Do You Use Chlorhexidine as a Root Canal Irrigant?

Jaz’s Introduction:
Let’s face it, you know, it’s a composite veneers. That’s where we gonna go on. But you know, this is super, super important stuff. And today’s episode which we streamed live to Facebook. So thank you, Dr. Lucy Nichols, for being part of that live. And so we do have a few shoutouts here and there. And thanks to all of you who joined live on Facebook, it’s on the Protrusive Dental Podcast facebook page, if you’re not part of it already. Occasionally we do the live and it was a great episode. These are the 10 COMMANDMENTS FOR STAYING OUT OF TROUBLE. And where they stem from is Lucy Nichols who is a general dentist, she does some dental legal work. And as part of seeing lots of cases, she saw a pattern that dentists, us dentist we’re getting in trouble. And were tumbling down as easy victims, booby traps, were falling into these obvious errors, which she wanted to share with you to make sure that we can be SAFER DENTISTS and avoid getting claims and having legal troubles. So, hopefully you’d like all these 10 Commandments by Lucy, so I only knew the first one and I loved it so much. I said, ‘Okay, come on. Let’s do the podcast, tell me the other nine.’ So, we’ll share them all with you.

The Protrusive Dental Pearl:
The Protrusive Dental Pearl I want to share with you before we get to that main episode is kind of related to the first thing I said in my introduction, which is DO WE MAKE TIME FOR THE RIGHT TYPE OF CPD? And on that topic of time, let’s take a step back right? MAKING TIME. We all have just 24 hours a day, every single one of us whether you’re Richard Branson, or Rishi Sunak, the new Prime Minister of the UK, I try not to get into politics. So, I’ll stay away from that one. But we all have a finite amount of time. And so really, we can’t say that, ‘Oh, I don’t have time for this, or I don’t have time for that.’ And I used to say this, ‘You know, I don’t have time for this, or I’m too busy for that.’ And really, we should reframe how we say that. We should not say that I don’t have time for something. Instead, we should say, ‘I’m not making that thing a priority in my life right now.’ So let’s say one I’m guilty of, okay, I’ve gotten the gym membership, I want to go more. But at this moment in this season, it’s not that I don’t have time for the gym, is that I’m not making my health a priority. And so once you identify that, you have then listen to yourself, and then listen to your feelings in terms of, how does that sit with you?

So, that thing that you’re not making time for whether it’s further education, these not so sexy topics, or something in your life that you think you should be doing, but you’re not doing it that you’ve chosen to make it a low priority in your life, once you recognize that you’ve made it a low priority. If that makes you feel happy, then great, keep making a low priority. Never do that thing. But for like me when I listen to myself say, ‘You know what, I’ve not been going to a gym in the last couple of weeks. I feel bad. And I don’t feel good about it.’ But that is a sign that okay, we need to change something. So it’s not that I don’t have time for certain things is that I choose to prioritize certain things of others and you gotta then listen to yourself, does that sit well with you? And then make changes accordingly.

So, reflect on that Protruserati, what do you make a priority in your life? And what should you be making a priority? All I appreciate that all things that could be doing, you’re joining me and my guests on Protrusive Podcasts really means a lot that you’ve joined us here today. Whether you’re driving, chopping onions, or watching on YouTube, or wherever you are. Or on the app, this one’s eligible for CPD just four questions after you listen or watch, and then you can get your CPD certificate. There’s lots of premium content coming. So next week, myself and Alan Burgin on the premium section have a whole one-hour video of discussing FULL PROTOCOLS STEP-BY-STEP, a full mouth rehab case that blew up on social media when Alan posted it.

So, shout out to Satnam Uppal, who recommended this episode to come into fruition. So that’s coming next week exclusively on the app, this won’t be on YouTube, it’s gonna be on the app only. So, download the Protrusive App on iOS or Android. To download the app, it’s absolutely free. But if you want to unlock a few extra features, it is a subscription which I hope to deliver immense value to you. Anyway, let’s join the main episode with Dr. Lucy Nichols. We are going live now. So hello, Protruserati. Welcome to this very rare live podcast I’ve got today. Dr. Lucy Nichols who does lots of dental legal work. And you’ve seen the title is The 10 commandments, which are Lucy told me were her 10 bugbears which I absolutely love and I’m really excited to get stuck into these. Usually when we do a podcast with a guest, I kind of know the questions I’m going to ask already but this is a little bit different. It’s one that’s I’m very excited for it because this is one that actually Lucy will be leading in a way that she is going to be guiding me through a 10 bugbears because she does so much dental legal work and has been involved in this space, she’s got these things, which I think are going to really help us to stay out of trouble. And that’s the purpose of this podcast to help you all STAY OUT OF TROUBLE, help me stay out of trouble. I don’t wanna get in trouble.

[Jaz] Main Episode:
So Dr. Lucy Nichols, I know we both qualified from Sheffield at various times, and you do a lot of, you’ve done lots of dental legal work over the years. Just tell us a little about yourself before we get into the 10 Commandments of Staying out of Trouble.

[Lucy]
Okay, well, hi, Jaz, and thank you so much for having me on. So yes, I qualified from Sheffield, just like you but a good few years earlier, I did a year of vocational training there. And then I moved to London and did a couple of years of hospital jobs in oromaxillofacial surgery. Then I went into practice, mainly NHS mixed practice, but mainly NHS and did that for a little while. And then I started to become a little bit disillusioned. I wasn’t enjoying it very much. I was starting to wonder if Dentistry was the right thing for me. And I reached a point where I realized that the question I had for myself was, is it dentistry that I don’t like or is it NHS dentistry that I don’t like? So I decided before I quit dentistry, I needed to try quitting NHS dentistry. And it can be quite competitive getting jobs in London. So I decided I needed to upskill so I started doing an MSc in restorative cosmetic dentistry, and-

[Jaz]
Was that Eastman or Kings? Or?

[Lucy]
It was uwchlan.

[Jaz]
Okay.

[Lucy]
And partway through that I moved to working in fully private practice. And through the process of doing the MSc and moving to working in private practice, I started to really love dentistry again, and was much, much happier. So, that worked out brilliantly. It was a fantastic move. And I’ve really enjoyed working in dentistry since then. It’s always-

[Jaz]
It’s very common, Lucy isn’t it in terms of going through that period in your career? Were thinking is it actually right for me? And I hear this from dentists all the time. And I think you summarized it really well. And you know, let’s forget NHS one, whatever environment you’re in, it could be a private practice, but in a toxic culture, a toxic environment. So, it’s really all about your environment. It might not be dentistry that you don’t like, it’s your environment that you’re not getting fulfillment from at that time.

[Lucy]
Yeah, absolutely. But also I find what’s really important for me is to keep learning. So even just enrolling on the masters and starting that program just reinvigorated me, I suppose and probably other people can as well. You get bored doing the same things all the time. So, when you’re learning and then doing new things, it just helps to keep it interesting. So, that’s what I’ve done, I guess. And over the years that I’ve been working in private practice, I’ve learned new skills, I started to do Invisalign, I started to play some restore dental implants. So you know, I’ve always been looking for what else can I add to keep it interesting. And then a few years ago-

[Jaz]
And then dental legal work?

[Lucy]
And then a few years ago, I started getting involved in in dental legal work, I’ve got three children. And it was something that allowed me to work part time clinically and part time from home. And that’s led to like a really good work life balance. My kids are getting a bit older now so that makes it easier doing the work at home. So, now about half of my time is clinical work and about half of my time is dental legal work. And I love that balance. It’s amazing to be able to sometimes work in my pajamas in bed if I want to, which I never thought I’d be able to do as a dentist. And just generally, I love the balance of having the clinical and the non-clinical works really well for me.

