Irish Dentistry Awards

Orthodontist Stephen Murray takes a philosophical look at his career and explains how digital technology has changed the way he works

Tell us a bit about your background?

The first half of my career was as a salaried dentist, largely orientated to oral and maxillofacial surgery when I was at a junior level, but I then moved into orthodontics and then took the leap into the dark to take on a private practice.

What or who made you choose a career in orthodontics?

One of my consultants told me ‘you have no aptitude for oral surgery’. That said, he also wanted the death penalty brought back for people who knocked over wheelie bins. He later qualified his remarks (about me; I think for safety, you should still leave his bins alone), but I was already applying for ortho training courses.

I wanted to do a recognised and structured specialty training and this was the best developed and most appealing career direction at the time – this was just at the early days of specialist registration.

Tell us more about Swords Orthodontics

It was an owner-operator place, first of its kind in the town. The owner wanted to move on and I was the associate and got first option to take it over. I could see some ways that it could embrace the 21st century – equipment, services offered, working practices, and décor.

How is the practice structured?

There’s a chart on the wall with all the practice roles and from time to time, different names are assigned to them. But when put into practice, it’s usually an increasing number of people telling me what they need me to do at any given moment.

There’s me, an associate or four, an orthodontic therapist, a lab technician on site, five qualified dental nurses.

The nurses have overlapping skillsets so they can do treatment coordinating, front of house work, administration in back of house and so forth as well as clinical assisting.

We have one who has the X-ray certification and three in training too. Several of them will have certain practice duties as part of their responsibilities too. This includes training, compliance, IT, recruitment, emergency medicines, facilities and maintenance, accounts etc.

How do you think orthodontics has changed since you first started practising?

To give you some context, I’ll explain the timeline – 30 years since I did it as a student, about 20 since I started specialist training. It’s changed in a few ways. Technology is the main one – here’s some examples.

Recently, we were doing an intraoral scan for an Invisalign patient and I had said that this wouldn’t have been imaginable to my dad’s generation of dentists when they were starting. My therapist turned around and said it wouldn’t have been imaginable to me, and she was right.

I was in the last cohort of specialist registrars allowed to submit their essays written by hand – the next bunch had to type theirs, but by the end of my master’s programme, I had a computer that the university didn’t need – with a Pentium chip, Windows 95 (or maybe Windows 3) and Word 6 – for my thesis.

Back then, the idea of sticking a laser in someone’s mouth and a few days later, a robot on the other side of the world making up an aligner for my patient wouldn’t have entered my mind for an instant.

My first British Orthodontic Society meeting was about alternatives to headgear. There was talk of using implants as skeletal anchorage. I had to give a report back to my unit as I was the only one at the meeting. This was met with general incredulity due to the cost of implants. I replied that CDs and VHS tapes used to be expensive, but now you could buy them in pound shops and was asked ‘what have CDs got to do with implants?’. My older colleagues couldn’t see this becoming mainstream.

Digital photography came in just as I finished up training. I entered the competition where you present your research at the British Orthodontic Conference. I made my slides on Powerpoint, and then a special machine near the top floor of the dental school could turn the Powerpoint slides into actual colour transparency slides to be loaded into a carousel for light projection. You were responsible for loading your own slides the right way around. The BOC would entertain computer Powerpoint presentations. But you had to ‘bring your own laptop’. I think they stopped non-digital projection the following year.

There was this big scare that people would ‘manipulate’ the digital images to make their work look better than it actually was. It would probably be easier to just use someone else’s work. The cameras cost more than cars.

So there was a lecture at Royal College of Surgeons where the speaker advised anyone starting their careers to consider digital photography. But anyone midway through could probably get by to retirement with colour slides. Meanwhile, another consultant I knew said it would never replace slide cameras because the quality was never as good.

So what I’ve learnt is not to sit there shaking your head and say ‘It’ll never replace the horse’. Particularly if you’re looking at a bicycle.

You are the immediate past president of the Orthodontic Society of Ireland – can you tell us more about that?

When you’re inaugurated as president, you receive a chain of office. I was expecting the key to the OSI Learjet and some nuclear missile codes.

We engage with the other ortho societies in Europe and around the world; I have represented the society at a World Federation of Orthodontists meeting for the last few years, and our previous president looks after our connections with the Federation of European Orthodontics and the European Federation of Orthodontic Specialist Associations. Obviously in the middle of the COVID-19 outbreak, all that had to change.

Can you tell us about your interest in dental photography?

