Student memories

This rather ugly example of classic 1970's concrete architecture houses the Leeds Dental Institute (as well as the medical school and other related courses). Of course, when I started as an undergraduate dental student in 1989 it was two separate entities, the Dental School and the Dental Hospital.

It might not be the most attractive building but I have very fond memories of this place, having spent a significant amount of my adult life here. After as four years and one term as a dental student I worked for nine months as a house officer (this post no longer exists!), returned to do some weekly teaching in oral surgery 1997-1999, and became a full time student and specialist registrar in orthodontics from 2002 to 2005.

This year marks exactly 20 years since I graduated as a dentist. It's hard to believe I've really been a dentist for that long, but I've checked the maths, and can't find an error, so it must be true! The actual date I graduated is sometime in December, maybe the 11th, but my memory isn't *that* good!

Two weeks ago I returned to the Dental Institute take attend the Alumni Day, organised by the reformed Leeds Dental Alumni Association. There was a full day of lectures by past graduates or staff on a variety of topics, from current student teaching, to 3D technology and some of the latest dental politics. Sadly only a handful of my year could make it, but it was brilliant to see those that could.  There were other familiar faces too, people from years who were there at the same time as me, and local dentists I have met or worked with over the years.

There was a lot of 'oh you haven't changed at all', which really was true, it was not difficult to recognise anybody! The same couldn't be said for the Dental Institute. Of course it has changed a lot in 20 years, but even in the 8 years since I was last there is looks and feels very different. I thought, perhaps for the  benefit of past students, I'd run down the obvious changes.

Outside the building itself is much the same. The surroundings, however are very different. New buildings have sprung up, most notably the Jubilee Wing of the LGI and the multi-storey car park, but also the research building right next to the Worsley Building. Further away, if you take a short walk into Leeds you'd find Millennium Square, new shops and shopping centres, and loads of new bars and restaurants.

Enter the Worsley building on level 4 (this being the ground floor!) and the porter's desk is still there, but I wonder where all those cheerful porters, with their weekly 'buy a square' raffle went? The dental students are now clothed in maroon pyjamas, no own clothes any more, and no button-down-the-back tunics, it's more traditional front fastened ones now.

The dental common room on level 6 is still present, but smaller, the part that had the pool table is now a seminar room, and the pigeon holes orange seats are long gone (RIP). Even the lecture theatre has been refurbed (more than once I think), no orange there either, and of course proper digital projection, none of those slide carousels anymore. Which must mean less problem with upside-down or back-to-front slides, or dual projection getting out of sync!

I'll come back to the rest of the dental school in a bit. We were lucky to have a tour of the Dental Hospital. This was the bit that most astounded me. It had already been upgraded since I was an undergraduate (I remember Cons being refurbed while I was there, we thought it was state of the art then), but it's recently undergone a major transformation. So much that I got disorientated and couldn't really work out where I was! Walls have been moved, clinics combined (no separate Perio, Cons, Pros any more, but 'Restorative South' and 'Restorative North'), even Ortho has totally changed. However, it does look great, the digital radiography must be a real boon, but when will they get rid of those yellow note cards and go fully digital?

The biggest change is in the labs on the 5th floor. The phantom head room and the lab room where we spent hours sitting round benches with bunsens and wax knives are gone. Where 13 students used to crowding round one demonstrator, who tried to show us the finer points of drilling a cavity in a an extracted tooth technology has taken strides forward. The demo can now be seen 'as live' on a screen, and screen show in detail the student's work. The bit that impressed us all was the 'Simodont' room.

These make use of 3D and virtual reality technology, and can teach good posture while the student is learning, as you have to sit at the correct focal distance. A touchscreen selects the tooth you want to 'treat', and wearing 3D glasses, like those at the cinema, you can see it through the window. Select the instrument you want to use and you can not only see it in the window (this picture doesn't convey the 3D-ness of it all!) but feel like you're holding it in your hand. The foot pedal turns the drill 'on', complete with the appropriate noise, and when you 'drill' the tooth it looks and feels like real tooth. This is the really amazing bit, it really does feel just like drilling a tooth.

The student showing us round watched me, and commented that it was good to watch how a 'real dentist' drilled a tooth. Little did she know that I haven't removed any decay or done any fillings for 11 years since I started orthodontics full time!

Whilst this is still no substitute for real patients, with real teeth, tongues, lips and saliva, the students will be much better prepared when they do reach that stage. They need to be, with more student numbers than in my day (90 per year, we had about 50) there is less overall time for treatments, and 'totals' no longer exist. Sadly I missed the lecture on current student teaching as I was giving my own lecture to postgraduate orthodontists, but the staff did acknowledge that current students leave with less experience than we did (the people who qualified in 1973 probably said that about us). However the postgraduate training pathway is now more structured to take account of this.

In the evening there was a black tie dinner and disco, which was even better attended than the daytime. There were 7 of us in total from our year, we managed to find time to get a picture taken. From L-R Rav, Rachel, Rob, Bea, Me, Andy, Sarah.

