Saturday, 31 January 2015

#Tubuleslive Event: Sinus Augmentation with Dr Alan Sidi

This week saw the return of #Tubuleslive, with Dr Alan Sidi talking about sinus augmentation for implants. Here is a summary of Dr Sidi's talk.

The lateral window technique for sinus augmentation prior to implant placement.


Whilst I can't really apply what I've learnt during this week's #Tubuleslive to my work in practice yet, I can certainly inform those patients who are interested in having implants more of what might be involved if they require such a procedure. 

  • Sinus lifts are one of the most common pre-prosthetic surgical procedures carried out in the UK
  • The maxillary sinus (or antrum) is one of the 4 paranasal sinuses which enlarges with age and growth can be rapid following the loss of posterior teeth
  • Paranasal sinuses are all connected which means that infection originating in one sinus can spread to the others. 
  • The maxillary sinus is a quadrangular pyramid in shape and can vary in size significantly, even extending as anterior as the distal of the lateral incisor
  • Some vital structures associated with the maxillary sinus include the facial artery and nerve, internal maxillary artery and the sub-orbital nerve
  • Maxillary sinuses sometimes contain septa, which although they look like spikes on DPTs, are actually walls running that divide the sinus
  • The sinus membrane is very elastic and thin (although this can vary), and can thicken on response to chronic irritation e.g. sinusitis, chronic periapical infection of maxillary molars
  • Pathology of the maxillary sinuses include tumours e.g. ameloblastoma, or more commonly sinusitis
  • Sinusitis is caused by a chronic irritant and can be viral, bacterial or fungal in origin.
  • Contra-indications to sinus augmentation include: radiotherapy patients, drug addicts, smokers, presence of an oral-antral fistula, complex medical histories
  • Patient suitability must be assessed in several ways:
       1. Clinically e.g. perio status, vertical height available, assessment of posterior support, current prostheses
       2. Imaging  - DPT, intra-orals and CAT scans 
  • CAT scans can assess the thickness of the buccal walls as well as the width and height of the alveolar crest, the presence of teeth, roots or septa. 
  • There are 2 principle sinus augmentation techniques: INTERNAL LIFT or LATERAL WINDOW
  • Dr Sidi mainly performs the lateral window technique as he feels it is more predictable
  • Once the sinus lift is performed, implants can be placed simultaneously (there must be 5-8mm of existing bone) or delayed (up to 12 months after surgery)
  • The lateral window technique involves raising a 3-sided mucoperiosteal flap, performing a window osteotomy in the buccal wall, elevating the sinus membrane, packing the exposed cavity with a bone graft e.g. BioOss
  • A major complication during the surgery is the tearing the sinus membrane, which is more likely to happen in thickened membranes or those sinuses with septa
  • If a tear happens, the bone graft may escape into the sinus and then become infected and therefore cause the bone graft to fail
  • Tears can be managed with collagen membranes, sutures or with a collagen sock (a tube made from the collagen membrane stuffed with bone graft)
  • Post-operative complications following the surgery include swelling and bruising as well as nosebleeds, infections and oral-antral fistula (especially if there is a tear in the flap).
  • Patients are advised not to bend over, blow their nose or play sports for 1 week following the surgery to minimise the risk of nosebleeds and infections. 

I've hope you've found the summary useful and many thanks to Dr Sidi for such as charismatic presentation and well done to the new members of the #Tubuleslive team for delivering such as successful first event of 2015.

To see a previous post about the role of dental implants in practice see here

The next #Tubuleslive event will be next week the 5th of January where I will be hosting my first event: CEREC integration in practice with Dr Colin Campbell.

Why not attend the live audience where you can get FREE CPD! Register online and I hope to see you there!


Have you had experience performing sinus augmentation in practice? Please comment in the section below!

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


Wednesday, 28 January 2015

MJDF or MFDS?

So I've just coughed up the money for my MJDF exam. Thought you'd be finished with exams now you've finished your BDS? Think again!



What are MJDF and MFDS?


MJDF - Diploma of membership of the Joint Dental Faculty of the Royal college of Surgeons of England. 
The newer of the two exams which replaced the MFGDP.

