Paediatric Dentistry Masterclass – Clinical Part 2 – PDP024

Jaz’s Introduction: Hello, everyone. And welcome back to part two with Dr Libi Almuzian after the first episode all about prevention, we’re going to follow on a little bit more about the clinical stuff. So for example, we’re going to discuss this type of cavity, this type of presentation, a deciduous molar with a cavity like that, how would a pediatric specialist manage that, we’re going to talk about the use of local anesthetic in children, is it always necessary? We’re going to have a big part of the podcast episode discussing about stainless steel crowns. And we’re gonna discuss why GDPs are not taking routine bitewings on children. As before, there’s gonna be quite a few downloadables and I’ll put them on the Protrusive Dental community. So it’s going to be the whole crown booklet by Dundee University, some more by SDCEP and a pediatric dental blog that I’ll put on there as well. So for those who are interested in this, they can follow up on that by joining the Protrusive Dental community on Facebook. I’m hoping that you’ve noticed that the audio is a bit cleaner for this part of the episode. When I switched to recording with a different software, it actually downgraded the quality of the audio. So I used to get a lot of messages in the initial episode saying ‘Jaz, how’s your audio so good, what kind of setup do you have?’, but I feel as though the audio quality has dipped in a little bit. So I apologize for that. But we’ve got a way around it. So I’m hoping this already sounds better in your headphones while you’re on your job while you’re cooking or in your car. So I’m hoping that in future episodes unfortunately got bit of a backlog of three or four episodes before this technology with improve sound. Hat tip to Dr. Zak Kara who helped me improve my sound. So in a future episodes, around three, four episodes time from now, the entire episode hopefully will have as crisp as audio as you can hear it now. Anyway, we’ll join Dr. Libi in just a moment. But I want to give you a Protrusive Dental pearl for this episode, which is basically this, during this lockdown period, it can be quite difficult to be your usual productive self because everything is now alien. It’s weird being at home, you know, the temptations of daytime television, daytime drinking, all these sorts of things are in the way and you may be feeling that you’re not as productive. So I certainly felt that way. So one thing I started to employ is a trick by someone called Brian Tracy, who has numerous books, which I read. And one of them I believe is called Eat That Frog. And the way he says is Eat That Frog. So what Eat That Frog philosophy means is when you wake up in the morning, do the most difficult thing and get it out of the way. So that thing that you really can’t be bothered with, can’t be asked with, you really don’t want to do, do that thing first. So that’s what I’ve started to do over the last week or so in terms of what I’ve been doing. And I think it’s made a huge difference by eating that frog first thing in the morning. It’s actually improved my day, I think so is that. His other book, Getting Things Done was really influential to me around about eight years ago when I read it or when I listened to it. And it’s all about getting things done. So checklists and whatnot. But the main tip I can share with you from that book is the philosophy of mind like water. Now what mind like water means is, I used to be someone who I used to have my to do list up here in my head at random points throughout the day, I might be thinking, right, I’ve got to do ABC, I’ve got to take the bins out, I’ve got to make sure I finish this project, I’ve got to make sure that I message that person send this email, oh, I am, I’ve got to pay that bill or whatever it is. But if you actually have a system so that your mind is like water, you don’t store anything like that in your mind. Instead, you have a system for example, for me, it was a robust to do lists. So every one of my thoughts, every one of my tasks is on a system. And I never have to worry about my tasks because my mind is like water. So I hope that made sense. So those two tips from Brian Tracy, I hope they help you during this lockdown period. And as always, I’ll join you in the outro of this episode.

Main Interview: [Jaz] I want to talk about now, probably the most stressful thing for GDPs which is emergency child patient and I’m not talking trauma because trauma is always stressful because trauma is something we don’t see very often but when we see it’s really important and that could probably have its own five part episode of trauma but Let’s talk about something that really used to stress me out a lot when I was earlier qualified. And it still worries me when I see an emergency you know it’s like 1pm and suddenly it at 3pm, a child’s booked in with an emergency. It’s still something that stresses me out. So, you know, it’s difficult to manage a child when they’re in pain. And it’s difficult to manage a child in any way. But when they’re in pain, when they’re suffering, whether it’s an abscess, or whatever. So I want to hear some tips on managing childhood prevention. And let’s talk about, Can I share that clinical case with you? [Libi] Yes [Jaz] Let’s start with this. So that for those listening on the podcast, I’m going to describe the what we’re seeing. But for those obviously watching on YouTube right now, then you can see this. So what we’re seeing here is an upper left D, on a 10 to 10 1/2 year old girl. Can you see that okay, Libi? [Libi] Yeah. Okay, thank you. [Jaz] Brilliant. So the C was removed around about six months ago upon the recommendation of an orthodontist, because the three is that looking like they’re maybe ectopic. What I realized at this appointment was that having a look at the recalls, because I’d seen the patient remove the teeth, and I’d seen the patient because of some other issue, she’d actually had not been seen by any of the dentists of practice for routine checkups. So one little tip there is make sure that when you see a child for emergency, have they had their recalls? Because this should have been picked up at recall. But the patient never had a routine examination appointment. Anyway, she comes in complaining of a pain on chewing. And when I had a look, there was no signs of an abscess, the tooth wasn’t really that tender to percussion. But as you can see, there is some subgingival caries. And obviously, we know this cavity has been there for some time, because there’s gingival overgrowth into the cavity. I’ve had half an hour to manage this. And you know, I put my hand up, I’m slow dentist, half an hour to manage this in the way that I want to, in the style that I want to and you know, given the child lots of time, that’s not enough time to me in an emergency appointment. So can you talk us through what you advise in a situation such as this, and how to ultimately manage a situation like this.

