Salutary lessons

Readers will note that this issue of Dental Update contains three articles which deviate to some degree from the normal clinical fare that is Dental Update, but, on reflection, they don't, insofar as the papers discussing the so-called Francis Report are central to UK's clinicians' understanding of how they should treat patients. The articles will also provide a legal backdrop to all that we do in our practices.

The statement attributed to Florence Nightingale may readily be adapted to the dental surgery and recent issues of Dental Update contain salutary lessons for dental professionals. For example, in the early days of dental implants, there was widespread expectation that these would provide long-lasting treatment solutions, with 100% success rates. We now know that this is a long way from the truth, with the work of Simonis and colleagues indicating that 65% of implants (with their associated crowns) survive for 16 years, 1 perhaps a salutary lesson in the dental field. In addition, the term peri-implant disease has only come into dental speak in recent years, with the article by Warreth and colleagues in the last issue providing an in-depth review of this problem2 and indicating that, in some studies, 40% of implants were affected. The lesson is obvious – in most circumstances, keep teeth going for as long as possible!

Salutary lessons arrive from time to time. The restoration for toothwear that failed (unexpectedly) when I thought that I had done everything right, but had obviously not examined the extreme lateral occlusal excursions, the resin-retained bridge in which I had not achieved sufficient resistance form to protect the bond. We work in a difficult environment, with saliva and blood as potential contaminants, and patients who don't really want to be in our chairs. However, it is how we deal with the failures, and learn from the salutary lessons (to do more thorough occlusal analysis and a wrap around preparation for the resin retainers in the cases that I mentioned above), that matters. That is what the Francis Reports are all about. How we deal with the gangster treatments in which a vast amount of sound tooth substance is destroyed in the name of appearance is a different matter, given that the clinician who is carrying out such treatment (it is still going on – I saw a case yesterday!) has a total lack of insight and has probably never heard of the Francis Report.

I recently read a book entitled Complications – A Surgeon's Notes on an Imperfect Science.³ In this, the author, Atul Gawande, describes a variety of mis-diagnoses and failed operations. What is particularly relevant to us is the M&M (the Morbidity and Mortality Conference), which takes place, once per week, in the hospital in which he is a surgeon. All surgeons are expected to attend this meeting, which is held behind closed doors. In it, the mistakes, untoward events and deaths that have occurred over the week are reviewed and discussions follow regarding what to do differently next time, with ‘nothing’ being an unacceptable answer. Of course, some of the presentations are awkward. The author adds that ‘unlike the courts or the media, human error is not something that can be deterred by punishment’. In one's practice, for M&M, substitute the practice meeting, in which the good points and bad points of how patients' clinical problems and/or complaints have been dealt with, noting the lessons and auditing whether changes or improvements have been instituted. However, for the provider of the gangster treatment, punishment might, alas, be the only option.

I am sure that readers, having read the articles on the Francis Report, will see their relevance to the dental surgery. Another three short articles on the subject will follow in the next issue.