BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES 7. - Teeth
RADIO 4
TUESDAY 18/05/04 2100-2130
PRESENTER: MARK PORTER
REPORTER: LESLEY HILTON
CONTRIBUTORS: MICHAEL ESCUDIER
TIM DUCKWORTH
MONTY DUGGAL
JONATHAN PORTNER
DAIRE BREHEN
PRODUCER: HELEN SHARP
NOT CHECKED AS BROADCAST
PORTER
Today's programme is all about the mouth and how to look after it.
I'll be finding out why some children are having their milk teeth removed?
ROBIN
She pulled them out using a pair of pliers and that's when it made a lot of noise. I didn't actually feel anything when it was happening, I just heard lots of cracking.
PORTER
I'll be discovering how to tell the difference between a troublesome mouth ulcer and a potentially life threatening cancer.
BREHEN
It was decided that major surgery would be required to the cheek, to the side of the face, to remove basically the inside of the cheek. And I was prepared for the fact that this might involve removing the side of my face.
PORTER
And I'll be finding out how the state of your gums could predict your odds of having a heart attack or stroke.
My guest today is Michael Escudier, he's a consultant in oral medicine at Guy's Hospital in London.
Michael, what happens to a tooth to cause the sort of damage that needs a filling?
ESCUDIER
Well this usually relates in the vast majority of patients to the ingestion of sugar, which is then fermented by various bacteria and so it's a bacterial breakdown …
PORTER
And these are the bacteria that normally live in the mouth?
ESCUDIER
Indeed.
PORTER
And that actually dissolves away the tooth?
ESCUDIER
They produce acids which dissolve away the tooth structure.
PORTER
If you need a filling does it matter what sort of filling you have? There's been a bit of controversy, I know, in the past about mercury contained in amalgam, amalgam being the sort of silvery black ones that most of us have, there's been some concerns in the press that mercury can leach out of these fillings and cause problems. What's the latest evidence?
ESCUDIER
Well, in terms of which type of filling you have really you need to be guided by your general dental practitioner because it will vary on the amount of tooth substance which is being lost and the particular site within your mouth because there may well be aesthetic or functional considerations to be taken on board. I personally have amalgam restorations, which I've had for many years and which I'm quite happy to have residing in my mouth.
PORTER
Is there any evidence that the mercury does leach out and cause problems that you know of?
ESCUDIER
There's no hard evidence that they do significant harm at the present time.
PORTER
And presumably having them drilled out could cause more problems than it solves.
ESCUDIER
Indeed in actually drilling them out you actually do raise your mercury levels, both within your blood and then urine immediately afterwards. But there is a small sub-group of people who are sensitive to amalgam or sensitive to the mercury within amalgam or indeed can be sensitive to other common dental filling materials, such as maybe involved in metal ceramic crowns - the traditional crowns you have from your dentist - now those people can be tested and indeed if we find that someone's sensitive to any of those compounds we would actually advise that they're not put in and indeed in some instances, particularly if they'd led to oral manifestations, we would actually advise that those types of restorations are removed and an alternative placed.
PORTER
Well before we all get our adult teeth we have to grow and lose a set of 20 baby or milk teeth. The first of these normally appear at around six months but some children may be born with them - Napoleon evidently came out of the womb sporting a set of front incisors one historian described as "capable of gnawing upon a hard crust". Most children have a full set by their third birthday and have lost them all again by their 12th. But what happens if they don't fall out? Robin had to have his last four removed as Lesley Hilton discovered.
ROBIN
I just sat down in the chair and the dentist gave me some mouthwash which made my mouth go partially numb, and then she gave me a couple of injections which made it go fully numb and then she just yanked the teeth out. She pulled them out using a pair of pliers and that's when it made a lot of noise.
PORTER
Robin is 13. On a recent visit to the dentist he was told his second teeth weren't coming through fast enough and that he should have his last four milk teeth removed. But what function do our milk teeth fulfil? Tim Duckworth has a dental practice in Leeds.
