Wednesday, 29 October 2014

Top 10 Hot Topics in Dentistry

So those of you whose DF1 interviews are swiftly approaching may want to know what topics are popular to discuss recently and may come up in one of the stations.

Here is an overview of some of the hot topics in dentistry at the moment:

1. ARF hike

A very contentious issue at the moment. A proposed 64% increase to £945 annual fee to maintain your registration with the GDC; their reasoning being the increased litigation they have to deal with recently pushing up their own costs.

The decision will be taken on October the 30th and there are currently 3 fee levels proposed ranging from £850 to £945.
As a young dentist, this issue really concerns me as I have just come out of university with a backlog of debt weighing me down and now I need to find at least another £300 to be able to practise as a dentist just before Christmas!

There's a lot of negativity towards the GDC from dentists at the moment, not only do some dentists feel like our regulator is out of touch with the profession, but a recent Daily Telegraph advertisement by the GDC, which advised patient's to complain directly to them if they had a problem with their dentist, has caused outrage.

The infamous Telegraph Ad

The BDA's lawyers are fighting hard to prevent an illegal increase in retention fees. Hopefully they will be as successful as they were with DF1 places for UK graduates and the abandonment of the DF1 pay cut this August.

See my recent post about how Young Dentists feel about this fee increase.

2. Direct access

Dental Care Professionals (DCPs), specifically dental hygienists and therapists can now see patients without a prescription from a dentist.
This came into force summer 2013 and has caused some confusion amongst the profession and the public alike.

Dental therapists and hygienists can now work within their scope of practice as long as they are appropriately trained and indemnified to do so although this is not compulsory - DCPs can still work with a prescription of dentist if they prefer and a DCP must have consent from their practice owner to see patients under direct access.

This is currently only relevant in private practice at the moment as under the current NHS contract, a full examination by a dentist is required, although this may be subject to change under the new contract (see below).
DCPs are also limited as they cannot use local anaesthetic (a prescription only medicine), take radiographs or carry out tooth whitening without the prescription from a dentist.
These barriers are currently being discussed and debated, so it is likely direct access will change in the near future.

See this BDA article to learn more about Direct Access.

3. The new NHS contract and the pilots

Having graduated from Newcastle Dental School, I've heard no end about the proposed new NHS contract and the current piloting being trialled around the country.

After Jimmy Steele's 2009 review of the current NHS system, dental professionals together with the government have been trying to come up with a fairer more efficient system.

The main issue with the current contract is that there is no incentive for dentists to prevent disease, only to treat it.

During the past 2 years, the new pilots have been running throughout the country, emphasising the 'traffic-lighting' risk assessment of patients for the 4 domains of oral health: caries, periodontal disease, tooth wear and oral cancer.
There is also an emphasis of the skill set of dentistry and utilising DCPs as well as patient care pathways.

This has manifested in levels of carers:
Level 1 is a safe beginner with no higher accreditation e.g. a GDP
Level 2 are those practioners with additional skills (these are not specialists, but perhaps those with 'special interests')
Level 3 are high street specialists
Level 4 would be a consultant, who would plan and oversee treatment

Having experienced a pilot practice on outreach last year I found the system was much more time consuming than the current system I now use in practice and there is a lot more paperwork for the patient to help educate them about their oral health.
There's still a way to go with the new contract, but with the elections coming up this summer, I doubt it will be addressed before then.

4. FiCTION trial

Filling Children's Teeth, Indicated Or Not?

Another project you hear a lot about in Newcastle, but also involving other dental schools (pioneered in Dundee) and practices around the country.

The trial aims to explore the clinical and cost effectiveness of fillings in children's teeth, comparing 3 different ways of managing childhood caries: conventional fillings, prevention alone and biological methods of managing decay e.g. Hall crowns.

To read more about the FiCTION trial, see their website, or see my summary of the London Paediatric Dentistry conference here.

5. Minimal intervention dentistry

Like the FiCTION trial, there is a move in dentistry away from conventional destructive fillings and more towards a minimal intervention (MI) approach.

See my previous post about MI dentistry here.

6. Implants in dentistry

Public awareness about implant dentistry is ever increasing and more and more dentists are taking up more training and qualifications in order to provide implants for their patients.

A topic that is often overlooked at dental school, I have been exposed to countless patients in practice who either have implants or are interested in having them.

See my previous post about a #Tubuleslive event discussing implants here.


Something that will definitely kick off in practices in the next decade or so, Computer Aided Design and Computer Aided Manufacture (CAD/CAM) in dentistry could mean that restorations could be make chair side in under an hour, the most popular system being Cerac at the moment.

Instead of taking impressions for veneers, crowns, bridges, implants etc, a scanner can take an image of the prep and use this to mill a restoration directly from ceramic, composite or metal.

This takes out the delay from making a restoration in a lab and the scanning of the prep can be more efficient than taking impressions.
At the moment, the use of CAD/CAM is quite limited as costs for scanners and especially 3D printers (or millers) are very high.

Scanners at the moment are more commonly used to scan poured up models rather than scanning preps directly in the patient's mouth.

See more about CAD/CAM in dentistry here.

8. Orthodontics in practice e.g. invisalign

It is becoming very popular for GDPs to start offering simple orthodontic treatment in practice rather than refer all cases to specialists.
Companies such as Invisalign, Smilelign, In-Line, Six Month Smiles etc offer comprehensive packages for GDPs to learn how to assess and treatment plan for these cases, and the results can be very rewarding.

