Thursday, 14 December 2017


An update following my previous post a couple of years ago about bisphosphonates, this post is based on a talk by Claire Curtin who spoke at the Royal College of Surgeons Special Care Dentistry Study Day. 

What is MRONJ?

'Medication Related Osteonecrosis of the Jaw' (previously BRONJ, bisphosphonates), is an area of exposed bone, or bone that can be probed through an intra-oral or extra-oral fistula, in the maxillofacial region that has persisted for more than 8 weeks in patients with a history of treatment with anti-resorptive or anti-angiogenic drugs, and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease to the jaws. 

Cause is unknown, but is likely to be multi-factorial (genetics and environment). Mechanisms are likely to be:
  • Suppression of bone turnover
  • Inhibition of angiogenesis
  • Toxic effects of soft tissues
  • Inflammation
  • Infection

What medications can cause MRONJ?

1. Anti-resorptives: Bisphosphonates (These carry a life-time risk of MRONJ), Denosumab (The risk diminishes 9 months after completion of treatment)

2. Anti-angiogenics: Bevacizumab, Aflibercept, Sunitinib

These drugs are used to treat: 

  • Osteoporosis
  • Prevention of cancer complications e.g. fracture, bone pain
  • Treatment of non-malignant bone conditions e.g. Paget's
  • Slow cancer progression
  • Treatment of multiple myeloma
The incidence of MRONJ in people with osteoporosis is 0.01%-0.2%, whereas people who have cancer is around 1%. The risk is thought to increase if both types of medications are taken (and if steroids are added into the mix). 

How to Manage?

1. Identify patients at risk

  • Full medical history is key
  • Have they been prescribed any relevant medication now or in the past?
  • How long for?
  • What condition do they have?
  • Do they have a history of MRONJ?
  • Are they taking any steroids?

2. Classify the patient's risk

  • LOW RISK - taking bisphosphonates < 5 years or Denosumab < 9 months with no steroid usage
  • HIGH RISK - receiving the treatment for a malignant condition, taking bisphosphonates > 5 years, steroid usage or a previous history of MRONJ

3. Patient Education and Prevention

  • Ideally prior to any prescription of anti-resorptive or anti-angiogenics a full dental assessment and prevention regime should be implemented. 
  • Any extractions or treatment to minimise mucosal trauma should be prioritised e.g. denture eases
  • Encourage patients to cessate smoking, have a healthy and balanced diet and see their dentists for regular check ups

4. Treatment

  • LOW RISK - Carry out extractions as normal, no need for prophylactic antiseptics or antibiotics. Review in 8 weeks
  • HIGH RISK - Seek alternatives to extractions if possible e.g. RCT; otherwise carry out extractions as normal, no need for prophylactic antiseptics or antibiotics. Review in 8 weeks

5. Identify and refer suspected MRONJ cases

  • Educate patient about symptoms e.g. tingling, numbness, pain, altered sensation around the extraction socket
  • Signs are exposed bone after 8 weeks
  • Always refer if in doubt

6. Report MRONJ via the Yellow Card Scheme

Many thanks to Claire Curtin and the RCSEd for organising the study day. Please read the full guidance from SDCEP for further information. 

What do you think about the new guidance and what's your experience of MRONJ? Let me know in the comments below. 

Tuesday, 28 November 2017

Careers In Special Care Dentistry: RCSEd Study Day

Thinking of a career in Special Care Dentistry? I recently attended a study day with the Royal College of Surgeons of Edinburgh which helped me understand what options there are out there in Special Care....

Routes to Specialisation

There are 2 main ways to specialise in Special Care Dentistry:

1. Special Care Registrar Training (SPR/STR)

A 3 year training pathway which may include opportunities to do a Masters in Special Care or the RCS Diploma (see below). 

These posts at the moment are released on Oriel on a regional basis but it is planned by 2018 to be a national recruitment process much like some of the other specialities e.g. orthodontics. Posts can be purely based in the community, in secondary care or a mixture of both. Following the 3 years training you will then take Royal College Exit Exams to become a Specialist (as well as completed a portfolio, competencies etc.). 

