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Contents...

1 Sterilizers in dental practice............................................................... 8

5 Red oral lesions....................................................................................... 56

Dental handpieces............................................................................. 12 Benchtop sterilizers.............................................................................. 14 Use and testing of benchtop sterilizers.............................................. 14 Daily testing and housekeeping tasks............................................... 18 Packaging and related decontamination strategy....................... 18 Storage of sterilized instruments/devices.......................................... 20

6 Neoplastic oral lesions & pigmentation......................................... 62

2 Using radiographs in the diagnosis of dental caries for children and adults.............................................. 26

Inflammatory lesions............................................................................ 56 Geographic tongue (erythema migrans)........................................ 56 Dentureâ&#x20AC;&#x2018;related stomatitis.................................................................. 57 Aetiopathogenesis.............................................................................. 58

Child caries diagnosis......................................................................... 26 Caries risk assessment......................................................................... 27 High caries risk...................................................................................... 28 Moderate caries risk............................................................................ 29 Low caries risk....................................................................................... 29 Adult caries diagnosis......................................................................... 30 High caries risk...................................................................................... 31

Classification........................................................................................ 62 Reactive lesions................................................................................... 62 Atrophic lesions.................................................................................... 63 Erythroplakia (erythroplasia).............................................................. 63 Hyperpigmentation............................................................................. 64 Causes of Intrinsic discoloration include:.......................................... 65 Localised areas of pigmentation may be caused mainly by:....... 65

7 Potentially malignant disorders......................................................... 68

3 Guidelines for surgical endodontics............................................... 32 Introduction.......................................................................................... 32 Indications for surgical endodontics................................................. 33 Contraindications to surgical endodontics...................................... 33 Clinical assessment.............................................................................. 34 Radiological assessment.................................................................... 34 Diagnosis............................................................................................... 35 Treatment planning and referral........................................................ 35 Clinical management......................................................................... 35 Anaesthesia.......................................................................................... 36 Magnification....................................................................................... 36 Soft tissue management..................................................................... 36 Hard tissue management - Osteotomy............................................ 36 Periradicular curettage....................................................................... 37 Root-end resection.............................................................................. 37 Root-end preparation......................................................................... 37 Root-end filling..................................................................................... 38 Closure of the surgical site.................................................................. 38 Post-surgical considerations............................................................... 38 Post-operative pain............................................................................. 38 Haemorrhage...................................................................................... 39 Post-operative swelling....................................................................... 39 Ecchymosis........................................................................................... 39 Infection................................................................................................ 39 Outcomes of surgical endodontic intervention.............................. 39 Acknowlegements.............................................................................. 41

What is the natural history of PMDs?................................................. 69 What is the recommended management of patients with PMDs?........................................................................ 71 Conditions associated with PMDs...................................................... 72 Erythroplakia (erythoplasia)............................................................... 72 Leukoplakia.......................................................................................... 73 Lichen planus/lichenoid lesions......................................................... 73 Actinic cheilitis..................................................................................... 73 Submucous fibrosis............................................................................... 73

8 Safeguarding children.......................................................................... 76

Staff member to lead on child protection....................................... 76 The person............................................................................................ 76 Their role................................................................................................ 77 Child protection policy....................................................................... 77 Listening to children............................................................................ 77 Information for children...................................................................... 78 A safe and child-friendly environment.............................................. 78 Other relevant policies and procedures.......................................... 78 Step-by-step guide of what to do if you have concerns............... 79 Best practice in record keeping........................................................ 79 Basic personal information................................................................. 79 Clinical records.................................................................................... 79 Regular team training......................................................................... 81

Complaints handling.......................................................................... 84

4 Medical emergencies in practice: the more unusual causes.................................................................... 42 Angio-oedema.................................................................................... 42 Vomiting................................................................................................ 44 Panic attacks....................................................................................... 45 Aggressive or hostile behaviour......................................................... 48 Adverse reactions to local anaesthetic injections.......................... 49 Intravascular injection......................................................................... 50 Injection into a muscle........................................................................ 50 Facial palsy........................................................................................... 50 Cardiovascular reactions................................................................... 51 Local anaesthetic overdose.............................................................. 51 Needle fracture................................................................................... 51 Local anaesthetic allergy................................................................... 51 Post-operative bleeding..................................................................... 52

First tier complaints.............................................................................. 85 Encouraging early resolution............................................................. 86 Supporting and encouraging good complaints handling............. 87 Encourage patient feedback in the practice................................. 88 Notable practice in complaints handing......................................... 89 Facilitated resolution: the current position....................................... 89

10 Minimal Intervention Dentistry for the management of dental caries................................................ 92

Is the traditional treatment for managing dental caries and carious lesions still justified?........................................................ 92 How successful has the dental profession been in serving the public worldwide?...........................................................................93 What is understood by Minimal Intervention Dentistry?.................. 93 What is the rationale for Minimal Intervention Dentistry?................94 Which proven outcomes of research were instrumental in the .... development of MID?......................................................................... 95 Atraumatic Restorative Treatment: an example of an MID approach...................................................................................95 Epilogue................................................................................................ 95 Concluding statement...........................................................................96

Contents... 11 What worries patients about dentistry?........................................ 98

Getting there........................................................................................ 98 Being on time....................................................................................... 99 How long will I have to wait?............................................................. 99 How the practice is organised?......................................................... 99 Being reprimanded............................................................................. 100 Meeting the dentist............................................................................. 100 The equipment..................................................................................... 101 The instruments..................................................................................... 101 The drill.................................................................................................. 102 What will be done?............................................................................. 102 Why is the dentist doing this?............................................................. 102 Will it hurt?............................................................................................. 103 Will it hurt afterwards?......................................................................... 103 Lying down........................................................................................... 104

12 Abuse of vulnerable adults.............................................................. 106

Who is a vunerable adult?................................................................. 106 Defining abuse of vunerable adults.................................................. 107 Who abuses vulnerable adults and in what circumstances?........ 107 Incidence and prevalence................................................................ 108 Why are elderly and disabled adults more vulnerable to abuse?............................................................................................. 108 Assumptions and attitudes of others................................................. 108 Services for vulnerable adults............................................................ 109 Impairment factors.............................................................................. 109 Presentation......................................................................................... 110 Management....................................................................................... 110 Table 1................................................................................................... 111 Table 2................................................................................................... 111 Physical abuse..................................................................................... 112 Neglect................................................................................................. 113 Psychological abuse........................................................................... 113 Financial abuse.................................................................................... 113 Sexual abuse........................................................................................ 114 Table 3................................................................................................... 114

13 Improving outcomes following dental trauma......................... 116

Appraisals............................................................................................. 122 Giving feedback................................................................................. 124 Remedial feedback:........................................................................... 125 Interview techniques........................................................................... 125 Trouble shooting................................................................................... 125 Trust and confidence.......................................................................... 125 Staff training and development policy............................................. 126 Policy and procedure......................................................................... 126

Cerebral palsy...................................................................................... 138 Learning disability................................................................................ 139 Oral health care for people with learning disabilities..................... 140 Down syndrome................................................................................... 140 Oral and dental disease in Down syndrome.................................... 141 Autism and Asperger’s syndrome...................................................... 141 Oral and dental disease in Autistic Disorder Spectrum.................. 142 Muscular Dystrophy............................................................................. 142 Oral and dental disease in muscular dystrophy.............................. 142 Rickets and osteomalacia.................................................................. 143 Oral and dental disease in rickets..................................................... 143 Rheumatoid arthritis and juvenile arthritis......................................... 143 Osteogenesis imperfecta (brittle bone disease)............................. 143 Spina bifida and hydrocephalus....................................................... 144 Hydrocephalus..................................................................................... 145 Oral and dental disease in spina bifida............................................ 145 Sensory impairments........................................................................... 145

17 The role of saliva in mineral equilibria – caries, erosion and calculus formation.................................... 146

Bob ten Cate....................................................................................... 146 Saliva-pellicle-plaque......................................................................... 146 Enamel composition........................................................................... 147 Saliva and the Stephan curve........................................................... 148 Caries and remineralisation............................................................... 149 Erosion................................................................................................... 150 Calculus................................................................................................ 150 Clinical Highlights................................................................................. 151 Table 1................................................................................................... 152

18 Helping the dentally anxious patient........................................... 154 Relaxation and distraction skills......................................................... 154 Building and maintaining rapport..................................................... 154 Controlled breathing.......................................................................... 155 Progressive muscle relaxation............................................................ 155 Ideas for distraction............................................................................. 155 Setting homework................................................................................ 156 Summary and feedback.................................................................... 156 Systematic desensitisation.................................................................. 157 Module 1: Entering the surgery and sitting in the chair................... 158 Module 2: Oral examination.............................................................. 159 Module 3: Injections............................................................................ 159 Module 4: Drilling................................................................................. 160 Table 1................................................................................................... 160

19 Antimicrobials and periodontal surgery...................................... 162

15 Conditions causing dental pain..................................................... 130

Other causes of dental and orofacial pain..................................... 135 Acute maxillary sinusitis....................................................................... 135 Craniomandibular disorder (CMD).................................................... 135 Somatic pain........................................................................................ 136

16 Impairment in childhood – oral health implications................. 138

Improving outcomes following dental trauma................................ 116 Examination.......................................................................................... 118 Suturing................................................................................................. 119 The avulsed tooth................................................................................ 119 When should a tooth not be replanted?.......................................... 120 How should an avulsed tooth be replanted?.................................. 120 Splinting................................................................................................. 120 Extirpation............................................................................................. 121

14 Appraisals, staff training and development policy................. 122

Dentine hypersensitivity or reversible pulpitis (vital pulp)................ 130 Cracked tooth syndrome................................................................... 131 Irreversible pulpitis (vital pulp) ........................................................... 132 Acute periapical abscess (non-vital pulp)....................................... 132 Acute periodontal abscess (vital pulp usually)................................ 133 Acute pericoronitis.............................................................................. 133 Localised (alveolar) osteitis –dry socket........................................... 134 Acute Necrotising Ulcerative Gingivitis (ANUG).............................. 134

Antimicrobials....................................................................................... 162 Systemic antibiotics............................................................................. 162 Chronic periodontitis........................................................................... 162 Aggressive periodontitis...................................................................... 162 Necrotising periodontal diseases....................................................... 163 Periodontal abscess............................................................................ 163 Local delivery antibiotics.................................................................... 163 Periodontal surgery............................................................................. 164

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Chapter 1

Sterilizers in dental practice

Make this CPD Verifiable Turn to page 167 to find out how

The Department of Healthâ&#x20AC;&#x2122;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 4 of the document which gives advice to dentists and practice staff on sterilizers, their operation and management. 4.1

Types of sterilizer

4.2

Saturated steam under pressure delivered at the highest temperature compatible with the product is the preferred method for the sterilization of most instruments used in the clinical setting.

