was successfully added to your cart.

Basket

Category

Members

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

 

SH

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 – https://www.youtube.com/watch?v=wLvd_ZbX1w0

 

 

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?

Dissatisfaction

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?

Fear?

Inertia?

Lethargy?

Ignorance?

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 :)

 

SH

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 – https://www.amazon.co.uk

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 – https://dentallawandethics.co.uk/contact-2

 

Thanks

 

SH

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.

 

Life is actually pretty damned good

By | Members, Uncategorized

Humans often have a tendency to see the bad in everything.  Sometimes that strategy works.  A lot of the time though it can send you down a negative spiral.

Personally, I think the trick is to be able to see the weaknesses in the society around her whilst revelling in its strengths.  You don’t live in denial but you appreciate the heights of human civilisation.  You have to remember we as a species have never had it this good.  Despite what the GDC and the politicians come up with, we have a quality of life that the Kings and Pharos of the past would have killed for.  The toil of a thousand slaves can be replaced by the flick of a light switch..  So let’s have a look at the best humanity has to offer.

  • How’s about the 18-year-old kid who discovered he could use his 3d printer to make replacement limbs for less than a $1000.  This has revolutionised the provision for amputees and those where were born without said limbs.
  • Stem cell therapy allows us to cure 3rd-degree burns without scarring or pain
  • The deadliest viruses known to humanity are being used to cure cancer by the Mayo Clinic
  • The level of excellence our entertainment has reached is astonishing.  Remember the stale acting in those old black and white movies.  Look at the films and the TV series that are being created now, where people can be swallowed up in a thousand realities.
  • You have access to the totality of human knowledge and understanding at your fingertips.
  • Yes, we go on about SJW’s and political correctness, but that is because we have raised a generation who have never had to suffer the trauma of war.  In the West, we don’t have to wake up to the fear that our cities will be bombed from the skies or that our sons will have to die in the fields of Europe for our freedoms
  • I can buy food from over 100 countries.  I can also visit those countries for a reasonable price
  • We still have the fear of war, but the technology of warfare invariable always finds its way into commercial hands.
  • Technology seems to evolve to solve any problem we face.
  • The science of human excellence had never been so advanced.  From business to success to the Olympics, humanity keeps defeating the odds set against it.
  • The greatest minds of our civilisation can now share their ideas with the world
  • The technology available for you to do your job improves every year

Forget the cretins in Whitehall and the letter from m’leanred friends…just for a few days.  Maybe now isn’t the time to feel down, and I’m not stupid enough to forget that some people struggle at this time of year.  For most people though, if we figure out what you are grateful for and ask yourself if things really are as bad as we keep telling ourselves.  Remember, for some people to get clean water for their children, they have to make a five-mile round trip.  Some people live in fear of genocide and true poverty.  Even that will be solved as humanity makes its strides forward.

We just figured out how to create oxygen from chlorophyll without the need for plants.  Think what that means for space travel.

Just some thoughts to keep Santa happy

“The world is like a ride in an amusement park, and when you choose to go on it you think it’s real because that’s how powerful our minds are. The ride goes up and down, around and around, it has thrills and chills, and it’s very brightly coloured, and it’s very loud, and it’s fun for a while. Many people have been on the ride a long time, and they begin to wonder, “Hey, is this real, or is this just a ride?” And other people have remembered, and they come back to us and say, “Hey, don’t worry; don’t be afraid, ever, because this is just a ride.” And we … kill those people. “Shut him up! I’ve got a lot invested in this ride, shut him up! Look at my furrows of worry, look at my big bank account, and my family. This has to be real.” It’s just a ride. But we always kill the good guys who try and tell us that, you ever notice that? And let the demons run amok … But it doesn’t matter, because it’s just a ride. And we can change it any time we want. It’s only a choice. No effort, no work, no job, no savings of money. Just a simple choice, right now, between fear and love. The eyes of fear want you to put bigger locks on your doors, buy guns, close yourself off. The eyes of love instead see all of us as one. Here’s what we can do to change the world, right now, to a better ride. Take all that money we spend on weapons and defences each year and instead spend it feeding and clothing and educating the poor of the world, which it would pay for many times over, not one human being excluded, and we could explore space, together, both inner and outer, forever, in peace.” – Bill Hicks RIP

 P.S:  The price rise for my new book “The Secret World of Dentists” has been postponed till after Xmas.  Buy it on Amazon – https://amzn.to/2SeaHyZ

SH

 

 

 

 

 

The power of feedback…

By | Members, Uncategorized

Patients give you feedback every day.

Some of it’s useful, even when the feedback is negative because it allows you to look at what you are doing from their perspective.  And from my 22 years in the profession, I’ve come to the conclusion that it’s rare that what people say should be ignored…especially when you have worked to select a patient base you are in rapport with.  Trust and rapport will often give the patient the permission they need to tell you when you need to improve.

And that’s fantastic.