2. Special Care Academic Clinical Fellow

As above, another 3 year training pathway but divided into 75% clinical training and 25% academic. The target following any ACF post is to secure funding for a pHD and become an academic. 

The day to day timetable is very similar to an SPR. These posts are usually funded by the university rather than a deanery. 

The Royal College of Surgeons Diploma

The Royal College of Edinburgh offer a Diploma in Special Care Dentistry for those who wish to grow their portfolio and qualification in Special Care Dentistry. The diploma is available to those who can demonstrate experience in working in a special care environment for 1 year e.g. community. The diploma consists of 4 parts:
  • Log book of clinical experience relevant to Special Care Dentistry 
  • Case presentations x 2
  • 7 Unseen Cases Exam
  • Simple Best Answer Exam

The exam takes place twice a year, the next sitting is in March. For more information see the RCSEd website

Where do Specialists work?

Of course this doesn't just apply to specialists; there are plenty of clinicians with lots of experience in Special Care Dentistry who are not on the Specialist Register, especially since SCD is the newest dental speciality! In general, there are 3 environments that specialists can work:
  • In general practice (NHS or private)
  • In community dentistry/salaried dental services
  • In secondary care e.g. dental hospital
Often, specialists may divvy up their time in more than one environment. They can also be involved in other areas of dentistry e.g. commissioning, education. Broadly, most SCD specialists work within the NHS; however, there are skills SCD have that are highly valued in the private sector too e.g. sedation skills. 

SCD is a unique speciality as it encompasses all areas of dentistry. This means that specialists will have a broad range of skills in all areas of dentistry: from surgical extractions to molar endodontics! 

Many thanks to those who spoke on the day not just about careers, but some common topics that I experience (and often need help with!) throughout my day to day life in community! 

Is a career in special care dentistry for you? Are you on a specialist training pathway? Let me know in the comments below. 

Saturday, 18 November 2017

Pathway and the Faculty for Homeless and Inclusion Health: Regional London Meeting

Last week, I attended the regional London Meeting for Pathway and the Faculty of Homeless and Inclusion Health.

What is Pathway and the Faculty?

PATHWAY is the UK's leading homeless healthcare charity. They aim to integrate care within the NHS and voluntary sectors for homeless people: from GPs, nurses, housing professionals, hospitals and of course us dentists! They help with the logistics of accessing healthcare for homeless people e.g. recovering important documents, linking to community services, registration with GPs etc. 

The Faculty for Homeless and Inclusion Health is a network of health professionals working together to help those who find accessing health care most difficult:
  • The homeless
  • Vulnerable migrants
  • Travellers
  • Sex workers
It is free to join the network if you are health professional who manages these groups of people. This will help you keep up to date with current research as well as linking with other professionals in your area who also work with these people. Click here to join!

Homelessness, Physiotherapy and Autism

The regional meeting held at UCLH covered a couple of very interesting subject matters and there was lots of discussion within the audience. 

1. Physiotherapy and patients who are homeless with Jo Dawes

Jo Dawes discussed her plans to set up a research project into access to physiotherapy for patients who are homeless and how physiotherapy treatment can positively impact a homeless person's quality of life. It was interesting to compare how different cities may have different needs for their homeless populations: Jo explained how the service in Glasgow where she previously worker, provided care for their homeless population. 

2. Autism and homelessness with Dr Paula Grant

Dr Paula Grant explored the links between autism and homelessness and presented the findings of her recent research in the area. I found this talk particularly interesting as within my day to day practice, I manage both autistic patients and the homeless. She spoke of how she found that the lifestyle of the homeless has some advantages to people who are autistic e.g. not fitting into social norms, flexibility, limited interaction with others. 

Many thanks to those who spoke at the meeting and it was fantastic to meet others who are passionate about providing health care to hard to reach groups. Homeless and Inclusion Health hold an annual conference in London, March 7/8th. Hopefully I can get to go and see some of you there. Click here for details. 

Do you treat any of these socially excluded groups? Let me know how you manage these patients in the comments section.