The evening provided a less formal means of catching up with all the people I knew, and a few I didn't,  plus some boogie-time on the dance floor. I did decline to join the more recent graduates at a nightclub in Leeds, with the excuse of not being able to walk in my heels.

Hopefully with the new committee in place and earlier notice we will get more of Year of 1993 along next year, or we'll be waiting for the next major milestone in four years time.

Submerging deciduous teeth and the value of x-rays

In dentistry and medicine we try hard to reduce the amount of x-ray radiation we use, it is a basic rule of radiation protection. This means we should only use x-rays when we really need to, when it could potentially alter our treatment. I take less radiographs now than I did when I qualified as an orthodontist. The standard I was taught as a dental student for orthodontic assessment was a panoramic (to show all the teeth) and an upper anterior occlusal (to check for supernumerary teeth and midline problems). As panoramic quality has improved the occlusal view is rarely needed, and I only take cephalographs in more severe cases now.

Sometimes there's a risk of not taking radiographs when we really need to, and there seems to be a real reluctance from some dentists to take radiographs on children, when they can help to manage a case.

The picture above is from an 11 year old boy I saw yesterday. His second deciduous molars are still present and are submerging quite significantly, being now below the contact points of the molar teeth and almost at gingival level. Having looked in the mouth I was certain that the premolar teeth must be missing, as is often seen when the deciduous molars submerge. A radiograph was indicated to confirm this before I decided on treatment.

Have a look at the radiograph and you can see that they are in fact all present and relatively well positioned. I have to admit to being rather surprised, but it does demonstrate that radiographs can be useful tools when correctly used.

Has it changed my management of the case? In the short term, no, as teeth submerged this far are best extracted anyway. But it does change my follow up of the case and the long term management (it also makes the IOTN 5s, so what appears to be a mild case now has a high need for treatment). I will need to make sure the space is maintained until the premolars erupt, I don't anticiapte any problems with this but I will review the patient regularly until the premolars erupt. If the premolars had been absent I'd have been more likely to allow some natural space closure before orthodontics (his anterior teeth are mildly crowded).

If you are a GDP please remember to monitor for submerging deciduous teeth, in this case the patient had been referred for another reason. If you are registered on Dentinal Tubules have a look at this thread which shows more severe sequalae for untreated submergence.

Don't believe the hype

A story in the dental press caught my attention today, quoting research from America that has shown that injections of dental anaesthetic in young children might stop wisdom teeth developing in the future.

Wow, that seems pretty amazing doesn't it? That a simple injection might stop the wisdom teeth developing, reducing the risks of pain, infection and surgical complications in the future. The authors seem pretty clear that the difference is significant, but I've never heard of anything like this before and I'm sceptical.

Now before I continue I should say that I haven't got access to the full article which I would need if I was going to do a full critique, but just reading through the reports it's pretty easy to pick out some flaws in the research.

The researchers looked back at records of children who had a dental x-ray at 7 years old or over and examined them to see if the wisdom teeth were developing. Already I'm a bit concerned as before the age of 10 the wisdom teeth are unlikely to appear and up until the age of 12 I wouldn't be confident that they were definitely missing.

Then they divided the children into two groups depending on whether they'd had a dental injection in the lower jaw between the ages of 2 and 6 and compared them to see which had the most wisdom teeth. I guess they could only know that if they'd had treatment at the same clinic. What if they'd had treatment elsewhere they didn't know about? Asking the patient or parent is not reliable either (though they don't appear to have done this).

The total number of patients was 220, giving 439 sites where wisdom teeth might develop, so that would be one on either side of the lower jaw for each patient (there's a missing one somehow!). 63 sites had received injections (comparison group) and 376 hadn't (control group), not very equal groups. Comparing 'sites' rather than 'patients' could confuse the results, as the left and right sides are not independant. So if the left wisdom tooth is missing it's more likely that the right one is too. Hopefully in the full results they explain if or how they've allowed for this.

This is the 'headline' though, "In the control group, 1.9% of the sites did not have X-ray evidence of wisdom tooth buds. In contrast, 7.9% of the sites in the comparison group – those who had received anaesthesia – did not have tooth buds. The comparison group was 4.35 times more likely to have missing wisdom tooth buds than the control group." They've applied some statistical analysis and found that this is significant, though I can't see what analysis they've used, if there was a sample size calculation or what level of significance, again I hope this is explained in more detail in the full paper. Looks pretty good though doesn't it, 4.35 times more likely to have a missing tooth if there's been an injection?

How about the numbers though? 1.9% is just 7 sites in the control group that didn't have a developing wisdom tooth. 7.9% of the comparison group is 5 sites. Remember that's 'sites' not 'patients', so this could represent as few as 4 and 3 patients! These numbers are pretty small and I'd say too small to make statistics meaningful, though I'm surprised it's not higher considering the age of the children when xrayed.

