Monday, 25 May 2015

A Guide to Oral Cancer

Last month I attended the Oral Cancer Conference in London. Here is a summary of what I learnt from the day.

Oral cancer screening is one of the four domains of oral health that dental professionals need to be aware of. I feel that there isn't a lot of public knowledge about this type of cancer in comparison to others such as breast or lung cancer, despite there being around 9000 new cases each year. 

Worryingly, oral cancer is increasing in incidence in younger people and there is a widening gap between lower socio-economic groups compared to groups which are less deprived. This is probably down to social differences, namely the use of tobacco and alcohol. Other factors can also be implicated such as the Human Papilloma Virus (HPV), sunlight exposure and poor diet e.g. low in fruit, so low in antioxidants. 

22% of adults smoke in the UK - still a large proportion but nothing compared to the 70% of men who smoked in the 1960s! Practising in East London has also made me aware of other forms of tobacco which are popular in some ethnic groups such as Paan or Khat. 

Smoking together with alcohol multiplies the risk of the development of oral cancer. Do we all ask our patients if they drink and how much they drink? 

What is a unit of alcohol?

This is the amount that is equivalent to 10ml of pure ethanol, which corresponds to roughly:

25ml shot of spirit (of 40% alcohol)
Half a 175ml of wine (12.5% alcohol)
Half a pint of lager (4% alcohol)

Department of Health Guidelines:

Men should not regularly drink more than 3-4 units a day
Women should not regularly drink more than 2-3 units a day
Pregnant women are recommended to avoid alcohol

Oral cancer screening is a GDC core competency, so if you suspect an oral cancer what do you do?

Urgent Referrals

Look up the guidelines and protocols for your local area hospital but it usually looks like this:
  • Fax or send the referral via a secure email account ASAP
  • If this is not possible, send a letter urgently but also give your local team a phone call
  • Use the word CANCER if you suspect as this will fast track the referral
  • Other things to include should be medical history, risk factors, signs and neck lumps
Delay in referral can affect the outcome for these patients and hospitals have to see these urgent referrals within 2 weeks.
If there is late detection in the cancer, the 5 year survival rate is 51%, but if it is detected early this increases to 80%

Potentially malignant conditions

  1. Leukoplakia (this is a diagnosis of exclusion which can be granular, specular, nodular, verrucous, homogenous and non-homogenous)
  2. Erythroplakia (uncommon but with a increased risk of malignancy)
  3. Oral lichen planus
  4. Submucous fibrosis
  5. Chronic hyperplastic candidosis
  6. Discoid lupus erythematosus (DLE)
  7. Iron deficiency e.g. B12 or folate

Histological classifications

  • Intraepithelial neoplasia
  • Carcinoma in Situ (this means that the dysplasia has not reached the basement membrane)
  • Dysplasia (mild, moderate, severe)
Sites that are most commonly affected by malignant lesions are the tongue and the floor of mouth.

Management of dysplasias

  1. Excision by laser or surgical 
  2. Prevention measures i.e. decrease smoking and alcohol intake. 50% of leukoplakias can disappear if the patient stops smoking
  3. Increase antioxidant intake 
  4. Regular reviews 

The management of oral cancer is multi-disciplinary, with treatment managed by ENT and Maxfax sugeons, oncologists, radiologists, dentists, speech and language therapists and dieticians. 
The later the diagnosis of the oral cancer, the more likely that treatment will need to be more radical, have a poorer prognosis and ultimately, decrease the quality of life for that patient. 

Not only will large resections change the life of that patient, adjunctive radio or chemotherapy also have severe side effects. Whilst plastics can now to wonders in terms of facial reconstruction, the functional implications of having a large portion of their mouth resected can be debilitating.

The take home message from the conference was on early diagnosis! You should be performing oral cancer checks for all your patients at EVERY appointment, and if there is anything suspicious send on urgently. These referral centres would rather see something innocent every now and then rather than run the risk of late presentations of poor prognosis.