[Libi]
And Firstly, the fact that it was missed, it’s not surprising, because what would have happened is it started interproximately, like we were talking about earlier, we need to be focusing more on interproximal cleaning. And what’s happened is finally the enamels become undermined occlusally, and it’s broken off, and you’ve ended up with this huge hole. So I’ve actually had a few instances, you know, where you get some parents who are quite upset that they’re bringing their child in for regular checkups. But these things are then all of a sudden appearing. And it’s trying to explain to them the reasons why. So that’s one hurdle because you get this parent who’s coming in upset that you know, I’ve been, I’m bringing my child in to see the dentist and why have they missed this to the point where it’s become painful. Now, the first thing to consider is you need to actually ask, you know, do a good pain history. So when you’re saying pain on biting, to me that’s probably because the gingiva is being traumatized. So now it’s exposed that gingiva was being traumatized if that patient didn’t have any pain, due to from hot and cold, or wasn’t keeping them, even if they had it too hot and cold, but it wasn’t keeping them up through the night. I would say that that tooth could probably have a stainless steel crown, okay? So I think this is something which is underutilized by GDPs. As soon as your tooth, the baby tooth has two surfaces involved, or interproximal surface involved, I would go for a stainless steel crown. The main reason being, you cannot put on a rubber dam on a child and get adequate isolation and place a robust composite restoration that you can guarantee you will last five years, which is usually the span that you need, because if they’re coming in at six or seven years old, and they’ve got holes in, a big hole in the tooth, that tooth needs to last until it’s going to expoliate we were looking at five to six years. So ideally stainless steel crown is the option. Now the thing is you said this patient is 10 and a half years old, okay? And they’re already sort of undergoing various treatments for ortho, interceptive orthodontics, let’s say

[Jaz]
I feel like it might be a bit delayed because there was no mobility of the DFE so maybe we’re looking at really 12- 12 and a half by the time this one goes away.

[Libi]
Okay. So let’s say we still need to keep that tooth for two years. First thing is, why aren’t GDPs taking x rays? Why are GDPs scared of taking bitewings for children? Do you know that I use taking a bitewing as a measure of cooperation of the child? If you think that that child cannot tolerate bitewings, how are you expecting them to tolerate treatment? Right?

[Jaz]
Absolutely

[Libi]
So you need to tell them, you need to say to them, “We need to take a picture, because I forgot my X ray specs today, I can’t see inside your tooth, we need to see how deep this hole is, we need to see how.” So you’re going to see quite a few things from this bitewing but you’re going to say to the child, you know, “It’s so easy. It’s just like taking a selfie, feels a little bit uncomfortable when you bite down on it, but you can probably help me, you’ll be really good at positioning it for me.” And you get them to put it in their mouth with you. Because having the bite wing holder rammed into your mouth is not fun. Especially not for a child but getting them to do it and say “Bite gently. Oh, yeah, you’re doing it perfectly. Thank you so much, you’re helping me so much,” You get the x ray taken quickly. Fantastic. Lots of positive reinforcement, “You are so amazing.” You know, you either say to them, children younger than you manage this, or you say to them, “You’re doing better than children who are older than you.” Just anything you need to say, to get them excited about doing and it’s literally takes seconds on each side. So just getting those x rays is invaluable. You’re going to be able to

[Jaz]
Can I just ask you now? Because obviously, that’s amazing point. And I think not enough GDPs aren’t taking radiographs for various reasons. But what is the youngest that you start taking bitewings? Because I think that’s the first question everyone’s thinking, okay, what age should I be thinking about it? Is it due to eruption pattern? Or what you might suggest?

[Libi]
Yeah. So if you, in the SDCEP guidelines, I think it says from four and above. So [Jaz] even if they’re low risk? [Libi] I see, now this is where it is. So if they’re low risk, you have no reason to think that there is caries. But if you had any doubt, if there was any shadowing, if the child had high risk from dietary factors that you identified, they weren’t brushing, well, then your indicate, you can take a bitewing. But if you have a space dentition you can see in between the teeth, obviously, you don’t need to take a bite wing, if the child is you know, has parent reports phenomenal diet and, you know, excellent brushing, you can’t see anything clinically, that would give you any doubt, then no, you’re not going to do it

[Jaz]
Maybe their siblings who are older, who’ve had no issues and they’re good as well.

[Libi]
That’s another reason. But if you can see a slight shadow or you know, you just feel like the oral hygiene isn’t there, you know, because usually, when a parent brings a child in for assessment, this is when they brush the best, you know, this is my best brush before I see the dentist, still not on point, then you’re thinking, ah, usually it’s probably worse. So just if you can identify any factor that would make you think, are they higher risk than I think, take a bite wing, it’s very low radiation, it will also help to sort of measure the cooperation of the child going forward, you know if they can tolerate having a bite wing they will be probably cooperative for treatment as well. And like we said, it starts interproximally and you you’ll be surprised, one of my colleagues actually did a research about it, about the difference between the clinical examination and radiographic examination

[Jaz]
Is this eight times more? Because I remember a study saying that you see eight times more

[Libi]
Probably, I can’t remember exactly, I have to go back and ask her. But she did that. And it did show that radiographically, we were finding much more cariers than we were clinically. And it changes your treatment plan. And so taking bitewings is really important. So for this child, if this child that you had seen now 10 and a half have had bite wings previously, that would have been spotted earlier before the occlusal surface was undermined. But anyway, we’re always talking about we addressed what situation we have. If we take an x ray to this tooth at this point, what we need to see is how much of the root is resorbing. Because sometimes when you’ve got an infection in a tooth, it can resorb earlier, even if you know and is it worth doing heroics on a tooth which is resorbing? And it’s going to exfoliate earlier than its counterpart on the other side, which is not infected. So that’s one thing to keep in mind. Another thing is to see the depth, so, a hall crown on a non symptomatic tooth. So if you are seeing that the only pain she has is on biting. I would say that that’s probably due to food impaction and not actually

[Jaz]
Yes. I thought that as well. That was my diagnosis.

[Libi]
Yeah. So if I don’t have any other symptoms, and that tooth has a band of dentine radiographically visible between the cavity and the pulp, I would put a stainless steel crown on that and monitor it. Because you’ve given it the best chance of a seal. It’s, you know, you’re never gonna get a great seal with a composite or a gic.

[Jaz]
Can I ask a really clinical question now? [Libi] Yeah [Jaz] In that scenario because we can talk about placing hall crowns and some mistakes I’ve made in the past. But in that situation, when you’re seeking the hall crown, the gingiva, the overgrown gingiva can trap itself between the crown and the cavity. Do you see what I mean? So my way of managing would be I would anesthetize and I would curettage this gingiva away, and then I’ll be able to, then I feel confident I can place restoration or in my hands usually stainless steel crown. Am I being too aggressive? Should I be worrying about this? This is me, it’s my restorative dentistry mind, you know?