See my previous post about the BDIA showcase which summarises a couple of the orthodontic systems here.

9. Amalgam

Despite amalgam's 150 year history of being used in dental restorations, the recent Minamata Convention has agreed on a phase down of it's use as a dental material.

There is no evidence throughout it's extensive history that the mercury in dental amalgam causes any harm to patients - the phase down is more to do with the environmental issues with disposing of mercury waste and the harm it can do if not disposed of properly.

As mentioned above, MI dentistry is also becoming the school of thought when restoring teeth rather than cutting away extensive tooth tissue in order to retain amalgam restorations, we should instead consider the use of adhesive dentistry when restoring teeth, although this isn't always possible e.g. where there is poor moisture control.

Patient's in general will always opt for composite or white fillings over these 'ugly' silver fillings (although I think if done correctly, a well carved and polished amalgam can be more aesthetically pleasing than a tooth patched together with composite). 
This can be more of an issue in NHS dentistry where in order to obtain 'oral health', a lot of dentists will always place posterior amalgams (a cheaper material) and then charge a patient privately if they preferred composite. 

I personally think that amalgam can be a great material to work with and has some advantages over composites but with its phase down, dentists need to be aware of other options for restoring posterior teeth such as composites and inlays or onlays. 

To read more about the phase down of dental amalgam, read this BDJ article or this presentation I went to with Prof Trevor Burke.

10. Tooth whitening

A recent change in EU legislation in 2012 has confused and baffled the profession.

What concentration of the bleaching agent can I legally use on my patients?
As long as the patient is over 18, it is clinically justified and the exposure of the bleach is limited, we can prescribe between 0.1%-6% of hydrogen peroxide releasing chemicals, although most studies advocate the use of 10% carbamide peroxide (this breaks down to 3.4% of hydrogen peroxide).

Only dental practioners can prescribe tooth whitening products which contain more than 0.1% hydrogen peroxide - DCPs can carry out tooth whitening but only on prescription from a dentist.
Before this EU directive, it was common for beauty therapists to offer tooth whitening with higher concentrations of hydrogen peroxide.

Since this treatment has been defined as cosmetic treatment, under 18s cannot use products containing more than 0.1% of hydrogen peroxide. This may be an issue if a teenager presents to your surgery with a discoloured incisor following endodontic therapy.
What would you do, turn them away and say you can only treat the discolouration when they turn 18?
Opt for more destructive treatment such as veneers because you can't legally bleach the tooth effectively?

This can be quite a dilemma and I'm not sure what the right answer is!

See the GDC's guidelines for more information on tooth whitening.

I hope that this helps in your preparation for the interviews! 
Is there any other topics that are popular in Dentistry today? Please comment in the section below!

Monday, 27 October 2014

Modern Caries Conference with Professor Avijit Banerjee

In September I attended the Modern Caries Conference with Professor Avijit Banerjee as one of my study days.
It was a bit surreal to realise that the speaker was the principle author of Pickard's Manual of Operative Dentistry, a textbook which was widely used and recommended at Dental School. 
The day's main message was Minimal Intervention. Here is a summary of the main points from the conference. 

What is Minimal Intervention?

This is a holistic approach to dental care to help maintain long-term oral health. This uses long term prevention plans and techniques to promote remineralisation of dental decay (caries) and involves all members of the dental team such as dental nurses and therapists, not just the dentist.

This cavitated carious lesion could be causing pulpal symptoms, but it could be possible to manage this lesion more conservatively than opting straight for root treatment, allowing the dentine to remineralise and the caries to be arrested.

Main Principles behind MI Dentistry

1. Comprehensive disease diagnosis

Using a caries risk assessment and detection of lesions from early demineralisation to cavitation
Understanding the histo-pathology of lesions and their progression in order to determine restoration     selection suitability

2. Prevention of lesions
Remineralision of non-cavitated lesions and optimising the patient's control of the disease process i.e. oral hygiene, diet advice, fluoride therapy

3. Non-invasive and minimally invasive operative treatments if necessary 

Including the repair or refurbishment of previous restorations rather than systematic replacement. When deciding how and if to restore a lesion or existing restoration, the primary concern to create a surface that the patient is able to keep plaque free.

4. Maintenance and assessment of caries management 

At every patient visit i.e. 'patient-centred care'

5. The 'Golden Triangle' 

The principles that lead to successful management of caries. The histo-pathology of caries and tooth tissues, materials science (adhesive dentistry and bonding systems) and clinical handling.

