The stomach has acid and an enzyme called pepsin which begins the process of digestion before the contents are propelled towards the small bowel or intestine where the process continues for absorption to begin. In fact the only products that can be absorbed by the stomach wall include water, alcohol and aspirin. This explains their rapid effects when thirsty with a drink of water, the feeling of relaxation after an alcoholic drink or the rapidity of the cure of a headache after taking 2 aspirins.

John Farrell conducted an experiment at Bristol Dental Hospital over 30 years ago where he arranged for his students to swallow muslin bags with food to be swallowed without chewing. After 30 minutes the muslin bags were retrieved with attached lines and the contents inspected.

All the contents were completely digested, irrespective of the size of the particles of food, proving scientifically that chewing was an irrevelance to digest food. However chewing does stimulate gastric/stomach secretion of acid and prevents choking. Every one has had the opportunity to observe a dog bolting it’s food with no chewing. In fact, the dog is incapable of chewing due to the design and arrangement of it’s teeth that only allow for tearing and ripping off flesh from bones.

Social courtesies dictate that we chew in public to conform. Obsessives will often promote the need for chewing (Nancy Regan) a minimum of times before swallowing but these are to be regarded as purely a manifestation of her own personal neuroses and insecurities associated with anorexia.

Chewing does not contribute one iota towards digestion, but choking to death in front of fellow diners is considered bad manners…

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Even for those of us not in the public eye, a damaged tooth is not only painful but can shatter your confidence and takes a long time to heal. The recovery process is often not as simple as dropping into the dentist to get it fixed.

The price of losing a tooth

Everyone experiences tooth loss from a young age – memories of earning our first payment from the elusive tooth fairy paints a pleasant picture of the experience, although at least 15% of children damage front teeth before the age of 18. In adults, a huge array of incidents can damage or displace teeth resulting in anything from discomfort to severe pain.

Knowing who to call when an accident happens can save valuable time and gives you a better chance of saving the tooth. Talk with your dentist or find out what facilities your local hospital has in place.

If you play sports, ensure you have a properly fitted mouth-guard fitted accurately by your dentist (avoid purchasing over-the-counter mouth-guards).

What should you do if you chip a tooth?

Fractures can initially appear minor – as chipping or damage to the enamel (visible part of the tooth) but this can hide invisible cracks which can cause an abscess near the root of the tooth. You should see a dentist to assessed and x-rayed on the day of the accident.

What should you do if you displace a tooth?

An avulsed tooth (knocked out completely) must be re-implanted within 30-60 minutes. Microscopic analysis has shown that only 25% of cells that connect the root to the socket will survive the first hour – so timing is critical.

If your tooth is displaced

1. Put the tooth in salty water, milk or your own saliva to protect the cells of the tooth. Do not leave a tooth in the mouth of a young child (retrieval may be delayed)
2. Contact a dentist or hospital immediately and request to be seen within 30-60 minutes
3. If there is any delay, it is essential for a dentist to secure an impression and make a temporary denture to avoid adjacent teeth from moving.
4. A re-implanted tooth will always require root canal treatment to avoid an abscess.
5. Ensure you get regular follow-ups with your dentist to ensure further treatment is provided swiftly.

ANY delay of treatment will increase the risk of tooth loss, discolouration and abscess formation. Immediate attention from a dentist is essential.

If you have been affected by a broken or fractured tooth, you should seek advice from a specialist dentist in Restorative Dentistry. The General Dental Council help the public find accredited specialists. Visit http://gdc-uk.net and search for registered specialists in your local area.

Are you looking for a specialist consultant?

Toby Talbot is offering the opportunity to discuss your dental problem on Mondays from 8am.
Add 07802 760780 to your mobile phone under “dental emergencies” so if you do ever have a problem you can speak to Toby without delay.

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Unfortunately there have been some cases in which general dental practitioners make claims implying they offer specialist services in order to gain attention of the public. This can seriously undermine the patients confidence if the outcome fails to provide the desired result.

It wasn’t until 1921 that an act of parliament restricted the practice of dentistry to graduates with formal university training. Mirroring the General Medical Council for doctors, the Dentist Act gave rise to the General Dental Council (GDC) – designed to protect the public from professional misconduct.

Today, the GDC investigates formal complaints from the public (or colleagues) and any dentist found to be guilty of serious misconduct would be ‘struck off’ the register or admonished depending upon the severity of the ‘misdemeanour’. More recently, the GDC also review cases on ‘Fitness to Practice’ issues which covers complaints related to dentists failing to gain informed consent, to comply with recognised clinical protocols and exercising a duty of care.

This also includes any marketing statements which could mislead the public.

Be warned: Some beauty salons have recently gained the attention of the GDC for unlawfully providing tooth-whitening services.

Here are some common phrases often used to imply specialist services (that have led to formal warnings issued by the General Dental Council).

. . .I’m an Implantologist. . .

NO dentist can claim to be an Implantologist exclusively, as it requires a team of experts.

. . .we offer permanent replacements for your dentures. . .

ALL dentistry eventually fails as nothing is permanent, a claim like this is misleading.

. . .we are Cosmetic Dentistry Specialists. . .

Cosmetic Dentistry is not recognised as a speciality by the GDC.

Remember:

References to ‘cosmetic dentistry’, ‘smile centres’ and ‘implant clinics’ may indicate a dental practitioner has special interest in the field, but only the GDC website http://gdc-uk.net will identify the accredited specialists. You should always refer to the GDC if in any doubt.

In the news

Dental patients put at risk by banned fake-gold implants – Sunday, 13 June

The Independent reports that some dentists are using cheap yellow alloys (or fake-gold) for crowns and bridges in order to maximise profits on their UDAs, units of dental activity from the NHS in return of a monthly salary (introduced in 2006).

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That her or she is committed to preserving your teeth, even though the process may be long and complicated?

… You could be in for a shock! Some dentistry experts believe that many general dentists lack the expertise or inclination to save teeth through complicated procedures such as root canal work. Traditional family dental care is at a turning point.

