Sunday, 28 June 2015

An Interview with DENTEETH

Many of you may have seen a new website being publicised on social media called Denteeth. But what is it?

Kalpesh Prajapat is a fourth year Dental student and director of Denteeth. Kalpesh was awarded the prestigious Frank Ashley undergraduate prize for his innovation aiming to improve global oral health care and here he shares his aims with his new venture.




 1. What is Denteeth? 


Denteeth is a new innovative hub for Oral health care, our core aim is to improve global oral health through our innovative products and most importantly, through education. 

In modern day Dentistry, there is now increasing emphasis on the prevention of behaviours detrimental to ill health so by helping to reduce common preventable dental diseases, the biological and financial costs of invasive treatment can be minimised.  

In the UK alone the NHS spends £3.2 billion on dental services. In addition, patients amongst the general public spend £653 million on treatment, which can commonly be a prevented. Denteeth aims to develop products and provide services that help reduce this biological and financial burden.  


2. What is planned for the future? 


Currently we are working on our revolutionary oral health app for children. We aim to create an interactive and powerful app that not only educates children, but rewards them for their behavioural compliance. Structured in a game format, users are immersed as their chosen avatar into a virtual world where they build points for good oral health behaviours. Using augmented reality, users activate the app triggering educational songs and videos with an on-screen timer for brushing. 

With 4.75 billion smartphone users and over 195 million tablet users globally, the application has enormous global potential. With a user-friendly design, high quality animations and clear voice-overs the product will be popular with children.  

The app aims to be launched during 2015, on both android and apple iTunes platforms 

The prototype of the application has already been acknowledged by the British Society of Periodontology for its capacity to educate patients in the prevention of gum disease.  


3. What did you find the most challenging when setting up Denteeth? 

Time management has been tricky, especially balancing dental school with meetings, travelling and of course social life.  Fortunately Skype and Facetime have allowed face-to-face meetings at the comfort of my desk! 

 4. How do you think Dental Practitioners can use Denteeth in their everyday practise? 


Denteeth.com is an online resource for oral health and hygiene where dental professional can direct patients to for further information regarding maintaining good oral health.  

In Dentistry prevention of disease is integral to good overall health and Denteeth features educational videos and advice which can work as an adjunct to the dental health professional. 


5. Where do you see the future of Denteeth?  


Although Denteeth is in its infancy, we are already working with international oral care manufacturers such as TePe as well as several other health care product manufactures who have shown interest in the concept.  

Following a successful launch at the 2015 BDA Exhibition in Manchester, Denteeth aims to continually grow and expand with in-store commercial oral health products, together with innovative technology ultimately promoting better oral health.  


A fantastic concept which can help us as dental professionals educate and therefore improve the health of our patients!

Be sure to check out the Denteeth site where I have written a blog post on what patients can expect from NHS dentistry - click here. Let me know what you think of the site in the comments below!



Tuesday, 23 June 2015

A Guide to Temporomandibular Disorder

Following my first post from a study day with Riaz Syed, here is part two: A guide to temporomandibular disorder (TMD). 



TMD is another dark art at dental school and a lot of general practitioners are unsure of how to manage this condition, opting to refer on to secondary care for it's management. TMD is common and we should be able to manage simple cases in a primary care setting. 

70% of the population will suffer from TMD of some sort at some point in their life. 

Classification of TMD

  1. Internal derangement - with (clicking) or without (locking) reduction
  2. Myofacial pain
  3. Osteoarthritis 
  4. Chronic facial pain
  5. Developmental defects
  6. Trauma
  7. Pathology/neoplasia
The first two are the most common and the types you are likely to see in practice.

Patient History

When a patient presents with TMJ or facial pain and you suspect TMD, these are some of the questions you need to ask:
  • Is there pre-auricular pain? (in front of the ear)
  • Pain in the face, eyes, ears, any headaches where their doctor has not found a cause?
  • Is there a clicky jaw? Or a jaw pop, grate, catch or lock?
  • Is difficult or painful to chew?
  • Does their bite feel comfortable?
  • Are they aware of clenching or grinding their teeth? (In 20-30% of cases this will be the cause)
  • Have they suffered trauma to the head, neck or jaws?