Minimal intervention is not always possible. The caries in this tooth extends into the pulp cavity and has lead to pulpal necrosis. Options for this tooth will be more conventional: endodontics or extraction

Caries Risk Assessment:

Risk assessing or 'traffic-lighting' patient risk for dental disease is a concept that is most likely to be the base of the new NHS contract so every clinician needs to be able assess patients effectively in order to plan and treat them suitably.
Some factors to take into account when assessing a patient's risk for caries include:

  • Disease history: current caries? history of caries?
  • Oral hygiene
  • Medical history e.g. bulimia, Sjogren's syndrome, radiation to head and neck, hypo-salivatory medication?
  • Social history
  • Use of fluoride
  • Diet: high in non-milk extrinsic sugars, acid
  • Presence of plaque retentive factors e.g. braces
  • DMFT score

Minimal Intervention Approaches

1. Minimal caries excavation

Despite being doggedly taught to 'clear the ADJ' during caries removal, MI is based on maximal preservation of tooth structure and the placement of a restoration is only to support, seal and potentially heal cavities created after caries removal.
Removing tooth tissue for the sole purpose of creating retentive features, for example for retaining an amalgam, should be discouraged especially since the event of adhesive dentistry. Only soft, wet and infected dentine should be removed, especially when lesions extend close to pulpal tissue.
Caries can be removed with hand-excavators or with more conservative techniques such as air abrasion, ultrasonics or chemicals e.g. Carisolv

2. Preventative Resin Restorations (PRRs)

This aims to to prevent the initiation of a carious lesion. Sealing is indicated in enamel lesions and early stage dentine lesions.
This technique helps to decrease the bacterial flora to below the lesion progression threshold.

3. Resin Infiltration

The use of a strong hydrochloric acid etch is introduced to early demineralised teeth surfaces which encourages low-viscosity resin infiltration into widened pores.
The pores fill and therefore porosity decreases which reduces the risk of further progression of the lesion.
More evidence is needed in order to determine the long term efficacy of this treatment method.

4. Biodentine

A more recent material designed to repair damanged dentine in both restorative and endodontic fields.
It's trisilicate core helps preserve pulp vitality and can stimulate the deposition of reactionary dentine.
You would use the biodentine much like a lining material such as Life, and the material is compatible with composite.
For more information see here.

5. Atraumatic restorative technique (ART)

This technique usually uses GIC to restore cavitated lesions.
Soft, wet, infected dentine is manually excavated and the GIC is placed using a press-finger technique.
This eliminates areas of plaque retention and the GIC acts a fluoride reservoir to prevent caries from progressing further.
Once the patient's oral health is stabilised and the patient's oral hygiene and diet habits have improved, a more definitive restoration can then be placed if necessary.
This approach can be very useful in both adults and children alike.

6. Stepwise Caries Removal

This involves incomplete caries removal over pulp horns to avoid exposure. The floor of the cavity can then be lined with calcium hydroxide or other materials such as Biodentine and a GIC placed.
This allows for reactionary dentine deposition over the pulp horns so that when the cavity is reaccessed some time later, there is a reduced risk of pulpal exposure when placing the definitive restoration.

7. Hall Crowns

This technique, pioneered by Dr Innes, is mostly used on children and involves placing a preformed metal crown over a carious primary molar with little or no caries removal.
This is particularly useful in children as there is no need for local anaesthesia and evidence has shown this type of restoration outperforms conventional amalgam restorations in these teeth.

The Role of Saliva and Fluoride

Roles of saliva in terms of the prevention of caries:
  • Neutralisation of acids produced from dental plaque
  • Reservoir for calcium and phosphate ions for the remineralisation of dental tissues
If saliva production is disturbed, this can increase the risk of caries as plaque acids are not neutralised and there is less of a reservoir of ions to remineralise tooth tissues. 

Some conditions that can affect saliva production or disturb the oral pH balance include:
  • Systemic medications/polypharmacy
  • Head and neck radiation
  • Autoimmune disorders e.g. Sjorgren's syndrome
  • Eating disorders
  • GORD
Dental management of this conditions:
  • Diet advice - reduce acid intake or consume milk/cheese after each intake to neutralise the acid
  • Refrain from toothbrushing after acid intake
  • Chewing gum to stimulate saliva production
  • Mouthrinses or toothpastes that contain baking soda may decrease the levels of cariogenic S. mutans in saliva and plaque
  • Oral lubrication products e.g. Biotene or salivary substitutes can be presribed.
  • Fluoride therapy: high fluoride toothpaste e.g. 5000ppm with fluoride varnish, prescription fluoride mouthrinse e.g. 0.05%

Barriers to MI in Practice

1. Dentists

Not all dentists have the skills to plan and risk assess patients effectively, or the technical skills and knowledge to implement a minimally invasive treatment plan.
Whilst I was taught at a dental school pretty keen on this sort of patient management, there are a lot of dentists out there who were and are still being taught the older school of thought of 'drill and fill'. Changing these dentists' practises can be difficult, especially if they have been practising in the same manner for years.

Another issue is that MI dentistry is more time consuming and a less efficient use of a dentist's skill set.
Especially in NHS dentistry at the moment, where there is no financial incentive to prevent disease. This issue could possibly be addressed in the new NHS contract where dental care professionals (DCPs) could be employed to provide some aspects of MI.

2. Patients

Not all patients will take responsibility for their oral condition. No matter how much you lecture a patient on oral hygiene, oral health may not be a priority in their life.
The option isn't just to 'drill and fill' in these cases as this will only postpone the problem, but dentists should make sure they take time and care communicating effectively with these patients and of course to document everything in detail.

Evidence supporting this approach to managing caries is growing. It is almost always preferable to maintain as much natural tooth tissue as possible (except where the vitality of the pulp is in question), as long as a good seal is produced using adhesive dental materials.
Managing disease biologically instead of surgically is a concept all dentists should practice - in no other field of medicine would chopping off a huge area of diseased tissue be more acceptable than trying to cure that area of disease.

