Kevin Lewis: does the term 'dentistry' need a rethink?

Whoever would have guessed that a debate on gender identity would have such resonance for dentistry? Kevin Lewis uncovers some unexpected lessons for us to consider.

Last month’s landmark ruling in the Supreme Court on the sensitive question of legal gender ie what is and isn’t a ‘woman’ in the eyes of the law, has unexpected parallels for dentistry. The recent ruling was specifically in relation to the correct interpretation of sex and gender in the context of the Equality Act, of course, but its practical tentacles have spread much wider than that and opened up a much wider debate.

The parallels to which I refer are topical questions like what is or isn’t a ‘dentist’, what is or isn’t ‘dentistry’, and why most university degree courses still cling to the somewhat historic description of ‘dental surgery’. Which invites the further question of what is or isn’t ‘surgery’. Rather like the debate on gender, we all thought we knew the meaning of these terms but perhaps it’s time for a rethink?

‘Eery silence’

A fundamental aspect of that rethink is the GDC’s ongoing review of its Scope of Practice guidance – which started way back in 2019 and in the intervening years has included stakeholder virtual workshops, online events, independent research, formal consultations and other kinds of virtual activity. It even resulted in the emergence of a draft of a revised guidance, and a consultation on that, but latterly the drawbridge has been raised, discussions have been happening covertly and never seeing the light of day in the public record of the Council’s regulatory work, and an eery silence on the subject has descended.

Whether or not the Council members have been kept in the loop is anyone’s guess. This never-ending story is unhealthily bound up with the government’s ambitions for addressing the dental workforce crisis, and unsurprisingly there are growing suspicions of government and other external interference in a supposedly independent regulatory process.

The irony of all this intrigue is that while all this nefarious activity is designed to lay the ground for individuals to widen their scope of practice (with little or no checks or quality assurance by the GDC, it appears), other factors are at work which result in individual registrants shrinking or limiting their scope of practice – especially in the NHS.

The calamitous UDA system has de-skilled a large slice of the dental workforce in England and Wales, who allegedly have convinced themselves that they can no longer carry out many of the things they were trained to do during their years at dental school. Complex restorative work and endodontics, along with minor oral surgery have since 2006 become opt-out aspects of a dentist’s scope of practice (SOP) – and seemingly with the GDC’s blessing given the wording of both the existing and draft revised SOP guidance.

Thanks, but no thanks

And then there is the uncomfortable fact that most of today’s graduating dentists have no appetite for spending their career treating caries and periodontal disease, and relieving pain, when they could be more gainfully occupied on cosmetic dentistry and facial aesthetics or finding minor malocclusions to shuffle with aligners.

Part of the strategy (it appears) is to avoid long-term relationships with regular patients who might need treatment and ongoing maintenance, and instead to use social media to seek out lucrative one-night stands with patients who want (rather than need) specific high-ticket and usually cosmetic procedures to enhance their personal perception of body image.

I have made the point in previous columns that abandoning the stage of everyday ‘dentistry’ and leaving it unattended is not without risk for dental registrants because it is almost inevitable that a tipping point will be reached and others will arrive on stage to fill that vacuum. Almost certainly with the blessing of the government of the day.

We can learn a lot from the twists and turns that have been engaging our medical colleagues and the General Medical Council over the issue of physician associates and anaesthesia associates. In both general practice and hospital settings, exotic new species have been appearing and increasingly involved in patient care and it is little wonder that patient surveys have revealed that patients have little or no idea of who’s who or who does what these days. From the politicians’ perspective, just what the doctor ordered methinks?

The GDC is at pains to point out that its SOP guidelines set out the range of skills and competencies that registrants in each registration category should have, at the point of their (first) inclusion on the register. After that their scope of practice is likely to change reflecting further training.

The GDC is quite prescriptive in its oversight of the undergraduate curriculum up to the point of first registration, but inexplicably hands-off in its oversight of any training undertaken by individuals beyond that. And that laissez-faire approach extends across all registrant categories, leaving individuals free to decide when they are appropriately and sufficiently trained (and competent) to carry out any procedure that they fancy undertaking.

I wonder if this was explained to all those patient representative stakeholders who attended all those online/virtual workshops and other events?

Undergraduate

The dental schools and the degree-conferring universities beyond them are left in an increasingly strange position – training students to carry out procedures that they may well never undertake after graduation, while studiously not training them in the very procedures that the students can’t wait to get their teeth into (so to speak).

Given the cost of delivering any kind of higher education, let alone dentistry which is amongst the most costly and largely borne by taxpayers, it is an open question as to whether or not the status quo is sustainable, or even logical.

The consequences are amplified by the fact that too many new and recent graduates then get their training in these procedures – implant dentistry being foremost amongst them – from sources which have a direct commercial interest in promoting these procedures and expanding the market, and no responsibility whatsoever when things go wrong.

The fact that these courses are shorter, cheaper and less structured and challenging than more formal, recognised and reputable training programmes in the market, makes them (dangerously) more attractive to the impatient and indebted young graduate.

Perhaps we should call in the services of the Supreme Court to tell us the difference between a recognised education provider, and some of the illusory ‘academies’, ‘institutes’ etc that purport to be the direct equivalent, led by impressive-sounding professors, associate professors, visiting professors and honorary professors of educational institutions that the world has yet to hear about.

Safe spaces

A lot of the debate about sexual identity and gender has centred on the need for and desirability of so-called ‘safe spaces’. Similarly, surely a dental surgery should be a ‘safe space’ where members of the public can be assured that they are being treated by someone who is appropriately qualified, trained and competent and who is not left free to ‘big themselves up’ on social media and then attempt procedures that they are wholly unprepared to carry out and/or retrieve if things don’t go to plan.

While it is true that the GDC can step in and exercise its fitness to practise procedures after the event, that is hardly the point. And nor is it effective regulation to sit back and allow bad things to happen when with a bit more effort and application, they might have been avoided.

Girls on top

But having lured you in to this column by a title promising sex, there is a slight justification for my having done so. Back in the 1990s, 70% of registered dentists were male. The allocation of dental school places was then genetically engineered to address this imbalance, and today male dentists are in the minority, only 47% being male, against 53% female. Amongst younger age cohorts the female majority is much greater.

But across other registrant categories the gender split is extreme – much more extreme than for dentists back in the 1990s. Ninety eight percent of dental nurses and 94% of orthodontic therapists are female, as are 91% of hygienists and 86% of dental therapists. But at the other extreme, only 30% of dental technicians are female, and a tiny 1.5% of clinical dental technicians.

I should clarify here that the calculation of 1.5% of CDTs is on a more scientific basis than Keir Starmer’s curious assertion in 2023 that: ‘99.9% of women haven’t got a penis’. How he came to that conclusion remains a mystery – and will hopefully remain so – but we are told that he now welcomes the clarity that the Supreme Court ruling has provided. I am sure we are all pleased for him.

Does the term ‘dentistry’ need a rethink?