ISFE Feedback October 2008

Series of three pictures of a bone anchored palatal expansion device. 1) device in situ, 2) showing Le Fort I osteotomy cuts 3) postexpansion

Questions – What is it? What does it do? What other types of expansion devices are there? What advantages/disadvantages does this type have over other types? Tooth movement, bony change, evidence, complications, orthodontic preparation, surgical procedure (what cuts are made where) etc.

Whch patients is it suitable for (age) and what is the underlying biological basis (distraction osteogenesis)

History of thirty year old lady who is concerned about her “changing bite” this was supported with a lateral ceph which showed a patient with an increase FMPA, AOB, skeletal II base and an increased overjet.

Questions – How are you going to management this patient on your new patient clinic? History, what does pt mean by “changing bite”? what was occlusion like before she noticed it changing and over what time period has it changes? Is it processing or not? Differential diagnosis and primary diagnosis?

Suggested causes/risk factors and management for Idiopathic condylar resorption? Photographs and articulated study model to determine a baseline form which to measure further change. Once stabilized, to discuss management options? Surgical procedures – posterior maxillary impaction, mandibular auto rotation and advancement and costo-condylar grafting including discussion about the similarities of the fibro cartilage of each of the joints. Aim of orthodontics - to keep upper incisors proclined to compensate for the posterior impaction, align and coordinate arches etc. Consent – risk of relapse, future resorption etc.

Urgent referral from GDP and photos of one their patients after having early functional appliance therapy with a Twin Block incorporating a labial bow and some mild discolouration of the central incisors. Accompanied with peri apicals of the maxillary incisors.

Questions – Suspicious of devitalised central incisors? Diagnosis of problem – colour, mobility, percussion, sensibility tests (ethylchloride and electric pulp testers – merits of each), pain/swelling. History from patient – history of trauma, what type, when?

Trauma discussion – what types of dental trauma? Long term effects? Monitoring periods for different types of trauma? Treatment options both if the trauma occurred before the start of treatment or during a course of treatment?

Photograph of a fixed appliance in situ with temporary anchorage devices placed anteriorly and between the UR3+4.

Questions – Tell me what you see? What are TADs? What types of TADs are available? What are the advantages and disadvantages of the different types? What are they used for? What are they being used for in this particular case? What is the process of inserting them – consent (NICE Guidelines etc), stents, length/ widths used, pilot hole or not, angle of placement, anaesthetic used, post op recovery – immediate loading or not, monitoring use via audit ( BOS – national audit )?

Photo of a 18 year old RHS CLP patient with a mild pan facial asymmetry and a skeletal III base (mostly due to maxillary retrognathia) and missing lateral incisor, Lateral Ceph and OPT of the same patient, showing different condylar morphology on either side.

Questions – Tell me what you see / describe this pt? Role of orthodontics in orthognathic preparation. Importance of coordinating the arches and including all the teeth into the appliance. Treatment options in this particular case, extraction patterns and camouflage options for the missing lateral incisor. Members of the cleft team and who would the patient see prior to orthognathic surgery. Risks of orthognathic surgery in CLP patients and techniques for minimising the risk of velopharyngeal incompetence (advantages and disadvantages including techniques for preop VPI assessment (video fluoroscopy and nasendoscopy)

Intra-oral frontal photograph of an adult with retained maxillary left deciduous canine, missing maxillary right lateral incisor with the maxillary canine in its place, which has been restoratively camouflaged with either a veneer or crown. The contralateral lateral incisor is restored with a crown with its gingival margin at the same height as the canine and central incisor on that side. The patient is unhappy about their appearance – what can you do? Discussed gingival margin aesthetics, options for replacing missing lateral incisors, restorative only options, combined options, camouflage techniques for disguising canines and first premolars as lateral incisors and canines respectively, anchorage limitations and methods of anchorage control/reinforcement. Disadvantages of leaving a deciduous canine in situ – future restorative consequences. Other options such as dentoalveolar ridge development, why is it so useful in this situation (3D enlargement therefore ideal for implant placement, bone preservation, canine root longer therefore more resilient to resorption, Class I canine) and who described this technique ( Kokich)

