TOOTH GERM: Dental Public Health

Teeth at the Wellcome Collection

21:47

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The Salaried Dental Services: What do they do?

I've been working in the Salaried Dental Services for almost 2 years and I've had a pretty wide range of experiences. I often get asked what it's like working in the SDS (otherwise known as the CDS in England and Wales, PDS in Scotland) and there are lots of different options. Here I will outline what possibilities there are...

Special Care Dentistry

I've previous blogged about what sort of patients this involves (here).

Special Care Dentistry as defined by NHS England, is

'concerned with the improvement of the oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of these factors.'

This can range from an elderly patient on multiple medications to a non-verbal autistic teenager. When treating these patients you provide whatever dental treatment they require - often the treatment itself is not complicated but managing the patient is. This can include behaviour management, clinical holding ,the use of the hoist, a wheelchair tip or bariatric dental chairs for obese patients.

Paediatrics

I often see children who have complex medical problems or special needs e.g. autism, epilespy but also children who cannot cope with treatment with their high street dentist or have complex social issues.

Often they have rampant dental disease as I work in very high needs areas of London. We provide treatment such as extractions, stainless steel crowns and conventional restorations as well as preventative advice. We also have the means to provide more specialist care e.g. pulpectomies (if the case is appropriate). Seeing children doesn't suit everyone, but it's an excellent opportunity to develop communication and management skills in order to allow treatment. It can also be great fun!

Sedation/GA

With both subsets of patients mentioned above, there may be a need for some form of conscious sedation or in some services, general anaesthetic.

Not all SDS provide sedation or GA - indeed mine refers all the GA to another service. Sedation can be inhalation (especially in children), IV, intra-nasal, oral or a combination. Some services are also accredited with IACSD to train those in their service in the provision of sedation.

Access

In some areas of the country, salaried Access clinics still exist. These are meant to serve those who find registering with GDPs difficult - this could be due to remote location or an area of high needs.

The patients often do not have any special care need, but may have a high level of dental disease that needs addressing. These services are less likely to be in highly populated places e.g. London, where there are a higher number of GDPs.

Outreach/Epidemiology

Outreach involves going out of clinic to access patients - this can be screening in settings such as care homes, oral health promotion, use of mobile dental units (which can be for the homeless, parked in schools or areas of high need) or to local schools.

The SDS also collects epidemiological data for BASCD e.g. in the Child Dental Surveys. You are trained specifically for this and calibrated against a national standard before screening. This can run in tandem with other oral health promotion schemes e.g. school fluoride applications.

Some SDS will have specific oral health promotion teams that will include Extended Duty Dental Nurses (EDDNs) and hygiene therapists alongside dentists. I am the outreach dentist for my service where I head out to homeless day centres for screening, oral health promotion and treatment on our mobile dental vans. I also provide domiciliary services (See below).

Domiciliary Care

Domiciliary care (doms) involves treating patients in their homes, care homes, hospitals or day centres and provides care to those who cannot or find accessing a fixed site clinic difficult. Often, this is associated with treatment of the elderly, but not always e.g. agoraphobics, mental health problems, in-patients in hospitals.

Doms can vary depending on the service or area you work in. Different services may have pool cars you drive (like my service), or drivers to take you out to patients. Others may expect you to use your own car or even see patients on foot. Providing care in these environments can be challenging and there are often issues to think of that are not obvious until you are in that situation e.g. risk assessing a home where the owner has 3 Alsatians, ensuring your car is insured to carry oxygen, manual handling risks when your patient lives on the 4th floor and the lift is out of order!

There are specific doms guidance on the BSDH website.

Prisons/Immigration Centres/Secure Units

Some services are either exclusively, or have an element of either working in a prison, immigration centre or forensic secure unit.

There are specific challenges with working in these environments, one of which is staff safety. You will require specific conflict resolution training to work in these environments. It can be very rewarding providing care for these patients who are often forgotten and may have found accessing dentistry difficult even more their institutionalisation.

Our service provides care for a secure mental health unit both inside the unit and also bringing patients to our fixed site clinic. Historically we have provided care both on side in a specific dental clinic and also on our mobile dental unit. Often these individuals have high levels of disease that require addressing.

