Sunday, 6 August 2017

Body Dismorphic Disorder in Dentistry with Professor Tim Newton

A couple of weeks ago I attended an evening lecutre held by the BDA metropolitan branch with Professor Tim Newton who taught us about managing Body Dismorphic Disorder (BDD) in dentistry. 



I think this topic is only going to become more prominent within the field of medicine and dentistry, with social media like Snapchat and Instragram being the benchmark for attractiveness in many young person's lives. During the talk I kept thinking of cases I had experienced already in my short practising career so far and how I may have managed them better. Below is a summary of what I learnt from the lecture. 

What is BDD?


BDD is a somatoform disorder; this means it is a recognised mental disorder categorised in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It includes:
  1. Preoccupation with a perceived defect in appearance
  2. This preoccupation causes clinically significant distress or impairment of socialising, occupation or other areas of function
  3. This preoccupation is not better attributed for by another mental disease e.g. anorexia nervosa

Who is affected?

  • Late adolescents
  • People in their early 30s
  • Equal ratio of men to women
  • 38% of cases are preceded by a social phobia
  • Obsessive Compulsive Disorder (OCD) is commonly related, as is alcohol dependence 
  • Prevalence is reported at 0.7-3% in the general population and 7-15% in the cosmetic surgery world

How is the person affected?

  • The person often has obsessive thoughts regarding a particular trait
  • Their obsession can move from one body part to another 
  • They often have compulsive behaviours e.g. checking mirrors, not leaving the house without make-up on, comparing their appearance to others
  • This can interfere with their daily life as it can be time-consuming e.g. their working life can be affected
  • Individuals suffer from higher levels of depression, anxiety and anger
  • 27% are housebound
  • 78% have suicidal ideations
  • 17-33% have attempted suicide

How has the medical world encountered these patients?

Whilst research in the field of dentistry in this area is sparse, there have been studies mostly in the field of cosmetic surgery. According to these studies:

71-76% of BDD sufferers have sought cosmetic treatment

64-66% of BDD sufferers received some sort of cosmetic treatment

Only 35% of BDD sufferers were refused treatment

There is one study which focuses on orthodontic patients, which had around 7.5% of patients who sought orthodontic treatment suffered from BDD.


How can we assess and manage these patients in dentistry?

1. Setting

Establish a rapport with the patient and ensure you are in a private setting. Try to minimise the number of people present

2. Questions

Ask your usual questions but you may find it useful to ask:
  • Why are they seeking a solution to their problem now?
  • When did they become aware of the problem?
  • What do they hope can be achieved from treatment?
  • How much do their concerns interfere with their life?
  • Do they have support from family/friends?
  • Have they seen any other health professionals before seeing you?
  • Do they have any diagnosed psychiatric disorder or have in the past e.g. OCD, depression, eating disorder?

3. Formal Assessment

I.e. refer onto a psychologist for a formal BDD assessment when you have a strong suspicion or if they disclose any suicidal ideations.

Management

  1. Cosmetic treatment to address their concerns. This does not address their underlying BDD
  2. Cognitive Behavioural Therapy (CBT)
  3. Pharmacology e.g. Selective Serotonin Reuptake Inhibitors (SSRIs) although there is no evidence for these

Managing these patients and identifying them early can be really tricky! Prof Newton gave us a few example cases he had seen in the past and honestly with a few of them, on initial presentation it wasn't that obvious they were suffering from BDD. I think what I learnt was to ask in depth questions early on e.g. have they seen anyone else for their problem before, is there any pressure from family/friends/partners to improve their appearance? Breaking the news to them can also be a very awkward situation and the right wording can be hard to find. A good phrase Prof gave us was:

 'The solution to your problems is not further treatment.' 

To read more about BDD, a good resource is the Mind website.



Have you seen any patient who you suspect suffered from BDD? How did you manage them? Let me know in the comments below. 





References:

Phillip, Grant et al 2001
Crerand et al 2005
De Jongh and Adain 2000
Max Cunningham et al 2004
Hepburn and Cunningham 2006

Thursday, 27 July 2017

3M Rising Stars: Golden Ticket to Willy Wonka's

If you follow my Instagram, you may have seen my trip to Germany with 3M a few weeks ago....but what was I doing there?

The group invited to Seefelt
3M (no longer 3M ESPE) kindly invited me to their research and development site in Seefelt along with several other inspiring dentists. A chance to sample the Bavarian culture as well as see the insides of where the dental products I use are made!

It felt well and truly like being able to see the inside of Willy Wonka's chocolate factory and I was humbled to be invited alongside some pretty well known names in dentistry. I also learnt that 3M not only make dental and orthodontic products but post-it notes, adhesive tape and even the glue that holds planes together. 

After a rocky plane journey from London, we landed in Munich greeted by the the UKs 3M staff: John, Gavin and Amy. Although we only spent 2 days with each other, by the time it we had to journey back to the UK, I felt like I'd known the others for much longer and it was a fantastic way to get to know other dentists throughout the UK. 


Proudly showing off my visitor's pass
The first day we learnt about some of the post popular 3M dental products like Impregum, RelyX and Scotchbond and of course have a little play. One of my favourites was the new heavy VPS impression material Imprint which sets much quicker has it gives off heat during setting. All of us then of course had to take a blob in our hands and feel it get hot as it set. 

In the afternoon we had a fantastic time designing our ideal resin cement and the packaging along with it! Everyone gave it 120% and I think some of the groups came up with cutting edge innovations (see our box below where our cement is a universal shade that adapts to it's environment.....hence the name) and some impressive shelf lives (5, 10, 15+!!). 



