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Contents...

1 Medical emergencies in the conscious patient......................... 6

8 Xerostomia and salivary gland hypofunction............................. 64

Acute chest pain................................................................................. 6

Introduction.......................................................................................... 64

SIGNS AND SYMPTOMS........................................................................ 6

Aetiology of xerostomia and salivary gland hypofunction: salivary

MANAGEMENT..................................................................................... 10

gland pathology.................................................................................. 66

Asthma attack..................................................................................... 10

Systemic diseases................................................................................ 68

Inhaled foreign body.......................................................................... 14

Medications......................................................................................... 69

SIGNS AND SYMPTOMS........................................................................ 14

PREVENTION......................................................................................... 14

9 Radiology in dental practice............................................................. 72

MANAGEMENT 1.................................................................................. 14

Patient identification........................................................................... 74

MANAGEMENT 2.................................................................................. 16

Clinical evaluation.............................................................................. 74

Dislodging an object from the airway.............................................. 16

Training and education...................................................................... 74

MANAGEMENT 3.................................................................................. 17

Incident reporting................................................................................ 76

Background information..................................................................... 17

Reducing the probability and magnitude of

Hyperventilation................................................................................... 18

unintentional exposures...................................................................... 76

MANAGEMENT..................................................................................... 19

Quality assurance................................................................................ 76

Cross infection control........................................................................ 80

2 Safeguarding vulnerable adults....................................................... 20

Defining abuse of vulnerable adults................................................. 20

Who abuses vulnerable adults and in what circumstances?........ 22

Barriers to reporting abuse................................................................. 22

The management of the abuse of vulnerable adults..................... 24

Further reading.................................................................................... 24

10 Communication and the dental team: relationships with patients ...................................................................................................... 84

What is abuse?..................................................................................... 26

Categories of abuse........................................................................... 26

Recognising abuse and neglect....................................................... 28

What exactly are we trying to achieve?.......................................... 85

Last thoughts........................................................................................ 88

Principle Three: Obtain valid consent................................................ 90

Principle Five: Have a clear and effective complaints procedure...92

12 Oral health of older people................................................................ 96

4 The orthodontic team............................................................................ 34

Why do we need to relate well to patients?.................................... 84

11 The General Dental Council’s Standards: Consent and complaints procedure.......................................................................... 90

3 Child protection and the dental team- abuse and neglect.. 26

Team members.................................................................................... 34

Oral effects of ageing......................................................................... 98

Teeth...................................................................................................... 98

5 Dental practice management – dealing with rights and grievances.............................................. 40

Bone ...................................................................................................... 99

Oral tissues............................................................................................ 99

Disciplinary and grievances procedures.......................................... 42

Saliva and salivary glands.................................................................. 100

Disciplinary procedures...................................................................... 42

Oral status............................................................................................. 100

Grievance procedures....................................................................... 42

Disciplinary policy and practice........................................................ 44

Stages of the process.......................................................................... 44

13 Decontamination of instruments – an overview......................... 102

Warnings............................................................................................... 46

Dismissal................................................................................................ 47

6 Mouth cancer.......................................................................................... 48 What are head and neck cancers?................................................. 49

What are mouth cancers?................................................................. 50

What are the types of mouth cancer?............................................. 51

What is the international classification of mouth tumours?............ 52

W.H.O International Classification of Diseases................................. 52

Diagnosis and management............................................................. 62

Key points for patients......................................................................... 63

Risk factors............................................................................................ 112

Signs and symptoms............................................................................ 114

Parallels with periodontitis.................................................................. 115 Treatment options................................................................................ 116

15 Minimally invasive operative caries management.................. 118

Terminology.......................................................................................... 58 Recurrent aphthous stomatitis (RAS; aphthae; canker sores)........ 59

Quality assurance system and audit................................................. 110

Introduction.................................................................................................. 118

7 Oral medicine - Ulceration................................................................. 58

Segregating instruments..................................................................... 109

Risk factors............................................................................................ 55

decontamination areas...................................................................... 109

Investigations........................................................................................ 115

Epidemiology....................................................................................... 52

Movement of instruments to and from adjacent

14 Peri-implantitis: a condition of our time......................................... 112

Introduction.......................................................................................... 48

‘Golden triangle’ of MID..................................................................... 118

Clinical factors..................................................................................... 119

Minimally invasive operative techniques.......................................... 121

Air-abrasion.......................................................................................... 122

Chemo-mechanical caries removal................................................. 123

Conclusions.......................................................................................... 125

3

Contents...

16 Antibiotics; past, present and future............................................... 126

A century of use................................................................................... 126

Classification........................................................................................ 126

Resistance............................................................................................ 127

Antibiotics and daily practice............................................................ 127

Prescribing an antibiotic..................................................................... 129

Antibiotics – the future?...................................................................... 129

Barriers to development..................................................................... 130

Antibiotic guardians............................................................................ 130

17 Partial dentures – the story continues............................................. 132

The RPD option............................................................................................. 133

Outline and classification of saddles................................................ 134

Determination of the restoration of the saddles.............................. 135

Determination of the nature of the support for the prosthesis....... 135

Determination of the means of retention for the prosthesis........... 135

Determination of how the saddles will be connected................... 136

Identification of anti-rotational elements......................................... 136

Determination of how components are joined............................... 136

Legends to Figures............................................................................... 137

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18 Visualising the end result – techniques to improve the predictability of aesthetic dentistry................................................. 138

Psychological failures.......................................................................... 138

Technique failures................................................................................ 138

Communication failures..................................................................... 139

Digital imaging..................................................................................... 139

Diagnostic wax-up.............................................................................. 139

Trial smile............................................................................................... 140

Living splint............................................................................................ 140

Provisional restorations........................................................................ 141

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Pre-temporisation................................................................................ 141

Prep guides.......................................................................................... 141

Case study............................................................................................ 141

19 Body dysmorphic disorder and aesthetic dentistry.................. 144

Body Dysmorphic Disorder: An overview.......................................... 144

Assessment of patients who are suspected of having BDD........... 146

Management strategies..................................................................... 152

Provision of the requested cosmetic treatment.............................. 152

Pharmacological and psychological therapy................................ 152

Conclusions.......................................................................................... 153

Resources for clinicians....................................................................... 153

20 An Update on Endodontic Issues..................................................... 154

Access cavity....................................................................................... 154

Mechanical preparation.................................................................... 156

Measuring working length.................................................................. 156

Limitations of rotary NiTi instrumentation........................................... 158

The ‘single file’ concept..................................................................... 158

Implants and endo.............................................................................. 159

The diagnosis of periodontal-endodontic lesions (PEL).................. 160

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Chapter 1 Medical emergencies in the conscious patient

By M H Thornhill, M N Pemberton and G J Atherton

Acute chest pain Causes Severe acute chest pain is usually the result of myocardial ischaemia. The main differential diagnosis is between angina (reversible ischaemia) and myocardial infarction (irreversible ischaemia). Either may be precipitated by exercise, stress, emotion or anxiety.

Prevention

• Take a good medical history

• Identify patients with a history of angina, myocardial infarct or other

cardiovascular disease. If there is a history of worsening angina control, liaise

with the patient’s general medical practitioner for assessment prior to treatment

• As far as possible, keep to appointment times for these patients

• Do not overburden their capacity for exertion

• If possible, use a downstairs surgery

• Ensure they have taken their normal medication

• If they are supposed to carry any drugs for prophylaxis of angina, such as

glyceryl trinitrate, ensure these are readily to hand while they are in the dental

surgery

• It is essential to minimise stress, anxiety and pain in patients with a history of

angina.

SIGNS AND SYMPTOMS

• Severe, crushing retrosternal pain

• Pain may radiate to the arm neck and jaw, usually on the left side (see Figure 1)

Features suggesting angina The pain is short lasting and is relieved by rest and glyceryl trinitrate (GTN) Features suggesting myocardial infarction (MI)

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• Pain is persistent and more severe

• Pain is not eased by rest or GTN

• There may be breathlessness, nausea and vomiting, loss of consciousness and

the pulse may be weak or irregular

MANAGEMENT

• If the patient has their own anti-angina drugs, these should be administered,

otherwise use glyceryl trinitrate spray sublingually

• Monitor carefully until the angina pain has resolved

• Postpone planned treatment until another occasion.

If there is no relief of pain in 3 minutes, the cause is likely to be an infarct

• Summon assistance - call for an ambulance

• Keep the patient in a comfortable position – if conscious this is usually sitting up -

• If you have an RA machine, give nitrous oxide and oxygen (50/50) to relieve

laying them flat may make breathlessness worse pain and anxiety

• If nitrous oxide is not available, give oxygen

• If the patient is not allergic, give 300mg aspirin. This can be left to dissolve in

the buccal sulcus or swallowed if the patient is able. (N.B inform the ambulance

personnel that aspirin has been given)

• Reassure and monitor the patient

If the patient loses consciousness, initiate basic/advanced life support

Asthma attack Causes Exposure to an allergen, anxiety, cold, exercise or infection can precipitate an acute asthmatic attack in a patient predisposed to bronchospasm. Most attacks come on rapidly (within 30 minutes) and occur in patients with a known history. An acute asthma attack should not be taken lightly; if a patient fails to respond to treatment, they should be referred to hospital.

Prevention Avoid anxiety, pain and known allergens. Ensure that the patient has had their normal prophylactic medication and has their bronchodilator readily available.

If a nebuliser is not available a similar effect can be obtained by administering 4-6

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puffs of a bronchodilator into a large volume spacer and getting the patient to inhale through the spacer.

This can be repeated every 10 minutes if necessary. A makeshift large volume spacer can be formed by administering the bronchodilator through a hole in the base of a large disposable cup or 500ml soft drink bottle that the patient holds to their mouth.

Signs and symptoms

• Breathlessness and a tight chest

• Wheezing on expiration

• Accessory muscles of respiration in action

Features of an acute severe attack

• Inability to complete a sentence in one breath

• Respiratory rate greater than 25 per minute

• Heart rate greater than 110 per minute

Features of life threatening asthma

• Exhaustion, confusion

• Feeble respiratory effort or cyanosis

• Heart rate less than 50 per minute

Management

• Keep the patient sitting upright- laying them flat will increase breathlessness

• Encourage them to use the bronchodilator they normally use

• Offer a salbutamol inhaler if they do not have their own available

• If available administer 4-6 activations from a salbutamol inhaler via a large

volume spacer device

• Give oxygen

• Patients requiring additional doses of inhaled bronchodilator to control

their asthma should be referred to their general medical practitioner for further

assessment of their asthma control

• Note: Bronchodilator inhalers are blue, steroid inhalers are brown.

If the patient continues to be distressed or develops features of severe or life threatening asthma

• Call for an ambulance

• Give nebulised salbutamol 5mg (VentolinR) with oxygen, or continue to give 4-6

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• Give Oxygen

If the asthma is life threatening or part of an anaphylactic attack

• Give 0.5mL of 1:1,000 (500μg) adrenaline (epinephrine) i/m

Inhaled foreign body Causes Inhalation of a foreign body such as a tooth, inlay, crown or reamer is an everpresent risk in dentistry. An object lodged in the upper airways may cause respiratory obstruction. Smaller objects may be inhaled into the lower airways where, if left, may result in a lung abscess.

SIGNS AND SYMPTOMS Upper airways obstruction

• An object lodged in the upper airway will stimulate a cough reflex

• If the patient is choking, the object is large enough to cause respiratory

obstruction

• The patient may grasp their throat

If the object blocks the airway completely they will be silent, unable to breathe or speak

• The skin will become cyanosed; this is especially evident in the lips

• They will make exaggerated efforts to take breath

• Eventually they will lose consciousness

Lower airways obstruction The patient may be totally unaware that they have inhaled anything

PREVENTION This event is far easier to prevent than to treat and the use of a rubber dam will prevent all but the most bizarre incidents. An efficient high volume aspirator is also useful in aiding retrieval of any object dropped in the mouth. Be especially careful when trying-in crowns or inlays or using small instruments in the mouth, ensure that burs are properly secured in the handpiece.

MANAGEMENT 1 If the patient is not choking or having difficulty breathing

14

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• Check if the object is still in their mouth or clothing

If the object cannot be found or is known to have fallen into the throat:

• If the patient is supine, do not allow them to sit up but place the dental chair

head down, allowing gravity to return the object to the oropharynx from where

it may be retrieved

• Rolling the patient into the recovery position and encouraging them to cough

may also help

If the object cannot be retrieved:

• Explain what has happened

• Refer to a hospital accident and emergency department for further

assessment. (chest and abdominal radiographs may be taken – a further

sample of the lost object shown to the accident and emergency doctor can

help with assessment and radiographic identification)

• If the object is found to be in the gastrointestinal tract (i.e., to have been

swallowed), it is normally left to pass per rectum

• If the object is found to be in the respiratory tract, removal may require

endoscopy or thoracic surgery

MANAGEMENT 2 If the object is larger and is causing breathing difficulties or choking

• Encourage the patient to cough forcefully to dislodge the object

• Lean the patient forward and give up to 5 sharp blows between the shoulder

blades (see below)

• If this does not dislodge the object, give up to 5 abdominal thrusts (see below)

• If this fails re-check the mouth and remove any obstruction and continue to

alternate 5 back blows with 5 abdominal thrusts

Dislodging an object from the airway Back blows Lean the patient forward, for example over a chair, so that when the obstructing object is dislodged it is ejected from the mouth rather than going further down the airway. Use the heel of your hand to give up to 5 sharp blows between the shoulder blades.

16

Abdominal thrusts (Heimlich Manoeuvre) Form a fist with one hand and grip it with the other hand while encircling the patient with your arms from behind; your arms should be positioned just below the patient’s ribs. Pull upwards and towards you, delivering a firm, upward, inward thrust to the patient’s diaphragm to expel air and the object from the chest.

At any time the patient may become unconscious. Unconsciousness may relax the muscles around the larynx and allow air to pass into the lungs.

MANAGEMENT 3 If the patient becomes unconscious

• Lay them flat

• Commence CPR

Note. The pressure generated in the chest by performing chest compressions may also help to dislodge the foreign body.

Background information Judging by the paucity of discussion of this subject in the literature, this type of event, although common, only rarely causes serious problems. The use of a rubber dam and tethering of fine hand instruments is advisable. Take extra care with those patients who may have a reduced gag reflex, such as those under sedation, who are more at risk of swallowing or inhaling an object. Positioning of the patient may be a factor; some believe that treating patients while they are supine decreases the risk of aspiration or swallowing, while others believe that this increases the likelihood of these events occurring. There are reports of objects passing into the trachea without eliciting a cough or any other symptom suggesting inhalation.

The effect of a foreign object passing into the oropharynx depends on its size and shape and where it ends up. A sharp metallic object could theoretically pierce the lining mucosa at any point of its journey either into the respiratory or gastro-intestinal (GI) tracts and cause a mediastinal or abdominal infection. A pneumothorax may result if the lung wall is pierced. It may become impacted in the oropharynx; an object large enough to block the opening to the trachea may obstruct the airway and cause the patient to choke. If the object enters the respiratory tract it will lodge in the bronchial tree and it is important that it is retrieved as quickly as possible.

The intense inflammatory response provoked by the object will make removal by bronchoscopy much more difficult if there is delay and surgical removal may then become necessary.

17

If the object passes down the oesophagus into the stomach, more than likely it will pass uneventfully through the GI tract. Sharp objects, such as reamers, tend to pass through the intestines with the sharp end trailing in the centre of the faeces once they reach the transverse colon. Bloody stools or abdominal pain suggest perforation of the gut wall. Many authorities suggest chest and abdominal radiographs to locate the object and, if it is in the GI tract, serial radiographs to monitor its passage.

However, in the absence of symptoms, some may think repeated irradiation of the abdomen and reproductive systems, especially in growing patients, to be excessive.

Results from a British survey suggest that objects passing beyond reach into the oropharynx are approximately 30 times more likely to be swallowed than inhaled.

According to a review of the Japanese literature, the majority of dental foreign objects swallowed or inhaled were dentures and the majority of instruments ‘lost’ during dental treatment were reamers.

Hyperventilation Causes Extremely anxious or hysterical patients may hyperventilate in response to the stress of the dental surgery environment. The over-breathing washes out carbon dioxide from the lungs which results in over-excitability of nerves. They may complain of dizziness and tingling around the mouth; there is also tetany which is caused by hyper-excitability of nerves, characterised by spasms of skeletal muscle, especially the hands (carpo-pedal spasm) and the larynx; there may also be paraesthesia. If severe, there may be laryngospasm, which can obstruct the airway, and cerebral vasoconstriction, which can eventually lead to collapse.

Signs and symptoms

• Flushed appearance

• Anxious or distressed

• Rapid pulse

• Dizzyness

• Tingling in face, hands or feet

• Tetany of muscles of face, hands or feet

Prevention

• Anxiety is the main precipitating factor for the hyperventilation response.

• A calm, inviting reception and friendly staff will help to allay many

patients’ fears

18

• Avoid keeping patients waiting and attend to their anxieties,

• Reassurance and pain free dentistry are important preventative measures.

In a patient with a previous history of hyperventilation, prophylaxis with an anxiolytic may be helpful e.g. diazepam 5 mg the night before and 5 mg 2 hours before the procedure or temazepam 20-40 mg one hour before the procedure. However patients should be warned of the sedative effects, to avoid driving or using machinery and the need to be accompanied. If tachycardia is a particular problem, prescription of a beta blocker by the patient’s GP may be helpful.

MANAGEMENT

• Reassurance and explanation

• Get the patient to re-breathe their expired air, containing exhaled CO2, by

breathing in and out of a paper bag held over the mouth and nose.

Background information When a patient hyperventilates, the excessive, hysterical over-breathing causes the patient to blow off carbon dioxide. The partial pressure of CO2 in the circulation falls (hypocapnia) and the blood pH rises (respiratory alkalaemia). There is a fall in the level of calcium ions and a consequent increase in nerve excitability. This causes numbness and tingling (paraesthesia) of the hands, feet and face and can be followed by muscle spasms of hands and feet (tetany) and stiffness of the face and lips, all of which may increase the anxiety. The alkalosis causes a constriction of cerebral blood flow resulting in blurred vision, dizziness and light-headedness.

Loss of consciousness is not common as the cerebral hypoxia, resulting from vasoconstriction, causes the vessel walls to relax and the cerebral blood flow is reestablished.

The episode of hyperventilation and the resulting alkalosis reduces the respiratory drive due to carbon dioxide and may well be followed by a period of depressed or even absent breathing then a period of intermittent breathing. This results in a build up of carbon dioxide in the blood and reversal of the alkalosis so that normal breathing eventually resumes. Increasing the CO2 concentration of the inhaled air, by getting the patient to re-breath their expired air, reverses the physiological changes induced by hyperventilation.

19

Chapter 2 Safeguarding vulnerable adults Summarised from The Management of Abuse: A Resource Manual For The Dental Team, By Elizabeth Bower et al.

There has been a growing awareness in recent years of the abuse of vulnerable adults, perhaps as a result of the similar exposure given to child abuse and corresponding child protection. Who is a vulnerable adult?

A vulnerable adult is defined as a person aged 18 or over “who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation” (Department of Health, 2000). This where community care services includes all care services provided in any setting or context.

The weakness of this definition rests in its exclusion of a number of individuals who have mild or moderate learning disabilities and who manage their lives relatively independently but remain very vulnerable to exploitation within their local communities.

Defining abuse of vulnerable adults Abuse is defined as “the violation of an individual’s human and civil rights by any other person or persons”. Like the abuse of children, it can take the form of a single or repeated harmful act, or a failure to prevent harm. Abuse can be physical, sexual, psychological, or financial, and/or take the form of neglect. Examples of abuse are given in Table 1.

The definition also encompasses discrimination, particularly in regards to the person’s age or disability, and institutional abuse, where the ethos, culture, management, and organisation of an institution lead to abusive practices at a corporate level.

Examples of institutional abuse include poor care standards, inadequate staffing, a lack of responses to complex needs, rigid routines, a lack of training on antidiscriminatory practice, and an insufficient knowledge base within the service.

Abuse can occur over a long period, such as in ongoing family problems where domestic violence between spouses or generations is a long term feature of family life. Alternatively, it may be situational, where abuse arises in a previously satisfactory relationship due to deterioration in the health or behaviour of the vulnerable adult or

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deterioration in the health and social situation of the carer. Difficulties due to debt, alcohol or mental health problems in the carer may contribute to the neglect of the vulnerable adult. Abuse may also be opportunistic, such as theft occurring because money has been left around. Serial abuse, in which the perpetrator seeks out and ‘grooms’ vulnerable adults, usually involves financial or sexual abuse.

It is important to note that the definition does not include self-neglect, which usually occurs due to the inability of an independently living, mentally competent elderly or disabled person to meet the needs necessary for their own physical and mental wellbeing. Such an adult is able to refuse care unless they are at severe risk of harm.

Who abuses vulnerable adults and in what circumstances?

Vulnerable adults are usually abused by people with whom they are in regular contact rather than strangers. Such people can be relatives, professional staff, paid care workers, volunteers, other service users, neighbours, and friends. It is estimated that two-thirds of abused older people are harmed by family members who act as carers. Sexual abuse by other service users accounts for up to half of the reported incidents of sexual abuse in adults with learning disabilities.

Abuse can take place in any context, including places previously assumed to be safe. It may occur in a vulnerable adult’s home, whether the adult is living alone or with a relative. It can also occur within residential or day care settings, nursing homes, hospitals and in public places (Department of Health, 2000).

Barriers to reporting abuse Vulnerable adults are often reluctant to report abuse. A fear of retaliation and escalation of the abuse may prevent disclosure. Victims may be ashamed and embarrassed to admit that they are being abused or even feel that they deserve the abuse. They may fear that if the abuser is removed or punished, no one will take care of them.

Many vulnerable adults, particularly elderly people, are socially isolated and powerless. The only person in contact with the victim may be the abuser on whom the victim is totally dependent for personal care, making it difficult for the vulnerable adult to access support services.

Severe cognitive and physical disabilities may prevent the victim from communicating the abuse to others. Vulnerable adults with severe cognitive disabilities may not know that they are being abused. Table 2 lists the potential indicators of abuse that the dental team might see in the domiciliary setting.

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The management of the abuse of vulnerable adults The management of the abuse of vulnerable adults revolves around early detection, appropriate referral, and provision of ongoing treatment and support. It is the responsibility of the dentist who has examined the vulnerable adult to ensure that appropriate action is taken with the help of team members.

It is important to focus on the needs of the vulnerable adult, rather than the needs of the carer, related family problems and potential solutions to those problems. Whilst the other issues may have to be addressed by various agencies in the medium and long term, the dental team’s responsibility is always to the health and wellbeing of the vulnerable adult.