Emergency Dental Services

Historically, the Emergency Dental Services (EDS) including out of hours care for the NHS was provided by the Salaried Dental Services. Indeed, many areas of the country still operate in this way; however, there are areas that have moved away from this model and GDPs have won the tenders to operate the Out of Hours EDS (I work for such as service in London).

Different EDS work in different ways - in some areas dentists are also involved in the triaging of patients, not only the treatment. To read about my experiences in the EDS, read my previous post here.

Other Specialist Dental Services

In some areas, SDS provide the specialist contracts for primary care services e.g. MOS, endodontics, periodontics (as well as sedation as I have mentioned above).

These are performed by specialists or practitioners with a special interest in that area of dentistry where patients can be referred to not only internally, but also from GDPs.

As you can see, there are lots of options when deciding if you want to work in the SDS and the opportunities vary depending on the area of the country, or indeed, which country it is you work in. Look out for a future post explaining some of the advantages of working as as employed dentist rather than an associate.

Do you work in the SDS, CDS or PDS? In which area do you work in? Would you recommend? Let me know in the comments below.

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10:00

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CDS

How are the Community Dental Services changing?

I have mentioned in my previous post about special care dentistry that recently there have been some changes in how the Community Dental Services (CDS) are functioning; certainly in London. Here I shall outline how the services I have worked in have changed...

Why?

Last year, the tenders for the community dental services in London ran out and so different trusts and other organisations such as social enterprises were able to bid for each service area. The trust who held the contract for one of the services I work in lost the bid for the provision of the CDS in East London. What this means is that the NHS commissioners decided that another trust will be given the contract to provide the service; in this case at a lower contract value.

The reason is the push for more and more services to be provided in general practice which is more cost effective for the NHS for example the provision of out of hours emergency dental services which used to be part of some CDS. Together with this is encouraging GDPs to treat certain groups of patients in practice rather than refer to CDS as our management of these patients wouldn't be any different to how they would be managed in practice.

New Referral Criteria

So naturally with a cut in funding means CDS will be seeing fewer patients; therefore referral criteria have changed and become much stricter. If you see the post I linked earlier on in the post, you can see the types of patients we used to see. We only accept referrals that are deemed Level 2 or above by NHS England for both special care and paediatric dentistry. What this means is:

We now only accept paediatric referrals where there has been a failed attempt at treatment with their GDP or children with complex medical or social problems or learning disabilities. We expect GDPs to acclimatise children in practice
We no longer accept referrals for patients with blood born viruses e.g. HIV unless they fit into one of the other criteria
We only accept those with complex medical problems if this directly impacts a patient's treatment in a way a GDP could not manage e.g. if a patient is on warfarin, a GDP can liaise the patient's warfarin clinic if required
We do not keep many patients for recalls within the service; instead we complete courses of treatments then discharge to their GDP i.e. promotion of shared care
A GDP cannot refer a child directly to a hospital, the CDS triages the patient and acts as a gateway for general anaesthesia - similarly for special care adults this applies
There is one universal referral form in London for paediatric dental services; similarly in special care adults
We are seeing fewer phobics and encouraging GDPs to refer for one off treatments e.g. extractions to practices with sedation contracts
Our domiciliary service is now only for patients who are truly housebound. Patients who can make it to clinics in taxis or transport are now being booked into clinics rather than receiving home visits

Closure of clinics and services

Naturally, with a changeover in overseeing trusts some of our sites had to be closed as the new trust does not own the buildings. This has been difficult for patients as they now need to travel much further to access our clinics and unfortunately has meant our previous close links with undergraduate training in East London are much weaker so sharing care is much more difficult.

Not only have services been affected in East London but London wide. I used to also work on bank at the urgent dental service based in community in North London. Since the re-tender i.e. April, the funding was removed for this walk in urgent care service. Ultimately, this results in putting pressure on the remaining services e.g. out of hours GDP services and acute dental departments in teaching hospitals.

There are exciting times ahead however; with our service winning the homeless dental provision which is planned to be based on our mobile dental units.

