Friday, 30 August 2019

8 Top Tips when Managing Ventilated Patients in Dentistry

Across several sites that I work I see patients with varying respiratory issues, included those who are ventilated. But how do I manage these patients...



What is Assisted Ventilation?


Sometimes known as mechanical ventilation it is when mechanical means are used to assist to replace spontaneous breathing. This can involve a machine (a ventilator) and can be invasive (through a tracheotomy) or non-invasive (through face or nasal masks). 

Ventilation can be positive pressure, where air is pushed into the lungs, or negative pressure where air is sucked into the lungs by stimulating movement of the chest. 


What Oral Health Problems do these Patients have?


  • Dry mouth - as a result of either multiple medications or being ventilated
  • Excessive oral secretions or mucous/dried secretions in the mouth - many patients are taking medication to dry up their airway secretions in order to maintain their tracheotomy. This can also affect oral secretions which can become dry and stick of mucosa
  • Tooth grinding/clenching - especially if these patients have an associated brain injury
  • Care resistant behaviour - if they have a brain injury or reduced cognitive ability
  • Dental neglect - if patients cannot provide their own oral care they may rely on a third party to maintain their oral hygiene, which may be compromised
  • Calculus build up - especially if patients are PEG fed and not having any oral intake
  • Poor oral clearance due an impaired swallow



Top Tips in Managing these Patients


Managing these patients is often most suitable by Special Care Dentists or by the Community Dental Service as they may have other co-morbidities e.g. be wheelchair bound, have a reduced capacity to consent. But if you do see these patients, here are my top tips:

  1. When providing dental treatment for these patients, give them plenty of breaks as they may feel like they become breathless or have an impaired swallow
  2. If they have a tracheotomy, ensure that an appropriately trained health professional such as a nurse supervises the trache and brings the appropriate kit in case it becomes dislodged during treatment, requires suctioning or the patient attempts to pull it out
  3. Consider patient positioning. Many patients will be most comfortable sitting up and become breathless if laid flat
  4. Recommend appropriate oral health products and advise for those providing oral care. Poor oral health in these patients can increase the risk of aspiration pneumonia which has a high mortality rate. Oral health plans are therefore essential for ventilated patients and consideration should be taken whether an SLS free non-foaming toothpaste is most appropriate 
  5. When providing dental treatment, ensure excellent suctioning when using water to reduce the risk of aspirating 
  6. Communication can be challenging with these patients; whether it be because there is a cognitive issue from a brain injury, or simply because a patient cannot talk when they have the cuff up on their trache. Communication card aids may be useful, or liaison with the patients Speech and Language Team to work out how is best to communicate
  7. There may be a role for saliva replacement gels such as Biotene or Oralieve for patients who get very dry mouths. These gels are also useful when removing dried secretions - massage the gels into the secretions to break them up before removal, otherwise it can feel like pulling off a sticking plaster!
  8. If sedation is required for these patients, this should be provided in secondary care and the appropriate attachment should be available if oxygen is required to attach to the trache. Careful consideration should be taken whether sedation is appropriate and there should be liasion with the patients medical team.

For more information, check out a presentation I did on this topic to the Special Care MSc students at KCL click here



Have you treated patients who are ventilated? How was it? Did you have to make an adjustments to how you treated them? Let me know in the comments below!


Tuesday, 27 August 2019

What I Learnt From The Future Finance Scholarship Campaign

I spent 2 weeks at the end of July canvassing for votes for a £20,000 scholarship with a private student loans company called Future Finance. Unfortunately, I did not win the funding but I learnt so much during the process...



Why Did I Apply?


As a part of my speciality training in Special Care Dentistry, I have the opportunity to undertake a Masters in Special Care to fulfil the academic element of the curriculum. 

London and South trainees complete this MSc usually during the first 2 years of their StR training spending 2-3 days a week at Guy's hospital. Since I have been doing my first year of training part-time, this September I would be starting this MSc - however, the cost of the degree is funded by the trainee, which is a huge sum of money amounting to almost £30,000. Since I really want to this I had to think creatively about how I could raise the funds... and that's how I stumbled upon Future Finance. 


What is Future Finance?