[Libi]
Yeah, so you’re restorative dentist, I’m pediatric dentist, I’m thinking how can I minimize, do the least treatment for this child? So what I would do is if I was really concerned about the gingiva, but it was a little bit of gingiva, I would not be concerned about that when I sit the crown going inside the crown and just dying off and living happily ever after, if I felt like it was really overgrown. Okay, I would put in a gic. Okay, so I would push the gingiva aside, I put some topical anesthetic, I push the gingiva aside with a plastic instrument, I would place some gic and allow the gingiva to grow in a more favorable manner, bring the child back the week after. So I would put in some separators if I needed as well. So besides the gic filling, and what I’ve done is I’ve built up that tooth to push the gingiva away. And then the next time they come in, you just put the hall crowd up. Okay? [Jaz] Okay [Libi] So you’ve sort of pushed the gingiva out of the way you can put a hall crowd on. Because anesthetising a child is not ideal. Even although you know, you’ve had this child has had an extraction, so they might be more cooperative.

[Jaz]
She’s very good. She’s fantastic. So that’s why I was happy to even consider anesthetising remove that gingiva and place a hall crown. But then again, look, for me, it’s only in this case, it’s only gonna last a year and a half, two years. And I know for a fact that mom’s a bit anxious about having metal, which I know we can easily talk about , parents have objections to hall crowns because of the metal. I know, you’ve told me about a white alternative before and we can you can touch on that. But in this case, what I’m probably gonna do just because the parents are pressured, and the fact that they only has to last a year and a half to two years, I’m probably gonna place the best restoration I can. But if she was around about two years younger than I agree with you, I’d really try and convince the parent about having a stainless steel crown.

[Libi]
It’s all, you know, there’s so many factors to consider when you’re doing treatment for any patient and pediatric patient is no different. So you have so many factors in play, the parents preference, the child’s preference, you know, I’ve had parents who don’t want the stainless steel crowns And then you tell them Well, you’re saying well, the alternative is that I have to give them an injection and, you know, clean out and put a composite in, and it takes time and they don’t, some of them don’t realize the impact of that until they actually see it happen. And I have had children and parents backtrack and say, actually, you know, once they’ve seen their child be upset by having to have local, be upset by the whole procedure that being longer and you know, having to have your mouth open for so long. They say actually, it’s fine, just put a crown on and I think the stainless steel crowns are just invaluable I think. They do such a good job. I mean, the study in 2018 BaniHani said that it’s the outcome of doing a pulpotomy Okay, on a tooth is the successes 95.3 and the success of the hall crown is like 95.8

[Jaz]
Wow. And no anesthetic needed. It’s just a no brainer.

[Libi]
It’s like why would you put your child, Why would you put a child through having anesthetic having to have a rubber dam on, all those smells of the zinc oxide and the ferric sulfate. It’s like, it’s a no brainer to me, I would rather put a hall crown on and hope for the best, usually it is the best than put a child through all of that and you know what, they come out, they’re so excited. “Look at me with my Iron Man tooth, with my princess crown,” you know, and they show it off to people, they get excited. And again, with the parents, the parents can get upset because they feel like when people look in their child’s mouth that they’re a failure. But look, my child has needed metal in his mouth because his teeth are so bad. Again, it seemed to them, we use these crowns for many reasons, some teeth don’t form properly. And that’s why we have to cover them with these things. Lots of children happen these days for different reasons that isn’t just because of holes in your teeth. And just making them feel a bit reassured that you know that nobody’s judging them for that.

[Jaz]
I think there’s two, that’s a really good point and in managing the parent and reassuring them. But I think there’s two reasons why there may be more, you might you probably know more than that. But I think there are two reasons as a GDP, why some, a lot of GDPs are not using stainless steel crowns. One is not really their fault, lack of training, it wasn’t taught at the time that they’re at dental school. So lack of training is one and then therefore, they never get the hands on experience. So if you can recommend anything for them to channels for them to learn, and the other one is probably not having the kit, because you know what, the kit is like a 350 pounds, 400 pounds, I think it’s from 3M, I personally think it’s a great investment, because restorations will last longer, less emergencies, less fillings falling out. So I think number two, we can really dismiss and I say you know, speak to your principal, get them to stop being so cheap and buy the bloody, stainless steel crowns. So I think really what we need to tackle is the first point, lack of training.

[Libi]
So in terms of placement, there’s the hall crown. There’s like a guide that you can you can get off the internet,

[Jaz]
The University of Dundeen, right?

[Libi]
Yes. So that’s an, I would say read through that and practice, what I tend to do is put separators, so I use the elastomeric orthodontic separators, the small blue ones. And what I do is at the, so you do an appointment, and then you can have the second appointment a couple of days later or a week later, it’s up to you sort of, I wouldn’t go more than a week because usually they’ll, the space will be created and they’ll fall out and then you start to lose the space. But what that does is it just gives you a tooth that sat on its own spaced, really easy to fit and cement a crown and then the teeth will go back to normal occlusion afterwards. I think it’s about not being scared to do it. So the first appointment putting in the separators is it feels almost the same as having the crown on. So it’s like an introduction to the child. So I put in the separators. And you can use floss or you can use separating pliers. And some children might get scared from seeing separated pliers. But actually how I introduce is I say, “These are my magic fingers because my fingers are too fat to hold this tiny donut” So it’s donut, it’s not seaparator, of course they get you, you get smirk from them when you go, do you want, “I’m gonna put some donuts in your mouth” and they go ‘What is this dentist talking about?” You know, So I’m like “No sugar donuts? Do you really think I’d give you sugar donuts? So yeah, we’re gonna pop in these donuts, they’re so tiny, and can use my magic fingers. And look, the magic fingers can stretch it and squeeze it in between your teeth. And we’re going to wiggle, so I’m going to put it in between your teeth, you have to wiggle as well.” So you get them to wiggle and you’re wiggling. Just to place it in that contact point. Once it sits in you see, it’s gonna feel like you’ve got an a piece of Apple skin or something stuck in between your teeth. If it feels like that it means it’s right. [Jaz] Brilliant. [Libi] So it’s reassuring them that, that sensation is the one that we’re looking for. If you tell them, “You’re not going to feel it, you won’t even notice it’s there.” If you say that, and then they feel it’s there. They feel that you’re lying to them. Whereas if you tell them upfront, “This is what it’s going to feel like it might feel like this, it might feel like that” Some people wouldn’t notice it. So within a few days, you’ll have forgotten about it. They usually forget about it as soon as they walk out the clinic to be honest, but it’s just reassuring them that this is “Oh, it feels like that fabulous. We’ve done the job right? Well don.” You know, just positive, always upbeat. And don’t please

