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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 www.bda.org 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.

Chapter 24- Non-destructive Cosmetics.

One of the concepts in medicine is that the patient should be better off when you have treated them than before you started or at least no worse off.

The mantra is ‘do no harm’.

‘Cosmetic’ as an adjective is used to refer to substances or treatments that are intended to improve the appearance of something without changing its basic structure.

Now obviously there is a place for everything and everything in its place.

If you had a nose that was 3’ long or thighs that were bigger than your waist no matter how hard you dieted, if it made you miserable I think most of us would want to do something about it if such a treatment was available.

So with any type of treatment that is ‘elective’ ie not medically necessary [let’s leave your mental health, self-confidence etc out of it for a minute] the benefit to the patient has to well outweigh the risks involved in the procedure.

Benefit is ‘actual’ benefit, that is an improvement to the patient’s health [including their mental health and wellbeing] and ‘perceived’ benefit by the patient, as in, how they themselves feel about it.

Now I might have a patient who has a whole load of crowns at the front of their mouth they had done years ago. These are chipped, cracked, showing dark margins etc. [Why they had them done in the first place is another matter which we won’t go into now]. So these crowns, the patient really dislikes them, their confidence has gone down the drain, they don’t smile in photographs etc. They want to do something about them. This is understandable. As long as the dentist has completely explained the treatment required, the benefits, costs, risks, time frame involved, allowed the patient time to think about it and the patient has asked and given consent for the treatment to proceed then this re-treatment is fair enough.

No one nowadays would do this treatment on a patient from scratch ie crown all their virgin front teeth. As soon as you put a drill on a tooth it is on the long slippery slope to being lost. So anything done to a patient has to be as non-destructive as possible and the benefits, actual and perceived must be greater than the risk involved. This of course means that any reputable dentist will refuse to do treatment requested by the patient for whatever reason, if they feel that the treatment is unwarranted and will be harmful to the patients’ health and wellbeing.

Many years ago there used to be a dentist who advertised in one of the British dental rags with pictures of his ‘cases’. Usually perfectly reasonable looking young women whose front teeth he had cut down to ‘pegs’ and then crowned with a set of overly bright ‘tombstones’. Why his adverts were accepted for publication I have no idea. One can only assume that there was no one dentally qualified on the editorial body.

‘Nothing is forever with teeth’. No artificial material placed on or in a tooth is going to last forever. So why replace a patients perfectly good enamel [the tooth’s protective armour as it says in the advert] with something that is artificial, will chip, break, show the margins, need replacing probably many times over a lifetime? It doesn’t make sense. Think of the cost if nothing else!

Now obviously there are often very good reasons for crowning a patients front tooth;- car crashes, olive stones, trips and falls to name but a few but anything done, should be done in the least destructive, minimally invasive way possible.

I find it very strange when patients say to me of a previous dentist ‘He/she just did ‘whatever’ to me’.

What on earth were they thinking of? Why didn’t they say ‘hang on a minute I’d like to know a bit more about it first’? You wouldn’t let someone drill a hole in your leg and fill it full of metal or plastic resin without a ‘by your leave’, so why would you let someone do it to your tooth? Your tooth is as alive as your leg, it’s part of you and connected to the rest of you by its blood and nerve supply. I’m not saying the treatment was unnecessary, it may be just a question of bad communication and a lack of information. You have to give consent to treatment and to give consent you have to be ‘enlightened’, that is, not only do you have to be ‘informed’ about the treatment proposed you have to understand it. The dental team’s job is to try to put the information necessary to you in a way that is understandable. This could be as simple as a pencil sketch or as sophisticated as a 3D computer demonstration.

Non-destructive Cosmetics.

So nowadays the only type of elective/ ‘cosmetic’ treatment done in dentistry should be as minimally invasive and non-destructive as possible.

Now let’s get this straight before we go any further there is no such thing as a ‘Cosmetic Dentist’. It is not a speciality recognised by the GDC [General Dental Council]. There are no further qualifications in ‘Cosmetic Dentistry’. All of us do ‘cosmetics’ ie we try to make our restorations look nice and we might do minimally invasive treatments to improve someone’s appearance at their request. By definition if you are going to have ‘cosmetic dentists’ that implies that the rest of the profession are ‘non cosmetic dentists’, well who would want to be one of those?

