Regulating Dentists in the UK by Stephen L. Jacobs

The mention of Wimpole Street in the West End of London, used to induce thoughts of high end dentistry being carried out by the best in our profession, in grand old seven story buildings, a stones throw from Regents Park. However, mention that street now to many dentists and a common reaction could easily be a cold sweat, increased heart rate and a sinking feeling in the stomach.

The reason for this can be explained by the fact that this is the address of our regulatory body, the General Dental Council, otherwise known as the GDC.

Please do not mistake this for the GDC referred to by Shameek Popat elsewhere in in this edition of Dentaltownuk…..this latter institution being the Glasgow Distillery Company, distillers of fine Scotch Whisky, a very different animal altogether.

The last several years has produced increasing concern and controversy on the modus operandi of the GDC, as the number of investigations, potentially leading to Fitness to Practice (FTP) hearings, has escalated, causing years of stress, anxiety, loss of sleep and just the shear worry of the implications of that letter, with that address, with those three letters, when it drops on a doorstep.

We all, including our teams of DCP’s, seem to be living under the spectre of a GDC complaint and the potentially life changing ramifications of what often starts out as a simple, sometimes innocuous complaint.

Let me state at this point, that the GDC is a body designed to regulate our profession and protect the public and therefore our patients. It is thus an essential body and a requirement in the United Kingdom, but what is being questioned is the process and whether many of these cases are actually in the public interest, or whether many of the complaints should be handled locally and resolved at a much earlier stage.

The GDC is aware of these issues and steps are being taken to modify the system, something that has been met with universal welcome within our profession. But on many occasions, the original complaint gets thrown out, yet the defendant still has to defend a litany of administrative anomalies, usually concerned with record keeping.

There is no financial upside for the patient, as if they wish this, they need to take a civil legal action, and sometime they do this as well! This is very unlike the system in Europe, United States and beyond.

I wrote this article originally for the Academy of Osseointegration’s publication, ‘Academy News’, and for the purposes of this particular publication, will not go into the way our GDC works, as we all well aware of the process. But to give an example of how things have changed, around the time I qualified, over 30 years ago, the GDC allocated around 30-50 days a year for FTP hearings, now it is over 1500 days (they use multiple sites) and rising.

As it so happens I don’t think it helps the patients to immediately create an adversarial system where a wall is erected and no communication occurs apart from through solicitors. This is not how victim support works and is not genuinely what people emotionally want in a situation where things have not gone to plan. There will be a better system and it is up to the profession in the UK through our associations and political representatives to find this improved set up, especially while there is a will at the GDC to change things.

So let me get to the point as this is not a resume of the GDC, many of our colleagues have written extensively on this. The reason I write this brief summary of our system is to highlight a recent case that came into my office last year and has caused me to reflect and maybe even understand the reasons for the GDC’s often draconian approach. I am, if you like, presenting a devil’s advocate approach, even somewhat supporting the position that the GDC take.

This is particularly relevant now that we have firm guidance on our responsibilities with obtaining a detailed report for all Cone Beam CT scans that we prescribe. It is the responsibility for clinicians referring for a CBCT examination to provide or obtain a report. I now do not send out any scan to a referring practitioner without a report.

Mrs P was referred for an implant to replace a lower incisor, which appeared a very straight forward case. She also highlighted a missing upper left first molar that she may also wish to treat after the lower central.

After going through the whole assessment process, including intra-oral radiographs, justified, graded and reported of course, we took a cone beam CT scan of both jaws. This showed a good implant site at the lower incisor, a reasonable site at the upper left first molar, but the right maxillary sinus appeared ‘cloudy’ with no visible lumen, it was completely opacified; the left sinus appeared normal. For those who regularly take CBCT’s of maxillae, showing the inferior part of the sinus, this is not an uncommon incidental finding.

Even in the absence of symptoms, when I see this appearance especially unilaterally in a sinus, I refer to a local ENT surgeon, who will normally see the patient and investigate, initially with telescope through the nasal cavity through the osteum and into the antrum. I am fortunate in that we have in our region a very talented and prominent ENT surgeon, who is sensitive to the sinus procedures we carry out in implant dentistry, and is very cooperative when we need to organise a referral. The resulting report is normally an antral cavity full of mucous or even a blockage in the ethmoid region and on many occasions, no further treatment is required, my ENT surgeon will often treat these blockages surgically, through the telescope, if the patient so desires.

For Mrs P, unfortunately this was not the case, because following a further, full skull CT scan and consequent biopsy, the mass visible on our CBCT was diagnosed as a squamous cell carcinoma of the antral lining, with some papillary cells within. Treatment was a wide excision back to the bone, with further biopsy and adjunctive radiotherapy….there goes her upper left molar implant!

As the outlook is positive and Mrs P appears to be relatively lucky as this incidental finding, in the absence of symptoms resulted in an early diagnosis, and from at first being quite a difficult patient to manage, she is extremely grateful and probably a friend for ever. She wrote to me a few months ago saying that all was well, and thanking my team for potentially “saving my life”….a very humbling thought.

Which brings me to the reflective part and to tie in with the first part of this article. If our GDC were not so strict and prescriptive about justification and more importantly reporting on imaging, would I have noticed the left antrum? Would I have referred it? What if I had missed it and the scan was subsequently requested much later, possibly after a diagnosis following symptoms? The potential answers are too terrible to contemplate.

When I mentioned this to my ENT surgeon, and the fact that this had spooked me somewhat, he firstly congratulated me on a very good and timeous referral, but then reminded me of a statement he makes when he lectures on my sinus course - “with findings on CT scans, be scared…..be very scared!”

The postscript to this story is this; in my office we take around 10 CBCT scans every week, give or take, around half of them would be maxillae. In preparing this article, I have referred 5 cases in the last three months, of unilateral opacified sinuses for ENT investigation. Two of these were reported as being mucous filled thickened linings, two of which were blockages higher up in the ethmoid region, and not in the field of view (FOV) of 8.5 x 5.0 or 8.5 x 8.5, my standard maxillary FOV for implant and sinus planning.

One however is now being investigated as potentially neoplastic, which would be the third in three years that we have picked up, if unfortunately it turns out to be as such.

So what are the morals of this story, and what advice can I offer;

Report carefully on all images, including CBCT’s, we take on patients, even areas outwith our immediate focus

Attend a CBCT interpretation course, there are now two or three excellent ones in the UK

If unsure about anything on a scan, have it reported by a dental radiologist

In the case of the maxillary sinus, find and refer any abnormality to a local ENT surgeon, ideally one who is sympathetic to, and understands the work we carry out in sinuses

Any anomaly discovered or reported, refer, refer, refer We have this responsibility to our patients.

Scott Dickinson, DMD