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CASE NOTES
Tuesday 28th June 2005, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION

RADIO SCIENCE UNIT

CASE NOTES

Programme 5 - Dentists

RADIO 4

TUESDAY 28/06/05 2100-2130

PRESENTER:

MARK PORTER

REPORTER: LESLEY HILTON

CONTRIBUTORS:

PHIL LOUGHLANE
JANICE FISKE
ALEX CRAWFORD
JO INGLEBY
RICHARD PALMER

PRODUCER:
BETH EASTWOOD

NOT CHECKED AS BROADCAST

PORTER

Hello. In today's programme I'll be exploring the world of dentistry - in particular how to care for our teeth as we get older.

I'll be finding out about how titanium implants are being increasingly used to provide a permanent solution to missing teeth and wobbly dentures

CLIP
The implant can have anything fitted on to the top of it - it's a bit like a Mecano set if you like, you can screw a crown, a false tooth, you can screw on another sort of attachment perhaps to support a denture. So it's very adaptable to various needs that we find in the mouth.

PORTER
And Lesley Hilton visits the Gentle Dental Clinic to find out what's being done to make a visit to the dentist less traumatic for people who have dental phobia - the most common excuse given by the 20 million or so British adults who admit they only ever go to see a dentist when they are in pain, and have no choice.

All of which is pretty academic if you don't even have a dentist. Over the last decade NHS dentistry has collapsed in many parts of the UK as a growing number of dentists concentrate on more lucrative private patients. But a recent survey by a private health insurer suggests that 4 out of 10 families can't afford to pay for private dental care - so what happens to them?

The gravity of the situation isn't lost on the government, which pledged an extra £370 million last year to boost dental services across England alone - money that was supposed to support the recruitment of an extra 1,000 dentists by the end of this year. So has it made a difference?

Well the simplest way for me to find out was to try and register locally - unfortunately all the dental practices in my area are still closed to adults wanting to register as an NHS patient and none of them could see me. So I called NHS Direct for help. They pointed me in the direction of my local NHS dental access centre which offers appointments at three centres across my home county and every part of the country should have a similar back-up service.

So could I register with the service as an NHS patient, and how long would it take for me to get in for a routine check up - the very backbone of good preventative care?

ACTUALITY - PHONE CALL
Good morning. Dental [indistinct word], can I help?

Yeah hi, I'm just ringing to find out the procedure for registering with the service for an NHS dental check up. I've tried my local surgeries and they're not accepting new NHS patients at the moment.

We don't actually register people here, we just haven't got the facilities to register. So normally what happens is you've got a waiting list, when you come to the top of the list you get your exam, any treatment relevant and then you can't actually go back on the waiting list for another year.

Okay. There isn't anything wrong with my teeth I just want to come in and have them looked at really.

I can't book anybody in, you have to go on the list. So the list is probably about nine months to a year anyway.

Okay, that's great. Thanks for your help.

Alright then.

Bye.

PORTER
Not all dental practices are closed to NHS patients and you may be luckier in your area, though the problem is widespread. Phil Loughlane at the Chipping Manor Dental Practice in Wooton-Under-Edge had 800 people queuing up to join his list when he opened his doors to NHS patients earlier this year. Phil is the first to admit that the scale of NHS fees can make it difficult to run a profitable practice.

LOUGHLANE
If a dentist is providing a filling to a child it's almost impossible to do that in a profitable way. If the next patient comes in and has profitable treatment then you may cancel that out but if you have a run of those kind of treatments I think that's when dentists get to the point that they feel they'd rather work privately so that they have more time and the patients get the treatment they need.

PORTER
Why then are you opening your books because as a practice, aside from the fact that you have staff here who are willing to take on NHS patients, it's not financially a good thing to do or is it, are things changing?

LOUGHLANE
I think there are two reasons. Firstly, from a business point of view when patients come in and they're happy and they have an individual explanation of what the different private or NHS treatment could mean to them in that particular instance some patients will choose to have private treatment. So in that way we get to see people who perhaps would be put off if they thought the practice was solely private but they may choose individual options. And the other reason is we're a training practice, we're very proud of the fact that we've got high standards, we've been assessed by the university as meeting the requirements to have a newly qualified dentist. So when Dave joins the team, this is his first job, and it's really a requirement for dentists to get an NHS number that they work in an NHS practice for a year.

