The Benefits of being a Treatment Co-ordinator at Absolute Dental, Kingsbridge

It was my pleasure recently to act as treatment co-ordinator and nurse for a new patient to the practice. He and his family had moved to Devon from London in an attempt to alleviate his sons asthma. The patient is male, 44 years of age, a saxophone player who suffers from asthma. This patient originally presented at Absolute Dental due to a broken tooth in the upper left quadrant. On examination it was clear that although the UL8 required immediate restoration, there was no carries present, and also that the patient had a severely worn dentition.

During his consultation with Rhodri John we found out that he was aware of bruxing in the past, approximately 15 years ago which was associated with the stress of a high powered city job. Since ‘retiring’ to a more stress free lifestyle the tell tale symptoms and signs have ceased. As this was investigated more we found out that the patient’s diet was also quite acidic (including fruit juice, cordial and white wine). The patient also suffered with indigestion and possible acid reflux (probably stress induced) although the patient had never sought a medical diagnosis or treatment for this. At this appointment the options for restoring the worn dentition were only briefly discussed and only the UL8 was repaired, as this was the patients primary need.

When the patient returned to us for a scheduled New Patient Consultation we were able to take a more detailed history from the patient and discuss his “wants” in more detail. Our previous discussion with the patient had caused him to consider the possibilities for his worn upper dentition. His grinding was discussed in more detail and the patient revealed that although he had experienced pain in his TMJ on waking previously, he had not been aware of it for some time, nor had he been told that he was grinding at night for some time. Our options had been full mouth rehabilitation involving extensive crown work, which would mean removal of more
of the natural tooth surface, which had already been compromised by the patients
grinding/erosion; composite build ups on the upper 3-3 to give the patient anterior occlusion only, allowing the posterior teeth to over-erupt into occlusion (Dahl principle) or to leave the patient and carry out no treatment.

Because we had seen and treated this patient previously, we had already begun to build a rapport with the patient and his confidence and trust in us was growing. This meant that although the patient had decided to dismiss the idea of having the teeth crowned, he had decided that he wanted to improve their appearance and wanted to discuss the composite build ups further. The patient was amazed that until moving to Devon and visiting Absolute, the only options for improving the function and appearance of these anterior teeth had been invasive and non-reversible treatment. The patient said that he was willing to try the composite build
ups, and understood that if he couldn’t cope with the anterior only bite, the whole procedure could be reversed.

Our radiographs at this initial consultation showed some areas of bone loss, most noticeably in the lower left molar region where there was some furcation involvement. It was believed that this bone loss was consistent with past periodontal disease, but likely exacerbated by the patients previous bruxism; the patient may need to see our periodontal specialist for bone regeneration therapy in the future. The radiographs were shown to the patient and discussed in some depth so that the patient could see that his grinding habits were not only affecting the appearance of his teeth, but also the supporting structures.

Once again, the patient was grateful for our explanation as he had never understood this before. Picture 1 shows the patients dentition at his initial appointment.

This patient was now ready to make a positive decision on the treatment and chose to have the composite veneers placed, after a course of home whitening and routine periodontal therapy. Impressions were taken for the whitening trays and study models were cast and articulated. Our dental laboratory made diagnostic wax ups which were used to help in the treatment planning and help the patient to visualise the final result.

Once the patient had achieved the shade he was happy with through the whitening we saw him to begin the composite veneers. This took place during a 2 and a half hour appointment where, without local anaesthetic, the patients upper incisors and canines were transformed from their worn flattened appearance into teeth that looked so natural healthy that the patient was quite literally lost for words. Layers of composite were built up gradually replacing dentine and enamel, adding translucency at the incisal edge for a more natural appearance, starting with the
upper right canine and incisors first (picture 2).

At this stage the effect is already staggering, and as the dental nurse assisting in this procedure, I am already aware at how much of an impact the final result will have on the patient. More shades of composite are combined, like an artist mixing their palate for a painting, as the left side is completed; and then it’s time for the reveal.....

Now, I know how good they look and how clever the dentist is to have worked freehand to transform these worn teeth into the natural looking composite veneers that the patient now has, but there is always a moment when you wonder if the patient appreciates the complexity as
much as the dental team. As I hand the patient the mirror he simply beams widely and says “Wow – they look amazing!” And do you know what – he was right (picture 3).

This patient is by no means out of the woods yet, only time will tell if he can tolerate his occlusion in this transition period, or if he is indeed still grinding his teeth, in which case these composite veneers might need adjusting, but what is clear at this stage is that this patient wanted a solution to his worn dentition that was non invasive and gave him his confidence back – and we’ve helped him to achieve that.

In the post treatment video testimonial that I took from this patient he described the treatment as comfortable and relaxing (so much so that he nearly nodded off at one point), and that he was grateful to have been offered this treatment for the first time and had the treatment explained and delivered to him in such a competent and professional manner.

I love cases like this; I feel proud to work with such a talented dentist like Rhod and to help a patient in such a dramatic way and I look forward to monitoring his progress closely over the coming months.