[Jaz]
Fantastic. Well, I just want to say some hello’s. Hello to Suleiman from West Cumbria. Hello Narni, from Sheffield. Narni is always a pleasure to see you on here. And guys, if you’ve got any questions, please come on in. If you’re on here, and you’re enjoying the themes that we’ll be covering, please share it to, you know, the Protrusive Group or any other groups that you’d like share it to. Any friends that you want to join in this live version, it’ll go in the main podcast, Spotify, etc. But there’s a magic about being live.

So Lucy, when you spoke on the phone, you shared your first bugbear with me, and I loved it so much. So, why don’t we start with the top 10 commandments, which stem from your frustrations and the angle and the approach and correct me if I’m wrong, Lucy if I’m putting words in your mouth, but the reason you’ve identified them is because you almost got sick of seeing people falling into the same booby trap. People point the same traps, they must think will save so much money by GDC and medical legal costs. If this if this these 10 things were done better. Would you agree with that?

[Lucy]
Yeah, absolutely. Absolutely. So it seems to be things that maybe some of them are people realize they should be doing. Maybe some of them aren’t quite so obvious, and that they’re things that people maybe don’t quite realize that they need to know. So yeah, I’m really hoping it’ll be helpful for people.

[Jaz]
Well, let’s go with number one, which I love. And I told you not to tell me the other nine because I want to do it live. So, just remind me and everyone else are watching from it probably in their pajamas right now. What is the number one bugbear, not necessarily the most important, but just on the one on your list?

[Lucy]
Okay, number one on my list. Yeah, so number one is, ‘Thou shalt take bitewings on children.’ So I don’t know where this comes from. But it just seems to be a thing that dentists don’t take bitewings on children like literally none. You know, I see cases with children been going to the same practice every six months from when they were really young. Through 6, 8, 10, 12, 14, 16. No bitewings at all. And when you have a child who has kept primary carriers to the pulp, and they’ve been going to the dentist every six months, then how are you going to be able to defend that in the claim if you’ve never taken bitewings? And I think sometimes people assume or they might even have written in the notes that a child is low-risk for caries. But how do you know if you’ve not taken the bitewings? Because it might well be that there is carries there that’s developing and progressing towards the pulp. And you just haven’t seen it because you haven’t taken the radiographs.

[Jaz]
Very true. And you’re eight times more likely to diagnose caries through bitewings. Just compared to just clinical examinations, there’s this staff I remember from Helen Rod at dental school at Sheffield. So it is fundamental, and I wholeheartedly agree with you. I think we do as a profession needs to take it is. As though we look at the guidelines for radiograph taking and we completely blur out and ignore the children recommendations which mirror-

[Lucy]
It’s bizarre.

[Jaz]
Well, the adult ones completely agree. So it’s a massively frustrating thing,

[Lucy]
They mirror them. But the FGDP guidelines for taking bitewings are to take them for adults at 6, 12 and 24 month intervals for high medium and low-risk for caries. But for children, that are actually 6, 12 and 18 month intervals. So, they’re putting in more emphasis on potentially taking them more frequently for children than they are for adults. Yet what happens in practice is people just don’t bother taking them at all. It’s bizarre. So I don’t know, why-

[Jaz]
Why do you think that is? I mean, is it just to save time and just be quick in and out?

[Lucy]
I don’t know. I mean, for me working in private practice, if I take x-rays, I get paid for it. So I understand that it’s difficult for colleagues who are working in NHS practice either they take X-rays, it’s not going to get them any extra few days to do that, I understand that they are under a lot of pressure. And that is difficult. If you do take the bitewings though, and there is caries, it might allow you to get the three As that help you to meet your targets. And also you’re potentially going to avoid getting sued from because you’re not going to miss the caries. And you know, and ultimately, it’s the right thing to do because it’s proper patient care. So-

[Jaz]
Yeah, agreed. So guys, let’s start taking bitewings in children. If your practice doesn’t have biting holders for children, that’s the first thing to do tomorrow morning. Just get those audits, right? As if we know, the smaller films.

[Lucy]
Yes, smaller films. That’s what I was gonna say. I think what maybe puts people off as children not being able to tolerate them. So if children aren’t tolerating them, make sure that you’ve got smaller films. And I think even with the smaller films for children, sometimes what you also need is the little paper tabs, because the holders can be too bulky and uncomfortable. But those little paper tabs that they’re really quite comfortable. I think that they’re not too awkward in the mouth compared to what a film holders like so I think children tend to get on pretty well with those you can manage to get bitewings on pretty young kids with those.

[Jaz]
See, I’m just thinking that bitewings are nowadays, it’s like a birthday present when you’re 18.

[Lucy]
Yes.

[Jaz]
It was like that really? Right. So fine, let’s get the correct films and correct holders guys and let’s crack, get cracking. We know we need to do this. Let’s do it.

[Lucy]
Yes. And do at 6, 12 or 18 month intervals, as your meant to.

[Jaz]
Any guidelines to what is the lower limit in terms of like age three, age four? What guidelines can we use for the younger patient?

[Lucy]
Well, for the age to start doing it-

[Jaz]
The first bitewing.

[Lucy]
The first bitewings? Well, I think the idea here is to do it once the contacts close the interproximal contacts between the deciduous teeth closed, which is about the age of four or five. I mean, I think in reality, it is going to be challenging to take x-rays on a lot of four or five year olds, but I certainly think by eight to 10, you shouldn’t be attempting and if they can’t tolerate them, they can’t tolerate them. But you’ve you’ve tried, and you’ve written in notes that you’ve tried. So, you know you’ve done your best and you’ve covered yourself and that’s all you can do.

[Jaz]
So ‘Thou shalt take bitewings for children.’ Number two, Lucy.

[Lucy]
Number two, very similar, but I’ve made it slightly separate. ‘Thou shalt take bitewings on adults.’ So, the reason I made them separate is because it seems to me like this thing with children is a really, really specific thing that people just aren’t bothering to take X-rays on children at all. So I put the adult slightly separately as it is I feel like it’s a slightly different issue. People generally are better at taking bite wings on adults, but I really feel like they’re not good enough. I do still see it far too often that people take them somewhere to rack erratically or still often it’s not that unusual for me to see people who just for years and years and years and just don’t take them at all.

[Jaz]
What I’ve seen a lot of Lucy in practice I’ve worked in is that they like clockwork but every two or three years and then they like clockwork so that it doesn’t change dynamically as a patient changes. It doesn’t become 18 months. It doesn’t become annual for the right indications for higher cariers. It just stays. ‘Oh, it’s been our last time 2019, it’s 2022, okay, it’s been three years, let’s take it because we’re gonna cover ourselves all over.’ So, it needs to be a bit more bespoke to the individual.

[Lucy]
It does, it does. So, people seem to ignore caries risk. And like you said, they just take them too early for everyone. So, the guidance is six monthly for high-risk and 12 monthly for moderate risk and 24 monthly for low risk. So, it is really important to pay attention to the caries risk. And another point that I find as well is you can take bitewings on patients who are pregnant, the guidance says it’s safe to do so. Personally, I always give patients the option, I let them know that the guidelines says safe to do so. So usually they will have it, but if if they would rather not, then that’s fine. I’ve offered it, I’ve given them the correct information about the guidance that they’re saying that it is safe. But at the end of the day, you know, we can’t force patients to do anything. And if they choose not to, then that’s their decision.

[Jaz]
Yep, absolutely fair. Number three, thou shalt.

[Lucy]
Okay, number three, ‘Thou shalt always be suspicious of a non-healing socket.’ So, don’t keep treating a socket as a dry socket when it’s not healing. Beyond two weeks, you would be surprised the cases I’ve seen where even after two to three months, somebody keeps coming back to the practice. Keeps having the sockets irrigated and Alveogy put in. It’s just not normal. I mean, why would you not think that something’s up, you know, two months after a tooth has been taken out when somebody keeps coming back? So, the funny thing here is that in the NICE guidelines about oral cancer, non-healing socket does not get a mention, it’s a bit of an anomaly. I really strongly feel it should be in there. I do feel that it is basic undergraduate knowledge. It was certainly something that we were taught at Sheffield, I was in my year, I’m sure you were as well.

