Some you lose

Its not often that I have a 'failure' to report, but one has happened this week.

A lady in her 60's asked me to improve her crooked lower teeth. Together we decided the best option would be to remove one lower front tooth to create space and fit a ceramic fixed brace to straighten the teeth and close the space. As with everyone I treat we discussed the possible problems she could face especially discomfort during treatment. Everyone will experience some level of discomfort, from either achy teeth or the braces rubbing on the inside of the lips, but this is usually temporary. For most people it takes 1-2 weeks to get used to wearing braces, but it does vary a lot.

Mrs H came to see me several times with areas of rubbing or soreness and in most cases I could help by suggesting orthodontic products or trimming sharp ends. However this week she has decided it is all too much and asked to have the braces removed. We discussed a few options but finishing treatment now was the final decision so she is now very relieved to be free of her braces, even though she does now have a small gap at the front.

Of course, I'm disappointed that it hasn't worked out for her, but this is only the second time in 6 years as an orthodontist that I have had to end treatment for these reasons. I think this shows that for most people the discomfort is temporary and can be tolerated for the end result. My mission is to make people happy, and if wearing braces is having the opposite effect then I'm not being very effective in my mission! I will always try and work with my patients for the best outcome, and this means taking every case separately and listening to their needs.

What gumshield?

September heralds the return to school for many people and the school season for sports like hockey and rugby. You've probably got the PE kit already, but does it include a gumshield?

Gumshields are essential for anyone participating in contact sports, in the UK that mainly includes hockey, rubgy and lacrosse, plus boxing and martial arts like judo, taekwondo or karate. Usually made to cover the top teeth they offer protection to the teeth in case of a direct blow. This greatly reduce the risk of the teeth being broken or knocked out. This will reduce the need for prolonged and possibly expensive dental work.

However, the protection from a gumshield goes a long way beyond just protecting the teeth, they protect the bone supporting the teeth and the jaws too, cushioning the impact that might occur between the teeth and jaws from a blow to the chin. They can also reduce the risk of concussion from a similar blow, absorbing the impact and reducing shock to the brain.

Many schools and sports clubs now have good policies about gumshield use, you should wear one any time you are training, playing or competing. However, there is more than one type of gumshield, how do you know you have the right one that offers the best protection? A gumshield must also be comfortable to wear or the player will stop using it.

There are three main types of gumshield available.
1 Stock gumshields cost a few pounds, are preshaped and simply fit over your teeth. The likelihood is that they will not fit very well and therefore offer very little protection.
2 "Boil and bite" gumshields are adapted by the player, usually by immersing in warm water then placing in the mouth until it cools. I've tried one of these, it was difficult to get a good fit and was very uncomfortable to wear. Again, protection levels are low, but these remain popular options as they are usually less than £10.
3 Custom gumshields, which will require a dental impression of your teeth. These are the most expensive ranging from £30-£70 approximately, but as they are customised to the individual they are not only the most comfortable but they offer a very high level of protection from injury by having an even amount of material over the teeth. The cost can be off-putting, but for this you should get a choice of colours and often a storage box as well as a named gumshield. For more serious sports participants, eg adults and older teens in boxing or club rugby, the gumshields can be made of several layers to get the highest level of shock absorption possible.

Custom gumshields are also ideal if you are wearing fixed braces, they can be made to fit over the brace and also to allow some space for the teeth to move. I find they generally last a season. Dealing with injuries to teeth while wearing braces can seriously compromise the teeth and the orthodontic treatment as well as prolonging the total time wearing braces.

A lot of schools arrange for a company to come to school at the beginning of term to take impressions for custom gumshields, if this is not available ask your dentist or orthodontist about having one made. If it does not fit or is not comfortable return to your dentist as it may be able to be adjusted. It may seem like a lot of money for a small piece of sportskit, but how much do you value your front teeth, your jaw and your brain?

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?