Grenfell Tower, dental forensics, and the state of NHS dentistry

Please don't read this blog if you may be upset or offended by discussion about the fate of the Grenfell Tower residents. This is my own personal opinion.

I'm sure, like me, you're well aware of the recent tragedy of the devastating fire at Grenfell Tower in London two weeks ago. I was shocked by the scenes which seemed impossible in a developed country, and have been incredulous at the inadequacy of the fire systems and flammable nature of the cladding and how that could have been allowed. Estimates today put the number of dead at 80, but from the start there has been strong wording that the real death toll may never be known, and some victims may never be identified.

It's fairly easy to realise that the poor people who were caught in the fire may be burned beyond recognition. Identification by sight may work for anybody overcome by fumes and smoke, but I'm guessing  the fierceness of the fire will have mostly caused damage way beyond that. Those corpses will be fragile and probably difficult to safely move. This is often where dental identification comes in. Just yesterday I had an email alert from my indemnity society with a reminder about confidentiality of dental records and their release to police for assistance in identification, which I assume has been precipitated by a high number of requests following the tragedy. I've also heard that practices near Grenfell Tower have been asked to search their records by postcode.

I've had an interest in dental forensics for many years. Before I trained as a dentist I quite fancied the idea of being a pathologist, but realising it was a long route which first involved medicine I decided against it. At dental school we had several lectures about dental forensics, and the forensic department at Leeds was, I believe, very good. I particularly remember that they were involved in identifying a lot of the people who perished in the Bradford stadium fire in 1985, four years before I became a dental student. (As an aside, when I worked at Bradford St Luke's Hospital we shared a ward with the Plastic Surgery team, who had developed new techniques of treating extensive burns because of the number of victims from the incident. Advances in trauma management often happen as a result of large scale disasters or wars.) As well as identifying bodies forensic dentistry can be used in many ways. For example bite mark assessment can confirm and help convict an attacker,  approximate age can be determined by dental development, and minerals taken into the teeth as they develop might indicate a country of residence. Dental identification helps in many cases where the victim can't be visually identified, for example extensive trauma to the face and head, burns, or prolonged submersion in water. I know a large team of dentists helped with identifying bodies after the Boxing Day tsunami in 2004.

So how do dental records help? If I am remembering correctly x-rays are usually taken before any more detailed examination. This is useful where bodies are fragile as they can be x-rayed without disturbing them too much. Then the mouth might be examined to check for the teeth present and any fillings, and any damage that might have occurred at the time of death or afterwards. X-rays and records can be compared to existing records to look for a match. Now, this is where it gets tricky because unlike a DNA or fingerprint database there is not a national dental records database. Dental records are held by the treating dentist, and not passed around with the patient like your GP records are. Some dentists still have paper records, though most will now have a computerised system. Even then x-rays don't really work like fingerprints, I'm not aware of a way of matching records or x-rays against a large database of people.

This means the best way to identify someone is to have an idea of their identity in the first place. Ask their dentist for their dental records, and then compare the records to the information you have. Occasionally the dental press send round a dental chart and an artist's impression of an unidentified body, but even if they have some quite unusual features this is quite a shot in the dark.

Cast your mind back to the Grenfell Tower residents. Some are known to be missing and their known flat and location found will help. Some may be in different flats, some may not have been expected to be there at all. Many are in social housing and low socioeconomic groups and some are refugees. How many of these are regular dental attenders? I suspect that many will not visit the dentist unless in pain, some may never have had dental care. NHS dental access is generally poor, I don't know the statistics for Kensington and the area around Grenfell, but across the UK the number of NHS dentists is falling and waiting lists are increasing. The residents are unlikely to have been in a position to pay for private care. Like much of the NHS, dentistry is underfunded and the system is broken. In some ways I feel that if there is money for the NHS is should be spent on hospitals, nurses and doctors, and NHS dentistry should be limited to urgent care in those that need it most and can't afford private care. Yes, I'd love NHS dentistry for all, but I realise the pot is limited, unless Theresa really HAS got a magic money tree.

So, if we have an idea who the potential victims are, we also need to know if they have seen a dentist and which dentist. We also need them to have had a dental charting, an x-ray (ideally several), and not have just attended for an emergency. We need the dentist in question to have accurately charted the teeth, kept the records and the x-rays safe, and be able to retrieve them. We have to keep records for 11 years, but if someone hasn't attended for a while they might be archived, in storage, and of course computer systems sometimes fail and paper records sometimes get lost or damaged.