[Jaz]
Probably by the same person, Mrs. Freeman et al?

[Lucy]
Probably. Probably. And it was certainly an undergraduate textbooks. So, I’m not sure why it’s missing from the NICE guidelines, but it definitely should be. I’ve come across a few of these cases now. And when I think about my own practice, you know, you get patients who come back with a dry socket from time to time. Usually they come, you’ll irrigate the socket, but put some Alveogy in, they won’t come back again. Occasionally, they’ll have to come back for a second time. And you’ll do that again. And I think maybe I can probably count the number of times on one hand that somebody’s had to come back on three occasions to have a socket dressing. And I would I’m pretty sure that’s all been within the first two weeks from extraction.

[Jaz]
Yup.

[Lucy]
But beyond two weeks, that’s not something I see. I don’t see people coming back with problems with the socket after two weeks. And if I did, I would be concerned. So, obviously it could be cancer, but it could also be osteomyelitis. It could be medication-related osteonecrosis. So you know, MRONJ, so and if it’s not cancer, if it’s osteomyelitis, or MRONJ either way, you’re going to want to get that referred ASAP.

[Jaz]
Yeah, I’ve seen a few MRONJ. But nothing like a cancer from an underling socket. But yeah, I’ve seen a few MRONJ. And it’s very simple to diagnose, of three weeks where the mucosa is, is it’s still not looking like it should be. And sometimes a patient’s not even feeling discomfort, but it’s an observation that you’ve made, because maybe the first few few days that they were in discomfort, then you review them. And if you’re still not looking better, get that referral sorted.

[Lucy]
Exactly. Yeah, I mean, either way, whether it’s any of those things the cancer, the osteomyelitis, MRONJ or whatever it is, you need to get that referred as soon as possible beyond two weeks, just get it referred. Don’t mess around. It’s because it’s not normal.

[Jaz]
That’s simple. I think that’s a simple and self explanatory one. Very good. Let’s have number four.

[Lucy]
Number four, ‘Thou shalt always be suspicious of sore patches on the side of the tongue or on the cheek.’ So, I see cases where people will come and they’ll complain that the side of the tongue is sore, and the dentist says it has a look in the mouth and writes in the notes that the cusps of the molars are rubbing on the side of their tongue. So, they don’t write that the cusps are fractured, or a fillings broken or that there’s any reason why these cusps are suddenly making the tooth sore when they never did before. But they take a bath and they drill down the cusps a bit and they write that they’ve smoothed the cusps, and then the patient comes back and the side of the tongue is still saw.

So, they write again all that that cusps are rubbing the tongue and they smooth it down a bit more. So, this just makes no sense to me. If the cusps weren’t rubbing the tongue before, why have they suddenly started doing it now? You know, it just makes no sense. Similarly, with with cheek biting, if somebody’s got a lesion, the back of the mouth and it you think maybe they’re biting their cheek? You know, you’re going to review that. But it seems to be a recurrent problem. Do they just keep biting their cheek? Or is there something else going on? Is there maybe an underlying mass that’s pushing the tissues out so that they’re getting bitten more often? Because the patient might actually say I’m biting my cheek. But why have they suddenly started biting their cheek when they didn’t before? Don’t just assume that because they say that they keep biting their cheek, that it’s as simple as they keep biting their cheek, and you need to drill the cusps down a bit. So yes, this is-

[Jaz]
In those scenarios, it would be a pitch a guideline, like if someone does come in with a some sort of, we suspect at the time, trauma from a broken tooth, a sharp filling, and usually, hopefully, we’ll see something sharp rather than just smoothing out enamel basically, that’s not associated with a fracture or wear or whatever.

[Lucy]
Yeah, exactly.

[Jaz]
And then, we’ve seen them again, in two weeks is a fair recommendation, you think?

[Lucy]
Yeah, see them again in two weeks. And the problem is that I’m seeing cases where people are drilling down cusps on teeth, where it’s just the same cusps that have always been there, and they’re not broken teeth. So, there’s no reason for this to happen. And then when they come back, and the problem is recurring or still going on, then the dentist is thinking, still thinking that they keep biting. And they’re not realizing that there’s something else going on. So, you need to be suspicious of sore patches on the tongue and cheek, even when the patient might say that they’re biting their cheek or that they’re catching their tongue. You need to think why.

[Jaz]
Always, always there should be something obvious there.

[Lucy]
Not just assume it’s friction, trauma, because that’s what the patient said. And that’s what the patient is implying anything. Why would that suddenly start happening out of nowhere?

[Jaz]
See them again, two weeks? And if in doubt, refer, don’t just keep smoothing teeth.

[Lucy]
Exactly, exactly. Especially when the teeth weren’t even broken. So, there’s no reason that should suddenly be happening.

[Jaz]
Very good. Number five, please.

[Lucy]
Number five, ‘Thou shalt know how to deal with a hypochlorite injury.’

[Jaz]
Oh, this is a good one.

[Lucy]
Yes. So, one of the things that happened when I see these cases is and I’ve seen a lot of hypochlorite injury cases actually, and they can be pretty horrific. I see the patient’s account of what happens and they describe how it felt. So, they always, always describe that even though they’re completely numbed up. The moment that hypochlorite hits the tissues, they feel an immediate burning and stinging sensation. So, they’ll immediately tell the dentist. They always say they immediately told the dentist when it happens, so they will tell you straight away. So, when they tell you this, you need to get in there straightaway and irrigate with water or saline if the nurse needs to go to a different room to get some saline and it’s going to take them a few minutes to get it, just use your purified water that you’ve got from the chair but just get something in there and irrigate immediately.

Just think of it if you burn your hands, you’re going to want to get that cold water on it straight away every second that hypochlorite is in there on the tissues undiluted, it’s causing damage and that will happen very fast. So, you need to act really, really quickly. And you need to really get in there with the irrigation and you’re not going to irrigate for two or three minutes. You need to irrigate for 15 minutes with saline or water.

[Jaz]
Good tip there, okay.

[Lucy]
Keep irrigating, keep irrigating, keep irrigating. So, what happens if you don’t deal with this properly, then people can end up having these areas of necrosis and ulceration where it comes through the soft tissues which look horrific.

[Jaz]
They look like they’ve had a facial trauma, sometimes a bruising and looks very nasty, very concerning for the family.

[Lucy]
Yeah, absolutely. They can have facial deformity. I’ve seen a couple of cases say an upper pre molar hypochlorite injury, where in the longer term after all the initial healing, it’s caused the tissue damage and fat necrosis that has been caused by the hypochlorite injury means that they have a dent in their cheek. So, then the parts of the claim can come sometimes become having filler injections to repair, then fill out the dent in the cheek and they will need to be repeated every couple of years for life.

[Jaz]
Lucy, just had a question or are we talking about this from Mark? Hi Mark. Mark is asking, when you irrigate with water, any guidelines in terms of like, do you do it with pressure? Because I mean, on that same note, when I irrigate with hypochlorite the safe technique I was taught is I don’t use my thumb. I use my index finger and I always find that a safer way less likely to put more pressure it’s a bit more controlled. But then perhaps if I was to cause a hypochlorite or not cause but if a hypochlorite accident was to happen because sometimes anatomy lends itself to it of the tooth and then do I want to go in with pressure with the water try and chase it down? Are there any guidelines we can follow? ‘Cause it’s very scary thing if that happens.

