There was a time when the understanding of patients was broadly aligned with professional standards – Kevin Lewis asks how this has changed in a world of conspiracy theories and social media driven expectations.
We live in an age of conspiracy theories. The existence of such theories is hardly a new phenomenon but they have blossomed because they now have what they have always dreamed of – rocket fuel to propel them to a whole new global audience in the shape of social media, coupled with a cloak of anonymity for those who feel the need for it.
Many do not, of course; instead they actively crave the attention and pseudo-celebrity that they can receive from fellow conspirators.
On local TV recently I was listening to the parents of a young child (aged six-ish) who had already endured three general anaesthetics to remove 16 of the primary dentition after the teeth had ‘crumbled’ and the child was in agony with toothache.
Various dentists had explained that (and you are probably ahead of me here) caries was evidently the root cause of this sad state of affairs, coupled with the parents’ unwillingness to follow the dietary and oral hygiene advice that been offered.
But all these dentists were wrong, the parents insisted… The real explanation was to be found on social media, where their extensive research had uncovered a massive ‘cover up’ by the local water authority involving illegal discharges of toxic chemicals which were known to ‘rot’ bones and teeth. The source of the toxic chemicals was a local factory, the owners of which all had shares in the water company etc, etc. You can probably invent the rest of the story yourself, and possibly even the denouement when the permanent dentition enters the fray.
The customer reigns supreme
In addition to living in an age of conspiracies, we certainly live in an age where the consumer reigns supreme and what the consumer wants, the consumer should get. Both provide opportunities for misinformation and disinformation to flourish, and alongside this it is also necessary to ‘rubbish’ any real evidence or information that does not suit whatever end you are trying to achieve.
the world’
I would love to think that a healthcare profession like dentistry is above all that, but then again, I am an old-fashioned boy who still believes in the tooth fairy. I also believe that the consumerist lobby and agencies like the (then) Office of Fair Trading did dentistry and dental patients no favours back in 2001 and 2012 respectively when they pressurised the government and, as a result, the GDC into relaxing many of its traditional views on advertising and the promotion of dental services, the balance of power in the dentist-patient relationship, and the flow of information to patients who are weighing up their dental care options especially in the private sector.
The Cresta Run aside, it was about as slippery as a slippery slope can get.
The social media explosion
And here we are in 2025, with UK dental patients left much less protected than in most other developed countries around the world. The no-doubt-well-meaning changes lobbied for by the above agencies could not have anticipated the social media explosion but they have brought us to a more dangerous place, nevertheless. And by ‘us’ I mean patients and dentists alike.
The risk for patients is that they will be ‘groomed’ to want and seek out procedures that they don’t need and which they may well come to regret, like extensive and highly interventive procedures that they hope will emulate their Instagram, Tiktok and Love Island icons and role models.
Picture if you will an elderly care home in years ahead, where every resident has been nipped, tucked, plumped, filled, whitened, aligned, Turkeyed and otherwise ‘enhanced’ in their earlier life. What a depressing image to conjure with. And it’s my bet that Non, Je Ne Regrette Rien will not be on the playlist for the Christmas party.
Smash and grab
It’s not good enough for dentists to argue that they were only providing what the patient wanted (or ‘demanded’) – and especially not when they go to such great lengths to steer all patients down the same, maximum intervention treatment routes. These practices operate on a strictly ‘table d’hôte’ basis, and no à la carte alternatives are available. They favour a ‘smash and grab’ one-night stand over long-term relationships.
At its worst, it is driven by pure commercial interest and greed and the plundering of patients to achieve short-term, maximum profit.
But it is also true that dentists are (mostly) human and naturally prefer spending their time on some things rather than others. Being on a specialist list is the purest form of this, but even back in the day when pretty much all dentistry was on the NHS, treatment patterns differed widely.
I am reminded of a wonderful moment early in my dento-legal career when the (then) Dental Practice Board was questioning why a dentist was providing close to 200 complete dentures per 100 patients treated. She explained that she only worked part time, providing all the complete dentures on referral from colleagues in a large group practice. She added that she had tried crowns, bridges, inlays and onlays, veneers and fillings – but the only thing she could get to stay put on edentulous ridges was complete dentures.
When I stopped laughing, I was lost in admiration because in my experience the only place one of my own full denture creations stayed put was in a glass of water by the patient’s bedside.
Ahead of the game
The GDC has fought a half-decent rearguard action in the shape of its guidance on consent within Standards for the Dental Team.
Unlike many other sources of guidance, it has stressed the importance of treating each patient as an individual, tailoring the information provided to each individual and recognising that consent is a process, not a one-off event – the aim being not just to pass on information but crucially to achieve understanding of all the options and their relative benefits, limitations and risks (and having records to demonstrate how you did all of that).
The GDC was ahead of the game in those days, all this guidance being in place before the much-quoted Supreme Court decision in the case of Montomery a decade ago.
McCulloch versus Forth Valley Health Board
But since then, there has been another landmark Supreme Court judgement that for some reason has received less attention than Montgomery. This was the 2023 case of McCulloch versus Forth Valley Health Board in which the detailed decision was illustrated by a hypothetical situation where there are 10 possible treatment options.
If, say, three of them would not be considered reasonable by a responsible group of clinicians working in the same field then there is no legal obligation for a clinician to discuss those options (although it could be argued that there is still an ethical obligation because a competent patient is still free to choose even the most barking mad treatment options – but note the caveat below).
But the decision then went on to clarify that: ‘It is important to stress that it is not being suggested that the doctor can simply inform the patient about the treatment option or options that the doctor himself or herself prefers.
Rather, the doctor’s duty of care, in line with Montgomery, is to inform the patient of all reasonable treatment options applying the professional practice test.’
Best interests
The caveat to which I refer above is that a clinician can still decline to provide treatment which (s)he considers inappropriate (or barking mad). If it might be considered reasonable by a separate group of responsible clinicians acting reasonably, the clinician should still present this to the patient as an option, explaining why they are not recommending it. It is not acceptable to airbrush this option out of the consent discussion altogether.
The GDC confirms that dentists should not provide treatment against their better judgment, nor treatment which they consider to be against the best interests of the patient, nor in circumstances when they are placing their own commercial interests above the patient’s best interests.
The gap that has opened up in the years since Montgomery, through McCulloch and up to the present time, needs filling by the GDC. And soon. Digital marketing and practice promotion through social media, practice websites and in conversations taking place in many hundreds (or thousands) of the UK’s dental practices, is flying in the face of the law and thumbing its nose at the current (unenforced) GDC guidance and patients are being unnecessarily harmed.
We cannot expect to be treated like a profession unless we act like one, and collectively we are being let down by those whose heads have been filled with the populist myth that dentistry is not special, but a lucrative free-for-all that is ripe for the picking.
Read more articles from Kevin Lewis here:
- Is dentistry at the back of the queue for reform?
- Does the term ‘dentistry’ need a rethink?
- In search of answers
- Why the NHS never seems to get the message about dentistry
- When is a patient not a patient?