There are dentists however who specialise in ‘cosmetics’ that is they limit their practice to bits of dentistry they enjoy/ are good at and that may be the more ‘cosmetic/ appearance improvement’ side. Just like you might have a painter and decorator who specialises in special finishes like marbling. There is nothing wrong with this and there are some very talented, knowledgeable, artistic, ethical practitioners in this field.

For further information visit The British Academy of Cosmetic Dentistry at http://www.bacd.com The BACD’s mission ‘is to make a difference to peoples lives by providing exceptional, ethical, cosmetic dentistry’.

Elective [rather than replacement] non-destructive cosmetic treatments encompass; – orthodontics, bleaching and adhesive dentistry [sticking things on to things].

Orthodontics.

Orthodontics [tooth straightening/ moving etc] is a speciality [as recognised by the GDC see Chapter 22] within dentistry. It takes many years to train. All of us with the basic qualification are allowed to perform orthodontics but orthodontics has become so complicated and sophisticated to produce much better results than years ago, that I don’t think many of us in general practice would attempt anything other than the simplest treatments if that.

You can have orthodontics at any age, obviously most is done on children and young people as at that age you have time on your side, the patient is still growing and you can go for the ‘perfect’ [or as near to perfect as you can achieve] result. However since one or two people in the public eye have been seen with braces people have started to realise that there is no age bar. There are quite a lot of adults who have things about their teeth they don’t like. They have not had orthodontics when younger ether because it wasn’t offered/picked up, they didn’t fancy the idea of treatment at the time, they played a wind instrument so it wasn’t possible or because they had treatment but they didn’t follow instructions in wearing their retainers and the treatment lapsed.

Two very common issues adults have with their teeth are; – crowding of their lower front [anterior] teeth and slightly crooked upper anterior teeth.

As we all get older we get a phenomenon with our lower front teeth called ‘mesial drift’, so our lower teeth shuffle forward a bit leading to crowding. This can often be simply improved by taking one of the 4 lower front teeth [incisors] out and shuffling the other 3 incisors into a nice even line. You scrutinise your teeth from 2 inches away in the bathroom mirror but most people see you from about 3’ away, ‘a social distance’. We all know irritating people who talk ‘right in your face’ and we don’t feel comfortable with it. No one on the bus is looking at you thinking ‘she’s only got 3 lower incisors’ so you can get away with a bit of an optical illusion.

If you have slightly crooked upper anterior teeth [with or without crooked lowers] then Invisalign Orthodontics may work for you. Quite a few general dental practitioners [GDPs] offer it, as it is a system of simple orthodontics invented for use by GDPs to treat the ‘social six’- canine to canine top and bottom jaw. Each case must be assessed individually, not all concerns can be addressed, it has limitations but for the right case very nice results can be achieved. If Invisalign is not applicable in your case you need the services of a specialist orthodontist. Your practice may have someone they normally refer to but if not ask your friends etc.

When it comes to simple systems like Invisalign that anyone can do, choose wisely, avoid garish adverts,’ buy one get one free’ merchants, anyone claiming to be ‘the only’ [they aren’t], ‘the first’ [highly unlikely], ‘the best’ [even more unlikely], anyone who promises the ‘earth the moon and the stars’ [you won’t get it], anyone promising ‘a revolutionary treatment just arrived from abroad’ usually the USA land of the formulistic cheerleader smile [highly unlikely] etc. Anyone too self-important who promises too much is either a crook just after your money or an idiot.

Anyone trustworthy will err on the side of caution in explaining what is achievable, give you options one of which is to do nothing and give you plenty of time to think about it first.

Bleaching/ Whitening.

Ones teeth darken with age, what often makes people realise their teeth have become a little darker is when they realise they have become darker than the crowns they had done years ago. We can now bleach teeth. The profession tends to call this whitening to discourage people from putting household or hair bleach on their teeth.

