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Guarantees in Dentistry, Great Seats of Learning and the Perils of Male Bovine Excrement.

October 04, 2016

Last week I was at two great lectures the first with Dr Iain Chapple, many thanks to Denplan for bringing him to N.Ireland, I have read his books and have wanted to hear him speak for many years. The second lecture was by Martin Kelleher, a native of these shores, organised by the N.I branch of the FDGP.

There were good reasons for me not to attend either lecture, the first on Thursday was in Newcastle, I had been unwell all week and didn’t fancy the drive. The second was on the day I was to fly out to Cambridge to see my eldest off to Uni and had to hot foot it straight to the airport as soon as the lecture finished.

However I was so glad I did attend, as they presented me with information that led me to stop, reassess and reaffirm my dental  “True North Star ”

The first rule that is often overlooked by dentists or is lost in the sea of technology at our disposal, is;

“NOTHING COMPARES TO A NATURAL TOOTH”

I know I have been truly successful as a dentist when a lifelong patient leaves to go to uni without any filings. At the practice the vast majority (over 90%) of our kids have no fillings.  As ever this is a team affair between my team, the parents and most importantly, the patient. But it is a simple formula, a reasonable diet and reasonable brushing.  That’s it, the mouth is amazing, capable of repair and can easily cope with the occasional sugary indiscretion.

The next rule in Dentistry, is

“ALL THE WORK I DO WILL EVENTUALLY FAIL

This rule applies to every dentist, no matter how great they tell you they are, however as always there are exceptions to this rule.

  1. Extractions

Extracted teeth have yet to grow back for me, once they are in the bin, the tend to remain there, so I can pretty much guarantee as soon as I extract a tooth it is defunct and so if at all possible I avoid it, a tooth is usually of more value in the mouth!

2) Preventative Dentistry (see above)

If followed, prevention always delivers, this is the most successful form of dentistry that any practitioner can provide; painless, effective with no side effects or downsides. Some sensible, small changes to our diet, a little bit of exercise and a few minutes a day cleaning our teeth can lead to a huge change in our total health and wealth.

If we accept that a natural tooth is better than any crown, veneer, implant or filling, and that all operative dentistry will fail, then surely we should pay more for preventative advice to keep our natural tooth rather than having to accept treatment delivering a second rate outcome. And yet, dentists pride themselves on the quality of the work, advertisements always show shiny new crowns, implants, smile design, but these all represent a failure between the patient and dental team to conserve and protect the natural tooth.

When doing any other dental treatment, as we know it will fail, we must plan what to do when the failure occurs. This also has a simple rule; it depends on how much natural tooth remains after the dentist is finished drilling. The more natural tooth that is left, the longer the restoration will last and the more tooth that is left the better the chance that it can be re-restored at a later date. Yet again it is the natural tooth that is the prime factor in success, the one thing a dentist cannot recreate.

The next rule is

WE HAVE GREAT MATERIALS BUT NONE OF THEM COMPARE TO THE NATURAL TOOTH STRUCTURE”.

All these materials will continue to be developed and improve, it is a bit like Windows 10. This new version is the best ever, promises everything, is without equal, until the next newer, better, all round improved version arrives, then it is crap! However when compared to the natural tooth complex, there is no comparison.

A natural tooth is designed to last a lifetime, it is incredibly hard (the hardest material in the body), yet it flexes naturally, it will absorb energy, crack and has the ability to repair itself. Despite being incredibly hard we can detect fragments less than the width of a hair within the mouth. The teeth are designed to deal with multi-directional, multi-strength forces in a range of temperatures, for a lifetime.

As dentists we are witness to this amazing structure of the mouth, we still do not fully understand all the workings and mechanisms at play. We don’t fully understand the actions and interplay of the bacteria within the mouth. Even saliva is a marvel, it is best thought of as a liquid layer of enamel, a lifetimes work to fully understand.

However familiarity breeds contempt and although we do not understand it or cannot come close to recreating it. Dentists are guilty on a daily basis of lifting a powerful drill to cut teeth without thought. Every time a dentist intervenes in the mouth it starts a cascade of events that plays out over a lifetime (certainly of the tooth) that is usually less than good.

When I started in Dentistry adverts for dentists were limited to their name, qualification, opening times, address and phone number. In one of the most misguided acts this was relaxed.  NR has lead to increased marketing, glossy pictures of before and after shots and testimonial videos. This is were the male bovine excrement creeps in. Glossy shots, testimonials, super-fast teeth straightening, immediate implants, all these are both meaningless and without worth. What you need to know is how it has held up after 10, 15, 20 years. Success can only be judged in that time frame, the natural tooth is designed to last a lifetime and so we should judge our interventions over the same period, only then can we judge it a success.

As a dentist in my 50’s I have my share of fillings and dental treatment, my teeth show a degree of natural wear and have darkened. I couldn’t be bothered to bleach them, although I have considered it.  I would never consider veneering or crowning my teeth to mask the natural wear and ageing effect, I don’t think any dentist would ever suggest it to another dentist and yet we see cosmetic ads constantly for this type of work.

I have had two crowns placed, one was root filled, fractured then extracted. All the failed work was well done, it just exceeded the limitations of the materials, I still go to the same dentist and am delighted with his work. I am paying for earlier childhood mistakes in diet and brushing. I have a couple of other teeth lost as a result of an accident and so have several spaces. I could have an implants or bridges, but I am able to eat and speak as normal, one gap is slightly visible, it doesn’t bother me and because I am aware of the long term effect of dental treatment I choose to continue without treatment: my mouth is healthy and functioning.

In the future I may need implants or more complex work but the longer I can put this off the better, the materials will have improved and as I age I won’t need it to last as long. If I make it to 85 I would happily get a big bridge or multiple implants and expect a lifetime guarantee.

As I progress through my career I can assess my own work across the years, much of what I was taught at dental school in the 80’s was wrong. As a young dentist I had a misplaced faith in my abilities and materials. In good faith I have carried out treatment that now I would never consider. I have bridges and crowns that have lasted 20+ years, but that is part – luck, definitely due to the hard work of the patient and their brushing/diet. But even in these cases that are undoubtedly a success I always have the nagging thought of “what will I do when these fail”. I have lifelong patients, that are still with me from my very first days – that is a blessing and a curse as I need to deal with the consequences of my decisions and actions.

I have always enjoyed dental courses, in the late 90’s I studied part time at UCL over a 5 year period. It was hard work but enjoyable.  Unfortunately a lot of the teaching has been superseded by new techniques and materials and is no longer valid. I had been considering my next round of education and had looked at courses on smile-design and fast orthodontics systems, both are useful and have a place in Dentistry.

However as I walked around Cambridge I came across a dental practice with glossy glamorous picture of a lady with a huge super-white oversized cosmetic smile. The practice offered smile design makeover, power whitening, same day implants, free cosmetic consultation and 0% finance. I was struck by how depressed and angry I was with this type of dentistry and advertising bull.

Slowly I realised that the above courses were not for me, I had previously looked at a 3 year MSc at Kings College London in Advanced Minimum Intervention Dentistry, I wasn’t sure if I wanted to commit to the rigours of an MSc but now, regrettably  feel it is the course for me.

My final night, we all went for a meal, joined by a friend also studying at Cambridge, like any Uni town it was buzzing with students, the atmosphere was great and I felt a pang of jealousy to be young, back at university with a career in front of them.  We headed across parkland back to the house in front of us in the distance I could see strange shapes in the dark on the grass. Just as I realised it was a herd of sleeping cows I stepped into a huge cowpat, and thought “bullshit always gets you in the end”

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