PORTER
The other way of looking at it of course is that the NHS patients are getting newly qualified or training dentists, so I mean you could be forgiven for saying that they're being practised upon.

LOUGHLANE
Certainly not, the practising in dentistry happened the day four years ago when he was on a patient simulator. He's now fully qualified when he joins the practice. The difficult part of his learning now is learning the NHS rules. There's a 200 page book that I have some basic grasp of, that I hope he will have some basic grasp of, but I certainly expect to learn some clinical tips from him.

PORTER
What about the long term future of NHS dentistry, what's the feeling over a pint of beer with your dental colleagues, do you think there's a future in NHS dentistry, do you see more dentists coming back into it?

LOUGHLANE
There is a lot of moaning about money. The system we've got is this fee per item system, so dentists get paid for every tooth they drill. And there is a growing appreciation that that isn't the way for patients to receive the best care. The new contract that comes in, in April, will mean dentists get paid a set figure for the whole year, so that your last year's figures will dictate what you earn in future. And that will be split up into twelfths and you get that amount. And certainly the experience is dentists who work in that kind of scheme seems to be about 5% less treatment, are able to take on a few new patients and seem to enjoy working in that way.

PORTER
What extra do you get if you go to see a dentist privately?

LOUGHLANE
There are some items that aren't available on the NHS. Like all porcelain crowns, so that you can get the most realistic appearance by visiting the technician who will make your crown totally from porcelain which transmits some light through it, so it'll look very natural. That type of treatment isn't available on the NHS but that's the kind of treatment some patients would select, perhaps for upper front teeth that are very visible.

PORTER
If you're having something done purely for cosmetic purposes presumably the NHS doesn't pick the tab up?
LOUGHLANE
There are a number of patients who do have cosmetic treatment, that's actually probably a growing area of practice here - we have a number of patients who've had a dozen or more crowns done where that is covered by the NHS and even if the patient has to pay their own fees they pay the maximum charge, which is £386, so it's quite ironic that I've got one patient who had I think 25 crowns fitted and she works in an office with somebody else who had a single crown fitted and they both paid about the same amount for their treatment.

PORTER
That's an interesting point but what makes the person - the one eligible for NHS treatment, do they have terrible teeth?

LOUGHLANE
No, no she's just registered at an NHS practice, it was somebody who had a lot of wear to her teeth, so she hadn't suffered any dental disease, it was a case of rebuilding her smile. We had to crown all of her teeth to ensure that the teeth would bite and meet comfortably.

PORTER
I can see lots of people joining the next queue - if another surgery locally opens up there's going to be more than 800 people I think if they can get their teeth crowned for free.

Dentist Phil Loughlane bucking the trend at his Wooton-Under-Edge practice by opening his doors to new NHS patients.

My guest today is Janice Fiske, who's a consultant in Special Care Dentistry at Guy's, King's and St. Thomas's Dental Institute.

Janice, what do you think, do you think we can expect a significant improvement in NHS dentistry?

FISKE
I hope there'll be an improvement, that's what the government has planned in trying to introduce the new dental contract. We heard Phil talking about the fee per item contract at the moment, where the dentist gets paid for each filling or crown that they do and that system was introduced in 1948 and really focuses on doing treatment rather than preventing dental disease. The new contract would pay the dentist a salary, which would allow them then to focus more on prevention.

PORTER
Is there any evidence that during this problem era - the last decade really - there's been any damage to the nation's teeth, are our teeth suffering?

FISKE
Almost to the contrary because both the most recent adult dental health survey and the most recent national children's dental health survey has shown that the nation's teeth are improving.

PORTER
How does our dental health compare to that of the past in general, I mean looking at my - I've got two teenage children and neither of them have got a filling and the outlook looks pretty good to them when I compare what my teeth were like, I haven't had any fillings recently but I had most of them done in my teen years?

FISKE
There are certainly fewer children and fewer adolescents with experience of decay and having to have fillings and extractions done. But there is still a significant proportion of those populations that have a lot of decay. So if you like all the decay is concentrated in a small proportion of the population now.