These changes although already in motion, undoubtedly will take time to filter down to referrers and others in the profession. I am still repeatedly sending back inappropriate referrals or discharging patients and it can be frustrating as some of these patients are still waiting months on our waiting lists unnecessarily.

Click to access information from commissioners about Levels of care in Special Care Dentistry and Paediatrics to ensure your next referral to the CDS is appropriate!

I'd love to hear how these changes have affected both GDPs or other CDS services throughout the country. Let me know in the comments below.

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18:49

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Community Dentistry

Public Health Matters: Mayor's Newham Town Show 2017

Last weekend was the annual Mayor's Newham Town Show in East London and time for the local Community Dental Service to get involved...

This post can also be found in the BDJ team magazine.

Just some of the fantastic team who helped out over the weekend!

The weekend saw over 50,000 people attending and involved live music over 2 stages, dancing, sports and a real sandy beach! There were lots of stands set-up and the at the public health area we had the company of Healthy Eating, Cancer Research, Smoking Cessation and more alongside our dental stand.

Over the weekend we had a total of 3, 478 contacts at our oral health stand; teaching children and parents about oral hygiene, dental-specific diet advice and going to the dentist. The team included our oral health promoters, therapists, dental nurses and dentists and everyone had lots of fun. It was incredible to see such genuine interest from the public and eager children filling in our quizzes and word-searches or brushing our set of giant teeth in order to win a toothbrush holder or tooth fairy wand!

As well as our oral health stand, we were able to provide oral health screening on our mobile dental unit. Over the 2 days we saw 485 adults and children for oral health screens; many of whom required signposting to dentists as they required treatment. With live music blasting in the background and copious amounts of free toothbrushes and toothpaste to give out, there was a lively and festival-like atmosphere inside the unit that helped to acclimatise some of the more nervous or younger children into learning how a visit to the dentist can be fun!

Me inside the dental unit providing some dental screens (consent for publishing photographs obtained)

I found it very surprising to see how many people either didn't have their own dentist or had no idea how the NHS dental services work. There were many people who had very healthy mouths, indeed I haven't seen so many cooperative children in a long time; however, there were a few shockers. For example I saw a 3 year old who had around 8 carious teeth and had not ever been to the dentist. It was important for the dental team to direct people onto where they could access care and of course explain how screening did not replace a full dental assessment with x rays. Lists of dentists in the local area were given out as well as information about dental charges and exemptions.

We were very lucky that the weekend's weather matched our moods and we had lovely sunshine for the 2 days and certainly I went home on the Sunday evening with a warm sense of fulfilment after such a philanthropic effort from all the team. I think getting the dental profession more involved in public events like this is essential at tackling our public health issues head on and can be really effective with passionate individuals and the appropriate support from NHS services and dental charities such as the Dental Wellness Trust, Oral Health Foundation etc.

Many thanks to all the team at Newham Community Dental Services and bring on next year's event! Check out the highlights video from the show:

Did you attend the Town Show? Or run similar events in your area? Let me know in the comments below.

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18:01

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Community Dentistry

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.

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20:21

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Antibiotics

Evidence Based Dentistry Conference

So if you have read my previous post about Evidence Based Dentistry, you will know that this year I have been working on an EBD project. The EBD conference held on Friday was where I was able to present my findings, but also raised the issue of where is the evidence base in dentistry?

All of us on the North East London DF1 Scheme, with our PAD Sana Movahedi

This year, our scheme was the pilot to run a new idea; that during our foundation year we should carry out a project based on evidence in dentistry.

I decided that my topic would be on: 'Class V Cavities; Composite or GIC?'

The morning of the conference was based on the background of EBD where we had Dominic Hurst and Jan Clarkson speaking.

Dominic raised the issue that the reasons why evidence is not used in practice are that:

Clinicians are out of date
Research available is suboptimal

This leads to a suboptimal patient outcome, therefore we need to generate better research and get clinicians using high quality evidence in practice.

But what makes up EBD?

The three components of Evidence Based Dentistry.

For more information about what EBD is, see my previous post here.

Jan Clarkson spoke about some of her ongoing research projects such as FiCTION, iQuad and Interval which should help to create some evidence behind our common practises in dentistry. She caused much upset when she revealed to us there is no evidence to suggest flossing is beneficial!

