Kate Quinlan interviews dental therapist Mariam Al-Ani, 28, from Leeds. Mariam works for a specialist paediatric dental service based at Clarendon Dental Spa in Leeds with lead clinician David Auld, three other paediatric dentists, a second dental therapist, a team of dental nurses and a dedicated paediatric manager.

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Clarendon Dental Spa

The paediatric dental referral service has been available at Clarendon Dental Spa for 12 years.

The referral service is an NHS service and is a historic model of excellence in paediatric dentistry. It treats patients aged 0-16, where necessary under inhalational sedation. Before the COVID-19 pandemic it was receiving over 200 new patient referrals every month. Once a child has had their treatment and been given prevention advice, they are usually discharged back to their dentist. Those children requiring a general anaesthetic for multiple extractions are referred directly to Leeds Dental Institute where a consultant colleague will work from the Clarendon team's treatment plan.

Interview

How did you first get into dentistry?

Mariam: I owe this one to my eldest brother. I remember when he was a dental student he used to bring me back plaque disclosing tablets and tell me they were sweets to make sure I was brushing! He once took me to Leeds Dental Institute where he studied for a check-up and some dental treatment and I remember thinking this place looks awesome! From then on it was always an interest that I had.

I've always wanted a job in healthcare and a job where I could take care of people. I never wanted to be in a job just because the income is good; I've always wanted to make the most of my fortunate situation to improve the quality of people's lives.

Can you describe your route to becoming a dental therapist?

A lot of the students on my dental therapy course were actually dental nurses first and that is how they got their foot in the door to studying dental hygiene and therapy. I was one of the few that came straight from A-levels. I received interviews at Manchester, Birmingham, Teesside and Leeds. I was fortunate enough to be offered a place to study in three out of the four. I realised once I was on the course that I was really fortunate to receive these offers as it is a very challenging course to get on due to the limited number of places.

Where did you study dental therapy?

I studied at the University of Leeds [like my brother] and graduated in 2015.

When I first started the course it was a shock to the system; I'm usually a very sociable and confident person but at first I had a lot of personal struggles in my first year and my social anxiety was quite tough to keep on top of. I didn't really share that with others and from the outside it was probably hard to tell but first year was definitely the toughest for me.

At first I wasn't sure how honestly to answer this question but I can't help but think that if there is someone who's currently studying on the course and they are reading this, and they feel like they are really struggling, I want them to know that it's going to be worth it and they can do it! Sometimes I felt that the tutors were really tough on me but honestly, I feel that it shaped me to be the dental therapist that I am now. Maybe we can call it tough love.

By the time I was in second year I felt like I fully grasped things; I found my own technique for studying and that's when I really started to get into the swing of things. I had built such a good rapport with my patients and genuinely felt like I was in the right place.

I've had a few patients that go from being too embarrassed to smile to not being able to stop smiling, and that's what makes it all worthwhile for me.

What do you find rewarding about being a dental therapist?

Seeing my patients' confidence grow! I see a lot of nervous adults and children and as the weeks and months go by, I see a change in them during the course of their treatment. They go from being too afraid to sit in my chair to having me need to make sure I don't run too late after their appointment is over because we can't stop having a good chit chat at the end!

However, saying that, the most important thing of all is seeing the improvement in the general health of my patients, most commonly my paediatric patients. Many come to me with abscesses and dental pain that keeps them up at night and away from school. Once their course of treatment is complete, they turn into different children.

After graduation, where did you work?

Answering this question makes me realise how much of a workaholic I am. In the last five years I've been working six days a week! I started off working in Cheltenham, Bristol and Birmingham (all three at the same time - I certainly don't miss my 5 am starts to make sure I got to work on time). After a year I moved back to Leeds and started working at Clarendon Dental Spa six days a week.

I'll never forget that feeling when I saw my first patient without having a tutor supervise me. I still remember that it was a seven-year-old child who needed two extractions. I was definitely nervous.

Have you always been able to use your full scope of practice as a dental therapist?

Yes. I realise how lucky I am to say this. I wanted to make sure that the first job offer I accepted was in dental therapy because I didn't want to become deskilled and be too afraid to carry out therapy work.

When I worked in Cheltenham I was in a very high caries area and was lucky enough to build up my therapy skills there.

It's when I got to Leeds that my paediatric therapy really took off. I have a really good working relationship with the paediatric dentist at Clarendons, David, who likes to keep me on my toes! I carry out a variety of restorative treatment from stainless steel crowns and pulpotomies to extractions and restorative fillings. This is all thanks to the specialist referral service we have at Clarendon Dental Spa. Without it I wouldn't be able to provide this treatment to children.

