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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme no. 2 - Cosmetic Dentistry
RADIO 4
THURSDAY 19TH JUNE 2008 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: MARTIN FALLOWFIELD
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
MYERS
Hello. If your teeth are really bad then you may have no option but to invest in treatment, whether it's dentures to replace missing teeth, braces to straighten crooked ones or crowns or caps for those that are broken or chipped. But what about the optional extras that are widely advertised nowadays to enhance your smile? Porcelain veneers to resurface your teeth can now be made so thin and translucent that they're being described as contact lenses for the mouth. As for teeth whitening - well just how bright do you want your smile to be?
In search of the perfect smile, is it just possible that we could be making things worse? How much pain is involved for how much gain, especially if you hate the dentist?
Well with me to answer your questions about cosmetic dentistry today is Martin Fallowfield, he's a spokesman for the British Dental Association and is himself a dentist with a special interest in cosmetic dentistry practising in Peterborough.
And our first caller is on the line waiting for us - Melanie Glen-West - and wondering about her choice of treatment. Tell us about your teeth and why you're wondering whether cosmetic dentistry might help you Melanie.
GLEN-WEST
Hi Barbara.
MYERS
Hi.
GLEN-WEST
I'm currently looking at the two routes to go with my teeth at the moment because I really would like to improve them.
MYERS
What's wrong with them?
GLEN-WEST
Basically they're not straight - they're kind of oversized I feel - and they're not white, they're kind of yellow. So when you see all the kind of styles in the press and nice white straight teeth it's something that I aspire to.
MYERS
There's a lot to live up to these days, haven't we, yes okay.
GLEN-WEST
Absolutely. So I'm looking at the two routes at the moment. The first which is keeping my own teeth and then using whitening and brace work to try and straighten and correct them and the second route is veneers. My concern is with veneers that you have to in effect destroy your own teeth underneath and whether that's actually advisable to do in the long term.
MYERS
Right, well you've come on to the right programme to ask the right person because Martin Fallowfield is a specialist in this subject. How would you advise Melanie if she was in your dentist chair?
FALLOWFIELD
Hi Melanie. I'm sure you've chattered through some of these options with your dentist. And if not then I'd encourage you to do that. I think most of us who work in the field would always favour orthodontics and whitening as a route forwards. We like to preserve as much of your teeth as possible. And that would always be preferable. The difficulty I suppose with it is that whilst in America adult orthodontics is quite common and it wouldn't be unusual to see an adult wearing tram track type braces it's perhaps slightly more unusual here and in my experience patients will often choose the faster route of either veneering or bonding, coupled with whitening because they want a quicker solution. Where you were looking at probably 18 months to two years for adult ortho and then coupled with that - but you will always - almost always - get the better result by moving the teeth and keeping your own natural teeth and whitening them.
MYERS
Martin, I have seen or heard about invisible braces and of course you're right the tram track look isn't a great look at any age and a lot of people are leading busy lives, they really just feel that they can't quite go there so what about these invisible braces?
FALLOWFIELD
There are a couple of potential solutions for hiding braces, one of which is to put the brackets and the wires on the inside of the teeth, that's a growing technique, it's not available everywhere but certainly if you discuss it with your dentist you'd be able to look at referral to somebody who's doing that. And the other one is that - the commonest one is this series of invisible little splints that go other the teeth and they're made sequentially to move the teeth a little bit at a time. They're not suitable for everybody and major discrepancies in the positions of the teeth are a bit tricky with that technique. But that's a lovely technique but very expensive in terms of laboratory work because you have to have up to 20 or 30 these little splints made, so quite a lot of lab work involved in that.
MYERS
But the baseline really for you is where you can, if you can, get the teeth straightened so that you keep your own teeth and that's really your kind of permanent solution whatever it might take to achieve that?
FALLOWFIELD
I think so, I think that's what most of us would want.
MYERS
Okay Melanie, I hope - I hope that's been of some help but of course stay on and listen to the rest of the programme because we will be talking more about veneers, which as you have said, could be another option. And Sally in fact has joined us from Colchester, wants to talk about veneers. Is this something you're considering Sally?