Examination

1. Palpate lateral and inter-auricular area - if this is tender can indicate the capsule is tender due to trauma to lateral pterygoid

2. Measure incisal opening (fingers or ruler) - if this is limited then it can indicate infection or inflammation in the muscles. Average is 35-40mm

3. Feel and listen to clicks with a stethoscope - note whether single or multiple, intermittent or consistent, early or late, soft or loud, painful or not. Note that most clicks are asymptomatic.
Intermittent early clicks tend to be due to myofacial pain, rather than consistent late clicks which are due to internal derangement (the later the click the poorer the prognosis). 

4. Lateral pterygoid - cannot examine this muscle manually, best way is to record the response to resisted opening as this is a high endurance muscle

5. Masseter and Temporaralis - check for tenderness in muscles when clenching

Radiographs are not needed to diagnose TMD unless you suspect osteoarthritis and you should consider other imaging methods such as MRI if this is the case.


Internal derangement - disc displacement with reduction

Usually an asymptomatic and consistent click when opening and closing. This is due to displacement of the disc which can be: anteriorly or medially displaced or both.

Causes include:
  1. Injury to the bilaminar zone or disc
  2. Hypertonicity of the lateral pterygoid
This leads to an altered range of movement and a transient deviation. To confirm the diagnosis ask the patient to open and close edge-to-edge....the click will disappear (but only if the disc is anteriorly displaced)!

Treatment

  1. Counselling and patient education
  2. Not always necessary to provide active treatment but general preventative advice such as not opening their jaw wide, supporting it when they yawn, no hard foods, raw vegetables, tough meat, chewing gum and avoid biting with front teeth
  3. For anterior displacements, anterior repositioning splint - splinting patient in an edge to edge incisor relationship worn 24/7 for 3 months to allows for healing and reattachment of bilaminar zone. The earlier the click, the better the prognosis. After 3 months, slowly wean off 
Note that ALL patients with clicks, no matter if the click is symptomatic will require a mouth prop when providing dental treatment to avoid overusing their lateral pterygoid. 


Internal derangement - disc displacement with reduction

This will present with a LOCK rather than a click. Other symptoms include:
  • Decreased incisal opening (20-23mm)
  • Pain in pre-auricular area  
  • Sudden onset of locking and no clicking
  • There will be a history of a click
  • Lasting mandibular deviation towards the TMJ with the displacement

Treatment

  1. Counselling and patient education
  2. Physiotherapy ASAP to prevent chronic compression of the disc (either a private referral or urgent to NHS TMD clinic). This will increase blood flow and relax the muscles, decrease inflammation. This can be aided with a hot or cold compress
  3. Muscle relaxant e.g. 10mg Temazepam for 7 days
  4. If this treatment is successful, the click will REAPPEAR, if it does not consider a referral

Myofacial Pain

Aetiology: bruxism, recent dental interventions, trauma

Signs or symptoms:

  • Pain on palpation of TMJ and muscles of mastication
  • Limitation/deviation of mandibular movements 
  • Intermittent joint sounds
  • Headache
  • Neck pain

Treatment

  1. Explain, reassure, educate
  2. Soft diet, rest jaw
  3. Physiotherapy e.g. short wave diathermy, ultrasound, megapulse, laser, acupuncture
  4. Ibruprofen gel over joints

Signs of bruxism

  • Scalloped tongue 
  • Pre-auricular pain
  • Cheek ridging (due to vacuum in mouth at night times and decreased salivary flow increases keratin production)
  • Headaches
  • Teeth sensitivity
  • Teeth wear and fractures

Treatment of bruxism

  1. Soft bite guard for 3 months at night time and wean off - works by separating teeth or possibly placebo effect? For 80% of patients it improves the situation, but in 10% it makes worse
  2. Michigan Splint - this gives the patient the 'ideal' static and dynamic occlusion. This will need a facebow articulation and similar to the soft bite guard should be worn at night for 3 months and then weaned off
  3. Localised occlusal interference splint - an acrylic plate which overstimulates proprioception of 4 teeth (the canines) and is a habit breaker although some patient will still continue to brux. Worn at night time for 3 months and then weaned off
Other conditions of the TMJ are rare. Do not feel pressurised into treatment if you are unsure of the diagnosis or how to treat, in these cases refer!