My groups innovation new resin cement... and yes that is a chameleon not a fish. 
During the 2 days we also had the chance to have a guided tour around the labs which was very exciting. We weren't allowed to take any pictures of course but memorable bits including seeing the huge vats of impression materials being mixed (honestly the size of a smart car) and the conveyor belt of robots loading up the local anaesthetic cartridges. We also got to product test some of the new materials coming out soon from 3M and meet the inventors of some of their big-sellers (like Filtek Bulkfill). 

Not only were there educational activities, but we had a delicious traditional Bavarian meal (with Bavarian beer of course) alongside the lake Stamberger See where we had the most beautiful view of the sunset that I spammed all over my Instagram. 


The view of the lake while we were having dinner. 

I'd like to thank all of the 3M team for their hospitality and organising this fun and educational trip - it was great to meet everyone. I'd definitely recommend the trip if you get the chance!


Do you use any 3M products? Or been to Seefelt in person? Let me know in the comments below. 

Sunday, 16 July 2017

Public Health Matters: Mayor's Newham Town Show 2017

Last weekend was the annual Mayor's Newham Town Show in East London and time for the local Community Dental Service to get involved...

Just some of the fantastic team who helped out over the weekend!

The weekend saw over 50,000 people attending and involved live music over 2 stages, dancing, sports and a real sandy beach! There were lots of stands set-up and the at the public health area we had the company of Healthy Eating, Cancer Research, Smoking Cessation and more alongside our dental stand. 

Over the weekend we had a total of 3, 478 contacts at our oral health stand; teaching children and parents about oral hygiene, dental-specific diet advice and going to the dentist. The team included our oral health promoters, therapists, dental nurses and dentists and everyone had lots of fun. It was incredible to see such genuine interest from the public and eager children filling in our quizzes and word-searches or brushing our set of giant teeth in order to win a toothbrush holder or tooth fairy wand!

As well as our oral health stand, we were able to provide oral health screening on our mobile dental unit. Over the 2 days we saw 485 adults and children for oral health screens; many of whom required signposting to dentists as they required treatment. With live music blasting in the background and copious amounts of free toothbrushes and toothpaste to give out, there was a lively and festival-like atmosphere inside the unit that helped to acclimatise some of the more nervous or younger children into learning how a visit to the dentist can be fun!

Me inside the dental unit providing some dental screens (consent for publishing photographs obtained)

I found it very surprising to see how many people either didn't have their own dentist or had no idea how the NHS dental services work. There were many people who had very healthy mouths, indeed I haven't seen so many cooperative children in a long time; however, there were a few shockers. For example I saw a 3 year old who had around 8 carious teeth and had not ever been to the dentist. It was important for the dental team to direct people onto where they could access care and of course explain how screening did not replace a full dental assessment with x rays. Lists of dentists in the local area were given out as well as information about dental charges and exemptions. 

We were very lucky that the weekend's weather matched our moods and we had lovely sunshine for the 2 days and certainly I went home on the Sunday evening with a warm sense of fulfilment after such a philanthropic effort from all the team. I think getting the dental profession more involved in public events like this is essential at tackling our public health issues head on and can be really effective with passionate individuals and the appropriate support from NHS services and dental charities such as the Dental Wellness Trust, Oral Health Foundation etc.  

Many thanks to all the team at Newham Community Dental Services and bring on next year's event! Check out the highlights video from the show:




Did you attend the Town Show? Or run similar events in your area? Let me know in the comments below. 

Monday, 10 July 2017

The Management of Mental Health and Homelessness in Dentistry

Managing these vulnerable patients has been a devotion of mine since I worked in an acute dental setting in secondary care last year. I thought I'd share with you the reasons why...



Why are mental health and homelessness relevant to dentistry?


  • We often encounter forms of mental illnesses in dentistry e.g. anxiety and depression. This can commonly be in the form of dental phobias. One study reports 78% of general dental practitioners encountered patients with diagnosed mental health issues.
  • Patients who suffer from mental illnesses or who are homeless suffer a greater burden of disease. In a community-based psychiatric clinic for example, 52% of patients were suffering from dental pain and of the homeless patients attending a dental clinic in East London; 40% presented in pain.
  • There is a high prevalence of mental health issues in the homeless population: 25-30% according to Crisis.
  • Depending on the dental setting, some settings will see high levels of these patients attending e.g. community dental services, acute services.
  • Mental health issues are still stigmatised and can go undiagnosed and untreated. Not only in patients but also within the profession.

What problems can arise when seeing these patients?

  • Their general management and interactions can be difficult
  • Attendance can be sporadic
  • Consent can be an issue e.g. capacity with mental health issues or if they are under the influence of drugs or alcohol
  • Communication can be difficult in those with severe mental health issues or indeed in patients where English is not their first language
  • There can be extensive dental neglect in these patients e.g. I see a lot of homeless patients who are on methadone
  • Patients medical histories can be unclear or complex e.g. clotting issues in alcoholics
  • Motivating patients to stabilise their oral health can be difficult or even impossible. Often their priority is not their teeth!
  • Access to care is a huge issue
  • An issue many of the staff encountered at the acute dental setting I worked at last year was patients threatening suicide. I am planning a post in the near future about this so keep an eye out!

How can we improve the care we provide for these patients?