Sometimes though, the patient isn’t right for your clinic.  It happens.  Either the ethos of how you do things isn’t right for them, or your personalities just clash.  And even feedback from these individuals can give you a powerful insight into the road you have chosen to travel on.  Accept it and move on,

It’s the same with writing books, which I’ve been doing for nearly 10 years now.  Sooner or later, something you write is going to hit a nerve.

Take for example this 1-star review to Stephen King’s classic, “The Stand”

“I found this book heavy on religious content, where good and bad are the only shades of being. Add to this the jingoism of the survivors, who I would imagine would loathe all things responsible for their plight and therefore I believe that this book is 1320 pages too long.”

How about this 1-star review to Ulysses by James Joyce.

” I actually got as far as page 3, then somehow lost the will to live.  At least I tried!”

And then there is this classic 1-star review for Lord of the Flies” by William Golding.

Bad

 

Are these reviewers wrong?

Well no, far from it.  A review is their own personal opinion on what they have read.  You can be critical of any factual inaccuracies in their review, but other than that you just have to sit back and accept what is written.  Have you noticed though how some of the reviews can actually be witty in their own way, cutting sarcasm often used to relay their disappointment.  Sometimes the review turns into a personal attack on the author, and that too can be understandable.  When you read a book you don’t like, you often feel disappointed because you put time and money into the whole affair.  You sit down, get comfortable and plough into something that you are often quite excited about…only for the words to sour because it wasn’t what you were expecting.

In essence, you lose the readers trust.  You do that with a reader, you might get a nasty review on Amazon.  You do that with a patient and the penalties can be much more severe.  That’s why trust and rapport become so important and why I keep on saying that if there is no rapport, there should be no treatment (except for perhaps urgent care).

My latest dental book got a 1-star review right off the bat, and I think that’s great.  It highlighted the deficiency in my Amazon description and solidifies the controversial nature of what I’ve written.  Of course, if all it gets is 1 stars, then we know that maybe I’ve been blowing smoke up my arse and should thus stick to writing zombie novels :)

 

Time will tell

 

Dentist, heal thyself

By | Members, Uncategorized

When I qualified, long before the dark days of the UDA, there was a phenomenon known as the ‘Old Boys Network’ who worked amongst themselves to maximise any benefit they could get from the NHS system and from dental politics. I saw it first hand, and much of that has evaporated as the elders of the profession passed into retirement. It was generally a benign unofficial structure that didn’t cause much harm to dentists unless you somehow fell afoul of one of their number.

From my personal experience, it didn’t do much to improve the patient experience.

From a dentists perspective, things have changed in that regard, but not for the better. It would appear there is a growing trend for a hard-core of dentists who seem eager to throw their fellow professionals under the bus. They do this in numerous ways:

  • They try to use the GDC as a weapon in business disputes.
  • They will be overly critical of another dentist’s work, often encouraging the patient to sue their last dentist.
  • Some have even taken to taking screenshots of social media posts that they deem offensive, posting these off to the GDC in the hope the regulator will impose some kind of sanction. Is this really what the GDC is for?
  • They flaunt their wealth on social media, giving an unfair representation of the financial rewards that can now be achieved (the days when the majority of dentists could make an astounding amount of money from dentistry are long gone). This is potentially damaging to the egos of younger, more naive dentists, who often don’t appreciate that some of the wealth on display is either rented wealth or, more annoyingly, parental wealth.  The really successful people don’t need to show it off because they have nothing to prove.
  • Expert witnesses working for the GDC who don’t understand their remit and who feel they should be an advocate for the complaining patient, rather than an impartial expert. By their actions, they break the code of what an expert witness should be and risk unfairly ruining the lives of their fellow dentists. Although it hasn’t happened yet from what I can tell, there will come a moment when an expert witness gets sued for this, and then all hell will break loose. There have already been cases where expert witnesses, by failing in their duty, have been referred to the GDC. This all makes the profession, as well as the GDC, look bad.

Seriously, this madness needs to stop because it’s reprehensible, and anyone who does it for the wrong reasons should be ashamed of themselves.  It is damaging people’s lives and fracturing the profession into camps that actively attack each other on formats such as Facebook.

A GDC referral for some can have devastating consequences. I would remind the bus throwers (who probably aren’t reading this, to be fair) of the research done by Sarndrah Horsfall[1].  In a ten-year period, twenty-eight doctors killed themselves whilst undergoing fitness to practice procedures. Is that worth a petty squabble? Do you really want such a thing on your conscience? And also, do you want the social media scrutiny that such a case would create? … it would almost be inevitable for your name to come out as the instigator of the complaint. And no, I’m not saying registrants should refuse to abide by their whistleblowing obligations, but dentist-on-dentist referral to the GDC has to be made for the right reasons.

And all the while the government sits back and chuckles as we do their job for them, self-imploding and stripping ourselves of any semblance of our once-lauded professionalism.

Dentists are already starting to pick the bones clean and have ordered pudding.

If you want more on this topic, get my latest book “The Secret World of Dentists”.  The price goes up saturday.

