Education | The Incisal Edge

If you’re in London on Thursday evening head for Kings.

Posted on December 6, 2016 by Alun Rees

A smorgasbord of Dental talent.

Kishan Sheth and the KCL Dental Society join forces to bring you one of the most anticipated dental events of the year. Chaired by Dr Lewis-Greene, supported by Prof Dunne and sponsored by Henry Schein.

www.facebook.com/kcl.dentalsociety/

5.30-8.30pm

Thursday 8th December 2016

New Hunt’s House Lecture Theatre 1, Guy’s Campus, King’s College, London

Speakers:

Dr Raj Ahlowalia
Dr Subir Banerji
Dr Anoop Maini
Dr Alun Rees
Dr Nilesh Parmar
Mr Kishan Sheth

Attendees receive 2.5 hours CPD certificates or certificates of attendance for students.

£3 donation upon entry for Evelina Children’s Hospital.

By the end of the evening we would like to have raised £1000 for this amazing cause.

Seats allocated on first come first served basis.

What’s not to like?

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Ten Year Anniversary of Child Protection and The Dental Team

Posted on April 7, 2016 by Alun Rees

I was pleasantly surprised to bump into my old friend Richard Welbury at the BDA conference 10 years ago, I hadn’t realised at the time what a milestone he and his colleagues were making. Richard was the first person I knew who shared the facts around oral signs of child abuse, his memorable talks produced a determination from everyone who heard them to do everything they could to ensure that children would stay safe. Their work is worth remembering and continues.

From The British Society of Paediatric Dentistry via Dentinal Tubules

A decade ago, dental neglect in children was a neglected issue. But this is no longer the case thanks to the guidance Child Protection and the Dental Team (CPDT) which was launched at the BDA conference in 2006 by the then Health Minister Rosie Winterton.

The document and its associated website (http://www.cpdt.org.uk/index.aspx) came about after Jenny Harris, a paediatric dentist in Rotherham, wrote to the Chief Dental Officer, Raman Bedi, to raise her concerns. This was in the aftermath of the death of Victoria Climbié in 2000 and Lord Laming’s Inquiry report in 2003.

Said Jenny: “I asked myself: If a child like Victoria walked into my surgery, would I recognize her. Would I know what to do and would I have done it? For months I checked the dental press but there was nothing new to educate us about child protection.”

Jenny had already set up a dental neglect working group in Rotherham. Her job was to define best practice so that children in her area would not slip through the net. But she still felt the dental profession needed expert national guidance.

After receiving her letter Professor Bedi met Jenny and invited her to chair an expert group to produce an educational resource. She was given a generous budget but just a year to complete the project.

The input of Jenny’s paediatric colleagues proved invaluable. She sent out a questionnaire (1) to BSPD members who were asked about their knowledge and experience of safeguarding as well as to share examples of good practice. This research is being repeated for the 10th anniversary to see how much has changed.

In the decade since its launch, CPDT has been highly influential. In 2008, a survey of GDPs (2) showed that dentists had taken on board the new guidance and it was influencing knowledge, training and policies in the practice.

And there has been extensive involvement with other bodies, both in and outside dentistry. Jenny has become:
• BSPD’s representative on the NSPCC’s Health Liaison Committee – she presented a paper on dental neglect in children as recently as September 2015
• A contributor to the development of a NICE clinical guideline: When to suspect child maltreatment
• Lead author of the first BSPD policy document on dental neglect in children
• Initiator of a working group bringing BSPD together with the Royal College of Paediatrics and Child Health (RCPCH), the NSPCC and the Advanced Life Support Group (ALSG) to adapt standardized child protection training – a recognition and response course – for the paediatric dentistry specialty trainees

The May anniversary is also an opportunity to celebrate the valuable contribution of the rest of the expert group: Professor Richard Welbury, an early champion of child protection in dentistry, Peter Sidebotham, a leading community paediatrician, Ranee Townsend, a CDS clinical director, Martyn Green, a dentist and vocational trainer in Devon, Janet Goodwin, a dental nurse representative and Chris Franklin, postgraduate Dean.

Now working as a community-based consultant in paediatric dentistry in Sheffield, hardly a week goes by without someone somewhere in the world contacting Jenny for information or advice and she helps where she can. Child protection and the dental team has already been translated into Croatian and Greek, with work on Spanish and Arabic versions now in the hands of enthusiastic teams of paediatric dentists.

Jenny believes there is still some way to go: “We have got better at recognizing signs of child maltreatment and at referring it but it does make a huge extra workload for clinicians and that hasn’t yet been recognized.” Jenny also believes the dental profession needs to have someone in every region who is identified as being responsible for safeguarding children leadership. Currently too much is down to the goodwill and enthusiasm of individuals.

