Wednesday, 29 April 2015

#TubulesLive Event: Principles of Bone Augmentation for Implant Dentistry

So here's a bit of catching up, one of the recent #TubulesLive events was with Koray Feran who spoke about the principles of bone augmentation in implant dentistry; is less really more?

Sinus lift augmentation and bone graft

So why do we need bone for implants?


  1. For the stability of the implant for primary placement but also during functional activity
  2. To create bone contour for the planning of an ideal prosthetic restoration
  3. Stability of peri-implant issues in the long term i.e. the volume and vascularity of bone which does not resorbs
Koray talked us through his presentation with a variety of cases he's treated. Each case demonstrated the advanced techniques that are now used to aid in the predictable placement of dental implants. Here are some of his main points from his talk:
  • Literature suggests that 8mm is desirable amount of vertical bone to place an implant, but anything above 6mm is acceptable
  • What is more important than height is the WIDTH of bone, therefore augmentation of bone width is more important than bone height
  • Recession around implants is caused by a lack of width of bone, the incorrect positioning of the implant or the bone around the implant resorbing over time
  • It has been shown that labial soft tissue thickness is related to bone width
  • Bone augmentation can either be particular or block grafting
  • You should generally approach treatment to minimise loss of tissue and maximise the natural healing process e.g. immediate implant placement, ridge preservation techniques, atraumatic extractions
  • You should also plan prosthetic restorations well with CT scans and 3D imaging
  • Implants in the aesthetic zone should be placed into the palatal bone to prevent recession
  • You should always try to augment thin labial plates to increase the quality of the soft tissue 
  • Graft material can be synthetic or autogenous - a novel way to contain a synthetic graft is with a titanium cage
  • Autogenous grafts can be harvested from the oblique ridge of the mandible but you will need to CT scan before you do this to check the position of the ID nerve
  • The problem with block autogenous bone grafts is that the bone isn't very vascular so it is not ideal to withstand occlusal forces
  • Augmenting a lower resorbed mandible can be difficult because of the ID nerve but also because it tends to resorb to a knife-edge. 
  • Bone-rings can also be used for bone augmentation which the implant will hold in the correct position - these can be set sizes or custom made
  • Bone-rings will revascularise better than autogenous block grafts

Have you used bone-rings or titanium cages when augmenting bone? Or do you have any other tips? Please leave your comments in the section below!


To see my posts about previous #TubulesLive events see here

Sunday, 26 April 2015

Top 8 Things to Do in Hong Kong

Following my previous post with my Top 10 things to do in South East Asia, here are my top things to do in Hong Kong for those of you thinking of going out there.

What language is spoken there?
Cantonese but it is very easy to get around as most people speak English and signs and menus are in both languages.

What is the currency?
Hong Kong Dollars. At the moment, it's around 11 Hong Kong Dollars to the pound

How do I get around?
Getting around is easy with the bus and MTR (metro) systems. Taxis are also really cheap and its easy to flag one down, most speak english.

Local culture
Locals are really friendly and culture is generally very similar to western countries. The only thing I would say is that it is seen as polite to give and receive money with both hands. 


1. Wooloomooloos Bar

This rooftop bar in Wan Chai on the Island side has fantastic views day and night! A great place to have a chilled drink, or the start of an eventful night out in the area!

View of Wan Chai from Wooloomooloo's

2. The Races

Hong Kong has a couple of racecourses, the most famous is Happy Valley but when we were out there it was closed for refurbishment so we had to make do with Sha Tin Racecourse.

The only place in Hong Kong where you can legally gamble, see the locals getting vocal over their favourite horse, have a few beers and get your betting slips out for an evening of fun!


3. Sai Kung

Out in the northern territories of Hong Kong this famous fishing village has some fantastic seafood restaurants with the numerous fish tanks outside where you can pick your dinner. It's also a lovely place to have a stroll away from the city and you get hop on a boat to some of the small islands out to sea to relax on the beach.

Keep an eye out for the shark nets that surround each beach!



One of the many Island Beaches around Sai Kung

4. The Peak

The highest point of Hong Kong Island, you can get the Tram up to the top, or even a bus or taxi but I'd recommend walking back down the steep winding roads to get full appreciation of the view over the harbour. 

By walking down you also avoid some of the crowds right at the top by the shopping centre - try to time your visit so that you can see some the Light Show that is held at the Harbour every evening. 


View from the Peak

5. Lantau Island

You'll all pass through Lantau Island on your way in and out of Hong Kong as that's where the airport is, built on an artificial Island just off of Lantau. 

