There are still dentists and dental care professionals who haven’t returned to work after dentistry resumed in a limited way during the summer. Those dental professionals who have still had no patient contact for months are concerned about the return to work and the change in circumstances in practice. I interviewed one such practitioner.

My Own Long Break From Dentistry

I can only imagine what it’s like working in dental practice at the moment. As somebody who would prefer to just squint rather than let my nurse try to find the orange table-tennis bat to shield my eyes during a composite light-curing, I think I would find adhering to stringent Standard Operating Procedures incredibly irksome and dispiriting.

As someone who rarely hit my UDA target because I worked at the speed of a slug on diazepam, I think even I would baulk at the impediment presented by hour-long fallow times. The other day, I spoke with an NHS colleague working at my old corporate. The corporate hasn’t yet thought of investing in air-exchange units and is still relying on good old sash windows to drag the coronavirus out the surgery and into the faces of compromised pensioners walking down the High Street to get to JD Sports. The corporate is working on one hour fallow times, with no prospect of a reduction in the near future, unless someone rewrites Einstein’s theory of time and relativity in the next couple of weeks.

Occasionally since I’ve retired, I’ve thought about how it might be ‘nice’ to return to dentistry for one or two days a week in a relaxed little private practice, maybe concentrating on providing full dentures. Then the drugs wear off and I question my own sanity, remembering the stark reality of my dental life – mainly that I hated every single second of it, save two years - from roughly my first fortnight in practice, to the day I retired.

I know that sounds bad, but as they say on Facebook, my relationship with dentistry was ‘complicated.’

Having been an 11-plus failure (the 11-plus was a thing we old folk had to go through in order to earn a place at a school where they actually taught you stuff), I had a bit of a fight getting to dental school. Firstly I had to take my ‘A’ levels at evening classes while working full-time and then I had a bit of a battle getting a place since I was considered a bit long in the tooth to be applying for an undergraduate degree at the age of 29. Finally, I was accepted, and the rest is mediaeval history.

So even though I hated it, I couldn’t walk away from dentistry. I’d invested a lot of years and sweat in achieving my degree and no one was going to take it away.

Not even the GDC, or a potentially life-altering illness could drag dentistry away from me.

It was 1992 and I was in the middle of my dream job, four years after qualification. The two dentists who had inspired me to go into dentistry in the first place, finally offered me an associateship after years of subtle hinting. It was perfect. The practice was a massive, luxurious open-plan affair, where you had colleagues working just the other side of partition screens. There was a feeling of safety. You knew that just over the lead-lined partition, your colleague was having as bad a time as you were. I drew a lot of comfort from that. Had the practice still been going in that format, I doubt it would have passed CQC requirements on confidentiality and GDPR, but back then, it was pure paradise. My spell of two years at this practice gave me something approaching dental ‘happiness,’ though I don’t know quite if the ‘happiness’ was the real thing or an illusion.

The other reason I loved this practice was that there wasn’t a massive commute for me to endure every day. Prior to the landing of this job, I was travelling between 60 to 80 miles a day in order to get to the three practices I was working at, part-time. At that time, my late wife and I lived just three miles away from the practice. I thought it would be a great idea to get fit by cycling to work in the mornings. I bought an old black bone-shaker and started happily peddling down the country lanes into the edge of the city where the practice was located.

One morning, I struggled to get on the bike. The bar across the frame was for some reason suddenly in the wrong position and I had to lie the bike on the ground, put my leg over the prostrate frame and then haul the cycle up underneath me. I should have abandoned the idea of cycling there and then and took the car. Mercifully, for the sake of the other road users and innocent pedestrians in the county, I persevered and cycled off, very wobbily it has to be said.

I fell off my bike twice on the way into work, but it didn’t bother me in the slightest. I felt fantastic and found the falls hysterically funny.

Somehow, I weaved my way through the edge-of-city traffic and made it into the practice. I can’t remember where I dumped my bike and I have to admit, I don’t remember ever seeing it again. I greeted colleagues a cheery good morning and made my way to my open-plan…’unit’ I suppose you would call it. It wasn’t actually a surgery.

