‘Action not words’

Jill Harding talks to Dental Sky about the UK’s oral health crisis

A healthy smile is fast becoming an indicator of our socioeconomic status. With a wealth of studies to evidence the correlation between oral health and income, occupation and social background, the current shortage of NHS appointments has further deepened health inequalities in the UK.

Issues of access are widespread. Amid the crisis, patients who can afford private dental care have migrated away from the long NHS waiting lists, whilst those who cannot are missing out on regular check-ups, risking their health and quality of life.

With NHS dentists beset by what was considered by many an unworkable contract, the pandemic exacerbated the problems of access. Appointment delays created a backlog and the steep rise in living costs are now adding to the problem.

NHS Digital reveals that the number of adults seen by NHS dentists within recommended timeframes decreased by 9.5% in 2021-22 against the previous year. [1]

Two years ago, a report by Public Health England outlined the influences on public dental health, stating that ‘there is clear and consistent evidence for social gradients in the prevalence of dental conditions, the impact of poor oral health and service use’ [2].

It recognised that oral health inequalities ‘remain a significant public health problem’ and that reducing them ‘is a matter of social justice, an ethical imperative and, for public bodies across the health sector, a legal duty’.

This year, National Smile Month (16 May-16 June 2023) is shining a light on the importance of toothbrushing. Every year the campaign champions the benefits of having good oral health and promotes the value of a healthy smile.

The 2023 campaign is ‘Brush for better health’ – clarification of the systemic links between oral health and overall well-being vital to public health messaging. But with the pandemic’s impact still reverberating and the financial crisis forcing people to carefully consider their outgoings, the nation’s oral health is paying a heavy price.

There are health implications for people in vulnerable groups or those with lower socioeconomic status and failure to access dental care is among the challenges. These populations often have considerably poorer oral health across all assessed outcomes. For some, this may even involve limited access to toothbrushes and toothpaste or limited places to clean their teeth.

The Wrigley Oral Healthcare Programme’s Oral Health Index recently revealed that more than half (54%) of its 6,000 respondents believed there is a postcode lottery accessing dental services. With 68% agreeing there is a crisis in the provision of dentistry, three-quarters (77%) felt the government could do more to promote oral health. [3]

With fewer NHS appointments available and many areas with long waiting lists to register, it can impact the quality of life for those people for whom private dental care is unaffordable. Sometimes, they take matters into their own hands with media stories of DIY dentistry highlighting deeper problems.

Dentaid The Dental Charity has been operating mobile dental units across the UK for many years. The charity’s volunteers visit homeless shelters, soup kitchens and community buildings to provide free dental screening, advice and treatment for underserved-communities who are unable to access NHS dental care.

The charity’s efforts to break down barriers and help people who most need dental care access essential dental treatment are a vital lifeline for many. But it has cast its net beyond the people experiencing homelessness and other vulnerable groups of late to include public-access clinics. This focus had to change when the pandemic limited opportunities to help populations overseas. But their work has highlighted needs here in the UK, and demand has skyrocketed in the last 2 years.

Jill Harding is the communications director at Dentaid The Dental Charity.

Back in 2008, Dentaid The Dental Charity was refurbishing and delivering dental equipment to countries in need. It then developed its work to care for those in pain by funding outreach clinics and sending teams of volunteers to support local dental professionals. Now, although its overseas work continues, it is very much focused on helping the UK population.

Jill says: ‘The pandemic was not solely the catalyst for the charity’s work on home soil. It had already started working in the UK when, in 2015, it responded to a cry for help from people in Kirklees in West Yorkshire who were using a soup kitchen but unable to eat the food due to toothache.

‘It was a slow evolution for the first couple of years but, since lockdown, demand skyrocketed partly due to the backlog created by the pandemic. This also led to heightened awareness about the groups of people who have always faced challenges in accessing dentistry.’

Earlier in the year, the charity updated its branding, too, to better reflect its work.

‘The old logo had an image of the globe within it, but times and our charity have moved on’, Jill says.

The new Dentaid logo

So, whilst it was always the charity’s intention to develop its UK work, the growth in demand has been ‘almost exponential,’ Jill says. ‘Dentaid The Dental Charity has always been fleet of foot. When opportunities to help more people present themselves, we make the most of them. There is now a vast geographical spread, and we are looking to work in new areas all the time. The team has expanded rapidly – we now have 28 members of staff and are currently planning to expand our regional hubs, too. We already have one operating near Halifax and are about to open one in Kent and base a mobile dental unit in Northern Ireland. We are mindful of environmental impact, so this helps reduce the need to travel.’

The charity will run at least 500 clinics in the UK this year. After its unveiling at the BDIA a new unit will be based at Maidstone, Kent run by a clinical supervisor and mobile unit officer from a hub that will serve the southeast.

Disengagement with traditional services can include logistical challenges, too. Often, vulnerable groups haven’t the contact details necessary for registration, or they may not have anywhere to store their belongings while they are treated.

‘Our outreach work in mobile dental units takes our services to places where vulnerable groups feel safe and comfortable – hostels, day centres and night shelters. We are breaking down the practical, emotional and mental barriers to them accessing dental care.’

But sustainability is key here. As Jill says: ‘Our work needs to be sustainable, which is why we offer oral health education alongside all of our clinics that return to locations regularly. We must start conversations with patients about their teeth to ensure long-term health. Many of the people we treat haven’t attended for so long that they are disconnected from dentistry, which is why we return regularly. During sessions at our mobile units, volunteer clinicians offer oral health advice and hand out toothbrushes and toothpaste. Volunteers on our BrightBites programme, an oral health education scheme that visits schools, also hand out these resources.’