[Lucy]
Yeah, I’m not sure that there’s any, I haven’t read any specific guidance telling you that when you’re irrigating after it’s happened, how much pressure to use, I would assume that you will need to use a little bit more pressure because if you’re doing the super careful, gentle irrigation to try and stay in the canal or not go beyond the canal that you would do normally with the hypochlorite, then yet then obviously that there’s a risk that it won’t get through the perforation perhaps this happened or whatever it is, or the overprepared apex or whatever, you’re going to need to get through that for it to actually get into the tissues and dilute the hypochlorite.

[Jaz]
So 15 minutes of caline or water?

[Lucy]
So, 15 minutes of irrigation, and then you want to give them a short course of, so I’ve had a hypochlorite accident happened once, and luckily I dealt with it very well and the patient absolutely fine afterwards. I had caused a small perforation, which luckily I was able to repair well and everything worked out but when it did happen, she immediately told me about this burning, stinging sensation. I immediately realized I did the copious saline. And I-

[Jaz]
Was your heart racing, were you?

[Lucy]
Yeah, I wasn’t happy that happened, that’s for sure. So, I prescribed antibiotics to prevent any secondary infection occurring from the potential tissue damage, so short course of amoxicillin three days and a three-day course of dexamethasone. So, a lot of patients with hypochlorite injuries end up in a&e later. And quite often they will be prescribed steroids in any. So, I feel like let’s cut out the middleman and get them on it straightaway. Because they’re going to benefit from that. I don’t want them sitting around- in Singapore

[Jaz]
In Singapore, Lucy, I used to work in Singapore, we used to give it after surgical wisdom teeth. And from the papers, I’d read the time as well. It’s great for reducing inflammation after surgeries like that where is quite involved. Now, I’ve never actually prescribed it in the UK. Any guidelines because I’ve read many indications to prescribe dex for to help with post operative pain, any guidelines to how you prescribe that you keep some of the practice in your private practice. How’s it work?

[Lucy]
No, I don’t keep any. So, I’ve only had to do this for once. And I’d probably, if I didn’t do the dental legal work I do, I wouldn’t have done it because I wouldn’t have known but because I’ve seen it been prescribed in a&e when people have gone there after having hypochlorite injuries, I knew what they prescribed, I had made a note of it for future reference.

[Jaz]
And was it a private prescription?

[Lucy]
And yeah, it was a private prescription. So, it was four milligrams, three times a day for three days. So, the patient was taking TDs for three days, both amoxicillin and dexamethasone, and I told her to use cold compress as well. And she was absolutely fine. No problems or whatsoever.

[Jaz]
Amazing.

[Lucy]
So luckily, that worked out. But also very important point to note as well is make sure that this is on your consent form. Because when a hypochlorite injury does occur, and somebody hasn’t been informed that this is a risk of root canal treatment before they agreed for you to do it, then it’s going to be found potentially by the court that you didn’t obtain fully informed consent.

[Jaz]
Okay, I’m gonna get my slap on the wrist. And this is why we do this podcast I’m learning all the time, I will I will start to make a big deal of it. Now, consent forms, when I do a consent form, I’ll actually go through it with a patient. I’ll annotate it and I’ll make a point of going through that from after this podcast. Let’s just talk, just start to spend labor on it for too long if it’s a simple anatomy, which talk about sometimes the good stuff goes through and it can be burning let me know if you feel any burning.

[Lucy]
Yeah, I say that there’s a very, very small risk of a chemical injury that can cause tissue damage or nerve damage because actually these on my list I think I didn’t mention one of the things that can happen as well as the necrosis and the facial deformity, you know, a dent in the face for example, is quite often an area of paraesthesia that is quite a typical long term outcome after these kinds of injuries.

[Jaz]
It’s a rare thing but it’s a significant thing that needs to be known so it’s a rare but significant thing that should be mentioned.

[Lucy]
That’s why it’s really important that when it does happen, you need to be prepared.

[Jaz]
Brilliant. Well, I will definitely change that in my practice. So, that was a good one, was a meaty one. I think people in the chat were a bit more engaged on the live so guys, I’m appreciating the engagement. Silliman and everyone, Mark, just any questions as we go along. Please bring them through. So, just summarize the five so far. Guys if in case you’ve just joined us, number one was take bitewings for children. Number two was take bitewings for adults. Come on guys, don’t just do it every two years, look at the risk of the patient. Number three was be suspicious of non-healing sockets. Number four was be suspicious of a sore tongue or a sore cheek and it’s not affiliated with a sharp cusp or a broken filling and don’t just keep smoothing it.

Think what might be going on because something else be going on. And number five just now was a quite a meaty one, it’s hypochlorite incidence. What to look out for, what to do afterwards, ie flushing with the saline 15 minutes, antibiotics, steroids. And I guess we didn’t talk about this but you know, that’s kind of patient you want to invite the next day, that’s kind of patient wanna hold their hand. Call them on phone and really just follow up and show them that you care.

[Lucy]
Yeah, absolutely. And what I didn’t say but I hope it’s obvious is how to avoid doing it in the first place is, you know, use a side venting needle. Don’t use too much pressure. And don’t drill through the roof to any old angle to create a massive perforation and then pump hypochlorite through it hard, which unfortunately some people do

[Jaz]
Very, very sound advice. Okay, brilliant. So, we’re past the halfway point, Nazar just asked why we’re on here in your consent. Okay. Well, it’s interesting. So Nazar asked in your consent, do you actually mention that hypochlorite is used? Now, interestingly, when I’ve seen this make the news maybe you’ve seen the same article I had some years ago, where it was like a Daily Mail thing like, Dentists use bleach inside her tooth and cause all these issues and like, how do you even begin to talk about that kind of stuff? But Nazar is asking. Thank you Zara. Do you mention that you’re using sodium hypochlorite?

[Lucy]
On my consent form, it doesn’t say sodium hypochlorite. But it does warn of a chemical. I think it says chemical injury caused by disinfectants.

[Jaz]
Sometimes I’ve told patients that okay, we use bleach to clean out the bugs, and they’ve been okay about it. But I can see that it’s a little bit of a funny thing. So I think it’s a chemical that can cause damage, that’s a patient need to know it’s a disinfectant. So fair enough. Thanks for answering that. Thank you Zara for asking. This episode is brought to you by the good guys at Enlightened Smiles, the premium brand of teeth whitening who do a fantastic training seminar online for any dentists even if you haven’t used them before, or you just want to learn more about good quality whitening, what are the parameters of success? What are the things to avoid? What about the trade designs? The gel concentrations, the A to Z is covered by that man, Dr. Payman Langroudi. So, check out the training, you need to go to protrusive.co.uk/enlighten. Wherever you are in the world, you can join this education for free. So, check it out now. protrusive.co.uk.enlighten. Payman and Team Thank you so much for supporting this podcast. So number six, please.

[Lucy]
Okay, number six. ‘Thou shalt not please don’t, thou shalt not use corsodyl mouthwash as your root canal irrigant.’ Who is teaching this?

[Jaz]
Amen. Tell me Jaz, who is teaching this?

[Lucy]
Tell me Jaz, who is teaching this? Who is it? We weren’t taught that in Sheffield, were we?

[Jaz]
No no, no.

[Lucy]
Who is teaching people to use corsodyl mouthwash to irrigate root canals? Because I’m telling you, a lot of people are doing it

[Jaz]
That’s like, what it’s like 0.02% or 0.05%.

[Lucy]
It 0.2%. And it is not effective at disinfecting root canals. It’s a mouthwash, it is not a root canal irrigants. Now there is-

[Jaz]
And it doesn’t get rid of necrotic tissue either.

[Lucy]
Yeah. Now that is some literature that would support the use of 2% chlorhexidine as a root canal irrigant. Now that is 10 times stronger than chlorhexidine mouthwash, and you can buy 2% chlorhexidine for use as a root canal irrigant from endodontic suppliers. So, that bottle of corsodyl mouthwash is not the same as that bottle from the endodontic supplier. One is 10 times stronger than the other, one will not kill anything in the root canal on one. Maybe will but you should probably still use hypochlorite.