Are you using Minimal Intervention techniques in practice? What are your thoughts? Please feel free to comment in the section below!


A Banerjee. ''MI'opia or 20/20 vision?' British Dental Journal. 2013 ; vol 214, no 3

A Banerjee. 'Minimal intervention dentistry: part 7. Minimally invasive operative caries management: rationale and techniques.' British Dental Journal 2013 ; vol 214, no 3

A Banerjee and S Domejean. 'The contemporary approach to tooth preservation: Minimum intervention (MI) caries management in general practice.' Primary Dental Journal. 2013 ; vol 2, no 3

Saturday, 25 October 2014

A Guide to Photography in Dentistry

My latest Study Day was with Dr Ian Cline about Dental Photography.
This is a topic that isn't really taught much at Dental School - certainly in Newcastle whenever I required clinical photographs I booked my patients in with the resident Dental Photographer.

Here I will summarise the key points of the day which was really informative and fun too as we got to practise taking photos of each other! 

What Makes a Good Photo?

  1. Focus - how clear the photo is
  2. Framing - what is in the photo i.e. the only things including in the frame are the areas of interest
  3. Exposure - the photo is not too light or too dark

How does the Image Travel through a Camera?

  • It image enters through the Lens - this focuses the light 
  • The Aperture then controls how much light enters the camera
  • The image is then detected on the Digital Sensor of the camera

What is exposure?
This is how light or dark the image is.
This is affected by 3 things: time (i.e. shutter speed), the aperture and light 

What is Aperture?
Also know as F Stop. This is the opening into the camera which allows light through.
This ranges from a big opening e.g. F2.8 to small openings e.g. F22
The aperture determines the depth of field i.e. the area in the image that appears sharp.
A small aperture creates a shallow depth of field, whereas a greater aperture creates a sharper overall image.

What is ISO?
This is the sensitivity of the digital sensor. The Lower this value, the less sensitive the camera is to light and the less 'noise' is created in the image

What is White Balance?
This is the change of the overall colour of the image e.g. auto, daylight, shade, flash, fluorescent etc. This can be changed after an image is taken.

What is Flash Exposure Compensation?
This is a setting on some cameras to compensate for the flash being too dark or light. You can use this to highlight translucencies.

What is Cross polarisation
This is effectively a 'sunglasses' attachment for the camera flash which takes out glare. Useful when taking shade photos for your technician

Photographic Views in Dentistry and Camera Settings

1. Smile (left, right, centre; natural, forced, relaxed, retracted) 
    Centre view - Focus on the canine for maximum depth of view and centre on the central incisors
    Right and left views - focus and centre on the lateral incisor
    F22 aperature and magnification ratio 1:3

2. Anterior Close up
    F22 aperature and magnification ratio 1:1.5
    Use a contraster and focus on the central incisor for centre views or the lateral for left or right views

3. Occlusal 
    F22 aperature and magnification ratio 1:3
    Warm a mirror (this prevents fogging)
    Focus on the midpoint between the premolar occlusal surface and the midline of the palate
    Centre on the horizontal through the premolars and the vertical through the midline

4. Portrait (relaxed, smile teeth apart, smile relaxed, profile, 3/4 profile)
    Useful in orthodontics
    Use a plain background ideally black or white
    F11 aperature and magnification ratio 1:10
    Focus on the eyes and teeth
    Use an anti-red eye function
    Include just below the chin and the top of the head
    Centre on the midline of the face
    Use pop up flash rather than ring flash

All modes should use a fast shutter speed of 1/200 - this prevents blurring

The ISO should be set for as low as possible such as ISO 100 apart from portrait views which should be set for higher values to allow more light in.

The White Balance should be set for Flash mode as you should always use a flash in dental photography.

A natural centre smile view of my teeth - you can clearly see the areas of hypoplastic enamel.

What Camera Equipment do you need?

Dr Cline stated that by far the best camera to take clinical photographs is a SLR camera.
Whilst you can take ok pictures of some of the views with compacts or even an iPhone, SLRs are the best quality camera to pick up fine details.

Components to a clinical camera:

  1. Camera body 
  2. Lens (100mm macro is the best for close up work)
  3. Ringflash

Nikon, Canon or Sigma were brands recommended by Dr Cline and all together it should cost around £1000
This is a lot of money for young dentists (especially if you're thinking of buying loupes too), but it's a good investment for the future and you could always save a bit of money on the ringflash by buying a cheaper make called a Skyblue that can be found on amazon. 

If you can't afford this at the moment you can buy flash and magnification attachments for smart phones e.g. SmileLite or even lenses for compact cameras. 

An example of an SLR camera with a 100mm macro lens and a ringflash.

Other Equipment you will need

  • Retractors (these can be seen the in title photo - cheek and occlusal retractors)
  • Mirrors (different sizes, with handles if possible)
  • Contrasters (these stop distractions in the image)
  • Consent forms

Uses of Clinical Photographs

  • Clinical case presentations
  • Medico-legal reasons to keep in the patient's records
  • Lab communication - demonstrate multiple shade tabs, zooming in for translucency/white spots, colour mapping. Use different angles to show different characteristics. Can take pictures of preps too which is important for all ceramic restorations 
  • Orthodontic work
  • Bleaching to demonstrate shade changes
  • Marketing

So do I have a SLR camera to use to take dental photographs? 

