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

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...

This post can also be found in the BDJ team magazine

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.

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