4.3

To facilitate sterilization, load items should first be thoroughly cleaned and disinfected (where a washer-disinfector has been used). In the case of newer machines, the parameters monitored for each cycle will be stored and/ or available as a print-out to provide a short-term record. The use of automated data-loggers or interfaced small computer-based recording systems is acceptable provided the records are kept securely and backed- up. These records should be copied, as the quality of the print-out fades over time. Manual recording using a logbook is also acceptable, and in any case will be a necessity if a machine does not have any automatic print-out function (see paragraph 4.14 for further details on manual recording). The record should, at minimum, document the absence of a failure warning or the temperature/ pressure achieved as appropriate to the indications provided. Records are required for every sterilization cycle. It is recommended that records be maintained for not less than two years.

4.4

It is likely that steam sterilizers used in dental practices will have a chamber volume of less than 60 L and thus be considered to be small devices within the standards applied by national and international bodies.

4.5

Standards describe three types of benchtop sterilizer used within the healthcare setting:

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Type N: air removal in type N sterilizers is achieved by passive displacement with steam.

They are non-vacuum sterilizers designed for non-wrapped solid instruments. •

Type B (vacuum): type B sterilizers incorporate a vacuum stage and are designed to reprocess load types such as hollow, air-retentive and packaged loads. A number of different cycles may be provided. Each cycle should be fully validated and used in accordance with instructions provided by both the sterilizer manufacturer and the instrument manufacturer(s).

•

Type S: these sterilizers are specially designed to reprocess specific load types. The manufacturer of the sterilizer will define exactly which load, or instrument, types are compatible. These sterilization process data can be recorded by an automatic printer sterilizers should be used strictly in accordance with these instructions.

Types B and N are most frequently used in dental practices. 4.6

In each case, practice staff should consult with the manufacturer/supplier of the sterilizer(s) to ascertain the status of the machine in respect of validation/verification and the recording of parameters achieved during sterilization cycles.

Dental handpieces 4.7

Practices can seek the advice on the decontamination of handpieces from the handpiece manufacturer. Dental handpieces are constructed with a number of features that are difficult to clean and sterilize. The use of a validated washer-disinfector may be successful provided that the handpiece and washer-disinfector are compatible. Where this is established, sterilization using a type B or type S sterilizer is likely to be useful, although it should be accepted that it is unlikely that sterility will be achieved – whatever sterilizer is used – due to the presence of lubricating materials. The information above should be used by practices to make an informed decision on the choice of sterilizer (Type B, S or N).

4.8

If no validated and compatible washer-disinfector is available, steam sterilization will generate a reduction in contamination. Accordingly, progress towards best practice may be seen as a further risk reduction measure in this context.

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Benchtop sterilizers 4.9

Benchtop sterilizers should be operated to ensure that:

•

They are compliant with the safety requirements stated in this guidance and in the manufacturer’s notes;

•

They are installed, commissioned, validated and maintained appropriately in compliance with the manufacturer’s instructions

•

They are operated in accordance with the equipment manufacturer’s instructions.

Pre-wrap instruments only where this is recommended by the manufacturer and where the sterilizer is vacuum-assisted. The sterilizer should be validated for the intended load and is likely to be of type B or S. The use of a type N sterilizer is not appropriate for wrapped instruments. 4.10 All steam sterilizers are subject to the Pressure Systems Safety Regulations 2000 and must be examined periodically by a Competent Person (Pressure Vessels).

Use and testing of benchtop sterilizers 4.11 To ensure the safety of this device, the following points should be adhered to: 1.

Each sterilizer will have a reservoir chamber from which the water is delivered for steam generation. This should be filled, at least daily, using distilled or RO water. However, more frequent draining and refilling offers quality advantages in terms of the appearance and suitability of the finished instruments. At the end of the working day, the device should then be cleaned, dried, and left empty with the door kept open. For single-shot types, which do not store water between cycles of use, these rules still apply in terms of the water quality to be used.

Validation is necessary to demonstrate that the physical conditions required for sterilization (temperature, pressure, time) are achieved. Consultation with appropriately qualified engineers will be necessary. A Competent Person (Decontamination) or service engineer will be able to ensure that validation is achieved and that the instrumentation used for parametric release is functioning and calibrated appropriately. The Competent Person (Decontamination) or service engineer will be needed to validate or revalidate the equipment.

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Parametric release is defined as the release of a batch of sterilized items based on data from the sterilization process. All parameters within the process have to be met before the batch can be released for use.

Testing is an integral part of ensuring that a benchtop sterilizer consistently performs to operating parameters set during the machine’s commissioning. Failure to carry out routine periodic tests and maintenance tasks could compromise safety and have legal and insurance-related implications for the Registered Manager.

A schedule for periodic testing should therefore be planned and performed. The schedule should provide details of daily, quarterly and yearly testing or be in accordance with manufacturers’ guidelines. Each sterilizer should have a logbook (file) in which details of the following are recorded:

• • • • •

Maintenance Validation Faults Modifications Routine tests.

4.12

Health Service Circular (HSC) 1999/053 and the subsequent ‘Records management: code of practice parts 1 and 2’ (April 2006) provide guidance on the length of time for which records should be retained. Reference should be made to the time period of legal rights of patients, and all relevant documentation should be retained for the practice to meet any request within these rights. The code requires that these records be maintained for not less than two years, although longer periods may be applicable subject to local policy-making.

4.13 The logbook should contain all information pertaining to the lifecycle of the equipment (from purchasing through to disposal). 4.14 If the sterilizer has an automatic printer, the print-out should be retained or copied to a permanent record. If the sterilizer does not have a printer, the user will have to manually record the following information in the process log: • • • •

Date Satisfactory completion of the cycle (absence of failure light) Temperature/pressure achieved Signature of the operator.

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Daily testing and housekeeping tasks 4.15 Some benchtop sterilizers require a warm-up cycle before instruments can be processed. The manufacturer’s instruction manual should be consulted to find out whether this is the case. 4.16 The daily tests should be performed by the operator or user and will normally consist of: • • •

A steam penetration test – Helix or Bowie-Dick tests (vacuum sterilizers only) An automatic control test (all benchtop sterilizers) in line with manufacturers’ instructions A record of the temperature and pressure achieved at the daily test, to ensure this is satisfactory before the autoclave is used for sterilizing instruments.

4.17 These outcomes should be recorded in the logbook together with the date and signature of the operator. 4.18 The tests may be carried out at the same time. 4.19 The manufacturer’s advice should be sought on whether the daily tests can be carried out while instruments are being reprocessed. 4.20 Before carrying out the daily tests, the user should: • • • •

Clean the rubber door seal with a clean, damp, non-linting cloth Check the chamber and shelves for cleanliness and debris Fill the reservoir with distilled water or RO water Turn the power source on.

4.21

If the sterilizer fails to meet any of the test requirements, it should be withdrawn from service and advice should be sought from the manufacturer and/or maintenance contractor. Any instruments processed in an unsuccessful cycle should not be used.

Packaging and related decontamination strategy 4.22 There are three combinations of steam-sterilization and instrument-wrapping strategies that can be used within dental practices:

a. Instruments should be cleaned and dried before being wrapped with purpose-designed materials compatible with the sterilization process. These packaging materials should either conform to BS EN ISO 11607-1 or, for Type

S sterilizers, be validated as suitable by the sterilizer manufacturer. These instruments are suitable for storage for up to 12 months in their original packaging as long as their packaging is intact. Practices will need to have systems in place to be able to demonstrate that the 12-month storage time is not being exceeded.

b. With a displacement steam sterilizer (type N), the instruments will not be wrapped prior to sterilization. Immediately after removal from the sterilizer, instruments should be aseptically wrapped using suitable sealed view packs. This could be achieved by the use of forceps, clean gloves or any other appropriate process. In addition, the entire tray may be placed within a sealed pack for storage purposes. In both of these instances, storage for up to 12 months is recommended. Practices will need to be able to demonstrate that this storage time is not being exceeded. c. Unwrapped following processing in a displacement steam sterilizer (type N).

4.23

In all three cases, the instruments should be dried using disposable non- linting cloths and be appropriately handled. It is essential to ensure that the cloth is adequately dry and free from contamination. Accordingly, the cloth should be disposed of after each sterilizer load.

4.24 Regardless of the packaging used, where instruments are to be stored, the date by which they should be used or by which they are subject to a further decontamination cycle should be clearly indicated on the packaging.

Storage of sterilized instruments/devices 4.25

Regardless of the approach described above, it is essential that stored instruments are protected against the possibility of recontamination by pathogens. A barrier(s) should therefore be maintained between the instruments and the general practice environment. This may be achieved by ensuring that instruments are stored in an environment where they are protected against excessive heat and where conditions remain dry.

Note: BS EN ISO 11607-1:2006 Annex A provides a useful summary of â&#x20AC;&#x153;sterile barrier systemsâ&#x20AC;?. In practice, these are sealable trays or wrappings, which may be of value in dental practices. In summary, the systems referred to are:

a. Flexible peel pouch (sealed view pack). This is typically supplied sealed on three sides with the remaining side open for the insertion of dental instruments. This packaging, subject to manufacturersâ&#x20AC;&#x2122; advice, may be used to post-wrap instruments after steam sterilization in order to protect against recontamination.

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b. Pre-formed rigid tray with die-cut lid. The lid may be permeable or impermeable. These trays are potentially suitable for use with displacement or vacuum sterilizers. Subject to manufacturersâ&#x20AC;&#x2122; instructions, the trays may be used to contain dental instruments during the sterilization process and in subsequent storage.

c. Sterilization bag. This is constructed from porous medical paper and sealed before sterilization of the contents. The bag is essentially designed for use with vacuum sterilizers.

d. Header bag. This is manufactured as a sealed bag with a heat-sealed permeable closure, which can be peeled off. This type is suitable for storage of larger items.

e. In larger-scale operations, automated systems such as form/fill/seal (FFS) or four-side-sealing products may also be used. The choice of system used will depend on the decontamination, sterilization and storage options chosen by the practice. The manufacturers of each of the products should be consulted on the standards applied and compatibility with the other products employed.

4.26

There should be control of storage of wrapped instruments, including the maintenance of records, clear identification of content of instrument packs, if not visible, and storage times. For commonly-used instruments, a first-in first- out principle will be helpful. Where packs are non-transparent, it may be useful to use a label to indicate the contents.

4.27 As a general rule: â&#x20AC;˘

The storage of reprocessed surgical instruments should ensure restraint of recontamination. This will often mean protection against aerosols and sundry contact with other equipment. The area in which the packaging of sterilized instruments (that is, those reprocessed in a type N sterilizer) takes place should be an open bench area. It should be kept free of clutter and wiped clean by the use of detergent and and/or disinfectant wipes at sessional intervals.