You are the consultant in a busy district general hospital. A memo arrived from your directorate manager stating they want you to make a 10% saving by year three. How are you going to achieve this? Initially planned to discuss the options of increasing income generation, but told (at the start of the viva, and after the planning period) that increased income generation and staff reductions were NOT options to be discussed. Discussed data gathering process, i.e. financial accounts for the previous 3-5 years to establish current expenditure – capital and running costs. Methods of reducing costs – departmental charges e.g. radiology, Mortuary!, physiotherapy etc costs – are they appropriate and properly calculated. Lab costs, materials, heating, lighting, maintenance of equipment and building – contracts length and cost etc, carrying out a stock take to minimise waste of products expiring and overspending.

The PCT approaches you, as the consultant of a district general hospital, to set up a Managed Clinical Network. How are you going to do this? BOS suggestions, types of MCN’s? Roles of the MCN’s? Who’s involved as the main stakeholders? Funding support? Secretarial support? Organisational set up (Committee structure) how to plan meetings, circulating minutes and creating agendas.

A teenage patient attends for a bond up with his mother and you notice that the mandibular right first premolar has been extracted by the GDP rather than the mandibular right first molar which has a poor prognosis. What are you going to do? Initial management – what you tell the patient and his mother? What records are you going to take? Who are you going to contact? What investigations are you going to do? (Not to assume that that it is the GDP’s fault, it may a mistake in the extraction letter). Incident reporting, root cause analysis, learning from mistakes. Do you bond up or delay treatment? Orthodontic management – Impact of the wrong extraction upon treatment. keep the first molar or extract it? Restorative opinion, use of TAD’s to close space. Duty to the patient – informing them of their rights, involvement of solicitors, what you should tell them (facts only), limitations on claims – time, cost, process of litigation.Where to get information about expert witnesses, who can be one and the different types of legal reports that can be produced.

A new post CCT trainee has just started in your department. You are told the first three patients have not have sufficient explanation about the proposed treatment. You review the cases and find that the notes have not been written up, and the alginate impressions which have been sent to the lab are poorly taken and deficient. How do you manage this?

Don’t make assumptions – investigate. It could be due to trainee deficiencies (capability or ill health) or systematic problems within the service (inadequate appointment time, language difficulties and no interpreter, lack of introduction into the department – standard expected). Who do you speak to? Nurses, former trainers (where was trainee trained – within the UK, within the EU, outside the EU – standards vary), patients, other staff.

Management of an underperforming trainee – Patient safety first, discussion with trainee, stop trainee treating patients, shadow consultant, monitor/supervised treatment. Training Programme Directors and Post Graduate Dental Deans involvement, the RITA process etc

You are a single handed orthodontic consultant in a district general hospital. The local TPD approaches you to see if you could take on an overseas registrar for one day a week? Assessing the practicalities – clinical capacity, impact on other members of staff – nursing cover, increase in lab work, secretarial support and reception. Decrease in consultant output due to training commitments. Discussion with management – income (PBR), costs – materials, support (nursing, lab, reception, consultant), help manage 18 week RTT. Differences between overseas registrar and UK registrar – competitive entry, possible previous experience/ability difference, registration with GDC, independent practitioners (if not, unable to work if consultant not present) etc.

The head nurse approaches you to discuss assisting the nurses within the department obtain the required CPD. What is the required CPD for nurses (hours and specific subjects)? When did it come into force? Organisational issues – nurses having time off or undertaking it in their own time, funding sources for courses, where courses are held (within the department, region, deanery) etc. How to arrange CPD and it’s requirements ( aims, outcome, feedback, certificate). How to generate funding to create a study/slush fund ( arranging courses or study days, selling toothbrushes, charging patients for repair/replacement appliances ).