Whilst it is important to be sensitive to the cultural background of the patient in managing the case, there are no circumstances in which the abuse of vulnerable adults is acceptable. The Department of Health state that cultural factors cannot be used as justification for abuse, and that anxiety about being accused of racism should not prevent a dentists and the dental team from taking action to safeguard the welfare of a patient. This will include:

• Recognising the signs of abuse

• Respecting what the victim says and being sympathetic

• Providing treatment for oro-facial injuries and referral for treatment if necessary

• Assessment of risk to victim

• Making appropriate referrals

• Giving helpful information not advice

• Keeping comprehensive records

• Supporting and following-up

Further reading Department of Health (2000). No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. London, HMSO. Department of Health (2001) Valuing People: a New Strategy for Learning Disability for the 21st Century. London, HMSO.

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Table 1 Examples of abuse of vulnerable adults

• Failing to arrange for a dentist to examine an elderly person with broken or ill-

• Leaving a housebound person alone for days on end

• Hitting a vulnerable adult when s/he doesn’t do what you ask her/him to

• Opportunistic theft of an elderly person’s purse whilst providing care in

fitting dentures

the home

• Failing to ensure a vulnerable person is kept clean

• Swearing at an elderly relative when he/she asks for help to go to the toilet

• Preventing an elderly relative from seeing her friends

• Coercing an elderly person into changing his/her will

• Failing to help a physically disabled person to clean their teeth

Table 2 Potential indicators of abuse in the general dental practice or domiciliary visit setting.

• Appointments often missed • Difficulties in arranging appointments/frequent cancellations • Poor compliance with treatment regimens • Injuries are inconsistent with explanation given • Explanations of injuries are conflicting or vague • Delay in presentation for treatment of dental problems/injuries

Patient • Appears passive or afraid of carer • Remains quiet while carer responds to questions • Withdrawn/detached • Anxious • Poor eye contact

Carer • Attitudes of indifference or anger to the vulnerable adult • Ignores vulnerable adult • Doesn’t allow vulnerable adult to speak for him/herself • Inappropriate displays of affection by caregiver • Blames vulnerable adult (e.g. for bad behaviour, incontinence, or forgetfulness)

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Chapter 3 Child protection and the dental team - abuse and neglect Adapted from Child protection and the dental team by Jenny Harris et al.

What is abuse?

Whilst most children grow and develop in loving, nurturing environments, it is a sad fact that a significant minority suffer harm either intentionally or inadvertently through the actions or omissions of their parents, carers or others. The reasons for such abuse or neglect are often complex and it may present in a variety of ways. Most child abuse occurs within a child’s own family by persons known to the child. However, children may be abused in institutional or community settings by those known to them or, more rarely, by a stranger.

Categories of abuse Abuse and neglect are described in four categories, as defined in the Department of Health’s document ‘Working Together to Safeguard Children’. Some level of emotional abuse is involved in all types of ill treatment of a child, though it may occur alone.

Physical abuse Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately causes illness in, a child.

Emotional abuse Emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve causing children frequently to feel frightened or in danger, or the exploitation or corruption of children.

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Sexual abuse Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-penetrative acts (oral sex). They may include noncontact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.

Neglect Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.

Neglect may occur in pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to provide adequate food and clothing, shelter (including exclusion from home or abandonment), failing to protect a child from physical and emotional harm or danger, failure to ensure adequate supervision (including the use of inadequate care-takers) or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.

Recognising abuse and neglect An approach to assessment Abuse or neglect may present to the dental team in a number of different ways:

• Through a direct allegation (sometimes termed a ‘disclosure’) made by the

child, a parent or some other person

• Through signs and symptoms which are suggestive of physical abuse or neglect

• Or through observations of child behaviour or parent-child interaction.

However it presents, any concerns should be taken seriously and appropriate action taken.

Because of the frequency of injuries to areas routinely examined during a dental check-up, the dentist has an important role in intervening on behalf of an abused child. It is assumed that the dentist will be examining a child who is fully dressed, so this will be the focus of discussion.

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Physical abuse Orofacial trauma occurs in at least 50% of children diagnosed with physical abuse. It is always important to remember that a child with one injury may have further injuries that are not visible so, where possible, arrangements should be made for the child to have a comprehensive medical examination. It is important to state that there are no injuries which are pathognomonic of (that is, only occur in or prove) child abuse although some injuries or patterns of injury will be highly suggestive of it.

The assessment of any physical injury involves three stages:

• Evaluating the injury itself, its extent, site and any particular patterns

• Taking a history with a focus on understanding how and why the injury occurred

and whether the findings match the story given; accidental injuries usually match the history

• Exploring the broader picture, including aspects of the child’s behaviour, the

parent-child interaction, underlying risk factors or markers of emotional abuse or

neglect. Non-accidental injuries are often to both sides of the body.

Bruising Accidental falls rarely cause bruises to the soft tissues of the cheek but instead tend to involve the skin overlying bony prominences such as the forehead or cheekbone.

Inflicted bruises may occur at typical sites or fit recognisable patterns. Bruising in babies or children who are not independently mobile is a cause for concern. Multiple bruises in clusters or of uniform shape are suggestive of physical abuse and may occur with older injuries. However, the clinical dating of bruises according to colour is inaccurate.

Bruises on the ear may result from being pinched or pulled by the ear and there may be a matching bruise on its posterior surface. Bruises or cuts on the neck may result from choking or strangling by a human hand, cord or collar. Accidents to this site are rare and should be looked upon with suspicion. Particular patterns of bruises may be caused by pinching (paired, oval or round bruises), grabbing or hand-slaps. Bizarreshaped bruises with sharp borders are nearly always deliberately inflicted. If there is a pattern on the inflicting implement, this may be duplicated in the bruise; so-called tattoo bruising.

Abrasions and lacerations Abrasions and lacerations on the face in abused children may be caused by a variety of objects but are most commonly due to rings or fingernails on the inflicting hand. Such injuries are rarely confined to the orofacial structures. Accidental facial

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abrasions and lacerations are usually explained by a consistent history, such as falling off a bicycle, and are often associated with injuries at other sites, such as knees and elbows.

Burns Approximately 10% of physical abuse cases involve burns. Burns to the oral mucosa can be the result of forced ingestion of hot or caustic fluids in young children. Burns from hot solid objects applied to the face are usually without blister formation and the shape of the burn often resembles the implement used. Cigarette burns result in circular, punched out lesions of uniform size.

Bite marks Human bite marks are identified by their shape and size. They may appear only as bruising, or as a pattern of abrasions and lacerations. They may be caused by other children, or by adults in assault or as an inappropriate form of punishment. Sexually orientated bite marks occur more frequently in adolescents and adults. The duration of a bite mark is dependent on the force applied and the extent of tissue damage.

Teeth marks that do not break the skin can disappear within 24 hours but may persist for longer. In cases where the skin is broken, the borders or edges will be apparent for several days depending on the thickness of the tissue. Thinner tissues retain the marks longer. A bite mark presents a unique opportunity to identify the perpetrator.

Eye injuries Periorbital bruising in children is uncommon and should raise suspicions, particularly if bilateral. Ocular damage in child physical abuse includes acute hyphema (bleeding in the anterior chamber of the eye), dislocated lens, traumatic cataract and detached retina. More than half of these injuries result in permanent impairment of vision affecting one or both eyes.

Bone fractures Fractures resulting from abuse may occur in almost any bone including the facial skeleton. They may be single or multiple, clinically obvious or detectable only by radiography. Most fractures in physically abused children occur under the age of 3 years. In contrast, accidental fractures occur more commonly in children of school age. Facial fractures are relatively uncommon in children. When abuse is suspected, the presence of any fracture is an indication for a full skeletal radiographic survey.

A child who has suffered sustained physical abuse may have multiple fractures at different stages of healing.

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Intra-oral injuries Damage to the primary or permanent teeth can be due to blunt trauma. Such injuries are often accompanied by local soft tissue lacerations and bruising. The age of the child and the history of the incident are crucial factors in determining whether the injury was caused by abusive behaviour. Penetrating injuries to the palate, vestibule and floor of the mouth can occur during forceful feeding of young infants and are usually caused by the feeding utensil.

Bruising and laceration of the upper labial frenum is not uncommon in a young child who falls while learning to walk (generally between 8-18 months) or in older children due to other accidental trauma. However, a frenum tear in a very young nonambulatory patient (less than 1 year) should arouse suspicion. It may be produced by a direct blow to the mouth. This injury may remain hidden unless the lip is carefully everted. Any accompanying facial bruising or abrasions should also be meticulously noted.

Differential diagnosis Although dental practitioners should be suspicious of all injuries to children, they should be aware that the diagnosis of child physical abuse is never made on the basis of one sign as various diseases can be mistaken for physical abuse. The lesions of impetigo may look similar to cigarette burns, birthmarks can be mistaken for bruising and conjunctivitis can be mistaken for trauma. All children who are said to bruise easily and extensively should be screened for bleeding disorders. Unexplained, multiple or frequent fractures may rarely be due to osteogenesis imperfecta; a family history, blue sclerae and the dental changes of dentinogenesis imperfecta may all help in establishing the diagnosis.

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Chapter 4 The orthodontic team Sameer Patel, Orthodontic Specialist, London

The healthcare team has undergone significant changes over the 20th century from a hierarchical model where the Consultant and Senior Matron ruled over junior doctors and nurses with limited roles for those without a medical degree to a healthcare system that recognises the value that each member of the team can provide to patient care. It is often the case that the most junior, fresh pair of eyes can identify areas of practice that may be improved. The General Dental Council have released documentation in relation to teamwork that feeds into the core standard “co-operating with other member of the dental team and other healthcare colleagues in the interests of patients”.

However, in order to ensure a well-functioning dental team, it is important that there are clearly defined roles for each member, with knowledge of each person’s training and competency. Much has been discussed in relation to the role of dental hygienists and therapists, particularly because of the recent changes to allow direct access but this article aims to explain and clarify the roles within the orthodontic team, where there may be subtle differences compared to the wider dental team.

Team members The orthodontic nurse is a dental nurse who has undertaken further training in orthodontic nursing. Following successful completion of appropriate dental nurse training, the dental nurse is eligible for enrolment onto appropriate training programmes such as the NEBDN Certificate in Orthodontic Nursing. These courses are often similar to dental nurse training on a ‘day release’ type programme where classroom based learning is augmented by chair side experience. These qualifications may also include impression taking and photography providing increased support to the orthodontist during the examination and record taking phase of treatment. Orthodontic nurses are qualified to provide oral hygiene instruction to patients with orthodontic appliances but, similar to their dental counterparts, are not considered competent to undertake any form of orthodontic treatment independently.

Many orthodontic nurses and other dental care professionals who wish to become more involved in orthodontic care choose to pursue a diploma in Orthodontic

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Therapy, a DCP role established in 2007. Course structures can vary but are usually undertaken on a part time basis for one to two years with the support of an orthodontic specialist to support chair side skills. Orthodontic therapists are competent to undertake reversible orthodontic treatment which ultimately covers a significant amount of orthodontic treatment including the changing of archwires, fitting of headgear and fitting retainers under the prescription of the supervising clinician (dentist or specialist orthodontist). There has been some debate regarding the level of supervision required for an orthodontic therapist and a 2015 Working Group between the BOS and Orthodontic National Group have developed guidelines for the level of supervision required.

The orthodontic technician, while often not physically present, plays a crucial role within orthodontic treatment ranging from the fabrication of removable orthodontic appliances, retention appliances and shade taking where patients may have missing teeth. The role of the orthodontic technician is particularly important for patients who require orthognathic treatment, where she/he undertakes a mock surgery on the orthodontic models (model surgery) to help the orthodontic team confirm their surgical plan and to construct wafers used during surgery to ensure a predictable outcome. Given that the orthodontic technician is distant from the rest of the healthcare team, robust communication is vital for both written prescriptions and advice via phone and email. Many technicians train in all aspects of dental technology before self-specialising into the field of orthodontics.

Dentists with a special interest in orthodontics have historically provided a significant proportion of orthodontic treatment in the UK, particularly in the Midlands. These dentists completed a two-year clinical assistantship scheme to be recognised as a dentist with enhanced skills, though now training is often via longitudinal training supported in a hospital or specialist practice. New NHS commissioning guidelines for all dental specialties recognise the value of general dentists with specifically enhanced skills. Within orthodontics, these Tier 2 practitioners are able to provide orthodontic treatment of limited complexity as long as they start 50 cases per year to prevent degradation of their skills.

Orthodontic specialists have undertaken a three-year full time training programme entered into in a competitive process. During this training, they will undertake a higher research degree (at Masters or Doctorate level) and successfully pass the Membership of Orthodontics examination held by the Royal Colleges of Surgeons.

These specialist practitioners work within the primary care or community services and are able to treat and diagnose anomalies of dental development and facial growth and undertake a wide range of treatment including those which may require multidisciplinary input.

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After completion of specialty training, specialists may choose to undertake further hospital training in order to be eligible to apply for consultant posts within the secondary care service. This training involves the treatment of patients who require multidisciplinary care including orthognathic and hypodontia cases as well as specific training in treating patients with cleft lip and palate and obstructive sleep apnoea. A hospital consultant can also be involved in the teaching and training of specialty trainees and undergraduate students, helping to manage local clinical networks and undertake academic research.

Overall, each team member provides a specific and unique role within patient care but a vital member if the team is the general dentist. Without timely and appropriate referral of patients to orthodontic services, the purpose of the team becomes moot.

It is therefore important that general dentists have a solid understanding of treatment criteria within the NHS service and how to monitor important aspects of the developing dentition including impacted canines and the effect of poor prognosis first molars on orthodontic treatment planning. These are supported by Royal College Guidelines and the development of managed clinical networks and local professional networks help improve dentists’ confidence with what can sometimes seem like a secret art.

The success of the orthodontic team, like many others, depends on a clear understanding of the roles and competencies of each team member and excellent communication between team members including the general dental team.

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Chapter 5 Dental practice management – dealing with rights and grievances Glenys Bridges, Adapted from Dental practice management

The aim in all dental practices is to have a harmonious and efficient team for whom coming to work is a pleasure and not a chore. Although this is not always possible, taking some simple but comprehensive steps in employment contracts and procedures can help.

Employment rights are dependent upon whether the employment status is classed as an ‘employee’, ‘worker’ or ‘self employed’ which in turn depends on the type of contract a person has with her or his employer.

The contract of employment should specify:

• Date on which contract is given

• Names of parties

• Date of employment

• Wages - including overtime/calculation of bonuses

• Intervals at which wages will be paid

• Hours of work

• Holiday entitlement and what happens on leaving

• Job title and/or description

• Place of work

• Notice requirements.

In addition, information must be given about sick pay, pension schemes and the duration of employment if it is temporary. Also, it is advisable for employment information to be supported by a staff handbook in which the relevant details are set out and is a convenient way to include the following topics as these must also be communicated to all staff members:

• Grievance and disciplinary procedure

• Reclaiming training costs

• Confidentiality

• Restrictive covenants

• Maternity leave

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• Sickness policy

• Notification of absence and evidence of incapacity requirements

• Any other benefits

There are many more additions which the handbook can contain, such as: equal opportunities policy, telephone protocols, complaints procedure and uniform requirements. The handbook should be tailor made to meet the businesses needs and must be clear, accessible and understood by all team members.

Disciplinary and grievances procedures All the above elements of a contract are important but one of the essential management tasks to get absolutely correct is that of disciplinary and grievances procedures.

The ACAS Code of Practice Disciplinary and Grievance Procedures is a crucially important code to be followed as an employment tribunal will adjust any awards made by up to 25% for unreasonable failure to comply with it. Legislation setting out disciplinary and grievance procedures seeks to provide a clear and transparent framework for dealing with difficulties which can arise from either the employer’s or employee’s perspective. They standardise how everybody in similar circumstances is treated and ensure fair and reasonably interactions. Practice managers should consult and follow the ACAS Code of Practice for handling disciplinary and grievance issues as outlined below.

Disciplinary procedures These are needed so that employees know what is expected of them in terms of standards of performance or conduct (and the likely consequences of continued failure to meet these standards) and to identify obstacles to individuals achieving the required standards (for example training needs, lack of clarity of job requirements, additional support needed) and take appropriate action.

The procedures also provide an opportunity to agree suitable goals and timescales for improvement in an individual’s performance or conduct and to try to help resolve matters without recourse to an employment tribunal.

Grievance procedures These are needed to: provide individuals with a course of action should they have a complaint (which they are unable to resolve through regular communication with their line manager), provide points of contact and timescales to resolve issues of concern and to try to resolve matters without recourse to an employment tribunal.

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Disciplinary policy and practice There are two main areas where a disciplinary system may be used: capability and performance, and conduct.

Capability/performance: Capability issues may arise because an employee does not have adequate training, or is unable to do the work to a satisfactory standard for another reason. An employer must try to identify the reason and give appropriate support, before taking disciplinary action. An individual who is unable to do their job because of ill-health may also fall into this category. In these instances an employee should be dealt with sympathetically and offered support. However, unacceptable levels of absence could still result in the employer making use of warnings.

Conduct: Employee misconduct could range from continued lateness, failure to follow a reasonable management instruction, abuse of the organisation’s computer system or Internet access, bullying behaviour or creating a hostile work environment, through to theft, fighting and committing criminal offences. The more grave offences may constitute gross misconduct. In all cases, an employer should follow the recommendations in the ACAS Code.

Stages of the process If action is to be taken, it should observe at least the following three stages: a letter, a meeting and an appeal. There must always be a full and fair investigation to determine the facts and to decide if further action is necessary. The ACAS Code recommends at least these three steps, however in some cases a second meeting stage may be appropriate.

When matters begin to escalate be sure to keep good records of all interactions, you will need to produce these records should a case be taken to an employment tribunal. Your records should include:

• All meeting minutes

• Emails

• Attendance notes

• Notes of telephone calls

• Copies of correspondence etc.

Managers should be trained and supported in the conduct of disciplinary interviews so that they are able to ensure all the facts are investigated in advance (including consulting the individual’s personal file for relevant information) and plan how the meeting is to be approached. The employee must know from the letter inviting them

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to the meeting why they have been asked to attend and that they have a right to have a companion present. This should be done with reasonable notice, ideally more than 72 hours, and so that they have a chance to arrange an appropriate representative to attend if they wish. Appropriate statements from people involved in advance of the meeting, together with any key information you intend to rely on should be prepared and ideally another member of management can be there to take detailed notes and help conduct the interview.

The outcome of a meeting should never be pre-judged. The interview should start by stating the complaint to the employee and referring to appropriate statements from people involved, giving the employee ample opportunity to put forward their side of the story and call any supporting witnesses. Employers can also call witnesses, but they can only be in the room for the relevant part of the interview, not the duration. Adjournments can be used to take a break to consider and obtain any extra information needed before reaching a decision and can be be useful if things become heated or people are upset during the interview. The decision should be given (with reasons, taking into account any mitigating circumstances), review periods confirmed and details provided of how to appeal. Confirm the decision in writing.

It is important that everyone involved in disciplinary action understand the importance of following the correct procedure, as even if the case against an employee seems proven, they can still be deemed to have been treated unfairly if the correct procedures are not followed.

Warnings Alternatively, the employer may decide to give the employee a warning. An organisation’s policy should outline exactly what warnings will be given, but the following are examples of warnings and organisation may use:

• Verbal/ oral warning (ACAS no longer recommends this stage as part of a

formal procedure but, for cases of minor misconduct, this will often be a

reasonable method to prevent a problem escalating)

• First written warning/improvement notice

• Final written warning.

Employers should specific a ‘life’ for formal disciplinary warnings after which they are disregarded for disciplinary purposes. Typical timescales suggested in the non statutory guidance for the types of warning are six months for a first written warning and one year for a final written warning.

46

It may be appropriate for a warning to continue to be regarded for a longer period, provided the timescale was specified in the organisation’s disciplinary policy from the outset. The time period employers select for warnings to remain current, and the penalties imposed, must be reasonable in all circumstances. For example, they must take into account the nature of the misconduct, the employee’s disciplinary record and be consistent with penalties imposed in similar cases.

Dismissal There are currently six potentially fair reasons for dismissal:

• Capability or qualifications

• Conduct

• Illegality or contravention of a statutory duty

• Some other substantial reason

• Redundancy

• Retirement - though this differs from the other potentially fair reasons for

dismissal, regarding both the procedure and how ‘fairness’ is decided.

Employers need to be sure that any decision to dismiss an employee will be seen as ‘reasonable’ by an employment tribunal. The employer must follow the ACAS Code prior to any dismissal and also have been fair overall, for example by complying with internal procedures, treating employees consistently and carrying out a proper investigation.

Overall, it is essential that grievances from employees are treated in the same fair manner and that all practice managers are familiar with their organisation’s grievance procedure.

47

Chapter 6 Mouth cancer

By Professor Crispian Scully CBE, Professor emeritus, UCL, London and Mr Nicholas Kalavrezos, Maxillofacial & Reconstructive Surgeon of The Head, Face & Neck, University College London Hospital and The Harley Street Clinic.

Introduction Cancer is caused by DNA mutations, which lead to altered cell proteins and function. Mutations can be spontaneous or caused by various mutagens such as tobacco, alcohol or viruses (Figure 1). Several DNA mutations are necessary before the affected cells change appearance and behaviour to a recognisably pre- or potentially malignant cell characterised by an ability to proliferate in a less-controlled fashion than normal (they become autonomous). The effects of these changes may be seen under the microscope as dysplasia – disordered cell size and arrangement, with abnormal cell divisions (mitoses). This can transform to cancer - characterised by malignant epithelial cells (keratinocytes) which proliferate and invade across the epithelial basement membranes as a ‘growth’ into the underlying tissues. The mass is termed a malignant neoplasm.

Ultimately, the cancer spreads locally, often causing a swelling (tumour) and, via lymphatics and blood (metastasis –or ‘secondary’ growth) spreads to lymph nodes, bone, brain, liver and elsewhere. Finally, even with treatment, many cancers recur and can be fatal. People with one particular cancer are also predisposed to develop another malignant neoplasm - a second primary cancer (second primary tumour; SPT) - in the case of mouth cancer, SPTs may be in the mouth, or aerodigestive tract (pharynx, larynx, bronchi, oesophagus).

Figure 1 The early progression of cell mutation

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What are head and neck cancers?

Cancers can arise in any of the tissues or organs in the head and neck: there are over 30 different sites that can be affected (Figure 2). The mouth is the most common site in the head and neck region in which cancer develops.

Cancers can develop on the lips, tongue, floor of the mouth (beneath the tongue), the buccal mucosae, the palate, the gingivae or oropharynx (Figure 3). Head and neck cancers can also affect the throat, and there are rarer cancers of the nose, sinuses, salivary glands, skin and middle ear, or arising in other tissues.

Figure 2 Head and neck anatomy

49

Figure 3 Oral anatomy showing common sites of cancer development

(A) What are mouth cancers?

Mouth cancers can include:

• Lip cancer; most develop on the lower lip

• Intra-oral cancer; most develop on the lateral tongue & the floor of the mouth

• Oropharyngeal cancer; most affect the tonsils and base of the tongue.