Dr Julian Webber, a former president of the British Endodontic Society, believes that a growing number of high street dentists – private and NHS – are incapable of high-quality root work and are more interested in removing teeth, then replacing them with gleaming white artificial replacements.

Read the full story on Times Online

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I am an American trained Restorative Dentist established in Bath. My new purpose-built clinic is located at Tasburgh House that offers ample parking and glorious views across the 7 acre meadow and gardens. Combined with the neighbouring hotel, the clinic offers a relaxing and enjoyable experience to compliment our professional specialist dental services.

As a Restorative Dentist and expert legal witness, I’ve had experience in reviewing many dental treatments that have not been in the best interest of the patient. I feel more public awareness about the risks associated with dental treatment is needed so informed decisions can be made. This will have a positive impact on patients and the wider dental service available in the UK.

Over the coming months, I will be posting articles about Specialist dental services such as Prosthodontics, Periodontics, Endodontics, Implantology and Restorative dentistry.

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There are many mini-cures for bad breath on the market, just google it and you’ll find a huge number of solutions ranging from mouthwashes to chewing herbs.

Although there is no instant cure (some products will have you believe this) a specialist dentist will help to identify the root of the cause and provide an effective treatment.

Causes and Cures

Bad breath can originate from the mouth, sinuses, nose and stomach and is predominantly a result of bacteria that are referred to as ‘anaerobes’. Anaerobic bacteria are those bacteria that dislike the presence of oxygen and tend to reside in sites of the body where there is less available oxygen. Dental decay and periodontal disease with gum infections are the source of 80% of all cases of bad breath.

An assessment by a Restorative Dentist or Periodontist will ascertain the source of the bacteria in the pockets of the gums affected.

Tongue hygiene can be easily and swiftly managed with the use of a dry toothbrush. The suggestion that a specially designed ‘tongue cleaner’ is required is wholly unfounded. The simple use of a toothbrush that has not been pre-wetted is highly effective at scrubbing the back of the tongue on a daily basis.

Naturally, dietary habits, like eating powerful smelling food and drink, may be the source of bad breath. Recent consumption of your favourite fish dish or curry, or the more obvious alcoholic drinks and smoking, may be the source of that unpleasant odour.

Dehydration can cause a dry mouth with the reduction of saliva producing odorous smells. Any condition that contributes to a dry mouth, such as drinking little water or using sleeping tablets, anti-depressants, diuretics (tea and coffee) and anti- hypertensive medications that reduce the flow of saliva can magnify the problem.

Specific medical conditions, such as diabetes or gastrointestinal disorders, can cause halitosis and you may need the condition to be diagnosed by your GP.

Chronic sinusitis or tonsillitis may indicate a referral to a GP or Consultant ENT surgeon. Medical and surgical intervention may be indicated.

If you have been affected by the thought of bad breath, you can seek advice from a specialist dentist in Restorative Dentistry or Periodontology. The General Dental Council can help you find an accredited specialist. Search http://gdc-uk.net for registered specialists in your local area.

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As a former Hospital Consultant in Restorative Dentistry, I have worked closely with colleagues in Orthodontics for joint treatment strategies, where our two areas of expertise complimented each other.

More recently, we have joined forces to provide treatment for patients in London and Dubai.

Eric and I have become a double act, he, being the strong silent type with an obsessional interest in golf, whereas I am the ‘delinquent chatterbox’ who rarely keeps quiet.

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Early 19th century breakthrough

Prior to the breakthrough of amalgam fillings in 1819, the common lack of oral hygiene meant many of our ancestors had to endure the unpleasant symptoms caused by tooth decay, which often led to multiple tooth loss. Drilling away the damaged surface of a tooth and sealing it with a protective filling became common practice by dentists across the world and remains to this day.

The materials used for fillings have traditionally been either precious alloys (such as gold, platinum, palladium), non-precious alloys (such as nickel or cobalt chromium) and amalgam alloys (combining mercury, silver and tin). As well as being cheap and readily available, these amalgam fillings were highly effective and became the material of choice.

For the past few decades the benefits of amalgam fillings have become a controversial subject of discussion in the media, with stories recounting many adverse or damaging effects from the presence of mercury in the mouth. Many of these articles site examples of side effects including: headaches, chronic fatigue, allergies, depression and go on to link mercury fillings as causes for Alzheimer’s disease, Parkinson’s disease, diabetes, cancer, immunological dysfunction and early death.

There is no dispute about the deadly toxicity of mercury, but the foundation of these stories was born from the evidence that dental amalgam releases tiny amounts of elemental mercury. This is either inhaled or partially enters the body through swallowing and is eventually excreted by the kidneys. The levels of this mercury vapour released into the body from fillings is minute compared with other sources such as contaminated oily fish from the North sea.

Many of the stories in the press also refer to the ban of mercury fillings in Sweden, but this has been taken out of context. It was not due to health concerns with dentistry but for environmental reasons to reduce the industrial exposure and environmental contamination, in general, of heavy metals.

Dentistry only accounts for less than 0.1% of heavy metals used compared with other industrial sources such as the extraction of gold from ore, glass production, long-life battery production, and now the production of long-life electric bulbs. The Swedish ban includes use of mercury in dentistry but is not made as result of concerns with amalgam fillings in teeth.

Science vs Scaremongery

Since 1840 there have been 4 major international reviews of the safety of mercury amalgam fillings and each time the results show no systemic disease has been attributed to the use, insertion or removal of mercury in teeth. The few cases in which there were reactions to amalgam fillings were attributed to some of the constituents from the amalgam fillings that didn’t necessary contain mercury (ie silver, tin, or copper). The continued use of amalgam fillings has been endorsed by both the British Dental Association & the American Dental Association.

Amalgams are incredibly durable and in most cases will successfully protect a tooth for over 20 years. Alternatives to amalgams are available and used for cosmetic reasons (to match the colour of the patients teeth) but invariably fail and break after only 3-5 years.

There is an increased risk of higher exposure to mercury vapour during the installation or extraction of fillings but common procedures to protect the patient have been established for many years.

