"I Vaguely Remember Him. Was That The One With The 'Tache?"
What Will Be YOUR legacy?
"I Vaguely Remember Him. Was That The One With The 'Tache?"
What Will Be YOUR legacy?
When You Take Your Problem Patients time With You - Treating Members Of Your Family, By DentistGoneBadd
Please Don't Make Me Cluck Like A Chicken" - Hypnosis In Dentistry. By @DentistGoneBadd
"Beware That Patient's The HS2" - When Patients Act Like Express Trains. By DentistGoneBadd
Like many dentists I know, I absolutely love new gadgets and innovations in dentistry. I was therefore excited when the Daily Mail headline proclaimed “The End Of Dental Fillings” the other day. Of course, it isn’t. I couldn’t accurately estimate how many times I’ve read “The End Of Dental Fillings” or “The End Of The Dental Drill” over the years, only to have my hopes crushed by scientific reality and human trials.
Professor Damien Walmsley squished my hopes like a bug when he projected that the in vitro growth of an enamel-like material by researchers at Zhejiang University’s School of Medicine wouldn’t be ready for practical use for “ten to twenty years.” Drat! I’m still waiting for a fully-formed Boots own home tooth-growing kit promised by researchers back in the early 1980’s.
This latest breakthrough does sound exciting though. I won’t bore you with the details but the Chinese scientists found that a material composed of calcium phosphate ion clusters could be used to produce a precursor layer to induce the epitaxial crystal growth of enamel apatite. This then mimics the biomineralization crystalline-amorphous frontier of the hard tissue developed in nature. They also found the CPIC-caused epitaxial growth recovered the enamel strength, with H and E values of 3.84 ± 0.20 GPa and 87.26 ± 3.73 GPa, respectively. I was staggered. Oops. I bored you.
I’m such a sucker for gadgets of any description, I once couldn’t help buying them. Years ago, the practice manager of my own practice banned me from going to Dental Showcase for my own financial safety. I seem to recall that was triggered by me coming back from a show with my arms full of boxes of disposable spring-loaded BPE probes, which I never ever used. Just last night I was glued to the Apple iPhone launch event, salivating, more like drooling over a phone that looks identical to the one in my pocket except the new one has three knobbly bits on the back.
I think I can say that during my career I kept fully abreast of new developments and never feared embracing a piece of kit with a warning beep built in. I don’t know if that was a good thing or a bad thing, a total waste of money, or just plain scary.
I was lucky enough to be given the opportunity after about four years post-qualification, to work with the dentist who first inspired me to become a dentist. My dentist and his partner were two forward thinking professionals who were constantly on expensive courses and they picked up hundreds of tips which they imparted to me and the other associate, as well as spend thousands on bits of kit which they occasionally let us use.
One day, the senior partner appeared at my side, wearing a pleading face, despite the fact he was about to give me the opportunity to try out his latest purchase. The new addition to the practice’s armamentarium was a crown removal system, which I believe is still available. I can’t remember the name of the product, but I can say it was incredibly effective - maybe TOO effective for my liking. After giving me quick instruction on how to use the device, I suddenly found a consultant medical surgeon in my chair, one of my boss’s best private patients.
The ‘device’ was basically a cube of what looked like solidified Rowntrees jelly. You may have come across the material – I don’t want to teach my grandmother to suck eggs (to be honest it was the only way my grandmother could eat eggs because I made her dentures) - but it was a very hard material and had to be softened in hot water. After it reached a nice pliable consistency, the material was placed by the crown and surrounding teeth on the occlusal surfaces and the patient was then instructed to bite down and hold it. The idea was that you let the material cool and once it was set, the patient opened the mouth violently. The desired result was a detached crown in the set jelly.
