Dental CPD Now DCP Edition by Professional Dentistry

PROFESSIONAL DENTISTRY PRESENTS...

DENTAL CPD NOW 2019 Edition

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Contents... 1 New periodontal classification system........................................................ 6 Implementation.............................................................................................. 7 The role of BPE in the new system................................................................. 8 Staging and grading of periodontists ......................................................... 10 Grading ........................................................................................................... 11 Summary.......................................................................................................... 12 References...................................................................................................... 14 2 Enhanced CPD guidance.............................................................................. 16 How we look in detail at the GDC’s eCPD regulations.............................. 16 Summary of requirements.............................................................................. 16 Spreading activity over the cycle................................................................ 19 The personal development plan (PDP)........................................................ 19 The log of completed activity....................................................................... 20 The evidence required from each activity.................................................. 22 Linking to the Standards for the Dental Team through development outcomes................................................................................ 22 Reflection......................................................................................................... 23 Your end of cycle statement......................................................................... 23 3 Oral medicine: Lumps and swellings in the mouth..................................... 28 Causes of lumps and swellings according to site....................................... 30 Diagnosis of the cause of a lump or swelling.............................................. 31 Position............................................................................................................. 32 Investigations................................................................................................... 34 Chronic granulomatous conditions.............................................................. 35 Orofacial granulomatous.............................................................................. 35 Crohn’s disease.............................................................................................. 35 Sarcoidosis....................................................................................................... 36 4 Mouth Cancer diagnosis............................................................................... 38 Diagnosis.......................................................................................................... 38 Why is early cancer diagnosis important?................................................... 38 Diagnostic delays........................................................................................... 39 What features are suggestive of mouth cancer?’..................................... 39 Other features that may be suggestive of OSCC are any persistent...... 40 What are essential for diagnosis?................................................................. 42 What are the essential physical examinations?.......................................... 42 What are the latest oral diagnostic methods?........................................... 44 What about cancer screening?................................................................... 46

Face and eye protection for decontamination procedures.................... 72 Clothing, uniforms and laundry.................................................................... 72 Removal of PPE............................................................................................... 73 Surface and equipment decontamination................................................ 73 Environmental conditions.............................................................................. 73 Surfaces and equipment - key design issues.............................................. 74

8 GDC’s ethical guidance on social media and advertising....................... 76 Guidance on using social media ................................................................ 76 Professional standards ................................................................................... 76 When using social media, dental professionals must:................................ 77 Privacy............................................................................................................. 77 Maintaining confidentiality ........................................................................... 78 Raising concerns............................................................................................. 78 GDC social media monitoring...................................................................... 79 Advertising guidance..................................................................................... 80 Advertising services........................................................................................ 80 Endorsing products......................................................................................... 81 Marketing websites......................................................................................... 81 Websites........................................................................................................... 81 Specialist titles................................................................................................. 82 Honorary degrees and memberships.......................................................... 82 9 Financial management in dental practice.................................................. 84 Follow the money........................................................................................... 85 Manage stock levels...................................................................................... 85 Reward performance.................................................................................... 85 Financial terminology..................................................................................... 86 Financial literacy............................................................................................. 86 Profit and Loss Accounts (P&L)...................................................................... 87 Balance sheets................................................................................................ 87 Cash flow statement...................................................................................... 87 Notes to accounts.......................................................................................... 87 Accountancy.................................................................................................. 88 Management accounting information....................................................... 88 Record keeping.............................................................................................. 88 Cash flow......................................................................................................... 89 Break-even...................................................................................................... 90 Capital expenditure....................................................................................... 90 Revenue expenditure.................................................................................... 90 Budget management ................................................................................... 90 A cash flow forecast consists of.................................................................... 91 In the short term (over the next four weeks) - remedial action................ 91 In the middle term (4 weeks to 6 months ahead) - conciliatory action.. 91 In the long term (beyond 6 months)- business planning........................... 92

5 Medical emergencies - defibrillators to the rescue................................... 48 Effects of defibrillation.................................................................................... 48 How a defibrillator works................................................................................ 50 Shockable rhythms......................................................................................... 50 When the AED arrives..................................................................................... 51 If a shock is advised........................................................................................ 52 If no shock is advised..................................................................................... 52 Items to keep with your defibrillator............................................................. 52 Using a defibrillator on a child....................................................................... 54 AED signage.................................................................................................... 54 Maintenance of the AED............................................................................... 54 After the emergency..................................................................................... 55 A guide to resuscitation and emergency life support............................... 56 When somebody collapses in front of you, what do you do?.................. 58 Automated external defibrillatior (AED)...................................................... 59 Resuscitation................................................................................................... 59 CPR on a child or baby.................................................................................. 61

10 Child abuse and dental neglect................................................................... 94 Spotting the signs............................................................................................ 94 Physical abuse................................................................................................ 94 Some of the signs an individual may have been a victim of physical abuse include ................................................................................. 95 Sexual abuse................................................................................................... 95 Neglect............................................................................................................ 95 Dental neglect................................................................................................ 96 Stage 1. Preventive dental team management........................................ 97 Stage 2. Preventive multi-agency management....................................... 98 Stage 3. Child protection referral................................................................. 98 Recent research............................................................................................. 98 Table 1.............................................................................................................. 99 Table 2.............................................................................................................. 100

6 Recent changes in dental x-ray equipment regulations........................... 62 Where does ionising radiation occur?......................................................... 63 Second recent change in dentistry............................................................. 64 Electrical safety............................................................................................... 64 References...................................................................................................... 66

11 Saliva and the control of plaque pH............................................................ 102 Resting plaque pH.......................................................................................... 102 The decrease in plaque pH........................................................................... 102 The minimum plaque pH............................................................................... 103 The rise in plaque pH...................................................................................... 103 Maintenance of plaque pH by saliva.......................................................... 104 Bicarbonate.................................................................................................... 104 Phosphate....................................................................................................... 104 Other factors................................................................................................... 104 Buffering capacity of plaque........................................................................ 105 Age and site of plaque.................................................................................. 105 Diet history....................................................................................................... 106

7 Decontamination............................................................................................ 68 Hand hygiene................................................................................................. 68 Drying of hands............................................................................................... 69 Skincare........................................................................................................... 69 Facilities and procedures for hand-washing............................................... 69 Personal protective equipment for decontamination process................ 70 Gloves.............................................................................................................. 70 Disposable plastic aprons.............................................................................. 71

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Contents... Plaque pH and salivary clearance............................................................... 106 Plaque pH and fluoride levels....................................................................... 106

Posture............................................................................................................. 136 Proximity........................................................................................................... 137 Position............................................................................................................. 138 Body Contact................................................................................................. 138 Do we say what we mean? - Verbal communication............................... 139 The open question.......................................................................................... 139 The focused question..................................................................................... 139 The closed question....................................................................................... 139 The leading question...................................................................................... 140 The compound question............................................................................... 140 Social exchanges........................................................................................... 140 Facilitation....................................................................................................... 141 Repetition........................................................................................................ 141 Restatement.................................................................................................... 141 Clarification/interpretation……..................................................................... 141 Last thoughts................................................................................................... 142

12 Dementia in dentistry. Adapted with acknowledgment from the Dementia - Friendly Dentistry Faculty of General Dental Practice (UK) 39................ 108 How to raise concerns and approach the subject of dementia............. 109 Potential indicators of dental problems in people living with dementia.109 Medication...................................................................................................... 110 Types of dental treatment............................................................................. 111 Middle stages of dementia........................................................................... 112 Later stages of dementia.............................................................................. 113 Additional issues.............................................................................................. 113 13 Dental pain...................................................................................................... 114 Pain history ...................................................................................................... 114 Location........................................................................................................... 114 Timing............................................................................................................... 114 Character........................................................................................................ 114 Frequency....................................................................................................... 115 Duration........................................................................................................... 115 Time.................................................................................................................. 115 Precipitating factors....................................................................................... 115 Relieving factors............................................................................................. 115 Other factors................................................................................................... 115 Examination .................................................................................................... 116 Special tests .................................................................................................... 116 Pulpal responsiveness .................................................................................... 116 Electric pulp test (EPT).................................................................................... 117 Cold test.......................................................................................................... 117 Heat test.......................................................................................................... 117 Anaesthetic test.............................................................................................. 118 Transillumination.............................................................................................. 118 Percussion ....................................................................................................... 118 Wedge test ..................................................................................................... 119 14

17 Impairment in adults: systemic disease....................................................... 144 Coronary heart disease................................................................................. 144 Cardiovascular diseases................................................................................ 145 Oral side-effects of medication used in cardiovascular disease............. 146 Blood disorders................................................................................................ 146 Red blood cells- anaemia............................................................................. 147 White blood cells............................................................................................ 147 Leucopaenia.................................................................................................. 147 Leucocytosis.................................................................................................... 147 Platelets........................................................................................................... 147 Clotting and bleeding disorders................................................................... 148 Respiratory disorders...................................................................................... 148 Asthma............................................................................................................. 148 Chronic obstructive airways disease............................................................ 148 Tuberculosis..................................................................................................... 148 Cystic fibrosis................................................................................................... 149 Gastrointestinal disease ................................................................................ 149 Oral aspects of GI disease include.............................................................. 149 Side effects of some of drugs used in GI disease include......................... 149 Liver disease.................................................................................................... 150 Renal disease.................................................................................................. 150 Endocrine system disorders........................................................................... 150 Diabetes mellitus............................................................................................. 151

Using cognitive behaviour techniques for anxious patients..................... 120 All sessions of should have roughly the same structure............................. 120 The following exercises have been used at the King’s College London Dental Institute Health Psychology Service................................... 120 Explaining the role of beliefs.......................................................................... 120 Identifying thoughts about the dentist or dental treatment..................... 121 Distinguishing between helpful and unhelpful thoughts........................... 122 Cognitive restructuring................................................................................... 122 Useful questions include................................................................................. 123 An example of disputing and restating thoughts is as follows.................. 124 Pre- treatment session to increase perceptions of control and predictability........................................................................................... 124 Expressive writing concerning traumatic dental experiences.................. 125 Writing letters................................................................................................... 125 Other useful topics for letters include........................................................... 126

18 Root canal morphology................................................................................. 152 The root canal system.................................................................................... 152 Lateral and accessory canals....................................................................... 153 Maxillary central incisors................................................................................ 153 Maxillary lateral incisor................................................................................... 153 Maxillary canine.............................................................................................. 154 Maxillary first premolar.................................................................................... 154 Maxillary second premolar............................................................................ 154 Maxillary first molar......................................................................................... 154 Maxillary second molar.................................................................................. 155 Maxillary third molar....................................................................................... 155 Mandibular central and lateral incisors....................................................... 155 Mandibular canine......................................................................................... 155 Mandibular first premolar............................................................................... 156 Mandibular second premolar....................................................................... 156 Mandibular first molar.................................................................................... 156 Mandibular second molar............................................................................. 156 Mandibular third molar.................................................................................. 157 Pulp stones....................................................................................................... 157

15 Risk factors for periodontal disease*............................................................ 128 Local risk factors............................................................................................. 128 Systemic risk factors........................................................................................ 128 Tobacco use .................................................................................................. 128 Diabetes.......................................................................................................... 128 Stress................................................................................................................. 129 Medication...................................................................................................... 129 Other considerations...................................................................................... 129 Emerging evidence........................................................................................ 130 Tobacco and periodontal health................................................................. 130 Setting patient expectations......................................................................... 131 Periodontal treatment for smokers............................................................... 131 Systemic disease and periodontal health................................................... 132 References and further reading................................................................... 133 16 Verbal and non-verbal communication..................................................... 134 Non-verbal communication.......................................................................... 135 Dress and appearance................................................................................. 135 Facial expression............................................................................................. 135 Eye contact..................................................................................................... 136

19 The development and management of dentine carious lesions.............. 158 How does an enamel carious lesion progress into dentine?.................... 158 The importance of the direction of enamel rods....................................... 159 How does one increase the life of a tooth that requires a restoration? . 160 Soft Dentine..................................................................................................... 162 Firm Dentine.................................................................................................... 162 Hard Dentine................................................................................................... 162

CHAPTER 1

Make this CPD Verifiable

New periodontal classification system

Turn to page 162 to find out how

The 2017 World Workshop Classification system for periodontal and peri-implant diseases and conditions was developed in order to accommodate advances in knowledge derived from both biological and clinical research, that have emerged since the 1999 International Classification of Periodontal Diseases. The aim, as determined by the joint European Federation of Periodontology (EFP) and American Academy of Periodontology (AAP) management committee, was to adopt a reductionist model in order to create a system that could be implemented in general dental practice, the environment where over 95% of periodontal disease is diagnosed and managed. A further aim was to create a system that captured and distinguished the severity and extent of periodontitis (a reflection of the amount of periodontal tissue loss) on one hand, as well as a patientâ&#x20AC;&#x2122;s susceptibility for periodontitis (as reflected by the historical rate of periodontitis progression). In addition, the system needed to accommodate the current periodontal status of a patient (probing pocket depth [PPD], and percentage of bleeding on probing [BoP]). The classification is a live system to be regularly updated by a task force to accommodate future advances in knowledge, either clinical or biological (for example, biomarkers), as they emerge1. In order for a clinician or student to understand periodontal assessment and diagnosis in the context of the 2017 classification system, it is critical to understand that the first step is to determine the type of periodontal disease (Table 1). For the first time, the 2017 classification system gives clear definitions of periodontal health and gingivitis for:

Patients with an intact periodontium

Patients with a reduced periodontium due to causes other than periodontitis

Patients with a reduced periodontium due to periodontitis.

For a detailed discussion of the evidence and rationale behind these definitions, the reader is referred to the consensus paper of workgroup one of the 2017 World Workshop2. In the 2017 classification system, the distinction between chronic and aggressive periodontitis has been removed on the basis that there was little evidence from biological studies that these two were separate entities, rather than variations along a spectrum of the same disease process. The exception was classical localised 6

juvenile (aggressive) periodontitis, where a clearly defined clinical phenotype exists, however, there was unease about including this as a distinct and separate entity within the classification system. The only other distinct types of periodontitis that the 2017 classification system recognises are necrotising periodontitis and periodontitis as a manifestation of systemic disease. Once a patient has been diagnosed with periodontitis, staging and grading should be performed (Table 2). However, as the periodontitis stage and grade are a reflection of historical disease experience, it does not directly map to established screening tools (for example, the widely used basic periodontal examination [BPE]) and it lacks a direct link to periodontal parameters that indicate current disease status (that is, PPD, BoP). Therefore, determining a patient’s current disease status is an important second step, particularly in patients who have received periodontal therapy in the past. Importantly, a successfully treated periodontitis patient remains a periodontitis patient for life because the disease may progress at any time if periodontal maintenance is sub-optimal and risk factors are not controlled. However, at any given time following therapy a periodontitis patient may represent a case of health in a successfully treated patient (stable), or a case with recurrent gingival inflammation (BoP ≥10%) at sites with PPD <3 mm and no PPD >4 mm (disease remission), or a case of recurrent periodontitis, where there are bleeding sites ≥4 mm or any PPD ≥5 mm (unstable). The 4 mm threshold is critical as it determines periodontal disease stability at non-bleeding sites following successful periodontal therapy. However, it is important to note that a higher probing depth of 5 mm or 6 mm in the absence of bleeding may not necessarily represent active disease, in particular soon after periodontal treatment. Therefore, clinicians need to exercise careful clinical judgement when considering the need or lack of need for additional treatment such as re-instrumentation or surgery for such sites.

(A) Implementation (B) Principles Comprehensive oral health assessment of any patient includes a periodontal assessment. This will typically commence by screening for periodontal diseases using a system like the BPE and, if applicable, a full diagnostic workup/periodontal assessment. The principle change from current practice is that a complete diagnosis of a patient with periodontitis will include staging and grading of the disease. It is important to understand that the new classification system of periodontal diseases and conditions is not a diagnostic system or diagnostic algorithm, the diagnosis must accommodate both the classification (type of periodontal disease and, if applicable, staging and grading based on bone loss or clinical attachment loss [CAL]), and also current disease status (based on PPD and BoP). Secondary to

the diagnosis, but equally important, is the third stage of determining a patient’s risk factor profile. The diagnostic work-up of periodontal patients will always include a detailed medical and dental history, oral examination and further investigations (including, where appropriate special tests, radiographs and a radiological report) which will allow the differentiation between the different types of periodontal disease (for example, gingivitis, necrotising periodontal disease, periodontitis associated with systemic disease, non-plaque-induced gingivitis etc), and importantly, the recognition of alveolar bone loss or attachment loss due to causes other than periodontitis (for example, surgical crown lengthening, orthodontic treatment, perioendo lesions, impacted third molars, restoration margins, etc), referred to in the new 2017 classification as a ‘reduced periodontium in a non-periodontitis patient’.

(B) The role of BPE in the new system The BPE is a clinical application of the epidemiological community periodontal index of treatment needs (CPITN) (or community periodontal index [CPI]) tool, developed by the British Society of Periodontology in order to rapidly screen for periodontal disease in patients with no overt signs of periodontal disease based on visual inspection alone. Hence, the BPE is a screening tool employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis or periodontitis, irrespective of historical attachment loss and bone loss (that is, irrespective of staging and grading). As such, the BPE guides the need for further diagnostic measures before establishing a definitive periodontal diagnosis and appropriate treatment planning. Performing a BPE entails ‘walking’ the probe around each tooth, and recording only the worst score (code 0–4) in each sextant for efficiency. The markings of the BPE/WHO probe at 3.5 mm and 5.5 mm are designed to allow the clinician to easily establish the presence or absence of PPD of at least 4 mm and 6 mm, respectively. Specifically, as soon as the black band of the probe is partially obscured, the PPD is at least 4 mm (BPE code 3), and as soon as the black band of the probe is completely obscured, the PPD is at least 6 mm (BPE code 4). The BPE and its equivalent systems have been well established in the clinical community across Europe due to its relative simplicity and efficiency. The pathway described here is entirely consistent with current BSP guidance on the use of the BPE, that is, its prosecution and interpretation has not changed. However, it is important to recognise that the BPE is of limited value in patients who have already been diagnosed with periodontitis. This is particularly relevant in the context of the new classification system, as staging of periodontitis is based on radiographic bone loss and/or CAL, which is not captured by the BPE. For example, the BPE is unable to identify patients with historical periodontitis, as it is based upon BoP and PPD, rather than recording attachment and bone loss. 8

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Valuing patient plans

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Therefore, clear and obvious evidence at initial presentation of historical periodontitis ascertained through history, examination (interproximal recession/attachment loss) or radiographs should trigger a full periodontal assessment immediately, as the BPE is effectively redundant in such patients. For example, using the BPE on a patient with a history of periodontitis and no BPE scores over 2 would wrongly result in a provisional classification of periodontal health (<10% sites with BoP), localised gingivitis (10–30% sites with BoP) or generalised gingivitis (>30% sites with BoP), rather than capture the fact that the patient is a periodontitis patient with a current status of health or gingival inflammation. As per current BSP guidance a maximum BPE code of 3 would trigger a panoramic radiograph and/or selective periapical radiographs, which will allow determination of percentage bone loss relative to the root length. A maximum BPE code of 4 would trigger periapical radiographs (or a panoramic radiograph) and a detailed pocket chart. Following a radiological analysis and report and, where appropriate, additional diagnostic tests, a final diagnosis of the type of periodontal disease is made (Table 1).

(A) Staging and grading of periodontitis An important underlying principle of the staging process, which is to be performed at the initial assessment, is that patients cannot regress to a lower stage of periodontitis due to treatment, therefore, periodontal parameters that are significantly affected by treatment (for example, BoP and PPD) cannot be employed to determine disease stage.

(B) Staging The staging of periodontitis reflects the severity of disease at presentation, which is also associated with the complexity of overall patient management. The BSP implementation group recognised several challenges with the proposed periodontitis staging grid for implementation in general dental practice, specifically:

• The lack of an unambiguous decision rule that describes how the various

parameters in the staging grid should be combined to determine a patient’s

disease stage

• The fact that clinical attachment loss is not routinely measured in clinical

practice

• The inclusion of complexity measures such as tooth loss due to periodontitis

and alveolar ridge defects, which may be difficult to ascertain and/or may

not be well defined.

For a patient diagnosed with periodontitis, there is a simplified staging grid based on radiographic bone loss alone (Table 2). For reasons of simplicity, this is based on percentage bone loss in relation to the root length, which is an intuitive measure already used by many practitioners. We recognise that for some patients, in particular for those with early stage periodontitis, the availability of radiographs may be limited to bitewings in the posterior regions and no radiographs may be available for the anterior sextants. In such cases, and when periapical or panoramic radiographs are not indicated for clinical reasons, the clinician should use bitewings or CAL measured from the CEJ to estimate percentage of bone loss. The bone loss is taken as the worst value at any site in the mouth, where it is clear that the bone loss has arisen due to periodontitis and not for an incidental reason such as a root fracture or a previous surgical intervention (for example, wisdom tooth removal). In rare situations where a patient is clearly known to have lost teeth due to advanced periodontal bone loss, likely to have been within the apical third of the root, then clinicians may, on a case by case basis, immediately assign a stage IV classification.

(B) Grading Grading is designed to reflect the patient’s susceptibility to periodontitis because historical disease experience at a given age essentially accommodates all risk determinants that have conspired to cause periodontal bone loss over that patient’s life course. Moreover, the periodontal disease experience of a patient at presentation has been widely demonstrated as being the best predictor of future disease experience in the absence of treatment. The ratio of percentage of bone loss/age was thought to be the most pragmatic and thus suitable for use in clinical practice because it:

• Maps directly to percentage of bone loss determined as part of the

staging process

• Reflects the average rate of disease progression over time

• Is an intuitive measure that is already employed to gauge disease susceptibility

by many clinicians, albeit not in an explicitly formal way.

The use of progression rate determined by the evaluation of successive radiographs is impractical in many clinical situations as such radiographs are rarely available and they convey little additional information compared to the percentage of bone loss/ age ratio. As periodontitis is a complex multifactorial disease, a plethora of causal factors determine the host response to the microbial challenge, including genetic, epigenetic, environmental and behavioural factors. The percentage of bone loss/ age ratio captures the historical disease susceptibility due to the life-long exposure to

all causal factors of a specific patient at that moment in time, including established, modifiable risk factors such as smoking and suboptimally controlled/undiagnosed diabetes. As such, it is also the best possible estimate of future disease susceptibility, although disease susceptibility may change as the result of changes in a patient’s risk factor profile and following periodontal treatment. For example, a patient may quit smoking or develop uncontrolled diabetes. However, the mere presence or absence of an established, modifiable risk factor (for example, smoking, diabetes), should not override or modify the disease grade assigned based on the percentage of bone loss/age ratio, which comprehensively reflects a patient’s past susceptibility. For example, it would not be meaningful to assign a grade C (highest susceptibility/rate of progression) to a 70-year-old patient with Stage I periodontitis (maximum bone loss <15%), just because he/she smokes 20 cigarettes per day, as this patient clearly exhibits limited susceptibility and a low rate of progression, despite the exposure to smoking. However, this does not negate the importance of a comprehensive risk factor assessment, as the risk factor profile should form the third part of a complete periodontal assessment documented alongside the diagnosis and, if applicable, the elimination or reduction of risk factors is an essential component of periodontal management. The thresholds of the percentage of bone loss/age ratio used to define the different disease grades are necessarily arbitrary. However, they should be easy to calculate mentally for a clinician, and the resulting grade categories should have reasonable coverage of the spectrum of periodontitis susceptibilities encountered in the general population.

(A) Summary The new classification provides a contemporary and future-proof system for classifying the periodontal status of undiagnosed patients. The major novelty is the introduction of staging and grading for periodontitis patients and the loss of the term ‘aggressive periodontitis’. The staging/grading system is designed primarily to capture and distinguish; (i) a patient’s history of periodontal tissue destruction, as defined by bone and clinical attachment loss; and (ii) a patient’s historical rate of disease progression as a measure of the patient’s disease susceptibility and, therefore, a predictor of future disease progression in the absence of intervention for risk factor control and treatment. Moreover, once a patient has had periodontitis it cannot be reversed and the attachment loss needs to be reflected in their current diagnosis, even if they have been successfully treated and are currently a case of health, because stability requires careful maintenance and continued risk factor control.

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Dominic currently spends 3 days a week undertaking advanced restorative, aesthetic and implant dentistry and private practice 13

References

1. Dietrich T et al. Periodontal diagnosis in the context of the 2017 classification

system of periodontal diseases and conditions â&#x20AC;&#x201C; implementation in clinical

practice. Br Dent J 2019; 226: 16-22.

2. Chapple I L C, Mealey B L, Van Dyke T E et al. Periodontal health and gingival

diseases and conditions on an intact and a reduced periodontium: Consensus

report of workgroup 1 of the 2017 World Workshop on the Classification of

Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol 2018;

45 Suppl 20: S68â&#x20AC;&#x201C;S77.

Table 1 Basic classification of periodontal diseases and conditions Health: Intact periodontium Reduced periodontium* Plaque-induced gingivitis: (localised /generalised gingivitis) Intact periodontium Reduced periodontium* Non plaque-induced gingival diseases and conditions Periodontitis:** Localised (< 30% teeth) Generalised (> 30% teeth) Molar-incisor pattern Necrotising periodontal diseases Periodontitis as a manifestation of systemic disease Systemic diseases or conditions affecting the periodontal tissues Periodontal abscesses Periodontal-endodontic lesions Mucogingival deformities and conditions *Reduced periodontium due to causes other than periodontitis, for example, crown lengthening surgery **All patients with evidence of historical or current periodontitis should be staged/ graded at initial consultation

Table 2: Staging and grading of periodontitis1 Staging of periodontitis Stage I (early/mild) Interproximal bone loss*

Extent

Stage II (moderate)

<15% or <2 mm** Coronal third of root

Stage III (severe)

Stage IV (very severe)

Mid third of root

Apical third of root

Grade B (moderate)

Grade C (rapid)

Describe as: Localised (up to 30% of teeth), Generalised (more than 30% of teeth) Molar/incisor pattern

Grading of periodontitis % bone loss / age

Grade A (slow)

<0.5

0.5â&#x20AC;&#x201C;1.0

>1.0

Notes: If a patient has interproximal attachment loss but BPE codes of only 0, 1 & 2, (for example, a previously treated, stable periodontitis patient), and radiographs are not available/justifiable, staging & grading should be performed on the basis of measuring attachment loss in mm from the CEJ and estimation of concomitant bone loss. If a patient is known to have lost teeth due to bone loss likely to have been within the apical third of the root, stage IV may be assigned

1. *Maximum bone loss in percentage of root length.

2. **Measurement in mm from CEJ if only bitewing radiograph available (bone

loss) or no radiographs clinically justified (CAL).

CHAPTER 2

Make this CPD Verifiable

Enhanced CPD guidance

Turn to page 162 to find out how

Here we look in detail at the GDC’s eCPD regulations. Keeping your skills, knowledge and competence up to date throughout your career is at the heart of what it means to be a dental professional. Continuous, lifelong learning and maintenance of skills are commitments you make as a professional to provide safe and appropriate services to the public. Continuing professional development (CPD) for dental professionals is defined in law as ‘learning, training or other developmental activities which can reasonably be expected to maintain and develop a person’s practice as a dentist or dental care professional, and is relevant to the person’s field of practice’. The approach to CPD is not one-size-fits-all for professionals, but needs to be tailored to the individual needs of your role, work setting and your patients. That is why the enhanced CPD scheme is designed to be flexible, so you can plan activity to suit your professional needs, and adapt your activity as required across your cycle. Keeping up to date and engaging in development activities helps assure the GDC and other bodies that you provide dental services safely to the public. This is the key reason for CPD being a requirement of registration. The requirements for the scheme are set out in law, ‘the CPD rules’, which give the GDC powers to act if registrants don’t comply with their obligations.

Summary of requirements Enhanced CPD: Your 5 year cycle must include: Professional

Min hours/cycle

Dentist

100 hours

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This must also include:

1) Your personal development plan (PDP);

2) Your log of CPD activity completed;

3) Documentary evidence (e.g. certificate) from the CPD provider for all

activity completed;

4) An element of reflection.

You must do CPD regularly, at least 10 hours every 2 years and each CPD activity must have at least one of the GDC’s development outcomes. You can log onto eGDC at any time to make your statement for each year. You will be declaring:

• The number of CPD hours you have done in that year;

• That you have kept a CPD record;

• That the activity you have done is relevant to your practice as a professional.

The enhanced CPD scheme is designed to support dental professionals to gain maximum benefit from CPD activities. The plan, do, reflect, record model encourages you to proactively think about your professional needs, field of practice and the Standards for the Dental Team before embarking on CPD activity. In this way, the activity becomes more meaningful and applicable to areas that you have identified to maintain or build on.

Plan The personal development plan (PDP) is used to help you identify your CPD needs for your cycle. You will create a plan for maintaining and developing your skills and knowledge within your field of practice, and how this relates to the GDC’s development outcomes.

Do You will identify the verifiable CPD activity that best meets the professional needs set out in your PDP, and then complete your CPD activity consistently throughout your cycle. You might find that your field of practice or needs change, and you will need to adjust your plan and activity accordingly.

Reflect Reflection is an important process for you to evaluate the impact of your CPD activity on meeting your professional needs for maintenance and development. Taking some time to review and reflect on your activities allows you to assess what benefits you have gained and how you have implemented your learning. After reflecting, you may find that you need to adjust your PDP and activity.

Record You need to record what CPD activity you have completed. A complete CPD record includes your log of activity with development outcomes linked to each activity, your personal development plan, and the evidence you have collected from each activity. You must also submit your annual statement each year to let the GDC know you are keeping up with the requirements of the scheme. You will be notified to make your CPD statement when you get your annual renewal notice, but you can update your statement at any point in the year on eGDC. You may continue to do non-verifiable CPD, however all hours submitted to the GDC must be verifiable. The minimum hours requirement is not designed to drive your planning and activity. You should plan activity around what learning and maintenance needs you have, and for many dental professionals this will go beyond the minimum hours requirement. If you are registered under more than one title, you must do at least the minimum amount of CPD for the title with the highest CPD hours requirement. The CPD you do must include activity that is relevant to your current or intended field(s) of practice under all the titles you hold.

