Wednesday, 29 July 2015

Roadtripping in Bali

Following my previous post with my Top 10 things to do in South East Asia, I decided that I would write about some of the time I spent in Bali. We were only there for 3 days and in hindsight, I definitely think we should have stayed longer.

To cram in as much as possible in the time we were there, we hired a man and his taxi to drive us to some of the top attractions on the island in one day. This sounds expensive, but if there are a few of you (another girl from our hostel came along too), you can split the cost which isn't too bad. I think in the end it came to around £30-40 and this was a long day; from around 11am to 7pm!

Before I describe the itinerary we did, let's get some basic facts about Bali. 

What language is spoken there?
Indonesian 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?
Indonesian Rupiah. At the moment, it's around 20,000 Rupiah to the pound

How do I get around?
The best way to get around and possibly the easiest is local taxis which are relatively cheap. There are a limited number of buses on the Island, mainly connecting to the main airport. 

Local culture
Unlike the majority of Indonesia, Bali is a Hindu region so you unlike the other Islamic regions of Indonesia you do not have to worry so much what you wear out and about.

View over some of the rice fields at Ubud

1. Rice Fields and Kopi Luwak

First we headed to the central of the island to the town of Ubud to the famous terraced rice fields. There are lots of different views you can see, but we went to a place where they made Kopi Luwak - coffee made from beans that have been partly digested by the Civet (a small cat like animal).

At the farm you will see the civets (cute but smelly!) and see how they make and process the coffee as well as having some FREE coffee at the end (although you'll have to pay to sample the actual Luwak coffee).

You can sit on the top terrace and look out over the fields drinking a nice cup of coffee, or if you're like me and don't like coffee, tea or hot chocolate!


2. Monkey Temple

Next we headed to the famous Monkey Temple and Forest in Ubud to meet some very cheeky monkeys. It was amazing how bold and fearless the Macaque monkeys were - we saw them ambush some old ladies at a banana stall at the entrance to the forest and they'd climb up on top of your head as if you were a tree!

I'm not sure whether these monkeys or the ones I experienced at the Batu Caves in Malaysia (see my post about it here) were more cheeky!

In the middle of the forest is a Hindu Temple where the monkeys make themselves at home. To find out more see their website

Not too shy to pose for a photo!

3. Bali Zoo

I know it's a bit clichĂ© to go to a country abroad and go to a zoo, but there was a big variety of different animals which are indigenous to Indonesia and the surrounding Asian countries compared to what you would find in any zoo in Europe. 

Of course we had to get up and personal with an Asian elephant and if you pay a little extra you get go on a ride on it. It's touching to see the relationship between each elephant and their personal keepers - the keeper for the elephant we rode said that she was his 'wife'.

We also got the opportunity to feed a Bengal Tiger and a Crocodile (scary!), as well as holding a baby crocodile and a bear cat (Google it, so cute!). 


Enjoying our new ride!

4. Balinese dance

Finally later on in the evening we watched a traditional Balinese dance performance which told the story of Rama and Sita, a Hindu Diwali story.

All the costumes and make up were spectacularly elaborate and their dance was very elaborate with intricate hand, arm and eye gestures like they were in a trance. There was also a chorus of local men chanting constantly during the story 

It was quite hypnotic at times and very entertaining, the perfect end to a long day of site-seeing!


Have you been to Bali? 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!


Saturday, 25 July 2015

Fifty Shades of White - Shade Taking in Dentistry

There's one thing that as an undergraduate I really struggled with - Shade taking. Sometimes you can't always rely on your lab to take a shade. Here are some of the key principles of shade taking.



What makes up shade?

Hue - colour e.g. blue, yellow, orange

Chroma - saturation of the colour

Value - brightness of the colour, i.e. how much grey there is

When taking shades, the most important component is VALUE which you should take from the mid 1/3 of the tooth, take the hue from the cervical 1/3.


