I Hate the Dentist!: (But I Hate Toothache More)

By Tim Coates

Why is an electric toothbrush better than a manual? If you brush after snacking will you still get decay? Is fluoride bad for you? Why can’t you find an NHS dentist?

If these are questions you often ask yourself, this is the book for you! I Hate the Dentist! (But I Hate Toothache More) covers all facets of oral health, when and how things can go wrong and what individuals can do to keep their mouths healthy. It also delves into the various treatments and services offered by dentists and the relationship between dentistry and the NHS, a hot topic in the ongoing tense political climate, whilst dispelling some of the many myths surrounding the industry as a whole.

Although written by a dentist, the book breaks these complex subjects into accessible chapters, using everyday language that can be understood by any reader with no previous knowledge of dentistry. Learn tips on how to alleviate tooth pain at home and use oral health strategies that can keep tooth problems at bay for years. A valuable resource for dental students or anyone thinking of a career in dentistry, anyone picking up this book will be sure to learn everything they'd ever think to ask and keep their smiles bright for years to come.

• Language: English
• Publisher: Troubador Publishing Ltd
• Release date: Jul 28, 2023
• ISBN: 9781805146179

Tim Coates

A former bookseller, Tim Coates is the editor and publisher of Uncovered Editions, a series of historic official papers from the archive of the British and American governments. This is his first book for Bloomsbury.

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Copyright © 2023 Tim Coates

The moral right of the author has been asserted.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.

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ISBN 9781805146179

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A catalogue record for this book is available from the British Library.

Matador® is an imprint of Troubador Publishing Ltd

To the memory of my parents Cecil and Mary, my wife Cathy and my sons Mike and Matt; My past, present and future.

Contents

Introduction

The idea for this book came to me when I realised how often my patients kept asking the same questions over and over again during the course of my daily work as a dentist. These were not particularly complicated questions, but they were questions, the answers to which I felt should be made available to the general public, because that knowledge could help everyone look after their teeth and gums better. There also seemed to be some glaring gaps and misapprehensions held by many people, which I felt also needed to be explained and made clear.

There are a handful of easy-to-follow golden rules that, if followed faithfully, will reduce gum and tooth issues to zero for most people. These became clear to me as I trained to become a dentist twenty-two years ago. I myself follow these golden rules and I haven’t needed a filling or suffered from inflamed gums to date.

I also wanted to highlight the value dentistry adds to our oral and general health, which I believe is greatly underappreciated. Lastly, I became increasingly irritated by the way the dental profession is manipulated and made to carry the can for successive governments’ incompetence in managing NHS dental care provision. This book explains how NHS dentistry has evolved into the dysfunctional entity it is now and why so many dentists are leaving the profession.

This book is for anyone who wants to make sense of their dental treatment plan. Are you booked in for root canal treatment? Are you wondering why? If you want to understand what causes dental problems like decay, abscesses and gum disease, read on. All of this is explained in straightforward language, in an accessible way. To those who want to find out how to look after their teeth with a view to minimising future dental treatment, this book will be of immediate use.

For anyone who is wondering what the difference is between NHS and private treatment, and what caused the slide away from the NHS to private, the answers can be found within.

This is a highly recommended read for anyone considering a career in dentistry too. It will give a clear idea of the range of treatments dentists carry out, the environment they operate in and the challenges they face, leading to a better understanding of dentistry as a career.

Acknowledgements

My thanks go firstly to my wonderful patients, who allowed me to take the photographs that appear here and without whom this book would not have been written.

To my wife, Cathy, for her encouragement, manuscript editing and offering numerous useful suggestions.

To my son, Matt, for his photography and photo-editing services.

I would also like to take this opportunity to thank Professor Bruce Matthews, a greatly valued mentor and friend, for his encouragement and support throughout my time as a dental student and during my career as a dentist.

Finally, my heartfelt thanks go to those brave souls who read my proof, fixed my errors and made useful suggestions for improvements. Thank you, Alex Macdonald, and especially Paru Edwards for your insightful suggestions.