There are also malignant tumours that arise from other structures including the salivary glands and paranasal air sinuses, or other tissues, but these cancers do not share a similar natural history and should be considered separately (Figure 4).

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Oropharynx

Hypopharyynx

Figure 4 Sites of oropharyngeal and other cancers

(B) What are the types of mouth cancer?

Cancers can be described according to the cell type where the cancer began.

In the oral mucosa the most common malignancies, and nine out of 10 arise from keratinocytes, are oral squamous cell carcinomas (OSCC) which are more common:

• In older people and in men (as with most cancer)

• In people who have already had mouth or oropharyngeal cancer or potentially

malignant disorders: women have a higher risk of a SPT than men

• In people who have had some other types of cancer such as:

• Cancer of the oesophagus

• Squamous cell skin cancer

• Cervical, anal or genital cancer in women

• Cancer of the rectum in men.

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Oral precancerous (potentially malignant) disorders include especially:

• Erythroplakia (red patches); over 75% can become cancerous

• Leukoplakia (white patches); from 3-35% can develop cancerous changes

• Submucous fibrosis; from 1- 10% can develop cancerous changes.

• Lichen planus; from 1- 3% can develop cancerous changes.

(B) What is the international classification of mouth tumours?

Of the many malignant neoplasms that can affect the mouth, oral squamous cell carcinoma (OSCC) is the most important. Cancers of the ‘oral cavity and oropharynx’ as classified in the WHO International Classification of Diseases (ICD) include cancers of the lip, tongue and mouth (oral cavity) [ICD-10: C00-06], and oropharynx [ICD-10: C09-C10], but excludes the salivary glands [C07-08] and other pharyngeal sites [C11-13] (Table 1). ICD-9 is shown for comparison.

W.H.O International Classification of Diseases

Table 1 WHO Classification

Epidemiology (B) What is the size of the mouth cancer problem?

About 2 out of every 100 cancers diagnosed (2%) are mouth cancers (oral and oropharyngeal) and these are the most common cancers of the head and neck.

The most common are in the tongue and mouth, collectively accounting for 60% of cases in 2010. Cancer of the lip accounts for around 6% of cases.

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(B) What is the epidemiology of mouth cancer?

Worldwide, approximately 500,000 new cases of head and neck cancer are diagnosed annually, with three quarters of cases affecting people in the resourcepoor, developing world. Factors important in mouth cancer include especially lifestyle modifiable risk factors but are also related to: • Age

Mouth cancer is more common in people over 45

• Gender

Mouth cancer is generally more common in men than women, attributable to

heavier indulgence in risk habits (tobacco and alcohol) by men and exposure

to sunlight (for lip cancer) as a part of outdoor occupations

• Social class

Oral cancer is a problem particularly of people of lower social and economic

status (SES), especially in males.

(B) Resource-rich populations.

OSCC is the eighth most common form of cancer overall in people in developed countries, though the ranking varies a great deal among countries. The incidence is generally higher in ethnic minorities in developed countries. There is concern about an ongoing increase in younger patients and in women. The prevalence of intraoral cancer appears to be rising in many countries, especially in younger people. More than one in ten cases is now diag¬nosed in people below age 50.

Cancer of the lip is uncommon in the UK, with around 340 people diagnosed with it each year. Intra-oral cancer is more common by tenfold. Around 1,900 people have been diagnosed with cancer of the tongue each year and 1,800 diagnosed with cancers affecting other parts of the mouth. There are 14 new oral cancer cases for every 100,000 males in the UK, and 7 for every 100,000 females. By 2030 it is predicted there will be 9,200 cases of oral cancer in the UK every year.

The rates do not differ significantly between England, Wales and Northern Ireland for either gender. In the UK, incidence rates of mouth cancer are highest in Scotland but Ireland had higher rates; rates are also high among South Asian women and in recent/new migrants from eastern EU. (B) Is the UK epidemiology of mouth cancer changing?

Since the mid-1970s, incidence rates have increased overall for all of the broad age groups, except males aged 80+ . There are likely to be several reasons for the

53

increases, including the ageing population, changing demographics and changing lifestyles such as past changes in the prevalence of major risk factors, such as heavy alcohol consumption, smoking and infection with the human papilloma virus (HPV).

Chewing betel is also a risk factor for oral cavity cancer (ICD-10 C02-04 and C06) and this and shisha may have contributed to the increasing trend.

The number of people being diagnosed with mouth cancer is now increasing, with notable rises in incidence in younger people and in females. Oropharyngeal carcinoma, which has risen in incidence in the same time frame has appeared in a younger, nonsmoking population. High-risk human papillomavirus (HPV) subtypes have been identified in a significant fraction of these tumours. Greater numbers of sexual partners, early age of first sexual intercourse, and high-risk sexual behaviour are emerging as risk factors for HPV-related disease independent of tobacco and alcohol abuse.

(B) Is mouth cancer survival changing?

The best outcome for overall 5 year survival rates for treated mouth cancers is over 90% for lip cancer, which relates presumably to the very early diagnosis at this site. The 5 year survival rates for treated cancers of the tongue, oral cavity and oropharynx however are around 50-60%. Survival rates for oral and oropharyngeal cancers have risen slightly over the last 20 years.

In general, prognosis decreases with advanced disease, low SES, advanced age and continuing risky lifestyles. Mouth or oropharyngeal cancer due to HPV generally has a better outlook than in cancers not associated with HPV. Generally speaking, the earlier a cancer is found and treated, the better the outcome is likely to be (Figure 4). However, patients frequently delay seeking professional advice on average for periods up to 3 months after having become aware of any oral symptom that could be linked to mouth cancer.

Figure 4 Five year survival rates

54

(A) Risk factors (B) What are cancer risk factors?

A risk factor is something that increases the chance of developing cancer. The cancer risk depends on a combination of genes, environment and modifiable aspects of our lives (Figure 5).

Figure 5 The interaction of risk factors

However, having a risk factor for cancer does not mean necessarily that cancer will develop: some people with risk factors never develop cancer, and yet other people without known risk factors can still develop cancer. Research is always trying to unravel the reasons. Anything that increases DNA mutations increases a person’s chances of developing cancer and is called a ‘cancer risk factor’. It is impossible to control mouth cancer risk factors such as gender and age. However, many other factors can be controlled – known as modifiable risk factors – and many of these relate to the lifestyle chosen. Some risk factors are definitive and others are only possible risk factors.

The main known definitive risk factors for mouth cancer are using tobacco and drinking alcohol: it is thought that about 3 out of 4 head and neck cancers (75%) are linked to tobacco or alcohol use. Other risk factors include betel, radiation (e.g. sunlight, ionising), and infection with the virus human papillomavirus (HPV), which play a role in cancers at the back of the mouth (the oropharynx) oropharyngeal cancer.

55

Tobacco and alcohol are the main definitive risk factors for mouth cancers in the resource-rich world. Cigarettes and alcohol contain nitrosamines and other chemicals known to cause cancer. Sunlight exposure predisposes to lip cancer.

Immune defects or immunosuppression underlie some cases of mouth cancer.

Environmental and genetic factors may also play a role but are generally less important than the modifiable lifestyle risk factors. There is protective benefit from a healthy immune system and from diets rich in fruit and vegetables.

56

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Chapter 7 Oral medicine - ulceration

By Professor Crispian Scully, Dr Jane Luker and Dr David Felix Adapted from Oral medicine – update for the dental team

Ulceration is a breach in the oral epithelium, which typically exposes nerve endings in the underlying lamina propria, resulting in pain or soreness, especially on eating spicy foods or citrus fruits. Patients vary enormously in the degree to which they suffer and complain of soreness in relation to oral ulceration. It is always important to exclude serious disorders such as oral cancer or other serious disease, but not all patients who complain of soreness have discernible organic disease. Even in those with detectable lesions, the level of complaint can vary enormously – some patients with large ulcers complain little; others with minimal ulceration complain bitterly of discomfort. Sometimes there is a psychogenic or cultural influence.

Terminology Epithelial thinning or breaches may be seen in: Mucosal atrophy or desquamation Terms often used for thinning of the epithelium which assumes a red appearance since the underlying lamina propria containing blood vessels shows through. Most commonly seen in desquamative gingivitis (usually related to lichen planus, or less commonly to pemphigoid) and in geographic tongue (erythema migrans, benign migratory glossitis), a similar process may also be seen in systemic disorders such as deficiency states (of iron, folic acid or B vitamins).

Mucosal inflammation (mucositis, stomatitis) This can cause soreness; viral stomatitis, candidosis, radiation mucositis, chemotherapy-related mucositis and graft-versus-host disease are examples.

Erosion Which is the term used for superficial breaches of the epithelium. These often initially have a red appearance, since there is little damage to the underlying lamina propria, but it typically becomes covered by a fibrinous exudate and then has a yellowish appearance. Erosions are common in vesiculobullous disorders such as pemphigoid.

58

Ulcer This is the term used usually where there is damage both to epithelium and lamina propria. An inflammatory halo, if present, also highlights the ulcer with a red halo, around the yellow or grey ulcer. Most ulcers are due to local causes such as trauma or burns but recurrent aphthous stomatitis must always be considered.

Causes of oral ulceration Ulcers and erosions can also be the final common manifestation of a spectrum of conditions, ranging from epithelial damage resulting from trauma, to an immunological attack as in lichen planus, pemphigoid or pemphigus, to damage because of an immune defect, as in HIV disease and leukaemia, infections as in herpesviruses, tuberculosis and syphilis, or nutritional defects such as in vitamin deficiencies and some gastrointestinal disease.

Ulcers of local causes At any age, there may be burns from chemicals of various kinds, heat, cold, or ionizing radiation or factitious ulceration, especially of the maxillary gingivae.

Children may develop ulceration of the lower lip by accidental biting following dental local anaesthesia. Ulceration of the upper labial fraenum, especially in a child with bruised and swollen lips, or subluxed teeth or fractured jaw can represent nonaccidental injury. At any age, trauma, hard foods, or appliances may also cause ulceration. The lingual fraenum may be traumatized by repeated rubbing over the lower incisor teeth in recurrent coughing as in whooping cough or in self-mutilating conditions.

Most ulcers of local cause have an obvious aetiology, are acute, usually single ulcers, last less than three weeks and heal spontaneously. Chronic trauma may produce an ulcer with a keratotic margin.

A useful mnemonic for the causes of local ulcers is: SMLAD: So Many Laws And Directives, for: Systemic diseases, Malignant disease, Local causes, Aphthae, Drugs.

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) RAS is a very common condition which typically starts in childhood or adolescence and presents with multiple recurrent small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey base. RAS affects at least 20% of the population, with the highest prevalence in higher socio-economic classes.

Virtually all dentists will see patients with aphthae.

59

Immune mechanisms appear at play in a person with a genetic predisposition to oral ulceration. A genetic predisposition is present, and there is a positive family history in about one third of patients with RAS. Immunological factors are also involved, with T helper cells predominating in the RAS lesions early on, along with some natural killer (NK) cells. Cytotoxic cells then appear in the lesions and there is evidence for an antibody dependent cellular cytotoxicity (ADCC) reaction. It now seems likely therefore that a minor degree of immunological dysregulation underlies aphthae.

RAS may be a group of disorders of different pathogeneses. Cross-reacting antigens between the oral mucosa and micro-organisms may be the initiators, but attempts to implicate a variety of bacteria or viruses have failed.

Predisposing factors Most people who suffer RAS are otherwise apparently completely well. In a few, predisposing factors may be identifiable, or suspected. These include:

• Stress: underlies RAS in many cases. RAS is typically worse at examination times

• Trauma: biting the mucosa, and dental appliances may lead to some ulcers

• Haematinic deficiency (deficiencies of iron, folic acid (folate) or vitamin B12) in

up to 20% of patients

• Sodium lauryl sulphate (SLS), a detergent in some oral healthcare products,

may produce oral ulceration

• Cessation of smoking: may precipitate or aggravate RAS

• Gastrointestinal disorders particularly coeliac disease (gluten-sensitive

• Endocrine factors in some women whose RAS is clearly related to the fall in

enteropathy) and Crohn’s disease in about 3% of patients

progestogen level in the luteal phase of their menstrual cycle

• Immune deficiency; ulcers of a similar appearance to RAS may be seen in HIV

and other immune defects, although clearly the aetiopathogenesis is different

• Food allergies: in some studies hypersensitivity to various food additives has

been shown to be important, although this is not a universal finding.

Drugs (see below), Behcet syndrome, HIV, Epstein-Barr virus, auto-inflammatory states (periodic fevers) and skin diseases, such as erythema multiforme, may occasionally produce aphthous-like lesions.

60

Key points

• They are so common that all members of the dental team will see them

• It is important to rule out predisposing causes (sodium lauryl sulphate, certain

such as Behcet syndrome that can cause aphthous-like lesions

• It is necessary therefore to enquire about eye, genital, gastrointestinal or skin

foods/drinks, stopping smoking or vitamin or other deficiencies) or conditions

lesions and fever

• Topical corticosteroids are the main treatment.

Clinical features There are three main clinical types of RAS, though the significance of these distinctions is unclear and it is conceivable that they may represent three different diseases.

1. Minor aphthous ulcers (MiAU; Mikulicz Ulcer)

• Occur mainly in the 10–40 year age group

• Often cause minimal symptoms

• Are small round or ovoid ulcers 2–4mm in diameter in most situations but often

more linear when in the buccal sulcus, a common site. The ulcer base is initially

yellowish but assumes a greyish hue as healing and epithelialization proceeds.

They are surrounded by an erythematous halo and some oedema

• Are found mainly on the non-keratinized mobile mucosa of the lips, cheeks,

floor of the mouth, sulci or ventrum of the tongue. They are only uncommonly seen on the keratinized mucosa of the palate or dorsum of the tongue

• Occur in groups of only a few ulcers (1–6) at a time

• Heal in 7–10 days

• Recur at intervals of 1–4 months

• Leave little or no evidence of scarring.

2. Major aphthous ulcers (MjAU; Sutton’s Ulcers; Periadenitis Mucosa Necrotica

Recurrens (PMNR))

• Are larger, of longer duration, of more frequent recurrence, and often more

painful than minor ulcers

• Are round or ovoid like minor ulcers, but they are larger and associated with

surrounding oedema 61

• Reach a large size, usually about 1 cm in diameter or even larger

• Are found on any area of the oral mucosa, including the keratinized dorsum of

the tongue or palate

• Occur in groups of only a few ulcers (1–6) at one time

• Heal slowly over 10–40 days

• Recur extremely frequently

• May heal with scarring

• Occasionally found with a raised erythrocyte sedimentation rate or plasma

viscosity.

3. Herpetiform ulceration (HU)

• Are found in a slightly older age group than the other forms of RAS

• Are found mainly in females

• Begins with vesiculation which passes rapidly into multiple minute pinhead-sized

discrete ulcers

• Involve any oral site including the keratinized mucosa, increase in size and

coalesce to leave large round ragged ulcers

• Heal in 10 days or longer

• Are often extremely painful

• Recur so frequently that ulceration may be virtually continuous

• Despite the name they have nothing to do with herpes infection.

Diagnosis and management There are no specific tests, so the diagnosis must be made on history and clinical features alone. Biopsy is rarely indicated, usually where a different diagnosis is suspected.

Other similar disorders, such as Behcet syndrome, must be ruled out. Predisposing factors should then be corrected. Fortunately, the natural history of RAS is one of eventual remission in most cases. However, few patients have spontaneous remission until after several years and, although there is no curative treatment, measures should be taken to relieve symptoms and reduce ulcer duration. Good oral hygiene should be maintained and chlorhexidine or triclosan mouthwashes may help. There is a spectrum of topical anti-inflammatory agents that may help in the management of RAS and topical corticosteroids can usually control symptoms. Common 62

preparations used include four times daily: medium potency topical betamethasone sodium phosphate (eg Betnesol), or higher potency topical corticosteroids (e.g. beclometasone – Clenil modulite).

The major concern is of adrenal suppression with long-term and/or repeated application but there is no evidence that these cause this problem. Topical tetracycline (e.g. doxycycline), or tetracycline plus nicotinamide may provide relief and reduce ulcer duration, but should be avoided in children under 12 who might ingest the tetracycline and develop tooth staining.

If RAS fails to respond to these measures, systemic immunomodulators may be required, under specialist supervision.

Key points for patients

• These ulcers are common

• They are not thought to be infectious

• Children may inherit ulcers from parents

• The cause is not known but some follow use of toothpaste with sodium lauryl

sulphate, certain foods/ drinks, or stopping smoking

• Some vitamin or other deficiencies or conditions may predispose to ulcers

• Ulcers can be controlled but rarely cured

• No long-term consequences are known.

Websites and patient information http://www.doctorsofusc.com/condition/ document/11983 http://emedicine.medscape.com/article/867080overview http://www.cks.nhs.uk/patient_information_leaflet/ mouth_ulcer

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Chapter 8 Xerostomia and salivary gland hypofunction Professor Mahvash Navazesh, Herman Ostrow School of Dentistry of USC, LosAngeles, USA

Introduction Saliva plays a significant role in the maintenance of oral-pharyngeal health.

Subjective complaints of a dry mouth (xerostomia) and objective evidence of diminished salivary output (salivary gland hypofunction) are common conditions, particularly in medically compromised older adults. They can result in impaired food and beverage intake, a sundry of oral disorders, and diminished host defence and communication. Persistent salivary gland hypofunction can produce permanent oral and pharyngeal disorders and impair a person’s quality of life.

Global estimates of xerostomia and salivary gland hypofunction are difficult to ascertain due to limited study design, differences in study populations, usage of the terms xerostomia and salivary gland hypofunction interchangeably, utilisation of different diagnostic criteria and saliva collection methods, and limited sample sizes.

Overall, the prevalence of xerostomia and salivary gland hypofunction increases with age and affects approximately 30% of the population aged 65 years and older.

There are multiple causes of xerostomia and salivary gland hypofunction the most common being drug-induced, since most older adults are taking at least one medication that causes salivary gland hypofunction. It is difficult, however, to estimate the true prevalence of xerostomia in older adults taking medications. The prevalence of xerostomia is nearly 100% among patients with SjÜgren’s syndrome, an autoimmune exocrinopathy affecting between 1-4% of older adults. Radiation of the head and neck for the treatment of cancer causes permanent xerostomia, which has a 100% prevalence rate if the dose is >25 Gy, but the numbers affected are relatively small compared with those older adults susceptible to medicationinduced xerostomia. Estimates of the prevalence of xerostomia in adult ambulatory and nursing home populations range from 16-72%. Combining the prevalence of xerostomia-associated conditions with the percentage of adults with these conditions who complain of xerostomia yields the above-mentioned general estimate of approximately 30% xerostomia prevalence among adults 65 years and older.

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Approximately 80% of all persons over age 65 have at least one chronic condition and 50% have at least two. Hypertension and heart diseases, diabetes, arthritis and cancer are the most frequently occurring conditions among older adults.

These conditions, and the medications often prescribed for their management, could impact the structure and function of salivary glands leading to complaints of xerostomia or clinical evidence of salivary gland hypo-function. More than 400 medications list dry mouth as a potential adverse effect. In May 2011 the United States Food and Drug Administration (FDA) added dry mouth to its consumer health information.

Aetiology of xerostomia and salivary gland hypofunction: salivary gland pathology Intraoral sources of salivary gland pathology can be divided into three broad classifications: infectious, non-infectious, and neoplastic. Bacterial infections are more common in older adults who experience salivary gland hypofunction secondary to medications, head and neck radiation, systemic diseases, or dehydration. Acute parotitis was commonly seen before the antibiotic era in terminally ill and dehydrated patients and contributed to mortality by sepsis. Now, acute parotitis is observed infrequently. Chronic parotitis is not unusual and it follows obstruction of a parotid duct with subsequent bacterial colonisation and infection.

Signs and symptoms of bacterial salivary infections include swelling, purulence from the major salivary gland duct, and pain.

Viral infections occur in persons of all ages, particularly in immunocompromised patients, and preferentially involve parotid glands. Mumps is caused by paramyxovirus, and presents as bilateral parotid gland swelling in children.

Cytomegalovirus infections tend to be mild with non-specific findings, and are observed primarily in adults.

Non-infectious (reactive) causes of salivary pathology are most commonly due to obstruction of a salivary gland excretory duct and can be divided into acute and chronic conditions. Acute sialadenitis usually results from an immediate partial or complete ductal obstruction (i.e. sialolithiasis), whereas chronic recurrent sialadenitis occurs as a result of prior infection and/or ductal scarring.

Mucoceles are the most common reactive lesion of the lower lip and are caused by local trauma. When a minor salivary gland duct is severed mucin leaks into the surrounding connective tissue resulting in a smooth-surfaced painless nodule in the submucosal tissues. Mucous cysts of the sublingual gland, and, less frequently, the submandibular gland, are referred to as ranulas. They present as either unilateral

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circumscribed lesions (subsequent to ductal obstruction and cystic dilation) or plunging lesions (following extravasation of saliva herniating through the tissues of the floor of the mouth and the mylohyoid muscle). Both types of ranulas require surgical excision and possible marsupialization of the cyst.

Most calculi (sialoliths, stones) develop in the submandibular duct system and are caused by calcification of mucous plugs and cellular debris, typically as a result of dehydration and glandular inactivity. Sialoliths occur infrequently in the parotid duct system and are considered rare in the sublingual and minor salivary glands.

Most salivary gland tumours are benign, arising from epithelial tissues; however, neoplasms may originate from any adjacent tissue or structure (adipose, nerves, blood vessels, lymph nodes, lymphatics). The preponderance of benign salivary gland neoplasms occurs within the parotid gland, with the majority (80%) being pleomorphic adenomas. These tend to be unilateral and most commonly present as an asymptomatic mass in the tail of the parotid gland. They are slow growing, well delineated and encapsulated. Malignant salivary gland tumour incidence increases with age, and these tumours are more common in the submandibular and sublingual glands compared with the parotid gland. When epithelial neoplasms arise in the submandibular or sublingual glands, only 50% are benign.

Mucoepidermoid carcinoma is the most common malignant salivary gland tumour, followed by adenoid cystic carcinoma (cylindroma), acinic cell carcinoma, adenocarcinoma, squamous cell carcinoma, and carcinoma arising in a pleomorphic adenoma. The most commonly affected intraoral site is the palate followed by the upper lip. Adenoid cystic carcinomas are aggressive tumours that undergo perineural invasion. They have good 10-year survival rates, but long-term mortality is likely. The signs and symptoms of a malignant salivary gland tumour include a swelling with facial nerve paralysis, pain, or facial paresis.