You can get a cable car up from Tung Chung which gives you good views all of the Island and the airport (if you don't mind queuing for it) which drops you right by the Big Buddha which was a gift from the Chinese government. 

If you can handle all the stairs to the top you can go inside the actual Buddha to see how it was constructed. Whilst you're on Lantau I'd recommend catching a bus to one of the local fishing villages such as Tai O where there's the traditional stilted houses. 


The Big Buddha on Lantau


6. Ocean Park


This theme park/zoo/aquarium on the Island can take up a whole day if you want! There are two parts to the park: the base part of the park is mainly the animal side with the aquarium, pandas and other animals whereas the top side of the park is mainly a theme park with roller-coasters and other rides but there's also a dolphin show. 

The two parts of the park are connected with cable cars or with a train. It's a great place to take kids, but also a fun day out especially if it's a really nice day! 

The Aquarium at Ocean Park

7. Star Ferry


The ferries that cross Victoria Harbour and connect the Kowloon and Island sides of Hong Kong give a great view of that busy area of Hong Kong and is a cheap and charming way to get across the harbour even though there are now easy ways to cross with the road and MTR system. 

View of Victoria Harbour from the Star Ferry

8. Lan Kwai Fong


Head to LKF for a bustling night out, some great food or a spot of shisha. Where Wan Chai is full of locals, LKF is the area where there are more expats, check out the 10 shot street bars!


I hope you've found this post useful and if you're heading around South East Asia in general, check out the Top 10 places I recommend you visit here.


Have you been to Hong Kong? Been to any of the places I've recommended or are there any other things that you'd recommend doing or seeing when out there? Please leave your comments in the section below!



Thursday, 23 April 2015

Top Tips for Unseen Cases

So it's approaching that time of year: Exam Time. It's easy to panic, especially when it comes to tackling those tricky unseen cases. But don't worry, here are my tops tips for a successful unseen case. 



General Tips

Think before you speak!

It's easy to get intimidated by the situation and sometimes by the grilling but remember to think before you blab! Take a deep breath, don't be afraid to ask examiners to repeat questions or clarify what they mean and admit if you don't know something - they will move on!


Takes Notes

Simple things to help jog your memory during the presentation and don't be afraid to say this to the patient - 'Ok just give me moment to jot this down'. A lot of the patients are used to it, either they will have seen numerous other students already or they are invited back each year so they know the deal. 


Don't get caught up talking to patients 

Some of the patients may be lovely but try not to get distracted by talking to them about other things than their mouth! You have limited amount of time and it is easy as you're nervous to get side tracked. Just politely say that you're a bit restricted for time and they'll understand. 


Be structured in your presentation

Having a structure to the way you present your patient will really show confidence, clarity and concision! Structure it how you would do an exam, for example:

  1. Patient age, gender, and main complaint
  2. History of complaint
  3. Medical history
  4. Social/Dental history
  5. Examination: E/O, I/O, ST, HT, occlusion
  6. Special investigations and what they show e.g. radiograph reports, vitality tests, biopsies
  7. Differential Diagnoses
  8. Proposed treatment plan


Lead the presentation

By having a structured approach as above, you should be the one doing all the talking. Don't get thrown off if any of examiners interrupt you with questions, just jump back into the flow of the presentation and importantly, don't jump straight into the diagnosis - they want the story leading up to it, even if your patient comes right out with 'I've got that Lichen Planus thing' (this is what one of my unseen cases did!)


Don't forget the basics

Importantly medical histories, even if there is nothing of note! I've heard stories of students failing finals as a result of not taking a medical history. Also don't get caught up in the complex treatments. What they are looking for are safe beginners, so it's perfectly acceptable to say you'd refer for a second opinion. 


Keep the above tips in mind, here are some examples of some of the common things that come up. If your have placements on consultant clinics, this is where most of the recruitment for finals cases comes from so make use of these clinics!

Restorative:

  • Tooth Wear 
  • Periodontal disease
  • Prostheses and their design e.g. dentures, bridge designs
  • Complicated medical histories
  • Management of teeth with necrotic pulps/failed endodontics

Oral surgery/medicine:


  • White lesions e.g. Lichen Planus, Leukoplakia, Candida
  • Radiolucencies of the jaws e.g. odontogenic keratocysts, ameloblastoma
  • TMJD and other pain disorders e.g. trigeminal neuralgia
  • Complications of extractions e.g. OAC, nerve para/anaesthesia
  • Trauma e.g. mandibular #, orbital blow outs
  • Pemphigus and Pemphigoid
  • Oral cancer and dysplasia

Child Dental Health:


  • Eruption and calcification dates
  • IOTN 
  • Trauma 
  • Differential diagnosis of white spots/mottling e.g. flourosis, MIH, AI, DI
  • Ectopic canines/submerged teeth/hypodontia/supernumeraries
  • Prevention e.g. fluoride guidelines, diet advice etc.
  • Balancing and compensating extractions
  • Sedation
  • Consent/Parent responsibility/Gillick competency/NAI


I hope you've found this post useful! Good luck everyone, if you have any questions or other handy tips please leave them in the comments below!