Future finance are a company who specialise in private student loans. They were founded in 2014 based in Dublin and lend to both undergraduate and post graduate students. 

I initially considered whether I should take a loan from the company who offer very low repayments during time of study (as little as £5 a month) which then increases once you finish studying. The interest is higher than the Student Loans Company, but you can borrow up to £40,000, pause repayments and not be penalised if you pay off the loan early.

However, I then discovered that they were offering a Scholarship of up to £20,000 for someone to become an ambassador for the company... so I applied!!



What did I learn?


I was really fortunate to be shortlisted from almost 750 applicants to the final 15! Looking back on this I realise this is a huge achievement in itself and it was amazing that the Future Finance team bought into my values, goals and aims by wanting to complete this MSc where I can hopefully make a difference to those who are most vulnerable and cannot access basic healthcare. 

The response I received during the 2 week campaign was incredible. People I didn't even know or who I hadn't spoken to since school or university sending me well wishes and sharing the voting link with their networks was awesome and I am so grateful for everyone's support. 

I also realised how stressful campaigning and PR work is - constantly trying to promote myself and the work I have been doing was exhausting. You may follow me on social media like Instagram or Twitter and know I do regularly post on those channels, but for those 2 weeks, I did feel like a broken record constantly sharing my campaign. To be honest, after the 2 weeks I was a bit relieved that I could take a break and recover! 

So although I received 2200 votes over the 2 weeks, I didn't win. Congratulations to the winner of the Scholarship and the other finalists too. This result has not changed my determination in trying to find a way to make doing an MSc work. I'm working through options, Plan B, Plan C.... until I hit Plan Z. Being able to complete this degree and gain the valuable academic and research skills to make meaningful and sustainable change in the way we design and deliver healthcare services to socially excluded groups is my passion. I will achieve this. I know this because since this campaign everyone's support and words of encouragement has spurred me to keep going. 

Life is full of difficult times and hurdles but each knock down makes us stronger and more resilient. 


Thank you to the following for all your support in my campaign:

  • The British Dental Association
  • The British Society for Disability and Oral Health
  • NHS England's Clinical Entrepreneur Programme
  • Faculty of Medical Leadership and Management and all their fellows
  • Health Education England
  • Surrey & Sussex Healthcare Trust and their Postgraduate Education Team
  • NHS England Kent, Surrey & Sussex region
  • Guy's and St Thomas's Sedation and Special Care department
  • Newcastle Dental School
  • Kent Community Health Foundation Trust & their director of dental services Mark Johnstone
  • Community Dental Services CIC & their clinical director Michael Cranfield
  • Ignition Law LLP
  • Dentists of Instagram
  • Everyone who voted, shared with their colleagues, family and friends thanks so much!



If anyone has any ideas of how I can access other funds please leave a comment below!


Friday, 16 August 2019

CQC Smiling Matters: Oral Health in Care Homes

At the beginning of July, I attended a round table discussion about the eagerly anticipated CQC report: Smiling Matters...

All the stakeholders at the round table discussion


You guys asked me for a summary of the findings of report so here you go! This report was something I had been waiting for as a clinician who regularly sees patients from care homes, whether they be older people or those with learning disabilities. 

The conclusions of the report highlighted the need to prioritise oral health in this vulnerable population of people and recommends the following:

  1. People who use these services, their families and carers need to be made more aware of the importance of oral care
  2. Care home services need to make awareness and implementation of the NICE guideline 'Oral health for adults in care homes
  3. Care home staff need better training in oral care
  4. The dental profession needs improved guidance on how to treat people in care homes
  5. Dental provision and commissioning needs to improve to meet the needs of the people in care homes
  6. NICE guideline NG48 needs to be used more in regulatory and commissioning assessments 

For some of you who regularly see patients who live in care homes (or who are cared at home) I am sure none of these conclusions are groundbreaking news for you. What is important is this report now gets this issue of the public platform with backing from an organisation with clout such as the CQC. But we need to take action and use this report at the grassroots making changes in our local areas!

To read my opinion piece on the report and the round-table discussion see my blog on the BDA




How can you use this report to make changes in the area you work? Any ideas out there to make meaningful change? Let me know in the comments below!


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