I also carry out a lot of periodontal work, which I also really enjoy, and again find so rewarding. I have such a good rapport with my patients; I've known some of them for almost five years now and to see their periodontal status go from one extreme to the other and see how it changes their confidence really makes my day. I've had a few patients that go from being too embarrassed to smile to not being able to stop smiling, and that's what makes it all worthwhile for me.

What are the more challenging elements of your role?

From the paediatric point of view, it's the nervous children and parents that I get. These patients have been referred to Clarendons to see the paediatric dentist for complex dental care and the majority of the time it's because they're too anxious to be treated by their regular GDP.

I have some kids that will refuse to sit in my chair, or will scream to the point it shakes me to the core and we haven't even said hello yet. That's when I take a step back and realise that we need a whole lot of behaviour management before we start anything. This is where I find out what their favourite cartoon character is or favourite thing to do/favourite food is and get the child to be my friend before doing anything else.

You'll often find me watching Sponge Bob, Captain Underpants or Paw Patrol and Marvel so that I can distract and debate with children over which character is best and why. Sometimes by the end of a treatment session I feel like I've lost my voice because I don't stop talking to the child to keep their mind off what I'm doing. My nurse is always amazed at how much I can talk!

It's also tough when the parent is also nervous. For example, once I'm about to administer a buccal infiltration I sometimes get a parent saying 'right get ready, this part hurts' and then I have to start the behaviour management all over again. But that's why I always have a quick chat about which words to avoid in front of children.

The most rewarding part at the end of all of this is having a child that was once too scared to walk through my door running into my chair and chatting to me like I'm their best friend. We go from easing them in with toothbrushing and diet instructions to being able to carry out fillings, crowns, pulpotomies and extractions. The majority of these children have been referred because of how complex their treatment needs are and for having dental anxiety.

Can you tell us more about how the paedatric dental service works at Clarendons?

I work very closely with Dr David Auld. David sees the patient first for a check-up, and depending on the patient's needs, and if it's within my remit, he will then refer the patient to me to carry out the treatment with a plan to follow.

Having a dental therapist work alongside the paediatric dentist significantly helps reduce the waiting list at the practice as we are often inundated with patient referrals.

The paediatrics referral service at Clarendons really is invaluable. It allows GDPs who haven't been successful in carrying out the treatment themselves or have a patient with complex needs an opportunity to refer them to get them the urgent care that they so desperately need.

The practice also offers treatment under sedation with the dentist which is often used with patients who have severe dental anxiety and require complex treatment.

It breaks my heart to see how many children are so desperate for dental care, especially when it's not in their hands at all. So many of my patients have had countless visits to A&E and have been given antibiotics in the interim. They come to me with so much pain and discomfort that has led to them having sleepless nights and missing school.

The idea that it is not essential for a dental hygienist to have a dental nurse is mind-boggling to me. This rule is beyond unfair and sets the hygienist and patient at a great disadvantage.

This is why the preventative care we also offer is so important at Clarendons. It's rare that I see the same patient more than once after the course of treatment is completed and I believe this is down to the educational and preventative work that we carry out which covers toothbrushing and dietary advice.

How has your role changed in 2020 as a result of the pandemic?

When the pandemic first hit I went from working six days a week for five years to zero days a week for almost six months. I was beyond bored; I was really missing dentistry and wanted to stay as relevant as possible, so I made educational videos to send out to our patients. I was worried that with all this time off the progress I had made with some patients would be lost. A lot of treatment was disrupted halfway through.

I bought a giant toothbrush and tooth model and made two paediatric videos about diet and toothbrushing and sent an email out to parents linking to where they can find advice about how to take care of their children's teeth. The British Society of Paediatric Dentistry (BSPD) has great educational tools for both parents and clinicians and really is an invaluable tool to have to hand; I refer to them on a regular basis. Alongside the educational videos that I created I was also able to link some useful information for parents found on the society's page.

I also posted the videos on Clarendons' YouTube channel and Instagram page (@dentalaware) which was set up during the pandemic.

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Do you always work with the assistance of a dental nurse?

Yes, I couldn't do my job without them. Dental nurses help me with behaviour management and they support me and help me keep on track. The idea that it is not essential for a dental hygienist to have a dental nurse is mind-boggling to me. This rule is beyond unfair and sets the hygienist and patient at a great disadvantage.

How is it possible to carry out a 6 pocket chart and monitor a periodontal status effectively without a nurse? When your patient has a code 3 or 4 and needs periodontal charting, how can you not carry it out? I don't see how it's possible to do a full mouth 6 pocket chart without a nurse, unless you stop every minute to update the chart yourself, and even then I don't see how you can do this efficiently and accurately. It would be neglectful not to carry the charting out. What happens if there is a litigation? Who will support the clinician? As clinicians we are trained to write who nurses with us mainly for that reason. It is a protective net that we need and a rule that needs to change.