My first patient came in for treatment but before I could actually do anything dangerous, my two bosses appeared by my side. The senior partner gently took the turbine out of my hand and said something like “Not today, I think.”

I hadn’t realised that my switched-on nurse had noticed I was acting really weirdly (I wasn’t aware of that) and had phoned down to the partners. I was physically escorted to the office (I could neither stand up or walk straight) and within an hour was in the city hospital’s A&E department, being scanned for signs of a stroke.

It was only many weeks later that I realised that I hadn’t been functioning properly for a couple of weeks. I had been getting profound memory lapses for a few days prior to the cycle-ride and to this day I can’t remember the ambulance ride to the hospital. Similarly, I couldn’t remember treating a good friend of mine in practice, the previous day. She was apparently, unharmed.

A Worse Diagnosis Than Irreversible Pulpitis

Long story short, after two days in hospital, having blood tests, speech tests, lumbar punctures and EEG’s, it was concluded that I had multiple sclerosis, especially since I appeared to be experiencing euphoria – one of the classic signs of MS. I was immediately put on IV drips of 500mg prednisolone and I DO remember rather an embarrassing conversation with the consultant physician, who told me he was 95% sure of his diagnosis and then advised me that when I was discharged from hospital, I should see my GP to discuss whether I could even carry on working as a dentist and discuss the inevitable urinary incontinence I was due to develop soon. All the time I was getting this bad news, my only thoughts were of getting back to the practice.

 

 

By the end of a week or so in hospital, I was feeling much better. Well I say ‘better.’ I actually felt brilliant with the euphoria and so getting ‘better’ was a massive disappointment.

The only other test the physician wanted was an MRI scan, the gold standard test for MS. This was due to be done at an outpatient appointment in at the John Radcliffe Hospital, Oxford, some six weeks down the line and two counties away. In the early nineties, MRI scanners were not that plentiful and it seemed an awful long time to wait. The consultant was reassuring though. He was supremely confident I had MS since my cerebrospinal fluid showed much elevated IgG antibodies and my EEG was “very sluggish.”

When I was discharged, I wasn’t allowed to go back to work by my GP until I had the MRI scan and so, since I was constantly fretting about how quickly I could get back to work, I battered away at the Oxford hospital till I managed to get a cancellation appointment.

Before I got the scan results, I was back in hospital, with exactly the same symptoms that had put me there in the first place, but this time my stay was for longer. After a day or so in hospital, I was given the result of the MRI scan, which was it was ‘inconclusive.’ There were hints of plaques on my spinal cord, but there was nothing outrageous. I ended up with another lumbar puncture and EEG and both showed the same results – raised IgG antibodies and an EEG tracing which looked like the bottom of the Atlantic Ocean.

This time it was decided to let me go after two weeks, with a differential diagnosis of what is now called CIS (Clinically Isolated Syndrome) – a single episode of demyelination, OR encephalitis. I was so desperate to get back to work that I tried to discharge myself from hospital. I was only allowed to leave provided I promised to go for a psychometric assessment at the local psychiatric hospital since my memory and language skills had declined somewhat. Eventually, I was sent to an organisation called Headway, which supports people with head injuries.

 

 

Eventually it was decided that rather than multiple sclerosis, I had now either developed ME as a result of encephalitis, or I had ME all along. The only thing that ruled out ME was that my clinical investigations and results were suggestive of MS. Again, long story short, I have had a long-term problem with over-exertion. If I ever had to stand up to do treatment on a patient who wouldn’t lie back, after half an hour I was fit for nothing, even up to the point I retired only 20 months ago.

Now although I was raring to go back to work, I started to become extremely anxious about it. By the time the above had all occurred, I had been off a couple of months and I hadn’t had any patient contact at all in that time, except with the bloke in the bed next door who attempted to play the Trumpet Voluntary on his anal sphincter every morning at 5.30am.

