This is the way

By Members

This newsletter is aimed at the younger spectrum of my readership, although it might have some insight for any and everyone.  However, if you are one of those who becomes angry when you feel your view on the world is threatened, perhaps don’t read it.

So let’s get my inane and flawed thoughts out there

Did you know that you are being conned?  Society gives you several paths that you are supposed to follow.  By not following that path, your society tells you that you are somehow flawed, broken and possibly even dangerous.

Here is one such the path:

  • Get good grades
  • Go to university
  • Get a good degree
  • Join one of the professions
  • Work long hours and work your way up through the hierarchy
  • Year on year take on more responsibility so you can earn more
  • At some point, you should get married and settle down
  • You should buy a house and get a nice car
  • Perhaps have children so that they can be put in a nice school (and repeat the cycle)
  • You should buy nice things because you are worth it
  • Perhaps invest in the stock market in your ISA
  • Retire and live off the fruits of your labour.

Well let’s look at some of those points shall we because that’s A path not THE path:

  • If you go to university you will be saddled with a significant amount of debt that you will be paying off when you are at the beginning of your earning phase
  • What is your university degree in?  Obviously most of those reading this are dentists, but you may have noticed that the days when dentists could make vast sums just by being dentists are over.  It’s possible, but the silly money is now only for the top 10% at best.  So huge wealth shouldn’t be expected in this career although it is still attainable.
  • The professions used to be respected and looked up to.  That is no longer the case, many of them being vilified.  Even our medical friends are suffering in this regard, and most of them are abused by the state as well.
  • Ah yes, the hierarchy.  FD, to associate to partner/practice owner.  When I did it, it seemed to make sense.  I’m not so sure now, not with the prices being asked for practices.
  • I’ll not mention the divorce rate
  • Buying a house eh?  Again, the affordability of housing is an issue for many.  And the bigger the house, the more issues can arise.  I mean, how many rooms do you need.  You can only occupy one at a time.  And I know, you need somewhere to put all your stuff…but why do you need so much stuff?  You keep upgrading your box to a bigger box so that you can have more boxes to keep your boxes in.
  • And don’t start me off on cars.  Now I know, there are some of you who can make cars work as an investment.  But for most of us, we get the flash car with money that we don’t really have, often to try and impress people we don’t even know.  And then you find someone kes it in Waitrose car park.  The tyres cost more than some people pay in rent.
  • The nice things you buy do not bring you happiness.  They deliver a brief endorphin rush, which then needs to be topped up by more stuff.  Thus you end up in a never-ending spiral of consumption that forces you to earn earn earn so you can spend spend spend.

Society is designed to keep you trapped and cash poor.  The cost of doing business increases each year, which means you need to earn more to keep yourself at the same level.  at the same time the threats to your income increase through things like litigation, the GDC and ineffective social health care forcing you down the road of private health insurance.    It’s almost as if things were designed like this.

Back in the old fee per item days, we called this the treadmill.  For many, the treadmill still exists, and I know dentists who make almost obscene amounts of money compared to the average, and yet they have to keep that income churning because the cost of their lifestyle is very high.  One major illness, one GDC hearing, one broken limb, and they will be in severe trouble.

They are doing dentistry to service their lifestyle, which means they end up working more than they want to.  If you break the cycle where your expenses rise to meet your income, you find you have money left over which can then be invested.  These investments then start to bring a return which means you can earn less and less to cover your overheads.  Once you passive income covers your day to day living, you find yourself working because you want to, not because you have to.

Then you are free.

It’s easier to do this if you start early, so that compound interest works in your favour.

3.5 days a week.  That’s the optimum workweek for dentists according to the Pankey Institute.  Just think of all the other things you could do if you weren’t fetling around in someone’s mouth 6 days a week.

As the Mandalorian would say, “This is the Way” :)



My thoughts on profitable dental practice

By Members

I hear it can be difficult to make a decent profit in dentistry these days.  When I talk to the few dental accountants I know, they all tell me that some practices are struggling, that dentists are having problems making their UDA’s and that practice expenses keep rising.

I keep hearing the same from dentists, more and more of the owners I know now selling up.

Then I look back to my own experiences and I find I don’t totally understand why this is (don’t get me wrong, I fully understand why nobody would want to own a practice anymore).  It’s probably because I’m biased in how practices should be run based on how I ran mine before I sold it.

This is what I keep hearing:

  • A lot of dentists spend too much money.  They often have cupboards full of gadgets that they never use.
  • They spend hundreds of pounds on courses and never implement what they learn.
  • They muddle through the patient consultation without having a proper system for communication.
  • Their personal expenses are often ego-driven rather than reality-based.
  • They consistently don’t put enough aside for tax


There’s a reason I was able to retire from chairside dentistry at 45.  I’m not suggesting this, by the way, I’m just saying it’s a better option to be in.  Being in the position to work because you want to, not because you have to has a degree of power behind it.

