Onwards at the forefront of continuing education

For time and the world do not stand still. Change is the law of life. And for those who only look to the past or present are certain to miss the future.

John F Kennedy, 1963

I used the above title for my first editorial in May 1996,¹ and it seems appropriate to use it again, becaue this is my final Comment, but the ethos of Dental Update remains the same. As I wrote in 1996, that ‘Dental Update will continue to strive to produce material of interest and relevance to clinical practice’, reflecting what was written in the journal's first editorial in 1973,² namely, that the content would be ‘grounded in the realities of the daily work of the dental practitioner’.

Being editor of any journal is a privilege, given that an editor is the first person to pass ‘judgement’ on the work that authors have spent a lot of time writing, and often feel very close to. Deciding to reject a paper that has been submitted is therefore a decision that should not be taken lightly, but, part of the job of an editor is to be aware of what his/her subscribers might wish to read in their journal and, hence, it is necessary to sometimes make difficult decisions, even if those are unpalatable (no pun intended!) to the author(s).

Given that Dental Update is ‘a clinicians’ journal, written by clinicians for clinicians', a phrase that I have used often, it is therefore essential that the editor is clinically active and abreast of current clinical developments: hence, I made a deal with myself some time ago, that the honourable thing to do was to leave the Editorial Director position when I was not so involved at the ‘tooth face’ as in the past. I still see patients, but generally only those who request a second opinion about their treatment (often having been told that they need an implant when they do not – there is no rule that says that every lost tooth should be replaced!) or those who have suffered tooth damage in an accident and who need a report on their injuries, and how much it will cost to put things right. Another factor is that social media seems to have become central to life, and it has been suggested that the Editorial Director be more active on that: I have no plans to be on X every day! Last reason, the 50th Anniversary issue, published almost a year ago, was, in my view, the high point of my publishing career, given that it provided a history of the various disciplines in dentistry and took a look towards the future, a true reference text to be kept by readers. I therefore see the 50th Anniversary issue in similar vein as Stuart Broad's haul of wickets in his final Test – namely, can it be bettered? Perhaps by the 60th anniversary issue, but I will not be involved in dentistry when that time comes!

Regrets, I have a few, but then, not too few to mention (adapted, with credit to ‘My Way’, lyrics by Paul Anka). What are those? First, although this is a clinical journal, I have occasionally digressed, as did my predecessor Ted Renson,³ into dental politics, although that is much better left to excellent commentators, such as Kevin Lewis, a co-author in this issue, who always has his finger on the pulse of dental political affairs. My comments have mainly been related to the so-called ‘New Dental Contract’ of 2006, which, at that time, introduced the UK dental profession to a nonsensical method of payment called Units of Dental Activity (UDAs). Why nonsensical? Payment was the same for one restoration as it was for 10! I railed against this before it was implemented (writing a Comment titled ‘Dawn or disaster’), because this would not be tolerated in any other walk of life.⁴ However, ‘disaster’ is now facing NHS dentistry, with its diminishing workforce, with ministers expressing surprise when dentists decide, almost 20 years on, that this is not a civilised and/or honest method of remuneration. Now, the final demise of NHS dentistry is being discussed in the media, with the worsening problems in accessing a dentist, the funding squeeze, and other factors creating a widespread crisis. The Health and Social Care Select Committee has called for fundamental reform to end the crisis of access, and the government promised a Dental Recovery Plan, which, at the time of writing, has just been released. Whether the offer of £20k to set up an NHS practice in a rural area, a slightly increased UDA value for some, or an additional payment for taking on patients who have not had a ‘check-up for years’ will reverse the trend out of the NHS remains to be seen. I remain of the view that it is UDAs that are the main bugbear, and as mentioned in the recent report from the Nuffield Trust,⁵ ‘UDAs were envisaged at the time as a short-term transitional arrangement towards contracting arrangements which would fully promote and incentivise preventative care, maintenance and continuity alongside necessary treatment’. However, the transition didn't come about, and UDAs have disincentivised NHS dentists. Now, dentists will need to be incentivised and funded to deliver additional activity to increase access and reduce the backlog of work, but, as I alluded to recently, it might be too late.