 

[1] https://www.gmc-k.org/media/documents/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf

Defensive dentistry

By | Members, Uncategorized

When health care professionals feel their careers are at risk through any and all patient interactions, their practising profile changes. This results in an overall decrease in the quality of patient care for subsidised care (NHS, insurance) or an increase in cost for private care. Defensive dentistry results in:

  • Some dentists will write great essays in the clinical notes, mentioning the slightest aspect of the patient interaction. This takes time – time that could be spent treating other patients. It also makes it difficult to see what treatment has actually been done because it is lost in a sea of batch numbers and pointless minutia.
  • Private dentists find themselves having to write huge, multi-page treatment plans to explain the risk benefits of the treatment involved. This raises the cost of treatment for the patient because that time has to be paid for … no dentist should now be doing such for free in my opinion.
  • Some dentists will avoid what they perceive as high-risk procedures (high-risk with regards litigation and regulatory complaint), referring patients on to an already overburdened secondary care system or on to well-respected private referral practices. This means patients either wait longer for their treatment (often getting trapped in a back and forth ping-pong between disenfranchised healthcare providers), or pay vastly more for treatment than perhaps they were expecting. It also de-skills the profession, which loses the ability to deal with treatment that dentists considered routine just fifteen years ago. This hits the most vulnerable, because the affluent, and those with the will, can be seen quickly via the private specialist network existing in the country. This is what happens when the population of a country embraces an adversarial, blame-led legal system. So perhaps there is some substance to the saying ‘A country gets the dentistry it deserves’.
  • Dentists also start referring more with regards soft tissue lesions, due to the fear that they might ‘miss something’, swamping Max Fax departments in a deluge of biopsy requests, which means it becomes harder for genuine cases to be seen and diagnosed. Clinical intuition becomes drowned out by the fear of being negligent.
  • It will likely go to the American extreme, where full-mouth radiographs become standard (absent from the other extreme, the worrying trend in many NHS practices, where supervised neglect is embraced due to time and cost issues), so as to ensure absolutely nothing is missed, irradiating the population above what is clinically necessary.

 

So, how is the patient served by a regulatory and litigation framework that promotes this?  Until action is taken on those issues, dentistry in this country will not be the career is should be.  Whilst we as individuals can change and adapt to combat the threats being hurled at us, only the government can fix this by radical overhaul of health care regulation and negligence law.  The fact that they haven’t tells me they fund the present situation desirable.

 

Just a thought.

The ethics of water fluoridation

By | Members, Uncategorized

Introduction

Water fluoridation is a controversial topic to some people and has, over the decades since its implementation, promoted furious debate, even within the dental profession.  The idea that the dental profession is 100% behind water fluoridation is nonsense, as can be seen by online forums and social media posts.  It is credited by many as being a public health miracle but is castigated by others who see it as a danger to the public.  So before we start discussing the ethical basis for water fluoridation, I feel it prudent to first briefly outline the legal position in this country that allows for it.

I will admit that I have an inherent bias against water fluoridation based on my own beliefs.  I feel it is therefore ideal to see if my opinions stack up when scrutinised by the ethical principles and the available evidence.

 

Legal basis

Fluoride in the drinking supply occurs naturally in some areas.  In others, it has been artificially added, and in the UK, the first instances of artificial fluoridation was in the year 1955.  Watford, Kilmarnock and part of Anglesey were chosen as the first sites and a 5-year study done against three control sites.  The results of that study indicated fluoridation lowered the caries rate.  Prior to 1974 responsibility rested with local authorities as part of their duties for promoting public health.  However, in 1974 this responsibility was passed to the newly created health authorities.

In 1985 the government passed the Water (Fluoridation) Act 1985.  This act allowed local health authorities to increase the fluoride content in the water artificially and also outlined what public consultation was required.  Something I find interesting when it considered consultation, is that the act used the word SHALL instead of MUST which suggested that perhaps it wasn’t a mandatory requirement.  Still, the need for public consultation did see the implementation of fluoridation stall, and by 1990 less than 6 million people were drinking fluoridated water.

The 1985 act was possibly a reaction to one of the few court cases regarding water fluoridation.  In Scotland, McColl v Strathclyde Regional Council [1983] S.C. 225, Lord Jauncey found that “It was beyond the council’s legal authority to fluoridate, it might harm consumers, it constituted a breach of duty, and that fluoridation was supplying a medicinal product without the required licence”.  He ruled that that fluoridation should fall under the Medicines Act 1968.

The later consolidation of the 1985 act into the Water Industry Act 1991 sections 87 and 88 also impacted this.  It was under the Water Industry Act 1991 that the court case R. (on the application of Milner) v South Central SHA occurred. Here the judge determined that

Public opposition was only one argument to be weighed in the balance by a health authority in reaching its decision and could not trump any public health argument in favour of fluoridation

Possibly one of the causes of the lack of fluoridation was the wording of the actual legislation in both the Water Fluoridation Act 1985 and the Water Industry Act 1991, an idea put forward on the British Fluoridation Society website: “To a large extent, it was disagreement between health authorities and water companies over the meaning of the word ’may’ that blocked progress on fluoridation…

There were further amendments to the law by S.58 of the Water Act 2003.  The judicial stance that public opposition was not a deciding factor in water fluoridation was also adopted in further legislation that impacted fluoridation.  The Health and Social Care Act 2012 amended the Water Industry Act 1991 with the effect that responsibility for conducting public consultations on fluoridation was moved from Strategic Health Authorities (SHAs) to first tier Local Authorities with effect from 1st April 2013, taking everything pretty much back to where it started.  Interestingly, this statutory instrument required the local authority to judge both local support and also the strength of the scientific evidence whilst also considering the cost.  So we can already see some of the four ethical principles creeping into the legislation there.

