Kevin Lewis: turf wars in dentistry

Do we really reap what we sow? Kevin Lewis examines whether or not the old proverb is right.

Sod it. And I mean that in a constructive, horticultural kind of a way, rather than in any defeatist or exasperated sense. Although on reflection that might change before we reach the end of this column.

We have seen it happen in just about every other profession, industry or market sector so we should hardly be surprised that it’s been happening in dentistry too.

Once upon a time petrol stations sold petrol, newsagents sold newspapers and ticket offices sold tickets. And in those far-off days not only did dentists do dentistry, they also enjoyed an enviable level of legal protection when doing so (for example, the titles ‘dentist’ and ‘dental surgeon’ were legally reserved for registered dentists, and that remains so today).

These days, petrol stations have become roadside emporia, selling coffee and just about anything and everything that fits into the boot of a car – and petrol too. Newsagents still sell newspapers (and cigarettes) but fewer of both.

And ticket offices (when they exist and are open) provide information, excuses and apologies to people who bought their tickets online because it’s cheaper, and now wish they hadn’t bothered. And most of the above outlets are keen to sell vapes and vaping accessories to anyone who isn’t buying cigarettes or newspapers. Or petrol.

Businesses diversify when their core market drifts away from them, when they feel threatened competitively, or when they sense encroachment upon their traditional ‘turf’.

Or in the case of dentistry, sometimes simply because they sense that the main chance lies elsewhere and don’t want to be left out in the cold clutching a mirror and probe when the real party starts.

Call me Doctor

It was 29 years ago this very month that UK dentists were freed from the longstanding prohibition relating to using the courtesy title ‘Doctor’ as adopted by most medical practitioners. While many dentists were quick to grasp this new freedom with both hands and felt it gave them an enhanced status in the eyes of patients and third parties, many others chose not to use the title.

The slight anomaly was that dentists are technically dental surgeons, and their direct medical counterparts choose to demonstrate their own distinctive status by shunning the courtesy title ‘Doctor’ and instead referring to themselves by their alternate title (Mr/Mrs/Ms/Miss) (other pronoun options are also available – but that’s another story).

Dentists’ use of the courtesy title sparked an epidemic of complaints made to the Advertising Standards Authority (ASA) on the grounds that consumers were being misled into believing that the dentists were medically qualified, when they were not. Several ASA rulings ensued, preventing the dentists in question from placing advertisements which referred to themselves as ‘Dr’, even though it was permitted by the General Dental Council (GDC).

It later came to light that almost all of these complaints had originated from local medical practitioners directly or indirectly, essentially because they resented mere dentists encroaching upon their ‘turf’. A bit rich, given that these medics graduate – just like dentists – with bachelor’s degrees rather than doctorates.

Specialist squabbles

Barely a couple of years later the GDC was establishing its first specialist lists, and that took the topic of dental ‘turf’ to a whole new level.

Those who had completed recognised, formal specialist training and achieved higher qualifications – with a significant investment of time, money and effort – did not take too kindly to the battalions of general dental practitioners who were claiming equivalence without having made a comparable investment and wanting to be included on the same specialist lists (and in many cases, several of them) with all the attendant benefits.

A couple of decades have passed since that unsavoury arm-wrestle, but the debate about opening up new and easier routes to specialist status has not gone away. In July of this year, the GDC launched a 10-week consultation on some proposed amendments to the Specialist List Assessed Application (SLAA) routes based on equivalence – so brace yourselves.

On the subject of bracing yourselves, orthodontics was regarded by many as a kind of specialty long before formal specialties were created in the shape of specialist lists. But some time later a hungry new kid appeared on the block.

The aligner companies were keen to reach the softer underbelly of the much bigger GDP non-specialist market and they had become adept at doing that, persuading the clinicians that it was easy peasy, predictable and profitable, and helping them to persuade patients that it was quicker, cheaper, simpler, invisible and less intrusive than conventional ortho, especially for adults (which is where the big money resided).

Then the direct-to-public approach gathered pace with not-always-gifted amateurs doing digital scans in shopping malls and having the aligners mailed to the patient without troubling a dentist. Very quickly, the dental profession wanted to know what the GDC was doing to stop that.