There was also a certain amount of good fortune to it.  I was able to buy my practice relatively cheap and sell it at the top of the market.  I worked in Chesterfield which meant I had low overheads compared to ridiculous places like London.  I was able to work with a UDA value better than most which meant I could do dentistry without having to worry about the udder games many dentists feel they are forced to play.

But those weren’t the main reason.   My ability to retire, I believe, came from the systematisation of my practice and my ability to keep my living expenses under control.  With regards to the former, I wrote flexible systems for the most common situations that kept arising.  Where possible, this allowed staff to deal with any issues without bothering me.  When people aren’t given guidance, they do their best with the resources they have.

Without systems, even the best staff end up winging it or bothering you when you are trying to find that difficult MB2.  Most practices have policies and procedures, but these invariably don’t cover things in a systematic approach.  And let’s be honest, most of this just ends up in a folder unread and ignored until the CQC come round.

It’s good practice to have a policy for whistleblowing for example.  But do you have a system for how to answer the phone, or to control the patient journey through the practice?  Do you have a system for how to get new referrals from existing patients or for what to do when the compressor breaks down?

Do you want a good example of a system?

Ask yourself what you would do in a medical emergency.  You would follow a step by step approach that determines what the emergency is and how you deal with it.


Wouldn’t it be better if you could just get on to do the dentistry?

And I will give you a tip.  If you want a fully systemised practice (which can even include setting out how dental procedures should be done so patients have consistent care from dentists within a practice) always involve your staff.  They need to be on board with the development and the reasons for the systems.  Otherwise, the systems will be ignored.


Now you could spend several weeks in front of a computer doing this.

Or you could give yourself a head start –


Just a thought


Are you worrying about the wrong thing?

By Members

Are you a bit of a ranter?

Do you go on Social Media and vent your spleen about the state of the

  1. Country
  2. Politics
  3. Dental education
  4. The price of fish
  5. Global warming
  6. [Insert random horror]

How does doing that make you feel?  Is your life improved by that?

Let me put it another way.  The thing you are obsessing about, watching youtube videos regarding and formulating opinions that often do not concur with your peers….have you any hope in hell of making any kind of change or impact in that thing that annoys you so much?

Take a deep breath now…

If you can’t change it, why are you bothering?  Why are you spending your life’s energy and producing cortisol for something that will carry on regardless?

Don’t get me wrong.  If you think you can have an impact, make an actual difference, then go for it.  But if you are like most of us in that you are just having a bit of a moan…what’s the point?  Can you perhaps even be harming yourself?  Can you be creating stress that is adding to your overall burden?

Some of you have noticed I don’t post as much as I used to on Social Media.  And there’s a reason for that… it all comes into this “staying off mobile devices” and distressing yourself craze that hasn’t started yet ;)

Unfollow the ranters on Twitter and Facebook, stop venturing down the YouTube black hole of doom and put yourself aside from all the useless opinions the Mainstream media are shoving down your throat.

As an example…Does it have any impact, on your life, that Trump said something bad on Twitter?  Would he care, one jot, that you protested about his last visit?  Could it be that he even enjoyed being the centre of so much attention?

Just something to think about.  But remember Social Media isn’t FREE, because at the end of the day, you the user are the product.



Life is so hard…

By Members

Here follows more ramblings from my biased and possibly unhinged mind.  These are my opinions, they might be flawed and they might be wrong, so remember that if you feel the hate begin to flow.

There was recently a discussion on the facebook group “The Dentist” talking about how new graduates don’t seem to have any experience compared to the older generation.  Within that discussion, some people put forward the notion that dentistry has been ruined by the older generation.  This led to people saying that:

  • Practices are now unaffordable for younger dentists
  • Associate incomes are dropping
  • Dentistry is now too risky
  • Young dentists are scared of their shadows.


Times change, get over it.  When I bought a practice I got it relatively cheap.  The people who sold it to me got it even cheaper.  The person before them started it from scratch.  It’s the natural cycle of the market, some things increase in price to the extent that they become unaffordable, but other opportunities present themselves that weren’t available to the generation before.  So yes, the young dentists of today don’t have some advantages that presented themselves to me.  But technology and innovation move on.  Examples?

  • When my mother was a child she had to wash in an iron bath in front of the fireplace and they had no central heating
  • When I was a child there were three TV channels and no internet
  • My Mum and Dad bought their first house for £5000
  • My first phone had a battery life of about forty minutes and texting was the new revolution
  • When I graduated Stem Cell therapy had never even been heard of and implants?  Some mad wizardry from Scandinavia

The young of today will have disadvantages and advantages I never had.   Here are some of the latter.