PORTER
And for the group where things have got better, is it better dental hygiene, fluoridation of water, a combination of the two or some other factor?

FISKE
I think it's a combination of all those things and also more social awareness about appearance.

PORTER
Assuming your teeth don't go wrong, so excluding dental caries - tooth rot, what poses the biggest threat to them, given that we're all living longer, we want them to last a lifetime?

FISKE
For adolescents I think the biggest threat is erosion from fizzy drinks and fruit juices.

PORTER
This is literally dissolving of the teeth.

FISKE
Yes. And for older people who are retaining their teeth more now into old age, rather than losing them all and ending up with complete dentures, the problems really are maintaining sometimes quite complex dental treatment into old age where they maybe lose the ability to maintain their oral hygiene on a daily basis.

PORTER
Janice, I want to come back to that point later. But assuming that it takes someone - I'm 42 years old, I've got no symptoms, my teeth, as far as I'm aware are very healthy, how often should I have be having my teeth checked?

FISKE
There have recently been some guidelines brought out by the National Institute of Clinical Excellence - NICE - that have looked at exactly that and they have said that a check up should be anything from six months to two years. And that should be based on the individual's risk to dental disease.

PORTER
So tailoring the intervals to the individual. Well that's good preventative advice. But what if you're petrified of the dentist? We sent Lesley Hilton to the Gentle Dental Clinic to find out.

DRILL NOISES

HILTON
The sound of a dentist's drill, probably none of us like it but, for some, going to the dentist is almost unbearable

VOX POPS
Ultimately I was terrified, I kind of looked like some kind of comical Roald Dahl character sat in the chair with my shoulders straight up to my ears because I was just absolutely petrified. And now although I have the guts to sit in the chair, I still am very, very scared.

I didn't like the scrapping of metal against my teeth, having my teeth drilled at all. I had some extractions done, maybe the last time I went to the dentist, which was not very pleasant even though I was under sedation. But generally I was just very unkeen having people poke around in my mouth.

HILTON
Dental phobia can take many forms such as fear of needles, drilling or having something put in the mouth. But sometimes there is no specific focus. A key to overcoming some people's dental phobia is making sure they feel no pain. Collette Gilmartin has a phobia about needles. It's so strong that she stayed away from the dentist for 12 years. Eventually she was persuaded to go to a support group and now, although not totally happy about it, she will have treatment done. The turning point for her was a numbing gel that her dentist uses before giving an injection and the fact that all needles are kept out of her sight.

GILMARTIN
It's not like it's even a sensation - you feel nothing, it's a completely dead numbing gel. And when I had that done, at that point it was almost like I wanted to cry. I think if you've got something that's really big in your life and you realise that you've got over the first hurdle of it and then the filling part of it afterwards, it kind of - you don't like the sensation of somebody being in your mouth and you know that ultimately they're drilling but I could get over that once I'd kind of done the first hurdle.

ACTUALITY - DENTIST ALEX TALKING TO SAM
So Sam, this happy area is something that we'll use next time you come and it's designed to make it feel calm and relaxing for you at the dentist's, so you don't feel all tense and jumpy. We've just got to get this little bobble to fit nicely and then I'll show you how it works, it should just fit snugly on to your nose.

HILTON

Alex Crawford runs the Gentle Dental Clinic at Wythenshaw for the Central Manchester Primary Health Care Trust. He sees a lot of children and adults who are phobic about dentists and his role is to help them back into dental treatment. He says it's not just the fear of pain that frightens patients, some feel out of control.

CRAWFORD
Some people do say about the dentist - I said how frightened I was and they said - Oh grow up, oh don't be silly. In other words they didn't really take on board my real concerns.

INGLEBY
It's usually the perception of control that is important to patients, to understand that if they wish to stop by either raising their hand you will stop.

HILTON
Jo Ingleby, a private dentist in Manchester agrees.

INGLEBY
The other thing we can do is give control right from the start, from explanation as to the patient's needs and then for them to choose the sort of treatment they want and the times at which it's done. So that even though they're lying back it's happening for them and not to them.

HILTON
People with dental phobia can often have other anxieties in their life and for this reason Alex Crawford believes it's essential that a dentist builds up a complete picture of the patient, not just their dental history.