Vita Shade Guide

When you take the shade from the vita guide, instead of having the tabs in the order of As, Bs, Cs and Ds; arrange in order of value

The Vita Guide arranged in order of value

Each of the letters have different hues:

A - Orange
B - Yellow
C - Grey
D - Brown/Grey/Orange (most translucent)

Taking shades with the Vita guide does not take into account metal cores for bonded crowns or the porcelain opaquer. To decrease the brightness, you could reduce the value by mixing the grades as follows:

A1 - 80% A1, 20% C2
A2/B2 - 70% A2, 30% C2
A3.5/B3.5 - 70% A3.5, 30% C3
A4/B4 - 70% A4, 30% C4

For C grades, there isn't a need to mix the proportions as above. 


Tips for shade taking

  • Sit the patient upright when shade taking
  • Take any of the patient's lipstick off
  • Place the tab parallel to the tooth
  • Hydrate the tab
  • Use a light correcting lamp
  • Move the shade guide from left to right. Rather than finding similarities in shade, eliminate tabs
  • Your cones that detect colour tire quickly, so look at each tab for maximum 5-7 seconds

Opalescents (effects)


Some effects that you need to take note of:
  1. Mammelons
  2. Combs
  3. Windows
  4. Stains
  5. Cracks
  6. Snowflakes
Draw out the tooth on the lab docket (before you prep it!), draw out any effects like the ones above as well as the strongest chroma, the highest value and the enamel colour. 


Still struggling?

Still not sure or if it's a single anterior tooth (the most difficult situation), then you may want to get help from the lab.
Either send your patient directly to the lab for shade taking, or take clinical photographs to send (pre-op as well as the preps and take with a couple of different shade tabs in the shot).


I hope that clears up a few things when taking shades! Please leave any questions or comments in the section below!

Thursday, 16 July 2015

Cosmetic Veneers - Aspire Dental Academy Part 2

So here is part 2 of my days with Aspire Dental Academy following my first post about composite (click here to go to the post). This post will focus on veneers in dentistry.

Some of my Practise Veneer Preparations

40% of medico-legal world is down to patients who are unhappy with their veneers - but if a patients asks you how long a veneer lasts, what would you say? 

According to studies, veneers have a failure rate of 3% per year (mostly down to debonding), however, success rate is related to aesthetic outcome for the patient i.e. are they happy with the way the veneers look?

Aims of Veneer Treatment

  1. Ensure the veneers look aesthetic - refer to the pink and white aesthetic score (i.e. teeth and gums)
  2. Ensure the veneers do not come off

When offering veneers as a treatment option, you must make sure there is NO inflammation as this will lead to bleeding when you place retraction cord. Apart from excellent oral hygiene, you can also recommend using Chlorhexidine 3 days before the patient is booked in for their preparation appointment. 


Planning Stage

This is the most important and difficult stage of the process of veneers and you must take your time with this. Here are some things you need to take into account:

1. Patient Expectations

What is the current situation like? If it's the colour they're unhappy with then why don't you consider whitening? If it's the alignment, consider orthodontics? And if it's the shape, you could consider composite bonding

How does the patient perceive their problem and what is their desired outcome? To help you consider what treatment is necessary, use the principles of Smile Design (see my previous post about this). 

After you've decided if veneers are appropriate for the patient then you should consider what material to choose: this could be composite, porcelain or Emax

2. Shade assessment

This is something that a lot of dentists are not confident in taking. Remember that the strongest chroma is at the cervical edge. 

If you're unsure, take clinical photographs: pre-operative with calibrated shade tabs and also when you've prepped the tooth.

To see more about shade taking, see my recent post here

3. Soft tissue assessment

  • Gingival aesthetics (height, asymmetry)
  • Gingival disease
  • Gingival biotype (thin, thick or mixed. Thin types are more prone to recession)
  • Biological width
Bear in mind that if you place veneers in a patient with a thin biotype, their gingiva will eventually receed and expose the margins of the veneers.

Avoid placing the margin of the veneers in the junctional epithelium or connective tissue as this will lead to inflammation and recession. Make sure you place the margin slightly sub-gingival (0.5-1mm) and therefore leave 2.5-3mm between the margin and the osseous crest.  

A good tip to help you place the margin in the right place is to draw the gingival margin on the tooth then when you place the retraction cord it will retract around 0.5-1mm so use a William's probe to measure the appropriate distance. 

