Advance Dental Care

In 2009 I had the privilege of providing a week of work experience to Lucy, a sixth form pupil from a school many miles from our practice. I’m always happy to open the doors to someone who feels that dentistry might be the profession for them. For the most part, the school students really have no idea of what dentistry is about. Their only experience is their family dentist back home. Sometimes I AM that family dentist. Seeing the job from the driver’s seat is a very different experience. Often the student appears ambivalent about their career choices and I often hear back that they changed their minds or didn’t get the grades. It’s all part of what work experience is all about. As a young lady said to me this year when I was relating some of the downside to the job, “You’re not selling dentistry as a career very well.” It’s not my job to sell dentistry as a career. You’ll spend 40 years doing it so you really want to make the right choice.
Too often I come across young people who are studying dentistry because their parents thought it would be a good career. Maybe they’ll get lucky and discover a passion and talent for the job. Maybe they won’t and will bumble through a career plagued by dissatisfaction and never even try to fulfil their potential. With most school pupils it’s hard to tell what they’ll be like. With some it leaps out at you that dentistry is not for them.

Back to Lucy. In all the years I have have opened the practice to work experience students, no one made a greater impact than Lucy. From the first day I felt she had a real interest in the work and was passionate about being a dentist. I’m pleased to say that, over the week, I was able to fan the flames and she grew even more determined that dentistry was to be her profession. As a person Lucy was friendly, intelligent and showed great empathy and ability to communicate (a skill many teenagers have yet to develop).
After the week was over I was invigorated and really felt that this was exactly the sort of young person the profession should be attracting.

Last week I heard that Lucy had applied to study dentistry at a UK university…….. and had been rejected. She wasn’t turned down for lack of academic ability, she has that in spades. Lucy was advised that, on the basis of a tick-box personality test, she wasn’t suited to dentistry. Yes, a tick-box personality test. Who decides these things? Probably the sort of people who develop tick-box personality tests. Well I don’t have a tick-box personality!
Unfortunately we are turning into a society based on ’systems’ and management-speak. Funds are directed away from front-line services toward ‘monitoring’ and ‘accountability’ in our hospitals, inspections in dental practices are more concerned about paperwork than the quality of the clinical care and young people have their futures decided on the basis of a few ticks on a sheet of paper, interpreted by a computer.

My advice to Lucy is that she should take a year to see the world and reapply for entry in 2011. At least they can’t doubt her commitment then.
My advice to the admissions staff at the university concerned is that they don’t deserve students of Lucy’s calibre.

Adrian Stewart

This is a term I use a lot and it’s one all dentists (and patients) should be familiar with. How does the cost stack up against the benefit?
Will my patient be better off after the proposed treatment or will they have suffered detriment?
I have been prompted to consider this by an article I read today in an American dental publication. It was a case report of “Instant Orthodontics”, as our American colleagues like to call it. The author, with the help of some excellent photographs, presented the case of a lady in her mid forties who presented with mild-moderate crowding of her upper anterior teeth. Her teeth were healthy but a little irregular. Also, the colour was slightly darker than many people would consider the ideal nowadays.
If this lady presented to me I would have proposed that we provide a course of home whitening followed by referral to a specialist for a course of orthodontic treatment to align and straighten her natural teeth. After 6-12 months of orthodontics she would have been left with a beautiful, healthy smile with no damage to her teeth.
What I wouldn’t have done is carried out excessively heavy veneer preparations, removing so much tooth that the preparations passed right through to the back of some of the teeth, then fitted 10 veneers of varying thicknesses with length to width proportions dictated by the crowding and not conforming to the ideals we understand about perceived beauty in the natural dentition (the teeth all had to be quite narrow to fit into the previously crowded arch).
And yet, this is exactly what the dentist did. His justification was that the lady did not wish to undergo orthodontics (wearing a brace). If this was the case it simply means that he did not explain thoroughly enough the disadvantages of having the invasive option.
The result of the treatment showed a smiling patient with straight teeth. The dimensions of the teeth were not great as space was limited but the smile looked OK. The view of the teeth from the back showed just how much damage had been done in pursuit of a quick fix.
From a technical point of view there were problems with the preparations. Veneers work excellently when they are bonded to the thin enamel layer on the outside of the tooth. Once you breach that layer, the bond strength goes down and the failure rate goes up, therefore; veneers should really only be used to enhance rather than replace tooth structure. Had the patient in this case had orthodontics carried out and still wanted veneers, the treatment would have been much less invasive, the dimensions of the veneers would have conformed better to ideal proportions, the veneers would have been thinner and they would have been bonded to enamel and more likely to last for a much longer time.
Every time a dentist touches a tooth there is some loss of natural tooth structure and trauma to the nerves inside the tooth. It is imperative that any procedure carried out by the dentist carries a greater benefit than cost. The more tooth we can keep undisturbed, the healthier the teeth will remain for longer. Every treatment has a lifespan, but so does every tooth. I am often asked by patients about the projected lifespan of a restoration. I always turn that around and talk about maximising the lifespan of the tooth. It is always better to be conservative and create as much benefit for the least cost, in terms of tooth tissue, possible.
Why do I get so stressed about cases like this? Consider a dentist who perhaps does not have a lot of experience in dealing with cosmetic problems or is in the early stages of their career. A patient presents with a similar problem and they immediately think, “Oh yeah. I was reading a case almost exactly like this last week…..”
So what is likely to happen to our American patient? Hard to say, but if we were to examine her in 10 years time I would be very surprised if some or all of the veneers had not been replaced by crowns and several of the teeth undergone root canal therapy after their nerves had died.
There used to be a TV programme called “10 Years Younger” which did a lot to raise awareness of what is possible in the field of aesthetic dentistry. The negative aspect of the programme however was that it often made challenging restorative dental procedures appear to be nothing more complex than popping into the hairdresser for a change of hairstyle. Unfortunately, if a little too much comes off, in the case of dentistry, it’s not growing back.