[Jaz]
Libi that is a routine for you. Because you do this day in day out. Oh my god that Apple skin analogy is I have to just say that Apple skin analogy is amazing. I think

[Libi]
It’s just all about being truthful with children, children know when you’re lying. So even when you’re giving them local, and you don’t say you’re not gonna feel a thing you say it’s gonna feel like and then you give them something that feels like so I’ll go into that when we talk about local. But going back to the separators I placed the separators because it’s going to help me to size and fit a crown much easier. And it’s going to help the child it’s like in a climatization for them. So you can put fluoride and put in some separators in one appointment. That’s a climatization for them. The next time they come in, you’re gonna say “Oh, have you looked after my doughnuts for me or did you eat them?” Sometimes they’ll have fallen out. Sometimes there’s space created, sometimes there isn’t. If you can get a separator in, you could probably get the crown in, but it’ll need a bit of a push. So if you know if you’ve lost the separator, but you have been able to place the separator there, the space that you need for the crown is less, but it might need a bit of a push, and it’s knowing whether the child would tolerate that or not. If you feel that they’re too anxious, then take place a separator again, bring them back sooner, or place a thicker separator and bring them back sooner, so it doesn’t fall out. And when you fit the crown, it’s about getting a click. So if it clicks on, you say to them, “Oh, it clicked perfect. That’s what we’re looking for.” And also joking around with them. “What size do you think you are? What size tooth are you?” Because you know, we have sizes from two, three to seven. And I’ll say “What size are your feet? Do you think your tooth is as big as your feet? Let’s see, and it’s just like getting a new pair of shoes, we have to try a few sizes to see which one fits.” And they’re gonna say “Does it hurt?” I’ll say “No. Does it hurt when you put a hat on your head?” “Okay, no.” “It just feels like putting a hat on your head.” And I’ll take the crown and maybe put it on their pinky finger. “See, just like putting it like that.” And once I’ve got the right size. Of course, for airway protection, what I do is I cut a piece of half the band, you know, like it’s almost like a plaster strip. And I attach it to the tooth and I say “This is a mermaid tail. So we’re gonna have a tooth with a mermaid tail or a fish tail, or a dinosaur tail” whatever you want to call it. And I say “That so that I don’t drop it. I’m really bad at dropping things.” So you’re just explaining as you’re going and “Let’s try it on. You’ve try it on. It’s the right size. Right? Let’s get the glue. And this is really special loopy glue made by the tooth fairy and Mr. maker.” So Mr. makers, like this popular crafting guy on TV on CD. [Jaz] Okay, I didn’t know that [Libi] And most kids know it, I think, but anyway, so I say the tooth. So I’m chatting away while I’m doing all this. “Yeah, the tooth fairy Mr. maker get together and they make this special glue for us. It doesn’t taste very good. But if you, once I’ve stuck it on, I’ll wipe away the extra bits so you don’t have to taste it.” There’s all about reassuring them that you’re doing the best to make them comfortable. You stick it on, you give them a cotton roll, you ask them to bite down you say “Now I need you to bite as hard as you can like a tiger” You can do a practice of it beforehand, saying “When we’ve got the Iron Man tooth, I’m gonna ask you to bite on this. You’re gonna bite as hard as you can like this or like a tiger, like a lion” you know, just all those analogies and you’re cheering them on when they’re doing it. And then you wipe away the excess I use a wet gauze because I use gic to cement it, which doesn’t taste very nice. Taste some of them are a bit acidic. I’ve actually, I actually taste my cement. You know, somebody told me, one of my supervisors when I was training said, ‘Oh, it tastes like salt vinegar, when you say it tastes like salt vinegar, Chris, I think it says it in the manual actually tastes like tell the child It tastes like this [Jaz] That’s what I say as well [Libi] Great, but have you ever tasted it? [Jaz] No. [Libi] No? So actually, I tasted a few and one of them tastes really lemony. Why didn’t taste like some vinegar crisps? Because it’s just like so that you can when you’re saying something, you know, it’s the truth to taste your cement, see what it tastes like? Like and you can and I say to them, “I know because I’ve tasted it.” Anyway, so we stuck it down, we’ve got them to bite, we’ve washed, we wiped away the access, you can go in with a bit of floss, “Oh here’s our tooth fairy floss, let’s check everything is clean. I want to make sure it’s really shiny for you. Now, do you want that tail, the mermaid tail on? Or do you want me to take it off? Do you want to walk around with the tooth with the tail? That’s what I asked. It’s just all distraction, because now they’ve got this new thing in their mouth. And it feels weird. It’s putting a bit of pressure on their gingiva. If it’s done well. So you’re trying to distract them this whole time from actually linking the feeling to their brain and getting upset. So you’re just constantly talking and saying things to them to distract them. And you’ll say to them, “It’ll feel funny because it’s something new in your mouth.” And I always say to them, especially if they’re a bit older, you know, “Your mouth is so sensitive. Even if you have a grain of sand in it, your teeth can sense that so imagine you’ve got a brand new tooth and you know, it’s amazing and I want you to keep it shine for me.” And at this point, “Fantastic. You’ve done a great job off the chair” Reward.

[Jaz]
Two things I want to because I assume you’ve moved on to a reward now which is great, but two things I want to ask about the nitty gritty clinical things which I like to do drop. One is when I place a hall crown or sends to crown should I be able to to always be able to floss because it’s so tight sometimes. Is it some scenarios where I won’t be able to floss to help clean the cement? If so, how do you manage that?

[Libi]
It is possible. And if the child is really upset, I would advise the parent and say there’s still some cement left, which will probably be cleaned away by brushing. But we can check it the next time they come in, because I don’t want to sit there and be so pedantic about a piece of gic stuck in between the teeth, which is going to leech fluoride onto the tooth beside it fantastic. It’s like an added bonus for me. But I’m not gonna sit there and be pedantic about getting rid, to floss, because that will probably upset the child. Yeah, and it’s just giv you more chair time [Jaz] That’s my biggest worry. [Libi] Yeah. So if I would say try with a probe, flick it out. If you can’t, there’s still, so there’s a couple of ways I manage it. The first way is if they tolerate the three in one and suction, I will as soon as I’ve seated it, go at it with the three and one water and air at the same time, blast it through the interproximal and get it you know hoovered up by the dental nurse. And then I will go through it and floss as well, I find this because the gic cement is still viscous, it washes away really quickly. And then you don’t have to do as much cleanup. If they don’t tolerate the 3 in 1, I will use a damp gauze straightaway after, straightaway go through with the damp gauze and get in there with the floss as soon as you can. If you can’t due to cooperation or whatever reason, and it stays there. And it’s interproximal. If you can’t flick it out with the probe, I would just settle for it the way it is and then just see it will brush away gradually. And you know, and try and get in there next time with some flosses, especially if you’re seeing them again.

