Tuesday, 16 January 2018

Crisis at Christmas 2017

After last year's post about Crisis, of course it's clear that I wouldn't resist returning for another year volunteering to help the homeless population access dentistry at Christmas.

One of the dental vans in use this year


To learn more about Crisis, read my post from last year here

This year, I decided to volunteer at the other centre in South London and also on the set-up day. 


Setting-up Day


The first day that you can volunteer for Crisis at Christmas is the set-up day. Each centre (usually  at a school) needs to be made ready for guests to visit and stay over the Christmas period. For the dental team, this mostly is making sure the vans are ready to be used. 

I have worked on mobile dental units not only last year at Crisis, but also during my time working in my community dental service - but usually by the time I arrive, the van is all ready to go! The 2 vans donated by the community dental services (Kings, Bedford CIC, KCHFT) needed to be plugged and piped in. The process was useful for me to see especially as I am now heading out more in our dental van (in fact one of the vans donated to Crisis), so I can now rely on our drivers much less! 

We made sure not only each van was up and running, but also fully stocked up. As well as the vans, we also decorated the guest's waiting area with copious amounts of Christmas decorations that were kind donations. 

One of the most challenging parts of the day was setting up the decon area (a challenge for many dentists at the most of times!), in one of the school labs once we established how to turn the main water switch on. Aaaand with that we were READY!


Treatment Day


The next day, our Crisis team fully assembled with tinsel and wearing our best smiles, we set about treating the first Crisis guests of the year. 

I spent the morning on my van seeing whoever wanted to see us for whatever they may need or want! This included simple scale and polishes, fillings, extractions and I painted fluoride wherever I could. I loved chatting with the guests, especially learning about their backgrounds and personalities. Quite a few of the guests weren't British and required someone to translate especially when taking consent or filling in medical histories, but there were plenty of multi-lingual volunteers around. 

Despite it only being the first day, it was non-stop on the vans all day. In the afternoon, I split my time between running instruments between the vans and decon, attempting to sterilise instruments (and then immediately dropping them on the floor!) and drumming up business around the centre itself. 

Drumming up business also meant we got to check out what was going on in the rest of the centre, which included some classic karaoke and we spotted the hairdressers who seemed just as busy as we were!

I met some fantastic people in these 2 days and it was really nice to see everyone pull their weight and work together as a team so the service could run as smoothly as possible for the first day!

Our fantastic Crisis Team for Day 1

This year Crisis saw 431 guests of exams and treatment and amazingly this year for the first time ever, the other dental centre piloted a denture service which provided 24 dentures. Before this year, Crisis was unable to provide dentures for the guests and from my experience of seeing homeless patients so far, dentures are one of the most common requests when seeing a dentist. Thanks to DenTech for providing this service!

Once again, I had a fabulous time at Crisis and cannot recommend it enough if you have spare time over the Christmas period.

Bring on Crisis 2018!


Have you volunteered for Crisis Experience? What was your most memorable moment?  Let me know in the comments below. 

Thursday, 14 December 2017

MRONJ: SDCEP's NEW Guidance

An update following my previous post a couple of years ago about bisphosphonates, this post is based on a talk by Claire Curtin who spoke at the Royal College of Surgeons Special Care Dentistry Study Day. 



What is MRONJ?


'Medication Related Osteonecrosis of the Jaw' (previously BRONJ, bisphosphonates), is an area of exposed bone, or bone that can be probed through an intra-oral or extra-oral fistula, in the maxillofacial region that has persisted for more than 8 weeks in patients with a history of treatment with anti-resorptive or anti-angiogenic drugs, and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease to the jaws. 

Cause is unknown, but is likely to be multi-factorial (genetics and environment). Mechanisms are likely to be:
  • Suppression of bone turnover
  • Inhibition of angiogenesis
  • Toxic effects of soft tissues
  • Inflammation
  • Infection


What medications can cause MRONJ?


1. Anti-resorptives: Bisphosphonates (These carry a life-time risk of MRONJ), Denosumab (The risk diminishes 9 months after completion of treatment)

2. Anti-angiogenics: Bevacizumab, Aflibercept, Sunitinib

These drugs are used to treat: 

  • Osteoporosis
  • Prevention of cancer complications e.g. fracture, bone pain
  • Treatment of non-malignant bone conditions e.g. Paget's
  • Slow cancer progression
  • Treatment of multiple myeloma
The incidence of MRONJ in people with osteoporosis is 0.01%-0.2%, whereas people who have cancer is around 1%. The risk is thought to increase if both types of medications are taken (and if steroids are added into the mix). 