  • Implant technology has made great strides
  • Composite technology and the ability to learn how to use it through courses has expanded far in excess of anything that was offered to me on graduation
  • The science and technology of marketing and data capture eclipses what I had in my graduation years
  • The existence of social media to create a loyal following and celebrity (is that an advantage lol)
  • The number of postgraduate courses is staggering. When I graduated all that was available was Tipton and Mike Wise.  Your ability to learn new skills is incredible.
  • Botox? Short term ortho?  What were they?
  • There had never been a greater opportunity to leave the shackles of the NHS

I think what I’m trying to say is that if you take on a victim mentality and moan about how the previous generation “ruined it for you” you trap yourself.  I can moan about how the generation before me “earned so much more”.  Believe it or not, from the perspective of what can be achieved with the materials and delivering care that is in the patient’s best interests, there has been no greater time to be a dentist.  Yes, if you want to make a high income, it’s more difficult now, especially on the NHS.  But is that a bad thing, really when you think about it?  Should the NHS be allowing associates to make a higher income than a child cancer specialist as was often the case in the 1990’s?  Should the taxpayer be funding that?  The NHS isn’t about making people rich, it’s about delivering effective care as cheaply as possible.

With notable exceptions, Dentistry in the 70’s, 80’s and 90’s was all about turning up and churning out volume.  This wrecked the dentist’s health and led to whole generations of patients who didn’t value the science of what dentistry “could be”.  Oh and it also made millions of people fear us, much of that fear created by a previous bad experience.  That has now changed.  More and more, dentistry is converting to a true patient led health field.  No more plastic bucket seats in reception.  No more “sheep dipping” patients in and out of the dental chair (not if you want to keep the lawyers at bay at least).  No more wiping down the bloody forceps with an alcohol wipe so it could be used on the next patient.  No more pulling teeth that can be saved.

The cost of delivery for dentistry has thus increased markedly, which means it becomes more difficult to make a profit, especially on systems funded by central government.  This means there will be less left over for the hapless associate.  But that just reflects the wonders that can be done now.  Finally, dentistry is becoming a meritocracy.  No longer can Joe Average make a fortune in the job, the lawyers and the regulators filtering out those who think they can trick the population with fancy mouth sounds whilst delivering sub-optimal care.  As the NHS slowly dies, now only the best of us will be able to make those eye-watering sums.  And we will do this from developing our skills, developing our approach to patient management and marketing and from developing ourselves.

Many of you younger dentists reading this will miss out unless you take matters into your own hands and become the best dentist you can be.  The courses are there.  The information is there.  The people ready to help and mentor you are there.  Business coaches, gurus and online CPD were all things I never had the benefit of.  So why not make the most of it?

So what are you going to do?  What action, today, are you going to take to try and get into that top 20% of the profession whose skill is truly reflected by the income they earn?


I merely ask the question




Is it time to walk away from the NHS?

By Members

I said a few things about the NHS in my last blog post, but let me just clarify my own personal opinion and specific opinion on the matter.

I subcontracted my time to the NHS for 22 years.  In that time, I saw how the system changed, the noose gradually tightening around the necks of practitioners.  Despite having a good UDA value and a stable patient base, I felt I could no longer do dentistry to the standards I was happy with, so I sold up to let someone younger take forward the practice I had helped build.

I will never work as an NHS GDP again.  Why?

The NHS, as an organization, is underfunded, awash with unnecessary management, compliance officers and box tickers. The hierarchy often does not care about the actual patient care, and the patients often do not care about their part in causing the institution’s downfall. It has become a bureaucrat’s dream, health care often taking second place to the diktats of the inane and the corrupt. This has resulted in a demoralised and stressed frontline workforce, sometimes being forced to deal with litigious and self-righteous patients who care only for their own convenience (and yes, I freely accept that a considerable amount of the litigation we see is justified).

No place do we see that more than in dentistry, where financial compliance, contract uncertainty, regulation, clawback and patient non-attendance are now the biggest threats to NHS practice viability. The will to fix the problem at the level of central government is not there, instead a continuous procession of ‘pilots’ are unrolled, allowing the DOH (Department of Health) to kick the HTM (Health Technical Memorandum)-0105 compliant can down the road another few years, although there is a promise that a new contract will arrive in 2020 (I’m not hopeful). And all the time the NHS system deteriorates into something that Kafka would have been proud of, with vulnerable NHS patients being fined for not understanding what benefits they are on, as well as dentists unable to verify what is and what isn’t available under NHS contract. Over ten years in, even knowing the rules on how to deliver that treatment is like trying to thread a needle in a darkened room, whilst wearing thick woolly mittens … with the windows open in a hurricane.

It is my opinion that every primary care dentist working under NHS contract should formulate an action plan to extricate themselves from the financial mess that will inevitably unfold. I also believe that those in secondary care should consider doing the same. You are underpaid, underappreciated and undervalued. And yes, I know that is easier said than done but those who do this might be in a better position several years from now.

And let us not kid ourselves that it is just dental staff that are under siege here. Whilst many in the NHS structure overseeing the NHS contract are good, honourable people (doing the best they can in a difficult situation), good people can’t survive untainted in a broken system that was never fit for purpose. Many in NHS management structures find themselves under intolerable stress, ground down by a huge bureaucratic machine that cares only about maintaining the status quo and protecting itself from criticism. I imagine the same could be said for the various insurance schemes available in America.