DUCKWORTH
Milk teeth are every bit as valuable as adult teeth in terms of what do they achieve. Their main function is chewing our diet - feeding ourselves, therefore we need functional healthy mouths no matter what age we are. The problem with milk teeth is that they grow quite rapidly underneath the gums prior to coming into the mouth. They are not very dense and they are very prone to disease. Dental decay is quite prevalent in society as we all know. Milk teeth can go decayed very, very quickly indeed.
ACTUALITY
Now what I want you to do is …
HILTON
Milk teeth are usually all gone by the age of about 12 but the different teeth come out at different times, as Monty Duggal, Professor of Child Dental Health at the Leeds Dental Institute explains.
ACTUALITY
Let's have a quick look sweetheart.
DUGGAL
The first milk teeth to come out are the lower front ones and the upper front ones and they usually fall out by the age of about six, between six and eight. The back molars, the set of baby molars, they don't fall out sometimes till the age of 12 and in some cases they could stay till the age of 13 and 14. So the molars start to fall out by the age of about - between nine and 10 and it's not complete - the process is not completed till the age of about 12 in most children and that is about the normal time.
HILTON
Robin wasn't particularly worried about having his teeth out but for his mother, Jenny, it brought back unpleasant memories.
JENNY
When it was suggested that he had some teeth removed I wasn't terribly keen on the idea because I had teeth removed quite a while ago when I was his age and it wasn't a particularly pleasant process then. But obviously it didn't feel as bad for Robin as it did for me and it was all done very quickly and very efficiently. Until the anaesthetic wore off he didn't appear to be having any problems at all with it, it didn't bleed very much, anything like that.
HILTON
But why do we need to remove milk teeth at all if there isn't a pressing medical reason? If they're retained into the teenage years will they cause damage to the second teeth? Tim Duckworth.
DUCKWORTH
Retained milk teeth won't necessarily damage the adult teeth. If the retained tooth is diseased and deteriorating there's a possibility of infection getting into the gums and at critical times when teeth are developing damage can occur but again it's - hopefully the child in question will have sought treatment prior to that occurring and it will be managed.
HILTON
Some dentists disagree over whether milk teeth should be removed or not after a certain age. Tim Duckworth believes that it depends on what permanent teeth are in place.
DUCKWORTH
Most milk teeth will eventually drop out no matter what. This assumes that there is a permanent adult tooth that will be in succession to that milk tooth. There are occasions when milk teeth have no permanent successor and therefore will not drop out under any circumstances. Is it best to remove them? I will say yes to that, I believe that retained milk teeth will eventually wear out in the adult dentition if left behind and it is easier to manage the outcome of that in the early years than it is in the latter years.
HILTON
If milk teeth aren't taken out and don't drop out by themselves what happens to them? Can they stay in the mouth for ever? Monty Duggal.
DUGGAL
It's fairly common. What happens is that the way that baby teeth fall out is because your second teeth which are developing underneath eat away the root, they resorb, we call them, the root of the baby tooth gets eaten out gradually as the second tooth pushes its way into the mouth. In some children the second teeth are missing - it's called hypodonture in scientific terms - and if your second tooth is missing then the baby tooth root will not resorb and those teeth are retained, we call them retained primary teeth, they're retained in the mouth in some cases till the age of 40 or 50 because the roots never got eaten away.
HILTON
Apart from the usual pain when the anaesthetic wore off Robin had no problems having his teeth out. So are he and his mother relieved that he had it done and what happens next?
ROBIN
I just wait for six months for the new teeth to come through. Then I go to the orthodontist again and he'll tell me whether I need a brace or not.
JENNY
I'm relieved they're out and that the new teeth are coming through. And if he does need a brace, I think, as he says, sooner rather than later - a brace at 13 won't be the same as having a brace when you're 15.
PORTER
Robin's mother Jenny talking to Lesley Hilton about her son's prospects of needing braces.
Michael - lots of my daughters' teenage friends, including both my daughters incidentally, have braces. They're much more common than they used to be aren't they?
ESCUDIER
Yeah that's certainly the finding I think and one thing that takes account of that is the evolutionary change - we're definitely developing smaller jaws and there's also the fact that our diet is much softer than it once was and as a result of that there's less wearing of the interproximal area of the teeth, in other words the area between each adjacent tooth, which used to take up or take away a little of the tooth structure and give a bit more room within the mouth. So as a result of that we're now seeing greater levels of crowding, which is what you then see when patients seek the orthodontist's opinion for the slightly irregular teeth.