MFDS - Diploma of membership of the Royal College of Surgeons of Edinburgh or the Royal College of Physicians and Surgeons of Glasgow, depending on which college you choose to take the exams. 


Why should I sit them?


More and more young dentists are sitting these exams as soon as they can, so whilst gaining an extra qualification stands you in good stead, it no longer makes you stand out from the crowd when applying for jobs.

If you want to work in hospital or gain entry onto a specialist training pathways, either one of these qualifications is usually desired, as is if you want to go back to university to study a medical degree. 

You also get to put some more letters after you name (yay)! But the most important reason is to enhance your future job prospects. 

To read more about careers in dentistry, see one of my previous posts here.

What's the difference?


There's not much difference to be honest and it doesn't make much difference to which one you choose to sit.

Which one you choose will mostly be down to where you live as you'll probably choose the one whose exam is closest to you. There are minor differences in fees, but there have been rumours that since MJDF is the newer exam, it may not be as widely recognised globally as MFDS - but I don't have any solid evidence to support this. 

How much do they cost?


Quite a bit! So make sure you're ready to take them and prepare sufficiently, otherwise you'll throw a considerable amount of money down the drain!

MJDF - part one costs £522, part two costs £660

MFDS - part one costs £505, part two costs £695

Beware that you'll have to pay an annual subscription fee to the college which you hold your qualification with if you want to use the letters after your name! 
With the memberships you can access research funds and discounted journal subscriptions. See the respective collages for more information.

What are the exams like?


MJDF Part 1: One paper of different formats including multiple choice questions (MCQs), extending matching questions (EMQs) and single best answers (SBAs). The paper is 3 hours long and has 150 quetsions. 

MJDF Part 2: Structured professional skills assessment (much like an OSCE) comprising of 18 stations. 

MFDS Part 1: Single multiple choice paper which is 3 hours long with 200 SBA questions. 

MFDS Part 2: OSCE much like MJDF part 2. 

Locations of the exams vary with some colleges offering multiple sites. See the respective collages for more information.

When can I take the exams?


You can take part 1 of either collage as soon as you've passed your BDS - the first round of exams in October/November time, then another sitting is around March/April time.

To take part 2, you must have passed part 1 and have at least 12 months postgraduate experience of practising dentistry.
You can change collages between part 1 and part 2 if you wish. 


To find out more please visit the MJDF or MFDS websites. 

So although there are a few options available to you, whichever you choose it shouldn't make much difference, it's the extra qualification that counts!


Good luck to anyone who is taking either exam! Do you have any further questions about MJDF or MFDS? What was your experience of these exams if you have already taken them? Please leave your comments in the section below! 



Sunday, 25 January 2015

Dentinal Tubules: What's the Deal?

As you may have noticed, I blog about Dentinal Tubules quite a bit, although there has been a bit of a hiatus for the past couple of months but not to worry, #Tubuleslive events are back with a bite this week!

But what is Dentinal Tubules? What's the deal?



What is Dentinal Tubules?


Dentinal Tubules is an online forum and resource library,set up by Dhru Shah, a specialist periodontitist who is genuinely one of the most inspiring people in the dental profession!

As well as the countless articles and forum posts available on the site, there are audiocasts and videos which can all contribute to your CPD requirements (there is over 400 hours available at the moment!). And I haven't mentioned #Tubuleslive yet...


Why should I join?


Not only can you learn with from the great names in dentistry and develop your own skills you can also add your own content to the site to teach others and showcase your work. 

There are practice packages available for the whole dental team, as well as groups for young dentists and students too! 

And as you may know, every few weeks there is a live streaming event: #Tubuleslive.

This exciting new way of learning, much like the popular TED talks, allows you to interact live with the speakers and you can either attend the audience live or stream the event live from the comfort of your home! We've had some great speakers in 2014, and there's lots more to come!


What's coming up in 2015?


Lots of prestigious speakers are coming to #Tubuleslive this year. Not only this, but the Tubules Team has some new members, including new presenters and others behind the scenes.