Results of Pan London Antimicrobial Audit

So it was down to me and another colleague in my group to present the findings of the antimicrobial audit that all London trainees have carried out this year.

You can scroll through our presentation below (for those who are squeamish, I'd skip the video at the end!), but our main findings were that antibiotics in particular were being over-prescribed without local measures taking place, but on our second round of audit there was a significant improvement in practice.

I also raised the issue of possible reviewing of the 2008 NICE guidelines against antibiotic prophylaxis to prevent infective endocarditis. There has been a significant increase in the number of cases of infective endocarditis since the guidelines were put in place both in low and high risk individuals. Although there has been no causal link at the moment, it does make you question whether this policy has caused harm and that the evidence that they used in order to justify setting these guidelines was flawed (it looked at the incidence of IE in children!).

IE has a 40% mortality rate, so this is a serious issue that needs to be addressed - was this just a guideline to help save the NHS money?

Poster Presentations

So our afternoon was spent presenting the findings of each of our posters to the rest of the London trainees (that meant presenting 26 times as they were split into smaller groups....exhausting!).

Well done to all the trainees presenting their posters and keeping up the enthusiasm despite the heat. There were a variety of topics presented; from fluoride to ferrule, from articaine to smoking cessation. Everyones' posters looked great and the hard work paid off - special congratulations to the winners of the prizes Hazel and Noor!

To see a copy of my poster click here, but if you're just looking for the answer to the question I asked, you should use:

Composite
A 2 step self etching system
Roughen the cavity prior to placement

To see a copy of my patient decision aid, please click here.

Me looking very happy in front of my poster!

Massive thanks to Sana and Dominic, without them this whole idea would not have existed!

Do you have any thoughts or questions about my poster or any of the others you saw on the day? Please leave your comments in the section below!

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18:21

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Cancer

A Guide to Oral Cancer

Last month I attended the Oral Cancer Conference in London. Here is a summary of what I learnt from the day.

Oral cancer screening is one of the four domains of oral health that dental professionals need to be aware of. I feel that there isn't a lot of public knowledge about this type of cancer in comparison to others such as breast or lung cancer, despite there being around 9000 new cases each year.

Worryingly, oral cancer is increasing in incidence in younger people and there is a widening gap between lower socio-economic groups compared to groups which are less deprived. This is probably down to social differences, namely the use of tobacco and alcohol. Other factors can also be implicated such as the Human Papilloma Virus (HPV), sunlight exposure and poor diet e.g. low in fruit, so low in antioxidants.

22% of adults smoke in the UK - still a large proportion but nothing compared to the 70% of men who smoked in the 1960s! Practising in East London has also made me aware of other forms of tobacco which are popular in some ethnic groups such as Paan or Khat.

Smoking together with alcohol multiplies the risk of the development of oral cancer. Do we all ask our patients if they drink and how much they drink?

What is a unit of alcohol?

This is the amount that is equivalent to 10ml of pure ethanol, which corresponds to roughly:

25ml shot of spirit (of 40% alcohol)

Half a 175ml of wine (12.5% alcohol)

Half a pint of lager (4% alcohol)

Department of Health Guidelines:

Men should not regularly drink more than 3-4 units a day

Women should not regularly drink more than 2-3 units a day

Pregnant women are recommended to avoid alcohol

Oral cancer screening is a GDC core competency, so if you suspect an oral cancer what do you do?

Urgent Referrals

Look up the guidelines and protocols for your local area hospital but it usually looks like this:

Fax or send the referral via a secure email account ASAP
If this is not possible, send a letter urgently but also give your local team a phone call
Use the word CANCER if you suspect as this will fast track the referral
Other things to include should be medical history, risk factors, signs and neck lumps

Delay in referral can affect the outcome for these patients and hospitals have to see these urgent referrals within 2 weeks.

