Tuesday, 31 January 2017

Top 10 Tips when taking Dental Radiographs in Children

Since starting working in a community setting, I've had much more experience treating children. One aspect I felt less confident in when I was in general practice was taking X-rays in children. I feel like this is echoed throughout the world of general practice as many of the referrals I see for children, GDPs have not attempted to take them. So here are my top tips when taking X-rays in children. 


So many referrals I see do not include x rays. In some cases this is due to the child not being co-operative or not having an OPG machine but in many cases when I take bitewings I can manage them quite easily! Just because they are a child doesn't mean you shouldn't take x rays. 

You should start to take bitewings from children around 6 years of age onwards if possible to assess for interproximal caries and the position of the first permanent molars.

2. Use a small film

It seems obvious but children's mouth are smaller than adults, so a regular sized film is way too big and uncomfortable for the patient. You can even get XS films! So when should you try to switch to the regular size? This depends on the size of the patient, but I would usually recommend once the 7s are starting to erupt.

3. Explain!

Children are commonly afraid of the unknown (as are adults a lot of the time!) so taking them through the process step by step in a child-friendly way is important. It's easy on adults where they've probably had multiple x-rays taken over the years and know what's happening, but often it will be the first time this child has had any form of x-ray! 

I like to show them the film and tab/bitewing holder and I call the x ray tube my camera, often practising placing in the correct position before attempting for real. A good analogy for helping them remain still I use on smaller children is pretending we are playing musical statues and the music has gone off until I press the exposure button that starts the music again, so they need to stay still. 

4. Tabs/foam

Bitewing holders are bulky and cumbersome and actually for children they can limit your view on bitewings as the plastic bite plate is too thick. 

Instead in children aged 6-10 I would recommend the use of cardboard tabs or even little rectangles of foam for them to bite on instead. It's more comfortable for the patient and the quality of your radiograph can be improved. 

5. Vertical Bitewings

I was never taught as an undergraduate what vertical bitewings were and how useful they can be! Imagine on a 6 year old child where you have a carious LLE and you want to assess if there is pathology or where it's successor is. You can't really take a PA, an OPG could be useful but it may not be available or the quality may not be sufficient enough to be diagnostic.

This is where vertical bitewings come into their own. Essentially you turn the tab vertically so the film is portrait in the patient's mouth. This allows you to see more apically on both upper and lower arches and is very handy both in children, but you could also take it to assess bone loss in periodontal disease in adults. 

A useful video on how to take vertical bitewings can be found here

6. Practice

Let them practice! Whether that be in the chair on that day or what I've found quite successful is giving the patient a film to take home to practice with. This may not be possible in a practice where things are digital but if you're still on film or can give them the protective slips with the card in if you're using phosphor plates, this could be a great way to increase compliance.

7. Demonstrate on their Parent

Again to help the patient with the fear on the unknown, a good tip is to demonstrate on their parent (obviously don't take the x ray but position everything as you would). This is a basically tell, show, do technique.

8. Bimolars

Bimolars can be very useful in patients with poor compliance e.g. learning difficulties, autism etc. If you're looking into providing these views I would recommend some hands on training, but these are useful views where the patient holds a film/cassette to the outside of their face (or a parent/carer does) to visualise the molars on one side. You need special sized films for this.

To see more about bimolars see here.

9. Patience

Take your time, keep your patience and keep persevering! Young children need lots of encouragement but in the majority of cases, a bit of practice and patience you'll get there in the end! Even if you don't manage to take the radiograph that visit, keep trying. Children can surprise you. Last week I saw an autistic boy who we couldn't take an x ray on. I gave him the film to practice at home with and a few days later I saw him again and the first thing I did was to try again and guess what, I managed to take the film. Don't be disheartened and don't lose your patience. 

10. Standard Occlusals

Again, I wasn't really taught how to take these as an undergraduate. They are much simpler than I thought they would be and in a lot of cases taking an USO is much simpler than taking a PA. 