I could detect that the crown in this particular patient (an upper right 4) was very slightly wobbly but just as I placed the material, I realised that the unrestored UR3 and UR5 were also slightly wobbly. My blood ran cold. I was already committed and I braced myself for the embarrassment of having a consultant surgeon let out a blood-curdling scream as his teeth were ripped out without local anaesthetic, and the trial of having to replant them back into the sockets. Mercifully, only the crown became detached and I marched the patient back downstairs to the private part of the practice. Afterwards, my senior male colleague said “Phew, close call. Well done, my dear.”
It was while I was at this practice that I was also introduced to a miracle product.
The bane of any dentist’s life, in addition to all the other banes, is failed anaesthesia. Particularly miserable, is the inferior dental block, especially when you have a patient who doesn’t like needles. My two bosses came back from a course one Monday and announced that all our blocky worries were about to be over. Ten days or so later, the other associate and me were introduced to something called Lido-Hyal. The drug was administered in a dental syringe the same as anaesthetic and it worked by virtue of it containing hyaluronidase. The enzyme facilitated permeability within the tissues so the anaesthetic could penetrate easily to where it was needed. I can’t honestly recall which way round I administered it, but I think I probably gave the local first, followed by the Lido-Hyal. Even the most resistant patients in the practice succumbed to deep pulpal anaesthesia within a couple of minutes and it seemed worries about local failure was banished forever. The only contraindication was that you couldn’t use if there was any suspected infection around for fear of spreading it deeper into the tissues.
I pretty much used Lido exclusively for ID blocks and it never let me down. The problem with Lido was that it wasn’t licenced in the UK and it had to be imported from Switzerland. When I moved to my own practice in the early 90’s, I found that I couldn’t live without it, although I used it rarely. I had probably about three shipments until one day I received a caution from Her Majesty’s Customs and Excise henchmen, who issued a stern warning and a demand for the import tax I’d apparently been wilfully avoiding. I hadn’t, I was just someone who hadn’t previously imported anything in his life and was also a completely incompetent businessman. That put me off, as did an off-the-cuff remark from my associate who reckoned that using Lido would dissolve patient’s condyles. It never did, but it planted the fake news seed and that was enough for me. I never used it again, for fear of turning local patients into drooling, rubber-jawed yokels.
Before my bosses discovered Lido, one of them experimented with intra-osseous anaesthesia. He reckoned it was great for ‘hot’ pulps and avoided the post-op dribbling associated with ID blocks. I never tried the technique myself, the demonstration patient being enough for me. I think the system I saw being used isn’t available any longer, but it involved using a hollow trephining drill to sink a hole in the cortical bone that went through the cancellous bone of the alveolus. The outer part of the trephining drill was left in situ and the local was administered through the hollow tube. My boss reckoned the procedure was less painful than delivering an ID block, but I saw the patient squirm when he numbed the intra septal gingivae and saw the patient slowly wriggle down the chair when his cortical plate was being drilled. I’m sure it works perfectly well in the right hands but it turned my stomach, and apparently his. The system was in a cupboard gathering dust within what seemed a fortnight.
An innovation that I DID think might change my professional life, was jet anaesthesia. I was an early adopter, grabbing jet anaesthesia enthusiastically, with both hands. You needed to use both hands because if you didn’t, the retort was like that I would imagine you’d experience from an AK-47. The patients loved the idea of no needles, but they didn’t like the thud and kick-back from the unit, despite the ineffective rubbery cushion on the end. I found the unit difficult to use, particularly getting the large business end flat against the buccal bone of the upper molar areas. The main problem was although it got the soft tissues numb, it rarely got the pulp numb enough to work on the tooth. Most patients ended up screaming for ‘the proper needle.’ Having read a couple of papers on the modern units, it would seem they are pretty ineffective, though I would be first to admit it could have been operator error in my case.