SALLY
Yes it is. I was getting quite interested in them because one of my front teeth has started to get quite discoloured and bluish since I had root canal treatment about 20 years ago. And I was getting quite keen and mentioned it to a couple of friends who told me an absolute horror story about somebody who'd had the work and got an infection and had to have a lot of their gum cut away to treat the infection, which sounded horrible and really put me off the whole idea.
MYERS
Certainly it gives you pause for thought.
SALLY
So I wondered how risky it was.
MYERS
Okay and just to be clear then - the veneers of course you're talking, Sally, about using those to cover up a discoloured tooth that's dead effectively and of course ...
SALLY
Yes, one tooth that's gone rather blue grey over the years.
MYERS
Right and in Melanie's case if she was to be given veneers it would be about using them to kind of bulk out and to sort of make a sort of front to the teeth so that any crookedness disappeared in that way. But what about this possibility then of infection in the gum as a result of placing veneers Martin?
FALLOWFIELD
Sally, I would want I think to start by reassuring you that the techniques involved in placing veneers or preparing you for veneers are not in themselves going to cause infection, it would be very, very unlikely that that was the cause. You can sometimes get associated problems afterwards if the veneers, for example, are ill fitting or if there was a pre-existing gum condition going on.
MYERS
But placing the veneers doesn't sort of infringe the gum margin then?
FALLOWFIELD
Not at all, well it shouldn't, veneers should be fitted absolutely microscopically - you shouldn't be able to feel them, you certainly shouldn't be able to get to touch them or for them to cause any gum infection around them. There's one thing I wanted to say to Sally though which is about the concept of this one tooth that's gone a bit dark. A lot of dentists would want to talk to you about a process called internal bleaching with that one Sally, where you seal off the root filled bit and actually seal some bleaching agent inside the back of the tooth and bring the colour of that one back. And certainly if you were looking at veneering them or generally whitening them it would be better to try and reduce the difference first by a bit of internal bleaching on that one tooth.
MYERS
Sally, did you know about that - is it something that's been offered?
SALLY
No I didn't, I only know about the veneers because I asked my dentist if he could do something about the tooth and he said well yes he could.
MYERS
Well either ask again about bleaching internally, certainly for one tooth I have seen that done and it is extremely effective I must say. Could I - thanks for that call Sally - but could I move to an e-mail quickly in relation to veneers, there's a chap who wants to remain anonymous, partly I think because he says in his e-mail that he's been a bit vain about his teeth. But he's had some veneers fitted and he's very happy with them, although he said he had difficulty for the first few months saying the letter F, so perhaps they were a little bit thick and bulky and we can deal with that but his real concern - and in fact he's off to the dentist this afternoon which is why he can't join us on the phone - but he says that a veneer has dropped off. Now that's not handy is it.
FALLOWFIELD
It certainly isn't handy and certainly I've come across in my experience people - they do drop off at the most inappropriate times unfortunately. They don't come off that often and I think it's something that you have to be aware of and it's hopefully something that dentists would explain as part of their going through the treatment plan is that occasionally they will come off, usually they can be put back on. What is important though is that the tooth underneath and the veneers themselves are both cleaned up again very efficiently and we use little micro sand blasters to clean both. And then you can bond them back on again. Sometimes, you know, you might have a bad batch of the material or whatever that had gone wrong and you get more than one coming off but usually they stay on.
MYERS
And what about the fears - and I guess one that I would express - the feeling that if you don't need it desperately is there a kind of a way in which you're breaching the integrity of the existing tooth underneath in order to provide a suitable surface for the veneer and then if things go wrong you've rather lost a good tooth possibly?
