Now, if you’re like me (which in all fairness you probably aren’t, because you don’t likely spend a fair proportion of your week driving up and down motorways or waiting for late trains) you’d find yourself picking up all sorts of extraneous messages and
thinking: “Now, how might that apply in dentistry?” As I say, you’re probably not like me, so the subject of the threat to Giant Sequoias probably hasn’t crossed the threshold of your perception. But there we go.
Now the Giant Sequoia (GS) is probably the largest living entity ever to have arisen on the Earth, with a trunk that may exceed 40ft in diameter, and a height of, oh, I don’t know, 400ft or something. Anyway, they are huge, simply huge. They’ve been around since at least the dinosaurs, with the oldest specimens possibly 2,000 years old. You get the idea, but the problem I picked up on is that climate change is potentially threatening their future (this was on Radio 4, honest). So the US
National Parks Authority has set up a task force to consider what, if anything, should be done about it.
For some reason, at the time, I was thinking about our own ‘dental climate change’ issue. How – more or less about the time of the dinosaurs – I used to go into care homes (they were called old folks’ homes then) and re-make, repair and copy full-full dentures. There was the occasional stump for removal, but mostly it was trial by acrylic.
Now the picture is very different. For one thing, you can’t trust a dentist to go into a care home alone anymore. Chaperonage, risk assessments, clinical waste protocols and the CQC and so on have all conspired to make such a visit on a par with an attempt on the summit of Everest. But I digress. The other big change is that the residents of care homes have
teeth… lots of them. Many of them are, at least when they’re admitted, pretty vital, many with restorations or root canal fillings or crowns. That’s quite a change of climate.
Unfortunately, we don’t have any equivalent of the US National Park Ranger service. So residents are often left to their own dental devices. If someone notices that they’re not eating, or in obvious pain or discomfort, it’s often down to the relatives to arrange transport to a local dental practice. A few areas do have some sort of regular coverage, but the salaried dental
services are sorely stretched these days and such domiciliary services are not in general commissioned through primary
care contracts. So first, as the elderly population increases, we need some rangers.
Back to the GS. The rangers, after a lot of thought, have come up with the ‘Four Re’s’. And I want to commend them to
you, because I think they’ve come up with a paradigm for dentistry, especially in the elderly (people as well as trees).
Firstly, restraint. That’s as in ‘restrain the impulse to intervene’. Or, only do something if you’re certain you’re not going to make the situation worse in the long run. Do your planning carefully.
Second, resistance. Do everything you can to make sure that the patient can cope with the challenge: apply fluoride,
fissure seal, make self-cleansing, advise and inform.
Thirdly, resilience. Make sure that whatever you’re going to do will not negatively affect the patient’s ability to maintain optimal health in the longer term.
And fourthly, very much fourthly (it’s still a bone of contention even in the National Parks Service) re-configure. After much deliberation and only when you’re sure the first three strategies aren’t going to work, think about reconfiguration.
Now, in the tree sense, this was all about trying to make the best of the current situation, and only when all others seemed poor options, consider replanting the groves by seeding new trees at a higher (cooler) altitude.
In the dental sense, and echoing the one thing that works for me in the new GDC Standards, this could mean, “treat every patient preventively and holistically”.
As I said at the beginning, you’re probably not like me (thank heavens, I hear you say, with all this tree stuff). But as a mantra for looking after our increasingly long-lived dentitions, often, as time goes by, with co-morbidities and long-term conditions such as dementia, the four Re’s have quite a bit going for them. Now we just have to find the rangers.