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.

"Why is your Invisalign more expensive?"

That's a question I often get asked, and it's usually specifically about Invisalign rather than other type of orthodontic treatment I provide.

Do a quick internet search and you will see lots of offers for Invisalign treatment, some significantly cheaper than others. Have a look at your local orthodontic specialist and they will probably charge more than the general dentist down the road. In areas of high competition like London the price differences are even bigger and there may well be aggressive marketing on the internet or in magazines.

So why has this happened and why is a specialist more expensive than a general dentist? Have a read of this article by American orthodontist Ted Rothstein to see a bit of the background.

To summarise, Invisalign is one of a few orthodontic treatments that are easy for any dentist to start using, requiring a one day course to become certified and able to provide treatment (though there are now other similar treatments like ClearStep and Inman Aligner with similar issues to Invisalign). If you were a dentist who could now offer the treatment direct to your patients then why not, rather than referring to a specialist who will take the fees that could otherwise come to you? Why subject your patients to treatment with fixed braces when they can wear invisible removable braces instead? If you are the consumer why should you pay more to see a specialist when the same treatment can be bought for less?

Here's a quote from the article; "Dr. Rothstein reports that he is seeing in recent years a growing number of patients on consultation in treatment with Invisalign by the generalist who simply lacked an understanding of the limitations of the Invisalign appliance. General dentists are not fully trained to recognize the many nuances associated with effective treatment, or even foresee the potential problems lying in wait as they proceed. Training and experience really do make a difference.
There are also cases in mid-course where the general dentist had no idea how to handle the problem that the patient was encountering and cases where the end result of the Invisalign treatment were so lacking that the only recourse was to finish the case with fixed braces."

I'm sure there are some general dentists who get comparable results to a specialist, but only with the right experience and attention to detail, and how do you know who these are? Be sure to ask questions about your potential treatment and also about what is included. Does that cheap fee include hidden extras like refinements and retainers and how often will you be reviewed? What sort of customer service do you get and do you enjoy your visits?

It's a bit like getting your hair cut. Do you prefer to go to the small salon that has out of date magazines and faded decor, see the junior stylist at a medium salon or pay the extra to see the senior stylist at the best known salon in town? The end result is important but so is the experience you receive.

You should know that Invisalign offers significant discounts to providers who commit to providing a large number of treatments per year, they have to get the numbers in or risk paying large penalties. Even with these discounts some offers I've seen are so low it must be costing the practice money instead of making it. As a small practice and a specialist offering many types of treatment my numbers are relatively low so I can't always take advantage of this, or do "extras" like tooth whitening, hygiene or veneers to gain extra revenue.

I'll finish with a final quote from the article which puts it better than I can; "...isn't the consumer better served by the orthodontic specialist even though having to pay a higher fee? Indeed when the consumer pays more to engage the services of the specialist isn't he receiving more in the way of experience and wisdom that far outweighs the additional fees the consumer may have to pay"

Porcelain Deficiency Disease?

There is an interesting opinion article by dentist Martin Kelleher in the recent Faculty of Dental Surgery journal. He highlights what he terms "porcelain deficiency disease", a made up condition where dentists over-prescribe porcelain crowns and veneers. Unfortunately it has been taken out of context by several tabloid papers with the purpose of shocking the public about "greedy dentists", which is not really what he was trying to say. For a summary of the article click here, for the full article click here..

It's probably not escaped your notice that there is a recent trend for straight white teeth (think Simon Cowell). One way of achieving a very white, very regular smile is to place porcelain crowns or veneers on multiple teeth. A crown is a complete covering of a tooth, whereas a veneer is more like a facing glued to the front. Both are common dental treatments which are widely used for a number of purposes, mainly for restoring teeth that are decayed or broken, but they can also be used for altering the shape, size or colour of teeth. However, in order to accommodate the thickness of the porcelain the tooth is usually reshaped which often involves removing healthy tooth.

Martin Kelleher uses his article to highlight several cases where patients' dental health has suffered following extensive crownwork. The risks of crowns and veneers are well known, and include pulp death leading to root filling, fracture of the tooth underneath and gum disease due to rough edges or poor cleaning. Any responsible dentist will explain the risks to their patient and balance this against the benefits. What happens in a few cases is that the patient is prescribed crowns for EVERY tooth and sooner or later suffer dental health problem because of it. Another dentist then has to try and salvage what they can for the disappointed patient.

So why is this happening? There is certainly a pressure from patients who want to look like their favourite celebrity or their friend who has just had treatment and now looks ten years younger. But there must be a lot of pressure on dentists who perhaps see a colleague down the road doing such treatment and feel they need to keep up to survive, especially in financial terms. Whilst most dentists I know are very ethical and always have the best interests of the patient at heart there are some (like in any profession) who simply want to make money. If a patient appears in your surgery with a fat wallet and requesting complicated expensive treatment then why shouldn't you do what they ask? If you refuse will you lose out when they and all their friends go to a neighbouring dentist?

So, if you want to improve your smile what should you do and who should you believe?