Disclaimer

This book is presented solely for educational purposes. The author and publisher are not offering it as an alternative to expert or professional advice. While best efforts have been used in preparing this book, the author and publisher make no representations or warranties of any kind and assume no liabilities of any kind with respect to the accuracy or completeness of the contents and specifically disclaim any implied warranties of merchantability or fitness of use for a particular purpose.

Neither the author nor the publisher shall be held liable or responsible to any person or entity with respect to any loss or incidental or consequential damages or injuries caused, or alleged to have been caused, directly or indirectly, by the information contained herein.

Every person and situation are different, and the advice contained herein may not be suitable for your particular situation.

If in doubt, you should always seek the services of a suitably qualified professional.

© Tim Coates, June 2023

Chapter 1

Introduction to Teeth

What are teeth for? A frequently asked question, especially from those who visit the dentist with pain!

Here is a short list of their uses:

•Chewing and eating

•Speaking

•Expressing emotions – smiling, anger

•Supporting cheeks and lips

The first three are obvious, but the role of the teeth in physically supporting the lips and cheeks is often only appreciated after the teeth have been lost, causing the lips and cheeks to collapse inwards – a very ageing appearance.

The teeth lie symmetrically either side of the centreline, an imaginary line dividing the face into right and left halves. Assuming a full set of teeth and starting at the front of the mouth, adults have on each side two incisor teeth, one canine (eye tooth), two premolars and three molars. This is the same on both upper and lower jaws making thirty-two teeth in total, although the incisors are normally smaller on the lower jaw. Children with a full set of deciduous (first/milk) teeth have two incisors, one canine and two molar teeth per side – twenty teeth altogether. There are no deciduous premolar teeth. The deciduous molars are small and replaced by premolars in the adult dentition. Children often lose deciduous molars due to decay. This can cause problems since they act as ‘place holders’ for the premolars and, if lost prematurely, can allow adult molars to drift forward, which may make the premolars erupt (grow out through the gum) in the wrong position or not at all.

Starting from the front of the mouth, incisors are thin and chisel-like for biting off chunks of food. The teeth in each jaw form an arch shape (the dental arch) and the canines lie on the ‘corner’ between the incisors and the premolar and molar teeth. The canines are strong teeth and serve to guide the bite so that the teeth on both jaws meet together properly. The incisors and canines, especially on the upper jaw, are prominent in the smile, so it is important to most people that they are aesthetically pleasing.

Premolars and molars are used for chewing. Molars are bulky teeth with multiple roots to resist the forces of chewing and broad biting surfaces to hold the food being chewed. The other teeth (with the exception of first premolars on the upper jaw) are single-rooted.

In most people, the incisors and canines in the upper jaw fit around the outside surfaces of the incisors and canines of the lower jaw and the outer edges of the upper canines and molars overhang the outer edges of their partners on the lower jaw. Some people do not have this regular bite, which is perfectly OK if they are happy with it and does not cause them any issues. Otherwise, an orthodontist may be able to help (see Chapter 18).

I have described the ‘anatomically perfect’ human adult with thirty-two teeth. Reality is often different. For example, teeth may be missing or extra teeth may be present due to random natural genetic variation. Certain conditions (for example, cleft lip and palate) can lead to missing or displaced teeth, which may require surgical and orthodontic input to correct. Minor anomalies may not be noticed by the patient and may need no treatment.

Structure of the Tooth

We need to have a brief look at the structure of the tooth since this holds the key to how they go wrong and cause problems.

Figure 1.1 Structure of a tooth. Drawing of a back (molar) tooth, although the general structure is shared with the other teeth.

The tooth can be broadly divided into two areas: the crown – the part of the tooth that is visible above the gum, and the root – below gum level and not normally visible.

Enamel

The outer layer of the crown is called enamel and is up to 2mm thick. Enamel is the hardest material in the body. The surface can contain indentations called pits and fissures, especially on the biting surfaces of molar teeth. Pits and fissures are significant as they may trap plaque leading to decay (see Chapter 4).

Gums

The crown joins the root at gum level. Instead of enamel, the root has an outer layer of cementum, which is soft and easily worn away, making it more susceptible to decay. The tooth is surrounded by gum, which makes a leakproof seal around the tooth and prevents bacteria and debris leaking through. The gum is attached to the tooth 1–2mm down from the top edge of the gum and so there is a shallow pocket of gum all around the tooth. The depth of this gum pocket is measured during routine dental check-ups, giving the dentist a valuable measure of gum health (see Chapter 5). A small triangular-shaped piece of gum (the papilla) fills the space between adjacent teeth.