CRAWFORD
If it's a child I'll be talking about what they like to do at school and the way they relate within the family. And of course adults also have got other concerns - we've had adults who've suffered from assaults of some kind or another, which might have had some relationship to their dental anxiety. I think the patient feels that by talking about it the dentist sees him in a different perspective and will treat them differently to the way they were treated before.

HILTON
There are several methods for treating phobic patients, from hypnosis, relaxation and distraction techniques, to various methods of sedation. Mark Widdby went for nearly 40 years without seeing a dentist after bad experiences as a child. When he did have bouts of bad toothache he resorted to whisky and pain killers! But now after a couple of sessions of hypnosis he uses visualisation to overcome his fears.

WIDDBY
I visualise a scene from a skiing trip in Norway - pine trees covered with snow and the blue sky and sunshine. And if things get really bad I just try and conjure up that image in my mind and try not to worry about what is happening.

HILTON
The best way of managing dental phobias is to prevent them from happening in the first place. As many stem from childhood, Jo Ingleby thinks it's vital to encourage children to have positive thoughts about their visit to the dentist.

INGLEBY
One of the best things to do with children is something called modelling which is where they watch someone and model their behaviour. Modelling works best when it's someone who they can relate to, so for a child to see an older brother or sister be in the chair, be treated happily, then they will usually skip in happily. As a parent it's very important that the situation is not perceived as threatening. So, as you would never say - Come to the park, don't worry it won't hurt - it's great if we can not mention the word hurt and say come to the dentist we'll have a play on the magic chair.

HILTON
While phobic patients can help themselves by learning relaxation techniques, obviously having a sympathetic dental team makes the whole experience less stressful. But that takes time and in the NHS dental service time is money. While some NHS dentists - like Alex Crawford - do take that time to help patients, many people with phobia end up having to go to a private practice where they can buy that time.

CRAWFORD
We're very task oriented people and there's a shortage of dentists, as you know, and we feel we have to get the treatment done and there are a lot of people waiting and we've only got 10 minutes booked in and we can't spend a lot of time talking to you. But this is what the patients need. They want us to understand them and that conflict in the dentist's mind between the time it takes and the time they have causes dreadful stress.
HILTON
Most phobic patients can be helped to overcome their fears. The key is to shop around for a dentist that has the time and the experience to deal with them. But within the current NHS service that can sometimes be hard.

PORTER
Lesley Hilton talking to dentist Alex Crawford.

You're listening to Case Notes, I'm Dr Mark Porter and I'm discussing dentistry with my guest Janice Fiske, who's a consultant in special care dentistry.

Janice, you must see quite a lot of patients with this problem.

FISKE
Yes, the department I work in specialises in treating patients with anxiety and phobia, so we get more than our fair share. And they come for all the reasons we've just heard about. But there's also a group of patients who come because they have a profound gag reflex - a retch reflex - so they can't cope with anything in their mouths ...

PORTER
It makes them literally heave.

FISKE
Makes them heave, that's right. And some people that happens when you actually put the instrument in their mouths and for some other people it's merely the thought of coming to the dentist and they'll be heaving as they walk into the dental surgery.

PORTER
So how do you deal with that?

FISKE
Well there are a number of techniques and all the techniques that have been outlined for general anxiety can be used for gagging. But we've been particularly successful in our department using the technique of acupuncture. And particularly ear acupuncture.

PORTER
I was just thinking the patient's thinking so you're going to stick a needle in them, where do the acupuncture needles go?

FISKE
The acupuncture needles go in their ears, so they're out of sight. And what you've just said is so true because many people will say - Well you know what my worst fear is.

PORTER
It doesn't hurt very much does it though?

FISKE
It hurts a little bit but it's very quick and they're very fine.

PORTER
Have you done any sort of scientific research into that, is it your belief that it works or do you have some data to back that up?

FISKE
It's not scientific research but it's data that was collected objectively, looking at whether it works and it's worked tremendously well and it's also worked for other people who've tried the technique, either because they've been trained in acupuncture or a dentist who's got an acupuncturist in to help them with the technique.
PORTER
But not very widely available I wouldn't imagine?

