You wear it well
What is your professional background and what led you to establish the London Tooth Wear Centre?
Having qualified from King’s in 1986, I subsequently went to the Eastman for my postgraduate training and completed a Masters in Conservative Dentistry in 1990.
Currently, I am Director of Education and CPD at the UCL Eastman Dental Institute and Associate Dean for Continuing Education at the UCL School of Life and Medical Sciences. As a Specialist in Restorative Dentistry and Prosthodontics, I also maintain a referral specialist Private Practice in Central London.
Over the years, I have developed a special interest in the aetiology, demographics and clinical management of patients with tooth surface loss and, in particular, those patients with compromised function and aesthetics as well as sensitivity. I am Co-Editor of the BDJ book on Tooth Surface Loss and have recently established the London Tooth Wear Centre.
Academic interests also include innovative teaching methods and the impact of training on patient outcomes in clinical practice and I was particularly delighted to have received a Provost’s Teaching Award in 2010, the highest accolade for excellence and innovation in teaching and learning at UCL.
How prevalent is tooth wear in the UK?
The latest Adult Dental Health Survey, published in 2009, reports that over 50% of children and 76% of dentate adults show some form of tooth wear and that the prevalence of tooth wear is increasing. In contrast with the other major diseases of teeth that may cause tooth loss, this compares with 31% for primary or secondary coronal or root caries and 45% for some form of historical or current over periodontal disease.
Such surveys have tended to report on the rather more measurable patterns of wear. However, what are sometimes overlooked are the rather more mundane aspects of wear. For example, when we chew or grind, each of our teeth move to varying degrees. As a result, the contact points between adjacent teeth rub against one another causing inter-dental attritional wear resulting in broader contact areas.
In summary, we all have tooth wear. This is a global problem of growing enormity as longevity increases and people will be retaining their teeth longer.
The issue is whether the degree of tooth wear is chronological (ie in harmony with what would be seen in a significant number of other people of the same age) or pathological (ie in advance of a significant number of other people of the same age) and whether the loss of tooth tissue is mild, moderate or severe. These factors, when considered together, will help to inform decision-making and treatment planning.
How does tooth wear arise and is there any interplay between the various mechanisms?
Tooth wear has been reported throughout the ages and the types and degrees of damage are well documented. In broad terms, abrasion, attrition and erosion are the main culprits with abfraction having been described more recently.
Strategies for successful prevention and management rely heavily on identifying the cause. However, more often than not, the aetiology is multi-factorial. By way of example, an individual may have both an acidic and abrasive diet and also grind at night.
So, it is essential to obtain a detailed history, carry out a thorough clinical assessment and assess the patterns of tooth surface loss in order to determine the causative factors and then the aetiology. Only then can a personalised treatment plan be prepared to address the various issues.
Why is it important to treat tooth wear?
In very broad terms, there are three main reasons.
Firstly, for relief of symptoms such as sensitivity or pain as the wear causes loss of enamel and dentine often exposing the root canal system in the worst of cases.
Secondly, to maintain satisfactory function and protect the masticatory system as stability and effectiveness of the occlusal relationship normally decreases as the amount of wear increases.
Thirdly, and often most important from the patient's perspective, is to re-establish satisfactory facial and dental aesthetics as teeth can become both short and sharp.
What sort of treatment can you offer patients suffering from abrasion, attrition or erosion?
Having arrived at a diagnosis and instigated preventive measures, treatment options vary greatly and are directed toward addressing any dental damage or wider health issues whilst also fulfilling patient expectations as best possible in what are sometimes very challenging circumstances.
As a result, the simplest dental treatments might include replacing small amounts of missing enamel and dentine with adhesively-retained tooth coloured fillings whereas at the other extreme are comprehensive reconstructions involving varying amounts of treatment for individual teeth at an increased occlusal vertical dimension.
Whatever the treatment need, monitoring levels of wear is an essential aspect of treatment with clinical photographs and study casts being the most useful indicators of ongoing changes. Tooth wear indices are well reported in the dental literature but are most useful for epidemiological studies rather then monitoring small changes over time in the primary care setting.