The first event of 2015 is this coming Thursday 29th with Dr Alan Sidi speaking about sinus augmentation for dental implants - and there are lots more events coming up.

Take at look at the Dentinal Tubules website for the full list of events.

Take a look at my presenter profile below!

video



In summary, joining Dentinal Tubules doesn't just give you access to hundreds of videos and resources, but it's a great way to network and learn from other dental professionals! I hope to see you at the live streaming events in London where you can get some FREE CPD

To join Dentinal Tubules click here

If you have any questions or thoughts please leave them in comment section below!

To see my posts about previous #TubulesLive events see here

Thursday, 22 January 2015

A Guide to Safeguarding in Dentistry

As some of you may have read in my previous post about a LCF law event I attended late last year, I won a CPD afternoon run by TempDent. Last week a representative from the company came to our practice and taught us about safeguarding. Here a summary of the afternoon. 


There are 3 levels of safeguarding in dentistry:

Level 1 - a basic understanding of safeguarding principles in practice
Level 2 - a more detailed understanding of safeguarding procedures who can observe and alert others to possible issues
Level 3 - a practitioner who holds the decision of what to do when issues arise. Involved in assessing, planning, intervening and evaluating the needs of people deemed at risk. Must be able to share information safely.

According to the Department of Health, 'Health services have a duty to safeguard all patients but provide additional measures for patients who are less able to protect themselves from harm or abuse.' 

Who may be 'at risk'?
  1. Children i.e. anyone < 18 years 
  2. Vulnerable Adults i.e. a person > 18 years and is or may be in need of community care services by reason of diability, age or illnes; and is or may be unable to take care of themselves or unable to protect themselves against significant harm of exploitation.
Examples of vulnerable adults:
  • Autistic patients
  • Patients with down syndrome
  • Dyslexic patients
  • The elderly
  • Patients who cannot communicate effectively e.g. language barriers, blind/deaf
  • Dementia patients
  • Patients with significant social histories e.g. lower social classes, alcholics, drug addicts, homeless people
  • Patients with mental health issues

There are 2 principles in safeguarding: Prevention and Reactionary.


Staff Checks


There are several procedures and policies you must abide by when employing and training staff to comply with safeguarding guidelines.
  • Disclosure and Barring Service (DBS), formerly Criminal Records Bureau (CRB).
  • Immunisations
  • References
  • Whistleblowing policy
  • Raising concerns policy
  • Appraisals
  • Health and safety policy
  • Complaints policy
  • Child protection policy
  • Safeguarding protocol and flow chart
CQC requirements state there must be a person who is level 3 trained to be registered as a lead and all other professionals need be registered with a professional body. 



Types of Abuse


1. Sexual

2. Emotional

These 2 are sometimes difficult to spot. Look for changes in behaviour, self harm, unusual relationships and the general interaction with the patient. 


3. Physical

Look for bruises (characteristic slap marks or bite marks), fractures and burns (such as iron, hair straighteners, cigarette)


4. Neglect

Can be in terms of parents, but also health care professionals i.e. supervised neglect


What to do? The 5 R's


Recognise - what type of abuse it is?

Respond - to the abuse appropriately

Report - to relevant personnel confidentially

Record - in the appropriate area 

Refer - to police or relevant organisations that deal with this abuse


Who should you go to if you have concerns?


For advice:
  • Consultant paediatrician
  • Child protection nurses
  • Social services (informal discussions)
  • Child's health visitor, school nurse or GMP
If you have serious concerns:
  • Discuss with your defence organisation (as you should try to gain consent to refer to other services but this may not be appropriate e.g. if you think there may be serious risk of harm to a child)
  • Refer for a medical examination
  • Social services (phone and written communication)
  • Police 
  • Nominated safeguarding personnel in the area e.g. hospital safeguarding officer
  • NSPCC
And to remember to record everything factually and in detail in the safeguarding policy folder or even in the dental notes of the patient. 


In summary it is important to be vigilant when dealing with vulnerable patient groups especially since now there is a lot of awareness of safeguarding with cases such as Baby P and Jimmy Saville fresh in our minds.