About 30 odd years ago the only thing to be done if you had darker teeth than you would like or any other unpleasing characteristic was to veneer them but now we have a much less destructive treatment for improving the appearance of ones teeth.

There are lots of different reasons for teeth being a less than perfect colour, texture, shape etc and it is absolutely essential that the cause for whatever discolouration you may have on one or more of your teeth is correctly diagnosed by a qualified dentist. There may be more than one reason present on different teeth in your mouth.

There are various different types of bleaching applicable to different problems [such as tetracycline staining, measles lines, non-vital/ dead teeth etc]. Assuming that you are not a ‘special case’ with complicated reasons for any discoloration, the easiest, most cost effective, gentlest, most researched, long lasting method is the ‘night guard/ at home’ method.

In a nut shell this is how it works; – bleaching trays are constructed from a set of models made from a computer scanned or conventional impression. They are like very thin gum shields one wears for sports, so thin you can turn them inside out. These are fitted by the dentist, the technique taught, instructions given and the patient administers the bleaching material themselves at home for several weeks as instructed returning at regular intervals to the surgery for the dentist to check all is well, see how it’s going, check the shade progression, advise on any problems that may have arisen [very rare], check the patient has mastered the technique etc. It’s more complicated than this but this is the gist of it. This method also gives the most stable, long lasting colour. How destructive is it?- well about as destructive as drinking a can of coke a cola a day, which I would rather my patients didn’t do but it’s a lot less destructive than more traditional methods of improving ones appearance.

Faster ‘in office’ methods using stronger chemicals and special lights [often erroneously called laser whitening by the public] may be applicable if you are getting married tomorrow say, but give greater relapse. Sometimes if speed is of the essence a combination of both techniques may be used.

Every case is different, speak to the professional.

Only a qualified dentist may bleach teeth. Other dental care professionals [DCPs] are allowed to bleach teeth on prescription from a dentist after a thorough examination and diagnosis of the patient’s problem. The only DCPs allowed to bleach teeth after having received the relevant training are; – dental hygienists, dental therapists and clinical dental technicians. Beauticians and hairdressers are not allowed to bleach teeth, it is illegal and several beauticians and sadly, dental nurses have been prosecuted for doing so.

A word about whitening toothpastes, these will not whiten your teeth, but they may help to keep the stains down and as long as you use a reputable brand licenced for use in the UK then they will do you no harm even if they do you no good!

Over the counter bleaching strips from the chemist contain a much milder bleach and may give you a little lift for a party tonight but the effect will not last.

A word of warning DO NOT BUY BLEACHING PRODUCTS/ KITS ON THE INTERNET. Many of these products and systems are unregulated in the UK, USA and Europe, contain strong acids, abrasive substances and can cause lasting damage to your teeth.

When it comes to bleaching teeth as a rough rule of thumb you need your teeth to be no lighter than the whites of your eyes [sclera]. The human eye is drawn to things that are unusual. If you, for example meet a woman at a party with a blob of lipstick on her tooth or someone with something horrible hanging out of their nose you can’t keep your eyes off it. So it is with ‘cosmetics’, everything has to look harmonious- ‘the pelmet has to match the curtains’ as a patient said to me once which is a very good expression. We can all name film and TV personalities whose teeth are too, unnaturally white. You don’t want your teeth to proceed you into the room, you want people to notice you, your personality, to look at your eyes when they are talking to you, not be mesmerised by your teeth. You want your own teeth but slightly nicer, you want people to think ‘she looks well’ not ‘I’m sure she’s had something done to her teeth’.

Adhesive Dentistry.

Nowadays we can ‘glue things together’ which we couldn’t do years ago. A Maserati is stuck together likewise we can stick many more materials on without having to cut into healthy teeth to achieve mechanical retention. Dental materials are constantly evolving and improving and more and more appearance enhancing treatments can be achieved without sacrificing healthy tooth tissue.