  • Educate the profession in the management of patients with mental illnesses so we learnt not to stigmatise them
  • Forge close links within the dental profession and other health professionals in order to liaise easily and link up care e.g. CDS, GDPs, GP, homeless charities, psychiatrists
  • Make access to care as easy as possible e.g. self-referrals, free care for those who are homeless
  • Further research is needed to help us understand how many of these patients access dental care and what barriers they encounter


To read a talk I presented at a local meeting regarding some research into how many of these patients access care, click here



Do you see these patients in practice? Let me know in the comments below. 

Sunday, 25 June 2017

Bilateral Double Teeth: Dental Update Letter

So my letter to editor of Dental Update Journal was published this month...



This was a case that presented to me in Community Dental Services. The little boy was referred for extractions but I noticed this unusual appearance of his lower incisors. 

The appearance is of two teeth that had joined together (fusion) or two teeth that had failed to separate, much like Siamese twins (gemination). 

It's natural when you see something unusual clinically that you want to share it with colleagues. It's an excellent opportunity for your learning as well as shared learning throughout the profession. In this case, although no active treatment was required for the anomaly at this stage, I documented the case and this encouraged me to do some further reading about this sort of dental anomaly. 

I would encourage you, if you see some unusual cases or cases that are interesting to take clinical photos and document them well as an opportunity may arise where you can share the information, such as in this case a written case report, oral presentations or like I have done in the past, poster presentations.

To read the full letter click here


Have you seen any double teeth in practice before? Let me know in the comments below. 



Sunday, 4 June 2017

Top 5 Dental Emergencies

I blogged about my top 5 hidden causes of dental pain; now time for the top 5 most common dental emergencies.



1. Irreversible Pulpitis

The obvious one! I would say the most common dental emergency and cause of toothache. In these cases the patient will report:
  • On/off or constant throbbing/pulsating pain
  • Pain which is worse on hot or relieved by cold
  • Often painkillers are ineffective in managing the symptoms
  • Sleep is often disturbed
  • The patient may report previous pain which was milder and subsided before this acute severe episode of pain
  • The patient often cannot localise the pain e.g. it radiates or feels like coming from both top and bottom teeth
Antibiotics are in most cases ineffective at managing this pain as there is no acute infection but instead the pain is from the inflammation of the pulp. Management in these cases is either extraction or extirpation of the inflamed pulp. 


2. Facial Swellings

One of the true dental emergencies, facial swellings should be treated with urgency. Sometimes swelling can be subtle and present with a mild facial asymmetry that is difficult to distinguish (often you rely on a patient reporting the swelling). In contrast, some patients will walk in with a very obvious facial swelling. Some questions I ask in addition to my usual history if I notice a facial swellling are:
  • How long has it been there?
  • How quickly has it come up? (this will help me determine the severity/progression of the swelling)
  • Is there any difficulty or pain swallowing?
  • Is there difficulty breathing?
  • Is there any fever/temperature?
  • Is there any feeling of unwellness/nausea?
If you notice a swelling, try to take a patient's temperature and check for nodal involvement. Always try to drain the infection (e.g. incise and drain) as well as prescribing antibiotics appropriately according to guidelines

3. Pericoronitis

Pericoronitis is most common with lower third molars; however it can affect other teeth e.g. upper wisdom teeth, second molars etc. The issue is often food and plaque trapping around the operculum as the tooth erupts and from my own experience of this I can vouch it to be quite painful! 

As I mentioned in my previous dental emergency blog, sometimes pericoronitis doesn't present as the obvious case of pain - read here. Management will include:
  • Irrigation underneath the operculum either with saline, peroxide or chlorhexidine digluconate (CHX) mouthwash 
  • Good oral hygiene - I often either give the patient the Monojet syringe I use or advise a single tufted brush in this area
  • Mouthrinses with saline, peroxide or CHX
  • Appropriate analgesic relief - often NSAIDs are the most effective
  • Prescription of antibiotics if appropriate - metronidazole 400mg as per guidelines


4. Trauma

I'm sure many of you know the bible to the management of dental trauma - The Dental Trauma Guide (although now you have to pay for some aspects) which is a great resource of access. I have seen lots of dental trauma, but I must say in most cases it is relatively simple to manage in an acute setting as mostly I see concussion, subluxation or enamel-dentine fractures. 

Of course I do see more extensive traumas from alveolar fractures to avulsions which are more challenging to manage. But in simple cases I will manage as follows:
  • 2 radiographic images at right angles to rule out any fractures e.g. occlusals, PA 
  • Soft diet for 2 weeks
  • Appropriate analgesia
  • Avoid contact sports 
  • Good oral hygiene - use of CHX gel or mouthwash if brushing is difficult
  • Composite or GIC bandage if there is a tooth fracture
  • Follow up with their GDP in 2 weeks
I also warn the patient of possible sequelae e.g. pulpal necrosis, resorption etc. 


5. Periodontally-Involved Teeth

I see this a lot in the area I work in East London. A lot of people have underlying chronic periodontitis and present to me in an emergency with an excessively loose tooth which is now causing them pain. 

Often, a patient will walk into your surgery requesting an extraction straight away but remember to give all the options to the patient is you think that there is a chance of saving a tooth e.g. periodontal therapy In some cases, the prognosis is hopeless and the only option is extraction, especially in patients who are irregular attenders with generalised chronic disease (and in the case of where I am in East London, are paan chewers). 


After a while of working within an acute service, you will be able to diagnose the patient within the first few minutes of history taking. Of course, this isn't always the case so always be mindful and don't fall into traps! If you are unsure, take radiographs to help your diagnosis or refer on. 


