed colleagues can currently muster the enthusiasm to get up in the morning. Thankfully, they do.

The weather is nice today. I’ve been charged with the task of weeding the patio.

Now where DID I put that enthusiasm?