Spreading activity over the cycle It may not be possible for professionals to do CPD in every year of their cycle. However, CPD is more beneficial when spread throughout the cycle, rather than a large amount of activity in a short period of time. To encourage you to do regular activity, there is a requirement for you to do a minimum of 10 hours CPD for every two consecutive CPD years. You must not declare two consecutive years of your cycle with zero CPD. You may have more than one zero hours year for your five year cycle, as long as you are doing at least 10 hours every two years. The evidence you collect from your CPD must match the hours you are declaring for each year in your annual statement, so please ensure you are submitting this accurately. Keeping a CPD record is an important part of maintaining your registration. You must keep a complete CPD record, which is made up of:

• A plan (which the GDC refers to as your personal development plan);

• Your log of completed activity;

• The evidence (e.g. certificates) you have collected from each activity.

The personal development plan (PDP) The PDP gives you the opportunity to think about what CPD will give you maximum benefit for maintaining and developing your practice as a dental professional. At

the beginning of your cycle you will identify your maintenance and learning needs in your field of practice, and how this relates to the GDC’s development outcomes. You can then plan how you will meet these needs through CPD activity regularly across your cycle. Your PDP can be created individually or in conjunction with your peers, your employer/line-manager/commissioner or your wider dental team. Many health professionals find it useful to work with a mentor to develop their learning needs, and the GDC encourages you to build this kind of relationship where possible. An appraisal or learning needs assessment is encouraged to assist in identifying your maintenance and learning needs at the beginning of a cycle. You can also use information derived from patient feedback, complaints, audit, peer review, significant event analysis and processes, or dental practice evaluations, for example, to drive your planning and activity. For the GDC, your PDP must include:

1) The CPD you plan to undertake during your cycle, which must include CPD that

2) The anticipated development outcomes that will link to each activity;

3) The timeframes in which you expect to complete your CPD over your cycle.

is relevant to your current or intended field(s) of practice;

You might find that your field of practice or learning needs change, and so you should adjust your plan and activity accordingly. The GDC encourages you to review your plan annually as it relates to your role and daily work. Please note: The PDP is for your personal use. Having a PDP in place assures the GDC that your CPD activity supports your work as a dental professional. The GDC may ask to see your PDP to check you are keeping records which meet the minimum requirements as set out above. Beyond this, the details about which CPD you plan within the PDP are not evaluated by the GDC. A PDP template is available on the GDC website but you are free to choose any other tools or templates instead, to help you get the most out of your CPD. You may create your own, use one created by your employer, colleagues, associations, professional bodies etc., as long as the GDC’s requirements are met.

The log of completed activity As part of your CPD record for the GDC, you must keep a log of all verifiable activity you have undertaken, which must include the following details:

• The title and description of the CPD activity you completed;

• The date(s) it was undertaken;

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• The number of hours, as shown on the evidence of completion (e.g. certificate)

provided by the course provider. (Breaks and travel time do not count towards

the number of hours of CPD);

• The GDC’s development outcome(s) achieved from each CPD activity.

It should also include a reflective element, or an indication that reflection has taken place.

The evidence required from each activity As part of your CPD record you must also obtain evidence of having completed the CPD activity. The evidence from the provider must include the following details:

• The subject, learning content, aims and objectives;

• The anticipated GDC development outcomes of the CPD;

• The date(s) that the CPD was undertaken;

• The total number of hours of CPD undertaken;

• The name of the professional who has participated in the CPD activity;

• That the CPD is subject to quality assurance, with the name of the person or

body providing the quality assurance;

• Confirmation from the provider that the information contained in it is full and

accurate. It should also include your registration number. In most circumstances, this evidence should come in the form of a certificate, where all the required information is included on one document (this may be a physical or electronic copy). However, in some circumstances and depending on the activity, different forms of evidence may be collected. You must use your professional judgement to determine what evidence you need to demonstrate the activity is verifiable. You must keep all the evidence you collect for the duration of your five year cycle, and for five years after the completed cycle, in case the GDC requests to see your CPD record.

Linking to the Standards for the Dental Team through development outcomes The four development outcomes encourage you to link your learning activity more closely to the standards, and support you to embed the principles further in your working life. You must make sure each planned and completed activity has at least one of the outcomes (A, B, C, or D) linked. Below are the development outcomes and examples of what kinds of CPD might be linked to each. It is possible for some CPD activities to link to multiple outcomes.

A Effective communication with patients, the dental team and others across dentistry, including when obtaining consent, dealing with complaints, and raising concerns when patients are at risk; B Effective management of self and effective management of others or effective work with others in the dental team, in the interests of patients; providing constructive leadership where appropriate; C Maintenance and development of knowledge and skill within your field of practice; D Maintenance of skills, behaviours and attitudes which maintain patient confidence in you and the dental profession and put patients’ interests first.

Reflection The aim of reflection is for you to think about the outcomes of your CPD activity, focussing on what you have learned from the activity and how this influences your daily practice and duties. Reflection is an individual process that has a different meaning and applications for everyone. You should reflect in the way that suits you best. This might be after each individual activity, or more periodically throughout the year. You might like to reflect on your own, or with a mentor, peer or employer. The enhanced CPD scheme is not prescriptive about how you reflect, or how you record that reflection has taken place.

Your end of cycle statement In the final year of your cycle, your annual statement includes:

• A declaration of the total number of hours of CPD you have undertaken in your

• A declaration that you have kept a CPD record;

• A declaration that you have kept a plan (PDP);

• A declaration that the CPD you have completed and recorded is relevant to

• A declaration that your statement is full and accurate.

five year cycle;

your current or intended field of practice;

The start of your CPD cycle depends on the date you first registered with the GDC. Your CPD cycle is always five years long. Tables are available on the GDC website for which CPD cycle you are in, depending on the year you joined the register. You can also log onto eGDC to check what your cycle is. Please note: you will not routinely be asked to provide your CPD record or evidence when making any of your CPD statements. We will request this from you if you have

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not met the requirements of the scheme, if you have failed to make one of your statements, or if you are randomly selected as part of our regular sampling to check that requirements are being met. Prior to 1 January 2022 for dentists and 1 August 2022 for DCPs and depending on where you are in your cycle, you may have to complete CPD based on both the 2008 CPD scheme and enhanced CPD scheme to be compliant at the end of your cycle. A pro-rata approach will be applied, taking into account the requirements of the old and new scheme. You can log onto eGDC where an individual calculation has been done for each dental professional to show you what your specific requirements are over the transition period. For a general idea of how the transition period works check the online transition tool. Once your current cycle ends, you will start the next cycle on the enhanced CPD scheme only. â&#x20AC;&#x192;

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CHAPTER 3 Oral medicine: Lumps and swellings in the mouth

Make this CPD Verifiable Turn to page 162 to find out how

Lumps and swellings in the mouth are common, but of diverse aetiologies and some develop into ulcers, as in various bullous lesions and in malignant neoplasms. Many different conditions, from benign to malignant, may present as oral lumps or swellings including: Developmental: unerupted teeth, and tori–congenital bony lumps lingual to the mandibular premolars (torus mandibularis), or in the centre of the palate (torus palatinus are common causes of swellings related to the jaws. Inflammatory: dental abscess is one of the most common causes of oral swelling. However, there is a group of conditions characterised by chronic inflammation and granulomas, which can present with lumps or swellings. These, include Crohn’s disease, orofacial granulomatosis (OFG), and sarcoidosis, which are discussed below. Traumatic: haematoma may cause a swelling at the site of trauma. The flange of a denture impinging on the vestibular mucosa may stimulate a reactive irregular hyperplasia (denture-induced hyperplasia). Neoplasms: benign epulides, fibrous lumps or malignant tumours such as oral squamous cell carcinoma (OSCC), Kaposi’s sarcoma and other neoplasms may present as swellings. Occasionally, metastatic malignant disease may present as a lump. Fibro‑osseous lesions: fibrous dysplasia and Paget’s disease can result in hard jaw swellings. Hormonal and metabolic: pregnancy may result in a gingival swelling (pregnancy epulis). Drug-induced: a range of drugs can produce gingival swelling – most common are phenytoin, calcium channel blockers and ciclosporin. Allergic lesions: angioedema in particular can cause swellings. Viral lesions: papillomas, common warts (verrucavulgaris) and genital warts (condyloma acuminatum) are all among the lumps caused by human papillomaviruses. 28

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(A) Causes of lumps and swellings according to site Carcinomas and other malignant neoplasms and pyogenic granulomas can present at any site.

(B) Gingiva Sometimes hyperplasia is congenital. Rapidly developing localised lumps, usually associated with discomfort, are most likely to be abscesses, usually a dental abscess. Other localised swellings are usually inflammatory, such as the pyogenic granuloma, or neoplastic. Most generalised gingival swellings are due to hyperplasia with oedema related to plaque deposits, occasionally exacerbated by hormonal changes (puberty, pregnancy) or drugs. Such changes often develop slowly – over weeks rather than days – and are usually without discomfort. There are very few serious causes of generalised enlargements of the gingivae appearing spontaneously or rapidly, but leukaemia is a prime example.

(B) Palate Lumps of the hard palate may develop from structures within the palate (intrinsic) or beyond it (extrinsic). Thus, for example, torus palatinus is an intrinsic bone lesion, whereas a dental abscess pointing on the palate (usually from the palatal roots of the first and second maxillary molars, or from upper lateral incisors) is extrinsic. Unerupted teeth, especially permanent canines, or second premolars are relatively common. Other causes of palatal swellings are uncommon but it should be remembered that the palate is the second most common site (after the parotid) for pleomorphic adenomas and other salivary neoplasms. Invasive carcinoma from the maxillary sinus may produce a palatal swelling. Kaposi’s sarcoma, typical of HIV/ AIDS, may also present as a lump in the palate, or elsewhere. Developing unilateral hard palatal swellings, characteristically disturbing the fit of an upper denture in older patients, may denote Paget’s disease.

(B) Floor of mouth Swellings in the floor of the mouth are more likely to arise from structures above the mylohyoid muscle than below it. The commonest swellings in the floor of the mouth are denture-induced hyperplasia and a salivary calculus. Other lesions producing swellings in this area are a mucocele arising from the sublingual salivary gland (known as ranula because of the resemblance to a frog’s belly) and neoplasms of the sublingual salivary gland (usually malignant), but these are relatively uncommon.

Patients occasionally describe a lump which proves to be a swelling of the lingual aspect of the mandible (more characteristic of ameloblastoma than of dental abscesses or cysts). Swellings of the submandibular salivary gland and adjacent lymph nodes may occasionally be described by patients as being in the floor of the mouth. However, only very large swellings below the mylohyoid muscle are likely to produce a bulge in the mouth. Swellings in the floor of the mouth may inhibit swallowing and have an effect on speech. Mandibular tori produce bony hard swellings lingual to the lower premolars.

(B) Tongue and buccal mucosa Discrete lumps may be of various causes – congenital, inflammatory, traumatic or neoplastic. The tongue may be congenitally enlarged (macroglossia) in, for example, Down syndrome, or may enlarge in angioedema, gigantism, acromegaly or amyloidosis. Causes of swellings include haematomas from trauma (such as occasional biting), infections, angioedema, fibroepithelial polyps, fibrous lumps, mucoceles, vesiculobullous lesions and, occasionally, insect bites. Systemic conditions such as Crohn’s disease, orofacial granulomatosis and, occasionally, sarcoid may produce lip swelling or widespread irregular thickening (cobble-stoning) of the cheek mucosa. Some ‘lumps’ become ulcers, as in various bullous lesions, in primary and tertiary syphilis and in malignant neoplasms. The flange of a denture impinging on the vestibular mucosa may stimulate a reactive irregular hyperplasia – the so-called denture granuloma or denture-induced hyperplasia. Salivary neoplasms in the lip may simulate, but are usually harder than, mucous cysts. Mucoceles are uncommon in the upper lip; discrete swellings there may well be a salivary gland neoplasm.

(A) Diagnosis of the cause of a lump or swelling When patients refer to a lump in the mouth it is important to establish when it was first noticed. The tongue often detects even very small swellings and patients may also notice a lump because it is sore. Most patients have only a passing interest in their mouths but some examine their mouths out of idle curiosity, some through fear (perhaps after hearing of someone with ‘mouth cancer’). Indeed, it is not unknown for some individuals (including dentists!) to discover and worry about the parotid papilla, foliate papillae on the tongue, or the pterygoid hamulus. The medical history should be fully reviewed, and there should be a thorough examination, since some systemic disorders, such as neurofibromatosis, may be associated with intra-oral or facial swellings.

Features of a lump which can be diagnostically useful are:

• The number of lesions, particularly with regard to whether the lesion is

bilaterally symmetrical and thus possibly anatomical

• Alteration in size

• Any discharge from the lesion (clear fluid, pus, blood)

• Duration. Important features to consider when making the provisional diagnosis of the cause of a lump or swelling include:

(B) Position The anatomical position should be defined and the proximity to other structures (eg teeth) noted:

• Midline lesions tend to be developmental in origin (eg torus palatinus)

• Bilateral lesions tend to be benign (eg sialosis – salivary swelling in alcoholism,

diabetes or other conditions)

• Most neoplastic lumps are unilateral.

Other similar or relevant changes elsewhere in the oral cavity should be noted: Size: The size should always be measured and recorded. A diagram or photograph may be helpful. Shape: Some swellings have a characteristic shape which may suggest the diagnosis: thus a parotid swelling often fills the space between the posterior border of the mandible and the mastoid process. Colour: Brown or black pigmentation may be due to a variety of causes such as a tattoo, naevus or melanoma. Purple or red may be due to a haemangioma, Kaposi’s sarcoma or giant cell lesion. Temperature: The skin overlying acute inflammatory lesions, such as an abscess, or a haemangioma, is frequently warm. Tenderness: Inflammatory swellings such as an abscess are characteristically

tender, although clearly palpation must be gentle to avoid excessive discomfort to the patient. Discharge: Note any discharge from the lesion (eg clear fluid, pus, or blood), orifice, or sinus. Movement: The swelling should be tested to determine if it is fixed to adjacent structures or the overlying skin/mucosa such as may be seen with a neoplasm

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Consistency: Palpation showing a hard (indurated) consistency may suggest a carcinoma. Palpation may cause the release of fluid (eg pus from an abscess) or cause the lesion to blanch (vascular), or occasionally cause a blister to appear (Nikolsky sign) or to expand. Sometimes palpation causes the patient pain (suggesting an inflammatory lesion). The swelling overlying a bony cyst may crackle (like an egg-shell) when palpated or fluctuation may be elicited by detecting movement of fluid when the swelling is compressed. Palpation may disclose an underlying structure (eg the crown of a tooth under an eruption cyst) or show that the actual swelling is in deeper structures (eg submandibular calculus). Surface texture: The surface characteristics should be noted: papillomas have an obvious anemone-like appearance; carcinomas and other malignant lesions tend to have a nodular surface and may ulcerate. Abnormal blood vessels suggest a neoplasm. Ulceration. Some swellings may develop superficial ulceration such as squamous cell carcinoma. The character of the edge of the ulcer and the appearance of the ulcer base should also be recorded. Margin. Ill-defined margins are frequently associated with malignancy, whereas clearly defined margins are suggestive of a benign lesion. Number of swellings. Multiple lesions suggest an infective or occasionally developmental, origin. Some conditions are associated with multiple swellings of a similar nature, eg neurofibromatosis.

(A) Investigations The nature of many lumps cannot be established without further investigation.

• Any teeth adjacent to a lump involving the jaw should be tested for vitality,

and any caries or suspect restorations investigated.

• The periodontal status of any involved teeth should also be determined.

• Imaging of the full extent of the lesion and possibly other areas is required

whenever lumps involve the jaws. OPT and special radiographs (eg of the

skull, sinuses, salivary gland function), computerized tomography (CT scans)

or magnetic resonance imaging (MRI), or ultrasound may, on occasions, be

indicated. Photographs may be useful for future comparison.

• Blood tests may be needed, particularly if there is suspicion that a blood

dyscrasia or endocrinopathy may underlie the development of a lump.

• Biopsy is often required, especially if the lesion is single and chronic, since it

may be a neoplasm or other serious condition.

(A) Chronic granulomatous conditions There are a number of conditions which present as chronic swellings or lumps, and on biopsy have histological evidence of non-caseating epithelioid cell granulomas. These conditions include orofacial granulomatous, Crohn’s disease, and sarcoidosis.

(B) Orofacial granulomatosis Orofacial granulomatosis (OFG) is an uncommon but increasingly recognised condition, seen mainly in adolescents and young adults, which usually manifests with facial and/or labial swelling, but which can also manifest with angular stomatitis and/or cracked lips, ulcers, mucosal tags, cobble-stoning or gingival swelling. Some patients with similar features have, or develop, gastrointestinal Crohn’s disease or sarcoidosis. The aetiology of OFG is unknown but in some there is a postulated reaction to food or other antigens (particularly to additives/preservatives such as benzoates or cinnamaldehyde), or metals such as cobalt. Most patients appear to develop the problem in relation to dietary components such as chocolate, nuts, cheese or food additives. Conditions related to OFG include Miescher cheilitis, where lip swelling is seen in isolation, and Melkersson-Rosenthal syndrome, where there is facial swelling with fissured tongue and recurrent facial palsy. Diagnosis is clinical, supported by blood tests, endoscopy, imaging and biopsy to differentiate from Crohn’s disease, sarcoidosis, tuberculosis and foreign body reactions. Specialist care is usually indicated. Management is to eliminate allergens such as chocolate, nuts, cheese, cinnamaldehyde or food additives and treat lesions with intralesional corticosteroids or occasionally systemic clofazimine or sulfasalazine.

(B) Crohn’s disease Crohn’s disease is a chronic inflammatory idiopathic granulomatous disorder. Many causal factors have been hypothesised but not proved. Crohn’s disease affects mainly the small intestine (ileum) but can affect any part of the gastrointestinal tract, including the mouth. About 10% of patients with Crohn’s disease of the bowel have oral lesions. Oral lesions may be seen in the absence of any identifiable gut involvement and are the same as those seen in OFG – reddish raised lesions on the gingiva, hyperplastic folds of the oral mucosa (thickening and folding of the mucosa producing a ‘cobblestone type’ of appearance, and mucosal tags), ulcers (classically linear vestibular ulcers with flanking granulomatous masses), facial swelling and angular cheilitis. There may also be features of gastrointestinal involvement, such as abnormal bowel movements, abdominal pain, rectal bleeding or weight loss.

Diagnosis is by oral biopsy, haematological, gastrointestinal and other investigations may be required in suspected Crohn’s disease especially to exclude sarcoidosis. Specialist care is usually indicated. Histologically, the epithelium is intact but thickened, with epithelioid cells and giant cells surrounded by a lymphocytic infiltration. Management is by topical or intralesional corticosteroids which may effectively control the oral lesions but more frequently systemic corticosteroids, azathioprine or salazopyrine are required.

(B) Sarcoidosis Sarcoidosis is a multi-system granulomatous disorder, of unclear aetiology, which most commonly affects young adult females, especially Afro-Caribbeans. It typically causes bilateral hilar lymphadenopathy, pulmonary infiltration and impaired respiratory efficiency, skin and eye lesions, but can involve virtually any tissue. Because of its vague and protean manifestations, sarcoidosis appears to be underdiagnosed. Gingival enlargement, or oral swellings may be seen but sarcoidosis can involve any of the oral tissues and has a predilection for salivary glands, causing asymptomatic enlargement of the major salivary glands and some have xerostomia. The association of salivary and lacrimal gland enlargement with fever and uveitis is known as uveoparotid fever (Heerfordt’s syndrome). The most helpful investigations include:

• Chest radiography (for enlarged hilar lymph nodes)

• Raised levels of serum angiotensin-converting enzyme (SACE) in acute disease

• A positive gallium or PET scan of lacrimal and salivary glands

• Labial salivary gland biopsy (for histological evidence of non-caseating

epithelioid cell granulomas).

Patients with sarcoidosis but only minor symptoms often require no treatment. If there is active ocular disease, progressive lung disease, hypercalcaemia, or cerebral involvement or other serious complications, corticosteroids are given. Patients to refer include suspected malignancy in neck including lymphoma, suspected metastatic disease in neck, and unexplained lymphadenopathy.

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CHAPTER 4

Make this CPD Verifiable

Mouth cancer diagnosis

Turn to page 162 to find out how

Mouth cancer theoretically should be largely preventable or detectable at an early stage. Dental training equips dentists and other dental clinicians with the best way to diagnose oral disease and the importance of the history and examination are stressed in training. There is evidence that education helps diagnostic outcomes not only of oral but also orofacial disease. In the UK, only 25.2% of GMPs but 54.1% of GDPs in one study felt that they had sufficient knowledge regarding detection and prevention of mouth cancer. Failure to diagnose oral cancer has led to GDC disciplinary action in the UK and already is the second highest cause of dental malpractice in the USA.

Diagnosis Clinical diagnosis of an early cancer can be quite straightforward if the clinician has adequate level of awareness and suspicion, but potentially malignant disorders (PMDs) that are likely to transform are far more difficult to decide upon. Lesions in ‘high risk’ patient groups should be regarded with especial care but it is dangerous not to consider a diagnosis of cancer just because a patient is apparently not in such a ‘risk group’.

Why is early cancer diagnosis important? Early diagnosis of mouth cancer is important mainly in order to improve the prognosis and minimise the adverse effects of treatment. Early, localised tumours with no spread to the cervical lymph nodes can be effectively treated and cured, with 5-year survival rates around 80%. When cervical lymph nodes are involved, 5-year survival falls to less than 20%. Delayed diagnosis may also result in poor quality of life, mainly from maxillofacial deformity, disturbances in speech, mastication and swallowing. There is often still a mean delay of around 3 months during the cancer journey. Delays are associated with up to a 3-fold increase in mortality.

Diagnostic delays Patients may delay seeking professional advice after having become aware of any oral symptom that could be linked to oral cancer, and diagnosis is often delayed by up to 6 months, even in developed countries, despite exhortations over the past 25 years to increase the index of suspicion. Delays are common in many different countries but are generally longer in:

• Heavy smokers

• Heavy alcohol drinkers

• People of lower socio-economic status (SES);

• Males. The reason for a patient to be diagnosed with advanced disease can be related to delays in recognition of the disease, delayed referral to the appropriate healthcare worker, or to system delays. Late stage diagnosis is mainly because of a lack of patient awareness related to socioeconomic status/education or cognitive function, rather than because mouth cancer is hard to discover. Many patients think that their symptoms of many diseases are trivial, will get better by themselves and give little thought as to whether it might be serious. Patients frequently know little or nothing about the disease. Nevertheless, healthcare systems should endeavour to minimise delays, which may include the patient’s delay in seeking medical care, limited access to a doctor or a dentist, misdiagnosis in primary care, referral delays, or mismanagement in diagnosing and treating the patient once he/she attends the referral centre. Simple, clear, failsafe, fast-track referral schemes may diminish the delay. The identification of a ‘scheduling delay’ in mouth cancer justifies additional educational interventions aimed at the whole healthcare team as well as at dental and medical practices. Diagnostic delays in primary care account for a minority of these cases but are potentially modifiable. Clinicians need to be aware of several different factors when assessing the risk for oral cancer, including the changing epidemiology of mouth cancer, the role of HPV and new trends in tobacco consumption, for example the increasing use of waterpipes. Opportunistic screenings would yield earlier discovery by healthcare professionals. Dental practitioners and dental care professionals should remain vigilant for signs of potential malignant disorders (PMD) and oral cancer whilst performing routine oral examinations.

What features are suggestive of mouth cancer? Dental clinicians are all trained in careful inspection, examination and palpation of all the oral tissues - Conventional Oral Examination (COE) - and regional (cervical) lymph nodes.

Early mouth cancer, such as oral squamous cell carcinoma (OSCC), may be symptomless, with no pain or other symptoms. The patient may eventually notice mild symptoms, such as a persistent lesion or ulcer that does not heal within a couple of weeks. Any single lesion that cannot be wiped off the mucosa and persists more than 3 weeks, particularly if:

Red

Ulcerated

Lump

Especially with induration (a firmness on palpation)

- the acronym RULE - should be regarded with suspicion and a histopathological

diagnosis established by biopsy examination.

Other features that may be suggestive of OSCC are any persistent:

• Red lesion (erythroplasia or erythroplakia)

• Mixed red/white lesion (erythroleukoplakia)

• Nodular white lesion (verrucous leukoplakia)

• Lump

• Ulcer with fissuring or raised exophytic margins

• Pain or numbness

• Abnormal blood vessels supplying a lump

• Loose tooth

• Extraction socket not healing

• Induration, i.e. a firm infiltration beneath the lesion

• Fixation of lesion to deeper tissues or to overlying skin or mucosa

• Regional lymph node enlargement

• Dysphagia

• Weight loss.

If any of these changes are noticed, help should be sought from a dentist, doctor, or another healthcare professional without delay. The dentist is usually the person best trained in early diagnosis of mouth issues. However, early lesions can lack these warning features. Characteristics of oral cancer in the asymptomatic early lesion include:

• Granular or smooth surface 82%

• No elevation (with <1 mm) 80%

• No ulceration 85%

• No bleeding 98%

• No induration 90%. 40

“So glad I had Traxodent retraction paste for this case!” Dr. Timothy Bizga describes how he successfully used Traxodent® Hemodent® Paste Retraction System to help capture an outstanding final impression By: Timothy M. Bizga, DDS, FAGD The pre-operative situation. Tooth No. 20 had root canal therapy and a large composite build-up. A full coverage crown was recommended, and the patient agreed. Because of the size of the build-up I was certain that a subgingival preparation would be needed and adequate tissue management for a good impression.

Occlusal view of the completed preparation on tooth No. 20. Based on the amount of sulcular fluid and blood, tissue management and hemostasis was needed. Although much of the preparation ended up being equi-gingival, there were some areas of the marginal gingiva that were traumatized during the procedure to ensure clean margins on sound tooth structure.

Traxodent paste in-place. Traxodent retraction paste was dispensed around the tooth. Even with careful dispensing, more bleeding is seen from the surrounding inflamed tissue.

Other lesions can mimic carcinoma. Occasionally, pyogenic granulomas or similar less serious lesions can clinically and histologically mimic OSCC. The main differential diagnoses for OSCC include PMD; other malignant diseases such as lymphomas, sarcomas and metastases, which grow rapidly as opposed to a typical OSCC; salivary neoplasms; and chronic infections, such as syphilis, tuberculosis, or histoplasmosis. It should also be noted that clinically differentiating PMD and OSCC from benign lesions can be taxing, even for highly trained professionals. Not uncommonly, PMD and OSCC are asymptomatic, and appear innocuous and some can be overlooked. Thus fewer than 27% of leukoplakias, a common PMD, are ever subjected to biopsy. As discussed above, even biopsy can leave cancers undetected in PMD. As a result, some OSCC must surely mistakenly remain untreated and be left to progress to more advanced stages of cancer. A high index of suspicion is clearly indicated.

What are essential for diagnosis? Dental practitioners and dental care professionals should always be vigilant for signs of potentially malignant disorders (PMD) and mouth cancer whilst performing routine oral examinations. Red, white, ulcerated lesions or lumps are the common presentations of OSCC. A high index for suspicion is warranted. Red oral lesions usually are more dangerous than white oral lesions. Diagnosis is from these clinical features, always supported by biopsy.

What are the essentials of physical examination? Dental practitioners and some other clinical dental care professionals are trained in the examination (inspection and palpation) of the mouth. Dentists are trained to spot early signs of mouth cancer and can easily examine with a good dental light, dental mirror and good retraction, parts of the mouth difficult for the person or others to see, so annual examinations by a dentist, even if the person is edentulous, are advised. All areas should be scrutinised using a good light and retraction and these are best available in a dental practice setting. Lesions always must be palpated after inspection to detect induration and fixation to deeper tissues. Examine the entire mucosa because widespread dysplastic mucosa (field change) or a second neoplasm (see ‘Staging’) may be present. Carefully record the location of suspicious lesions, preferably on a standard topographic diagram. As recommended (Ogden, 2013), ‘The screening of all oral mucosal surfaces should be carried out (and recorded) every time a patient attends and be practice policy (and open to audit to ensure it’s done). Dentists and DCPs should identify patients who are at increased risk of mouth cancer. One way is through the use of medical history sheets that include lifestyle questions.’ Therefore, to increase the chance of early diagnosis, it is important for yearly 42

examinations to be carried out by a clinical dental professional. The patient should be aware of what is normal for them, keep an eye out for any changes, and seek advice from a dentist or clinical dental professional or GMP if they suspect anything out of the ordinary. Early referral to a specialist with oral surgery or oral medicine competence is advised. Bear in mind that:

• A typical malignant ulcer is hard with heaped-up and often everted or rolled

• The most common sites of mouth cancer include the lower lip, the lateral

• Most lip cancers manifest on the lower lip at the mucocutaneous junction as a

edges and a granular floor margin of the tongue, and the floor of the mouth chronic small lump, ulcer, or scabbed lesion

• Intra-oral cancer can have a highly variable clinical appearance mainly a

• Most intra-oral cancers manifest on the middle third of the lateral margins of

red or white area, ulcer, lump or fissure the tongue with an erythroplastic component and, sometimes, induration

• Late tongue cancer may manifest as an exophytic lesion, an ulcer, or an area

• The sump area or ‘coffin corner’ at the posterior tongue/floor of the mouth is a

of superficial ulceration with induration

common site for cancer but may be missed by cursory inspection; special care

is needed to ensure close examination.

The floor of the mouth is the second most common intra-oral site for cancer and more commonly is associated with leukoplakia. Most cancer arises in the anterior floor of the mouth as an indurated mass that soon ulcerates, resulting in slurring of speech;

• Carcinomas of the alveolus or gingiva are mostly seen in the mandibular

premolar and molar regions, usually as a lump (epulis) or ulcer. The underlying

alveolar bone is invaded in 50% of cases, even in the absence of radiographic

changes, and adjacent teeth may be loose

• Carcinomas of the buccal mucosa are mostly seen at the commissure or

in the retromolar area. Most are ulcerated lumps, and some arise in candida

leukoplakias

• Carcinomas can affect the palate or elsewhere.