Do you work in an acute dental setting? Do you encounter these situations commonly? Leave your comments in the section below!



Sunday, 21 May 2017

The Mental Capacity Act in Dentistry

I remember having to write an essay about the Mental Capacity Act (MCA) during my undergraduate years; yet it took me over a year in practice to fully understand it's relevance and how to use it...



Since working within the community dental setting and treating special care patient groups, I find myself referring to the Act almost every day!

What is the Mental Capacity Act?

The Act, passed into law in 2005 and all health professionals have to follow its Code of Practice when treating patients - in particular this could be in those who may have a cognitive impairment or learning disability, I find most commonly I use the act when treating patients who suffer from dementia. 

5 Principles:

  1. A person must be assumed to have capacity unless it is established that he lacks capacity
  2. A person is not treated as unable to make a decision unless all practicable steps to help him do so have been undertaken without success
  3. A person is not treated as unable to make a decision because he makes an unwise one
  4. A decision made under this act must be done or made in his best interests
  5. Least restrictive measures must be undertaken if possible e.g. a patient may not able to consent for a general anaesthetic, but they may be able to consent for treatment under local

Who lacks capacity?

According to the act, someone who lacks capacity to consent cannot:
  1. Understand the information relevant to the decision
  2. Retain that information for sufficient amount of time
  3. Weigh up that information as part of making the decision
  4. Communicate this decision

How do you use the MCA in practice?

If you work in a trust or other hospital or community environment, it's likely they will have their own trust policy on MCA that you should follow. We also have additional paperwork to fill in (a template framework) which is very useful, as well as additional consent forms for those who lack capacity to consent for themselves. If you work in practice, this may not be available to you. In these cases here are some of my tops tips.

Top Tips:

  • Do not assume someone lacks capacity. This can be tempting if a patient attends with their carers or family, but try to engage them in the decision making process
  • Break things down into simple stages and reintroduce these at the beginning of appointments (this can be particularly useful for dementia patients or those with learning disabilities). Don't overwhelm them with information in a short space of time
  • Information may have to be delivered in several formats, especially if there are sensory difficulties. For example, verbal, written (large print or with illustrations) or the use of an advocate/interpreter
  • The environment you are in may affect the ability for a patient to have capacity e.g. familiar settings, the same surgery or staff, or even treatment in the domiciliary setting may help 
  • Take into consideration time of the day; early morning appointments may mean a patient is less disorientated
  • You may need to take opinions of other individuals into account when making a best interest decision e.g. carers, family members, other professionals, Powers of Attorney (POA)
  • There are 2 different POAs: Health and Financial. Even if the patient has a health POA, they still cannot consent on a patient's behalf but can input their opinion when making decisions 
  • In our service, if things are relatively simple e.g. an unrestorable and symptomatic tooth requires extracting, 2 dentists will sign the appropriate consent form
  • If things are a little more complex, a best interests meeting will be set up with the patient, more than one dentist, if there are available the patient's carers/family members/POAs and if necessary an Independent Mental Capacity Advocate (IMCA).
  • Record keeping is key in this case and always be mindful of any safeguarding issues. 

If you are still unsure or don't feel confident in these cases, consider referring these patients onto the your local community dental services as we are experienced in managing these cases. 

For more information, see the Mental Capacity Act.


I hope this clarifies things! Do you find yourself using the MCA in practice? What do you find challenging? Let me know in the comments below!






Monday, 15 May 2017

The Dental Awards 2017

This weekend was spent out of the capital again.... up to the Midlands to Birmingham.


If you follow my Instagram feed, you may know I was shortlisted for YOUNG DENTIST OF THE YEAR!! Firstly this was amazing, especially when I saw who else was on the shortlist; but my second though was what was I going to wear!! 

The Awards ceremony was held on the Friday around The Dentistry Show and it was huge! The venue was packed with what looked to be a thousand dental professionals and we all know dentists know how to party.

It can be amazing how small the world of dentistry can be sometimes... I ended up sitting at a table with a lab I used to use last year! Of course the evening was a blast with entertainment from a group of Magicians called 'Chicks and Tricks' followed by a disco. Awards were presented from dentists to technicians to receptionists and entire dental teams. 

I didn't win the award (co-founder of Dental Circle, Amit Patel beat me to it!) but there were so many worthy finalists... everyone deserved to win! Well done to all the finalists and thanks to the organisers of the event. 

I'm proud to say that I actually made it to the Dentistry Show the following day (a little bit worse for wear). Bring on next year's event! 

Check out the winners of the awards on Dental Republic



Were you shortlisted for one of the awards? Or go to the ceremony? What did you think? Leave your comments in the section below.



Sunday, 7 May 2017

BSDH Spring Conference 2017: Making a Good Impression

This week was the Spring Conference for British Society for Disability and Oral Health (BDSH) and so a trip up to sunny Liverpool was on the cards. After missing my train I did manage to get there on time (phew)! It was great to catch up with some familiar faces as well as hear some fab talks about special care dentistry. 

Arriving into Liverpool for the conference


One of the afternoons we had break out sessions which included a hands on impression taking session. This session I found really useful and was something a little bit different. I thought I would summarise what I learnt as this applies to GDPs as well as those who are in Special Care. 

