TOOTH GERM

Work Life Balance? My First Blog Post in Almost 6 months!

I can't believe it's been almost 6 months since I have last blogged... that is the longest time ever between blog posts since A Tooth Germ came into existence!! I feel a bit ashamed and sad about that, but the past 6 months have been a blur of busyness, various clinical and non-clinical workloads piling up... plus my little one is now almost 2 years old and you know what people say about the terrible twos....

So why have I been so busy.....?

I've been a dental consultant for coming up to a year now, and while my team were very kind in letting me find my feet and settling in, I am well and truly past the honeymoon stage of a Consultant post! I am seeing the most complex patients I have ever seen in my career, in a challenging environment of long waiting lists and stretched NHS resources with healthcare staff strikes, increasing patient needs and a NHS dental access crisis. So no wonder I have barely time to breathe!

My role as a Consultant takes me out of the main dental hospital to community clinics and our district general hospital and I love these clinics seeing patients locally and setting up/building on spoke services. But this does mean when I am at work I juggle the workloads of my CDS patients, my district general patients and my dental hospital patients which takes some organisation.

On top of that my role at Dentaid the Dental Charity is becoming increasingly busy as our team is expanding and with our first partnership with an NHS ICB to deliver a huge number of clinics in a area where patients are facing difficulties in accessing care. And my role within the British Dental Association as Young Dentist Committee Chair means squeezing in meetings left right and centre with the access crisis becoming evermore prominently in the public eye and debated in parliament.

How do I get the balance?

I often get asked on social media and when speaking at events, how do I fit it all in?! I used to really see that as a compliment and I do still value having a portfolio career and fingers in a few pies, but the past few months have seen me reflecting on what I am currently doing.

I have been a dentist for almost 10 years and have built up various experiences across sectors. I now think it is time to really decide what I enjoy doing and refocusing on what I really enjoy. Particularly now I have a family, there is only so many hours in the week and I don't want to work myself to death.

I think it is hard for mothers and working parents to really say they have a balance between work and personal life. I enjoy going to work as I feel like 'me' not just 'a mum', and even when I am at home with my little one I find myself thinking how can I squeeze a few emails in or a meeting. The result is yes productivity and getting stuff done, but at the end of the day I cannot tell you how tired I feel! So that is why an evening blog post has been pushed down to the bottom of the priority list for the past few months.

The Future of A Tooth Germ

So is there a future for this blog? I am so proud of what I've achieved with over 9 years of typing away on this site. I still feel that glow when someone says to me they read my blog, particularly when they say it's really helped them with an aspect of their career.

And so I will continue to make space to blog and post on here. It might to be as often as 5 years ago and I might change direction a little, but A Tooth Germ is here to stay! And of course I will continue to offer my platform to those who wish to write something themselves. I have always meant my blog to share ideas and education across Dentistry and support those coming through their careers - and even though I'm almost 10 years a dentist and a Consultant, I would still consider myself to be a Tooth Germ....

Thank you for those loyal readers who got to the end of this... let me know what you think I should continue to post about in the comments below!

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16:45

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Alcohol

Top Tips when Managing People with Substance Misuse in Dentistry

Some patients might reveal to you either a past or current use of substances such as recreational drugs or alcohol... but how does that affect dental care?

Which Substances can be Misused?

Cannabis - the most commonly abused drug in the UK
Cocaine - the second most commonly abused drug in the UK
Alcohol
Heroin/opiates
Nitrous Oxide
MDMA
Ketamine
Spice
Poppers
Over the counter medication e.g.opioids, benzodiazepines

What are the Oral Manifestations of Substance Misuse?

Oral manifestations of substance misuse can be very specific to the substance, or more general or as a consequence of the effect of the substance. For example, some substances cause sugar cravings or binges, which increases the risk of caries.