â&#x20AC;˘

Instruments should be decontaminated in an area and in manner that enforces the flow from dirty to clean through the successive processes that comprise decontamination, such that, at no stage is an instrument recontaminated via a surface that has been contaminated at a previous decontamination stage. Dental practices must ensure that the correct processes and flows are rigorously maintained.

•

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•

Unwrapped instruments should be transported and stored in a way that minimises contamination. Appropriate personal protective equipment is required for the aseptic transfer of instruments from a type N steam sterilizer for storage. The worktop on which the tray or shelf of instruments is to be placed must be cleaned with a pre-prepared or single-use disinfectant wipe and allowed to dry. The decontamination area should be cleaned after each decontamination cycle is completed. The most important factor is to prevent direct or indirect contamination with patient blood and body fluid.

•

Sterilized instruments should be stored in dedicated areas. If stored in areas used for clinical work, to meet essential quality requirements, this will require that the instruments be as far from the dental chair as reasonably practicable. Best practice requires that instruments not scheduled for current use with the current patients be stored in a separate environment, ideally in the clean area of the separate decontamination room.

•

The storage area should be appropriately designed to prevent damage to instruments and to allow for the strict rotation of stocks.

•

Cupboards should be capable of being easily cleaned and used in conjunction with sealed view-packs or covered/sealed trays.

•

Products should be stored above floor level away from direct sunlight and water in a secure, dry and cool environment.

•

Although air movement is often difficult to control in non-purpose-designed premises, whenever possible, airflow should be from the clean to dirty areas.

4.28

Before being used, the instruments should be checked to ensure that:

•

If packed, including the use of view-packs, the packaging is intact

•

The sterilization indicator confirms the pack has been subjected to an appropriate sterilization process (if a type B sterilizer is used)

•

If a covered container is used, the instruments have remained covered

•

Visible contamination is absent (this is to comply with EN Standards).

4.29 As part of essential quality requirements, instrument storage should not exceed the limits given.

Chapter 2

Using radiographs in the diagnosis of dental caries for children and adults Adapted from FGDP Online Standards Programme Nigel Pitts and David Ricketts

Make this CPD Verifiable Turn to page 167 to find out how

Early diagnosis of dental caries has become of greater importance in recent years partly because techniques have developed to enable this at an earlier stage than was previously possible and also because minimal intervention dentistry is designed for prevention and smaller operative activity. Radiographic diagnosis has also taken on new significance as the advent and development of digital radiography has now been accepted as the standard for general dental practice. Most of the available research on radiographic diagnosis of dental caries concerns children and there are several reasons for this. There are greater risks of ionising radiation for children due to their rapid growth and also because of their historically higher prevalence of caries, combined with a greater focus on prevention. In recent years there has also been an increasing emphasis on caries risk assessment, changes in caries risk and assessing the activity of individual lesions in patients of all ages. When assessing caries risk, clinicians should note that in 2003â&#x20AC;&#x201C;2004 the Guideline Development Group and the National Institute for Health and Clinical Excellence Collaborating Centre reviewed the evidence on caries risk in relation to recall frequency, leading to the issue in 2004 of Dental Recall: Recall Interval Between Routine Dental Examinations1. Readers should refer to this guidance for a checklist for assessing caries risk in relation to recall frequency. More recent consideration of personalised recall frequency and the use of bitewing radiography in lower caries risk groups can also be found in Clarkson et al.2 and Mejare and Kidd3.

Child caries diagnosis Posterior bitewing radiographs are an essential adjunct to clinical examination and should be considered even for pre-school children. Not only is the bitewing radiograph necessary for approximal caries detection it can also offer a significant yield in the detection of occlusal caries. The magnitude of the increased diagnostic yield from the use of radiography on occlusal surfaces is related to the method of clinical visual assessment employed. Meticulous visual assessment of clean dry teeth with criteria such as ICDAS10â&#x20AC;&#x201C;11 can disclose many lesions which would be

otherwise missed. Periodic bitewings can contribute to an individual’s care plan for preventive and operative dental care. Information about lesion behaviour over time (progression, arrest, regression) can be added to the caries status assessment made at the first visit and can contribute to an appraisal of the patient’s response to preventive therapy. Although there is a need to ensure that radiographic exposures are kept as low as reasonably practicable, this concern must be balanced against the ethical question of not employing a diagnostic aid that may help detect clinically significant lesions which might otherwise remain hidden and therefore untreated. Even when approximal contacts are open, bitewing radiographs have a role in identifying occlusal lesions. The importance of a high-quality, standardised technique, using image receptor-holding and beam-aiming devices and ensuring proper processing, cannot be over-emphasised. Increased use of digital radiography overcomes some of the errors previously associated with the processing of conventional radiographic films. A patient should only have radiographs taken after a thorough clinical examination and an assessment of caries risk, categorising them as high, medium or low. The importance of the individual factors will vary from patient to patient and it must be remembered that risk status may change over time. This assessment of risk is central to deciding when to take subsequent radiographs. The time interval will vary widely but it should be specific to each patient. Although reliable risk assessment can be problematic, clinicians are particularly good at identifying high-risk individuals. The taking of ‘routine’ radiographs based solely on time elapsed since the last examination is not supportable and intervals between subsequent radiographic examinations must be reassessed for each new period as individuals can move in and out of caries risk categories over time. Caries risk assessment The evidence around caries risk assessment is complex and there are multiple risk factors and indicators which carry a range of weightings. The strength of evidence varies between children and adults. For all ages, by far the most important factor is past caries experience however other factors include diet, social history, medical history, use of fluoride and plaque control. While the evidence supporting the use of other individual risk factors may not be strong at a group level, there is still value at the individual patient level to aid in the development of an individualised and targeted preventive and disease management plan.

High caries risk Expert opinion and a body of evidence supports taking bitewing radiographs at the initial examination for all children designated as being at high caries risk. There is a significant diagnostic yield associated with taking bitewing radiographs for use in conjunction with clinical examination for both approximal and occlusal caries detection, even in the absence of clinically detectable decay. The degree of benefit is variously reported as being between 167% and 800% of the yield from clinical diagnosis, with or without fibreoptic transillumination assistance. It is recommended that all children at high caries risk have six-monthly posterior bitewing radiographs taken until no new or active lesions are apparent and the individual has been categorised as in another risk category. Bitewings should not be taken more frequently and it is imperative to reassess caries risk in order to justify using the same time interval again. In adults with a history of high caries risk and previous restorative care of varying complexity, bitewing radiographs are felt to have increased importance in detecting defective/overhanging restoration margins and caries adjacent to restorations on obscured tooth surfaces. In terms of the contribution that radiographs might make to individual patient care plans, current evidence suggests that: •

If a small lesion is detected which radiographically appears to be less than halfway through approximal enamel, the lesion’s location should be recorded and periodic review arranged. Preventive treatment should be instigated.

•

If an approximal lesion extending to the inner half of enamel is detected, or if an outer-half lesion is seen to progress, preventive therapy should be instigated and the results of such therapy should be periodically monitored.

•

In a high caries risk individual, approximal lesions extending into dentine, detected radiographically, have a great likelihood of exhibiting cavitation.

•

Additionally, it has been demonstrated that radiographic evidence of occlusal dentine demineralisation is significantly associated with heavily infected dentine; therefore, the bitewing radiograph should contribute to operative care plans for individuals with radiographic occlusal dentinal lesions.

It has been shown that even in individuals with high caries risk, lesions can still take up to three or four years to penetrate approximal enamel in permanent teeth. The time taken for caries to progress from the enamel-dentine junction to the pulp is unknown. Many authors consequently recommend six-monthly radiographs for all high caries risk individuals until no new or active lesions are apparent. 28

Moderate caries risk The evidence also supports the diagnostic use of bitewing radiographs for children with a moderate caries risk. Many authors report significant addition to the diagnostic yield from the use of bitewing radiographs, varying from 150% to 270% of the yield from clinical examination alone which relates to both approximal and occlusal caries. On balance, the evidence supports the taking of posterior bitewing radiographs annually for children who are designated as being at moderate caries risk.

Low caries risk Compared to the evidence regarding children with high and moderate caries risk, there is less evidence available to support the taking of posterior bitewing radiographs in children designated to be at low risk of developing caries and the need to take bitewings is unclear. Although the diagnostic yield from posterior bitewing radiographs is comparatively lower than the yield from higher-risk groups, high-quality studies still show a significant yield. In one study, radiographs revealed two to three times more carious lesions than clinical examination alone. The evidence reviewed suggests that: •

Even in low caries regions, selective radiography should be conducted on surfaces that are clinically suspected to be carious. There is continuing concern that hidden dentinal caries may affect significant numbers of low caries risk individuals, although there is a lack of high-quality studies on this.

•

In the primary dentition, detection of three or more discoloured enamel lesions or dentinal lesions has been claimed to be a good predictor of the presence of additional dentinal lesions on radiograph, undetected by visual examination.

•

In low caries risk groups, the time taken for approximal enamel lesions to progress through to dentine in permanent teeth is estimated to be in excess of six to eight years on average, and clinical decisions to restore must reflect this slow progression.

•

There are particular problems associated with assessing sealed occlusal surfaces in children with low caries risk; bitewing radiographs can provide a significant diagnostic yield, if used appropriately.

In the low caries risk category, it is therefore important for individual clinicians to apply risk-benefit calculations to each of their patients in order to make appropriate

decisions. A child patient with little or no caries activity does not require bitewing radiographs at every recall appointment; however, it is important to reconsider the childâ&#x20AC;&#x2122;s caries risk status. The weight of expert opinion supports the view that children with low caries risk should be radiographed at approximately 12 to 18-month intervals in the primary dentition and at approximately two-year intervals in the permanent dentition. More extended radiographic recall intervals may be appropriate if there is specific evidence of continuing low caries risk.