Examine the teeth and periodontium in good lighting: advanced caries, periodontal disease, or periapical lesions may need early attention, especially if radiotherapy is to be used in management of a tumour. The presenting features of mouth cancer usually relate to local effects of the primary tumour, and only occasionally to regional spread, metastatic disease, or paraneoplastic phenomena.

What are the latest oral diagnostic methods? A Conventional Oral Examination (COE) with white light (‘incandescent light’) (visual and palpation examination) as above, still constitutes the gold standard for the diagnosis of oral pre-cancer and cancer. There is no doubt that clinician education improves the diagnostic skills and that experience counts. However, a range of potential diagnostic aids is appearing on the market, or in the literature, and these include:

• Vital (toluidine blue) staining

• Exfoliative cytology/brush biopsy

• Autofluorescence spectroscopy/imaging

• Chemiluminescent illumination

• Narrow band imaging

• Confocal microscopy.

Analysis of the evidence thus far of the adequacy of diagnostic aids has shown that there is insufficient evidence that:

• Commercial devices based on autofluorescence enhance visual detection

• Commercial devices based on tissue reflectance enhance visual detection

beyond a conventional visual and tactile examination beyond a conventional visual and tactile examination

• Transepithelial cytology can assess the validity of seemingly innocuous

mucosal lesions.

Vital (toluidine blue) staining Vital staining using the dye toluidine (tolonium) blue has been available for at least 50 years but is insufficiently specific or sensitive, a problem faced by virtually all such ‘aids’.

Exfoliative cytology/brush biopsy This technique of transepithelial cytology is also insufficiently specific or sensitive but in future may be used with modern techniques, such as DNA Image Cytometry (DNAICM), DNA analysis (aneuploidy), MALDIToF MS (Matrix-Assisted Laser Desorption/ Ionization Time of Flight Mass Spectrometry) or Peptidome profiling.

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Autofluorescence spectroscopy/imaging Autofluorescence spectroscopy/imaging is available as, for example: DentLight Oral Examination (DOE); Sapphire plus and VELscope. Early studies suggest promise in this area but, meantime, until the evidence base improves, COE plus biopsy, despite limitations, remains the gold standard.

What about cancer screening? Cancer screening means testing people for early signs of cancer before they show any symptoms. At first sight it sounds an excellent and attractive proposition. However, an effective and accurate test is needed, reliable at detecting cancers but not giving false positive results in people who have no cancer, nor false negative results when cancer is present. Screening can also be expensive; it is most cost-effective to screen people who have an increased (high) risk of developing cancer (typically older people of low SES with exposure to known cancer risk factors), but of course it is often those groups who do not avail themselves of the opportunities for early detection. There is therefore currently no UK national screening programme for mouth cancer because these cancers are also uncommon and the Cochrane Library (2010) determined that currently there is insufficient evidence to show that a screening programme for mouth cancer can help detect mouth cancers earlier, and concluded that there is insufficient evidence to recommend screening of the general population for OSCC, either by using visual examination or adjunctive tools (eg toluidine blue, brush biopsy, fluorescence imaging) to decrease mortality. Those authors recommended regular screening by visual inspection by qualified healthcare providers for high-risk groups. In a recent study, high-risk groups with tongue OSCC were:

• Age >80

• Widowed

• Socially marginalised

• A current smoker, or

• A smoker-heavy drinker.

Risk factors in people with floor of mouth cancer were being: age >70 and socially marginalised. Having a regular dentist was protective.

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CHAPTER 5

Make this CPD Verifiable

Medical emergencies – defibrillators to the rescue

Turn to page 162 to find out how

Of the 30,000 out-of-hospital cardiac arrests that happen in the UK each year, 80% take place at home and 20% cent in public places, which includes dental practices. Here we take a look at the crucial importance of defibrillators in helping survival. Cardiac arrest can happen to almost anyone at any time and with approximately 100 incidents a day in the UK alone these can take place in young and old, fit and poorly, at work, at school, playing sport, sitting down… the circumstance are as endless and they are unpredictable. Which is why access to a defibrillator can prove crucial to the survival of the sufferer. It is vital that anyone experiencing a cardiac arrest receives immediate and appropriate treatment using cardiopulmonary resuscitation (CPR) and an automatic external defibrillator (AED). Being prepared for such an eventuality is covered in the General Dental Council’s Scope of Practice (2013): ‘A patient could collapse on any premises at any time, whether they have received treatment or not. It is therefore essential that ALL registrants are trained in dealing with medical emergencies, including resuscitation, and possess up to date evidence of capability’.

Effects of defibrillation Administering defibrillation within 3–5 minutes of collapse can produce survival rates as high as 50–70%. Dental practices are therefore encouraged to have an AED on the premises. In the event of a cardiac arrest in a dental practice, while calling 999 for an ambulance, a colleague should be sent to fetch the AED and resuscitation equipment whilst starting chest compressions. Each minute of delay before defibrillation reduces the probability of survival by 10%, meaning that hundreds of people are alive today entirely due to the prompt and appropriate use of one. AEDs are now easily accessible at numerous locations; train and tube stations, shopping centres, dental and GP practices, sports grounds, leisure centres… and are available for the general public to use. They can be semi-automatic (you still need to press the shock button when indicated) or fully automatic (the machine shocks automatically when a shock is advised).

Defibrillators are absolutely vital in their ability to bring someone back following a cardiac arrest. CPR keeps the heart and brain full of oxygenated blood and acts as a life support machine; however, it is the AED that enables the heart to be shocked back into sinus rhythm. These two interventions together give the casualty the very best chance of survival. Cardiac casualties are likely to remain in a highly unstable state and may well require further shocks so it is best not to remove the defibrillator pads even when they appear to have recovered, as the defibrillator may be needed again and there may be a limited number of pads immediately available.

How a defibrillator works A defibrillator should only be used when someone is unconscious and not breathing. The working basis is the administration of an electric shock to stop the heart, with the intention of enabling the heart’s own system to ‘reboot’ and in doing so to restart its own sinus rhythm. The machine analyses the heart rhythm of the casualty, only allowing a shock to be given if they are in a shockable rhythm. It is not possible to override this with an AED and if a shock is not advised you should continue to give CPR until the ambulance arrives. Ensure the team are all competent and confident in performing the best possible CPR – pushing down 5-6 cms on the centre of the chest at a rate of about 2 compressions per second and ensuring a release from pressure in between compressions - to enable the heart to refill.

Shockable rhythms An AED will only allow the administration of a shock when someone is in ventricular fibrillation (VF) or ventricular tachycardia (VT). VF causes the casualty to become unconscious and stop breathing. It is a shockable rhythm and if a defibrillator is used promptly there is a strong chance that stopping the heart with the shock will allow it to restart in a normal rhythm. The longer someone remains in VF the less likely it is that their heart will restart normally. If an area of heart muscle is damaged due to a heart attack, the casualty may well survive, depending where the damage occurs and how much heart muscle is lost. Because the heart has so many back-up systems, even if one of the pacemakers is damaged, the heart itself may still be able to generate sufficient electrical impulses to contract. The heart comprises cells capable of independently generating impulses; the two pacemakers work together initiating the correct impulses and ensuring that the heart beats to a fairly regular rhythm. When an area of heart muscle is damaged it becomes unstable and often fires off its own impulses independently and this interferes with the co-ordinated rhythm generated by the pacemakers. This misfiring affects the rhythm of the heart and causes it to become irregular. If the heart experiences a ‘misfiring’ beat at the point

when the cells are re-charging, this can upset the whole system and the different cells fire independently of each other causing the heart to quiver erratically and chaotically. This is known as ventricular fibrillation and whilst the heart is shaking instead of pumping, it is incapable of effectively circulating the blood around the body. VT is another shockable rhythm. In this, the heart rate has become so fast that the chambers are incapable of refilling and so there is little or no blood being pumped around the body. If the casualty is unconscious and not breathing a defibrillator can be used which will stop the heart and hopefully re-start a normal rhythm.

Asystole – Flat-lining. This is too late for a defibrillator as the heart has run out of oxygen and is now still. Personal checklist:

• Danger – do not put yourself in danger

• Response – if no response, shout for help and if possible get a bystander to call

• Airway – open the airway and check for breathing

• Breathing – If the casualty does not appear to be breathing normally and

for an ambulance and locate a defibrillator if there is one

there are less

• than two breaths in a 10 second period you will need to start CPR

• If you are on your own – call 999/112 and get the AED as quickly as possible

• If you have help – the bystander will need to let the emergency services know

that the casualty is unconscious and not breathing and bring the AED as

quickly as possible. Continue CPR whilst waiting for the defibrillator.

When the AED arrives As soon as the AED arrives it should be activated (usually done just by opening the lid, or pressing an obvious button). It will then start speaking to you. If there are two of you, one should continue with the CPR, whilst the other, attaches the leads to the AED (if necessary) dries the chest (and shaves them if necessary) and places the pads on the chest as per the diagrams (Figure 1).

• The backing should be peeled off the back one at a time and placed onto

the dry chest according to the accompanying diagram.

• Place one pad below the casualty’s right collar bone

• Place the other on the casualty’s left hand side, over their lower ribs.

• (If you realise you have put the pads on the wrong way round – do not

remove them as the AED will still work fine. The AED may offer a trace that appears upside down but this will not affect the functioning of the device)

• The AED will analyse the heart rhythm. Stop CPR when instructed and ensure

no one is touching the casualty.

If a shock is advised:

• Check the whole length of the casualty to ensure no one is touching them.

Loudly shout ‘stand clear’ ¾ Press the flashing shock button as directed (fully automated AEDs will do this automatically once a shock is advised)

• Continue with CPR as directed

• Keep going with 30 compressions to 2 breaths (Keep any time off the chest to

• Do not stop to check them unless they begin to regain consciousness and

an absolute minimum) start breathing normally

• The machine will reassess their heart rhythm every 2 minutes and advise

another shock if indicated.

If no shock is advised:

• Continue with CPR and follow prompts

• Keep going until help arrives, you are too exhausted to continue, or the

• The machine will reassess their heart rhythm every 2 minutes and advise a

casualty begins to regain consciousness and starts to breathe normally shock if indicated

• If there is more than one rescuer swap every couple of minutes.

When the paramedics arrive they will need to know what happened, how long you have been doing CPR, whether a shock was advised by the AED and if so, how many shocks have been given.

Items to keep with your defibrillator: • Spare pads • Paediatric pads • Resuscitation mask • Tough scissors to cut through clothes • Gloves • A towel • A razor to remove excessive chest hair. 52

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Safety considerations when using an AED:

• Electric Shock – The risk of electric shock from an AED is extremely small.

Providing the chest is dry and the pads are well stuck, there is little chance

of the charge arcing and causing a problem. However it is always sensible to

check no one is touching the casualty when the shock is given

• Jewellery – avoid placing the pads over metal jewellery as it can conduct

electricity and burn the casualty. Jewellery does not need to be removed

• Ensure the casualty is still when the AED is analysing the rhythm, to avoid an

inappropriate rhythm assessment

• Switch off vehicle engines and vibrating machinery if possible

• Medication patches – remove any obvious patches on the casualty’s chest

and do not place pads over them. Some heart patients wear GTN (glyceryl

tri-nitrate) patches and these would explode if a shock was passed over them

• Implanted devices – most pacemakers are on the left hand side of the chest.

Don’t place pads over strange bumps or scars

• Flammable atmosphere – turn off oxygen when giving the shock, do not use

in the presence of petrol fumes.

Using a defibrillator on a child Some defibrillators have a switch or key that adapts it for child use. If you have a child over the age of one year who needs a defibrillator, but only have adult pads available – adult pads can be used with one on the front of the child’s chest and the other placed directly opposite, on the centre of their back. If it is a baby that needs resuscitating, you must use paediatric pads or the paediatric capability.

AED signage All clinical dental areas should have immediate access (within the first minutes of a cardiorespiratory arrest) to oxygen, resuscitation equipment for airway management including suction, and an automated external defibrillator (AED). The standard AED sign should be used in order to reduce delay in using a defibrillator in an emergency (Figure 2).

Maintenance of the AED:

• Follow the manufacturer’s recommendations for the maintenance of the

AED. It should be kept in a prominent place and everyone in the building

should have easy access to it and know where it is kept

• Check the expiry date for the battery and pads and order replacements in

good time

• Spare pads and a battery are highly recommended

• Most AEDs have warning lights and alarms to alert you if there is a malfunction

or if the battery is running low

• Some have a gauge that indicates battery charge. Ideally the AED should be

• Most units have a battery life of around 5 years.

briefly checked daily to ensure it is in good working order in case you need it

After the emergency: Ensure appropriate paperwork and accident forms are completed and that there is a written log of all the emergency treatment and any drugs given (including oxygen) Restock anything that has been used Ensure that everyone is ok afterwards and make time to talk things through Dealing with a medical emergency can be extremely stressful and some people need professional help and counselling following such an episode. It is perfectly normal to feel any of the following:

a) A feeling of elation and an adrenaline buzz

b) Anger

c) Confusion

d) Flashbacks and bad dreams

e) Depression

Figure 1 - Placing the defibrillator pads

Figure 2 The standard defibrillator signage

A guide to resuscitation and emergency life support Cardio-respiratory arrest is rare in primary dental practice. However, it is essential that all dentists and dental care professionals are competent in treating it. A patient could collapse on any premises at any time, whether they have received treatment or not. It is therefore essential that ALL registrants are trained in dealing with medical emergencies, including resuscitation, and possess up to date evidence of capability. (Quality standards for resuscitation published by the Resuscitation Council (RCUK))1. The RCUK’s Chain of Survival (Figure 1) describes a sequence of steps that together maximise the chance of survival following cardiac arrest.

• The first link in the chain is the immediate recognition of cardiac arrest and

calling for help.

• The second is the prompt initiation of CPR.

• The third is performing defibrillation as soon as possible.

• The fourth is optimal post resuscitation care.

Like any chain, it is only as strong as its weakest link, so if one stage is weak the chances of successful resuscitation are compromised. Heart attack and cardiac arrest mean different things. Although ‘heart attack’ is often used to refer to a sudden cardiac arrest, this is incorrect. A heart attack (or myocardial infarction) occurs when an artery supplying the heart with blood becomes blocked. This usually causes chest pain and leads to damage to some of the muscle of the heart. It may cause cardiac arrest, particularly in the early stages, but this is not inevitable. The risk of cardiac arrest, however, emphasises the importance of calling for immediate help if anyone is suspected of having a heart attack, so that they can receive treatment to reduce the damage to their heart and reduce the risk of a cardiac arrest occurring. Cardiac arrest means that the heart has stopped pumping blood around the body. This may occur for many reasons, but loss of the electrical coordination that controls the normal heartbeat is usually responsible. The most likely cause is ventricular fibrillation, in which the normal orderly electrical signal that controls the heartbeat becomes completely disorganised and chaotic, and the heart is unable to act as a pump. Ventricular fibrillation can be treated with a defibrillator that delivers a high energy shock to restore the heart’s normal rhythm. The RCUK describes how to do ‘Hands-only CPR’ as a general measure and we describe this in greater detail below in the dental setting.

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When somebody collapses in front of you, what do you do?

1) Check the person over. If they are not responsive and not breathing, then their

heart has stopped working and they are having a cardiac arrest.

2) Now, call 999. Then you do Hands-only CPR.

3) Lock your fingers together, knuckles up. Then push down, right on the chest.

Push down five or six centimetres. That’s about two inches. Push hard and fast

about two times a second, like to the beat of the song Stayin’ Alive. Don’t worry

about hurting someone. A cracked rib can be mended – just concentrate on

saving a life.

4) Keep this up until the ambulance arrives.

In the dental setting, accurate and up-to-date medical histories should allow those most at risk of a medical emergency to be identified in advance of any proposed treatment. Dental practitioners and other dental care professionals must be trained in cardiopulmonary resuscitation (CPR) so that in the event of cardiorespiratory arrest occurring they can:

• Recognise cardio-respiratory arrest

• Summon help immediately (dial 999)

• Start CPR, using chest compressions and providing ventilation with a pocket

mask or bag-mask device and supplemental oxygen. (Evidence suggests that

chest compressions can be performed effectively in a fully reclined dental

chair).

• Attempt defibrillation (if appropriate) within 3 minutes of collapse, using an

• Provide other advanced life support skills if appropriate and if trained to

Automated External Defibrillator (AED)

do so. Additionally, all dental professionals who work with children should learn how CPR in adults differs between children and adults and practise on paediatric mannequins. With other staff at their surgeries or clinics they should update their knowledge and skills in resuscitation at least annually. A system must be in place for identifying which equipment requires special training, (such as AEDs, bag-mask devices and oropharyngeal airway insertion) and for ensuring that such training takes place. All new members of dental staff should have resuscitation training as part of their induction programme.

Automated external defibrillator (AED) It is recommended that all dental practices should have immediate access to an AED (Figure 2). All AEDs are suitable for use in adults and children. If a casualty appears to be unconscious, there is a clear protocol as to what to do, beginning with the Primary Survey which is a fast and systematic method of finding and treating any life-threatening conditions in order of priority:

• Remove danger

• Check for response

• Open the airway

• Check for breathing.

If the patient is unconscious and breathing properly – at least 2 normal breaths in a 10 second period - then put them in the recovery position. If they are not breathing normally, or you are unsure – start CPR. For a baby or child: If you are on your own, you should perform 1 minute’s CPR before phoning for an ambulance (5 breaths, 30 compressions :2 breaths, 30:2 is about a minute). For an adult phone for an ambulance as soon as you realise that they are unresponsive and not breathing. An adult who collapses is more likely to have a heart problem and need a defibrillator and advanced life support while a child is more likely to have a breathing problem and your immediate intervention with mouth-to-mouth could bring them round. If there is someone else available, they should call for an ambulance as soon as it is established whether or not the person is breathing. If they are not breathing, get the defibrillator immediately. Using the defibrillator early in the procedure dramatically increases the patient’s chances of survival. When you are resuscitating someone, you become their life support machine. By pushing on their chest, you are their heart and by breathing into them, you are their lungs. You are keeping their heart and brain full of oxygenated blood and keeping them alive. When an adult collapses and is assessed as unresponsive and not breathing; they are likely to still have residual oxygenated blood remaining in their system. However, their heart is no longer working effectively, and it is therefore important to quickly circulate the oxygenated blood in their system to sustain the blood supply to their heart and brain, by pushing hard and fast on their chest.

Resuscitation

• Push hard and fast on the centre of their chest

• Push down to a depth of 5-6 cms – roughly a third of their chest

• At a rate of 115 - 120 beats per minute – roughly 2 per second

• Do 30 compressions then…to give someone the best chance, you will

need to: 59

• Tilt the head and lift the chin to take the tongue off the back of the airway,

hold their nose

• Give 2 breaths – sealing your mouth around their mouth and blowing into

them like a balloon.

Make sure their chest rises each time - if it doesn’t - try tilting the head a bit more. If it still doesn’t rise, go straight back to the compressions. Research has shown that it takes around 10 -12 compressions to reach sufficient pressure to get the blood circulating to the heart and brain, this is why it is advised that you do 30 compressions and then 2 short breaths to top up their oxygen. Use a face shield or pocket face mask to protect yourself. If you are trained in the use of airway adjuncts and a bag and valve mask (BVM) this is preferable to mouth to mouth. Keep going – you are being a life support machine and keeping them alive. Do not expect them to come back to life until the paramedics are there to help. Therefore, don’t stop to check for signs of life, just keep going, unless it is very obvious that there are signs of life. Use the AED machine as soon as possible. Deploying thus within 3 minutes if someone is unconscious, not breathing and in a shockable rhythm has been shown to increase the chances of survival from 6% to 74%. For every minute’s delay over that 3 minutes, the chances decrease by 10%. Ensure everyone in the practice knows where the AED is kept and how to use it. If there is someone to help, do cycles of compressions and breaths and swap every 2 minutes. One person should be responsible for the compressions and the breaths (unless you are using a bag and valve mask) – you should give 30 compressions to 2 breaths. When swapping compressions, aim to minimise the time when no one is pressing on the chest. When the 30 compressions have been completed, the person swapping out should complete their 2 breaths, whilst the person taking over gets into position to commence the chest compressions. Swapping every 2 or 3 minutes will maximise the effectiveness of the chest compressions and give time for those giving the compressions to recover before recommencing. CPR is hard work. If you are using a BVM ensure you are squeezing steadily and not over ventilating them.

When to stop:

• If you are too tired to continue

• When the paramedics have taken over

• Whilst the defibrillator is analysing the heart rhythm and if a shock is advised. Be

ready to recommence as soon as the shock has been given.

You should continue CPR until it is obvious the patient is breathing normally.

CPR on a child or baby Do 5 rescue breaths before you start compressions and phone an ambulance if on your own, after completing one minute’s CPR. Start with 5 rescue breaths to reoxygenate them as children do not retain residual oxygen in their system as adults do. It is also far more likely that they have experienced a respiratory arrest. Carefully tilt the head and lift the chin to open the airway, then give 5 rescue breaths to re-oxygenate them. Do not tilt a baby’s head too far back - just to horizontal is sufficient; over extending a baby’s airway can occlude it. For a baby, seal your mouth around their mouth and nose if you can fit your mouth over both and blow into them gently with a puff of your cheeks. For a child you can blow a little harder, just enough to inflate their lungs. If you overinflate them you will fill the stomach with air, which can displace its contents. Be ready with suction if they begin to gurgle.

• You will then need to circulate the oxygenated blood by pushing down hard

and fast on their chest. For a child use one hand, for a baby use two fingers or

thumbs:

• Push hard and fast on the centre of their chest – roughly between the nipples

• Push down by a third of the depth of their chest at a rate of 110 -120 beats

per minute – roughly 2 per second.

After about 30 compressions you will need to give them 2 more short breaths and then continue with the compressions again. 30:2:30:2:30:2… 1. www.resus.org.uk

Figure 1

Figure 2

The Resuscitation Council’s chain of survival

An example of an AED

CHAPTER 6

Make this CPD Verifiable

Recent changes in dental x-ray equipment regulations

Turn to page 162 to find out how

On 1 January 2018 Ionising Radiations Regulations 2017 (IRR17) replaced IRR99. Several subtle but important changes have taken place recently in regard to the use of dental x-ray equipment with respect to patient safety. A patient is specifically defined in the Ionising Radiation (Medical Exposure) Regulations (2017) (IRMER)1 as being under the care of the healthcare provider, in this case dentists. Relatives of the patients who might be seated in the waiting room are classed as members of the public but if a parent or other adult needs to hold a child patient, they become a ‘Comforter and Carer’ under IRMER, which is a new definition. IRMER and the Medical Device Regulations2 are two other regulations that apply with respect to the patient in terms of the use and installation of the dental x-ray unit. Dentists should be aware that with the new 2017 regulations, they need to employ the services of a Medical Physics Expert (MPE) as well as a Radiological Protection Advisor (RPA). The MPE provides support on optimising patient exposures and will give advice on quality assurance. Radiation employers will need to consult a suitable RPA for advice on complying with the regulations and that the RPA selected meets the criteria of competence in the HSE Statement on radiation protection advisers and has the relevant experience to make them suitable to provide the advice needed. If an individual wishes to act as a RPA they must either:

• Hold a valid certificate of competence from an organisation recognised by

• Hold a National or Scottish Vocational Qualification (N/SVQ) level 4 in

HSE as an Assessing Body for the certification of individual RPAs; or

Radiation Protection Practice issued within the last five years.

A reminder of the difference between ionising and non-ionising radiation. The main difference is that ionising radiation carries more energy than non-ionising radiation. Ionising radiation includes: x-rays, gamma rays and radiation from radioactive sources and sources of naturally occurring radiation, such as radon gas.

Ionising radiation has many uses in industry, such as energy production, manufacturing, dentistry, medicine and research and produces many benefits to society. However, it is important that the risks of ionising radiation are managed sensibly to protect workers and the public. Non-ionising radiation includes: visible light, ultra-violet light, infra-red radiation and electromagnetic fields. Sources of electromagnetic fields are used extensively in telecommunications and manufacturing with little evidence of related long-term health problems. Ultra-violet light is part of natural sunlight and also forms part of some man-made light sources. It can cause a number of health problems, including skin cancer.

Where does ionising radiation occur? Ionising radiation occurs as either electromagnetic rays (such as X-rays and gamma rays) or particles (such as alpha and beta particles). It occurs naturally (eg from the radioactive decay of natural radioactive substances such as radon gas and its decay products) but can also be produced artificially. People can be exposed externally to radiation from a radioactive material or a generator such as x-ray equipment, or internally by inhaling or ingesting radioactive substances. Wounds that become contaminated by radioactive material can also cause radioactive exposure. Everyone receives some exposure to natural background radiation and much of the population also has the occasional medical or dental x-ray. HSE is concerned with the control of exposure to radiation arising from the use of radioactive materials and radiation generators in work activities. This is to ensure that workers and members of the public are not harmed by these activities. The use of ionising radiation covers the use of radioactive materials and radiation generators in these work activities in:

• manufacturing, food production and waste processing

• construction • engineering

• oil and gas production

• non-destructive testing

• medical and dental sectors

• education and research establishments (eg universities and colleges)

• nuclear.

Second recent change in dentistry The other change is that if the patient is unintentionally exposed to radiation due to an equipment fault, this needs to be reported to your IRMER authority (which, for example, is the CQC in England). This is done in the same way as you would for incidents due to procedural failures (also under IRMER). In the majority of cases, the Medicines and Healthcare products Regulatory Agency (MHRA) will probably end up resolving the equipment failure using the Medical Device Regulations but, the failure may be for other reasons; it may be to do with it not being checked after an engineer has worked on something that affects the dose. Examples include leaving beam filtration out and the MPE does not check this (or is not asked). Dental radiation dose is relatively low compared with other medical x-ray exposures but it is not excluded in anyway – HSE are no longer responsible for patient-related over exposure due to equipment failure. Medical Devices are regulated to high standards throughout Europe and all dental x-ray units for use in the UK have to be CE marked which means they have been tested to standards depending on the risk to patients. There are two main risks; radiation and electric shock and both are minimised by thorough testing and manufacturing quality control. Suppliers and manufacturers have to follow rigorous procedures and labelling protocols which are also important because they help to compliment other regulatory frameworks. MHRA has previously issued an alert about cheap imported dental x-ray units giving the example of one purchased on the internet, which did not have a CE mark, had insufficient user radiation shielding and was provided with an unsafe power adaptor. If a medical device fails and the patient is harmed or could have been harmed, you should report this to the UK MHRA. They will then take it up with the supplier or manufacturer and by doing this, it helps them to spot trends and you may be helping other dentists with similar issues. If your RPA finds problems with the equipment, this is still for the attention of the MHRA and not HSE but importantly, the RPA will not approve its use.

Electrical safety All medical devices are put into risk classes and are tested to varying degrees dependent on the class. Technically, a particular term is used in device safety known as an ‘applied part’ which are components of the equipment that will come into contact with the patient. The equipment has to be built to provide electric shock protection and the applied parts will be tested to ensure the electric shock risks are minimised. The dental x-ray unit will have a mandatory label and one field will be ‘Type of protection’. If there is a B next to this, it means it has a type B applied part. Type CF 64

(C = `Cardiac - F = Floating) is the most stringent classification, being required for those applications where the applied part is in direct conductive contact with the heart or other applications as considered necessary. Type BF is less stringent than CF, and is generally for devices that have conductive contact with the patient, or medium to long-term contact with the patient. Type B is the least stringent classification, and is used for applied parts that are generally not conductive and can be immediately released from the patient. Type B applied parts may be connected to earth, while Type BF and CF are ‘floating’ and must be separated from earth. Although this system relates to the device design it also influences how the electrical supply wiring is designed. The Medical Device Regulations cover the device up to the mains supply terminals or the 13 Amp plug. The wiring up to this connection point is not regulated by UK legislation but instead by guidance produced to a set standard. The IET are the UK body with the responsibility for this guidance known as BS671, and this too has been recently updated with a version known as BS7671(2018) which can be purchased online. There is a special section for medical locations in BS7671 and this means particular attention has to be paid to hard-wired dental x-ray units. There is also recently updated guidance for the NHS that compliments BS7671. The IET will soon be releasing additional guidance on this very subject to help clear up ambiguities in this area. The most recent BS7671 (2018) guidance has been changed to make the earth requirements in medical locations simpler. However, the requirements of BS7671 require specific medical devices, those which have ‘applied parts’, to be connected to the building wiring in a specific way. The simplified system has had to have been complied with from January 2019. The change for those with a technical interest is that the resistance value for the earth conductors in group one medical locations is now the same as group 2 which is 0.2 ohms. Dental x-ray units will have to meet this requirement if the electrical expert decides it is a group 1 medical location. The general advice for new installations of dental x-ray units is to employ a specialist electrical expert who understands the specific requirements of BS7671 (2018). Nevertheless, the purchaser should check the labelling, which should conform with the Medical Device Regulations, to establish if the x-ray unit has applied parts. This is usually marked as a ‘B’ on the labelling for dental equipment. If this is the case, such units should be installed by an electrician who understands these requirements or one under the supervision of a relevant expert who has similar understanding. It seems to be generally agreed that dental x-ray equipment should be treated as a group 1 medical location. Medical locations and their groups are described in BS7671 and include private clinics/dental surgeries. These requirements are not unreasonable – the earth wiring and the wiring protection (trip) must meet the specific requirement for that medical location. It does not involve expensive

equipment â&#x20AC;&#x201C;only the correct sized earth wires and the correct protective trips (in the fuse board) which your electrical safety advisor will specify. It is always better to fit a new separate earth wire, a dedicated supply wire, connection point and specific trip for fixed x-ray equipment.

References

1. Legislation.gov.uk. The Ionising Radiation (Medical Exposure) Regulations

2017. Available online at www.legislation.gov.uk/uksi/2017/1322/contents/ made (Accessed January 2019).

2. Gov.uk. Medical devices: EU regulations for MDR and IVDR. Available online at:

www.gov.uk/guidance/medical-devices-eu-regulations-for-mdr-and-ivdr (Accessed January 2019).

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CHAPTER 7

Make this CPD Verifiable

Decontamination

Turn to page 162 to find out how

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 6 of the document which gives advice to dentists and practice staff on general hygiene principles.

