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)

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.

How long will I wear my braces?

A question I hear daily is "when can I get my braces off?". My normal answer is "when the treatment is finished!".

Of course I do try to estimate treatment time during the planning stages and be realistic about this, and in most cases I get it about right or slightly over-estimate. But it still doesn't stop the question being asked.

At the beginning of treatment teeth appear to move quickly. Towards the end of treatment the teeth can appear generally straight, and the changes will be mush smaller. Sometimes these can seem unnecessary to the patient, like getting that tooth 'just so' or trying to correct the bite. Patients often wonder why I'm spending time correcting something they are not concerned about.

Take the teenager I saw yesterday. His teeth look fabulous, they're straight and he's very happy with them. I'm concerned because the bite isn't correct, in his case the side teeth don't meet evenly and he doesn't have an obvious place to bite. I prescribed elastics to improve this, he'll need to wear them all the time to get the result, and this is the only thing that's left to correct, so if he wears the elastics well I'll be able to finish treatment in a few months. He wasn't exactly enamoured about wearing elastics, both for the appearance and the comfort of them and asked if he really needed them, after all, he's happy with the appearance now.

I find this a bit difficult as I think people perceive that I'm fiddling with the teeth for the sake of it and they won't get a real benefit, they'd rather finish treatment. It is certainly the detailing of the last few visits that makes a difference between a good result and a great result. Naturally I want to get the best result I can, at the end of the day I am the judge of my own treatments and I have high standards. But there's often more to it than that. Take the 'wrong bite' situation. Getting a good bite where the side teeth interlock nicely helps with long term stability, that's the teeth staying where I've put them. It prevents uneven wear on the teeth and puts less stress on the jaw joint and jaw muscles, which might cause problems later.

Will he wear his elastics enough? I'm not sure, but he's been informed why it's important and I hope he will successfully complete treatment. I really don't prescribe elastics (or any other form of treatment) for a joke, they are necessary in some cases, so please listen to your orthodontist and follow their advice, and ultimately, trust that all they are trying to do is get the best possible result. Isn't that worth a few extra months wearing braces?

Smile Awards 2012

The Smile Awards were held last week and for the third year in a row I'm delighted to have brought home a Highly Commended certificate, this time for 'Best Aesthetic Practice'.

Like many other industries and professions the dental industry has several awards ceremonies throughout the year, and dentists and practices are using these as a method of both team building within the practice and a way of promoting themselves to their clients. The other awards focus on things like marketing, teamwork or practice appearance, but the Smile Awards are the only ones to focus on clinical excellence. The categories cover the many ways of improving a patient's smile, whether this is through the use of white fillings, tooth whitening, crowns and implants or orthodontic treatment. Dentists submit photographs and a writeup of the case, which are judges anonymously by a panel of dentists and specialists.

The 'Best Aesthetic Practice' is a new category, to recognise a practice which provides aesthetic dentistry (which can encompass any type of dentistry which improves the appearance of someone's smile). I submitted a portfolio all about the practice, including photographs, testimonials, financial details, our branding and our staff.

The awards were held at the Landmark Hotel in Marylebone, London. I travelled down with Carly-Ann and Angela, its great to be able to dress up and enjoy a night out, we're more used to spending working time together. Here we are at the drinks reception.

The Landmark is a beautiful five-star hotel, with a large central atrium decorated with palm trees. It reminds me of a rhiad in Marrakesh, but on a much larger scale. The dinner was held in the grand ballroom and was delicious! Its always great to meet friends and colleagues and I'd arranged to sit with my friend and colleague John Scholey and his team, it was great to catch up and have a bit of banter!

After dinner the awards were announced, with the judges stressing the high standard of entries and how both the number and quality of entries had increased over the last few years. Sadly neither my fixed braces case nor my removable braces case picked up a prize in their categories. However John won the fixed braces and another orthodontist who qualified the same time as me, Darsh Patel, won the removable category. Although they showed before and after pictures on a large screen for all the shortlisted entries it wasn't possible to really tell why certain cases had won, but there were certainly some impressive smile transformations.

The last award to be announced was for Best Aesthetic Practice. Originally this was to be a regional award, but all nine practices were judged together. Having checked out the opposition beforehand (of course!) I really didn't think we had a chance in this, so it was a fantastic surprise to be announced as joint runner up and to be awarded Highly Commended along with a Harley Street practice, which shows a Yorkshire practice can really cut it with the big London practices!

Of course we had to have a little celebration...

The night didn't end there, Carly-Ann and Angela strutted their stuff on the dance floor and I enjoyed chatting with colleagues, some I'd met before and some I hadn't. It was great to finally meet some faces who I've been in touch with via Twitter, I'm pleased to say we got on just as well in real life as we do online! it was clear that everyone had real enthusiasm for their own branch of dentistry. We even got filmed for a promotional video, though I'll need to review it carefully before I post the link!