Adult caries diagnosis There is comparatively little evidence evaluating the present diagnostic yield of radiographs for caries in adults. It must be appreciated, however, that the carious process and caries activity are dependent upon interactions on a susceptible tooth surface of bacterial plaque with appropriate sugary substances, and that these factors far outweigh a patientâ&#x20AC;&#x2122;s chronological age. In the absence of experimental data from older age groups, it is reasonable, therefore, to extrapolate from the information available from studies of children and young adults. There are particular reasons to be cautious in assessment of caries and caries risk in adults. As a consequence of the genuine overall reduction of caries prevalence across the UK population, when caries is present it often progresses very slowly and can present very late; thus cavitation into dentine may be visible for the first time in young adults who appear to be caries-free. Similarly, caries risk assessments of adults must consider rapid behaviour and lifestyle changes that can have a significant dental impact. Changes in caries risk may follow the patient becoming less dextrous in plaque removal, a reduction in saliva following the use of some medications or the onset of Sjogrenâ&#x20AC;&#x2122;s syndrome, and/or dietary changes following events such as retirement, bereavement or a change in social environment. Thus, while interpretation of the clinical examination and social history must be tailored to the age of the patient and the circumstances indicating the need for the clinical examination, the diagnostic benefits and limitations of dental radiography for adults are essentially comparable with those for children. Overall, root caries is a growing problem for only a minority of adults, but an increasing proportion of this population are elderly patients. One specific clinical issue concerns root caries related to impacted third molar teeth and distal surface caries in second molar teeth. There is comparatively little evidence regarding radiographic selection criteria in relation to root caries. Care should always be taken to differentiate radiographic signs of root caries from artefacts such as cervical burnout. For these reasons, while suggesting that high-quality studies with adults are needed, the same recommendations as made for children are made for adults.

High caries risk It is recommended that all adults designated as having high caries risk have sixmonthly posterior bitewing radiographs taken until no new or active lesions are apparent and the individual has been categorised in another risk category. Bitewings should not be taken more frequently and it is imperative to reassess caries risk in order to justify using this interval again. it is also important to remember that the rate of caries progression in enamel and dentine will differ and that progression rates in adults may well be slower than in children.â&#x20AC;&#x192;

References 1.

National Institute for Health and Clinical Excellence. Dental recall: recall interval between routine dental examinations. London: NICE; 2004. Available at: http://guidance.nice.org.uk/CG19/Guidance/pdf/English. Accessed: May 2004.

Clarkson JE, Amaechi BT, Ngo H. Recall, reassessment and monitoring. In Pitts NB. Detection, assessment, diagnosis and monitoring of caries. Basel: Karger; 2009.

Mejare I. Kidd EAM. Radiography for caries diagnosis. In Fejerskov O. Kidd E. Dental caries: The disease and its clinical management. 2nd edition. Munksgaard: Blackwell; 2008. p69â&#x20AC;&#x201C;88.

Chapter 3

Guidelines for surgical endodontics From the RCS Guidelines revised by: Glynis E Evans, Karl Bishop and Tara Renton

Make this CPD Verifiable Turn to page 167 to find out how

Introduction The aetiology of periapical (periradicular) periodontitis is microbial: intra-radicular microorganisms induce an inflammatory and immune response within the periradicular tissues, resulting in bone destruction. Contamination of the periradicular tissues by microorganisms and root-filling materials may compromise healing. The aim of endodontic treatment is to disinfect the pulp space (reducing the microbial load and removing necrotic tissue) followed by sealing this space to prevent recontamination. Success rates of 47â&#x20AC;&#x201C;97% for primary orthograde root canal treatment have been reported, with failures more likely to be associated with preoperative presence of periapical radiolucency, root fillings with voids, root fillings more than 2mm short of the radiographic apex, and unsatisfactory coronal restoration. Options for the management of these failures can be non-surgical root canal retreatment or surgical endodontics. Non-surgical retreatment may provide a better opportunity to clean the pulp space than a surgical approach. However there are clinical situations when non-surgical root canal retreatment is inappropriate. A wide range of success rates for surgical endodontics has been reported (44â&#x20AC;&#x201C;95%). Systematic reviews comparing the outcome of non-surgical root canal retreatment and surgical endodontics reveal that, to date, there have been only two randomised controlled trials. The data from this limited evidence suggest that although surgery may offer a more favourable outcome in the short term, non-surgical retreatment offers a more favourable long-term outcome. There have been a number of studies evaluating contemporary microsurgical techniques and more biocompatible filling materials, which report more consistent success in healing outcomes (88â&#x20AC;&#x201C;96%). In order to attain a successful outcome, an accurate diagnosis of the aetiology of persistent pathology associated with a root-treated tooth and appropriate treatment planning is, of course, essential. In these guidelines, surgical endodontics describes a procedure combining root-end resection, apical curettage and root-end filling. Other procedures such as apical curettage or root resection alone, hemisection, intentional replantation, and regenerative procedures, have not been included.

Indications for surgical endodontics •

Periradicular disease associated with a tooth where iatrogenic or developmental anomalies prevent non-surgical root canal treatment being undertaken

•

Periradicular disease in a root-filled tooth where non-surgical root canal retreatment cannot be undertaken or has failed, or when it may be detrimental to the retention of the tooth (e.g. obliterated root canals, teeth with full coverage restorations where conventional access may jeopardise the underlying core, the presence of a post whose removal may carry a high risk of root fracture)

•

Where a biopsy of periradicular tissue is required

•

Where visualisation of the periradicular tissues and tooth root is required when perforation or root fracture is suspected

•

Where it may not be expedient to undertake prolonged nonsurgical root canal retreatment because of patient considerations.

Contraindications to surgical endodontics There are few absolute contraindications to endodontic surgery, however the following should be considered: • • • • • • • • •

Patient factors, including the presence of severe systemic disease and psychological considerations Dental factors including: unusual bony or root configurations lack of surgical access possible involvement of neurovascular structures where the tooth is subsequently unrestorable where there is poor supporting tissue poor general oral status The skill, training, facilities available, and experience of the operator, should also be considered.

Clinical assessment Extraoral examination A thorough examination should be undertaken, in particular noting: • • •

regional lymph nodes swelling mouth opening.

Intraoral examination Should include: • • • • • • •

general status of the mouth presence of local infection, swelling and sinus tracts presence, quantity and quality of restorations, caries and cracks quality of any cast restorations (marginal adaption, aesthetics, history of decementation) periodontal status, including the presence of isolated increased probing depths occlusal relationship – is the tooth a functioning unit or is there potential for function? sensibility and percussive testing of the suspected tooth, adjacent teeth and its contra-lateral partner.

Radiological assessment While a long cone parallel periapical view of the teeth and adjacent structures provides a good diagnostic yield, further information (eg root morphology in multirooted teeth, or when perforation by a post is suspected) may be gained by taking additional angled (horizontal/vertical) periapical radiographs. At least 3mm of the tissues beyond the apex of the roots should be radiographically assessed. If a large periradicular lesion is suspected further radiographs such as a dental pantomogram or occlusal views may be required. If a sinus tract is present then a radiograph should be taken with a gutta-percha cone in place to delineate the tract. Historical radiographs, if available, provide a longitudinal guide to changes in periradicular status. The high diagnostic yield of cone beam computed tomography has been described with particular reference to assessment of posterior teeth prior to periapical surgery.

The use of dental radiographs should, of course, be in accordance with national regulations including knowledge of radiation doses.

Diagnosis The purpose of careful clinical and radiological evaluation is to provide information about the nature, extent and possible aetiological factors of the disease thus facilitating a differential diagnosis.

Treatment planning and referral Following diagnosis and discussion of the treatment options and risks, consent should be obtained. Once it has been agreed that surgical endodontics is required, consideration should be given as to the appropriate setting for treatment. This will be determined by the competence and training of the practitioner and support staff, facilities available and the patientâ&#x20AC;&#x2122;s medical history. If appropriate, referral should be to a suitably trained colleague. The referring clinician should provide information as to the clinical findings on presentation, medical and dental history and forward any radiographs relevant to the case. An indication of any proposed restorative treatment of the tooth should be given. The dentist to whom the referral has been made should only provide the treatment requested where this is felt to be appropriate. If this is not the case, there is an obligation on the dentist to discuss the matter, prior to commencing treatment, with the referring practitioner and the patient.

Clinical management Pre-operative medication Recent systematic reviews indicate that prophylactic administration of oral antimicrobials to prevent systematic disease is not always in the patientâ&#x20AC;&#x2122;s best interest. Likewise, prophylactic administration to prevent postoperative infection (in patients not requiring prophylactic antibiotics for medical conditions) has not been shown to be beneficial. The use of chlorhexidine mouth rinses to reduce plaque formation may be beneficial. Systemic nonsteroidal anti-inflammatory drug therapy should be considered prior to surgery in order to reduce postoperative pain.

Anaesthesia Where possible, local anaesthesia should be the method of choice. Haemostasis is of benefit at the surgical site, which is more easily achieved when a local anaesthetic containing a vasoconstrictor is used.

Magnification The use and benefits of the dental operating microscope in terms of improved visualisation and control of the surgical site is well documented. The impact of magnification devices on the outcome of endodontic surgery had not been demonstrated until recently when a positive effect of magnification and a microsurgical technique on outcome was reported.

Soft tissue management Surgical flap design is variable and depends on a number of factors, including: • • • • • •

access to and size of the periradicular lesion periodontal status (including biotype) state of coronal tooth structure the nature and extent of coronal restorations aesthetics adjacent anatomical structures.

Relieving incisions should be placed on sound bone. The lack of predictability in determining the size of the periapical lesion, combined with increased incidence of scarring associated with a semilunar flap, precludes its use in endodontic surgery. It is not desirable to remove bleeding tags of tissue from the exposed bone or periodontal ligament fibres that were severed during tissue reflection as they will facilitate healing. The raised flap must be protected from damage and desiccation during surgery and retractors should rest on sound bone.

Hard tissue management Osteotomy An assessment of the length of the root and its axis should be made to ensure that bone is removed accurately from the desired site. If the cortical bone plate is thin or absent, curettes may be used to expose the apex of the root. Further bone removal should be carried out with a bur in a reverse-air handpiece, cooled by copious

sterile saline or sterile water. Steel or tungsten carbide burs produce less heat than diamond burs. The superficial osteotomy should be performed with a light shaving motion to reduce the heat generated and allow adequate visibility. Sufficient bone is removed to allow adequate access to the root end. A bony lid technique has been advocated for mandibular molar teeth. A microsurgical technique should be used where appropriate.

Periradicular curettage The soft tissue in the periradicular region should be removed with curettes to allow adequate visualisation of the root apex. In some cases it may not be possible to remove all the soft tissue around the root-end until the apex has been resected. The majority of the inflammatory soft tissue should be removed but the peripheral tissues may be reparative in nature and, if other anatomical structures are likely to be violated, then this tissue should be left. Pathological material should, if possible, be sent for histopathological examination.

Root-end resection Resection of the root should be carried out as close to 90 degrees to the long axis of the tooth as possible to reduce the number of exposed dentinal tubules and to ensure access to all the apical anatomy. If possible, at least 3mm of root end should be resected with a rotating bur (using saline or water coolant) thus eliminating the majority of anatomical and/or iatrogenic anomalies in the apical third. The resected root surface should be examined, preferably under magnification with a micro-mirror, to ensure that the resection is complete, that the surface is smooth and that there are no cracks in the root, and to check for canal irregularities. The application of a neutral, buffered, sterile dye to the root face may help visualisation of cracks as well as the outline of the root.