Note that the most common cause of inflammation around margins of veneers and crowns is not encroachment of biological width but actually excess cement left in situ. Use Loupes on high magnification and remove excess with a scalpel and ultrasonic scaler. 

If you do think that the inflammation is due to encroachment on biological width, remove the veneers and place temporaries. If that doesn't work, refer to a periodontist to removal of the inflamed tissue and reconstruction of the biological width. 

4. Occlusion

Most debonds are not caused by interferences with occlusion but actually poor cementation. Nevertheless, you need to check a patient's occlusion carefully - namely are they canine guided or group function and also protrusive movements. Teeth are designed to be loaded axially, not laterally, so if you introduce a lateral interference, restorations will fail - to read more about occlusion see my previous post here


Preparation Stage

What should you send to the lab?

  1. Photographs (pre-op with shade tabs, preps)
  2. Smile design results and changes
  3. Upper and lower silicone impressions (these can be used to make bleaching trays if appropriate but also diagnostic wax ups if you are changing the size and shape of the teeth)

Preparation

  • Prepare in 3 planes: incisal, mid-buccal and cervical
  • Prepare 0.5-0.7mm
  • Use a depth cutter in the 3 planes and draw in these on the tooth to help guide up (as I have done in the picture above)
  • Decide which incisal preparation you want: usually either feathered edge or butt joint (window and overlap are rarely used)
  • A butt joint should only be used if you want to achieve incisal edge characteristics e.g. opalescents, mammelons etc. (1mm should be removed)
  • You should not break the contacts unless: there is mild crowding, the teeth are rotated or you want to change the inclination of the teeth
  • If you do break contacts, be careful in patients who have had orthodontic treatment as the teeth may move!
  • Carry out Immediate Dentine Sealing (IDS). You should try to stay in enamel but in older patients, this may not be possible. 
  • If you are removing old porcelain veneers, use Loupes and use etch to help identify areas where porcelain in still present

Temporisation


If you are providing multiple preparations, use your diagnostic wax up to make a putty matrix and a composite based temporary material (such as QuickTemp), but don't take the temporaries off the teeth once they are set. Tidy up with a bur and relieve interproximally so a Tepe can get between. This means all the temporaries are joined together.

If you are preparing a single tooth, spot etch and bond the temporary to the tooth. 

To improve the appearance of the temporary, use the correct shade and place a glaze over the top. 

Try-in and Cementation


Always ask your patients to bring a family member for the fit appointment - they're the ones who will have to look at the result and will help the patient decide if they are happy with the result.
  1. Administer local anaesthetic
  2. Remove temporaries
  3. Clean with ultrasonic
  4. Place retraction cord
  5. Wash and dry the tooth
  6. Set up veneers in the correct order, load with clear try-in paste and place on dry teeth
  7. Check fit and occlusion and approve aesthetics with patient (tell them to be careful when sitting up!)
  8. If everything is ok, proceed to cementation!
  9. Place rubber dam
  10. Wash the try-in paste away then dry
  11. Prepare the veneer: wash, dry, scrub with hydrofluoric acid for 90 seconds, rinse then place 2 coats of silane
  12. Sandblast the tooth, etch then prime and bond separately
  13. Place veneer, remove excess cement with tepes, floss and with a microbrush which has bond on it
  14. If you have a rubber ultrasonic tip, use this to vibrate the veneer further into place, remove any more excess cement with a scalpel, then cure
  15. After your first round of cure, place glycerine and then cure again to prevent marginal staining
  16. Remove cord and remove any excess with a scalpel and ultrasonic scaler
Use a clear-try in paste as your technician would have compensated for any discolouration when making the veneers (as long as you've sent photographs!).

The big question: which cement should you use? The best ones to use are light cure resin cements such as Nexus, Variolink or Calibra


Thanks again to Raheel and Ahmed for a really interesting couple of days the hands on elements were fantastic! I know feel more confident in offering cosmetic composites and veneers for my patients.

Do you provide veneers in practice? Let me know what you think in the comments below!


Sunday, 12 July 2015

Pick, Lick and Stick - Management of Dental Emergencies in Children

If any of you watched the Truth about Teeth on BBC a few months ago, the phrase 'Pick, Lick and Stick' will be familiar. Management of emergencies in children can be overwhelming, especially in a primary care setting. Here I shall outline the simple management of two of the most common emergencies in children in dental practice.