Thanks to TempDent for this really informative afternoon, I would definitely recommend their CPD services which can be held the comfort of your practice!

Please let me know your thoughts on safeguarding in the comments section below!

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




Sources:










Sunday, 18 January 2015

Getting Balance in Your Life: Dental Property Club Webinar

This week I tuned in for an online webinar led by Harry Singh, founder of the Dental Property Club
The webinar was about how to gain balance in your life - here I will summarise the main points in achieving balance in order to make the most of life!



What constitutes balance?


According to Dr Singh, balance is measured with the 5 F's:

  1. Faith
  2. Family
  3. Finances
  4. Fitness
  5. Fun
In order to have a balanced life, all 5 of the above should be fulfilled. During the seminar, the participants were asked which F we felt we weren't happy with, can you guess which one it was?

63% of those people who answered were not happy with their finances? So which F are you not happy with?



Wheel of life


This is a visual aid to help assess which the overall balance of your life using 8 different aspects which all contribute to your quality of life. 
You can now easily track which areas that need improvement as you give each element a score from 1-10, 1 being the poorest and 10 being the best (which may not be achievable). 
The wheel of life is seen below:

Source: Harry Singh Dental Property Club.


Health - are you physically fit? How is your diet?

Wealth - are you financially free? How are your earnings compared to your expenditure?

Family/friends - are they supportive of you? How often do you socialise? 

Fun - how often do you put time aside to have fun? Do you regularly do what you love?

Relationships - do you feel in love? Do you spend enough time with the people that you love?

Career - are you where you want to be in your career? Are you heading in the right direction? Are you happy at work?

Personal Space - are you comfortable where you live? Do you work and live in a clean and tidy environment?

Spirituality - what do you do to impact other peoples' lives? Are you connected with the inner and outer world?


After completing the wheel you should ask yourself these questions:
  • Where are the gaps in your wheel? 
  • Which areas do you spend too much or too little time? 
  • What is the ideal situation for you?


Action Plan


After identifying which areas you would like to improve then you need to make an action plan:

Action
Changes
Things

You could use the MTO approach to set targets: Minimum Target Outrageous. That way you can aim for the outrageous goal so that you are more likely to reach one of the targets.

For example, to improve your health:

Minimum: 10k run
Target: Half Marathon
Outrageous: Marathon


Once you have set your 3 MTO goals, you can then use a RPM table like below:



This can help you to ask yourself why you'd like to achieve a certain goal and the massive action is the reward you can give yourself when you reach that goal. For example, you want to run a half marathon to improve your fitness and to reward yourself you could buy yourself a new pair of running trainers.

So how often should you review your wheel of life or your action plan? 
This depends on what you'd like to achieve and what you feel is appropriate? Writing yourself a weekly timetable or setting yourself a 90 day or quarterly challenge are just some suggestions to time frames you can work to!


Remember that everyone's goals are different - whatever you may decide to aim for, aim high! Let me know how you plan to get a balance in your life in the comments section below!



Tuesday, 13 January 2015

10 Things I See Most in Practice

Four months into my foundation training, I have noticed a lot of situations keep cropping up day after day. 
Being used to treating patients in a hospital setting, most of whom were being treated regularly by their GDP, some of the things that I have now been seeing regularly I have had little experience of at dental school

Here are the top 10 things that I have been seeing in practice.



1. Sensitivity

I would say that the majority of patients complain of some sort of sensitivity in one form or another. Common triggers include cold, hot or sweet foods and drink, or even sucking cold air through their mouths.

There are a lot of factors that contribute towards sensitivity, including food packing, caries, cracked tooth syndrome but the majority I see are dentine hypersensitivity as a result of gingival recession around the cervical areas of teeth; either as a result of toothbrush abrasion or periodontal disease.

I always tend to manage these lesions as conservatively as possible, starting with the application of fluoride varnish and prescribing either duraphat toothpaste or one of the sensitive toothpastes (I quite like Colgate Pro-relief) and keeping on review to see if there is any improvement.