Finally, we mentioned the 1985 judicial opinion that fluoridation the water supply was the delivery of a medicinal product.   The Medicines and Healthcare Products Regulatory Agency (MHRA) disagrees with this stance: “As drinking water is quite clearly a normal part of the diet the MHRA does not regard it (fluoridation) to be a medicinal product

This does contradict the European Union’s definition of a medicine – “presented as having properties for treating or preventing disease in human beings” – See infra, Article 1.2 of the EU Directive 2004/27/EC on Medicinal Products for Human Use.  This may however not be relevant two years from now. So because we have differing views, I am not able to reach a conclusion on this particular aspect.

 

Arguments for Water Fluoridation

It is unsurprising to find advocates for water fluoridation among the dental profession. But it is not just the dental profession. The American Centre for Disease control and prevention named water fluoridation one of the 10 great public health achievements of the 20th century.  The American Dental Association have set out the 4 main reasons why they recommend water fluoridation (although they provide no evidence to back up any of their statements).  These reasons are

  • Prevents tooth decay, protecting all age groups
  • Safe and effective
  • Saves money compared to treating tooth decay
  • Because fluoride is naturally occurring in some water supplies it can be deemed to be natural

But is there any evidence that it actually works?  This is an important question, because that will greatly impact the ethics behind its use.  There have been several major studies on water fluoridation, and the results have been inconclusive.

Jones (1996) argued that  “low levels of fluoride, less than 0.1 mg l–1, were associated with high levels of dental decay”.   The research done by Whelton and O’Mullane (2003) in Ireland also came to a similar conclusion: “The study shows that decay rates in Northern Ireland (un-fluoridated) are of the order of 50% higher than in the Republic (fluoridated)

A report by Public health England in 2014 found that 15% fewer five-year-olds experienced decay in fluoridated areas and that 11% fewer 12-year-olds experienced decay.  The report did seem to demonstrate that fluoridation is an effective preventative method for tooth decay However, not all the research found this.  For example, the Cochrane Review did a systemic review into Fluoridation.  They stated that “We did not identify any evidence, meeting the review’s inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries”.

Also, the much touted York Review seemed to give a big thumbs up to water fluoridation.  However, when looked at more closely, the results were not as positive as were first thought.  As reported in the British Dental Journal (2002) The review was critical of the body of evidence that was identified.  The authors of the report even went so far as to write a follow-up statement to their review in the CRD (2003):

We were unable to discover any reliable good-quality evidence in the fluoridation literature worldwide. What evidence we found suggested that water fluoridation was likely to have a beneficial effect, but that the range could be anywhere from a substantial benefit to a slight disbenefit to children’s teeth

Further research from Saudi Arabia by Dosari (2004) indicated that “There was no linear correlation between water fluoride level and caries experience”.  There are also arguments against water fluoridation, and we shall look at those as we examine the four ethical principles.

 

The key ethical questions relating to water fluoridation

To my mind there are several key questions that need to be answered

  • Is fluoridation mass medication, and if it is, is it acceptable to mass medicate a whole population in a way that makes it almost impossible to avoid without their full consent?
  • Do the benefits of fluoridation outweigh any risks?
  • If we are mass medicating, is it acceptable to do this when the dose cannot be controlled?
  • If the benefits are as described, is it acceptable to deprive fluoridation to those who could benefit from it?
  • Is it for the people to decide or the state?
  • And the most important question of all: does fluoridation meet the four ethical principles?

I will try and answer these whilst determining how the ethical principles relate to fluoridation.

 

Does Water Fluoridation respect the concept of autonomy?

For this essay, I will be utilising the Three Condition Theory of autonomy put forward by Beauchamp and Childress to assess whether fluoridation meets this ethical standard.  It would be very easy to get wrapped up in a long discussion on autonomy and whether fluoride is a medicine, but I think what would be easier is to simply accept that fluoride is added due to its reported therapeutic effect.

Intentionality: To meet this standard for autonomy the individual must intend to drink the water for the purpose of obtaining the benefits of fluoridation, even if that is only part of their intention.  If their intention is purely hydration, it could be argued that the addition of fluoride breaches this part of the ethical principle.  If I am thirsty and I drink water that is fluoridated, is my intent even remotely concentrated on the therapeutic benefits of that fluoride?