Tuesday, 7 November 2017

3 Top Tips in Managing Autism with the National Autistic Society

At our most recent staff meeting within our community dental services we received a talk from the National Autistic Society. This post is based on that talk...

What is Autism?

  • Autism is diagnosed by observing behaviour
  • The condition is a spectrum disorder i.e. it affects people in varying degrees
  • Asperger's Syndrome is on the spectrum of autism, but it may not be recognised as a separate diagnosis  soon
  • Prevalence is 1 in 100
  • The cause of autism is unknown; there is thought to be a genetic and environmental component
  • 5:1 ratio of male to female
  • 30% of autistic people also have an associated learning disability

The diagnosis of autism is based of a triad of symptoms: 
  1. Social interaction difficulty
  2. Repetitive behaviours
  3. Communication difficulties

Considerations when interacting with Autistic patients

1. Non-verbal Communication

Autistic patients will often take the literal meanings of words or phrases and have difficulties with non-verbal communication e.g. they do not create eye contact. 

Give increased processing time for these patients, don't give them too much information at once and give instructions in stages/allow them to prepare e.g. Ben, sit in the dental chair then open your mouth then I will use this mirror to look at your teeth. 

2. Structure/Routine

Try structure the environment so they are familiar with their surroundings e.g. see them in the same surgery with same nurse etc. Try to arrange an appointment time that disrupts their day as little as possible and stick to a structured appointment. 

Encourage the parents to create a routine surrounding their oral hygiene regime and create a reward system following the routine e.g. brush teeth, add a sticker to a tooth brushing chart. 

3. Hypersensitivities

Autistic people can be very sensitive to sound, light, touch and so it's something to be aware of in a dental surgery full of foreign experiences! Be aware of use of the dental light - many autistic patients do no like it as well as loud noises like the suction or dental drill. They may also be sensitive to the taste of your dental gloves, toothpaste, fluoride varnish etc. 

For light consider the use of sunglasses. Autistic patients often have ear defenders to block out sound. If patients do not like the sound of vibration of an electric toothbrush, use of a Dr Barman's toothbrush can be useful. 

A usual acronym with interacting with people with Autism is SPELL:


Positive approach (language use, visual)

Empathy and seeing things from another point of view

Low arousal, low stress

Links and consistency

To see other tips in managing Autistic patients see my previous post. Many thanks to NAS for the informative talk!

Do you treat autistic patients? Let me know how you manage these patients in the comments section.

Monday, 30 October 2017

3M Young Talent Award - Back to Seefelt

Seefelt twice in 3 months! But this time I was invited back to the 3M HQ to participate in their Young Talent Award. 

The participants for the awards.

When the UK 3M rep suggested I enter for this award back in the summer, I was very doubtful it would be accepted - but to my surprise I was invited to present one of my paediatric cases alongside some very respected clinicians from the UK and across the world!

There were participants from as far as South Africa and Pakistan and there was a broad range of topics presented. The Young Talent Awards are held every other year in Germany to celebrate some of the young talented dentists across the world! 

The day itself was packed with presentations every 20 minutes, 21 presentations in total from digital smile design, to dental material research, to impressive orthodontic case presentations! All the participants did a fantastic job and there were some very stimulating comments and discussions off the back of all the cases and research that were presenteds.

I presented one of my paediatric cases specifically talking about the Hall Technique (well I had to present a case where I used a 3M product!). 

To see my presentation click here

Of course we were the winning table at wine tasting! 

I didn't win (unsurprisingly), but many congratulations to all the prize winners and to all the other participants! There are some seriously good young dentists about! 

To celebrate, after a very swift costume change, 3M hosted a very entertaining evening of wine tasting which involved a quiz which of course we all got very competitive for! The following day was a bit of a struggle on 3 hours sleep but I had another opportunity to look around the 3M HQ and overall I met some really inspirational and genuine dentists from across the world. 

Many thanks to 3M for another amazing few days and for inviting me back to Seefelt.... I'm sure it won't be the last time!