Systemic diseases There are numerous systemic conditions that have been associated with xerostomia and salivary gland hypofunction, the most common being Sjögren’s syndrome, primarily a disease affecting women with a typical onset during the fourth or fifth decade of life. Clinically, Sjögren’s syndrome presents in either primary or secondary forms. Primary Sjögren’s syndrome is characterised by xerostomia and xerophthalmia (dry eyes) that are the result of a progressive loss of salivary and lacrimal gland function. Secondary Sjögren’s syndrome includes involvement of one or both of these exocrine sites in the presence of another connective tissue disease such as rheumatoid arthritis, systemic sclerosis, or systemic lupus erythematosus. Lymphocytic infiltrates of salivary glands increase as the inflammatory disease progresses, 68

ultimately producing acinar gland degeneration, necrosis, atrophy, and complete destruction of the salivary gland parenchyma. Diagnosis requires a combination of objective salivary, lacrimal, and serological criteria and subjective complaints of xerostomia or xerophthalmia.

Other autoimmune conditions associated with Sjögren’s syndrome and causing salivary gland hypofunction include rheumatoid arthritis, scleroderma, and lupus.

HIV+ infected individuals and those with AIDS frequently experience salivary gland hypofunction from lymphocytic destruction of the glands and as a sequela of medications. Diabetes may cause changes in salivary secretions, and associations have been made between poor glycemic control, peripheral neuropathies, and salivary hypofunction. Alzheimer’s disease, Parkinson’s disease, strokes, cystic fibrosis, Hepatitis C and dehydration will also inhibit salivary secretion.

It was previously thought that salivary function declined with greater age, yet it is now accepted that output from the major salivary glands does not undergo clinically significant decrements in healthy older adults. There are reports of agerelated decrements in several salivary constituents, whereas other studies report age-stable production of salivary electrolytes and proteins in the absence of major medical problems and medications. It is likely that numerous systemic diseases (e.g.

Sjögren’s syndrome) and their treatments (medications, head and neck radiation, chemotherapy) contribute significantly to salivary gland hypofunction in the elderly. It has been demonstrated that the salivary glands of older adults are more vulnerable to the deleterious effects of medications compared with those of younger individuals, confirming the finding of greater xerostomia prevalence among older adults, particularly those taking medications.

Medications The most common causes of salivary gland hypofunction and xerostomia are prescription and non-prescription medications. For example, 80% of the most commonly prescribed medications have been reported to cause xerostomia, with over 400 medications causing a side effect of salivary gland hypofunction. The intake of prescription medications increases with age, and more than 75% of persons over the age of 65 years take at least one prescription medication. Further, with the increased intake of prescription medications, there is an increase in xerostomia.

The most common types of medications causing salivary hypofunction have anticholinergic effects via inhibition of acetylcholine binding to muscarinic receptors on the acinar cells. This prevents initiation of the cascade of physiological events that ultimately result in water movement through acinar cells, into the ductal system, and ultimately into the mouth. Importantly, any medications that inhibit neurotransmitter 69

binding to acinar membrane receptors, or that interfere with ion transport pathways, may also adversely affect the quality and quantity of salivary output.

These medications include tricyclic antidepressants, sedatives and tranquilizers, antihistamines, antihypertensives (alpha and beta blockers, diuretics, calciumchannel blockers, angiotensin converting enzyme inhibitors), cytotoxic agents, anti Parkinsonian, and anti-seizure drugs.

Chemotherapy for cancer treatment has also been associated with salivary gland hypofunction. These changes appear to occur during and immediately after treatment. Most patients experience a return of salivary function to prechemotherapy levels, yet long-term changes have been reported. Finally, radioactive iodine (I131) used in treatment for cancers of the thyroid gland may cause parotid, but not submandibular, salivary gland hypofunction in a dosedependent fashion, since the salivary glands concentrate iodide to levels much higher than those in the blood.

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Chapter 9 Radiology in dental practice

The use of ionising radiation in dental practice is subject to the requirements of the Ionising Radiations Regulations 1999 (IRR99) and the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R). IRR99 relates to the protection of the patient, and the basic requirements that patient exposure must be kept as low as reasonably practicable (ALARP). IR(ME)R relates to written procedures and protocols that demonstrate how this optimisation of dose is achieved.

Dental radiology is an important aspect of any practice. Legally, the responsibilities for compliance with IRR99 and IR(ME)R rests with the ‘employer’ but what matters is that there is a clearly defined person or body corporate who takes legal responsibility for radiation safety. That person, or body is referred to as the legal person.

In order to comply with the relevant statutory requirements a Radiation Safety Policy may be made stating:

• The legal person and their responsibilities (usually the employer)

• A named person responsible for drafting, issuing and annually reviewing clinical

procedures and protocols (possibly a practice manager)

• A named person responsible for health and safety arrangements

• A named person responsible for ensuring an effective quality assurance

• Who the Radiation Protection Adviser (RPA) is and their contact details (usually

programme is maintained at the practice (possibly a head nurse)

an external contact)

• Who the Radiation Supervisor is (usually an internal person at the practice, like

a dentist)

• What a referrer, practitioner, operator is

• Notification details to the health and safety executive (HSE).

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Patient identification Every patient must have their identity confirmed by the dentist or whoever is going to take the x-rays prior to a radiological exposure. If the operator is not the same as the referrer then patient checks should be made prior to exposure such as, name, address and date of birth for confirmation.

Clinical evaluation The objectives of a clinical evaluation are to ensure that every dental exposure undertaken has such an evaluation. The operator is responsible for ensuring that this is recorded in the patient’s records and he or she will be a dentist, dental nurse, hygienist or therapist who is qualified and trained to do so.

The evaluation should include:

• The patent identity

• Signature or initials of the operator

• Details of all the findings e.g. charting of caries

• Findings relevant to the patient’s management/prognosis.

A simple practice audit at regular intervals ensures that these criteria are met and may flag up areas of importance which could be managed at the next practice meeting.

Training and education This ensures all competent operators receive qualifications complying with IR(ME)R and training for the duties they undertake, and that records of this are maintained and reviewed annually. For example dentists (who can prescribe, refer, set up and take x-rays) must have an undergraduate degree and attendance at a formal course every 5 years to cover radiation protection and the requirements of IRMER. It is equally important that they also undertake continuing professional education and training after qualification including, in the case of clinical use of new techniques, training related to these techniques and the relevant radiation protection requirements. This currently amounts to the nature of any training which they have had and when it was completed, and for registration with the GDC, they currently require 5 hours in any 5 year period.

On induction and with the implementation of any new radiation equipment or equipment software there must be associated training which must be documented within the duty holder’s training record. Their scope of practice should also be

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reassessed by an appropriate person (such as a Radiation Protection Advisor). It may also be useful to have the local rules at each x-ray unit so that the staff who are competent to use the machines are fully aware of what protocols are used in a particular practice.

Incident reporting The idea of an incident report is to ensure that incidents and near misses involving patient overexposures are properly investigated and recorded. These must be reported to the appropriate statutory authority promptly. The Named person is then responsible for carrying out an investigation of the incident and when necessary, liaising with the Radiation Protection Adviser (RPA) or Medical Physics Expert (MPE) regarding the patient dose as soon as possible.

The MPE or RPA is responsible for making an assessment of the dose to the patient and for advising the Named person on whether an incident needs to be reported to the relevant statutory authority or if any other steps need to be taken.

The dental practitioner must decide on whether to inform the patient or not. This must be documented in the patient’s dental /electronic records. The patient should be informed unless it is deemed not to be in their best interests. If the patient is not informed of the incident, the reasons why should also be documented.

Reducing the probability and magnitude of unintentional exposures The employer must ensure that an equipment inventory is kept on all radiation equipment and that the equipment is maintained in accordance with manufacturer’s instructions. This may be done every 3 years or so, but the practice’s Radiation Protection Adviser (RPA) will advise when it is required. Practitioners and operators must ensure that the doses arising from an exposure are kept as low as reasonably practicable consistent with the intended purpose. A yearly log in the maintenance folder or radiation folder will help keep this up to date.

Quality assurance The main objective of a QA programme is to ensure that radiation doses are kept as low as reasonably practicable. It is therefore necessary to monitor patient doses on a regular basis. Patient dose cannot be maintained as low as reasonably practicable unless the x-ray equipment complies with recommended standards. Dental x-ray equipment must be subject to the following tests:

• A critical examination by the installer, following installation

• An acceptance test before the equipment is put into clinical use

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• Further routine tests at appropriate intervals and after any major maintenance

procedure.

The recommendations are that such routine tests are carried out at intervals not exceeding 3 years. However annual testing is recommended. QA tests can be used to monitor the overall performance of film processing, and regular use of these tests can identify problems with film processing before they affect patient films. Checks can be made on the chemicals, cleaning procedures of the automatic chemical developers , dark rooms, developer temperatures, x-ray films (for out of date x-rays, storage etc), intensifying screen inspections, viewing facilities etc.

The other dental recommendation is that a simple, subjective quality rating system is in place for the radiographs. This can easily be done by qualified nurses. Using the system below a regular analysis of image quality can be performed at the practice. Such an analysis can be undertaken prospectively, whereby image quality is assessed as each radiograph is viewed, or retrospectively, where a representative sample of radiographs are drawn from the clinical records. The radiographs being assessed can be rated from 1-3 as defined below. The ratings should be recorded in a suitable log.

There is a minimum recommended standard that quality ratings should meet (see below).

Practices should aim to achieve these within 3 years of implementing a QA programme. Risk assessment

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This covers the application of the Ionising Radiations Regulation 1999 to work with dental x-ray equipment. The assessment concerns the exposure to radiation of employees and members of the public. The following persons are identified as being at risk:

• Operators directly involved with the radiography

• Other staff members outside of the radiography areas e.g. practice managers,

receptionist etc

• Members of the public e.g. patients in the waiting rooms.

Special considerations may also be given to employees who are pregnant or under the age of 18.

This will involve the whole set up of how you take the x-rays for example:

• That no one is in the controlled area except the patient

• The distance the operator stands from the primary beam

• That the exposure switches are audible and a visible warning light shows that

• The positioning of the operator’s control panel so that the operator can always

x-rays are taking place see the patient and the equipment warning lights during exposure

• Quick access to the isolation switches from the mains supply without having to

enter the controlled area.

Cross infection control During any dental radiography procedure, the radiographic equipment can become contaminated with the patient’s saliva and /or blood if aseptic techniques are not practiced. Dental health care professionals can also become at risk for occupational exposures to these contaminants as the microbes can survive on the equipment and developer and fixer solutions for a period of time.

Cross infection must be strictly adhered to in order to prevent disease transmission between both the staff and the patients, thus helping to protect both. Simple procedures can be followed to help prevent contamination, these may included the following:

• The use of disposable and heat sterilisable x-ray accessories

• Immersion of heat sensitive items in liquid disinfectants

• Surface covers

• Disinfectant spray used on clinical contact areas

• The use of personal protective equipment (PPE) such as gloves and masks 80

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• Training for anyone involved in helping to take the x-rays.

It may be easier to divide the clinical areas for a radiographic procedure into the following: A. Tasks before the radiographic procedure:

• This may include sterilisation of all intraoral x-ray equipment, and any disposable

equipment set up.

• Surface covers on any areas that may get clinical contact e.g. x-ray tube

heads, x-ray control switches etc

• All equipment required is set up

• All staff involved in the procedure have PPE on

• Label film mounts or envelopes or create the patient file if digital.

B. Tasks during the radiographic procedure may include:

• Keep all PPE on

• The x-ray film can have a protective /disposable pouch

• Touch as few surfaces as possible

• Remember clean and dirty zones.

C. Tasks after the radiographic procedure:

• Place reusable film holders in a designated contamination area

• Carefully remove the film packets from their protective pouches, allowing the

• Remove all covers from the surfaces and discard

• Disinfect uncovered contamination surfaces wearing gloves.

films to gently fall out of their pouches

D. Tasks associated with the x-ray developing.

• Transport the films in disposable containers e.g. a plastic cup

• Process films

Disinfect uncovered areas of the developer with new PPE. Infection control for dental radiography employs the same materials, processes and techniques that you would use whilst treating a patient in the surgery. The protocols and procedures given in this article are generalised as every practice is individual with is staff and employers. Your Radiation Protection Advisor should help you ensure your set up is correct.

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Chapter 10 Communication and the dental team: relationships with patients Professor Liz Kay, Foundation Dean Peninsula Dental School

Why do we need to relate well to patients?

Relating well with patients, quite apart from other advantages that it confers upon the practice, enables you to get appropriate information from the patient quickly and easily. The more skilled the dental team, the less difficulty the patient will find in describing or explaining their problem. So, establishing a good rapport with a patient at the outset will enable you to define the patient’s problem and determine an appropriate solution rapidly. And they’ll like that because they’ll believe that you care, as indeed you do. Approximately 80% of the information we need in order to make a diagnosis comes from the ‘chat’ which precedes examination.

Practices often like to call this part of a visit a consultation, but to the patient it is a chat about himself or herself. Thus, skills in non-verbal and verbal communication enable a dental practice to bypass irrelevant information and to quickly pinpoint the most important issues and facts, without offending the patient, or appearing to be disinterested.

A further reason for competency in interpersonal relationships with patients is that, at some point we are going to have to explain the nature and cause of their oral ill-health, advise them about the treatment options, make clear what we plan to do and have them recognise their own role in the treatment. Finally, it will be necessary to both explain why we are suggesting one particular option as the best course of action and ask them to pay for their treatment. Most importantly remembering that the actions and behaviours a person undertakes on a day to day basis, at home, will have infinitely more effect on their ultimate oral health than anything we may do in the surgery) we will need to let the patient understand what they need to do to help them deal with their problem on their own.

Finally, a good relationship between health care personnel and the recipient of care has a powerful therapeutic effect. For example, it has been demonstrated that 64% of patients suffering from pain, clicking and limitation of movement of their temporomandibular joints will report a noticeable improvement in their symptoms when their only ‘treatment’ has been an explanation about the nature of their disease and enthusiastic reassurance that their symptoms will subside. So, a good relationship with patients can actually make them feel healthier!

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What exactly are we trying to achieve?

The first stage of a dental consultation is to determine the nature of the patient’s problem in physical and social and psychological terms.

Most patients attend a dental practice because they either have a problem, which they believe to be related to their oral health, or because they wish to avoid certain events that they would regard as a problem, for example, loss of teeth or toothache.

Those who do not regard the loss of teeth as a problem tend not to attend for dental care. Suggesting that ‘defining the problem’ is a good first step is not the same as saying that the best thing to tell the patient what disease, or pathology, is present in her or his mouth. The ‘disease’ is not the same as the patient’s perception of a problem (or potential problem).

It may be that the patient has attended because they have toothache - in that case, the problem is a physical one. However, what of the patient who claims that they are attending because their gums bleed? Often, the bleeding has been present, perhaps only intermittently, for many years. Perhaps their real ‘problem’ (as opposed to their ‘complaint’) is that they fear they have bad breath. In this case, their problem may be socially rooted (they have no friends and rather than admit that it is their habits and behaviour which make them unpopular, wish to blame their lack of social life on their unpleasant breath).

Worse, someone may have confided to them that they smell unpleasant. Such a devastating revelation would be highly likely to trigger a dental visit. Informing such a patient that they have ‘periodontal disease and marginal gingivitis’, although it may make the dental team marvel at their own fabulous diagnostic powers, will do nothing towards solving the problem. Such a patient will then merely have the added worry of a terrifying-sounding disease alongside their social unacceptability.

A further example of the psycho-social, rather than pathological nature of oral ‘problems’, would be the burning mouth syndrome patient. Many patients who report an intense burning sensation in their mouths are actually terrified of oral cancer or other terminal or incurable diseases. Exactly why such worries are translated into oral symptoms is not known, but many such patients will repeatedly visit various dental and medical practitioners with their complaint, until someone recognises the psychological cause of the symptoms. ‘Chopping’ a piece of tissue out of the patient’s mouth in the form of a biopsy will make the problem worse, rather than better.

And what of the patient who attends the dental surgery, saying that their teeth are wearing away because they grind them at night? Is that person’s problem really

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the loss of tooth tissue, or is the real problem, which they wish to share the stress that is causing the grinding and clenching. Or, perhaps, it is simply that their partner is moaning about the grinding noise at night? It is vital that the dental care professional determines the true nature of the ‘problem’ before embarking upon lengthy, complicated and expensive procedures to ‘treat’ it. If the dentist has wrongly diagnosed that the patient’s concern is the appearance of worn teeth and complex treatment is undertaken to solve the tooth wear, it will actually do little to alleviate the true problem (the grumbling moaning partner) – in fact it might make it worse by adding to the patient’s worries about how to explain the large bill to the sleep deprived partner.

The second stage of a dental consultation is to communicate your understanding of the problem to the patient.

Unfortunately, recognition of the patient’s perception of the problem is not enough.

Patients are not psychic. Unless the dental team communicates its understanding to the patient, the patient will remain unaware that the dental practice recognise anything other than oral disease. Imagine the patient who says to the receptionist: “I hear the dentist has just been on a course about implants”. Would it be helpful in this situation for the receptionist to say: “Yeah, it’s great, we can now do operations where we drill a bit of metal into the gum to hold false teeth in place”?

It is vital that the receptionist picks up that the patient is interested, and perhaps not unworried that the dentist has just acquired a new technique, which he may want to practise on his patients. A more useful response would be to express back to the patient the understanding that the news is of concern, and reassure the worried individual that this does not mean that the dentist will, from now on, be treating his patients differently! For example: Patient:

“I hear the dentist has just been on a course about implants.”

Receptionist:

“Yes she has, but it won’t affect your treatment. It’s only used on very

difficult cases”.

Patients do not know that their worries, concerns and problems, and the impact that these have on their lives, have been understood, unless someone communicates that understanding to them.

However, equally, it is may be that the patient has heard, or read, about the success of implants in improving quality of life but is conscious of seeming to be too vain in asking directly about them. Here a dental team member with a sensitivity to the patient’s motive might answer the same point:

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“Yes. Implants can make such a positive difference to people’s lives

nowadays and we wanted to be able to offer the benefits to our patients

too. Would you like to know more about how they could help you?”

The third step in a dental consultation is to decide upon the best treatment option taking into account the patient’s social circumstances.

Once a member of the dental team (often this will not be the dentist) has recognised the true nature of the patient’s problem, and have communicated their views on, and understanding of, the problem to the patient, the dentist must then, using his/her professional knowledge and skills, decide upon a course of action which is the most appropriate. This will be dictated not only by the problem, but also by the attitudes, beliefs, wishes and lifestyle of the patient. For example, it might be inappropriate to decide upon a six-visit programme for full mouth restorations, if the patient happens to be the mother of five toddlers, who lives thirty miles from the practice and does not possess a car. Thus, the life-circumstances of each patient will and should influence which treatment option is chosen as offering the best solution to the problem. The preferred ‘technical solution’ may not be the best solution if the patient is considered a person rather than a biomechanical problem.

The fourth stage of the consultation is to involve the patient in the decision about the best solution to the problem.

Having suggested one, two or possibly more viable options aimed at solving the patient’s problems (not just his or her disease), it is vital that they then have some degree of control over the decision. Patients should ideally choose what is to be the course of action and be fully aware of the possible outcomes. Involvement of patients at this stage is the key to their satisfaction with the treatment provided. If a treatment plan includes root-treating and crowning three teeth, the patient needs to understand the length of time required for such treatment. He will then have to make a decision as to whether he can afford the time and the expense involved.

The team must also ensure that the patient fully recognises the home after-care that the patient’s mouth will then require. There are often cases where a seemingly ‘sub-optimal’ treatment plan is actually the one that offers the patient the most acceptable solution to the problem.

The importance of this shared responsibility for the outcome of treatment cannot be overemphasised. Dentists are not gods or goddesses and do not, on their own, hold all the solutions to all their patients’ problems. If they are acting together, the dental team and the patient have a much greater chance of a satisfactory outcome and this partnership approach, rather than ‘us-and-them’, approach has a variety of other benefits which we will attempt to explain in greater detail in later chapters.

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Suffice it to say that it can be an immense relief to drop the omnipotent ‘healer’ role and develop joint responsibility with patients. Despite many advances in oral health care, we still do not have all the answers and, therefore, really should not pretend that we have. While we sometimes have the ‘right’ solutions in the ‘scientific’ sense and while we undoubtedly bring a wealth of knowledge and expertise to our patients, it is desperately important to remember that so do the patients. Just because the team’s information is based on clinical science, this does not mean that it is any ‘better’ than the patient’s views, which are founded on their own personal experiences and the ideas prevalent in their social group. Because you are right in science, does not mean you are necessarily ‘right’ in the patient’s eyes.

Last thoughts Many studies have shown that patients understand, accept and act upon the information given to them by health care professionals if the health professional’s view is consistent with their own beliefs and personal explanations of health and disease. Therefore, the members of a dental practice ignore their patients’ perceptions at their peril. Unless the dental team elicits and understands the beliefs of the patient, the patient is unlikely to heed or understand the views of the professionals. The patient’s interpretation of her or his symptoms and problems has validity and authority in their own lives and social circles, even if it does not accord with the professional interpretations of health and disease. It is perhaps wise to remember that ‘science’ has got things wrong in the past (vis a vis “calcium builds strong bones and teeth”, “eating raw vegetables gives you healthy gums”, both of which have been used in dental health campaigns). Equally, tincture of foxglove is actually digitalis (digoxin) and really did/does help heart failure, even though it was thought of as an old wives’ tale.

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Chapter 11 The General Dental Council’s Standards: Consent and complaints procedure

In this article we look at two of the General Dental Council’s Standards, relevant to ethical behaviour and to complaints procedures. These are especially important nowadays with the GDC receiving many more complaints than previously. The Standards are applicable to all dental team members and are available to download at the GDC’s website: www.gdc-uk.org Specifically we focus on: Principle Three: Obtain valid consent and Principle Five: Have a clear and effective complaints procedure

Principle Three: Obtain valid consent Standard 3.1 You must obtain valid consent before starting treatment, explaining all the relevant options and the possible costs.

3.1.1

You must make sure you have valid consent before starting any treatment

or investigation. This applies whether you are the first member of your team

to see the patient or whether you are involved after other team members

have already seen them. Do not assume that someone else has obtained

the patient’s consent.

3.1.2

You should document the discussions you have with patients in the process

of gaining consent. Although a signature on a form is important in verifying

that a patient has given consent, it is the discussions that take place with the

patient that determine whether the consent is valid.

3.1.3

You should find out what your patients want to know as well as what you

think they need to know. Things that patients might want to know

include:

• Options for treatment, the risks and the potential benefits • Why you think a particular treatment is necessary and appropriate for

them 90

• The consequences, risks and benefits of the treatment you propose

• The likely prognosis • Your recommended option

• The cost of the proposed treatment

• What might happen if the proposed treatment is not carried out

• Whether the treatment is guaranteed, how long it is guaranteed for and

any exclusions that apply.

3.1.4

You must check and document that patients have understood the

information you have given.

3.1.5

Patients can withdraw their consent at any time, refuse treatment or ask for

it to be stopped after it has started. You must acknowledge their right to

do this and follow their wishes. You should explain the consequences or risks

of not continuing the treatment and ensure that the patient knows that they

are responsible for any future problems which arise as a result of not

completing the treatment. You must record all this in the patient’s notes.

