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Teeth and a Sun Tan??

Anybody who knows me well, will be aware that I am a bit of a collector of dental text books. Over the years I have bought dental books on tooth morphology, local anaesthetics, pharmacology, extractions and so many on root canals! One of my favourite books is actually one on Porcelain Laminate Veneers. This is not because I do loads of veneers (I actually don't do that many!) but the book, written by a fabulous dentist called Galip Gurel, is just awesome! Dr Gurel is an amazing dentist from Istanbul. The book is beautifully presented with amazing photography and the smile results are stunning. It brings me on to the point of this blog which is about having treatment abroad.

Lately there seems to be a trend in having dentistry abroad; Turkey and Goa spring to mind. Predominately the reason behind this seems to be due to the cost savings....... and maybe having a holiday at the same time! Personally I am not sure if going to the dentist whilst on holiday would be my idea of a nice break but each to their own.

I am often asked by patients about my thoughts on going abroad to get treatment done. My feelings are always the same; there are fantastic dentists all over the globe. For instance, you would be very lucky to go to have veneers done by Dr Gurel....... but if you are not going to see him then you just have to pick your clinic wisely. You have to thoroughly research the clinic and the dentist who will be carrying out the work. I also personally feel that extensive treatment needs to be planned carefully and often the 'planning' stage takes far longer than the 'doing' stage. The planning bit is so vitally important. Planning veneers for instance, often involves taking photographs, radiographs (x-rays), assessing oral hygiene, thoroughly examining the bite and how the teeth move over one another, making wax ups (trial versions of the veneers), trying in trial veneers and making sure the foundations are perfect before starting treatment. Personally I couldn't plan extensive treatment if a patient just sent me a couple of photographs of their teeth from their phone. After all the planning is completed, and we are all on the same page (sometimes what patients want and what the dentist thinks they want can be two different things!), the teeth are prepared, the bite is recorded and trial veneers are sometimes fitted to make sure the patient is happy with the appearance and checking function, comfort and aesthetics. It also give the gums time to settle before making and fitting the new veneers. This can take a number of weeks with adjustments and tweaking things before communicating this with the laboratory and having the veneers made properly.

There are various types of porcelain which may be used. Some porcelain can be harder than others but may not be as aesthetic/natural looking. Some can be bonded to tooth structure and some can't. For instance, I may use Zirconium Porcelain on back teeth where aesthetics are less important but strength is required, whilst I would endeavour to use Emax (lithium desilicate ceramic) crowns on front teeth where aesthetics is vital.

There is definitely a worrying trend to have a full mouth of Zirconium crowns. Zirconium on front teeth may not as easily match the aesthetic appearance of natural teeth.

I was very saddened recently to see some photographs of a patients' daughter who had been abroad and had 24 Zirconium crowns fitted (12 upper and 12 lower teeth). I never examined the lady, I only saw photographs on her Dad's phone of her before and after the treatment. She was a pretty girl with very nice natural teeth before having the crowns done. There was some very minor crowding but they were a nice feminine shape and with a bit of whitening, maybe the odd position correction with composite bonding they would have been as perfect as you could get with very minimal dental commitment. However, she had gone and had 24 Zirconium crowns. This would have involved extensive drilling down of healthy tooth structure to fit the porcelain crowns over the top. They were Hollywood white and all very similar in shape and length. I much preferred the natural appearance before!! (Personal choice!) I often joke that undergoing this level of treatment leaves you married to the dentist- you are potentially stuck with having dental treatment for the rest of your life.

Lets get slightly more serious, CROWNS CAN KILL TEETH- there we are, I have said it. Crowns can kill teeth and bridges can do it quicker! Around 20% of teeth which are crowned become non vital.

How does this work?

What does this mean?

This means if 10 teeth are crowned there is a high risk that 2 out of these teeth will die and potentially become infected, leading to a dental abscess and needing root canal treatment or extraction. If, like in the sad situation above, 24 teeth are crowned it is highly possible (based on the evidence) that around 6 will have nerves which eventually die! Thats scary!! This becomes more likely with teeth that have been heavily reduced (drilled down) to alter their position in the smile or when full coverage thick all porcelain crowns are used.