I was also one of the first customers for surgical loupes with built in fibre-optic lights. These particular units were built in the USA and cost a packet. They were wonderful, but… In those days the light generating unit was a box which to my recall was about the same size as a small fridge which sat on the work surface behind me. The loupes were connected to the light unit by a reasonably lengthy fibre-optic cable and to be fair, it allowed quite a bit of free movement – except if an idiot was wearing the loupes. One day a patient asked me a question during treatment. I couldn’t make out what he was saying and I pulled my mask off and moved to face him so I could lip read as well, forgetting I was still tethered. Fortunately, that act didn’t pull the light unit off the work surface because my nurse dived on it, but my loupes were pulled off and they smashed on the floor. After a couple of weeks on their holidays in the USA, they returned as new. The kind suppliers repaired them free of charge. About two months later, they took a flight to the States again – pretty much the same reason. This time there was a modest charge with an accompanying note asking me if I would like a representative from the company to come and give me a free demonstration on how to use the loupes. I thanked them, but politely refused their offer. My motto over the years seems to have inadvertently been, ‘Once bitten, twice bitten,’ so when my loupes, which I adored, finally hit the deck again, I gave up on them. Eventually I found a local optician who gave me decent magnification in prescription specs, which served me well till I retired.
There were quite a few gadgets I DID resist over the years. Lasers were one of the innovations I shunned. I knew of a good practitioner locally who had spent a lot of money on one and shelved it within a month, advertising for it sale in a dental journal for nearly a year before the ad disappeared. I had heard he failed to shift it.
The early Cerec machines I also dismissed, though mainly on the grounds of cost. In my opinion, the results I saw when they first came out had all the aesthetic beauty of a toilet bowl created by Armitage Shanks. I’d call the shades available in the early days as ‘Comfort Station White.’
Ozone healing was the other ‘breakthrough’ I pretty much ignored. It was promoted originally as being effective way of treating early caries, particularly in pits and fissures. Being old-fashioned, I preferred to witness that I’d dealt effectively with the caries and regarded ozone treatment as snake oil. I note that it’s not currently recommended for the treatment of decay, by NICE.
As for ‘breakthroughs’ like the elimination of filling and drilling, I am a sceptic. Back in the 80’s, at the welcome address by the Dean of my dental school, he told us that caries would be eliminated in the developed world within ten year and that our futures lay in the ‘Third World.’ It was a pretty dour introduction to dental school. I note we are still waiting for the caries vaccine he promised.
I’ve just noticed a tiny chip in the back of my mobile. I think I need a new phone. The iPhone 11 looks nice.
Negative reviews can be upsetting. Could the answer be an App? "We'll Be With You In Ten Minutes Mate" Should We Adopt The Uber Model? By @DentistGoneBadd
They sell tooth whitening kits on the Internet. You can even buy temporary crown kits from the web. Guess what you can buy now? Brace Yourself - DIY Orthodontics Via Webcam By ADentistGoneBadd
Believe it or not, it’s just over ten years since the CQC came into being.
I know! It doesn’t seem five minutes since the CQC burst into existence. Sometimes it seems like it’s been hanging over dentistry forever - like the extended impact winter that wiped the dinosaurs out after that postulated asteroid crash-landed without warning – which was a bit like the CQC itself really.
In England, the CQC is the independent regulator for the quality and safety of care, although to many practitioners, it’s more regarded as a major irritant – another regulatory body to which you have to kowtow, pay an exorbitant fee and produce a forest’s worth of paperwork.
I vaguely remember that the CQC landed on dentistry’s doorstep in about 2011. I was a practice owner in those days and I remember only too clearly, spending most of my spare time writing policies to fulfil forthcoming CQC requirements and being too busy to notice I could have just downloaded them from the internet.
I didn’t have any direct contact with the CQC until I had to go down to one of the organisation’s regional headquarters in the Midlands, for the registered manager’s interview, sometime in 2012. I seem to remember then having to go again a few months later, when the bizarre individual who was about to buy my practice had to have his registered manager’s interview and we had to tell the CQC how we were going to effect the ownership changeover. Naively, I had thought he would simply give me the dosh, and I would skip over the horizon, happily whistling the ABBA hit, Money Money Money. But no, the CQC wanted to make it more complicated and we had to outline our contingency plans for provision of treatment if the practice was consumed by a flood or a volcano. I thought I’d made that clear at my first interview – canoes and a Dyson.
