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Mathew Parris is usually some one you can rely on for sensible comment but on this occasion (Saturday’s edition of The Times 16.07.2011) he is guilty of rehashing a disappointingly familiar misconception of dentistry. In his article “The Next 20 Scandals” Mathew states -
Dentistry and the NHS are a murky business where the service and private practice appear to live in a baffling symbiosis on which dentists thrive and for which patients, both paying and would-be NHS users, choose between the queue and financial ruin. Dentistry should be like car repair: it’s only teeth, for God’s sake. Where’s the market?
This statements contains all you need to know about a lot of peoples feelings about dentists and dentistry but it really does not stand any degree of scrutiny.
1) “a baffling symbiosis”. The symbiosis between private and NHS is not in the least bit baffling. You either pay privately or you pay for NHS (unless you are exempt NHS charges). This is hardly baffling. Dentists are required to explain their fees before treatment begins and must indicate if work is being provided on a private or NHS basis. If they fail to do this it is not a fault with the system, more a fault with the dentist.
2)”On which dentists thrive“. Maybe its me being paranoid but the implication seems to be that dentists thriving is a bad thing. If it is a bad thing then lets look at a world where dentists don’t thrive- a world where they employ less people, generate less taxable revenue, invest less in training and technology, reduce the time and money invested in improving services for patients, spend less time on treatments to help them boost falling revenues, take fewer risks in expanding their businesses, leave the profession for alternative employment, give less freely of the time for teaching of students and their peers- is this really a better world?
3)”Choose between the queue and financial ruin“- really is that the only two choices out there. Are none of us offering staged treatment plans, payment options, prevention advice to lower disease activity, mixed practices to try and offer all service levels?
4) “dentistry should be like car repair” – what we after here- grubby surroundings, wildly unrealistic estimates, unlicensed premises with no regulator bodies, no compulsory post graduate training (no undergraduate training for that matter)? Would our patients be happy with no comfortable relaxing waiting areas, no highly trained and efficient reception teams, written treatment plans and estimates derived from careful discussion of their needs? Would they really prefer us to take one look inside their mouths, do the ubiquitous sharp intake of breath and say the immortal words “it’s gonna cost ya”?
5) “it’s only teeth for gods sake” Perhaps the most telling comment of the lot and certainly the saddest. How an intelligent and educated man such as Mathew Parris can give voice to this view is beyond me. They are only teeth until they go wrong- then they are a source of pain, infection (potentially fatal), misery, social embarrassment, childhood teasing and bullying. Oral health and general health are intimately linked and the treatments are carried on people who often have complex medical and psychological concerns that need our expertise and understanding. We help people with these problems on a daily basis and are happy to do it. No one with tooth ache will tell you they are just teeth; no one who struggles socially and is desperately unhappy with their smile will say they are only teeth; no one who’s child has fallen of a bike and smashed their front teeth will say-don’t worry they’re only teeth.
6) “where’s the market”- Our market is the entire population who need our help, advice, treatment and care throughout their entire lives.
The saddest thing of all is that Mathew is right, there is a scandal coming but it is not the one he alludes to. You can take your pick from the effects of an ever increasing burden from unnecessary and restrictive bureaucracy (do MPs really need to discuss whether people should be allowed to have whiter teeth) , the continuing chaos in the General Dental Council (the fitness to practice panels struggling to cope) , the massive cuts in hospital based dentistry( multiple unit closures and reductions in consultant posts in London alone), the spiraling costs of providing care, the exponential increase in litigation fueled by “no win;no fee” lawyers……etc. I doubt these will be given much voice in the press as these require a more sympathetic view of dentists and their teams but these are the ones that will really shape the future for dentists and their patients. Lets start discussing these now, before it’s too late.