I don't think this is a good enough piece of research to change habits and make people start injecting small children in the hope their wisdom teeth might not develop. In any case, I'd like to see an argument that it's desirable have them missing, what happens if other teeth fail to develop or are lost through dental disease or trauma? But what it should do is stimulate more research. Larger groups and prospective trials or follow up studies would be better. I don't think the stats are good enough to support a study that would randomise to two groups, one with injections, one without, and long term monitoring with xrays though, as well as the eithical issues that would go with administering injections and xrays to children with no dental disease!

I think it's a good reminder that when we see a piece of research that tells us something we want to hear, or even something we don't (how often do we hear conflicting reports about whether wine or chocolate is good or bad for us) that there is often much more to it than that. A little probing into the facts and figures can often turn up flaws in the findings and we must be cautious not to believe the headline straight away.

Which brace is better?

On Saturday I attended the British Lingual Orthodontic Society (BLOS) spring meeting. (For those who don't know lingual orthodontics is the treatment of misplaced teeth using braces that are attached to the back of the teeth, rather than the front.) I am a committee member for BLOS and having helped with organising the meeting I'm pleased to say it was a really great day.

The meeting was fully subscribed showing a growing interest in lingual orthodontics in the UK (plus there were some European delegates). The venue was the Four Seasons Hotel at Canary Wharf, who were incredibly helpful and provided some amazing food during the breaks, especially the chocolate themed afternoon coffee break (yes dentists eat just as much chocolate as anyone else!).

This meeting brought together some of the best lingual orthodontists in the world, with practices in Paris, Berlin, Italy and Tel Aviv. Many of these ONLY use lingual braces! Each spoke about the lingual system of their choice with reasons why they preferred it over another. There were lots of clinical cases showing some fantastic treatment results and many happy patients. Each system has its own advantages and disadvantages, but there were a few things that really came over as a whole.

• Lingual orthodontics is in demand. The number of people wanting treatment that is rising and as orthodontists we need to be able to select braces that will get the result the patient wants as aesthetically as possible.
• If we, as orthodontists, do not get interested in lingual treatment we risk getting left behind. The UK may be behind other countries but we do follow the same trends eventually.
• Technology is becoming increasingly important. Most of the systems demonstrated used advanced Cad-Cam technology to plan and manufacture the braces. This makes it easier for the orthodontist to plan treatment, the patient to see the potential result, and gives greater accuracy of the braces and the final result.

But the thing that really came over, and was stressed by Dr Silvia Geron, is something that probably applies to all orthodontic treatment. It is not the 'system' that gives a really good result. It doesn't matter whether you choose Harmony, Incognito, eBrace or any of the other lingual systems, as the final result is in the hands of the orthodontist. It's down to how we assess, plan and use the braces that is important, rather than a specific brand. The skill and experience of the person doing the treatment is what really makes the difference between a good result and a fantastic result.

Too Old for Braces?

Prospective clients often use the phrase 'at my age...' or 'I thought I was too old for braces'. So I thought I'd have a look at who my 'typical' adult patient is.

You might be surprised to hear that last year more than half (59%) of my patients were aged 17 or over. The proportion is growing each year, when I started the practice in 2006 adults made up about a third of my clients. I think this reflects both the growing demand for cosmetic dentistry and the availability of more aesthetic types of braces. It's probably not so surprising that women make up 70% of my clients, but the proportion of men seeking treatment is also growing.

The mean age of my adult clients when they started treatment was 38, but this doesn't really tell the full story. My oldest client was 66, with the biggest proportion being the 30-44 year olds, but nearly a third being aged 45 or over. There is no age limit to braces, though the treatment plan may need to be modified depending on missing teeth or dental disease, and sometimes combined with other dental treatment like whitening, crowns or implants.

The types of braces used also reflect the wish of adults to keep treatment as discreet as possible. For teenagers it's quite acceptable to wear metal fixed braces and they often decorate them with bright colours. Whilst a few adults will opt to have this type of treatment I usually use more aesthetic treatments instead. For many years aesthetic fixed braces were considered inferior but modern braces are virtually equivalent so I rarely offer standard metal braces to my adult clients.

The choice of braces is determined both by the problem and the type of tooth movement to be carried out, and the preference expressed by the patient. Standard, or labial fixed braces are attached to the front of the teeth, usually using ceramic brackets which blend fairly well with the teeth. This is the simplest treatment and is often chosen over other, less obviously visible brace types for reasons of time, cost and comfort, which is why it makes up half of the treatments I carry out. Clear aligners are mainly Invisalign, removable clear braces that are virtually invisible. Lingual fixed braces like Incognito are fixed to the back of the teeth so they can't be seen at all, they are perhaps less popular due to cost and worries about comfort, but it's probably the biggest growing area in orthodontics at the moment.

So if you don't notice adults with braces every day, it's probably not because adults don't have them - just that these invisible treatments are often very hard to see!

The truth is, I don't have a 'typical' adult patient. I treat people of all ages, from all walks of life - some of whom travel quite a distance - for all sorts of problems. And I'm happy to say I have a range of skills and treatments available, so I can usually find a treatment to suit each person: it's all part of your assessment, when we sit down together and chat about what you'd like to do. 

It's actually quite common for adults to take action to get the smile they want. So if you'd like to pop in and see us, please do get in touch.