Frontline Reflections – In the Clinical Workplace. Contradictions and Dilemmas of Providing the Best Care. Part 1 of 2.

I had a sense of dread before this morning came. Appear, today, it did. The client arrived and was sitting, awaiting my call. I read the clinical notes from previous locum hygienists, looked at the dreaded BPE scores and sighed, there was no staging and grading, but there were 4’s in much of the sextant readings. That wasn’t so unsurprising. I’ve seen many, even missed doing some myself on occasion or seen scores not warranting them only to find it necessary upon my assessment. These are trying days, indeed. I saw their age, insurance plan status of 2 appointments only a year and no evidence that further appointments were required or deemed necessary. I hoped, more than anticipated, that this was an aberration and that a miracle would occur upon venturing into the client’s mouth. This would be a routine appointment with little or nothing to concern me.

 
There were multiple mobile teeth, loose multi-unit bridgework and the telltale redness in the free gingivae, generalised and pleading for release from long-established, chronic ill health. The client’s initial concerns were a loose denture, and I ventured that they might be able to reline it in the future. This was before they alluded to being mistaken and had a mobile upper anterior bridge that had been loose for quite some time. The elderly client was very stoic and compliant with the treatment I provided them, with clearly understood explanations of what I was carrying out and where it was the most concerning. The causes and processes required by me and, ultimately, themselves to help restore stability to their oral health and long-term function. My carefully crafted questions considered and directed at their responses to instrumentation and their current oral health homecare practices. At every moment, I was acutely aware of the precariousness of this poor mouth and the lack of knowledge and information they possessed. Would the bridge work fail during the appointment due to my instrumentation? I sensed they were concerned, and I trod carefully and cautiously to mitigate that potential outcome. Under my breath, I cursed my misfortune in treating this poor soul. They were worried enough to come for care, ignorant of the fundamental nature, poor dental health, and their mouth and the likely outcomes that could affect them dentally.

I felt helpless and knew they needed multiple appointments, even a referral to a Specialist in Periodontology. Going on what they had experienced before, I knew this would be a considerable surprise and potential cost to them. This is the culmination of, more than I could mention, similar situations where a cool head and a calm hand were essential to deal with the case at hand. Deep in my clinical soul, I am enraged about this. I am struggling to find answers to such dilemmas and am considering retraining in something less distressful after more than thirty years of practice. This situation is getting worse than what I experienced from similar practices before I left to live and work in New Zealand in 2013.

 
As an aside, the bigger question is, what in the hell happened to dental health in the UK in my absence? This is based purely upon my experience journey, perhaps not the big picture but cause for concern as I look to see the end of my clinical career on the looming horizon. Firstly, The Pandemic greatly impacted the population, the provision of dental care, and approaches to dental hygiene practice in particular. Anecdotally I recall reading many social media threads about the trials and tribulations of not being able to use the trusty ultrasonic scaler in preference to hand instrumentation, weeks, months, even in lockdown, unable to treat clients in whatever periodontal status they had at the time. The emotional, physical and economic stress to both client and professional must have been immense, and its impact not understated. Secondly, the apparent lack of proper instruction, such as deep debridement or supra gingival hard deposit removal, appears to be negligent. Is this because of a clear singular approach to instrumentation?The evidence demonstrated that there was no preferential benefit from either, both needing essential oral health instruction to ultimately bring about healing and resolution. Is the only utility of ultrasonic instrumentation one of goal production? Is this at the expense of guided, blended care withoral hygiene instruction in all its facets? I see Dental Corporates now breaking down dental hygiene care into 15, 20 and 30-minute blocks for scaling, scaling and polishing and the latter with an element of so-called “education”. Have things sunken so low? Have the shades of dental health in the UK been thus polluted? The future appears grim from my perspective, if this is truly the case.

 
Back to the individual, I saw this morning. My oral health advice was simple, measured and guided. Effective electric toothbrushing and shaped interspace brushes were demonstrated intra-orally and with a mirror for split bristle adaptation subgingivally. They left, saying they had never had such professional, in-depth plaque and hard deposit removal with care. I felt uneasy as I knew I had not removed all that I could but beckoned them to return in 6 months, their allotted recall time. I felt devastated as I could do no more as time only permitted what I could achieve. Likewise, would asking them to consider paying for extra appointments, the recommended standard approach, be seen as an admission of potential negligence by previous practitioners as they have been seen regularly every six months to that point, despite COVID? At this point, my grievance extends to “so-called” auto-generated written notes, not contemporaneous in any way, shape or form. They are just cut and pasted, edited, added to, and display an inappropriate lack of intimate and essential information. It is, in my opinion, a crude “cut and paste, get me out of jail” card if they poorly treat and get hauled up in front of the GDC for poor professional care in the name of defence practice. It sickens me we seem to have to do this now.

To end this part of my reflection, I am awaiting the outcome of a discussion with the practice owner regarding this case and a few other things that made handling this with care more complicated than it should be. This involves one very slow computer, the sale of 2 three pounds sterling Interspace toothbrushes, and the doctrine of the practice regarding giving them to the clients, on occasion, for free, in the name of best mindful and clinical practice. This is unwritten as yet but I am concerned that I may “lose it”, hence the beauty of being pre-reflective, on this occasion.