Often, treatments need to be personalised with regard to the aetiology. There are many examples and just a few include parafunction and splint therapy, dietary modification in relation to erosion, athletes and sports drinks, swimmers and chlorine-related erosion, recreational drugs and bruxism, beauty models or dancers and anorexia/bulaemia.
Complicating management of the dental issues may be medical problems such as stomach acid regurgitation or psychological problems. In such situations, close collaboration with medical colleagues is essential for success.
Whatever the scenario, supportive hygiene therapy remains an essential aspect of care whether this be in relation to dietary assessment and advice or appropriate oral hygiene techniques to limit future loss of healthy tooth tissue.
Most important is a holistic approach to care taking into account dietary, social and work-related issues as well as any medical problems, to ensure successful management of the presenting dental challenges.
At what stage should GDPs consider referring patients experiencing abrasion, attrition or erosion?
More often than not, the management of patients presenting with tooth wear is well within the scope of general practice.
Experience suggests, however, that there are three main areas where specialist assistance may be beneficial to both patients and their GDPs. These include (1) identifying the causes and how to address some of the rarer factors (eg recreational drug habits), (2) designing an appropriate treatment plan (eg where there may be multiple and ongoing problems) and (3) delivering certain aspects of care (eg management of TMJ problems or increasing the occlusal vertical dimension).
It is for this small group of rather more complex and challenging patients that the London Tooth Wear Centre is able to offer GDPs and their patients either (1) support and advice or, (2) alternatively, comprehensive care.
Who inspires you professionally and why?
I have had the great privilege of having been inspired by four superb mentors over the years.
The first, Professor Sir Ian Gainsford, was my Dean at King's when I was an undergraduate dental student. We subsequently became colleagues and close friends. To this day, Sir Ian has kindly continued to act as a referee for me and always offers wise counsel.
My first "boss" on qualifying was Dr Martin Kelleher. I was his House Surgeon and then Clinical Assistant over a period of two and a half years between 1987 and 1989. It was his inspirational teaching and guidance that led me to undertake my Masters at the Eastman.
My Programme Director at the Eastman was Professor Derrick Setchell, one of the UK's leading lights in Restorative Dentistry. During his term as Head of the Department of Conservative Dentistry and then Prosthodontics, my career flourished through part-time posts over twelve years between 1990 and 2002.
My career then took a dramatic change in direction during Professor Crispian Scully's second term as Dean of the UCL Eastman Dental Institute when, in 2002, I was invited to become Director of UCL Eastman CPD and then additionally, in 2005, Director of Education.
I am truly grateful to all of these inspirational colleagues who have each made such a positive contribution to my career in so many different ways.
What is the most satisfying aspect of your work?
There is no question that the triad of clinical care, education and research and how each informs the other that has maintained my overall professional stimulation twenty five years since qualification.
We all have tooth wear!
The 2009 Adult Dental Health Survey reports that more than 50% of children and 76% of dentate adults show some form of tooth wear and that the prevalence of tooth wear is increasing. In contrast with the other major diseases of teeth that may cause tooth loss, this compares with 31% for primary or secondary coronal or root caries and 45% for some form of historical or current over periodontal disease. However, what are sometimes overlooked are the rather more mundane aspects of wear. For example, when we chew or grind, each of our teeth move to varying degrees. As a result, the contact points between adjacent teeth rub against one another causing interdental attritional wear resulting in broader contact areas. We all have tooth wear. This is a global problem of growing enormity as longevity increases and people will be retaining their teeth longer. The issue is whether the degree of tooth wear is chronological (ie: in harmony with what would be seen in a significant number of other people of the same age) or pathological (ie: in advance of a significant number of other people of the same age) and whether the loss of tooth tissue is mild, moderate or severe.
What have been your biggest professional challenges so far?
There are three.