Only if there is no improvement I would then look to placing restorations - failure rates are quite high (I am currently looking at this for my Evidence Based Dentistry project that I'm working on). I would also attempt one of the resin sealers such as Seal and Protect which contains triclosan and also releases fluoride. 

When a patient does not report any improvement, upon questioning a lot of them have not be regularly applying the toothpaste topically to the areas of sensitivity - when they comply with my instructions, in most cases this approach works.

2. Fractured amalgam restorations

In hospital you see patients for a relatively short period of time and there is little continuation of care, whereas in practice you can get to see patients who have attended there for many years so you can monitor restorations and treatments which have been placed previously.

I have been seeing a lot of chipped or broken teeth, the majority of them having been restored with amalgam. Unfortunately, the part of the tooth that fractures doesn't tend to be the filling, but more often than not, a cusp of the remaining tooth tissue. 

This underpins the idea that the best material to have in your mouth are teeth - not fillings or crowns or implants. Once you place a restoration in a tooth you are starting a timer to how long that tooth will last. That filling will eventually fail, then you'll have to place a larger filling, which may fail too and then you may need some extra-coronal restoration of some sort and when that fails the tooth may not even be savable at all. 

Whilst I do really enjoy working with amalgam, the downside is that essential, the filling will probably last longer than the tooth it's in.

3. Fractured or lost post crowns

Probably as a result of dentists placing post crowns on teeth that are unrestorable due to a lack of ferrule (see my previous post which explains what ferrule is).

The majority that I see end up being unrestorable anyway as a result of a root fracture and multiple debonding of a post crown suggests a fracture of some sort. 

The main problem I experience as a result of this is a VERY difficult extraction. Sometimes the root fracture extends very unfavourably subgingivally and the roots tend to be very brittle anyway due to the fact they have been endodontically treated.

I've already had a couple of cases where I've had to refer after a failed attempt at extracting the root remnant, despite mine and my trainer's best efforts!


4. Tori

Remember when you first saw a torus in real life? Did it gross you out as much as it did me? And how much of a big deal did you make of it when presenting to your supervisor?

I see tori all the time! Mostly mandibular tori more than palatal. These bony exotoses only cause issues when constructing dentures, although sometimes they do tend to get in the way when taking bitewings or when making an impression (sometimes they stop the tray from fully seating). 


An example of a palatal torus


5. Silver GIC

Being used to using GIC like Fuji at university, I was quite surprised the first time I asked for GIC my dental nurse pulled out a bottle full of silver powder. 

The silver (or silver amalgam) in the GIC reinforces and improves the mechanical properties of the GIC and also makes the material radiopaque. 

It's a nice material to work with and is handy for repairing small chips in amalgams or as a long term provisional material in posterior teeth.

6. Tooth wear


Literally SO many people have tooth wear and most of the time it's multi-factorial. The most common causes include brushing too hard (leading to abrasion lesions), grinding their teeth at night time (leading to pictures like below, attrition) or drinking too many fizzy drinks or fruit juices (erosion).

I have seen a couple of interesting erosion cases, one being a bulimic patient who was also a bruxist (nightmare combo) and another guy who upon questioning, revealed he liked to drink cider vinegar!

The difficulty I find is knowing when to intervene and provide treatment for these patients. For a lot of them, this will be the first they've ever heard of suffering from tooth wear and some aren't very receptive to the idea of a mouthguard to wear at night or get defensive when you ask about their diet habits.

In this attrition case below I managed the wear with composite build ups that I had used a putty matrix made from a lab wax up in order to help me create a stable occlusion and a good aesthetic result the patient was very happy with.

Before and after snaps of a tooth wear case (please forgive the after photo which was taken with my phone as I forgot my camera that day!)

7. Stained Composites


The worse cases are in smokers and heavy coffee drinkers!

Over time composites will pick up marginal staining, which can be made worse if you use a bonding agent instead of a wetting agent in finishing composites (see my previous post about composites that explains why).