Hand hygiene 6.1 The term hand hygiene covers not only hand-washing, but also alternative and

additional measures such as hand disinfection using antibacterial-based hand-

rubs/gels.

6.2 Hand hygiene is crucial in preventing the spread of infection and the

recontamination of surgical instruments and devices. Clean hands are an

essential counterpart to the use of gloves. Neither measure is a substitute for

the other.

6.3 As part of essential quality requirements, training in hand hygiene should be

part of staff induction and be provided to all relevant staff within dental

practices periodically throughout the year.

6.4 Hand hygiene should be practised at the following key stages in the

decontamination process so as to minimise the risk of contamination:

• Before and after each treatment session

• Before and after the removal of personal protective equipment

• Following the washing of dental instruments

• Before contact with instruments that have been steam-sterilised (whether or

• After cleaning or maintaining decontamination devices used on

not these instruments are wrapped) dental instruments

• At the completion of decontamination work.

6.5 Mild soap should be used when washing hands. Bar soap should not be used.

Apply the liquid soap to wet hands to reduce the risk of irritation, and perform

hand-washing under running water. Ordinarily, the hand-wash rubbing action

should be maintained for about 15 seconds. After the exercise, the hands

should be visibly clean. Where this is not the case, the hand hygiene procedure

should be repeated.

Drying of hands 6.6 Effective drying of hands after washing is important because wet surfaces

transfer microorganisms more easily than when they are dry, and inadequately

dried hands are prone to skin damage. To prevent recontamination of washed

hands, disposable paper towels should be used.

Skin care 6.7 Hand cream, preferably water-based, should be used to avoid chapped or

cracking skin. Communal jars of hand cream are not desirable as the contents

may become contaminated and subsequently become an infection risk.

Ideally, wall-mounted hand-cream dispensers with disposable cartridges

should be used. Any staff that develop eczema, dermatitis or any other skin

condition should seek advice from their occupational health department or

general practitioner (GP) as soon as possible.

6.8 Fingernails should be kept clean, short and smooth. When viewed from the

palm side, no nail should be visible beyond the fingertip. Staff undertaking

dental procedures should not wear nail varnish and false fingernails.

6.9 Rings, bracelets and wristwatches should not be worn by staff undertaking

clinical procedures. Staff should remove rings, bracelets and wristwatches prior

to carrying out hand hygiene. A wedding ring is permitted but the skin beneath

it should be washed and dried thoroughly, and it is preferable to remove the

ring prior to carrying out dental procedures.

Facilities and procedures for hand-washing 6.10 In accordance with the advice above, a separate wash-hand basin should be provided.

The basin should not have a plug or an overflow and be fitted with a remote

running trap (that is, the U-bend is not directly under the plughole). It should

have a sensor-operated or lever-operated mixer tap and taps should not

discharge directly into the drain aperture as this might generate aerosols.

6.11 Wall-mounted liquid hand-wash dispensers with disposable cartridges should

be used. It should be ensured that the nozzle is kept clean. Refillable hand-

wash containers should not be used as bacteria can multiply within many of

these products and are therefore a potential source of contamination.

6.12 Hand hygiene is an essential part of preventing infection in the practice. A

cleanable poster depicting a six- or eight-step method should be displayed

above every clinical wash-hand basin in the practice.

Personal protective equipment for decontamination processes 6.13 The local infection control policy should specify when personal protective

equipment (PPE) is to be worn and changed. PPE training should be

incorporated into staff induction programmes.

6.14 Appropriate PPE should be worn during decontamination procedures. PPE

includes disposable clinical gloves, household gloves, plastic disposable

aprons, face masks, eye protection and adequate footwear. PPE should be

stored in accordance with manufacturers’ instructions.

6.15 When used appropriately, and in conjunction with other infection control

measures, PPE forms an effective barrier against transmission of infection.

Gloves 6.16 Gloves are needed:

• To protect hands from becoming contaminated with organic matter and

microorganisms

• To protect hands from certain chemicals that will adversely affect the

condition of the skin. Particular care should be taken when handling

caustic chemical agents, particularly those used in disinfection and for

washer-disinfectors

• To minimise the risks of cross-infection by preventing the transfer of organisms

from staff to patients and vice-versa.

6.17 Used gloves should be replaced before performing activities that require strict aseptic precautions or when touching equipment that is difficult to clean. A separate wash-hand basin should be provided for use by staff conducting decontamination. This basin should be distinctly separate from the sinks used in decontamination PPE includes disposable clinical gloves, plastic disposable aprons, face masks and eye protection

6.18 It is important that gloves fit properly if they are to produce the level of

protection against the expected contaminants. The use of latex gloves is

subject to a Health & Safety Executive recommendation, which calls for

local risk assessment. This is partly attributable to reports of long-term allergy

development in some users. The use of vinyl or nitrile gloves may be a

satisfactory substitute and should be made available to staff within

the practice.

6.19 Powdered gloves should not be used. Individuals who are sensitised to natural

rubber latex proteins and/or other chemicals in gloves should take advice from

their GP or occupational health department for an alternative to latex gloves.

6.20 All disposable clinical gloves used in the practice should be CE-marked and

should be:

• Low in extractable proteins (<50 μg/g)

• Low in residual chemicals

• Powder-free.

6.21 Gloves other than domestic household types are single-use only. They should be

discarded as clinical waste.

6.22 Jewellery (for example watches, dress rings, bracelets etc) may damage the

integrity of the glove and may pose an infection risk.

6.23 The following additional guidance is provided

• Long or false nails may also damage the glove, so keep nails short and clean

• Glove integrity can be damaged if in contact with substances such as

isopropanol or ethanol; therefore, alcohol rubs/gels should not be used to decontaminate gloves

• Gloves (except household gloves) should not be washed as liquids may be

• Storage of gloves should follow manufacturers’ recommendations

• Domestic household gloves, if used, should be washed with detergent and

absorbed into the glove and compromise the efficacy of the barrier

hot water and left to dry after each use to remove visible soil. Replace these

gloves weekly or more frequently if worn or torn or if there is any difficulty in

removing soil.

Disposable plastic aprons 6.24 These should be worn during all decontamination processes. 6.25 Aprons should be used as a single-use item and disposed of as clinical waste.

Plastic aprons should be changed at the completion of each procedure. 71

Face and eye protection for decontamination procedures 6.26 During cleaning procedures, there is a risk of contaminated fluids splashing onto

the face and into the eyes. Therefore, the dental team should ensure

protection of their mucosa from splashes and other contaminated fragments

that may escape during these procedures.

6.27 Face masks are single-use items and should be disposed of as clinical waste. 6.28 Spectacles do not provide sufficient eye protection unless specifically designed

for the purpose. It is advisable to wear a visor or face shield over spectacles; this

gives added protection for prescription glasses.

6.29 Eye protection may be reusable but is often difficult to clean. It may be reused

if cleaned according to manufacturers’ instructions. This should take place

when it becomes visibly dirty and/or at the end of each session. Disposable

visors are available and may be used.

6.30 Footwear should be fully enclosed, in good order and comply with health and

safety guidance. Particular care should be taken concerning the risk of

chemical or hot water spillage onto feet.

Clothing, uniforms and laundry 6.31 A wide variety of clothing is worn in dental surgeries and in many practices is

used to reinforce the corporate image. Overall guidance is provided in DH’s

(2006) ‘Uniforms and workwear: an evidence base for developing local policy’.

6.32 Clothing worn to undertake decontamination should not be worn outside the

practice; adequate changing and storage facilities that are accessible from

the decontamination area should be provided. A similar approach is

recommended for clinical clothing.

6.33 Short sleeves allow the forearms to be washed as part of the hand hygiene

routine. Dental staff need to be aware of the hazards that may be

encountered in the decontamination process and may wish to wear long-

cuffed gloves or disposable long-sleeved gowns to protect their arms.

6.34 Clothing/uniforms can become contaminated with microorganisms during

procedures. It is important that freshly laundered uniforms are worn everyday.

Sufficient uniforms for the recommended laundry practice should be provided,

as staff who have too few uniforms may be tempted to reduce the frequency

of laundering.

6.35 Uniforms and workwear should be washed at the hottest temperature suitable

for the fabric to reduce any potential microbial contamination (see the

Department of Health’s (2010) ‘Uniforms and workwear: guidance on uniform

and workwear policies for NHS employers’).

Removal of PPE 6.36 Depending on the type of PPE worn, items of PPE should be removed in the

following order:

a) Gloves should be removed first (so that the gloves end up inside-out).

Make sure hands do not get contaminated when removing gloves. Wash

hands thoroughly, if visibly contaminated, before removing the rest of

the PPE.

b) Plastic disposable apron. The plastic apron is removed by breaking the neck

straps and carefully gathering the apron together by touching the inside of

the apron only. Avoid touching the outer contaminated area.

c) Face mask. Remove the mask by breaking the straps or lifting over the ears

and dispose of into a clinical waste receptacle (see HTM 07-01). Avoid

touching the outer surface of the mask and do not crush the mask before

disposal. Masks should never be left to hang around the neck and should be

disposed of immediately after use.

d) Face and eye protection. Take care not to touch the outer surfaces. Single-

use eye protection should be disposed of into the clinical waste receptacle.

e) Wash hands thoroughly again.

Surface and equipment decontamination General 6.37 Surfaces and equipment used in the decontamination of dental instruments

should be cleaned carefully before and after each decontamination process

cycle. The procedure used should comply with written local policies.

6.38 All surfaces should be such as to aid successful cleaning and hygiene.

Wherever possible, surfaces (including walls) should be continuous and free

from damage and abrasion. They should be free from dust and visible dirt.

Environmental conditions 6.39 The environmental conditions in decontamination facilities should be

controlled to minimise the likelihood of recontamination of sterilised instruments.

Key considerations include the cleanability of surfaces, fittings and equipment. 73

6.40 Ventilation and air quality are important considerations. In non-purpose-built

facilities, the control of airflow is a challenging issue. Responsible persons

will need to consider how good standards can be achieved without resorting

to unreasonably complex or expensive ventilation systems. Through-wall fan-

based ventilation and extraction units will often be useful in this context. In

particular, cassette-based systems can be simple to install and produce a

balanced airflow at low cost. The use of free-standing or ceiling-mounted fan

units, however, is not recommended.

6.41 Mechanical ventilation systems may be advantageous, particularly where best

practice requirements are being pursued. However, these systems can be

expensive in terms of both capital and running costs. Accordingly, designs

that make best use of natural ventilation in clinical areas may be

advantageous, while the use of simple fan-based systems in decontamination

areas will be helpful. It should be remembered that protecting against

recontamination of instruments is always a key aim. Detailed guidance can

be found in BS 5925:1991.6.42. The ventilation system in the decontamination

area or room(s) should be designed to supply reasonable quantities of fresh air

to the positions where persons work and to remove excess heat from

equipment and processes.

6.43 Where used, mechanical extract units should be ceiling- or wall-mounted. Care

should be taken to ensure that airflow is from clean to dirty.

6.44 Where full mechanical ventilation solutions are used, the extract system should

be located and sized to draw about one-third of the air across the

decontamination benches in the clean-to-dirty direction.

6.45 Mechanical ventilation equipment should include coarse air filtration on the

input side. This will require periodic maintenance. Practices are advised to

consult a heating and ventilation engineer if choosing to install a mechanical

ventilation system.

Surfaces and equipment â&#x20AC;&#x201C; key design issues 6.46 All work surfaces where clinical care or decontamination is carried out should

be impervious and easily cleanable. They should be jointless as far as is

reasonable; where they are jointed, such joints should be welded or sealed.

6.47 Flooring in clinical care and decontamination areas should be impervious and

easily cleanable. Carpets, even if washable, should not be used. Any joins

should be welded or sealed. Flooring should be coved to the wall to prevent

accumulation of dirt where the floor meets the wall.

6.48 It should be ensured that surfaces can be easily accessed and will dry quickly. 6.49 Manufacturers’ advice should be sought in terms of the compatibility of

detergents and disinfectants with the surface materials used.

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CHAPTER 8 GDC’s ethical guidance on social media and advertising

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The rapid growth of social media has left many of us, and many organisations, running to keep up, especially from the ethical and professional aspects. Here we look at the General Dental Council’s (GDC) guidance on both social media and the often related subject of advertising.

Guidance on using social media Social networking sites and other social media are effective ways of communicating with others on both a personal and professional level. Social media is a term that covers a number of internet based tools including, but not limited to, blogs, internet forums, content communities and social networking sites such as Twitter, YouTube, Facebook, LinkedIn, GDPUK, Instagram and Pinterest. Professional social networking websites aimed solely at dental professionals are also forms of social media and are also covered by the GDC’s guidance.

Professional standards 4.2.3 of the GDC’s Standards for the Dental Team states: ‘You must not post any information or comments about patients on social networking or blogging sites. If you use professional social media to discuss anonymised cases for the purpose of discussing best practice you must be careful that the patient or patients cannot be identified.’ The standards expected of dental professionals do not change because they are communicating through social media, rather than face to face or by other traditional media. Dental professionals have a responsibility to behave professionally and responsibly both online and offline. However, because anything that is said on social media is instantly made public, it creates new circumstances in which the standards apply. Professional responsibilities, such as patient confidentiality and professional courtesy, are still fundamental when using social media.

When using social media, dental professionals must:

• Maintain and protect patients’ information by not publishing anything which

• Maintain appropriate boundaries in the relationships with patients and other

could identify them on social media without their explicit consent members of the dental team

• Comply with any internet and social media policy set out by an employer.

Additionally, Standard 6.1.2 of the Standards for the Dental Team states: You must treat colleagues fairly and with respect, in all situations and all forms of interaction and communication. You must not bully, harass, or unfairly discriminate against them. This includes interaction and communication on social media and so it is important not to instigate or take part in any form of cyber bullying, intimidation, or the use of offensive language online. Keep in mind too that sharing any such content posted by someone else, can still mean that the sharer can be held responsible even though they did not create it.

Privacy Social media has blurred the boundaries between public and private life so that an apparently ‘private’ online image can in reality impact on professional life. Consequently dental professionals should not post any information, including personal views, or photographs and videos, which could damage public confidence in them as a dental professional. Posting information under another username does not guarantee your confidentiality. Even if you do not identify yourself as a dental professional, you must still follow the standards and this guidance when using social media. For example, you should think carefully before accepting friend requests from patients. Because anything posted on social media is instantly made public it can be easily accessed by others and can be copied and redistributed without you knowing. You should presume that what you post online will be there permanently, even if you delete it afterwards. You should regularly review your privacy settings for each of your social media profiles or accounts. However, you should be aware of the limitations of privacy online, and remember that even the strictest privacy settings do not guarantee that your information will be kept secure. Ultimately, any information that you post could be viewed by anyone including your patients, colleagues or employer. You should remember that information about your location may be embedded within photographs and other content, and may be available for others to see.

Maintaining confidentiality Social media can be a useful and effective way of sharing information for the benefit of your work or business, for example an effective means of advertising products and services. Online discussions about anonymised patients and best practice can have an educational and professional benefit. Sites and groups for dental professionals can be useful places to find advice about current practice in specific circumstances. Many dental professionals use social media sites that are not accessible to the public to share and find information. However, you must remember that many social media groups, even those set up for dental professionals, may still be accessible to members of the public. If you decide to upload clinical information, including radiographs and photographs to any form of social media, you should carefully consider who may be able to view this information. You must be careful not to share identifiable information about patients without their explicit consent. When obtaining consent you should specify to the patient how exactly the information you propose to share will be used, for what purpose and where it will be available. If you are sharing anonymised patient information, you must also take all possible precautions to make sure that the patient cannot be identified. Although individual pieces of information may not breach a patient’s confidentiality on their own, a number of pieces of patient information published online could be enough to identify them or someone close to them.

Raising concerns Social media should not be used as a way of raising concerns. If you believe patients are being put at risk by a colleague’s conduct, behaviour or decision-making, or by your working environment you should, where possible, follow the whistleblowing procedure at your workplace. For advice or information on raising concerns you can:

• See Principle 8 of the Standards for the Dental Team

• Call the independent advice line set up for dental professionals

on 0800 668 1329

• See the GDC’s advice for dental professionals on raising concerns

• Seek advice from your employer, defence organisation, or

professional association. You may also find it helpful to contact your professional association or indemnifier for further guidance on the responsible use of social media.

GDC social media monitoring Responding to a series of questions sought under the Freedom of Information Act, the GDC gave the following replies: Q1 Please detail all recorded details of your social media monitoring policy with

specific regard to how targets are chosen and how access is gained to those

subject’s social media accounts.

There is no social media monitoring policy and we do not target individuals or

individuals’ social media accounts. Social media monitoring for the GDC is

provided via a third party monitoring service which sends the GDC

Communications team a report of instances where the GDC is referred to, or

engaged with, on social media. This is designed to provide the opportunity for

the GDC to respond, where appropriate, to conversations relating to it. The

social media monitoring search parameters are:

(‘general dental council’” OR generaldentalcouncil OR (gdc NEAR/15 (dental

OR dentist* OR teeth OR tooth OR oral)) OR author:GDC_UK OR at_

mentions:GDC_UK OR url:www.facebook.com/GeneralDentalCouncil) No

further search terms or social media monitoring is in place.

Q2 All recorded details of your social media monitoring team, specifically, the

number of employees, remit and scope of their activities.

The GDC does not have a social media monitoring team.

Q3 Whether the social media monitoring team or other officers of the GDC have

been instructed to use fake/proxy profiles for the purpose of gaining access to

registered dental professional’s social media postings.

Firstly, you may find it helpful to read our fitness to practise section on our

website which explains how fitness to practise concerns can be reported. Part

of the GDC’s role as a regulator is to investigate complaints that we receive

about dental professionals’ fitness to practise. Fitness to practise complaints are

initiated when the GDC receives information from a complainant. Using fake/

proxy profiles for the purpose of gaining access to registered dental

professional’s social media postings is not part of the fitness to practise

investigatory process. Q4 Has any registered dental professional had FTP proceedings initiated against

them due to information gained from the GDC social media monitoring team?

If so, please give details.

A The GDC does not have a social media monitoring team and therefore no

fitness to practise proceedings have been initiated on the basis of information they have obtained.

Advertising guidance 1.3.3 of Standards for the Dental Team states that: ‘You must make sure that any advertising, promotional material or other information that you produce is accurate and not misleading, and complies with the GDC’s guidance on ethical advertising.’ All information or publicity material regarding dental services should be legal, decent, honest and truthful. Your advertising can be a source of information to help patients make informed choices about their dental care. Advertising that is false, misleading or has the potential to mislead, is unprofessional, may lead to a fitness to practise investigation and can be a criminal offence. Patients may be confused and uncertain about dental treatment so you should take special care when explaining your services to them. This includes providing balanced, factual information which enables them to make an informed choice about their treatment. You must not exploit the trust, vulnerability or relative lack of knowledge of your patients. Misleading claims can make it more difficult for patients to choose a dental professional or dental services and can raise expectations which cannot be fulfilled. In more serious cases, they can put patients at risk of harm from an inappropriate choice. Patients can check whether you are registered and whether you are on a specialist list, but they are more likely to rely on information that you provide such as practice leaflets or certificates on the practice wall. You must be honest in the presentation of your skills and qualifications.

Advertising services Whenever you, your practice, or any place where you work as a registrant, produce any information containing your name, you are responsible for checking that it is correct. You must:

• Ensure information is current and accurate

• Make sure that your GDC registration number is included

• Use clear language that patients are likely to understand

• Back up claims with facts

• Avoid ambiguous statements

• Avoid statements or claims intended or likely to create an unjustified

expectation about the results you can achieve.

You must make clear in advertisements and other practice publicity whether the practice is NHS (or equivalent health service), mixed or wholly private. If you wish to offer services which your training as a dental professional does not qualify you to provide, you must make sure you undertake appropriate additional training to attain the necessary competence. You must not mislead patients into believing that you are trained and competent to provide other services purely by virtue of your primary qualification as a healthcare professional, but you should make clear that you have undertaken extra training to achieve competence.

Endorsing products You should only recommend particular products if they are the best way to meet a patient’s needs. If you endorse products, you must ensure that you only provide factual information about the product which can be verified by evidence. You should also be careful not to express or imply that your view is shared by the whole profession.

Marketing websites If you promote your services on marketing or social networking websites (e.g. Groupon, Living Social and Facebook) you must make clear that the treatment advertised may not be appropriate for every patient and that it is conditional on a satisfactory assessment being carried out. You must assess the patient, obtain appropriate consent, obtain a medical history and explain all the options before carrying out any work.

Websites In line with European guidance (The Council of European Dentists’ (CED) EU Manual of Dental Practice) if you are mentioned on a website as a dental professional providing dental care you must ensure the following is displayed: your professional qualification and the country from which that qualification is derived; and your GDC registration number. If you are responsible for a dental practice website you must ensure that the following information is displayed:

• The name and geographic address at which the dental service is provided

• Contact details of the dental service, including e-mail address and

telephone number

• The GDC’s address and other contact details, or a link to the GDC website

• Details of the practice’s complaints procedure and information about who

patients may contact if they are not satisfied with the response (namely 81

the relevant NHS (or equivalent) body for NHS treatment and the Dental

Complaints Service for private treatment)

• The date the website was last updated.

You must update the information showing on your website regularly so that it accurately reflects the personnel at the practice and the service offered. You must also ensure that you do not display information comparing the skills or qualifications of any dental professional providing any service with the skills and qualifications of other dental professionals.

Specialist titles If you are a dentist and are on a GDC specialist list you can use the title ‘Specialist’ or describe yourself as a ‘specialist in….’ If you are a dentist and you are not on a GDC specialist list you must not use titles which may imply specialist status such as Orthodontist, Periodontist, Endodontist etc. There are no specialist lists for dental care professionals. If you are a dental care professional you must ensure that you do not mislead patients by using titles which could imply specialist status, such as ‘Smile specialist’ or ‘Denture specialist’. If you are not on a specialist list you must not describe yourself as ‘specialising in…’ a particular form of treatment but may use the terms ‘special interest in..’, ‘experienced in..’ or ‘practice limited to..’.

Honorary degrees and memberships Patients may think that letters after your name indicate that you have gained further qualifications. You must not list memberships or fellowships of professional associations, or societies or honorary degrees in an abbreviated form because it may mislead patients.

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CHAPTER 9

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Financial management in dental practice

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Glenys Bridges Adapted from Dental practice management

In bygone days a ‘sensible’ approach to income and expenditure was enough to maintain a profitable dental business. At that time acceptable financial record keeping would be an accurate account of patients’ payments and suppliers’ bills. Some people may yearn for those times past, however nowadays every dental business needs a competent financial manager to optimise the practice’s finances. Alongside providing excellent patient care, dental businesses must also provide an income for the dental professionals it employs. This requires managers to set a broad span of performance objectives and monitor performance to them. Financial results, based on projected income and expenditure are an essential part of the business plan’s cash flow projections set before the start of the financial year. Then, using financial governance systems, the practice manager can produce management accounts to record financial transactions and respond to variances from target, before they reach crisis proportions. Although almost every dentist is aware of their gross monthly income, many are less clear about their net profit, which is calculated by deducting operational expenses from gross income. In most cases this is due to a lack of systematic management accounting. Financial governance is most effective when every team member has a part to play, from the most junior nurse to the clinical directors and when each team member understands their contribution to practice profitability. The practice manager’s role in financial management is pivotal, it must include educating and informing the team about the ‘Financial Plan’ and implementing financial controls through standardised policies and procedures. The Care Quality Commission (CQC) has set a range of Key Performance Indicators (KPIs) to measure and improve dental practice operations, one such category relates to financial performance. These indicators aim to quantify and measure the efficiency of practice operations. Financial KPIs for dental practice would include income and expenditure to target in respect of:

• Proportion of accounts receivable banked

• Operating expenses

• Average production costs per patient

• Gross production costs. 84

The data collected are used to monitor performance, so that corrective action can be taken to address deviations between ‘actual’ values and ‘target’ values. Soaring overheads can have a devastating effect on profitability. Unless effective accounting systems are in place it can be difficult to know when overhead costs such as salaries, supplies, rent, insurance, and other expenses, are too high. Excessive overheads jeopardise the success and financial security of the business. Calculating overheads as a percentage of practice revenue is important for gauging its economic health. As a practice grows, its overhead percentage should remain stable or decline, even though actual overheads may increase. Keeping the overhead percentage within range of the national average can be difficult. However, the following can help control overhead, and increase profitability in the practice:

Follow the money

Track where the money comes from and where it goes by monitoring fees

collected, purchases and expenses including salaries. This is reasonably easy

to do when using one of the accounting software packages readily available.

It is a good idea to ask your accountant which package they advise you

to use, since when you use the system they prefer it is quicker, and therefore less

expensive for them to produce your end of your tax accounts.

Manage stock levels

During stocktaking some practices find they have disproportionate stock levels,

they have laid out cash on supplies that will carry them for months, rather than

using a ‘just in time’ stock system which can prevent expired items having been

purchased that can only then be disposed of. Determine the materials used

over the previous year then calculate productivity. In this way you can project

requirements in the current year. Benchmarking against past performance can

help a practice ensure accurate ordering of supplies to avoid waste.

Reward performance

There are two kinds of overheads: fixed and variable. Fixed overheads must

be paid no matter how the practice is performing. Variable overheads,

increase only when productivity increases. Therefore a bonus system of key

performance indicators is variable overhead which when well managed offers

a ‘win-win’ situation for the practice and its team.

Meeting the costs of doing business is part of running a practice, but only by eliminating unnecessary expenses can you ensure the financial health of the

practice. Many dentists and their teams overlook opportunities to reduce costs and improve financial performance. Financial performance is gauged by calculating the proportion of income which is profit. For example if the average net profit generated per principal practitioner in a typical private dental practice was £113,576 and in comparison, the average net profits generated per principal practitioner in a typical NHS dental practice was £120,521 (as in a previous year). These figures and others provided by dental chartered accountants can be used by the practice manager to benchmark performance against the national averages. Each year practice managers with financial responsibilities should sit down with the principal dentist and set budgets and profit targets for each area of activity. These should be built into the cash flow forecast and translated into monthly management accounts. Management accounts determine how the practice is performing and whether any corrective action is needed.

Financial terminology In most areas of management the practice manager role has ‘come of age’, even so it is surprising how many managers still have restricted access to information about the practice’s finances. Large numbers of practice managers are not allowed full access to financial data. This restricts their ability to manage as they are not able to base management decisions upon hard financial facts. With a restricted view of the bigger picture, they cannot make evidence-based decisions to secure the practices’ profitability. A lesson to be learned from the international financial melt down is that we cannot afford to be nonchalant when it comes to business finances. Now is the time for practice managers without formal training in business finance to up their game and become financially literate. At the very least they need to maintain an overview of the practice’s financial health by using monthly management accounts and acting upon the Notes to the Accounts (the financial review your practice accountants produce as the rationale for your accounts.)

Financial literacy The accounting world has a language of its own, which can seem impenetrable to those of us who have not spent years studying its intricacies. Nevertheless, solid financial rationale should underpin all business decisions, so it is essential to become financially literate. This begins with learning how to read the practice accounts and pick-up and respond to trends, which in turn requires a working knowledge of the following financial reports:

1. Profit and Loss Accounts (P&L) Also known as the income statement, P&L accounts show income received from the sale of goods and services, along with the cost of sales - how much you have spent to generate this income. This includes staff wages, materials and overheads. The role of the manager is to ensure the percentage increase in costs is less than the percentage increase in revenue, in which case you have controlled your direct cost base. The aim is to calculate the operating profit, the money earned from your business activities after deducting direct cost of sales and indirect expenses; showing profitability.

2. Balance sheets This gives the practiceâ&#x20AC;&#x2122;s financial position at a specified point in time: it shows the total value of business assets (what the business owns), less liabilities (what the business owes). There are several ways to calculate these figures. Traditionally the price paid for assets has been used in this calculation, although in the current financial climate, it can be more provident to use the market value of assets at a given time to prevent assets from being over valued and so making the balance sheet meaningless. When all liabilities have been settled, the remaining value of the practiceâ&#x20AC;&#x2122;s assets is known as equity.

3. Cash flow statement This is the most important working document, which should be consulted by practice managers on a day- to- day basis for decision making. It tracks the actual movement of cash into and out of a business over a financial period. This is in contrast to the profit and loss, which records income when it is earned and expenses when they are due for payment, whether or not the cash has been received/paid. It is not unknown for businesses with a healthy P&L to go under; because the money they need to settle with their creditors is not immediately available, although it has been earned but not paid to the business.

4. Notes to accounts Practice managers need to be able to interpret the information provided in the financial documents discussed above. They also need to be able to read between the lines of the annual accounts produced by the practice accountants. Annual accounts will be supplemented by Notes to the Accounts. These notes provide background information, such as how decisions on the value of assets have been reached. Many company owners read financial statements from back to front, in this way they can understand the underpinning judgements before looking at actual results.

Each of these financial statements needs to be considered in conjunction with each other to give an insight of the financial health of the practice. Dental businesses need to closely monitor their cash flow. Cash is the life blood of all businesses and is the primary indicator of business health. Most businesses can survive several periods of making a loss, but they can only run out of cash once. Cash flow is crucial at times when access to cash is difficult and expensive as in the present economic climate. In its simplest form, cash flow is the movement of money in and out of your business. It is not profit and loss, although trading clearly has an effect on cash flow. The effect of cash flow is real, immediate and, if mismanaged, totally unforgiving. More businesses fail for lack of cash than for want of profit and is the single most important reason why many businesses fail, regardless of how good the business is. Therefore, cash needs to be monitored, protected, controlled and put to work.

Accountancy Management accounts These usually comprise an overview of the businesses progress over a stated period of time, in comparison with previous comparable periods. There is no rule as to what financial information is presented or how, as these accounts are for internal use only, to assist the company directors with managing the business. Usually prepared monthly management accounting or managerial accounting is concerned with providing managers with information to base business decisions upon, that will allow them to meet the business objectives set out in the business plan.

Management accounting information is:

• Designed and intended exclusively for use by managers within the

organisation

• Usually confidential and not publicly reported

• Forward-looking, instead of historical

• Determined on a needs basis, rather than in line with general financial

accounting standards.