 Making a Good Impression with Phil Smith

The golden triangle of complete denture success is made up of:
  1. Retention
  2. Support
  3. Stability
Making a good working impression starts with a good primary imp i.e. one that captures all functional anatomy including:
  • Residual ridge, tuberosities, hamular notches
  • Functional sulci and frenae
  • Junction of hard and soft palate
  • Retromolar pads
  • External oblique ridge
  • Lingual sulcus and frenum
  • Mylohyoid ridge, retromylohyoid area
For primary impressions choose rigid disposable stock trays and a viscous mix of alginate if there is a reasonably firm ridge. For more resorbed ridges, use soft putty; for 'flabby' ridges use a thinner mix of alginate and for gagging patients use compound. 

For secondary impressions, tips I learnt that were particularly useful include the use of bite registration paste e.g. JetBite, HydroBite, Blu Mousse, Memosil to border mould instead of putty or green/pink stick. It is much less messy as well as being quick setting. Place the paste as in the photos below. 

My hands on practice impressions (very strange to do on a phantom head!) The white material is the bite registration paste where you would place then border mould

For the special trays ask for tissue stops which should shine through if you fully seat and also finger rests for the lower arch. For good ridges use alginate (if you want to check retention after border moulding do not ask for a perforated tray, as this will not allow). For resorbed ridges use PVS heavy or medium +/- a light PVS wash

What happens if I get an airblow?

To avoid this in the first place consider prepacking or syringing whichever mix you are using into areas of undercuts or in the palate (especially if they have a high arched palate). But if you do get an airblow then...
  • Alginate - you cannot add to, retake the impression. If small blows you can add wax to the deficiencies
  • Silcone - add more silicone (usually light body) to the areas and reseat. If the hole is large, you can create 2 holes in the impression tray in that area and injection mould when the tray is seated in the patient's mouth
Remember that a highly detailed surface impression is good in the upper arch to help increase retention, but in the lower arch it will create blobs of acrylic that will rub the patient when it is in function. 


Many thanks to Phil Smith for delivering such as useful session and BDSH for organising this year's Spring Conference, I will look forward to the next one!



Did you go to BSDH this year? Or have any other tips on making impressions in the edentulous patient? Leave them in the comments section.



Sunday, 30 April 2017

Extractions in children: Top 8 Tips

So far this year in community I have learnt so many new tricks in the management of children (like how to take radiographs). One of the most feared procedures to perform in children are extractions. Indeed perhaps that may be why extractions under general anaesthetic are becoming a national public health concern. Here are some tips I've picked up so far...

A monster E I took out recently


1. Be honest

Never lie to a child when providing treatment: you will lose their trust completely and they will become uncooperative. The most common situation where it can be tempting is always the question 'Will it hurt?'. Delivering local anaesthetic is almost always uncomfortable and you need to communicate this to the child in a way that doesn't instantly put them off. 

Parents sometimes try to lead you in becoming misleading or tricking the patient; I remember one child who refused to let me use a handpiece but was otherwise compliant. During treatment (which she was let me do), her dad kept gesturing for me to use the handpiece. This is sure fire way to lose compliance. 

2. Consider the use of articaine

Historically there has been some controversy about the use of articaine in children and many clinicians prefer the use of traditional lidocaine. However, there are some situations that I find articaine particularly useful. For instance, you can avoid ID blocks for lower teeth and because articaine diffuses really well, in some cases you can avoid palatal infiltrations. 

There is evidence that shows articaine (in smaller doses) is safe in all ages. The only precaution is to warn the child and parent about the more profound anaesthesia that can increase the risk of self-mutilation post-operatively. 

3. Topical is a must

Always always use topical! Not just for its pharmacological effect, but also as a distraction technique. Sometimes if there is a very mobile baby tooth, I would not even use LA but just topical. I call topical my 'magic cream' or 'sleepy cream'. Some tips on using topical are:
  • Dry the mucosa first with cotton wool to make sure the topical is not diluted by saliva
  • Don't over do it. Using too much can put off children too as it can numb their tongue/throat and other areas
  • Leave the topical in for a couple of minutes, not long enough and it won't work but too long the patient will get distracted and saliva can disperse the effect
  • I sometimes ask the patient to hold the cotton wool roll with the topical on it in place, it helps them to feel in control
  • There are different flavours available from mint to bubblegum, explain this to the child before you apply
  • Don't delay administering the LA after you remove the topical or the effect will wear off. 
  • I also use the end of the cotton wool roll to rub the topical into the gum. This is not evidence based but I feel like it helps the topical penetrate, you may get a gate control effect (i.e. activating Aβ fibres and inhibiting C fibres) and it also acclimatises the patient to the feeling of numbness if they haven't experienced it before. 


4. Explain in a way they understand

Stick to child friendly language and analogies. Avoid fearful words like 'needle' and 'injection' (although parents will often drop you in it by using these words). Some examples I use are:
  • Sleepy cream for topical and sleepy juice for LA
  • 'Putting your tooth to sleep'
  • When I check anaesthesia I check by 'tickling the tooth'
  • Wiggle wiggle the tooth out

5. Involve the parent

As I mentioned above, sometimes parents can make your life more difficult. But in majority of cases, parents can be very helpful  in helping the patient comply with what you're trying to do and I always recommend having them stay in the surgery. First, check the parent is ok staying (I've had more than one faint on me previously) and I usually ask them to sit close to the chair to reassure the patient by holding their hand or whatever the patient finds reassuring. 

The parent is then close to reassure and encourage the patient during the treatment.