It is my view that any patient or practitioner who attributes any systemic disease to the use of amalgam fillings is wholly misguided and has been misinformed. Any practitioner who suggests or implies that a systemic disease may be influenced by the removal of amalgam fillings should find themselves before a Disciplinary Committee at the General Dental Council.

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Accidental Dental Injuries

If a patient is involved in a road traffic accident and sustains injuries to their teeth, the Solicitor representing the Insurance Company of the injured party may pursue damages for the costs of the treatment. This civil claim will be directed towards the insurers of the parties to blame for the accident. In due course, the Solicitors will issue instructions to a Dental Expert Witness to examine their client to assess the extent of any dental injuries sustained and to attribute costs for putting things right. A number of Health Authorities are now contacting insurance companies directing to seek payment for the costs of medical/surgical care as a result of those injuries.

Equally, any injury that should occur to someone’s teeth while at work or following a fall may involve the owners of the site; an employer, or the local council if the injury should occur on public land. Sports injuries at school will invariably lead to an admission of liability if the school has failed to ensure that a child has not worn a mouth guard. The civil action is directed to the indemnity insurers representing the parties concerned.

The dental records of the injured party are forwarded to the Dental Expert Witness to determine the state of the teeth before the incident and the cost of treatment (known as Quantum Damage). A report is provided to all parties concerned and is used to determine the final outcome.

Dental Negligence

As a society, the public have become increasingly litigious when things go wrong and wish to apportion blame. Dentistry is a form of bioengineering with the management of bacterial invasion and subsequent restoration and/or replacement of teeth. Biological systems can be unpredictable and the outcome disappointing. Most cases of negligence can be a result of poor management of a patients’ expectations rather than the treatment itself. You may read my previous article on ‘When Dentistry Fails’ in Bath Life 143 or on the Talbot Clinic blog at http://blog.talbotclinic.co.uk/

If a patient is dissatisfied with the treatment outcome they may consider consulting a Solicitor to pursue a dental negligence action. The Solicitors acting on behalf of the client will instruct a Dental Expert Witness to review the clinical records of the treatment provided to the patient. Notes are provided on the quality of care provided and examination of the patient is carried out to assess the current condition and prognosis for future treatment requirements plus provide a summary of the costs of treatment to correct any outstanding dental problems.

There has been considerable increase in civil actions against clinicians in the last 10 years with greater sums awarded for compensation in view of the increased costs of complex dental treatment. The NHS paid out over £800 million last year alone for clinical negligence claims.

Second Opinions

Patients may wish to have a second opinion with respect to any dental problem. A patient can contact a Specialist Dental Practitioner for a consultation. The patient may just want advice before proceeding with treatment or may elect to have the treatment carried out by the Specialist. If the patient wishes to be seen by a Hospital Consultant, a letter of referral is required from the general dental practitioner. Understandably, the public hospitals have to prioritise those patients with major dental problems involving head and neck cancer, cleft palate and lip deformities and major hard & soft tissue loss associated with gun shot injuries. Delays for consultation are inevitable in view that the Bristol Hospitals have only two full time consultants in Restorative Dentistry for the whole region. Direct access to a Specialist in Restorative Dentistry can save the patient considerable time.

The General Dental Council assists the public in identifying Accredited Specialists by visiting http://gdc-uk.net/ and searching for all registered specialists in the local area. You can also search for an Expert Witness on http://legalhub.co.uk/

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Relationships

Trust, confidence and mutual respect are an absolute necessity between the patient and the dentist. Experiencing pain or receiving ‘brusk’ treatment in any way can damage this trust for a patient, regardless of the quality of the treatment provided. Try to make your concerns and thoughts about your treatment as clear as possible to your clinician throughout the treatment.

Continuity / Attendance Record

Patients who repeatedly change their dentist will inevitably create confusion. The new dentist hasn’t the luxury of referring to previous records to assist with a consistent plan of action. Different dentists may actually contradict each other and confuse the patient. If a patient chooses to only attend when they have a perceived problem at irregular or lengthy intervals a dentist is likely to treat the patient more quickly, causing higher chances of tooth loss than another patient who visits their dentist at regular intervals throughout their lifetime.

Communication Skills

The first consultation at a dentist is critical for the right diagnosis, and for some people can be nothing less than traumatic. Clinical trials have shown that nervous patients may find it difficult to communicate their concerns or listen to the details of what is being said, leading to subsequent misunderstandings. Try to write down your dental problems in preparation of your next visit to the dentist so you don’t miss anything, and request a written report of the diagnosis.

Emotional History

Patients with a chronic history of anxiety or depressive illness find it difficult to cope with stressful life crises. A visit to the dentist can be such a crisis and as a consequence the patient’s adaptation to changes introduced with treatment may prove to be too much. It is well established in clinical research that highly stressed or emotionally charged individuals suppress their immunological competence which may lead to slow healing after surgery or a poor response to dental infections. Greater discomfort can also be experienced and cause exaggerated symptoms, potentially causing ‘over-treatment’ or additional problems than first diagnosed. It is often suggested that the patient should request the support of a friend or family member to ‘coach’ them through the treatment, which often leads to a less stressful and more successful outcome.

Expectations

As information has become increasingly more available through the media of television, the Internet, etc., patients are often far better informed than those in the past. As more and more dentistry is prescribed and provided by private practitioners (outside the remit of the NHS) inevitably expectations are raised. Risks and benefits of any treatment must be understood by every patient so that suitable actions can be taken to manage expectations correctly.

Primary Disease Control

I’m sure it’s no surprise that any dentistry will inevitably lead to recurring problems if a patient does not assume responsibility for their oral health as much as the dentist does. Both the dentist and patient have equally important responsibilities to ensure treatment is successful. So, don’t forget your toothbrush!

Mechanical Factors

It shouldn’t be surprising to learn that a dentist may prescribe a metal filling to a boxer and a porcelain filling to a ballerina. Many of the choices provided by a dentist will take into account the nature of the patients’ needs. All materials used by a dentist will have a finite life, some more than others.