The specialist orthodontists were often left to pick up the pieces, muttering ‘I told you so’ under their breath no doubt.

On manoeuvres

Some general dental practitioners have gone walkabout into non-surgical cosmetic injectables and other areas of facial aesthetics – including laser therapies, IPL, microneedling, dermabrasion and facial peels – but have been properly miffed when the health and beauty industry fought back and invaded areas like tooth whitening.

We have all just emerged from Halloween and a huge amount of money will have been spent on green, red, black and orange tooth glaze and clip-on and/or stick-on Dracula fangs and witches’ teeth.

Incidentally, some of them look heaps better than many of the full dentures I fitted in my youth, and their online vendors got paid a lot more than I ever did. But nobody is suggesting that this is the (illegal) practice of dentistry because it doesn’t carry a big enough ticket to worry about.

Snoring/sleep apnoea is another, bigger-ticket area where dentists are not the only people who feel that they have the best skillset to treat this, and the most skin in the game.

Implant dentistry is not recognised as a formal specialty but is probably the most contentious and fought-over turf for the dental profession, and not surprisingly several specialties lay claim to being its natural home.

They would say that, wouldn’t they? The implant manufacturers and suppliers are not blind to the fact that non-specialist GDPs are by far the biggest and potentially most lucrative market sector and the ‘come on in, the water’s lovely’ seminars and training courses are purpose designed to stake out and capture their share of that market before somebody else does.

History repeats itself in one country after another so there should be few surprises for us in these developments, and we are also seeing that unfold in terms of the current promotion of zygomatic and pterygoid implants, extending the market by literally reaching the parts that other implants cannot reach.

As for how much time your average undergraduate dental student spends in and around the zygoma and pterygoid aspects of the sphenoid bones, I have my doubts. Likewise ribs and iliac crests, although some enjoy visiting those distant planets quite regularly.

So the jury is still out as to whether all this falls within the scope of dentistry at all (and if so, is that only within the scope of the dental specialty of oral surgery?) or whether it is more properly part of the scope of the medical specialty of oral and maxillofacial surgery. Ask these three groups and you will get four different answers.

Monopoly

A long 20 years ago, dentists lost both their almost-complete monopoly on the business of dentistry (ie owning and operating a dental practice) and their exclusive right to contract with NHS bodies to provide dental services, but they still enjoy a near-monopoly status regarding the practice of dentistry.

Bang in the centre of that surviving near-monopoly are the very things that many dentists appear not to want to do any more (at least, not on the NHS).

But solicitors lost their monopolies on conveyancing and grants of probate some time ago, just as opticians lost many of their historical monopolies in stages from the 1980s. Barristers have seen the erosion of their monopoly on rights of audience and advocacy in certain courts, and medics would be hard pressed to remember which (if any) monopolies they still have.

The moral of the story is that if you leave your turf unattended, or are seen to be acting fast and loose with it, you run the risk that others will invite themselves (or be officially welcomed) onto it. Nothing lasts forever.

On which subject, there is no greater mystery and intrigue in dentistry right now than the current state of play regarding the GDC’s long-promised and much-consulted-upon revised Scope of Practice guidance.

While curiously keeping the final version (promised September 2024) under strict secrecy and armed guard, the GDC is going to unprecedented lengths to assure everyone that nothing within that guidance will change the scope of practice of any registrant group (note the weasel words here).

So much so that one is left fearing that they are indeed going ahead with their draft proposal to leave each and every individual registrant free to decide what they can and can’t do, how far off-piste they can stray and whether they are sufficiently trained, competent and indemnified to carry out a particular procedure on a particular patient on a particular occasion – all with no checks and balances falling on the GDC’s shoulders.

The individual registrant becomes accountable if they get it wrong – but the GDC does not. If that remains the case, then the GDC’s preferred approach is abdication, not regulation, and it looks and feels increasingly like a politically-inspired cop-out which is designed to protect and serve the interests of the GDC (and the NHS), not members of the public.

Perhaps it is safer and better for all concerned that this guidance remains buried deep in the long grass into which it has been kicked for so long. And if that grass isn’t long enough, then we might need to sod it after all.

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