Understanding: Can the British population, whose average reading age is eleven, understand the proposed benefits of water fluoridation?  And what about people who have not been informed, who do not know the water contains fluoride?  When I bought my practice in 2000, I wrote to the local water supplier to ask if the water they supplied to my practice and the surrounding neighbourhood was artificially fluoridated.  Whilst they did show me that there had been 3 episodes in the last 6 months where the water supply was accidentally contaminated with faecal matter, they were unable to answer my question about fluoride. One would hope matters are different now, but how can the local authority ensure everyone is informed that the water they are drinking has been altered so as to provide a therapeutic effect?  What about people travelling to the area from a non-fluoridated area, businessmen and tourists?  If even one competent adult is drinking the water without the knowledge that it contains fluoride, surely this means again this ethical principle is breached.

Non-Control: There should be no coercion.  The problem arises in that we, as human beings cannot live without water.  It is a requirement for life.  So whilst there are alternatives available (bottled water, filtration systems), these are more expensive than drinking tap supplied potable water, and this discriminates against those of a lower wage.

Also, drinking is not the only way humans consume water.  We use it in cooking and bathing, and there is some speculation that fluoride can be absorbed through the skin, which negates its therapeutic effect. Unfortunately, there is very little that the average person can do to negate this aspect, thus should they wish to avoid fluoridated water completely, as is their autonomous right, it is almost impossible to do so.  This is one of the big arguments against water fluoridation, that it is mass medication of the population without consent, and that argument does seem to hold ground when scrutinised.

As fluoridation is now the decision of the local authority there is the argument that this is part of the democratic process.  But if that is the case:

  1. a large proportion won’t have voted for those representatives
  2. whilst there is a requirement for public consultation, there is no overriding requirement for the publics views to be the primary deciding factor on whether water should be fluoridated.

Is this not classic paternalism, the very opposite of autonomy?, Water is life, and so it can be strongly argued that the coercion, whilst not coming directly from the state, can come indirectly due to our inherent need to consume the product.  One cannot even use the principle of therapeutic privilege here, because the pop, on the whole,e whole could not arguably be harmed by being informed their water is fluoridated.

Up until now, we have been discussing adults who are competent to make decisions about their own health.  If water fluoridation is potentially paternalistic (even if it is more a soft rather than hard form), especially to those on a low income, what about children and those deemed mentally incompetent?  Who decides for them?  The state or those with either parental or legal responsibility?  Does fluoridation risk compelling the incompetent to drink fluoridated water?

My initial opinion, therefore, is that water fluoridation fails the ethical principle of autonomy because the prevention of tooth decay can be achieved by other means that allow for autonomous choice.  A counter-argument to this is that the very alternatives to water fluoridation may not be readily available to those with limited funds or limited understanding of the issues, and I will address this later.

And there is also another issue that comes to mind.  If Fluoridation is done for therapeutic benefit, then does this not set a precedent?  There have already been talks about adding other compounds to the water, for example, Lithium and Statins.  I believe that water fluoridation therefor also risks the nefarious slippery slope of paternalism that threatens the very concept of personal autonomy.  The argument that fluoridation is OK because it occurs naturally in some areas does not hold merit to me, because in its additive form it is far from natural, being in some instances an entirely different compound.

I am therefore in agreement with Cohen and Locker (2001) in their statement that “the demands of moral autonomy cannot be made compatible with what could be regarded as the involuntary medication of populations.”

 

Does Water Fluoridation respect the concept of Nonmaleficence?

Whatever else, we should do no harm, or the least harm to create the most benefit.  We will therefore need to investigate the safety of water fluoridation because any harm must be outweighed by the benefits (for example a dental anaesthetic injection can be uncomfortable, but it is preferable to the pain that can be caused by its absence).  There are a lot of scare stories on the internet about fluoride and water fluoridation.  The image in the mainstream media is far from favourable.  From conspiracy theorists like David Icke and Alex Jones, to conventional media like the Daily Mail, there is a message that fluoride should be avoided, with headlines like:

  • “Is fluoride good for us?” (Briffa)
  • “Is your tap water poisoning you? The troubling question on everyone’s lips as scientists warn fluoride put in water to protect teeth could spark depression” (Naish 2015)
  • “Fluoride ‘could give you bone cancer’ claim experts as they call for a halt to adding the chemical to drinking water” (Curtis 2015)

It is therefore important to examine the arguments made against fluoridation, which I think are best summed up by Peckham (2014) who suggested that the benefits do not outweigh the risks:

This review argues that the modest benefits of ingested fluoride in caries prevention are thoroughly counterbalanced by its established and potential diverse adverse impacts on human health

So what are the reported risks?

 

Cancer:  Opponents often claim that fluoridated water is carcinogenic in nature, and a lot of research has been done in this area.  From the research I have read, there is no evidence that there is any carcinogenic risk from fluoridated water.  This was a finding backed up by the York Review on page 58 of the report, stating that “from the research evidence presented no association was detected between water fluoridation and mortality from any cancer

Fluorosis:  Fluoridation causes fluorosis, there is no denying this, and this can vary from mild to severe.  The York Review found high levels of fluorosis, as reported on page 45: “The prevalence of fluorosis at a water fluoride level of 1.0ppm was estimated to be 48%”.  The question then arises, is this an acceptable price to pay for the reported benefits of fluoridation?  As there are alternative approaches to providing fluoride, and as tooth decay could better be addressed by removing the cause, local and central government has a challenge to say that this potentially disfiguring condition is an acceptable price to pay when children can readily access sugar so easily and so often.  As a professional, I am challenged by the lack of public information awareness campaigns, by the prevalence of vending machines in schools and the poor attendance of children at a dental practice.  To think that fluoridation is somehow a silver bullet concerns me.