Thanks to all the speakers from the day. Do you have any thoughts or experiences of seeing oral cancer in practice? Leave your comments in the section below!

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

Sunday, 17 May 2015

A Day Trip to Singapore

Continuing my travel posts after my Top 10 things to do in South East Asia, I thought I would write about my top things to do in Singapore in one day!

When I visited Singapore, I was only there for just over a day. Singapore is small enough to get around in a relatively short period of time so using it as a stopover between destinations in Asia is ideal. Singapore is also expensive in comparison to the neighboring countries in the area, so if you're backpacking it' probably best to limit the time you spend here.  

What language is spoken there?
Mandarin 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?
Singapore Dollars. At the moment, it's around 2 Singapore Dollars to the pound

How do I get around?
Getting around is easy with the bus and MRT (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, you'll feel like you're in a hotter cleaner London!

Morning - Chinatown

Not only a great place to get some of the local food; check out the Maxwell Centre and chicken rice!

There are markets, museums and places of worship like the Buddha Tooth Relic Temple. It's also somewhere relatively cheap to stay if you're ok kipping in a hostel and is a bit closer to things than Little India (the other area which is dense with hostels).

Singapore also do a tourist travel card which you can use on buses and the MRT for one or two days depending which one you buy. This card also allows you to hop on and off their city tour bus which is a good way to see the sights around Singapore in a short space of time.

Lunchtime - Marina Bay 

Marina Bay is probably most famous for the Marina Bay Sands Hotel with it's infinity pool at the top. But that's not just all there is at Marina Bay.

If you can stand the heat at this time of day, take a walk around the the Marina, check out the famous Lion Fountain. You do get a pretty good view from the viewing platform at the top of the hotel, although it probably is a bit overpriced and unfortunately only hotel guests can use the pool at the top. 

There is also a huge mall at the bottom of the hotel - if you're looking for somewhere to shop, the mall has pretty much everything and grab something to eat while you're there.

Afternoon - Gardens by the Bay

Just behind the Marina Bay Sands hotel are the Gardens by the Bay:

'Turning the Garden City into a City in a Garden'

The place is so full of greenery you wouldn't think you were in the middle of the city and there are countless large plant-like structures, some with a walkway between, one with a restaurant at the top if you're still peckish. 

Evening - Night Safari

One of the top attractions in Singapore aside from Universal Studios on Sentosa Island. There are 3 wildlife parks that you can go to: the Night Safari, Singapore Zoo and the River Safari. If you want to go to all 3 (which will probably take you more than one day) you can get a discount.

The Night Safari was the only one I went to, but it was really good and brought a new perspective to the zoo experience. 

We bought our tickets at a discounted rate from our hostel and although there is a shuttle bus that runs directly from areas of Singapore to the zoo, it was still really easy to get the MRT and a regular bus there. 

At the Night Safari there are a couple of 'shows' at set times but the main attraction is hopping onto a safari train to get driven through the night around the zoo and see the animals up close. You can also hop off the train to walk around the trails to get an even closer look and a lot of the animals are up and about rather than sleeping. See more at their website

Night - Clarke Quay

If you're still full of energy after your busy day, head to Clarke Quay where there are countless restaurants and bars to keep you entertained - there's even a Hooters!

Since taxis are pretty cheap and easy to come by, I'd probably recommend catching one back to your hotel or hostel afterwards!

Have you been to Singapore? Is there anything else you'd recommend people do when out there? Please leave your thoughts and experiences in the comments below!

Thursday, 14 May 2015

#Tubules Live Event: 7 Stage Approach to a Successful Business

This week's TubulesLive was with Laura Horton of Horton Consultancy - a specialist consulting agency in dentistry. 