The government’s failure to address political and public health failures is difficult to ignore. Considering the litany of challenges dentistry faces, it must impact the team hugely. But Jill is keen to stress the importance of action rather than words.

‘As a charity, it isn’t for us to say why these services are not available to everyone or comment on funding in dentistry. What we do focus on, however, is being out there and doing something – running our clinics for the communities that need us most. We now have seven mobile units and one trailer servicing the UK. We have a fundraising events programme and encourage practices to hold events. We are always looking for volunteers and welcome input from across the profession.

She adds: ‘Dentaid The Dental Charity has always stepped in where there is a gap in care. Our services are delivered by much-valued volunteers who have often identified a need within their communities. Quite simply, we are committed to helping those who are the hardest to reach – wherever they might be.’

For more information, visit https://www.dentaid.org/

References

Dentistry’s biggest questions answered

Are you struggling to recruit and retain good staff? Are you thinking about leaving the NHS and moving into private practice? Is your practice being affected by the cost-of-living crisis?

Questions! Questions! Questions!

We all know what some of the problems are in dentistry at the moment, but what are the solutions? You may find some of them at the Dental Business Theatre located within the British Dental Conference and Dentistry Show (BDCDS) at the NEC in Birmingham on 12th and 13th May. Once again, the Dental Business Theatre is being programmed by Practice Plan and this year’s aim is to not only pose some of the biggest questions in dentistry, but also to answer them.

Six sessions will be held on both days, with panels including industry-renowned names such as dental business coaches, Chris Barrow and Lucie Simic along with sustainability expert, Mark Topley. All of whom will answer questions on subjects including how best to go about attracting great staff members, as well as how to keep your current team happy. Whereas Chair of the GDPC at the BDA, Shawn Charlwood, Head of Indemnity at the BDA and practising dentist, Len D’Cruz’ along with, Practice Plan Sales and Marketing Director, Nigel Jones, will discuss arguably the biggest question at the moment: “Is there a future for NHS Dentistry?”.

In his session, Shawn Charlwood’s views are likely to be informed by his recent experience of providing oral evidence to the Health and Social Care Select Committee’s inquiry into NHS Dentistry. “As I told the Committee this really is a make-or-break moment for NHS dentistry,” he said. “The tweaks we’ve seen to a failed contract will not halt the mass exodus of dentists or restore access for millions. At the very same time dentists in mixed or wholly private practice will face real pressure as the result of the cost-of-living crisis. It’s an invidious position and colleagues should tread carefully and join us for the key debate of conference.”

How best to go about the recruitment and retention of staff also throws up big questions for dental practice owners and managers. Sustainability expert, Mark Topley believes the answers can be found by moving away from the traditional focus on hourly rates and percentage splits to methods that chime more with what potential employees value in their lives. “Post-pandemic, what people look for from an employer has changed,” Mark states. “Good associate dentists and dental nurses are in demand so, to stand out from the crowd, practices need to do more than just keep offering higher rates of pay. That just sets up a bidding war and gets everybody nowhere. In my session, Chris Barrow, Lucie Simic, Emma Anastasi and I hope to show you what other things you need to do to be able to attract the right team members for your business and, more importantly, for them to want to stay with you.”

Anyone inspired by the sessions in the Dental Business Theatre who want to find out more about making the move from NHS to private, or to switch plan provider, then Practice Plan Regional Support Managers will be available on Stand K50 to talk about how to go about making the move. Colleagues from Wesleyan Financial Services will also be on hand to advise on how to go about ensuring your income is protected as a private dentist, too.

If you’re unable to come to the BDCDS and would like to find out more about your options away from the NHS and are looking for a provider who will hold your hand through the process whilst moving at a pace that’s right for you, why not start the conversation with Practice Plan on 01691 684165, or book your one-to-one NHS to private call today: practiceplan.co.uk/nhsvirtual

For more information visit the Practice Plan website: www.practiceplan.co.uk/nhs

Start your clear aligner journey with ClearCorrect®

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The ClearCorrect^® Level 1 Accreditation Course is the perfect opportunity to immerse yourself in the world of clear aligners, building confidence and gaining the knowledge you need to safely prescribe clear aligner therapy.

Enter the world of clear aligners

Providing clear aligners from ClearCorrect^® presents a number of unique benefits. The aligners are engineered for precision, comfort, and aesthetics using the innovative ClearQuartz™ tri-layer material combined with a high, flat trimline to enable you to achieve your orthodontic goals. ClearCorrect^® aligners are the ideal solution for your practice, enabling you to provide a new treatment type to a high standard, as well as retain and attract patients.

In addition, ClearCorrect^® offers a streamlined digital workflow helping you to completely customise treatment for the unique needs of each patient. Innovative digital features include: the ClearCorrect^® Sync Mobile App, which enables you to capture patient photos and add them to new case submission drafts with ease; the Doctor Portal, which enables you to select your optimal treatment protocols with advanced customisation options; and ClearPilot™ 6.0, which offers optimised 3D controls for enhanced customisation.

