Saturday, 23 June 2018

Paediatric Dentistry for General Dental Practitioners: Top 10 Tips

As I have mentioned in a previous post about the the Community Dental Services (CDS) in London have changed in the past year and GDPs are expected to take on treatment of children according to the Paediatric Commissioning Guidance

My experience of talking to GDPs as well as the impact on the rejecting of referrals on patients is that some GDPs do not feel confident in managing children or do not see it financially viable to treat them in general practice. 

However, prior to working in CDS I didn't have much experience treating children and alongside working in CDS I also work in general practice. I have learnt with practise and patience, that actually treating children can be just as efficient and effective as treating adults! Here are my top tips in managing children:

1. Try!

I can't count the number of referrals I get in CDS where the dentist has not even tried any treatment with the child. In some cases, any attempt may not be possible e.g. children with autism or a severe phobia, but there are so many cases I have treated where initially, the child wouldn't even sit in my dental chair and eventually I have managed extractions and restorations with just local anaesthetic (LA). 

Sometimes children surprise you. It can be overwhelming seeing wall to wall caries in a child, but even attempting atraumatic restorative technique (ART) to place restorations can be successful in stabilising a patient to a certain extent. You do not know how a child will react to dental treatment unless you try!

2. Take Radiographs

I have written a post on tips to take radiographs in children so check it out.

Radiographs are essential in the diagnosis of caries in children as without them, you sometimes do not spot caries until it's cavitated and its much more progressed. Also in interproximal caries, in Ds especially, the pulp horns are so superficial that apical infection is present where you may just think from looking clinically a restoration is needed.

I would recommend bitewings are routinely taken from 6 years old if possible, or where there is suspected caries. Depending on if you have an OPG machine and how diagnostic they are for caries you could consider taking one if a patient doesn't tolerate bitewings. Tolerance of taking bitewings is usually a good indicator of whether they will tolerate dental treatment. 

3. Get them in early

The most recent public dental campaign is Dental Check By One from the BSPD. It's very important to get children into a dental setting early, hopefully before any problems develop so that preventative messages can be delivered and children are acclimatised to the dental setting.

I always try to encourage parents to book in their babies for dental check-ups when I see them coming in with older siblings or when I see any pregnant women. Emphasise that check-ups are free for children and that even if the dentist doesn't get a proper look in their baby's mouth, that it's important to get them used to coming to see the dentist. 

4. Use their Siblings or Parents

If a child is particularly anxious or not cooperating, I try to demonstrate or do tell show do on their parent or sibling. 

Often in practice I will have a family booked in with more than one child. If one is scared, I will see another child first to build up their confidence. Demonstrating taking radiographs on their parent or sibling can be useful. If a child also doesn't like me applying fluoride varnish, I will ask the parent to practice painting on the varnish with a dry brush. 

5. Prevention, Prevention, Prevention

I cannot emphasise the importance of prevention. Even if you do not do any treatment on the child, please make sure you dedicate time to discuss with them and their parents the cause of decay and how to prevent it. 

Use the Department of Health Toolkit for Delivering Better Oral Health to focus on tooth brushing advice and diet advice. Also discuss with parents the importance of regular fluoride varnish applications tailored to a specific caries risk assessment. 

6. Hall Crowns

See my previous post with specific tips for using stainless steel crowns in the management of caries in children.

Honestly, Hall crowns will change your practice with children. Children prefer them, often parents do once you explain the evidence behind them. I understand there is an initial cost implication of buying the kit, but in the long term just think of all those GICs or composites that need to replaced after they fall out and the repeated visits. Once you get good at Hall crowns, they are also much quicker to place than a conventional restoration.

7. Child-friendly Language

Although we know to avoid jargon in adults, it's also very important to adapt your language for children. Never talk about injections or needles, but adapt appropriately depending on the age the of child. Some of my favourites are:

LA = Sleepy Juice
Topical = Magic Cream
High Speed = Water Cleaner
Slow Speed = Buzzy Bee
Suction = Hoover
Etch = Shampoo
Excavator = Tiny Spoon

8. Fissure Sealants

I don't understand why more GDPs don't do fissure sealants. They have been shown to be clinically effective and are a simple procedure that can be very useful in acclimatising a child to treatment in a dental chair. 

If you are sealing in caries or performing a PRR, it is also a very simple band 2 treatment. Please make sure you have radiographs beforehand to check for caries. Also remember you can also consider placing them on primary teeth as well as adult teeth. 

9. Know when to Refer

No matter how much you try, sometimes treating some individuals is not possible with just LA. This is when you should think about referring patients onto your local CDS or hospital where behaviour modification techniques, inhalation sedation or GA could be considered. 