The NHS is filled with good people working in an intolerable situation.

The idiots (I chose that word carefully) in government do nothing to change all this because many of them really do not care about you or your patients. Those rare individuals who do give a damn and who do try to improve things only find themselves ground down by the system that cares about one thing – protecting itself.


It’s time to get out before you get crushed by the machine.

That’s the way it looks from here, and remember this is my biased opinion.  it is not to be considered advice




Thoughts on the upcoming NHS contract

By Members

To date we don’t really know how it will look, so I am basing the following opinions on my experience and history with the NHS over the last 30 years, as well as my history and experience with how government works.

This means my analysis might be flawed, wrong, off base… the writings of a complete basket case in other words.  It will also contain my inherent biases, both known and unrealised.  So of you were to make any future decisions based on what I have to say, it might mean you have rocks in your head :)

In many ways, the new NHS contract will be worse than what we have now.  Worse for associates, worse for patients, worse for staff and worse for the image of the profession as a whole.  It will, somehow, be beneficial to central government and corporates, as well as likely being tolerable to practice owners, especially those with large practices.

Why do I say this?  There is no doubt in my mind that progressive governments have felt that dentistry should be removed from the NHS, but nobody in Whitehall has had the political will or the guts to take that final step.  So they tinker and manipulate the profession, hoping that there will be a mass exodus so that the “greedy dentists” can be blamed for the demise of NHS dental care.  Why there is this reticence confuses me, because it occurs to me that dentistry is hardly a sacred cow that politicians risk sacrificing their careers for.  Likely it is just cowardice, but there might be other reasons that I am not seeing.

The NHS contract has corrupted care in the majority of practices, the dentists delivering that care lowering standards in many cases to try and “get the contract to work”.  I have seen first-hand how the goalposts and the rules were changed, often without the workforce being informed.  Said workforce reacted with fear and compliance rather than risking all by standing up to the general tide of oppression that was thrown over those “lucky” enough to be in possession of an NHS contract.

If you were to ask me, I would state that the NHS was no longer a vessel dentists should consider sailing in, with maybe an exception made for the salaried services.  Working under NHS contract is now filled with suspicion and mistrust, and unfortunately, a lot of that is down to the profession itself.  Some of you may shout your ire at me for that statement, but let me remind you that in the first year of the new contract, the provision of Band 3, single tooth partial acrylic dentures rose by over 70% compared to the years before the contract.  Dentists will make systems work, and often that is by taking whatever lifeline they can find, even though the end of the lifeline is often attached to a bear trap.

I remember in 2007 eating curry with 5 NHS practice owners who were all rejoicing in the way they could make money out of the contract.  None of that conversation, to my recollection, had anything to do with the actual care of patients.  I did my best to avoid such games, but it helped that I was in possession of a relatively high UDA value.  Others weren’t in that situation.  I won’t use the word lucky, because I entered the 2006 contract with a systemised plan.

In a time when the country is close to bankruptcy (the UK national debt grows by the rate of £5170 per second) is it any wonder provider and performer activity is being scrutinised under the most powerful of accounting microscopes.  We created a rod for our own back, and we did it willingly.

Here is what I predict will happen with the new contract

  • There will be a grace period as practitioners are allowed to adjust.  Flaws and loopholes will be found that will be exploited by dentists trying to keep their practice viable.  These will quickly be closed down, as the mechanism for oversight and monitoring will likely be maintained by NHS England (instead of being closed down as happened in 2006).

  • The % paid to associates will come under pressure.  I also feel the wording of the contract will further hamper the ability of NHS associates to claim self-employed status.  The NHS is heading for an employee model for non-practice owning dentists.

  • There will be vastly greater amounts of paperwork associated with the new contract.

  • Dentists will realise that really they should leave for the private sector, but too many of them will cling on for reasons only known to themselves.

  • The contract delivered will be inadequate and completely the wrong mechanism for delivering dental care to the population.

  • Workforce numbers will continue to fall and it will be increasingly difficult to fill positions as the younger generation of dentists realise their future is outside the NHS

  • The contract will be designed to be beneficial to corporates, but their own shabby business practices will see them destroy that perceived benefit

  • The contracts will be time-limited 

  • The new new contract will ultimately fail

If you presently own or work under an NHS contract, you might want to do your own risk analysis.  Whilst I have no connection with Practice Plan, an organisation like this might be a suitable mechanism for NHS practice owners to transition into the light.

Hey look I own a Ferrari

By Members

Some more mindless drivel for you.  Sorry, it’s been a while, but I have been concentrating on my latest fiction project which I have nearly completed.

It is becoming more and more evident that social media is toxic to a lot of people.  Not only is it now being censored by huge multinationals in favour of the left of politics (which will cause huge problems in the long run) it is also now a place for you to compare your life to others.  You log on and see the pictures of some “friends” gleaming new car, the holiday snaps, their night out and their constant parade of selfies proclaiming the glorious life they are leading.  The temptation is to compare yourself to these individuals, not knowing the inner turmoil and struggles that are likely occurring within their souls.