Management of Avulsion


See my previous post about the general management of dental trauma for the gold standard of treatment - bit in general practice what are the practical steps of how to treat this condition?
  1. Irrigate the socket and administer LA
  2. Replace the tooth in the socket and ask the patient to bite down on some gauze
  3. Isolate as best you can - rubber dam may not be practical in a distressed child
  4. Etch the middle third of the tooth; wash, dry and bond
  5. Place the wire in place first with the tooth that you are splinting too. The last tooth you apply onto the splint is the avulsed one
  6. Push hard to get the tooth fully seated through the blood clot
  7. Ask your nurse to stabilise the wire when bonding
  8. Splint to one tooth either side. This means the splint is flexible
  9. If you do not have orthodontic wire in practice, unravel a sterile paperclip and use that
For management of trauma, the only time you should consider using a rigid splint i.e. splinting to 2 teeth either side, is for alveolar bone fractures. In other injuries, a rigid splint will prevent physiological movement and therefore promote ankylosis. 

Management of Irreversible Pulpitis in a Primary Tooth


A child attends your practice in pain from a tooth - this can be a nightmare situation with a tired and distressed patient and a parent who is worried and upset. 

It is likely that if the child is young and hasn't had that much of an experience with dentists, that their compliance will not be very good either so management can be difficult. A useful tip to assess whether a patient may be compliant for treatments is to try to take bitewing radiographs. If they will not let you place the holder in their mouth, or will not sit still to take the radiograph, the best thing to do is to refer on to either a hospital or a community dental setting.

Management of emergency irreversible pulpitis in a compliant patient:

Extractions in cases of irreversible pulpitis are not always possible in patients who are distressed, in these cases: Dress with Ledermix and Kalzinol. This kills off the nerve but in case the patient suffers an acute abscess, you can flick off the dressing to allow drainage. 

Medication tips:

  • Advise Calpol and ibruprofen for pain relief
  • Alternate with these medications every 2 hours so that they do not overdose if they suffer severe pain
  • For antibiotics, oral suspensions of both amoxicillin and metronidazole are available
  • Always look up doses in the BNF, but remember you can DOUBLE the doses in severe infections
  • If you are concerned of the risk of admission of the patient, make sure you give the parents the warning signs e.g. raised temperature, difficultly swallowing and breathing and give them details of their nearest Accident and Emergency with a Maxfax unit

I hope that this simplifies things! Please leave any comments or thoughts in the comments section below!



Wednesday, 8 July 2015

Top 5 Things to Do in Kuala Lumpur

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 Kuala Lumpur, Malaysia.

On our trip through South East Asia, KL was a must stop as I have family who live in the capital. Having a free tour guide in the form of my Uncle was great as we saved a lot of time finding things to do and knowing which activities were worth doing.

Like the other big cities in the area like Singapore and Hong Kong, KL is a bustling city but a lot of the infrastructure is being improved at the moment which lead to some long tail-backs in the car when trying to get about.

What language is spoken there?
Malay. It's not too difficult to find someone who speaks English though. 

What is the currency?
Malaysian Ringgit. At the moment, it's just less than 6 Ringgit to the pound

How do I get around?
Getting around is probably easiest with Taxis or the Malaysian version of the underground MRT (which is really cheap). We were lucky knowing someone to drive us around most of the time! 

Local culture
In Malaysia there are 3 main cultural groups: Malay, Chinese and Indian. In KL there is both an Indian hub and a China town. Despite what you may hear in the national media, there still is segregation between each culture and being Malay is highly favoured if you want a government job.

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


1. KL City Centre (KLCC)

In the main business district of KL, the famous Petronas twin towers (which were once the tallest buildings in the world) dominates the skyline.

The shopping mall attached is a good place to pick up some goods and it's huge so you could definitely spend a day there without feeling you've got around the whole place! There's also a park behind the towers which is a nice place to sit and soak up the sun with the impressive back drop of those towers. 

It's quite difficult to get tickets to go up to the bridge that connects the two towers and you will need to get up early to get in the queue!