[Jaz]
Okay, which cement are you using?

[Libi]
Previously, I used Fuji 1, which I find is good because it’s quite fluid. And you sometimes you need that bit of extra time with kids as well. Because you know, you might have a bit of a faff around until they let you seated properly. You don’t want something too quick setting

[Jaz]
Can Dentists use Fuji 2 or Fuji 9? Can they use that? Should they use that?

[Libi]
And I think it just depends on the work.

[Jaz]
Because that’s what they have. That’s what they have in their drawers. Right? Like a gic. I’m just thinking for those starting to use this technique should they? Is it just worth two cents?

[Libi]
I think try it see how this gets it is. I’m not too familiar with the other, I think because I was in pediatric department when we just had that as standard. And now I’m using relyX. But it’s the one that mixes as you squeeze it through the tube, I can double check which one it is exactly. But that one it gives a bit of a longer working time and is viscous. So I think it’s, you just need a bit of a longer working time to make sure that you’ve got that extra leeway to sit because what you don’t want is the child loses cooperation or something or they don’t bite down straightaway. Or you know there’s you’re unable to sit it properly immediately. And you don’t want that gic to set quickly. And then

[Jaz]
based on how you said there then it makes sense. If it was a situation where you only have Fuji 2 or Fuji 9. Fuji 2 is the RMGIC light cure of a version right? Or it’s a dual cure? So it’s way more runny and without the light it can take a long time to set which might make sense for those who only have the option to use a Fuji 2 rather than the Fuji 9 which should be quicker setting is far more viscous. So I don’t think, the Fuji 2 sounds better.

[Libi]
Fuji two would be the better option. Yeah, definitely.

[Jaz]
Brilliant. So we’ve talked about that. And then the other thing I want to say is that when I’ve placed a hall crown, let’s say on the upper left D or E, then to reassure those who may be trying this technique for the first time that actually, when they bite together, it can be alarming as a restorative dentist to see someone and they’ve got a massive like opening and the contralateral side is three or four millimeters opening, but every time they come back [inaudible], the occlusion just magically settles. So just to speak on that.

[Libi]
Yeah, I think they said it takes around a week for child’s occlusion to settle where you have to bear in mind is they’re not adults, they’re not fully grown, they’re in mixed dentition, they will go through phases where different parts of their occlusion are open, you know, tight contact space, you know, they they’re just going through so many changes that actually it doesn’t make, it doesn’t impact them significantly, and sore tooth would impact them much more significantly in or not being able to eat on that

[Jaz]
But it’s worth mentioning isn’t it? For those doing it for the first time because it actually can be as a I did the first time I did as a student I was oh my gosh, how is this ever gonna settle and it does.

[Libi]
If you do feel like it significant open bite, and what you would do is monitor it. So if over the course of, let’s say, a month it didn’t settle or the child was complaining that it was bothering them, then you could take off the crown. So you’d have to cut it off and redo it. So But usually, I haven’t had any cases where that’s been the case.

[Jaz]
I think it’s a good tip also, and please correct me if I’m wrong, Libi is Never do opposing teeth and never do an upper left E and a lower left E Hall crown the same time because the opening will just be ridiculous, right? Is that still something that you follow?

[Libi]
The rule? Yeah, so the rule is that you can do two in the same arch on opposite sides. So you can do D and D upper, you can do D and D lower, you can do E and E upper, ED upper at the same time, DE lower at the same time, but you can’t do contralateral. So like you can’t do top and bottom on opposite sides. And you can’t do the same site like upper and lower. Okay? So that’s all in the hall crown manual. So if you have read through that, that’s all.

[Jaz]
I will stick that on, because I think it’s a really fantastic resource. I know that Dentinal Tubules are setting up a Tubules live for hall crowd. So they’re gonna have study clubs all over the UK, where people will get dentists, will get to place hall crowns on models and stuff. So that there is that coming on, and I’ll share the date with you as well. Because for those GDPs in your network, who because there are some study clubs in Scotland, and maybe you know, if you can go to one of them, be a mentor for these GDPs maybe that might be a good thing. So I’ll be in touch with you about that. So let’s talk about something. We’re gonna have to wrap it up eventually. But let’s talk about a clinical point where local anesthetic in children. I’ve done it both ways. In my earlier years, when I used to work in mixed practice, let’s say and time is of the essence. I’ve done it before that I was okay. It will be okay with that anesthetic and you’re there for the first time pieces doing what you can and then with the slow handpiece roten bur and then just restore to the best of the ability without anesthetic, and I’ve done it also, more routinely now I’m using anesthetic, and what is your take? And what is your advice for GDPs about local anesthetic use when it comes to restorations. Because for Hall crowns where you would advocating not to use LA. But for restoration. Obviously extractions, mostly we’re gonna use LA, but we’re talking about fillings.