PORTER
And we're not so aesthetically tolerant are we, I mean that's what worries most people - when they look at - compare the average American's teeth, historically 20 years ago they were like piano keys compared to the average, in fact the Americans call them English teeth don't they, slightly wobbly smile.
ESCUDIER
I mean there's no doubt that there are a number of patients who require orthodontic treatment for functional reasons so that they can chew adequately and also so that they can avoid jaw joint problems. But as you rightly say the vast majority of orthodontics now is done really for aesthetics. Principally as we've become much less tolerant of any form of irregularity and principally driven by the media and what people see on the television.
PORTER
How are braces actually working because they move the tooth and its root completely just by applying pressure or is it more complicated than that?
ESCUDIER
Simplistically yes you can apply pressure to a tooth and if you apply pressure to the tooth the side that's being pushed away will actually exert pressure on the bone and if you exert pressure on bone it will actually resorb, so it'll go away and the tooth can then move into that area and bone will be laid down behind, similarly where there's a lack of pressure. There's a difference between the two different types of orthodontic appliance that you can use in this respect however. If you use a removable appliance - a brace - where you have the piece of acrylic linking the wires that tips teeth rather than move them bodily. If you have the train tracks - as people colloquially call them - then those can actually move a tooth in all three dimensions and move it bodily.
PORTER
And how - you can do that at any stage, I mean I saw a picture recently of Tom Cruise wearing some form of brace, presumably adults, if they weren't happy with their cosmetic appearance, could have braces as well?
ESCUDIER
Indeed, as you've rightly alluded to a significant number of celebrities and adults indeed throughout all walks of life are increasingly seeking orthodontic intervention. They tend to be more conscious even than the younger children regarding the aesthetics of the braces themselves and there are ways of dealing with that. Certainly you can have ceramic brackets, as opposed to metal brackets and you can also use a particular type of orthodontic treatment called invisaligne, which has see through gum blocks effectively, or rather gum shields and they are a sequence of them which will slowly but surely move the teeth to the new position.
PORTER
Because you can end up wearing these for a couple of years often aren't you.
ESCUDIER
Most of them will take 18 months to two years and then there will be a period of retention.
PORTER
Now in this day of - it's getting very difficult to see an NHS dentist. This morning I rang up the 10 closest practices to where I live, I live in Gloucester, and the first nine refused to see me as an NHS patient for a routine check, that was not for emergency, the tenth said yes but not until November and that was 2005. So there's a big problem in primary care in NHS dentistry but an awful lot of these people are having their braces done on the NHS, how do hospitals and orthodontic departments decide whether people should be paying for this which is often a cosmetic procedure?
ESCUDIER
Indeed. Certainly within the hospital service there's an assessment which is based on rigid criteria and it's a dentist's perspective of whether you do or don't need treatment and it's based on an index of orthodontic treatment need. And so hospitals may well decline to treat you because they don't perceive that your problem is sufficiently significant. In practice that index of orthodontic treatment need may not be quite so rigidly applied.
PORTER
But as a broad rule if you're having the braces because you need it for a functional problem - your bite or whatever - then the NHS will pay?
ESCUDIER
Yes.
PORTER
If it's purely for cosmetic then you're likely to have to pay yourself.
ESCUDIER
More so - yes.
PORTER
Roughly speaking.
You're listening to Case Notes, I'm Dr Mark Porter and my guest is dentist Michael Escudier.
Michael, we've already mentioned diseased teeth, but gums are important too of course aren't they. How can people tell if there gums are in good nick? What are the tell tale signs of gum disease?
ESCUDIER
Well first of all you should get used to what your mouth looks like, it does you no harm to look around it on a regular basis yourself, much as we tell ladies they should examine their breasts and we tell men they should examine their scrotum, all patients should be examining their mouth. If your gums are healthy they should fit, if you like, quite nicely around your teeth and they should look quite nice and pink. Indications that these gums are not as healthy as perhaps they once were would be if they start to become a little more purple or a little more swollen and classically people describe bleeding when brushing. And all of these may be indications that all is not well.