How many new patient referrals is the service receiving now, as 2020 draws to a close?

We are still inundated with around 220 referrals a month. Due to the pandemic there is a real backlog of patients. At one stage during 2018-2019 we had on average 280 referrals a month over a six-month period.

Are there any particular patient cases that stand out in your memory?

I have a few cases that stand out to me and will probably stay with me.

One paediatric case involved a little girl who used to always cry when she would have to visit the dentist and she would complain of a headache. She was clearly nervous and I can imagine in a typical general practice where NHS dentists don't have much time, not much behaviour management was carried out. Once I figured out her favourite things to talk about were Disney and food, I had one foot in and convinced her to sit in my chair.

We started off with just basic tooth brushing and diet advice and worked our way up to three extractions, four crowns and three fillings! The little girl went from crying that she had a headache to running up to me and wanting to give me a great big hug and thank you. When she realised our treatment was completed together she actually started to cry and I felt so bad.

Another paediatric case involved a ten-year-old boy who had been in agony with a toothache. He had severe dental anxiety and wouldn't allow anyone to carry out the extraction for him. I somehow managed to convince him to let me have a go, and he was shaking and so upset. Just as I managed to take the tooth out the relief on his face was priceless and he hugged me straight after and wouldn't let go! He actually took me by surprise and made me want to cry too. I know dental pain is one of the most horrific things for an adult to go through, so I can't imagine how it feels for these children.

What are your hopes for your working life in 2021?

I have mixed feelings about 2021. I don't know how long it will take for normality to resume or if we will have to embrace this way of dentistry as the 'new norm' (if I had a pound for each time I've heard this expression I'd be a millionaire).

I'm excited because I can't wait to have patients flowing back through the door and getting them back to maintenance. But I am also pregnant with my first baby at the moment so I know I will have another six months off in 2021.

I was actually so nervous to be getting back to work while being pregnant so I invested in a hood respirator. It has become my new best friend, a great conversation breaker with patients. I've been referred to as an astronaut and alien by both my paediatric and adult patients! The hood is great as patients can see my face clearly and isn't as intimidating as a regular respirator mask. Work doesn't actually feel that different, PPE aside, and I'm glad to have some sort of normality back before going on maternity leave.

I have some kids that will refuse to sit in my chair, or will scream to the point it shakes me to the core and we haven't even said hello yet. That's when I take a step back and realise that we need a whole lot of behaviour management before we start anything.

I desperately wanted to get back to work before I was on maternity leave because all I could think of was my maintenance patients that had missed all their recalls. I would say 95% of my patients' periodontal status is stabilised and I want to keep it that way. I'm really proud of them. I was taken aback at how desperate they were to come back and see me after the first lockdown. I personally called these patients to book them back in and it was a nice way to check in on them - it took me days to do so though!

What do you like to do outside work?

I'm a big family person; that's why I found lockdown so hard because I couldn't see them. I can imagine it was the same for so many others. Any spare time I had in normal circumstances was spent with family on a weekend; on weekdays I would see my friends after work too. I had got really into fitness prior to lockdown and was weight training at the gym too. But that's on hold now for obvious reasons...

I did underestimate my cooking and baking capabilities before lockdown. They are no way as good as my mother's, but it's good to know my Middle Eastern cooking genes are there to be expressed when needed.

Do you have any ambitions you would like to share?

Obviously being pregnant I want to be the best mum I can be: if I'm half as good a parent as my mum and dad I will be happy. My parents are so hard working and provided me with everything I needed to be where I am now.

I would love to become a tutor in dental hygiene and therapy one day; all I remember is my nervous little self as a university student and I want to be there for that person. I always loved teaching and tutoring and we occasionally get university students from Leeds who come to shadow us with a question booklet and I love sitting with them and explaining everything.

Who do you live with and what do you do to relax at the end of the day?

I live with my husband; this is going to sound so funny but if I ever had a crazy day at work and I needed to wind down, I would just drive to the supermarket near home and have a browse and food shop! I could spend hours at the supermarket… it drives my husband crazy; he won't come with me anymore.

Special plans post-pandemic?

God willing, I will have probably have given birth by then. I did want a holiday to Dubai. Right now I'm just hoping that I can hug my parents; it was really hard to tell them the good news that I was pregnant and not be able to hug them.

Are you pleased with your career in dentistry so far?

Yes, I am so happy that I chose a career in dental hygiene and therapy. It's the best decision I ever made. I remember once a dentist in an interview told me that I was very enthusiastic towards patients care and that over time this will diminish. I was really taken aback by this. I'm happy that five years later I love my job more and more. The more experience I gain the better clinician I become and the more rewarding it becomes. I love my job because of the patients.