I finalised my practice sale in 2013 so I’ve had no real exposure to CQC fees since, but I seem to remember a registration fee of £1500 or thereabouts. I had a quick Google this morning and there nowadays seems to be a complicated formula for working out how much dental practices have to pay in fees, based on the number of chairs the practice has, and if you are insane enough to work at more than one site.
I remember that there was a lot of resentment among dental practice owners around
2011-2012 at the introduction of the CQC to the dental field. Many questioned the need for yet another authority to oversee the profession. We’d already got the Health and Safety Executive, the Primary Health Care Trusts (as they were then) and the General Dental Council. Did we REALLY need another?
Yes. We certainly did.
Over the 19 years I had my practice, I had only a couple of informal routine visits from an NHS dental practice advisor. Near the introduction of CQC registration, I had a visit from the area infection control coordinator (until that point I didn’t know such a person existed) to ensure we were complying with HTM-01-05. As it happened, we weren’t - a sink in the decontamination room was in the wrong place and we had to move it to comply with the rules. Apart from that, there was no real oversight of the practice. In most of my ownership days, we still had the random checks from the RDO where the Dental Practice Board would choose a few patients for inspection at the local correction facility (as I liked to call the community dental clinic), but that was it. What went on in your practice was very much your own affair. Nobody randomly checked to see if you were boiling the instruments properly in new saucepans, or diligently spraying the reusable patient bibs with Febreze.
As it happened (and it was probably more luck than judgement), apart from a few bits of paperwork we needed to spruce up, we were pretty near compliant before the CQC came-a-calling. But having worked in a number of practices as an associate before I bought my own place, I can attest that there were a lot of places that would have really struggled to come up to basic CQC expectations, let alone those required by the CQC.
I will describe ONE such practice that I worked at.
It was 1990 and I’d been qualified a couple of years. I joined an old established practice on the Cotswolds border as an associate. The practice had five surgeries and was manned by a husband and wife who were the owners, a long-term associate, a hygienist and moi. The bosses had taken over from two very old school and respected dentists, one of whom appeared to have been grandfathered on to the dental register from his primary job as a barber and blood-letter.
The practice was set in a grand Georgian terraced house, and once you went above the surgeries on the first floor, it appeared that the last vacuum cleaner ever to be used on the 2nd and 3rd floors, was the Batty-Fang Carpet Beater 1900. I never saw those floors during my interview, and neither did I see my surgery. When I turned up for the interview, my surgery was in use by the hygienist (apparently) and I couldn’t see into it, the door being solid wood. When I arrived for my first day of work, my surgery was decorated in the style of a 1940’s London Underground station lavatory. Every square inch of the walls, ceiling and floor were tiled in a faded turquoise and the pipes for the aspirator and services lay on top of the floor, presenting a tripping hazard to anyone entering the room. I found out later in the day that the practice was supposed to be haunted. The legend went that the house was originally owned by a well-to-do family and the man of the house had an affair with the housemaid, who I shall call ‘Flora.’ When it all went pear-shaped and Flora became pregnant and was shamed, she hung herself in my surgery (which was the kitchen originally – the fireplace was still in the one wall). Her feet would have dangled over the reclining headrest. It’s another story, but my associate colleague heard Flora singing late one night on the top floor, and truly I saw an outline of her brushing her hair through a window, one dark winter’s afternoon.
After a week I could stand no more. I discovered that Tanya the hygienist only worked in the practice two days a week and although not spectacular, it at least had an acceptable, if dirty wall-covering. I asked if I could swap rooms and poor Tanya found herself in the lavatory. She never thanked me. I asked the practice owners if I could decorate the room myself and at my expense. The bosses agreed. I did it in a nice bright pink and I put some decorative borders up. The husband came in first thing on the Monday after I had decorated, put his head around the door and said without a hint of humour: “It looks like a bleeding tart’s boudoir in here.”
