All in the detail

Happy New Year.

As a profession we are, necessarily, obsessed by detail. This probably explains at least partially why dentistry attracts the people it does, the people like us who find problem solving, particularly along practical lines, so satisfying. We enjoy figuring out why, diagnosing and then treating. As time and research continue, we increasingly have the knowledge and tools at hand to accomplish these actions more effectively and efficiently. But what if we didn't have to do any of these other than prevention?

I have mused previously, albeit in 2008 while attending a dental exhibition, on how the foundations of the whole giant construct of the world of dentistry are balanced on microorganisms: ‘My staring took me along rows and rows of other stands, corridors of numbered booths, carpeted lengths of exhibition space in a dozen or more halls from which sprung countless suppliers, exhibitors, sales teams and service providers. What fascinated me most was that it was all there, and we were there and every delegate and visitor was there because of the effects of one of the smallest forms of life, the microorganism. All this huge effort, this vast industry, this enormous and complex profession have been created and continue to thrive, variously, because of the activities of organisms that we cannot even see with the naked eye'.¹

Despite this, it remains difficult to reconcile how the need for prevention is apparently understood and given so much verbal credence by so many but practised by relatively few. That is until one considers human nature and motivation. Prevention in many forms pays us back on so many levels - health, finance, sustainability, convenience - and yet we are all guilty of giving it lip service personally and professionally at one time or another, and often times disregarding its benefits entirely until it is too late. The hope was that the pandemic would provide us with not only pause for thought but with a renewed passion for comprehending the importance of prevention and implementing it with renewed vigour. As I have already observed, I see little evidence of this. In terms of acceptance, we are up against the barrier of human behaviour. In terms of providing it effectively, the difficulty is that dentistry as almost exclusively practised worldwide to date is assessed by the method of counting. How many fillings, crowns, dentures rather than how beneficial is any preventive intervention? How to count that?

So, we are left with interrogating the detail and to this point the future looks increasingly as if the sensible road to tread is that of minimal intervention

The essence here is the divide between qualitative and quantitative service. When it comes to the law, for example, we accept that the process costs money. No one ‘goes to law' with anything other than the knowledge that it will be expensive; none of us expects to receive it at a discount or for free but instead with varying reluctance and ultimate capitulation we resolve to afford it as a necessary fact of life. A crucial factor here is that the service we pay for is qualitative albeit charged quantitatively by measure of fee per hour. Yet we seem unable at worse or reluctant at best to accept the same premise for the delivery of health care, notably dentistry.

So, we are left with interrogating the detail and to this point the future looks increasingly as if the sensible road to tread is that of minimal intervention (MI). However, this is a double-edged sword as it does require a lot of detail and that does cost money. A wonderful example is the paper by Lim et al.² which takes the majority of its length to describe in entirely appropriate, indeed exquisite, detail the minimally invasive selective caries removal from just one permanent molar. While not in the least critical of this approach, I cannot help but wonder at the resources that it took to restore this single tooth. What price the prevention of the microorganism mediated cause? If MI had been applied earlier, perhaps all this time and resource could have been diverted. But other routes to prevention require similar admirable application of skill and knowledge. The remarkably intricate exposition of the use and maintenance of scaling instruments in our Top Tips series exemplifies the dedication required to appreciate angles of honing, degrees of sharpening, and pressure required for optimal plaque and calculus removal.³ Who would have thought it? Do our patients fully appreciate it?

Perhaps then the key to our future progress is to find a way to devise an acceptable way to remunerate the MI route. It has to make sense, but it is all in the detail.