Posing outside the Petronas Towers

2. KL Tower

This old satellite tower actually has a view which is higher than the viewing platform at the Petronas Towers - it's actually the 7th tallest building in the world.

You get a fantastic 360 degree view of the city and can use the binoculars around the tower to get a closer look.

There is also a revolving restaurant and outdoor viewing platform - you will have to pay more for these, as well as an aquarium and other outdoor activities surrounding the tower.

A view of the twin towers from the KL tower


3. Kuala Selangor

A hour or so drive out from KL is this small fishing village on the River Selangor.

You can hire boats and go see the famous fire flies (Kampung Kuantan), but the main attraction here is the food. The fish restaurants here serve amazing seafood which you pick out from the tanks if you wish, and the restaurants themselves project out on stilts into the river itself.

We were there are sunset and the view across the river was magical!

Sunset over the Selangor river

4. Batu Caves

These Hindu caves on the edge of the city are a hot spot for tourists, if you can handle the stairs!

Batu is Malay actually means rock, and at the top of the x stairs there is a Hindu temple which is the most popular Hindu attraction outside of India. There are other relics surrounding the caves, but the aspect you need to be careful of are not the 272 steps or the heights; beware of the monkeys!

These Macaque monkeys are very cheeky and bold - we saw one pinch a bottle of coke right out of a man's pocket! Do not feed them, but they are very willing to pose for photos!

As well as the temple you can actually enter the pitch black caves for a guided tour and there is also a museum at the bottom which has a reptile house, dancers performing regularly (they'll try to get you involved too) and a exhibition of Hindu Gods.



5. Royal Selangor

In the past, Malaysia's main export was Pewter. On the outskirts of the city, there is a Visitor Centre where you can learn about the importance of pewter in Malaysia's history, have a go at finishing a pewter tankard and wander through the main factory to see how their products are made.

The centre also runs workshops where you can make your own jewellery! I would never have considered seeing this attraction before my trip, but my Uncle recommended it and of course at the end of the tour we spent a while browsing the gift shop. 

Centuries ago when there was no official currency in the country, the way that goods were exchanged was with the exchange of different weights of pewter either in the shape of animals or as a money tree (which is seen as a good luck charm now). We found this so cool that we bought replica of a little crocodile which was used for such purposes as well as a turtle as a gift for a friend. 


Posing with the largest pewter tankard in the world!



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



Monday, 6 July 2015

Dental Circle Networking Party

Anyone who follows any of my other social media accounts may have noticed a few updates from the Dental Circle Networking Party at Vanilla (especially the vodka luge!).


What is Dental Circle?


Dental Circle is the a new social network especially for dental professionals! Only professionals registered with the GDC can join the network so the website isn't only a great way to meet people but a safe and secure way to share your cases.

The site is also a way to get some online mentoring, register for local events and courses and to log your CPD. With the job market flooded with dentists (especially in London), this tool could help you promote the work you provide for your patients and give you an advantage over others when applying for jobs. 

To see more or to sign up head over to their website.

The amazing Implant Vodka Luge!

The evening held in central London at Vanilla was a fantastic event to meet dentists of all ages. Seeing some familiar faces as well as meeting new people outside the structure of a conference was really refreshing. 

There was still plenty of dental chat though and some really experienced clinicians were about to give me some advice and tips about patients, careers and dentistry in general. As the night grew later however, chat did turn into some people strutting their stuff on the dance floor!

After a few Mojitos, Amit and Dev cracked out the vodka for the ice luge and the party went on late into the night - shout out to those party people who made it to the end. Could've done with some of those tasty canapé burgers at 2am!

Massive thanks to Dental Circle for organising such a fun event - on a side note the photo booth idea was so great I'm going to have to include it for everyone else to check out.

To anyone that I met on the night I hope to see you around at another event soon; perhaps the masquerade ball at the weekend!




Did you attend the party? What did you think? Or more importantly, which cocktail was the tastiest? Let me know in the comments below!



Thursday, 2 July 2015

Creative Composites - Aspire Dental Academy Part 1

Some of you have read one my posts from last year about a Composite Day with iCAD Academy. Recently I have been on another course with Aspire Dental Academy. Here is what I learnt from the day. 

