Previously

Trends come and go. One that I have noticed recently is the use of 'previously' at the beginning of television series' episodes. Most often it is a male voice with a serious, usually slightly mysterious nuance spiced with a pinch of menace. In line with everything being shortened to as few characters as possible it replaces 'the story so far'.

Previously, when I was studying dental public health as a postgraduate, I had the privilege of attending lectures by the late and great Professor Aubrey Sheiham. One particularly engaging presentation was his analogy for caries prevention. He asked us to picture a warm, pleasant summer afternoon in the country with someone walking along a riverside. The tranquillity is suddenly, urgently, broken by cries of help from a person drowning. Wading and diving in, the walker emerges some minutes later and the two of them land wet but safe on the bank. Hardly any time elapses before a second casualty is seen flailing about in the water and the walker splashes back in to successfully make another rescue. Remarkably, the scenario continues with person after person requiring assistance to the extent that even those hauled from the waters and now sufficiently recovered are taught to life-save and dive back in for the common good.

As the banks get congested with those recuperating and training, our walker takes a moment to think and ensuring that the growing population can do without his immediate presence, paces upstream. Turning a corner, a bridge can be seen where with horror the walker observes someone urging and even throwing people into the rapidly flowing waters below. The reason for the casualties is now starkly revealed, prevention may not be straightforward or easy but at least the cause is clear, progress can be made.

The glittering world of high grades, high entry standards and high achievement is in some cases crashing and burning the lives of young people.

Previously, in November 2020 we published a paper which surveyed the stress, distress and burnout in UK dental students.¹ What I find disturbing is that, like Aubrey's riverbank Samaritan, these authors identified a root cause of some of the mental ill health that is being repeatedly discussed within dentistry today. We continue to receive submissions of letters and opinion pieces from young people clearly touched by these troubles. Yet what are we doing to stop them falling from the bridge? And I pause here for a moment having carefully considered the proximity of this analogy to the real world of distress. I concluded that, from personal experience in deference to, and in memory of, colleagues lost through mental ill health that they would approve the juxtaposition if it does, as it should, prompt prevention.

The study found high levels of burnout and psychological distress in their sample of dental students, higher than that typically reported in the literature with a large number classified as being perfectionists (nearly 80%). This, the authors surmise, is not entirely surprising given that places in dental school are highly competitive, with an emphasis on high grades and personal standards. Coupled with a desire to excel, this has been postulated to explain the comparable proportion of adaptive perfectionists seen in medical students, which can equally be applied to dental students. However, this research also found a high level of maladaptive perfectionism (35%), higher than that typically found in the student population levels of perfectionism. This seems to be increasing over time, attributed to cultural changes such as the rise of greater competition, meritocracy and demanding parents.

We, that is wider society, parents, peers, career advisors, admissions tutors and dental colleagues are at the least negligent and in the further extreme complicit in urging on this system. The glittering world of high grades, high entry standards and high achievement is in some cases crashing and burning the lives of young people. Were there not ways of predicting this we might be forgiven. But as the paper by Collin et al. clearly demonstrates there are tests that can be done to identify, and therefore caution those with personality characteristics who might have a predilection towards stress and distress in a profession widely acknowledged as tough and liable to threaten their wellbeing. Think for a moment of other areas of preventive medicine where testing and assessing the results leads to advice to take, or not to take, and courses of action.

To borrow a saying from our cousins across the Atlantic 'there's another national anthem and it's not the one that's playing in the ballpark'. So the trend at the dawn of 2021 as it heralds the beginning of a whole new way of thinking about and delivering oral care should not be 'previously', not even subsequently, but consequently. It is time to pause on the riverbank and think seriously.