Laura uses her hand on experience in dentistry to help practice owners get the most out of their businesses. The main points of her talk I will summarise below:

  • Every dental practice should have a business plan which is not just a file full of spreadsheets and figures, but a strategy to make the most out of their business
  • Similar to the Wheel of Life (which I have talked about in one of my previous posts), Laura has her Wheel of Business with 7 elements to it which contribute to a successful practice
1. World class marketing
2. Human resources
3. Effective sales system
4. Optimisation and maximisation i.e. having strong systems
5. Effective business map
6. Financial systems
7. Patient experience
  • Marketing and branding is everything to do with your business: from the brand logo, to the patient experience to the way the receptionist answers the phone
  • You need to identify who you want to come to your practice and target your marketing towards them as well as marketing to existing patients
  • Being able to tap into patients' emotions and enhance the experience you give them will lead to them recommending them to their friends which is the best sort of marketing
  • Make sure if you do decide to run offers that these offers have deadlines. Be careful not to get caught up in the 'race to the bottom' with your competitors
  • Make sure you have Call to Actions e.g. free consultations and follow these up with phone calls or emails
  • A good team works well together when they are given good opportunities and are trained well
  • Ensure every person has a detailed job description so they know what's expected of them
  • Perform appraisals every 6 months and see this as a opportunity to be positive and thank your team members
  • Consider extending roles for team members e.g. Treatment Coordinators, Extended Duties Dental Nurses
  • You need to proactive in your financial management: work in REAL TIME i.e. don't wait until you have to submit your yearly accounts to review things
  • Make sure you forecast and have a trading account
  • Your outgoings can be divided into fixed and variable; the variable costs will be the ones that can catch you out in terms of cash flow
  • Some Key Performance Indicators (KPI) that need to reviewed regularly include: treatment mix, recalls, unbooked time, DNA rate, staff sickness etc. 

This TubulesLive was a nice change in aspects of dentistry from our usual talks and was really refreshing. Check out Laura's website here

Let me know your thoughts about how to make your dental business successful in the section below!

To see my posts about previous #TubulesLive events see here

Tuesday, 12 May 2015

BDA Conference Manchester 2015

So this weekend it was the BDA conference in Manchester - what a weekend!

The conference was held from the Thursday to the Saturday, the first two days seemed to be full to bursting of foundation dentists like me. Most of the schemes across the country had made at least one of the days compulsory. It was great to see so many familiar faces, swapping stories from life in practice and to gossip in general!

Much like the Dentistry Show and the BDIA showcase, this weekend was not just a weekend of CPD and socialising - the exhibition allowed us to check out the latest products, chat to reps and of course to get ample samples and freebies!

I managed to part with close to a grand for my Loupes (from Optiloupe). To see how I've gotten along with them, see my review here


There were plenty of opportunities for CPD over the weekend with lectures held throughout the day in multiple rooms from some great speakers. 

Some of the highlights were; Alignment, Bleaching and Bonding with Tif Qureshi (this will really change the way you think about lower anterior crowding especially!), Richard Field's talk on ICON (if anyone wants to practise on me give me a buzz) and Basil Mizmari's talk on ceramic restorations.

Not only were there lectures, there were demonstrations like medical emergencies and also sessions where you could have your say.

Being a recent graduate, the Young Dentist panel held on the Friday morning was a really interesting and reassuring session where I could empathise which what worries young dentists have at the moment. Whilst a lot of concerns revolved around the GDC ARF hike and the new NHS contract, there was also a lot of talk about whether we receive adequate training before we graduate. 

There has been many a time during my foundation year where I have doubted my ability as a dentist - mostly when I have been unable to extract a tooth or when I can't quite get to the apex during a root canal treatment. With so much theory to learn which only grows as the years go by, is it really a surprise that younger dentists are getting less and less clinical work? I think what everyone agreed is that we need to support each other as a profession. In our careers we will continuously be learning and developing our skills, but we need to know our limits and when to ask for help. 

Getting involved as a BDA member is therefore essential! Our trade union supports us and lobbies on our behalf - we can't just sit back and assume other people will be acting in our interests. Getting involved in local meetings is not only a way to show support and receive support when you need it, but networking in this way can help when you are looking for jobs and is just a nice way to get involved socially instead of becoming isolated in the box that is your dental surgery.

