Saturday, 25 May 2019

BSDH Spring Meeting: Drugs and Homelessness in Dentistry

Back in April, I attended the British Society for Disability and Oral Health's spring meeting. I presented a poster WHICH I WON, but also learnt lots across the 2 days including lots about managing substance misuse... 

The 2 days of the conference were cram packed full of interesting talks, from learning about the city of Bradford, to the Special Olympics. I'm going to summarise a talk by Caroline Graham about drugs in dentistry since it really helped give me practical tips I could relate the work I have been doing with the homeless. 

Is Drug Misuse a Problem?

Depending on the area and the population you deal with, drug misuse can be a day to day occurrence with your patient group. Certainly in East London on the mobile dental van, it was something I came across all the time. 

1 in 11 adults have taken drugs last year, with 2.1% of the population using them frequently - most commonly, cannabis and cocaine. Often, the drug use has co-morbidities associated such as mental health problems, complicating medical problems (such as blood borne viruses), as well as complex social situations such as homelessness or domestic violence. 

How is Drug Addiction Treated?

There are some amazing drug and alcohol services out there. The services I come into contact with in Tower Hamlets is Reset and in Newham CGL: both provide amazing support for those engaged in their services and include outreach onto the streets. 

A client is often assigned with a specific keyworker who can support them. Treatment can be:
  • Substance replacement prescriptions e.g. Methadone
  • Harm reduction treatment
  • Detox
  • Family support


Many of you may have seen the effects of this replacement for heroin: Meth mouth. 

Methadone is gradually titrated as heroin use is reduced; eventually with the idea to wean completely off the methadone but people can be taking it for years. The overall success rate for methadone programmes is 26%. 

The problem with methadone which means it can cause significant caries is twofold; it causes xerostomia which increases the risk of decay, and traditional constituents were sugary syrups. Nowadays, services are more aware of the effect of sugars so often prescribe sugar free solutions. 

Methadone is a less potent analgesic than heroin, so once clients switch over, chronic pains such as toothache which were masked by the heroin become an issue. Prescriptions are usually given daily as among users there is a trade of the drug, especially since a tolerance is built over time.

Oral Effects of Drug Use

The effects we can see of current or previous drug use include:
  • Xerostomia
  • Oral Cancer
  • TSL (erosion due to vomiting, bruxism often in stimulant use)
  • Mucosal erosion/perforation (common in cocaine use)
  • BBV (50% of IV users are Hepatitis C positive)
  • Vascular damage from chronic injecting (DVTs, abscesses, increased risk of infective endocarditis)
  • Caries - due to chaotic lifestyles, poor OH and diet
  • Periodontal disease due to poor OHI and smoking
  • Late presentation of problems. Patients have marked pain and infection, acute anxiety and stigma 

Top Tips in Management

I really related to these tips for managing not only patients with substance misuse, but all groups that can experience social exclusion e.g. homeless, travellers, sex workers. 

  • Treat patients in the contexts of their lives i.e. should you just treat their symptoms and leave that retained root not causing an issue, should you address the class V cavities on their incisors rather than providing RSD?
  • Improve health wherever you can, make every contact count and signpost to other services the patient needs
  • Work out how you can improve motivation e.g. making them a spoon denture to replace a front tooth to improve self esteem which could motivate them to improve self care
  • Patient's pain tolerance can be poor especially if they have just started treatment with methadone. Make sure you have adequate LA
  • Note of possible cardiac interactions with LA for those taking stimulants. Consider reducing dose
  • Sedation is rarely appropriate and can be unpredictable, so treatment should ideally be with LA
  • Access to services is important and may need some adjustments e.g. drop in clinics, mobile surgeries, appointment reminders

My Poster

During the conference, I presented some of the work I have been doing with the homeless population in East London including background work before launching our Mobile Dental Surgery!

The poster that was displayed at the conference presented the planning of how we decided where the van visit as well as planning and logistics around this. 

To see a copy of my poster, click here.

Overall, I had a wonderful time up in York at the conference bumping into familiar faces and making new acquaintances! See everyone at the Winter Conference in London!

Have you managed patients with substance misuse problems? What adjustments did you make if any? Let me know in the comments below!

Tuesday, 21 May 2019

Top Tips in Managing Patients with Chronic Kidney Disease

Recently, I have been seeing lots of patients with chronic kidney disease. How does this impact the dental care I plan for these patients...?

Causes of Kidney Disease

Kidney disease can be mild, moderate or severe with the main 2 causes being:

  1. Uncontrolled hypertension
  2. Uncontrolled diabetes leading to diabetic nephropathy
This can manifest as chronic renal failure, or renal osteodystrophy where increase plasma phosphate leads to secondary hyperparathyroidism. 