FISKE
I'm afraid not at the moment.

PORTER
Janice, you're a consultant in special care dentistry, so you're obviously seeing patients with lots of other needs, can you give me some examples?

FISKE
Well we see a whole range of people and they may be people with learning disabilities such as Down's Syndrome or autism. People with complex medical conditions - so they'll perhaps have three, four conditions, so not just somebody who's got diabetes but somebody who has diabetes, profound asthma and maybe heart disease as well. And in the past I've done a lot of work with older people, doing home visiting and carrying out their care at home or in residential homes.

PORTER
As a GP that's an area of obvious interest to mine because if they've got a lot of other things wrong with them, they're in a residential or a nursing home, it's very difficult to get them transported to the dentist. I mean dental care probably goes pretty way down the list.

FISKE
I think it can do and there's been a lot of work to try and move that up the list. One of the things that's going on at the moment is the chief dental officer for England has commissioned a strategic review into the oral healthcare of older people, which should be reporting in August of this year, which will make some recommendations on how PCTs can commission services to fulfil some of those needs.

PORTER

And by PCT you mean primary care trust?

FISKE
I do.

PORTER
And Janice it's presumably very important that we look after the teeth of older people because they are particularly vulnerable.

FISKE
Yes they are. And in residential homes even more so than for old people living in their own homes. And it's particularly important that their oral hygiene is looked after so that they don't lose more teeth.

PORTER
Well talking of lost teeth Janice I want to move on to titanium implants. These are screws placed into the jawbone to act as an anchor for a replacement tooth or crown, or for fixing a clip for a denture plate - and they're an increasingly common solution for people with missing teeth - whatever the cause. And you don't need to go into hospital to have them fitted - the whole procedure can now be done in less than a day in a high street surgery, although it pays to go more slowly in some cases, as I discovered when I spoke to Richard Palmer, who's professor of implant dentistry at King's College.

PALMER
If you want to be as sure as you possibly can that the implant is going to work you would insert it into the jaw and you would leave it unloaded, unused, for a period of about three months. And if you do that then the bone is almost certainly going to join on to the implant and form a very firm union. If you do try to use it earlier there is a risk - and it is a real risk - that the implant maybe wiggled around a little bit and then it won't form a union and will unscrew.

PORTER
But presumably many of the patients who are coming forward for this sort of surgery are doing so because they want a better cosmetic appearance and I suppose therefore the quicker they can get the implant - they don't really want to go without a tooth for three months do they.

PALMER
Well you almost give the patient a temporary tooth while they're waiting for that implant to heal and to be functional. I think it's very important, if you are going to provide something that you expect to last very many years and perhaps the lifetime of the patient a wait of a few weeks really is I think fairly insignificant compared with the long term use of that implant.

PORTER
You talk about them lasting a lifetime, how do we know that because this is relatively recent technology?

PALMER
The evidence really comes from the earliest studies using the titanium implants that have really been in use for something like 30 years and then we would take further evidence of patients perhaps that we've treated over the past 10 years and we could show that the implants have been very stable, there's no reason why they shouldn't carry on functioning. If it comes to the part that goes on top it's quite possible that that could wear a little bit and you would need to replace the crown on top.

PORTER
Why do people have teeth missing - is this something that's happening with ageing or is it as a result of trauma?

PALMER
The types of patients we treat within the health service tend to be people who either have teeth that failed to develop, then there's a group of patients who do suffer from trauma and particularly that suffer from trauma where they may lose one or two teeth but all the rest of the teeth are absolutely in perfect health. And then patients who have no teeth whatsoever and they have tremendous difficulty in wearing dentures because their jaw bones don't really provide a good foundation for dentures.

PORTER
How do implants help someone with dentures then?

PALMER
You can either put in perhaps two to four implants which have an attachment on them so that the denture clicks on to these attachments, so the denture is still removable but the implants help to stabilise the denture in functioning. The alternative is that you place in a number of implants and then they are used to support a rather large bridge which may replace 10 or 12 teeth and this bridge then is fixed in the mouth.

PORTER
What about eligibility for this sort of treatment under the NHS? Let's start with the dentures, it sounds ideal - you sort of click them in position and take them out at the end of the day. Why aren't more people coming forward for that sort of treatment?