Marginal staining doesn't necessarily mean the composite needs replacing. Obviously if the composites are in the aesthetic zone and this bothers the patient it would be best to replace them, however if there is no evidence of caries both clinically and radiographically, you can monitor them instead of jumping in and replacing them. I would recommend clinical photos be taken to properly monitor the restoration.


8. Dodgy implants/bridge designs


There are some not so credible dentists out there offering dentistry on the cheap and even more questionable treatments being carried out abroad with little or no after care being provided when back in the UK.

See this example of a strange bridge design that is somehow still hanging around 2 years in..... 


9. Scalloped tongues

So many people grind their teeth; whether they are aware of it or not. Treating a lot of patients who work in health care, many report being stressed or tired out which may contribute to their bruxism. 

Scalloped tongues as well as characteristic bite marks along the occlusal plane in their buccal mucosa point towards a bruxism habit, as well as tooth wear and reports of aching jaws or headaches. 

See a previous post which outlines the prevalence of bruxism among people who work in London.

10. Caries

This is probably the most obvious thing out of the list; however, in the demographics of my practice mean that tooth decay isn't the most common thing that I see - although I do see it often!

And a lot of the time when I see caries I don't immediately reach for my drill. The idea of Minimally Invasive Dentistry is becoming ever more popular and there is good evidence out there to support it. Of course, you can only remineralise tooth decay up to a certain point - the case in the photo below wouldn't really benefit from fluoride varnish application alone. 

For more information about minimally invasive dentistry, see my previous post summarising a conference I attended with Professor Banerjee here




Do you see these things commonly in practice? Is there anything else you see regularly? Please leave your comments in the section below!


Sunday, 11 January 2015

A Guide to Dental Trauma in Children

Following one of my previous posts about a Paediatric Dentistry conference, here is a summary of how to manage dental trauma in children based on a talk that was held during the day.


A crown fracture in a permanent incisor


Trauma in the Primary Dentition


Fractures

Uncomplicated crown - reassure and monitor, smooth or restore if co-operative

Pulpal exposure - extract

Root - if mobile or severe displacement extract (leaving the apical fragment if danger of damaging the developing tooth germ), otherwise monitor

Concussion and Subluxation - reassure, monitor, soft diet and corsodyl gel.

Extrusion and Lateral Luxation - if mobile or interfering with occlusion extract, if no mobility allow for spontaneous alignment within 6 months

Avulsion - DO NOT REIMPLANT! Confirm avulsion with radiograph and establish if tooth was inhaled

Intrusion - monitor carefull to allow spontaneous re-eruption or extract if embedded palatally close to underlying successor.

Always review tooth trauma for at least 1 year. The injuries which have the highest incidence of damage to the successor are avulsion, intrusion and palatal lateral luxation.

Sequelae of Primary Tooth Trauma

  • Discolouration (grey/yellow)
  • Pulp necrosis (sinus/swelling)
  • Internal resorption (pink discolouration)
  • External resorption
  • Cyst formation
  • Permanent displacement/malocclusion
  • Damage to successor tooth
  • Delayed eruption of successor tooth


Trauma in the Permanent Dentition


Extrusion - reposition (with LA), non-rigid splint for 2 weeks, soft diet, analgesia and corsodyl mouthwash.

Subluxation - soft diet, corsodyl gel, analgesia, relieve occlusion if needed, may require splinting.

Luxation - reposition (with LA) , non rigid splint for 2 weeks, soft diet, corsodyl mouthwash, analgesia

Avulsion - reimplant asap, do not handle the root, wash gently with saline, flexible splint 2 weeks, soft diet, corsodyl, antibiotics

DO NOT reimplant if:
  • There are other injuries, patient will need to be admitted to ICU
  • If there is a compromised medical history that leads to reduced immunity
  • Immature permanent teeth with short roots and wide open apices with prolonged extra-oral time
Storage media:
  • Cold fresh milk
  • Saline
  • Saliva
  • Contacts lens solution
  • Hank's solution
60+ minutes of dry extra-oral time there will be very few viable PDL cells left therefore extremely likely tooth will become non vital and/or become ankylosed. 