Ligament

The root is surrounded by a rubbery ligament (the periodontal ligament), which has several important functions. Firstly, it allows a small amount of movement between the tooth and its supporting bone and acts as a ‘shock absorber’. Secondly, it contains sensory nerve endings, which tell the brain how hard you are biting. Note that the only known sensation the tooth itself can give (generated by the pulp) is pain. The nerve endings in the periodontal ligament are important in some types of toothache (see Chapter 7).

Dentine

The bulk of the tooth under the enamel and into the root is made of dentine. This is much softer than enamel and is shot through with tiny pores called dentinal tubules, which radiate out from the pulp, the innermost structure of the tooth. The difference in hardness between enamel and dentine accounts for the rate at which decay eats through the tooth, slowly through the enamel layer and rapidly in dentine. The region where the roots of multirooted teeth divide (e.g. molars) is known as the furcation. The furcation is not normally visible in the mouth unless the gum has receded due to gum disease (see Chapter 5).

Pulp

The pulp is the live part at the centre of the tooth, often referred to as ‘the nerve’. It actually contains blood vessels as well as nerves, which play a role when teeth get painful (see Chapter 7). When dentine gets exposed to the external environment, the pores provide a means to let the pulp know about it, in other words pain. This is hypersensitivity and is explained in Chapter 7. The pulp extends down the root of the tooth inside the root canal and emerges from the root tip (apex) as a bundle of nerves and blood vessels into the bone of the jaw.

All of these structures work together to make up teeth and their immediate environment. As long as they remain healthy and intact, biting and chewing happens effortlessly. Unfortunately, there is quite a lot that can go wrong where the services of a dentist are needed.

Many of the problems with teeth are due to today’s sweet and sloppy Western diet and develop gradually over a period of years. These are described in detail in the following chapters. In general, if problems with teeth and gums are picked up early, before the patient becomes aware anything is wrong, they are much easier and less costly to fix than if they are left. This is the rationale for having regular dental check-ups even if the teeth seem to be giving no issues.

Chapter 2

The Dental Team

Before launching into the various treatments, and why and how they are done, it is worth taking a few minutes to consider how a dental practice works and who are the professionals working within it.

The Receptionist

The first person you see when you visit a dental practice is likely to be the receptionist. Their job is to make you feel welcome and at ease and, of course, to arrange appointments. They are often not dentally qualified so are unable to answer any technical questions, but they do know how long a particular procedure or treatment will take and so will block off the necessary amount of appointment time. This varies according to the treatment planned. A routine examination (check-up) may be allocated ten minutes while a filling may take twenty minutes. A more complex procedure, such as a root canal treatment, may be booked in for as much as an hour, but it is unusual for appointments to exceed ninety minutes.

A patient who arrives ten minutes late for a check-up is probably not aware that no time remains for them and the dentist is by now treating the next patient on the list. Dentists do their best to accommodate patients who are not on time. The next time your dentist is running late, it could well be because they have had to squeeze someone into a non-existent gap in their appointment book.

The receptionist is also responsible for receiving payments from patients, and often plays an important part in the general administration and running of the practice.

The Dentist

Your dentist bears full responsibility for drawing up a treatment plan, carrying out the treatment plan, and for the outcome of your treatment. They may own the practice (practice principal) or work there as a (usually) self-employed dentist (associate dentist). The dentist can answer any questions relating to treatment and will discuss alternative treatments when appropriate. The dentist can refer some of your treatments to colleagues within or outside the dental practice. For example, you may be referred to the practice hygienist for a scale and polish, or to an oral surgeon specialist in another practice for a difficult tooth extraction. The dentist receives no fee for the referral.

The Dental Nurse

The dentist is supported by a nurse, or dental assistant, who is responsible for maintaining the surgery, keeping up a supply of sterilised instruments and assisting the dentist with their work. The nurse has an extensive knowledge of all dental procedures and, like the dentist, is fully trained in handling medical emergencies (e.g. diabetic collapse, anaphylaxis, fainting) that can occur during treatment. Dentists often work with the same nurse for many years, forming a highly efficient team, facilitating work to be carried out smoothly and rapidly.

