Sunday, 30 April 2017

Extractions in children: Top 8 Tips

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

A monster E I took out recently

1. Be honest

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

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

2. Consider the use of articaine

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

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

3. Topical is a must

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

4. Explain in a way they understand

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

5. Involve the parent

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

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

6. Delivering LA 

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

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

7. Don't go digging

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

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

8. Keep going

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

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

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

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

Saturday, 15 April 2017

10 Steps to start your own Dental Blog

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

1. Find something you care about

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

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

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

2. Read other blogs

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

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

3. Choose your blog's name

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

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

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

4. Choose your platform

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

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

5. Start small

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

6. Build your Social Media

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

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

7. Use Widgets

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

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

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

8. Be patient

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

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

9. Decide your domain

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

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

10. Find the time!

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

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

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

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

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

Tuesday, 11 April 2017

BASCD Spring Meeting: Posters and Networking

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

Presenting my poster at the Meeting

Who are BASCD?

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

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

What did the day look like?

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

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

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

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

Another Poster!

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

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

To read a copy of my poster click here

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

The Radcliffe Camera in Oxford

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

Saturday, 1 April 2017

Hall Crowns: Top 10 Tips

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

1. Avoid small Ds

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

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

2. Seps are uncomfortable

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

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

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

3. Prepping isn't bad

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

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

4. Don't worry about occlusion

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

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

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

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

6. You need to press HARD

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

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

7. Consider for 6s if poor prognosis

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

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

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

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

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

9. Consider preventative SSCs

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

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

10. They are tight!

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

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

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

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

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