If you were ever foolish enough to seek my advice, I would say you should never compare yourself to someone else if you wish to remain healthy.  Instead, try comparing yourself to who you could become.

Look, I don’t really care what car you drive, the house you live in or how many Rolex’s you have.  Have at it if that’s what your ego wants to spend its money on.  I’m old enough that the post with someone with his new [INSERT RANDOM DOODAD] on display means nothing to me.  In fact, often it makes me sad in that I can pretty much instantly tell how much money that individual LOST by not investing that money instead.

Admittedly, my brain is a bit weird.

Yeah Steve, but you can’t take it with you.  True, but by spending it all you also can’t get to a position (at least not easily) where your investments allow you to work because you want to, not because you have to.

Flash cars, electronic trinkets and holiday homes are not displays of wealth, but they can give the illusion that the individual is wealthy.  Why anyone would think anyone actually cares is beyond me, but there are still some who like to parade their purchases and their achievements on the various social media platforms.  This will create several reactions, based on what part of the planet you come from

  • Apathy
  • Envy
  • Inspiration
  • Anger

And there is a problem with all that

We live in a country riddled with lawyers.  Lawyers only survive when there is a steady inflow of cash, and a good way for them to achieve this is by promoting the belief that you can sue an individual for a perceived wrong.  The judicial system backs this up and actually aids in this belief by penalising defendants who don’t settle (should they lose the case at trial).

The thing is, lawyers will only go after you if you have money.  If you are on benefits living on a council estate, there is little point engaging in litigation because you just won’t have the money to pay for any judgement against you.

Have you guessed what I’m trying to get at yet?

Open displays of wealth (even if that “wealth” is paid for by a vast amount of debt) can attract the worst of humanity into your life.  Envy is a powerful emotion, and I certainly wouldn’t want to attract that into my life.  In this litigious society, being seen to have money is a dangerous game that can cost you dearly.  I’ll not even mention the risks of crime.

The Americans learnt this the hard way.  If you read the book “The millionaire next door” they showed that the average US millionaire lives a very outwardly frugal life without blatant displays of wealth.  It acts as a form of self-protection.

So if you were again to be hat stand enough to ask my flawed advice, I would perhaps suggest that you should keep your life off social media, and just live it instead.  Unless of course, you are posting amusing cat videos, because you can’t go wrong with that.

Just a thought



The Tide of life

By Members

Do you ever think you are swimming against the tide?  Do you ever feel like you are making great progress in your life, only for a rip current to come and suddenly pull you under?

No matter what you do, doesn’t it always seem that life comes up with some cunning plan to make your life a little more odious and a little more difficult?  A new tax, a difficult employee, a divorce, a health crisis?  Brexit? :)

I think what we forget is how easy life actually is now compared to the history of our species.  It wasn’t that long ago where a simple infection could kill you, and where the average life was a misery interspersed with brief flashes of vague, drunken happiness…if you were lucky.  We forget the trauma of working in the fields, or down the coal mine.  We have forgotten the days before indoor plumbing and electricity, before antibiotics and the combustion engine.

Life used to be much harder than it is now.  Compared to our ancestors, most of us have it easy, and yet so many of us live in a constant well of depression.  Even a homeless person on the street can get access to lifesaving health care that wouldn’t have been available to the wealthiest individual a hundred years ago.

And we invented whole stories to help us deal with all these horrors.  We developed multiple religions and belief systems to try and explain why life was so difficult.  But as technology makes life easier, many of us have found those beliefs are no longer needed.  But still, the suffering continues.

You live your life, doing the best you can… and then the tide hits.  That’s going to happen, it’s inevitable.  You can’t avoid it, you can’t reason with it.  Tragedy and calamity will strike your life just as it does to everyone else.  And you can let yourself be pulled down under the water and submit, or you can fight.

What matters most is how you walk through the fire,” – Charles Bukowski.

Some of how you deal with this comes from how you prepare.  That’s why you buy insurance, why you create trusted networks and why you write contemporaneous clinical notes.  Most people who get pulled under, often they feel they are engulfed by things they could never have predicted.  But a lot of time, the warnings were there, the pattern of history often foretelling what is to come.  We overstretch our businesses and our lives, often focusing on the wrong thing.  Some people go on the hunt for the almighty £ whilst neglecting their families.  Others get wrapped up in their passion and let their health suffer.  Some of us, well some of us do everything we think we can and the shit still comes hurtling towards us.

Now, this might sound depressing and soul-crushing, until you think about it.  Acceptance and planning are two of your greatest weapons we can use against the inevitable suffering that enters our lives.  Even the best of us and the happiest of us suffer.  And the only thing you can do is accept that and do what you can to make things just that little bit better.  Because when you do the best you can, you can make the good things better.  Sometimes, you can even reach the dizzying heights of ecstasy.