ClearCorrect^® your partner in ortho

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The two-module in-person course is split over eight weeks, and is comprised of lecture-based sessions presented by Clinical Advisors, Dr Kim Ganga-Raju and Dr Rob Wood, and experienced ClearCorrect^® users, Dr Sanaa Kader and Dr Sarah Weston. This Accreditation Course is ideal for those who want to build their confidence in clear aligner treatment, to enable them to safely prescribe this in-demand treatment option to their patients. On completing this course, professionals should feel comfortable and knowledgeable enough to offer clear aligner treatment to patients with mild to moderate orthodontic concerns. Delegates can expect support to be available for their first three cases, all the way from case selection, through to completion.

: Dr Kim Ganga-Raju

: Dr Rob Wood

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: Dr Sanaa Kader

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A modern look at CBCT

Dr Simon C Harvey, consultant in dental and maxillofacial radiology at the Eastman Dental Hospital, will be giving a modern overview of CBCT during his speaking session at this year’s British Dental Conference & Dentistry Show (BDCDS), taking place on the 12^th and 13^th May at the NEC in Birmingham.

Specialist in dento-alveolar CBCT and co-designer of the BDA’s CBCT Masterclass, Simon’s lecture at BDCDS will take a practical look at CBCT doses and provide clinicians with helpful advice on how to integrate CBCT into all areas of dental practice. ‘I’ll be looking at a modern imaging practice for all dentists. I want to have a look at what we’ve done historically, what we’re doing right now, and perhaps what we’re going to do in the future. We’re all pretty familiar with the intraoral views that we often do, but wouldn’t it be amazing if we could look at some of those newer techniques and see how clinicians can fit them into their practice? Things like 3D imaging techniques, which are predominantly CBCT. I’ll be showing how we can integrate these techniques into everyone’s practice, and essentially why cone beam is no longer only the preserve of dental hospitals and specialists. Cone beam is incredibly versatile and is great for things like trauma, endodontics, implants, impaction – either orthodontic impaction or oral surgery impaction. So whether you’re starting out as a foundation dentist, whether you’re an experienced associate, a principal, whether you work in a hospital, wherever you are in your practice, I’d like you to think about how cone beam can fit into your practice if you’re not already using it. I’ll even be showing a few cases where cone beam CT can be integrated into the NHS fee schedule. You might think that’s not possible, but hopefully I’ll show you the cases where I think it could be reasonable, and how it can really improve what clinicians are doing.’

The impact that cone beam computed tomography has had on dentistry is undeniable. By instantly providing clinicians with a detailed 3D view of the teeth, surrounding soft tissue, airway and bone, CBCT has massively improved diagnostics and treatment planning in dentistry, as well as saving huge amounts of clinical time and improving patient experience. ‘Cone beam is probably the biggest gamechanger in dental imaging in the last 30 years or so. Not to quote a cliché, but it’s given us that extra third dimension. It really has pushed dental imaging on, and its benefits are huge. I don’t know if people realise the really exciting thing about cone beam CT, which is that unlike some of our other imaging methods, cone beam is only going to get better. We’re not at the peak of the technological curve yet with cone beam CT. Its benefits are ever-growing, and each year we’re getting more and more research out.’

One issue that CBCT has faced until now is the presence of artefacts which could potentially interfere with the diagnostics process. However, the rapid evolution of CBCT technology means that artefacts are no longer likely to be an issue in modern CBCT. ‘Those of you already using cone beam CT probably already realise that artefacts are a bit of a problem. With the next generation of machines, the image quality is only going to get better. The new machines will have advanced, reconstructed algorithms which are going to reduce, minimise, and even eliminate those artefacts. So we’re going to get better pictures with fewer artefacts, all while keeping those doses really low. And that’s the really exciting thing about cone beam, the technological advances are still coming.’

Outside of cone beam, there are also a number of other technological advances pushing dentistry forwards, notably the introduction of AI technology. ‘For me as a radiologist, the biggest new development in dentistry right now is AI. It’s really exciting and I think everyone can already see the potential of it. Obviously, most people have heard of ChatGPT, or if not, your kids will have heard of it. And some of you will have had a play on it and seen how amazing this technology is. We’ve essentially got this algorithm that is learning all the time and giving really coherent answers to relatively obscure questions. And we’re doing the same thing when we’re translating this into healthcare. People all look different in a skeletal sense. We’ve all got slight anatomical variations. So we’re going to give the AI systems loads of data, and we’re going to teach it to recognise what is normal, and what’s not normal. Some of you will know there are a couple of AI systems out in dentistry already. The ones I’ve seen I don’t think are really fit for clinical use yet. They’re quite basic, they make regular misses. We need to get a system that’s getting over 99% accuracy. It’s got to be something that’s better than humans. At the moment, there are a few big tech companies that are just on the cusp of releasing their software. It will be interesting to see who’s in the dental market, and who’s got a really rounded, viable system for dentistry. It’s going to be amazing to see how we all respond to that as clinicians, and how we accept it and integrate it into our practice.’

As well as sharing his CBCT expertise with delegates during his lecture, Simon is also looking forward to the social aspect of attending BDCDS. ‘I think the biggest thing I’m looking forward to, and I mean this honestly, is the face-to-face contact. It’s going to be seeing people, rather than just broadcasting. When you’ve got that computer-to-human interaction, it’s so limited, and you just feel like you’re talking to pixels. Actually being there in a lecture theatre, really teaching people and engaging with people, it’s great. I’m also looking forward to the trade show itself. It’s going to be amazing to see what’s going on with the industry, especially because we’ve had this enforced break for a while. I really feel like now we’re in 2023, we’re out of the worst times, and it should be a really good show. It will be great to see manufacturers, dental colleagues, and just see who’s doing what.’