In young children you can use a standard sized film and ask them to bite in between their teeth as far back as you can take it. In older children you will need to order the larger size in order to get all the teeth on. A tip is to keep the occlusal plane parallel and the x ray tube bisects it (around 60 degrees). 

I hope this helps next time you need to take radiographs on a child! Please leave your own tips and thoughts in the section below.

Saturday, 28 January 2017

Crisis at Christmas - Dentistry for the Homeless

So this year I spent a couple of days over the Christmas period volunteering for Crisis. This is something I've wanted to do for the past couple of years but I've always been away over the festive period. What was my experience like?

The dental vans which were our base over the Christmas period

Who are Crisis?

Crisis are a UK-based charity for homeless people who are dedicated to ending homelessness by delivering life-changing services and campaigning for change.

Crisis at Christmas helps support homeless people during the festive period; organising centres across several cities in the UK to provide companionship and essential services to tackle the loneliness and isolation that these people can feel throughout the year. 

Services that I saw at the centres weren't just a soup kitchen but doctors, nail bars, sewing services, laundry, podiatry, opticians as well as dentistry! There were also lots of social events organised: one guest who I treated was telling me how she'd stayed up half the night before singing on Karaoke!  

Let me tell you about my 2 days at Crisis. 

Day 1

Each of the shifts at Crisis is lead a clinician who helps organise the day and what roles you are placed in. 

First thing we do is have an induction getting to know the people in the team as well as being shown around the vans and the centre if it was our first day. I was surprised by how many volunteers came down to London from places like Birmingham, Taunton and Kent to come volunteer at the dental centres. There were also so many dentists both the days I was there, we were never short of a pair of clinical hands!

On my first morning I paired up with another dentist with a little more experienced than me and had also been at the centre on a previous day. It was reassuring to have his support (especially as a young dentist with such a baby face as mine!) and we took it in turns seeing patients. As well as us, there were two other nurses in the van with us - a bit of a squeeze when the guest came in; but it was great fun getting to know each other as well the guest and you'd spend a good few minutes chatting before even getting round to looking in their mouths!

The treatments that I provided that morning varied from check ups, to scale and polishes, fillings and extractions. One of the challenges of working in these mobile vans (excluding the freezing temperature when we first started!) was trying to find things that you needed. Sometimes we'd need someone to run across to the adjacent van to find a rosehead bur or odontopaste. I had also never used self-developing x rays before which was a little tricky in some situations. I struggled taking a PA of a lower 7 with the huge tag of the developing film dangling out the guest's mouth like some additional alien tongue!

After a busy morning, I moved onto being the decon nurse for the afternoon. With so many dentists to nurse ratio, the dentists needed to be flexible with the roles that were needed. Before this afternoon if you stuck me in the decon room I'm sure I would've probably caused the autoclave to explode or some other catastrophe; however, with a little guidance I got into the routine of sterilising the instruments for the vans in a make-shift decon room set up in one of the centre's classrooms. 

During the afternoon, my other colleagues were seeing guests who had been brought across from the dependency unit in another centre in London. Later on in the day, we were running a bit late with the guests getting a bit agitated waiting to be seen and I jumped back onto the van to see some of them. This included a lovely chap who came into my van crying as he had been pushed over that morning and smashed his front tooth. He was very upset and plenty of tears were shed because of the pain he was in and when I managed to look his UR1 had a mid 1/3 root fracture and was very mobile. The extraction was of the tooth was uneventful but as soon as we had finished, the tears vanished and he gave me a wonderful grin (now a little gappy) and couldn't stop saying thank you. All of the team went home with smiles after this!

Day 2

The second day I did was actually the final day we were able to see guests so things were a little busy!

In the morning, instead of being in the vans I went out to one of the other centres to do screening and triaging; the aim being to bring back some guests to be treated in the afternoon.

It was really interesting to get to know the guests and their priorities during that morning. I saw plenty of people who needed a couple of fillings or who like a clean but the prospect of leaving the centre for an entire afternoon was not a priority for some who needed to do their laundry or had appointments booked at CV workshops. We also saw a huge variety of guests, some who just needed a scale and polish and clearly looked after their mouths, to those who had multiple carious teeth, retained roots or signs of Meth Mouth. Even if the guests didn't want to come back to the vans with us we were still able to give out our information leaflets about where to find a dentist throughout the year (see picture below), as well as oral health advice and fluoride varnish applications. 