Sunday, 19 April 2015

#TubulesLive Event: Bio-emulated Indirect Posterior Restorations

A bit belated, but here is the summary of the #TubulesLive event that was held a few weeks ago with the charismatic and funny David Gerdolle. 



So are bonded restorations safe? Bonded restorations require flat preparations but does this compromise the lifespan of this sort of restoration? Here I shall summarise the points from Dr Gerdolle's talk. 

  • Bonded restorations (either ceramic or composite) can be BIOMIMETIC i.e. they can mimic the natural appearance of the tooth tissues
  • According to some studies, the 10-15 year survival rate of these restorations is similar to that of conventional full coverage restorations
  • The difference is not the lifespan, but what happens when the restoration fails. 
  • Very few failures with bonded restorations are catastrophic failure compared with conventional prepared restorations as you are preserving more of the tooth tissue 
  • You can produce a more aesthetic outcome, not only because the restoration is tooth-coloured, but you are also preserving more of the natural tooth
  • The key pillars of tooth preparation are:
  1. Biological imperative - Immediate Dentine Sealing (IDS) with bonding +/- composite. This is the ideal as it seals the freshly cut dentine which increases the bond strength and protects the pulp during the temporisation stage. It also prevents bacterial leakage and contamination with the temporary cement. This also means that you will not require anaesthesia at the cementation appointment which will help you protect the pulp when curing the luting composite
  2. Cementation imperative - consider the Configuration Factor (C Factor) when designing the cavity, MOD cavities are unfavourable as the shrinkage stress will product micro-cracks, therefore the best preparations are the 'flat'
  3. Prosthetic material imperative - materials usually require 2-3mm of room so that they are thick enough for resistance but thin enough to allow you to polymerise through. You should use calibrated burs to help you achieve this as it is best to prepare the tooth under rubber dam
  • Deep margin elevation (DME) can be used in teeth with deep subgingival margins. The other options is to do crown lengthening, but this means that the papilla disappears
  • There is evidence to support that DME is an effective treatment option as long as you can properly isolate the margin with the rubber dam and matrix system
  • Some hands on tips include not removing all the cusps or old restorations when preparing these cavities as they will help you isolate the tooth properly and using a sandblaster to remove any corrosion products and remnants of the old restoration
  • If you need to elevate a box, the best material to use is restorative composite rather than flowbale as the flowable will shrink
  • Use preheated 'hot' composite to cement the restoration in the following steps:
  1. Remove the temporary and sandblast the preparation with a matrix around the preparation to protect the adjacent teeth
  2. Etch with phosphoric acid
  3. Silaning agent application
  4. Hydrophobic bonding stage
  5. Apply the hot composite which makes the composite more viscous. Using a dark shade is best to prevent a translucent line at the margin
Dr Gerdolle's presentation was of fantastic quality and he was very engaging despite having spoken for the majority of the day. He really helped me to understand this biomimetic approach to restoring heavily restored teeth. 


Do you use this sort of approach when providing patient's with indirect restorations? Or used hot composite before? Please leave your comments in the section below!


To see my posts about previous #TubulesLive events see here

Sunday, 12 April 2015

Bling, Gore and a Menagerie: The Tower of London

So this Easter weekend we decided to visit the Tower of London. Why not pick the busiest weekend of the year to visit this popular tourist attraction?



Back in October, I visited the tower to see the breath-taking poppies but I didn't end up going inside the Tower. I've been eager to spend a good amount of time inside the Tower but I don't think we chose the best weekend to do it - there were so many people and big queues for the main attractions. I'd probably recommend going as early as you can in the morning to avoid the crowds and to not pick a bank holiday weekend or a weekend where the kids are off school!

Tickets into the Tower aren't too cheap at around £25 for an adult but there are lots of different things to visit inside and definitely worth a visit if you're in the area. 

Yeoman Warder tour

The Yeoman Warders hold tours twice an hour through the main aspects of the Tower and the grounds. These Yeoman Warders live inside the Tower (amazing!) and despite what you may think initally, they are not tour guides in fancy dress: they are ex-military who have served for at least 22 years before joining the Warders at the Tower. 

