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.

Sunday, 7 May 2017

BSDH Spring Conference 2017: Making a Good Impression

This week was the Spring Conference for British Society for Disability and Oral Health (BDSH) and so a trip up to sunny Liverpool was on the cards. After missing my train I did manage to get there on time (phew)! It was great to catch up with some familiar faces as well as hear some fab talks about special care dentistry. 

Arriving into Liverpool for the conference

One of the afternoons we had break out sessions which included a hands on impression taking session. This session I found really useful and was something a little bit different. I thought I would summarise what I learnt as this applies to GDPs as well as those who are in Special Care. 

 Making a Good Impression with Phil Smith

The golden triangle of complete denture success is made up of:
  1. Retention
  2. Support
  3. Stability
Making a good working impression starts with a good primary imp i.e. one that captures all functional anatomy including:
  • Residual ridge, tuberosities, hamular notches
  • Functional sulci and frenae
  • Junction of hard and soft palate
  • Retromolar pads
  • External oblique ridge
  • Lingual sulcus and frenum
  • Mylohyoid ridge, retromylohyoid area
For primary impressions choose rigid disposable stock trays and a viscous mix of alginate if there is a reasonably firm ridge. For more resorbed ridges, use soft putty; for 'flabby' ridges use a thinner mix of alginate and for gagging patients use compound. 

For secondary impressions, tips I learnt that were particularly useful include the use of bite registration paste e.g. JetBite, HydroBite, Blu Mousse, Memosil to border mould instead of putty or green/pink stick. It is much less messy as well as being quick setting. Place the paste as in the photos below. 

My hands on practice impressions (very strange to do on a phantom head!) The white material is the bite registration paste where you would place then border mould

For the special trays ask for tissue stops which should shine through if you fully seat and also finger rests for the lower arch. For good ridges use alginate (if you want to check retention after border moulding do not ask for a perforated tray, as this will not allow). For resorbed ridges use PVS heavy or medium +/- a light PVS wash

What happens if I get an airblow?

To avoid this in the first place consider prepacking or syringing whichever mix you are using into areas of undercuts or in the palate (especially if they have a high arched palate). But if you do get an airblow then...
  • Alginate - you cannot add to, retake the impression. If small blows you can add wax to the deficiencies
  • Silcone - add more silicone (usually light body) to the areas and reseat. If the hole is large, you can create 2 holes in the impression tray in that area and injection mould when the tray is seated in the patient's mouth
Remember that a highly detailed surface impression is good in the upper arch to help increase retention, but in the lower arch it will create blobs of acrylic that will rub the patient when it is in function. 

Many thanks to Phil Smith for delivering such as useful session and BDSH for organising this year's Spring Conference, I will look forward to the next one!

Did you go to BSDH this year? Or have any other tips on making impressions in the edentulous patient? Leave them in the comments section.

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