Record keeping Numerous computerised bookkeeping software packages are widely used in modern businesses. In most cases businesses will chose their software package after taking their accountant’s advice.

Expenditure – management accounts Accounting Year -1 April 3000 to 31 March 3001 Budget Area

Annual Budget

Month - May 3000

Year to date

Variance

Wages

£200,000.00

£15,000.00

£30,000.00

+ £3,333.00

Materials

£500,000.00

£45,000.00

£105.000.00

(£21,666.00)

Communications

£25,000.00

£2,000.00

£5,000.00

(£ 833.00)

Marketing

£10,000.00

£5,000.00

£6,000.00

(£4,333.00)

Insurances

£5,000.00

£600.00

£3,600.00

(£2,766.00)

Professional services £10.000.00

£1,500.00

+£166.00

Totals

£69,100.00

£156,100.00

(£29,600)

£750.000.00

N.B. For the purpose of giving an example the figures in this table have been rounded up. Actual accounts would be accurate to the penny. (Bracketed numbers show over spends to date ‘+’ - figures show budgets not fully spent)

Income management accounts Year -1 April 3000 to 31 March 3001 Budget Area

Annual Budget

Month - May 3000

Year to date

Variance

NHS

£215,000.00

£18,000.00

£36,000.00

(£166.67)

Private Patients

£600,000.00

£45,000.00

£95.000.00

£5,000.00

To consultants

£24,000.00

£ 2,000.00

£4,000.00

£0

Sundry goods sales

£12,000.00

£ 900.00

£1,500.00

£500.00

Totals

£851,000.00

£65.900.00

£136,500.00

£5,333.33

Surgery Rental

(Bracketed numbers show income shortfalls to date ‘+’ - figures show better than forces performance)

Cash flow Cash flow management is all about balancing the cash coming into the business with the cash going out. Unmanaged there is a danger that cash inflows lag behind the cash outflows, leaving the business short of cash. This money shortage is the cash flow gap. When a business is trading profitably, each time the cycle turns, a little more money is put back than flows out of the business. Difficulties occur if corrective action is not taken when needed. When cash flow is monitored managers are able to forecast business outgoings and ensure the cash is available to meet them. The cash flow cycle occurs in every dental practice as it uses cash to acquire resources. Those resources are put to work and goods and services produced. These are then sold to customers. You collect their payments and make those funds available for investment in new resources, and so the cycle repeats. Inflows are the cash inflow of money coming into the business: outflows are the money, naturally, which you pay out. 89

Break-even Business managers must always be aware of their break-even requirements which are calculated from of the income statement and cash flow statements to define the sales needed to meet all of your fixed and variable expenses. Break-even analysis can help you when projecting when you will make a profit, deciding how much to charge for procedures and setting sales targets.

Capital expenditure This is the term applied to money spent on acquiring permanent assets - such as buildings, or equipment - that are necessary for the running of the business, anything that lasts for more than a year can be called capital expenditure.

Revenue expenditure Money spent to run the business. This includes cost of stock, and expenses like heating bills and can be split into two categories:

Fixed expenses are expenses that you would have regardless of the level of sales

of products or services (e.g. sales, rent, insurance, maintenance contracts, etc.).

Variable expenses are incurred in direct relation to the amount of products or

services provided (e.g. consumables, utilities, tax, etc.).

Budget management When financial controls are delegated it is essential practice managers are given defined budgets to work within. A budget depicts what you expect to spend (expenses) and earn (revenue) over a time period. Amounts are organised into categories, activities, or accounts (for example, telephone costs, salaries, materials etc.). Budgets are essential for forecasting and monitoring whether practice finances are running to plan. They are also useful for projecting how much money you will need for future initiatives. The overall format of a budget is a record of planned income and planned expenses for a fixed period of time.

Cash flow forecast The cash flow forecast, or budget, projects your business cash inflows and outflows over a certain period of time. It can help you see potential cash flow gaps and allows you to take steps to avoid expensive uncontrolled overdrafts, or being unable to meet crucial payments such as wages. For dental businesses a six-month cash flow budget is required. At a bare minimum, all businesses should be able to make an accurate cash forecast for 13 weeks ahead, long enough to spot potential problems

and capture quarterly costs, but short enough to be realistic on sales and debt collections. This ought to be a rolling forecast, re-calculated weekly or even daily, and is particularly useful when the business is under stress or during a credit crunch.

A cash flow forecast consists of:

• Projected cash inflows (a realistic assumption of income, based on a previous

period with adjustments)

• Projected cash outflows (payments you will need to make: operating

expenses such as rents, taxes, wages and utility bills falling due)

• A profit and loss projection, when the net cash flow is added to or subtracted

from opening bank balances, any likely funding gaps can be quantified.

When a negative cash flow gap is predicted early enough, it is more likely that you can take steps to manage it for example:

In the short term (over the next four weeks) - remedial action

• Encourage patients to make cash payments

• Collect all fees before treatment

• Check stock levels and place a hold on non essential purchases

• Only make immediate payments to suppliers when worthwhile discounts apply

• Reduce variable costs where possible

• Seek outside sources of cash, such as a short-term loan

• Produce and analyse management accounts.

In the middle term (4 weeks to 6 months ahead) - conciliatory action

• Evaluate patient payment procedures and the payment performance of

patients

• Introduce inventory management- set optimum operational stock levels

• Recalculate your hourly rate

• Ensure your prices cover the costs of production; plus profit

• Increase the credit taken from suppliers

• Make medium and short term cash flow forecasts and update them regularly

• Review staffing levels

• Promote high end treatments

• Monitor management accounts

• SWOT analyse performance.

In the long term (beyond 6 months)- business planning

• Calculate the Return on Investment (ROI) for major purchases

• Compare bank facilities on offer to reduce charges

• Sell off or return obsolete equipment or materials

• Consider ways to develop a competitive edge.

Cash is the life blood of businesses. At any given time the manager should be able to produce accurate and current income and expenditure figures. These should then be viewed in conjunction with working budgets for the practice’s operation, it is advisable to also produce best possible case projections, (the most you can earn with the resources available) and worst possible case projections (the absolute minimum for business survival), plus your working projections. The quality of these projections will be completely determined by the standard and reliability of the underlying research. An impressive set of projections is of little benefit if it is unrealistic, or based on mere speculation.

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CHAPTER 10

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Child abuse and dental neglect

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There has been a lot of attention, and rightly so, to spotting the signs of child abuse and neglect in recent years. The emphasis has also shifted from child abuse to child protection and child safeguarding, a subtle change but one which emphasises the preventive role that we can all play as professionals, as well as the important duty to recognise warning signs in our child patients. What is often striking about the subject is the large number of different presentations of maltreatment that are seen. Sometimes it is an injury, sometimes there a delay seeking treatment or that something in the explanation for the injury or situation just ‘didn’t add up’. This can manifest as the interaction between the parent and child which alerts the professional.

Spotting the signs There are many signs of abuse and neglect some of which are easily picked up while others are more hidden. For example, a child who comes into the practice with adult handprint-shaped bruises on their upper arms gives immediate warning signs, whereas a child’s quiet, withdrawn nature is a much more difficult sign to assess. Similarly, there are a lot of signs of apparent abuse that may turn out to be perfectly innocent. Childhood encompasses many challenges and a child learning to ride a bike might catch their ankles or fall off and graze a knee or two. This is perfectly normal, as is the fact that many individuals are naturally shy and may come across as nervous or frightened, but this may not necessarily have been caused by abuse. It is therefore always good practice to ask a child, or a vulnerable adult for that matter, how the injury happened, or how they are feeling, if you suspect that there may have been abuse. Professional sense as well as all the other information you have available or can piece together will then enable you to reach a conclusion about whether or not there is cause for concern.

Physical abuse It is important to keep in mind that injuries can happen to anybody at any time for perfectly innocent reasons, and this is especially the case for young children and older children who enjoy being outdoors and playing sports. Certain locations on the 94

body are more likely to sustain accidental injury. These include the knees, elbows, shins, and forehead. However, protected body parts such as the back, thighs, genital area, buttocks, backs of legs, and face, are more common as the sites of nonaccidental injury (physical abuse).

Some of the signs an individual may have been a victim of physical abuse include (but are not limited to):

• Injury to the mouth such as bruised, burnt or cut lips

• Torn or bruised mucosa around frenum

• Fractured incisors

• Various injuries at different stages of healing

• Object marks, such as clear outlines of objects

• Inconsistent explanations of how the injury happened.

Sexual abuse Some children are sexually abused from a very young age and consequently they may not understand until they are much older that what has happened to them is wrong. By this point, it may be difficult for them to disclose their history of abuse due to feelings of shame, guilt, fear, or the threat of further harm. The majority of sexual abuse cases in the United Kingdom are carried out by someone the victim knows well. The perpetrator may be a family member, a close friend, or another person in a position of trust. Adults and children, male and female, can be a perpetrator or a victim of sexual abuse. Some of the signs of sexual abuse that may become apparent in the dental setting include (but are not limited to):

• A fear of medical examinations

• Excessively affectionate or sexual behaviour towards others

• Changes in mood or sudden withdrawal from activities

• A detailed sexual knowledge inappropriate to the age of the individual

• Sexually explicit language or behaviour

• Older boyfriends or girlfriends, or relationships where there is a difference

in power.

Neglect Neglect can develop quickly or over a period of time. It may not always be immediately obvious as everyone has different standards of living. There are a variety of reasons why, and situations in which neglect may occur. Long-term, sustained neglect is damaging emotionally, socially, and educationally, and it is likely to cause

far more developmental delays and medical impairments than any other form of abuse. Some of the signs that an individual is being neglected include (but are not limited to):

• Poor hygiene

• Frequent accidental injuries and illnesses

• Constant hunger and/or tiredness, malnutrition, stealing food

• Parent or caregiver appears stressed and unable to cope

• Developmental delays

• Parent or caregiver treats them differently.

Dental neglect When we talk about child maltreatment (abuse and neglect) a good place to start is to consider children’s rights and children’s needs. Children themselves learn about their rights. They learn that they have a right to be looked after and not to be hurt by other people. But it goes much further than this: under Article 24 of the UN Convention on the Rights of the Child, children have a right to1 “enjoyment of the highest attainable standard of health, and to facilities for the treatment of illness and rehabilitation of health.” Children have a right to have someone to provide for their dental needs and to look after their oral health. Dental neglect is a common problem worldwide. It is a problem that presents both to general dentists and to specialists, it can present early in childhood or at any time through to adolescence, and it is present at some level in populations that generally enjoy excellent standards of health and wellbeing, as well as in those that are known to experience high levels of poverty and deprivation. In the UK the specific definition of dental neglect, adapted from our statutory definition of neglect, defines it as ‘the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral health or development.’ This definition emphasises persistence and the likelihood of serious impairment of the child’s health or development. Importantly, it makes no reference to parental motivation; whether dental neglect is intentional or entirely unintentional (such as when due to lack of education or resources), the need for action to protect the child is the same. The scientific literature that directly addresses this subject is fairly limited, but a well-conducted systematic review2 gives us an evidence base for identifying the features of oral neglect:

• Failure to seek or delay seeking dental treatment

• Failure to comply with or complete treatment

• Failure to provide basic oral care

• Impacts such as pain and infection (Table 1). 96

There are three features that experts report giving particular cause for concern:

• Obvious dental disease, especially that which is clearly obvious to a lay

person or non-dental health professional.

• Impact on the child - ideally discovered by asking the child, but parents,

carers or others involved with the family, such as nursery school staff, must also

be asked

• That acceptable care has been offered yet the child is not receiving

treatment. This last point indicates our responsibility to facilitate care by providing family-friendly dental services that are convenient and meet the needs of children and families. Dental neglect, like general neglect, presents along a spectrum of severity. At one end optimal oral health and, at the other, unacceptable dental neglect. It is a challenge for us to decide at what point along the continuum we classify it as dental neglect. At what stage does the team need to do more to support the family? And at what threshold do we need to take action to ensure the child is protected from harm? It is important to be aware of some particular circumstances in which children may be vulnerable; not to stigmatise them but to ensure they receive the support they need. Children with disabilities are known to be at greater risk of maltreatment of all kinds. A range of family circumstances may lead to chaotic lifestyles that impact on children’s welfare: circumstances such as homelessness, parental mental health problems, alcohol or substance abuse. We will of course want to look out for children who are already known to social services and are subject to a child protection plan or are looked after in care, so that we can support them and their families, but we know that they are probably just the tip of the iceberg and there are many more maltreated children that never come to the attention of the authorities. Of course it is not enough simply for the dental team to notice dental neglect; we must take action too. It is helpful to think in terms of a tiered response using three stages of intervention, depending on the level of concern:

Stage 1. Preventive dental team management - this involves raising concerns

with parents, offering support to meet the child’s oral health needs, setting

targets, keeping records and monitoring progress. Every single member of

the dental team has a role to play. Comprehensive dental treatment must

be arranged with an initial focus on relief of pain and provision of preventive

care. In order to overcome problems of poor attendance, dental treatment

planning must be realistic, achievable and negotiated with the family. If

concerns remain, management should progress to the next stage.

Stage 2. Preventive multi-agency management - the dental team then liaises

with other professionals, such as the health visitor or school nurse, general

medical practitioner or social worker, in order to share information, to ask if

concerns are shared and to clarify what further steps are needed. It should be

checked whether the child is subject to a child protection plan. A joint plan of

action should be agreed and documented, with a date specified for review.

Stage 3. Child protection referral - if the situation is found to be too complex or

deteriorating, and there is concern that the child is suffering significant harm, a

child protection referral should be made to children’s social services according

to local procedures.

Recent research To illustrate how these principles can be applied in clinical practice, a recent study used the occurrence of paediatric dento-facial infections as a potential tool for identifying children at risk of neglect4. In this retrospective audit, the authors reviewed children below sixteen years who were admitted under oral and maxillofacial surgery for incision and drainage of a dental/facial abscess, under general anaesthesia, between January 2015 and January 2017, to understand if they had experienced dental neglect. They also assessed if they were or had been known to Children’s Social Services (SS) before hospital admission. Twenty-seven children were included in the study, eleven children (40%), were known to social services and on average 3.2 teeth were extracted with an average hospital stay of 2.5 days. This indicated that a significant number of children admitted for maxillofacial space infection are already known to social services and the authors recommended that all children admitted under such circumstances, where dental neglect may be present, should be discussed with the local safeguarding team. 1. Office of the High Commissioner for Human Rights. United Nations Convention

on the Rights of the Child. Geneva, Switzerland, 1989.

2. Bhatia S K, Maguire S A, Chadwick B L, et al. Characteristics of child dental

neglect: a systematic review. J Dent 2014; 42: 229–39.

3. Harris J, Sidebotham P, Welbury R, et al. Child Protection and the Dental

Team: an introduction to safeguarding children in dental practice. Sheffield:

Committee of Postgraduate Dental Deans and Directors (COPDEND)UK, 2006

(updated 2013). www.cpdt.org.uk www.bda.org/childprotection (accessed

15 October 2018).

4. Schlabe J et al. Paediatric dento-facial infections – a potential tool for i dentifying children at risk of neglect? Br Dent J 2018; 225: 757-761.

Table 1 Impacts of dental disease • Toothache

• Repeated antibiotics

• Crying

• Dental general anaesthesia

• Stopping playing

• Lower body-weight, growth and

• Disturbed sleep

• Difficulty eating or change in

• Poor dental appearance

food preferences

• Local infection

• Severe infection

• Absence from school

quality of life

Suggested team member/s responsible

Guide for action

Action required

Raise concerns with

Explain clinical findings, the possible Dentist

parents

impact on the child, and why you are concerned

Explain what changes

Explain treatment needed and

Dentist/Therapist, hygienist or

are required

expectation of attendance. Give

dental nurse as appropriate

advice on changes needed in diet, fluoride use and oral hygiene Offer support

Consider giving free fluoride

Dental nurse/ receptionist

toothpaste and brush. Offer

All team members

the parent or carer a choice of appointment time. Listen for indications of a breakdown in communication, or parental worries about the planned treatment, and offer to discuss again or to arrange a second opinion if this is the case Keep accurate records Keep accurate clinical records. Keep accurate administrative records of appointments and

Dentist and/or other team members Dental receptionist

attendance Continue to liaise with

Keep up open communication with All team members

parents/carers

the parents and repeat advice, so that they know what is expected of them

Table 2 Preventive dental team management of dental neglect: a whole team approach (Harris et al, 2006.3) Guide for action

Action required

Suggested team member/s responsible

Monitor progress

Arrange a recall appointment

Dentist and dental receptionist

If concern that child is suffering harm, involve other agencies or proceed to make a child protection referral

Consult other professionals who have contact with the child (e.g. health visitor, nursery nurse) and see if your concerns are shared. Take further action without delay if indicated

Dentist and/or other team members Any member of the team

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CHAPTER 11 Saliva and the control of plaque pH Michael Edgar and Susan M Highman Adopted from Saliva and oral heath 4th edition

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Acidogenic bacteria in dental plaque can rapidly metabolise certain carbohydrates to acid end-products. In the mouth, the resultant change in plaque pH over time is called a Stephan curve (Figure 1). Under resting conditions the pH is fairly constant although differences are found among individuals, and among sites in one individual. Following exposure of the plaque to fermentable carbohydrate the pH decreases rapidly to reach a minimum after approximately 5-20 minutes before slowly returning to its starting value over 30-60 minutes or even longer.

Resting plaque pH The term ‘resting plaque refers to plaque 2-2.5 hours after the last intake of dietary carbohydrate as opposed to ‘starved plaque’ which has not been exposed to carbohydrates for 8-12 hours. Resting plaque pH is usually between 6 and 7 whereas the starved plaque pH is normally between 7 and 8. A large range of plaque pH values seem to be compatible with oral health, but due to the multifactorial nature of dental caries, what may be healthy for one individual may be unhealthy for another. Resting plaque contains relatively high concentrations of acetate compared with lactate. The predominant free amino acids in plaque are glutamate and proline, with ammonia also found at significant levels. The presence of elevated levels of acetate is due to the accumulation of end products of amino acid breakdown as well as those of carbohydrate metabolism. These metabolic products are present at much higher concentrations than in saliva. This is partly due to the fact that they are constantly produced from the metabolism of intracellular and extracellular bacterial carbohydrate stores, and from the breakdown of salivary glycoproteins. Their diffusion out of plaque is hindered by the slow salivary film velocity under ‘resting’ conditions when saliva is unstimulated.

The decrease in plaque pH Two main factors affect the rate at which the plaque pH decreases:

• The presence of exogenous, rapidly fermentable carbohydrate, usually sugars

• Low buffering capacity of saliva at unstimulated flow rates. 102

The fall in pH has been related principally to the production of lactic acid. Simultaneously, acetate and proprionate are lost from the plaque. These acids were assumed to be lost to the saliva but there are indications that they may diffuse also from the plaque into the tooth. In terms of the pH change in plaque, the amount of a low pK acid such as lactate relative to a higher pK acid such as acetate is very important. The high pK acids can provide a buffering system because they can absorb the hydrogen ions generated by dissociation of the low pK acids. The fall in pH could thus be enhanced by a reduction of the buffering power of plaque acetate. The nature of the acids in plaque may be important because they differ in their ability to attack enamel. As the pH of plaque decreases, the concentrations of amino acids and ammonia in plaque also fall rapidly. This fall may be due to the bacterial uptake and utilisation of nitrogenous material for anabolic reactions, stimulated by the availability of energy from carbohydrate fermentation.

The minimum plaque pH The minimum value of plaque pH and how long the pH stays at that minimum are determined by several factors:

• Whether any fermentable carbohydrate remains in the mouth, and whether

the carbohydrate has been cleared from the mouth e.g. by swallowing, rather

than being metabolised by plaque bacteria.

• The pH may fall to values at which bacterial enzyme systems are no longer

functioning properly.

• The buffering capacity, both in plaque and saliva but particularly in stimulated

saliva, may be critical.

The minimum pH corresponds with the greatest concentration of lactate produced during a Stephan curve and with a reduction in acetate, succinate, propionate, most of the amino acids, and ammonia. The length of time that the pH remains at its minimum is important since if it reaches the so-called ‘critical pH’, which is the pH at which saliva and plaque fluid cease to be saturated with respect to enamel mineral, then the dissolution of enamel may ensue. The pH minimum usually occurs after salivation ceases to be stimulated, and although the buffering power of poststimulated saliva remains higher that that of unstimulated saliva for some minutes, it eventually falls: this fall in salivary buffering may coincide with the minimum pH in plaque, thus allowing it to remain low. The benefit of continued stimulation of saliva throughout the Stephan curve is discussed below.

The rise in plaque pH The steady rise in pH back to the resting value is influenced by all the factors mentioned above, including diffusion of acids out of the plaque into saliva. It is also 103

influenced by base production in plaque. Ammonia is highly alkaline and can thus neutralise acid and cause a rise in pH. It is derived mainly from the breakdown of salivary urea but also from the deamination of amino acids. Another group of basic products in plaque are amines – formed from amino acids by decarboxylation. These bases are thought to have an important neutralising action in plaque, especially under conditions of moderate carbohydrate intake. Any residual dietary carbohydrate, as well as bacterially stored carbohydrate, may be broken down during the pH rise phase, thus slowing the process. Although the pH approaches the resting value after 30-60 minutes, the organic acid profile does not return to the resting state for several hours.

Maintenance of plaque pH by saliva Many years ago, researchers compared the Stephan curves produced following a sucrose rinse, with and without salivary restriction. The results showed that by excluding saliva, by cannulating the ducts of the major glands and diverting their secretions out of the mouth, the minimum pH was lower and the return to the resting value delayed. Regulation of the intraoral pH by saliva can be largely attributed to the neutralising and buffering actions of its bicarbonate content, with smaller contributions from phosphate, and other factors. Bicarbonate: This is the most important buffering system in stimulated saliva. Metabolically-derived bicarbonate increases in concentration with increased salivary gland activity, so that bicarbonate provides an increasingly effective buffer system against plaque acid, especially at high flow rates when concentrations may reach up to 60 mmol/L. The rise in bicarbonate concentration also leads to a rise in salivary pH, which directly neutralises the plaque acidity. Phosphate: In unstimulated saliva, concentrations of phosphate may peak at around 10 mmol/L. These concentrations fall, however, at high rates of flow, and the phosphate system is of minor importance as a buffer. The protective role of salivary phosphate is due more to its contribution to the saturation of saliva with respect to enamel mineral.

Other factors As seen above, saliva contains urea at concentrations similar to those in blood. Many plaque bacteria possess urease activity, converting urea to ammonia, thus raising plaque pH. Saliva also contains peptides, known as ‘pH rise factors’, which have been suggested to maintain plaque pH. The best-established of these is a basic peptide containing arginine which has been named ‘sialin’. Some bacteria

104

can decarboxylate the amino acids from such peptides to form basic amines. Base production in the form of ammonia and amines is responsible for the fact that the pH of starved plaque is often higher than that of the saliva bathing it. Urea has been added to chewing gum to increase salivary concentrations and raise the pH of plaque. Recently, salivary concentrations of urea after chewing ureacontaining gum were measured and their effect on an artificial ‘Stephan Curve’ evaluated. The beneficial effect of urea was shown to occur only after a sucrose challenge – if the gum was chewed before the challenge there was no reduction in plaque pH fall.

Buffering capacity of plaque Plaque has intrinsic ‘fixed’ buffering capacity due mainly to bacterial proteins and other macromolecules in plaque. These fixed buffers are in equilibrium with ‘mobile’ buffers – phosphates and bicarbonate – which exchange with those in saliva. Calcium phosphate crystals are thought to be present even in young plaque and can dissolve under acid conditions to increase greatly the buffering capacity. This can also raise the concentrations of calcium and phosphate ions, and thus help to oppose the demineralisation of the tooth. A negative correlation exists between calcium phosphates in plaque, and caries activity.

Age and site of plaque The age and site of plaque in the mouth are important considerations in plaque pH studies since they influence the chemical and microbial composition and thickness of plaque, and the access of saliva to the plaque. The age of plaque is usually defined as the time elapsed since plaque was last removed, for example, by professional or by very thorough home tooth-cleaning. This definition is limited, however, because plaque is constantly being disturbed and removed by the action of tongue, lips and cheeks, and by foods. The thickness of plaque is therefore a more rational parameter, although difficult to measure. Thickness affects microbial composition, and the velocity of diffusion of substances through plaque. Thicker plaques are more anaerobic, and so in their inner layers will favour the growth of more strictly anaerobic bacterial species. The rate of penetration of nutrients into, and metabolic products out of plaque will vary with the square of the thickness of plaque, and also on the molecular size and charge of the diffusing substance. Calcium and phosphate levels in plaque increase with time; 10-day-old plaque has about 25% of the mineral content of calculus. Most plaque pH studies use plaque in subjects who have refrained from oral hygiene procedures for 24 or 48 hours. It is sometimes suggested that tooth-brushing may be more effective before meals, as the residual plaque is too thin to lead to a large drop in pH, and with fluoride

105

dentifrice the metabolism of plaque bacteria will be inhibited. However, the salivary stimulation during eating is known to accelerate the clearance of fluoride from the mouth, and this disadvantage may outweigh the advantages of brushing before meals.

Diet history The dietary history of plaque is one of the most important factors affecting the Stephan curve. Even a modest restriction of sugar intake for 1-2 days will considerably influence the shape of the curve. For example, when plaque pH in humans is compared before and after a sequence of sucrose rinses over 3 weeks, there is a decrease in both resting and minimum pH. Many oral bacteria produce extracellular polysaccharides in the presence of excess sucrose. These include glucans which are thought to increase plaque adhesion and thickness, as well as fructans which are subsequently broken down to acid. Some bacteria form intracellular polysaccharide stores, the breakdown of which is an ongoing contribution to acid production in resting plaque.

Plaque pH and salivary clearance Salivary clearance refers to the dilution and removal of substances from the mouth. The flow rate of saliva has the greatest influence on the rate of clearance â&#x20AC;&#x201C; the faster the flow, the faster the clearance rate. Patients with rapid clearance rates have a shallow Stephan curve, whereas those whose clearance is slow have deeper curves as lower pH values are reached. Studies have shown that the labial and upper anterior region is a site of slow clearance, the lingual and lower anterior region a site of rapid clearance, and the buccal area a site of intermediate clearance. The plaque pH in these regions relates well to the rate of clearance. The approximal surfaces of the upper anteriors have the lowest plaque pH, since clearance is slower from these sites. This also relates to the caries prevalence in anterior teeth, being higher in upper than lower approximal surfaces. The residual volume of saliva after swallowing has been found to be important in determining the clearance rate: the smaller the residual volume, the faster the clearance. A significant positive correlation between the residual volume of saliva and the caries experience of an individual has been found.

Plaque pH and fluoride levels Salivary fluoride levels, even in a fluoridated area and with the use of fluoride dentifrice, are quite low, about 0.5-2.0 Îźmol/L (0.01-0.04 mg/L) although immediately after brushing the concentration from dentifrice is much higher (100-200 mg/L) and 106

a small increase (around 0.05 mg/L) is detectable in the saliva of fluoride dentifrice users 18 hours after brushing. These minor changes in salivary fluoride can lead to increased levels of fluoride in plaque. Plaque fluoride concentrations are high for up to 8 hours after a fluoride rinse â&#x20AC;&#x201C; i.e. they are retained directly from the rinse and not recycled via saliva. Fluoride levels in plaque are usually 50-100 times higher than those in whole saliva. Systemic fluorides have only a small effect on plaque acid production, but their effect may be great enough to tip the scales between demineralisation and remineralisation of the tooth enamel. Part of the fluoride in plaque is in bound form, but is released into the plaque fluid when the pH falls. This can be potentially beneficial in favouring remineralisation and modifying subsequent bacterial metabolism. Topically administered fluorides have antibacterial actions but this is a direct effect and not mediated by saliva. However, fluoride from dentifrices, gels and other vehicles may bind to the soft tisssues or precipitate on the tooth surface as calcium fluoride, which then slowly dissolves into the saliva leading to the raised concentrations noted above. Fluoride-containing chewing gum has been investigated as an anti-caries product for daily use; doses range from 0.1-0.5 mg F as sodium fluoride. Salivary fluoride concentrations are elevated, especially on the chewing side, and may promote increased remineralisation of enamel and dentine.

Figure 1. Diagram of a Stephan curve â&#x20AC;&#x201C; the plaque pH response to a 10% glucose solution (Redrawn from G N Jenkins, The physiology and biochemistry of the mouth Blackwell, London, 1978) (4th Edition).

107

CHAPTER 12 Dementia in dentistry. Adapted with acknowledgment from the Dementia-Friendly Dentistry Faculty of General Dental Practice (UK) 39

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Many dentists have a personal relationship with their patients; they may treat the whole family and are able to build up a comprehensive picture of their patients as individuals. As such, they may be more likely to notice changes in behaviour over time, or instances where the patient doesnâ&#x20AC;&#x2122;t quite seem themselves. Indeed, in the early stages of disease it may be rather difficult to identify whether an individual has any problems. However, the first step lies in approaching the subject, and any concerns that a dental professional may have as to whether the individual has (or considered whether they might have) dementia. As with all patients there are some general considerations to take into account when discussing care. People with dementia want information that is clear, easy to understand and presented in a positive way. The importance of written material cannot be overstated. Remove unnecessary words and keep to one subject in each sentence. Avoid jargon, and explain all terms and concepts clearly or through a glossary. Keep language simple, but aimed at an adult audience. Colour can be used to distinguish between different sections of information. Set out text in one column. Use bullet points, bold text, titles and headings to separate information in manageable chunks or boxes. Bigger type, clear font without serifs with a font size of at least 12-14pt. Present information logically, one piece at a time. Diagrams and pictures alongside text are helpful. These should be relevant and not used simply for decoration. Include contact information, so that if further clarification is needed, it is clear how to get in contact. The ability to comply with oral hygiene procedures and dental care is often influenced by past dental behaviour and experiences. Some people with dementia who have had regular dental treatment throughout their lives seem to remember what they are expected to do in the dental surgery. They have little difficulty co-operating with simple procedures until the late stage of the disease. Familiar surroundings, routines and people may be reassuring and aid co-operation. In certain circumstances a home visit may be helpful. This can be less stressful and confusing for the person, and may increase co-operation. Having a carer present and remaining in the personâ&#x20AC;&#x2122;s sight while they are having treatment and, where appropriate, offering reassurance by holding the personâ&#x20AC;&#x2122;s hand can be of great assistance. However, in general it is recommended that wherever possible a patient 108

is seen in a practice setting where the clinician has access to the full range of facilities and equipment necessary to provide high quality care.