[Jaz]
Very true. I mean, if you saw this, I’d Sanj Bhanderi on a few weeks ago on the podcast, we talked about acute pulpitis. And how to manage extirpation quickly and we talked little bit about this and he says that, ‘You know what, most dentists that do use chlorhexidine. They don’t even use the good stuff. They don’t use the 2%, they just using any old mouthwash.’ And like you said that’s not going to do anything. And I just want to take this moment to say guys, unfortunately, Sanj felt a little bit unwell. He’s okay for me to tell you this. He has been very acutely unwell. We wish him all the best. He is stable. He is doing more positive. I’m not going to post group function 017 on post op pain with him until I get the all clear that he’s absolutely fine and doing well. So, from the Protruserati, we wish Sanj a speedy recovery. We love you mate. We hope you’re doing okay. And a good recovery. So yes, absolutely any other points on not using chlorhexidine as your irrigant?

[Lucy]
Yeah, a very interesting point here, which ties into my last point. I think the reason that people use corsodyl mouthwash often as the irrigant is because they’re worried about hypochlorite injuries. So, I’ve just been talking about how you can potentially, although I wouldn’t use 2% chlorhexidine as a root canal irrigant. But if you’re going to do that, you should know that if you do use the 2% chlorhexidine, and you have a perforation and you inject that through a perforation, you will cause an injury that is identical to an hypochlorite injury.

[Jaz]
I had no idea. I had no idea.

[Lucy]
Absolutely. I have seen it. In a cases that’s come across my desk. And I’ve seen it in the literature as well when working on the case, I’ve had to go back and look at the literature. So yeah, absolutely looks identical in the photos. You can’t tell the difference. So-

[Jaz]
If you’re a dentist who’s afraid of using hypochlorite because you’re not going to injury and you’re using 2% then there’s no point.

[Lucy]
Yeah, exactly. You might as well just use the hypochlorite-

[Jaz]
The good stuff. Use the good stuff.

[Lucy]
Because it’s gonna be better anyway, so just use hypochlorite, use it sensibly. Use it carefully. Don’t cause perforations, you know, be careful with what you’re doing.

[Jaz]
Well out on the St. Lucy, from speaking to lots of dentists, some dentists just don’t use rubber dam, you know, they don’t have rubber dam in the practice, they just don’t do it. Okay, and fine. It’s the elephant the room, you know. And so I think the reason why some people might use the mouthwash is because they’re not using rubber dam. And they just want to, they want to irrigate with something. So, what can I use that’s safe, pulling around the mouth, and not having to just irrigate the canals of saliva. They’re thinking, let me use chlorhexidine. But we all know, we don’t need to labor this point. It’s not good enough.

[Lucy]
It’s not good enough, and it doesn’t work. And to be honest, I don’t think that the hypochlorite, if you’re not using rubberdam, I don’t think that’s a reason not to use hypochlorite anyway. I mean I’ve, hypochlorite when certainly when it’s happened to me, when it’s leaked through a breach and the rubber underneath the rubber dam, that the patient’s got, ‘Ugh, I can taste something.’ You have to lift up the rubber dam, wash it out underneath and suction it up, and then make sure you’ve got your seal on your rubberdam. There’s not causing any kind of injury because it’s on the surface of the tissues. So when you inject it, and it’s going, you’re injecting it into the bone-

[Jaz]
In the planes of the tissues.

[Lucy]
Basically, into the tissues, that’s when it causes a problem. So, if you’re not using rubberdam, I mean, obviously, you shouldn’t be but that’s not a reason not to, it doesn’t stop you using hypochlorite, I would say.

[Jaz]
Absolutely. All right, number seven, please.

[Lucy]
Okay, number seven, ‘Thou shalt do further charting, when you have 3s and 4s on your BPE.’

[Jaz]
Yes, okay.

[Lucy]
So many, many, many people out there. Do their BPEs, they write the 3s and the 4s and then don’t do anything more.

[Jaz]
Lucy, I’m gonna pause you for one second. It’s so important to mention for the international audience and in the States, correct me if I’m wrong, Lucy if you know this, but the colleagues I speak to the states and also when I was in Singapore, speaking with dentists from the States, there’s no such thing as BP, like there’s no basic periodontal exam, they actually do six point charting, or they assess the gingiva. They look the radiographs, but there’s no a basic screening tool like that. So, for those internationally, BP is a basic periodontal examination. It’s got code from zero all the way to four, we’re not, it’s not going to be a tutorial on the BPE as a screening tool. So, once you found through your screening tool that this patient has got a screened positive for potential periodontitis because you can’t confirm that as a diagnosis without doing further investigations, radiograph, etc. But yeah, we don’t just screen it’s like screening someone of high risk of anything, and then just leaving them to it, you got to then probe further.

[Lucy]
Absolutely. Yeah, yeah. So you know, if they’ve got threes and fours, they’ve basically got pocketing every 3.5 millimeters. So, when somebody has 3 and 4 you don’t have to do a six point pocket chart where you write in everything, and you write all the ones and the twos, you don’t have to do that the guidance actually says you don’t have to do that, you have to write the fours and the fives and the, you know, the sixes that the ones that are over three, and you have to write where they are. So personally, in my practice, we have SOE, so you go into the six point pocket chart, you open a new chart, and you just have to put it in those isolated sites. And you know, most patients, it’s just a few sites, it’s not everywhere, you know, maybe sometimes with new patients who’ve not been to the dentist for a long time, and they’ve got really widespread perio, you know, you might have quite a lot to do. But for a lot of your regular patients, it’s just going to be a limited number of sites, and you just need to record where they are. So, you just put in those limited number of sites and it really shouldn’t take very long at all. So again, I am very aware that I work in private practice, and that time is a real issue for people who are working in NHS practice. But if you are just putting in those isolated types, it’s really very quick to do. And-

[Jaz]
Amazing. That’s a very good top tip there. So that if you’re a dentist who thinks that ‘Okay, 3 means I need to now do the entire sextant.’ It’s not gonna say the case, get find those deep pockets, and then label them where they are and what number they are. And so then you can repeat that in the future. And it doesn’t add to extra time to the equation.

[Lucy]
Exactly. And you might have a couple of code 3s, and it might literally be two teeth, one on the upper left, one in the upper right, that have got a four millimeter pocket. And, you know, if you don’t want to open up a chart, I mean, this isn’t particularly guidance, this is just my personal opinion, you could just write in the notes, you know, for millimeter pocket, and B for mesio-buccal upper left six, for example. And same for upper right six, that if you’ve written that descriptively in the notes, you’re essentially recording exactly the same information that you would do on a perio chart. But for a very limited number of sites like that, because it’s showing somebody who’s going to look at that, that there’s a code three here, because of that one pocket at that particular site on that particular tooth. And that’s how deep it was. And that that’s the information they need to know. Because otherwise, if you’ve got a code three there could be pockets all over that sextants. So, if you at least when there’s just a couple of slides just just right where they are and how deep they are. And if there’s a few more just pop them in a chart, but you don’t have to do the whole chart.

[Jaz]
That’s very good real world advice and obviously it make sense do it in the official chart, because in the future, two years down the line, it’s so much easier to find than digging through notes. But it’s a valid point that you know, if you just had to, there’s just one pocket and you had to not do a chart for it. Make a note. Be descriptive where it is. And that’s good. Now we’ve got a question from Osama. Hi, Osama. hope you do well buddy. If the patient seeing hygienist for perio can we write it in the instructions to the hygienist? Now, I’m thinking here Lucy, immediately that ideally, a practice needs to have a policy or protocol for managing their perio patients, who does the pocket charting? How often do you guys do it? How do the dentist and the hygienist work together? That’s the thing is kind of going through my mind. But how would you answer Osama’s question in terms of, can we just write the, can we just delegate it to the hygienist? So, you found let’s make it really tangible. You found a code for upper right, instead of doing the chart, can you now, can you medical legally covered if say, ‘Code four found, informed patient. Andrew, the hygienist, can you please do the six month charting next week when you see them?’