Is it important we know who the victims are? Can't we just have a list of missing-presumed-dead? I'm sure friends and family need to know to be able to grieve. A death certificate is needed for the legalities to be able to be carried out after a death, insurance, financial settlements, inheritance, and later remarriage of the spouse. I also remember reading something about people taking advantage of a large-scale tragedy to disappear, something that is known to have happened after 9/11. So yes, I think it is important, and I know that many forensic dentists, pathologists and forensic scientists will have to deal for months to come with the grisly nature of the aftermath of the terrible fire. I don't apologise for the grim nature of this blog, I hope you have found it interesting and informative. Please join me in wishing strength to those dealing with loss and anyone in contact with them.

Can you tell someone's age by their teeth?

This question has been in the news today in relation to verifying the age of child migrants wanting to enter the UK. It has been suggested that their teeth should be examined to determine their age.

In my first year at dental school I was taught to identify different types of teeth and had to learn the ages that teeth came through into the mouth. In addition I had to learn the ages each tooth type started forming and the ages that the roots were fully formed, these can only be determined from an xray of the mouth. That was quite a lot of dates to learn! Once you know these you can determine the dental age of a patient from their mouth or an xray (an xray being more accurate as you have more information on unerupted teeth and the root development). This is possible because the order in which the teeth develop is fairly consistent.

Notice that I used the term 'dental age'. The dates that I learnt are based on averages. Much as the height or development of a child cannot tell you their exact age, dental age is the same. Dental age can be the same, more, or less than actual age. The main clinical purpose for its use is to monitor how the teeth develop and look for anomalies, for example teeth not appearing at the time they should. Alterations in the order that teeth develop is (to me as a clinician) more important than a difference between dental age and real age. Dental age is also used in forensics to help with determining age at time of death, but this would always be in conjunction with other data and could only give an approximation.

For example, the age that all the milk teeth are lost is 12 years old on average. A year or even two either way is not unusual, and I have seen it very between 9 and 15 years, that's quite a big difference! Once all the adult teeth are through it become more difficult to estimate dental age, and this might be done using an xray to look at development of the wisdom teeth if they are present, or looking at wear or dental damage. I'd expect someone with a poor quality of life living in a refugee camp to have poor dental health, which would cloud the issue. So using dental age on someone between the ages of 15-21 would be likely to be very inaccurate, this is just the age group that would need it most in this situation.

If dental age was to be used it might be necessary to take an xray to do so. However we have strict guidelines about the use of ionising radiation (of which xrays is one form) due to the risks to both individuals and the public in general. Xrays should only be taken when they are clinically necessary, that is they could alter how the treatment is carried out. Dental professionals have a responsibility to keep xray exposure 'as low as reasonably achievable'. Taking an xray purely for the purpose of determining dental age is therefore unethical and should not be done.

I do understand the need to try and determine someone's age to be able to help those genuinely in need, but dental age is not going to help in this situation.

Incognito Expert Forum, Nice

At the weekend I visited Nice, France for an expert forum on Incognito lingual braces. I've been using braces hidden behind the teeth for 9 years, and now use the Incognito brand almost exclusively for this type of treatment. Incognito braces are completely custom made to the specialist's prescription, leading to fantastic results and a great 'wearing experience' for the patient. This was a new meeting by invitation only, so I was delighted to be one of only 20 UK orthodontic specialists to attend, and the only one from Yorkshire. The meeting was held at the Hotel Negresco, a spectacular if rather unusually decorated hotel on the main Promenade des Anglais. Fortunately we had lovely weather, a complete contrast to Storm Abigail in the UK!

There were about 150 specialists, mainly from Europe, plus technicians from the German laboratory where they custom make each appliance. (Sadly some people hadn't made it due to the terror attacks in Paris affecting travel, more on that later.) The technology is incredible, Incognito started with 3D printing technology in 2001 when it was very new, and have continually developed the process and made it almost fully digital now. Many orthodontists are buying oral scanners which remove the need for taking impressions and sending by post. There were audible gasps of 'wow' in the audience as Incognito revealed the new digital light printer that can do the work of 40 of their previous printers. It's really useful to know what happens in the lab in between taking impressions and fitting the braces as it helps me to plan the treatment and understand what can and can't be achieved. I'm sure it's also useful for the technicians to see the clinical side and get to know the doctors.