Make sure you know your local services and create close links with them as many services how employ shared care. In London all children have to be referred to the CDS who are the gatekeepers to hospital services. 

Think about how much treatment is required and the child's age when deciding whether to treat in practice or refer on. If I see a 4 year old who needs 4 teeth out, even with inhalation sedation it's highly likely I will lose compliance throughout the treatment plan and therefore a GA referral is most appropriate. This of course, depends on the patient and also their parent's opinions and preferences. 

10. Practise

My last tip is to really encourage you, even if you have barely seen any children, to not shy away from seeing them. The more you treat them and treatment plan them, the more confident you will become! 

If you want more support, pair up with a mentor perhaps one of the dentists in your practice, or a local contact in your local CDS to help support you with tips and assist in treatment planning cases. 

Ultimately, remember if you can treat children effectively in practice, then you could stop a child from having to experience a GA for their dental treatment! 

What tips work for you when treating children? Let me know in the comments below. 

Sunday, 17 June 2018

Teeth at the Wellcome Collection

This weekend my inner geek was satisfied when I got to explore the new Teeth exhibition at the Wellcome Collection in London. 

A longer version of this article can be found in the Summer edition of DentalTown UK Magazine

The exhibition, which has been open since 17th May, was inspiring by Richard Barnett's The Smile Stealers (a copy of which I grabbed from the gift shop afterwards and I'll be sure to blog about once I've finished!). 

There were over 150 objects on display from letters to the Toothfairy to historic dental chairs. I was surprised how busy the exhibition to be honest... Teeth are pretty niche! 

Dental chair of the mid 20th century
Below: Phantom heads used to be a little bit creepier and Public Health messages still sound pretty familiar today! 

As well as objects, there were interactive displays which showed public health videos promoting oral health from America and the UK post war. The exhibition displayed the history of dentistry, the development of dentistry through the NHS as well as current practices and issues with oral health such as the child GA crisis for tooth extractions. 

One of my favourite parts was the display of letters to the tooth fairy from real patients! I would definitely recommend the exhibition and the Wellcome collection in general which I have previously visited several times. Their gift shop is definitely one of the best museum gift shops in London!

The exhibition runs until the 16th of September so make sure you don't miss out! To find out more visit the Wellcome Collection

Have you visited Teeth? Which was your favourite object? Let me know in the comments below. 

Friday, 8 June 2018

The State of the Nation: BDA AR Conference

Back in May, I attended the national BDA Accredited Rep Conference. This blog post is based on a talk by Martin Jones at the conference. 

So what is the state of our nation and NHS....?

70 years anniversary of the NHS!

Our national pride and envy of the world.... our National Health Service was 70 years old this year! Something to celebrate? So if it's been going on this long, there must be something going right?

The NHS is one of the largest employers in the world since it's inception in 1948. But how will the NHS survive the following challenges?

Hypothecated Tax

Hypothecated tax is a tax collected solely to fund the NHS. This would be an additional tax for the public to pay and in general, there has been widespread support for it not only within the public, but also across political parties.

The only resistance is the treasury who would be responsible for collecting the tax. Is this something that will be enforced in the future?

Brexit and Employment Challenges

We are facing a recruitment crisis within the NHS which is down to many reasons:
  • Fewer nurses in training due to removal of bursaries
  • There are more leavers than joiners within the NHS
  • Brexit may have an impact with again more EU leavers than joiners
  • We have an aging workforce, with senior staff approaching retirement age without a younger generation to replace them
  • Nurses are being pulled off research, special projects and admin work to plug clinical gaps

Accountable Care Organisations

These organisations (previously STPs) are local organisations who ally together to collaborate in delivering health and social care rather than compete. These can include hospitals, community organisations, GPs or third sector organisations. They lead in commissioning and work with local authorities in improving health and social care. These can potentially sit across a large geographical area.  


Increasingly in the NHS private companies are delivering services across many sections. This includes for profit organisations (e.g. Virgin) and also Social Enterprises (see a previous blog post to find out more about Social Enterprises). 

Private companies have increased from 7.3% to 7.7% of the health and social care budget this year. The increase has mostly been in community and mental health services, which includes the community dental services. Many CDS services are run by social enterprises or private companies (CDS CIC, Virgin etc.) Is this a good thing? I'm not sure, but it is certainly a change which we need to adapt to. 

AFC Pay Rise

The Agenda for Change (AFC) unions have recently agreed to the offer of pay increase the department for health have suggested. The BDA and BMA are also negotiating for a pay increase so us dentists will have to watch this space!

What challenges do you think the NHS is facing in modern times? What do you encounter working in the NHS? Let me know in the comments below. 

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