The recently published report from the Nuffield Trust⁵ spells out the perilous state of NHS dentistry. Readers will be aware of many of them: growing difficulties with access to dentistry; poor public perceptions about access and cost; charges growing well above inflation; persistent inequalities in access and outcomes; wide variations in treatment between regions; NHS underspending on dentistry; concerns about the workforce and the availability of NHS dentists; and, lastly, a contract that is unfit for purpose.

Is there a solution? Let me first state that I understand that the Exchequer will wish to retain a cash-limited solution. The problem is surely that they have not had, or provided, sufficient cash. The previous contract reform trials ended suddenly in tears, so, if something new is to be developed, it surely must be evaluated – but not for more than 10 years, as previously. A solution could be to allow NHS dentists to again have a ‘list’ of patients for whom they are responsible, as part of a well-designed capitation scheme. Aha, readers say, that does not allow any room for expanding one's practice, for those who might wish to do so. Therefore, a cash-limited fund would have to be set up to allow (fee-per-item) treatment to be carried out on patients who have expressed a desire to improve their oral health, alongside dentists who were willing to treat such patients. Such dentists would apply for the funding, presumably having met certain criteria, and, having made the patients ‘dentally fit’ (to borrow a phrase from the past), they would enter into the NHS capitation system. The Reference Dental Officer system, or similar, would be revived, in order to guard against supervised neglect. Indeed, in my view, it has been a scandal that since 2006 much public money has been spent on NHS dentistry with not so much as a check to ascertain (a) that the treatment claimed for has been carried out, and (b) to a reasonable standard. I find it hard to believe that in these days of financial probity, this has never been a source of questioning in Parliament. Hopefully, sense will prevail, and a scheme devised. Otherwise, the days of NHS dentistry are seriously numbered.

Another sadness is my failure to influence and/or halt the continuing sacrifice of dental enamel (and, often, dentine also) on the altar of dental cosmetics, with no thought of the survival of the treated tooth (treated is not the right word, butchered sometimes is!) Another commentator who uses words much more eloquently than I, namely, Martin Kelleher, also an author in this issue, has warned of the evils, the damage, caused by wanton destruction of teeth for only one reason, it seems: money. I quoted another great commentator, Gordon Christensen,⁶ some time back when he wrote about ‘Too many crowns’, stating ‘Crowns are considered to be an easy treatment’, and, ‘The revenue produced by crowns is among the highest in dentistry when compared with that produced by other treatments’, and ‘There are numerous more conservative procedures that can be used instead of crowns’. Need I say more?

Alas, while my campaign against tooth destruction for veneers may have borne fruit, Instagram is now awash with evidence of gross tooth destruction for the dubious intent of instant straight white (crowned) teeth. This seems to have led to the rise of so-called ‘Turkey teeth’, where patients who cannot obtain affordable treatment in the UK travel abroad to receive low-cost treatment, later to find that it is not what they expected. On the other hand, it is only recently that a warning was published showing that the dangers of overtreatment are not confined to dentists abroad, with Koray Feran⁷ showing illustrations of a patient treated in London having a mouthful of unnecessary crowns and having so much pain thereafter that she asked for all her teeth to receive root canal fillings. I have also seen such gross overtreatment at first hand in Birmingham.

What can be done to halt this drift away from professional behaviours to that of the money-grabbing salesman, i.e. outright commercialism? But, patients are patients, and some seemingly can be led to believe that a mouthful of white ceramic is much better than a mouthful of enamel and dentine. Martin Kelleher8 has termed this ‘porcelain ‘ornography’! More of that, and the profession will be back with the barbers, from whence the Royal Colleges were derived.