You can see Dr Simon C Harvey’s lecture ‘A modern look at CBCT for 2023’ in the BDA Theatre on Friday 12^th May at 14:50 at this year’s British Dental Conference & Dentistry Show.

BADN and Dentaid collaborate with CleanCert on Decontamination Survey

CleanCert Hygiene is conducting a nationwide Dental Survey to provide an insight into the challenges of dental decontamination for all dental professionals.

Working in collaboration with The British Association of Dental Nurses (BADN) and Dentaid The Dental Charity, the survey will bring together opinions and experiences from all dental professionals with the aim of improving patient treatment outcomes.

The survey should only take 4-6 minutes. Participants will be emailed with a summary of the findings and be in with a chance of receiving one of the £100 Amazon vouchers. Refer a friend to be in with more chances of winning!

Survey closes 28 May 2023.

Start the survey here.

General Dental Council publishes Costed Corporate Plan 2023

As part of the General Dental Council’s (GDC) approach to strategic planning, the regulator has today published its Costed Corporate Plan 2023 – 2025.

This year’s plan sets out what the GDC will do over the next three years, the fees that it will charge, and includes its forecast of income and expenditure for 2023, as well as reporting on its progress in 2022.

The pandemic has continued to impact the GDC’s work that can be delivered and is still having a significant impact on the dental sector and wider economic landscape. The GDC has continued to deliver its statutory purpose throughout the pandemic; to protect patient safety and ensure that the public have confidence in the services provided by dental professionals. In order to do this, the regulator reprioritised some work to ensure that it continued to operate efficiently and effectively. 

The GDC has been able to deliver much of what it set out to do at the start of the year. The regulator’s plan for 2023 – 2025 will enable it to continue to deliver against its regulatory remit.

This year’s publication includes:

An overview of the GDC’s Corporate Strategy for 2023 – 2025, which was published in early 2023. Integral to this is its four new strategic aims. All its activity aligned with at least one of these aims.
A review of the 2022 plan, including achievements and progress made, and a summary of the unplanned work undertaken in 2022.
A summary of the 57 projects on the 2023 – 2025 work programme, by strategic aim.
The GDC’s forecast expenditure for 2023 – 2025 which shows an increase of 1.3% compared to the agreed budget set in 2022. This is due toincreased resource requirements across its support services as part of the regulator ensuring compliance, and inflationary pressures.
Details of the Annual Retention Fees for the next three years. However, if high inflation is sustained, Council will consider if the fees should increase in 2024 and 2025 but any increase will, at most, be in line with the rate of inflation at the time.

This year’s plan supports the GDC’s ambition of creating greater understanding of the relationship between our regulatory activity by strategic aim, and the fees that it charges.

ADG launches “Six to Fix” for NHS dentistry in Scotland

Following the ADG’s first roundtable meeting of its new Scotland branch in February in Edinburgh the trade body has launched their Scottish “Six to Fix” policy proposals to narrow oral health inequalities in Scotland and create a more sustainable workforce in NHS dentistry.

The “Six to Fix” mirrors the ADG’s approach in England where proposals have been taken up by policy makers to improve the delivery of NHS dental services.

The Scottish “Six to Fix” includes:

Increase the number of training places in Scotland
We need government to create a new dentist recruitment campaign backed by a target to increase the number of training places within Scotland. Post graduate training places need to be better aligned with areas with the highest oral health inequalities. This will start to help improve the medium to long-term picture.
Recognition of EU trained dentists
We need continued access to UK dentistry for EU-trained professionals, who made up 29.5% of new GDC registrants in 2021.

Recognition of overseas qualifications
We should make much more of our links to Commonwealth countries. Before 2001, the UK had bilateral agreements with Commonwealth dental schools including Australia, Singapore, Hong Kong, and South Africa whose qualifications met UK standards and potential agreements should be explored again.

More flexibility for dentists to work across multiple practices in Scotland
In Scotland to see NHS patients a dentist needs to hold a list number at a particular practice. To see NHS patients at another practice another list number is needed. The listing process can take up to three months and needs to be reformed. Allowing dentists the flexibility to provide NHS care at neighbouring practices would make better use of the workforce and help improve access to NHS care particularly in the more remote and rural “dental deserts.”

Promote prevention
Scotland has much to be proud of in relation to oral health improvement measures – in particular the “ChildSmile” programme, however they were badly hit by the pandemic period. A continued commitment to funding these programmes by all political parties in Scotland is a crucial part of fighting oral health inequalities.

Reform the NHS dental contract
The Scottish National Party has promised to abolish all NHS dental patient charges over the lifetime of the current Parliament and “shape a reformed funding arrangement for NHS dentists, so that they are supported for the future.” We welcome the ambition for a more administratively simpler and more clinically focused system which needs to come out of the current reform process to ensure a sustainable future for NHS dentistry which attracts and retains NHS dentists in Scotland.

Neil Carmichael, Chair of the ADG, said: “The latest statistics are a stark warning of the growing oral health inequalities in Scotland. Barely half of all “registered” patients have seen an NHS dentist in the two years to September 2022. Of even more concern, children and adults from the most deprived areas were much less likely to have seen a dentist in the past two years – by a margin for children of 55.9% compared to 75.8% – the highest reported difference.

“Access cannot improve without building the workforce – since 2019 the number of dentists providing NHS care in Scotland has fallen 10%. Our own members have found that recruitment difficulties mean parts of Scotland are becoming “dental deserts,” with more deprived or rural areas having fewer NHS dentists than those in more affluent areas.”