If there is late detection in the cancer, the 5 year survival rate is 51%, but if it is detected early this increases to 80%

Potentially malignant conditions

Leukoplakia (this is a diagnosis of exclusion which can be granular, specular, nodular, verrucous, homogenous and non-homogenous)
Erythroplakia (uncommon but with a increased risk of malignancy)
Oral lichen planus
Submucous fibrosis
Chronic hyperplastic candidosis
Discoid lupus erythematosus (DLE)
Iron deficiency e.g. B12 or folate

Histological classifications

Intraepithelial neoplasia
Carcinoma in Situ (this means that the dysplasia has not reached the basement membrane)
Dysplasia (mild, moderate, severe)

Sites that are most commonly affected by malignant lesions are the tongue and the floor of mouth.

Management of dysplasias

Excision by laser or surgical
Prevention measures i.e. decrease smoking and alcohol intake. 50% of leukoplakias can disappear if the patient stops smoking
Increase antioxidant intake
Regular reviews

The management of oral cancer is multi-disciplinary, with treatment managed by ENT and Maxfax sugeons, oncologists, radiologists, dentists, speech and language therapists and dieticians.

The later the diagnosis of the oral cancer, the more likely that treatment will need to be more radical, have a poorer prognosis and ultimately, decrease the quality of life for that patient.

Not only will large resections change the life of that patient, adjunctive radio or chemotherapy also have severe side effects. Whilst plastics can now to wonders in terms of facial reconstruction, the functional implications of having a large portion of their mouth resected can be debilitating.

The take home message from the conference was on early diagnosis! You should be performing oral cancer checks for all your patients at EVERY appointment, and if there is anything suspicious send on urgently. These referral centres would rather see something innocent every now and then rather than run the risk of late presentations of poor prognosis.

Thanks to all the speakers from the day. Do you have any thoughts or experiences of seeing oral cancer in practice? Leave your comments in the section below!

Why not take a look at my other Clinical Guide posts?

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10:48

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Clinical

Our Patients are Changing....

How many of your patients are the 'elderly'? The increasing life expectancy of our patients together with the improvement of oral care means that people are keeping their teeth for longer.

Back in March I attended the Gerodontology conference in London - this blog post is based on this study day.

I have previously touched on the implications of this shift in our patient demographic on periodontal health in a previous post (see here), but the increasing age of our patients has other implications in other areas of their mouths than just their gums.

Failing restorations and Tooth Wear

Older patients present with a challenge to dentists - one of the main issues is their polypharmacy. Specifically, some medications can lead to a decrease in salivary flow (i.e. xerostomia) which can cause problems such as root caries, periodontal breakdown and tooth wear as a result of the prolonged retention of their teeth.

Therefore, the main risk factors for caries in older patients are:

Poor oral hygiene
Xerostomia
Diet

The elderly are more at risk from root caries due to their decreased salivary flow, dentures, lack of dexterity, a shift from complex to simple sugars and poor oral hygiene.

Treatment options for root caries:

Remineralise (fluoride, CPP-ACP)
Recontour
Restore intra-coronally
Restore extra-coronally

Should all missing teeth be restored?

No - if the patient can function i.e. eat and speak effectively, you can accept spaces e.g. Shortened Dental Arch. You can then avoid problems that are introduced with removable prostheses e.g. caries, poor adaptation in older patients, candida etc.

Treatment and classification of Tooth Wear (Tulloch and Watson)

Catagory 1 - appearance is satisfactory but treatment is required

Discuss the cause of the wear with the patient, prevention measures should be taken (diet, fluoride), place plastic restorations to restore function and prevent further wear, nocturnal appliances in bruxists should be supplied, full or partial coverage restorations if required and regular review.

Catagory 2 - appearance is unsatisfactory, treatment is required and there is space for the placement of restorations

As above

Catagory 3 - appearance is unsatisfactory, treatment is required and there is no space for the placement of restorations

These cases may require referral to specialist or secondary care if you are not confidence in reorganising their occlusion or opening their OVD.

Thanks to Professor David Hussey for his talk.

Prosthetics

Is there still a need for removable prosthetics in the UK?
94% of UK adults are dentate, but in the over 75 group, 34% of them are edentulous and fixed prostheses are not always appropriate e.g. lack of tooth tissue, alveolus, resources. Therefore, despite the decreasing demand for prosthetics, it it still important to be able to provide these treatments in practice.

