Chapter 25- The Heavy Metal Generation

In the UK the NHS came into being just after WW2 in July 1948, launched by Aneurin Bevan the Health Minister in Clement Attlee’s post war government and what a wonderful organisation it is, we are very lucky to have it! Lots of people had access to dentistry that didn’t have access before. Previously only the wealthy could visit a dentist. The only dental help available to most people was extraction of a painful tooth hopefully by someone who was qualified to do so!

In 1948 ¾ of the UK population over 18 did not have their own teeth! In the first 9 months of the new NHS 33 million artificial teeth were provided rising to 65.5 million in the year 1950-51!

Dentistry was free in the early days of the NHS, charges for dentures were introduced in 1951 [1st charges for any kind of NHS treatment which lead to the resignation of Aneurin Bevan]. You can look all this up yourself at The Story of NHS Dentistry- British Dental Association

However dentistry was all about ‘drilling and filling’ in those days and continued to be so for many years, no thought and much less was known about prevention or causes of dental disease.

Now of course we know about these things and as with medicine we know just fixing things when they go wrong is no good the best way to deal with any disease is to stop it happening in the first place. Prevention, prevention, prevention!

So you have a whole chunk of the population with heavily restored teeth, but we are living longer and WE WANT TO KEEP OUR TEETH.

The average life expectancy of someone born in 1950 was approximatly 67 years [difficult to read off a graph], for a baby born in 2021 it is 81.52 years. This rate is increasing more or less steadily so by 2100 [80 years’ time] average life expectancy in the UK will be just over 90 years. [This information comes from the UN world population prospects and Wikipedia freely available on the internet].

At one time people felt that it was inevitable that they would lose their teeth.

In 1968 the first Adult Dental Health Survey in the UK was carried out. This has taken place every 10 years since. 2009 was the 5th such survey.

In 1968 38% of adults over the age of 16 in England and Wales did not have their own teeth and wore full dentures. By 2009 this had fallen to 6% [in England, Wales and Northern Ireland].

People are also keeping more teeth. The minimum number of teeth considered to be essential for a functioning dentition is 21. There is some debate about this, personally I think as long as you have 16 units ie 8 teeth that bite against each other you are fine, or rather you can cope, though obviously the fewer teeth you have the more strain is put on the ones you have left which is not good if they are not teeth designed for chewing ie molars.

Anyway in 1978 the number of people with 21+ teeth was 73% this had risen to 86% by 2009. It is expected that 90% of those aged 35-44 in 2009 will hopefully have 21+ teeth by the age of 80.

The key findings from the 2009 survey are:-

  • In 2009, 94% of the combined populations of England, Wales and Northern Ireland were dentate, that is had at least 1 natural tooth.
  • The proportion of adults in England who were edentate [no natural teeth] has fallen by 22 percentage points from 28% in 1978 to 6% in 2009.
  • The overall mean number of teeth amongst dentate adults was 25.7, with the majority of dentate adults [60%] having between 27 and 32 teeth. Dentate adults had an average of 17.9 sound and untreated teeth but this varied hugely with age.
  • Only 17% of dentate adults had very healthy periodontal [gum] tissues and no periodontal disease
  • 10% of dentate adults had excellent oral health.

I have quoted these key findings directly you can look it up yourself just put 2009 Adult Dental Health Survey into Google or similar and you will find it.

Why are people keeping their teeth?

Lots of reasons;- better nutrition, fluoride in toothpaste, better understanding of dental disease, more emphasis on prevention, improved dentistry [see below] and last but not least a change in attitude amongst the population- people EXPECT AND WANT to keep their teeth.

Many years ago [and certainly in the North East where I qualified] it was the fashion to have your teeth out and a nice set of dentures for your 21st Birthday present or if you were a woman when you married so your husband would not ever have the expense of your dental treatment!

If you look at a baby they have flat jaws, the top one is the maxilla and the bottom one the mandible. As your teeth grow they start growing from the tip of the crown [the bit you see in your head] and carry on growing until the crown is complete and then they grow the root. As they grow, they grow bone up with them in-between the roots to hold them in place- the Alveolar Bone. Think of it like a ‘Toblerone Bar’ bent round with a tooth stuck in each gap. This ‘ridge’ of bone is known as functional bone- you only have it if you need it, if you don’t need it, it shrinks away. So if you have your teeth out in your early 20’s by the time you get to 45 or so you have no ridge to put your dentures on!

So you have a population that is living longer, have kept their teeth, want to keep their teeth, expect to keep their teeth but HAVE HEAVILLY RESTORED TEETH. This is THE HEAVY METAL GENERATION of which I and probably most of the people reading this are a part.

Several things to consider-

  • If you drill a hole in a tea cup it will never be as strong as it was before, you can repair it but whatever you do and however good the repair it will never be as strong as it was before.
  • If you grow your first adult molar when you are 6 and you live ‘till you are 85 you are asking that little tooth to survive for nearly 80 years. You would never expect a road, a bridge, a car or a house to survive that long without care and maintenance so how can you expect a tooth to do so?
  • Accidents happen!

So most people with heavily restored teeth from many years ago will have amalgam fillings/ silver fillings. Now amalgam is a very good, hard wearing filling material which has stood the test of time, however it is not ‘stuck’ to your tooth it is merely packed into a cavity which has been cut to provide mechanical retention. The cavity has been undercut, it is bigger on the inside than on the outside so the filling is wedged in the hole, like an upside down flowerpot. Apart from the fact that perfectly healthy tooth tissue has to be sacrificed to provide that mechanical retention it also means that your cusps become undermined. A back tooth [molar] has 4 cusps/bumps on its biting [occlusal] surface, premolars [the ones half way along your arch] have 2 cusps. If you have a big filling in the middle of your tooth and you bite on that for many years the cusps are constantly twanged sideways. Eventually after many years of this either one or more cusps breaks off or worse still your tooth splits up the middle and has to be extracted. Premolars are notorious for splitting in two as they have 2 cusps and a valley gutter in the middle. I myself have lost 2 premolars in this way, one from biting on a bit of shot in a pigeon and one from crunching on ice cubes in a drink. Accidents happen!

Also if you have a filling in your tooth which is not just in the centre of the biting surface but extends to both sides and goes down between your teeth, your tooth is even weaker. The structure of your tooth’s enamel is such that it provides a ring of strength around its circumference. The best analogy I can give is if you take a plastic cup from a vending machine, fill it with coffee or similar, it will hold the liquid even though it’s really quite a flimsy material but if you cut through the rim of that cup with a pair of scissors it will lose its strength, eventually split and your coffee will be lost. The strength and integrity of that cup is in its rim.

All this leads to me saying that if you are a person who has heavily restored teeth you will probably eventually need what is known as cuspal coverage on some of your teeth, that is something that goes over your tooth, down the sides a bit and changes the biting load on your tooth from a ‘point load’ in the center, to one that is more evenly distributed all over your tooth. Sometimes this can be achieved with a large ‘stick on’ filling, a composite resin restoration which not only fills up the cavity in your tooth but goes over the top of your cusps as well to hug your tooth and sometimes you will need a crown, a hat that goes over your tooth and basically ’holds the bits together’!

Time for a little diagram.

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