Said Jenny: “I am grateful to BSPD Council for encouraging me to forge links and raise awareness of dental health among other professions involved in safeguarding. There is much more interest in children’s teeth than when we started a decade ago.”

(1) http://www.nature.com/bdj/journal/v206/n8/full/sj.bdj.2009.307.html and http://www.nature.com/bdj/journal/v206/n9/full/sj.bdj.2009.356.html

(2) http://www.nature.com/bdj/journal/v210/n2/full/sj.bdj.2011.3.html

Note to editors:
For more information, contact Caroline Holland on 020 8679 9595/07974 731396

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A couple of Orthodontic posts from Kevin O’Brien

Posted on March 8, 2016 by Alun Rees

Orthodontics can be a hidden art and it’s often perceived by non-orthodontists as a secret language. Most undergraduates know a something about it, but not much, similar to knowing a few key phrases. “good morning”, “where is the bus stop?” and “two beers please”. That’s where it ends. After graduation it used to be kept (mostly) to the confines of those who had been through, what the New Scientist once called, “the years of crawling subservience under the gaze of the white coated moguls that control our great teaching hospitals”. Then, when deemed to be fluent in the language, the specialists with their M.Orths, headed off to their own planet in the Orthodontic universe to fiercely guard their patch and occasionally share a few simple phrases of ortho speak with their referring dentists.

Times have changed and with the relentless march of a thousand aligner systems everyone has a phrase book – or at least they think they do. Or could it be that they have the dodgy Hungarian Phrase Books?

I am not looking to fan the flames of the GDP v Specialist debate, there’s way too much of that about, rather to present Professor O’Brien’s last two blog posts for your consideration because I think they are both worth a read. I find him to be readable, thought provoking and that sometimes rare thing someone constantly questions what he does and WHY he does it.

First up:

A thinking about Orthodontics blogpost. In its entirety.

This is a short blog post to read just before the weekend, or just after if you are in Australia! I have just attended a major symposium in the UK and I was asked to give a major lecture. The preparation of this took some thought. During the meeting I listened to some great presentations and this got me thinking about orthodontics. I have been working as an academic orthodontist and research since 1986, spent a large amount of time researching clinical matters, I have trained too many people for me to remember and spoken at many major orthodontic conferences. But what do I know about orthodontics? Here is a list of my academic knowledge and opinion.

This is a precursor to a more thoughtful blog post that I am going to post next week, so here we go. You may not agree with me..

Malocclusion is caused by a combination of genetic and environmental factors
There are many ways to treat particular malocclusions.
Evidence based orthodontics is a combination of clinical experience, patient opinion and scientific research. The proportions of influence of these factors varies according to our level of scientific evidence.
Arch form and dimensions should generally be accepted
Functional appliances and other bits of plastic, pistons and springs do not change or influence facial growth. They tip teeth.
To my knowledge there is no high quality scientific proof that orthodontics, extractions, appliances, expansion, myofunctional orthodontics influence breathing, posture, academic attainment, sleep disordered breathing etc
Class I molar non extraction treatment is very easy
I wish that I knew how to intercept malocclusion…
Extraction of permanent teeth is required for the treatment of some malocclusion..but treatment mechanics are as important as the extraction decision
You can only “drive” upper molars 2 mm distally
Temporary Anchorage devices are better than other anchorage reinforcement method by about 2mm
Wire and bracket properties do not influence the efficiency of alignment
None of the new developments that are supposed to speed up orthodontic treatment seem to work; according to new trials..
There is no such thing as non-compliance treatment
I simply do not understand clear aligner systems
Self Ligating brackets do not have any advantages over conventional brackets. The self ligating practitioner should explain this to their patients.
The alternative orthodontist should explain to their patients that there treatment is not mainstream.
The General Dental Practitioner who has been on a short course to learn speedy orthodontics should explain to their patients the limitations of their training and knowledge
There has been and there continues to be great high quality research being done in orthodontics and don’t tell me that our evidence base is weak!
Nearly all orthodontic treatment relapses to a degree and this is probably caused by ageing and we cannot stop time…………….

That’s about it, does anyone want to add to the list?

Now here’s the second one:

Evidence based orthodontics is not as straightforward as it seems…

Should we practice evidence-based orthodontics?

This is a basic point and a good place to start. It has been pointed out to me several times that orthodontics is different to other part of dentistry because it is more of an art than a science. Furthermore, it is difficult for us to do harm because the harms that we may cause are usually minor, for example, decalcification and root resorption. It is, therefore, not necessary for us to practice evidence based care.

I must disagree with this sentiment. This is because we need to practice ethically by ensuring that our treatment is based on evidence, when it is available. We also need to inform our patients of all the potential risks and benefits of treatment. To this end we should be particularly careful of making statements that are not based on good research evidence. I can think of the following examples, the proposed benefits of non-extraction treatment, methods of speeding up treatment and orthodontics that is provided to reduce sleep disordered breathing in children.