Intrusion - if mild (<3mm) leave to re-erupt over 3 months, moderate (3-6mm) leave to re-erupt over 3 months or rapid ortho extrusion (2-3 weeks), severe (>6mm) surgically reposition and splint or reposition and ortho extrusion. If the tooth has a mature apex, flexible splint for 4 weeks and commence RCT. 

Fractures

Crown - reassure, monitor, smooth, composite restoration or reattach fragment if available. 

Complicated crown - as above, plus either direct pulp capping, pulpotomy, pulpectomy.  

Root - 2 x-rays at right angles required to diagnose. If not mobile monitor vitality and advise soft diet, if mobile reposition and splint or extract coronal fragment. If the tooth becomes non-vital extirpate to fracture line and obturate (using either calcium hydroxide or MTA to create an apical barrier). 

Crown-root - poor prognosis, either extract or if possible extract loose fragment and only RCT if can create a good seal. 

Alveolar - reposition and splint, monitor pulp vitality in affected teeth


Mineral Trioxide Aggregate vs. Calcium Hydroxide


When trying to create an apical barrier in immature teeth in order to root treat a traumatised tooth there are two approaches: using calcium hydroxide or mineral trioxide aggregate (MTA). 

Calcium hydoxide takes a much longer time (5-20 months) with multiple visits for the patient in order to replace the dressing. This means that problems arise in trying to provide a temporary restoration with a good seal as well as reports of root fractures before the end of treatment.

MTA on the other hand has the advantage of fewer visits as it sets within 3 hours, creates a good seal and is biocompatible so it can stimulate repair. Whilst the initial cost of MTA is more than calcium hydroxide, since the treatment is completed much faster, MTA is probably more cost effective. 

Splinting Guidelines

7 DAYS - Subluxation

2 WEEKS - Avulsion
                  - Extrusion
                  - Lateral luxation

4 WEEKS - Root fracture
                  - Intrusion (surgical repositioning)


For more information please see the Dental Trauma Guide.


I hope you've found this guide useful! Please leave any questions or comments in the section below!

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



Thursday, 8 January 2015

Blurred Lines: NHS Rules and Regulations in Dentistry

So when I started my foundation year I thought providing NHS dental treatment would be relatively simple. Think again. Once you start practising you'll realise there are lots of little clauses that you need to be aware of - otherwise you might end up in trouble!

Thankfully I had a study day just before Christmas lead by Raj Rattan and Len D'Cruz on NHS rules and regulations. There is a summary of the main points I took away from the day.


Structure of NHS dentistry


The 27 Local Area Teams (LATs) throughout the country get contracted a set number of Units of Dental Activity (UDAs) which are then dished out to providers. Providers are not necessarily the dentists who provide NHS dentistry; they can then contract these units out to individual performers i.e. associate dentists. 



For foundation dentists like me, we are given a target UDA value of 1875, but this is just a target and there is no penalty for not reaching or surpassing it.

Associate dentists usually get 50% of their UDA value, with the other 50% going to the practice owner in order to cover practice costs and the average UDA value is around £20.

UDA values for courses of treatment are as follows:

BAND 1 - examination, scale and polish, prevention, denture alterations. 1 UDA

BAND 2 - everything above plus fillings, extractions, periodontal treatment, endodontics, denture repairs and additions. 3 UDAs

BAND 3 - everything above plus crowns, bridges, dentures, mouthguards. 12 UDAs

URGENT treatment is the same charge as band 1 for the patient, but you receive 1.2 UDAs

Additional NHS services in primary care:

  • Orthodontics
  • Sedation
  • Advanced Mandatory Services 
Therefore unless you have a separate contract with your LAT for one of these services, they cannot be provided under NHS care. 


Courses of Treatment (CoT)


What is a course of Treatment?
An examination of a patient in order to assess oral health, planning of treatment and provision of planned treatment (and any treatment planned at another time to initial exam). Includes all proper and necessary dental care and treatment.
Therefore it is treatment that a patient needs rather than what a patient wants - you can then justify saying to a patient since they do not need tooth whitening in order to obtain oral health, you may charge privately for this treatment. 