Thanks to Riaz Syed of the Red Square Academy for an informative day on some very difficult topics in dentistry!


How do you treat TMD in practice? Please leave your questions and comments in the section below!

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



Tuesday, 16 June 2015

London Theatre Guide: War Horse on Stage

So this weekend the mother came down to visit - just one of the fun things we did was see War Horse at the National Theatre. 


Similar to when me and mum went to see Miss Saigon earlier on in the year, we decided to rise early to try to get day tickets for the Saturday matinee showing of War Horse as the play had been recommended by one of my patients. 

There was less of a queue outside the theatre than last time and day tickets were just £15! Being first in the queue, we actually got tickets sitting together this time and right on the front row.

The play which is based on a book by Michael Morpungo (and has also been adapted into film) is the story of the relationship between a boy and his horse. During the first world world the horse gets sold into the military so the boy, Albert, enlists into the army in order to find him. 

The life-size animal puppets were truly incredible - at times you would forget that the horses trotting about on stage were not real. My favourite was the goose which was hilarious. I never knew humans could make such good impersonations of horse or goose noises!

The performance was very interactive with the actors running down the aisles, sitting on the edges of the stage  or underneath the stage as if they were in trenches. I was expecting more a musical, but the few songs that were performed were not by specific characters, but more of a score for the play to be performed. 

I have not actually read the book or seen the film as I felt a bit sceptical about the storyline, but I think seeing those puppets on stage has really changed my mind and I would definitely recommend it!

For more information, see the War Horse website


Have you seen War Horse? Would you recommend it? What are your thoughts about the show? Please leave your comments in the section below!

Thursday, 11 June 2015

A Guide to Occlusion

A couple of months ago I had a study day about occlusion and temporomandibular disorders with Riaz Syed. Being two of some of peoples' favourite topics at dental school (*cough*) it's taken me a while to write these up. But here is the first part, based on occlusion. 

Practising facebow - check out my occlusal plane


Occlusion is a topic that a lot of dentists are scared off and don't understand fully. Things can get pretty complicated, but here I shall summarise the points from the day trying to keep things as simple as possible.

When you place a restoration, you either CONFORM or REORGANISE a patient's occlusion.

Use the STOP approach to manage a patient's occlusion when placing restorations or prosthetics:

Survey existing occlusion, mark with articulating paper
Tactile - check for fremitus
Observe/listen. Ask for patient to tap together, the sound should be crisp
Patient feedback 

So when are teeth in contact?
When you swallow - teeth are not actually in contact when eating therefore there are in contact on average 17-18 minutes a day. 
If this time is increased it can lead to: wear, fractures, pain due to pulpal inflammation

Causes of fractured teeth:

  • Interferences
  • Parafunction
  • Habits
  • Restorations in other teeth

Possible consequences of changing ICP i.e. too high fillings

  1. Fractured teeth or restorations in occlusion or cracks
  2. Overeruption of teeth out of occlusion without occlusal stops. This leads to no spreading of load and no feedback which leads to interferences as teeth are not in the occlusal plane
  3. Pain
  4. Mobility, bone loss and widening of PDL
  5. Inflammation of pulp
  6. TMD and myofacial pain due to deranged occlusion (forward posturing and anterior tooth wear) or parafunction
Patients can adapt to these changes, so consequences may be hard to undo.

Consequences of infraocclusion 

Other teeth take the load of occlusion, which may lead to no short term problems unless the patient bruxes but the tooth with over-erupt over time.

Why does this happen?
We do not check occlusion before preparation of crowns or fillings which leads to accidental reorganising

If we are conforming, occlusion must be: 1. Reproducible
                                                              2. Stable
                                                              3. Enough occlusal contacts at correct OVD

What is ICP (intercuspal position, centric occlusion, habitual bite)?
Position of maximum interdigitation of teeth with mandible at its most cranial position. Tooth determined position therefore restorative dentistry can change this position

What is centric relation?
Mandibular-maxillary relationship when the condyles are in 'upper most anterior' position in glenoid fossa. Anatomically less vital but health of tissues are important i.e. unstrained and non-inflammed muscles: Position of Health.