Back in Yorkshire I've had time to reflect and for this to really sink in. I've worked really hard over the last six years to make this practice a success. Many said it couldn't be done without an NHS contract. It has been tough at times, particularly when the recession hit as orthodontics is a 'luxury' item, but many dentists have found that cosmetic treatment is still a growing area, we all need to feel good after all.

I couldn't have done this alone, and I really have to say a big big 'Thank You' to my husband Jack Cooke and his business partner Richard Moon. Jack and I started on the road to our own practices when we bought the property in 2005, and I still share facilites and staff with their practice Ashby Dental. Their rebrand and redecoration last year prompted my own rebrand and together we've both introduced treatment coordinators (Carly-Ann and Angela) who've really helped to grow our businesses. At the risk of this becoming an Oscar acceptance speech I should also thank Chris Barrow for his business coaching excellence since 2005, all the dentists who refer patients to me, and my patients, especially those who recommend us to their friends. And of course my family, not just Jack but my children and my parents-in-law who often help out with childcare.

This isn't the end though, I plan to keep improving Wetherby Orthodontics and making many more patients happy with their new smiles. Its not all about awards, in fact my patients are far more important. I am confident of giving my patients great service and great treatment, awards are just an extra way of recognising this.

Groupon? Not for me!

A few weeks ago I had a phone call. "Hello its Mark from Groupon, wishing you a very Happy New Year. And by the way, we've got a front page offer you might be interested in." I politely wished him a Happy New Year but declined his offer and asked not to be called again.

"Why?" you might cry, especially if you love Groupon or any of the similar discount voucher sites, in fact you may even have seen offers for for treatment such as tooth whitening or Invisalign.

I did write a really long blog post about the ethics of offering discounts on dental and medical treatment and why the figures don't stack up, and why it might work for businesses like restaurants and beauty salons where they can sell additional items or gain from repeat business.

I've deleted because I think the sort of clients I treat can see that and understand that and don't need it spelling out. There are certain brands you wouldn't expect to see on a discount site, like BMW or Porsche, Armani or Prada, The Ivy or The Manoir Aux Quat'Saisons. If these brands did start offering huge discounts it cheapens the brand, makes it less exclusive, just think what happened to Burberry a few years ago when the products suddenly became just that bit too popular.

So perhaps I'm going a bit far comparing myself to luxury brands, I certainly don't want to make myself and my treatments seem elitist, but much as some people will save up for that certain car, item of clothing or special meal many of my clients are seeing orthodontic treatment as an affordable luxury that will make them feel good about themselves. The true value is not in the cost but in how it makes you feel. Much as a Skoda will transport you, a coat from Primark will keep you warm, or a meal from Pizza Express will fill you up, that cheap braces offer may straighten your teeth, but will you get the same experience, the thing to treasure, to talk about, to make you feel good?

So, please don't ask me for special offers. I don't artificially inflate my prices so I can't offer discounts as this is a business and my livelihood, as well as my passion. I don't even mind if you 'window shop' a bit, by all means visit that practice offering a cheap deal, but come visit me too before you decide.

(If you still don't understand, read about the cupcake disaster, concerns from the ASA and OFT, the problems of time-limited medical offers and the General Dental Council's view of discount offers.)

It's not always about braces

I guess the common perception of an orthodontist is that we fit braces. Of course that is a big part of what I do but I don't advise braces for every patient I see. Take two cases that I have seen this week.

S is 12 and not bothered by the appearance of his teeth. He is pretty adamant that he doesn't want braces, he has thought about this and lists several very valid reasons why. His teeth are a bit crooked, but not too bad and the main reason for doing treatment would be aesthetic. That's not to say appearance isn't important, but in S's case he was happy with his appearance. In his case treatment will still be possible if he changes his mind when he gets a bit older, even when he is an adult.

In this situation the patient's opinion is key. Wearing braces is a big responsibility and is not without risks. I need patients to be on my side to make the treatment easier for all of us. Apart from a few specific situations (for example where treatment timing is critical or dental health is an issue) I will never persuade people into treatment they don't want.

C is also 12 and has a very different situation. Her teeth aren't very crooked either but four of her adult teeth have failed to develop and one is in a poor position, that's her x-ray above showing the milk teeth remaining in position. Orthodontic assessment in a case like this is essential to plan what to do. If her teeth were really crowded we would remove the milk teeth and use the space to straighten the front teeth so that there won't be long term spaces, but in C's case this would be too complicated and wouldn't actually improve the position of her teeth by much, in fact she'd probably end up in a worse situation. So I didn't suggest braces for C either, she needs to take care of all her teeth, including the milk teeth that remain as they can sometimes last for years. Her dentist can plan how to replace these teeth when they are eventually lost but orthodontics can't really offer much to her.