So, if you are unhappy with your smile and have decided you want to have some radical aesthetic dentistry, be sure to talk it well through with your dentist. What are the options? What are the pros and cons? Is there something less radical which can give me the result I desire? Is my dentist experienced in the sort of treatment I need?
A good dentist will be happy to talk you through the options and should guide you to a decision that will have a cost/benefit ratio tilted towards the benefit side.

Adrian Stewart

As a first blog post I thought I’d borrow a theme from a friend and colleague, Richard Hellen, in Carlisle (www.yorkplacedental.com). Richard recently had a bit of a rant about what he viewed as the dire standard of periodontal care which a new patient had received at his previous dentist. The gentleman had been a regular six-monthly attender at his previous dentist but, at his first consultation, Richard diagnosed chronic periodontal disease. This subject struck a chord with me as it is a familiar finding. Unfortunately I have seen at least one patient who has lost all their teeth as a result of undiagnosed/untreated periodontal disease, despite having attended their previous dentist every six months.
What is periodontal disease? We all know that gingivitis is inflammation of the gums, caused by plaque bacteria. We all have some areas of mild gingivitis unless we are absolutely fanatical flossers. Left untreated and given the right circumstances, this inflammation can progress down into the support structures of the tooth, the periodontium. ‘Pocketing’ starts to develop and the nature of the bacteria in those pockets starts to change to more aggressive, destructive bacteria. You’ve now got periodontitis. This leads to loss of the attachment of the gum to the tooth and loss of bone around the teeth. Untreated the eventual outcome is loss of the affected teeth.

Can periodontal disease be treated? Yes. With intensive cleaning of the root surfaces under local anaesthetic and excellent oral hygiene practice from the patient the disease can be arrested, however; the bone loss around the teeth cannot be recovered.

Can periodontal disease be prevented? Definitely. Prevention is the key. Some people are more susceptible than others. Although bacterial plaque is the source of the disease, other factors promote it. These include genetics (having a family member with the disease puts you at higher risk), smoking and diabetes.

So, what’s a BPE and where does it come in? The British Periodontal Society recommends that each patient should have the Basic Periodontal Examination at least once a year. At our practice we usually carry out BPE at each six-monthly consultation. This takes only a few minutes and involves gently inserting a special, ball-ended probe around each tooth in turn and recording a highest score for each of six regions in the mouth. These scores relate to whether there is bleeding from the gums on probing, whether there are any factors which make cleaning difficult (tartar or rough fillings) and how deep the crevice 0f gum around the tooth is (1-2mm is healthy). Depending on the scores recorded we either refer to the hygienist for hygiene treatment or bring the patient back for a more intensive examination (which can take up to an hour).

As a result of this protocol we know the periodontal status of all our patients and I’m glad to say our patients have generally excellent periodontal/gingival health.

I know most of our colleagues are under pressure to be able to carry out the “Exam, scale and polish” in 5 minutes, but that does not change the recommendation that each patient have a BPE at least once every 12 months. Our patients put their trust in us to carry out each procedure, including examination, to the standards expected of or profession. Overlooking something so basic as the health of the very foundations of the teeth is, in my opinion, indefensible. If you’ve been a regular, six-monthly attender at your dentist and, after some years of attendance, you are advised that you have advanced periodontal disease and need to lose one or more teeth, you have to ask, “Why was this not detected and treated before it got this bad?”.

Do you ever notice bleeding from your gums after you’ve brushed your teeth? Does flossing make your gums bleed? These are early warning signs for gingivitis.

Next time you’re at the dentist, ask what your last BPE score was. If you’re met with a blank stare perhaps you should consider the standard of care you are receiving.

Adrian Stewart

PS As a postscript to this post, it is worth mentioning the topical nature of the subject. The highly publicised findings of research in the British Medical Journal indicate that poor oral hygiene and the concomitant gum infection are linked to increased risk of heart disease. The causative mechanism appears to be the chronic exposure to bacteria entering the bloodstream and triggering an inflammatory response. http://www.bmj.com/cgi/content/full/340/may27_1/c2451