And of course I just need to mention how much fun the Spring Ball was on the Friday night - fab to see everyone and who can resist an opportunity to dress up?!

Did you go to the BDA conference? Which lectures did you enjoy the most? What do you think about the future of young dentists in today's climate? Please leave your comments in the section below!

Thursday, 7 May 2015

London Museum Guide: The Science Museum

Another bank holiday weekend, another touristic activity to do in London.

I had visited the Science museum probably about a decade ago (wow scary) and visiting South Kensington there's plenty of choice if you're looking for a museum: from the Science Museum to the Victoria and Albert to the Natural History Museum.

Founded in 1857, the museum is huge with a vast collection of items from clocks to steam engines to agricultural models - and the best thing is that entry is FREE
The museum isn't just a collection of items either; there are plenty of interactive things to do including flight simulators, lots of hands on exhibits at the Launchpad and even an iMAX theatre.

Trying to get around the entire museum in one afternoon got a bit tiresome by the end and there were definitely bits that interested me more than others.

My favourite section by far was the Science and Art of Medicine - we spent the most time up there on the 5th floor (if you get a chance take a peek out of a window, the views are great too!).

Of course those of you loyal readers will guess, the part of that exhibition that interested me most were the dentistry related things, especially since I watched that programme on the BBC: 'Drills, Dentures and Dentistry: An Oral History'.

It was really fascinating to compare my everyday tools to those I saw exhibited like foot powered drills or hand burs. Or the chunky denture blocks used as false teeth made of Hippo Ivory which would rot in the mouths of patients (ew!).
Some things weren't too unfamiliar though, like the trays used to make impressions for dentures which looked pretty familiar to what I use day to day in practice (although not made of gold).

I know it sounds cliché but seeing how medicine has developed throughout history really does make you grateful for the health service you can get today, despite all the faults of the NHS.

After going around this part of museum, my boyfriend then asked me what I thought was the most important development in medicine in the past few centuries..... and the answer probably reflects the area of medicine I practise everyday, but I said local anaesthetic, but what do you think? 

Some of the dental-related items at the museum, working clockwise from top: a denture block carved from hippo ivory, a selection of instruments used to restore and fill teeth, ivory dentures including George Washington's, Vulcanite dentures and denture trays used to take impressions.

To find out more about the Science Museum, check out their website.

Have you been to the Science Museum? What was your favourite part? Please let me know in the comments below!

Monday, 4 May 2015

Our Patients are Changing....

How many of your patients are the 'elderly'? The increasing life expectancy of our patients together with the improvement of oral care means that people are keeping their teeth for longer. 
Back in March I attended the Gerodontology conference in London - this blog post is based on this study day. 

I have previously touched on the implications of this shift in our patient demographic on periodontal health in a previous post (see here), but the increasing age of our patients has other implications in other areas of their mouths than just their gums. 

Failing restorations and Tooth Wear

Older patients present with a challenge to dentists - one of the main issues is their polypharmacy. Specifically, some medications can lead to a decrease in salivary flow (i.e. xerostomia) which can cause problems such as root caries, periodontal breakdown and tooth wear as a result of the prolonged retention of their teeth.

Therefore, the main risk factors for caries in older patients are:

  • Poor oral hygiene
  • Xerostomia
  • Diet
The elderly are more at risk from root caries due to their decreased salivary flow, dentures, lack of dexterity, a shift from complex to simple sugars and poor oral hygiene. 

Treatment options for root caries:
  1. Remineralise (fluoride, CPP-ACP)
  2. Recontour
  3. Restore intra-coronally 
  4. Restore extra-coronally
Should all missing teeth be restored? 
No - if the patient can function i.e. eat and speak effectively, you can accept spaces e.g. Shortened Dental Arch. You can then avoid problems that are introduced with removable prostheses e.g. caries, poor adaptation in older patients, candida etc. 

Treatment and classification of Tooth Wear (Tulloch and Watson)

Catagory 1 - appearance is satisfactory but treatment is required

Discuss the cause of the wear with the patient, prevention measures should be taken (diet, fluoride), place plastic restorations to restore function and prevent further wear, nocturnal appliances in bruxists should be supplied, full or partial coverage restorations if required and regular review. 