So I was extremely anxious about my return to work, despite my desperation to – frankly – earn some money. I still had loans to pay off from my student days. I wasn’t even sure if I would remember what to do after all that time off. This was a real anxiety since I had experienced memory problems before and since the hospital episodes. It was only roughly eight weeks from the time of my first hospitalisation, but it seemed an eternity and despite my eagerness to get back to work, I didn’t know, deep down, whether I was actually up to it. It was a real worry that in view of the short-term memory lapses, I might have actually forgotten much of how to do dentistry. I eventually did return to work initially part-time and within a couple of weeks was back to normal (although slow) working. The rest, is Physical Geography.

 

Shaun’s Tale 

The reason that whole episode came back to me this week, was after a message chat with a good friend who is still not back working as a dental therapist in the community dental service and is still redeployed within the NHS. Over the months since the initial dental shutdown, he has been a medical supplies delivery driver, delivering medical stores and pharmaceutical items to remote health centres and has also delivered and collected self-test COVID-19 kits and then despatched them to laboratories for testing. He was also redeployed into directly assisting in an NHS COVID Assessment centre before entering his current temporary post, an administrative position in which he is responsible for the acute and social care PPE procurement and supply administration and distribution of PPE for NHS Scotland in Shetland.

I’ve known Shaun for a few years now, and am constantly in awe of his knowledge and enthusiasm for dental education. Shaun qualified as a hygienist while in the army and relatively recently gained a BSc in Oral Health Sciences to qualify as a dental therapist, in 2018. A former Grenadier Guard, Shaun served in Germany, Canada, the Falkland Islands, Belize and saw action in both Iraq and Kuwait in 2003 as a reservist. On leaving the military, he worked in private practice, specialist practice and the NHS. Shaun also sat on the GDC fitness to Practice committees for 5 years and even worked in a corporate. Shaun has in the past been a fierce and outspoken critic of the corporates. Of the corporates, he says “They certainly have a place but they are relentless in their pursuit of profit. The demands placed on clinicians is unsustainable and probably explains the extremely high turnover of staff.”

So if there’s one thing you can definitely say about Shaun in the light of the above - he is no wimp.

 

I was therefore surprised when Shaun told me the other day “I'm close to not wanting to go back.”

Before the dental shutdown, Shaun worked as a therapist in the Community Dental Service for NHS Scotland. He said “I last picked up an air rotor on the 18th March 2020. Some put theirs down sooner, some later, but that was my last clinical day. Whilst I have been involved in dentistry since 1991 and have taken breaks from clinical practise for prolonged periods for various reasons over the years, this time it feels very different.” He added “I am genuinely struggling with the thought of returning to practise.”

 

“I was a little confused when the shutdown of dental services first happened, and remain somewhat perplexed. This whole saga is full of fear for many, that some of us don't feel” said Shaun. “I honestly believe there was some ridiculous un-evidenced scaremongering early in this pandemic. Of all the groups that should have shown a spike in cases (dental hygienists and dental therapists), we never did. There were obviously some, it would be churlish to suggests there were not, and indeed, I have a friend who has suffered and continues to suffer. We were working, creating aerosols that Banksy would be proud of yet there was no spike. It would be very difficult for my friend to prove it was work that caused her illness given she travelled regularly on public transport in London.” He added “The pandemic has affected individuals in many different ways and I wholly sympathise with those who are living in fear of this novel virus. Other individuals are ambivalent about it.”

“This is a personal thing and I understand why people are scared. I think it was sensible to shut down to assess, but for me personally, I realised that we (dentistry) did things well and extremely safely and I felt no threat from COVID-19.”

Shaun raised an interesting point that he had considered during his enforced dental break. It’s something I had thought of occasionally over the years, but to my shame, had never really explored with female colleagues. How do female dental colleagues cope when they return to work after taking maternity leave?