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

Monday, 23 October 2017

Dental Foundation Training Interviews: An Update

DFT interviews were the first thing I ever blogged about when I set up 'A Tooth Germ' over 3 years ago so I thought it was about time I posted an updated blog since the application process has changed recently...

My DFT preparation course last year

This year, I decided not to run my own course as I had way too much on my plate already! Instead I lectured on a course organised by one of my own delegates from last year where all the money raised go to charity - Akshaya Patra.

The 2 weekends that the course was held over saw some very enthusiastic and knowledgeable final years - good luck to all of you! 


1. Timings of the Situational Judgement Test (SJT): Previously, the SJT was at the centre on the day of the interview. For the first time this year it is being held separately online which you have to book onto between 1st-7th November

2. Pre-release of the Communication and PML station scenarios: Again for the first time this year you will receive the questions for both the communication and the PML stations one week before your interview. This is to help make the process fairer. Do not assume that there will not be any further questions interviewers may ask off the back of the main questions

3. Timing of ranking of scheme preference: This has been for the past few years the deadline for the ranking of your scheme preferences is after the interview itself between 4th-18th December

Common Scenarios to Revise

Common themes come up throughout the SJT and both stations and it's very important that you know the themes inside out! These include:

  • Clinical Governance
  • Raising Concerns
  • Complaints 
  • GDC standards
  • Whistleblowing
  • Consent
  • Capacity
  • Safeguarding
  • Confidentuality
  • Teamwork

Remember to practice, practice practice! Ask friends/family to practice interviewing you and timing it!

Again from my course - one on one interview practice is essential!

Where to find further information

There lots of resources out there to help prepare you (apart from just this blog!):

  • BDA final year guide
  • Dental Foundation Interview Guide
  • GDC standards for Professionals
  • COPDEND website
  • Society guidelines e.g. NICE, FGDP, AAE, BSP, BSPPD

If you have any queries please let me know in the comments below.

Friday, 20 October 2017

The First Inaugural Dentinal Tubules Congress 2017

Things have been very busy this month, starting with the FIRST EVER Inaugural Dentinal Tubules Congress!

Tubules Family!

Dentinal Tubules has come a long way since I first started getting involved in 2014; from a video library to live stream videos - 2017 has been a great year for Tubules and this October there was some more exciting news announced; for those who were there to see it at the congress, the news of the new Tubules Foundation was very emotional and Dhru is certainly one of the most inspirational people I know!

The 2 days of the Congress were held at the Grove Hotel in Watford which was a great venue (the England football team were staying there while we were there!) and the theme of the Congress was Top Tips in Dentistry. 

The first day of the congress was a hands-on day where delegates could choose which course they wanted to learn from. Some fantastic names like Dr Mahul Patel, Dr Jason Smithson and Prof Giulio Rasperini (just a few) were there to share their knowledge and expertise in their fields of dentistry. I chose to refresh some of my rusty surgical skills with hands on sinus lifts and ridge-split technique with Dr Sam Lee and Dr Arthur Lyford from the USA. 

I really enjoyed the hands-on element: we must have put the local butchers out of business with the supply of pig jaws we had access to!

With a little help, me avoiding that pesky sinus!

After the usual catch-ups with the Tubules gang in the evening, we were up again bright and early for a packed day of lectures from another amazing line-up: Prof Guilio Rasperini, Dr Carlo Poggio, Dr James Baker, Dr Jason Smithson, Dr Finlay Sutton, Dr Sam Lee, Dr Alessandro Conti, Dr Roberto Rossi and Davide Bertazzo

There was a huge range of topics discussed with some excellent cases and presentations discussed. The atmosphere was different from any other conference  I have been to: a much more interactive audience that truly represented the Tubules family ethos. 

As I mentioned above, Dhru announced some amazing news with the Dentinal Tubules Foundation helping raise funds for education for the poorest across the world! Of course there was a little fun as well (which is becoming a bit of a Tubules tradition), with the Mannequin Challenge which you see can the video for below! Can you spot yourself?

The conclusion of the conference of course was a rowdy Tubules party! It was great to catch up with the Tubules family and share the vision that Dhru has created with his Tubules team. Well and truly #Tubulised! I can't wait for next year!