PORTER
If you notice a bit of blood when you spit out afterwards.
ESCUDIER
Indeed.
PORTER
What sort of effects can gum disease have within the mouth?
ESCUDIER
Well the most obvious problem is that your gums and indeed the peridontium or the surrounding tissues and bone that the teeth reside in are the support structures for your teeth. And much as if you took the foundations away from under your house it would fall down, if you take the foundations away from your teeth and they have nothing to reside in they will be lost.
PORTER
And do you see much of that?
ESCUDIER
You still see a significant number of patients who have advanced peridontal or gum disease and a significant number of adults have no teeth.
PORTER
What about the other effects because I've been reading recently in a number of the journals there's increasing interest in a link between the state of your gums and your general health - I was looking a German study recently that was making the claim possibly that there's a link between stroke and gum disease and that if you have gum disease you're up to four times more likely to have a stroke. What do you think of that?
ESCUDIER
The difficulties in these studies are principally that many of the patients who've been recruited are also smokers and so smoking is viewed as very much a confounding factor. Now there are …
PORTER
Because there's a big link between smoking and gum disease as well isn't there.
ESCUDIER
There is a link between smoking and gum disease, smokers definitely have worse gum disease and are predisposed to gum disease and there are a variety of reasons why that's the case. But in addition smoking has a number of direct causative relations with various medical conditions. Now …
PORTER
Like heart disease …
ESCUDIER
Like heart disease and stroke. And so the difficulty is, is it actually the smoking that's causing the problem with both the gums and the heart disease rather than the gums causing the problems with heart disease.
PORTER
And Michael there's been some research in America, hasn't there, looking at the importance of gum disease in pregnant women.
ESCUDIER
There has indeed. That data's not actually been reproduced within some studies in this country however, who actually found that there was no link for the groups that were studied here between pregnancy outcome and maternal gum disease.
PORTER
But the Americans had suggested that there was hadn't they - they thought that there was an increased risk of premature labour was it or …?
ESCUDIER
They had suggested that there were various problems within pregnancy potentially related to that. But in the UK studies the only possible exception has been the risk of late miscarriage or still birth which is a tiny percentage - it's a very rare complication. So in general our studies have not reproduced their findings and it's too early to be able to say that that's a direct causative factor, so we need more research in that particular area before we can say that it's definitely causative.
PORTER
Well it's obviously attracting a lot of interest, what do you think might be the linking factor - let's take smoking out of the equation and assume that that's not what's causing this problem - that there is some link between gum disease, premature labour, heart disease, stroke, I mean how could that be?
ESCUDIER
Well one could potentially envisage a situation where the inflammatory mediators, the chemicals that actually cause the inflammation within the mouth, can obviously leave that site and circulate or could indeed lead to other activation of mechanisms within the body that may affect other sites.
PORTER
So in the case of heart disease and stroke possibly inflaming blood vessels supplying the heart or brain possibly?
ESCUDIER
Potentially.
PORTER
Thanks for now Michael. I want to move on to suspicious ulcers. There are around 3,000 news cases of oral cancer every year in the UK and the first tell tale sign is typically a troublesome ulcer. Dr Jonathan Portner is a dentist in North London with a special interest in oral cancer and Daire Brehen, a broadcaster and barrister who developed cancer on the inside of her cheek - and it all started with a sore that just wouldn't heal.
BREHEN
In 1999 I had gone back to study for the first time in 20 years and I was doing my first set of exams since I graduated and I got a mouth ulcer. I thought it was stress, I've never had a mouth ulcer in my life before. Went to the doctor after a week or so of complaining to my husband and he said yes you're right, it's probably just stress here have some mouthwash, have some cream and it should clear up in a couple of weeks and if it doesn't come back to me. In three weeks it hadn't cleared up, I came back to him and he said probably still stress but to be on the safe side we'll have it biopsied. That was in February, it took until May to get an appointment to see a consultant. It took until June to get a hospital appointment for the biopsy. And then I was supposed to get the results of that in July but the hospital cancelled that appointment and said I wouldn't see them until November. Well I rang up and said I think that might be a bit long for a diagnosis for a potential cancer, even though I wasn't concerned about it at the time, I really didn't think that's what it was. So after a bit of a fuss being kicked up I got my appointment moved back to July and that's when it was diagnosed.