What can be stuck on depends on what bit of tooth tissue you are trying to stick it to [enamel or dentine], the forces that are going to be acting on that particular bit [is it on a biting surface or not], how dry a field you need [if you are trying to stick your tea pot together you need clean dry surfaces or it won’t stick] and a host of other considerations.

Every case is different.

In summary.

As with cosmetic surgery, fillers, botox etc the art is in the subtlety. I certainly know people who’ve had too much filler in their lips or their cheeks and I am sure we can all name people in the public eye with ‘trout pout’, ‘pillow cheeks’ or faces that don’t move and have no expression. A really good practitioner of these types of treatments knows when to stop, knows what will enhance but not obliterate or look unnatural. Less is often more in these situations.

So it is with ‘cosmetic’ dentistry. If a patient wishes to improve/ change /enhance the appearance of their teeth anything done must be as minimally destructive as possible. Modern dentistry thanks to improving materials, techniques, philosophies and understanding of tooth biology means more and more appearance enhancing effects can be achieved with minimal destruction of healthy tooth tissue.

There is still a place for more ‘traditional dentistry’- crowns, veneers etc but only if a gentler treatment is not possible or will not achieve the desired effect.

I find for most people who are not a ‘special case’ just teeth darker than they would like, a few crooked bits here and there, they may even be enquiring about veneers, if I just bleach their teeth first they are often so pleased with the result they forget about their other concerns.

Most people are looking at you from a ‘social distance’ about 2-3’ away, they are not scrutinising the little irregularities in your teeth as you do in the bathroom mirror they don’t see those. You want your teeth to look natural, the little odd bits are part of the personality of your face.

You want to look like you and you alone, you are unique.

Chapter 23- X rays

X rays should be more correctly called radiographs. Photographs are pictures made with light rays and so radiographs are pictures made with x rays.

X rays are a type of electromagnetic radiation [others are visible light, ultra violet light and microwaves] that possess energy. X rays have high energy and so can pass through human tissue to a greater or lesser extent depending on the density of the particular tissue concerned.

This property is useful in medicine as it allows us to see ‘below the surface’.

If you think of it in terms of a photographic plate if the ray goes through you it will hit the film and the film will be dark when developed, if the ray can’t go through [say where you have metal restorations] it will not hit the film and so this bit of the film will not develop. Different body tissues have different radiopacities meaning the rays go through depending on the density of that particular tissue. This property produces an image that is ‘reverse from real life’, the denser bits of you are white and the not so dense bits darker to a greater or lesser extent.

X rays can also cause us damage because as they pass through us if they hit an atom of matter directly they release energy [either by being scattered or absorbed] and can cause cell damage, cell death or a mutation in the DNA of a cell.

It is important therefor that the lowest dose of radiation, for the shortest period of time is used when taking radiographs for diagnostic purposes. There is no ‘safe level’ of exposure to x rays, so there are very strict guidelines and regulations in place to protect patients. Your dentist has to register their equipment with the health and safety executive [HSE], the Care Quality Commission [CQC], a medical physics department at a hospital or other similar body and there has to be a radiation protection advisor, a medical physics expert, a radiation protection supervisor and a ‘legal person’ that is someone in the surgery who makes sure all this is done and all the guidelines and recommendations are followed. So if you are having x rays at the dentist you can rest assured that it is done in the safest way possible.

If your dentist is taking radiographs of you there has to be a reason [this is called clinical justification]. The dose has to be as low as possible, for the shortest period of time, to the smallest area of you to produce a ‘functional image’. This means a picture that is good enough for the clinician to see what they need to see. It’s no good exposing someone to x rays if the picture obtained is rubbish and doesn’t tell you anything.

It is also important that only the patient receives the radiation, that everyone else is out of the measured area, that the equipment is safe, regularly serviced and inspected, that the quality of the images is regularly audited, emergency procedures are in place should it malfunction, that any member of staff involved in any way is properly trained and last but not least that the images produced are ‘reported on’ ie that they are read and interpreted by someone who is trained to do so. It’s no good exposing someone to xrays if you are not going to write down what you see.

All dentists and DCPs who are allowed to take radiographs have to regularly update their knowledge of xray use by doing mandatory Continuing Professional Development [CPD] in the physics, regulations and operating skills required.