After bringing back about 8 guests, I spent the afternoon on reception chatting to the guests while they waited, giving out oral health packs to other guests in the centre and helping to organise checking people in and out of the vans for their treatment. 

The Crisis leaflet given to guests after their treatment letting them know where homeless people can access dental care throughout the year

I absolutely loved my time at Crisis; working in such an enthusiastic and kind team was a pleasure, everyone was willing to get stuck in wherever they were needed. Over the Christmas period, the 2 dental sites saw over 400 guests! I think there would definitely be demand for more if there were more dental vans. I did notice that on both days there were more dentists than dental nurses. If you are a dental nurse and you'd be interested in volunteering keep an eye out around October to apply. 

To see more about Crisis go to their website

Have you volunteered for Crisis at Christmas? What was your experience like? Let me know in the comments below. 

Thursday, 12 January 2017

Dental Foundation Interview: After the Interview with Dental Spotlight

It's a pleasure to once again be featured on the wonderful blog: Dental Spotlight.

So this week it was offers week for final year dentists. Back 3 years ago I was in the same position and wow has that time flown by. But I remember that day clearly....the constant refreshing of my email page. The futile attempts to try to distract myself. Until finally 4pm hit and I got that confirmation email.

For me, that day was a day of celebration, but I know this is not always the case for everyone. 

I was asked by Akta (founder of the Dental Spotlight) to put together some advice of what to do after this stage; whether you were offered a place or not. Not only this but what sort of things you need to take into consideration when you finally get to choose the practice where you will have your very first job as a dentist!

You can read the article here.

Unsure of what to ask when you get the chance to meet the trainers? Want to know what life is like as a DFT in London? Leave your questions in the comments section below.

Sunday, 8 January 2017

Special Care Dentistry: Autism Spectrum Disorder

Since starting in community, seeing children with learning disabilities has become an everyday regularity for me. Seeing those with ASD (or autism) has been a bit more challenging than I intially expected and managing these patients is very different from any other set of patients.

As part of one of our training days, we were given a really informative and useful talk about managing these patients by Wendy Bellis. This blog post is based on her talk. 

What is ASD?

According to The National Autistic Society, ASD is a lifelong developmental disability that affects how people perceive the world and interact with others. It is not an illness or disease and cannot be 'cured'. The disorder is a spectrum that can affect people in different ways and can be associated with other learning disabilties, mental health issues or other conditions in 70% of cases e.g. ADHD, epilepsy, OCD, anxiety.

A diagnosis of ASD is commonly described as a triad of symptoms:

  1. Difficultiies in socialisation
  2. Difficulties in communication
  3. Limited and repetitive patterns of behaviour and dislike of change
Recent figures have estimated in the UK 1 in 100 children have some form of ASD. There is also a 4:1 ratio of male: females.

What are the types of ASD?

As I mentioned above, ASD is a spectrum but there are some different labels given to individuals.

Asperger's Syndrome are of average or above above intelligence. They don't have as many issues with speech (such as 25-40% of autistic children who are non-verbal), but may have problems understanding and processing language. Some high profile fictional characters with Asperger's Syndrome are Rain Man (from the film of the same name) and Christopher from the novel and play 'The Curious Incident of the Dog in the Night Time'.

Children with Pathological Demand Avoidance (PAD) share the aspects of difficulties in interaction, communication and imagination but they are driven to avoid demands and expectations. They have an anxiety based need to be in control and are able to use their better understanding of social interactions and communication to their advantage compared with others on the spectrum.

What problems you can encounter when seeing these patients?

Children with ASD can be hypo/hypersensitive to sensory inputs such as light, smells, tastes. This can mean that the things you experience every day in your dental surgery such as the dental light, the smell of your materials, the taste of your gloves can be overstimulating for those on the spectrum.