Continues here

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Getting Started in Facial Aesthetics – Guest Blog from Harry Singh

Posted on February 2, 2016 by Alun Rees

Getting Started in Facial Aesthetics

Although frown lines and crow’s feet are natural signs of ageing, some patients may want to eradicate them. With this in mind, this piece will consider the role of wrinkle relaxing injections, describing their benefits and presenting an overview of their clinical use.

‘What do you think I need, Doctor?’ By far and away this is the most commonest question I get asked by my facial aesthetics patients. My standard response for the past few years has been, ‘No one needs wrinkle relaxing injections, its all about what you want’.

Wrinkle relaxing injections is a wants based treatment. No one needs it, no one is going to get ill from not having it and certainly no one will die if they don’t undertake it.

Wrinkle relaxing injections work on motion lines, these are lines that worsen or appear when the patient contracts the muscle. Generally speaking, we are dealing with the upper third of the face, but I do use wrinkle relaxing injections in the lower face area (smokers lines, chins, gummy smile, Massetter, corners of the mouth). If lines/folds are present at rest and do not worsen when the muscles are contracted, then fillers will need to be considered.

There is the Glogau Classification of Photoaging. This was developed to objectively measure the severity of photoaging and especially wrinkles. It helps practitioners pick the best procedures to treat photoaging. There are 4 groups that a patient will all under:

Group 1 – Mild, typical age – 28-35. No wrinkles. Early Photoaging present: mild pigment changes, no keratosis, minimal wrinkles. This group will not require any wrinkle relaxing injections as they have no wrinkles.

Group 2 – Moderate, typical age – 35-50. Wrinkles in motion. Early to Moderate Photoaging: Early brown spots visible, keratosis palpable but not visible, parallel smile lines begin to appear. This is the best group to treat with wrinkle relaxing injections, since they have no wrinkles at rest and only in motion.

Group 3 – Advanced, typical age – 50-65. Wrinkles at rest
Advanced Photoaging: Obvious discolourations, visible capillaries (telangiectasias), visible keratosis. We can still treat this group with wrinkle relaxing injections, since the wrinkles worsen when they contract their muscles. However we cannot guarantee to either reduce or eliminate any wrinkles they have at rest.

Group 4 – Severe, typical age – 60-75. Only wrinkles. Severe Photoaging: Yellow-grey skin colour, prior skin malignancies, wrinkles throughout – no normal skin, cannot wear makeup because it cakes and cracks. This group cannot be treated with wrinkle relaxing injections as the muscles are not causing any wrinkles.

Once the patient has elected to undergo any form of wrinkle relaxing injection, they, unlike our cousins across the Pond, what to achieve a natural result and not the frozen ‘I’ve been botoxed’ look. What does this natural look entail. In my eyes and my patients eyes, this natural look with wrinkle relaxing injections is achieved by the patient still being able to express themselves using the facial musculature without the appearance of, or at least the reduction of wrinkles on the treated areas.

The main benefits of wrinkle relaxing injections are based on the temporary nature of its effects. The toxin used will work at the neuro muscular junction to inhibit the neuro muscular messenger acetylcholine (a neurotransmitter) sending a signal to the muscle to contract. However after a few months (anything between 3 and 6) new nerve terminals reestablish connection with the muscles, allowing it to contract again. This gives our patients the confidence to try the treatment and if for any reason they don’t want to continue, they are restored back to their original appearance.

Patients also love that fact that the duration of treatment is very short and associated with this, the downtime is very minimal. On average the treatment of the upper third of the face should take no longer than a couple of minutes. Immediately after the procedure, the patient will have areas of swelling, but this should last no longer than 20minutes. This is where the media have latched on the phrase ‘lunchtime miracle cure’.

As we can see the main benefit of wrinkle relaxing injections is to smooth out wrinkles, however it has numerous medical benefits such as stopping excessive sweat, reduce/eliminate migraines, use in arthritis pain, blepharospasm, cervical dystonia and bladder control.

Considering whether to start a patient on wrinkle relaxing injections depends on balancing the risks of treatment against the potential improvements. Potential risks associated with this procedure can include, but are not limited to: swelling, bruising, headaches, flu like symptoms, ptosis of eyebrow or eyelid, non responsiveness.

As with all clinical procedures correct assessment, a detailed examination, informed consent obtained with an explanation of the realistic results expected are all mandatory.

Wrinkle relaxing injections when used on the correct patient will leave the patient more confident, looking fresher and appreciative of your work.