Root-end preparation The preparation should be 3mm deep, in the long axis of the tooth and incorporate the whole pulp space morphology. To achieve these objectives root-end preparation is best carried out with an ultrasonically powered tip. In comparison with a bur in a micro-handpiece, the use of ultrasonic tips minimises the amount of bone removed to gain access for root-end preparation, allows a preparation that more readily follows the long axis of the canal, and facilitates debridement of isthmuses. The tips should be used at low power and with a light touch to reduce the risk of root cracking. Rootend preparation should be carried out with sterile saline or water as a coolant. Consideration should be given to removing the smear layer with

EDTA or citric acid, especially if a bur has been used. The root-end cavity should be examined to ensure that the walls are free of debris, including previous root filling materials.

Root-end filling The root-end preparation should be isolated from fluids, including blood. A suitable haemostatic agent should be placed in the bony crypt and the rootend cavity dried. The root-end filling material should be compacted into the cavity with a small plugger to ensure a dense fill. There should be no excess material on the resected root face. A biologically compatible material should be used where possible. Mineral trioxide aggregate is an osteoand cement-inductive material and is associated with a high clinical success rate. Of the other materials that have been investigated super EBA, glass ionomer, composite resin (with a dentine bonding agent) and reinforced zinc oxide-eugenol are also considered suitable. Amalgam is not recommended. There should be careful debridement of the bony crypt to ensure that haemostatic agents, root-end filling material and debris are removed. Radiographic verification of the quality of the root end filling is appropriate before wound closure.

Closure of the surgical site The soft tissue flap is re-apposed with sutures, optimum healing being achieved with primary closure. After suturing, the tissues should be compressed with damp gauze for 3–5 minutes. Sutures are removed 48–96 hours post-operatively (providing the wound is stable), when reattachment of the periodontal fibres at the gingival margin has taken place. Sutures left longer than this may become infected by ‘wicking’, particularly if they are of the multi-filament type. Synthetic monofilament sutures are therefore the preferred choice in order to minimise microbial colonisation.

Post-surgical considerations Post-operative complications should be uncommon. Post-operative pain May be controlled with non-narcotic analgesics. A long-acting local anaesthetic given at the end of the procedure may also be beneficial. Long-term pain as a result of surgical damage to the peripheral nerves occurs rarely.

Haemorrhage Must be controlled intra-operatively. Soft tissue bleeding is controlled by haemostatic agents delivered via local anaesthetic, epinephrine pellets, ferric sulphate, electrosurgery and/or with sutures. Bleeding in the bony crypt is also affected by the vasoconstrictor in the local anaesthetic agent and topically applied agents. The latter should be removed from the crypt prior to closure of the surgical site.

Post-operative swelling Minimised by applying cold compresses with an ice pack for the first 4â&#x20AC;&#x201C;6 hours after surgery. Chlorhexidine mouthwashes help to prevent plaque accumulation for the period when tooth brushing is less than optimal.

Ecchymosis Patients should be informed that bruising may occur, that it is self-limiting and will usually resolve within two weeks of surgery.

Infection Infection of the soft tissues may result in secondary haemorrhage, cellulitis or local abscess formation. It is best prevented by maintenance of good oral hygiene measures and the use of chlorhexidine mouthwashes immediately preoperatively and post-operatively. Antimicrobials should be prescribed where signs of systemic involvement are present with pyrexia and regional lymphadenopathy, in combination with surgical drainage if appropriate. Clear, written post-operative instructions given to the patient, together with telephone communication within 24 hours avoids misunderstandings and allows further supportive care and advice.

Outcomes of surgical endodontic intervention An initial review appointment is required to remove sutures and assess early healing. Thereafter, regular review appointments should be made to assess healing using criteria based upon clinical and radiological examination. Radiological examination should be conducted at annual intervals until healing is observed. Periapical radiographs should be taken, endeavouring to achieve the same angulation as the pre-operative view to allow accurate comparison. Outcomes may be classed as successful, incomplete, uncertain and unsuccessful. Outcomes must be defined and

quantified to enable audit to establish best practice, as there is a shortage of reliable clinical data. A range of 37â&#x20AC;&#x201C;91% has been reported for healing following surgical endodontics. Successful outcome

Clinical This is achieved when the presenting symptoms and signs of the disease associated with the tooth have been eliminated.

Radiological The treated tooth should show a normal periodontal ligament width or a slight increase, not wider than twice the normal periodontal ligament space. The periradicular rarefaction should be eliminated and the lamina dura and osseous pattern should be normal. There should be no root resorption evident. Clinical criteria cannot be used to determine the amount and type of repair histologically. The aim should be to provide an environment that allows regeneration of the cementum and periodontal ligament over the resected root apex. However, in many cases repair of the tissue takes place with the formation of a fibrous tissue scar. Incomplete outcome

Clinical There are no signs and symptoms.

Radiological There is partial regeneration of the periapical bone. This may be due to the formation of fibrous scar tissue and is often associated with a through and through lesion where both buccal and lingual cortical plates have been perforated by infection or during the surgical procedure. Uncertain outcome

Clinical

There may be vague symptoms, which may include mild discomfort or a feeling of pressure and fullness around the treated tooth. Radiological There is partial regeneration of periapical bone Unsuccessful outcome

Clinical The presence of signs and/or symptoms of periradicular disease, including root fracture.

Radiological There is no regeneration of periapical bone. Should failure occur after surgery then the cause needs to be established prior to a plan of treatment. Further surgical intervention has been associated with a lower success rate (35.7%).

Acknowledgements These guidelines were originally compiled by Professor W Saunders in 2001 and have been revised by Glynis Evans, Karl Bishop and Tara Renton (December 2010). The full guidelines with references can be found at www.rcseng.ac.uk/fds

Chapter 4

Medical emergencies in practice: the more unusual causes By M H Thornhill, M N Pemberton and G J Atherton

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Mention of medical emergencies always conjures up the notions of panic but correct training and good anticipation mean that all such incidents can be effectively managed. While the overwhelming majority of situations in the dental setting are, thankfully, of a minor nature and most often to do with fainting there are some more unusual ones that it is important to be aware of and which we detail here.

Angio-oedema Angio-oedema is a rare condition characterised by the sudden onset of localised swelling which usually fades over the subsequent 24-48 hours. The face, mouth and throat are commonly involved. Severe swelling of the upper respiratory tract may lead to respiratory obstruction and can be fatal.

Causes Non-allergic angio-oedema may be hereditary or acquired. Hereditary angiooedema is due to an inherited defect in the production or function of C1 esterase inhibitor, a component of the complement cascade. The consequence is an over-active or sensitive complement system which, when triggered, results in uncontrolled tissue oedema. Acquired angio-oedema is usually idiopathic in origin although several predisposing factors have been identified including drugs, such as angiotensin converting enzyme (ACE) inhibitors and analgesics. In susceptible individuals an acute attack may be precipitated by the simple manipulation of the oral tissues that occurs during dental treatment. The term â&#x20AC;&#x2DC;allergic angio-oedemaâ&#x20AC;&#x2122; is used to describe a type 1 allergic response with tissue swelling affecting the face, mouth and throat. If severe it may be accompanied by profound hypotension causing the patient to lose consciousness and collapse, in which case it is called anaphylaxis. Allergic angio-oedema can be precipitated by allergens commonly used in dentistry such as latex or penicillin.

Signs and symptoms • • •

Oedematous facial swelling of rapid onset Swelling of the tongue and soft palate Respiratory difficulty

Prevention Check the medical history for previous episodes or family history. If the history is suggestive of angio-oedema, arrange for hospital investigation of the cause. Patients with hereditary angio-oedema should have any extractions or surgical procedures carried out in hospital with appropriate C1 esterase inhibitor concentrate cover. If angio-oedema is allergic in origin, avoid known allergens.

Management Depends on the severity of the reaction Mild reaction: (mild tissue swelling, no respiratory difficulty, patient conscious) • • •

Give an oral antihistamine, e.g. chlorphenamine (Piriton®) 4mg up to four times daily for 5 days Arrange a review and refer to hospital as appropriate Severe reaction: (severe tissue swelling/respiratory difficulty or patient unconscious) Treat as for anaphylaxis

Background information Angio-oedema describes oedema in the subcutaneous tissues which occurs quickly and then gradually subsides over a day or two. Urticaria (a blotchy rash, usually white or pink on reddened skin) can also occur in association with the angiooedema. Although allergy is sometimes the cause, many patients develop these conditions for non-allergic reasons. When true allergy is the cause, the relationship between exposure to the allergen and the development of the reaction is usually clear. In idiopathic angiodema and urticaria, the rash and swellings often occur with no pattern or relationship to a trigger factor. In these cases the mast cells become hyper-responsive and release histamine in response to simple stimuli such as pressure (including manipulation of the oral tissues), heat or cold or for no obvious reason. Factors that can increase the hyper-responsiveness of mast cells include drugs such as angiotensin converting enzyme (ACE) inhibitors and non-steroidal antiinflammatory drugs (NSAIDs), some food colourings and preservatives and following viral infection. 43

Angio-oedema secondary to ACE inhibitor drugs has increased in frequency as these drugs have become more widely used in the treatment of cardiovascular disease. There seems to be some predilection for the resulting angio-oedema to affect the head and neck particularly, and deaths due to ACE inhibitor related angio-oedema have been recorded. There is evidence that people of Afro-Caribbean origin are more at risk than other racial groups. Awareness and identification of these groups of patients is important as alternative cardiovascular drugs are available. Hereditary angio-oedema is a very rare cause of oedema which is due to an absolute or functional deficiency of C1 esterase inhibitor. Patients suffering with this condition require specialised hospital management for oral surgery procedures.

Vomiting Causes Much dentistry is carried out with the patient lying supine and there is the potential for patients to vomit while in this position, especially during impression taking. It may also occur during conscious sedation. There is also a chance that a patient who has just fainted and is unconscious may vomit and aspirate the vomit into the lungs, a potentially serious problem.

Signs and symptoms Vomiting is often preceded by: • Feeling unwell or sick • Pallor • Sweating • Salivation • Retching.

Prevention Vomiting is more likely on a full stomach. Aspiration of vomit is the most serious consequence and this is more likely if the patient is supine, sedated or unconscious.

Management If the patient is conscious: • Remove any instruments or loose items from the mouth • Allow the patient to sit leaning forward • Provide a receptacle for the vomit • Reassure • Provide good ventilation. If the patient is unconscious: • •

Place them in the recovery position Use suction to keep the mouth and airway clear.