There should be information displayed in the waiting room at your dental surgery and if you have any questions what so ever about having xrays you have every right to ask your dentist to explain what you wish to know and to provide you with any further information you may require.

You also have every right to refuse to have them [or your children under 16 to have them] BUT you must be aware that without radiographs your dentist will not be able to completely inspect your mouth and diagnose any problems you may have. Some treatments may not be possible without radiographs such as extraction of wisdom teeth and root fillings.

There are 2 types of radiographs your dentist may use-

Film based [sometimes known as analogue]-  this is the type we are all used to. The xrays come out of the machine on the wall, go through you and hit a film. Just like in an old fashioned camera. This film is then developed in a dark room or in an automatic processor to produce an image [picture].

Digital- the xrays come out of the machine on the wall, go through you and hit a digital sensor. The information goes down a wire to a computer which by some magic then turns it into an image on the screen [there is another type where the sensor is not connected by a wire but is put into a machine which reads it and sends the information to the computer].

BOTH THESE TYPES, FILM AND DIGITAL USE X RAYS- there is no magic!

The advantage of digital radiographs is they can be enlarged, the contrast altered and they can be sent to someone else [for example if you need to see a specialist].

Radiograph Views.

So if your dentist wishes to take a radiograph/s they will want to take a particular ‘shot’ to get the best view of what they want to see.

Radiographs are either intra oral [with the film/ sensor inside the mouth] or extra oral [with the film/ sensor outside the mouth].

The commonest intra oral views are;-

Bite wings these are taken usually of either side of your mouth to look for cavities in between your teeth which are not visible on the surface.

Periapicals these show your tooth from top to bottom, the crown and the root. These might be taken perhaps to look for an abscess at the end of your root.

Both these types are usually taken with a film holder/ aiming device to hold the film/ sensor in the right place which also means that the same view can be exactly replicated in the future.

The commonest extra oral view is;-

Dental Panoramic Tomograph [DPT] which looks a bit looks like a school photo with all your teeth on it, this is not so good for looking for early decay but is excellent for looking for things such as buried wisdom teeth, cysts and  un erupted teeth. It is also the commonest view an orthodontist might take at your initial visit.

How much radiation do you receive?

This is a difficult question to answer because of the way radiation is measured and because different views need different amounts of radiation to produce an image.

We receive radiation all the time in the form of ‘background radiation’, cosmic radiation and if you live somewhere like Cornwall from the ground beneath us [Cornwall is built on granite which emits radon]. It’s thought that a little bit is actually good for us [I mean a tiny little bit].

Of course people are concerned to receive more than is desirable or necessary and no clinician would wish to subject a patient to unnecessary radiation.

 X ray doses in perspective.

1 dental x ray is the same dose as 8 hours background radiation/ eating a handful of brazil nuts/ eating 20 bananas.

2 dental xrays is the same dose as a flight to Paris [from cosmic radiation].

15 dental xrays is the same dose as a flight to Malaga [from cosmic radiation].

A dental xray has a 1 in 10 million chance of producing a malignancy.

A chest xray has a 1 in a million chance of producing a malignancy.

You have a 1 in a 100 chance if you smoke 10 cigs a day and a 1 in 10,000 chance of dying in a road accident.

3D imaging.

So the x rays you would normally have at the dentist produce a 2D image and most of the time that’s fine, that’s all you need but a 2D image of a 3D object will in some cases not be enough.

You will have seen on the TV people having whole body scans, where the patient goes through a long tunnel and the machine takes lots of little ‘slice’ radiographs. These images are then fed into a computer and by magic produce a 3D image of you. This can be turned around, seen at different levels all sorts of wonderful things that have completely revolutionized diagnosis and treatment in medicine.

In dentistry specialists will also use scans BUT you don’t need a scan of the whole of someone’s head [irradiating their ears, eyes not to mention their brain] to just look at a tiny area. So in dentistry we have what’s called a ‘cone beam scan’. It’s the same thing but it just produces a 3D image of a little cylinder of you, like a little can of beans measuring 5 x 5cm [this is the usual size]. The clinician might want this information to for example see how big a cyst is, see if the roots of a wisdom tooth are wrapped round a nerve and a host of other reasons.