Missing teeth – aetiology, diagnosis and management

Brian Bourke, non executive director from Dentists’ Provident, reviews the aetiology, diagnosis and management of missing teeth in this article, an abridged version of which appears in CPD 4 DCPs Volume 16

A tooth or teeth may be absent from the mouth for several reasons:

Extraction or traum
Tooth agenesis
Failure to erupt into the mouth

When a tooth is missing following extraction, the cosmetic effect of the space, the impact of the space upon the other teeth in the dental arch and upon the occlusion may, individually or in combination, lead to a desire for orthodontic treatment. A space may be accepted, closed by orthodontic treatment or filled by a dental prosthesis. Such a prosthesis may be soft tissue-, dentally- or implant-borne.

Examples of such prostheses in order include: an acrylic partial denture, a resin-bonded bridge and an implant crown or bridge. Depending upon the age of a patient at the time of extraction, it may be appropriate to close a space if orthodontic treatment is required for other reasons such as moderate to severe dental crowding or dental centreline issues. Balancing (contralateral side of the dental arch) and compensating (opposing dental arch) extractions, however, may then be required in order to treat to a symmetrical outcome with a satisfactory occlusion.

Failure to note the absence of a tooth in the mouth at examination can lead to undesirable clinical consequences, especially where the tooth is present but unerupted. At any dental examination, it is important to count the teeth present carefully and to note any dental unit which is absent. If a tooth, other than a third molar, is missing but has not been extracted, or naturally exfoliated in the case of a child presenting with deciduous teeth, then it is either congenitally absent or unerupted.

Presentation of a missing tooth

Depending upon the age of the patient, it may be that the tooth is present and delayed in eruption, so there may be no cause for concern, unless this delay is significant. A significant delay indicating further investigation is where a tooth is absent from the mouth and 6 months have passed since the eruption of the contralateral tooth.

If a tooth is missing due to a failure in development, the condition is referred to as hypodontia. The condition may be further classified as:

Hypodontia – 1 to 5 teeth absent
Oligodontia – 6 or more teeth absent excluding third molars
Anodontia – complete absence of teeth

Failure of a tooth to develop may be due to environmental or genetic factors. Environmental factors are those which have a negative impact upon early tooth development by physical or chemical means such as trauma, high dose irradiation, drugs such as trans-placental Thalomide and endocrine disturbances such as Hypoparatharoidism and Pseudohypoparathyroidism.

Genetic factors include Idiopathic Hypodontia, which can have a family history and conditions such as Ectodermal Dysplasia, Cleft Lip and Palate and Downs Syndrome¹. Mutations in a number of genes including MSX1, PAX9 and EDA are commonly involved in hypodontia of genetic aetiology². The teeth which are most frequently congenitally missing are those which are most distal in their series in the dental arch, namely: the lateral incisor, the second premolar and the third molar³. When third molars are included, up to 20% of the population are missing one or more teeth; when third molars are excluded, this percentage drops to approximately 5% of the population.

Hypodontia in the deciduous or primary dentition is relatively rare, occurring in 0.5%-0.9% of children⁴. When a deciduous tooth is congenitally absent, however, the successor tooth of the permanent dentition will also be absent. This is thought to be due to the development of permanent incisors, canines and premolars arising from a tooth bud that forms through further proliferation of cells on the lingual aspect of the deciduous tooth germ proliferating from the embryological dental lamina⁵. Consequently if the deciduous tooth germ fails to develop into a tooth, the permanent successor will also be absent.

The negative consequences of hypodontia are multiple including size and shape anomalies in the teeth which are present such as peg-shaped lateral incisors, enamel hypoplasia, spacing and occlusal discrepancies such as deep overbite, due to a lack of posterior occlusal support and occasionally due to the microdont nature of the incisors, which can occasionally accompany hypodontia. The cosmetic impacts of hypodontia upon psychosocial development can be significant.

Tooth eruption failure

The third principal reason for a missing tooth or teeth is through eruption failure: in other words, the tooth has developed but has failed to erupt into the mouth. Causes of eruption failure include:

Dental crowding
Ectopic development
Physical obstruction
Abnormal physical development
Primary Failure of Eruption

Dental crowding can precipitate a situation where a tooth which erupts at a later stage, such as a permanent canine, has insufficient space available in the dental arch due to encroachment of the earlier erupted lateral incisor and possibly the first premolar, into the canine space. This can be exacerbated by premature exfoliation of the deciduous canine, thus facilitating this encroachment with accompanying drifting of the dental centreline between the central incisors to the affected side. The permanent canine will usually be evident as a bulge in the buccal sulcus or under the buccal attached gingival tissues. In most such occasions, the permanent canine will erupt into a buccally crowded position but in a minority of cases, the permanent canine will become impacted in the line of the arch and will fail to erupt.

Ectopic development, or more usually, an ectopic path of eruption is frequently associated with palatal impaction and eruption failure in maxillary permanent canines. Impaction or ectopic eruption of the permanent maxillary canine occurs in approximately 1-2% of the general population⁶ with palatally ectopic canines occurring with twice the frequency of buccally ectopic canines⁷. The maxillary permanent canine should be identifiable as a bulge high in the maxillary buccal sulcus in a child aged 9-10 years. If there is an asymmetry in the presence of this buccal sulcus bulge, or if neither canine is palpable by 10-11 years, then further investigation is indicated⁸.