Background information Vomiting is a primitive protective response. It is controlled by the vomiting centre in the medulla of the brain. This centre is close to those that control respiration and cardiac function. As such, the vomiting centre is not easily depressed by general anaesthesia unless it is so deep as to suppress the other vital centres, hence the risk of vomiting under general anaesthesia. Chemicals and bacterial toxins can induce vomiting and do so by stimulating chemosensitive receptors in the medulla close to the vomiting centre. Some general anaesthetic agents tend to stimulate these centres. Other receptors will also trigger vomiting, for example stretch or touch receptors in the pillars of the fauces. Vomiting can also be provoked by pain or emotional distress.

Panic attacks Causes Panic attacks are discrete, recurrent attacks of acute anxiety. They begin suddenly and last usually about 10-30 minutes. They usually represent a morbid fear or anxiety out of all proportion to the situation. Most such phobias are centred on particular situations e.g. flying, general anaesthesia or dental treatment. Patients generally protect themselves from attacks by avoiding the situations that precipitate them. Sometimes phobias can be part of a more severe disorder such as depression, personality disorder, obsessive neurosis or a chronic anxiety state.

Signs and symptoms • Sudden onset of extreme anxiety or fear • Palpitations • Giddiness • Tremor • Sweating • Flushing • Shortness of breath or hyperventilation • Paraesthesia • Dry mouth • Blurred vision • Weakness.

Prevention Patients with phobias relating to dental treatment require careful, sympathetic handling and lots of patience. Often the anxiety is increased by a feeling that they have no control over the situation. A clear understanding of precisely what induces the phobia may allow the patient to undergo treatment by providing them with some control over the precipitating situation. Sometimes the use of anxiolytic drugs or conscious sedation will help them undergo treatment.

Management • • • • •

Recognise a panic attack for what it is - an anxiety condition rather than a serious medical problem Be sympathetic, reassuring and patient You may need to postpone treatment and withdraw the patient from the situation provoking the anxiety Monitor recovery Consider carrying out further treatment with some form of anxiolytic regimen, such as intravenous sedation or oral diazepam 5mg the night before and 5mg 2 hours before the procedure or temazepam 20-40mg 1 hour before treatment. The patient should be warned about the dangers of sedation - driving and using machinery - and the need to be accompanied.

Note: Hyperventilation is often a feature of a panic attack and should be treated by getting the patient to rebreathe their expired air by holding a paper bag over their mouth and nose.

Background information Panic attacks are sudden onset attacks of anxiety, out of all proportion to the cause, that are precipitated by a particular situation. They are usually accompanied by an array of autonomically mediated symptoms that often increase the patient’s level of anxiety. Sympathetic effects include palpitations, chest tightness or pain, shortness of breath and hyperventilation, which may induce dizziness and paraesthesia. Parasympathetic effects may include nausea, an urge to defecate, blurred vision and weakness. Attacks are frequently accompanied by a gross misinterpretation of the danger they represent. Patients fear dying, going mad or collapsing; they may be convinced that something terrible is happening to them - the sympathetic effects may lead them to believe they are having a heart attack. Attacks may be triggered by anxious thoughts or the anticipation of a phobic situation, such as a trip to the dentist.

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Aggressive or hostile behaviour Causes Acute anxiety, often exacerbated by fear or pain, can cause perfectly normal individuals to become complaining, aggressive or panicky in the dental surgery. Hyperventilation may be a feature of anxiety or a hysterical personality. Alcohol, drug abuse or organic disease such as diabetes, psychiatric disease or head injury may also result in abnormal behaviour. Alcohol or drugs are often taken by patients in an attempt to relieve dental pain or to find the courage to attend the dentist. Diabetics who become hypoglycaemic may become irritable and aggressive, while patients with head injuries may show disturbed behaviour because of brain damage. Psychoses and psychiatric personality disorders may also result in abnormal behaviour. Signs and symptoms • Anxiety • Confusion • Aggression • Disturbed or difficult behaviour. Prevention • • • • • •

A calm inviting reception with alert but friendly staff Sit down rather than stand to confront an aggressive individual Try to avoid keeping patients waiting and be aware of their anxieties Be alert to the patients’ behaviour to anticipate any difficulties at an early stage Tact and diplomacy are useful in preventing any problems If anxiety is the main problem, prophylaxis with an anxiolytic may be helpful.

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Management • • • • •

Adopt a calm, understanding, non-confrontational but firm approach Sit down rather than stand to confront them whenever possible If the patient is unresponsive or difficult to manage, it is advisable to try and get them to return on another occasion If you think the patient could become violent or is disturbed, call the police Do not put yourself or any members of staff at risk of injury from aggressive patients or their escorts.

Background and information Unfortunately, aggressive and hostile behaviour by patients towards healthcare workers is becoming an increasingly common occurrence. It has long been a problem in the emergency departments of hospitals, where the effects of alcohol and fear play a large part in the problem. However, in recent years there has been an increasing problem with violent and aggressive attacks on general medical practitioners and their staff. Although this probably occurs less frequently in dental practices, a survey of 3,078 dental practice staff found that 80% had experienced some form of aggression at work. In general, practice staff were twice as likely to be the target of aggressive behaviour as dentists. The survey also recorded 23 incidents of physical assault by patients or their relatives. In this case dentists were twice as likely as staff to be the target.

Adverse reactions to local anaesthetic injections Causes The most common adverse reaction to injection of a local anaesthetic is a simple faint. Other causes of collapse following an injection, such as anaphylaxis, are very rare. Most other types of reaction associated with local anaesthetic injections are the result of intravascular injection, inaccurate placement or overdose. Problems associated with local anaesthetic injections • Fainting • Intravascular injection • Injection into a muscle • Facial palsy • Cardiovascular reactions • Local anaesthetic overdose • Fractured needle • Local anaesthetic allergy. 49

Intravascular injection Causes Failure to aspirate correctly before injecting (to check that the needle tip is not in a vessel), or too rapid an injection. Signs and symptoms • Possible effects may include: • Agitation • Palpitations • Confusion/drowsiness • Failure of anaesthetic • Fits or loss of consciousness. Prevention Use an aspirating syringe, aspirate correctly and inject slowly. Management • •

Give oxygen Offer reassurance.

Most patients will recover spontaneously within half an hour. If fits or loss of consciousness supervene, institute appropriate management.

Injection into a muscle This occurs most commonly while attempting to give an inferior dental nerve block. It usually results in discomfort and trismus due to stretching or tearing of muscle fibres and haemorrhage into the muscle. The patient should be reassured and the situation explained. The pain and trismus will usually resolve over a few days. Gentle jaw exercises may speed this process and analgesics may help by reducing the pain. Since injection into a muscle is usually the result of a misplaced injection it is also often accompanied by failure of anaesthesia.

Facial palsy Temporary facial palsy, diplopia (double vision) or localised facial pallor occasionally occur when the local anaesthetic is misplaced or tracks towards the facial nerve or

orbital contents. The effect is only temporary, lasting a few hours, and the patient should be reassured. If the eyelids are affected they should be closed and covered with a protective dressing until the anaesthetic wears off.

Cardiovascular reactions Palpitations are the most common cardiovascular reaction to the injection of local anaesthetic and are usually caused by the vasoconstrictor. Reactions occur most commonly following overdosage or intravascular injection. The patient should be reassured while the symptoms subside. If the reaction is severe, then treat as for chest pains.

Local anaesthetic overdose Overdose with local anaesthetics is uncommon. The amount required to produce an overdose remains controversial; however, for a healthy adult an upper limit of 5 dental cartridges has been suggested. In children, the elderly and those with liver disease the upper limit will be considerably less. Overdose reactions vary from drowsiness to convulsions. You should reassure the patient, keep the airway patent and give oxygen. Rarely, respiratory failure or even cardiac arrest occur and should be treated appropriately.

Needle fracture Modern disposable needles rarely fracture unless the needle is re-used or is repeatedly bent and straightened. If the protruding end of the broken needle cannot be grasped easily with mosquito forceps, the patient should be immediately referred to a surgeon for its removal.

Local anaesthetic allergy Allergy to local anaesthesia is very rare. Collapse following a local anaesthetic is far more likely to be due to a faint or another cause. If the allergic reaction is severe and life threatening, it is managed as for anaphylaxis. If the systemic reaction is less severe, without marked respiratory difficulty or symptomatic hypotension, then it should be managed as described for angio-oedema.

Post-operative bleeding Post-operative bleeding normally has a local cause, either gingival bleeding resulting from trauma to the soft tissues or oozing from damaged vessels in the socket. Anticoagulants and drugs that alter platelet function (e.g. aspirin) also predispose to haemorrhage. Systemic causes of bleeding are uncommon and can usually be identified by taking a careful medical history. Primary haemorrhage occurs at the time of surgery and is caused by damage to the tissues. Reactionary haemorrhage usually occurs a few hours after surgery and is due to the effects of the vasoconstrictor in the local anaesthetic wearing off. Following an extraction it may also be the result of the blood clot being dislodged from the socket. Secondary haemorrhage occurs a few days after the procedure and is usually caused by post-operative wound infection. It is relatively uncommon following routine extractions. Medical conditions associated with increased risk of haemorrhage • • • • • • • •

Haemophilia A and B Von Willebrand’s disease Vitamin K deficiency Liver disease Disseminated intravascular coagulation Fibrinolytic states and fibrinolytic drug therapy Other situations where coagulation may be affected include: Polycythaemia, myelofibrosis, leukaemia, lymphoma, chronic renal failure, gram-negative shock, following massive transfusions and where antibodies have developed to clotting factors.

Signs and symptoms •

Post extraction bleeding is usually quite obvious and may be quite alarming to the patient and their relatives. A little blood makes a lot of mess, particularly when mixed with saliva.

•

To identify if bleeding is coming primarily from the soft tissue or the socket, pinch the soft tissues against the walls of the socket between forefinger and thumb. This usually stops soft tissue bleeding, while bleeding from the socket will continue to well up from within the socket.

Prevention Take a careful medical history to identify any underlying medical condition or anticoagulant medication that could increase the risk of postoperative bleeding.

Patients with a medical condition predisposing to haemorrhage should be referred to a hospital oral and maxillofacial surgery unit for assessment and management of their extractions. Patients on long acting anticoagulants e.g. warfarin, acenocoumarol (nicoumalone) or phenindione should have their INR checked: for most patients the INR is maintained between 2 and 4. If the INR is below 4 you can proceed with minor surgery (simple extraction of up to 3 teeth, gingival surgery or single surgical tooth extraction) without anticoagulant dose adjustment. Any postoperative bleeding should be controlled by local measures. The socket should be packed with an resorbable haemostatic dressing and sutured (see below). If the anticoagulant dose requires adjustment this must be done in consultation with the patient’s anticoagulant clinic. Do not instruct the patient to make these adjustments yourself. The INR should be checked within 72 hours of the extraction. If the INR is unstable (e.g., requires weekly monitoring, or those who have had some INR measurements greater than 4.0 in the last 2 months), it should be assessed within 24 hours of the extraction. If possible, carry out a single extraction first to confirm adequate haemostasis. More major surgery or patients with complex medical histories should be treated in hospital. The risk of post extraction bleeding will be reduced by: • • •

Minimising trauma to the tissues at the time of surgery Ensuring haemostasis before discharging the patient from the surgery Providing postoperative instructions including advice on how to avoid dislodging the blood clot from the socket.