I'm afraid not at the moment. I am currently using my own camera which is a compact camera with a 14-45mm lens which takes good smile and portrait photos but doesn't capture the detail of close up views quite so well.
I will definitely invest in some sort of SLR sometime soon though, you can definitely tell the different between the quality of the photographs. 
Maybe I'll but it on my Christmas list - together with Loupes and my ARF. Let's hope Santa is generous this year!

For more information and for Dr Cline's presentation from the day please see his website.

Has anyone got any other tips for dental photography? What sort of camera do you use? Please comment in the section below!

Why not take a look at my other Clinical Guide posts?

Thursday, 23 October 2014

Top Tips to Survive Final Year

So 4 years have flown by and now it's come down to the crunch: Final year.

I'm sure you'll be fed up of the standard 'You're in final year now' spiel and are generally a bit overwhelmed and scared of the pressure that finals and job applications bring!

But don't fret, here I will outline how to get through this year without losing all your hair!

Top Tips

1. Be organised
Set deadlines for work you want to achieve and stick to them!
I find google calendar really helps me plan my time but use whatever method works for you.
Know what work you have outstanding and identify areas of weakness so that you can target them when revising. 

2. Sort out your case portfolio early 
Don't leave everything to the last minute. Identify the required number of suitable patients with backups too, patients sometimes let you down.
Start writing cases up if you can already (you'll have more pressing things to worry about in the new year) and make sure you have the appropriate study models and photographs - you don't need a last minute panic trying to squeeze your patient into photography when everyone else is doing the same thing. 

3. Get on top of in course assessments and quotas
As I said earlier, set deadlines and stick to them.
If you're struggling with quotas or getting suitable patients for competencies, then let your tutors know as soon as you can - especially consultants. They can look out for patients for you on their clinics and pass them on to you. 

4. See lots of patients 
Gain as much experience as possible whilst you're at dental school. It's tempting to leave clinics free so you can have more revision time but you learn better from treating patients.
It's also reassuring to learn a new procedure whilst still in an environment where you are surrounded with other more senior staff to guide you through the treatment.
In a couple of years you will either be an associate or working in a hospital - you'll be the one providing treatment and it's likely that there will be no one will be there to help you out. 

5. Start revision early
This is really important. You don't have to go crazy at this stage in the year but making sure you're topping up knowledge at home and write a plan so you make sure you cover everything (there is a lot!)


Start as early as possible
Again a bit of repetition here but whenever your exams are, get started on revision early. I know it's tempting to leave things to closer to the time but there is a lot to learn so start slowly but asap!

Vary your revision methods
Just reading through a textbook may work for a while, but I find it best to mix up revision techniques, not only so it doesn't get boring but it also helps me consolidate my knowledge.
Make notes, flashcards, highlight books (as long as they belong to you!), watch or listen to lectures.
Why not try using my Quizlets - a great website where you can create your own flashcards or use the ones I have already created last year for finals. You can also test yourself with tests or match up the terms.

Revise with your friends
Test each other, hold revision sessions or seminars. This can help a lot if there is something that you are a bit confused about.
Get in touch with staff members too - our clinicians at Newcastle were really willing to hold revision seminars and lectures if you asked for them or meet one on one if there was anything you needed to discuss.

Overlap your topics
It's tempting to spend one day revising restorative and the next revising child dental health but remember topics overlap!
Link topics together, it'll save you time but more importantly it will help you understand topics fully!
Dentistry isn't a set of modules, it's one big interlinking subject!

Some useful text books
Here are some of the texts that I found useful for finals.

Clockwise from top left: Master Dentistry Volume One Couthard et al, Paediatric Dentistry Welbury et al, Applied Dental Materials McCabe et al, Introduction to Orthodontics Mitchell, Master Dentistry Volume Two Heasman,  Oral Pathology and Oral Medicine Cawson and Odell, Textbook of Human Disease in Dentistry Greenwood et al, Prosthodontic Management of the Edentulous Patient Basker et al and Pocketbook of Oral Disease Scully et al. 

There's a lot of content to cover for finals, do here's a summary of topics you will definitely need to cover.


1. Restorative and Conservation dentistry

2. Child Dental Health

3. Dental Public Health

4. Radiology

5. Oral Medicine

6. Oral Surgery

7. Oral Pathology

8. Endodontology

9. Periodontology

10. Special Care Dentistry

11. Prosthodontology

12. Occlusion

13. Dental Materials

14. Human diseases and Medical Emergencies

15. Temporomandibular disorders

16. Orthodontics

So good luck everyone! If there is anything you would like to know, or if anyone has any additional tips for final year dentists, please comment below!

Tuesday, 21 October 2014

Tower Poppies and Tower Bridge

The past few weekends have been pretty busy socialising with different friends so this weekend I wanted to do something a bit touristy and get to see some of the sites of London.

My flatmate and I decided we'd go visit the poppy installation at the Tower of London; we'd seen a lot of pictures of it about on social media and wanted to see it in person - although in hindsight maybe a Sunday afternoon wasn't the best time to go (there were so many tourists!).

The installation has been there since the beginning of August and will be until November 11th when the poppies will be picked.
There is going to be  888, 246 ceramic poppies all together surrounding the walls of the tower, each representing a British military death in the First World War. Volunteers are still adding to the installation, each day 'planting' 7000 new poppies.