Dr Harry Singh BChD MFGDP has been carrying out facial aesthetics since 2002 and has treated over 3,000 cases. In his last dental practice (focused on aesthetics) he ended up performing more facial aesthetic treatments than dental treatments. Due to the very high profit margins associated with facial aesthetics, he decided to concentrate on facial aesthetics and currently has over 700 facial aesthetic patients. He has published numerous articles on the clinical and non-clinical aspects of facial aesthetics, and spoken at dental and facial aesthetics conferences on these topics. Harry was shortlisted at the Private Dentistry Awards in 2012 and 2013 in the Best Facial Aesthetics Clinic category and was a finalist in 2012 at the MyFaceMyBody awards for the Best Aesthetics Clinic.

For further information on Harry’s courses and to download a video ‘Getting Started in Facial Aesthetics’ free of charge, please visit www.botoxtrainingclub.co.uk

2016 #27

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Hands-on training for complex dental implant procedures.

Posted on January 17, 2016 by Alun Rees

A challenge faced by dentists is: How to get hands-on training for complex dental implant procedures on cadaver heads?

Quality trainings are few and hard to find because cadaver heads are not easy to organise. We have created such a training that we are hosting in Coventry, UK, in March 2016 over a long weekend.

Interested? Visit the link below.

http://vssa.co.uk/courses-for-dentists

One of the main reasons for failures in treatment is due to inexperienced assistant. Hence, the faculty welcomes you to bring along a dental nurse who will also be trained alongside.

Regards, VSS Academy

P.S. We can order a limited number of cadaver heads only. So book your place right away to avoid disappointment. We allow for only two dentists per cadaver head for optimal practical hands-on experience.

2016 #17

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South West Young Dentist Group – One Day Conference

Posted on January 8, 2016 by Alun Rees

Wearing my Western Counties BDA President’s hat I’d like to bring your attention to the second YDG Conference. This year the venue has moved down the M5 from Bristol to Sandy Park, Exeter home of the Exeter Chiefs Rugby Club and a recent World Cup Venue. Date Saturday 20th February 2016.

There’s a good line up of speakers and the organising committee under the chairmanship of Ahmad Nounu are working hard to ensure it’s as successful as last year.

Here’s a link to their Facebook Page

2016 #8

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What do you tell (medical) students about the future?

Posted on September 8, 2015 by Alun Rees

Nice piece on UK medicine, those who will work in it and their readiness – or not. I knew little of what I was entering in 1978. How will they see things in 25 years I wonder?

Full piece here: reestheskin.so/?p=2010

More about the author here.

What do you tell students about the future?

I was gossiping with a bunch of fourth year students the other day about what medicine might look in a few years, and how possible changes will affect their lives and careers. Big topic, with few certainties. One of the clear messages was that they felt that nobody really critically talks about these issues to them. Instead, there appears to be lots of what might be called soft propaganda: how there is a shortage of GPs, and how important it is for them to serve by becoming these GPs; how the UK model is self-evidently superior to that available in the rest of the world; or denial of the observation that people voting with their feet (as in migrating) is one of the key ways human societies advance. Despite the ‘global health’ movement, they seem to know little about how health care is organised in different countries, especially those just across the channel. And they seemed interested to know more, so I suspect the fault is ours, not theirs. Little is done (it seems to me) to move beyond the tired stereotypes of US medicine (show your credit card or you will be declined emergency care etc) on the one hand, and the NHS ‘free’ but ‘world class‘ health care on the other (world-class, along with ‘holistic’ is the canary in the mine for bullshit).

Such views are of course lacking in depth. Much of mainland Europe provides lessons for how to provide good health care and maintain solidarity across social strata. Anybody who knows a little about health care in England (think, Circle and dermatology; and NHS dentistry) knows that it is likely that for much of their careers many of our students might not be employed by the NHS, but by private for profit corporations, and that the exercise of monopoly power by government is stronger now than ever. The main political parties in England want to privatise health care, and seem to believe that corporate culture plays no role in delivery of ‘any service’: Virgin, United Health Care, it is all just the same, or so New labour believed. Waitrose, or Walmart: it doesn’t matter! Just look at Steve Ballmer and Steve Jobs: clones aren’t they? When independent regulation has been lost, and most health care is delivered by the same organisation that controls training in ever more microscopic ways, economics 101 will make predictions about what will happen to salaries and working conditions and —here is the crunch — how providers will manipulate customers / clients / patients. Indeed, gossip to many doctors in any hospital and you can make guesses as to what awaits many of these young people. For some for them, Australia seems closer than it did to me.

We need to educate our students to look to the world, not their own backyards, something that Scotland was once very proud of. I have just shown a US visitor the plaques on the wall of the old Edinburgh Medical School in Teviot Place, commemorating the contributions our students made to both medicine and society (ies) across the world. Not one of them, a ‘widget’, I wager.

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