FALLOWFIELD
No you are absolutely right Barbara, there's a huge number of dentists who are very uncomfortable with cutting into natural enamel. One particular member of one of the universities in London is very keen on preserving enamel and says that we should treat it like diamond. And so he's very anti-cutting into enamel at all. And there are quite a lot of us now who are doing much more of techniques involving bonding, it's similar to the white filling material but there are - there's a much greater range of colours and densities now and we have like a paint by numbers kit and we can slowly build up very natural looking teeth masking staining, masking flecks or whatever and that's a great starter, you can always go on to veneers later with those.
MYERS
So the bonding - you're painting a material on to the tooth?
FALLOWFIELD
Absolutely, it's very, very time consuming to do it, it's very technique sensitive and in fact I was planning - unfortunately it clashed with a family holiday - to go on a course in Italy this summer with sort of the world expert on this and it's just stunning, the results you can get are lovely.
MYERS
So it's beginning to come in, won't be that widely available. But I'm interested in your point - you're saying you're able to even incorporate such things as flecks and lines, in other words making teeth - because when you look at them closely of course they are not dead white, they are not dead straight, they have their own life and vitality and particular sort of unique profile, do they not and that's makes a natural smile?
FALLOWFIELD
Oh absolutely and when we're talking about putting white fillings in back teeth I'm perhaps a little bit of a purist, if you like, in terms of aesthetics and I like to draw the little brown lines in because most people who have natural teeth have those fissures, slightly stained, and we try and put those back in now because we're just trying to get the natural look.
MYERS
There's an artist at work. Well I wonder what you might be able to offer Diane who's in West Cumbria and is waiting I know to speak to us about her daughter's teeth which are discoloured, I think due to fluoride. So how discoloured Diane and where are you up to with trying to seek some sort of remedy for this?
DIANE
Hello Barbara.
MYERS
Hi there.
DIANE
Yeah, my daughter's teeth are quite badly discoloured. They're pitted on the surface and they have white flecking and brown marks and they've caused her a great deal of self consciousness over the years. She actually has the worst ones veneered unfortunately they now need replacing, which is going to cost her a lot of money but she also has other teeth at the front of her mouth and I believe there might - there might be other alternatives and I think those have just been discussed to covering that. So firstly I'm wondering - well my first query is actually why add fluoride to the water when it's obviously causing further dental problems because there are a lot of people in our area who show signs of dental fluorosis? And secondly yes what can she do about it?
MYERS
I'm taking it your daughter's not a child anymore - grown up daughter.
DIANE
No she's an adult now.
MYERS
Yes okay, well I know fluoride is quite a big debate which we haven't got time for here but if we took the idea of these kind of discolorations in this case caused by that and veneers having been tried etc., I mean is there anything you can do for what are mottled discoloured because just whitening them would clearly - I'm imagining - wouldn't make all the difference you would need?
FALLOWFIELD
Yeah I think we should perhaps touch on Diane's point about fluoridation and it's all dentists or virtually all dentists would be in support of it, just because of the beneficial effects. I accept fully that occasionally you see fluorosis, it tends to be where children ate toothpaste off the brush in addition to - the fluoride in the water will almost never cause fluorosis, not in this country, we don't see levels that are high enough.
MYERS
And this really has helped with dental decay?
FALLOWFIELD
Oh absolutely, I mean the misery of a child in toothache all night and in fluoridated areas they don't see those - there's nothing more traumatic than seeing a child with an abscess. So I think yes it's unfortunate - the effect of fluorosis - and that's what led in fact to this - the development of these children's toothpastes which have much lower fluoride in for the under sixes ....
MYERS
So that they're not getting a double dose?
FALLOWFIELD
They're not ingesting that fluoride, so it's a very low fluoride in the children's. And again for advice for mums out there - no more than a pea shaped blob of toothpaste on the kids' toothbrushes when you're cleaning their teeth.
MYERS
Well a bit late for Diane's daughter of course.