Hygienists

Many dental nurses undertake further training to become dental hygienists. Hygienists can also enter training straight from school with the appropriate A levels. They play a key role in disease prevention by removing the hard deposits that build up at and beneath gum level, which cause gingivitis and gum disease (see Chapter 5). They also give oral hygiene and brushing advice, and can provide preventative topical fluoride and sealant treatments. Most dental practices have a hygienist. The hygienist is able to accept patients referred by their dentist for this time-consuming but vital work, freeing up the dentist to do more complex treatment.

Dental Therapists

Dental nurses and hygienists can also take further training (a degree or diploma) to qualify as a dental therapist. Therapists can perform all the work of a hygienist. In addition, they are qualified to give local anaesthetic, extract children’s deciduous (milk) teeth and place fillings in adult and children’s teeth. Therapists are usually found in large, busy practices where they can relieve the dentist of many of the routine treatments.

The Practice Manager

Many dental practices, especially larger ones, employ a practice manager. Practice managers are able to take on administrative tasks such as organising staff payrolls and holidays, hiring locum staff, maintaining stock levels and ensuring that the many records demanded by the Care Quality Commission (CQC) and the General Dental Council (GDC) (see Chapter 22) are kept up to date. Previous experience as a dental nurse, giving in-depth knowledge of dental practice, is useful in this responsible and demanding role.

Laboratory Technicians

The dental laboratory technician is the unsung hero of the team. Some dental practices have their own dental laboratory, but usually dental laboratories are independent businesses. They frequently offer a pickup and delivery service, so impressions (moulds) can be sent off and the work returned from the lab in a predictable timescale. Usually working from impressions, the dental technician will fabricate items for dental treatment that require specialist skills, equipment and processes that are not practicable in the dental surgery. These include dentures, crowns, bridges, orthodontic retainers and sports mouthguards.

Clinical Dental Technicians

Lab technicians who have trained and registered as Clinical Dental Technicians (CDT) are able to provide complete dentures (where patients have no teeth left) direct to the public. Where patients have standing teeth or dental implants, they must first be examined by a dentist who gives the CDT a treatment plan to work from.

Continuing Professional Development

Hygienists, therapists and technicians work independently of the dentist but, for the most part, must follow the dentist’s prescription (instructions) for the work they do. All members of the dental team except receptionists must by law be registered with the General Dental Council (GDC). An annual registration fee is payable for this. All except receptionists are expected to undertake continuous professional development (CPD) courses where training is provided to either reinforce current knowledge (for example, in dealing with medical emergencies) or provide new training (for example, in using a new dental implant system).

GDC registrants have to pay for their own CPD. A further requirement is for all registrants to maintain a ‘personal development plan’, which the GDC advises should be used to ‘design your own learning and development’ (General Dental Council 2022). The amount of CPD required to be completed varies according to role in the dental team. The average minimum number of CPD hours required per year are:

•Dentists: 20 hours

•Dental therapists, hygienists and clinical dental technicians: 15 hours

•Dental nurses and technicians: 10 hours.

Dental Practice Ownership

The vast majority of general dental practices are privately owned businesses. These may be individual practices owned and run by dentist principals or chains of practices owned and run by a dental corporate business. Either of these can offer NHS or private treatment, or a mixture of both. Practices that accept NHS patients must have a contract with the Local Area Health Trust (now known as Local Area Teams) to be paid an amount corresponding to the number of Units of Dental Activity (UDAs) they are expected to complete throughout the financial year (see Chapter 20).

Being private businesses, like your local garage or fruit and veg shop, dental practices are responsible for paying their own mortgages, business loans, consumables, equipment, repairs and maintenance of premises, council tax, utility bills and staff wages. Practices offering NHS treatment are contracted to deliver for a fixed fee a set amount of NHS dental treatment measured in Units of Dental Activity (UDAs). UDAs are explained in Chapter 20. NHS dentists and orthodontists (dentists who straighten teeth, Chapter 18) in general practice are usually self-employed, not salaried employees. The exception to this is dentists who work