PORTER
Jonathan what are the early tell tale signs that a person might spot themselves that they've got a problem?
PORTNER
It may be something very innocuous such as a small ulcer that doesn't heal within 7 to 10 days or a red patch or a white patch in the tongue, the pallet, inside the cheeks - any of the soft tissues - the lips even.
PORTER
It must be quite easy for somebody to miss a red patch or a white patch somewhere in their mouth but an ulcer you'd think they'd pick up on because they're quite painful.
PORTNER
Yes ulcers are painful but people go to the pharmacy and buy lots of self help remedies and then probably go along to a GP often too late. I'd rather they erred on the side of being more cautious and coming to a dentist earlier on.
PORTER
So you would regard an ulcer that persisted for how long as being suspicious?
PORTNER
I'm concerned if the patient doesn't have recurrent ulceration, if it's a one off ulcer in particular and it bothers them then if it hasn't cleared up within 7 to 10 days I advise my patients to come and see me straightaway.
BREHEN
It was reddy and raw, it was about the size of a five p coin and it was extremely irritating and by the time I was brought into hospital for the biopsy it had got to the point where it was keeping me awake at night and it was extremely painful and at that stage I actually thought I don't care whether it's cancer or not, as long as they can just whip it our and get this pain away.
PORTER
So what do you do if somebody comes to you with a suspicious ulcer?
PORTNER
I would ask the patient how long they'd had the ulcer, take a full history and whether they had any pain, whether it had changed or not and if I didn't like the look of it whilst trying to reassure the patient that it's probably nothing sinister …
PORTER
And most cases won't be will they.
PORTNER
No, the vast majority are not sinister at all but of a certain handful I would say to the patient to be on the safe side we would ideally like a biopsy of that which is to look at it under a microscope and take a little sample.
BREHEN
In July it was diagnosed and I was told that a course of radiotherapy would probably cure it. I did that, it caused a big rawness on the side of my face, it was as if somebody had put an iron on the side of my face. It didn't hurt as such but the inside of mouth became very, very raw and scarred. Came back for a check up, was told everything was fine but a few months later came back for another check up and was told that the radiotherapy hadn't worked at all. And in fact the cancer was back with a vengeance. So at that stage, this was now 2000, the summer of 2000, the cancer had spread, they could give me no indication of why it hadn't responded to radiotherapy - apparently most of these cancers do but mine simply didn't. So then it was decided that major surgery would be required to the cheek, to the side of the face, to remove basically the inside of the cheek. And I was prepared for the fact that this might involve removing the side of my face. I was very fortunate that they didn't have to remove the actual outer coating of the cheek, so although I now have a sunken dimple on one side it wasn't as drastic as we thought.
PORTER
Does dental hygiene make any difference, is it a problem that's more common in people who don't look after their teeth well?
PORTNER
We think so, we think so, the traditional oral cancer patient was the heavy smoker, person that drank quite a lot of alcohol and didn't go to the dentist. Now how each of those risk factors added up is a bit difficult to ascertain but for sure chronic irritation in the mouth, which would include sharp teeth, broken teeth, is likely to cause an ulcer which possibly could change with the other factors.
BREHEN
It gets a sort of stiffness every now and again, I have still got a numbness on the side of the face where the nerves were damaged and the one thing I can't do is eat spicy food. So the Indians are out, most Thai food is out, I must avoid everything that has chilli in it. There are occasionally things that I taste and I absolutely adore them but I pay with this stinging feeling in my mouth. But it's a very, very small price to pay.
PORTER
And what sort of treatment might they be looking at?
PORTNER
Well more often than not it's not cancer and it'll just be local measures that you probably could buy yourself over-the-counter. But if the biopsy shows cells which are cancerous or pre-cancerous then it's going to involve, depending on how deep and whether there's any spread or not, local surgery but it could go, if it's advanced, towards deeper surgery, removal of lymph nodes, removal of, for example, a part of the tongue and it depends on how severe it is.