Management • • • • • • • •

Reassure the patient and ask relatives to leave unless the patient is very young Clean the mouth with a swab soaked in saline and use suction to locate the source of bleeding Get the patient to bite firmly on a gauze swab, correctly located such that pressure is exerted over the socket, for ten minutes Enquire again into the patient’s medical history, especially family history, drug history and previous operative history, to exclude systemic causes If bleeding continues: Give local anaesthesia. This will often slow or stop the bleeding If bleeding is primarily from the gingival soft tissues: Use a horizontal mattress suture to compress the soft tissue vessels against the socket walls Apply local pressure by getting the patient to bite on a gauze swab Keep the patient rested until the bleeding stops

If bleeding is primarily from the socket: • • • • • •

Insert an oxidised cellulose gauze or sponge (e.g. Surgicel, Oxycel) or a collagen sponge (e.g. Haemocollagen) Pack the socket (if available, use ribbon gauze soaked in Whitehead’s varnish) Insert a horizontal mattress suture to compress the soft tissues and hold the pack in place Apply local pressure by getting the patient to bite on a gauze swab Keep the patient rested until the bleeding stops If it is not possible to identify if bleeding is from the soft tissues or socket: Employ both the above approaches - If it is not possible to identify if bleeding is from the soft tissues or socket - If the bleeding is uncontrollable, call an ambulance.

Background information Management of patients taking anticoagulant drugs is still an area of debate. Until recently, the general advice was that the INR should be adjusted to below 2-2.5 before extractions or other minor oral surgical procedures are performed. However, this advice has recently changed as a result of concern about the increased risk of thrombosis in patients whose INR is lowered prior to dental procedures. Current evidence suggests that this risk outweighs the increased risk of haemorrhage for patients undergoing dental procedures when the INR is below 4. Therefore, patients whose INR is 4 or less should not have their anticoagulant dose adjusted before undergoing simple minor oral surgical procedures. Post-operative bleeding should be prevented by the pre-emptive insertion of a haemostatic dressing into the socket, and suturing before getting the patient to bite firmly on a gauze pack placed over the socket. Current evidence suggests that local measures are effective in preventing post-operative haemorrhage in these patients and that other measures, such as the use of tranexamic acid provide no additional benefit. Intramuscular injections are contraindicated in patients on anticoagulants or in those with a bleeding disorder. If possible local anaesthetic should be given by infiltration or by intraligamentary injection. If unavoidable, regional nerve blocks should be given cautiously using an aspirating syringe. Many drugs have the potential to interact with anticoagulants; for example aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), carbamazepine, antibiotics such as metronidazole, and antifungals. When prescribing drugs for a patient who is taking warfarin, the potential for interaction should always be considered and checked in a suitable reference source such as the BNF. If analgesics are required, paracetamol should be used.

Many patients now take antiplatelet medication to prevent cardiovascular disease or stroke. These drugs include: • Low dose aspirin (75-300mg daily) • Clopidogrel • Dipyridamole. Current evidence suggests that this therapy should not be stopped or altered prior to dental surgical procedures in primary care. Their effect on primary haemostasis is minimal and easily controlled by normal local measures. It is suggested that where multiple extractions are required, no more than three teeth should be extracted at any one visit. Similarly, scaling and gingival surgery should be restricted to a limited area first to assess if bleeding is likely to be a problem. If post-operative analgesia is required, paracetamol is the drug of choice as aspirin and NSAIDs could enhance the antiplatelet effect of these drugs and increase the risk of bleeding.

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Chapter 5

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

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Red oral lesions are commonplace and usually associated with inflammation in, for example, mucosal infections. However, red lesions can also be sinister by signifying severe dysplasia in erythroplasia, or malignant neoplasms (Table 1). Inflammatory lesions Most red lesions are inflammatory, usually: • Geographic tongue (erythema migrans) (Figure 1) • Viral infections (eg herpes simplex stomatitis) • Fungal infections • Candidosis: • Denture-related stomatitis; discussed below, is usually a form of mild chronic erythematous candidosis consisting of inflammation beneath a denture, orthodontic or other appliance • Median rhomboid glossitis; a persistent red, rhomboidal depapillated area in the midline dorsum of the tongue • Acute oral candidosis; may cause widespread erythema and soreness, sometimes with thrush, often a complication of corticosteroid or antibiotic therapy. Red lesions of candidosis may also be seen in HIV disease, typically in the palate (Figure 2) • Bacterial infections • Cancer treatment-related mucositis; common after irradiation of tumours of the head and neck, chemotherapy, eg for leukaemia • Immunological reactions; such as lichen planus, plasma cell gingivostomatitis, granulomatous disorders (sarcoidosis, Crohn’s disease, orofacial granulomatosis), amyloidosis, and graft versus host disease.

Geographic tongue (erythema migrans) Geographic tongue (erythema migrans) is a very common condition and cause of sore tongue, affecting at least 1–2% of patients. There is a genetic background, and often a family history. Many patients with a fissured tongue (scrotal tongue) also have geographic tongue. Erythema migrans is associated with psoriasis in 4% and 56

the histological appearances of both conditions are similar. Some patients have atopic allergies, such as hay fever, and a few relate the oral lesions to various foods, eg cheese. A few have diabetes mellitus.

Clinical features Geographic tongue typically involves the dorsum of the tongue, sometimes the ventrum and, on occasions, it may affect other oral mucosal sites. It is often asymptomatic, but a small minority of patients complain of soreness and these patients are virtually invariably middle-aged. If sore, this may be noted especially with acidic foods (e.g. tomatoes or citrus fruits) or cheese. There are irregular, pink or red depapillated map-like areas, which change in shape, increase in size, and spread or move to other areas, sometimes within hours. The red areas are surrounded by distinct yellowish slightly raised margins. There is increased thickness of the intervening filiform papillae.

Diagnosis The diagnosis of geographic tongue is clinical mainly from the history of a migrating pattern and the characteristic clinical appearance. Blood examination may rarely be necessary to exclude diabetes, or anaemia, if there is confusion with a depapillated tongue of glossitis.

Management There is no cure and treatment is therefore aimed at controlling symptoms and reassuring the patient, particularly that there are no long-term consequences. Zinc sulphate 200 mg three times daily for 3 months or a topical rinse with 7% salicylic acid in 70% alcohol are advocated by some and may occasionally help.

Patient information and websites: http://www.eaom.eu/files/geographic_tongue.pdf http://www.mayoclinic.com/health/geographic-tongue/DS00819

Dentureâ&#x20AC;&#x2018;related stomatitis (Denture-induced stomatitis; denture sore mouth; chronic erythematous candidosis)

Denture-related stomatitis consists of mild inflammation of the mucosa beneath a denture – usually a complete upper denture. This is a common condition, mainly of the middle aged or elderly; more prevalent in women than men.

Aetiopathogenesis Dental appliances (mainly dentures), especially when worn throughout the night, or in patients with a dry mouth, favour development of this infection. It is not caused by allergy to the dental material (if it were, it would affect mucosae other than just that beneath the appliance). However, it is still not clear why only some denture‑wearers develop denture-related stomatitis, since most patients appear otherwise healthy. Dentures can produce a number of ecological changes; the oral flora may be altered and plaque collects between the mucosal surface of the denture and the palate. The accumulation of microbial plaque (bacteria and/or yeasts) on, and attached to, the fitting surface of the denture and the underlying mucosa produces an inflammatory reaction. When Candida is involved, the more common terms ‘candida-associated denture stomatitis’, ‘denture-induced candidosis’ or ‘chronic erythematous candidosis’ are used. In addition, the saliva that is present between the maxillary denture and the mucosa may have a lower pH than usual. Denturerelated stomatitis is not exclusively associated with infection, and occasionally mechanical irritation is at play. Clinical features The characteristic presenting features of denture-related stomatitis are chronic erythema and oedema of the mucosa that contacts the fitting surface of the denture. Uncommon complications include: • Angular stomatitis (soreness and erythema at the commissures (Figure 3) • Papillary hyperplasia in the vault of the palate. Classification Denture-related stomatitis has been classified into three clinical types (Newton’s classification), increasing in severity: • • •

A localised simple inflammation or a pinpoint hyperaemia An erythematous or generalized simple type presenting as more diffuse erythema involving a part of, or the entire, denture-covered mucosa. A granular type (inflammatory papillary hyperplasia) commonly involving the central part of the hard palate and the alveolar ridge.

Diagnosis Denture-related stomatitis and angular stomatitis are clinical diagnoses, although may be confirmed by microbiological investigations. In addition, haematological and biochemical investigations may be appropriate to identify any underlying predisposing factors, such as hyposalivation, nutritional deficiencies, anaemia and diabetes mellitus in patients unresponsive to conventional management.

Management The denture plaque and fitting surface is infested with micro-organisms, most commonly Candida albicans and, therefore, to prevent recurrence, dentures should be left out of the mouth at night, and stored in an appropriate antiseptic which has activity against yeasts (Table 2). Cleansers containing alkaline hypochlorites, disinfectants, or yeast lytic enzymes are most effective against Candida. Denture soak solution containing benzoic acid is taken up into the acrylic resin and can completely eradicate C albicans from the denture surface. Chlorhexidine gluconate can also eliminate C albicans on the denture surface and mouthwash can reduce the palatal inflammation. A proteasecontaining denture soak (Alcalase protease) is also an effective way of removing denture plaque, especially when combined with brushing. The mucosal infection is eradicated by brushing the palate with chlorhexidine mouthwash or gel, and using miconazole gel, nystatin oral suspension or fluconazole, administered concurrently with an oral antiseptic, such as chlorhexidine, which has antifungal activity. Blood tests, microbiological studies or biopsy may be required if the lesion is unresponsive.