So just because you need to see an orthodontist it doesn't mean that braces is the immediate or obvious solution. As an orthodontist I am trained to understand the development of the teeth, the jaws and the face, as well as knowing how to correct problems that can occur. So be honest with me about how you feel, listen carefully to my advice and don't be afraid to ask questions.

In Praise of Patients

I treat a really wide range of patients, from about the age of 9 up to 60+. I treat boys and girls, men and women, nervous patients and confident people, housewives, teachers, business men...you get the picture.

One of the lovely things about orthodontics is that because I see my patients every 6-8 weeks over the course of one to two years I get to know them well. I've seen patients through pregnancy and love it when they bring in the babies. I like to hear about exam results, holidays, sporting results (one young girl is a national triathlete) and weddings. Sometimes I need to lend a sympathetic ear in times of bereavement, divorce or job loss. It works both ways, they ask me about my children, my holiday and my dental nurse Carly about how she's getting on with her braces.

I consider all this part of the job and one of the things that makes it interesting. I often hear "I couldn't look at teeth all day" and if as a dentist or orthodontist that's how you perceive your role then no wonder you don't enjoy it. It's the people that make it worthwhile and make no two cases alike.

I know that I make a difference by the smiles and the thank-yous I get when I finish treatment. The best way of thanking me is by recommending me to family and friends, it's not only a great compliment it's one way my practice grows. Some patients choose to show their thanks by gifts, in recent weeks I've been given wine, chocolate, running socks, a plant and some pink champagne (its a tough call as to whether the socks or the champagne are my favourite!). It's not necessary but I am really touched when people take the time to buy a gift or write a card.

So thank you to all my patients, I really couldn't do this without you!

Treatment fit for a Queen?

Did Kate have braces to improve her smile before her wedding day?

There is a lot of speculation that the Duchess of Cambridge had treatment with lingual braces before her wedding day including reports that she visited a specialist on Harley Street and an article in Hello magazine this week. Her smile is certainly fantastic, I'm sure any bride wants to look their best on their wedding day but when you will be seen by millions around the world and the images will form part of history it's even more important!

You might know that Prince William had braces when he was a teenager, as did brother Harry and cousins Eugenie and Beatrice. This is nothing unusual, it's estimated that up to a third of children have a need for braces and there will be more that have them for cosmetic reasons.

So how did Kate manage to keep braces a secret? It's likely she wore lingual braces, braces that are fixed to the back of the teeth to keep them hidden, rather than being invisible. It's not a new treatment but this type of treatment is growing in popularity and celebrities like Myleene Klass have chosen them. I think it's highly likely Kate also had some tooth whitening as well.

The good news is you don't have to be a future queen or go to Harley Street to have this type of treatment. I have been treating patients with lingual braces for several years, from self-conscious teenagers to middle-aged business men. The thing they have in common is wanting a better smile without wearing "Ugly Betty" braces, and they are suitable for most orthodontic problems. I use a system called Incognito which is highly customised to make the braces more comfortable and more accurate. Not only do you keep your braces hidden but you get the benefits of straighter-looking teeth whilst still wearing them!

If you are interested in having treatment fit for a queen then please give us a call and book an appointment for an assessment, and soon you can be smiling like Kate and William on their wedding day.

Orthodontic Tourism

You've probably heard of dental tourism, going overseas to have complex dental treatment done because it's cheaper and it can be combined with a holiday. Whilst it seems like a good idea you have to consider who will maintain your dental treatment and what would happen if you had any problems. It is difficult enough to assess the competence of a dentist but even more so if you are unable to visit the clinic in advance or talk to other clients.

Today I had a call from a patient with a request I am hearing more and more frequently, and I know my colleagues are too; "If I have my braces fitted abroad will you monitor and adjust them for me?" In this case the patient wanted to go to Poland to have the braces fitted then have me adjust them.

Orthodontics is a complex treatment and ideally should be carried out by a specialist or someone who has had additional training and experience. Each orthodontist may approach the same case in very different ways, for example some may extract teeth and some may not. There are many different treatment systems out there (brackets, wires, ways of moving teeth) which may require a different skill-set. The most important part of the treatment is the planning stage, so wherever possible treatment should be planned and carried out by the same person (or at least supervised by the same person or in the same clinic).  Therefore, if someone is hoping to save money by having braces fitted elsewhere then I am not willing to treat them, the treatment should be carried through from start to finish at the same place.

Of course, occasionally people do move or emigrate part-way through their treatment, I've had patients who have moved to Australia and Northern Ireland. In these cases the treatment should be formally transferred to a new orthodontist. I always send a letter detailing the treatment plan and the progress in treatment so far together with copies of x-rays, study models and photographs. I'd expect the same if patients transfer to me, in fact I have taken on patients from Brazil and London and successfully completed treatment. I'd also see someone who might be temporarily in the area if they have a problem during treatment, but usually only to make the brace safe so as not to interfere with a colleague's treatment.