FALLOWFIELD
Indeed. In terms of this fluorosis and the mottling that you get with it and the pitting then yes there are solutions other than full veneers. One technique, if the staining or the little flecks and things are very close to the surface, is a technique called micro abrasion where we use a very weak acid solution and pumice and polish those areas away because often there's natural tooth colour underneath. The other one is to just disc those areas away and use the same technique we've just been talking about - rather than bonding the plastics over the whole tooth just to fill in the little areas. And because of this range of colours that we've got now we can almost always match, so that you can then polish it back to a gloss surface. In - a few years ago we just didn't have the range of the densities of the fillings because they were designed to go into a tooth and take colour from what's around them but now we have the ability to mask as well, we have denser ones available. So those are available. And yes indeed where it's very marked and very mottled then veneers are still there as a solution.
MYERS
So find really a specialist, obviously, someone who's up to date with all the latest treatments and obviously I dare say be prepared to spend the necessary money, I mean of course it's going to cost but arguably these are new techniques, you have laboratories and so on and so forth ....
FALLOWFIELD
I think unlike in most of healthcare when it's aesthetic related then it's going to be a private option, yeah, I think so.
MYERS
Hope that's helpful Diane. We'll go to Southend now, to Liz who's waiting and wants some advice about whitening, we've touched on it. What are your concerns around the possibility of having your teeth whitened Liz?
LIZ
Oh hello.
MYERS
Hello.
LIZ
I'd really like to have my teeth whitened, they're not terribly discoloured, they're slightly grey, but my two upper front teeth - incisors - one is a porcelain crown and the other is a veneer and they're both about sort of 10 years old and now the crown looks very white compared to the rest of my teeth and the veneer has sort of faded a little bit as well.
MYERS
So it's a bit of a multi-coloured smile.
LIZ
Yeah, it's not terrible uneven it's just that over the years the crown as has become more and more prominent. I mean the reason I had the veneers was because the crown stuck out a little bit more than the front tooth next to it, so it was to kind of thicken up - to bring my two front teeth so that they were move even.
MYERS
So it's a dynamically changing landscape in your mouth, by the sounds of it, yes okay well let's see what Martin has to say.
FALLOWFIELD
Hello Liz.
LIZ
Hello.
FALLOWFIELD
It's interesting that you should raise this point about the two front ones because actually there are some cosmetic dentists who will charge almost double the fee for a single central because it's almost the most difficult thing in the world to match, just to do that one front tooth on its own. So it's much easier to do the pair because visually people will pick up less if the colour change is either side of those but when it's in the mid-line getting the colour right there is very difficult. Now to come on to your point about whitening - whitening will bring the other ones back up perhaps to match the colour of your existing restorations. The thing to be very aware of with whitening is that it isn't going to change the colour of existing restorations at all, so that's crowns, veneers, bridge work or even white fillings are not really going to change colour. And so it would be better to get the whitening done and then look at those restorations and see how happy you are with them afterwards and then take a view on whether you're going to replace those as well once you've had them whitened. There are two techniques for whitening and I'm sure your dentist will have been through this with you. There's the technique where you have little custom vinyl trays made and then wear them for a minimum of an hour a day - it can be during the day or some dentists advocate wearing them at night. And using solutions - various strength solutions are out there - don't go for more than 10% - the evidence from America is that 10% of carbamide peroxide is the optimum. And there's not a great deal of gain to be had from using stronger solutions and in fact they're more - perhaps more likely to cause sensitivity if there is any. And the other technique, of course, is the light activated ones that you will have seen where the whitening is carried out in surgery over the course of an hour or two hours.
MYERS
Okay and the light really speeds the whole process up?
FALLOWFIELD
With some of the techniques it does and it's difficult because there's one - there's one technique which is a bit more expensive than all the others and certainly those of us who are using that technique are happier with that. The evidence suggests that some of the others it's just a light shining on the veneers and it's done instantly in the surgery.
MYERS
And if I can ask on Liz's behalf what about the alternative - another option - which is you can see tooth whitening systems advertised and sold across the counter, perfectly respectable chemist shops sell these things these days, do they have any place in this story?