A radiograph such as an Orthopantomograph or Dental Pantomograph will illustrate the teeth that are present and give some information as to the location of any unerupted teeth. This radiograph alone, however, will not usually be sufficient to locate the position of the ectopic maxillary canine should this tooth not be palpable buccally. It should also be remembered that a severely ectopic tooth may fall outside the focal trough of a dental tomograph and thus be overlooked. In order to locate the position of an ectopic canine with 2-dimensional radiographic imaging, it is usual to expose two intraoral radiographs, such as periapical views, of the canine applying a Horizontal Parallax technique. This involves exposing two radiographs of the maxillary canine region from two different directions of source of the X-ray beam, or, alternatively, an OPT and an intraoral periapical radiograph with camera angle shift. Vertical parallax can also be employed using an intraoral periapical radiograph or occlusal radiograph and an OPT.

It is desirable to have as large an angular shift in the horizontal (or vertical) plane as possible when carrying out this technique. When the two radiographs of the unerupted maxillary canine are compared, the change in position of the unerupted canine relative to the erupted adjacent teeth will indicate where the canine lies bucco-lingually. When using the horizontal parallax technique, the object which is further away from the source of the X-rays, in this case, a palatally ectopic canine, appears to move in the same direction as the X-ray camera source when the two x-ray images are compared. If the canine appears to move in the opposite direction to the X-ray source, then the canine is buccal to the dental arch.

The acronym SLOB (Same – Lingual(palatal), Opposite – Buccal) is helpful in remembering how to apply the parallax technique. If there is no shift in position of the canine, this indicates that the canine lies in the line of the dental arch⁹. In the great majority of cases, this technique will be sufficient to establish the location of the unerupted canine. There are occasions, however, such as when the unerupted ectopic canine has caused some root resorption of the upper lateral or central incisor, where a three dimensional image like a Small Field of View (FOV) Cone Beam CT (CBCT) scan will provide further information which may guide the management of the case. In cases of moderate to severe incisor resorption, the damaged tooth may have to be extracted and in such a situation, it is usually desirable to preserve the canine if possible and to incorporate it into the dental arch.

Physical obstruction of the path of eruption of a tooth can cause eruption failure. Examples of this include the presence of supernumerary teeth impeding the eruption of underlying teeth, as in the case of an upper midline supernumerary tooth and an unerupted upper central incisor. Multiple unerupted teeth associated with overlying supernumeraries is a classic feature of Cleidocranial Dysostosis. The presence of local pathology such as an odontome, a cyst or a tumour can also impede the eruption of a tooth. The surgical removal of the impeding object will usually allow the unerupted tooth to erupt, but in some cases assisted eruption with orthodontics is required.

Abnormal physical development can cause failure of eruption when the root of the tooth has been harmed or distorted during its pre-eruption development. Severe root dilaceration, where trauma on a developing permanent tooth germ through an impact in early childhood that caused intrusion of the deciduous tooth overlying it, can cause malformation in the root of the permanent tooth. This is most frequently seen in the roots of permanent maxillary incisors and can often lead to a distortion or dilaceration in the root of the affected incisor by up to 90o, which in most instances prevents eruption of the dilacerated incisor.

Primary Failure of Eruption is a rare condition with a prevalence of 0.06%¹⁰. It can affect deciduous or permanent teeth but is more common in the permanent dentition. It is most frequently observed in molars and premolars and all teeth distal to the most medially affected tooth tend to be affected¹¹. Affected teeth may exhibit complete or partial failure to erupt and are prone to ankylosis.

Management

The management of a space in the dental arch will normally involve one of the following options:

Accept
Orthodontic space closure
Orthodontic alignment of the unerupted tooth/teeth
Autotransplantation
Prosthetic replacement of the missing tooth or teeth

Accepting a space or gap may be the preferred option for a patient who is not interested in active treatment, cannot access orthodontic or restorative dental care, has poor oral hygiene or has health problems which contraindicate complex orthodontic or restorative dental care. The space of a missing tooth in the posterior region of the mouth may not present a significant cosmetic or functional problem for the patient and they may be content to live with the space. It is important, however, to inform the patient: of the risks of leaving an unerupted tooth in situ, of further tooth movement of adjacent teeth into the space and of the possibility of over-eruption of an opposing tooth if it is not in occlusion.

If a tooth is absent from the mouth, it may be feasible to close the space as part of an orthodontic treatment plan. This may involve extractions, e.g. of premolar teeth, in other quadrants, if there is significant dental crowding present and subject to the nature of the patient’s occlusion. If an upper lateral incisor is congenitally absent, there is usually a choice to be made as to optimising the size of the space with orthodontic treatment in order to facilitate prosthetic replacement of the missing incisor or closing the space with modification of the permanent canine to mimic the missing lateral incisor. The nature of the presenting malocclusion and the position of the upper dental centreline, the size, colour and shape of the permanent canines and their suitability to mimic one or both lateral incisors and the size and shape of the first premolars and their suitability to take the place of the maxillary canine are some of the factors which must be examined before finalising a treatment plan. The advantage in closing the space of an upper lateral incisor is that it avoids the need for prosthetic dental treatment and aftercare for the rest of the patient’s life with its associated financial and time costs.