6. Delivering LA 

Sometimes the biggest obstacle in performing an extraction is delivering the LA. Of course if you have equipment like The Wand or can provide inhalation sedation these will make your life easier, but often these are not available. In these cases here are some of my top tips:

  • Try not to show the syringe to the patient, keep it off your bracket tablet covered by a tissue or something else until you need it
  • Try to make sure your LA is not cold, ask your nurse to hold it in their hands to warm it up slightly as it will feel less uncomfortable when you administer it
  • Ask the patient to close their eyes when delivering the LA so they don't see the syringe. I say so I don't get sleepy juice in their eyes and send them off to sleep!
  • Explain that you keep the sleepy juice in the freezer so it can feel cold when putting it in
  • Emphasise the need to stay still when delivering the LA. If they move it can be unsafe and also hurt them more 
  • Deliver SLOWLY!! It's tempting to get it over and done with, but if you deliver the LA quickly then it will be more painful
  • I always try to avoid palatal infiltrations or even lingual ones but doing a buccal infltration and then walking around then finally through the papillae distally. You should look out for the blanching of the palatal mucosa with this technique. You could also use articaine which I mentioned above. Here is a good video of how to use this technique. 
  • Use suction if needed to remove any extruding LA. LA tastes horrible and children really dislike it (although it can distract the patient at the same time) 


7. Don't go digging

Some dentists will really hate the idea of leaving anything behind when doing extractions. Sometimes in children I would recommend avoid digging deep to try and get that final bit of apex out. Firstly it's not nice for the patient and sometimes you can lose compliance this way, but also remember there will be a successor tooth underneath somewhere. You may inadvertadley damage the successor if you slip. 

Baby teeth have spindly roots (sometimes these can be quite long, like in the picture above) and little apical portions can easily fracture off during the procedure. These will more often than not, exfoliate by themselves uneventfully as the socket heals or the adult tooth pushes through. Also remember not to mistake root resorption for a fractured apex. If the tooth is close to exfoliation or there is long standing infection, their roots may be resorbed. 

8. Keep going

I say this, but this can depend completely on the situation and the patient. What I mean is that more often than not, when I take a tooth out even when I know that the tooth is completely numb, the child still yelps a little or sometimes even yells. This often happens because of the feeling of the pressure as the tooth comes out and the surprise if they've not had the experience before. Taking baby teeth out often takes seconds and if you stopped, the child may not let you back in their mouth to finish off the treatment. 

Sometimes this can feel horrible especially when the child is crying, but overall you are acting in the patient's best interests and the treatment needs to be done. I always reassure the parents afterwards as they can often can be worried that you are hurting their child and I always praise the child after and give them a reward (usually a sticker). Children can surprise you, they often bounce back very quickly and with good behaviour management you won't lose their compliance for the future. I always try to distract them by asking them how much the tooth fairy will leave them and what they will spend the money on! 


These are just some of the tips I've picked up from managing anxious or uncooperative children. Of course this approach doesn't always work and you'll have to think of plan B e.g. referring for inhalation sedation or in the worse case general anaesthetic. With the changes in how the community dental services are changing (look out for a future blog post), GDPs need to be seen to at least try if a child requires extractions before referring on, otherwise their referral may not be accepted any longer. 



What tips do you have when performing child extractions? Leave them in the comments section.



Saturday, 15 April 2017

10 Steps to start your own Dental Blog

So it's approaching 3 years since I started my blog! I can't believe how far it's come and how time has flown by. I've had some people asking me how I started my blog so I thought I'd write something a little less dentally focused for a change and explain the 10 steps that helped me start my own blog. 



1. Find something you care about

This is probably the most important part of starting a blog, but it can also be difficult. If you're wanting to attract people to reading your blog you need to find a USP (unique selling point). There is so much content on the internet, what will make you stand out?

One thing is to actually blog about what you care about and are passionate about. If you are not passionate about dentistry then it will show through your posts. Whether you decide to blog about student life, life as an associate dentist, travelling tips for dentists, whatever it is you need to care about it. 

Think about it long and hard... and it may not come to you instantly. I noticed how there weren't any blogs really in the dental profession, especially young dentists' experiences. That's why I decided to start A Tooth Germ!


2. Read other blogs

I have written about my favourite dental blogs to follow previously, but don't just read dental blogs. Think about other blogs that you may follow already. Why do you read them? What do you like about them?

Think about how they are written, how long their blog posts are, how they have formatted their blog pages. For instance, I like short concise blogs with good quality photos. Write down all the things you see that you like and think about how you can emulate or even improve them when it comes to your own blog. 


3. Choose your blog's name

This can either come naturally or can be very difficult. Many professionals just name their blog after themselves which can help if you want to build your own brand. This may feel like an Apprentice task but don't over complicate things. 

After you have chosen your name then you may want to think about a logo. There are so many companies out there that will design this for you if you like (relatively cheaply), but then you can just design your own if you are feeling creative. Be aware of copyright if you want to use a stock image. 

A good site I used to design my logo was PicMonkey.


4. Choose your platform

I use the Blogger platform as it integrates nicely with all my Google accounts and devices, but many people like to use Wordpress for their blogs. 

My experience of blogger is that it is relatively easy to use once you get the hang of things. The most time consuming element is setting up your blog and formatting it. Once that is set up, writing new posts is as straight forward as writing a word document. Some people prefer more of the freedom you can achieve with Wordpress as you can move gadgets and elements around your page more freely. I have never used Wordpress but now I know how Blogger works, I imagine if I switched it would be akin to switching to an Iphone rather than my trusty old Android phone. 