Diane

Periodontal Disease and Diabetes Mellitus - The Link and how this is managed at Absolute Dental

Periodontal Disease and Diabetes Mellitus- The link
We have known for some time that medical conditions affecting other areas of the body often reflect in the oral cavity.
One of the conditions which we have been focusing on, as it is on the increase, is Diabetes Mellitus.
Diabetes is on the increase globally and the World Health Organisation figures indicate that as many as 180 million people world-wide have Diabetes. This equates to 5% of the worlds population. Numbers are on the increase and by 2030 they estimate that this will increase by 103%!
When we look at the factors leading to the increase, they include obesity and inactivity, an increase in the ageing population and a reduction in the mortality rate of diabetics as we are living longer and medical science moves forward in treatment regimes.
Why are we concerned and what are we doing about this at Absolute Dental?
A large body of evidence exists that suggests diabetes can be linked to an increased prevalence, extent and severity of periodontal disease and that uncontrolled glycaemic levels can increase an individual’s susceptibility to the disease and the inflammation associated with oral diseases can trigger a number of systemic changes in the body that can result in insulin resistance.
There are lots of reasons why diabetics are more prone to developing periodontal disease. However, the good news is that conversely, periodontal therapy, and its associated reduction in oral inflammation have been linked to an improvement in metabolic control as well as limiting the progression of other complications associated with diabetes.
How we help you at Absolute. There are many key points to managing our diabetic patients which depend both on the information patients give us and what we find in the mouth.
Information from our patients
- Medical history. This is paramount for us as some changes to your health might have an impact on your dental health and also affect some aspects of the treatment we provide for you. We often ask for you to complete a written medical history to help us keep up to date with you. For diabetic patients, the details of the classification of diabetes and how it is controlled are particularly important.
- How long had the patient had diabetes? It appears that the earlier onset, the more susceptible the patient is to diabetes.
- Is the diabetes well controlled? Patients with poor metabolic control are more susceptible to periodontal disease.
- Oral Hygiene. Good oral hygiene is imperative for diabetic patients and we need to find out how the patient cleans, both tooth brushing and inter-dental cleaning.
- Appointment times. It helps us if patients tell us when good times of day for them are to attend and does not interfere with their eating and insulin routines.
How do we look after our patients in the surgery and what are we particularly looking for.
- Patient positioning. Diabetes can cause orthostatic neuropathy and so we raise the chair slowly to an upright position.
- Intra-oral examination. Thoroughly examining the mouth is imperative as there are many oral side effects including xerostomia, where there is a reduction in saliva production. This can contribute to an increase in caries and plaque accumulation. Glossitis, which is inflammation of the tongue, taste disturbance and burning mouth syndrome.
- Assessing the periodontal health. We complete this every time we by carrying out a Basic Periodontal Examination. This helps us to identify by a general screening, areas of bleeding, calculus formation and pocketing. We can then compare these to past charts and identify if there have been increases in any of these criteria, despite patients good efforts with their oral hygiene.
- A further full mouth pocket chart is also completed by the hygiene team providing in depth pocket depths, bleeding and recession.
- Monitoring patients during treatment is important as sweating, confusion, nausea and mood changes may indicate diabetic complications e.g. hypoglycaemia.
- Maintenance and monitoring. At each appointment we consistently assess and check medical history and oral health as if we can identify subtle changes early, these may be key in identifying early signs of diabetes. Helping not only your dental health but general health as well!

written by Maureen Milne

Study Group Success

Last night we had our 3rd Study Group meeting of the year at The Watermark in Ivybridge. These groups are an excellent opportunity for other practices in the area, who use our referral service for their patients, to come and learn about a variety of current topics to ensure we all stay abreast of the changes within this evolving industry of dentistry.

Last nights speaker was Fiona Stuart-Wilson, director of UMD Professional Ltd, which provides award winning management training and qualification for dentists and practice managers. The topic of the evening was "The Care Quality Commission (CQC) - A View From Whose Chair". The aim of the evening was to look at the public and professional expectations of CQC registration and the role of the whole dental team in meeting the CQC outcomes. The CQC is ultimately a government quango set up with the aim of ensuring patient safety and protecting the public (for EVERY health care provider). It was founded after a study found that, despite how well we feel we might be doing as a dental practice, there is a growing mistrust in the general public in all areas of health care. This has not been helped recently with such high profile cases as Winterbourne View Care Home in Bristol or Dr Harold Shipman.

For years, as dental professionals, we've been regulated by the General Dental Council (GDC), but the CQC looks at the workplace or practice as a whole, rather than just regulating individuals. It will ensure that the policies and systems we have in place in the practice are working for our patients - not just for ourselves.

All dental practices in the England will be visited by a group of inspectors, and all staff questioned to ensure they know every single system in place, how it has been checked and verified, and how often it is audited to ensure patient safety.

Many practices have been overwhelmed by the thought of preparing for this inspection, but Emma had already worked closely with Fiona to ensure we are prepared for whatever the CQC may ask of us.

Last night Fiona gave a really concise overview of the CQC, she was encouraging and motivating and for the practices represented last night, will have been a valuable source of much needed information to help them in these times when such vital information has been hard to come by.

As a practice we all love to meet with other local practices in these semi-social settings, and to ensure our knowledge is as up to date as it can be, to ensure our patients are receiving the very best care we can offer.