[Libi]
Fillings. So the thing with LA and even with hall crowns, by the way you can use a topical just around the gingiva if the child is is quite uncomfortable if you just paint a bit of chop lines that’s around the gingival margin that can help you with the seating just to make it a bit more comfortable. But topical anesthetic has another use, which is to quantize a child. So most children, what they hate about the local anesthetic is how it feels afterwards. So when they’ve had it, they don’t understand that feeling. So if they’ve never had local before, and you numb them up, and all of a sudden their face feels really weird. And they keep touching it, we keep biting it because they don’t understand or know how to process this, they can actually process pain better than they can process that sensation of being numb. Because it’s something brand new. So sometimes, if you know that next time they’re going to come in, you might use local anesthetic if you give them some topical anesthetic on cotton roll and you ask them to put it on their tongue and say, “Oh, doesn’t your tongue feel funny now? Doesn’t it feel weird? That’s because it’s gone to sleep. And usually when your tongue is asleep, you are asleep. But this time you are awake and your tongue is asleep. That’s why it feels weird.” So that’s wat I say to them, and then it’s about reassuring them that it’s going to go back to normal. So you’re gonna say to them, “I know it feels weird now, but in a few minutes, it’s going to go back to normal. Now, after a few minutes, when it starts to go back to normal, they say “She was telling the truth, it’s going to go back to normal,” They believe you, okay? Even if they go home, and then they realize, “Oh, it’s gone back to normal,” you know, they say it’s reinforcing the message that you’re giving them. Then when you need to give them a local and you tell they have this really strange sensation. You reassured them and say “Do you remember when we did it with the topical aesthetic? How it went back to normal with a magic jelly? It’s going to feel the same again, it’s going to go back to normal. And it’s just because it’s asleep, they’ll wake up later.” So that’s sort of one hurdle with giving them local anethetic. Sometimes in a child who has non painful tooth, so let’s say they have caries in their tooth. It’s not painful to them. Okay? At the moment. They’re not complaining of pain, but you can see the cavity, it needs to be restored.

[Jaz]
That’s the most of scenario and that’s exactly what I want you to answer for GDPs.

[Libi]
So I think high speed with water is very difficult to tolerate without LA, because you’ve got the added coldness, which will stimulate the pulp and just the cold water along with the high speed is going to bring about some reaction. So going at first with a slow speed is actually probably more favorable. So if you were going to go without LA, you would, you can say to the child first. So the thing is, if they know what to expect, you’re more likely to get a better outcome. So if you say to them Halfway through once they’ve started to have pain, that actually “I can give you something to make your pain go away”, they’re not going to be cooperative. But if you say to them from the beginning, “I can make your teeth sleepy, which would feel a bit uncomfortable to begin with, but then your tooth would be asleep, and we could clean it really quickly and well.” Or “We could try with the small buzzy toothbrush first. And if it feels uncomfortable, then I can give you the med, the special jelly and medicine to make it sleepy so that you’ll be comfortable.” But it’s, if you say “Some people feel comfortable with the buzzy toothbrush without having the sleeping medicine and others don’t. So do you want to try?” So it’s giving them the options. And then also, you know, they feel a bit in control. And you give them a signal. So you say “If it feels uncomfortable, I want you to put up your left hand” and it’s always the left hand, you say “the left hand so you can hit my nurse, not me.” So I say “You can hit Chloe, but don’t hit me.” And I say “And if you put your hand up, I’m going to make sure it’s safe. And then I’ll stop.” So you don’t say I’m going to stop straightaway. So you don’t give them unrealistic expectations. You make them feel that you care about them. So you saying “I will make sure it’s safe. And I will stop as soon as it’s safe for me to stop once I’ve seen your hand signal, okay?” And you have to follow their hand signal. Even if it gets really annoying, even if they’re doing it every two minutes. If they start to do it too much. And you feel like they’re just doing it for the sake of doing it. Then you go for another tactic, which is to say, “We’ll use the buzzy toothbrush for five seconds. And then we’ll stop.” So we’ll count to five and then we’ll stop and when you’re doing count to five, “Okay, let’s increase it to 10.” Now a child in pain, you’ll realize they’re in pain, you’ll know when it’s just you know, you can tell when somebody is in pain, you’ll see their legs switch, you’ll see their, you know, some kind of reaction body reaction. And if you you can also use the slow speed on their nail, you can draw a [Jaz] Yes, I do that. [Libi] Yeah, so you can use the slow speed on their nail, and just explain to them how it’s going to feel ‘that it’s going to feel bumpy, it’s going to be a bit noisy, it might feel a bit bumpy on your teeth might feel a bit tickly.’ So I think you can do some restorations without local. And the reason being that now we know that if we seal in caries. So if we’re sealing in the caries, we’ve got a good clean margin, that’s actually more important than going deep and taking out every single bit of affected dentine. So if you are taking away the soft dentine and you are leaving affected dentin that isn’t soft, but you have a clean periphery of the cavity, and you can get a good seal on that, then I think that is sufficient to give a good outcome, restoration wise. I don’t think you’re going to get any better by making sure that you’re digging deeper and digging deeper might need local. So it’s kind of balancing up. It’s very different for each child. And some children once they’ve felt it without the local, they will prefer having local. And it’s just gauging that. But like I said just introducing it from the beginning that it’s an option. And I will use it if you want me to, that makes them feel in control when they’re asking for something, then they’re more likely to accept it as well.

[Jaz]
I really liked that giving them the control and choice and I like your tips about the hand signal. And following that a tactic I use quite a bit is okay, we’ll do 10 second bursts and we’ll see how many bursts we need. So I’ll count down and as you mentioned, that’s a bit quite effective for you as well. So that’s brilliant. In terms of the clinical questions, I want to wrap up in terms of because there’s so much value that we can talk about here. So, two questions I’m gonna wrap up, I’ll ask you in a way and then you can answer them. One will be at what point do you think a child, what is the threshold where you think, Okay, this child really needs to be sent to you. For example, you can contrast that with some children that you see and really you think this could be managed in primary care quite easily. So you can, you know, touch on those both things. So what point Should they be being referred to a pediatric specialist or pediatric dentist? And the other question I want to ask you is, what’s the one tip you can leave everyone with your one main big tip, you can be a repeat tip, what you said in terms of how to be better on Monday morning with children. So those two things, when should we refer essentially? And your overarching Doctor Libi’s Tooth Fairy tip.