Start by speaking to your dentist about your concerns. A good dentist will take time to find out exactly what your problem is and discuss the options. There will always be more than one possible treatment. Your dentist should discuss the advantages AND disadvantages of all options, but will probably guide you to one preferred option. Any comprehensive treatment should be planned out very carefully, usually with photographs, x-rays and models of your teeth, and sometimes with mockups of the predicted result. Ask to see pictures of previous cases and if you are unsure about anything get a second opinion. If you have irregular teeth has your dentist discussed the possibility of orthodontics? I accept that having treatment with braces is not for everyone, but in most cases it can mean that your natural teeth will be preserved which is much better for your long term dental health. Of course orthodontics itself is not without risks and I always discuss these with my patients before they start treatment.

Sadly there will always be rogue dentists who make headlines and there will always be journalists who will write horror stories about them. This is a very small minority of dentists and the rest are ethical, caring and well trained and would only prescribe veneers or crowns when appropriate. I will certainly be working with my referring dentists to make sure they consider orthodontics as an option.

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!

Goodbye to the Tooth Fairy

The end of an era was reached last week as my younger daughter lost her last baby tooth.

Also known as milk teeth, or more correctly deciduous teeth, your first twenty teeth are shed to make way for the adult, or permanent teeth. Generally the first one is lost around about the age of 6, and the last one about the age of 12. However there is a large variation and two years either way is fairly normal, and as long as the normal sequence of teeth erupting is followed this is not of any concern or consequence. My daughter was particularly young, being 9 years and 7 months.

I am sure you will know of the tooth-fairy tradition of leaving the tooth for the fairy to collect, who leaves money in exchange. In some countries there are variations, like a tooth-mouse, but it's a fairly popular tradition worldwide. The first visit from the tooth fairy when she was aged 5 caused much excitement. Over the years she has developed a little routine of leaving a note for the fairy, who usually replies, so we now know that our fairy is called Lilac, lives somewhere nearby under a mushroom, and has all sorts of excuses for non-attendance like a sprained wing or a trainee fairy!

This is her last letter along with the tooth and the tooth box. I did think that at the age of 9 and with an older sister she might have realised the tooth fairy secret, but she was genuinely upset that the fairy would never visit again, to the point of tears! Awww!
Thankfully this time the tooth fairy attended on time and left a lovely letter, complete with lilac ink and a picture.

The tooth fairy was good enough to let me keep the teeth, shown in the picture at the top. Three are missing, I know at least one was swallowed, not sure where the other two went! I'm pleased to report they are all healthy, thank goodness, being the daughter of two dentists would you expect anything less?

Tooth Whitening

I wrote a blog in March about cheap tooth whitening and how you should always have whitening done under the prescription of a dentist. In general it is safe and effective when used correctly and plenty have research has shown this to be the case. Although I have used whitening in the past I do not offer it to my patients but refer them back to their general dentist for the procedure.

I feel it is time to comment again, not least because there is someone locally who is offering cheap tooth whitening illegally, a situation which is being repeated around the country. There have been adverts in local magazines and makeshift billboards in the verges on the approach to Wetherby. Looking at the website they seem to have done some research and explain, along with some out-of-context quotes, that in their opinion it is not illegal, but they seem to have overlooked some pertinent points.

The General Dental Council (GDC) regulate dentists and dental professionals and are very clear about what constitutes illegal dentistry. They even have a page dedicated to the practise of tooth whitening. They say "The practice [sic] of dentistry is limited to GDC registrants. It is the Council’s view that applying materials and carrying out procedures designed to improve the aesthetic appearance of teeth amounts to the practice of dentistry. So too does the giving of clinical advice about such procedures. Therefore all tooth whitening procedures, including bleach and laser treatment, are seen as the practice of dentistry by the General Dental Council." I have now alerted the GDC to the operations of this salon but until they investigate the salon continues to operate. The GDC recently prosecuted successfully for illegal practise against a similar type of clinic.


What is concerning in particular is that illegal dental procedures are putting patient's dental and general health at risk. As dentists we train for at least five years which includes diagnosing dental disease like decay or gum disease and understanding why teeth may be discoloured. We have rafts of legislation we have to adhere to both personally and with our practices and make sure we keep up to date with current treatments and guidance. How can someone who is not a dentist (or dental professional) and has had one day of training be sure that there is no dental disease before they whiten and how can they identify fillings or crowns which will not change colour? Are they aware of cross-infection control procedures which are used to prevent spread of disease, including serious conditions like Hepatitis B and HIV? How are they cleaning equipment after use and disposing of contaminated materials like gloves? 


I should mention that there is a legal issue surrounding the use of hydrogen peroxide products to whiten teeth, due to the fact that whitening agents are classed as cosmetics (read to the lower part of the page), even when used by dentists, which is how these salons think they can get away with it and why some dentists are not offering whitening at the current time. Some illegal clinics are not using peroxide based agents, but it is unclear exactly what they are using and whether it has been correctly tested. As peroxide is the most effective agent, at the right concentrations, are the results with something else going to be satisfactory? Promising "10 shades whiter" with a single treatment is totally unrealistic as a dentist would know.


So please, if you are considering getting your teeth whitened DO NOT visit the salon offering tooth whitening at what seems like a good price. Similarly do not use that Groupon offer that seems too good to be true. At worst you could end up with damage to your teeth or even an unwanted infection, at best you will probably be disappointed with the results and will have wasted your money. Please don't buy whitening gel on the internet either, it is often fake and is usually not subject to strict quality control. Go and visit your own dentist and discuss the options, and please tell your friends too and spread the word.

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.