Systemic Signs of Kidney Disease

Cardiovascular: Hypertension, congestive cardiac failure, atheroma, cardiac arrhythmia

Gastro-Intestinal: Anorexia, vomiting, nausea, peptic ulcers

Neurological: Headaches, tremor, sensory disturbances

Dermatological: Itching, hypepigmentation

Haematological: Anaemia, increased bleeding 

Metabolic: Thirst, nocturia/polyuria, electrolyte disturbances, secondary hyperparathyroidism

Treatment of Kidney Disease

Management of mild/moderate kidney disease can be to control causative factors such as anti-hypertensive drugs or more effective diabetic control. Otherwise in severe cases, treatment can be:
  • Peritoneal haemodialysis  (inside the body using the periotonium)
  • Extra-corporal haemodialysis (outside of the body exchange)
  • Transplant

Oral and Dental Manifestations of Kidney Disease

When examining patients with kidney disease, you may come across the following signs:

  • Oedema around the face (peri-orbital is common) or ankles
  • Oral ulceration
  • Pale oral mucosa 
  • Opportunistic dental infections e.g. candidiasis, herpes zoster due to immunosuppression
  • Gingival hyperplasia (induced if patient is taking ciclosporin)
  • Swelling of the salivary glands - parotid is most common

Tops Tips

  • Patients should be treated under local anaesthetic if possible, as sedation or general anaesthetic drugs will have a impaired excretion. Liaison with a patient's physician and anaesthetic team is recommended
  • Avoid NSAIDs and some antimicrobials e.g. tetracycline, erythromycin
  • Consider prescribing reduced doses of other antimicrobials e.g. acyclovir, amoxicillin, and recommend paracetamol for post op pain
  • Patients are at an increased bleeding risk mostly down to platelet dysfunction rather than the effect of the heparin used during dialysis (which has a very short half life). Investigatory bloods may be indicated and use of local haemostatic measures
  • Treat patients the day after dialysis to allow the effect of heparin to be eliminated and when patient is feeling most well
  • Patients undergoing haemodialysis may have an arterio-venous fistula access in an arm - DO NOT use this arm for venous access
  • If patient has had a kidney transplant, they may be immunosuppressed. If they are taking steroids, steroid cover for surgery may be indicated. Ciclosporin as mentioned above also can cause gingival overgrowth. Antibiotic cover may be necessary and consideration of bleeding risk if they are also anticoagulated. 

Overall, mild or moderate kidney disease should be suitable to be seen in primary care. For patients undergoing dialysis or who have had a kidney transplant it may be more practical for them to be seen in secondary care especially if co-coordinating care with their renal team. To read more about the management of these patients, see this BDJ article

Have you managed patients with chronic kidney disease? What adjustments did you make if any? Let me know in the comments below!

Sunday, 12 May 2019

5 Top Tips for Speciality Training Interviews

It's been over a year since my Speciality Training Interviews but with everyone's coming up in the next couple of weeks here are my top 5 tips...

1. Read the Personal Specification

As you will know, most of the information you need for StR and DCT posts is on the COPDEND website; but most importantly you must read the personal specification for your chosen speciality.

This will really help guide you to how many boxes you tick and how to answer questions in the interviews. If you're looking to apply to training in the future this is a good guide to identify areas to strengthen your application.

2. Prepare your Portfolio

For most interviews you will need a portfolio. Some will give you a template to work to, some there is very little guidance - you may have a dedicated station for this or just asked to bring it along to view at some point in the interview. 

If you don't have a template to work to check out my previous post which gives you a guide. Working on your portfolio is time consuming but really important so give yourself plenty of time. You may not think you have a lot to include but think laterally e.g. lunch & learn presentations, if you've written any patient information leaflets. Make sure you are succinct and organise the portfolio clearly. 

3. Know your Stations

Most of speciality training is via national recruitment where at the interviews are broken up into stations very similar to DCT interviews. Depending on your speciality these may include:

  • Clinical station - testing your clinical knowledge of the speciality
  • Academic station - testing your knowledge of research, academia and evidence based dentistry 
  • Practical station - depending on your speciality depends on whether you have this station and what practical skills are tested
  • Communication station - with a actor to test your communication skills
  • Portfolio station - testing your commitment to the speciality and achievements to date
  • Situational Judgement Test - not in every speciality yet but may be further in the future
Check on Oriel what stations you have, their length and structure or ask previous candidates for a guide. 

4. Practice, practice, practice

With all interviews I would recommend practising scenarios and interview techniques with peers and mentors to build up your confidence beforehand. By now you have done quite a few different interviews and had practice of these but from your reading of the personal specification and information on oriel you will know how this interview is structured so you can practice accordingly.

5. Be prepared

Set aside enough time to prepare for this interview it's a toughy! Don't worry if you don't get a post first time round, plenty of good candidates have to apply several times before they get a post. Depending on your speciality the material you chose to read before the interview will vary but generally I would recommend:
  • Read this Medical Interviews Book... it has excellent guidance on all types of medical interview. It is medical focused but you can apply most of it to the dental interviews. 
  • Read guidance that applies to your speciality e.g. NICE, SDCEP, BSDH, FGDP etc. 
  • Read recent published articles applicable to your speciality and pick a couple you really like and critically appraise them 
  • Read of any recent changes in your speciality and be aware of brief outline of the StR curriculum that applies to you
  • Be aware of national issues in dentistry e.g. Never Events, recruitment, WHO checklists

And finally good luck! Don't get too stressed and support each other. National recruitment is stressful but there is always another year to apply!

Do you have any tips for StR interviews? Let me know in the comments below!

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