Reading radiographs.

Dentists are unique amongst medical professionals in that we take our own radiographs [I think vets do as well].

A person who takes the radiographs/ scans is called a radiographer.

But it’s not just a question of taking the radiographs you have to be able to read them and interpret them. The person who does this in a hospital is a doctor who is a specialist in radiology- a radiologist.

In dentistry in practice we are our own radiographer and radiologist. We are trained to take and interpret [read] our own radiographs as far as our field of expertise extends. That is I would not be allowed to report on a radiograph of your leg or your brain. I would have a pretty good idea of what I am looking at because I am used to reading radiographs but I don’t have an in depth knowledge of the anatomy of other bits of you because it is beyond my field of expertise.

‘X rays are only an aid to diagnosis’ this is a mantra in dentistry and no doubt medicine too. It means you have to take all the information;- the history [the story], the symptoms [what the patient tells you about what’s wrong], the signs [what the clinician sees] and come to a provisional diagnosis. You might then decide radiographs are required to confirm your diagnosis.

X rays and pregnancy.

Although the dose of x-rays used in dentistry is very low and would probably be quite safe in pregnancy, no one would knowingly irradiate a pregnant woman because of the [very small] possibility of damaging the fetus. In an absolute emergency in the 3rd trimester [the last 3 months] it is probably quite safe as the baby is just growing by this stage not developing.

If you are trying to get pregnant and you need radiographs you need to time your visits to the start of your period and the time before you ovulate in the middle of the month.

If you are at all in doubt ASK THE DENTIST FOR ADVICE.

I would always err on the side of safety.

Chapter 22- Specialists.

Your GDP [General Dental Practitioner]/ family dentist is like your GP. They see you ‘cradle to grave’ get you into good habits, teach you how to look after your teeth, keep on teaching you ‘till you can do it and they do most branches of ordinary dentistry to as [obviously] good a level as they can but dentistry like medicine has specialities. Some of them you will have heard of; – orthodontics [braces], oral surgery [things like wisdom teeth] and some you may not have.

A dentist can’t just call themselves a specialist, they have to be on the ‘Specialist Register’ kept by the GDC [General Dental Council- the regulatory body] and they have to have further qualifications in their particular subject, whatever that particular discipline requires.

These further qualifications are granted by the Royal Colleges of Surgeons of England [London], Edinburgh, Glasgow [Scotland being of course the home of medicine and surgery and incidentally veterinary surgery], Royal Collage of Radiologists and The Royal College of Pathologists amongst others.  It takes at least 5 years of further training from basic qualification to become a specialist.

There are 13 specialties recognised by the GDC and they are:-

  • Dental and Maxillofacial Radiology.
  • Dental Public Health.
  • Oral and Maxillofacial Pathology.
  • Oral Medicine.
  • Oral Microbiology.
  • Special Care Dentistry.

These specialists tend to work in specialist departments in hospitals, teaching facilities or specialist clinics.

  • Endodontics [root fillings].
  • Oral Surgery.
  • Orthodontics [braces].
  • Paediatric Dentistry [children].
  • Periodontics [gum disease].
  • Prosthodontics [false teeth].
  • Restorative dentistry [complicated restorations, crown and bridge, implants etc].

These specialists may work in specialist departments, teaching facilities, specialist clinics or in private practice [NHS and ‘private’] either as a specialist within a General Practice or in a ‘Specialist Practice’.

These are the only ‘Specialities’, all other expressions such as; – Cosmetic Dentist, Smile Specialist, Holistic Dentist are merely marketing expressions.

All qualified dentists are entitled to and are trained to perform all of the disciplines definitely in the 2nd list but part of being any good at anything is to recognise ones limitations. If your dentist suggests you see a specialist for some of your treatment it is not because they are hopeless but because they recognise you need the services of someone more qualified, knowledgeable or skilled for your particular problem. The skill in being a ‘generalist’ is to have an overview of all disciplines and to guide, advise and send the patient in the right direction so your needs are managed properly in your best interests. So you are looked after, advised and if need be treated by the best person for the job.