How to raise concerns and approach the subject of dementia The individual personality of a dentist and their relationship with the patient dictates the communication style used in approaching this subject. For many it may be a sensitive and tactful approach, with gentle probing and leading questions to investigate difficulty with memory or changes in behaviour, either with the patient, carer or family member. This can be termed ‘softer questioning’ and examples include:

• “What did you have for breakfast this morning?”.

• “Did you have a good journey? How did you travel here today?”

For others it may be a direct, clinical approach with a frank, objective question such as:

• “Have you had any change in your health recently?”

• “Have you noticed any change in your memory?”

• “Do you struggle to recall things you have heard, seen or read?”

• “Do you ever forget names of people or everyday objects?”

• “Do you have any difficulty following conversations?”

Confidentiality is central to trust-based relationships between clinicians and patients, and appropriate information sharing is vital for the provision of safe and effective care. The General Dental Council (GDC) publication Standards for the Dental Team stipulates that dentists should explain to the patient the circumstances in which they may share information, that they seek the patient’s consent to do so wherever possible, and that in information sharing they are prepared to justify those decisions and any action taken. If a dentist feels there may be some evidence of memory difficulty or deterioration, they can mention to the patient that they wish to write to the GP suggesting the need for a more thorough check-up or review. The dentist can write briefly to the GP, describing their observation and the reason for concern, requesting that the patient be reviewed. If there is concern regarding the patient’s mental capacity, advice or confirmation can be requested. Once a diagnosis has been made, it is essential that the dental team are fully involved in the multidisciplinary care resulting from that diagnosis.

Potential indicators of dental problems in people living with dementia There may come a time when the person with dementia is unable to voice that they are experiencing pain or discomfort from their mouth or teeth. They will need to rely on other people to notice and interpret their behaviour and to arrange a dental appointment. There are however several behavioural changes that may indicate 109

that someone with dementia is experiencing dental problems. These include:

• Refusal to eat or drink (particularly hard or cold foods)

• Frequent pulling at the face or mouth

• Leaving previously worn dentures out of their mouth

• Increased restlessness, moaning or shouting

• Disturbed sleep

• Refusal to take part in daily activities

• Aggressive behaviour

• Bruxism.

Physical signs that may also indicate a problem exists include drooling saliva, redness, and or swelling. These signs should be taken in context with the clinical findings, previous behaviours and knowledge. A pain diary collated by the carer may also be helpful. If there is no explanation for the change in behaviour, arrangements should be made to identify the cause, which may involve contacting the patient’s GP.

Medication There are no drug treatments that can cure Alzheimer’s disease or any other common type of dementia. However, medicines have been developed for Alzheimer’s disease that can temporarily alleviate symptoms or slow down their progression. There are two types of medication used to treat Alzheimer’s disease: acetylcholinesterase inhibitors (often shortened to just ‘cholinesterase inhibitors’) and N-methyl-D-aspartate (NMDA) receptor antagonists. The generic names for the cholinesterase inhibitors are donepezil, rivastigmine and galantamine. Donepezil was originally patented as the brand name Aricept, but is more widely available now as just generic donepezil. Rivastigmine was patented as Exelon and is now also available as other brands, as well as generic rivastigmine. Galantamine was patented as Reminyl and is now also available as generic galantamine and the brands Reminyl XL, Acumor XL, Galsya XL and Gatalin XL. The NMDA receptor antagonist is memantine. It was originally patented as Ebixa and is now also available as generic memantine. Other UK brand names for memantine include Maruxa and Nemdatine. Antipsychotic drugs (also known as neuroleptics or major tranquillisers) are a group of medications that are usually used to treat people with mental health conditions such as schizophrenia. They are also commonly prescribed for behavioural and psychological symptoms in dementia. This is because in some cases they can eliminate or reduce the intensity of psychotic symptoms, such as delusions and hallucinations, and can have a calming and sedative effect.

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Antipsychotic drugs benefit less than half of the people with dementia who take them but can be an important part of their treatment. However, they can cause serious side effects, especially when used for longer than 12 weeks. Possible side effects include:

• Sedation (drowsiness)

• Parkinsonism (shaking and unsteadiness)

• Increased risk of infections

• Increased risk of falls

• Increased risk of blood clots

• Increased risk of stroke

• Worsening of other dementia symptoms

• Increased risk of death.

It is important to consider that antipsychotic drugs may help reduce behavioural and psychological symptoms, but because of these side effects, this may be at the expense of the person’s quality of life.

Types of dental treatment Early stages of dementia In the early stages of dementia, most types of dental care are still possible. The dentist should plan treatment keeping in mind that the person with dementia will eventually be unable to look after their own teeth. It is important at this stage that there is strategic long-term oral care planning which avoids end-stage crisis management. Care planning should be based on a detailed oral health risk assessment. Factors to consider in the pre-dependent early stages oral health risk assessment are:

• Caries risk: number of exposed root surfaces; patient’s perception that

their mouth is dry (xerostomia); reduced saliva flow (salivary hypofunction); medications; diet and nutrition; oral hygiene

• Periodontal disease risk: presence of active disease; diabetes; smoking

• Manual dexterity: the ability to maintain oral hygiene; level of fatigue when an

individual is undertaking oral hygiene themselves

• Dependency: extent of dependence on carer/family member or

residential care

• Drugs and other co-morbidities: cardiovascular factors; Parkinson’s; diabetes.

Preventing further gum disease or decay is very important at this stage. Rigorous preventive measures (both home and surgery-based) should be put in place so that they become routine for both the individual and their carer. Prescription of high fluoride toothpaste (5000ppm) may be considered, and professional application of high fluoride varnish twice yearly may be beneficial. 111

Restorative treatment should be high quality and low maintenance. Where possible, treatment should be simple, serviceable and (ideally) easily cleansable. Key teeth should be identified and restored, such as canines, molars and occluding pairs. Crowns, bridges and implants should only be considered if someone is prepared to carry out daily brushing for the person living with dementia, should the person reach a stage where they cannot do this for themselves. At this stage, when the person is able to participate in discussions about their treatment, some consideration should be given to long-term outcomes, such as a shortened dental arch with the aim of securing adequate function and nutrition. In cases where the patient may need to be rendered edentulous, consideration might be given to two-implant retained overdentures. As dementia is a progressive condition, it is important for the individual and their carer to receive continuing advice on prevention from the dentist and the dental team. They may need to be reminded to carry out the task, or they may need to be supervised. If they need help, the carer can try offering them the brush and toothpaste and showing them what to do. As manual dexterity decreases, an electric toothbrush, or toothbrush with an adapted handle to improve grip, may help maintain independence.

Middle stages of dementia During this stage of dementia, the person may be relatively physically healthy but have lost some cognitive abilities. The focus of treatment is likely to be on prevention of further dental disease, from restoration and rehabilitation to maintenance and prevention. During this stage, the person is often relatively physically healthy, but increasingly cognitively impaired. Patients with support may still be able to receive dental care with little or no difficulty. For some, however, changes in behaviour – including agitation or aggression – may occur when a person feels threatened, intimidated or agitated. With reduced powers of logic and reason and heightened emotional responses, people may lash out where they previously might have behaved in a very different way. The decision will be based on the individual’s ability to co-operate, their dental treatment needs, general health and social support. Rigorous prevention should be continued, adapted visit procedures considered and more frequent recall visits and support for carers arranged as appropriate. At this point it may be decided that the patient no longer has the capacity to consent to their dental treatment. It is during the middle stages that issues around consent to treatment may start to arise. This is where the Mental Capacity Act states that we must assess capacity, act in the patient’s best interest and choose the least restrictive treatment option. Having been involved in treatment decisions the patient may have made previously, this is where the GDP is truly valuable, especially as they

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are already aware of who may wish to be involved in communication about the patient’s care. At this stage, the GDP may also choose to refer to a special care dental service for specialist advice and continuing care, which may include sedation or general anaesthesia for their dental treatment.

Later stages of dementia In the later stages of dementia, the person is likely to have severe problems with thinking, reasoning and memory and will often be physically frail or disabled with complex medical conditions. Treatment at this stage focuses on prevention of dental disease, maintaining oral comfort and provision of emergency treatment. Dental interventions should be as non-invasive as possible, for example using Carisolv® for caries removal, atraumatic restorative techniques (ART) such as glass ionomer cement restorations, and regular application of high fluoride varnish to control root caries. Changes in an individual’s ability or desire to maintain oral health are likely. They may lose the ability to clean their teeth, or an interest in doing so, and carers may need to take over this task. Even people with very advanced dementia can retain the capability of tooth brushing if handed a toothbrush. A dentist or hygienist can provide guidance and support on how to clean another person’s teeth. The technique will vary depending on the individual concerned.

Additional issues The dental professional can help support good practice in managing dementia by being aware of other conditions that have a bearing on the its impact. For example, dehydration can have a negative effect on people with dementia, causing a worsening of symptoms and leading to medical problems. A person with dementia should drink at least 1.2 litres of fluids a day. Dehydration can lead to:

• Headaches

• Increased confusion

• Urinary tract infections

• Constipation.

These can all worsen the symptoms of dementia. As people get older, the sensation of thirst changes, which can lead to people being unaware that they are dehydrated. A person with dementia may have similar difficulties. They may also be less able to provide drinks for themselves. The person should be encouraged to drink throughout the day, but placing a drink in front of someone does not mean they will drink it. An empty cup does not mean the contents have been drunk; it may have been spilled, drunk by someone else or poured away. Daily living aids such anti-spill mugs, beakers or protective drink lids should be considered. 113

CHAPTER 13

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Dental pain

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A very common reason for patients to seek dental treatment is for the alleviation of dental pain. In most instances the pain has a physical origin. A correct diagnosis of the source of the pain is essential to ensure that the appropriate treatment is provided. This is achieved through a sound knowledge of the causes and symptoms of dental pain, the taking of a detailed pain history as part of the dental history, and a thorough dental examination that often involves special tests such as pulpal, transillumination and radiographic assessments. Less often, patients with sensorimotor disorders may require routine dental treatment.

Pain history An accurate pain history must be taken before undertaking the examination. Carefully taken, this will frequently indicate a probable diagnosis even before visual, tactile and other methods of examination have been made. The following classical list is a guide to the information required regarding the presence of dental pain:

Location Patients may be able to locate the source of the pain with some accuracy, e.g. apical periodontitis. However, with pulpal pain the location may be both vague and inaccurate. Does the pain radiate? Does it cross the midline?

Timing When did the pain start? Was it hours, days or weeks ago, and can it be related to any incident, such as biting on something hard, a blow or even a recent dental visit?

Character The type of pain may provide an indication of its cause, with popular descriptors being sharp, dull, throbbing, burning, aching, etc. Have there been changes in its character and is it improving or getting worse?

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Frequency Is the pain constant or intermittent, if so what is the interval time? Does it occur at a particular time of the day or night?

Duration Does the pain last seconds, minutes or hours?

Time The pain may be present at the time of examination or it may be found to occur at particular times of the day, such as on rising in the morning, or at night when lying down.

Precipitating factors Pain may be spontaneous or brought on by certain stimuli, such as eating, biting, sweet or spicy foods, temperature change (either heat or cold), lying or bending down, wearing of dentures.

Relieving factors The pain may be relieved by biting on a particular tooth and then relaxing, by a hot or cold mouthrinse, or by the action of a drug. If so, how quickly and for how long is the pain relieved? (This gives an indication of its severity).

Other factors A patient can often provide information regarding symptoms and signs which, however, are not uppermost in his or her mind; such as sensitivity to heat, cold and sweetness, food impaction, bleeding gums, pain or clicking in the temporomandibular joint (TMJ), discomfort from or inadequacy of prosthetic appliances. Pain is always experienced as being projected onto an image of a body part created by the brain, even when that part may be missing as with phantom limb pain. Although most individuals have a largely uniform sensation threshold for pain, the actual perception of pain and the responses to this perception are influenced by previous experiences and many individual psychological and cultural factors. An exaggerated pain history and response to apparently minor injury and pain are not unusual among persons from some cultures. Conversely, stoical persons from other cultures may refuse local analgesia and endure painful dental treatment without complaint. The effects of placebos, hypnosis and distractions in pain control are also well known. These effects are explained by the â&#x20AC;&#x2DC;gate control theoryâ&#x20AC;&#x2122; of pain where 115

pain messages from damaged tissue have to pass through several gates before they reach the brain. This concept has resulted in newer treatment methods for blocking chronic pain in particular.

Examination The patient should first be asked to point using a single finger to the exact intraoral site of the pain. The patient’s attempts to do so are a valuable indication of the possible cause. A thorough examination should then be done very carefully as some patients may not have slept well, are apprehensive and will guard the painful site. The probable tooth or teeth involved should be isolated then gently air-dried. Direct vision with good illumination and magnification can sometimes be sufficient to confirm a diagnosis. Gentle palpation and pressure may reveal areas of tenderness and changes in soft tissue consistency. In addition, careful probing may be of value in diagnosing recurrent caries beneath old restorations, and in locating cracked cusps and exposed dentine. However, do not probe deep cavities where there is the likelihood of pulpal exposure, or exposed hypersensitive dentine. Instead, use a gentle stream of air from the triple syringe to locate regions of obvious sensitivity. Evidence should be sought of recent trauma and restorative procedures, including recent restorations and ‘high spots’, large deep restorations, cracked restorations, loose and missing restorations. Other conditions may include dental caries, cracked and fractured teeth, exposed cervical and occlusal dentine, sinus tracts and ulcers, localised swellings of the soft tissues, and abnormal tooth mobility. A deep narrow ‘periodontal pocket’ may indicate a sinus tract associated with a root fracture and pulpal necrosis. A recent metallic restoration, on contacting another dissimilar metallic restoration or metallic inserted object, may elicit a very brief painful response due to galvanism. Coating the recent restoration with a thin layer of resin-based sealant is usually sufficient to prevent the problem which, however, generally resolves without treatment within a few days.

Special tests In addition to the visual and tactile examination, a number of special tests can be performed to assist with the diagnosis. When possible, normal sites should be tested first before comparing them with the affected similar site.

Pulpal responsiveness The pulpal responsiveness of a tooth gives an indication of whether the pulp is vital or not. Laser Doppler flowmetry involves the assessment of pulpal blood flow, but the high costs and time-consuming procedure, and the interference of light transmission by blood pigments within discoloured teeth, have limited the use of this method.

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Therefore, rather than testing the integrity of the vascular supply to the pulp, most tests rely on obtaining a response to stimulation of the A- nerve fibres. Though quick and relatively accurate, the results are not absolute. They must be compared with those from similar, apparently healthy teeth. There are several different tests that can be used to provoke pain, including: Electric pulp test (EPT): An electric pulp tester will usually indicate only whether the tooth is probably vital or non-vital. Variations in battery strength, the size and position of the electrode on the tooth, the conducting medium used and the testing of multi-rooted teeth all result in variable readings, which may be of little comparative diagnostic use. The teeth must be saliva-free, the testing electrode must be kept away from the gingivae and restorations, and the electrode tip coated with a thin layer of electrically conductive medium such as prophylaxis paste or toothpaste. The EPT cannot be used in the presence of metallic and ceramic crowns, unless a bridging technique is possible by placing an explorer tip on tooth structure below the crown margins and then placing the EPT probe on the explorer. The sensitivity (correct recognition of disease), specificity (correct recognition of health), and accuracy of the EPT were found to be slightly lower than comparable results for the cold test. However, more than one test method and the testing of several tooth surfaces and similar teeth are recommended when either a negative or a hypersensitive response is elicited. The EPT may often result in false-negative responses in instances of teeth with immature apices, recent dental trauma and when narrowing of the root canal from extensive calcification is present. False-positive responses may occur from incorrect use, apprehensive and child patients, partial pulp necrosis and the presence of pus from liquefaction necrosis. Cold test: Cold is applied to the tooth, either by dichlorodifluoromethane refrigerant sprays such as Endo-Ice (Coltene/Whaledent) and Endo-Frost Cold Spray (Roeko) at -50°C and ethyl chloride liquid at -26°C on large cotton wool/foam pellets, or by a stick of carbon dioxide snow (dry ice) at -78°C produced by the Odontotest (Fricar AG). The extreme sustained cold of dry ice will slowly penetrate through artificial allceramic and ceramo-metal crowns. Sensibility responses may also be obtained from pulps in narrow calcified root canals, and in teeth with immature apices. The extreme cold test, especially when using carbon dioxide dry ice, is probably the most reliable pulp response test method, apart from the ‘dentine drilling test’ that usually involves the removal of restorations without using local anaesthetic. Extreme, prolonged cold may cause crazing fractures in enamel. Heat test: Heat is applied to the lubricated tooth using a warm gutta-percha stick. This is the least reliable pulp test method and can be difficult to perform. The expansion of gas or pus within a non-vital pulp may produce a false positive sensibility response because of pressure on apical tissues. It is preferable to apply fairly hot water, using tightly-fitting rubber dam to isolate individually, in turn, the tooth distal

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to the suspected tooth, then the suspected tooth, and then the tooth mesial to the suspected tooth. No response is expected from a healthy pulp. (Ice water also may be applied liberally, using a large syringe, in the same manner over the same tooth before moving to the next tooth in the testing sequence. However, in this case, a positive response is expected from a healthy pulp). The procedure is slow, but progresses faster when using two dental surgery assistants. Inconsistent results from heat occur in permanent teeth with immature apices. Anaesthetic test: This method can be used when it is not possible to identify the tooth that is causing the pain. Each suspected tooth is selectively anaesthetised by infiltration injections until the pain is relieved, thereby identifying the tooth causing the pain. This method is more appropriate for maxillary teeth and for mandibular incisor teeth when using most types of local anaesthetics. However, when using 4% articaine with 1:200,000 adrenaline (Septocaine, Septodont), buccal infiltration anaesthesia of mandibular posterior teeth is also possible, because of the higher lipid solubility of the articaine molecule. There is some overlap of right and left sensory nerve fibres to the maxillary and mandibular central incisors. In some instances of referred pain, the pain may cease in one jaw after anaesthetising the suspect tooth in the opposing jaw. Dentine drilling (cavity) test: Drilling into dentine, without using a local anaesthetic, is sometimes the only way to confirm the sensibility response of a tooth. This method should only be undertaken as a last resort. In the case of a tooth with an artificial crown, if dentine in the cervical region of the tooth is not exposed, a small hole may have to be drilled through the crown to penetrate the underlying dentine. Restorations may be removed without the use of local anaesthetic. Occasionally, even the technique of drilling into dentine may prove fallible, and only when the actual vital pulp is exposed will pain be felt.

Transillumination This is the examination of teeth by the transmission of light through them. This method can be helpful for the diagnosis of interproximal caries in the anterior and premolar teeth in particular, and for examining teeth with suspected hairline cracks and fractures. The method is also very useful for locating a calcified canal. An intraoral camera or a separate fibre-optic light source can be very useful for these purposes.

Percussion Percussion can be used to determine whether a tooth has signs of periodontitis. Here, the tooth is extruded slightly from its socket as a result of inflammatory exudate in the apical or lateral periodontal tissues. This may arise either as a consequence of pulpitis, occlusal traumatism, or the spread of infection from adjacent tissues. In

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such cases, even gentle tapping may result in discomfort, accurately related to the tooth being percussed. The dentist should very gently tap the suspect tooth and the adjacent teeth, in a random order and from different directions, using the end of the handle of a reversed mouth mirror. A high-pitched ringing sound indicates that the tooth is undergoing replacement resorption (ankylosis).

Wedge test Cracked posterior teeth can sometimes be particularly difficult to diagnose (the â&#x20AC;&#x2DC;cracked tooth syndromeâ&#x20AC;&#x2122;). The teeth have usually been weakened by restorative or endodontic treatments, and commonly involve mandibular first and second molars, and maxillary premolars. Canine tooth guidance may be transformed by continued tooth wear over time into group function guidance, with heavy occlusal contacts then occurring on cusps weakened by previous cavity preparations for adjacent intra-coronal restorations. In some instances cracks can be identified crossing occlusal enamel marginal ridges and at the base of cusps. The teeth become painful to bite on and increasingly sensitive to thermal and osmotic stimuli due to microleakage. It is useful to place either a large fluted laboratory bur or a rubber polishing wheel sequentially over each cusp of the suspect tooth, then ask the patient to bite firmly, rock from side to side, and release quickly. The wedging action generated will often displace the fractured portion causing a sharp pain either on closing firmly or, more often, on rapid release as the displaced fragment springs back into place. Root canal filled teeth may also give painful responses when the fracture extends to involve the periodontal ligament. The wedge test may be combined with the application of methylene blue dye stain, to define more clearly any cracks. Long-standing cracks may become stained with organic material and corrosion products from amalgam restorations.

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CHAPTER 14 Using cognitive behaviour techniques for anxious patients

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The overall aim of the sessions where cognitive behavioural techniques (CBT) are adopted is to work with anxious or phobic patients to identify the thoughts (or ‘cognitions’) that they have that are associated with dental treatment, to identify the extent to which these are helpful or unhelpful, and then challenge them either through the use of structured thought processes or by conducting mini-experiments to test the validity of the thoughts. Finally the patient is encouraged to restate their thoughts as part of the process of changing the way they think about dental treatment.

All sessions should have roughly the same structure:

1. Set the agenda for the session.

2. Review homework and goals from the previous session.

3. Discuss with the patient the task you will be undertaking in this session.

4 Summary and feedback.

The following exercises have been used at the King’s College London Dental Institute Health Psychology Service:

• Explaining the role of beliefs about the feared stimulus/event

• Identifying thoughts about the dentist or dental treatment

• Distinguishing between helpful and unhelpful thoughts

• Cognitive restructuring.

Explaining the role of beliefs When using cognitive techniques, the starting point should involve explaining the rationale as to why and how this may help alleviate anxiety. This can be done by explaining the Activating Events – Beliefs – Consequences (A-B-C) model of CBT. The key message in the A-B-C model is that it is beliefs about activating events rather than the activating events themselves that underlie anxiety. Non-dental scenarios can be used as initial examples.

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For instance, on seeing a dog (the Activating Event), one person may think “that dog looks vicious and might bite me” (the Belief), and feel frightened (Consequence). In contrast, another person may think “what a cute dog, he reminds me of the dog we had when I was a child” (Belief) and her Consequent emotion is happiness. Changing the belief has different consequences to the same Activating event.

Identifying thoughts about the dentist or dental treatment This task can build on the assessments made in previous sessions where the patient is asked to make a note of the thoughts that they have about dentists and dental treatment. Some patients find this easy and can identify many thoughts. For others this may be more difficult and they may not identify anything other than a general fear. For the latter, prompts can be used such as:

“Do you have any concerns about what the dentist might say to you?”

“Do you feel worried or embarrassed about what other people will say?”

“Do you worry that something bad might happen?”

“Does going to the dentist now remind you of previous bad experiences

with dentists?” The idea is to make a list of all these thoughts, as many as possible since the more that can be identified at this stage, the more likely it is that beliefs underlying dental anxiety can be established. In helping the patient to unpick the beliefs underpinning emotions and behaviours it can be useful to start with some everyday emotions and behaviours and then move towards dental-related anxieties. An example of beliefs in a patient who feared fainting during dental treatment: “I am worried that I will just collapse in the surgery. I can feel the blood rushing up to my face and my head begins to spin and I think I’m going to go (Faint), and if I collapsed in the surgery well I don’t know what would happen” Beliefs: Unhelpful elements in this statement include possible magnification of the risk of fainting – the patient believes it is highly likely they will faint. Also catastrophising the consequences of fainting –while an undesirable event, a patient fainting is not catastrophic and the dental team would be well placed to manage this. The patient may feel that fainting would be embarrassing or that people would make judgements about him for fainting. There is an element of rumination – the patient expressed these worries for up to a week before the appointment – this is not helpful in that the patient is spending far more time than they need, thinking about it. Finally there is an implied ‘should’ statement. The patient feels they ‘should’ be able to have treatment without any problems.

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Distinguishing between helpful and unhelpful thoughts Having identified a list of thoughts and beliefs, the next step is to look at whether such beliefs are helpful or unhelpful in terms of the overall goal of overcoming dental fear. The beliefs may contain common patterns of unhelpful thinking. These patterns are very common both in people with fear and anxiety, but also in our everyday thinking, some examples are given below:

• Perfectionism: Striving to achieve high standards in everything, and feeling

bad or guilty when you fail to live up to these very high standards

• The tyranny of the shoulds: Telling yourself you ‘should’ be able to do certain

things. There are few shoulds in life.

• ‘Black and White’ thinking: Absolute thinking – things are right or wrong.

• Overgeneralisation: Inferring from one incident a general rule, so because

something happened once does not mean it will always happen.

• Selective focus: Focussing only on specific evidence, ignoring anything that

is contradictory. For example focusing on the times when things are bad and

ignoring the good times.

• Discounting the positive: Forgetting the positive things in your life or thinking

that these are overweighed by the negative.

• Jumping to conclusions: Forming conclusions on the basis of little or limited

evidence. Not waiting for the full picture – mind reading, that is, thinking you

know what other people are thinking or going to do.

• Magnification: Blowing small signs and symptoms up into large

potential threats.

• Emotional reasoning: Thinking from your feelings (that is making decisions on

the basis of your anxiety rather than what you know to be true).

• Negative labelling: Labelling yourself as ‘stupid’ or ‘silly’ is rarely helpful in

getting you to change your behaviour. Rather you should be telling yourself

that you can change, and have changed in the past.

• Personalising and blaming: Identifying yourself as the fault, perhaps ignoring

the effects of the situation (e.g. pressures of work).

Cognitive restructuring For each of the beliefs identified, the patient should be encouraged to explore the belief and test it for veracity and helpfulness – to what extent is the belief true, and how does holding that belief help the patient in overcoming their dental fear? 122

Through cognitive restructuring, patients are encouraged to challenge and alter unhelpful or maladaptive thoughts. Cognitive restructuring aims to facilitate a new understanding that the feared stimuli are unlikely to be dangerous and in turn that avoidance or other safety behaviours are not required. Thus, cognitive restructuring encourages patients to achieve more helpful cognitions. Cognitive restructuring can be achieved through disputation and Socratic questioning (the therapist asks the patient questions to elicit answers that are then questioned). The theoretical underpinning to this technique is that the original questions help expose cognitions and the secondary questions explore the validity of those cognitions.

Useful questions include:

• How helpful or unhelpful is it to hold this particular belief?

• What good, if any, comes from holding this belief?

• What is the downside of seeing things this way?

• If you see the world this way, how do you feel? How do others react?

• In your experience, what fits with this belief, what makes it seem true?

• Why might any of us have thought that at some time?

• Do you have any experience of this not being the case?

• Is there anything that doesn’t seem to fit with that thought?

• How might someone else view the situation?

• Is that so all of the time, or are there situations when things are different?

• Given what you have just described, how likely do you think it is that the worst

will happen?

• So just what is it that you fear will happen?

• How might your friend try to deal with this dilemma?

• What is the worst case scenario if this solution does not work? How might you

prepare for that? How might you guard against that happening? What could

you do if it did happen?

It is useful to ask patients to consider the long- and short-term benefits of holding on to and giving up their current way of thinking. This can help them to gain motivation to change their thought patterns. For example a patient may believe that a bad event will happen because it has happened to them in the past, however lots of other people have dental treatment without consequence, the patient themselves may have had successful dental treatment prior to their one bad experience. Where a patient has fears of specific events, discuss the actual likelihood of an event. For example, a patient may fear an adverse reaction to anaesthetic – how common is such an occurrence?

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It is also useful to encourage acceptance of the belief and normalisation. Many people believe that they are wrong to feel the way they do and that they are abnormal for doing so. Patients may feel embarrassed about their fear. One technique is to discuss how common dental fear and anxiety are, and suggest that an appropriate goal is not to get rid of dental anxiety altogether but to reduce it to a reasonable level. In reality most patients have some concern about going to the dentist, but this does not stop them going – this is a more reasonable expectation for a patient to have, than to expect themselves to overcome their fear entirely.

An example of disputing and restating thoughts is as follows: “I am worried that I will just collapse in the surgery. I can feel the blood rushing up to my face and my head begins to spin and I think I’m going to go (Faint), and if I collapsed in the surgery well I don’t know what would happen” A possible restatement: “The signs that I think mean I am going to faint are actually signs of anxiety. It is unlikely that I will actually faint. I would prefer not to faint in the surgery, but if I do then the dental team will know what to do. They are not likely to judge me in a negative way because I fainted – they will have seen patients do similar things before. Even if one of the team did make a negative remark – that does not mean I am wrong, it is only their opinion. Many people worry they may faint but don’t actually do so”.

Pre- treatment session to increase perceptions of control and predictability Dental anxiety can be reduced by increasing perceptions of control and providing information to minimise uncertainty and allow preparation for dental procedures. To increase patients’ perceptions of control, dentists can encourage them to use stop signals whereby the patient can signal the dentist (e.g. by raising their arm or pressing a button) to stop what the dentist is doing. The use of stop signals has been demonstrated to decrease dental anxiety as has even learning that stop signals are available is enough to reduce anxiety. A patient’s perception of control can also be enhanced by giving them choices throughout treatment. One way of increasing predictability is to use the ‘tell-show-do’ technique. This involves an explanation of what is about to happen, what instruments will be used and the reasons for this (‘tell’ phase), followed by a demonstration of the procedure (‘show’ phase). The procedure is then carried out (‘do’ phase). Information can dispel misconceptions that may be contributing to dental anxiety and increase predictability of the events during a dental appointment. Preparatory information includes sensory information (warning as to the sensations the patient 124

is likely to experience) procedural information (details the sequence of events that will (or may) occur) and behavioural information (behaviours that the patient should engage in to improve outcome or recovery). A pre-treatment session is recommended with the treating dentist or hygienist to practise stop signals and for the provision of preparatory information. Encouraging patients to ask questions during this appointment can also increase patients’ confidence.