The idea, christened 'Blood Swept Lands and Fields of Red', was thought up by Paul Cummins and brought to life by Tom Piper and they have currently sold every single poppy to raise money for 6 different service charities. 

Whilst the photos of the installation are impressive, actually being there in person was so different as you really got the scale of how many poppies there are and the huge loss of life suffered just by Britain in the first world war. 

For more information visit the Tower of London's website.

Tower Bridge

This area of the Thames has so many other attractions to visit, so we also went into the exhibition at Tower Bridge.

Before visiting the exhibition I had no idea that you could go into Tower Bridge but you can even event hire it out for events!

It was pretty reasonably priced too at £7 for adults and there are a few different parts to the exhibition including learning how the bridge was built, why it was built, other famous bridges of the world and how the bridge operates.

It was also impressive to learn that it only took 8 years for the bridge to be built! And when it opened in 1894 that it was the height to technology with its steam driven Bascules that raised the bridge for passing ships.
And of course, the views at the top give you a perfect view of the Thames and the City of London, at night as well as in the day.

For more information see the Tower Bridge website.

Other things to do in the vicinity:

  • City Hall - the offices of Major Boris
  • St Katherine's Docks
  • Borough Market
  • The Shard
  • HMS Belfast - with it's child friendly museum on board
  • The Design Museum
  • All Hallows church by the Tower

Have you been to either of these attractions? Please let me know your thoughts and recommendations in the comments section below!

Sunday, 19 October 2014

A Guide to Applied Anatomy in Dentistry

My latest study day this friday was with Dr Apollonius Allen from KCL about anatomy and pain control in dentistry. 
Having studied the anatomy part of the BDS in our first year, I was pretty rusty to say the least! Here is a summary of what I learn from the day. 

Of the 12 cranial nerves, the ones that us as dentists are most concerned about are the Trigeminal (V) nerve and the Facial (VII) nerve. 

There are 4 parasympathetic ganglion in the head:
  1. Pterygopalatine (where the greater palatine nerve originates from)
  2. Otic
  3. Submandibular
  4. Ciliary 

The Trigeminal Nerve (V)

The Trigeminal nerve is the most important nerve in dentistry: this is the nerve that you will anaesthetise when performing dental treatment. 

The nerve originates from the PONS and splits after the trigeminal ganglion into its 3 parts: V1 (opthalmic division), V2 (maxillary division) and V3 (mandibular division).

V1 exits the cranium through the SUPERIOR ORBITAL FISSURE
V2 exits the cranium through the FORAMEN ROTUNDUM
V3 exits the cranium through the FORAMENT OVALE

Other structures that go through the Foramen Ovale:
  • Accessory Meningeal artery
  • Lesser Petrosal nerve
  • Emissary veins

The anterior branch V3 is mainly motor whereas the posterior branch is mainly sensory

Anterior branch: nerve to temporalis, nerve to masseter, nerve to lateral pterygoid and the sensory long buccal nerve.
Posterior branch: lingual nerve, inferior dental nerve, auriculotemporal nerve and the motor nerve to mylohyoid.

Two nerves also come off the main trunk of V3: nerve to medial pterygoid and the tensor nerves (tensor tympani and tensor palatini)

Since V3 is mainly sensory you can give bilateral IDBs, contrary to what most of us have learnt at dental school. 
The reason we were given was because there is a risk of the patient swallowing the tongue, however, since the motor supply to the tongue is by the hypoglossal nerve (XII) which is not affected by the IDB, there is no chance of this actually happening. 

The Facial Nerve (VII)

This nerve emerges from the cranium through the stylomastoid foramen and it has 5 branches:
  1. Temporal
  2. Zygomatic
  3. Buccal
  4. Mandibular
  5. Cervical

This nerve supplies the motor function to the muscles of the face which can become apparent during Bell's palsy or when your IDB infiltrates the parotid gland.
A lot of the time this is due to incorrect operator error i.e. not hitting bone when giving the block, however, if the patient has an accessory lobe of the parotid gland which loops into the pterygomandibular space, this will be anaesthetised when you deposit the LA into the correct space. 

Paranasal Sinuses

There are 4 Paranasal Sinuses:
  1. Maxillary (this is only sinus that is present at birth)
  2. Ethmoidal
  3. Sphenoidal
  4. Frontal
The function of sinuses include:
  • They lighten the skull
  • They are lined with cilia to filter the air we breathe
  • They warm the air we breath
  • They create resonance for your voice
At dental school we were taught that if a root of an upper tooth (usually molars) fractures during an extraction, if it is within the apical third, you should leave it in situ as there is a risk of dislodging the root into the antrum if you try to remove it. 
Dr Allen taught us a novel method to help remove root remnants:
  • Clean the area so that it is free of blood and saliva
  • Locate the canal on the tooth you have removed and determine whether the canal is patent
  • If you can locate the root canal, use a size 20 K file to engage the root (insert and turn a quarter clockwise) and gently pull out.

The Nose

The nasal septum has 3 components:
  1. Septal cartilage
  2. Perpendicular plate of the ethmoid bone
  3. Vomer
Most of the paranasal sinuses drain into the Middle meatus in the nose except from the sphenoidal sinus and the posterior ethmoidal sinus.
  The sphenoid sinus drains into the Suprameatal recess.
  The posterior ethmoidal sinus drains into the Superior meatus.

