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)

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!

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.

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.)

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.

Another veneer article

Following on from my blog of a few weeks ago here is another article about cosmetic veneers, shorter but less biased than the previous one (its from The Times). Thanks to fellow orthodontist David Horobin who posted it on his blog.

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.