Expressive writing concerning traumatic dental experiences For patients who report very distinct memories of traumatic experiences at the dentist which are vivid and interfere with their ability to attend dental treatment, the use of expressive writing to explore the event can be helpful. The task is typically given as homework over 3 sessions. Session 1: The patient is asked to write about the traumatic experience. They are encouraged to write as much as they can and to provide as much detail as they can. Though for many this may be an event which occurred many years ago, we encourage them to write as much as possible. Session 2: The patient is asked to revisit the first draft and enlarge on the description, by including information on how they felt before during and after the event. Session 3: The patient now rewrites the event, drawing on the coping skills they have developed both in the years since the event as they have grown up, and as part of their treatment for their dental fear. They should rewrite the conclusion of the event as a positive one that they would wish to have. This task is designed to reconstruct the memory of the event, and focus on positive coping skills that the patient can use in their current dental treatment.

Writing letters Letters can be used in a number of ways to address unhelpful beliefs. For instance, as the patient prepares for their dental appointment following the systematic desensitisation and cognitive techniques, we typically ask them to write a letter to the dentist, explaining the techniques they have learnt for coping with their dental fear, and their preferences for their future dental treatment. Examples of such preferences might include:

• How much information they would like about the treatment (some prefer a

little, some prefer a lot)

• The use of ‘STOP’ signals

• Playing music or wearing earphones during treatment

• Regularity of breaks during treatment 125

It can then be useful to place a copy of the letter with the patients’ dental notes but encourage the patient to discuss the contents of their letter with the dentist themselves. This technique helps the patient to consider the type of treatment approach they prefer and to rehearse discussing this with the dentist.

Other useful topics for letters include:

• Writing a letter to a child to reassure them about what happens at the dentist

• Writing a letter to oneself describing (real or imagined) successful

dental treatment.

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CHAPTER 15 Risk factors for periodontal disease*

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The pathogenesis of periodontal disease is complex and evidence indicates that it is the patientâ&#x20AC;&#x2122;s response to the bacterial challenge which is the major determinant of susceptibility. Identifying the various inherited and acquired factors influencing susceptibility is thus an important part of the periodontal assessment. Risk factors are those factors that influence the likelihood of periodontitis developing in an individual and how fast the disease progresses.

Local risk factors Local risk factors can either be acquired (such as plaque and calculus, overhanging and poorly contoured restorations) or anatomical (such as malpositioned teeth, enamel pearls, root grooves, concavities and furcations). During an examination visit, it is essential to identify these factors and plan to either try to correct them (such as deficient restorations) or educate the patient about local oral hygiene measures (such as using single tufted brushes around malpositioned teeth).

Systemic risk factors A number of systemic diseases, states or conditions can affect the periodontium in a generalised manner. These are known as systemic risk factors. These can be modifiable, such as smoking, or non-modifiable, such as ageing or genetic risk factors.

Tobacco use The most important known risk factor for periodontitis is cigarette smoking. Smoking has a profound impact on periodontitis development, treatment response and likelihood of relapse.

Diabetes Poorly controlled diabetes increases the risk of periodontal diseases. Wound healing is adversely affected by diabetes, especially if poorly controlled. This can make treatment of diabetic patients more difficult. Assessment of diabetic control is important and communication with the patientâ&#x20AC;&#x2122;s doctor should be considered.

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Diabetes control is best assessed using HbA1c (glycated haemoglobin) values. People with diabetes are advised to maintain levels of HbA1c of 6.5% (48mmol/ mol) or lower. Requesting recent test results from the managing physician can be helpful to understand diabetes risk to periodontal health. However, control can vary substantially over time. Patients with undiagnosed diabetes may present with multiple, lateral periodontal abscesses in which case liaising with the patientâ&#x20AC;&#x2122;s GP to confirm the diabetic status of the patient is advised.

Stress Stress is known to affect both the general and periodontal health of patients. There are a few mechanisms by which this might happen. Prolonged or intense periods of stress can cause suppression of the immune system which might tip the host-bacterial interaction in favour of bacteria causing increased attachment loss. Stress also affects how well people look after themselves and might lead to less effective daily plaque removal, increased tobacco-use and poor nutrition. Asking patients about their stress levels and recording this in their notes is important. Making patients aware of the potential effects of stress on their general and oral health may be sufficient for patients to think about stress management or adopting coping strategies. Clearly, managing periodontal health in people undergoing significant stress requires recognition of this factor. Discussion with the patient about the implications is important and consideration should be given to modifying the treatment plan to provide additional supportive care or delaying complex treatment.

Medication Certain medications are known to cause gingival overgrowth. If drug-related gingival overgrowth is suspected, it is prudent to liaise with medical colleagues to determine if alternative drug therapies are available and appropriate, especially if overgrowth is severe or not reducing despite the patientâ&#x20AC;&#x2122;s best efforts at good plaque control and effective professional debridement.

Other considerations Hormonal changes are known to affect the gingivae, most notably during pregnancy. During this time, a greater emphasis on daily effective plaque removal and professional debridement should control periodontal health. Socioeconomic status is strongly associated with risk of developing chronic diseases such as cardiovascular disease, diabetes and increasingly with periodontitis. Currently, it is not clear whether this is because of shared risk factors for each such as tobacco use or poor nutrition, for example, or whether it is due to specific risk factors for periodontitis.

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Emerging evidence Although the evidence is not conclusive for alcohol abuse, obesity, lack of physical activity and poor nutrition, they may be important and are recommended to be included in overall periodontal health advice. As healthcare professionals, it is vital that we identify and make patients aware of the risk factors that might affect their health. A thorough history and examination should allow you to identify and document these risk factors so they can be considered in the treatment planning stage.

Tobacco and periodontal health Tobacco use is directly related to a number of medical problems including cancer, low birth weight babies, pulmonary and cardiovascular problems. As health care professionals, we should be prepared to take any opportunity to encourage patients to quit smoking. The provision of periodontal care can provide an ideal opportunity to provide this sort of health care message, as you and your team will be interacting with your patients over several appointments and often over an extended period of time. Smoking is one of the most significant risk factors in the development and progression of periodontal diseases. Smokers are up to six times more likely to show periodontal destruction than non-smokers, show a poorer response to treatment and are at increased risk of recurrence. This is thought to be due to a reduction in gingival blood flow, impaired white cell function, impaired wound healing and an increased production of inflammatory cytokines enhancing tissue breakdown. Many studies have shown that persistent smoking leads to greater tooth loss and reduced response to periodontal therapy in a dose-dependent fashion. Therefore, patients should be advised that even smoking 1-4 cigarettes a day increases their risk of developing periodontitis by almost 50%. Smokers often display:

• Greater calculus formation

• Higher mean probing pocket depths and more sites with deep pockets

• Greater gingival recession

• Greater alveolar bone loss and furcation involvement

• Less bleeding on probing.

Smoking cigars, cannabis and other smokeless tobacco products regularly carries a similar risk to that of cigarettes. The recent development of e-cigarettes means that the relative effect of these, compared to traditional cigarettes has yet to be investigated. Although they are likely to be less harmful to the periodontal tissues

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than traditional cigarettes, they are unlikely to be as good for periodontal health as not smoking. There is currently both a knowledge and research gap regarding e-cigarettes and patients should be made aware of this. A number of studies have shown that smokers do not show as good a response to periodontal treatment (even in the presence of good oral hygiene) as non-smokers. Smokers are also twice as likely to lose teeth in the longer term. If a patient does manage to stop smoking there is a benefit to treatment response.

Setting patient expectations It is your responsibility to make your patients fully aware of the effects that smoking will have on their periodontal health, response to treatment, risk of relapse and eventually, risk of tooth loss. How you and your team approach smoking cessation advice will depend on whether your patient is a contented smoker, is contemplating quitting or whether they have tried and failed to quit in the past. You should ask about tobacco use and document it. For people considering quitting, the current guidance (Delivering Better Oral Health, 2014) is to refer to specialist quit smoking services such as NHS Smokefree (www.nhs.uk/smokefree). For people who are unwilling to take up such a service, you or someone delegated by you should provide brief tobacco cessation advice. Stopping smoking is a process, not a single event and may require several serious attempts before success. On average, it takes seven serious attempts to quit smoking. Therefore, every â&#x20AC;&#x2DC;failedâ&#x20AC;&#x2122; attempt should be viewed as another milestone on what may be a lengthy journey. It is also important to warn patients of a possible transient increase in bleeding from the gingivae on smoking cessation as the oral vascular supply returns to normal and the masking effects of smoking are removed. You should note down your patientâ&#x20AC;&#x2122;s current self-reported smoking status at every regular recall appointment. It is also important to make note of the historic burden of smoking for instance in pack-years. This is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked.

Periodontal treatment for smokers The mainstay remains good daily plaque control and regular, high quality supra- and sub-gingival debridement with adjunctive local anaesthesia as required. Remember, smokers with gingival recession are at increased risk of developing root caries, so careful monitoring of diet and the caries status together with the provision of appropriate fluoride adjuncts may also be important for this group of patients. Given the reduced healing capacity of the periodontal tissues in smokers, periodontal management of these patients tends to avoid any surgical intervention and in particular any form of hard or soft tissue grafting. You should consider referral for nonresponding patients who smoke.

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Systemic disease and periodontal health There is a growing body of evidence that demonstrates that periodontal conditions might influence the systemic health of patients. The link between periodontitis and systemic diseases comes from a variety of sources including observational studies showing associations between systemic diseases (most notably cardiovascular disease and diabetes) and periodontitis. Evidence has also been gathered from interventional studies showing a possible beneficial impact of treating periodontitis on the systemic health of patients with certain chronic, non-communicable diseases or conditions. These associations were discussed in a joint workshop between the European Federation of Periodontology (EFP) and the American Academy of Periodontology (AAP). The papers from this workshop are freely available online and summarise the knowledge in this field very well. The biological mechanisms by which periodontitis might influence systemic health are linked to the fact that periodontitis causes gingival inflammation which compromises the barrier function of the gingival epithelium leading to an ingress of bacteria or bacterial products or inflammatory products into the systemic circulation. In severe cases, the wound area from periodontal inflammation can be as large as the palm of the hand. This area of inflammation, being present for decades in some cases, could have an impact on systemic health. Although it is established that periodontitis is associated with systemic diseases, such as cardiovascular disease and diabetes, there are challenges in establishing â&#x20AC;&#x2DC;causalityâ&#x20AC;&#x2122;. There are many reasons why this is challenging. Firstly, periodontitis and other common, chronic, non-communicable diseases share common risk factors such as smoking, obesity, diabetes, lack of exercise/a sedentary lifestyle, poor diet and increasing age. Secondly, the impact of periodontitis on these disease processes is likely to be small hence large-scale trials are needed to demonstrate this effect or lack of effect conclusively. Finally, there is a lack of consensus in the research community on a standard definition or criteria for periodontitis. This makes meta-analyses and amalgamation of data from individual trials more challenging. Consequently, people can be advised that periodontal disease is associated with other diseases but it is unclear if it actually causes them. However, what is important for general health is likely also to be protective for periodontal health. *Adapted from the Good Practitioner's Guide to Periodontology (www.bsperio.org. uk) with acknowledgement and thanks.

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References and further reading Chapple, ILC., et al. (2013), Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. Journal of Clinical Periodontology 40: S106-S112. European Federation of Periodontology http://www.efp.org/ Joint workshop between the European Federation of Periodontology (EFP) and the American Academy of Periodontology (AAP) (2013) Journal of Clinical Periodontology 40: S1214. http://onlinelibrary.wiley.com/doi/10.1111/jcpe.2013.40.issue-s14/issuetoc Public Health England. Delivering Better Oral Health 3rd Ed (2014) Section 7: 51-62. https://www.gov.uk/government/publications/delivering-better-oral-health-anevidence-based-toolkit-for-prevention Rosa EF. (2011), A prospective 12-month study of the effect of smoking cessation on periodontal clinical parameters. Journal of Clinical Periodontology 38 (6):562-71. Tonetti, MS., et al. (2013). Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. Journal of Clinical Periodontology 40: S24-S29. Van Dyke, TE. and van Winkelhoff AJ. (2013), Infection and inflammatory mechanisms. Journal of Clinical Periodontology 40: S1-S7.

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CHAPTER 16

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Verbal and non-verbal communication

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Do you remember your first day at senior school? The first time you encountered the rest of your class? Did you not in some way classify or judge each and every person - even though you hadn’t even spoken to many of them? There were the studious types, the hippies, the rebels, the ‘I’m going to be a prefect one-day’ type. We all make immediate (and sometimes rash) judgements about people we meet. We also find it disturbing when people leap out of the ‘pigeon-hole’ to which we’ve assigned them, and turn out to be completely different from how we’d imagined them to be. This stereotyping of individuals is a natural and necessary process that helps us to make sense of the world, but in the dental practice it can be somewhat unhelpful. If on first sight, you judge a patient to be a certain type of person (and which receptionist has not felt her heart sink as some people walk through the door?) we assign certain traits to them:

‘Bound to be an appointment-breaker’

‘Bet she gets stroppy about paying’

‘Oh no, here’s trouble’

and that judgement will taint the communication process thereafter. Also, in the same way that dogs can smell fear, patients will detect your expectations. Most people tend to live up, or down to the expectations which other people have of them. So, it’s important to remember that a seemingly aggressive person might be as meek as a lamb, and an apparently quiet and nervous one may prove to be obstinate and difficult. The dental team are likely to attribute personality traits to each individual they meet, just as the patients are likely to make judgements about the members of the dental team. It is desperately important that everyone within a practice tries to keep the channels of communication as open as possible, particularly with patients who carry an aura of ‘trouble’ around them. It is also true largely thanks to the media - that the public stereotypes the dentist and the practice team. So how do we make judgements about people who we do not know?

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Non-verbal communication A host of factors influence the type of person people judge us to be, and these are quite distinct from what is said between the parties concerned.

Dress and appearance There is little doubt that people would regard a receptionist with cropped dyed hair, and a nose ring differently from one who had a more conventional haircut and did not adorn their olfactory organs with metal. Some people might prefer the former but, in general, patients expect their dental team to be relatively conformist, and to adhere to the ‘status quo’. The important point is that we all make judgements about people based on what they are wearing, and what they look like. The clothes we wear signify a great deal. Members of a dental team, of course, often take this sort of communication to an extreme by opting to wear white coats. These are clearly not necessary for reasons of hygiene, but do convey important messages to patients about the dental staff’s status as professionals, and the highly ‘scientific’ nature of the work. White coats and uniforms make us ‘feel’ different, both in ourselves, and to our patients. However, because emphasising the differences between the dental team and the patient, rather than the similarities, is unhelpful, perhaps ordinary, easily washed clothes might be more appropriate.

Facial expression A very obvious clue to people’s current state of mind (rather than their general personality type) is their facial expression. This is particularly interesting because the expression of one’s emotions via the arrangement of one’s facial features is an ability that is ubiquitous within the human race, and this form of communication can transcend cultural barriers. For example, basic emotions, such as sadness, happiness and anger are expressed facially in the same way in almost every part of the globe. Have you ever been in a noisy place, where you cannot actually hear a word anyone says? If you observe the communication between people, they will laugh when others laugh, smile when others smile, drink when others drink - even though they haven’t caught a single word of what is being said. Humans are very good at deciphering facial, not-so-coded, messages. Therefore, the dental team and the people who visit their surgery are constantly sending messages to each other by way of their facial expression, even if they don’t realise it. We learn a great deal about how someone is reacting to what we are saying and doing, by watching their face. In fact their facial expressions will actually dictate to some extent, what we say and how we say it.

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Eye contact The oft (wrongly) quoted phrase about the ‘eye being the window of the soul’ has a lot to recommend it. Eye contact and gaze is a crucially important part of nonverbal communication. The length of time that two people in conversation spend looking at each other sends very important messages between them. Think of how much eye contact you have with:

• Your dearest beloved

• A shop assistant

• A friend.

If you changed nothing in your relationships with these people, except for mixing up the lengths of eye contact, you will end up with some very confused people. In general in conversation, people look at the other person for about 50% of the time BUT, mutual eye contact (where both parties look directly at each other at the same time) only occurs for about 25% of the conversation. We all know that increased eye contact is used as a particularly significant gesture. Mutual gaze is increased, even if only by seconds, between parties who find each other attractive. And most of us have felt disconcerted when the gaze of someone whom we find unattractive has rested upon us for just that split second too long. So, with patients, the ideal amount of eye contact is as in relaxed conversation. Gazing into their eyes will worry them! The amount of eye contact a patient uses is also important for detecting non-stated worries. Negative emotions such as anxiety or depression will reduce eye contact. Similarly the flow of the conversation is controlled to a large extent by the eye contact between the parties. A careful observer would notice that most patients tend to stop speaking, or at least slow their rate of speech when the practitioner looks down to write notes. Thus, notes should be left to one side, particularly at a first meeting with a patient, or when trying to glean important information.

Posture The posture of a person can give important clues as to their emotional state and their attitude to the other individual with whom they are conversing. If you were telling somebody something which you considered to be of great interest, if they were truly concerned with your story, would you expect them to lean backwards, or towards, you? Depending, to some extent on the position of the limbs, a backwards lean can suggest dominance, and if extreme, can be taken to be indicative of disinterest. In contrast, a slight forward lean, especially if combined with an open arm posture, indicates to the talker that you have interest and empathy with what they are

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saying. Any closed arm posture (i.e. arms folded across the body or crossed) can hint at rejection of what is being said. You will also notice that changes in posture often accompany a change of subject, or the end of a particular topic. Like any other skill, practice is the key. Take the opportunity when socialising to observe the body language of people engaged in conversation. Try out various postures when you are talking and watch the reactions of the other person.

Proximity We all carry around with us a personal space - a sort of invisible ‘bubble’ which encloses each and every one of us. Human beings become stressed if someone else enters this portable ‘territory’, but, the size of the bubble, and what constitutes an ‘invasion’ depends on who the other person is, and what relationship they have to the individual concerned. The first part of the zone is from zero, to about 18 inches away. The British are a notoriously non-tactile race, and in general they are only comfortable admitting lovers, very close friends and small children into this ‘intimate’ zone. In fact with the exception of children, ‘touching’ in public is almost completely limited to formal gestures such as handshakes, and that strange mutual jaw bashing gesture which women make when greeting each other (when they make kissing noises into the air next to the person they are saying hello to). Think how uncomfortable you feel when other people enter your intimate zone uninvited, or worse, unexpectedly. Most of us have had the experience at parties, or other such social functions, of meeting people who insist on talking to us with their face only inches from our own. The most natural reaction is to step away. By making careful observation you can usually spot pairs of people pursuing each other round the room, invading and escaping, reinvading and re-escaping! These ‘spaceinvaders’ make most people highly uncomfortable - and yet think of the process of dental care. Dental professionals invade people’s intimate personal space all the time. This invasion is sanctioned by the patient’s relationship with the professional, but this does not mean that it is comfortable for the patient. It is therefore advisable to remember the stress that the simple act of coming so close to someone engenders. The second layer of the personal bubble is from about 18 inches to approximately 4 feet. This is the characteristic distancing for interaction between people. Again, if complete strangers enter this layer of your bubble, you might feel disturbed. For example, most of us feel odd when squashed into a crowded lift, or on tube trains. We tend to stare fixedly into the middle distance, avoiding eye contact. Similarly, when seated next to someone on a bus, train or plane for a long journey, it is usual for the individuals concerned to make some type of conversation - thus they become ‘aquaintances’ rather than complete strangers, and it becomes slightly 137

easier to accommodate the other person within your territory. The same applies to dental patients. If they feel that they ‘know’ you, even only slightly, it will be less stressful for them to admit you into the space around them. The next zone, from 4 to 12 feet, is the part of our territory in which we feel comfortable with others. In most offices, doctor’s surgeries, and even shops the interacting individuals are separated by a distance of at least 4 feet.

Position What is the optimal seating position if you are to engage someone in conversation? Again, it is useful to think of normal everyday social situations. People are usually only found sitting absolutely opposite each other in romantic restaurants or when engaged in combative discussion. Sitting opposite someone means that eye contact is inevitable and unavoidable. Therefore, the more comfortable and usual seating position for two people who are not particularly familiar with each other is at a diagonal angle. This enables eye contact to take place, but makes it avoidable when it might not be appropriate. It also suggests equality between the involved individuals. We cannot think of any situation in which one person voluntarily sits behind the other whilst chatting - except in the dental surgery. Such a position obviates eye contact and is most unnatural. So, conversation will be easier if you sit where a patient can see you. Repeatedly straining one’s neck, trying to look at someone behind while you are talking, is most uncomfortable - and yet it is a position in which dental patients often find themselves.

Body contact As mentioned above, touching other people is almost taboo, especially in the UK. It is the most basic form of non-verbal communication and requires invasion of the personal zone. Dental care requires that we not only touch the outside of a person’s body, but continue the invasion into the oral cavity. We therefore completely violate a very strong social norm every time we examine or treat someone’s mouth. And yet, often, we find it hard to understand why people are anxious about dental treatment despite evidence about the source of that anxiety being all around us in day-to-day life. Unfortunately, despite the publication of much research studying the importance of body contact between individuals, its impact on the dental patient is not a subject which has been fully addressed. We must therefore base our actions on what we know from our own experience of life and on observations of those around us. What is clear however, is that dental personnel often forget what is ‘normal’ for others, because of what is ‘normal’ behaviour for them. We must guard against this breaking of the usual rules of polite behaviour. Every action we make has consequences for the patient and affects how they feel about the process of dental care. 138

Do we say what we mean? - Verbal communication Although we all know the general rules of conversation, knowledge of how best to go about consultation with a patient can help to ensure that you gather accurate information quickly and efficiently, whilst maintaining the rapport with the patient.

The open question The ‘open’ question is one that allows almost maximum scope in the answer. Whilst it is a good idea to begin your conversation with a patient with open questions, you need to be aware that a question like: ‘How are you?’ can elicit responses as varied as:

‘Fine’ ... to those such as:

‘Well, I was at the doctor last week and he said to me that it wasn’t right, you

know, my chest. I mean he didn’t actually say ..................., etc., etc., etc.’

The focused question These types of question define the area of enquiry more closely than the open question, but still give the other person some freedom to add description and detail to their answer. Q ‘What sort of pain is it?’ A ‘Well it’s not too bad ... It comes and goes ...’ OR A ‘Agony’

The closed question These are questions that can only be answered by the response ‘Yes’ or ‘No’ or with a number, for example: ‘Do you brush your teeth every day?’

‘How many children do you have?’

‘What is your age?’

Such questions do not allow you to glean any extra information or detail. So, if you begin a meeting with a patient with simple closed questions, you will miss important clues about the problem and cues to appropriate action. On the other hand, if solely open questions are used, the consultation may take an inordinate amount of time. It is therefore advisable to begin the conversation with more broad, open questions

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- ensuring during the patient’s answer that all possible information from both the verbal response and non-verbal signs are noticed - then gradually narrow down towards more closed-type questions. There are also questions that, although they will elicit a response, actually lead to false information being gathered.

The leading question These questions imply a specific answer. Special efforts should be made to avoid these, because patients are often passive and will agree with the question’s statement, even if it is not actually a true interpretation of the facts as the patient sees things. For example: ‘You haven’t been to the dentist for ages, have you?’

The compound question Compound questions are those that ask for more than one piece or type of information. This sends a mixed message to the respondent and therefore you are bound to get a confused answer. A common example of such a question is: ‘Do you brush and floss every day?’ If the patients answered ‘yes’, do they mean they brush and floss every day, or do they brush once a week and floss once a day. Who knows? Compound or double questions only serve to confuse everyone, so should be avoided. Obviously a consultation with someone is not and should not be, a simple question and answer session. Various other forms of verbal communication will be used to put the patient at ease in order to enhance the rapport with which information is gathered and to ensure that the patient knows that you understand what he has said.

Social exchanges Social exchanges are the polite, non-judgemental, greeting-type statements that are usually used at the beginning and end of a meeting in order to help to establish and maintain your rapport with the patient, for example:

‘Good morning’

‘Nice weather’

‘Goodbye - have a nice day’

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Facilitation Facilitation is the term used for the general words and noises which we say and make in order to encourage people to keep talking, or expand on what they are saying, such as, ‘Uh huh’, ‘Go on’, ‘You were saying...’

Repetition Repetition is exactly what it says, but is a very useful form of verbal communication. Again, this can readily be practised with very rewarding results at social gatherings. You simply repeat the last sentence, or part of a sentence which has been said to you. It will sound very obvious and forced to your own ears, but people find it very reassuring. It tells them that you are listening closely and are interested in what they are saying.

Restatement Restatement is similar to repetition except that you take what is said to you and restate it in your own words, for example: (Patient)

‘I can’t brush, ’cos my gums keep bleeding’.

(Hygienist) ‘Mm, so you’re having trouble brushing because of the bleeding’.

Clarification/Interpretation Again, this is similar to restatement in that you interpret a lengthy response into a statement of fact, and then check with the patient that your interpretation matches with what the patient feels. (Patient)

‘They only hurt when I eat, well drink, and even then it’s not with

everything. Tea, I can’t drink tea, or coffee really’.

(Therapist) ‘So your teeth only hurt when you drink something hot’. A plea for plain English! Just because a word is familiar and used every day among the members of the team, it is important to beware of the pitfall of assuming that it is equally meaningful to a patient. Biological and medical terms, even ones that are used in everyday language can give rise to immense amounts of confusion. It is known that the terms ‘anaemia’ and ‘heart disease’ are often thought of as similar complaints by many members of the public. ‘Palpitation’ is also a word that can have a range of meanings to different people - to some it is a ‘fright’, to others it means a feeling of breathlessness. And the word ‘flatulence’ can, to some, mean an acid taste in the mouth.

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So, care is needed in the way you express yourself, as you may not, to the ears of the listener, be saying what you think you are saying. Even a term such as gingivitis is completely meaningless to many people, explaining to someone how to prevent something, when they have no idea what you are talking about, is very probably a gross waste of time! The reasons why we slip so easily into ‘jargon’ are many. Firstly, complex biological terminology including naming items in Latin is sometimes used purposefully in front of a patient, in the mistaken belief that if they do not understand the language, it will reduce their anxiety about their problem. Secondly, use of a language that a second person does not know can be used to heighten the status of the first person. Doing so necessarily makes the second person feel powerless. Finally, jargon is sometimes used because there is an assumption that patients are ‘ignorant’, and will therefore be unable to understand medical ideas and biological/physiological systems. Enhancing patients’ sense of control over a situation is vital. The use of jargon only serves to do the opposite. It should be avoided - a dental team should feel that their professional status is compromised, not raised, if they need to resort to jargon. There is no shame in explaining things as they are. You would not like to be told about your medical condition in Cantonese, so why should dental patients not have the facts presented to them in an as accessible a way as possible?

Last thoughts The whole purpose of developing your communication skills is that you are able to encourage people to disclose their problems and any other information you might need in an efficient manner whilst letting the patient know that you care. In general, a successful meeting between a member of the dental team and patient is one in which the team spots associations between verbal and non-verbal signals, and picks up the points which are most important to the patient. Dental teams therefore need to develop their listening skills. Combined with appropriate postures and body language, those skills can go a long way towards encouraging trust and an atmosphere of partnership between patients and the dental team.

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CHAPTER 17

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Impairment in adults: systemic disease

Turn to page 162 to find out how

Oral disease and discomfort may be the direct result of illness or secondary to its treatment. Conditions where general health is compromised by oral health are also included in this article. Dental management may be complicated and pose a potential risk to health. Dental treatment may pose a serious health risk, particularly if a general anaesthetic is needed. To avoid crisis management, good preventive oral care including diet, oral hygiene and regular dental attendance are therefore a priority.

Coronary heart disease Coronary heart disease (CHD) is a largely preventable condition that is common in the UK and is frequently fatal. The death rate is higher than in many European countries and has fallen more slowly. In England about 300,000 people have a heart attack each year and 110,000 die as a result. Demographically, it affects the unskilled male at more than three times the rate of those in managerial and professional occupations. The wives of manual workers have more than twice the risk of being affected compared to the wives of managerial and professional workers. Angina, heart attack and stroke are also more common in those with manual occupations. The death rate is higher for people born in the Indian sub-continent by 38% for males and 43% for women. The major approach to reducing the impact of CHD is via a National Service Framework. This brings together all members of the health care teams and social care with a clear plan to:

• Set national standards for prevention and treatment

• Recommend service models

• Suggest clinical audit and indicators to assess quality of prevention and

treatment

• Set goals

• Provide examples of practical tools.

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Risk factors for CHD The major risk factors for CHD are: • Smoking

• Excess alcohol

• Diabetes mellitus

• High cholesterol

• Family history of CHD

• Sedentary lifestyle

• Obesity. In addition there has been considerable recent research into the links between oral disease and CHD. Periodontal disease is a chronic infection and a possible source of infection which can enter the circulation (bacteraemia). A recent review concluded that periodontal disease appears to be associated with a 19% increase in risk of future cardiovascular disease. It is also clear that smoking is a cofactor in both periodontal disease and CHD. A ‘common risk factor’ approach to both CHD and oral health is a logical for prevention of both these common diseases. Promotion of a healthy diet, healthy lifestyle, good oral hygiene and smoking cessation are the principal components.

Cardiovascular diseases There are a range of cardiovascular diseases that pose a risk for oral health, often as a result of the medications used. The following aspects of cardiovascular disease will affect dental treatment and careful medical history taking and treatment planning is needed:

• Chest pain

• Angina

• Myocardial infarction

• Hypertension • Syncope

• Shortage of breath

• Rheumatic fever

• Infective endocarditis

• Cardiac arhythmia

• Cardiomyopathy

• Coronary artery bypass graft

• Valve replacements

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• Congenital disorders

• Cardiac transplants

• Venous/lymphatic disorders.

For these aspects of cardiovascular disease effective dental treatment and prevention will often involve collaboration with the wider health care team. Dental treatment will usually avoid general anaesthetics and the use of adrenaline containing local anaesthetic is often indicated. The timing for dental treatment may be affected by the phase of the disease, e.g. delaying treatment until after three months post-myocardial infarction. Antibiotic cover may be needed in some conditions, e.g. Rheumatic fever, to avoid infective endocarditis.

