Wednesday, 22 March 2017

A Week in the Life of a Community Dental Officer

So many of you know, since the end of last year I've been working in the Community Dental Services in East London. But what does my average week look like?


Monday and Tuesday

Mondays and Tuesdays I see patients in Hackney; mostly special care adults

Read one of my previous posts to see what type of patients we see in special care (click here). I see a lot of vulnerable adults such as patients who are housebound or with severe mental health problems who require transport to help get them to clinics and so appointment can be lengthy to ensure we get as much treatment done as possible. 

For these patients I may need to use a hoist or body board to help transfer them to the dental chair if they are unable to themselves but also I have to consider whether these patients have capacity to consent for treatment. We often have to have joint appointments with other clinicians for best interest meetings. 

I provide all general dental treatments and I am lucky to be able to refer any complex endodontic cases to one of my specialist colleagues in the service. 


Wednesday

I have one day a week working almost exclusively with children in Tower Hamlets, one of the worst boroughs in London in terms of dental health. These can be children who have learning difficulties or other complex medical problems, children who are very anxious or have not coped with treatment with their GDP as well as children with complex social issues. 

I am lucky that at this clinic I also work alongside an Orthodontist who is able to help me out with treatment planning some children (especially poor prognosis 6s) and I have been able to work with her to provide simple removable orthodontic appliances. 

To learn more about the dental management of autistic patients read here

In the evenings, I also work in emergency dental settings: one an emergency walk in service run by a community dental service, the other an out of hours clinic which patients can access via 111. To read about my tips in the management of dental emergencies read here


Thursday

Thursdays are spent on Brick Lane at a dental clinic above a homeless and substance abuse service. This means I see a lot of patients who are temporary housed or living on the streets as well as those who are drug abusers or alcoholics. 

These patients often have severe dental disease, but not always. When I see these patients I try to link with their key worker or social worker as they are often poor attenders and similar to what I mentioned above, I try to do as much treatment as I can when I get to see them.

To read about my experience treating the homeless at Christmas, click here


Friday

Back in Hackney on Fridays, again treating mostly special care adults. As well as vulnerable adults we also see dental phobic patients where we need to use our behaviour management skills as well as means such as use of The Wand and conscious sedation in order to treat these patients. 

To read about the updated IACSD guidelines, read my recent post here


Saturday

If you read my post last year as a dental core trainee, you will already know I work in a general practice on Saturdays providing both NHS and private dental care. 

This keeps up my more complex dental skills e.g. composites, crown and bridgework, which I rarely use in patients with special care needs. 

To read 5 reasons to work at the weekend, read here


What's your week like? Leave your comments in the section below!



Thursday, 16 March 2017

What do IACSD Guidelines really mean? An update with Dr David Craig

Last week, I attended my local BDA branch meeting with Dr David who hoped to clarify the recent IACSD Guidelines. Here's what I learnt from the evening. 


Who are IACSD?

The Intercollegiate Advisory Commitee for Sedation in Dentistry (IACSD) released their guidelines in 2015 and included bodies from the Royal College of Surgeons, Anaesthetists, representatives from defence unions, FDGP and other members from dental specialities who came together to write comprehensive standards for the provision of conscious sedation in dentistry. 

To read the document click here

What is conscious sedation?

The definition of conscious sedation is well known and can be summarised below:

'A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.'

Sedation techniques in dentistry can include:
  • Nitrous oxide (relative analgesia i.e. RA)
  • Midazolam (IV/oral/intra-nasal)
  • Temazepam (oral)
  • Propofol
  • Ketamine
  • Opioid and midazolam
  • Sevoflurane

The IACSD guidelines have no changed the definition of sedation or the assessment process. They do suggest obtaining valid consent on a separate occasion to the day of the sedation e.g. at an assessment appointment, apart from in urgent situations. 

Does age matter and who is classed as a child?

Prior to these updated standards, there was confusion about who is classed as sedation and what types of sedation you can use in each age group. It now suggested in primary care:

Under 12 years = RA only
12- 16 years = RA/IVS/Oral/Intra-nasal
Over 16 years = adult


What are the possible complications of sedation?

Sedation in dentistry is very safe and if you look at the evidence, there are very few documented cases of serious complications in sedation. I have experienced some of the following myself, but some of the complications can be:
  • Respiratory depression (this is the most common)
  • Oversedation
  • Vomiting
  • Paradoxical response
  • Delayed recovery
  • Sedation failure
  • Undersedation


How can you train in sedation?

According to the new guidelines, if you are a beginner in sedation you need to enrol on an accredited course e.g. SAAD course, or have an accredited mentor. 

For a beginner, in order to perform sedation unsupervised you require:
20 recorded cases for IV 
10 recorded cases for RA

There are also grandfathering schemes suggested for those who already provide sedation. Any post-graduate courses at universities or training via Deaneries e.g. DCT automatically are accredited. 


As well as the IACSD Guidelines, SDCEP are also releasing updated standards in conscious sedation in dentistry. To read their current version, click here.