Unfortunately, the equipment was as old as the building and the delivery unit was the size of a modest Buckingham Palace fridge and it was about as manoeuvrable as trying to get a Dalek up the stairs. It had polyoxybenzylmethylenglycolanhydride (Bakelite) control switches and buttons and piping that had been repaired by shortening so often, when you moved the drills in a patient’s mouth, the unit was dragged with it. In the two years I was there, I never saw an engineer come in to service the equipment (not that the spare parts were still made for the units). I’m sure it would never have come through a thorough PAT test with flying or even submerged colours. My unit had a dodgy connection with the handpieces and every now and then there would be an explosion of air and what remained of the air-tubing would fly off and snake wildly about the room like a twerking cobra. I point blank refused to have anything to do with fiddling about with the equipment and so my nurse would go and fetch the husband. I REALLY want to name him, but I can’t, so I’ll call him Boris. Anyway, Boris would invariably come with a pair of scissors in his hand and a cannister of sturdy floss, and tie the tubing back on to the handpiece coupling until the perished rubber broke again.
Fortunately, the CQC also ensure premises are safe and up to the mark these days. Boris’s place wasn’t. I doubt that the electrics of the practice had been checked since Thomas Edison was a lad. One day I was doing a full denture try in. I had just given a deaf lady a mirror so she could have a good look and the small, white, straight set up. There was suddenly a loud bang and a flash from behind her. A Bakelite electrical socket (without anything plugged in) had just exploded with no provocation. I jumped and my nurse shrieked, but the patient just sat there wondering if the shade was maybe a little bit dark. She even carried on looking intensely at the denture while Boris ran into the room behind her with a fire extinguisher and started spraying powder all over the place. I can’t remember off hand if the socket was ever dealt with afterwards. We were probably told never to use it again.
One of the worst incidents that happened at this place and inspired me to look for a job elsewhere was when I was treating a patient and Boris’s nurse flew in and said “Can you give Mr Aguecheek a hand…NOW!”
I went into the lavatory-surgery to find Boris was struggling to keep a child anaesthetised. “Just pop the E out for me” he shouted. I went cold but did it. I hadn’t realised until that point that he was doing child general anaesthetics acting as operator and anaesthetist. I knew for a fact that his nurse wasn’t trained at all, being a newby. I rarely lost my temper, but told him as soon as the opportunity arose, that he was never to involve me in GA’s again.
But that probably wasn’t the worst of it. Oh no. I discovered while I was working my notice, that Boris and his wife Priscilla didn’t dispose of sharps through a clinical waste company. He apparently used to box them up and dispose of them just as the local tip was shutting and it was getting dark. I found that out from one of the receptionists as I was having a chat between patients. I had only just muttered “That is absolutely disgusting” to turn round to find Priscilla was standing behind me. Well it WAS disgusting and again, I told them that I would have to report them to the local Family Practitioner’s Committee (as it was then) if I witnessed them doing it again.
Suffice to say, they also ignored employment laws. A trainee nurse who had gotten fed up with £2.40 per hour they paid, handed in her notice. At the end of the first week of her fortnight’s notice, they withheld her wages, only giving them to her after the rest of the nurses and I, threatened to strike. After I put my own notice in, I found two of my monthly payments were delayed and Boris used to sneak out of the practice so he didn’t have to see me. He worked on the first floor and I was told by his nurse that he daily tiptoed down the stairs quietly so I wasn’t aware he was leaving. One morning, I finished early and waited for him. I flew out and ran at him, catching him halfway up the stairs. I’m not a big bloke, but when I get angry, I can make myself big. When he came back from lunch, he gave me two cheques.
The thing that was interesting here, and it accounts for the fact that I am not impressed by people on committees is that both Boris and Priscilla were ‘upstanding’ members of the local dental community. Both were big in the British Dental Association locally, and both had been LDC members, yet they operated like that.
So do we need the CQC?