Catagory 2 - appearance is unsatisfactory, treatment is required and there is space for the placement of restorations

As above

Catagory 3 - appearance is unsatisfactory, treatment is required and there is no space for the placement of restorations

These cases may require referral to specialist or secondary care if you are not confidence in reorganising their occlusion or opening their OVD.

Thanks to Professor David Hussey for his talk.


Is there still a need for removable prosthetics in the UK?
94% of UK adults are dentate, but in the over 75 group, 34% of them are edentulous and fixed prostheses are not always appropriate e.g. lack of tooth tissue, alveolus, resources. Therefore, despite the decreasing demand for prosthetics, it it still important to be able to provide these treatments in practice.

Anatomical considerations that can cause issues when making complete dentures:

  • Atrophic mandibular ridge
  • Flabby ridges
  • Big ridges
  • Frenal attachments
  • Tuberosity
  • Genial tubercle
  • Mylohyoid ridge
So how can we overcome these challenges, specifically atrophic ridges.... Overdentures 

If using teeth as overdenture abutments, there can be some challenges e.g. endodontic treatment, maintenance requirements, fracture of the acrylic, undercuts or intra-arch space. 
Implants can also be used as abutments, but there may be medical or patient barriers to implant placement e.g. osteoporosis, bisphosphonates, ability to withstand surgery.

As mentioned above, the decreased saliva flow in older medicated patients can cause a lot of problems when constructing dentures. Whilst we can try to artifically substitute saliva when it is deficient, a lot of patients will prefer just sipping water frequently. 

Thanks to Professor Janice Ellis for her talk - it was nice to see a familiar face!


There are a number of endodontic challenges in older patients:

  • Patient factors e.g. ability to recline, to tolerate lengthy procedure or rubber dam, access (mouth props may be useful)
  • Medical history
  • Finances/attitude of patient
  • Tooth factors e.g. strategic importance, periodontal status, restorability, endodontic considerations
Since post-operative pain following endodontics in necrotic teeth is around 80-90%, our usual advice of taking NSAIDs to manage this may not be appropriate in patients on certain medications or medical conditions.  

Examples of strategic teeth that you would be more inclined to try to save by treating endodontically include:
  • Distal abutment to free end saddle
  • Overdenture abutments
  • Bridge abutments
  • Alveolar ridge maintenance
  • Local parameters
  • OVD maintenance 
Together with the above issues, older patients will tend to have calcified canals and pulp chambers particularly if the tooth has been subject to trauma or repeated dental restorations.

Top Tips for Calcified Canals

  1. Plan well by studying your radiograph
  2. If you have any concerns regarding orientation, disassemble the tooth first
  3. Good lighting and magnification are essential
  4. Use a DG16 prove to check where you are
  5. Irrigation copiously with EDTA/NaOCl
  6. Use safe-ended burs to refine the pulp floor and gooseneck burs help
  7. C-pilot files can be used to help negotiate calcified canals 
Thanks to Bhavin Bhuva for his talk. 

Domiciliary Care

Older people are more likely to have a limiting life long illness, some serious enough for the patient to be confined to their home or even to their bed. These patients will still require dental care and therefore the expansion of domiciliary services has to meet this growing need.

There are some specific issues that come up when practising out in the community in this way:
  • Appropriate training for staff
  • Mental capacity and consent for patients
  • Appropriate treatment within the domiciliary setting
  • Environmental risk assessment
  • Infection control - zoning, use of disposables 
  • Equipment e.g. portable units, light sources, portable suction, oxygen
  • Safeguarding
Techniques such as the Atraumatic Restorative Technique (ART) and use of agents such as Carisolv can be really useful in a domiciliary setting. 

Thanks to Debbie Lewis for her talk

How do you feel about the changing demographics of our patient base as well as their changing expectations? What challenges have you faced treating these patients? Please leave your comments in the section below.

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