My trial composite build up on a phantom head

Before deciding what composite course you want to go on (and there are so many to choose from), it is important to invest in yourself by investing in tools and equipment you need, especially composite! A lot of trainees like myself only have one option when it comes to composite (and sometimes even only one shade). Invest in good quality composite for example Venus Pearl; this equipment is an asset which is a patient builder and also tax deductible! 

Concepts of Smile Design


The components you should look for include:
  • Face
  • Lips (full, pinched, tight)
  • Teeth
  • Gingiva
  • Relationship
Is the facial midline coincident with the dental midline? Sometimes this isn't always essential for a pleasing smile, take a look at Tom Cruise's smile for example. Was is more important is whether there is a cant i.e. if the midlines are not parallel. Test this with floss. 

Lip line is determined by how mobile the upper lip is. Lip lines can be average, low, high or very high. Check this in a relaxed smile, forced smile and also when the patient is laughing.

Smile Lines can be:
  1. Positive
  2. Flat 
  3. Reverse
Smile line is the relationship of the upper anterior teeth to the lower lip. Remember how you learnt the set up of anterior teeth when constructing dentures as an undergrad? This is what Smile Line is - with the laterals incisors being slightly shorter than the centrals (0.5mm) etc. 

What is also important in smile design is incisor proportions i.e. width to length ratio e.g. for central incisors there should be 0.7-0.8 ratio.

An easy way to achieve the correct proportions is by having a trial composite try-in for build ups or even easier, ask your lab technician for a diagnostic wax-up!


Top Composite Tips

  1. Always take the shade before you prep the tooth or apply the rubber dam and draw a road map of characteristic features such as stains, snowflakes and halos
  2. Assess the tissues that you are bonding to e.g. enamel, dentine, sclerosed dentine
  3. Assess occlusion/parafunction/staining risks
  4. Achieve good isolation with rubber dam and take your time
  5. Bonding is best with 2 step i.e. etch, prime then bond
  6. Hot composite can improve it's handling properties and therefore it can be used for cementing restorations - you can buy heaters but a cheap way to do this is to use baby bottle warmer
  7. Do not use bond on your instruments as this will pick up staining, use a wetting agent instead
  8. After etching dentine, not do overdry as this will cause the collagen matrix to collapse; instead dry with the suction tip

Tips to bond to sclerotic dentine:

  1. Use an ultrasonic scaler to clean the surface
  2. Roughen with a bristle brush or pumice
  3. Sandblast the surface or use a rosehead bur if you don't have a sandblaster
  4. Etch the surface for 90 seconds
  5. Remove any unsupported enamel

Posterior composites:

  • Pre-wedge
  • Take a pre-operative occlusal check - make sure no contact points will be on the margin interface of the restoration and the tooth
  • After final enamel layer of composite, apply KY jelly then cure through this. This will polymerise the oxygen-inhibited layer and therefore, reduce staining over time

How to bond composite to composite?

  1. Clean the surface with an ultrasonic scaler
  2. Sandblast the surface
  3. Use a Silanating agent on the surface
  4. Apply resin bond (not the primer!)
  5. Start building up with new composite

How long should I etch for?

For enamel, etch for 25 seconds 
For dentine, etch for 15 seconds (longer is sclerotic)

Finishing and Polishing


Look at the anatomy of the contralateral tooth to guide you in recreating anatomy (you may need to take a photograph to refer to later on when the rubber dam is in place).

For anterior teeth, look at the tooth in it's 3 planes and polish in these 3 planes.

Primary anatomy - Adjacent tooth shape
Secondary anatomy - Grooves, transitional line angles, mammelons
Tertiary anatomy - perikymata ( to place this use a scalpel or goats hair wheel bur)

You can either draw out the tooth anatomy before you prepare the tooth to refer to, or once you've build the tooth up, draw the landmarks directly onto the tooth 

Finish the polishing with increasingly finer diamond polishing paste e.g. Enamel Plus Shiny, and finally with a felt wheel, finish off with aluminium oxide paste.


Thanks to Raheel and the Aspire team - I will be going to another day with them in a few weeks so keep an eye out for part 2!


Do you have any other tips for using composites? Please leave your comments in the section below!



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