At present there is a heightened risk that patients are suffering in silence, delaying a practice visit and treatment while their condition deteriorates. It is entirely possible that some patients are avoiding getting treated, even for issues that have progressed to dental emergencies – which can even represent a risk to their wellbeing.

As dental professionals we know well, that while dental care is localised to the orofacial region, oral health is well-established to have wider ranging effects. Poor oral hygiene and health can have a bidirectional relationship with various systemic and psychological health issues.

Unfortunately, some patients may not grasp that delaying treatment for something like a dental abscess or failing implant could cause a cascade of further health problems. Cardiovascular problems remain among the leading causes of death in England and Wales, and a common pathway for infective endocarditis is infection via the oral cavity.[1] Carious and infected teeth and gums can allow oral bacteria to enter the blood stream, and where a pre-existing valve defect is present, this can allow bacteria to colonise and spread, which can lead to heart failure. It is also possible for the bacteria to break off and spread from this site to other organs, including the brain. Over a third of infective endocarditis cases are traceable to dental infection.[2] While rare, infective endocarditis is fatal in around a quarter of cases, and can lead to lifelong complications in survivors. These can include stroke, heart valve replacement and perpetual anticoagulant medication. Half of all infective endocarditis cases occur in individuals without known cardiac valvular lesions.[3]

Odontogenic infections have also been implicated in other serious and life-threatening conditions. Brain abscesses, osteomyelitis, necrotising fasciitis, severe sinus and orbital infections, and, of course, sepsis have all been traced to infections originating in dental tissues.  The threat of serious infections arising from untreated odontogenic infections has declined in recent decades as access to dental care and oral hygiene education have improved. However, septicaemia remains to be a challenge to identify and treat in a timely manner. The disruptions of the past year are likely to have set progress back somewhat.[4] Patients may not fully appreciate that an oral complaint can have more far-reaching consequences, and decide to try to tough out or ignore a dental issue as a result. With patients potentially not being seen as regularly as pre-pandemic, right now it is especially important that patients are made aware of when to urgently seek care.

Against the backdrop of the current pandemic, many members of the public may feel an extra responsibility to not tie up resources and services that may be more urgently needed by others. While this self-sacrificing attitude can be commendable, members of the public often lack the experience or knowledge required to properly assess their own medical condition, and can only guess at institutional capacity. While it is difficult to ascertain just how many patients are behaving in this way, there have been reports that even A&E attendance and patients seeking treatment for heart attacks, circulatory system problems, mental health issues, diabetes and other serious conditions have seen huge drops this year ­– in some cases, the reduction is as much as fifty percent compared to previous years.[5]^{, [6]} If people are putting off seeking treatment for issues such as these, it is easy to envisage that they are likely doing the same over dental maladies. In addition, this year has placed vast numbers of people under considerable financial stress and many have either lost jobs or are concerned that they may. This is another factor that may keep patients away from practices.

While immunisation efforts are now well under way, it will still take quite some time to return to some semblance of normalcy. Dental practices have faced exceptional challenges this year, and dental teams have shown great adaptability in continuing to serve patients safely. However, practices across the country are dealing with considerable backlogs for even routine care and there is still the potential for further disruption. It is vital that urgent cases are still handled in a timely manner.

If you are dealing with an urgent or complex oral surgery case, consider referring your patient to the Centre for Oral-Maxillofacial and Dental Implant Reconstruction. Led by Professor Cemal Ucer – Specialist Oral Surgeon – the cutting-edge treatment centre offers a wide variety of oral surgery treatments such as surgical removal of teeth, cystic lesions and pathology as well as advanced dental and oral implantology procedures, major grafting including zygomatic dental implants for the rehabilitation of severely atrophic patients. It features cutting-edge facilities such as a day care operating theatre and recovery suit, in house digital laboratory and digital diagnostic imaging centre and has a clinical team that boasts considerable experience, ensuring they are well equipped to handle demanding, high risk and urgent cases.

It is extremely important that patients understand that urgent care is still available, and under what circumstances they should seek immediate care. When caught and treated early enough, the majority of oral health issues can be resolved without serious complications.

Please contact Professor Ucer at ice@ucer.uk or Mel Hay at mel@mdic.co

01612 371842

[1] Office for National Statistics. Monthly mortality analysis, England and Wales: October 2020. ONS. 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/monthlymortalityanalysisenglandandwales/october2020 December 3, 2020.

[2] Baldin M., Srinivasan B., Sharma S. Dental infection as a cause of bacteraemia in infective endocarditis. Dental Update. 2018; 45(4): 357-358. https://doi.org/10.12968/denu.2018.45.4.357 December 3, 2020.

[3] Robinson A., Tambyah P. Infective endocarditis – an update for dental surgeons. Singapore Dental Journal. 2017; 38: 2-7. https://doi.org/10.1016/j.sdj.2017.09.001 December 3, 2020.

[4] Bali R., Sharma P., Gaba S., Kaur A., Ghanghas P. A review of complications of odontogenic infections. National Journal of Maxillofacial Surgery. 2015; 6(2): 136-143. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922222 December 3, 2020.