3.1.6

You must obtain written consent where treatment involves conscious

sedation or general anaesthetic.

Standard 3.2 You must make sure that patients (or their representatives) understand the decisions they are being asked to make.

3.2.1

You must provide patients with sufficient information and give them a

reasonable amount of time to consider that information in order to make a

decision.

3.2.2

You must tailor the way you obtain consent to each patient’s needs. You

should help them to make informed decisions about their care by giving

them information in a format they can easily understand.

3.23

When obtaining consent, you should encourage patients who have

communication difficulties to have a friend, relative or carer with them to

help them ask questions or understand your answers.

3.2.4

You must always consider whether patients are able to make decisions

about their care themselves, and avoid making assumptions about a

patient’s ability to give consent.

This is a complex area and you should refer to the appropriate legislation.

91

You can find further information on the GDC website or you can contact

your defence organisation for further advice.

3.2.5

You must check and document that patients have understood the

information you have given them.

Standard 3.3 You must make sure that the patient’s consent remains valid at each stage of investigation or treatment 3.3.1

Giving and obtaining consent is a process, not a one off event. It should be

part of on-going communication between patients and all members of the

dental team involved in their care. You should keep patients informed about

the progress of their care.

3.3.2

When carrying out an on-going course of treatment, you must make sure you

have specific consent for what you are going to do during that

appointment.

3.3.3

You must tailor the way you confirm ongoing consent to each patient’s

needs and check that patients have understood the information you have

given them.

3.3.4

You must document the discussions you have with patients in the process of

confirming their ongoing consent.

3.3.5

If you think that you need to change a patient’s agreed treatment or

the estimated cost, you must obtain your patient’s consent to the changes

and document that you have done so.

Principle Five: Have a clear and effective complaints procedure Standard 5.1 You must make sure that there is an effective complaints procedure readily available for patients to use, and follow that procedure at all times 5.1.1

It is part of your responsibility as a dental professional to deal with complaints

properly and professionally. You must:

• Ensure that there is an effective written complaints procedure where

you work

• Follow the complaints procedure at all times

• Respond to complaints within the time limits set out in the procedure

• Provide a constructive response to the complaint.

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5.1.2

You should make sure that everyone (dental professionals, other staff and

patients) knows about the complaints procedure and understands how it

works. If you are an employer, or you manage a team, you must ensure that

all staff are trained in handling complaints.

5.1.3

If you work for a practice that provides NHS (or equivalent health service)

treatment, or if you work in a hospital, you should follow the procedure set

down by that organisation.

5.1.4

If you work in private practice, including private practice owned by a dental

body corporate, you should make sure that it has a procedure which sets

similar standards and time limits to the NHS (or equivalent health service)

procedure.

5.1.5

You should make sure that your complaints procedure:

• Is displayed where patients can see it - patients should not have to ask for

a copy

• Is clearly written in plain language and is available in other formats if

needed

• Is easy for patients to understand and follow

• Provides information on other independent organisations that patients can

contact to raise concerns

• Allows you to deal with complaints promptly and efficiently

• Allows you to investigate complaints in a full and fair way

• Explains the possible outcomes

• Allows information that can be used to improve services to pass back to

your practice management or equivalent

• Respects patients’ confidentiality.

5.1.6

Complaints can be an opportunity to improve your service. You should

analyse any complaints that you receive to help you improve the service you

offer, and share lessons learnt from complaints with all team members.

5.1.7

You should keep a written record of all complaints together with your

responses. This record should be separate from your patient records so that

patients are not discouraged from making a complaint.

You should use your record of complaints to monitor your performance in

handling complaints and identify any areas that need to be improved.

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Standard 5.2 You must respect a patient’s right to complain 5.2.1

You should not react defensively to complaints. You should listen carefully to

patients who complain and involve them fully in the complaints process. You

should find out what outcome patients want from their complaint.

Standard 5.3 You must give patients who complain a prompt and constructive response 5.3.1

You should give the patient a copy of the complaints procedure when you

acknowledge their complaint so that they understand the stages involved

and the timescales.

5.3.2

You should deal with complaints in a calm and constructive way and in line

with the complaints procedure.

5.3.3

You should aim to resolve complaints as efficiently, effectively and politely as

possible.

5.3.4

You must respond to complaints within the time limits set out in your

complaints procedure.

5.3.5

If you need more time to investigate a complaint, you should tell the patient

when you will respond.

5.3.6

If there are exceptional circumstances which mean that the complaint

cannot be resolved within the usual timescale, you should give the patient

regular updates (at least every 10 days) on progress.

5.3.7

You should try to deal with all the points raised in the complaint and, where

possible, offer a solution for each one.

5.3.8

You should offer an apology and a practical solution where appropriate.

5.3.9

If a complaint is justified, you should offer a fair solution. This may include

offering to put things right at your own expense if you have made a mistake.

5.3.10 You should respond to the patient in writing, setting out your findings and any

practical solutions you are prepared to offer. Make sure that the letter is

clear, deals with the patient’s concerns and is easy for them to understand.

5.3.11 If the patient is not satisfied despite your best efforts to resolve their

complaint, you should tell them about other avenues that are open to

them, such as the relevant Ombudsman for health service complaints or the

Dental Complaints Service for complaints about private dental treatment.

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95

Chapter 12 Oral health of older people Janet Griffiths

It is a well known fact that the UK population is ageing. The Government’s projections suggest that by 2020, the population will reach 63.9 million and peak in 2040 at around 66 million. The proportion of older people is expected to rise. Although the ‘baby boomers’ of the 1940s and 1960s are an important factor, the main reasons are longer life expectancy and a fall in mortality in older age groups. Over the next few years, the increase in numbers of old and very old people in society will exceed that for the population as a whole. By 2020, more than 12 million people of pensionable age will be living in the UK, with twice as many females as males over the age of 85. The UK population of older people is not a homogenous group. It will also be more ethnically and culturally diverse as second and third generations of immigrants reach older age.

In discussing the needs of older people and their use of services, the increase in impairment and disability with age must also be considered. The 1988 Office of Population Census and Surveys (OPCS) survey, the first of its kind in the UK to look at this from a functional rather than a medical perspective, estimated that 6.2 million of the adult population of Great Britain, of which 4.2 million were aged 60 or more, had a level of ‘disability’ above that laid down by criteria for the survey. The overall rate of ‘disability’ increased with age, accelerating after the age of 50 years. ‘Disability’ rose very steeply over the age of 70, with almost 70% of ‘disabled’ adults aged over 60, and almost 50% aged 70 or over. The most severely ‘disabled’ lived in residential or institutional care. Mobility was the most frequently reported functional problem with hearing impairment and the inability to manage personal care affecting more than a third of ‘disabled’ people. In the 60–74 age group, approximately 20% were estimated to have impaired mobility, rising to 46% in those aged over 75.

More recent reports confirm that long-term illness limits the lifestyle of over a third of the population aged 65 to 74, and almost half the population over 75, particularly:

• Loss of mobility increases with age

• The greatest decline in mobility is in people aged 75 and over

• Sensory impairments become more common as people age

• Around 80% of people over 60 have a visual impairment

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• 75% of people over 60 have a hearing impairment

• 22% have both visual and hearing impairment.

The numbers with cognitive impairment will increase because the chances of developing dementia rise sharply with age. The Alzheimer’s Society estimates that there are currently 700,000 people in the UK with dementia. The majority are aged 65 years or older. However progress in the understanding of conditions such Alzheimer’s disease may lead to developments in its prevention and treatment so predictions must be viewed with caution.

The National Service Framework for Older People distinguishes between people who are functionally independent and those who are functionally dependent or frail regardless of age.

Effective mouth care requires motor skill and manual dexterity. Older people who are active and independent should have little difficulty maintaining oral health.

However functional impairment will pose limitations on the management of personal oral hygiene and is likely to severely restrict access to dental care and information on services. The Government’s report, Access to NHS Dentistry confirmed the fact that older people and people with dementia experience particular problems accessing NHS dental care. Older people in residential care do not receive uniformly high standards of oral health care and this is confirmed by a number of studies. Guidelines to address these issues provide a framework for developing standards to improve oral health in residential care settings.

Oral effects of ageing Tooth loss is not an inevitable consequence of ageing, although there are changes in oral tissues and surrounding structures associated with the ageing process. The degree of change depends on a variety of individual factors:

• Genetic influences

• Lifestyle • Habits

• Experience of disease

• Nutrition.

Teeth Tooth structure undergoes changes with age. Attrition, loss of tooth substance through wear is related to diet, habits such as bruxism and to the extra load

98

that is placed upon the remaining teeth when some teeth have been lost.

Attrition of the biting surfaces may lead to loss of facial height, although this is sometimes compensated for by an extra deposit of cement around the roots (hypercementosis).

Enamel may also be lost due to erosion or abrasion as a result of excessive or incorrect brushing techniques. Abrasion is most pronounced at the cervical surface (neck) of the tooth where the gum may have receded. Enamel also appears to darken with age due to the formation of additional layers of dentine within the tooth structure. The overall effect is that teeth become less sensitive to external stimuli.

Decay occurs more frequently in exposed root surfaces (root caries). It is thought to be due to gingival recession (receding gums) exposing dentine which covers the root surface. Dentine is less resistant to caries than enamel, and together with poor oral hygiene and a soft diet create ideal conditions for root caries, the characteristic pattern of dental caries in older people.

Changes in structure with age make teeth more brittle. This increases the risk of fracture, particularly during extraction. Deposits of cementum around the roots may create complications for extractions and these are important considerations in planning dental treatment.

Bone Age changes in bone affect the maxilla, mandible and other facial bones. Increased porosity and bone resorption follow tooth loss which leads to a greater potential for fracture. The cortical (surface) bone becomes thinner and in many older people, loss of bony ridges to support and stabilise a denture leads to difficulty in wearing dentures, particularly in the lower jaw.

Bone previously affected by periodontal disease is resorbed more quickly. Loss of function and wearing dentures that are entirely supported by soft tissue rather than by teeth can also contribute to increased bone loss. The changes described predispose to fracture and delayed healing, which have implications for dental treatment, leading to greater difficulty in construction of stable dentures.

Oral tissues Mucous membranes generally atrophy with age. The rate at which this occurs in the mouth depends on diet, habits, denture wear and oral hygiene. The epithelium covering the cheeks and lips tends to become more keratinised, while the palate becomes less keratinised. Thinner oral mucosa is more easily damaged and penetrated by food substances and medication which may give rise to an itching or burning sensation.

99

Saliva and salivary glands There is a considerable body of evidence to demonstrate the impact of salivary flow on oral health; with a lower flow rate the composition of saliva appears to have fewer protective properties. Changes in structure of the salivary glands are recorded and medication and salivary gland disease may reduce salivary flow, leading to dry mouth (xerostomia). Age and medication are significant risk factors for xerostomia but medication is a better predictor of risk status than age. The onset of xerostomia is associated with an increase in other oral symptoms, and problems with eating, communication and social interaction. Thinner oral mucosa and a reduction in saliva can lead to serious problems that have an impact on an individual’s quality of life.

Oral status In 1968, 63% of the adult UK population were dentate, whereas the 2009 Adult Dental Health Survey reported that 92% of all adults had some natural teeth. If the trend continues it is predicted that by 2028, the percentage with some natural teeth will rise to 96%. A small but varied group of people will continue to become edentulous (no natural teeth). Many older people are edentulous but the numbers are gradually declining; this is notable among younger age groups who are themselves approaching retirement age.

If the trend continues, future generations of older people will be more likely to retain some natural teeth. Many of the ‘young-old’ who retain their natural teeth have more positive attitudes to oral health and it is likely that their expectations of dental health will be greater. In planning dental services for future generations of an ageing population, it is anticipated that fewer complete dentures will be needed, but more partial dentures, fillings, crowns, and treatment for periodontal disease.

Most surveys of oral health in older people demonstrate a high need for treatment.

Surveys carried out in residential or sheltered accommodation, on patients in hospital continuing care and on specific community populations of frail or functionally dependent older people produce fairly consistent results that treatment needs include:

• Lack of dentures

• Loose dentures

• Ill fitting dentures

• Denture related pathology

• Improved standards of oral hygiene.

• Ulcers 100

• Dental caries

• Periodontal disease

• Extractions.

Amongst the frail or functionally dependent, it is general agreed that poor standards of oral hygiene and lack of access to professional oral health care contribute to high level of need. This is cause for serious concern as under-reporting of oral problems is common in older people.

Research paints a depressing picture of the outcome of poor standards of oral health care in residential accommodation. In a sample of 412 residents in 22 nursing homes:

• Over 70% had not seen a dentist in the previous 5 years

• 22% experienced some form of oral pain or discomfort requiring treatment, yet

a dental examination had not been arranged

• 82% of denture wearers were unable to clean their dentures

• 33% had denture related pathology generally associated with poor denture

hygiene and night denture wear

• 95% of dentures were considered to be un-hygienic

• 75% of dentate were unable to brush their teeth, yet none received regular

assistance

• Very high levels of plaque deposits and moderate gingivitis were recorded in

the dentate

• 63% had root caries and 82% had deposits of calculus.

These problems are fairly consistent with those reported in other surveys.

Most residents required help with oral health care but many did not receive it. Levels of plaque and associated disease were high because staff did not deliver effective oral health care appropriate to residents’ needs and this in an environment where complete personal care of residents is assumed and expected.

Dental services that are tailored to the needs and wants of the individual must address these barriers. Identifying frail and dependent individuals can only be achieved by an outreach approach in liaison with health, social care and voluntary agencies who provide care and support for older people. By providing information on the oral health needs of older people, the availability of appropriate dental services and the principles and practice of good oral care, primary health care professionals will be better equipped to identify problems, provide appropriate oral care and access dental services.

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Chapter 13 Decontamination of instruments – an overview

The Department of Health’s document, Decontamination Health Technical Memorandum 01-05: Decontamination in primary care dental practices, often better known by its shorthand name HMM 01-05 gives the guiding principles and details of the requirements for cross-infection control in dental practices. Here we review Section 2 of the document which gives advice to dentists and practice staff on the decontamination of instruments.

2.1

Decontamination is the process by which reusable items are rendered safe

for further use and for staff to handle. Decontamination is required to

minimise the risk of cross-infection between patients and between patients

and staff.

2.2

Decontamination of instruments (also known as reprocessing) is a complex

process that involves several stages, including cleaning, disinfection,

inspection and a sterilization step.

2.3

Instruments should be reprocessed using a validated decontamination

process including a validated steam sterilizer, and at the end of the

reprocessing cycle they should be sterilized.

2.4

In maintaining and developing dental decontamination practices, all the

following should be included:

a. A local infection control policy subject to update as required by the Code

of Practice or at two yearly intervals, whichever is the shortest.

b. The above policy should have detailed requirements/procedures for the

decontamination of instruments.

c. The practice should have a nominated lead member of staff responsible

for infection control and decontamination.

d. The storage, preparation and use of materials should take full account

of the requirements of the Control of Substances Hazardous to Health

(COSHH) Regulations 2002. Particular care should be taken in the storage

and preparation for use of decontamination chemical products.

Manufacturers’ instruction sheets should be consulted for further 102

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information. Guidance on COSHH is available from the Health & Safety

Executive (http://www.hse.gov. uk/coshh).

e. Practices should have a clear procedure for ensuring appropriate

management of single-use and reusable instruments, which safeguards

their status.

f. Reprocessing of dental instruments should be undertaken using

dedicated equipment.

g. Dedicated hand-washing facilities should be provided.

h. Cleaning and inspection are key parts of satisfactory dental instrument

reprocessing. Instruments may be cleaned using an ultrasonic bath, but

this should be covered during use to restrict the release of aerosols.

Manual cleaning may also be used. Practices should plan for the

introduction of washer-disinfectors. Inspection processes should

ensure that the standards of cleaning achieved are visually satisfactory

– that is, that instruments are free from particulate contamination, salt

deposits or marked discoloration. The use of a simple magnifying

device with task lighting is required.

j. The separation of instrument reprocessing procedures from other

activities, including clinical work, should be maintained by physical

or temporal means. Decontamination equipment including sterilizers

should accordingly be located in a designated area. The layout within

this area should reflect the progression from the receipt of dirty,

used instruments towards clean instruments sterilized in a specific

controlled clean area. In the first instance, where practices are meeting

the essential quality requirements defined by this guidance, the

designated area for decontamination may be in, or adjacent to, a

clinical room. At a later stage of development, more complete

separation involving the use of a designated room or rooms will

become appropriate.

k. Instrument storage and wrapping recommendations:

i) Wrapped instruments may be stored up to 1 year

• pre-sterilization wrapped if type B or S;

• post-sterilization wrapped if type N.

ii) Unwrapped instruments in the clinical area: maximum storage 1 day.

104

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Instruments should be: dry and protected from contamination, for

example in mini-racks placed in cupboards or in covered drawer

inserts.

Instruments should not be stored on open work surfaces, particularly

in clinical areas. It is important that practices have well developed

protocols and procedures in place to prevent contamination of

these instruments by ensuring that those required for a particular

patient are removed from their protected environment before

treatment commences. This eliminates the need to open cupboard

doors or drawers during patient treatment. If an instrument does

need to be retrieved from a cupboard or drawer during treatment,

the practice should have protocols in place to prevent

contamination and to ensure that staff hands are clean and that

new gloves are donned before handling unwrapped sterilized

instruments. Regard all instruments set out for each patient as

contaminated after the treatment whether or not they have been

used. Instruments that are kept unwrapped should be reprocessed at

the end of the working day, regardless of whether they have been

used. Alternatively, instruments can be reprocessed at the beginning

of the next working day.

iii) Unwrapped instruments in a non-clinical area: maximum storage 1

week. Non-clinical area in this context is designated as a clinical

area not in current use or in a clean area of a separate

decontamination room. Instruments should still be stored as follows:

dry; and protected from contamination, for example in mini-racks

placed in cupboards, or in covered drawer inserts. Instruments should

not be placed on open work surfaces.

m. Develop a quality system approach so that the storage of wrapped

instruments does not exceed one year.

n. Equipment used to decontaminate dental instruments should be fit

for purpose and validated. This means that the device should be

commissioned, maintained and periodically tested by a Competent

Person (Decontamination) or service engineer, that records of

maintenance should be kept and that correct functioning should be

monitored and recorded.

p. The appropriate and controlled disposal of waste is a key aspect of risk

control in local dental practices.

106

q. A documented training protocol should be in operation with individual

training records for all staff engaged in decontamination.

r. The practice should carry out an assessment of the changes needed to

move from compliance with essential quality requirements to compliance

with best practice requirements.

s. Staff involved in decontamination should demonstrate current

immunisation for hepatitis B and, subject to local policy, tetanus. Staff must

be informed of the benefits (e.g. protection against serious illness,

protection against spreading illness) and drawbacks (e.g. reactions to the

vaccine) of vaccination. Note Vaccination is considered additional to,

and not a substitute for, other control measures.

t. The effective cleaning of handpieces in accordance with manufacturers’

guidance. Dedicated cleaning equipment is available and may be of

value. However, validation in this area is difficult, and the advice of

manufacturers/suppliers should be sought.

u. Separate wash-hand basins for use by staff conducting decontamination

should be provided.

v. Washing and rinsing of instruments can be achieved by: either two

dedicated sinks with a separate or shared water supply or one sink with a

removable bowl, which can be contained within the sink that can

accommodate the instruments for rinsing. This is the least preferred

option as it requires lifting and moving bowls of contaminated water with

associated spillage risks. The practice should have clear processes and

protocols in place to ensure that the removable bowl is not used for the

washing of instruments. These sinks should not be used for hand-washing.

2.5

This guidance is primarily focused on medical devices and instruments

used in dentistry. However, local policies must be broad-based and consider

a comprehensive view of hygiene and cleanliness across all aspects of

dental practice and associated facilities.

2.6

All dental practices should have an infection control policy together with

guidelines and procedures that contain the following information:

• A written policy with regard to minimising the risk of blood-borne virus

transmission, with particular attention to the possibility of sharps injuries.

The policy should include arrangements for an occupational health

107

examination of all staff thought to be at risk of hepatitis B. (This is related to

risk reduction in blood-borne virus transmission and general infection.)

Confidential records of all such examinations should be maintained. In

addition, a record of all sharps injuries must be maintained in accordance

with current health and safety legislation. Further detail can be found in

the Green Book (http://immunisation. dh.gov.uk/category/the-green-

book)

• A policy on decontamination and storage of dental instruments

(decontamination guidelines)

• Procedures for cleaning, disinfection and sterilization of dental instruments.

This should outline the approach used locally in sufficient detail as to allow

the ready identification of areas and equipment used

• A policy for the management and disposal of clinical waste (waste

disposal policy) (for further details see Health Technical Memorandum

0701)

• A policy for hand hygiene

• A policy for decontamination of new reusable instruments

• Local policies and procedures for the use of personal protective

equipment (PPE)

• Procedures for the management of dental instruments and associated

equipment in the context of infection control

• The recommended disinfectants to be used within the practice, their

application, storage and disposal (disinfectant guidelines)

• Spillage procedure as part of local COSHH arrangements

• Local policies and procedures for environmental cleaning and

maintenance. This should include, at a minimum, the methods used, the

frequency of each procedure and appropriate recordkeeping practices.

2.7

Dental practices may consult with local infection control specialist advisers in

order to obtain support in the writing of local policies, within the framework

provided here, and the design of local procedures together with guidance

implementation planning which gives general guidance on cleaning and

disinfection protocols within the practice).

108

2.8

The object of the measures outlined below is to reduce the risk of cross-

contamination between instruments.

Movement of instruments to and from adjacent decontamination areas 2.9

The practice should have safe procedures for the transfer of contaminated

items from the treatment to the decontamination area.

2.10

Sterilized instruments and single-use instruments should be clearly separated

from those that have been used and are awaiting decontamination.

2.11

A separate sterilized instrument tray should be used for each patient. These

trays should be of a suitable size to enable them to be placed in the sterilizer.

Alternatively, single-use instrument trays may be used, provided these have

been stored in a clean and dry environment.

2.12

Instruments for decontamination should be transferred as soon as possible

after use to the decontamination area in order to avoid the risk of drying.

Prompt decontamination is appropriate. Potable water immersion or the

use of commercial gels/sprays may be considered if a delay in reprocessing

is unavoidable.

Segregating instruments 2.13

Prior to cleaning, reusable instruments to be cleaned should be segregated

from items for disposal.

2.14

A single-use device should only be used during a single treatment episode

and then disposed of. It is not intended to be reprocessed and used again –

even on the same patient at a later session.

2.15

The re-use of a single-use device has implications under the Medical Devices

Regulations. Anyone who reprocesses or re-uses a device CE-marked for use

on a single occasion bears the responsibilities normally carried by the

manufacturer for the safety and effectiveness of the instrument.

2.16

There is a symbol that identifies single use items. This will appear on

packaging but might not be present on individual items. If in doubt, further

advice should be sought from the manufacturer.