Our tour had a lot of people in it so it was difficult to hear at times, but our Yeoman, Clive gave us a history of the Tower and talked through some of the more famous prisoners that have been held there, from Elizabeth I to Anne Boleyn to Thomas Moore. 

We also learnt that the Tower wasn't just held as a Prison - it held a Menagerie full of exotic animals that were moved to Regent's park in the 1830s, founding London Zoo. The Tower is also the home of the Crown Jewels, coins were minted in Mint Street in the Tower until the 19th Century and has been the residence of numerous Monarchs throughout the years. 


The Crown Jewels


The queue was a good 20-30 minutes to get into the Waterloo Barracks to see the Crown Jewels, but it was definitely worth the queue to get to see the famous bling of the tower.

Most of the jewels were objects from previous monarchs' coronations and the collection dates from the 17th century when it was almost entirely replaced following the destruction of the original jewels after the execution of Charles I.

Security was pretty impressive as you walked into the vault through thick vault doors and as you walk around the exhibition you get a history of the monarchs of our country (we made friends with some Americans in the queue who were extremely curious about the Queen and the Royal family - something I think Brits take for granted as normality).  


The Bloody Tower


Having queued for the Crown Jewels, we didn't fancy another big wait to get into the White Tower so we settled for the Bloody Tower which was in my opinion, more interesting. 

The tower got it's name after the disappearance of two Princes who were allegedly murdered by Richard III in the 15th century.  Having declared the 12 year old Edward V and his 9 year old borhter illegitimate, Richard III was named King instead. 

If the story is true, it's a pretty sad one as the boys were never seen again but then in the 17th century, two skeletons were found under a staircase which were assumed to be the boys' remains and were re-buried at Westminster Cathedral. 


So if you're planning on a trip to the Tower of London, I'd definitely recommend going on a weekday if possible to avoid the crowds, or as early as possible at the weekend! I think you could probably spend a good 3 hours there if you want to see everything especially it's a nice day as a lot of your time will be spend outdoors. 

To find out more about the Tower of London see their website.


Have you been to the Tower of London? What was your favourite part? And what did you think of the White Tower? Let me know in the comments below!




Wednesday, 8 April 2015

MJDF - The Exam



So last week I sat my MJDF part one exam. If you're still unsure what MJDF is or if you should sit it see my previous post here

Since I live in London, my journey to the exam centre (The Emirates Football Stadium), was considerably less than a lot of the other candidates that were at the exam. I was grateful all I had to do in the morning was hop on the bus from outside my flat and 20 minutes later I was there - much preferably to some of my friends journeys from Newcastle or Leeds. 

Preparation Tips

The sooner you take the exam after finals the better. Finals are much harder but you'll have all that information fresh in your mind. Some of my friends took the exam in October, but I think the majority do take the exam when I did as finances just after starting DF1 can be a bit stretched. 

There are some example questions on the MJDF website and their questions each year are very similar. If you know someone with a bank of previous questions, hassle them to share it with you! 

There are a few text books out there too that I would recommend in preparation for the exam:
  1. Best of Fives in Dentistry by Douglas Hammond
  2. EMQs for Dentistry by Douglas Hammond
  3. MCQs for Dentistry by Kathy Fan
  4. SAQs for Dentistry by Kathy Fan


Revision Hints for the Exam


Here are some of the question topics that come up a lot and from what I can remember from the exam:

  • IOTN 
  • Reasons for delayed eruption
  • Consent issues e.g. capacity, Gillick's competency, Parental Responsibility
  • Trauma in children
  • Fluoride guidelines
  • Eruption dates and calcification dates
  • Cephalometric values and points
  • Antibiotic classes and guidelines
  • Drug interactions e.g. warfarin
  • NHS banding system 
  • TMJ anatomy 
  • Practice policies e.g. appraisals, autoclave servicing, CPD requirements
  • Practice remit of dental professionals e.g. therapists, orthodontic therapists, clinical dental technicians
  • Cranial nerves and what they innervate
  • Bridge designs


Format of the Exam


The exam was 3 hours long which was plenty of time in my opinion. Quite a few people left early, but I thought I'd kick myself afterwards if I left early so I made sure I took my time and stayed until the end.

There were 150 questions and the exam was split into 2 sections. The first half were extended matching answer questions whereas the second half were single answer questions. All were multiple choice and the paper was not negatively marked. 

All stationary was provided and it was probably one of the most chilled out exams I've ever sat! For more information see the MJDF website.