Some oral manifestations are:

Caries
Periodontal disease
Xerostomia
Oral cancer/precancerous lesions
Soft tissue perforations (cocaine use)
MRONJ/osteomyelitis
Cluster headaches
Tooth surface loss (attritive from grinding, erosive from vomiting/alcohol use)
Oral ulceration
Burns (poppers)
Bleeding (alcohol)
Halitosis (alcohol)
Traumatic injuries (from accidents during intoxication)

Top Tips when Managing these Patients

1. Treat patients in the context of their lives right now

If the person is at a chaotic or unstable point in their life; perhaps their addiction is not under control, they don't have a stable place to live, or their mental health is really unstable, perhaps they only want to engage with emergency or ad hoc dentistry. Treat their expressed need so they are pain free and comfortable, and when they are ready to engage for comprehensive care, you will have gained their trust.

2. Tailor prevention messages

Are you able to adapt your prevention messages so they are relevant to the patient? If they are on methadone, advise them to rinse their mouth out or use sugar free gum afterwards to counteract the dry mouth effects. Can you prescribe high fluoride mouthwash for your patient to use if they frequently vomit after using alcohol

3. Work collaboratively

Make every contact count - if you can work together with Drug & Alcohol teams in terms of pathways, but also if you need support chaperoning patients or getting further information e.g. blood tests, advising sugar-free methadone.

4. Assess capacity

Just because a patient turns up to an appointment having consumed drugs or alcohol, doesn't automatically mean they lack capacity to consent. For many, they require their substance to be able to function and if you refused to see them after they've had a substance, you'll never actually get to treat them. Assess their capacity using the Mental Capacity Act's Code of Practice - even if they don't have capacity for treatment, are you able to do something to engage them like perform a check-up or give prevention advice?

5. Be wary of drug interactions with local anaesthetics and sedative agents

If patients have recently taken certain stimulants (cocaine, MDMA) there is a risk of interaction with adrenaline-containing local anaesthetics (hypertension, convulsions), so defer treatment.

Many substances, such as cannabis, stimulants, opioids, interact with midazolam sedation or make sedation unpredictable. Be cautious and offer alternatives (e.g inhalation sedation) if possible.

6. Listen to patient's pain!

Patient's pain thresholds might be very low if they are detoxing or have been switched to drug replacement therapy. They can be very sensitive to pain (for example even when delivering local anaesthetic), they might complain of toothache when coming off their substance as it had been masking their pain or they might require more than normal doses of local anaesthetic

7. Be aware of bleeding

Many of these patients will bleed and therefore you need to assess their risk when planning extractions. There is a high incidence of blood bourne viruses in IV drug users so they might have liver damage from hepatitis, or chronic alcohol excess will have caused cirrhosis of the liver.

Liaise with their medical teams for recent blood tests and ask the patients more about their bleeding. Do they bruise easily? For blood tests, Liver Function Tests (LFTs) will show deranged liver enzymes which are related to clotting factors, but I find that quantifying bleeding risk is more easily assessed by a INR, which will tell you how much longer it takes for a person to stop bleeding. Also consider local haemostatic measures, staging extractions and careful post operative advice. When in doubt, ask for advice from an oral surgeon or Special Care dentist.

To read more about drug misuse in dentistry, read one of my latest articles in Dental Update here.

If you have any questions about managing these patients, please leave comments below.

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21:55

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Community Dentistry

5 Tops Tips when Treating People with Physical Disabilities in Dental Practice

For patients who have physical disabilities, accessing a dentist can be a big struggle. So what can you do to help facilitate care for these patients?

An example of a wheelchair recliner - with me in it!

1 in 4 people in the UK have a disability. There are various forms of disability from learning disability, hidden disabilities, sensory disability and physical disabilities. Physical disabilities can be progressive, temporary or fairly stable depending on the individual.

Examples of physical disabilities include:

People who require assistance in walking e.g. walking sticks, walkers
People who cannot walk or self-mobilise and require the use of wheelchairs
People who cannot mobilise at all, often confined to their beds or require hoisting into a wheelchair
People with dexterity issues for example arthritis in their hands, tremors, reduced grip strength

These can be because of conditions such as cerebral palsy, multiple sclerosis, Parkinson's disease, epilepsy, spinal cord injuries, amputations etc.

Physical disabilities can be congenital e.g spina bifida, cerebral palsy, or acquired such as amputations, arthritis.