[Lucy]
I mean, I think lots of people do that. Lots of people will, particularly if they’ve got a hygienist that’s working with nursing support, then they’ll put them back to have a full charting done by the hygienist. And I think that’s okay. But I think if you are going to then send your patient off to the hygienist to have that full charting done, then you’re actually going to need to look at that charting, because it’s still on you then to do the treatment plan of exactly what their need is. So, you need to see the charting, look at it together with the X-rays, and then make your plan. Personally I do my six point charting to myself, I want to know exactly what and record where all the pockets are myself for that my own peace of mind. So yes, you can delegate some of this to the hygienist. But you’ve got to remember the bugs always going to stick with you. And if they are going to do that pocket charting, you’re still going to have to be looking at it because you’re going to have to be deciding on exactly what that treatment plan is going to be.

[Jaz]
Good. So you can delegate but that doesn’t mean that you’re now not involved in the care anymore, you need to then go for the next step. So, that’s absolutely reasonable. Number eight, please Lucy.

[Lucy]
Okay, so I kind of do my fingers that. Okay, number eight. Number eight, ‘Thou shalt not rely on only a single visit scaling without local anesthetic on patients with increased pocketing.’ So, if you’ve got a patient who’s got widespread pocketing, then no one is going to be convinced that a single visit was sufficient. So, even if you write in the notes that you’ve done perio debridement, if it’s been done, if you’ve done your perio debridement in one visit, everybody knows that basically means you just did a scale and polish or maybe just the scale and not a polish-

[Jaz]
A gross scale.

[Lucy]
A gross scale. I mean, a lot of it depends on time. It depends on how much time you spent and exactly how many pockets there are, it might be actually that you had quite a bit of time that day. And the number of pockets wasn’t loads. And you were able to go round really thoroughly with the ultrasonic then go around with hand scalars as well. And you’ve done a thorough job as was needed and could have been done in the time. But if that’s the case, you’re going to have to document that very clearly. But on the whole when you see you know, and I see a lot of these cases with patients with codes, threes and fours, when they’ve just had a single visit where it’s you know, they’ve just had a scan, it might be called a scaling, it might be called a periodontal debridement, fit they might have written root planing, I mean there’s root surface debridement that this of course now-

[Jaz]
A deep clean.

[Lucy]
A deep, deep, clean, deeply this and of course now we have the new term don’t we? PMPR, Professional Mechanical Plaque Removal. This is not my favorite term. I don’t know what you think of it.

[Jaz]
It just mumbo jumbo.

[Lucy]
I mean, okay, so to me that term just says you’re going to remove the plaque and leave the calculus behind really. I mean really on some of those patients that come in with all that calculus cakes every way you’re just going to remove the plaque and leave the calculus is that what they mean? I don’t know.

[Jaz]
Surely not. But you’re right it’s confusing term.

[Lucy]
That’s a bit of a strange term I think it’s a strange term. I don’t like it. I think I quite like perio debridement myself.

[Jaz]
Yep, same route service debridement right what I like perio debridement. Now, it’s so many times I’ve seen patients with code force and I can see that the history of code four has been continuous, ask them have you ever had local anesthetic before to have a deep clean whatnot? I never haven’t had a local anesthetic? For instance, last time I had a feeling 15 years ago, kind of thing. And in my perception of the world the moment if they haven’t had la. Have they really had a thorough debridement? That’s how I see it. Maybe I’m wrong. And Lucy I’m happy for you to say no, actuallyJaz you can do a deep. Good, good job without LA. Where do you stand on that?

[Lucy]
Okay, well, I would say it does sometimes surprise me. How much you can get away with cleaning deep pockets without local anesthetic and the patient doesn’t seem to flinch. And you know, so yeah, that does surprise me. Having said that, one of the things that I’ve noticed as I’ve become more experienced in my career, maybe I just get frustrated with damn perio and it not getting better that I become pretty brutal. Yeah, my period is brutal. I mean, I, I want them to be really numb, because I’m going to be really brutal and I feel that that’s the best way to get a good result. So, I wouldn’t want to do what I do. When I do, when I see patients, we’ve got quite a lot of pockets and I get them back for to visit perio debridement and I do you know, within the same week I’ll do right side and one day and left side and the other day and I’ll you know, numb them up on one side, go with it and be pretty brutal and then do the same on the other side. So, that’s how I usually manage it.

[Jaz]
It’s not a practice bill that unfortunately. It reminds your practices to work in Oxford. Now, I used work with these wonderful hygienists. Shout out to Morgan and Lou for listening. Absolutely brilliant what they do, you know really, really good forward thinking hyginiests and then when they’d have to refer to a periodontist for the tough patients. The patients come back saying they just did the exact same thing you did, except they scale me to within the inch of my life like they literally the periodontist, the only thing the periodontist did different was extremely thorough. Now, thorough is not the right word. Aggressive and brutal is the right term.

[Lucy]
Yeah. ]

[Jaz]
So yes, I think I completely agree with you. I think that’s the difference.

[Lucy]
Yeah. The other thing that I think really helps me with perio is my loupes. I think my now 5.5 or 5 magnification and the light as well. I blow what I’ve been scaling, then I blow air down to the pocket and it kind of blows it open. And I can see right down the pocket. It’s amazing.

[Jaz]
Yeah, it’s amazing how much sub gingival calculus you can spot.

[Lucy]
Yeah, but I mean, years back when I was nearly qualified, and I wasn’t working with loupes. I had no idea I was working in the dark, really. Whereas now I can see right down the pocket. It’s brilliant.

[Jaz]
Yeah, definitely agree. Almost coming to 10, guys. Number nine, please.

[Lucy]
Okay, number nine, ‘Thou shalt not underestimate ID nerve injuries.’

[Jaz]
Okay, interesting.

[Lucy]
We’ll know about ID nerve injuries. So, what we probably know about them is that when you take wisdom teeth out, the patient might end up with a numb lip, and it probably will be temporary, but it could be permanent. And I’m not sure that most people know a lot beyond that. So, one of the things that I’ve learned from doing the dental legal work is I have seen a lot of patients give their accounts to me in person, or I’ve read their accounts-

[Jaz]
Like you’ve interviewed them.

[Lucy]
Yeah, when they’ve come to see me for examinations. And I’ve seen their accounts with them that have the impact that an ID nerve injury has had on them. So, of course, it’s not necessarily that they ended up with a numb lip, they might have paraesthesia. So, they might have disturbed nerve sensation. They might have dysesthesia that’s a difficult one so, isn’t it? So, they might have a painful disturbed nerve sensation. So, can you imagine if you have damaged your ID nerve, and you’re getting continuous severe shooting nerve pains? I mean, how do you live with that? It’s just awful.

[Jaz]
Yeah, I mean, I don’t even know Doc Koray Feran, a fantastic dentist, someone I really admire he, he was lecturing once. And he described these patients from what he’d seen. And he says that it’s like pinching your lower lip, and really just pinching it for a minute. And then feeling what that feels like. And this is how some patients will describe how they’re living constantly, as if there’s a pressure on their lip bases, from his account of the patients you’ve spoken to. So, absolutely agree this is really a big, big issue for the patients that suffer with this nasty complication.

[Lucy]
So, the other things that they say almost always say is that they don’t eat out anymore, because they can’t tell if they’ve got food on their chin. And that’s quite sad. I mean, that’s a big part of their social life. It’s too embarrassing for them, because they just can’t tell when they’ve got food around their mouth or on their chin. So, they’re just too embarrassed.

[Jaz]
I have the same issue but with my moustache. I’ve learned to deal with it.

[Lucy]
Yeah.

