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.

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.