They can be be musculoskeletal affecting joints bones and muscles (musclar dystrophy, arthritis), where the disease leads to inability to perform movement of body parts due to deformities, diseases or degeneration of muscles or bones. Alternatively, they can be neuromusculoskeletal where the inability to move affected body parts is because of disease, degeneration or disorder of the nervous system (cerebral palsy, stroke).

How do Physical Disabilities affect Dental Care?

People with physical disabilities could have poorer oral health and difficulties accessing dental care compared to the general population. This can be because:

They find it difficult to get out of house. They might rely on carers or relatives to support them to mobilise or take them to appointments. They might require transport services to bring them to clinics, or a crew to get them out their house if there are obstacles for example stairs.
They might struggle travelling to appointments. If they rely on public transport they might find it difficult accessing these services, or they have to allow extra time. They might be uncomfortable travelling long distances for example, sores from being in the same position in a wheelchair.
Clinics might be inaccessible. For example, if there are steps or the clinic is up stairs without a lift. Doors and corridors might not be wide enough to accommodate a wheelchair. There might not be easy access or disabled parking available.
Patients might struggle to get into the dental chair or cannot transfer without a hoist
Oral hygiene can be challenging if patients cannot brush effectively

Top Tips in Managing these Patients

1. Complete Disability Awareness Training as a Team

It is so important that not just the clinical members of a team complete disability awareness, but also reception and admin staff.

This is because as soon as a patient contacts your practice or clinic, they might require reasonable adjustments according to the Equality Act to access care. This might mean accommodating them at the surgery at a certain time e.g. later on in the day if they have carers to assist them in the morning.

To read more about disability awareness in dentistry, read this blog here.

2. Think about your Clinic Environment

Are there simple adjustments you can do to increase accessibility at the surgery or clinic? For example:

Installing handrails for steps
Painting edges of steps in a different colour to make them visible
Installing ramps if possible
Ensuring there is a disabled parking space if possible
Removing obstacles which narrow corridors or spaces
Having a lower reception desk for those who are in wheelchairs
If you are replacing a dental chair, having a break-leg design can be easier for patients to get in and out of

3. Do you actually HAVE to transfer patients from their Wheelchairs?

If patients cannot or find it difficult to transfer from their wheelchairs to the dental chair, if appropriate, sometimes you can see them in their wheelchairs.

Some wheelchairs recline back which can really help with your access. Certainly for examination and possibly simple treatment you could think about treating them in their chairs. Be careful of yours and your nurse's posture though - you don't want to injure yourself!

4. Complete Manual Handling Training

If patients need some help transferring, only do so if you are confident and have completed manual handling training to ensure you and the patient are safe. Always ask patients permission if you think they need some help.

5. Adapt Oral Hygiene Advice

Some patients might struggle with brushing and other oral hygiene, so listen to patients and what they find difficult to help guide them. Examples of adaptations might be:

Brushing later on in the day for patients with arthritis who have 'morning stiffness'
Having thicker handled toothbrushes to help with grip. You can buy toothbrush sleeves, adapt with a tennis ball or even make a putty handle to attach to their current toothbrush - see below
Recommend an electric toothbrush or Dr Barman's 3 sided toothbrush if they get tired
Engage with a carer to relative to assist with oral hygiene
For interdental aids, using the long handled interdental Tepe brushes

Toothbrush adaptations. From left to right: Collis curve toothbrush, Tennis ball to adapt handle, putty to adapt handle & Dr Barman's 3 sided toothbrush

What about those with Severe Disabilities?

For those who cannot transfer from their wheelchairs or where it is very challenging to treat them due to physical disabilities, or those who require stretchers, referral to Special Care Dentistry might be required.

They will be able to offer adaptations, for example:

Patient transport to assist bringing them to clinic
Domiciliary visits for those who really struggle to get out their residence
Wheelchair recliners so the patient doesn't need to be transferred from their chair for treatment - see the top photo
Hoists
Access to stretcher lists

Treating patients with physical disabilities does sometimes take patience, out of the box thinking and really listening to patient needs - but all healthcare professionals have a legal and ethical requirement to make reasonable adjustments when seeing these patients.