What is RCP (retruded contact position)? 
First contact in centric relation. We are adapted to avoid this contact - our condyles are remodelling until we are 21 years old, but we are fully dentate at 14 years that's why there is a 90% discrepancy in the population of around 1mm between CR and CO.

When do we use these positions?

  • Dentures
  • Reorganising to create space
  • Stabilisation splint
  • Multiple crowns
  • Anterior guidance
What is a facebow?
This records the relationship of the maxilla to hinge axis of rotation. Use with a semi or fully adjustable articulator e.g. Denar.

Using a facebow can accurately record registrations but other tips for recording occlusions for lab work:
  • Recording using wax bites are inaccurate, using PVS if have to e.g. Blu Mousse
  • If patient is class I and stable occlusion, record may not be necessary as long as lab can hand articulate
  • Record PVS just over prep, not across all occlusal surfaces
  • Take accurate impressions, minimise air blows

Check out part two: a Guide to Temporomandibular Disorders

Do you use a Facebow in practice? Please leave your questions and comments in the section below!

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


Sunday, 7 June 2015

Evidence Based Dentistry Conference

So if you have read my previous post about Evidence Based Dentistry, you will know that this year I have been working on an EBD project. The EBD conference held on Friday was where I was able to present my findings, but also raised the issue of where is the evidence base in dentistry?

All of us on the North East London DF1 Scheme, with our PAD Sana Movahedi

This year, our scheme was the pilot to run a new idea; that during our foundation year we should carry out a project based on evidence in dentistry. 

I decided that my topic would be on: 'Class V Cavities; Composite or GIC?'

The morning of the conference was based on the background of EBD where we had Dominic Hurst and Jan Clarkson speaking.

Dominic raised the issue that the reasons why evidence is not used in practice are that:
  1. Clinicians are out of date
  2. Research available is suboptimal
This leads to a suboptimal patient outcome, therefore we need to generate better research and get clinicians using high quality evidence in practice.

But what makes up EBD?

The three components of Evidence Based Dentistry.

For more information about what EBD is, see my previous post here

Jan Clarkson spoke about some of her ongoing research projects such as FiCTION, iQuad and Interval which should help to create some evidence behind our common practises in dentistry. She caused much upset when she revealed to us there is no evidence to suggest flossing is beneficial!

Results of Pan London Antimicrobial Audit


So it was down to me and another colleague in my group to present the findings of the antimicrobial audit that all London trainees have carried out this year. 

You can scroll through our presentation below (for those who are squeamish, I'd skip the video at the end!), but our main findings were that antibiotics in particular were being over-prescribed without local measures taking place, but on our second round of audit there was a significant improvement in practice. 

I also raised the issue of possible reviewing of the 2008 NICE guidelines against antibiotic prophylaxis to prevent infective endocarditis. There has been a significant increase in the number of cases of infective endocarditis since the guidelines were put in place both in low and high risk individuals. Although there has been no causal link at the moment, it does make you question whether this policy has caused harm and that the evidence that they used in order to justify setting these guidelines was flawed (it looked at the incidence of IE in children!). 
IE has a 40% mortality rate, so this is a serious issue that needs to be addressed - was this just a guideline to help save the NHS money?




Poster Presentations


So our afternoon was spent presenting the findings of each of our posters to the rest of the London trainees (that meant presenting 26 times as they were split into smaller groups....exhausting!).

Well done to all the trainees presenting their posters and keeping up the enthusiasm despite the heat. There were a variety of topics presented; from fluoride to ferrule, from articaine to smoking cessation. Everyones' posters looked great and the hard work paid off - special congratulations to the winners of the prizes Hazel and Noor!

To see a copy of my poster click here, but if you're just looking for the answer to the question I asked, you should use:
  • Composite
  • A 2 step self etching system
  • Roughen the cavity prior to placement

To see a copy of my patient decision aid, please click here.


Me looking very happy in front of my poster!

Massive thanks to Sana and Dominic, without them this whole idea would not have existed!