General Health

Your health can directly impact dental treatment. Many health problems are known to cause oral hygiene problems such as diabetes or arthritis. Be sure to tell your dentist any changes in your health. Even catching a cold can slow the healing process.

Occupation

Your job can have both emotional and environmental impact on oral hygiene. Bakers commonly had problems with tooth decay as a result of refined flour in the air whereas many modern stressful careers can cause people to grind their teeth. Try to consider how your career might impact on the health of your teeth and gums.

Lifestyle

It has been well established that smoking can affect your general health and oral hygiene, as well as diet, eating disorders, or even personal habits such as thumb sucking. Be prepared to disclose as much as you are able during initial diagnosis to ensure your treatment is as effective as it can be.

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(Unless, of course thepatient dies first!)

Establishing the Diagnosis

On the very first visit, the consultation by a dentist will involve reviewing your medical history, a chronological account of any problems, a clinical examination of your mouth including teeth, existing restorations and the gums. X-rays and impressions of the teeth are often required to establish a diagnosis. The diagnosis established between a group of different dentists often remains relatively constant. However, the proposed treatments may vary widely, based on the individual training and experience of each dentist.

It is incumbent upon every clinician to clearly explain the pros and cons of each option proposed in a given treatment plan so that every patient has all the information necessary to make an informed decision that best suits their individual needs. Treatment should only begin once this process has taken place. This process however is not always experienced by patients, often leading to misguided expectations and disappointing results, irrespective of a perfectly executed treatment.

No two dentists are the same, and finding a dentist to offer the right treatment plan for your individual needs may appear challenging and a bit of a lottery. So what’s the best way to find a dentist that suits you?

Finding a Specialist Dentist

Recently, there have been vast changes in Specialists Dental clinic services. Where previously dental treatment was referred to hospitals, patients now have access to the Specialists in Dentistry directly. The public need to be aware that references to Cosmetic Dentistry, Smile Centres and Implant Clinics may indicate specific services provided by a general dental practitioner with a special interest in the field. The General Dental Council assists the public in distinguishing between those General Practitioners with a ‘special interest’ from the fully Accredited Specialists. Visit http://gdc-uk.net and type “Bath” into ‘Town’ field to find all registered specialists in the local area.

Choosing the right treatment for you

When considering the risks and benefits of a treatment plan offered to you, communication is paramount. Always ask your dentist about any concerns you have prior to treatment. In the end, the treatment that is right for an individual patient can just ‘feel’ right and fits with your expectations and lifestyle.

Much of the specialist services in existence today can be viewed as bioengineering, whereby damaged hard or soft tissues in your mouth may be replaced with a choice of materials and surgically restored. Tooth decay is removed and replaced with metal alloys, resins or ceramics (Restorative Dentistry). Infected nerves in teeth are treated with Root Canal treatments (Endodontics). Gums may be returned to health with the use of brushing and cleaning regimes involving toothpastes, antiseptic mouthwashes and other antimicrobial agents. The replacement of lost bone around the roots may be effected with the use of bone grafting and bone regeneration material with innovative surgical procedures (‘Periodontics’). Lost teeth may be replaced with dentures or bridges (‘Prosthodontics’) and with the advent of dental implants one can now replace roots to support crowns and bridges (‘Implantology’).

Successful Outcomes

The success of a dental treatment plan depends upon a myriad of factors, which may include the following:

• Relationships
• Continuity / Attendance Record
• Communication Skills
• Emotional History
• Expectations
• Primary Disease Control
• Mechanical Factors
• General Health
• Occupation
• Lifestyle

There is a multitude of factors to ensure you receive the treatment you should expect. Patients share the responsibility for a favourable outcome with your dentist. Biology may sometimes be unpredictable but when a practitioner explains the reasons for potential failures and provides you with ongoing care, subsequent failures’ may be accepted and managed effectively.

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A Common Problem

A survey demonstrated that 70% of all British school children would benefit from having orthodontic treatment to straighten irregular teeth. This figure compares with the fact that only 10-15% of British children actually undergo orthodontic treatment. The differences are attributed to patients own perceptions and the availability of services.

The causes of ‘malocclusion’ are often attributed to oral habits in growing children, such as finger or thumb sucking, regular biting of pens or other objects, even awkward or abnormal posture can influence the development of the dental arches.

Modern Techniques

The technology of orthodontics has made enormous progress in recent years. Long gone are removable plastic appliances with limited scope and metal bands with ‘train tracks’ utilised. Almost invisible tooth coloured or clear ‘brackets’ are now cemented directly onto the teeth with discrete nickel titanium wires requiring minimal intervention. In fact, these often only necessitate visits every 6-8 weeks to the surgery. ‘Lingual’ brackets may now allow for the brackets to be placed on the inside surfaces of the teeth so they are completely invisible to others. Finally, computer generated clear ‘Invisilign’ moulds have been used to fine tune minor tooth movements to effect invisible orthodontics. In other words, orthodontic treatment no longer needs to be unsightly.

Consultant Orthodontists based in hospitals and dental schools are invariably now involved with the treatment of the most complex irregularities of teeth often in conjunction with other facial anomalies such as cleft lip and palates.

Specialist practitioners in orthodontics are found in practice in the high street. They have attended 3 years post-graduate training programmes before being registered as a Specialist Orthodontist.

How to find an Orthodontist

There are two ways to identify the Specialist Orthodontist in your area:

1. The General Dental Council (GDC) assists the public in distinguishing between those General Practitioners with a ‘special interest’ from the fully accredited Specialists. Visit http://gdc-uk.net/ and type “Bath” into ‘Town’ field to find all registered specialists in the local area.
2. The British Orthodontics Society (BOS) is a dedicated group of 1800+ dentists promoting the study and practice of orthodontics, maintaining and improving professional standards and encouraging education and research in the specialism. Visiting their website on the following url: http://bos.org.uk/orthodonticsandyou/findanorthodontist/ will allow you to distinguish from the Specialist Orthodontist and the dentist with a ‘special interest’.