It’s funny how the public expect their GDP to be able to do everything. You would not expect your GP to pin you down in couch and operate on your knee if you had a problem with it. They might have a go with the aid of a text book if your appendix burst in the middle of an Artic expedition and it was a matter of life or death but under normal circumstances you would expect to be referred to the appropriate specialist. So it is with dentistry.

Some large general dental practices may have their own ‘in-house’ specialists. Just as your GP practice may have someone with further qualifications in something like dermatology. Some specialists work in ‘Specialist Practices’ all over the country.

‘Harley Street is an address it is not a qualification’.

There is no doubt about it that some very competent and highly skilled specialists and general dental practitioners work in Harley St and the surrounding areas either in practices that they are part of or in surgeries where they essentially rent the chair time like a hairdresser. Be aware though that a big chunk of the patient’s fee is the rent in Marylebone, Mayfair, Fitzrovia or Belgravia. One doesn’t eventually graduate to Harley St if one is a better dentist or specialist it is not part of the academic process. It simply means you can command the fees from whoever your patients are that cover the overheads incurred from practicing in that area of central London!

There are just as many, if not more, highly skilled general practitioners and specialists working all over the country. Perhaps some however just like to be able to pop into the back of John Lewis on the way home in the evening!

Chapter 21- The Dental Profession.

Lots of different professionals make up the dental team.

Dentists [also known as Dental Surgeons or Dental Practitioners] follow a 5 year degree course at a University Dental School leading to the qualification of Batchelor of Dental Surgery. They then have to be admitted to the register of the GDC [General Dental Council] and have in place Professional Indemnity before they are allowed to use the title of dentist or practice their profession. To go into NHS general practice in the UK they are then required to undergo a year of Foundation Training. There are other branches of practice such as the hospital service, the armed forces, the community dental service all having their own career pathways and requirements.

All dentists from qualification onwards in order to remain on the Dental Register and be allowed to practice have to undergo a mandatory, statutory no of hours ‘Continuing Professional Development’ [CPD] per annum and submit evidence of this to the GDC. They are also required to follow a code of practice set down by the GDC.

In the UK as in the USA and Europe are allowed to use the courtesy title Doctor [Dr] providing they do not imply they have a medical qualification. Some use the title some don’t.

All other personnel within the dental profession are called Dental Care Professionals [DCPS] some are allowed to treat the patient ‘hands on’ within their ‘Scope of Practice’ as laid down by the GDC. All have their own statutory qualifications, code of practice, registration, professional indemnity and CPD requirements.

Dental Hygienists and Therapists.

At one time this was 2 separate professions but has now been combined into a 3 year degree course leading to a degree BSc in Dental Therapy and Hygiene giving those qualified a broader range of skills than just the single diploma qualification.

Dental Technicians.

Dental Technicians are skilled craft personnel who construct dentures, crowns, bridges, orthodontic appliances [braces] and many other appliances on prescription from the dentist. Some technicians take a further qualification to become ‘Clinical Dental Technicians’ and can then treat the patient direct for full dentures or on prescription from a dentist for partial dentures.

Dental Nurses.

Dental Nurses [used to be called Dental Surgery Assistants] assist the dentist while he or she is treating the patient. They are responsible for maintaining a clean, safe environment in the surgery, maintaining and sterilising instruments and equipment, helping with administration and other general duties required for the smooth running of the practice. There are several paths to qualification in practice or a teaching hospital involving training ‘on the job’ with lectures, day release or online learning. Dental Nurses can also take further add on qualifications allowing them to perform such duties as taking Xrays [radiographs] and impressions or becoming an Oral Health Educator.

These are the main members of the dental team most people will come across but there are others such as orthodontic therapists and maxillofacial prosthetists and technologists.

The General Dental Council [GDC].