Did you go to the Congress? What was your favourite talk? Let me know in the comments below.

Wednesday, 4 October 2017

DFT and Beyond - KCL Talk

Last week, KCL's Dentsoc invited me to speak to their final year dentists about Dental Foundation Training (DFT) and beyond!

What to expect from DFT.

Many of my readers will have recently started DFT and the first month I'm sure will have flown by! The first few months will be a huge learning curve from transitioning from university to being independent in practice and learning how the NHS dental system works. 

If you have followed my blog, you probably have read previous posts about my experience of my DFT year. At this talk I focused on my main tips to keep in mind during the year - this post summarises my tips. 

Lots of opportunities will arise in this year including meeting some inspirational and knowledgeable clinicians through study days and networking. Make the most of these opportunities and start building the foundations of your support network.  

Membership Exams

Another thing to consider during your DFT if whether you should take one of the membership exams i.e. MFDS or MJDF

These exams are becoming part of the culture of young dentists but think hard before you consider taking them. Do you want to keep your options open regarding postgraduate training or specialisation? Weigh up the costs of the exams, especially pertinent in your early career, with what benefit they may give you in the future. Don't just do them because everyone is else!

See my previous post about the differences between MJDF and MFDS

Dental Core Training

One of the options after completion of DFT is Dental Core Training (DCT). I thoroughly enjoyed my DCT year and I learnt so many skills during my post. 

Applying for DCT is becoming more and more popular and posts are becoming much more competitive, especially in places like London. There are a variety of posts available and it's a great option if you are unsure of what route your career may take you or you want to learn more about dentistry in secondary care. 

DCT doesn't just have to be the one year. There are also years 2 and 3 as well as run-through DCT 2/3 posts. To read more about DCT and why it could be a good option for you read my previous post

Other Career Options

I also discussed the other career options that you could consider after DFT or DCT. I remember when I first graduated from dental school, my perception of my career was I would just be in practice. It's funny how your thoughts and ambitions change over time! 

I have plenty of posts about careers on my blog. 

It was a pleasure to speak to a dedicated group of students who were motivated enough to still be in a lecture theatre beyond 6pm!! I hope the message from my talk, to be ambitious and make the most out of every opportunity that comes your way, hit home even when the pressure of DFT interviews and finals are looming!

To see a copy of my presentation from the day, see here.

What tips would you give final years about DFT and beyond? Let me know in the comments below.

Saturday, 30 September 2017

How To Avoid Being Sued - Guest Post with Smith Jones Solicitors*

How can you avoid being sued as a dentist? In this latest post, Smith Jones Solicitors give their advice...

You will have heard how important it is to protect yourself from being sued. Dental malpractice is a rising phenomenon which should be taken seriously unless you wish to put your license to practise at risk. The fact is, if a dentist's treatment for a patient can be proven to be substandard it increases the chances of a lawsuit. Dentists must recognise the duty of care that is owed to a patient. Since any form of breach of duty of care could result in legal action against the dentist. The basis of any civil lawsuit against a dentist would mean the treatment given to the patient contributed to the unnecessary pain, suffering or injury to the patient. 
The question that needs addressing is why do most dentists think they will never face a malpractice lawsuit? Surely by exploring such a question, it would help a dentist avoid being sued. So is it a case of being complacent and feeling satisfied with your own abilities because unless you're one of those people who actually think about all possibilities the idea of your practice facing a legal action might not be something taken into consideration.