5. Start small

It can take months or even years to build up a blog. Start small, a few posts at a time and add elements in as you go along. A lot will be trial and error: remember big sites like Facebook and Instagram were pretty simple when they started and they still change and upgrade things as they go. Your blog will evolve and develop as time goes on... don't waste your time building up all the content and waiting to go live. 


6. Build your Social Media

Blogs are never stand alone any more. They are always linked closely with other social media for example, Instagram, Facebook, Twitter.

Create separate pages for your blog if you want to keep it separate from your personal accounts e.g. a page on Facebook or a stand alone Twitter account. Also consider other social media e.g. Pinterest, LinkedIn and Dental social media sites like Denteez, Dental Circle or Dentinal Tubules. 


7. Use Widgets

If you didn't know before, a widget is an application or component of an interface that enables users to perform a function. Think about any shortcuts you may have for apps on your phone or tablet. 

For blogs and webpages, widgets can be really useful. You can use them to show links to your social media e.g. the feed from your Twitter page. You can also use widgets to help increase your clicks within your blog e.g. most popular posts or related posts. 

You may be aware of widgets you like from looking at other blogs as I mentioned above. 


8. Be patient

Don't expect your blog to be an overnight success. Your only readers may be your close family and friends initially (my mum doesn't even read mine anymore!) but it will take time to build your audience. 

You will put a lot of hours and effort into your blog initially, but over time you will become more efficient with your blogging and hopefully your audience will grow over time. Be careful not to troll your social media with your new blogs every 5 minutes; it can be very tempting so you can see those page visits increase, but over time people will become annoyed and unfollow you. Be selective and think of your audience. 


9. Decide your domain

Again another technical word, but with blogging you will lots of things about technology and maybe even some coding! Domain is essentially buying the name of your website. You don't have to do this, in fact I only bought my own domain recently. 

If you choose not to, your website will have a suffix in its address e.g. yourblog.blogspot.co.uk. If you just want the name of your blog without this suffix you will need to buy a domain. They are relatively cheap around £10 a year or so and I bought mine through Google. 


10. Find the time!

Starting a blog can be very time consuming! As I just mentioned, setting it up is probably the most time consuming part. I set my blog up in the summer between graduating and starting my first job so I had plenty of time on my hands. 

But once you've set up your blog, you then need to find the time to actually write your posts! Not only that, but dedicate time to social media and ongoing maintenance and improvement of your site. It can be good to set aside a certain time per week to blog. 

Be realistic with your time. The first year of me blogging I thought I could bash out 2 blogs a week. Now on average it's around 1 a week. This means that I can spend more time on each post so they are of better quality and also not impact on my other activities and commitments during the week. Realistically, people are not going to read your blog more than this. Sorry for the cliche, but remember quality not quantity!


Good luck to anyone who is looking to start their own blog and I hope you have found this post helpful! Remember that nothing is perfect, in fact I still look at my own blog and think I can tweek this or that and make it better. Blogs are supposed to be informal... you're not writing an academic essay or anything. Keep practising and keep going!!!


Have you started a blog? What would your top tips be to those looking to start one? Leave your tips in the comments below. 

Tuesday, 11 April 2017

BASCD Spring Meeting: Posters and Networking

Last week I attended the second day of the BASCD Spring Scientific meeting which was held in picturesque Oxford. 

Presenting my poster at the Meeting

Who are BASCD?

The British Association for the Study of Community Dentistry (BASCD) are an alliance of individuals with an interest in population oral health and according to their website:
  • Work to provide a set of principles for the improvement of oral health and the development of oral health are and promote their dissemination
  • Influence policy at international, regional and local level
  • Support members with training, development, partnership working, networking and advocacy
  • Hold, develop and communicate a sound body of knowledge and evidence to facilitate their work

It was interesting to see that at the meeting there wasn't only dentists and dental care professionals, but other health and social workers e.g. pharmacists, public health advisers. 


What did the day look like?


The theme of the Spring meeting was networks within Dental Public Health. The line up of speakers was very interesting and varied; in fact there were few dentists talking!

The day started with Carol Gillanders speaking on how to successfully raise funds or sponsorship. She talked about the types of money you can raise e.g. major giving, sponsorship, leadership and how it is very important to know the value of what you are offering in exchange for sponsorship. 

Following this we learnt about networking as well as a hands-on practice with Shirley Clark. This was really fun and was a fantastic opportunity to meet the other delegates and get to know them in a structured way that also improved your own general social and professional skills! 

The afternoon discussed online networks including talks from psychologist Ciaran MacMahon, public health physician Prof Amanda Burls and Tony Jacobs, founder of GDPUK (which I've mentioned in a previous blog post). 


Another Poster!

As you can see from the picture above, I had the opportunity to have another poster chosen for this conference. The difference was, BASCD also asked you to present the findings of your poster to the room (which was a little intimidating to say the least!). 

The topic of my poster was some work I did last year when I was at Guy's Hospital working on their Acute Dental Clinic and is a topic that I really care about: how vulnerable patients access emergency dental services, in particular those with mental health issues and the homeless. 

To read a copy of my poster click here


A massive thank you to my co-author Janine! I enjoyed the meeting this year with a more non-dental approach to some of the issues we face in public health and community dental and I met some great people at the event. And of course, while in Oxford I had to take in the sights!

The Radcliffe Camera in Oxford


Did you attend this year's Spring Meeting? What did you think? Leave them in the comments section.



Saturday, 1 April 2017

Hall Crowns: Top 10 Tips

In community I see a lot of uncooperative or anxious children. A useful technique I use almost every day is the Hall technique in the placement of stainless steel crowns (SSCs) on primary molars. This was something that took a while to get good at; so here are my top 10 tips.