So please don't consider "orthodontic tourism". By all means get more than one opinion if you have several orthodontists in your area, realising you may well get different treatment plans and different costs, and be prepared to consider ALL the factors, not just the financial cost of treatment. Remember your treatment will take many months and require regular visits and you will need to have a good rapport with your orthodontist and their team.

How to choose an orthodontist

I came across this blog from an American orthodontist on Twitter. A few years ago this would not have been relevant in the UK. You take your child to the dentist, the dentist says they need braces and refers your son or daughter to the local NHS orthodontist they have always referred to. You didn't think to question that there might be a different orthodontist you could choose to see and when the treatment is "free" why should you question it?

This is changing and in many cases parents are researching who might be best for their child. Why? Partly due to the NHS changes meaning that there are long waiting lists and children with milder problems will not get treated, meaning parents may need to pay for private treatment. But there is more to it than that, parents and children want to be involved in the decision making process and want to understand what will happen, and be treated as an individual, not just another patient in a busy day.

As a private only orthodontist I see patients who have chosen to visit me for a number of reasons. In many cases its because they do not qualify for NHS treatment but still want to get straighter teeth, or because they do not want to wait for a year or more. But I am seeing an increasing number of children and their parents who are visiting more than one practice before they select who they feel most comfortable with to do the treatment. Its not just about cost or whether extractions are involved, its about how they feel about entrusting the dental care of their son or daughter to the clinician. You probably only get a real feel for this by visiting the orthodontist.

I'd actually disagree with the article about "Word of Mouth". Of course if you are not a dental professional you cannot assess the quality of work that is done, but I do believe that if someone takes pride and care in looking after their patients then they will probably take pride in their clinical work. Its important to me that I get a great clinical result, but its just as important that my patients feel happy and comfortable visiting me. I get a real sense of pride when I know I have been recommended by a former or current patient.

So how do you choose an orthodontist? Research on the internet, ask your friends and ask your dentist. Weigh up the practical side like how easy the surgery is to get to and get parked, the costs and the payment plans available. Consider the type of treatment that has been recommended, whether extractions are involved and how long it might take. But overall its about how you felt when you went to the surgery, the customer service, the pleasantness of the surroundings and most of all if you got a sense of whether you can trust the orthodontist. If you're not comfortable-get a second opinion!

Come on England!

How do you show your support for your World Cup football team? How about wearing the colours on your braces like this young patient?

Another sporting brace-wearer

Congratulations to British gymnast Beth Tweddle for her amazing gold medal for the floor exercise at the Gymnastics World Championships in London this weekend.

Not only is Beth proving that 24 year-olds are not too old to be top gymnasts, but that adults can wear braces too.

Veneers can damage your teeth

This article in the Daily Mail caught my eye yesterday. It details some problems patients have run into after having cosmetic veneers placed, specifically the nerves dying and needing rot-canal treatments. It makes quite horrifying reading!

Like all these things we need to look at the whole picture. Veneers are used in different circumstances to improve the appearance of the teeth, by changing the colour, shape or position of the teeth. They are usually thin porcelain laminates glued to the front of the teeth, if you watch "10 years younger" you will know what a transformation to someone's smile they can make.

It is certainly true that they are not without their potential problems. They don't last forever and will need replacing eventually. If the teeth are very irregular then some teeth will need to be reduced in size to ensure the porcelain is not too thick. Taking healthy tooth away for cosmetic purposes is obviously not suitable for everybody.

I often see patients who have rejected the idea of veneers because they do not wish to have otherwise healthy tooth tissue taken away. Orthodontic treatment can often give a similar improvement in appearance without cutting into teeth but it does take longer and obviously involves wearing braces! The picture show veneers which were inappropriately placed on crooked teeth. However, orthodontics is not without potential problems such as damage to the roots and enamel surface and relapse.

If you are considering any cosmetic treatment, whether it be veneers, tooth whitening or orthodontics, then please make sure you spend time talking to your dentist. Make sure they explain the advantages and disadvantages if treatment. If necessary, seek more than one opinion and try to see a specialist, or at least someone who is experienced in this sort of treatment and can show you examples of their work. Many of the dentists I know who do cosmetic treatment will spend several visit planning the treatment with your and will also place temporary veneers or crowns which can be adjusted until you are happy with the appearance.

Don't let this put you off treatment if you are unhappy with your teeth. But do make sure you are fully informed before committing to treatment, whatever it might be.

Look who's got braces!

This is British singer Estelle, currently nominated for a Brit award for "American Boy" which was a massive hit last year. She is wearing some aesthetic ceramic braces and already you can see an improvement in her teeth. She says "This was a me thing. I've wanted braces since i was 20." She even says it has not affected kissing! I think it's great that she is not afraid to smile and show them off.