2.17

Where instruments are difficult to clean, consideration should be given to

replacing them with single-use instruments where possible. In dentistry this

will include, but is not limited to, instruments such as matrix bands, saliva

ejectors, aspirator tips and three-in-one tips.

109

2.18

Where endodontic reamers and files are designated reusable, they should

be treated as single patient use or single use – regardless of the

manufacturer’s designation – to reduce the risk of prion transmission.

Practices must have effective procedures in place to exclude errors in

identifying the instrument(s) and associating them with the correct patient.

2.19

Care needs to be exercised in the cleaning of reusable endodontic

reamers and files. Where automated washer–disinfectors are used, the

risk of cross-contamination to other instruments would be very low, in view of

the dilution factors. These instruments do not need to be processed on a

separate cycle. However, owing to the variability in dilution during manual

washing, the files/reamers should be washed separately from other

instruments.

Quality assurance system and audit 2.20

Dental practices are required to establish and operate a quality assurance

system that covers the use of effective measures of decontamination

and infection control. This may best be demonstrated by undertaking audits

and assessments of their infection control and decontamination practices.

These audits should be filed for inspection as part of their risk management

system.

2.21

Compliance with this Health Technical Memorandum will be seen as

indicative of the presence of valid quality assurance systems. At a minimum,

practices should audit their decontamination processes every six months,

with an appropriate review dependent on audit outcomes. Note The

Infection Prevention Society/DH audit tool parallels the guidance provided

in this document. In addition, a number of other safety-related topics are

included in the tool.

2.22

It is important that the audits are made available to regulatory bodies for

inspection when required.

2.23

Audit documents should be stored for at least two years. They should not be

removed from the premises or destroyed. Taking instruments to other

locations 2.24

The practice should have safe procedures for the transfer of contaminated

items from the treatment area to the decontamination facility.

2.25

Transport containers should be such as to protect both the product during

transit and the handler from inadvertent contamination, and therefore

110

should be: • Leak-proof • Easy to clean

• Rigid, to contain instruments, preventing them becoming a sharps hazard

to anyone handling the goods and to protect them against accidental

damage

• Capable of being closed securely

• Robust enough to prevent instruments being damaged in transit.

2.26

Containers for transport of instruments for decontamination and of sterilized

instruments should be clearly marked as for each function and should not be

used interchangeably 2.27

Containers for transporting instruments for decontamination should be kept

visibly clean. When transporting sterilized instruments, to avoid

recontamination it is preferable that they are wrapped or separated from

direct contact with their container on a tray that itself has been sterilized.

If this is not feasible, sterilized instruments may be transported in a container

that has been disinfected with a single-use disinfectant wipe and allowed to

dry, but chemical disinfection is a lower quality assurance process than

sterilization 2.28

Where contaminated instruments are to be transported outside of the

healthcare premises on a public highway, those responsible for such

transportation should refer to the requirements of the Carriage of Dangerous

Goods and Use of Transportable Pressure Equipment Regulations 2007 and

the Health and Safety at Work etc Act 1974.

2.29

A protocol for transportation that ensures the segregation of contaminated

product from clean/ sterilized instruments should be followed.

2.30

Contaminated instruments will be regarded as low biohazard materials and

must be part of a noted consignment. This means recording details of the

group of items transported (that is, dental instruments), the time of dispatch

and the intended recipient. Records should be such as to allow each

movement to be traced and audited if necessary. The note should be

positioned prominently within any vehicle used for transportation and should

carry a contact telephone number.

2.31

Where instruments travel in a vehicle with a dentist or other expert person,

record-keeping may be simplified to cover the date and vehicle used only.

This rule is applicable to, for example, school and domiciliary visits.

111

Chapter 14 Peri-implantitis: a condition of our time

In scientific and clinical circles, it is somewhat reassuring to be able to say which came first in a particular circumstance, unlike with the chicken and the egg. Periimplantitis would not be possible without implants but does that evidence help us with prevention or treatment?

While it may be possible to feel smug in the knowledge that peri-implantitis only occurs in the presence of implants, the comfortable feeling wears off very quickly when one asks the questions, why does it happen and how do we treat it when it does?

It is defined as an infectious disease that causes an inflammatory process in the soft and hard tissues surrounding an osseointegrated implant, leading to the loss of supporting bone. The growth in recent decades of the number of dental implants being placed has been astounding and so it is probably not surprising that there has also been an increase in peri-implantitis. With the advent of the use of titanium as a material of choice and its demonstrably effective characteristic of promoting osseointegration the ground was prepared for a true revolution in clinicians’ ability to treat tooth loss and re-establish function and aesthetics. Despite the plethora of types of implants, estimates put this in excess of 1,300, and the variety of study and research methods, the overall success rates remain high, often well above 90%, which is enviable for any procedure. Those with a pessimistic outlook continue to err on the side of caution, warning that we still do not have enough long-term evidence to be sure, whereas those patients who have enjoyed the undoubted benefits of the appliances for many years seem more quietly convinced.

Risk factors There are a variety of risk factors that have to be considered before the placement of implants and which can influence the subsequent development of peri-implantitis.

These include:

• Poor oral hygiene

• Tobacco use

• A history of periodontitis and noncompliance to treatment

112

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• Systemic conditions that are not adequately treated or controlled such as

diabetes mellitus and osteoporosis

• Post-irradiated jaws

• Parafunctional habits such as bruxism

• Iatrogenic factors; e.g. insufficient primary stability and premature loading

during the healing period.

In addition to these specific factors overall important considerations that determine success are careful patient selection and implant placement (position, number and surgical competence).

Signs and symptoms As with other oral conditions, patients may not notice signs or complain of symptoms until a disease process is well established, periodontitis being an obvious example.

So regular checks are required for implant patients, the frequency being dictated by the individual and some of the risk factors above. Signs that may become apparent include:

• Increase in probing depth over progressive review appointments

• Bleeding on probing and poor oral hygiene

• Presence of inflamed tissue evidenced as swelling, bleeding, colour change,

plaque/calculus accumulation

• Suppuration and exudation from peri-implant space

• Continued loss of supporting bone on follow-up radiographs

• Loss of 0.2 mm annually of supporting bone once the anticipated physiological

alveolar remodeling has taken place.

While some of these signs will be non-symptomatic, the patient may complain of some or any of the following:

• Dull aches or tenderness when brushing or on palpation

• Occasional pain from the area

• A bad taste/bad breath: possibly when exudates are present

• Increasing mobility (in cases of a failed implant)

• Swelling in the facial/oral area, e.g. due to lymphadenopathy.

114

Parallels with periodontitis It is not surprising that peri-implantitis and periodontitis are mediated by similar organisms and processes, given that the anatomy and physiology of the implant surfaces and tissue environment are so similar and that the microcosm thus created is so comparable. So, does a history of periodontal disease predispose a patient to a greater risk of peri-implantitis? Research suggests that this is not the case, the more important factor being on-going good oral hygiene and effective plaque control rather than a history of periodontal pocketing, as a recent study has reinforced1.

This observation finds support too from a different angle in Cochrane Collaboration studies2,3. These have indicated that despite the huge range of available implants alluded to above, and despite their variety of smooth and roughened surface properties (much played upon in the rivalry of competing manufacturers) there is no evidence to date that one pattern has an overall superiority to any other. This contrasts with Cochrane conclusions in other areas where the superiority of powertoothbrushes in plaque removal might well be of particular value in the prevention of peri-implantitis4.

Investigations Given that implant treatment is time consuming, technically challenging and expensive patients are naturally concerned when it is suspected that all is not well.

Investigations therefore need to be fully explained to the patient as well as possible outcomes. This needs to be done with care and sensitivity.

Although covered in the original examination and assessment, verify whether iatrogenic factors have changed such as faulty restorations or impacted foreign material. Assess too whether biomechanical forces are in balance by evaluating the occlusion for the presence of parafunction or occlusal overload. There may be mobility and if so removal of the restoration such as a crown may be necessary to establish if it fractured or if the implant itself is fractured.

Checking for active periodontitis in other sites is routine but has this occurred or reoccurred since the previous review? Are there other pathologies of the bone? In some cases it may be necessary to perform exploratory surgery. The only differential diagnosis is for peri-implant mucositis.

115

Treatment options In the event that peri-implantitis is diagnosed, there are several treatment choices available, although again as Cochrane indicates3 there is no clear gold-standard in terms of positive outcome for any of these to date. As with the treatment of periodontal disease, the steps are first to try and reduce the adverse microbial load in plaque, followed by more radical surgical intervention. Culturing of the plaque and antibiotic therapy can prove effective but continuing good oral hygiene by the patient is also seen as crucial. Resective treatment to reduce pocket depth and enable improved patient access is the initial surgical response but finally, removal of the implant may be the only solution to the continuing bone loss; albeit the one that neither patient nor clinician desire.

The long-term goals are to stop the progression of the disease and maintain the implant site. Depending on the aetiology of the problem, a specific treatment is selected. Appropriate management of peri-implantitis often requires referral to a periodontist.

Any acute bacterial infection should be controlled to reduce tissue inflammation through mechanical debridement, localised and/or systemic antimicrobial therapy and most importantly improved patient compliance with oral hygiene until a healthy peri-implant site is established.

At re-evaluation, if the patient does not have a satisfactory response to the nonsurgical therapy, surgery should be considered. Detoxifying the implant surface can be undertaken using mechanical devices (e.g., high pressure air powder abrasive, laser decontamination) and/or by applying chemotherapeutic agents (e.g., supersaturated citric acid or tetracycline applied with cotton pellets or a brush). In terms of periodontal surgical approaches, flap management can be performed with either (or both) resective and regenerative approaches, depending on the morphology and size of the bone destruction5.

However, just as in any other clinical field of decision making, the treatment provided depends as much on professional culture and attitude as on the condition itself. A study recently published, for example, indicated differences of attitude between periodontists in the UK and Australia in terms of aetiology, prevalence, diagnosis and management of peri-implantitis6. Most specialists in both countries identified the prevalence of peri-implant pathology at between 0-25% but although there was agreement as to the role of plaque in the pathogenesis of the diseases, UK specialists were more likely to include adverse loading and smoking as aetiological factors.

116

The summary is tediously familiar. In spite of our advances in technical ability and scientific knowledge one universal truth still holds good; prevention is better than cure and optimal plaque control reigns supreme. Chicken, egg or micro-organism?

References

1. Cho-Yan Lee J et al. Residual periodontal pockets are a risk indicator for peri-

implantitis in patients treated for periodontitis. Clin Oral ImplantsRes 2012; 23:

325-333.

2. Esposito M et al. Interventions for replacing missing teeth: different types of

dental implants. Cochrane Database of Systematic Rev 2007, Issue 4. Art. No.:

CD003815.

3. Esposito M et al. Interventions for replacing missing teeth: treatment of peri-

implantitis. Cochrane Database Syst Rev 2010; (6): CD004970, 2012.

4. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington

HV, Glenny AM, Shaw WC. Manual versus powered toothbrushing for oral

health. Cochrane Database Syst Rev 2005; Apr 18; (2): CD002281.

5. Hsu A and Kim. How to manage a patient with peri-implantitis. J Can Dent

Assoc 2014; 79: e24.

6. Mattheos N, Collier S, Walmsley AD. Specialists’ management decisions and

attitudes towards mucositis and peri-implantitis. Br Dent J 2012; 212: E1 (2012).

Published online: 13 January 2012 | doi:10.1038/sj.bdj.2012.1

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Chapter 15 Minimally invasive operative caries management A. Banerjee, Professor of Cariology & Operative Dentistry, King’s College London Dental Institute, London

When patients present with cavities causing pain, poor aesthetics and/or functional problems restorations will need to be placed. Minimally invasive caries excavation strategies can be deployed depending on the patient’s caries risk, lesion-pulp proximity and vitality, the extent of remaining supra-gingival tooth structure and clinical factors (for example, moisture control, access). Excavation instruments, including burs/handpieces, hand excavators, chemo-mechanical agents and/or airabrasives which limit caries removal selectively to the more superficial caries-infected dentine and partial removal of caries-affected dentine when required, help create smaller cavities with healthy enamel/dentine margins. Using adhesive restorative materials the operator can, if handling with care, optimise the histological substrate coupled with the applied chemistry of the material so helping to form a durable peripheral seal and bond to aid retention of the restoration as well as arresting the carious process within the remaining tooth structure. Achieving a smooth toothrestoration interface clinically to aid the cooperative, motivated patient in biofilm removal is an essential pre-requisite to prevent further secondary caries.

Introduction The term MI dentistry or ‘MID’ has been used for many years with several meanings in the dental literature. Minimum(al) intervention dentistry is the holistic patient care philosophy that encompasses the complete patient-dentist team-care approach to managing dental disease by identification and diagnosis (including caries risk assessment), prevention and control, restoration and recall, so educating and empowering the patient to take responsibility for their personal oral health. Minimally Invasive Dentistry describes contemporary ultraconservative operative management of cavitated lesions requiring surgical intervention. It does not mean unduly early operative intervention of incipient lesions, which in most cases is unnecessary as more effective and appropriate non-invasive preventive approaches exist.

‘Golden triangle’ of MID A thorough understanding and appreciation of the interplay between three critical factors is required to achieve success clinically when using a minimally invasive operative caries management strategy (MI OCMS):

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• The histology of the dental substrate being treated

• The chemistry/handling of the adhesive materials used to restore the cavity

• Consideration of the practical operative techniques available to excavate

caries minimally.

Appreciation of these factors will enable the dental practitioner to embrace the contemporary oral physician’s biological approach to operative caries management as opposed to the surgeon’s mechanistic efforts of preparing cavities of a pre-determined shape, governed primarily by the properties of the chosen restorative material as opposed to the actual histopathology of the disease process and retention of tooth substance.

Clinical factors Practical considerations in restoration placement must play a part in deciding whether MI is a feasible option for particular individuals. These may include:

• Suitable access for instrumentation

• Ability to control moisture levels (ideally with rubber dam isolation)

• Appreciation of the final position of the cavity-restoration margin (supra- or

subgingival)

• Appropriate handling of adhesive restorative materials by the dental team (for

example, ensuring that dentine bonding agent bottle lids are replaced

promptly after dispensing to ensure minimal evaporation of any solvent carrier;

appropriate ratios of powder: liquid mixed when required etc).

Prospective long-term randomised controlled clinical trials have assessed the validity and efficacy of minimally invasive caries removal with or without indirect pulp capping in terms of restoration longevity and pulp status. Systematic analysis of the results has concluded that as long as there is a suitable patient-dentist team-care approach to maintaining oral health, adhesive sealed restorations placed in ultraconservative cavity preparations can last well in the functioning oral cavity. The issue of pulp capping using a separate ‘lining or ‘base’ material has been reviewed in the literature. In modern day MI OCMS, using adhesive restorative materials, the clinical need of a separate layer of pulp protection has been shown to be unnecessary (apart from the scenario where the pulp may be protected with a thin layer of glass ionomer cement beneath a large amalgam restoration with close pulp proximity).

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Minimally invasive operative techniques There are several clinical technologies available for cutting teeth and removing caries. Most are not self-selective for caries-infected dentine and involve active discriminatory action from the operator when considering MI OCMS. Dentists are highly trained at using dental burs in slow speed or air turbine handpieces as well as hand excavators, and although not self discriminatory in favour of cariesinfected dentine, a good operator can still practice MI OCMS effectively using these instruments as illustrated in Figures 1 –6.

Figure 1: Cavitated occlusal lesion 17 with demineralised, unsupported peripheral enamel and visible caries-infected dentine.

Symptoms were those of an early reversible pulpitis and the pulp was vital to electric pulp testing and ethyl chloride Figure 2: Radiograph of 17 showing demineralisation extending into the inner third of dentine towards the pulp.

]

The pulp chamber is clearly visible with a potential bridge of dentine between it and the advancing lesion. There is no proximal cavitation

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Figure 3: The peripheral unsupported enamel has been removed using a long tapered diamond bur in a high speed air turbine handpiece and the sound margins lightly bevelled

Figure 4: The dentine at the periphery has been initially excavated to a depth of caries-affected dentine but flakes of very soft infected dentine remain over the pulpal aspect of the cavity

Figure 5: The dentine adjacent to the enamel-dentine junction is both scratchy and slightly sticky to a dental probe, indicating it is affected histologically.

The peripheral enamel margin is sound histologically

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Figure 6: The final resin composite restoration has been placed and finished to reduce plaque biofilm adherence in the oral cavity

Ultrasonic and sonic instrumentation use the principle of probe tip oscillation and micro-cavitation to chip away hard dental tissues. Lasers transfer high energy into the tooth through water causing photo-ablation of hard tissues. Great control is required by the operator in order to harness this energy effectively and the effects on the remaining enamel, dentine and pulp continue to be investigated in terms of residual strength and bonding capabilities. A recent systematic review concluded that laser caries removal is not yet a viable general dental practice option for effective caries excavation. Enzymatic (including hypochlorite-, pepsin- and papain-based) solutions have and are being investigated to help further breakdown of collagen in already softened carious dentine in the hope of developing a more self-limiting technique of removing caries-infected dentine alone. Other chemical methods include photoactivated disinfection (PAD) where tolonium chloride is introduced into the cavity, absorbed by the residual bacteria in the cavity walls and then activated using light of a specific wavelength causing cell lysis, death and ozone (gaseous ozone infused into early lesions causing bacterial death). These technologies currently suffer from a paucity of clinical evidence to validate them for routine clinical use.

Air-abrasion Air-abrasion is a 68-year-old dental operative technique used for the removal of enamel and dentine during cavity preparation. Air abrasion units are capable of minimally invasive tooth preparation using 27 Îźm aluminium oxide (Îą-alumina).

However, dentists are used to the parameters of tactile feedback and an appreciation of finite cutting depth when using rotary tooth-cutting techniques, both of which the end-cutting alumina air abrasive jet lacks. This makes the use of alumina air abrasion highly operator-sensitive and requires careful education of clinicians to realise its potential for minimally invasive preparation and the prevention of cavity

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over-preparation. Studies have been published that characterise the efficacy of alumina air-abrasion and its cutting characteristics on both sound and carious enamel and dentine and collectively these show the technique to be efficient if specific operating parameters (for example, air pressure, powder flow rate and reservoir volume, nozzle diameter and working distance) are regulated judiciously by the operator. Clinical studies have indicated good patient acceptance of the technology in terms of the lack of vibration, no heat generation and the reduced need for local analgesia.

An important clinical use of air-abrasion is obtaining suitable enamel access in minimally invasive preventive resin restorations. Meticulous cleaning of the occlusal surface before visual examination using a rotary brush or air-polishing is essential for caries detection, followed by the use of a small head dental bur or alumina airabrasion for the removal of the carious, demineralised enamel. The microscopically roughened enamel surface created by alumina air-abrasion is devoid of weakened prisms and is therefore better adapted for adhesive bonding. However, lack of substrate selectivity and no self-limiting operator feedback when using these operative technologies can result in cavity over-preparation. Innovation in abrasive powder development has resulted in the production of a commercially available bio-active glass powder capable of removing extrinsic dental stain, desensitising exposed dentine and exhibiting an intrinsic selectivity towards carious, demineralised enamel and resin composite restorations. Research is ongoing into development of a self-selective air-abrasive powder for caries-infected dentine.

Chemo-mechanical caries removal After the development and subsequent demise of the Caridex™ system in the 1970s, chemo-mechanical caries removal techniques were resurgent with the commercialisation of Carisolv™ gel in the late 1990s. This hypochlorite/amino acidbased gel system assists the MI OCMS with special non-cutting hand instruments offering greater tactile sensitivity to the operator, thus permitting selective infected and affected dentine removal. Studies indicated good patient acceptance of this technique. An example of MI caries excavation using Carisolv™ gel is given in Figures 7-10. Developments in chemo-mechanical technology include the laboratory development of pepsin-based gels using specially designed nylon brushes and plastic disposable hand instruments to abrade the softened infected dentine as well as papain-based systems.

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Figure 7: Cavitated occlusal caries with soft infected dentine evident

Figure 8: Initially clear, slightly viscous Carisolv™ gel introduced into the cavity using the mace-tip hand instrument and left for 40 seconds before excavation

Figure 9: This process is continued until the gel has a muddy consistency when it is washed out of the cavity and the relative hardness of the remaining cavity walls tested using a sharp dental explorer

Figure 10: MI prepared cavity with affected dentine retained over the pulpal aspect of the cavity.

The peripheral margins in the case have purposely been excavated to histologically sound dentine to aid the restorative peripheral seal 124

Conclusions The evidence for the minimally invasive operative caries removal strategy in appropriately selected patients exists. The removal of grossly softened caries-infected dentine is recommended in most situations (except perhaps in a deep lesion overlying the pulp where its vitality assessment leans towards an acute inflammatory response and an adequate clinical seal can be achieved at the periphery of the cavity). Peripheral caries removal should extend to sound dentine where inadequate quantity and quality of enamel remains. It is at this tooth-restoration interface that the peripheral seal is critical to prevent further histopathological progress of the disease. The seal can be achieved using adhesive dental biomaterials that penetrate micro-/nano-mechanically to the mineral and collagenous components of enamel and dentine respectively. With judicious use of contemporary adhesives with their bacteriocidal/static properties, there is little need clinically for a separate lining/base layer to protect the pulp. A thorough understanding of the chemistry of the materials and how they relate to the histology of the tissues is necessary to ensure the best prognosis of a sealed, adhesive restoration.

Acknowledgements Figures 1–6 have been reproduced with publisher’s permission from Banerjee A. A large carious lesion. In Odell E W (ed) Clinical problem solving in dentistry. 3rd ed. pp 43–48. Edinburgh: Churchill Livingstone, 2010.

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Chapter 16 Antibiotics; past, present and future

Antibiotics are so familiar to us now that the thought of having to live without them is a very difficult one to contemplate. However, with increasing antibiotic resistance being shown by a variety of bacterial species it is a thought we have to treat seriously.

A century of use The antibacterial chemotherapy era began with the discovery of arsphenamine which was first synthesised by Alfred Bertheim and Paul Ehrlich in 1907 and used to treat syphilis. The first systemically active antibiotic, prontosil, was discovered in 1933 by Gerhard Domagk, for which he was awarded the 1939 Nobel Prize. Since the first pioneering efforts of Florey and Chain in the same year, the importance of antibiotics, including antibacterials, to medicine has led to intense research into producing them on a large scale. Following screening against a wide range of bacteria, production of the active compounds is carried out using fermentation, usually in strongly aerobic conditions. With advances in medicinal chemistry, most modern antibacterials are semisynthetic modifications of various natural compounds.

The advance in antibiotic diversity and production has enabled medicine and surgery to develop to provide the modern techniques and standards with which we are so familiar. Without the suppression of infections many such procedures would have been impossible and the lurking fear is that they may once again become impossible if we cannot find either new antibiotics or alternative measures to quash infection.