Saturday afternoon was taken up with lectures by specialists from France, Japan, Italy, Scotland, Germany and the USA. The lectures including a lot of clinical tips, really helpful for not only planning treatment but also getting the best out of the braces to achieve the best results for my patients. There were some challenging cases treated to a very high standard. It was also great to chat to colleagues about lingual braces, and also about many other orthodontic topics, as well as having a social catchup with some friends I've met before.

Sunday was split into smaller groups leading to interesting and stimulating discussion. I gave a short presentation on providing temporary 'false' teeth to disguise gaps during treatment, and picked up some very useful tips and tricks from other specialists. It was inspiring to listen to others who use the appliance in many different situations, often in preference to other types of orthodontic brace. I can certainly recommend Incognito braces in confidencewith the knowledge it will deliver results as good as, or even better than traditional fixed braces on the front of the teeth.

Sunday afternoon was free so I walked along the prom to the old town. I had a good impression of Nice and would like to return and explore it more fully. It was really encouraging to see residents and tourists behaving normally after Friday's terrorist attacks in Paris, with many people and families out for a walk. In fact, the organisers and locals had been keen to stress that we were safe and still very welcome, and getting home via Nice airport presented no problems. Obviously our thoughts were very much with the French people and the Parisiens in particular.

I'd like to thank 3M Oral Care and Incognito for the invitation, and look forward to another meeting next year.

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.

I won!

Just a quick blog while I'm on the train home with an update from last night's Aesthetic Dentistry Awards.

I'm returning with rather more luggage than I arrived, as I am bring back four awards! This is my fourth time at these awards (they used to be called The Smile Awards) and after three Highly Commended certificates I really wanted a trophy.

I'm absolutely delighted to have been awarded all three of the orthodontic case prizes, for Removable braces, Fixed braces, and Invisalign. I was rather surprised to also win the overall prize for Best Aesthetic Dentist, as there were some stunning examples of treated cases there, everything from whitening to complex cases involving implants.

In fact it was a great night for our table, as my orthodontic friend Maria McNally won the Interdisciplinary prize, and Bilal Bhatti, another orthodontic friend, was awarded a Highly Commended certificate. How great to be taking certificates and trophies back to the North!

Over the next few weeks I'll publish the details of the winning cases with before and after pictures. In the meantime, I'm on my way to York for the British Lingual Orthodontic Spring meeting, which I have helped organise. I'm speaking in the afternoon too, what a busy weekend!

Favourites

I have a confession to make *takes deep breath*

I have favourite patients.

There, I said it. I don't mean in a Bruce Forsyth "You're my favourite" sort of way. I mean that I have patients I really love to treat. It's a bit like being a parent, you're not supposed to have favourite children, you're supposed to love them all equally. But sometimes you can't help preferring some more than others. (I have two children, who, usually, I wouldn't pick between, but occasionally I like one more!).

Perhaps I should point out that in terms of clinical treatment I try really hard to give everybody the same care. I do pride myself on my clinical results and really try to get the best result for everybody I treat. I know that my team are also very professional and will be consistent with our work procedures.

However, there are some patients I look forward to seeing, and often I find we spend longer chatting than we do treating. Seeing patients regularly, about every 7 or 8 weeks means I can really get to know them. We discuss things like Christmas, holidays and school exams, weddings, babies and school proms, triathlons, marathons and climbing, illness, travel and traffic jams, and even random things like bra sizes!

I was genuinely pleased to review a past patient yesterday who excitedly showed us her new engagement ring. I spent five minutes chatting about unwanted christmas presents with another. I was sad to say goodbye after a long but successful treatment to an incredibly nervous lady who had just adopted a child. I finished treatment for a lovely teen last week who brought me the homemade cake in the picture above (it was delicious!).

Now, if you're thinking about this you might have realised that I also have less favourite patients. I suppose there are a few, usually it's the ones who repeatedly break the braces and my heart sinks a little when I see their name in the diary! But there aren't very many, they still get treated (and a stern talking-to if their brushing remains poor or breakages are frequent), and there's always the next person to look forward to.

People often say to me "I don't know how you can look at teeth all day!" I do believe that the thing that makes dentistry interesting is the patients, not the teeth. Yes, there are interesting or challenging cases, but making the job interesting is more about engaging with my patients. To use a very worn cliche, it's about treating people, not patients.