This sensitivity is not only an issue in your dental surgery, but at home oral hygiene routines can be affected. They may dislike the texture,  taste or smell of toothpaste or even the brush. As well as oral hygiene, this can affect their diet. Autistic children are notoriously fussy eaters and it may even be a struggle to get them to eat enough. Many of these children may be on high calorie drinks or substitutes which contain high levels of sugar!

It may not only be what they eat, but when they eat it. Parents may have gotten into habits like taking a bottle to bed or rewarding good behaviour with snacks. These are often a dentist's worse nightmare. I remember seeing an 8 year old severely autistic boy who was non-verbal and showed violent and disruptive behaviour so his mum used sweets to calm him down. The only way she could get him to sit in my dental chair was to entice him with sweets... and of course I could see the affect of this habit in his mouth. 

Moreover, the co-morbidities associated with ASD may have affects on their oral health. If they are on medications which contain sugar or induce xerostomia this can increase their caries risk. I remember seeing a child with ASD who also had epilepsy who had trauma to their dentition following a seizure. These are all things to remember but one of the most profound problems I have encountered is how exhausted the parents of these children can be. Asking them to manage to brush their child's teeth twice a day can be a big ask for some parents where even taking their children to school can be a serious challenge!

Tips in the management of these patients

  • Early contact is key! Sometimes these patients are diagnosed very late and so you see them when they are 4 or 5 and sometimes by then it's too late and there's caries already! Getting these children in when they are young to build up their confidence and acclimatise them to the environment is key, as well as instilling good habits in their everyday life
  • Sending out a pre-appointment letter can be useful to let the parent know what to expect from the appointment and you could also attach a ASD-specific questionnaire to get to know the child a little. For example, I saw a 4 year old boy with Asperger's who had an anxiety about seeing people in uniform, so we decided to change out of our scrubs to see him (and use other PPE instead of course).
  • Letting the parents take pictures of the practice and surgery to make a story to show to the child before their dental appointments can be a useful aid
  • Communication is very important. Remember children with ASD find it difficult to imagine things and can take what you say literally, so you may need to adapt your usual child language e.g. talking about using a hoover to suck up water in their mouth. You should also talk slowly and clearly to give the child enough time to process what you're saying. Also don't ask open ended questions, give them direct instructions e.g. 'First Christopher you need to sit in the chair, then open wide so I can see your teeth'.
  • Ask the parents what sort of day is it for the child. Sometimes they will be having a bad day e.g. if they haven't followed their usual routine of things, and so getting enough compliance for a dental exam may be impossible; but bringing them back on another day when things a little better may mean they will let you.
  • Children with ASD do not like to be kept waiting so be on top of your time management
  • Use counting as a timer e.g. counting down from 10 so the child knows when you will be finished
  • If the parent has been giving the child sweets as rewards, try to change the reward to something else e.g. stickers, grapes, sugar-free sweets
  • If there is difficulty with oral hygiene, try brushing without toothpaste to see if it's the taste/texture/smell of the toothpaste they don't like. Use of an electric toothbrush may help but sometimes some patients do not like the sensation of this. There are non-foaming toothpastes and unflavoured ones e.g. Oranurse available to use. 
  • Some children with ASD may respond well to tooth brushing charts. Also the longer it is left to get the child into a routine with brushing, the more difficult it can be as they get older so getting into good habits early is very important. 
  • Some children with ASD like the sensation of chewing on or biting things. Soft safe toys that be hung around their necks are available. Parents often see me thinking their child is in pain because they are chewing on things, but often it's just because they like the sensation (this is called Stimming). Sometimes this habit can lead to ulcers in their mouths. 

The most important point that I learnt from Wendy's talk as well as what I've learnt so far in treating these patients is get to know them. Every patient is different with different habits and behaviours. Building in some of the child's own preferences and habits into how you treat them can be a really useful skill. Being patient and calm is also very important, especially when things are not quite going to plan!

For more information about autism, see the National Autistic Society - they have a fantastic page about dentistry.

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

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