Why does this happen? When we anaesthetise teeth for crowns we use local anaesthetic. The Local Anaesthetic contains a vasoconstrictor to reduce the blood supply to the area keeping the local anaesthetic from being washed away- so it works longer. This means the tooth is initially compromised by having a reduced blood supply- at least in the short term whilst the tooth is prepared. Therefore it is less able to respond when undergoing the preparation phase (drilling down) part of treatment. After the tooth is drilled down, various impressions are taken and when temporary crowns are fitted, an acrylic resin is used. This resin becomes warm when it sets- remember chemistry at school- these under go an exothermic reaction. We actually had some temporary crown material recently which we sent back because it potentially became too hot when we practised with it before using it. A 9 degree rise in tooth pulp temperature can lead to irreversible pulp damage. The pulp can be heated up also if when drilling, insufficient water coolant is used.

Temporary crowns are cemented and the cement can irritate the teeth or if they are not cemented then bacteria can creep under them resulting in pulp irritation. Then the long term cement used to stick the crowns will cause pulpal irritation. Long term the crown margins will leak leading to bacteria from saliva penetrating and causing pulp irritation or even tooth decay under the crown.

The lifespan of a crown varies. Personally I feel there are two components to life span- One is the aesthetic life span (how long does it continue to look good for) and the other is how long does it ultimately last. Most crowns or veneers look good for the first 5-7 years- sometimes more, sometimes less. After this you may then start to notice more recession around the gum line. In terms of functional lifespan then crowns can last 20-30+ years but realistically 10-15 would seem a sensible figure to aim for depending on the foundations, how well they are looked after and the occlusion (bite of the patient).

Doing root canal treatment through these Zirconia crowns can be really difficult because they are incredibly stubborn to drill through. The one guarantee we can give to patients who have crowns/veneers etc is that one day they will fail!! Sadly nothing lasts forever and one day they are likely to require some further treatment. Tooth structure is incredibly precious and we need to do everything we can to preserve tooth structure and the old days of drilling them down for crowns and veneers should be a distant memory. We aim now to practice minimally invasive dentistry. Moving teeth with simple orthodontics (e.g Invisalign), whitening teeth and subtly modifying the appearance with reversible composite resin should always be the gold standard..... but this requires patience and planning and many people are after a quick fix.

The biggest problem with having treatment abroad is that when it fails, where do you go to get it fixed? Or if you have problems or discomfort do you have to book another flight to go back? It is so much more costly when it comes to repairing problems. Problems don't always present themselves early on but later down the line. Irritation of the gums due to crown margins can cause inflammation, gum recession and bone loss but this won't present straight away. Gum recession can then result in visible margins and dark lines around the crowns at the gums.

Implants abroad can be an even bigger problem. This is often due to different systems used abroad. Implants are a bit like mechano (or even LEGO to the younger readers). There are various screws and fixtures with implants and each system will have its own bits -lots of the systems don't match the others- a bit like needing a flat screwdriver and only having a Philips one!

Some of the cross infection standards in other countries are not regulated like the UK. We are the only country in the world where root canal instruments are discarded after one use. Our instruments are single patient use- they aren't abroad. Evidence has shown that root canal instruments cannot be cleaned after use. The instruments also pick up debris with each use which increases the risk of fracture.

As a profession we are regulated by the General Dental Council and we all must have Dental Indemnity (Insurance). This is not the case in all countries. Would your holiday insurance cover you if you were ill whilst you were having treatment done? What happens if you have a reaction to the local anaesthetic or another material which is used? Do they have the same emergency drugs available? Do they undergo the same training to look after you?

I have some amazing dentist friends abroad who I would trust without hesitation- America, Canada, Italy, Portugal, Germany and .....the Isle of Man (thats abroad isn't it!?)

But the moral to the story is to research your clinic wisely, consider the long term implications and be prepared of how you can deal with it when you come home if you have problems.... and how you fund it. Work out both the short term and the long term costs.

Have a chat with your regular dentist in the UK to gather their potential thoughts on treatment. See what the treatment plan in the UK would be.

Have a happy holiday!

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