BREHEN
There are a number of things that people just forget to tell you, there was no help for things like covering up the scarring during radiotherapy, which obviously is very embarrassing and only later did I hear that of course the Red Cross could have helped with camouflage makeup. And there didn't seem to be any assistance for those sort of small practical things that would have made a difference in your life.
PORTER
Daire Brehen who, I'm pleased to say, has had no further trouble since.
Michael, Daire had to wait some time there to get a diagnosis. One thing that has changed since 1999 is the two week rule, isn't it, that if we saw someone suspicious like this doctors and dentists can refer in to clinics like yours and the patient will be seen in two weeks.
ESCUDIER
Absolutely, I mean there's an open door policy in that sense. And we would welcome referrals along those lines and indeed faxes are a much quicker way than the traditional postal system.
PORTER
Now Daire went to her GP there, who is the best first port of call if you've got a mouth problem that's not obviously directly associated with your teeth, like an ulcer?
ESCUDIER
Well dentists are trained to look at all of the oral cavity including the mucus membranes or the cheek and the tonsils et cetera and indeed if you regularly attend your dentist they will be familiar with what your mouth normally looks like. So they're probably the best port of call. But if you don't have a regular dentist then better to see your general medical practitioner and enter the system rather than delay.
PORTER
In the ideal world - you talk about regular dental checks there - in the ideal world how often do you think people should have a general dental check, I know this is a bone of some contention at the moment because the government advisors - the National Institute for Clinical Excellence or NICE - are recommending that it should be variable - up to two years for people with healthy teeth?
ESCUDIER
I think that's right, I think one needs to take a sort of leaf out of the medical book and say can we tailor our recall period to the actual disease activity, so that frequency that you need to attend may vary through your lifetime. The classic example would be the teenager who accesses the tuck shop for the time and gets a lot of decay and may well need to go more regularly to just make sure that they're dietary advice is being heeded etc. and as you get older you may need to go less for a period of time or you may have some peridontal problems, as we've already spoken of, and they need to be addressed fairly frequently for a period of time.
PORTER
Looking at - you mentioned decay there - we talked about the effect of bacteria and sugars and things but there's also acids in our diet and mentioned fizzy drinks there, that's quite a problem for our teeth.
ESCUDIER
Fizzy drinks can be a significant problem, carbonated drinks are quite acidic and in susceptible individuals as little as one can or one bottle per day can lead to quite significant, what's called, tooth surface loss - loss of the enamel.
PORTER
Basically dissolving the enamel.
ESCUDIER
Exactly so - acid erosion. And you see that quite often in teenagers but you can also see it even in adults if they drink particular drinks - some lagers, for example, are quite acidic and can lead to loss of tooth surface.
PORTER
What about tooth brushing - the electric versus manual debate - what's the latest thinking on that?
ESCUDIER
Well there's a collaboration called the Cochrane Collaboration who look at evidence based studies and they've actually come down to say that electric toothbrushes, particularly rotating oscillating electric toothbrushes, are superior to the good old fashioned manual toothbrushing.
PORTER
So we should be using - and that's better for both the teeth and the gums presumably.
ESCUDIER
Better for both.
PORTER
What about pushing too hard, that's a problem I often see in practice - people who've got gum recession from brushing their teeth too hard, because that's irreversible isn't it once you've got that?
ESCUDIER
If you've had gum recession without having some form of surgical intervention to put back bits of gum it's effectively what's gone is gone and that recession may just be soft tissue recession - meaning the gum's gone back - but it may actually be an indication that you've also lost bony support in those areas. Again the electric toothbrushes are effectively designed to actually administer the correct pressure level.
PORTER
Michael, that's all we have time for, thank you very much.
Next week's programme is all about vaccines - I'll be finding out about research into a vaccine that could help smokers kick the habit and, more controversially, stop children ever taking it up. I'll also be discovering how close we are to a vaccine for HIV/AIDS and how immunisation could soon help people who are allergic to their pets - particularly cats.
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