When is a CoT finished?
When all treatment recommended at the initial examination has been provided

How long does a CoT last?
A reasonable period of time. Most dentists will probably say that following the initial completion of treatment that you planned as the examination, there is a 2 month window after submitting your claim where if the patient returns for any other treatment, this should be included in the initial CoT. 

So does crowning a tooth following root canal treatment have to be on the same CoT?
Not necessarily. Why? Because although the general opinion in dentistry is that root treated teeth need some sort of cuspal coverage restoration (usually in the form of a crown or onlay) in order to prevent fracture, according to a Cochrane review in 2012 there is no evidence to support this view. 
However, it is down to a clinician's experience to decide whether a tooth needs a crown (personally I have seen a few instances of fractured teeth which were root filled as a result of not have a cuspal coverage restoration) and if there is an active and symptomatic periapical infection, it may be wise to wait to see if the endodontic treatment is successful e.g. resolution of periapical radiolucency or symptoms. 
You need to communicate this very clearly and honestly to the patient for example: 

'After I have completed this root filling I would like to wait a while before reassessing you to measure the success of this treatment. If I think that the treatment has worked, it may then be sensible to have some sort of crown on this tooth as from my clinical experience, there is a higher risk of this tooth breaking than a tooth that has not been root filled.' 


When can I refuse to see a patient?


Any reasons for refusing to see a patient must be reasonable and must not be based on race, gender, age, religion, disability or their medical or dental condition.
Reasonable grounds could be for example:
  1. The patient decides to accept private services
  2. The patient has not paid. The NHS allows you to ask for full payment upfront, although some practices do make exceptions for band 3 treatments
  3. The patient becomes violent
  4. On the reasonable opinion of the contractor there has been a breakdown of the dentist-patient relationship


Urgent treatment


What is urgent treatment?
Treatment necessary to prevent deterioration of oral health or relieve severe pain. This may include:
  • Examination
  • X rays
  • Extirpation
  • Reimplanting a tooth
  • Repair or refixing a crown
  • Extractions
If a patient comes in with a broken filling, this is not urgent and therefore comes under band 2 and if the patient indicates that they want a course of treatment e.g. come back for fillings, then treatment will also come under band 2. 
Urgent treatment can also be split over more than one appointment. 


Guaranteed replacement


Some treatments should be guaranteed under the NHS for 12 months, this includes crowns, fillings, root fillings, veneers, inlays, onlays. However, this does not have to be honoured if:
  • Another person has provided the treatment
  • Their treatment has been placed as a provisional 
  • The treatment was not advised by the dentist
  • The failure is a result of trauma  

Grey areas


What band should fissure sealants come under?
If the fissure sealants are provided as a preventative measure, they will come under band 1; however, if they are provided to seal a composite restoration i.e. a Preventative Resin Restoration (PRR) they will come under band 2.

Do you have to provide a scale and polish for all patients?
No. It it down to your judgement as a clinician whether a patient would benefit from a scale and polish. However, if it is justified and the patient does not want to see the hygienist privately, then you must provide NHS treatment under band 1. 

Can I do molar endo on the NHS?
Yes, if it is a non-complex case. More complex cases e.g. curved canals, re-endos, poor access, can be referred to a practice with an Advanced Mandatory Services contract or to a dental hospital. You can also offer referral to a private specialist or if you have the expertise yourself, you can provide the treatment privately. 

If the patient returns after the initial completion of their CoT needing further treatment, does this come under a new CoT?
No but you can claim more UDAs; however the patient does not have to pay again (as long as it is within 2 months). 


The main thing I took away from the day is you can never say a particular treatment is not available under the NHS. Say this and if the GDC gets wind of it, they'll crucify you. Wording treatment options is a minefield in terms of communicating costs, especially when a patient asks you things like why do they have to pay more for a white filling or a chrome denture. 
Have template answers for these questions so that you are prepared and not caught off guard! Sorry to end things on a bit of a downer, but the threat of litigation or a GDC fitness to practice hearing are things that you really want to avoid!


For more information see Raj Rattan and Len D'Cruz's book, 'Understanding NHS Dentistry'.




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