The Nasolacrimal duct also drains into the nose, into the inferior meatus.

Turbinate bone is the term for the mucous membrane lined conchae.
A TURBINECTOMY can be performed for patients who suffer from chronic sinusitis or have difficulty breathing.

What causes nosebleeds?
Bleeding from the anastomoses of the intra and extracranial blood vessels. Several things can cause these to bleed:
  • Severe hypotension
  • Cold or dry air
  • Vigorous nose picking (yuck!)
  • High blood pressure
  • Blood dyscrasias
So how would you manage a nosebleed? 
Pinch the nose and lean forward to prevent blood from being swallowed (which could cause vomiting)

The Skull

There are 28 bones in the head:
  8 of these are in the cranium
  14 of these are facial bones
  3 are ossicles, the tiny bones in your ear

The Cranial Bones:
  1. Occipital 
  2. Sphenoid
  3. Frontal (this bone ossifies as 2 separate bones)
  4. Ethmoid
  5. Temporal x 2
  6. Parietal x 2
The Facial Bones:
  1. Nasal x 2
  2. Lacrimal x 2
  3. Zygoma x 2
  4. Palatal x 2
  5. Maxilla x 2
  6. Inferior concha x 2
  7. Vomer
  8. Mandible
The Ossicles:
  1. Stapes
  2. Malleus
  3. Incus

When you are born, your cranial bones (and your mandible) are not fused together, they are joined with cartilage: anterior and posterior fontonelles.
The anterior one fuses at 18-24 months and the posterior one fuses at 4-5 months old. If they do not fuse properly a Metopic Suture is formed. 

When you are born you also do not have a Mastoid process - this forms when the muscles for your neck start to develop i.e. when you can independently hold your head up, since the sternocleidomastoid muscle pulls on the bone to form the process. 

I hope you have found this summary useful! Please leave any comments or questions in the section below!

Why not take a look at my other Clinical Guide posts?

Thursday, 16 October 2014

#Tubuleslive event: Implants. Where do I start ? Where do Implants fit into your Treatment Plan ?

So this week's #Tubuleslive event was hosted by Dr Neel Patel and Dr Vinit Gohil: Implants, where do I start? 

As this week's event was in Stevenage, I was unable to attend the event in person but instead I watched the event live online which was great as I could sit down with a nice cup of tea in my dressing gown! 
It was interesting to watch the event online as you don't really get to see the ads and fillers when you attend the event live and I think it's quite a different experience from being there in person - I can't really decide which one I prefer as it's great to meet lots of different dental professionals at the events but I do like watching from the comfort of my sofa!

Here are the main points I have taken away from this talk:
  • 1% of people surveyed in the 2009 Adult Dental Health survey had some sort of implant
  • Implants have a rich history from Egyptian and Mayan civilisations, to the development of subperiosteal, endosteal and transosteal implants in the 20th century.
  • OSSEOINTEGRATION is the key concept behind dental implants - this is the formation of a structural and functional connection between the living bone and the implant
  • Implants can be in the form of single crowns, bridges, overdentures or maxillofacial prostheses. 
  • An implant is made up of 3 units: the implant, the abutment (i.e. the connector) and the prosthesis (crown, bridge, denture)
  • The prosthesis can be retained either by a screw attachment or by cement (much like a conventional tooth crown)
  • Making sure you have informed consent is crucial in implant dentistry. Always give the patient all other options: 1. Leave the space 2. Removable prosthesis 3. Bridgework (resin retained or cantilever) 4. Implant
  • SAC risk assesses each patient in terms of the expected difficulty of implant treatment taking into consideration factors such as the patient's medical history, their expectations, the site of the implant, whether a graft is needed etc.
  • It is essential to plan the final restoration when considering implant work; always work from the crown downwards. In order to do this you should consider 3D scans, wax-ups and locator stents
  • The McGill Consensus stated that an edentulous patient's quality of life is greatly improved with an implant-retained lower overdenture and that this should be the first line of treatment for these types of patients
  • There are different routes to get into implant dentistry: CPD events, certificates, diplomas, masters programmes and specialist or hospital training.
  • If you are considering implant dentistry you can be supported by other local referral practices, mentors, your local team and national and international implant organisations
  • There are over 1500 types of implant out there! Therefore when choosing which one to use on a patient it is important that there is an evidence base and you have been correctly trained and supported in the provision of that type of implant

As a recent graduate, I feel that this field of dentistry seemed to be skimmed over at undergraduate level and I have already seen quite a lot of patients who either have implants or who are interested in getting them.
I feel like this area of dentistry should be given more attention at dental school as it's a common source of interest with patients in general practice nowadays.
GDPs need to know how to manage patients who have implants and how to manage possible complications e.g. peri-implantitis. I think it is also important to know which types of patients are suitable for this type of treatment so that we can make appropriate referrals and give patient's realistic expectations.

Having seen a few patients which dubious looking implants which had been placed abroad, I think that GDPs should also have a basic understanding of implant designs in order to educate their patients to discourage unsatisfactory treatment as a result of dental tourism. But that is a different topic all together. 

The next #Tubuleslive event is on the 6th of November with Dr Rana al Falaki, Laser Periodontics: Where a Scaler and Blade just won't do.

Did you attend this webinar or watch it online? What are your thoughts about implant dentistry in general practice? Please let me know in the comments!

