For me, every day working in the Community Dental Service (CDS) is different. Because of my academic training role, I spend a day and a half doing research every week. During my clinical days, I could be working across any one of our community dental clinics in Sheffield, one of which is based in an outpatient mental health clinic. I may also do domiciliary visits, or go into our local spinal injuries unit where we can provide care for current inpatients. We have a big team here in Sheffield, and teamwork is essential for us in providing the level of care we do.
Features of community dentistry
People are referred to our services for different reasons. People may need more time in their appointments due to challenges in communication, mobility, and access. Or because they have complex medical and social care needs which can influence management. Our appointments can be longer to allow for reasonable adjustments to be made so people can receive their treatment. We also have access to specialist equipment such as wheelchair tippers, bariatric benches and dental hoists, to support people in having their treatment.
Those working in the CDS have a good understanding of these complexities, and a wealth of experience in managing and providing treatment for these individuals. This represents a very distinctive skillset, and demonstrates provision of holistic care, where we consider the person, their environment and social contexts as part of overall treatment planning.
There is crossover between the patients that our colleagues in the high street see and those we see in the CDS. Often we try to get our patients seen on a shared care basis – with our high street colleagues providing regular examinations and preventative support, and referring to us when treatment is required.
In terms of the treatment I provide, it is quite routine. I do check-ups, scaling, fillings, extractions, root canals, crowns, and bridges. Some of this might be provided using conscious sedation like inhalation sedation with gas and air, or with intravenous sedation. I also provide a lot of dentures in the CDS, including complete dentures.
No two days are the same in this job
The exciting thing about working in the CDS and what I particularly enjoy, is that there is no typical day or week. I may have certain things in my timetable like working in community dental clinics twice per week, then once a week doing intravenous sedation with a colleague or going on domiciliary visits. Depending on the week we may have a general anaesthetic list based in hospital.
There are many types of patients I can see, including people with learning disabilities, inherited conditions like haemophilia, spinal cord injuries, profound dental anxiety or phobias who may require conscious sedation, or those with a history of mental health issues, or recovering from substance misuse. I also see patients with dementia and other neurodegenerative conditions like Parkinson’s or Multiple Sclerosis. These are incredibly broad and diverse groups of individuals.
Being a community dentist is so rewarding
There are many aspects of this role which are very rewarding. For example, I may see someone who is in the process of recovering from substance misuse and requiring dentures. You hear things like “I’ve never been able to smile,” or “I don’t feel comfortable going for a job” and restoring this part of their self-image may be the next step for them in their recovery journey. It is potentially life changing for someone, and when you finally fit that denture and they smile for the first time, it can be very emotional!
You can also play an important a role in building the confidence of an individual. Patients might come in feeling very mistrustful and by taking the time to build that relationship, you can help them feel more confident not only in themselves, but in the dental team too.
For me, there are lots of little wins to be had. Someone may have never let anyone look in their mouth before, but with work building familiarity, when they let you look in their mouth, or you manage to get some fluoride varnish on or brush their teeth, it is a huge step for all involved.
"It is potentially life changing."
Community dentistry means teamwork
There can be a lot of liaising and planning around dental appointments and treatment in the CDS. We often need to contact patients’ medical teams to get a better picture of their current condition and management.
I may need to speak to social support teams and care teams responsible for patient welfare at home to find out more about them. For example, some people in supported living will have different packages of care at home which could influence how we provide care. If a patient needed intravenous sedation, we need to ensure there is someone at home to look after them for 24 hours afterwards.
For those lacking capacity, we may need to find out who should be involved in best interest decision making discussions, such as a court appointed guardian or deputy. Social workers can often tell us more about where the patients have been, their financial arrangements, and others involved in their care. Involving those familiar with or known to the patient can help to maximise their capacity and support them in taking part in these conversations.
Daily planning, and adapting to change is key
Having such variety means I need to plan ahead as far as possible, making sure I know who I am seeing, that any requests or referrals have been followed up and the results of any investigations are available.
We need to plan for any specialist equipment such as a wheelchair tipper or a hoist, to be available when it is needed. However, things can change very quickly throughout the day or between appointments, so you need to be able to be flexible and open to change in terms of what you had planned to complete in an appointment or how.
You need a number of different skills working in the CDS including excellent communication to enable you to manage peoples’ emotions and anxiety, as well as to establish their expectations and understand what they want from their dental visits. As CDS dentists we spend time getting to know people and those involved in their care. Sometimes you do need to see people a few times to become familiar with each other and build that trust, helping acclimatise them to the clinical environment.
There are still time pressures, but we try to bear in mind the longer-term care plan for each person. We try to be holistic in our approaches, considering not just the teeth in front of us, but the person, their environment, and social context too.
Common patient interactions
Most of my patient interactions go along these lines. For new patients especially, I find it helpful to get people from the waiting room myself – this was something I was encouraged to do at university - and engage them in conversation as we walk back to the clinic. It can take a minute or two to get from the waiting room to my clinical room, so during this time I ensure I smile and use positive, friendly language, and I can see how people respond to me.
Inside the clinic, I introduce myself and my nurse to the patient and ask who they have brought with them. I give them the option of sitting in the dental chair or another chair, and find out a little more about them, which can help to put them at ease. My nurses are great at this, and I really rely on them in ensuring a successful clinical experience is had by our patients.
Depending on the individual, the first appointment may only be a bit of a chat, and I may not even get a look at their teeth. Some patients feel very anxious; they do not want to sit in the dental chair, and they do not want you to look at their teeth. In these situations, it could really set someone back if you tried to immediately jump in and try to look. Respecting individuals and appreciating that people may need time can help to work through this. Often people just want to be listened to and tell their story in the first instance, rather than going straight into treatment.
Some individuals may not be able to verbally communicate that they have a problem with their teeth. However, their family or care team may report a change in behaviour or emotional state which might be an indication of pain. We have to carefully look for other signs or indications, piecing together the different clues to find out what might be going on. At other times, sometimes there is a clear swelling or evidence of a dental problem and depending on the individual we may need look into using sedation or general anaesthetic to get a closer look and complete any necessary treatment to resolve the issue.
I really enjoy working in the CDS. Sometimes it can be difficult; a lot of patients we see have experienced or felt marginalised within our healthcare system and have had to fight to get the services and care that they need. Hearing about their experiences can be difficult. Our work in the CDS is not just about providing dental treatment, but about breaking down barriers in healthcare, and supporting our patients to access the care they need and in a fair and equitable way. It is a meaningful and truly rewarding place to be.