[5] Williams R., Jenkins D., Ashcroft D., Brown B., Campbell S., Carr M. Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort survey. The Lancet. 2020; 5(10): 543-550. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30201-2/fulltext December 4, 2020.

[6] Bostock N. Millions of patients ‘avoiding calls to GP’ during COVID-19 pandemic. GPOnline. 2020. https://www.gponline.com/millions-patients-avoiding-calls-gp-during-covid-19-pandemic/article/1681384 December 3, 2020.

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The oral health impacts of COVID-19 already includes things like increased decay and disease as well as emergencies going unchecked due to problems with access. Now, dentists are reporting more cases of bruxism.[i] This isn’t just in the UK either, as towards the end of the year, several articles appeared from the US, indicating how practitioners there were recording the same. One Washington-based dentist was quoted as saying, “I’ve seen more patients with problems from grinding in the last few months than I have in the rest of my career”.[ii]

Chronic grinding and clenching will not only damage the teeth over time, but will also lead to problems such as pain in the jaw, headaches and migraines. Bruxism and stress have long been linked and, with the pandemic affecting mental health worldwide, it is no surprise that cases have risen over the past year. For context, the last time the UK was in recession, in 2010, dentists also reported a surge in tooth grinding, as people worried about their financial future.[iii]

More education, and the stress-sleep cycle

But we were a stressed society before COVID-19 and bruxism wasn’t considered rare during “better” times, either; with bruxist patients, you will have seen the impact it had on their quality of life.

Now we are seeing more cases, education needs to be a priority. “Stress” and “anxiety” come up over and over in any discussion about bruxism but grinding and clenching have also been linked to sleep disorders. One study found that people with “obstructive sleep apnoea syndrome” were at a high risk of night-time bruxism (“a stressful lifestyle” and “anxiety” were other major factors).[iv]

If a patient grinds solely at night, they might not attribute the pain in their jaw, or their frequent headaches, to bruxism. Chronic pain will always make someone feel low, but unexplained pain – especially now the value of feeling “well” has never been higher – can trigger stress and anxiety, both of which will hinder a good night’s sleep. This is why educating patients about bruxism, its causes and symptoms is so important; they might be oblivious to their habit but feeling its consequences and stuck in a cycle of pain, stress, poor sleep and more stress. Once diagnosed, there are simple, non-invasive solutions for nocturnal bruxism, such as a mouth guard. To be effective, though, a mouth guard must be fitted by a dental professional.

Education and thinking holistically

Daily jaw exercises can also be taught to perform at home. Other solutions include lifestyle changes to mitigate stress levels and manage any triggers. Learning to relax may seem hard at the moment but it is not impossible, and people should be encouraged to explore what works for them.

Promoting increased awareness of bruxism will also help patients acknowledge a day-time habit – if every evening, after a day of working from home/job hunting/yet another depressing news cycle, they find their jaw is painfully sore, they may have been clenching on and off for hours, without realising. But a tendency to grind and clench is something they will be able to control, with your support and guidance, which may include referral to their GP, or a mental health practitioner. The interlock of dental, general and mental health is being appreciated more; the events of this last year have, in some ways, helped people think holistically when it comes to how they take responsibility for their long-term wellbeing.

Oral health consultations, which you may be conducting virtually, are extremely useful if someone is presenting with what could be the early signs and symptoms of bruxism, allowing you to act before serious damage is done. However, if the bruxism is chronic and long term, the patient may require treatment to restore lost structure, for example, if a tooth has become fractured, or if there is tooth wear that inhibits function and/or aesthetics. With some of the composite bonding materials available on the market, these restorative treatments can be delivered conservatively, efficiently and economically, for both your patient and your practice. COLTENE has been leading the market in restorative materials for some time, with its range of no-nonsense composites, such as BRILLIANT™ EverGlow, a submicron hybrid composite which offers strength as well as beautiful aesthetics. There is also BRILLIANT™ COMPONEER, which comprise prefabricated, easy-to-process enamel shells for successful, stable restorative treatments, delivered chairside. 

The repercussions on our mental health from the pandemic have been, and will continue to be huge, globally. With dentists seeing more cases of stress-related bruxism, education and swift intervention will prevent more and limit any existing damage. Patients should also know that if dental treatment to rehabilitate a tooth or teeth is required, this can be delivered ethically too. Although bruxism is not solely linked to stress, this is yet another example of how being in good oral health cannot be separated from being in general good physical health and maintaining mental wellbeing.

For more on COLTENE, visit www.coltene.com,
email info.uk@coltene.com or call 0800 254 5115.

^[i] Bruxism: the impact of COVID-19 on the nation’s oral health. Dentistry Online, 16 September 2020. Link: https://www.dentistry.co.uk/2020/09/16/bruxism-impact-covid-oral-health/ (accessed September 2020).

^[ii] Teeth grinding is on the rise and it may be due to pandemic anxiety. The Hill, 25 September 2020. Link: https://thehill.com/changing-america/well-being/prevention-cures/518217-teeth-grinding-is-on-the-rise-and-it-may-be-due (accessed September 2020).