How to Manage?


1. Identify patients at risk


  • Full medical history is key
  • Have they been prescribed any relevant medication now or in the past?
  • How long for?
  • What condition do they have?
  • Do they have a history of MRONJ?
  • Are they taking any steroids?

2. Classify the patient's risk


  • LOW RISK - taking bisphosphonates < 5 years or Denosumab < 9 months with no steroid usage
  • HIGH RISK - receiving the treatment for a malignant condition, taking bisphosphonates > 5 years, steroid usage or a previous history of MRONJ

3. Patient Education and Prevention


  • Ideally prior to any prescription of anti-resorptive or anti-angiogenics a full dental assessment and prevention regime should be implemented. 
  • Any extractions or treatment to minimise mucosal trauma should be prioritised e.g. denture eases
  • Encourage patients to cessate smoking, have a healthy and balanced diet and see their dentists for regular check ups

4. Treatment


  • LOW RISK - Carry out extractions as normal, no need for prophylactic antiseptics or antibiotics. Review in 8 weeks
  • HIGH RISK - Seek alternatives to extractions if possible e.g. RCT; otherwise carry out extractions as normal, no need for prophylactic antiseptics or antibiotics. Review in 8 weeks

5. Identify and refer suspected MRONJ cases


  • Educate patient about symptoms e.g. tingling, numbness, pain, altered sensation around the extraction socket
  • Signs are exposed bone after 8 weeks
  • Always refer if in doubt

6. Report MRONJ via the Yellow Card Scheme




Many thanks to Claire Curtin and the RCSEd for organising the study day. Please read the full guidance from SDCEP for further information. 


What do you think about the new guidance and what's your experience of MRONJ? Let me know in the comments below. 


Tuesday, 28 November 2017

Careers In Special Care Dentistry: RCSEd Study Day

Thinking of a career in Special Care Dentistry? I recently attended a study day with the Royal College of Surgeons of Edinburgh which helped me understand what options there are out there in Special Care....



Routes to Specialisation

There are 2 main ways to specialise in Special Care Dentistry:


1. Special Care Registrar Training (SPR/STR)

A 3 year training pathway which may include opportunities to do a Masters in Special Care or the RCS Diploma (see below). 

These posts at the moment are released on Oriel on a regional basis but it is planned by 2018 to be a national recruitment process much like some of the other specialities e.g. orthodontics. Posts can be purely based in the community, in secondary care or a mixture of both. Following the 3 years training you will then take Royal College Exit Exams to become a Specialist (as well as completed a portfolio, competencies etc.). 

2. Special Care Academic Clinical Fellow

As above, another 3 year training pathway but divided into 75% clinical training and 25% academic. The target following any ACF post is to secure funding for a pHD and become an academic. 

The day to day timetable is very similar to an SPR. These posts are usually funded by the university rather than a deanery. 


The Royal College of Surgeons Diploma


The Royal College of Edinburgh offer a Diploma in Special Care Dentistry for those who wish to grow their portfolio and qualification in Special Care Dentistry. The diploma is available to those who can demonstrate experience in working in a special care environment for 1 year e.g. community. The diploma consists of 4 parts:
  • Log book of clinical experience relevant to Special Care Dentistry 
  • Case presentations x 2
  • 7 Unseen Cases Exam
  • Simple Best Answer Exam

The exam takes place twice a year, the next sitting is in March. For more information see the RCSEd website



Where do Specialists work?


Of course this doesn't just apply to specialists; there are plenty of clinicians with lots of experience in Special Care Dentistry who are not on the Specialist Register, especially since SCD is the newest dental speciality! In general, there are 3 environments that specialists can work:
  • In general practice (NHS or private)
  • In community dentistry/salaried dental services
  • In secondary care e.g. dental hospital
Often, specialists may divvy up their time in more than one environment. They can also be involved in other areas of dentistry e.g. commissioning, education. Broadly, most SCD specialists work within the NHS; however, there are skills SCD have that are highly valued in the private sector too e.g. sedation skills. 

SCD is a unique speciality as it encompasses all areas of dentistry. This means that specialists will have a broad range of skills in all areas of dentistry: from surgical extractions to molar endodontics! 


Many thanks to those who spoke on the day not just about careers, but some common topics that I experience (and often need help with!) throughout my day to day life in community! 



Is a career in special care dentistry for you? Are you on a specialist training pathway? Let me know in the comments below. 


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