Every dentist who is lucky enough to stay in the same practice for many years will be able to see their successful cases come back year after year and will enjoy the great sense of satisfaction and continuity that this gives us. It will also give us the opportunity to see our failures and how we respond to this opportunity probably shapes us more as people and clinicians than any other aspect. It is a certainty right up there with death and taxes that we will all have cases that did not respond the way we expected and the question I pose in the title is the one that I apply to each case. Getting an answer is by no means guaranteed and we just have to accept this sometimes.
The case I show here is a good example of what I am talking about. The molar tooth was root filled a year ago and the tooth responded well to treatment initially. The infection that was present cleared up and the symptoms settled; everything looked fine. Then a week ago I get a call saying the swelling is back and the radiograph I took showed that the infection had not gone away, it had merely become sub-acute but had spent the last 12 months getting progressively bigger.
On the face of it this case should have worked. The patient was a young fit healthy adult; the root filling was done under ideal conditions using all modern techniques such as microscopic vision and illumination, ultrasonics, rotary instrumentation, rubber dam and hypochlorite irrigation and the usual 4 canals were all accessed to a full working length. So why didn’t it? Part of the answer lies in the fact that I am assessing the tooth on a 2 dimensional radiograph when of course it is a 3 dimensional shape so there is plenty of scope for missed anatomy. Part of the answer will lie in the types of bacteria involved – their ability to colonize and survive in root canals, their ability to penetrate the walls of the root canals, their virulence factor etc. Part of the answer lies in the patient’s ability to combat infection and part will lie with the skill and experience of the operator (much as we like to overlook this aspect sometimes!).
Modern endodontics offers great success rates and we are able to restore teeth now that would never have been treated when I first qualified in 1989.The real truth is, sadly that sometimes we just don’t know why a case fails and we need to be always conscious of the chance of this when talking to our patients about possible treatment alternatives. Managing expectations, both our own and our patients, is really important and there should never be any promises of success. I pretty much offer only two guarantees with my work – 1) I will try my very best 2) If I take the tooth out, it won’t grow back. Beyond that there must always be some recognition of the risk of unexpected outcome and a pre-agreed Plan B, just in case!
Finish shot 12 months ago
Recent view with GP marker in sinus tract and extensive infection
Root canal fillings continue to give exceptional success and allow us to keep teeth for many years longer than we might have done. We should never be put off treatments because of the occasional disappointments like this but we should use them to make us constantly strive for a better understanding of the treatments which will in turn lead to greater success.
This case is a good example of what I do on a daily basis. The tooth in question is a lower premolar which has suffered extensive decay but is currently not causing any pain. (It should always be remembered by dentists and patients alike that tooth aches is a hopeless early warning system and almost always comes too late. The absence of pain does not = the absence of problems!)
As with every case such as this we have an extensive discussion regarding treatment options which on this occasion would range from trying to restore the tooth through to removing it and either accepting the gap or have a denture, bridge or implant retained crown. When discussing restorative options the phrase I use most is “delay the loss of the tooth for as long as possible”. I am not keen on the phrase “saving the tooth” as this can be seen to imply that it is a once only treatment that then keeps the tooth for life: this is rarely the case. There are never any guarantees in this sort of work only varying degrees of predictability. The predictability of this case is highly dependent on the patients ability to control their decay in the future. It is inevitable that the tooth will be lost at some stage in the future but if we can delay this by several years then this delays all the other treatment options. Dentistry is a one way street so we need to walk our patients down it as slowly as possible!
The technique I used here is a root canal filling and a fibre reinforced direct restoration. I used the SAF system to clean the canal as it was a very wide oval shape that does not lend it self to cleaning with conventional rotary instruments. I then used the everStick posts from StickTech which are placed directly and adapted to the shape of the canal. It is the case of the “Self Adapting File” meets the “Self Adapting Post”
This is a single visit procedure and one that is completed without any discomfort for the patient.
Decay under old filling
decay seen from another angle
Root filling and core in place
Restoration in place
If you would like to know if we can help you keep your teeth for longer then please do not hesitate to give us a call on 01580 752202 and we will be happy to help