Oral side-effects of medications used in cardiovascular disease Certain groups of medications used in the treatment of cardiovascular disease have a specific side effect on oral health. Beta blockers: These are used in the control of high blood pressure and cardiac failure. Side effects include xerostomia (dry mouth) and lichenoid reactions. Vasodilators: This group of drugs are used to decrease the blood pressure by dilating veins. One group, calcium antagonists, are used to control coronary and peripheral blood vessel dilation. Oral side effects include gingival hyperplasia. Immunosuppressives: These drugs are used post- cardiac transplant to reduce rejection of the new organ. Oral side effects include infection by Candida and gingival hyperplasia.

Blood disorders Abnormalities in the blood can be classified into disorders with:

• Red blood cells

• White blood cells

• Platelets

• Clotting and bleeding disorders.

It is important to detect blood disorders during the taking of a medical history prior to commencing dental treatment. Blood disorders can cause bleeding problems following surgical procedures and healing may be affected. The choice of type of local anaesthetic and technique may also be affected. There is a need for effective prevention to minimise dental interventions that often pose a risk for people with blood disorders.

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Red blood cells- anaemia Anaemia may be caused by one of a number of factors:

• Excessive haemorrhage: menorrhagia, gastro-intestinal ulcer/carcinoma,

trauma

• Abnormalities in red cell formation - aplastic anaemia

• Increased red cell destruction- haemolytic anaemia

• Malabsorbtion syndromes

• Pregnancy

• Nutritional deficiencies- iron, vitamin B12, folate

• Drug induced anaemia

• Malignancies

• Secondary to chronic disease

• Infection - malaria

• Inherited conditions- sickle cell disease, thalassaemias.

The oral signs and symptoms of anaemia include:

• Generalised soreness of the soft tissues

• Persistent ulceration

• Red, smooth tongue

• Candidal infection and angular cheilitis

• Abnormalities in taste sensation.

White blood cells White blood cell disorders can include:

• Reduced numbers (leucopaenia)

• Increased numbers (leucocytosis)

• Malignancy. Leucopaenia: This may be the result of HIV infection or early stages of leukaemia, or may be due to drug therapy. The clinical condition is known as aganulocytosis and causes an increased susceptibility to infection and oral ulceration. Leucocytosis: This is a feature of leukaemia.

Platelets There may be decreased numbers of platelets or failure in function. This can produce bleeding following dental surgery. Platelet function can be affected by drugs e.g. aspirin. 147

Clotting and bleeding disorders These disorders may be related to:

• Inherited - Haemophilia, Von Willebrand’s disease, Christmas disease

• Anti-coagulant drugs – warfarin, aspirin, heparin.

Dental treatment will need to be planned in conjunction with the haematology team to replace missing clotting factors in inherited disease. There are increased numbers of people taking anti-coagulants to reduce the risk of stroke. Dental surgery needs careful planning after assessing their bleeding time and careful control of postoperative bleeding.

Respiratory disorders Respiratory disorders are common, and in common with other systemic conditions they can affect the way that dental treatment is carried out. There is an increased risk with general anaesthesia, sedation and side effects with some of the medications which raises the importance of effective prevention. Respiratory diseases will always be affected by smoking, therefore this common risk factor also for oral disease should also be addressed by the dental team.

Asthma Asthma is a generalised airways obstruction which leads to the characteristic wheeze following muscle contractions in the bronchus. The condition is provoked by contact with allergens, stress and effort. Infrequent attacks are controlled by ventolin inhalers which act as a bronchodilator. More frequent attacks are controlled by regular use of salbutamol or inhaled steroids. The oral side effects of long term treatment are a dry mouth and increased risk of candidal infection.

Chronic obstructive airways disease This condition combines chronic bronchitis and emphysema and is a common smoking related disease. There is a combination of chronic sputum production and dilation and destruction of the bronchioles. Treatment involves bronchodilators and antibiotics. Steroids are also used which can affect the timing of dental treatment.

Tuberculosis Tuberculosis is an infection from Mycobacterium tuberculosis which has increased in prevalence in recent years. It is seen in immunocompromised people with HIV and in immigrants from non-industrialised countries who are malnourished. Lesions can occasionally be seen on the tongue. The condition is infectious when active which can affect the timing of dental treatment. It is treated by a combination of specific antibiotics. 148

Cystic fibrosis This is a common inherited disease seen in 1:2,000 live births. The condition affects the lungs and digestive system. Respiratory infections are common and require prolonged antibiotic therapy. Malnutrition is a problem of impaired digestion and there is a risk of diabetes mellitus and liver disease. The oral features include enlargement of the salivary glands, enamel hypoplasia and delayed eruption. Dietary supplements high in sugar are often used but a high caries rate is not seen, thought to be due to the long term antibiotics usage. Higher levels of calculus are seen which is thought to be due to a high calcium content of saliva in the condition.

Gastrointestinal disease Gastrointestinal diseases can have oral signs and the sequelae can have an effect on oral health. The dental management of people with gastrointestinal disease can be affected in the timing and choice of anaesthesia. Some of the aspects of GI disease include: • Anaemia

• Gastric reflux

• Vomiting

• Dysphagia (difficulty swallowing)

• Cervical node enlargement

• Facial and labial swelling in Crohn’s disease.

Oral aspects of GI disease include:

• Oral ulceration

• Glossitis

• Burning mouth

• Angular cheilitis.

Side effects of some of drugs used in GI disease include:

• Candidal infections following extensive broad spectrum antibiotics for gastric

ulcer treatment

• Oral irritation from pancreatic supplements

• Xerostomia from proton pump inhibitors.

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Liver disease There are few oral features in relation to liver disease. The common signs include jaundice, Dupuytren’s contracture and finger clubbing. There may be a bleeding tendency and intolerance to drugs used in dental care can affect dental management. Hepatitis poses extra precautions in cross-infection control.

Renal disease Oral features occur only in the less common renal disorders. Children with chronic renal failure may have delayed eruption, malocclusions and enamel defects. Aspects of renal disease include: • Anaemia

• Reduced salivary flow

• Keratin deposits (white patches)

• Oral infections in immunosupressed people after transplants

• Gingival hyperlasia following cyclosporin therapy.

Long term steroid therapy will also affect dental management.

Endocrine system disorders The endocrine system consists of the group of glands that produce hormones. The commonest disorder is diabetes and other include:

• Thyroid gland disorders: Hypothyroidism can reduce the immune response

and oral candidal infections may be seen.

• Oral contraceptive: may have reduced effect with antibiotics and increase

gingivitis.

• Adrenal gland disorders: Excess production in Cushing’s disease and Cushing’s

syndrome. Decreased production in Addison’s disease which will require

replacement steroids for surgical dental treatment.

• Parathyroid gland disorders: Hyperparathyroidism (excess production) may

present oral granulomas and that following surgery to the glands leads to

bone resorption.

• Pituitary gland disorders: Increased growth hormone production causes

acromegaly with increased growth of mandible, facial bones and hands.

• Diabetes Insipidus: Reduced anti-diuretic hormone can follow pituitary gland

tumour or injury. Features include high fluid intake and urine production

and xerostomia.

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Diabetes mellitus Diabetes mellitus is commonly referred to as diabetes and is a chronic and progressive disease that affects children, young people and adults of all ages. Diabetes comprises a group of disorders with many different causes, all of which are characterised by a raised blood glucose level. The condition is increasing and around 1.3 million people in England are currently diagnosed with diabetes, with hundreds of thousands having Type 2 diabetes without yet knowing it.

• In Type 1 diabetes (15% of cases) the pancreas is no longer able to produce

insulin. Daily injections of insulin are required the need to maintain blood

glucose within certain limits. Adjustments in diet and lifestyle are also needed.

• In Type 2 diabetes, (85% of cases) the insulin producing cells are not able

to produce enough for the body’s needs. The majority of people with Type

2 diabetes also have some degree of insulin resistance. People with Type 2

diabetes need to adjust their diet and their lifestyle. Many are overweight or

obese and will be advised to lose weight.

The incidence of diabetes is increasing in all age groups

• Type 1 diabetes is increasing in children, particularly in under fives

• Type 2 diabetes is increasing across all groups, including children and young

people, and particularly among black and minority ethnic groups.

Diabetes can result in premature death, ill health and disability via:

• Renal failure

• Neuropathy

• Vascular disease

• Ocular disease

• Cardiovascular disease.

People with well-controlled diabetes have no specific oral features. If poorly controlled, oral health may be affected by xerostomia, delayed healing, susceptibility to oral infections and periodontal disease. There is emerging research that links obesity to an increased prevalence of periodontal disease. There are numerous rare conditions which may compromise oral health. This article has summarised the most significant non-malignant medical conditions. For most of the conditions avoidance of dental treatment under general anaesthesia is a priority. Basic oral prevention to reduce plaque levels, access to fluoride and a diet low in extrinsic sugars is important. Regular dental attendance for preventive advice and treatment which avoids crisis management will make an important contribution to the maintenance of health.

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CHAPTER 18

Make this CPD Verifiable

Root canal morphology

Turn to page 162 to find out how

Both undergraduate students and dentists on postgraduate courses frequently state that the reason they find root canal treatment so difficult, and the reason surveys frequently report inadequate treatment standards is because they are working ‘blind’. Unless a surgical microscope is available it is impossible to see down the root canal – to visualise exactly what the instruments are doing. An understanding of the architecture of the root canal system is therefore an essential prerequisite for successful root canal treatment. There is still something of an obsession with the concept of a ‘root canal’ as a hollow tube in a root which has to be cleaned and shaped, eventually appearing as a nice white line on the post-operative radiograph. Undergraduate students learn the number of canals in each tooth by rote. However, many teeth have more than one canal and where two canals exist within the same root, for example the mesial root of a lower molar, lateral communication (anastomosis) in the form of fins or accessory canals also occurs between them. Even roots with a single canal will have lateral and accessory canals leaving the main canal. Unless this concept of an entire root canal system is clearly understood, and a method of cleaning and shaping it employed to address these anastomoses as well as the main canals, infection will remain and the treatment may fail.

The root canal system The pulp chamber in the coronal part of a tooth consists of a single cavity with projections (pulp horns) into the cusps of the tooth (Figure 1). With age, there is a reduction in the size of the chamber due to the formation of secondary dentine, which can be either physiological or pathological in origin. Reparative or tertiary dentine may be formed as a response to pulpal irritation and is irregular and less uniform in structure. The entrances (orifices) to the root canals are to be found on the floor of the pulp chamber, usually below the centre of the cusp tips. In cross-section, the canals are ovoid, having their greatest diameter at the orifice or just below it. In longitudinal section, the canals are broader bucco-lingually than in the mesio-distal plane. The canals taper towards the apex, following the external outline of the root. The

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narrowest part of the canal is to be found at the ‘apical constriction’, which then opens out as the apical foramen and exits to one side between 0.5 and 1.0 mm from the anatomical apex. Deposition of secondary cementum may place the apical foramen as much as 2.0 mm from the anatomical apex. It must be realised, however, that the concept of a ‘single’ root canal with a ‘single’ apical foramen is mistaken. The root canal may end in a delta of small canals, and during root canal treatment cleaning techniques should be employed to address this clinical situation.

Lateral and accessory canals Lateral canals form channels of communication between the main body of the root canal and the periodontal ligament space. They arise anywhere along its length, at right angles to the main canal. The term ‘accessory’ is usually reserved for the small canals found in the apical few millimetres and forming the apical delta. Both lateral and accessory canals develop due to a break in ‘Hertwig’s epithelial root sheath’, during tooth development when the sheath grows around existing blood vessels. Their significance lies in their relatively high prevalence, with 60% of central incisors with accessory canals, and 45% with apical foramina distant from the actual tooth apex. Lateral canals are impossible to instrument and can only be cleaned by effective irrigation with a suitable antimicrobial solution. Consequently sealing such canals is only moderately successful.

Maxillary central incisors These teeth almost always have one canal. When viewed on radiographs the canal appears to be fairly straight and tapering, but labio-palatally the canal will tend to curve either towards the labial or palatal aspect at about the apical third level. One feature to note is the slight narrowing of the lumen at the cervical level, which immediately opens up into the main body of the canal. An inverted-triangular shaped access cavity should be cut with its base at the cingulum to give straight line access.

Maxillary lateral incisor Similar in shape to the central incisors, but fractionally shorter, the apical third tends to curve distally and the canal is often very fine with thin walls. Labio-palatally, the canal is similar to the central incisor, but there is often a narrowing of the canal at the apical third level. The root is more palatally placed, an important point when any periradicular surgical procedures are carried out on this tooth. The access cavity is similar to the central incisor.

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Maxillary canine As well as being the longest tooth in the mouth, its oval canal often seems very spacious during instrumentation. However, there is usually a sudden narrowing at the apical 2-3 mm; this leads to a danger of over-instrumentation if too large a file is used at this level. The length of this tooth can be difficult to determine on radiographs, as the apex tends to curve labially and the tooth will appear to be shorter than it actually is. The oval shape of the root canal is reflected in the shape of the access cavity.

Maxillary first premolar Typically, this tooth has two roots with two canals. In many ways this is the most difficult tooth to treat, as it can have a complex canal system. Variations range from one to three roots but there are nearly always at least two canals present, even if they exit through a common apical foramen. The roots of these teeth are very delicate and at the apical third they may curve quite sharply buccally, palatally, mesially or distally, so instrumentation needs to be carried out with great care. In a small percent of cases the buccal root may sub-divide into two canals in the apical third. An oval access cavity should be cut between the cusp tips, being wider bucco-palatally than mesio-distally.

Maxillary second premolar In 40% of cases, this tooth, which is similar in length to the first premolar, has one root with a single canal. Two canals may be found in about 58% of cases. The configuration of the two canals may vary with two separate canals and two exits, two canals and one common exit, one canal dividing and having two exits. In one study, it was found that 59% of maxillary second premolars had accessory canals. As with the first maxillary premolar, the apical third of the root may curve quite considerably, mainly to the distal, sometimes buccally (Figure 2). The access cavity is similar to the first premolar.

Maxillary first molar This tooth has three roots. The palatal root is the longest, with an average length of 22 mm; the mesiobuccal and distobuccal roots are slightly shorter, at 21 mm average length. The percentage of mesiobuccal roots having two canals reported in the literature has increased steadily as research techniques have developed. In vitro studies have usually reported a higher incidence than in vivo studies. Such an unidentified and therefore uncleaned canal can be a major cause of failure. The canals of the mesiobuccal root are often very fine and difficult to negotiate; consequently, more errors in instrumentation occur in this tooth than in almost any

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other. Anastomosis between these two canals may take the form of narrow canals or wide fins, both almost impossible to instrument. The curvature of the roots can be difficult to visualise from radiographs, and the second mesiobuccal canal is nearly always superimposed on the primary mesiobuccal canal. The palatal root has a tendency to curve towards the buccal and the apparent length on a radiograph will be shorter than its actual length. The access cavity represents the shape of the pulp chamber, enlarged slightly, and flared up on to the mesio-buccal aspect of the occlusal surface to accommodate the angle of instrument approach when working at the back of the mouth.

Maxillary second molar This tooth is similar to the first maxillary molar, but slightly smaller and shorter, with straighter roots and thinner walls. Usually there are only three canals and the roots are sometimes fused. The access cavity is the same as for the first molar, modified further to accommodate the angle of approach.

Maxillary third molar The morphology of this tooth can vary considerably, ranging from a copy of the first or second maxillary molar to a canal system that is quite complex. They are best explored with a wide access cavity and direct vision of the individual canal anatomy.

Mandibular central and lateral incisors The morphology of these two teeth is very similar. The central incisor has an average length of 20.5 mm and the lateral is a little longer with an average length of 2l mm. Over 40% of these teeth have two canals, but only just over 1% have two separate foramina. Careful reading of the pre-operative radiograph may show a change in the radiodensity of the root canal, indicating division into two separate canals, and a correctly designed access cavity will facilitate checking for a second canal. This is oval in shape, commencing above the cingulum and almost notching the lingual incisal edge.

Mandibular canine This tooth is similar to its maxillary opposite number, although not as long. On rare occasions, two roots may exist and this can cause difficulty with instrumentation. An oval access cavity is again indicated.

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Mandibular first premolar The canal configuration of this tooth can be quite complex. The single canal normally found may divide into two canals and two apical foramina in 25% of cases. It is the way in which the second canal branches that can cause difficulty with instrumentation. Occasionally, the canal terminates with an extensive delta, making obturation of the accessory canals even more challenging. As in the upper premolars, the access cavity is oval between the cusp tips.

Mandibular second premolar This tooth is similar to the first premolar, except that the incidence of a second canal is very much lower. One study stated this to be 12%, while another revealed that only 2.5% had two apical foramina. Consequently, it is a much easier tooth to treat compared with the mandibular first premolar, unless the radiograph reveals a sharp distal curve at the apex.

Mandibular first molar This is often the most heavily restored tooth in the adult dentition and seems to be a frequent candidate for root canal treatment. Generally there are two roots and three canals: two canals in the mesial root and one large oval canal distally. It is thought that about one third of these molars have four canals and occasionally three roots are to be found: usually two distal and one mesial; rarely one distal and two mesial. Anastomoses occur between the canals and accessory communication with the furcation area is a frequent finding. The mesiobuccal canal tends to exhibit the greatest degree of curvature. The access cavity once again represents the shape of the pulp chamber, enlarged slightly, and flared up on to the mesio-buccal aspect of the occlusal surface to accommodate the angle of instrument approach when working at the back of the mouth.

Mandibular second molar This tooth is similar to the mandibular first molar, although a little more compact. The mesial canals tend to lie much closer together, and the incidence of two canals distally is much less. This tooth seems to be more susceptible to vertical fracture. Occasionally the root canals may join in a buccal fin giving a â&#x20AC;&#x2DC;C-shapedâ&#x20AC;&#x2122; canal, which may lead all the way to the apex. The access cavity is similar to that of the first molar.

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Mandibular third molar Together with the maxillary third molar, this tooth displays some of the most irregular canal configurations to be found in the adult dentition (Figure 3). However, the mesial inclination of the tooth generally makes access easier. The canal orifices are not too difficult to locate, but the degree of curvature of the apical half of the root canal system is often pronounced. Added to this, the apex is frequently poorly developed and lies close to the inferior alveolar canal. A large access cavity allowing direct visualisation of the floor of the pulp chamber enables the canal orifices to be identified.

Pulp stones Pulp stones are often seen as an incidental observation on bitewing and periapical radiographs. They are discrete areas of calcification within the pulpal tissue, and even after extensive research their cause is largely unknown. They may be classified as true or false stones according to their morphology, and they may vary in size from 50Îźm to several millimetres occluding the entire pulp chamber. They are normally free within the pulpal tissue and may be excavated once the access cavity has removed the roof of the pulp chamber, although occasionally they have become attached to the dentine, rendering their removal more difficult. Their main interest to endodontists is in the difficulty they may cause during access cavity preparation.

Figure 1 A cross section of a premolar showing the pulp chamber, pulp horns and root canal system.

Figure 2 The roots of maxillary second premolars can curve quire sharply

Figure 3 Irregular root configurations in mandibular third molars

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CHAPTER 19 The development and management of dentine carious lesions By J E Frencken Adapted from the book: The art and science of Minimal Intervention Dentistry and Atraumatic Restorative Treatment.

Carious lesions that are restricted to the enamel can usually be arrested by measures that include biofilm control, dietary change, the use of fluoride-containing products, and saliva stimulation. This means that controlling the carious lesion that affects only the enamel through restoring it is not justified. A restoration should be considered only when the caries process has extended into the dentine, resulting in a lesion with obvious cavitation that precludes cleaning.

How does an enamel carious lesion progress into dentine? Organic structures in dentine are destroyed and crystals dislodged as a result of reactions in cariogenic biofilm present at the enamel surface. The uncleansable cavity so formed harbours biofilm that cannot be removed by the patient. Such cavities are bound to progress since, under the influence of cariogenic stimuli, biofilm causes further destruction of the dentine. It has been shown that the lateral spread of demineralisation at the enamel-dental junction (e-dj) is very rare in uncavitated lesions. However, it occurs very frequently in cavitated lesions. Thus, the still commonly held belief that once a carious lesion has reached the dentine it will first rapidly spread laterally along the e-dj before progressing in a pulpal direction is largely incorrect. The loss of minerals in a dentine carious lesion causes changes in hardness of the dentine as one moves progressively from the e-dj towards the pulp. Owing to demineralisation at the e-dj, the hardness is very low. It gradually increases until sound dentine is reached. Then, as a result of the widening of dentinal tubules, the degree of hardness reduces closer to the pulp. In the context of a dentine carious lesion at the e-dj, dentine is completely destroyed and almost all the crystals have been dislodged. This layer is variously termed the ‘outer carious dentine’, ‘infected dentine’ or ‘decomposed dentine’ or ‘soft dentine’. Studies have shown this soft, decomposed dentine to be full of microorganisms, with no sensation, and largely incapable of being remineralised. In other words, it can be considered to be dead. Thus, this soft biomass is of no further structural use to the tooth and should be removed. Further away from the e-dj, the mineral content becomes higher and, consequently, the dentine is harder. This layer is called the ‘inner carious dentine’, ‘affected 158

dentine’, ‘demineralised dentine’ or ‘firm dentine’. It differs considerably from the soft, decomposed dentine in that it is vital, minimally infected by microorganisms, and has the ability to take up minerals. Therefore, firm, demineralised dentine has the potential to remineralise and to become harder and should thus be retained during cavity preparation. Here we use the term ‘decomposed’ in relation to soft dentine and ‘demineralised’ in relation to firm dentine.

The importance of the direction of enamel rods In an attempt to defend the pulp from the effects of carious lesion progression, the odontoblasts may form reactive dentine as a protective response. It is particularly interesting to look at the inclination of the direction of the enamel rods in relation to the occlusal and approximal surfaces as is apparent that the directions differ. In occlusal lesions, the direction of the rods leads to an opening that is usually smaller at the tooth surface than at the base, which shows a pyramid-like lesion. This results in demineralised enamel that is either unsupported or poorly supported by the underlying dentine. Some of this enamel has to be removed to gain access to the soft, decomposed dentine at the e-dj. Enamel should also be removed when it is thin and prone to fracture. In approximal lesions, the direction of the rods does not lead to a pyramid-like lesion. In this tooth surface, the size of the orifice of the cavity remains more or less the same throughout the enamel (Figure 1). Notice that the enamel that forms the cavity opening in pits and fissures is thin. This observation becomes important when the cavity needs to be accessed with hand instruments as part of the Atraumatic Restorative Treatment (ART) procedure. Does a cavitated dentine carious lesion have the ability to heal? The presence of cariogenic stimuli in the oral environment is the external cause of carious lesion progression. If these cariogenic stimuli are sufficiently reduced, the lesion will no longer progress. A natural defence process is in action in which crystals block the dentine tubules. This blocking results in the so-called ‘arrested dentine carious lesion’. Clinically, this lesion usually has a much darker colour than normal dentine or an active dentine carious lesion (Figure 2). If healing then takes place, this is due to the absence of cariogenic biofilm and to the remineralising effect of saliva. The effect is dependent upon the composition and flow of saliva as well as its access to the lesion. For instance, cavitated dentine carious lesions with a large opening have a higher chance of becoming arrested than dentine carious lesions with a small opening. The former is more exposed to saliva, the effects of biofilm control and fluoride. An attempt to remove biofilm can be exercised with just a toothbrush and fluoride toothpaste.

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How does one increase the life of a tooth that requires a restoration? Sealant-restoration Pits and fissures are the places on the tooth surface that are most vulnerable to becoming carious. If a dentine cavity in the mesial pit of the occlusal surface requires a restoration, simply restoring the cavity may not be enough. The fact that the mesial pit has developed a cavity is evidence that the occlusal surface is susceptible to demineralisation. It is therefore possible that a carious lesion might develop again somewhere else on the occlusal surface. To prevent this from occurring, the remaining pits and fissures should be sealed, which would preserve the tooth further. This procedure leads to a so-called ‘sealant-restoration’. This preservative restoration concept can also be applied to the occlusal surface of multiple-surface cavities. The effect of a sealant-restoration compared to a traditional single-surface amalgam or a resin composite restoration in permanent posterior teeth has been the subject of much research. One 10-year study showed that sealant restorations “were superior to unsealed ‘traditional’ restorations in conserving sound tooth structures, protecting restoration margins, preventing recurrent carious lesions and prolonging the clinical survival of the restorations”. This proves that sealing pits, fissures and restoration margins is currently the best way forward for preserving a tooth that has an obvious dentine carious lesion in the occlusal surface. Sealed restorations in smooth surfaces have not been researched but there is no reason for abstaining from this treatment if it is feasible. The concept of sealing the restoration margin is not new and first appeared in the literature in the 1970s. Examples include ‘the preventive resin restoration’, ‘the preventive glass-ionomer restoration’ and the ART restoration. What happens to soft, decomposed dentine that is not removed? The main factors involved in the carious process are: the tooth, microorganisms, substrate, saliva, fluoride and time. These factors need to work simultaneously in order to initiate and cause progression of the carious lesion into dentine. The tooth, saliva and time are self-regulating factors, whereas patients and dental practitioners can influence the presence of cariogenic microorganisms and the availability of substrate and fluoride. The worst-case scenario is that no soft, decomposed dentine is removed and a sealant-restoration is placed to fill the existing cavity. This situation, where only the available substrate to the underlying microorganisms has been blocked by a sealant-restoration, has been studied. Sealant restorations were placed over cavitated dentine carious lesions in occlusal surfaces. No instrumentation took place under the enamel of these sealant-restorations and only a bevel was placed at the margin. The lesions were filled with a chemically cured resin composite material

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and sealed over with a chemically cured resin sealant material. After 10 years, a carious lesion occurred at the margin in only 1 of the 85 restorations. Furthermore, on radiographic assessment, the sealant-restoration had arrested the progress of the decomposed and partly demineralised carious dentine left behind in the cavity. For this form of treatment to succeed, it is essential that the sealant remains intact. Further investigations support the findings of this study and report the hardness of the firm, demineralised dentine to have increased under restorations. Although carious lesion progression stops after sealing in soft, decomposed dentine, it seems logical to increase the chances of success by also reducing the number of microorganisms present in a cavity prior to placement of a sealantrestoration, a restoration or sealant. Studies have shown that microorganisms are present in abundance in soft, decomposed dentine but their presence decreases tremendously in firm, demineralised dentine. Only in deep dentine carious lesions are microorganisms present near the pulp. In such a situation, the pulp may get infected if further demineralisation takes place. The repair potential of the pulp is enhanced if microleakage between the restoration material and cavity walls is eliminated. This calls for the use of restorative materials that do not shrink during the setting process, such as glass-ionomers. Conversely, when sound dentine is cut with a dental bur, it has been estimated that the remaining cut dentine consists of some 34,000 dentinal tubules per square millimetre. This means that during any mechanical cavity preparation it is difficult, if not impossible, to eradicate all microorganisms completely. Consequently, some microorganisms will always be present in a cavity preparation even after preparing the cavity. But is this bad? In order for these remaining microorganisms to produce further demineralisation of dental structures, they need to have a cariogenic substrate and they need to be present in sufficiently large numbers to tip the homeostasis in the oral flora. If one was able to reduce the number of microorganisms and to keep cariogenic substrate away, the carious process would come to a halt. This hypothesis has been subjected to studies for more than four decades and found to be valid. Nowadays, there is consensus about this concept among many researchers, expressed in consensus statements supported by cariologists from around the world. It is accepted that if a bonded restoration and sealant are properly placed, a physical barrier is formed that prevents cariogenic nutrients from reaching microorganisms under that restoration or sealant. The type of restoration does not seem to matter. Studies have reported a marked reduction in microorganisms to a level of being â&#x20AC;&#x2DC;non-detectableâ&#x20AC;&#x2122; in dentine tissues under temporary, glass-ionomer, resin composite, resin modified glass-ionomers and amalgam restorations, and sealants. The latest development concerns glass-ionomers with antibiotic agents. The number of microorganisms in soft, decomposed dentine was markedly reduced one day after being sealed in with a glass-ionomer that contained metronidazole-

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ciprofloxacin-cefaclor. Likewise, a chlorhexidine-containing glass-ionomer substantially reduced the number of microorganisms in both soft, decomposed and firm, demineralised dentine over a period of seven days. The reduction achieved with both antimicrobial glass-ionomers was significantly higher than obtained with a common conventional high-viscosity glass-ionomer. Whether these special products are an asset is open to debate. The studies were of short duration and the antimicrobial agent in the glass-ionomer will cease to function after a while, which means that the glass-ionomer is likely to behave in the same way as a nonantimicrobial-containing glass-ionomer. By virtue of the fact that microorganisms will be reduced in number after a while anyway, antibiotic-containing glass-ionomers and antibiotic resin-based materials are largely superfluous. Should all discoloured dentine be removed? Specialists have agreed that removal of carious tissue from within a cavity should be based on the level of hardness of the dentine, and recommended three levels: Soft Dentine: Soft dentine will deform when a hard instrument is pressed onto it and can be easily scooped up (e.g., with a sharp hand excavator) with little force being required Firm Dentine: Is physically resistant to hand excavation, and some pressure needs to be exerted through an instrument to lift it Hard Dentine: A pushing force needs to be used with a hard instrument to engage the dentine, and only a sharp cutting edge or a bur will lift it. A scratchy sound can be heard when a straight probe is moved across the dentine. It is obvious that the soft, decomposed biomass is of no further structural use to the tooth and should be removed. This leaves a sufficiently cleaned cavity in the tooth that should be filled. Clinically, this part of the cavity is often discoloured or stained. Many dental practitioners have been and are still being educated in the understanding that the proper treatment of a carious cavity in dentine includes removal of all discoloured tooth tissue and continue this practice. It will be clear to the reader that this procedure is totally incorrect and that it will result in the loss of much valuable tooth tissue and, in some cases, in exposure of the pulp. This oldfashioned and unevidenced treatment does not contribute to the aim of MID: keeping teeth healthy and functional for life.

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Figure 1 Image of a dentine carious lesion cut in half. Demineralisation at the e-dj is much more extensive than at the top of the lesion. The cavity is surrounded by weak demineralised enamel that fractures easily under minor pressure

Figure 2 Dark colouring of arrested carious lesion in dentine

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