Orthodontic alignment of unerupted teeth following their surgical exposure is often a treatment option of choice for ectopic unerupted maximally canines. This treatment is not exclusively carried out for canines, however, as many favourably positioned unerupted teeth should be amenable to orthodontic extrusion and alignment in the absence of major contraindications such as poor oral hygiene or poor general health. When a maxillary canine is ectopic and unerupted, the age of the patient will be a determinant in how best the case is managed. Children from the age of 8 years should be assessed at their routine dental examinations to confirm that the maxillary permanent canine can be palpated as a bulge in the buccal sulcus. If it is not palpable by age 10 years, then further investigation is indicated8. In specifically selected cases, a palatally ectopic maxillary canine will improve in position following the extraction of the deciduous canine precursor. If the permanent canine is going to respond favourably, it usually does so within a year of the primary tooth extraction. A general dental practitioner should seek the advice of a specialist in orthodontics or consultant orthodontist colleague before proceeding with such an intervention.

In the event that the maxillary permanent canine fails to erupt, it must be assessed in terms of its suitability for surgical exposure and orthodontic alignment. Factors such as the location of the ectopic tooth must be established. It is important to note the distance of the ectopic canine from its target position in the dental arch in terms of: height relative to adjacent roots, mesio-distal position and angulation to the occlusal plane. It is also important to examine for root resorption affecting the roots of adjacent teeth due to proximity of the canine crown or pathological activity of an enlarged dental follicle or follicular cyst associated with the canine. The options for an ectopic canine are: to accept its position with appropriate monitoring, surgical extraction or accommodation of the tooth in the dental arch, which usually requires surgical exposure and orthodontic alignment. Historically, transplantation of the canine following its surgical removal into a surgically prepared socket in the dental arch was occasionally attempted but most of these cases resulted in failure and loss of the tooth, usually due to resorption of the root.

Where a tooth has been lost due to trauma, such as the traumatic avulsion of an upper central incisor, the option of autotransplantation of the lower first premolar may be considered. A high success rate is associated with this approach if it is carried out in the 10–14-year-old age group before apical development of the lower first premolar root has completed to closure¹².
A missing tooth space can be filled by a dental prosthesis. This may be removable, as in a partial denture which may be soft tissue borne (usually acrylic partial denture) or a combination of dentally borne and soft tissue borne (Cobalt Chromium partial denture). A prosthetic replacement for a missing tooth may be fixed in the form of a bridge (adhesive or full coverage) or implant borne.

Dental implants have become a popular choice for replacing missing teeth for many patients in recent years but for a successful long-term outcome, careful planning and execution and effective oral hygiene measures are essential. Smoking is a particular problem for the long-term survival of dental implants due to the negative effects of smoking upon the periodontal tissues and upon vascular health in the bone around an implant. There is some evidence that ongoing growth in the vertical dimension throughout adult life can cause cosmetic problems with relative intrusion of an anterior implant borne crown compared to the adjacent teeth¹³. This is particularly a matter of risk when an implant is fitted in later teenage years or in the early twenties, before vertical facial growth slows to its long-term adult rate, especially in patients with long faces and high maxillo-mandibular planes angles.

The appropriate management of missing teeth requires careful and timely investigation and, as such, it is usually in the primary dental care setting where this condition is first noticed and where the processes of diagnosis and treatment begins.

About the Author

Brian Bourke is a retired specialist in orthodontics, based in Cheltenham and a non-executive director of Dentists’ Provident, a leading provider of income protection insurance to the dental profession.

He has been an examiner for Fellowship of the Faculty of Dentistry of the Royal College of Surgeons in Ireland in orthodontics since 2011. He has previously been a Consultant Orthodontist and Head of Department at St. Columcille’s Hospital in Dublin, Chairman of the Orthodontic Advisory Committee of the Royal College of Surgeons in Ireland, member of the Specialty Advisory Committee in Orthodontics of the Royal College of Surgeons of England and Chairman of the Gloucestershire Orthodontic Managed Clinical Network.

References

Al Shahrani I, Togoo RA, Al Qarni MA. A review of hypodontia: classification, prevalence, etiology, associated anomalies, clinical implications and treatment options. World J Dent 2013;4:117–25. 10.5005/jp-journals-10015-1216
Cobourne MT. Familial human hypodontia—is it all in the genes? Br Dent J 2007;203:203–8. 10.1038/bdj.2007.732
Jorgenson RJ. Clinician’s view of hypodontia. J Am Dent Assoc. 1980;101:283–286.
Mehta V and Singh RK, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073584/ – Congenitally missing primary and permanent maxillary lateral incisors
Maria Hovorakova, Herve Lesot, Miroslav Peterka and Renata Peterkova. Early development of the human dentition revisited. J Anat. 2018 Aug; 233(2): 135–145. Published online 2018 May 10. doi: 10.1111/joa.12825
Fleming P, Scott P, Heidari N, Dibiase A. Influence of radiographic position of ectopic canines on the duration of orthodontic treatment. Angle Orthod. 2009;79:442–6.
Cooke J, Wang HL. Canine impactions: Incidence and management. Int J Periodontics Restorative Dent. 2006;26:483–91.
Husain J, Burden D, McSherry P, Hania M. Management of the Palatally Ectopic Maxillary Canine. https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/clinical-guidelines/
Singh WS, Pallak A, Kumar JA and Rahul S. Localization of Impacted Maxillary Canine: Comparative Evaluation of Radiographic Techniques. Journal of Nepal Dental Association – JNDA. Vol 15, No.1, Jan-Jun 2015
Baccetti T. Tooth anomalies associated with failure of eruption of first and second permanent molars. Am J Orthod Dentofac Orthop. 2000;118(6):608–610. doi: 10.1067/mod.2000.97938.
Proffit WR, Vig KW. Primary failure of eruption: a possible cause of posterior open-bite. Am J Orthod. 1981;80:173–190. doi: 10.1016/0002-9416(81)90217-7.
Stange KM, Lindsten R and Bjerklin K. European Journal of Orthodontics, Volume 38, Issue 5, October 2016, Pages 508–515, https://doi.org/10.1093/ejo/cjv078
Anna Klinge, Sofia Tranaeus, Jonas Becktor, Nicole Winitsky & Aron Naimi- Akbar (2021) The risk for infraposition of dental implants and ankylosed teeth in the anterior maxilla related to craniofacial growth, a systematic review, Acta Odontologica Scandinavica, 79:1, 59-68, DOI: 10.1080/00016357.2020.1807046

A light at the end of the tunnel?