Hypothyroidism: Professor Peckham, who seems to be an opponent of water fluoridation has done several research papers on the safety of fluoridation.  Whilst not proving a correlation, his 2015 paper did suggest there might be a link between an underactive thyroid and water fluoridation.  I could find no evidence to prove this link, however, and as such, I have chosen to reject this risk.

IQ: “The Nazi’s put in the water to the death camps” is an accusation often hurled at fluoridation, the idea being that it lowered the IQ of the inmates.  I have not been able to find any evidence that the Germans actually did this, but there has been a significant amount of research done on this particular aspect.  Mindal (2016) found that “Children residing in areas with higher than normal water fluoride level demonstrated more impaired development of intelligence and moderate dental fluorosis.”  Sebastian (2015) found that “School children residing in an area with higher than normal water fluoride level demonstrated more impaired development of intelligence when compared to school children residing in areas with normal and low water fluoride levels”.  And Anna (2012) also found that “In conclusion, our results support the possibility of adverse effects of fluoride exposures on children’s neurodevelopment”.  All these conclusions, and dozens more like them, have come post York Review which found that there was no effect on intelligence.

Skeletal Problems: On page 53 of the York Review, the authors showed they found no evidence for this risk, and that there were no associations between water fluoridation and hip fractures.

 

Much of what is put out by the anti-fluoride lobby is pure fiction and scaremongering.  They tout the fact that fluoride is a poison but fail to mention that poisons are dose-dependent.  From an ethical stance, we are purely concerned with whether the benefits outweigh the risks. It is my personal opinion that they do not.  It is an imperfect means to provide a benefit which has dubious evidence for its efficacy at best and where there is clear evidence that it can cause harm.  Is it right for the population as a whole to accept those risks for the reported benefits?  I would argue it is not and I feel that I have no option but to take the stance that fluoridation fails the ethical test when it comes to Nonmaleficence.

 

Does Water Fluoridation respect the concept of Beneficence?

This theory advocates that the best interests of other people are met.  A moral society should do whatever it can to protect and ensure that the next generation (the children) are allowed to grow to their true potential.  I mention this because it is primarily children that fluoridation is aimed at.  However, one cannot escape that, in trying to perform this beneficent act, the fluoridation of water is an imposition on the population at large, with a disproportionate impact on those with lower social status, what some would call the working class.  It thus creates a definite conflict with personal autonomy.  Perhaps a better alternative that respects both autonomy and beneficence is the use of public health campaigns like free toothpaste and supervised brushing in schools.  These directly involve the people involved through education, direct delivery and supervised care, rather than the more haphazard, shotgun blast approach of fluoridation.

Advocates of fluoridation would argue that this treatment benefits everybody equally, but this does not answer this conflict between autonomy and beneficence.  This also presupposes that the benefits of fluoridation have not been exaggerated.  The available evidence seems to indicate that there is a reduction in dental caries experience in fluoridated areas, but the proof is far from definitive, mainly due to the poor quality of the available research.  Really, therefore, before we can show that fluoridation can be used for the benefit of all, the evidence needs to be there.   I do not feel that the benefits significantly outweigh the risks already discussed with the available evidence.  Prove to me that it works, then we can have a proper debate.

Tooth decay causes pain and suffering, but it is rarely life-threatening, and even if the evidence behind fluoridation is to believed, it is not a cure for the disease.  It merely lowers the risk.  Once cannot use the arguments that would be used to combat national medical emergencies because caries is rarely a threat to life. It may be considered that we have a moral duty to protect those who cannot help themselves (children) but is it for the state to do this in this fashion for something that, as we have seen, has been proven to cause definite harm?  Most of Europe has seen marked reductions in caries rates over the decades without having to resort to water fluoridation, something that has been seen across this country also.  I feel the best interests would be met by a national dental public health campaign, with the empathise on sugar reduction.

 

Does Water Fluoridation respect the concept of Justice?

There are different theories on justice, and there is little room for me to discuss them in this assignment in great detail.  When we come to the four traditional theories of justice:

  1. Utilitarian theory, which states that the greater good goes to the greatest number of people, it would seem at first glance that fluoridation meets this (if we assume it is effective)
  2. Libertarian theory favours an individual’s rights. Clearly, fluoridation contravenes this.
  3. Egalitarian theory, which states that people should be treated the same. Yes, they all get the same water supply, but do we all take delivery of it in the same way?
  4. The Communitarian theory asks “is what I am doing make society better?” It is all about the good of society

In basic terms though, Justice is concerned with fairness and equality.  Is water fluoridation a just way of distributing resources?  Well if it works, then it will reduce dental caries.  Roughly forty-five thousand, six hundred children had teeth extracted in hospital under general anaesthetic in the 2013-2014 tax year in England, costing tens of millions of pounds.  This was also theatre space that could have been used for other conditions, thus stretching available resources and delaying operations.  For a condition that is predominantly preventable, this is an unacceptable burden on socialised medicine, not to mention the burden it imposes on the young bodies undergoing the procedure.