1. Avoid small Ds

In general, Es are easier to place SSCs on but sometimes you need to consider the same technique on Ds. Small Ds can be quite tricky to place with a Hall technique (especially lower Ds) due to their buccal bulbosity. 

Sometimes when I am assessing the tooth, if I see it's quite small (smaller than a D5 preformed crown), I wouldn't usually attempt a crown and instead opt for a conventional filling if possible. If you really want to place a crown on a D some useful tips I found useful are:
  • When placing the crown, roll it from buccal to lingual/palatal to overcome the buccal bulbosity
  • Try to always place separators (seps) to create space
  • If you are struggling, prep to remove the buccal bulbosity (you may need LA for this)
  • For very large Ds, consider using the smallest E size as a last resort when a D7 is too small


2. Seps are uncomfortable

Placing seps can be a pain and children often find it uncomfortable as you sometimes need to use a lot of force to floss the sep into the interproximal space. 

The teeth can also ache afterwards while the separator does its work. I have seen children pick them out as they don't like the feeling of them (imagine something stuck between your teeth that you can't get out!). 

I have also seen seps that are left in for too long and then have sunken through the contact point into the gingivae. This can be very uncomfortable for the patient and getting them out can be so even more and can be very tricky in a child who is not very compliant. Always warn the parents of these risks and ensure if you are going to place seps, they are ideally not in for more than 1 week. 


3. Prepping isn't bad

I know a true Hall technique involves no prep or caries removal. Ideally, you would want to remove some caries even if this is just with a hand excavator and in some cases a quick slice through a contact point with a bur doesn't even require LA and is a quick way to ensure you can seat your crown.

If you are going to prep, I tend to just remove the contact points and any buccal bulbosities. Be careful if you are prepping near a 6 to ensure you don't damage that tooth and in some children behaviour management can be challenging when using a handpiece. 


4. Don't worry about occlusion

You won't hear dentists say that much. In the primary dentition, occlusion is changing all the time and children are very adaptable. Evidence also shows that within weeks, increases in OVD are very minor and it is thought this is due to intrusion of the opposing tooth (there is no evidence that this damages the successor).

It can feel unnatural initially cementing in a crown where a child is clearly very jacked open but they adapt over time. Always warn the parents prior to cementing (and the child of course) and analgesics may be required to make it feel more comfortable initially. 


5. Avoid doing upper and lowers on the same side together

Although I've just said don't worry too much about the occlusion, avoid placing SSCs on opposing teeth at the same time. This is because the change in OVD can be quite significant and will be more uncomfortable for the patient.


6. You need to press HARD

Don't be afraid, in most cases you need to press firmly to seat the crown. The main method I use is to ask the patient to bite together hard either on a cotton wool, tongue depressor or orthodontic band seater. In some cases however this may not be appropriate e.g. if there is no opposing tooth. The other trouble with that method is you need the child to comply to bite hard - many either only bite gently because of the feeling of tightness of the crown, or in younger children or those with learning difficulties they may not be able to follow your instructions fully.

In those cases you will need to press down hard - the satisfaction when you hear the 'click' of the crown seating fully reassures you that the crown is seated fully (often the gingivae will blanch to show you it's seated slightly subgingivally, which provides an excellent seal).


7. Consider for 6s if poor prognosis

Most people only consider SSCs for primary molars, but they can be useful for 6s in the developing dentition. Obviously you will need different preformed crowns, but you need to use them slightly differently to primary SSCs (I wouldn't want to change the occlusion that much).

 I use SSCs in cases such as:
  • Hypomineralised 6s to protect against further breakdown
  • Carious 6s of poor prognosis where you would like to hang on to them until you take them out at the right time for the 7s to come into position (working alongside an orthodontist). Note you need radiographs before you place the crowns so that the extent of the caries can be assessed at a later date
  • On permanent molars which have been root treated in teenagers where you require cuspal coverage but you don't wish to do a conventional crown yet either for occlusal reasons or compliance issues. 



8. If you don't seat fully, it's not the end of the world

Getting that click as you seat and seeing blanching gingivae is the ideal, but sometimes it's not always possible to fully seat (for example if the child doesn't bite down fully).

You are aiming to seal in any caries, so as long as the caries is sealed in that is acceptable. In my experience, if this does happen it's most likely to be an exposed palatal margin. 


9. Consider preventative SSCs

Traditional Hall crowns have been indicated in:
  • Cavitated or non cavitated proximal carious lesions
  • Occlusal caries if a child cannot tolerate a conventional restoration
However, I also find placing SSCs in more of preventive approach can be useful. For example, for children with high caries rates who have caries in the majority of their primary molars at quite a young age, I would consider crowning at least all the Es even if they don't all have caries in them yet. 

I have also placed crowns in some children with complex medical issues or learning difficulties where they suffer from lots of reflux or vomiting to protect from wear. 



10. They are tight!

When I first started doing SSCs I didn't appreciate how tight they can feel for children. I have had many a child be a bit teary after I place them because of that feeling of tightness (they get used to it quickly) and you need to learn to reassure both them and their parents. 

Again preparation is key so explain to them it will feel tight. The analogy I use all the time is trying on a new pair of shoes that are tight at first until you wear them in. Always advise the parents to give appropriate analgesia in some cases for 1-2 weeks until the child adapts. 


To read more about Hall crowns, there is a really good summary article in the most recent BDJ.


Do you do SSCs? What tips do you have? Leave them in the comments section.



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