This is the regulatory body of the Dental Profession [dentists and all DCPs]. Its duties are set out in government legislation. Its role is to protect patients from harm and maintain public confidence in the whole dental profession. It does this by;- maintaining the Dental Register so only those with the relevant qualifications are providing patient care, ensuring all training programs are quality assured, setting the standards required of a dental professional and ensuring all dental care professionals fulfil their CPD to keep their skills and knowledge up to date.

Its other role is to investigate serious allegations of a dental professionals ‘fitness to practice’ with regard to skills, knowledge, character, health, criminal convictions or serious professional misconduct, it has the power to suspend someone’s registration or ‘strike someone from the register’.

The British Dental Association [BDA].

This is the professional body that most dentists belong to. It’s a bit like a cross between a club and a trade union. It provides training programs, CPD, advice, journals, toolkits, literature and much, much more.

In addition there are other Associations for General Dental Practitioners, Specialists and all members of the dental team.

Dental Practices.

Dentists in General Dental Practice in the UK can practice within the NHS, privately or a mixture of both.

A dentist treating patients under the NHS has to have an ‘NHS contract’ with their relevant health authority. The organisation and names of these authorities are constantly changing but this is the gist of it.

Years ago the patient went for treatment and for each ‘item of treatment’ the dentist was paid a certain fee. Patients paid part of this fee with exemptions for certain categories such a pregnant and nursing mothers, people on income support and other benefits, those under 18 or under 19 and in full time education. A form was filled in sent off and the dentist was paid- usually months later.

Now there is an equally unsatisfactory system which is essentially the same system in reverse, the dentist is paid in advance to provide a certain number of ‘Units of Dental Activity’ [UDAs] per year. Each item of treatment falls into a certain ‘band’ of UDAs. Unfortunately this means that the dentist is still paid to ‘do things to patients’ not to advise patients on how not to need treatment by preventing dental disease from occurring. There are other things wrong with this system too numerous to mention such as the dentist only receives the same money for 1 restoration as for 10, with no provision for the extra time, materials, staffing costs etc needed nor is there adequate remuneration for complicated treatments such as root fillings or surgical extractions, patients with special needs needing more time etc. Dentists do not have a ‘list’ like a GP, they are not paid per capita for patients.

All dental practices are small businesses with overheads;- rent, community charge, utilities, staffing costs including salaries, sick pay, maternity pay, pensions, holiday pay, training, dental materials, laboratory costs, costs of good sterilisation practices, property, business and public liability insurance, equipment purchase, running and maintenance, normal property maintenance, professional indemnity, other statutory professional registration such as Care Quality Commission, GDC and ICO, office admin costs such as computer systems, postage, telephone, printing.  The list is endless not to mention an income for the dentist/s.

Sadly with increasing costs, variations in expenses over differing parts of the country and an unsatisfactory remuneration system it is becoming increasingly difficult for dentists to practice within this system and consequently for patients to access NHS treatment. Obviously this has implications for the dental health of the nation especially for those on lower incomes.

This situation cannot go on- this is all I am going to say!

Private practices operate like any other business setting their fees according to their overheads and expenses. They also have the freedom to undertake any type of treatment they may wish, in a manner they see fit, without having to abide by someone else’s rules. Their only obligation apart from statutory obligations is to do their best for the person under their care.

Some private practices operate on a fee per item basis, some on a time basis and most on a mixture of the two. There are also various capitation schemes the most well-known of which is probably Denplan now operated by Simply Health [used to be called the HSA].

Some NHS practices survive by basically subsidising their NHS side with private treatment.

Whoever you choose to provide your dental care, choose someone nice you are going to build a relationship with over many years, especially if you are a worried sort of person at the dentist. How to find them? Same way you find anyone else ask your friends, phone them up and see if they sound helpful are they happy to answer all your questions, visit the website, visit them get some leaflets and see how you feel. You may have a few false starts but hopefully you will eventually find someone you like. You can go to a dentist anywhere not just near where you live, I have people who come from all over the country and abroad and I am sure I am not the only one. There will be dentists who are just as nice and just as competent near where they live but they feel comfortable with me and I am honoured to have them!