I encourage you to spend the next 8 minutes watching this video –



Readers Questions

By Members

So you might remember I asked my subscribers recently what things they were concerned about when it came to dentistry.  In response, I got sent the following question.  I’ll answer it as best I can, but do remember I am not a lawyer so my interpretation of the matters raised might differ from that given by our more legally minded friends.

I’m also going to post this to The Dentist Facebook page because I think we need a debate about this as opinions are clearly divided.


I was reading this month’s Dental Update and Tara Renton’s article “Inferior Dental Blocks Versus Infiltration Dentistry: Is it time for change?”  It is a very long article that tries to cover the very large topic of local anaesthetics in dentistry.  It left me with several questions.  The most mind boggling I shall try to explain below:  In her summery she says “A radical change in LA practice is required with regard to many aspects of patient safety based upon current evidence”.  She also seems to feel further research is needed – but concedes that funding is unlikely.

The article also says that dentists should warn patients undergoing Dental LA of possible nerve injury and material risks.  I wondered what the “current evidence” is?

Her article says:

  • the reported adverse reaction rate to dental LA is 1:1,000,000
  • and the death rate from dental LA is 0.000002% (I translated this to be 1:50,000,000)

When I happened to be discussing this with an Engineer – they pointed out that the Fatal Accident Rate for large commercial passenger flights in 2018 was 9:25,000,000.  He also added that he was more likely to drop dead of a heart attack walking along the street and that going to see a dentist was bad enough without being warned about what he feels is a statistically meaningless risk. 

I understand that since “Montgomery vs Lanarkshire Healthboard” – clinicians are to discuss risks in terms of Material Risk to that patient – however:

  • the risk of the risk of shoulder dystocia (in the Montgomery vs Lanarkshire case) is 9-10% (1:10) not 1:1,000,000.
  • Even if you apply the formula: VALUE = probability x Perceived Consequences => there is a massive difference simply because 1:10 is much more probable than 1:1,000,000

As a grass roots dentist I feel the important thing about dentistry is not to hurt people and to treat them in a kind and thoughtful and considerate manner.   If Dental LA is safer than Air Travel (which is the safest form of transport allegedly) then I do not understand why one would need to formally consent patients for having a dental LA?  I just wondered what you thought as you have a better understanding of the medico-legal side of things.  I do wonder what patients and the general public think of this as well actually.


Okay, let’s get down to the meat of this.  I have seen Tara Renton speak before, and I know she is not in favour of giving ID blocks, especially when using Articaine.  I haven’t read the article because it is behind a pay wall.  She has her reasons for saying this, and it is understandable that patients can be distressed from receiving an injury to their ID nerve from what to us is the simplest of procedures.

From the research I could find, ID nerve injury from an ID block ranges between 1:25,000 to 1:800,000, so it is a relatively low-risk procedure.  What we need to determine is whether we need to warn the patient about this under Montgomery and under the GDC standards.

I would say that for most people we probably don’t but there is a chance I might be mistaken.  So why do I say this?  Well, under Montgomery there are three types of risk:

  • General risks (Anaesthetic will leave you numb for example)
  • Treatment-specific risks (tuberosity # upon taking out an upper 8 for example)
  • Patient-specific risks

And ID nerve damage following an ID block is so rare, it really likely only comes under patient-specific risks.  For treatment specific, and general risks, the courts have made some movement on clarifying what a material risk is.

A v East Kent Hospitals University NHS Foundation Trust (2015) – Claim dismissed, the Judge finding that the material risk claimed by the claimant was NOT a risk that a reasonable patient in the claimants position would have attached significance – Dingemans J said that a risk of 1:1,000 could be described as “theoretical, negligible or background”


Tasmin v Barts Health NHS Trust (2015) – found for the defendant. Dismissing the claim, the judge said the risk of serious injury was negligible, of the order of 1:1,000. He held that this was not a material risk, citing A v East Kent Hospitals NHS Foundation Trust [2015] EWHC where Dingemans J described a risk of 1:1,000 as ‘theoretical, negligible or background’. However, he preferred to formulate the risk as being ‘too low to be material’. The claim therefore failed.


The Montgomery duty requires patients to be given choice. It is not enough to advise of the risks and benefits of a recommended treatment. Patients must be told of the risks of ‘the recommended treatment, and of any reasonable alternative or variant treatments’ – so for an ID block, if you felt the material risk was relevant to them, you would give the warning plus the alternative options (Supra crestal etc)

A consent form signed on the day of surgery, or at any time, doesn’t indicate valid consent.  Consent forms are only part of a process of advising and providing consent

Whether a risk is material or advice is adequate is not a matter to be judged by the standards of the medical profession. It is for the court.  – and that right there is the problem.

Montgomery requires a doctor to take reasonable care ‘to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it – so Mr’s Miggins down the pie shop probably doesn’t need to know about the risk from an ID block.  But someone who is an internationally renowned saxophone player, whose livelihood might be affected by a permanently numb lip…..?