PALMER
Sometimes it's ignorance, people are just not aware that the treatment is available, or that some of them do not have a problem with their dentures anyway. If you take people in the age group of say 65-75 years of age about one-third of them will have no teeth, now quite a lot of those people probably cope quite well with their dentures but the longer they've worn their dentures the more likely it is that their jaws gradually resorb away and particularly in the lower jaw where it becomes flatter and flatter it forms a very poor basis for the denture. It's been suggested that the majority of those people would benefit from having implants if they knew about them or if they were available to them within the healthcare system.

PORTER
Talking of availability I suppose it's a matter of price - how much are we talking about to replace a single tooth with an implant?

PALMER
Well I would say that the average price would probably be about £2,000 and could vary between £1,500 say and £2,500.

PORTER
And if I was to lose one of my front teeth, for instance, what would determine whether I had to pay for that privately or whether I'd be eligible for treatment by a centre like yours under the NHS?

PALMER
The number of people that are treated on the NHS is relatively few. So that if your front tooth never developed we would consider you for treatment under the NHS or perhaps if you had some trauma which was obviously no fault of your own and you had no other way of claiming damages through that trauma and the rest of your teeth were extremely healthy, we would consider that an implant would be such a good option and perhaps we could then treat you under the NHS.

PORTER
And for eligibility for fixing dental plates, presumably that's where your normal NHS dentist has tried all sorts of other things and cannot get a decent fix for you?

PALMER
That's right. A lot of people who have no lower teeth would certainly benefit from implants but it's up to their primary care trust whether they fund implants for their patients.

PORTER
You mentioned that these implants you would hope would last a lifetime in many cases, what sort of things can go wrong?

PALMER
They have to be looked after a little bit like your own teeth. So therefore if they were neglected they could get inflammation around the implant and they could even get bone loss around the implant and eventually the implant could succumb to disease, really quite like a tooth does. Of course they can't get dental decay, so you don't have a problem there, but the other thing that could happen is that they could be subject to wear and tear, so you need to look after it in that sort of respect.

PORTER
Because there is a growing trend for dental health tourism, where people are going abroad and having procedures like this done where they can have it done slightly cheaper than they can in this country. Does that matter, if they're then coming back here and they have a problem presumably it's important that the dentist here is familiar with that technology?

PALMER
I think it matters a great deal because we do see people coming back from abroad with implants and things go wrong and then they expect us to try to put it right and we find it almost impossible, we don't know the make of the implant, we don't know the design of the implant, we have no spare parts for it and they really have to go back to the people that provided it, I think, to get the thing serviced. So I wouldn't recommend going abroad for having dental implants.

PORTER
Professor Richard Palmer.

Janice, we've talked a lot about teeth but there's more to the mouth than teeth, what sort of other oral problems do you see in your patients?

FISKE
There are two things that come immediately to mind, one is dry mouth, which is often a side effect of medication that they're on for general health reasons and that doesn't just affect the teeth, although it can lead to dental decay, but it also affects quality of life, the enjoyment of food - being able to taste ...

PORTER
It's not very nice is it.

FISKE
No.

PORTER
So say we can't take them off the medicines that are causing the problem, what do you advise as a dentist?

FISKE
Mainly that they sip water to try and keep the mouth comfortable. There are other things available like artificial salivas but they tend not to work hugely well.

PORTER
You said two problems - the other?

FISKE
I did. The other one is oral cancer which is more common in older people than in other age groups. So it's important that people remember to look round their mouth.

PORTER
And that's something a dentist would do of course as part of a routine check up, although not many people will be aware that they're looking. What should people be on the look out for, what are the suspicious signs of a mouth cancer?

FISKE
An ulcer would normally look like a red area that had a white or yellow induration in the centre of it and if they spot an ulcer that's painless and it's there for two weeks then they should alert their dentist.

PORTER
So a painless ulcer that doesn't heal within two weeks.

Janice Fiske, thank you very much.

Next week's programme is all about first aid - but with a difference - mental health emergencies - what you should do when confronted with someone having a panic attack or threatening suicide. And first aid for parents - we'll be finding out about the Lifesaver course for babies and children.


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