Why have orthodontic treatment?

You may think the answer to that question is easy, you have crooked teeth, so you need them straightening with orthodontic treatment. But why should we straighten teeth? This paper published in the current BDJ looks at the value of orthodontic treatment, and I found it a really interesting read.

I often quote the three main reasons for orthodontic treatment as dental health, dental function and aesthetics. For the majority of people with crooked teeth function (eating and speaking) is not a problem. Anyone with significant impairment, such as a lisp, is likely to find that orthodontic treatment alone won't solve the problem. Whilst patients tend to perceive that their teeth will be easier to clean and keep healthy when they are straighter, the evidence for straight teeth being healthier than crooked teeth is very poor. Leaving aside a few dental health issues such as buried teeth that only affect a few individuals, this leaves aesthetics as the prime reason for carrying out orthodontic treatment.

So why should the NHS continue to fund orthodontic treatment for children if it isn't going to bring an improvement in health? The paper states that about 10% of the NHS dental budget was spent on orthodontics in 2010-2011, amounting to £248m. That's a lot of money for something that could be considered cosmetic. Are patients being 'vain' when they seek dental treatment or is there more to it than that?

A different way of looking at this is to explore the effect of crooked teeth into psychological and social well-being, which this paper addresses. Psychological well-being could be considered the person's own view of themselves, but is affected by many things and the impact of a single factor like teeth is difficult to measure. Social well-being is how easily the person interacts with others, so this could include school, work, friends or significant others. The importance of these values and their measurement is a growing area, and patient reported outcome measures (PROMs) are becoming more widely used.

One paragraph in the conclusion really stood out for me. Many of my patients tell me how much happier they feel since having their teeth corrected, especially in meeting and interacting with people. The value of this cannot be underestimated, and confirms that although something might be considered to be an aesthetic problem, rather than a dental health problem, it isn't necessarily less important.

"The main value of orthodontic treatment is to allow individuals to cope more effectively in social situations, without concern for the appearance of their teeth. In a health service context this is wholly compatible with the WHO definition of health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'."

The NHS funds orthodontic treatment for children with severe enough problems (how severity is measured is a different subject)), and I do hope this continues to be the case, even though I don't personally have an NHS contract. But for adults or children that have milder problems orthodontic treatment can still bring a valuable change. So please don't think you are being vain in seeking treatment, if your teeth are affecting how you see yourself or how you interact with others it could have a greater effect on you than you think.

What is the value of orthodontic treatment?

P. E. Benson, H. Javidi & A. T. DiBiase
British Dental Journal 218, 185 - 190 (2015)

'Hello my name is...' and dental charges

On Monday on Radio 2 Jeremy Vine's lunchtime discussion programme had two topics that were particularly relevant. Firstly a discussion on dental charges and especially whether these should be displayed, and secondly doctor Kate Granger talking about her 'Hello my name is...' campaign. (You can listen to the discussions on iPlayer from half way through the programme.)

I always worry when I hear a dental topic is about to be discussed. A half hour slot which is mainly filled with music is not long enough to really understand the topic and the sides of the story, and dentists feel it's very easy to be misrepresented. Interestingly that isn't always the case, as the discussion about Desmond D'Mello late last year brought out many patients on his side.

Hello my name is...
This is an excellent campaign and so important, but I am really quite shocked that it is needed. As a junior dentist I spent several years work in hospital on wards and outpatients. I remember being dressed down by an anaesthetist for entering an operating theatre without introducing myself, and I used to introduce myself to my patients. However I do remember being confused as to the 'rank' of my colleagues, and this perhaps even less easy now as white coats have disappeared and uniforms become more casual.

It's very easy to forget that patients are often nervous or apprehensive and this is a special occasion for them. I think it's important that they are aware of someone's name but also their standing, is this the consultant, the junior doctor or the nurse, as you cannot tell by someone's gender or age.

I always introduce myself to my new patients and shake their hand, usually using my first name. They are often aware of who I am as my photo is on my website and practice literature, and of course they've booked to see me specifically, but I never assume. I expect my nurses to do the same and will always introduce anyone new in the surgery, for example when we have work experience students. Our staff are trained to answer the phone using their first name and everyone has name badges as well. It's a basic courtesy that should extend to most walks of life, not just doctors and hospitals. Perhaps people feels it's a bit 'American' to be introduced to their waitress, for example, but in a service industry it's a simple change that will improve the level of customer service, make the staff feel more valued and the clients more satisfied.

Dental Charges
Dental charges have been in the news recently with a Which? report slamming dentists for not displaying charges and allegedly overcharging. I say allegedly, as the data was gathered direct from patients without comparing to actual treatment provided. This was also based on NHS dental treatment.

NHS charges are set nationally, whereas dentists set their own private fees. I'm not going to go into the setting of NHS charges and dental contracts as it's a complicated topic. Whilst NHS fees are set, private charges will vary depending on the practice location and its overheads. (Immediately you wonder how practices with different demographics survive on the same NHS fees!)

As a practice owner I do believe that it is important for dentists to be clear about charges. However talking money is something that most dentists find very difficult. As a student I learned how to treat patients, and nothing about how to run a practice or how to discuss money with my patients. It can feel embarrassing to ask for large sums of money. I had to learn very quickly when I started my practice in 2005 as I did not have an NHS contract (a long story) and therefore all my patients were treated privately. If I'd undervalued my treatments or wasn't able to discuss money I'd have struggled to keep the practice running. At this stage I should thank the brilliant Ashley Latter, his training courses on communication are excellent and have shaped how I talk to my patients and carry out assessment visits.

At Wetherby Orthodontics we don't display fees outside the practice or even on the wall. We don't have public information posters on display. This was a concious decision to make the practice feel less like a hosptial and more like a boutique hotel or spa. However, fees are included in the welcome packs I send to all new patients. These are expressed as a range as I do not set fees for treatment until I have assessed the patient. At the first visit I will discuss fees face-to-face and also send a written treatment plan and estimate, including payment options. I know some dentist who still do not like discussing money, but delegate it to a treatment coordinator, which is an excellent solution. There's really no excuse for not being up front with your patients, after all if you buy clothes, a car, or a house the prices are usually easy to see.

I thought Jeremy Vine's programme did a reasonable job of getting the issues of dental charges across in a limited time. If you are a patient do make sure you understand what you are paying, when you are paying, and what it covers, no reasonable dentist will mind you asking and should be providing you with that information.