There is still the notion, post-Montgomery that not all risks are material. So we aren’t at the point of having to warn of death for every LA injection.  But, as I have already said, only the court can ultimately decide whether a patient should have been warned.

The problem is, if we are now having to warn about such insignificant risks, where does it end?  Do we have to warn them about the risk of being involved in an RTA on the way to the surgery?  What about the risk that the electricity might go out mid-treatment (which in my career has happened several times)?

This is not what Montgomery was intended to create and I’m hoping we can get some clarity because it’s clearly something people are worried about.

What do you think?


By Members

It’s clear to me that most people you meet at their place of work are just going through the motions.  They wake up, groan, do their ablutions, have breakfast, moan, wander to work in some zombie-like trance where the lips never seem to move from anything from a frown.  They OD on caffeine, enter the job they hate and do as little as possible whilst they are there.  They engage in office politics to try and “spice things up”, cause their boss varying levels of grief, and then come home with that same dour expression.  This then repeats up the pyramid through the various levels of company hierarchy, till you get a company that can’t actually deliver any kind of meaningful customer service to its customers.

At their abode, these people then take no action to improve their lot and then blame society for the state of their lives.  They didn’t bother to take that evening course, learn that skill, read that book…but they can tell you exactly what is happening on the latest reality TV show.  But of course none of that is their fault because remember, when there is a blame there is a claim.

I see this every Thursday when I travel to Leeds.  Thousands of people miserable and dejected.  On the rare event you catch someone’s eye, their soul seems absent, a vast wasteland of lost potential present where happiness should be.  Working five days to somehow live one and a half.

Everyone has potential, most people waste theirs.

Let’s look at dentists as a classic example.  Nearly twenty years ago, Chris Barrow stood in front of a room of two hundred dentists and asked how many of them enjoyed their jobs.  Less than twenty per cent said they did.  That’s one in five.

Any different now?  Probably not if Fakebook is anything to go by.  There are so many of you living lives of quiet desperation, trapped in surgeries you don’t like with patients you don’t have any kind of rapport with doing dentistry you hate.  Where is the satisfaction?  Where is the joy?

And it’s not all dentists thank whatever God you pray to.  Some take action, forge ahead, make the changes needed to get to where they want to be.  But so many more don’t.  Instead, they blame the contract, the principal, the system, the BDA and the goddamn shape-shifting space lizards instead of pointing the finger as to the true culprit for their difficulties…the face in the mirror.


What one thing can you do, right now, to make your life better as a dentist?  You know the answer, it’s there, staring you in the face.  So why haven’t you taken action on that?





If you want a better life, there is only one person who can deliver that to you.  So what’s stopping you?  If you don’t like the UDA system, why are you still working in it?  If you don’t like the practice you work at, why are you still there?  If you aren’t happy with the amount of money you earn, why aren’t you earning more?  If you are treating the wrong type of patients, why is that?

As much as you don’t like the answer, there is only one.  I’ll not spell it out.

If you want change, it has to start with you.


Just a thought :)



The Bell curve

By Members

Dentists are an odd bunch.  Come on, admit it.  We complain a lot and yet tend not to take the necessary action to deal with our troubles.  We continue to put up with the machinations and manipulations enforced on us by ever-changing NHS rules.  We are divided and sometimes even at each other’s throats which makes us an almost willing victim for what parliament, our regulators and the lawyers want to throw at us.  We do not act in our own, unified best interests so we become an easy target for the population to milk through litigation and for the press as one of their ever-present whipping boys.

Some people like Dhruh over at Dentinal Tubules (as a random example) do their best to help, but so few of us seem to want to accept that help.  I don’t know why, it certainly isn’t the money despite what people often say.

What I have noticed in my 22 years as a dentist is that dentists are split into a bell curve distribution:

10-20% will work miracles.  They will create fantastic practices, work wonders with composite or ceramic.  They will build businesses that people want to work in and bring change to the profession through the example they set.  They produce raving fans rather than patients and become an example of what dentistry should be.

10-20% will cause damage to the profession.  They will engage in illegal and unethical practice.  They will play fast and loose with GDC standards and hoodwink patients into buying suboptimal treatment that they don’t need.

The rest struggle to do the best they can.  They will run businesses that are constantly firefighting.  They will struggle to get that tax payment in on time and have staff that cause them more problems than should be expected.  They will treat patients they don’t get on with, and will often drift into defensive dentistry out of fear for their own hides.  They can still be good dentists, clinically, ethically etc.  But they often find themselves pushing at the edges of the regulations or their own sanity.  And they might get all the dentistry and the business right, only to have their health fail because they don’t look after themselves.


That’s my biased opinion.  Most of those in that middle section will never make it into the top 10-20%, but it is very easy for them to fall into the bottom.  Society even makes it easy for you.  It provides a system of socialised dentistry that encourages supervised neglect and discourages courageous, adventurous business ideas due to the threat of clawback from not getting those damned udders.  It parades the “dentists are rich” message across social media enticing you to perhaps push your own moral boundaries if just a little bit.  But once pushed, it becomes easier to push a little more…and that’s a dark road to go down.  Money is not the root of all evil, but the love of money?  See, I told you I was biased.