Shaun said “I am genuinely struggling with the thought of returning to practise. I don’t know how long it will be before I return, but I feel I can now start to empathise with many of my colleagues who are forced into prolonged breaks due to illness, or indeed, to start families. I work in a female dominated profession and it’s therefore quite easy to be blasé about colleagues having time off to have children and not consider the problems of readjustment they face on their return to practise.”

“It probably sounds a bit melodramatic to say that I'm sympathising with my female colleagues who go away to have children, but I’ve personally found an enforced prolonged break from dentistry really hard to get my head around. I am trying to think of whether I can approach the needs of patients the in the same way that I used to. Can I meet those challenges that patients present day in and day out, now that I’m out of practice?”

“For the past seven months I've been in a sedentary, relatively easy role compared to what I'm used to. I'm not face-to-face with patients, parents or carers anymore. Instead, I'm currently interacting with people who think along the same lines as me - dealing with procurement and finance specialists. On the whole, my current work life is much easier to deal with.”   He added “I have no idea how I will face clinical practice again.”

Shaun considers a fundamental question. “Do I miss clinical practise? I am not sure I do. The inherent stresses of modern dentistry with the additional stresses caused by the pandemic on practise are not something I relish the thought of.”

Shaun wonders whether practitioners in a similar position need some support.

“Maybe policymakers and those that lead it should think ahead and start looking at mechanisms and support pathways for all practitioners in order to cope with returning to such a changed dental environment caused by the pandemic. I also think it's really important that the longer term picture is looked at. As much as anything, this is for the benefit of my colleagues who go and have breaks. I think it is essential that they   are really supported in a meaningful way when coming back into practice.”

“It doesn't surprise me that some individuals have a short working life in dentistry. When you've had a break and you come back work, it’s a really struggle. It's OK when you're all fired up but it's the motivation to get fired up which can be quite hard to find. That's my view. I don't know whether it's the wrong view, but it's where I'm at and I can imagine that there are many who are in a similar situation. I fully understand that and my heart goes out to you and I'm with you all the way.

I can really identify with the predicament of practitioners like Shaun. After my own enforced break, I was extremely anxious at the prospect of going back to work, although I wanted to. How would it be different when I went back was my main worry. Although there had been no radical changes in practice in the couple of months or so that I had been off, I had changed. The idea of going from my situation into the post-pandemic world would have frankly, would have completely freaked me out.

I know Shaun is not alone in considering the difficulties that lie in a return to work after such a long layoff.

A friend and ex-colleague, one of the most enthusiastic dentists I have ever known, was extremely anxious about the return to work. As the only working practitioner in her practice, after two locum associates suddenly became symptomatic when the new COVID dental protocols were announced, she had to manage the bulk of triaging duties in the practice and suffered a great amount of verbal abuse from patients not satisfied with the assessment, analgesic and antibiotic protocols demanded by the local urgent dental referral centres. She felt she wouldn’t be able to face many of the patients again.

I actually know of a dental hygienist who has left a part-time practice, instead of returning to practice, preferring to work from home for the NHS Track and Trace service.

Similarly, another dentist friend of mine has left her full-time job in practice to work in the Community Dental Service, part-time. Although it means a salary drop, she feels more relaxed and plans on supplementing her income with providing soft-tissue facial aesthetic treatments. I say ‘relaxed.’ She seems deliriously happy.

In September, registration figures released by the GDC showed there was a significant rise in the number of Dental Care Professionals who had not renewed their registrations, compared to 2019. There was some speculation that the rise was in the main due to the failure of the GDC to implement a payment by instalment scheme, but there may be other reasons.

 

 

Dental therapist David Bridges highlighted his theory on the increase in de-registrations on Twitter in response to Lori MacGregor, a non-dental advocate for the profession since the beginning of the pandemic. Dave’s view seems to have some anecdotal weight attached to it after my discussions with Shaun and ex-colleagues.

It will be interesting to see the GDC registration figures for dentists in February of March 2021. I think Dave’s theory has legs. Would I go back to practice now, after a seven-month layoff? Extremely unlikely. I take my hat off to those who do.