It’s no secret that, even prior to the COVID-19 pandemic, the dental recruitment landscape was suffering. Large swathes of dental professionals, from dentists to dental nurses, were leaving the profession, or cited that they were considering a career change. Many feel burdened by the patient backlogs, skeleton teams and their NHS commitments. Exacerbated by the cost-of-living and energy crises, many patients are left unable to find an NHS dentist and access the care they need.

It’s abundantly clear that real change is needed to help dental professionals and their patients. Interestingly, there have been talks about the General Dental Council (GDC) legislative framework for international registration overseas, with proposals made to make the pathway for candidates easier. What could this mean for dental recruitment?

Practising in the UK

According to the GDC, approximately a third of new registrations in 2021 were dental professionals who gained their primary qualification outside of the UK.[i] 30% were EU, European Economic Area (EEA) or Swiss qualified, while 9% had qualified elsewhere.[ii] Clearly, dentists who have gained their qualifications overseas make up a large percentage of our workforce, but the pathway for them is far from easy. One route for dentists who are qualified abroad is to sit the Overseas Registration Exam (ORE), in order for them to become registered with the GDC. Essentially, those who wish to practise dentistry in the UK must demonstrate their ‘competence, knowledge and familiarity’ with various areas within dentistry through the ORE.

It’s important that dentists who wish to practise in the UK are able to demonstrate that they can practise safely, for obvious reasons, but common complaints made about the ORE are the high fees, limited capacity and the fact the exam is split into two parts, which candidates must apply to separately. To further exacerbate the issue, the pandemic meant that the exams were suspended, leaving many candidates in a frustrating position. The recent announcements about potential reforms to the legislations surrounding international candidates and registration will, undoubtedly, be welcome by many, but what will it actually mean for dentistry?

What does this mean?

In order to allow the GDC to streamline the international registration process, the government is considering putting into place several proposals that were put forward. This comes as a result of a public consultation, conducted by the Department of Health and Social Care (DHSC), which sought views from both the GDC and Nursing and Midwifery Council (NMC). One of the reforms tackled in the public consultation was: ‘The requirement that an assessment for overseas dentists, such as the Overseas Registration Exam (ORE), must be provided by dental authorities, or a group of dental authorities, is removed’. Another was to grant the GDC the flexibility to ‘apply a range of assessment options’ to determine if international dentists and dental care professionals (DCPs) are fit to practise dentistry in the UK. Another outcome was to make up the lost time for candidates seeking to sit the ORE, but had to put it on hold due to COVID-19.

Hope on the horizon?

These proposals would allow the GDC more flexibility to make the registration route easier for individuals, while still ensuring that they demonstrate the standards necessary to practise in the UK. Some have voiced their concern that these changes are simply to fill in the widening gaps in the UK dental workforce – is this the case? The ripples caused by the numerous societal crises in the past few years continue to be felt, that can definitely be confirmed. Dentists and DCPs are leaving the profession, patients are unable to receive the care they need… a higher number of dentists and DCPs is not an unwelcome prospect. However, change to the rigid legislation would simply make the overseas registration process easier for those wishing to practise in the UK, giving those individuals more agency and the ability to plan more effectively for their careers and life in the UK. It’s not a total remedy to our recruitment crisis, but it may help make the pathway more straightforward for our overseas dentists and DCPs, who do make up a considerable proportion of our workforce.

As always, it’ll be some time before the changes made by these proposed reforms are felt by the wider profession and their patient bases. But, it’s a positive step forward nonetheless, to make the process less stressful for candidates, while ensuring they can still provide exceptional levels of dentistry.

For more information contact Dental Elite. Visit www.dentalelite.co.uk, email info@dentalelite.co.uk or call 01788 545 900

Lisa McCusker – Legal Recruitment Consultant at Law Elite
Lisa joined the Law Elite team in 2015. Her chief responsibility is to source legal jobs from law firms nationwide, and to provide her candidates with the opportunity to develop their career further within law. Providing outstanding candidate and client care is paramount to her work.

[i] www.gdc-uk.org. (n.d.). Reform of legislation governing international routes to registration moves a step closer. [online] Available at: https://www.gdc-uk.org/news-blogs/news/detail/2022/11/30/reform-of-legislation-governing-international-routes-to-registration-moves-a-step-closer [Accessed 18 Jan. 2023].

[ii] GOV.UK. (2022). Changes to the General Dental Council and the Nursing and Midwifery Council’s international registration legislation: government response. [online] Available at: https://www.gov.uk/government/consultations/changes-to-the-general-dental-council-and-the-nursing-and-midwifery-councils-international-registration-legislation/outcome/changes-to-the-general-dental-council-and-the-nursing-and-midwifery-councils-international-registration-legislation-government-response#:~:text=the%20GDC%20will%20be%20able,qualifications%20which%20reflect%20UK%20standards[Accessed 19 Jan. 2023].

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