Duty of Care

As mentioned above, the duty of care owed to a patient is important. You may wonder what is the duty of care and how it is owed to a patient? In simple terms, the concept of duty of care owed to another person would be mean an obligation is placed on a dentist to avoid taking actions or making omission which are foreseen to injure or harm the patient. The issue of a patient suffering a civil wrong due to the actions of a dentist would be examined under tort laws. 
It is often seen in many cases of medical negligence there has been a breach of duty of care. It is assumed dentists would be aware of their duty to comply with the standard of care which they need to provide for a patient according to medical and dental guidelines and regulations. The fact of the matter is in many claims of negligence the dentist did not provide the adequate standard of care. 
In the event of a breach of the duty of care, it would mean the dentist has been negligent in the standard of care of a patient. The requirement for the standard of care can cover various issues to do with the medical care of a patient. For instance, it is not sufficient to just diagnose and provide treatment for the patient. It would be a good idea to provide enough information to the patient before the start of the treatment an what the patient can expect as the result of the treatment. In any negligence claim, there must be evidence of injury or damage due to the treatment given by the dentist. They type of lawsuits which stem from medical negligence are complex and cover issues to do with not being given the right treatment. For instance, claims of negligence can involve the patient being misdiagnosed, given inadequate treatment or the work carried out on a patient is of a careless nature. However, as often is the case in dental treatment any form of natural pain or suffering would be automatically amount to a claim for negligence. 

 Complaints and Risk Management.

The quality of care given to the patients is very important and a feedback service should be provided to help address any concerns. The dental practice should be fully equipped with handling complaints. The quality of care should be focused on the treatment and providing the patients with a high level of safety at the dental practice. The focus of the duty of care should not only be concerned with the care of the patients but also their safety too. It would be good to check the risk management system of the dental practice and make sure it it adequate to handle complaints. 

Furthermore, it is a good idea to keep up to date with the new developments in the field of dentistry which could help to provide the right level of care to a patient. The aim of any dental practice must be to make sure their dentists have full knowledge as to what they are doing. In essence, the objective of a good dental practice would be to have in place a check and balance system to check the competence of their staff and maintain a high level of care.  

It is also a good idea to get written consent from the patients before any complicated or risky procedures are carried out. They use of obtaining informed consent from the patient can help to reduce the chances of a dispute and provide evidence as to what has been agreed with the patient. The issue which needs to be taken into account is a contractual relationship can exist between a dentist and a patient by express or implied terms of agreement. However, in recent years the scope of negligence clams have been widened to include claims made to the courts in which no contract existed between the claimant and the defendant. The continual evolution of the law would mean a dental practice needs to keep up to date with the changes and to make sure a system is in place to limit the chances of claims made against them. However, indemnity providers do no offer cover and support to protect against being sued, but that does not mean proper measures should not be put in place to reduce the chances of being sued. 

What are your thoughts on SJ solicitors tips? Let me know in the comments below.

*Sponsored post

Rachael Mulheron,  Medical Negligence: Non-Patient and Third Party Claims, Routledge, 2016
Kiyana Mills, Medical Negligence, AuthorHouse, 2012
Mark Lunney, Ken Oliphant, Tort Law: Text and Materials, OUP Oxford, 2013

Sunday, 17 September 2017

How are the Community Dental Services changing?

I have mentioned in my previous post about special care dentistry that recently there have been some changes in how the Community Dental Services (CDS) are functioning; certainly in London. Here I shall outline how the services I have worked in have changed...


Last year, the tenders for the community dental services in London ran out and so different trusts and other organisations such as social enterprises were able to bid for each service area. The trust who held the contract for one of the services I work in lost the bid for the provision of the CDS in East London. What this means is that the NHS commissioners decided that another trust will be given the contract to provide the service; in this case at a lower contract value. 

The reason is the push for more and more services to be provided in general practice which is more cost effective for the NHS for example the provision of out of hours emergency dental services which used to be part of some CDS. Together with this is encouraging GDPs to treat certain groups of patients in practice rather than refer to CDS as our management of these patients wouldn't be any different to how they would be managed in practice. 