Both the GDC and BOS websites lists the following Specialists in Orthodontics in Bath:

• Eric Tonge
  Bath Orthodontics, Sydney Road, Bath, BA2 6NR
• Christina Mathieson
  Bath Orthodontics, Sydney Road, Bath, BA2 6NR
• Graham Edwards
  Circus Orthodontics, 20 The circus, Bath, BA1 2EU
• John Kerrigan
  Circus Orthodontics, 20 The circus, Bath, BA1 2EU
• Helen Knight
  Edgar Buildings Dental, George Street, Bath, BA1 2EE
• Anthony J Ireland
  24 Newbridge Road, Bath, BA1 3NG
• Heidi Rowland
  10 Lambridge, Bath, BA1 6BJ

If you’re worried about misaligned teeth don’t hesitate to contact one of the Orthodontic Specialists listed here.

Toby Talbot, is Clinical Director of the Talbot Clinic in Bath and registered with the General Dental Council as a Specialist in Restorative Dentistry, Prosthodontics, Periodontics and Endodontics.

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NSFW (ie recommended ‘Not Safe For Work’ viewing)

Click here to view the embedded video.

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Article tags: Bad breath, Halitosis

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(endo=inside / dontics=teeth)

What are all these nerves doing in my teeth?

It may appear strange that nerve tissue inside a tooth exists in the first place. After all, why should sensitive teeth or tooth ache be useful to the patient?

The collection of blood vessels and nerve tissue with special dentine forming cells begins during childhood. Teething babies experience their discomfort as two opposing groups of cells line up inside their gum to form enamel and dentine. Gradually, the blood supply retreats and a bell-shaped structure begins to take form and grow through the gum, with the enamel on the outside and the dentine forming internally. As the crown of the tooth is completed, root formation with further dentine develops until finally the roots are complete, leaving the dentine forming cells, nerves and blood vessels entombed inside the tooth with an outlet at the tip of the root. The ability to form further dentine remains throughout the life of a patient.

Nerve Damage?

When damage is inflicted upon a tooth as a consequence of trauma or decay, this triggers the tissues remaining inside the tooth to begin further dentine formation for protection.

If the damage is minor or slowly developing, the nerve tissue has a greater chance of forming this protective barrier. But if it’s extensive or rapid, the nerve tissue itself may become damaged resulting in unwanted discomfort and pain. Using a sedative dressing with Oil of Cloves has been the mainstay for managing this painful condition since the Phoenicians in 2000 BC. But you may require an Endodontist to help.

Root Canal Treatment

The specialist in Endodontics will take an x-ray of the tooth to establish the position and shape of the nerve chamber before treatment begins. Each and every nerve canal extends to the tip of the root and is unique for every single tooth with respect to length and shape. A measurement of the length of the root is secured so that all the damaged nerve tissue and blood vessels are removed. The inside of the nerve chamber and canal is cleaned and the space remaining is then filled with an inert material. The tooth is then re-filled and restored.

Successful Outcomes

Clinical studies have demonstrated that elective root canal treatment carried out in the early phase of irreversible nerve damage is more successful than the unpleasant alternative of waiting for the nerve to die, allowing the formation of a dental abscess at the end of the root. This has implications to the patient to seek attention as soon as symptoms arise as the retention of the tooth could become more compromised.

As the root canals may be less than 1mm in diameter, the use of a microscope becomes a necessity for the Endodontist to carry out the treatment.

How to find an Endodontist

The General Dental Council assists the public in distinguishing between those General Practitioners with a ‘special interest‘ from the fully accredited Specialists. Visit the GDC and type your local area into the “Town” field to find all registered specialists near you (UK only).

The General Dental Council website lists the following Specialists in Endodontics in Bath:

• Gillian Boswell

  Edgar Buildings Dental, 7 Edgar Building, George Street, Bath, BA1 2EE

  Specialities: Endodontics

• Toby Talbot

  The Talbot Clinic, Tasburgh House, Warminster Road, Bath, BA2 6SH

  Specialities: Restorative Dentistry, Periodontics, Prosthodontics & Endodontics

If a General Dental Practitioner considers the shapes of the root canals difficult to negotiate, they may consider referral to the Specialist Endodontist. A recent review of root-filled teeth carried out by General Dental Practitioners demonstrated the presence of ongoing pathology/infection in up to 50% of root-treated teeth ~ compared to root-treated teeth by Endodontists showing an absence of pathology in 95% of teeth if uninfected and 85% of teeth if infected.

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History

The history of dental implants began with Mayan civilisations who used shell pieces as crude dental implants embedded into the sockets of missing teeth. It wasn’t until the 1950′s that independent maverick practitioners experimenting with various materials developed more modern techniques.

A Swedish Researcher in Orthopaedics carried out experiments studying the healing of wounds in the leg bones of rabbits. A titanium optical chamber that had glass windows either end allowed him to observe the healing process. He noticed that after a time he had great difficulty removing his expensive titanium chambers due to the rabbits bone healing tightly around the metal. This observation was revealed to the School of Dentistry in Gothenburg and eventually led to the replacement of chrome cobalt alloys & stainless steel implants with titanium now in use today. The researcher, Professor Brånemark, oversaw my first implant in a patient at the University of Washington School of Dentistry in 1981.

Modern Implants

There have been over 7 million of Brånemark implants placed via close collaboration of Specialists in Prosthodontics, Oral Surgery and Periodontics. Nowadays the procedures have become more simplified giving the opportunity for General Dental Practitioners with a special interest in this treatment modality to attend Postgraduate training programmes. There are now recommendations for training established by the General Dental Council before providing this treatment. This requires continued mentoring of the General Practitioners provided by established Specialists in Prosthodontics Oral Surgery and Periodontics.

However there are a number of contraindications to dental implants that may only be realised by the trained specialist. The public need to be aware that the title of a dental surgery which include references to “Implant Treatments”, “Implant Clinics”, “Implant Centres” or Advanced Restorative Dentistry may imply Specialist services that may not have full Specialist Accreditation.

The Implantologist

Implantology requires a team of experts, rather than any single individual clinician. Implantology requires the combination of skills shown.