There was a legendary Scandinavian dentist, Sverker Toreskog, who started a lecture once with, ‘If I had to do it all again, I would take more photographs.’ He explained how he envied orthodontists because we are always taking pictures. It would be typical for all ortho patients to be routinely photographed. When I trained, this was done by the medical photography department, and in 10 years of undergrad and postgrad training I never formally learnt it.

When I came to Ireland, I had to take my own photos. This wasn’t impossible. But I saw a huge variation in photographs in circulation so I knew there was a place for better teaching of it.

Digital photography has made it easier than ever before because you can see your results the second after you take the picture. It’s just up to you to decide whether it’s good enough or needs to be repeated. And so, if I go to an old photo and it isn’t good, it’s not just because I took a bad photo. It’s because I saved a bad photo, And I saved a bad photo because I hadn’t realised I had taken a bad photo.

So my tip is: trial and error is fine, but think about what you’re trying to achieve and see if you achieve it. If not, then do something different and take it again. Work on the ‘trial’ bit until you stop repeating the ‘error’.

How important is patient communication to you?

There are so many aspects to patient communication it’d be an article in itself. The main thing is that you can’t assume just because you and your patient speak English that you and your team will automatically communicate well with the patient without some sort of effort. And guess what? The patient won’t be doing any of the work. So the dentist has to work harder to be confident that they are being understood.

It begins a long time before you ever meet the patient: there’s the website, leaflets and brochures, first phone call, first greeting when they walk in. That’s why it’s important that everyone involved with the practice is clear about how we are going to communicate. We regularly train on these skills. I found Tracy Stuart, Ashley Latter and Lina Craven have been a big help to me in this area.

What do you think about all the controversy in orthodontics today and GDPs practising short-term orthodontics?

That’s the old controversy. The new controversy, the one that would engage us more, is orthodontics without any dentist at all. The idea being that the patient is a consumer who bypasses any clinical exam, sends in their own records and has a company make their braces (specifically an aligner series) remotely and then they embark on their treatment without actual supervision. No X-ray, no perio exam, no TMJ exam, and probably no consensus as to who’s responsible or accountable. I could see that causing problems.

How have patient expectations changed over the years?

The demands made on anyone in any field are unlikely to remain the same over time. They are almost always going to be expected to deliver results that are better, faster, cheaper. Why would patient demands on the profession be any different?

Not all expectations are demands. For my finals, I made complete dentures for two men. One of them fought at Monte Cassino. But the other was only 42 years old and had worn complete dentures for 20 years. Nowadays, no one expects to have lost all their teeth in their mid-40s, never mind their early-20s. And that’s clearly a good thing.

How do you stay abreast of techniques?

If you read The Art of War by Sun Tzu, you can appreciate that it’s important to have some knowledge of self. When I saw the Everett Rogers Curve of how well people take to a new idea, I realised that I’m not an innovator or even a particularly early adopter. In many non-dental areas, I’d be in the late majority area (eg I still buy CDs and DVDs). But professionally, I’d probably be in the early part of the majority.

Most new stuff comes to my attention at conferences. But I’d usually wait until someone I knew has been consistently successful with it. I need something to be reasonably established before I’d start to incorporate it into my own practice. I find that many ‘innovations’ are foisted onto the profession too early.

The companies or people behind them are expecting the profession to pay them to do their product or system testing for them. I’d prefer someone else to have ironed out the main problems before I start using the gadgets or systems. This is so I can concentrate on getting the best out of them instead of wondering, ‘Is it just me?’

Professionally, what are you proud of?

Probably the developments and achievements of my team since I took over the practice in 2012. We have had three dental nurses get their formal qualifications. Whilst another completed her radiology certification – and I have three more in training for that. We also supervised one of the first orthodontic therapists to be trained in Ireland.

Do you have any regrets?

Years ago I read a quote from James Hetfield of Metallica along the lines of, ‘I’d rather regret doing something, than regret not doing something.’ As I got older, I realised there are versions of this idea from Mark Twain, George Bernard Shaw and Lucille Ball. But the fundamental idea is a design for life. I do have regrets, but they tend to fall into the latter category – the things I didn’t do.

What are your plans for the future?

‘Life is what happens to you while you’re busy making other plans’ wasn’t an original John Lennon line. But he made the phrase famous, and you can add ‘no plan survives contact with the enemy’.

I tend to have more ambitions and goals than plans, and right now that means steering the practice through COVID-19.

This article was first run in April’s Irish Dentistry magazine. You can read the latest issue of Irish Dentistry magazine here