From the practice perspective, developing and maintaining a specialist practice right in the heart of central London at a time when "dental specialists" were just being introduced in the late 1990's and ensuring excellent working relationships with generalist colleagues in primary care. I am thrilled that the practice and these relationships continue to thrive fifteen years later.
From the Eastman perspective, getting the message across that what we offer is "high quality postgraduate training for all the dental team from qualification to retirement" and seeing UCL Eastman CPD become the leading provider of continuing dental education in the UK and probably also in Europe.
And finally, to support all of the above, EMAIL! Finding the time to respond fully and promptly can be a real challenge!
Is there a particular case of which you are most proud? Can you tell us about it please?
It is rather the overall philosophy of treatment that is important to me rather than the outcome of any single course of treatment. Let me explain.
Patients who present with tooth wear have already lost varying amounts of enamel and, possibly, dentine. The last thing that a dental professional should be contemplating is the loss of even more healthy tooth tissue than is absolutely necessary to provide protection, comfort, function and aesthetics.
So, my philosophy is based on being as conservative and as non-invasive as possible whilst delivering agreed treatment goals and satisfying patient expectations. It is maintaining this over-arching approach over so many years that makes me proud and similarly assures the confidence of our patients when considering our philosophy.
What was your motivation to write the book Tooth Surface Loss? At whom is it aimed?
In 1995, I was invited to become Chairman of The London Chapter of Alpha Omega, an international dental society. One of the Chairman's roles is to organise an evening lecture series over their year in office. Having been exposed to many patients with tooth wear both in practice and at the Eastman, I decided to arrange a themed series of lectures around this increasingly problematic clinical area.
The presentations were well received and we were encouraged to prepare these for publication in the BDJ which happened in 1999. The feedback on the series of articles was similarly positive and these were then compiled into the BDJ book, with some additional material, a year later. The book is a clinical guide and is aimed at undergraduates, GDPs and anyone who has an interest in the aetiology and management of paients with tooth surface loss.
With so many commitments, how do you manage your time?
There is no question that time management is one of my biggest challenges. In addition to the Eastman and my practice are commitments to the editorial boards of a number of journals, professional committees and also a number of community roles outside of dentistry. Thankfully, I have three great teams supporting me – at the Eastman, at the practice and, most importantly, at home.
How do you anticipate dentistry in general – and restorative treatment specifically – changing over the next decade or so?
The profession is on the precipice of enormous change with major organisational restructuring ahead to include the commissioning of primary and secondary dental care.
As a direct result, general practice is likely to look very different in the future with a greater emphasis on a team approach using a wide skill-mix and also the potential for an increase in specialist care in the primary setting. Restorative Dentistry, currently a hospital-based specialty, will need to be delivered within these new frameworks with monospecialists providing essential specialist care in the high street.
A word or two on tooth wear. Wth an ever-ageing population, teeth will be "wearing out" in increasing numbers as the battle against the ravages of dental caries and even periodontal disease is being addressed. Prevention and training will need to prepare the whole professional team.
Finally, the challenge of failing complex dentistry – and particularly problems associated with dental implants – will increasingly become a drain on time and resource in both the primary and secondary care settings based on the levels of treatment being provided globally at this point in time. One of my most significant concerns in this regard relates to the uptake of "cosmetic" dentistry over the last 5 – 10 years and the direct inpact this will have as treatments start to fail – as inevitably they will!
And what is next for you?
I thoroughly enjoy what can only be described as an "action-packed week" split between the Eastman, clinical practice and a multitude of other professional and community-based responsibilities.
Having now been qualified for just over 25 years, and from many valuable experiences during this time, I have been lucky enough to acquire a broad range of translational skills and am always on the look-out for new opportunities.
Currently, however, my focus remains developing and maintaining the highest standards of postgraduate dental education in my Eastman role and offering quality care for all patients in my practice.
In addition, and through the recent establishment of the London Tooth Wear Centre (website: www.toothwear.co.uk coming soon) in response to demographic changes, promoting public awareness is as much a priority as is the delivery of consultation advice for referring colleagues and also the delivery of patient care.
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