No one person in the world can tick every box to become an implantologist. As a consequence the title ‘Implantologist’ is totally inappropriate and misleading.

Implantology

The General Dental Council assists the public in distinguishing between those General Practitioners with a ‘special interest‘ from the fully accredited Specialists. Visit the GDC and type your local area into the “Town” field to find all registered specialists near you (UK only).

In Bath, clinicians with combined specialities working closely with a team include the following:

• Mark Vardon-Odonkor

  Dept Oral & Maxillofacial Surgery, Royal United Hospital, Combe Park, Bath, BA1 3NG

  Specialities: Oral Surgery, Prosthodontics

• Toby Talbot

  The Talbot Clinic, Tasburgh House, Warminster Road, Bath, BA2 6SH

  Specialities: Restorative Dentistry, Periodontics, Endodontics & Prosthodontics

I am often referred patients from general dental practitioners specifically for implants or patients may even refer themselves for implants when, after a proper assessment, indicates an alternative and more appropriate treatment.

It has to be remembered that the prescription of implants will be only one of several options for any patient who has lost teeth. The dedicated Dental Centre/Clinic led by a general dental practitioner may limit the wider considerations of treatment alternatives. This would be the equivalent of a patient referring themselves to a dedicated hernia clinic, only to find out that the “lump” isn’t a hernia and yet, still only being offered the hernia operation.

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School Education

Three A levels in biology, chemistry and physics with two A grades and one B grade will get you short listed for an interview at one of the university dental schools. A proven track record with the use of your hands with intricate attention to detail will be noted. I had served an apprenticeship in sheet metal engineering which appeared to gain more attention than my four A levels. An additional proactive interest in the arts is considered favourably.

University Education

Dental Schools are located in Dundee, Edinburgh and Glasgow in Scotland. London has 3 schools including Guy’s at London Bridge, King’s at Denmark Hill and The London at Whitechapel. The provinces include the well established redbrick universities of Leeds, Sheffield, Liverpool, Manchester, Birmingham, Cardiff and Bristol. Recent new additions include Southampton and Plymouth.

The first year involves joint lectures with the medical students involving anatomy including human dissection on cadavers, physiology, and biochemistry. The second year includes General and Oral Pathology, Microbiology, Dental Technology and Material Sciences. The final 3 years are devoted to supervised clinical activities on willing patients. An extraordinary situation whereby a person allows someone to practice and develop their skills with a drill rotating over 300,000 times a minute in their mouths.

The General Dental Practitioner

After successful passing of the exams a Bachelors degree in Dentistry is awarded by the University followed by mandatory registration with the General Dental Council. In fact to practice dentistry without registration is a criminal offence. This is then followed by a mandatory period of supervised clinical activity in general practice for one-or two years before the practitioner is able to become an independent principle. Approximately 35,000 general dental practitioners are currently registered in the UK.

Oral & Maxillofacial Surgery

Clinicians have both medical and dental undergraduate degrees and focused upon major head and neck surgery including trauma, developmental anomalies such as cleft palates and lips and the management of cancer of the head and neck. Many of these clinicians gained an initial degree in dentistry which helped finance the return to complete their medical studies. A long 8-9 year stint of undergraduate study before securing their first job.

Orthodontics

Another dental specialisation led to the formation of Orthodontists who were dedicated to the movement of teeth and to rearrange their positions with the use of braces and fixed appliances to provide a more pleasing appearance with the patients’ smiles. Traditionally, the vast majority of this work was performed on children but in recent years, this is now universally carried out also on adults.

Restorative Dentistry

Most recently, a third major specialisation in dentistry has led to the development of Consultants/Specialists in the field of Restorative Dentistry which also includes Prosthodontics, Periodontics and Endodontics. These Specialties involve restoration of damaged and missing teeth, treating gum disease and damaged nerves in the roots of teeth.

Are you considering a career in Dentistry?

Toby Talbot is offering you the opportunity for an informal chat on your career, call 01225 426222 on Mondays between 8-11am.

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The grandson of a prolific artist visited Bath this week to track down one of his Grandfather’s paintings after seeing it on the Antiques Roadshow.

The portrait by William Russell Flint painted in 1962 was featured on the BBC programme on Sunday after its current owner Toby Talbot sent it to the Assembly Rooms when the show was filmed in April.

Mr Talbot, a dentistry consultant at the Talbot Clinic in Bathampton, has owned the painting for five years after it was recovered from a dusty vault where it had been for more than 30 years. Russell Flint’s grandson Jamie saw it on the show and contacted Mr Talbot to arrange to see it.

Jamie said his family were constantly searching for original pieces of his grandfather’s work and, with the correct permission, copied them to keep his paintings in circulation.

The 46-year-old said he remembered little about his grandfather who died when he was seven. He said:

“He was a very kindly man but I don’t have a huge recollection of him. I love all of his paintings and we have a house full of them. This particular one was kept in a vault for more than 30 years and when you come and see it you realise what a fabulous picture it is. Finding pictures like this of his is getting rarer and rarer.”

Before the programme on Sunday, which saw the painting valued at £50,000, it hung on the wall of the dental surgery in Warminster Road. It has since been removed from the premises for security reasons.

Mr Talbot said he was talking to galleries in the city and hoped it would go on display for all to see. He said:

“I consider art is for public consumption – I refuse to let it sit in a bank vault.”

Russell Flint was an acclaimed Scottish artist, well-known for his watercolour paintings, who lived between 1880 and 1969. Mr Talbot added:

“He is regarded in the 20th century as the most accomplished and brilliant watercolourist the world has produced.”

He said he had fallen in love with Flint’s work several years ago when he was a junior surgeon. He said:

“I lived with a friend in the north of London and she had than 20 paintings in her house. “Every day I came in or went to work I would walk past these canvases and I absolutely loved them. “I waited 20 years for this piece to resurface.”

A stained glass window found under the Abbey Chambers, which is now Bath Tourist Information Centre, was also on the show. The second part of the programme filmed in Bath will be aired this Sunday on BBC1 at 7pm.