Yes we do. The pally pally relationship they must have had with the local dental practice advisor obviously didn’t address major problems with their practice. In these days where we are all faced with a torrent of potential litigation every day, at least complying with the high standards set by the CQC reduces risks marginally and prevents inadvertent swamping by an avalanche.
But it all turned out okay in the end for Boris and Priscilla.
They both dead now.
Have you ever regretted a decision? Have you ever leapt at a chance only to end up slipping on a banana skin? That pretty much describes my dental career. "Do I Get Another Go?" Rethinking A Dental Career After Retirement By @DentistGoneBadd
It's the summer, and soon you'll all be inundated with patients wanting their teeth fixed before they smile nicely for the border control people. Brace Yourselves, People - The Holidays Are Coming. By @DentistGoneBadd
NHS hospital doctors are understandably concerned about refusing treatment if overseas patients can't pay. But is it that hard to deny patients treatment?
I'll Do Anything For Teeth But I Won't Do That)
If your patients feel more confident using a bit of glue on your superb denture, do you despair? Well you shouldn't. It's all cool according to a new white paper.
Meeting A Sticky End
Why Dental Fixatives Are No Longer Taboo
Domiciliary dental care was in the news the other day — or rather a lack of it. Hopefully there may be some discussion now on adequate funding for treating the housebound. "Sorry. Don't Do House Visits"
I was initially quite scathing of the Tory Leadership selection process, but when I looked back critically at the way that I chose members of practice staff, I thought better of it. "You'll Do" How NOT To Choose Practice Staff By @DentistGoneBadd
The poet Philip Larkin wrote words to the effect of "They mess you up, your mum and dad." They may very well do, but I think dental school has exactly the same effect on dentists.
Dental School. The Worst Days Of My Life
Sometimes, keeping quiet is the best way to remain diplomatic in dentistry. There are various ways of stopping yourself from putting your foot in your mouth. Here is my favourite.
Stock Up With Lip Balm
When Biting Your Lip Is The Best Policy
Patients do some strange things, but so do dental product manufacturers sometimes. They're as bad as each other in my book. You're putting WHAT In Your Mouth? (Some DIY Dental Tips) By @DentistGoneBadd
The Definitive Guide To
Writing Referral Letters
Let’s start with the essentials. Referral letters should contain the basics; name, sex (if any – I don’t like to ask really), date of birth and reason for returning….oh sorry, that’s sending a parcel back to Amazon. Long gone are the days of “Please see and treat,” so try and give the specialist you are referring to, a bit of a clue as to the reason for your referral. Throw in a couple of vague differential diagnoses if you can, just to demonstrate you aren’t completely gormless, with proper medical terms like ‘epidermolysis bullosa’ or ‘squishy lump.’ It’s probably best not to refer a patient just because you don’t like the look of them, tempting though it is.
If you are worried about a lump, it’s best to send to a consultant lumpologist. But beware, some specialisms do cross over and consultants can get a bit elbowy and will fight over interesting lesions. I once witnessed a near fist-fight between an oral medic and an oral surgery registrar – both convinced they could write a paper about it. Every time, make sure you are referring to the most appropriate department. One department will treat a lesion with a spray and ineffective mouthwash, while another will cut it out and put an implant in its place.
Oral surgery referrals are probably the most common type made. It’s not quite clear why this should be. Fewer dentists get into trouble over oral surgery than perio neglect or root-treatments. I think that oral surgery is probably all a bit too gooey for a lot of dentals and the anticipation of complications is overthought. Because oral surgery departments are absolutely swamped, you have to make a convincing case. Warfarin patients are no longer a bar to treatment in practice, so throw in ‘difficult access’ and ‘a history of difficult extractions’ for good measure. ‘Proximity to the antrum’ doesn’t often wash. Since many oral surgery departments insist on you supplying a supporting radiograph, they can justifiably throw out the referral and tell you where to stick your jpeg when they realise it’s a lower molar you are talking about.