The way I go about life is to try and do something every day that makes me that little bit better.  Go to the gym, read a book, do some CPD, have a conversation that matters, write a blog or get that marginal ridge on that MI composite just right.  And every day I try and avoid things that will make my life worse.  I do what I can to limit the alcohol, to avoid the random 30 second mouth pleasure from something completely unhealthy.  I avoid wasting money on things I don’t need to impress people I don’t know and do what I can to stop the negative chatter that rattles around in my head.

One of the things I do to make my life a little better is to try and help others (even the horror fiction I write comes under that because, so I tell myself,  it gives people an escape from their troubles).  I was never in the top 10-20% for anything with my dentistry, but I got as close as I could.  I was an average dentist clinically, could build rapport with most people and learnt who NOT to treat.  I developed loyal staff, probably more through luck than anything.  I bought and sold my practice at exactly the right time in the market cycle and there was some luck there as well…although sometimes I wonder if it was simply because I took the opportunities when offered.

So now I write books.  I won’t be retiring off the proceeds, that’s not how publishing works.  There aren’t enough dentists in the country to make that happen, and most dentists tend not to read books from my experience (I don’t know how valid that experience is).  What I hope though is that somebody will find something in one of them to make the difference that makes their life and/or their career better.  The books and the website that this blog is on aren’t for everyone.  My thoughts on ethics don’t gel with some in the profession because I find much of the advertising and social media use questionable.  That’s just my opinion, it’s not a reflection on what anyone else is doing.

So if you are struggling with ethics, regulation, legislation or how to run a business, you might find some useful nuggets in one of the books I’ve written.  Will they change your life?   Don’t be silly, I’m not Tony Robbins or Deepak Chopra.  They might just help, however.

My Amazon authors page can be found here –

And if you have already read the books and liked them, why not drop me a review on Amazon.  Just as patient testimonials help your business, so Amazon reviews help push a book to the head of the algorithm that promotes it.

By the way, if you want to ask me anything, just drop me an email –





Resistance is futile?

By Members

The GDC (General Dental Council) is a necessary body in today’s world and it has, unfortunately in the opinion of many, lost its way, creating a climate of fear amongst the dental profession. The culture that has allegedly been created within the GDC over the last decade (whether actual or just perceived by those outside its hallowed halls) has damaged not only the profession but the GDC itself, to the extent that it is now having to correct its course. I say this because if the regulator was doing a ‘good job’, there would have been no need to drag it before the Health Select Committee. It finds itself under siege and was for several years criticised by its own regulator, the PSA (Professional Standards Authority).

There is an allegation made by many within the dental profession that the changes made at the GDC  were done deliberately, with the express purpose of breaking the back of the dental profession. I am not blessed with knowledge as to whether this is or is not the case, but the very fact that dentists are thinking this shows where the problem lies. Dentists feel threatened by the most expensive health regulator in the country (that dentists pay for) and are now finding themselves practising defensively in an environment of fear and dread. The majority (as shown by countless online polls) do not trust or respect the body that regulates them … and self-regulation cannot survive without the consent and cooperation of those regulated.

A regulator should not regulate through fear and tyranny but through earned authority and mutual respect. This respect was lost, not by the rise in the ARF (Annual Retention Fee), nor by the unfortunate advertising the GDC did to encourage patients to complain. The true loss of trust, in my opinion, came in the numerous charge sheets filled to the brim with (I’m going to say alleged to keep the lawyers happy) allegedly spurious and ridiculous allegations:

  • “You failed to keep your hair out of your face.”
  • “Bouncing balls of putty in the corridor.”
  • “Writing a prescription to yourself for toothpaste.”
  • “The post didn’t reach the apex.”
  • “You failed to justify why you did a try in.”
  • “Failure to document the site of LA for the extraction of an upper tooth.”
  • “Took a long time to perform a routine extraction.”
  • “Failure to diagnose a ledge to the filling for the LL7.”
  • “Not recording consent for the provision of a crown placed on an implant.”

There has been too much emphasis on filling charge sheets with as many allegations as possible instead of concentrating on the aspects of suboptimal practice that actually matter. Until that aspect of the fitness to practice process is fully corrected (and to its credit the GDC has taken significant steps in the right direction with its recent changes), the GDC will remain a body that attracts derision and produces fear.

Ironically, a lot of these issues weren’t solely the GDC’s fault.  The profession itself has to take a lot of the responsibility.  Dentists were the expert witnesses that helped formulate those charges.  Dentists were some of the committee members that didn’t resign when the ship started to be steered the wrong way.  How many of us wrote to the GDC to demand change?  How many of us sent an email to object to the ARF?  By our lack of unity, by our lack of resolve, we leave ourselves vulnerable.