Classification Antibacterial antibiotics are commonly classified based on their mechanism of action, chemical structure, or spectrum of activity. Most target bacterial functions or growth processes. Those that target the bacterial cell wall (penicillins and cephalosporins) or the cell membrane (polymyxins), or interfere with essential bacterial enzymes (rifamycins, lipiarmycins, quinolones, and sulfonamides) have bactericidal activities. Those that target protein synthesis (macrolides, lincosamides and tetracyclines) are usually bacteriostatic (with the exception of bactericidal aminoglycosides).

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Further categorisation is based on their target specificity. ‘Narrow-spectrum’ antibacterial antibiotics target specific types of bacteria, such as Gram-negative or Gram-positive bacteria, whereas broad-spectrum antibiotics affect a wide range of bacteria. Research and development in recent years has enabled the discovery of four new classes of antibacterial antibiotics that have been brought into clinical use: cyclic lipopeptides (such as daptomycin), glycylcyclines (such as tigecycline), oxazolidinones (such as linezolid), and lipiarmycins (such as fidaxomicin).

Resistance Although we think of the emergence of resistance of bacteria to antibiotics as a new phenomenon it reflects evolutionary processes that take place during antibiotic therapy and was demonstrated as early as 1943. Antibiotic treatment may cause the selection of bacterial strains with physiologically or genetically enhanced capacity to survive high doses of antibiotics. Under certain conditions, it may result in preferential growth of resistant bacteria, while growth of susceptible bacteria is inhibited by the drug. Antibiotics such as penicillin and erythromycin, which used to have a high efficacy against many bacterial species and strains, have become less effective, due to the increased resistance of many bacterial strains.

UK dentistry is estimated to account for between 6-9% of total antibiotic prescribing in this country with dentists selecting from a small range of oral agents which are found on the British National Formulary (BNF) list. Various studies suggest that a significant proportion of cases in which antibiotics are prescribed could be treated more appropriately by surgical intervention.

The urgency of addressing the situation has been emphasised by the World Health Organisation, European Commission and the UK Government and a ‘One Health’ approach is being promoted which recognises the intimate links between human and animal health and calls for concerted, international action on behalf of all stakeholders.

Antibiotics and daily practice But despite this awareness of the dangers of antibiotic overuse, figures suggest that around 10 million antibiotic prescriptions - out of the total of 42 million given each year - are inappropriate. Additionally, patients have been criticised for having an ‘addiction’ to them and doctors have been accused of being either too keen to prescribe them or too rapidly caving in to patient demand. An important part of the government’s programme is to now focus on patient education to try and explain when antibiotics are not the appropriate treatment.

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We can do more to ensure that we do not prescribe unnecessarily. In fact very few occasions arise in daily dental practice in which we need to reach for the metaphorical prescription pad. Generally, the vast majority of dental infections do not require the use of an antibiotic as treatment should focus on local surgical measures and provision of an analgesic, such as ibuprofen or paracetamol.

Dentoalveolar abscess The first line of action should be drainage, established and maintained either through the opening up of a root canal and/or incision of the soft tissues which is easily achieved when there is an intra-oral swelling. If a good flow of pus can be established then antibiotic therapy is not required in an otherwise healthy individual.

In the event that adequate drainage cannot be achieved, perhaps when an infection is spreading, or if the patient has a raised temperature then is it necessary to prescribe an antibiotic.

In the UK, amoxicillin is generally regarded as the antibiotic of choice in the treatment of an acute dentoalveolar abscess. Although erythromycin has been used as a classic alternative for patients hypersensitive to the penicillins, metronidazole is now often used due to the recognised importance of strict anaerobes in this condition.

Acute necrotising ulcerative gingivitis Thorough cleaning of the tissues affected by this this unpleasant and painful condition is best managed under local anaesthesia but, as above, there is no immediate need for antibiotics. Once again, if the condition is severe with systemic upset then metronidazole is the drug of choice, with amoxicillin being an alternative.

Pericoronitis The same principles apply in the first line of treatment for pericoronitis which should be surgical and consist of irrigation under the operculum preferably using chlorhexidine. If indicated, the opposing upper molar should be removed. Antibiotic therapy, consisting of either amoxicillin or metronidazole, should only be prescribed if the patient has trismus or a raised temperature.

Peri-implantitis The growing problem of peri-implantitis has been seen as a legitimate candidate for antibiotic therapy but the evidence suggests that this is not the case. Peri-impantitis responds to local mechanical and chemical reduction of the oral microflora immediately adjacent to the implant. Chlorhexidine irrigation has been shown to be beneficial and although the efficacy of systemic antimicrobial therapy has

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been investigated and needs further investigation the removal of organisms by conventional means seems to be the most successful course of action.

Prescribing an antibiotic When all else fails, generally a prescription should be for five days, although the patient should be instructed to take the medication for as short a time as possible, the concept of a ‘complete course’ being no longer regarded as good practice.

It is now considered that the longer an antibiotic is taken the greater the risk of developing bacterial resistance. Standard dosages, as outlined in the BNF, should be used for dental outpatients, although increased dosages may be used for severe infections where surgical drainage cannot be achieved.

It is a good principle to provide antibacterial therapy comprising a single agent only.

Antibiotics – the future?

The story of antibiotic resistance to date might be characterised as being a combination of complacency, misunderstanding and economic factors all of which have conspired to ensure that bacteria have had the opportunity to steal a march on the human race and defeat our hitherto cunning development and application of antimicrobials.

While media focus can be fickle in so many ways there is no doubt that their attention to the growing awareness of the rise in antibiotic resistance has helped public, professional and now political immediacy on this literally life threatening eventuality. Indeed it is calculated that currently in the order of 25,000 people die each year in Europe alone from infections resistant to antibiotics. So, what can we do about it and can we develop new antimicrobials to help us in the battle against bacterial mutations that create resistance?

The recent publication of NICE (National Institute of Clinical Excellence) guidelines (http://www.nice.org.uk/guidance/ng15) has helped to stimulate the debate on the sensible stewardship of this class of medicines. In essence the guidelines are aimed at health and social care practitioners (including dentists), organisations commissioning, providing or supporting the provision of care and people who are taking antimicrobials and their families and carers. The guidelines make recommendation on participation in antimicrobial stewardship programmes, antibiotic prescribing and introducing new antimicrobials.

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Barriers to development Factors surrounding the lack of development in recent decades include a reduction in the number of pharmaceutical companies due to take overs and mergers which have reduced the spur to competition and difficulties getting new antimicrobials through pre-clinical testing. But there are biological barriers too which mean that these agents are approximately five times less successful than other new drugs at successive stages of development. This is variously due to the mutability of the target, bacterial efflux mechanisms and the difficulty of reaching the appropriate body compartment of the host. Unfavourable costs also play a major part. It is estimated that it now costs £1.2billion over a 12 year period to bring a new drug successfully to market. However, the profitability of antibiotics is surprisingly weak due to their short courses, high dosages and low sale price. The consequence has been a dearth of investment in research.

Suggested methods of redressing this include the easing of regulatory burdens or the introduction of earlier licencing but with suitably heightened post-market surveillance. Other factors might be incentives such as tax breaks, research and development grants and patent extensions.

In the wider sense too stewardship is being promoted to improve awareness and education of health professionals and patients. European Antibiotic Awareness Day is now held every year on 18 November and includes joined up activities across government departments such as Health and DEFRA (Department for Environment, Food and Rural Affairs) since antibiotics are also widely used in animal husbandry.

Antibiotic guardians A further initiative is the setting up of a website (www.antibioticgaurdian.com) which encourages as many people as possible to sign up to increase public awareness of the immanent dangers of antibiotic resistance. Its three key messages are:

• Don’t ask for antibiotics. Treat your cold and flu symptoms with pharmacist

• Take antibiotics exactly as prescribed, never save them for later, never share

advice and over the counter medicines

them with others

• Spread the word, tell your friends and family about antibiotic resistance.

While these points do not specifically mention dentistry, given the influence of the media and of the universal availability of information on the internet it will become increasingly common for patients to question the need for antibiotics in any situation and ask whether alternatives are available. Which means that we too will have 130

pressure exerted to ensure that we undertake best practice in this field. Similarly, it is to be hoped that patient requests for antibiotics will also fall so that the insistence that toothache requires them will gradually, through education, become a thing of the past.

Will we all become things of the past as a result of these developments? The numbers are stacking up with over â‚Ź1.5billion spent each year EU wide for healthcare expenses and lost productivity due to antibiotic resistant bacteria. Not to mention the human cost. Part of all of us wishes not to consider a world without effective antibiotics. In which case an even bigger part in all of us needs to consider changing our habits in order to prevent the unthinkable.

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Chapter 17 Partial dentures – the story continues

Teeth may be lost by virtue of neglect, accident or via treatment planning; they may also be missing for congenital or acquired reasons. People with missing teeth may opt to have them restored, or not, largely because of sociological, functional or, in the case of non-restoration, for financial reasons.

How teeth are replaced largely depends on the level of (dental and technological) sophistication on offer. In eighteenth-century England, ivorine teeth ‘adorned’ the mouths of gentlemen but were removed at mealtimes; equally, there are records of Etruscan noblemen wearing bridges to replace lost teeth, the bridges being ‘fixed’ or ligatured in place by wires to the abutment teeth. At the turn of the twentieth century and for the next 50 years, dental technology developed as did options for replacement of lost or missing teeth. In the 1950s and 1960s, as dentistry and dental technology developed, so the list of treatment options increased.

Fixed prostheses became more predictable and more desirable. Where fixed replacement was contra-indicated, removable prostheses became more elaborate, with precision attachments being used to enhance stability and appearance by potentially eliminating clasps. This was truly the pinnacle of the mechanical age of prosthodontics.

In the late 1960s, the research work of Bowen and his team developed the use of adhesive techniques. The use of composite resins and glass-ionomer cements meant that silicophosphate cements became a thing of the past and that the minimally destructive (to tooth structure) techniques associated with adhesive dentistry resulted in potentially superior clinical outcomes allied to potentially superior aesthetic results.

If the next two decades were the beginning of the adhesive era in prosthodontics, then the decade from 1985 to 1995 must be seen as the beginning of the age of biological prosthodontics, in particular the dawn of the age of dental implantology based on evidence-based practice rather than clinical anecdote. As a result of sound clinical trials, the dentist’s quiver of treatment options has now been added to by the arrow of an implant option supporting either a fixed or removable prosthesis.

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The RPD option The option discussed in this article is that of the Removable Partial Denture (RPD) and it is perhaps appropriate that we consider the role of the RPD in the clinical climate of today. A rational overview might question the traditional classifications of RPDs which are either descriptive of the geography of the arches or the nature of support (Table 1).

In practical clinical terms, however, one might consider there to be three separate roles of RPDs, based on how they are to be used and/ or for how long they are used.

These are listed in Table 2.

Recent evidence confirms that the loss of teeth in partially dentate people affects their confidence in social mixing. However, it would appear that outcomes of treatment with RPDs are less well perceived by patients than those who receive fixed prostheses, when Oral Health-Related Quality of Life measurements are made.

The most recent Adult Dental Health Survey highlighted the effects of dental health education on levels of edentulousness in the UK population; in 1968, almost 40% of the adult population was edentulous; currently it is less than 8% and is predicted to fall in the future. In previous surveys, it was reported that the cut-off point for a ‘natural’ functioning occlusion was 20 or more teeth and this was an effective cut-off point for the wearing of RPDs. In addition to direct factors (namely comfort and psychological well-being) affecting patient choice of whether to wear a RPD or not, there are other indirect factors which must inevitably have an influence. These include the influences of the media and also normative influences. For example, clinicians were asked how they would restore missing posterior teeth, given set clinical circumstances relating to patients (e.g. case histories, radiographs and models). Where the scenarios comprised 20 healthy anterior teeth (10 in each arch), in healthy mouths, it was found that, in a fictitious patient aged 35 years, 31.5% of the clinicians would opt for treatment by fixed means and 3.9% by a cantilevered bridge. Similarly, it was found that, for a 65 year old patient and given treatment options of nothing, RPD, bridge or implants, dentists listed their preferences as: When the scenario was for a patient aged 65, the results were:

1) No restoration (63%)

2) Co-Cr - based RPD (25.2%)

3) Implant-supported prosthesis (7.1%)

4) Cantilevered bridge (3.9%)

5) Acrylic resin – based RPD 133

Compared to that for a 35 year old:

1) No restoration (49.6%)

2) Co-Cr - based denture (29.1%)

3) Implant-supported prosthesis (20.5%)

4) Cantilevered bridge (3.9%)

5) Acrylic resin - based RPD (2.4%).

One of the more favoured options listed above is no treatment. In cases of bilateral free-end saddles the philosophy of the shortened dental arch comes into play.

Essentially this works on the principle that middle-aged persons with 20 healthy units (i.e. 5-5 in each arch) are perceived to be able to masticate efficiently.

However, when patients were asked to view models of options for replacement of molar teeth, they listed their preferences as follows:

1) Cantilevered bridge

2) Cantilevered Resin-Retained Bridge

3) Implant-supported prosthesis

4) Acrylic resin-based RPD

5) Cobalt-chromium-based RPD

6) No treatment.

It is thus obvious that there will, for many years to come, be a need to select the treatment option of a RPD, for the reasons outlined in Table 2. To this must be added the fact that current undergraduate dental students are exposed to less clinical (prosthodontic) teaching than previously.

There will be a greater need, therefore, if patients are to receive appropriate treatment at an appropriate standard, for prosthodontic training to continue post qualification. This therefore underpins the importance that dental practitioners follow an accepted rationale of planning RPDs. The following is one such guideline: 1) Outline and classification of saddles The clinician should assess the position of saddles and also determine the clinical and patient related factors of the saddles, e.g. location, size, oral health, manual dexterity, perceived motivational aspects.

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2) Determination of the restoration of the saddles

Factors to consider here are:

• Conditions of all tissues adjacent to and in the saddles

• Conditions of remainder of mouth

• Inter-arch assessment, i.e. 3-D assessment

• Masticatory needs • Maintenance.

3) Determination of the nature of the support for the prosthesis

Philosophically, prostheses may be supported in one of six ways;

• Tooth supported. These prostheses may be fixed, removable or fixed and

removable.

• Implant supported. These may also be fixed, removable or fixed and

removable.

• Tooth and implant supported. These may also be fixed, removable or fixed

and removable.

• Tooth and mucosal borne. These may be fixed (e.g. Spring cantilever bridge)

or removable.

• Implant and mucosal borne. These tend to be removable.

• Mucosal. These are clearly removable.

4) Determination of the means of retention for the prosthesis

Retention is derived in a variety of ways;

• In the case of removable prostheses, retention is achieved principally from

direct retainers. Direct retainers may be :

i. Clasps: occlusally-approaching or gingivally-approaching

ii. Precision attachments: intra-coronal; extra-coronal; studs; bars and others

(e.g. Ipso-Clip) iii.

Guide Planes

iv. Planned use of soft-tissue undercuts.

Clinicians will also be aware of the occasional beneficial effects of denture fixatives on unretentive dentures. N.B. The clinician is required to use a surveyor to identify and quantify undercuts and to plan paths of insertion etc.

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5) Determination of how the saddles will be connected

In fixed prostheses, the connecting elements are called pontics. These may be

sanitary pontics or ‘conventional’ ridge-lapped pontics.

In removable prostheses, there are six forms of connector to consider in the

maxilla and five in the mandible. Anatomical and functional aspects should be

considered here, in addition to patient-related factors.

Maxillary connectors. The six varieties here are:

• Full palatal coverage

• Palatal bars (anterior or posterior)

• Skeletal design (anterior and posterior bars)

• Palatal strap • Horseshoe • Labial bar.

Mandibular connectors. The five varieties here are:

• Lingual bar

• Lingual bar and continuous clasp (Kennedy bar)

• Sub-lingual bar • Lingual plate • Labial bar.

6) Identification of anti-rotational elements

These elements ought to be considered in free-end saddle cases or Kennedy 1

cases where the prostheses are tooth and mucosa or implant and mucosal-

borne.

Indirect retainers are supporting elements which resist rotation on the other side

of the axis of rotation (e.g. clasp tip) from the saddle (Figure 2).

7) Determination of how components are joined

The clinician, in conjunction with the technician, has to plan the position and

form of e.g. minor connectors or, in fixed prostheses, if post-ceramic soldering is

required.

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8) Re-appraisal for health and maintenance

Here, the ability of the patient to achieve and maintain acceptable degrees

of oral cleanliness and health must be re-assessed as well as a determination of

how the prosthesis/es may be maintained.

Legends to Figures Figure.1.

This unilateral bounded saddle has been restored with a denture retained by two intra-coronal attachments Figure.2.

The shortened dental arch of the mandible (opposing a maxillary complete denture) has been extended by CRRBs bilaterally Table 1. Traditional Classifications of RPDs.

Table 2. Roles of RPDs based on usage.

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Chapter 18 Visualising the end result – techniques to improve the predictability of aesthetic dentistry Dr Elaine Halley Principal of Cherrybank Dental Spa, Perth , elaine@jmiuk.com

When restoring teeth for anterior aesthetics, there are a variety of techniques available which increase the predictability of the treatment outcome. In many cases the treatment indicated to improve the aesthetics of a smile is elective in nature and so it is essential that informed consent is gained, and that the patient’s expectations are fully understood. Paying proper attention to the planning phase using specific techniques will in turn:

• Improve the predictability of the final result

• Enhance communication thereby reducing errors in communication between

dentist and patient and dentist and laboratory

• Ensure only specific removal of tooth structure as indicated by the treatment

plan, thus minimising unnecessary loss of healthy tooth tissue.

Failures in aesthetic dentistry may be classified in the following way:

• Psychological failures

• Technique failures

• Communication failures.

Psychological failures In other words, no matter how good the dentistry and the aesthetics, the patient will not be happy with the result. Sometimes this may be due to unrealistic expectations but occasionally there are other underlying psychological issues e.g. body dysmorphia, which manifest in a dissatisfaction with the dentistry. Careful time spent in the pre-planning stage, asking questions, listening to the patient and clarifying their expectations may help identify these potential patients.

Technique failures These failures can be due to errors in the clinical situation or the laboratory procedures. There are obviously many possibilities for technique failures including failure to prepare the teeth adequately either for the clinical situation or for the material selected or a lack of understanding of the occlusal scheme. As clinicians,

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we need to do everything we can to minimise these failures, but also to accept that failures will occur to some degree. We should rectify them, critique ourselves and above all learn from our mistakes but we also need to be able to move on.

Communication failures These can be failures in the communication between dentist and patient or between dentist and laboratory. The techniques described in this article can help reduce the errors in communication in both these situations.

Digital imaging There are many programs available to the clinician to allow him or her to demonstrate to a patient how they may look with some changes in their smile.

Imaging can also be outsourced by emailing a photograph with a prescription to a company which specialises in dental imaging, for example www.smilevision.net Imaging can serve as a diagnostic tool and also improve communication between patient and dentist. However, care must be taken that imaging does not set up false expectations with before and after imaging (Figures 1 and 2). In this case, due to the asymmetric lip, it would be very important to diagnose and explain the need for crown lengthening on the right hand-side in order to match the imaged result. An understanding of smile-design and clinical limitations is essential.

Diagnostic wax-up Obtaining a good quality diagnostic wax-up on articulated models from a laboratory which understands smile design not only enhances diagnosis but allows a patient to visualise the end result. A template can be made from the wax-up which can be used to formulate a trial smile which is much more meaningful to a patient, and to formulate the provisionals after tooth preparation. In order for the laboratory to produce a good wax-up, they also need good quality photographs of the patient, especially full face, close-up smile and retracted smile, as well as a detailed description of the patient’s concerns and the dentist’s prescription.

A stick-bite is a very simple and effective tool that can be used to transfer information to the laboratory about the horizontal plane in relation to the occlusal plane. A silicone bite registration material is syringed onto the lower anterior teeth.

The patient is asked to bite together and a bend-a-brush or a wooden stick is twisted into the registration material in the horizontal plane. This is then levelled to the horizontal. It is very important that the patient is standing or sitting with their head in an upright position while the clinician levels the stick. It is often possible to imagine a horizontal line connecting the pupils and keep the stick level with that. However,

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in some patients, the level of the eyes is not horizontal and so it may be better to use an external frame of reference. A full face photograph of this bite in position is taken and sent to the laboratory so that they can be sure of the position of the incisal plane to the horizontal (Figure 3).

In the same way, it is useful to send the laboratory a photograph of the face bow in position. Whilst every care is taken to line the face bow up correctly with the horizontal and vertical, a photograph can relay more information in that regard.

Trial smile This is the technique which utilises a template made from a diagnostic wax-up. A temporary material (e.g. Luxatemp, DMG/Minerva) is flowed into the template and then seated over the teeth with no preparation. When it is removed, the material remains on the teeth. The excess flash can be removed with a hand instrument and the patient and clinician can view the results. A before and after photograph can be taken so the patient can review the results at a later date and discuss them with family members/ key decision makers as appropriate. Modifications can be made with flowable composite (e.g. Luxaflow, DMG/Minerva). The trial smile can then be removed with hand-instruments as no bonding has taken place.

The trial smile works particularly well in cases of diastema closure or increasing the length of the anterior teeth (Figures 4 and 5). It can also be used to demonstrate the effects of using a lighter porcelain in the restorations if a lighter shade of temporary material is used. It is not as effective in cases where teeth are flared buccally as these teeth will stick forwards through the provisionals and may prevent the temporary stent from seating at all.

Living splint For more complex cases involving full arch or full mouth reconstruction, where the occlusal scheme is being redesigned, the trial smile may be utilised as a definitive diagnostic. By etching and bonding the provisional material to the teeth, a template of the proposed restorations can be bonded in place, reviewed and adjusted as required over a period of weeks or months, in the same way as a splint may be utilised prior to tooth preparation. This can work very well in cases of extreme wear or tooth surface loss where the bite is being opened and restored into CR, and an allowance needs to be made for deprogramming of the muscles. Allowing a trial run of the occlusal scheme in composite that can be adjusted over a period of time as the condyle is able to fully seat prior to any tooth preparation is an advantage in obtaining a stable outcome for a complex case (Figures 6 and 7).

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Provisional restorations In the his textbook Functional Occlusion, from TMJ to Smile Design, Pete Dawson states “Never proceed with the construction of final anterior restorations until the patient is happy with the anterior restorations�. As clinicians, if we really take the time to finesse our provisionals we can then transfer this information to the laboratory and reduce their need for guesswork. A simple check-list can be used to evaluate provisionals for function, aesthetics and phonetics. Any modifications can be made and an impression can be taken of the modified provisionals to accurately transfer the information to the laboratory.

Pre-temporisation Galip Gurel in his textbook The Science and Art of Porcelain Laminate Veneers (Quintessence) advocates a technique whereby the provisional template is utilised to place the provisionals prior to tooth preparation, and then the depth cuts for material thickness removal are made through the provisional material. In this way, only the necessary enamel will be removed to provide enough thickness for the porcelain. This is an excellent technique to conserve as much tooth structure as possible. See Figure 8 for depth cuts in provisionals.

