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A recent dental school reunion (30 years) allowed time for reflection on how much dentistry has changed over this time, but in many ways has also remained the same. While most colleagues had worked in a single practice for 30 years and were now reaching the point of selling practices to corporates, it is unlikely that undergraduates who qualify today will have a similar route available, even if they did choose to follow it. Working in a dental school as I do, many students are looking for career portfolios, mixing and matching opportunities to allow personal development. However, what will be lost with an increasingly mobile workforce is the opportunity to learn from our errors, which often only become apparent with time, when working in the same practice over many years. Similarly, my experience in dentistry is that, on occasion, compromises may work, but most often they do not given the hostile conditions in the mouth, both microbiologically and physically. Time often brings to light the folly of clinical compromise, but for many we may not see this.
Learning from our errors and success is of course an important element of reflective practice, and reflecting on these over time, is part of any reunion. While some areas remain very similar to 30 years ago, many have changed and I highlight a few below.
Complaints. On qualifying, I cannot recall being remotely concerned about patient complaints or having much awareness that they occurred. Perhaps my awakening may be part and parcel of carrying out increasingly complex procedures, in an increasingly complex world. Complaints in society more generally, and in dentistry particularly, are increasingly common, and dentistry is an ideal environment about which to complain. While there are many day courses on complaint handling, until you have been on the end of one, it is difficult to know how you will respond. Key again is to reflect, what could I have done differently, what does resolution look like, and as is always the case, a problem shared is a problem halved, so do not suffer in silence. Resilience over a concerted period of time may be necessary, and reflecting, while supported by colleagues, can help during these difficult times.
Mentorship. On qualifying 30 years ago, it felt much easier to push the boundaries of your early training and develop clinically. This freedom perhaps no longer exists. Increasingly, mentorship becomes important to allow clinicians to push beyond their clinical comfort zone, safe in the knowledge that a more experienced colleague will be present to provide some supportive reassurance. This community of practice is becoming increasingly essential to balance the stresses of practice with our own mental health.
Managing patient expectations. A recent conversation with a legal colleague allowed some reflection on public perception of dental care. For example, while the use of luxators and periotomes has allowed improvement in extraction techniques, for the vast majority of clinicians, forceps remain the go-to instrument for extractions. While anaesthesia is now very consistent, the sensation of having a tooth extracted remains traumatic for most, and mitigation will never, in my opinion, entirely remove this. Managing patient expectations of modern dentistry and what it can and can't do remains essential, not only to avoid complaints when complications inevitably arise.
Material advances. Undoubtedly materials have improved significantly since qualifying 30 years ago. Simplicity of predictable bonding allows optimal outcomes, but, as with most areas where quality of outcomes is expected, time is of the essence. When it comes to materials, following instructions and optimising the ideal environment for placement leads to the best outcomes for patients.1,2
Unfortunately, the current NHS system of remuneration does not allow time, and so outcomes are inevitably compromised. Against a background of a more litigious society that often fails to recognize the unique challenges involved in dentistry, clinicians face an uphill struggle. It would be virtually impossible for a lay person to understand the challenges of placing a disto-occlusal amalgam with subgingival margins on an upper right seven for a patient with limited opening and a parotid duct in full flow. Do guidelines allow for these individual patient and tooth factors? Consideration of the harsh realities of clinical dentistry needs at least some attention when designing guidelines, managing patient expectations, or indeed, the expectations of our regulator.
Evidence-based dentistry. While 30 years ago clinical training was experiential, and almost akin to an apprenticeship in many respects, the advent of evidence-based medicine and consideration of the application of best evidence to dentistry was for many an epiphany. In my case, the publication of systematic reviews in periodontology3 was such a revelation. Colleagues who often picked evidence to support their views were now faced with a ready reckoner of evidence, allowing all to make decisions based on best evidence that had been kindly reviewed in a systematic fashion. While understanding how to use best evidence in clinical decision-making is essential for a reflective practitioner, in dentistry, there are many areas where there is only limited evidence available. The answer is more robust clinical trials in real-life circumstances, although managing this in busy primary care practices is often prohibitive.
Dental Update . Considering all of the above elements needed to be a successful reflective practitioner, Dental Update has remained consistent in presenting to clinicians examples of real-world dentistry, with peer review ensuring that the best evidence is presented. The journal was designed exactly for this purpose: to allow clinicians to have a ready source of clinical reflections and best evidence. Dental Update remains as relevant now as it was when I was an undergraduate, and as the journal enters its 51st year, it remains the go-to resource for clinicians across the dental team and across the years. The challenges remain many, but Dental Update remains a key element in our national community of practice. In unity there remains strength, and whether it is CPD, webinars, or a journal through the post, Dental Update remains as relevant now as it did 30 or 50 years ago, at the heart of our community of practice.