[Libi]
So, in terms of referring, I think, you don’t want to push a child to the point where they’re upset. If you’re getting to the point where you cannot do your treatment, without the child being visibly upset, and the parent agitated, then you need to stop. And there is no shame in stopping and saying, “I think that this child would benefit from having a more specialized approach, and a more time.” And you know, just a different approach. So I think that sometimes dentists will push a child and make them upset, but then they have to realize that afterwards, that child is going to regress and not be able to have dental treatment. So I have some children who is severely anxious, and you look in their mouth, and they’ve got crowns, and they’ve got restorations. And you think, Well, they’ve had all of this done. But they’ve had it done under duress, where they feel like they’re pressured into having it rather than them being cooperative, and being able to have that treatment comfortable. So I think what, I think a few of the signs are, if the child you know, is visibly upset and cries when you’re trying to do anything, doesn’t want to get on the chair, the parent can be, if a parent is dentally anxious, highly likely their child is. So if you know that their parents, the parent doesn’t like going to the dentist, and they’ll come in and say, “I’m really scared to the dentist” That means the child is going to be put off as well, so and children who ask lots of questions, so it’s like a delaying tactic. So you get these like seven, eight year olds, and every time you come near them, “Wait, wait, wait…” and they’ll ask you like 10 questions. “Wait, I’ve got another question. I’ve got another question.” So they’re all tactics for them to delay the treatment, and it’s just a sign that they are anxious. And if you cannot give them the time that they need to get comfortable, and to build that trust, then refer it to somebody who can, because you’re not doing the patient any favors, even if they will need one treatment done. And you know, you can push them and just get it done that day. You’re not doing them any favors in the long term. So I would say, that’s when you should be referring these patients. And another thing is when you see something that needs more inputs, like MIH, so Molar Incisor Hypo-mineralisation, that’s something that needs to be looked at, not with eyes that are looking at those teeth and thinking What can I do for them today, but actually, they need more long term monitoring and treatment. And if it’s outside of your scope, then I would say these refer to a pediatric dentist because there are windows of opportunity for treatment, which will minimize long term needs for that child. And you don’t want to be the cause of them missing out on those opportunities to have a better outcome in the long term.

[Jaz]
I’m sorry to interrupt you there, I’ve got a really good PDF, I believe from Guys hospital, about it addressed to parents about MIH in your child. So I’m going to include that in the file section as well. I send that to parents and they find it really educational.

[Libi]
Jaz, that is what I give to parents when I diagnose MIH, and that is the leaflet that I emailed them. I said this is what you need to know, because there’s just a simplified version but what I don’t like seeing, okay, and I don’t think I’ve, we’ve touched on this, but I’ve seen quite a lot of parents who are coming into me who have been to the GDP and have been shamed or guilted about the caries in their child’s sixes when the child has only you know, the tip of just erupted, it’s not caries. It’s carious because of MIH. And we need to recognize that and you know, I put together just a list of the signs that this is MIH and not caries. Okay? So warning signs are if they’ve had hyperplastic teeth, okay, so sometimes we get the either hyper plastic following that we get the MIH or they’ve had no caries in the primary dentition. So you get this child in who’s just got their sixes through, you know, a year ago or six months ago, and they’ve got caries in it. But they’ve never had caries in their primary teeth. That doesn’t make any sense to me. There’s nothing that could have changed significantly diet wise or health wise unless there is a significant event in their life. But there’s nothing to say, you know, if you’ve had no caries and primary dentition, why are you getting caries in your sixes? Okay? So that’s something which I wanted to bring attention to GDPs. And the only thing is when you spot white opacities on the front teeth, on the incisors, you know, that’s also another warning sign for MIH and creamy patches on the molars. So what you want to do at that stage is you do want a specialist input because you don’t want that child to miss out on the opportunity of having the ideal treatment for them to minimize their treatment in the long term. [Jaz] Okay [Libi] and I mean, it’s very preventing that as 40%, some studies are saying it’s 40% prevalence of MIH. So it’s something that we should all be regularly looking out for and checking up on.

[Jaz]
It’s something that, I don’t want to shame anyone because I feel as though just at the point when I was at dental school, we were getting taught about MIH, but I feel as though three or four years above me, maybe they that was when they weren’t. The pediatric dentists weren’t teaching so much about MIH, when I went on my elective, and I met these Canadian dentist or who I’m still in touch with today, lovely people, great dentist, and they had no idea about and they were 25 years of experience, they had no idea about MIH. And it’s something that a lot of dentists don’t know about. In my own practice where I worked in, when I sent everyone this handout, they were like, no, the hygienist or the dentist had no idea about MIH. So you’re totally right, we should be looking out for the signs. And I’m gonna put some more information for listeners about MIH so that they don’t have that situation, that they’re confusing it for clinical caries, because it just doesn’t match up.

[Libi]
And the thing is, these, the sixes that we’re talking about that are affected, they are sometimes sensitive. And so what happens is the child actually won’t brush those back teeth, because they’re too sensitive to the cold water. So one of the great tips is to just say to parents to use warm water when you’re brushing, which is just something so simple, but it can be a game changer. And then the second thing is because the enamel, the quality of the enamel isn’t the same, they actually the sealants won’t stick as well to them. So that’s another reason why we’re not able to protect them. And also, if you’re doing a restoration on these sixes, they aren’t numbed up as easily as normal sixes. So you’ve got this sort of this vicious circle that they can’t brush them because they’re sore, but then they’re more poor enamel, they’re getting holes in them. So I think this is the kind of thing that you need to refer to a pediatric dentist because it’s not a straight forward, putting sealants on and put, you know, doing restorations, it’s looking at the long term for that child what is best. So I think I would, I love it when I get referrals for MIH, because I know that I can give them the best chance going possibly, you know, going forward.

[Jaz]
I mean, the severity of MIH probably has huge bearing on your treatment plan because if it’s mild, and there’s no breakdown and you’ve got a good quality patient with minimal orthodontic needs that would benefit from a six removal. That’s the kind of child is saying, okay, we’ve noticed it, your dentist done a good job to identify it, you’re going to have to be a bit more preventive than the average child let’s say, but thankfully, we don’t need to do it. But on the other end is when there’s severe breakdown, then you have that window to have them removed, that the seven set the place. And that’s where it’s important to get those referrals in at the right time.

[Libi]
Yeah, and to get an orthodontic opinion at the right time. And you know, it might be a case of needing to temporize these teeth until the right moment to take them out. So this is all things that need to be decided by a pediatric dentist with an orthodontist. So it is outside of the scope of the general dentist.

[Jaz]
So what age like let’s say they’re six, and they’re coming through and there’s already breakdown, do we need to refer at age six, or wait until age eight, or?