These are probably a little more clear-cut, if you completely ignore IOTN, which I did. I doubt very much if it’s done now, but the acronym ‘FLK’ (Funny Looking Kid) in the margins of the old paper files, acted as a reminder to refer to the orthodontist once the overcrowding started to hurt your aesthetic sensibilities. I find FLK’s generally DO get orthodontic treatment, so providing they are reasonably competent with toothbrushing, and generally look as if they’re using the hairy end, send that referral. Again, don’t just ask to ‘see and treat’. Throw in ‘well-motivated,’ ‘optimal oral hygiene’ and ‘very stroppy mother’ to emphasise the need for action. Chuck in a couple of measurements if you can, and try and crowbar in a stab at a ‘division’ to show to the orthodontist you’ve given it some careful consideration.
This type of referral is usually done in panic five minutes after you have just unexpectedly lost a BPE probe down a previously scoring ‘1,’ so do try and keep the panic out of your letter. Make it sound like you’ve been closely monitoring things for a considerable period of time and really emphasise that when you first saw the patient, most of the damage was already done. ‘Despite my oral hygiene instruction’ also shows that you have been caring, but don’t get too down about having to refer and being condemned by the periodontist. The specialist will probably only see the patient for twenty minutes max anyway, and will never see them again, immediately throwing the patient into the ‘Pit of Hygienists.’
Endodontic referrals are becoming incredibly popular and you are highly unlikely to get one rejected, since they are often made to private specialists. Don’t bother trying to refer to your local dental hospital. The sun will have died well before your patient gets to the top of the list. Besides, dental hospital endodontists are exceptionally picky about what they treat. My local dental hospital won’t treat any tooth beyond a first molar. They aren’t that clear why, though I suspect it’s because trying to get to a seven is a bit ‘too fiddly.’ Failure in endodontics is a growing area of litigation and if you are an NHS dentist in particular, don’t risk ANY root-treatment – refer. You can throw a lot of information into your referral letter – sclerosis, unusual anatomy or “There’s a prominent squiddly-do on my radiograph” – but it doesn’t matter. These are endodontists. They have to pay for swanky microscopes and German Sportwagen. They’ll accept anything.
See Endodontic Referrals. Patients think they are the same thing anyway.
Tricky. Prosthetics specialists are a dying species. Their natural habitat in the 60’s and 70’s was gummy, but since forestation with teeth, the need for them has diminished. The few prosthetists left, tend to pack together at dental schools, desperately attempting to procure close relationships with implantologists, borne out of their innate instinct to survive. Having said all that, I have had more referrals rejected by prosthetics specialists than any other type. To be absolutely honest with you, whatever you say in your referral to a denture specialist, they’ll write back with “We would recommend extending the flanges and see no reason why this cannot be carried out in practice. Now leave me alone. I need to bury my nuts for the winter.” Good luck.
This is where you send all of your ‘challenging’ patients, or those that take an hour to do an enamel-only incisal edge composite on. Terms you should include in your letter are ‘wriggly,’ ‘anxious,’ ‘fearful,’ ‘phobic’ and ‘gagger,’ though be careful you don’t end up making it sound like a Facebook advert for happy hour at the local S&M Club. Make it absolutely clear that this patient needs sedation. Forget about suggesting GA. The clinicians at these emporia don’t stop talking about the risk of death from the time the patient enters the place having found it after previously mistakenly walking into the adjacent STD Clinic. If your local clinics have their own referral forms and it gives you the option to have the patient back if they refuse sedation, tick ‘NO!!!’
Quite a few restorative specialists lurk in dental schools, but despite this, they try not to have anything to do with teeth. There is only one important, indeed, CRITICAL sentence you need to include in your referral letter, and that is: “I am ALREADY monitoring the diet and wear.”
You will normally refer to the oral medicine specialists as a means of backing up your diagnosis, which is almost certainly, atypical facial pain/burning mouth syndrome. Often, you would save a lot of time by giving a nightguard or benzydamine hydrochloride rather than wasting your time on a referral letter.