Anatomical considerations that can cause issues when making complete dentures:

Atrophic mandibular ridge
Flabby ridges
Big ridges
Frenal attachments
Tuberosity
Genial tubercle
Mylohyoid ridge

So how can we overcome these challenges, specifically atrophic ridges.... Overdentures

If using teeth as overdenture abutments, there can be some challenges e.g. endodontic treatment, maintenance requirements, fracture of the acrylic, undercuts or intra-arch space.

Implants can also be used as abutments, but there may be medical or patient barriers to implant placement e.g. osteoporosis, bisphosphonates, ability to withstand surgery.

As mentioned above, the decreased saliva flow in older medicated patients can cause a lot of problems when constructing dentures. Whilst we can try to artifically substitute saliva when it is deficient, a lot of patients will prefer just sipping water frequently.

Thanks to Professor Janice Ellis for her talk - it was nice to see a familiar face!

Endodontics

There are a number of endodontic challenges in older patients:

Patient factors e.g. ability to recline, to tolerate lengthy procedure or rubber dam, access (mouth props may be useful)
Medical history
Finances/attitude of patient
Tooth factors e.g. strategic importance, periodontal status, restorability, endodontic considerations

Since post-operative pain following endodontics in necrotic teeth is around 80-90%, our usual advice of taking NSAIDs to manage this may not be appropriate in patients on certain medications or medical conditions.

Examples of strategic teeth that you would be more inclined to try to save by treating endodontically include:

Distal abutment to free end saddle
Overdenture abutments
Bridge abutments
Alveolar ridge maintenance
Local parameters
OVD maintenance

Together with the above issues, older patients will tend to have calcified canals and pulp chambers particularly if the tooth has been subject to trauma or repeated dental restorations.

Top Tips for Calcified Canals

Plan well by studying your radiograph
If you have any concerns regarding orientation, disassemble the tooth first
Good lighting and magnification are essential
Use a DG16 prove to check where you are
Irrigation copiously with EDTA/NaOCl
Use safe-ended burs to refine the pulp floor and gooseneck burs help
C-pilot files can be used to help negotiate calcified canals

Thanks to Bhavin Bhuva for his talk.

Domiciliary Care

Older people are more likely to have a limiting life long illness, some serious enough for the patient to be confined to their home or even to their bed. These patients will still require dental care and therefore the expansion of domiciliary services has to meet this growing need.

There are some specific issues that come up when practising out in the community in this way:

Appropriate training for staff
Mental capacity and consent for patients
Appropriate treatment within the domiciliary setting
Environmental risk assessment
Infection control - zoning, use of disposables
Equipment e.g. portable units, light sources, portable suction, oxygen
Safeguarding

Techniques such as the Atraumatic Restorative Technique (ART) and use of agents such as Carisolv can be really useful in a domiciliary setting.

Thanks to Debbie Lewis for her talk

How do you feel about the changing demographics of our patient base as well as their changing expectations? What challenges have you faced treating these patients? Please leave your comments in the section below.

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16:16

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Brownies

My Brownie Promise

Me teaching some of the Brownies about tooth anatomy

As many of you who follow my Facebook page may know, a few weeks ago I spoke at a Brownie's group in East London.

When I was at university I was part of an organisation called 'Brush Up' which similarly ran after school events from Brownies to Scouts to Rainbows. We spoke about oral health and ran lots of activities to get kids interested in what's in their mouths!

Having a friend who was a Brownie Leader, I was eager to get involved in this sort of activity again, especially since I don't get to see that many children in my practice.

What did I do?

I split the evening into 2 sections: one where we chatted in a circle about general oral health, and the other where I split the kids into 3 stations where they had an activity at each table.

It's always interesting to see how much children know about oral health and sometimes they do come out with some surprising stuff; I once had one 7 year old ask me what was ameleogenesis imperfecta!

These brownies knew quite a bit! When I asked them to brush their teeth with imaginary toothbrushes and stop when they were done, there were 3 kids still frantically brushing away after 2 and a half minutes! Whether they do this at home or not is another question, but they definitely deserved stickers after that!