FALLOWFIELD
Okay. I'd avoid them. I would say that, of course I would say that wouldn't I as a dentist. But actually certainly the things that are being sold over the counter in this country are probably not effective because they're not allowed to sell the same techniques as they can sell in America. And so the constituents are not the same as being used by a dentist ...
MYERS
Okay the advice is save up and go to a dentist for your teeth whitening?
FALLOWFIELD
Indeed. And above all avoid the salon ones because they're using - some of them of them are using some very scary chemicals like chlorine dioxide which is an acid, it's the stuff used to purify swimming pools, avoid it.
MYERS
So it is a marketplace, caveat emptor, try and get a decent dentist to give you the right kind of steer. But Margaret joins us, she's in London, and has got another alternative. Whitening strips - is that the thing Margaret?
MARGARET
My dentist gave me the website advert so I could get whitening strips from the internet but they weren't very much help and then I moved and my new dentist says that these strips are not licensed in the UK, which is why my dentist didn't give them to me himself.
MYERS
Okay let's get the top line advice really on whitening strips which you can apparently get on the internet.
FALLOWFIELD
Absolutely, yes they - your second dentist was absolutely right - they're not licensed for use in the UK. The way that they work is it's a bit like a very thin layer of bubble wrap and each of the bubbles contains the bleaching agent and you pop them on the teeth with the bubbles on the inside and run your finger across and you get that nice satisfying feeling that you get from bubble wrap as each of them pops. I did bring some personally back from the States when we were there and my staff nicked them all, so to speak, and actually they were quite effective and - but they're not available and not licensed here yet.
MYERS
Okay, again buyer beware in that case. Thank you very much. We'll go to Pam Hancock in Oxfordshire, talking about black fillings. What's your story about black or I suppose the sort of silvery black fillings, the sort of thing that I've got?
HANCOCK
Well I had most of my fillings done when I was in my late teens and early 20s and I had a mouthful of them because they used to fill sometimes just for - to stop the rot didn't they really.
MYERS
Yeah, they were very liberal with fillings when we were young.
HANCOCK
And I hated them, for years I've hated them and this year I finally plucked up the courage to go to - ask my dentist about having white fillings and over this last six months I've had all my fillings re-done, had them all done white and I just think it's great.
MYERS
Well that sounds extremely good. I mean - so any problems at all with this Martin or should we on Pam's advice rush and get all these nasty black fillings out and get white ones?
FALLOWFIELD
What a great story Pam and lovely to hear that a dentist made somebody very happy. We hear so many negative stories about relationships with dentists and it is an area where we can make significant changes to people's lives. And the only caveat I would put on that - and I think most dentists would have the same - there are some dentists who are really uncomfortable about putting white fillings in back teeth and that's because it's a very much technique sensitive area than putting the black ones in. The black ones will tend - if they start to leak, they corrode and re-seal the hole. The white ones have to be absolutely bonded all the way around the edges and mustn't leak and so they take a bit longer to do properly but fantastic technique, absolutely.
MYERS
And we've got another quick call, I think some - another satisfied customer. Liz tell us about your teeth?
LIZ
Oh hi. Yeah when I was very young and at university I was very, very ill with anorexia and bulimia and as the years have gone by my teeth have obviously shown the effects and I've had terrible trouble with them. But anyway now I'm retired and I've actually used some of my savings and gone out and got my teeth sorted and it's the best thing I ever did, it's the first time in years I've smiled really, really confidently, I'm really happy with them. And although I did save up it was worth every penny.
MYERS
Liz thank you, that's really good, you can smile, you made us smile with that very nice final call today, thanks for ringing in. And thanks very much to everyone who has called and e-mailed today. And thank you Martin Fallowfield for all the answers. If you missed anything in today's programme listen again to the whole programme if you wish by going to the 大象传媒 website, you follow the trail to Check Up. You can, of course, also download the programme as a podcast. If you'd prefer to speak to someone about sources of information then you can call this number: 0800 044 044.
And I hope you'll join me again at the same time next Thursday, that's 3 o'clock, when we'll be dealing with trying to win the battle against middle aged spread.
ENDS
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