I hope this helps those who are thinking about possibly sitting the exam at the next rotation in October. Bring on part 2 - any tips or hints on this would be greatly appreciated!!

To read more about MFDS part two, see my recent post here.

Did you sit the exam? What did you think of it? Please let me know in the comments below!


Saturday, 4 April 2015

Top 5 Things to do in Dubai

After my dental elective in the summer of 2013, on the way back to the UK we stopped over in Dubai. We were flying with Emirates who allowed us to extend our stopover in Dubai by 7 days for no extra charge! 

What language is spoken there?
Arabic but it is very easy to get around as most people speak English and signs and menus are in both languages.

What is the currency?
Dirhams. At the moment, it's around 5 Dirhams to the pound

How do I get around?
Getting around is easy with the bus and Metro systems. Taxis are also really cheap and its easy to flag one down.

Local culture
Dubai, together with the whole of the United Arab Emirates, is an Islamic area therefore you should dress modestly when out and about - make sure your knees and shoulders are covered at least. At the beach or in expat areas things are a bit more relaxed. Also be aware not to drink alcohol or appear drunk outdoors or to kiss in public as this is also frowned upon.


Luckily, we knew people out in Dubai to help give us an idea of what to do whilst we were out there, but for those of you who don't, here are my top 5 activities you must do out there!

1. Burj Khalifa

The tallest building in the world is not only pretty impressive from the ground, but amazing when you're up at the top. When I say at the top, it's not really at the top - probably three quarters of the way up but apparently any further up and the altitude would make you feel ill.

We went up to the 'top' at night time but they have these cool telescopes where you can see what the views are like day and night, and also what the landscape was like only a few years ago when the area around was just desert. It's amazing to see how quickly the area has built up in a relatively short time.

If you're scared of heights I would probably just stick to the view from the bottom and every 15-20 minutes there is a fountain show with music at the base of the building so check that out instead.

Night view from the top of the Burj Khalifa

2. Deira

An underrated area of Dubai in my opinion. We stayed in a hotel in Deira which is much cheaper than some of the more popular areas. You also get a taste of the large Asian ex-pat community here with cheap and delicious food everywhere.

The highlights of the area are the Souks - my favourite being the Gold Souk which is filled to bursting with tonnes of bling! Even if you're not looking to buy gold I would still recommend it and there are other things to buy there not just gold, from souvenirs and trinkets to traditional Asian clothing to belly dancing costumes and shisha pipes.

Endless amounts of gold in the Gold Souk


3. Jumeirah


The location of the 7 star Burj Al Arab and as well as the famous artificial archipelago Jumeirah Palm Sands.

If you're also looking for a beach there's one right by the Burj Al Arab just down the road from the Wild Wadi Water Park.

To get onto the Palm, there's a monorail where you get a pretty nice view of all the island. It which runs down the centre and terminates at the Altantis Hotel where there is an aquarium as well as another water park.


View of the Burj Al Arab from Jumeirah Beach


4. Malls


Dubai is a great place to shop! There are a staggering 69 malls throughout Dubai, all with their individual character!

Some of the malls I visited were Deira City Centre, Dubai Mall and Ibn Battuta malls.

Dubai Mall is the biggest and most visited and is just by the Burj Khalifa. It holds the Dubai Aquarium and underwater zoo and on our first night, we were surprised to find we could visit the aquarium at 1am!

Ibn Battuta mall is a bit further out but is really quirky as each of the different areas of the mall are a different region the arabic explorer Battuta visited.

One of the other famous malls in Dubai is the Mall of the Emirates which houses Ski-Dubai, an artificial ski slope in the middle of the desert city! 

China Court in the Ibn Battuta Mall


5. Desert safari


Venture out of the city into the surrounding desert. There are lots of tour companies who will arrange this for you and activities when you're out there include dune bashing, camel riding, quad biking and sand-boarding.

Depending on which company you end up with, there is may also be a camp set up with other things to do: holding falcons, dressing up in traditional arabic clothing, henna and shisha all culminating in a buffet dinner with magicians, belly-dancing and the traditional Tanoura arabic dance.


Out in the desert!


Dubai was a great place to visit, especially after spending 6 weeks in Africa. We definitely appreciated our nice hotel room, the ease of getting around at night-time and of course the shopping!
Like the other big international cities across the world like London, Hong Kong and Singapore, there is lots of do even after the sun goes down but it is also easy to escape to the beach to relax!

To see some of my other general travel tips see my previous post here.

Are you planning a trip to Dubai soon? Found this post useful? Or have you been and got any other top things to do that I've missed? Please leave your comments in the section below!


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