I had also filled an orange juice and a fizzy drink bottle with the amount of sugar in each and played a 'good food, bad food' game to help them learn what kind of foods can be harmful for your teeth.

At the stations, the girls dressed up as dentists and counted each others' teeth (there was a girl with some stainless steel crowns that got a lot of attention), played with my dentist playdough set (best christmas present ever) and at the third station I taught the girls about tooth anatomy and what happens when you get tooth decay.

One of the girls dressing up as a dentist

I really had a lot of fun with the Brownies who seemed to have lots of fun too; there were quite a few girls who said they wanted to be dentists by the end of the evening! If you ever get the opportunity to get involved with something like this I would highly recommend it - it's really fulfilling as you get to improve your skills with children as well as it looking good on your CV.

My promise

The Brownie Promise has changed a bit from back in my day, but as it says,

I promise that I will do my best: To be true to myself and develop my beliefs, To serve the Queen and my community, To help other people and To keep the Brownie Law.

Getting involved in the community is something I would encourage all dentists to get involved with and non-dentists as well! Helping others to understand the importance of oral health is something we should be responsible for as a profession. Whilst awareness of oral health is increasing with some of the TV documentaries that have aired recently, there is still a lot of work to do when the most common reason for childhood admissions to hospital is to have teeth taken out.

So whilst it's easy to turn off your dentistry brain when you leave your surgery, we need to seize these sort of opportunities to help all people, not just children, improve their health. So I promise to do my best to improve the oral health of the general population, not just the patients who visit my practice.

Do you speak at events like this or been to a school to treat patients? Let me know in the comments below!

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Photos taken with the permission of the Brownie Leader - Bethnal Green

18:23

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Caries

What are Fizzy Drinks doing to your Teeth?

If you follow my Facebook page you may be familiar with this picture.

We all lecture our patients about the dangers of high sugar and acidic diets, not only for our teeth but for our general health!

But sometimes I feel like patients tune us out - they are fed up with the lecturing and being told off. They need something more concrete to discourage bad health habits; that's why some of these health documentaries on TV really do work!

On one of my non-clinical days at work, I set up a little experiment: What is the effect of popular drinks on our teeth?

I set up 3 cups with equal amounts of Coca Cola, Milkshake and Orange Juice. The experiment was mostly looking at the effects of the acid in these drinks, as it is hard to simulate the effects of the sugars in these drinks without the presence of the oral micro-flora (i.e. the bacteria that cause decay).

The sugar content in each of these drinks is pretty shocking - per 100ml of each drink there is:

10.6g in Coca Cola

9.8g in the Milkshake

8g in Orange Juice

Watch this video to see a visual representation of how much sugar that actually is!

I left each tooth is the drink over a weekend - there wasn't too much change in the appearance in the milkshake tooth or the juice tooth, but check out the one that was left in the Coca Cola.

Before picture of the tooth

The effect of a weekend submerged in Coca Cola

This damage by the Coca Cola is due it's very low pH of 2.5. So not only does Coca Cola expose your teeth to high sugar levels and cause tooth decay, but the low pH of the phosphoric acid wears away your teeth!

There's a big push with the government to reduce the rates of tooth decay in children. As I've said in a previous post, the biggest admission to hospitals for children is to have teeth taken out under general anaesthetic which is shocking!

Top Tips to Protect your Teeth

Reduce intake of fizzy drinks and other high sugar foods or drinks. You shouldn't be having more than 3 intakes of high sugar foods and drink a day
If you find it hard to cut down, have the high sugary foods or drinks with a meal because you've already stimulated your saliva to be produced which can buffer the high acids and protect your teeth
Drink high sugar drinks through a straw to minimise contact with your teeth
Avoid brushing your teeth for half an hour after an acidic drink to avoid brushing the acid into your teeth
Avoid taking any drink apart from water to bed with you and avoid late night consumption of acidic or sugary drinks
Drink milk or water between meals
Chew sugar free chewing gum after sugary intakes to stimulate saliva production

Are you a coke addict? Or conducted an experiment like this before? Please leave your comments in the section below!

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Source:

'Effects of an acidic beverage (Coca-Cola) on absorption of ketoconazole.' T W Chin, M Loeb and I W Fong.

18:41

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