To see my other posts about previous #TubulesLive events see here

Wednesday, 15 October 2014

BDIA Dental Showcase Overview

So from Thursday to Saturday last week the BDIA Dental Showcase was held at ExCel in London.

Being a free event where I could also pick up some CPD as well as test out some dental products, I was eager to go even on a Saturday!

There were over 350 stands at the showcase with mini lectures running throughout the day.
Events like this aren't just for getting freebies (and there were a lot of free samples to have), they are great for learning about new developments in dentistry as well as areas of dentistry that you may not be so familiar with.
It's a great chance to meet new other dental professionals and network and pick up some dental products usually at a discounted rate.

I attended only a couple of the numerous mini lectures that were running on Saturday but the ones I went to were on topics that I didn't have that much knowledge of before the event.

Introduction to Myofunctional Orthodontics with Dr Dan Hanson

This talk really changed by way of thinking when dealing with treatment planning for orthodontics for children.

When at dental school I was taught that there are many different causes for malocclusions such as genetics and skeletal development. Dr Hanson however, believes that all malocclusions are caused by soft tissue disfunction.

Soft Tissue Disfunctions:

  • Mouth breathing
  • Incorrect lip and tongue function i.e. poor myofunctional habits
  • Incorrect swallowing reflex

If these issues are not resolved in childhood they can persist and cause problems as the child ages and have been linked to sleep apnoea and temporomandibular disorder in adults.
These habits are usually easier to correct whilst the child is still growing which can be achieved by using a functional appliance called the Myobrace (a type of Frankel appliance) as well as daily exercises to encourage the child to swallow correctly and breath through their nose.

Aims of Myobrace Treatment:

  • Lips should come together at all times except when eating or speaking
  • The patient breathes through their nose to assists the development of upper and lower jaws and to achieve the correct bite
  • There is no lip activity during swallowing - this allows the anterior teeth to develop correctly
  • Improvement of dental alignment
  • Improvement of facial development 

For more information about Myobrace please see their website.

Dr Dan Hanson presenting a case treated with Myobrace therapy

The Golden Rules of Success with Clear Aligner Therapy with Gary Dorman

Close friends have mine have already considered clear aligner orthodontics, but the name that always comes to everyone's mind first for this sort of treatment is Invisalign
This talk was given by a dentist who had used a different system on himself: In-Line

How is In-Line different to other aligner systems?

  • No attachments are needed for tooth movements
  • Aligners are made from a strong twin layer plastic 
  • Each aligner can produce 0.6mm of movement in 4 weeks whereas other systems move around 0.2mm in 2 weeks
  • Each aligner slots neatly into place so there is smooth and painless tooth movements
  • A comprehensive consent procedure is provided with post-treatment satisfaction certificates
  • There is choice of retention methods, but usually this is a fixed with a removable retainer for LIFE
  • Treatment times vary from 6-9 months
Therefore fewer aligners are needed, so lab costs are less and it takes less clinical time - you only need to carry out the interproximal reduction (IPR).

Suitable cases:
  • Quite severe crowding of anterior teeth
  • Tipping and rotations of incisor, canine and premolar teeth
  • Space closures
  • Slight anterior crossbites
Unsuitable cases:
  • Where molars need to be moved
  • Severe rotations
  • Changing of occlusions
  • Children - patients need to be at least 16 years i.e. when their occlusion is stable
In the above cases you should not try to treat the patient with clear aligners, instead they need to be referred to a specialist orthodontist
The In-Line lab will be able to tell you whether a case is suitable for treatment with clear aligners or whether they require a referral.

For more information please see the In-Line website or if you are interested in marketing aesthetic orthodontics in practice, see my summary of a Click Convert Sell webinar

Stalls at the Exhibition

One of the bigger stands at the exhibition: Colgate

Other stalls that I found useful to visit were the Oral B stand where you could try out their latest electric toothbrush (this was new to me as I had never used an electric brush before) and also some of the smaller stands such as Stoddard which designed some really funky looking interdental brushes.

I automatically refer to TePe's when talking about interdental cleaning (as well as floss) but some of these other companies as well as other big brands such as Wisdom manufacture interdental brushes of different designs which gives patients more of a choice when it comes to choosing which product they prefer to use. 

I also used the opportunity to try out some Loupes. As a DF1 I have heard constantly from different sources that I need to get Loupes, not only to improve the quality of my work but also to improve my posture so I'm not complaining about back ache 10 years down the line!
It was good to learn the advantages and disadvantages of the 2 main types of Loupes, which ones I could get my glasses prescription in, what magnification would be best for me (something between 2.4-2.8 I have been told) and also obviously the cost!

Heart your Smile also ran mentoring workshops throughout the day with different dental professionals - I attended one with a variety of different mentors from a dental therapist to a dental lawyer.
The system is there to help dental professional develop both professionally and personally, seeking help and advice from other people in the profession. They help match up the mentors and mentees so that they are compatible and it's a great way to network and get to know other professionals from all over the country. 

I had a great time at the showcase and I'm really looking forward to next years! 
(On the way out we also saw Peter Andre which seemed a little surreal considering we were at a Dentist event!)

Did you go to the BDIA Dental Showcase last week? Did you go to any of the mini lectures or buy anything there? What were your favourite stands and freebies? Let me know in the comments below! 

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