[Jaz]
And I’ve got close, close friends that will just say, Jaz, just over here.’ But yeah, if you’re not on your face, and you don’t have a beard like me, is that that’s a nightmare.

[Lucy]
Yeah, yes. And so another thing that I’ve seen come up a lot as well is that they don’t want to kiss their partner anymore because it feels weird and uncomfortable, and they don’t like it. And they consistently report that it puts a strain on their relationship. So-

[Jaz]
Absolutely.

[Lucy]
Who would have thought that? You don’t think about these things, but it’s, you know, impacts people’s lives so much. I can’t under you know, underestimate how big the impact of these injuries is on people’s lives. I’ve actually come across somewhere where an ID nerve injury was referred to as the suicide injury. Now, I can’t remember where that came from. And I don’t know whether there are documented cases of people actually committing suicide because they couldn’t cope with this injury. But, I think that the takeaway from that is that it is a pretty horrendous injury to have so don’t underestimate it so the take home there is just don’t go anywhere near the ID nerve. Avoid ID blocks if possible, because I have seen a lot-

[Jaz]
I was just gonna ask you about that because Tara Renton is obviously quite begin saying that ‘Okay, we got to be really careful with ID blocks are they’re a big source of problems.’

[Lucy]
Yeah, I’ve seen loads of them.

[Jaz]
I probably do- Yes. I was gonna ask you in terms of the injuries that you’ve seen, were they what percentage? Well, from like the standard culprit is like tricky wisdom teeth, tricky surgery, orthognathic surgery, and what percentage of the of them were the harmless ID block?

[Lucy]
I would say probably at least a third would be ID blocks.

[Jaz]
Wow.

[Lucy]
Rather than surgeries, I think. Yeah. So yeah, I mean, just just avoid ID blocks where you can.

[Jaz]
Do you do any ID blocks at the moment?

[Lucy]
Yeah, I do. I don’t use articaine. I know that the literature is a bit up and down about the significance of that, I use citanest for my ID blocks. Actually,I find that works better than Lignospan. Yeah. And I’m not sure but from the literature, whether that’s better, but it certainly doesn’t seem to be worse. I mean, maybe if we use it for ID blocks less but I haven’t really seen cases where using citanest has being associated with ID nerve injuries.

[Jaz]
You know, when it comes to ad blocks I’m probably doing around about and I’m working four and a half days, I’m very wet fingered, I’m probably doing about one a month at the moment. I do a fair few extractions, wisdom teeth, I’m doing a lot with infiltrations of articaine. Shout out to Janice Boyd from Canada, who motivated me to take the step to do like, you know, lower second molars were just articaine, buccal, and lingual and I’m getting fantastic results of that. So, that’s working well in my hands at the moment. So, I’m doing less and less than this ID block. So-

[Lucy]
I was trying to avoid them. But I’m still doing a lot more than you. So obviously, I need to work on that.

[Jaz]
You know, when I just heard what Janice was doing in Canada, and she really gave me the confidence that she’s doing second molar extractions under just infiltrations of articaine. So, that really gave me the step like, ‘Hey, you know what, let me test the limits here.’ And so far, I’ve only had once wear I just had to top it up with an ID block. But most cases, especially for like cracked teeth, I’ve been doing a lot of second molars quite commonly get cracked, I’ve been dealing with all exclusively with articaine infiltrations, making sure I go into the attached gingiva making sure I see it sort of-

[Lucy]
Launching.

[Jaz]
Spread up like a Wrangler, basically, bucally to sort of the collection of the anesthetic, so it’s kind of like subperiosteal, and sometimes going lingually as well. And that really has worked well on my hands. So, that’s a very good one. So, I’m gonna summarize in number 6-9. If we do the big reveal of the last one, it may or may not have any significance of being the last one. But hey, so we left off number five with how to deal with the hypochlorite injury and how debilitating they can be. Six was stop using corsodyl mouthwash as your endodontic irrigant. Come on, guys, we know that already. And number seven was if you’ve screened for periodontal disease, and you found an issue, ie got code 3s and 4s in the BPE which we saw in there in the UK, don’t just ignore that follow up, do some pocket depths.

And the big, big takeaway there was, you know, you can do isolated pockets, which is very good. And number eight is if someone just had a scale and polish or single appointment for their full blown periodontal disease, is that really sufficient? Probably not. So, you know, let’s get the full therapy for them. And don’t underestimate ID nerve damage. And Lucy described that about a third of the injuries anecdotally that she’s seen were from just the quote unquote, “harmless ID block.” So, something very good to note there. So-

[Lucy]
Well, just one more little point, just before we move on to number 10 that I was going to share that the ID blocks is that you know, obviously don’t go correcting the base of a socket when it’s close to the nerve. But another one that I think it’s not so obvious is that when you take a PA of a tooth before you’re going to maybe do an endo, often on the PA you might see the upper border of the ID canal but not the lower border and because you’re not seeing the double tramline, the upper border on its own might not be quite so obvious. So, sometimes you might end up doing an endo with the tooth with roots.

And actually people think it’s the eights that are sitting on the ID now but there’s plenty of seven and sixes and even fives that have the apex basically look in the nerve canal on the radiograph. So, you can end up doing endos on those teeth and you can cause ID nerve damage on those teeth as well. So, you’re gonna have to be very, very careful with your endo files when you are working on those teeth. And obviously with implants, I mean just have a massive, massive safety zone.

[Jaz]
Yep, yep, yep, and with the periapical radiographs that we take for endodontics so make sure that you can see sufficiently beyond the apex to make that sort of assessment on a first molar, on a second molar now on the chat, our good friend Andrew Miles from Trinidad and Tobago, I think it’s Tobago? One of them. Hello, Andrew. He says there are rare cases of emphysema in the neck and mediastinum due to forceful air aspiration around low teeth so puffing air and pockets should be done with that awareness. So, just be careful guys, when you do that for our point. Marks again hello again. Mark says how many ID blocks have done in the UK per year? Probably shit load. Trinidad. But probably less than less. I’m guessing we’re turning more towards articaine infiltrations. So, number 10, Lucy.

[Lucy]
Okay, so number 10, ‘Thou shalt always palpate for canines at age 10.’ So-

[Jaz]
Preach!

[Lucy]
And you know, if they’re not there, just refer don’t keep seeing them till they’re 15. And they’ve still got their C’s, by which time the impacted canines are like this over the roots of the ones and twos and have resolved half the roots of the ones and the twos. Yes, unfortunately, that seems to be another thing that people aren’t that hot on. They’re not palpating for canines.

[Jaz]
The basic thing to do, I think the big takeaway here guys is start implementing it tomorrow. But how will you implement it in your examination template for child exam? Is it even there? Is that even entry? If it’s not an entry, it’s never going to happen? So, just a simple tangible next step, the logical next step is make sure canines palpated, question mark, why stroke n and then delete the one as appropriate. And do that for every patient at age 10 and above. And I’ve got a few stories here. Like I thought that if I find any concern at around about age 11, 12, because the first time I’ve seen that child, and I’m thinking, ‘Oh, by time I refer them to orthodontist, they’ll see them for a year.’ But actually it doesn’t have to be like that.

If you email your orthodontic practice, your NHS orthodontic practice, actually very sympathetic towards this. And they will reply back saying, ‘Okay, we’ll make an urgent arrangement for them.’ So, I think pursue that avenue to get it assessed by the orthodontist, where it’s a good idea to do so. And the other one is a story is I used to treat this fairly well-known international celebrity in Oxford, and I saw his daughter come in and oh, my goodness, it was just, they weren’t threes. They were C’s and previously had all these teeth charted as permanent canines all these years. So, I have to break the news that actually the there’s a big buldge in the palate, and it’s a big issue. So, then it starts a whole fiasco.

[Lucy]
And how old is she?

[Jaz]
She was 14.