Felicity Crump

Courtesy of the Bath Chronicle

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Gingivitis and Periodontitis

A group of Norwegian Researches in 1963 used a group of compliant dental students to study the effects of stopping all oral hygiene methods. After just 3 days, their gums became red, swollen and bled when touched. Left untreated, this inflammation can spread to the bone below the gums and “melt” the bone away. The students resumed effective oral hygiene, and quickly recovered.

Over longer periods, slow progression of ‘Adult Periodontitis’ can lead to uniform bone loss around the roots. Alternatively, Juvenile Periodontitis results with faster, more aggressive bone loss in younger patients. In more extreme cases, ‘Rapid Progressive Periodontitis’ can result in quick, irregular bone loss.

Diagnosis of Periodontitis

The diagnosis and distinction between these susceptible patients is critical to identify as early as possible to reduce tooth loss. The disease can often go undetected by patients until the volume of bone loss becomes so extensive that teeth can move and become loose. The Specialist Periodontist will assess the extent of bone loss around the entire circumference of each tooth and put into action a treatment strategy according to the diagnosis.

Periodontal disease accounts for 60% loss of teeth after the age of 40 years. Late diagnosis with advanced and rapidly progressive bone loss accounts for a much greater percentage of tooth loss.

The Treatment of Periodontitis

The relatively slow Adult Periodontitis involves introducing the patient to effective plaque control measures with particular emphasis upon removing the bacteria in between the teeth effectively every 24 hours before the volume of bacterial colonisation produces the toxins to attack the bone. Deep scaling or root planing is carried out to remove the bacteria that have colonised below the gums. The more rapidly progressive forms of the disease may require topical, local or systemic antibiotics in addition to surgery. Recent surgical developments have introduced regenerative procedures to attempt to regrow the bone.

Implantology

Considerable bone loss or an unfavourable response to periodontal treatment may sometime require teeth to be removed to conserve remaining bone, allowing implants to be used in place of lost teeth.

Risk factors for Periodontitis

It is well established in the clinical literature that a genetic predisposition to periodontal disease is often confirmed in the family history of the patient. This predisposition can be exacerbated with poor oral hygiene and poor diet. Smoking can also contribute to greater bone loss, as nicotine directly reduces blood supply to gums. This means fewer white blood sells present to heal the gums and with the reduced production of saliva, the mouths’ natural anti-bacterial defence mechanism is compromised.

Needless to say, those patients not susceptible to periodontitis can get away with neglecting their teeth although an absence of oral hygiene may lead to an element of social isolation due to halitosis.

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Article tags: Periodontics

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Dentures, Bridges and Implants

The loss of teeth can be an unpleasant surprise, but dentures offer an attractive, rapid and cost effective option. Clever use of materials such as resins to allow simple adjustments and relinings with reduced costs, while metal frameworks provide precision fitting, reduced bulk and greater longevity. Dentures are particularly useful when there is uncertainty regarding the prognosis of some remaining teeth so that if one or more teeth are later lost, additions are able to be made.

Remaining healthy teeth may be used to support bridges that are cemented in place. Traditionally this necessitated considerable preparation of the adjacent teeth for crowns that were joined to support the “pontics” that replaced the missing teeth. Since 1978, research at the University of Maryland in Baltimore developed resin-retained bridges that allow for the adjacent teeth to be left intact and so preserve the integrity of healthy tooth structure.

In the early ’70s, Professor Brånemark of Gothenburg presented pioneering clinical research material with the first scientific approach to the use of Implantology (previously the domain of independent, self-promoting mavericks). His meticulous documentation and rational scrutiny has now revolutionised the use of this treatment. The use of implants allows for dentures or bridges to be fixed, more closely resembling the original teeth. The provision of this treatment requires the combined skills of surgery and deep understanding of Prosthodontics.

The Prosthodontist

The Specialist in Prosthodontics is able to manage those difficult situations that may arise whereby the functional or cosmetic aspirations of the patient are much higher than the norm. Patients experiencing long term problems with dentures due to their lack of stability and retention or patients experiencing tooth grinding, tooth wear associated with eating disorders or acid attack may contribute to much more complex treatment. Public figures and celebrities may have much greater “cosmetic” needs for restoring a beautiful smile or a professional singer in opera will be particularly sensitive to any changes with their teeth.

Success Rates

All dentistry will fail given enough time. Clinical studies, followed up with treatment have clearly demonstrated that prosthodontics carried out by the Specialist has a considerable greater success rate and longevity. Recent research has shown that review and maintenance are as much a necessity as the servicing of your car. Dentures may require relining and additions every 5-7 years. Mechanical wear and tear of bridgework accounts for 20% of bridges failing at 10 years and 45% of bridges failing at 20 years. Implant failure rates are very much dependant upon the patient with respect to general health and the meticulous attention to detail with surgery and the subsequent dental reconstruction. All dental treatment is dependant upon effective home care and a healthy diet. Smoking contributes significantly to poor oral health and, in my opinion, contraindicates the use of dental implants.

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Article tags: Prosthodontics

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Restorative Dentistry is that field of dentistry associated with restoration of the teeth.

Tooth decay

It’s common knowledge that teeth can decay without regular care. With the invasion of harmful bacteria on a daily basis, your teeth (healthy or otherwise) are in an everlasting battle.

It is well established in clinical research that, after prolonged periods of damage, once the size of a cavity or the destruction of the tooth through trauma amounts to more than half of the remaining tooth, a simple filling may not be adequate.

Tooth Tissue Loss

In some cases, the onset of tissue loss can be rapid due to accidental damage. In others, it can take years following gradual wearing (i.e. grinding teeth while sleeping). Other causes can be erosion from dietry habits with high citric acid content or acid reflux from the stomach, whether related to a hiatus hernia or an eating disorder such as bulimia can effect considerable damage to teeth.

Choice of Materials

Whether a tooth requires to be re-built for functional reasons such as eating and speaking or for cosmetic reasons involving the front teeth, a myriad of materials which include metal alloys, composite plastics and porcelains may be indicated depending upon the particular circumstances.