In the same vein, recent reports of the American rapper, singer, songwriter, record producer, and fashion designer, Ye (previously known as Kanye West) reportedly spending US$850,000 on shapeless titanium upper ‘teeth’ (the inverted commas are mine because they look nothing like teeth), to add to the diamond encrusted lower teeth that he received some years back. Worse still is the report that he designed the tooth structure himself. More worrying still is that, as an influencer, others will be hoodwinked into having similar treatment, but not at such great expense, since, given that Ye is estimated to be worth around US$400 million, the US$850,000 is a drop in his ocean. Questions must be asked, did a dentist actually carry out the treatment, and, if so, had he missed the seminars on dental ethics at dental school? According to media reports, Kanye's new ’denture’ was fitted by one Dr Thomas Connelly in Beverly Hills, alongside Naoki Hayashi, a Master Dental Technician. The question is – had Ye taken lessons in emergence profile before designing his own ‘teeth’? And, is the Commission on Dental Accreditation (CODA) seeking to interview Dr Connelly, given that they hold the registration of dentists in the US, in the same way as the General Dental Council do in the UK? Hopefully the sensible readers of Dental Update will resist the dollars or pounds offered by unknowing patients who do not value their own enamel and dentine. Hopefully they are also all aware of the ‘daughter test’, the essence of which is ‘would you carry out this treatment for your daughter’, and, if not, seek an alternative solution.⁹

Sir Nairn Wilson,¹⁰ in his well-documented history of Dental Update in the 50th anniversary issue, mentioned the themes upon which I have touched in my previous 260 (or thereabouts!) Comments, but there are a few quotations that I have used, which perhaps bear repetition. Don't ask me how I thought of writing about Pythagoras,¹¹ but I did! His theory for life was:

‘Consider your works of the day, where did I go, where did I not go, what did I do or not do that I should have done.’

The application of this to our daily lives is that it is easy to succumb to the pressures of running a busy list and take a short cut that will produce a restoration that will suffice as the patient leaves the surgery, but whose longevity might be compromised. The reflective practitioner, on considering such a situation, will take steps to avoid its recurrence. And, writing about the necessity of using peer-reviewed journals (such as Dental Update) to find the evidence upon which we plan our patients' treatment, I quoted Charles Dickens (1812–1870) (Hard times)¹²:

‘Facts alone are wanted in life. Plant nothing else, and root out everything else. Stick to facts!’

Finally, thanks to all authors who have sent their work for consideration for publication in Dental Update and who have graciously put up with my comments, reviewers' comments, requests for changes to articles, etc. Thanks are also due to the superb Editorial Board for their wise guidance: Edwina Kidd, who was on the Editorial Board when I arrived as Editorial Director and still gives us the benefit of her views, deserves a mention. Most of all, thanks to Dental Update's readers. Finally, thanks are also due to the talented team who are responsible for creating, eleven times per year, the attractive publication that we all know and love, Dental Update. Longstanding colleagues in publishing such as Lisa Dunbar, Fiona Creagh, and her predecessor Angela Stroud, and the publisher Stuart Thompson, and, more recently Rob Yates, are among those who deserve mention. Apologies to those who I have not mentioned.

I am delighted to hand over the Editorial Director role to Professor Ewen McColl, a prolific author with a great grasp of contemporary dentistry in the UK and the world at large. He has wide experience in both primary and secondary dental care: I am therefore certain that Ewen has a great awareness of what the readers of Dental Update will expect to read in future issues, and I expect him to inject new ideas that will enable Dental Update to go from strength to strength. An introduction to him follows this Comment.

PS: I will finish with a ps, as I often have done, as new thoughts come into my head! The Editorial Director's job has grown enormously since I took over – more than twice the number of pages per issue, which equates to more than twice the number of articles to be reviewed, checked and checked again. I have therefore agreed to stay on in the background for a time, but will stop when the new Editorial Director has ‘learnt the ropes’, which hopefully will give me the time to learn to speak French properly (albeit with a Northern Ireland accent!) and read music as well as I did when I was 12 years old!