Happenstance

There are certain words that have an aura about them. They are words that we probably do not think about for the most part but then, like a stray waft of a scent or a strain of a long-forgotten tune, they re-emerge to colour our memory of a time and a place. For me, happenstance is one such example. I first came across it many years ago in a short story in the magazine The New Yorker and loved its asymmetric wobble between happening and circumstance. Described as a North American noun, it is defined rather unemotionally as 'a circumstance especially due to chance'. Yet for me it has a backwoodsy, smokey type of a feel, a New England timber house with weathered painted panels and the candlelit patina of a story told by a flickering log fire while cuddled in a cosy, familiar jumper.

I have long wished to bring the word into an editorial. A search on the BDJ website brings up only one reference, in a paper in 2016 by Innes et al. '…Trials are often carried out with a providence that has more to do with happenstance and interest of the researcher than with efficiency and priority in mind.'¹ Bycoincidence, this neatly encompasses some of the thoughts I expressed in my previous editorial on dental research so, like the strain of a long-forgotten tune, I have decided that now is the appropriate time to use it.²

A circumstance especially due to chance. How often does that define, explicitly and implicitly, the complex weave of circumstances that make every patient we see unique, each of their individual health needs a challenge? We read and muse these woven patterns ceaselessly on a daily basis as we attempt to untangle the puzzles of our patients' often complex problems. A very good instance, although one out of millions of such, is given in a clinical paper in this issue, 'Why does my tongue hurt?'³ Diagnostically a combination of geographic tongue and burning mouth syndrome, in terms of detection and deduction the intertwining fibres of psychological issues, social considerations, questions about COVID-19, blood chemistry and microbiology make for an interpretation by professional experience of the tapestry of pathology and human interaction. We apply this too, almost subconsciously, as we guide our businesses through the wild weather of legislation, regulation, sustainability, finance and a myriad of other floods and heatwaves. The happenstance of life.

It also applies to our patients' view of oral health. What are the chances of them fully understanding that caries isn't hereditary? That the reason their parents had bad teeth and that they have bad teeth is about diet and education, not about genetic accident. That they believe they are registered with an NHS dentist when no such registration exists. The circumstances of their oral care to date suggest that it does, and no one has disabused them of the mistaken fact.

A circumstance especially due to chance. How often does that define [...] the complex weave of circumstances that make every patient we see unique...?

The same happenstance is also in the bloodstream of the systems in which we work. This is perhaps ironic since systems are supposed to dodge chance, avoid the obscure and cement certainty. The example of the Swiss cheese analogy in describing safety procedures comes to mind. If the holes in a stack of cheese slices are aligned, then a dangerous circumstance can whistle through the caesious tunnel; a single slice moved slightly to one side averts the disaster. To what extent can we apply this to NHS dentistry? We have to look back to the 1940s beginning when general dental practitioners decided that instead of going down the line of employment, as with general medical practitioners, they would opt for being independent contractors. Hardly happenstance. What has happened in the intervening years though points exactly to a series of circumstances due to chance, or at least unforeseen developments. The industry of our early colleagues in the new system meaning that government had almost immediately to change the payment schedules. The invention of the air rotor which meant that the profession all but stole another march on the political, or at least Treasury, masters. Fluoride; toothpaste in particular but also fluoridated water, substantially reducing caries and tilting the see-saw once more. From piece-work to capitation, and back. Half and half. Pilot contracts. Registration and then not.

The happenstance of dentistry. I am pleased that I have eventually found the opportunity to air it. For many of our patients, it is the comfort of a story told by a flickering log fire in a cosy, familiar jumper. For many of us currently, it is very much not that story. And I'm sorry for that.