New Referral Criteria

So naturally with a cut in funding means CDS will be seeing fewer patients; therefore referral criteria have changed and become much stricter. If you see the post I linked earlier on in the post, you can see the types of patients we used to see. We only accept referrals that are deemed Level 2 or above by NHS England for both special care and paediatric dentistry. What this means is:
  • We now only accept paediatric referrals where there has been a failed attempt at treatment with their GDP or children with complex medical or social problems or learning disabilities. We expect GDPs to acclimatise children in practice
  • We no longer accept referrals for patients with blood born viruses e.g. HIV unless they fit into one of the other criteria
  • We only accept those with complex medical problems if this directly impacts a patient's treatment in a way a GDP could not manage e.g. if a patient is on warfarin, a GDP can liaise the patient's warfarin clinic if required
  • We do not keep many patients for recalls within the service; instead we complete courses of treatments then discharge to their GDP i.e. promotion of shared care
  • A GDP cannot refer a child directly to a hospital, the CDS triages the patient and acts as a gateway for general anaesthesia - similarly for special care adults this applies
  • There is one universal referral form in London for paediatric dental services; similarly in special care adults
  • We are seeing fewer phobics and encouraging GDPs to refer for one off treatments e.g. extractions to practices with sedation contracts
  • Our domiciliary service is now only for patients who are truly housebound. Patients who can make it to clinics in taxis or transport are now being booked into clinics rather than receiving home visits 

Closure of clinics and services

Naturally, with a changeover in overseeing trusts some of our sites had to be closed as the new trust does not own the buildings. This has been difficult for patients as they now need to travel much further to access our clinics and unfortunately has meant our previous close links with undergraduate training in East London are much weaker so sharing care is much more difficult. 

Not only have services been affected in East London but London wide. I used to also work on bank at the urgent dental service based in community in North London. Since the re-tender i.e. April, the funding was removed for this walk in urgent care service. Ultimately, this results in putting pressure on the remaining services e.g. out of hours GDP services and acute dental departments in teaching hospitals. 

There are exciting times ahead however; with our service winning the homeless dental provision which is planned to be based on our mobile dental units. 

These changes although already in motion, undoubtedly will take time to filter down to referrers and others in the profession. I am still repeatedly sending back inappropriate referrals or discharging patients and it can be frustrating as some of these patients are still waiting months on our waiting lists unnecessarily. 

Click to access information from commissioners about Levels of care in Special Care Dentistry and Paediatrics to ensure your next referral to the CDS is appropriate!

I'd love to hear how these changes have affected both GDPs or other CDS services throughout the country. Let me know in the comments below. 

Wednesday, 6 September 2017

5 Books Every Dentist Should Read

I've been meaning to write this post for a while as it has been some time since I've written a self-improvement post. Here are some of my favourite non-fiction books I think every dentist should read...

1. Your Inner Fish - Neil Shubin

I was recommended this book in my first year of dental school by our anatomy profession when learning about embryology and the pharyngeal arches. He was explaining to us how these correspond to gills and can be traced through evolution and thus recommended Your Inner Fish.

The book is written by a paleontologist and professor of anatomy who traces where our organs originated millions of years ago and the chapter which particularly interested me as a dental student was how our heads were organised like that of a long-extinct jawless fish.

I would recommend this book, not only to revise your embryology, but to learn more about the history of evolution and how it links to us as humans - it's also written very well and doesn't have a textbook vibe unlike many books written by scientists.

2. It's All In Your Head - Suzanne O'Sullivan

I randomly picked this book up on one of my frequent browses in Waterstones. At the time, I had recently experienced some troublesome patients at the walk-in acute dental departments that I was working in who I suspected to have undiagnosed mental health issues. So the title really jumped out at me. 

Since then, I have been to talks within Special Care Dentistry where this book has been recommended. It is written by a neurologist who tells of cases where she has seen and attempted treatment for patients with psychosomatic illnesses i.e. illnesses with no organic cause. When reading some of the cases it did remind of some patients I have seen while working in a special care environment. For example, I have treated a patient with dissociative or non-epileptic seizures or patients with severe Chronic Fatigue Syndrome. 

Again, an easy read which you'll finish quickly. In fact my copy has done the rounds with several of my friends and colleagues it's been that popular! It did change my judgements about conditions like chronic fatigue and fibromyalgia and I feel like I take psychological treatments for conditions like these much more seriously - in fact I have referred patients with facial pain onto clinics where psychotherapy can be an adjunctive treatment as a result of reading this book. 