^[iii] Surge in teeth grinding is linked to stress of recession. Guardian, 28 February 2010. Link: https://www.theguardian.com/society/2010/feb/28/teeth-grinding-recession-linked-dentists (accessed September 2020).

[iv] Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population. Chest. 2001 Jan 1; 119 (1): 53-61.

There has been much debate surrounding the effectiveness and safety of skill mix within the dental practice. Ever since direct access was introduced, dental care professionals (DCPs) around the UK have been embracing the benefits brought to patients and practices with the opportunities this created. However, there have been some challenges to overcome, such as how to maximise skill mix in the practice while ensuring the safety of patient care and efficiency of daily practice life.

Offering her perspective will be Michaela O’Neill – a dental hygienist with nearly 30 years of experience, a Past President of the British Society of Dental Hygiene and Therapy (BSDHT) and the current Vice President of the International Federation of Dental Hygienists. She discusses what has traditionally caused unease among the dental team regarding skill mix.

“In the past, there has been a gap between what DCPs can do and what colleagues think they can do,” she says. “The GDC scope of practice helped a lot, demonstrating the skills that dental hygienists and dental therapists can have, and highlighting what they can do within their competency and with the right training”. However, this was not enough to give all clinicians confidence to utilise DCPs’ additional skills.

“Though a gap still exists, it is closing over time – more practice teams are utilising the capabilities of their DCPs. With any team, when you start working together and really come to trust your colleagues, you can better discuss how to treat patients collaboratively. You need mutual respect for each other’s skills, as well as open and honest communication. This often takes time, becoming easier as the professional relationship develops.”

While no one can predict how skill mix will be used in the future, it is interesting to consider what new opportunities may be available post-pandemic lockdown for DCPs in practices. Indeed, as Michaela goes on to explore, it may provide a chance to boost business recovery as well as patient care:

“This is a very interesting time – many clinicians are adapting and changing how they work. It’s been heart-warming to see so many team members helping their colleagues by taking on new roles and responsibilities or even giving up clinical time in order to give dental hygienists/therapists some clinical time too. People are really coming together, benefiting the profession and, ultimately, patients.

“I believe skill mix can be utilised differently today compared to how we approached it pre-pandemic. There is a huge push on prevention right now, which is definitely  one of the strengths of a dental hygienist/therapist. The fact that oral health education can be delivered virtually provides a new way for dental hygienists/therapists to utilise their skills, while overcoming some of the challenges of reduced chair time and patient footfall in the practice. We have to think creatively, now more than ever, to use our skills and deliver the care our patients need. Virtual technology is a very sensible way forward as it enables us to maintain relationships with our patients, without requiring any clinical time.” 

Offering some advice for fellow DCPs on how to encourage safe and effective skill mix in their practices, especially given the current situation, Michaela adds:

“I think DCPs need to have more confidence in their abilities and speak up. If you don’t talk about what you can do, you won’t get anywhere, so if you can offer something that will benefit patients and/or the practice, speak to the principal/owner. Be prepared to demonstrate the potential benefits of what you’re suggesting and get the conversation started. People are open to ideas – especially right now, when many of us have already implemented changes to deal with post-pandemic dentistry. Your opinion matters, so have the confidence to share it.

“I also believe that dental hygienists/therapists’ position in the practice could be made easier in future if they are able to utilise certain medications directly, without needing a prescription. Securing exemptions from the Medicines Act is one of the projects that the BSDHT and BADT continues to fight for, which would ultimately allow more flexibility in the practice and improve skill mix for simpler, faster and higher quality patient care.”

Michaela will be putting forward her side of the debate regarding skill mix at the ADI Team Congress 2022 as part of the highly anticipated Team Programme. Encouraging dental hygienists and dental therapists to attend, she adds:

“Dental implants are commonplace now in every practice and the importance of optimal oral hygiene to maintain these has been a constant drum beat within the profession. It is imperative to attend an event like this to develop and update our skills. I also believe if you are working in practice, you need to keep yourself motivated. The best way to do this is to learn more and mix with enthusiastic colleagues. It renews your passion and keeps you at the top of your game.”

The ADI has announced new dates for the next ADI Team Congress

“The Great Debate”

26-28 May 2022, Manchester Central

ADI members will be able to attend the ADI Team Congress for discounted rates. Join today.

www.adi.org.uk

When things are uncertain, it can be tempting to wait things out. But those who have prepared for the future will hit the ground running.

Celebrating its 25^th anniversary this year, Ucer Education’s Postgraduate Certificate (PGCert) in Implant Dentistry (EduQual Level 7) is a well-established course led by Specialist Oral Surgeon, Professor Cemal Ucer. The 12-month modular programme will give you an excellent foundation in all aspects of dental implant placement and restorations, with subjects including common complications and digital dentistry.

Training is one of the best investments you could make in yourself. Don’t stand still – maintain forward momentum with Ucer Education.

For more information on the PG Cert in Implant Dentistry from Ucer Education – supported by Geistlich, Megagen, Neoss, TRI Implants and General Medical – please visit www.ucer.education or call Prof Ucer on 07767 645331

Email ucer@oral-implants.com