[Libi]
Any tooth that you see with breakdown, refer. Because what’s gonna happen is the orthodontist is either going to say, you know, if they look like they have a class two tendency, you’re going to say, maybe I want to keep these teeth around until they’re 12. And all of the adult teeth are through and I’m going to use that space for orthodontic treatment, you know, so, it varies from patient to patient, but I would say if it’s mildly affected, and you feel like you can manage it with sealants, and there’s no breakdown, keep that child under your care. If there’s any breakdown at a young age especially you need to refer them in because even the window of opportunity for closing, for extracting and anticipating spontaneous space closure. We’re looking at the window between 9 and 11 depending on how advanced they are. Some children are, you know, their dental age is much higher than their chronological age. And they can you know, that window can be missed, because we’re not referring them early enough. But if they’re coming in at age six or seven, you can take an OPT, and you can see what is developing, do they have any missing teeth? Do they have, you know, this is all things factors that we need to take into consideration and how much will start to break down there is, I would say, Take clinical photos, if you can. And if it is breaking down quite quickly, put a stainless steel crown on it, take a picture of it, put a stainless steel crown, and then you can show that the dentist that you refer on to say, this is what it looks like I was proactive, and I put a stainless steel crown on it, because I didn’t want it to break down further because some of them they get to the point where you can’t even post stainless steel crown on them because they’re so broken down. And the only option you have is to extract tooth, even if it’s not the optimal time. So we don’t want the child to get to that point, basically. We want to be able to pick and choose when and if we’re going to extract.

[Jaz]
Amazing. Thanks so much Libi. And to wrap up, the final tip that you want to share to GDps?

[Libi]
Final tip, have fun, actually enjoy your patient. Be excited, you know, go at the weekend and watch a kid’s movie, take your niece, nephew, son, daughter, whoever go with your friend, go watch a kid’s movie so that on Monday morning, when you come in, you can “Say have you seen the latest movie? It’s amazing.” You know, and just have something to talk to them about. And just enjoy it because kids will bounce, you know, they’ll feed off that excitement that you have, and they’ll be excited to see you and that will make you in turn excited to see them. And just enjoy it. Kids are great. Kids are so much fun. And you know, I know they come into you with pain, but the reward that you will have that what you will feel after you’ve treated them and they’re out of that pain and you see how much they trust you and you know, they’re thankful to you and the parents who are grateful or make you feel amazing.

[Jaz]
Fantistic. I love it when you when you said that I punched the air so I don’t think the video caught that. But that’s it. A lovely ending point to finish on. Libi, how can we follow all the tips that you give? Because you always give them so many tips to GPDs, can you please tell us all your social media channels so we how we can follow your progress and your career and all the lovely things that you’re doing.

[Libi]
So I’m doing, I have a Instagram page @drlibi. And I have my page on Facebook, which is a bit more active than what I post on both of them. But my videos and things more on I do Facebook live videos and things like that on my Facebook, which is Dr Libi’s Toothfairy Tips. And I’m sure you’ll put a link, Jaz. From those two pages are actually aimed towards parents more than towards dentists. But I’ve found that dentists like to follow it because it gives them, they like to see how I word things to parents, and also just how to bring about the topic. So I’ll post about, you know, what I see in the supermarket that annoys me and all the things that are speaking to parents saying no added sugar, tricking them into thinking they’re doing the best for their child, you know, one of your five the day, but actually it sticks to your teeth and rots them you know, so we get lots of patients who have otherwise healthy diets and they’re having health foods in inverted promise . And but actually, they’re very sugar instinct to the teeth. And what I say about natural sugars to parents and kids is the sugar bugs don’t care where the sugar came from, they will eat it anyway. And poop anyway. So it’s eaten the ship the sugar bugs don’t look at natural sugar and go ‘Oh no Stand back. This is natural. We’re gonna back off.’ They’ll eat it anyway. So just those oral health messages that’s it’ll help you as a dentist to be able to spread them in a more empathetic way. And you know, I post my personal stories, one of the reasons why I have my Facebook pages actually for me to appear human to the children I see. So I say to the parents follow my page, they said I’m not really into Facebook, I see I know. But if I’m not going to see your child for six months, if within those six months, they see a few of my posts and see me going out with my girls and seeing that it makes me more familiar to them. And when they come back in, they know a bit of what I’ve been doing. And they will not feel you know, they won’t have forgotten me and it’ll just make them still be in that comfort zone with me and just keeping up to date and you know, and it helps to motivate them as well with brushing, videos of brushing and things like that as well. And there is a tooth fairy, there is a blog which I have started to follow which is really good on Facebook, which is aimed towards dentists. And I think it’s called Tooth FaiRead. I’ll email, I’ll send you the link for that. [Jaz] Please do that. Because anything that have value, I want to share it [Libi] Yeah. So that’s a new one that started that’s aimed more towards dentists. And they posted an excellent summary of MIH, just last week. And I shared it because I think it was an amazing concise, to the point what we need to be noticing, you know, dentist needs to be noticing. So I’ll give you the link for that. Just, yeah, follow my page. You’ll see that I post mixed things not all dental related sometimes about my life. And yeah, I think people find it interesting.

[Jaz]
Oh, absolutely. I love your posts. Always. I think my message to you Libi is keep doing your thing. I think you’re helping so many dentists. And you’re showing that you’re having fun. And I think I was saying to my speakers, you know, you are a massive role model to dentist, especially to you know, to audience, but women dentists, you know, we need more women like you in dentistry, sharing, teachings, spreading the word. So on both accounts, thank you so much for coming on the podcast today. I think my listeners over the two episodes have learned so so much. And I’m just in love with all your analogies, and I can’t wait to use them with children. So thanks so much for making me a better pediatric dentist and all the listeners who were listening. And it’s been a pleasure having you on.

[Libi]
Thank you so much. Thanks for your time. And thanks for your amazing podcast as well. It’s been a privilege.

[Jaz]
Thank you so much.

Jaz’s Outro: Thank you so much for listening all the way to the end. I hope you enjoyed it as much as I did. I really enjoyed speaking to Dr. Libi on both sort of parts of the episode, the first one being prevention. The second one just now as you listen to a bit more clinical. So if you enjoyed it, please follow Dr. Libi and what she’s doing on social media. She’s doing some great things. Got some really cool episodes lined up going ahead. Some great guests coming up. For example, I’m just gonna drop this one there, Chris Orr amongst many others have agreed to come on. I’ve got a great episode about complete dentures coming up as well. But all of that you have to wait for around about once a week I’m averaging at the moment. So again, really appreciate you listening. And if you’d like it, please tell a friend. Tell a dentists. Put a five star review on your platform that you listen to it on, whether it’s Apple or Google or Stitcher or whatever. And give me some feedback. If there’s anything I can improve for you. Let me know. Thank you.