15~20% of patients exhibit evidence of tooth grinding and clenching which can indicate stronger materials for their wear resistance over and above any cosmetic aspirations of the patient. The metal alloys available today can be matched to the physical demands that will be present whereas the composite resins and porcelain materials lend themselves very readily toward achieving a lifelike tooth coloured outcome but often times provide poorer physical characteristics with wear and a tendency for chipping/breaking. It is common to have to discuss with the patients the various benefits and risks associated with the use of the materials to ensure that for a particular patient the correct material is selected.

Cosmetic Dentistry

Whenever a patient is concerned about the appearance of their teeth, this may become the remit of the Specialist in Restorative Dentistry. Tooth coloured restorations, porcelain veneers and crowns offer exceptional optical properties when the clinician works closely with the Dental Ceramicist. The science of colour with a colour corrected day-light environment becomes a necessity. Even the colour of the walls of a surgery will influence the shade and colour of natural teeth.

Successful Outcomes

It is essential to understand that the success of any restoration is dependant on the survival rates of the treatment over time. Clinical studies have been conducted at 5 and 10 years following treatment to ascertain how long the restorations will survive and it’s worth noting that ALL dentistry has a finite life expectancy which is frequently overlooked. Many patients are likely to experience recurring tooth decay under a filling due to the loss of control of the primary disease process. Mechanical breakdown of all dental materials is inevitable and wholly time dependant although material selection is critical to avoid early failure. Sometimes the cosmetic aspirations of patients may dictate the use of a tooth coloured restoration even though its physical characteristics are inferior to the use of a metal alloy.

As long as the patient is made aware of the expected lifespan of the choice, its subsequent failure can be predicted and accepted prior to treatment.

Finding the right Specialist

The General Dental Council assists the public in distinguishing between those General Practitioners with a ‘special interest’ from the fully accredited Specialists. Only those practitioners on the GDC Specialist Register are entitled to call themselves Specialists in Restorative Dentistry.

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Toby Talbot is registered with the General Dental Council, Wimpole Street in London as a Specialist in Restorative Dentistry, Prosthodontics, Periodontics and Endodontics. He is currently Clinical Director of The Postgraduate Centre of Bath which he established at The Brock Street Clinic in 1992.

Chairman of Norlands

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I have fond memories of “working” in my godfathers’ dental practice in South Africa as a teenager. I had a great time at school but always knew that I would have to leave home at 18, after years of encouragement from Dad to go and see the world. And now I find myself, happily married and working with Toby, Fiona, Rachael & Helen. We have great fun and I love the company of our fantastic patients with all their interesting tales. I have been working as a dental nurse for over 6 years and qualified back in 2005. Working at the clinic has broadened my horizons and inspired me; it has changed my experience of dentistry as it does for our patients.

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After qualifying from Leeds dental school in 2001, I worked in Leeds and Hull. After several years developing my skills I moved to Bath with my wonderful husband-to-be.

The Talbot Clinic is a great environment for me to care for patients, and with such a wonderful location, the little extras ensure your experience will be second-to-none.

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Profile of a dentist

It takes 5 years of dedicated training to provide all undergraduates with a foundation of general dentistry, with an additional 2 years of clinical activity. A number of these clinicians will choose to become specialists, embarking upon further post graduate study and training for hospital positions, university careers or to become Specialist Practitioners in the high street.

Development from Surgery to Service

Historically, the first specialists in dentistry were Oral Surgeons who established their surgical skills during the Second World War. This pioneering work on facial injuries in young airmen led to the subsequent development of Oral & Maxillofacial Surgery whereby clinicians who had both medical and dental undergraduate degrees focused upon major head and neck surgery including trauma, developmental anomalies such as cleft palates & lips and the management of cancer of the head and neck. The foundation of Orthodontics, dedicated to the movement of teeth, rearrange their positions with the use of braces and fixed appliances, provided a more pleasing appearance with the patients’ smiles. Traditionally, the vast majority of this work was performed on children but, in recent years, this is now universally carried out on adults too.

Modern methods available in Bath:

• Replacement of missing teeth (“Prosthodontics“) This includes the use of dentures, bridgework or implant supported prostheses which may be fixed or removable.
• Treating Gum disease (“Periodontics“)As much as 20% of patients are susceptible to gum disease which causes bone loss with loosening of the teeth.
• Decaying and Infected teeth (“Endodontics“) The result of irreversible damage to the nerves within the teeth, requiring filling the root canals to allow the teeth to be re-built.
• “Screw-in” teeth (“Implantology“) As an alternative to dentures, teeth can now be permanently fixed to titanium implants, replacing lost roots.
• Restorative Dentistry (inc. Prosthodontics, Periodontics, Endodontics and Implantology) Modern cosmetic dentistry has been developed to help the restoration of damaged and missing teeth, treating gum disease and damaged nerves in the roots of teeth.

Finding the right specialist

Recently, there have been vast changes in Specialists Dental clinic services. Where previously dental treatment was referred to hospitals, patients now have access to the Specialists in Dentistry directly. The public need to be aware that references to Cosmetic Dentistry, Smile Centres and Implant Clinics may indicate specific services provided by a general dental practitioner with a special interest in the field.
Only The GDC website will identify the Accredited Specialist at http://gdc-uk.net/, a selection of which is provided below:

• Mark Vardon-Odonkor

  Dept Oral and Maxillofacial Surgery
  Royal United Hospital, Combe Park, Bath BA1 3NG

  Specialities: Oral Surgery, Prosthodontics

• Gaston King

  The Bath & Bristol Periodontal Clinic,
  506 Bath Road, Saltford, Bristol, BA31 3JF

  Specialities: Periodontics

• Gillian Boswell

  Edgar Buildings Dental
  7 Edgar Buildings, George Street, Bath, BA1 2EE

  Specialities: Endodontics

• Toby Talbot

  The Talbot Clinic
  Tasburgh House, Warminster Road, Bath, BA2 6SH

  Specialities: Restorative Dentistry, Periodontics, Endodontics & Prosthodontics

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Article tags: Endodontics, Implantology, Periodontics, Prosthodontics, Restorative Dentistry

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