3. Cure - Jo Marchant

A book I downloaded from Audible this book really caught my eye as a medic, I have been trained in the use of medicine in healing rather than any other means and I have a few patients who have experienced other means of healing e.g. alternative medicine. 

The author discusses how the mind can heal the body from alternative medicine, to meditation to the use of placebos. 

On the surface perhaps many medics brush off the importance of the power of the brain over our body; but how many times have you seen a severely anxious patient yell in pain when you are extracting a tooth when you know the tooth is numb? I recently had a lady who yelled when I wasn't even touching the tooth! You could say she wasn't feeling pain but she was just scared; however, if she could control her anxiety better perhaps with your assistance, she would not have reacted in such a way i.e. used the power of her mind to overcome her anxiety.

4. Bad Pharma - Ben Goldacre

From the writer of the book Bad Science (which is on my to read list), Bad Pharma is a must read for all doctors. I picked this book up in a charity shop and it is quite a thick read but in the age of Evidence Based Medicine and Dentistry, it's really surprising what the author reveals. 

Written by a doctor, he tells of examples of how the Pharmaceutical business sometimes mislead the public as well as the medical industry and how it has lead to harm to patients for example the use of Tamiflu in the Bird Flu outbreak. 

5. When Breath Becomes Air - Paul Kalanithi

I only finished this book in the past month and many other people recommended this to me. Although I bought the book, I ended up listening to the audiobook on the way to work, which proved rather awkward during the last chapter as I was walking down the road with tears in my eyes!

It is a true story written by a neurosurgeon and his journey through his cancer diagnosis. It is excellently written and really tugs at your heart strings. As dentists, if we suffered with conditions that we diagnose frequently, the implications may not be so serious, but the author addresses how we can become insensitive to diagnoses we see all the time; despite the impact they may have on peoples' lives, as well as what we really find important in our lives like family, friends or a career. 

I would just read the last 2 chapters in private, if like me, you can get a little teary!

Have you read any of these books? What did you think of them? Are there any other books you would also recommend? Let me know in the comments below. 

Tuesday, 22 August 2017

The Ultimate Test Drive: Review of Oral B Genius Electric Toothbrush

A few months ago my local Oral B rep introduced me to their latest offering in electric toothbrushes: The Genius 9000. What did I think?

What are the key features of the Genius?

As well as the usual features of the other Oral B toothbrushes, the Genius includes:
  • Position detection - connect your toothbrush by bluetooth to the Oral B App and the toothbrush along with facial recognition (like when taking a selfie) knows what area of the mouth you are brushing and helps tell you when to move on as well as highlighting areas you may miss
  • Pressure sensor - already a feature of many of the previous models, the pressure sensor lights up red if it detects you are pressing too hard. Brushing too hard can lead to tooth wear and gum recession
  • In built timer - the brush buzzes every 30 seconds, helping you to move around your mouth systematically and brush for the correct time

Test Drive

So not only did I get my own personal Genius to try out at home but also a modified brush to use on my patients. The brush can be disinfected and is supplied with single use disposable brush heads as well as barriers for the body.

How many times do dentists just blanket recommend electric toothbrushes to patients who have never used them before? Having the Test Drive to directly demonstrate in the patient's mouth makes it much easier for patients to see the benefit of the toothbrush. Specifically for the patients I see such as children with high caries rates or those with special needs (learning difficulties, mental health problems, dementia) where someone else is brushing on their behalf, demonstrations in their mouths are really useful. If you are demonstrating for their carers, letting them have a go themselves often converts them to using an electric brush as it makes their lives easier!

I can say after using the toothbrush myself I can feel the difference between it and a manual toothbrush and I think one of the most important things for me I now KNOW that I definitely brush for 2 minutes now! There are also different strength of brushing which might be useful if you were going to share the body of the toothbrush in a family where there are children or if you had particularly sensitive gums. I also like how you can change the colour this toothbrush lights up with!

To see a demonstration of the brush see the video below. 

To grab your own Test Drive, speak to your local Oral B rep! Massive thanks to Boris for mine.

Have you used the Oral B Genius? What do you think of it? Let me know in the comments below. 

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.


  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. 


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

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