Prep guides In the same way, utilising incisal and buccal prep guides made from the diagnostic wax-up can help the clinician to prepare the teeth predictably and conservatively.

An understanding of the materials to be used and how much space is required by the technician is essential in delivering adequate yet conservative preparations (Figures 9-12).

Case study A 67-year-old lady attended my practice stating that she had left her previous dentist because since he had replaced her upper anterior crowns, she had been unable to speak correctly. When I examined her, she had anterior porcelain bonded to metal crowns on the upper anteriors which looked to be of good quality and had good marginal integrity. However, her lower anteriors exhibited signs of wear.

She had repeatedly attended her previous dentist who had told her it was all in her mind and that she needed to get used to the new crowns. They had now been in place for two years and she was miserable. Certainly, I was unable to hear any phonetic problem myself and alarm bells were ringing that this could be a potential psychological failure.

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I took face bow mounted study casts and discussed the situation with my technician.

We felt that a possibility was that due to the wear on the lower incisors and loss of vertical dimension, these new crowns may have been altered in contour from her originals in order to re-establish guidance with the worn dentition.

I was reluctant to remove what looked to me to be perfectly good crowns when our only indication was phonetics – and more so, the phonetic opinion of the patient rather than any clinical observation on my part. The f- and v-sounds appeared within normal limits but it was the s-sounds and ‘th’ that the patient felt she had to consciously concentrate on every time.

A full mouth wax-up was indicated to restore the proper vertical dimensions and function. A CR bite registration was taken using a Lucia jig and face-bow recording allowed the models to be mounted. We spot-etched the porcelain with hydrofluoric acid, placed a trial smile over her existing crowns and left this in place for one week to evaluate the phonetics. At the review appointment, she was delighted. For the first time in years she felt she did not need to think about her speech.

This technique gave me the confidence that if we could replicate the provisionals with the final restorations this lady would be comfortable with the phonetics. In reality, this transformed this case from what I felt may be a psychological disaster if I touched her otherwise healthy teeth, to a successful outcome.

There are a multitude of factors that come into play when diagnosing, treatment planning and constructing restorations in aesthetic dentistry. Keeping abreast of the latest developments and techniques can help us to learn from our failures and improve our skills. Having a thorough understanding of smile design and best clinical practice can allow us to achieve predictable, functional and aesthetic results for our patients.

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Captions to figures Figures 1 and 2 Care must be taken that imaging does not set up false expectations Figure 3 Example of a stick-bite in situ Figures 4 and 5 The trial smile works particularly well in cases of diastema closure or increasing the length of the anterior teeth Figures 6 and 7 A trial run of the occlusal scheme in composit Figure 8 Depth cuts in provisionals.

Figures 9-12 The use of Prep guides aids both clinician and technician

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Chapter 19 Body dysmorphic disorder and aesthetic dentistry J T Newton1 & H C Travess2 Professor of Psychology as Applied to Dentistry, King’s College London Dental Institute, London; 2Consultant in Orthodontics, Stoke Mandeville Hospital, Aylesbury 1

More and more people are asking for aesthetic dental treatment and expressing ever higher standards of excellence in the appearance of their teeth throughout their lifetime. Clinicians have more treatment options available to meet these demands but are rightly concerned about treating the patient who appears to be overly preoccupied and distressed by minor (or non-existent) defects; such patients may be suffering from a psychological disorder called Body Dysmorphic Disorder (previously termed Dysmorphophobia). Here we will outline the features of Body Dysmorphic Disorder (BDD), and describe techniques for assessment and management.

Body Dysmorphic Disorder: An overview The diagnostic criteria for BDD are outlined in the Diagnostic and Statistical Manual of Diseases, version 4.0 (1). The criteria are:

• Preoccupation with an imagined defect in appearance. If a slight physical

anomaly is present, the person’s concern is markedly excessive in relation to the

nature of the defect

• The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning

• The preoccupation is not better accounted for by another mental disorder (e.g.

Anorexia nervosa).

The primary symptom of BDD is preoccupation with perceived defects. Concerns may be specific to particular body parts or a more pervasive vague concern about something ‘not being right’. The feature is felt to be unbearingly ugly, leading to high levels of shame and distress and low levels of self-esteem. Individuals with BDD are convinced of the severity of the defect, no matter how minor it may seem to others. Aspects of appearance most commonly the focus of this preoccupation are the skin (e.g. blemishes and moles), hair and nose, thus the face is frequently involved. However, the focus often shifts between body parts over the course of the disorder. Individuals with BDD have thoughts and concerns about the body part (e.g. everyone is staring at it; this body part is ‘disgusting’) which are experienced as uncontrollable and intrusive. These thoughts are likely to be worse in social situations.

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The usual age of onset of symptoms is late adolescence (the average age reported in a large sample of patients was 16.4 years), however people with BDD can go undiagnosed for many years and the typical age of presentation of psychiatric services is in the early 30s. The disorder is equally common amongst men and women. The course of the illness is continuous, that is it is unusual for symptoms to show periods of remission. Complete remission is rare and its occurrence is related to the duration and severity of symptoms, such that people who have relatively mild BDD which is not long established are most likely to remit. Comorbidity is frequent in individuals with BDD: the condition is commonly associated with the presence of other psychiatric disorders such as depression, anxiety, social phobia and obsessive compulsive disorder. For example, approximately 38% of people with BDD have previously experienced a social phobia, Alcohol dependence is also common, as individuals may attempt to manage their distress by using alcohol. Of great importance for clinicians who may treat individuals with BDD, suicidal ideation (considering suicide or making plans to commit suicide) is common, being reported in 78% of cases, and 17 to 33% of cases have attempted suicide. This is a critically important point in the assessment of individuals with BDD. Individual with BDD may engage in a variety of compulsive behaviours in relation to their body part. These behaviours are termed ‘compulsive’ because they occur at very high rates and are repetitive. Examples include; checking the body part in the mirror; comparing the self to others; ‘Skin picking’ (seeking to remove the blemish by plucking it or scratching it); applying make up; and camouflaging the body part with clothes. These rituals, while reducing anxiety in the short term, are counter-productive in terms of reducing anxiety in the longer term, as they tend to lead to increased focusing of the perceived problem and anxiety rather than reassurance. The rituals may occupy a number of hours each day leading to impairment in ability to function in work or relationships. For instance, 27% of people with BDD report having been housebound at some point in the disorder. This should be differentiated from a diagnosis of agoraphobia, individuals with BDD are housebound as a secondary consequence of their anxiety from their perception that people will stare at them, judge them and so on.

Individuals with BDD often believe cosmetic treatment is the only way to deal with the defect and in turn seek help from clinicians such as maxillofacial surgeons, dermatologists and plastic surgeons. A number of surveys of individuals with BDD have indicated that 71-76% had sought cosmetic treatment, and approximately 65% of all cases had received cosmetic treatment. The treatments most commonly undergone were rhinoplasty, liposuction, breast augmentation, though minimally invasive procedures were also common (collagen injections, tooth whitening).

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Refusal to treat is less common than might be expected, only 35% of treatments requested by people with BDD were refused.

Research on BDD and dental treatment is relatively sparse - various published case reports document patients with BDD attending for treatment in general dentistry and maxillofacial surgery. One survey of 40 patients attending for adult orthodontic treatment found an estimated prevalence of 7.5% for BDD, suggesting that individuals with BDD are likely to seek orthodontic treatment. This is supported by a recent investigation of patients presenting to two maxillofacial surgery outpatient clinics, where 10% of patients were found to demonstrate symptoms of BDD. In other work, patients were asked about their intentions to receive cosmetic dental treatment and it was found that those who reported being preoccupied with a defect of appearance were nine times more likely to consider tooth whitening and six times more likely to consider orthodontic treatment, compared to those without such a preoccupation. It follows that clinicians working in the field of aesthetic dentistry are likely to be visited by patients with BDD, and as such need to be aware of this condition and how to assess and manage patients suspected of having BDD. Assessment of patients who are suspected of having BDD The first consideration is to establish a ‘safe’ environment for the patient to talk with the dentist, and sufficient rapport to ensure open communication, there are a number of areas which the discussion should cover (see Box 1). Central to this is an assessment of whether the patient’s response is proportionate. Is it reasonable to hold such strong beliefs about the defect, be it imagined or real? Are the consequences of having such a defect proportional to the reported interference of the defect? For example being unable to maintain employment because of crooked teeth is unlikely to be a realistic consequence.

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Box 1: Areas to cover in an interview with a patient who is suspected to have BDD

• What is the main complaint?

> Is the patient’s perception of the blemish proportionate?

• When did the patient first become aware of the problem?

• Why has the patient sought help now?

• What does the patient expect/hope for from treatment?

• How much does the problem interfere with daily life?

> Is the patient’s assessment of the degree of interference proportionate?

• Is there anybody else exerting pressure for the patient to have treatment?

• Is there support from family/friends for the patient?

• Has the patient seen anyone else about this problem?

> Other dental / medical teams (is the patient “doctor shopping” that is

going from health care professional to health care professional until they

get the treatment they desire)

• Is there any Psychiatric / psychological involvement

• Are there any signs of Depression

> Sleep disturbance > Lethargy

> Inability to enjoy life

> Hopelessness / Helplessness

• Are there any signs of Anxiety

> Restlessness > Agitation

> Somatic symptoms: Dizziness, shortness of breath, stomach pains

• Has the person ever been diagnosed as having an Eating Disorder ?

• Has the person ever been diagnosed with an obsessive compulsive disorder?

• Is there evidence of substance misuse. Note units of alcohol per week, also use

of legal and illegal drugs.

• Is there any Suicidal ideation. The three questions given in Box 2 have been

validated for use as a screening tool for people who are at risk of attempting

suicide. If the patient scores within the range identified as at risk, an immediate

referral should be made to their General Medical Practitioner stating your

concerns.

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Management strategies Provision of the requested cosmetic treatment.

Once a formal diagnosis of BDD has been made, it is not advisable to commence with cosmetic treatment. Provision of the requested cosmetic treatment appears to be of little benefit to the patient and there is some possible harm. One study found that 91% of procedures administered to people with BDD resulted in no change in BDD symptoms, further there is strong suggestion that people with BDD express high levels of dissatisfaction with treatment. This often leads to further treatment (usually with different clinicians) or the shifting of the preoccupation to another part of the body.

Additionally there are numerous possible adverse effects for the treating clinician if they provide cosmetic treatments for people with BDD. As patients tend to be dissatisfied with the results of cosmetic treatment, there is the possibility that the patient may sue the clinician for their perceived poor outcome.

Instead, in a sensitive yet straightforward manner, clinicians should discuss with the patient that the cosmetic treatment is not in the patient’s best interest and recommend referral to psychological or psychiatric services for pharmacological or psychological treatment.

Pharmacological and psychological therapy A recent Cochrane review suggested that both pharmacotherapy and psychotherapy may be effective in the treatment of BDD. Psychological management, specifically Cognitive Behavioural Therapy (CBT), is recommended as the first line of management by the National Institute for Health and Clinical Excellence (NICE, http://www.nice.org.uk/Guidance/CG31). CBT is based on the premise that the emotions such as anxiety and distress are affected by thoughts (or ‘cognitions’) and beliefs, and by behaviour. CBT works by encouraging the reassessment of thoughts and actions. CBT often includes exposure to the feared stimulus (e.g. social setting) and response prevention whereby the patient is encouraged to face their anxiety without engaging in their repetitive ritual. This process is repeated until the patient no longer feels anxious. CBT can also involve changing beliefs connected to patients’ dissatisfaction with their body, teaching stress management techniques and provision of information about the condition.

Randomised controlled trials have indicated that, for example, reports that 55% of patients in CBT group improve, in comparison none of the no treatment control group improved and 14% were symptomatically worse.

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There is good evidence for the effectiveness of anti-depressive drugs in people with BDD. Given the prevalence of delusions amongst people with BDD, it has been suggested that anti-psychotic agents might be prescribed. However there is no evidence for the effectiveness of anti-psychotic agents in patients with BDD even when delusions are present.

Conclusions Patients with BDD are likely to present for aesthetic or cosmetic dental treatment.

This is potentially problematic since aesthetic dental treatment has little benefit for people with BDD and has potentially negative consequences for patient and the treating clinician. Clinicians should be aware of this possibility and be familiar with specific strategies to recognise and assess people with suspected BDD and appropriately manage them by referral to specialist services.

Resources for clinicians For guidance on assessment of people with BDD, see Cunningham SJ & Feinman C. Psychological assessment of patients requesting orthognathic treatment and the relevance of body dysmorphic disorder. British Journal of Orthodontics. 25: 293-298, 1998.

For information leaflets suitable for patients, and for information for clinicians working with individuals with Body Dysmorphic Disorder, see the National Institute for Health and Clinical Excellence (NICE) http://www.nice.org.uk/Guidance/CG31)

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Chapter 20 An update on endodontic issues

Although the basics of endodontics have not changed fundamentally since the early days of the specialty, the discipline has seen changes in recent years that have enabled practitioners to provide more comprehensive treatment and in some cases speedier outcomes than in the past. The introduction of rotary nickel titanium instrumentation has been a great asset in making the delivery of quality endodontic treatment easier for the general dental practitioner. Similarly, the improved use of lighting and magnification, especially the operating microscope, has meant that cases previously considered untreatable can be managed with confidence.

In this article we revisit some of the fundamentals of endodontics and also discuss two of the current issues prompted by recent research; the debate between root canal treatment and implants, and the diagnosis of the joint periodontal-endodontic lesion.

Access cavity While every stage of root canal treatment needs to be completed to the highest standard, creating a successful access cavity is the first crucial step. The subsequent preparation of the canal or canals can be made more difficult or severely comprised if this is not well executed. Inadequate access can lead to canals being left untreated, poorly disinfected, difficult to shape and obturate and may ultimately lead to the failure of the treatment. Good access design and preparation will result in a situation which will facilitate cleaning, shaping and obturation of the root canal system in order to maximise success.

Although diagrams or pictures are often published of an ‘ideal’ access cavity in relation to particular teeth, because of biological individual variation it is unlikely that many cavities will exactly match this ideal. The vast majority are in fact created in teeth where a significant amount of dentine and enamel has been replaced by restorative materials. It is therefore important that it is the anatomy of the pulp chamber that is being treated, and not a preconceived notion which attempts to dictate the outline form of the access cavity. The aims of the access cavity can be considered as:

• Removal of the entire roof of the pulp chamber in order to inspect the pulp

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• Creation of tapered cavity walls

• Creation of a smooth unimpeded pathway for instruments to canal orifices

• Preservation of natural tooth substance consistent with the above.

The technical aspects of root canal preparation can then be continued in three further phases:

• Pulp chamber penetration and enlargement

• Canal identification

• Cavity finishing.

Mechanical preparation The use of mechanical instrumentation is accepted as being one of the most important steps in root canal treatment. It is also recognised as being one of the more difficult practical challenges in operative dentistry. The main objectives of canal preparation include:

• The removal of vital and necrotic pulpal tissue from the root canal space

• The removal of microorganisms and their products from the canal space

• The removal of infected dentine

• To create a space that can be both irrigated and medicated

• Allow predictable placement of a root canal filling material

• Maintain sound root and coronal tissue to allow effective restoration and

function of the tooth.

There are basically two groups of design differences in rotary NiTi systems with regard to cross sectional shape: files with radial landed features and non-landed types. As a generalisation ‘landed’ files allow a slower, but slightly more predictable preparation because of their ability to stay centred in a canal. ‘Nonlanded’ instruments have a more effective cutting action, and usually allow a more rapid preparation technique although these require a higher level of operator care and experience in order to avoid preparation errors, especially in relation to working length determination.

Measuring working length This is a question that has been a matter of debate for many years. Most practitioners will aim to prepare to the apical constriction of the canal, the point at which the pulpal tissues become peri-apical tissues. However, locating this position can be difficult as it cannot be identified radiographically, it is highly variable in relation

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to the radiographic apex of a root, and disease processes may have altered or destroyed it. In practice a combination of measurement techniques, including radiography, electronic apex location, tactile awareness, and the use of paper point measuring techniques often allows a more consistent method of measurement than a single technique alone. Modern electronic apex locators are now so consistently accurate that they form an invaluable aid to endodontic treatment.

Limitations of rotary NiTi instrumentation If correct procedure is followed, many root canals can be effectively shaped using rotary NiTi files. A ‘golden rule’ is to explore the canal system using small, flexible hand files, usually sizes 8, 10 and 15, before inserting a rotary file to the same length.

This ‘scouting’ of the canal can provide valuable tactile information on the safety of the preparation case. Specifically, canals that exhibit sharp curvatures and recurvatures, division, or convergence with abrupt change of direction, can provide challenging environments for rotating NiTi files due to increases in torsional and flexural stresses. In these situations it is often prudent to complete preparation using pre-curved fine stainless steel hand files.

The ‘single file’ concept Many rotary NiTi systems require several files to achieve their preferred preparation shape. Along with concerns over file separation, decontamination and cost issues have driven manufacturers to try and reduce the number of NiTi instruments necessary to create an ideal shape. Some rotary NiTi systems are now available that have a greatly reduced number of files for example, Twisted Files® (Sybron Endo, Orange, CA), and others that utilise a single rotary instrument (One Shape®, Micro Mega®, Bescanson, France). Both these systems retain a full 3600 rotational motion, and TF files utilise an altered state NiTi alloy that is reported to be more resistant to distortion and fracture. More recently the use of NiTi files in a reciprocating motion have been commercially developed that claim to allow canal shaping using only a single file (Wave OneTM, Dentsply Maillefer, Ballaigues, Switzerland, and Reciproc®, VDW®, Munich, Germany). This concept was first reported by Yared where a Protaper F2 finishing file was driven in a reciprocating fashion rather than through a conventional 3600 rotation. The clockwise (1440) and anti-clockwise (720) motions were controlled via an electronic motor, and the root canal was only pre-negotiated by an ISO 0.02 taper size 8 file. Such an approach was claimed to be effective at shaping and maintaining canal curvature. Additionally there are advantages in reducing potential instrument cross contamination and associated cost reductions.

These types of instruments have now been launched commercially, with a small number of preparation files to simplify the clinician’s choice between small, medium

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and large canal sizes. Both these reciprocating systems are made from a modified NiTi alloy (M-wire) and claim to be able to prepare adequate canal shape with a minimised risk of file fracture due to the reciprocating nature of the file movement.

Reciproc® is recommended for use without the need to create a ‘glide-path’ before its introduction into the canal, a claim that appears to have some experimental merit in roots with little or moderate canal curvature. Another study compared the shaping and cleaning potential of these new designs compared to ‘conventional’ rotary NiTi systems. Both reciprocating systems maintained root canal curvature and were considered safe. The shaping time for the reciprocating files was naturally shorter due to the reduced number of files used, but it was noted that irrigation time of the canal should not be compromised by this reduced mechanical preparation time.

There is no doubt that the introduction of reciprocating files has generated a high level of interest, especially in the general dental practitioner population. Their use in selected situations can produce consistently good results and the reduced number of files needed to prepare adequate shapes has obvious financial and time saving potential. The need to purchase a specialised motor capable of driving the reciprocating file correctly does initially offset some of these cost savings, but many of these dedicated units also allow the use of more conventional rotary systems, allowing the clinician to apply hybrid approaches to canal preparation using a combination of instruments.

Implants and endo Recent debate has centred around the relative merits of conducting root canal treatments on compromised and infected teeth compared with the extraction of these teeth and their replacement with implant retained restorations. The evidence of outcome studies into both therapies suggest that they are both valid and that preference depends on particular clinical considerations and the opinion of the clinician. There are indications for both but the usual generalised summary is that a saveable tooth should not be extracted and replaced by an implant if reasonably possible. In essence, decision-making should be based upon proper treatment planning in each individual case. A systematic review found that both treatments had a high success, which was better in the long-term than fixed partial dentures.

Direct comparisons among studies were difficult because success criteria were very different. Interestingly, extraction of teeth without replacement was shown to produce poorer psychological outcomes in a direct comparison between a cohort of patients that had received root canal treatment and another that received implants. The success rate was the same for both treatments after an average of 36 months but

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implants required more post-operative treatments than root canal treated teeth (12.4% versus 1.3%).

In another study based over an eight-year period found that outcomes for the two treatments was essentially the same. In summary the decision to undertake root canal treatment or implant therapy cannot be based on outcome alone because both treatments are based on differing biological and diagnostic principles, failure patterns and patient preferences.

The diagnosis of periodontal-endodontic lesions (PEL) The diagnosis of pulpal/periapical or periodontal disease as distinct entities is based on a thorough clinical examination utilising pulp sensibility tests, percussion, transillumination, test cavities, probing pocket depths, an assessment of mobility, and identification of bleeding and, or suppurating pockets.

Occasionally, a localised problem such as an extensive periapical lesion that tracks coronally through an otherwise healthy periodontal ligament may present as a narrow sinus tract and mimic periodontal disease. This might be classified as a primary endodontic lesion with secondary periodontal involvement although this would not be included in the definition of a concurrent PEL suggested earlier in this paper. Consequently, the management would simply involve root canal therapy of the affected tooth. Concurrent PELs will usually affect a single tooth although multiple affected teeth may present in a patient where there has been widespread dental neglect.

The teeth involved may have extensive carious lesions and large restorations and will consequently fail to respond to sensibility tests. There will be increased, widebased probing depths with bleeding or suppuration from the pockets and the tooth may be tender to percussion in the presence of an acute apical or periodontal abscess (or both). Panoramic oral radiographs will reveal the extent, morphology and the severity of the periodontal bone loss and supplementary, conventional or digital periapical films may be exposed for those teeth which, on the basis of clinical findings and the panoramic film, appear to have apical pathology.

A periapical film will provide the required definition to ascertain the apical extent of the periodontal lesion (the point at which the periodontal membrane space assumes normal width) and the coronal margin of a periapical lesion and thus help in identifying whether or not the separate periodontal and pulpal inflammatory lesions communicate. Periodontal-endodontic lesions may be associated with teeth having previously been root filled and the limitations of conventional (two-dimensional) periapical radiographs must be recognised as they may not correlate with the three-

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dimensional quality of a root filling. An apparently well-condensed and well-adapted root filling associated with a PEL may need to be retreated if the long-term outcome for the tooth is to be assured. Furthermore, when conventional, plain films fail to provide sufficient diagnostic information limited-volume, high-resolution cone beam computed tomography may be justifiable for assessing and treatment planning periodontal-endodontic lesions.

Further reading Heasman PA. An endodontic conundrum: the association between pulpal infection and periodontal disease. Br Dent J 2014; 216: 275-279.

Waplington M, McRobert AS, Shaping the root canal system. Br Dent J 2014; 216: 293297.

Saunders WP. Treatment planning the endodontic-implant interface. Br Dent J 2014; 216: 325-330.

Adams N, Tomson PL. Access cavity preparation. Br Dent J 2014; 216: 333-339.

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