Surgical intervention is always going to be the more costly form of dealing with the problem.  But it is very easy to concentrate on tooth decay, rather than what is causing it, the predominant causative factor being dietary sugars.  As we know there is a recent surge in empathise that sugar is a cause of a great many of our ills.  Heart disease, high blood pressure, obesity and diabetes are all linked to high sugar intake and wreak havoc within the health service costing it billions.  Whilst water fluoridation (if the advocates are to be believed) reduces caries and thus saves money from dentistry, does it perhaps add a perverse incentive?  An understanding of human nature might suggest that, if people felt that there was some “magical” protective chemical in their water, they might not be so inclined to reduce their sugar intake, thus increasing the risk of other, more serious diseases.

Fluoridation might not be as fair as we think.  From a cost perspective in treatments avoided and the relative cheapness of its implementation (Studies in the USA show that, in 2017, fluoridation costs an estimated $1.04 per person-year on the average) it may appear at first glance that it might be the most cost-effective use of available resources (reportedly lowering surgical intervention for tooth decay).  It could, however, be argued that this cost saving is offset by the later need to intervene and treat fluorosis.  This might not even be an impact on the public purse, because as we hear time and again from the NHS (NHS Choices. 2017), cosmetic dentistry is not generally available.  So if the state is not willing to repair the damage caused by their intervention, is this not again impacting the lower social classes?  Where is the fairness there?

 

Summary

One of the conclusions I have come to is that fluoridation is a form of mass medication.  It is not an essential nutrient; in fact, the human body limits the amount in human breast milk no matter what the concentration of that consumed by the mother.  The only reason to add it is for its therapeutic effects. And I would argue that no health professional would want to prescribe a medication without some means of controlling the dose.  This cannot be done with water fluoridation.

So to answer the highlighted key ethical questions:

1) Is fluoridation mass medication, and if it is, is it acceptable to mass medicate a whole population in a way that makes it almost impossible to avoid without their full consent?  From the research I have done I would argue that it is.  Whilst beneficence is often placed above autonomy when it comes to matters of public health, they have to be taken together with the other ethical principles.  With the harm that is potentially caused, and the lack of any definitive evidence, I cannot see how the autonomy of the individual can be overridden through mass medication that allows the wealthy to escape its impacts should they wish to.

2) Do the benefits of fluoridation outweigh any risks?  No.  I feel that the evidence for fluoridations benefits are poor, whilst the evidence for its evident risk of harm are strong.

3) If we are mass medicating, is it acceptable to do this when the dose cannot be controlled?  For fluoridation to be effective, the water has to be consumed, and like with any medication that is taken outside of direct medical supervision, there is no way to control this.  So there is no way to determine if the people it is aimed at are even drinking it.  I have often heard the comment from a parent that their child “doesn’t drink water”.  Whilst at one part per million there is very little risk of overdoes from the water itself, we have to remember this is not the only source of fluoride, and that the effects could be cumulative.  If we are going to argue that fluoridation is a form of medication, then it’s dose must be controlled, and this cannot be done through the public water supply.

4) If the benefits are as described, is it acceptable to deprive fluoridation to those who could benefit from it?  Fluoride is limited in breast milk and it is not an essential nutrient suggesting it is not required for health.  To just rely on water fluoridation is lazy and risks being ineffective.  From an initial cost benefit it appears attractive, but as I have stated, I believe that this in itself is a form of inequality.  To use the emotional argument that its “for the children” deflects from the public duty that we as a society should be doing more for our children than dumping fluoride in the water they might not even be drinking.  I think it actually risks harming proper oral health delivery.

5) Is it for the people to decide or the state?  Our constitutional monarchy states that the people, through their elected representatives have the final say in how the country is run.  However, it is fair to say that the average person, with a reading age of 11, might not be able to understand complex medical issues and that policy should be guided by experts in the field.  Until definitive evidence is discovered the proves water fluoridation works however, I feel it is for local populations to decide on fluoridation.

6) Does fluoridation meet the four ethical principles?  From what I have found, I don’t believe it does.  It definitely doesn’t meet the principle of autonomy.  Its lack of clear evidence puts a question mark on its beneficence and the fact that it has been proven to cause harm indicates it fails the Nonmaleficence test.  I could not reach an opinion with regards to Justice.

 

I Therefor reject the concept of water fluoridation as unsound when based against all four principles of medical ethics.