Do you have any thoughts or questions about my poster or any of the others you saw on the day? Please leave your comments in the section below!


Thursday, 4 June 2015

No one says F*** it to Phuket

Continuing my series of 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 Phuket, Thailand.

One of the top destinations to hit up in South East Asia, Thailand is now an easy place to visit and get about. Due to the limited time that we were travelling about, we had just 5 days to kill between Singapore and moving on to Malaysia so where to go?

Phuket is a the biggest island in Thailand off the west coast and has become a popular beach getaway not just for tourists, but for Thai people themselves. It's a short cheap flight from most of the destinations around South East Asia so it was ideal for us!

What language is spoken there?
Thai. It's not too difficult to get around though as there is usually someone around with basic English, especially if you are staying in a particularly touristic area. 

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

How do I get around?
Getting around is probably easiest with Taxis or Tuk Tuks, but there are a few buses about if you wanted to save some cash. 

Local culture
Locals are so friendly in Thailand! If you're around the really touristic areas, you'll be faced with calls from ladies from massage parlours or street vendors trying to sell you their wears but never in an aggressive way. Plus if you're going on a night out you will get some hassle from people trying to get you to go into a certain bar, or have a picture with a ladyboy or come to a Ping Pong show! Just remain polite with them, even if you are trying to get away from them!

So there are the top 5 things I think you should do if you're heading out to Phuket!


1. Ko Phi Phi


This group of idyllic islands just off the coast from Phuket were the setting for the film The Beach.

Beautiful white sands and clear blue waters where you can top up your tan, go snorkelling or explore the caves around the rocky bays. 

The Phi Phi Don is the biggest island and the only one with accommodation on it. You can do day trips from Phuket town if you're on shorter trips which include snorkelling and lunch but if you're going in peak times these can be very busy! 

Go up to the viewing point on Phi Phi Don where you can see the whole Island!

One of the beaches on Ko Phi Phi

2. Phuket town 


A good base, the capital of Phuket is not as touristic as some areas of the island but still has lots to offer if you're looking for a quieter side of Thailand and to interact with some of the locals.

If you're heading to Ko Phi Phi, there are regular ferries from Phuket town but the town also offers a great Trick Eye museum.

The whole museum has various art scenes which you can pose which create some really funny and creative illusions! These sort of museums are becoming really popular in Asia.

Some pretty impressive stuff at the Trick Eye Museum

3. Muay Thai Match


This combat sport is really popular and also really entertaining to watch! We went to an evening of matches which started out with the younger less experienced fighters (they were really young, looked about 9 or 10!), and culminated in a big fight between an Australian fighter and a famous local Thai champion.

Grab a couple of beers, get involved with the locals running around betting on who will win and shout along to your favourites.  


4. Patong Night Life


One of the really touristic and busy areas of Phuket, Patong is full of life and it's famous nightlife sprawls along Bangla Street which is shut to vehicles during the evening and night to accommodate the rowdiness of a night out in Thailand.

As I said earlier, be ready to fight off Ladyboys, club promoters and Ping Pong show menus but a night out in Thailand is infamous and will go on late into the night.

My favourite place was were a Filipeno band played into the early hours of the morning, taking requests throughout the night.


5. Tiger Kingdom

Up close and personal with Tigers

Before going to Thailand I told myself that I wouldn't go to have my picture taken with a sleepy drugged up tiger. 

Admittedly, as soon as I stepped off the plane and saw that you could get up close to a tiger, my resolve wobbled. We asked a few people we met during our stay and finally on our last day, caved in and went to see the tigers. 

It was very different to what I expected. The tigers didn't really seem to be that sleepy, especially the younger ones who jumped around playfully, making cute little snarls at each other. According to the staff, they never drug their tigers and the tigers are brought in and trained from a young age to interact with humans. 

The big tigers were quite terrifying, especially when one came up behind me when I was taking photos! There were a few young children around crying because they were so scared! 

I haven't done enough research to definitely say that these sort of experiences are good for the tigers, but it certainly does raise a lot of money and awareness about the declining tiger population in the wild. I would say if you're really concerned do some research, but I certainly wouldn't feel guilty recommending this attraction!


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



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