Many thanks to Dr David Craig for his informative talk as well the Metropolitan Branch of the BDA for organising the evening (and for the fantastic refreshments!).


Do you provide sedation in practice? What do you think of the IACSD Guidelines? Let me know in the comments below!



Wednesday, 8 March 2017

What's causing my Dental Pain? Top 5 hidden Toothaches

Following my previous post on top tips to manage dental emergencies, I thought I'd share with you some of the less common reasons why a patient may be complaining of tooth ache.



1. Temporomandibular Disorder

When I worked in oral surgery, I remember seeing a lot of referrals from GDPs for extractions of wisdom teeth which actually turned out to be TMD

When a patient complains on pain on opening or tightness and pain that radiates up their head or lingers in the pre-auricular region that is worse in the morning you should think TMD (myofacial in origin). When you diagnose this issue, sometimes you get a mixed reaction from patients: some are relieved it is not a tooth issue; others can be disbelieving and still try to focus on a tooth problem rather than accept your diagnosis. In some ways I can sympathise. If there was a tooth problem this can often be solved simply (root canal treatment or extraction for example), but often the management of TMD doesn't offer an immediate cure of pain; rather a gradual improvement over months. 

For those with acute TMD issues I usually advise:
  • Soft diet
  • Jaw exercises and massages
  • Use of topical ibuprofen gel +/- use of systemic NSAIDs
  • Hot or cold packs
  • Resting jaw i.e. cessating any habits like nail biting or pen biting, supporting the jaw when yawning, not opening wide to bite into foods like burgers
  • Use of a bite raising appliance 
To read more about TMD, see my previous post here


2. Sinusitis

Patients who suffer from sinusitis can often have referred pain to their top teeth (particularly their molars). Similar to what I mentioned above, patients can either feel relief or disbelief with this diagnosis. 

In these cases, patients can complain of generalised pain with their top teeth which can feel worse on biting (often their 6s and 7s are TTP), and the pain will feel worse on tilting their head forward. You may also detect a blockage of their nostrils or the patient reports a recent history of cold or flu. On a PA or DPT you may also detect a thickened sinus lining on the affected side. 

For these patients SDCEP Guidelines suggest:
  • Prescription of ephedrine 0.5% spray TDS 7/7
  • Use of steam inhalation 
  • Appropriate analgesia
  • In some cases antibiotics are indicated: either amoxicillin 500mg TDS 7/7 or 100mg doxycycline OD 7/7 (with initial loading dose)
  • In recurrent or persistent cases, refer onto ENT


3. Pericoronitis

You may not think this one is a hidden toothache... it's obvious isn't it? An inflamed operculum around a lower 8 with food packing, facial swelling and suppuration?

But it's not always that obvious. Pericoronitits can affect any tooth (not just wisdom teeth) and can often affect upper 8s too! And sometimes you don't get the clinical symptoms described above. One thing I saw lots last year in oral surgery was an apparently unerupted wisdom tooth giving issues. On closer examination, there is often a pocket distal to the 7 and you can probe the unerupted tooth underneath. The tissues can become pericoronitic in these cases and give pain. 


4. Food packing

Ever got something stuck between your teeth? It's sore isn't it. But if you get lots of food debris (once or twice I've seen lots of floss fibres too) stuck interproximally, it can be very painful! 

In cases like this, there may be a particularly large interproximal space or something causing plaque retention e.g. a fractured filling or carious cavity. Patients complain of pain usually in the gum that is achy and sometimes a bad taste in their mouths. 

Management of this is rather simply: acutely irrigating to remove the food/plaque (either with ultrasonic or chlorhexidine mouthwash) and removing any plaque retentive factors e.g. placing a temporary filling. As well as what you do in your clinic is to advise the patient regarding their oral hygiene e.g. the use of tepes/floss in order to avoid the problem reoccurring. 

5. Cracked teeth

Cracked teeth are so difficult to diagnose sometimes. A lot of the diagnosis of a cracked tooth is listening to a patient's history which can sound a lot like irreversible pulpitis but one of the most important things to listen out for is PAIN ON RELEASE!

Top Tips to help identify a cracked tooth:

  • Use magnification if possible to help identify any cracks
  • Look out for signs elsewhere in the mouth that may give you a clue about whether a patient is bruxing e.g. wear facets, fractured restorations, soft tissue keratosis, tongue scalloping
  • Ask the patient if they have any habits e.g. pen biting 
  • Use a tooth sleuth to identify which cusp may the one affected. If this is not available, use a tongue depressor or a dry cotton wool roll
  • The use of orthodontic bands can help confirm a diagnosis
  • When in doubt refer on... do not feel tempted to drill into a tooth without being sure about the diagnosis!



Ultimately, common problems happen commonly. Always look for the obvious when a patient is complaining of tooth ache, but keep an eye out for some of the above; you'd be surprised!

Do you seen any of these in practice? Leave your comments in the section below!

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