[Lucy]
Right. Absolutely. And the thing is with these is that if you get to them quickly, the alignment cannot often spontaneously improve, or if it doesn’t, and they still need to intervene, that you know that they can expose them attach the gold chains, drag them down, the longer you leave it, the less likely it is that’s going to work.

[Jaz]
And in terms of guidelines, and here’s something that I probably need some advice from you on is I’m always seeking orthodontist guidance on this kind of stuff. Even though I got deployment ortho, I do say, ‘Okay, let me just get the orthodontist opinion. Should we extract the C’s or not?’ And their advice usually, is to do it. Now, should I be making that judgment call myself? So when I see that, okay, they’re 10. I can’t palpate the canines, bucally or palatally. And so should I then be saying to parents, ‘Okay, let’s get a little Tommy in and remove the C’s.’ Should I be making that call? Or should I get that call facilitated by the orthodontist?

[Lucy]
Personally, I would always check in with the orthodontist in a case like that. It’s peace of mind for me, I feel happier that we’re on the same page.

[Jaz]
Yeah, yeah, I think so. I think if you’re concerned about the age, and they’re like more 11, 12, and you’re worried, then do an urgent referral and get their opinion. And like I said, just take some photos, and OPG is good, because they can give the orthodontist some more information. So you know, first thing could do is maybe they can OPG attached to that email for the orthodontist, and just get some opinion. And you don’t have to like wait a year for them to get seen about this canine issue, it’s slightly more of a time sensitive issue. Would you agree?

[Lucy]
Yeah. Yeah. And, and of course, you can use your parallax technique as well.

[Jaz]
Very true. Very true. So brilliant. So, the last ten there is palpate the canines, the permanent canines at age 10. They should be palpable buccally. If you feel them palatally, you feel a palatal bulge, then yeah, kind of it’s going to be impacted at that stage. So, try to start having that relationship with the orthodontist to discuss these cases. So, that’s been a really good summary of the 10 Commandments. We’ll get them written up and email to everyone as well. And this will come out on the podcast proper. Now guys, if anyone’s got any questions for Lucy has kindly given up her time tonight to discuss all her wisdom for seeing all these cases and all these experiences that she’s had. We’d welcome any last questions that you had. Lucy, any points on any of those 10 Commandments that you feel now that we’ve talked about it that you want to go back and add something to?

[Lucy]
I’m not sure, really. I mean, I think the biggest ones where I think people just apparently they don’t know that they’re meant to be taking. It sounds bizarre, but they don’t know they’re meant to be taking vitamins on kids. I’m not quite sure how that works. But that seems to be the case.

[Jaz]
I think they just don’t do it for so long. Because of bad habits and they kind of just forget and dentistry can be very isolated. And if we’re all going on the composite veneer courses, Invisalign courses, no one’s going to the update in radiography guidelines courses, then.

[Lucy]
Exactly.

[Jaz]
So these podcasts, sessions like this are very important to remind everyone.

[Lucy]
Yeah, and the other one is this thing with using corsodyl mouthwash as a root canal irrigant. It seems like somebody must be teaching it because I don’t understand why so many people are doing it but who would be teaching it? So I’m just, I don’t know quite how it got started and how it became so widespread.

[Jaz]
I was gonna name the parent company of corsodyl but I’m not gonna do that in case this podcast gets sued. So, I’m definitely not teaching it don’t worry. It’s not that indication. I’m not gonna get sued by multimillion corporation. Salomon asked, how did you get involved? This one’s for you actually, Lucy. How’d you get involved in dental legal work? And any tips for those considering exploring it as an additional career avenue please? Thanks, James.

[Lucy]
Well, funny story, but true is one year, I got my quote through my annual update with dental protection. And yet again, it’s a jumped up again, you know, to some astronomical figure even though I wasn’t making any claims. And I just thought, ‘Wow, it’s so much money that you know, there must be so many claims going on.’ And then I thought, ‘Hmm, maybe that’s a potential avenue for here, avenue here for me.’ Maybe if there’s not much going on there. Maybe it’s something that I can become involved in. And that’s what gave me the idea. And to get involved in it. I just sort of started, I didn’t know nothing about it. Didn’t know what to do, or in what way to get involved. I just started googling. Really lovely guy who’s retired now called Mike Young, who had written a book.

[Jaz]
Did he also write that book? Managing a Dental Practice: The Genghis Khan Way?

[Lucy]
Yes, yes. He’s such a lovely guy. So, so helpful and supportive, great, great mentor. Really happy to help anyone out and give advice.

[Jaz]
Active on Twitter, if I remember.

[Lucy]
Yes, yes. I mean, he’s completely completely stepped away for a completely completely retired now. But he was really helpful to me a few years ago. And he introduced me to other people who were also really, really helpful. We have a lovely Whatsapp group of people. There’s about 80 of us involved in dental legal stuff now and this Whatsapp group that chat together. And you know, there’s always new people joining and getting a warm welcome from the group, giving each other tips. So-

[Jaz]
I mean, if someone wants to take the next step in terms of what to Google, or which courses they need to do is you know, a formal degrees or how to get a flavor of it, how can they start?

[Lucy]
It depends on on exactly what you want to do. Whether you want to work for an indemnity provider as a dental legal adviser, whether he wants to be an expert witness, or whether you want to become doubly qualified, as some people do, and become a solicitor or a barrister, that there’s lots of different routes. There’s the LLM qualification in law that some people do, there are various courses you can go on, there’s a company called Bond Solon that does courses on report writing and cross examination skills. So, you can do certificates and diplomas. There’s lots out there.

[Jaz]
Brilliant. If anyone wants to send you an email or get support from you, any anything that they could, any way they can reach out to you?

[Lucy]
Yeah, yeah, sure. I mean, you can look me up-

[Jaz]
Facebook, Twitter, where’s it? Where’s a quick, easy place? Your Instagram? What do you prefer?

[Lucy]
Easy to find my emails on my website. You just google me.

[Jaz]
Yep. Yep, I did Google, you now, saw your website. Very nice. Lucy, thank you so much for giving up your time to talk about these 10. Thanks for preparing it. Thanks for being mindful about it. Thanks for leveling us all up, including me, because there’s a few points that I relearned on as well. And I’m gonna implement straight away because guys, knowledge is nothing without implementation. So, if it’s the fact that you’re not palpating the canines because it’s not in your notes, it’s not in your checklist. Simple thing to do. And now we know how to manage our hypochlorite incidents, or hopefully it never happens where it does, you will remember Lucy and this podcast, Lucy, thanks so much.

Guys, I really appreciate you get up by Wednesday evening. Let’s face it, you’d rather be here then the cold murky weather outside. It’s miserable today. So, thanks for joining us and check it out again, when it comes on Spotify, Apple, etc. If you’re on the app this way very much suitable for CPD. So, you’re able to get CPD, just scroll down, click then answer a few question on the type form. And that’d be there with you. Lucy, any final words?

[Lucy]
No, I just would like to say thank you very much for having me. It’s been a real pleasure to be on.

[Jaz]
You’ve been very fun to talk to. Thanks so much.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. What changes are you going to make tomorrow morning to make sure that we don’t fall foul of these little issues that can become a big medical legal hassle for us in the future? My main takeaway was how I’m going to manage something hopefully that is never going to happen to me. But let’s face it, it could, it probably will happen in my in my career is a hypochlorite incident. Right. And I have more information about how to manage that. But more about dexamethasone and those severe cases that their role, and how am I have a role in those severe cases. So, hope you gained a lot from that. Listen, you’ve got an associate, a principal that you feel should listen to this episode. Please send this to them. Right. Share the love, pay it forward. Once again, don’t forget on the app to answer those questions. Get your CPD right now because let’s face it, you listen all the way to the end. I’m so thankful. You deserve some CPD. Anyway, I’ll catch you in the next episode. Same time, same place.