 

 

Bibliography

American Dental Association.  5 reasons why fluoride in water is good for communities.  Available at: http://www.ada.org/en/public-programs/advocating-for-the-public/fluoride-and-fluoridation/5-reasons-why-fluoride-in-water-is-good-for-communities (Accessed 24.04.17)

Anna L. Choi,1 Guifan Sun (2012).  ‘Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis’. Environmental Health Perspectives 2 volume 120 | number 10

Briffa, D. http://www.dailymail.co.uk/health/article-71246/Is-fluoride-good-us.html (Accessed: 24.04.2017)

British Fluoridation website.  Legal aspects and decision-making.  Available at https://media.wix.com/ugd/014a47_843402a2d7b740a79307b32f038cec11.pdf (Accessed 01.05.17)

Buachamp T, Childress J (2013)  Principles of Biomedical Ethics. Oxford University Press, 7th edition

CDC (2001)  ‘Centers for Disease Control and Prevention.Recommendations for using fluoride to prevent and control dental caries in the United States’. MMWR Recomm Rep. 50(RR-14):1–42. PMID 11521913.

Centre for Reviews and Dissemination (2003) What the ‘York Review’ on the fluoridation of drinking water really found Originally: 28 October 2003 A statement from the Centre for Reviews and Dissemination (CRD). Available at https://www.york.ac.uk/media/crd/Fluoridation%20Statement.pdf (accessed 24.04.2017)

Cohen H, Locker D (2001).  ‘The Science and Ethics of Water Fluoridation’. J Can Dent Assoc 67(10):578-80

Curtis, J (2015)  http://www.dailymail.co.uk/news/article-3374613/Fluoride-bone-cancer-claim-experts-call-halt-adding-chemical-drinking-water.html#ixzz4fA5rR1mp (Accessed 24.04.2017)

Das K, Mondal NK. (2016). ‘Dental fluorosis and urinary fluoride concentration as a reflection of fluoride exposure and its impact on IQ level and BMI of children of Laxmisagar, Simlapal Block of Bankura District, W.B., India’. Environmental Monitoring & Assessment 188(4):218.

Dosari, A etal (2004) ‘Caries prevalence and its relation to water fluoride levels among schoolchildren in Central Province of Saudi Arabia’. Int Dent J. 54(6):424-8.

EU Directive 2004/27/EC – http://www.biosafety.be/PDF/2004_27.pdf, accessed 02.05.17

Health and Social Care Act 2012, London:  The Stationary Office

Iheozor Z etal (2015) ‘Water fluoridation for the prevention of dental caries’, Cochrane systemic review.  Available at: https://www.ncbi.nlm.nih.gov/pubmed/26092033 (Accessed: 24.04.2017)

Jones SBurt BA (2005).  ‘The effective use of fluorides in public health’. Bull World Health Organ. 83(9):670-6 Sep 30.

McColl v Strathclyde Regional Council 1983 S.C. 225

McDonagh M etal (2000): A systematic review of public water fluoridation. Centre for Reviews and Dissemination, University of York

MHRA (2007). ‘Personal communication’.  Nuffield Council on Bioethics Public Health: Ethical Issues, p.130, reference 59.

Naish, J (2015).  Available at: http://www.dailymail.co.uk/news/article-2967791/Is-tap-water-poisoning-troubling-question-s-lips-scientists-war-fluoride-water-protect-teeth-spark-depression.html#ixzz4fA5h0PB9  (Accessed: 24.04.2017)

NHS Choices (2017) NHS Dental Services explained. Available at: http://www.nhs.uk/NHSEngland/AboutNHSservices/dentists/Pages/dental-services-available-on-the-NHS.aspx (Accessed:10.05.17)

Peckham, S.,  Awofeso, N. (2014). ‘Water Fluoridation: A Critical Review of the Physiological Effects of Ingested Fluoride as a Public Health Intervention’. The Scientific World Journal2014, feb 26, 293019.

Peckham S, Lowery D, Spencer S (2015).  ‘Are fluoride levels in drinking water associated with hypothyroidism prevalence in England? A large observational study of GP practice data and fluoride levels in drinking water’ J Epidemiol Community Health 69:619-624.

Public health England (2014).  Water fluoridation Health monitoring report for England 2014.  London: the Stationary office

  1. (on the application of Milner) v South Central SHA Queen’s Bench Division (Administrative Court) [2011] EWHC 218

Sebastian ST, Sunitha S. (2015). ‘A cross-sectional study to assess the intelligence quotient (IQ) of school going children aged 10-12 years in villages of Mysore district, India with different fluoride levels. Journal of the Indian’.  Society of Pedodontics and Preventive Dentistry 33(4):307-11.

The Water Fluoridation (Proposals and Consultation) (England) Regulations 2013 2013 No. 301, London:  The Stationary Office

Treasure E, Chestnutt I (2002).  ‘The York Review – A systematic review of public water fluoridation: a commentary’.  British Dental Journal 192, 495 – 497

Water Act 2003, London:  The Stationary Office

Water Industry Act 1991 sections 87 and 88, London:  The Stationary Office

Whelton H, Crowley E, O’Mullane D, Cronin M, Kelleher, V (2003) North-South Survey of Children’s Oral Health 2002. Cork: Oral Health Services Research Centre, University College Cork