Patient advice Keep the appliance as clean as natural teeth. Clean both surfaces (inside and outside) after meals and at night. Use washing-up liquid and a toothbrush and lukewarm water and hold it over a basin containing water, in case you drop it, which could cause it to break. Never use hot water, as it may alter the colour. A disclosing agent, for example Rayners Blue or Red food colouring (available at most supermarkets) can be applied with cotton buds, to help see whether you are cleaning the appliance thoroughly enough. If stains or calculus deposits are difficult to remove, try an overnight immersion (eg Dentural, Milton or Steradent), or an application of Denclen. Dentures should be left out overnight, so that your mouth has a rest. It is not natural for your palate to be covered all the time and the chances of getting an infection are increased if the dentures are worn 24 hours a day. Ensure you leave the dentures out for at least

some time and keep them in Dentural or Steradent, as they may distort if allowed to dry out. Special precautions for dentures with metal parts; Denclen, Dentural and Milton may discolour metal, so use with care. Brush briefly to remove stains and deposits, rinse well with lukewarm water and do not soak overnight. Before re-use, wash in water and brush the appliance to remove loosened deposits. Website and patient information http://emedicine.medscape.com/article/1075994-overview Table 1. Most common causes of red lesions. LOCALISED Inflammatory lesions Geographic tongue Candidosis Lichen planus

Reactive lesions

Atrophic lesions

Purpura

Vascular

Pyogenic

Geographic tongue

Trauma

Telangiectases

Squamous

(hereditary

carcinoma

granulomas Peripheral giant cell granulomas

Drug reactions

Lichen planus

Thrombocytopenia

haemorrhagic

Neoplasms

Kaposiâ&#x20AC;&#x2122;s sarcoma

Lupus

telangiectasia or

erythematosus

scleroderma)

Erythroplasia

Angiomas (vascular

Wegenerâ&#x20AC;&#x2122;s

Vitamin B12

hamartomas)

granulomatosis

Giant cell tumour

deficiency

GENERALISED Candidosis

Figure 2. Erythematous candidosis.

Avitaminosis B complex (rarely) Irradiation or chemotherapy-induced mucositis Figure 1. Geographic tongue.

Figure 3. Angular stomatitis (cheilitis).

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Chapter 6

Neoplastic oral lesions & pigmentation By Professor Crispian Scully, Dr Jane Luker and Dr David Felix. Adapted from Oral medicine – update for the dental team

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Classification Neoplastic oral lesions include: • • • •

Peripheral giant cell tumours Angiosarcomas, such as Kaposi’s sarcoma, a common neoplasm in HIV/AIDS, which appear in the mouth as red or purplish areas or nodules, especially seen in the palate Squamous cell carcinomas Wegener’s granulomatosis.

Vascular anomalies (angiomas and telangiectasia) include: • • •

Dilated lingual veins (varices) may be conspicuous in elderly persons; this is part of the normal spectrum Haemangiomas (Figure 1) are usually small isolated developmental anomalies, or hamartomas Telangiectasias – dilated capillaries – may be seen after irradiation and in disorders such as hereditary haemorrhagic telangiectasia and systemic sclerosis. Angiomas are benign and usually congenital. In general, most do not require any active treatment, unless symptoms develop, in which case they can be treated by injection of sclerosing agents, cryosurgery, laser excision or surgical excision. Vesiculobullous disorders, such as erythema multiforme, pemphigoid and pemphigus, may present as red lesions, especially localised oral purpura, which presents with blood blisters. Specialist referral is usually indicated.

Reactive lesions Reactive lesions that can be red are usually persistent soft lumps which include: • •

Pyogenic granulomas Peripheral giant cell granulomas.

Specialist referral is usually indicated.

Atrophic lesions The most important red lesion is erythroplasia, since it is often dysplastic (see below). Geographic tongue also causes red lesions. Desquamative gingivitis is a frequent cause of red gingivae (Figure 2), which is almost invariably caused by lichen planus or pemphigoid, and iron or vitamin deficiency states may cause glossitis or other red lesions.

Erythroplakia (erythroplasia) Erythroplasia is a rare condition defined as â&#x20AC;&#x2DC;any lesion of the oral mucosa that presents as bright red velvety plaques which cannot be characterised clinically or pathologically as any other recognisable conditionâ&#x20AC;&#x2122;. Mainly seen in elderly males, it is far less common than leukoplakia, but far more likely to be dysplastic or undergo malignant transformation.

Clinical features Erythroplakia is seen most commonly on the soft palate, floor of mouth or buccal mucosa. Some erythroplakias are associated with white patches, and are then termed speckled leukoplakia.

Diagnosis Biopsy to assess the degree of epithelial dysplasia and exclude a diagnosis of carcinoma.

Prognosis Erythroplasia has areas of dysplasia, carcinoma in situ, or invasive carcinoma in most cases. Carcinomas are seen 17 times more often in erythroplakia than in leukoplakia and these are therefore the most potentially malignant of all oral mucosal lesions.

Management Erythroplastic lesions are usually (at least 85%) severely dysplastic or frankly malignant. Any causal factor, such as tobacco use, should be stopped, and lesions removed. There is no hard evidence as to the ideal frequency of follow-up, but it has been suggested that patients with mucosal potentially malignant lesions be re-examined: 63

• • • • •

Within 1 month At 3 months At 6 months At 12 months and Annually thereafter.

Purpura (bleeding into the skin and mucosa) is usually caused by: • • • •

Trauma, occasional small petechiae are seen at the occlusal line in perfectly healthy people Localised oral purpura or angina bullosa haemorrhagica is an idiopathic, fairly common cause of blood blisters, often in the soft palate, in older people. Sometimes the use of a corticosteroid inhaler precipitates this Thrombocytopenia can result in red or brown pinpoint lesions (petechiae) or diffuse bruising (ecchymoses) at sites of trauma, such as the palate Suction (eg fellatio may produce bruising in the soft palate).

Diagnosis Diagnosis of red lesions is mainly clinical but lesions should also be sought elsewhere, especially on the skin or other mucosae. It may be necessary to take a blood picture (including full blood count and platelet count), and assess haemostatic function or exclude haematinic deficiencies. Investigations needed may include other haematological tests and/or biopsy or imaging.

Management Treatment is usually of the underlying cause, or surgery.

Hyperpigmentation Oral mucosal discoloration may be superficial (extrinsic) or due to deep (intrinsic – in or beneath mucosa) causes and ranges from brown to black. Causes of extrinsic discoloration include: Habits such as tobacco or betel use Coloured foods or drinks (such as liquorice, beetroot, red wine, coffee and tea) Drugs (such as chlorhexidine, iron salts, crack cocaine, minocycline, bismuth subsalicylate and lansoprazole).

Black hairy tongue is one extrinsic type of discoloration seen especially in patients on a soft diet, smokers, and those with dry mouth or poor oral hygiene. The best that can usually be done is to avoid the cause where known, and to advise the patient to brush the tongue or use a tongue-scraper. Causes of Intrinsic discoloration include: • Melanoma • Kaposi’s sarcoma • Wegener granulomatosis in view of associated systemic disease. Localised areas of pigmentation may be caused mainly by: • • • • • •

Amalgam tattoo (embedded amalgam). Typically, this is a single blue‑black macule in the mandibular gingivae, or at least close to the scar of an apicectomy (Figure 3), or where amalgam has accidentally been introduced into a wound, is painless, and does not change in size or colour. A lesion suspected to be an amalgam tattoo is best radiographed first to see if there is radio-opaque material present, though not all are radio-opaque. If the lesion is not radio-opaque, it is best biopsied to exclude naevi or melanoma. Similar lesions can be caused by other foreign bodies (eg graphite tattoo), local irritation or inflammation. Melanotic macules are usually flat, single brown collections of melanin- containing cells, seen particularly on the vermilion border of the lip and on the palate. If there is any doubt over the diagnosis they are best removed to exclude melanoma. Naevi are blue-black, often papular, lesions formed from increased melanin- containing cells (naevus cells) seen particularly on the palate. They are best removed to exclude melanoma. Pigmentary incontinence may be seen in some inflammatory lesions, such as lichen planus, especially in smokers. Malignant melanoma is rare, seen usually in the palate or maxillary gingivae. Features suggestive of malignancy include a rapid increase in size, change in colour, ulceration, pain, the occurrence of satellite pigmented spots or regional lymph node enlargement. Incisional biopsy to confirm the diagnosis followed by radical excision is indicated. Kaposi’s sarcoma is usually a purple lesion seen mainly in the palate (Figure 4) or gingivae of HIV-infected and other immunocompromised people.

Generalised pigmentation, often mainly affecting the gingivae (Figure 5) is common in people of colour, and is racial and due to melanin. Seen mainly in black and ethnic minority groups, it can also be noted in some fairly light-skinned people. Such pigmentation may be first noted by the patient in adult life and then incorrectly assumed to be acquired. In all other patients with widespread intrinsic pigmentation, systemic causes should be excluded. These may include: 65

• Drugs – Tobacco, which can also cause intrinsic hyperpigmentation – smoker’s melanosis – Antimalarials, oral contraceptive pill, anticonvulsants, minocycline, phenothiazines, gold, busulphan and other drugs • Heavy metals (such as mercury, lead and bismuth) not used therapeutically now, rarely cause pigmentation through industrial exposure • Pregnancy • Hypoadrenalism (Addison’s disease). Hyperpigmentation in this is generalised but most obvious in normally pigmented areas (eg the nipples, genitalia), skin flexures and sites of trauma. The mouth may show patchy hyperpigmentation. Patients also typically have weakness, weight loss, and hypotension. Diagnosis The nature of oral hyperpigmentation can sometimes only be established after further investigation. In patients with localised hyperpigmentation, in order to exclude melanoma, radiographs may be helpful (they can sometimes show a foreign body) and biopsy may be indicated, particularly where there is a solitary raised lesion, a rapid increase in size, change in colour, ulceration, pain, evidence of satellite pigmented spots or regional lymph node enlargement. If early detection of oral melanomas is to be achieved, all pigmented oral cavity lesions should be viewed with suspicion. The consensus of opinion is that a lesion with clinical features, as above, seriously suggestive of malignant melanoma, are best biopsied at the time of definitive operation. In patients with generalised or multiple hyperpigmentation, specialist referral is indicated. Management Management is of the underlying condition. Patients to refer: • •

Erythroplasia/erythroplakia – in view of high risk of malignant transformation Squamous carcinoma.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Vascular hamartoma

Desquamative

Amalgam tattoo.

Kaposi’s sarcoma,

Racial pigmentation.

(haemangioma on

gingivitis.

palate.

tongue).

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Chapter 7

Potentially malignant disorders

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Adapted from Oral cancer; an update for the dental team. Professor Crispian Scully CBE, Professor Emeritus, UCL, London and Mr Nicholas Kalavrezos Maxillofacial & Reconstructive Surgeon of The Head, Face & Neck University College London Hospital and The Harley Street Clinic.

Some mouth cancers are preceded by clinically obvious potentially malignant disorders (PMDs); most are probably not and arise in clinically apparently normal mucosa. Nevertheless, molecular changes must precede histopathological and clinically detectable lesions. Risk factors for the PMD are generally those as for oral squamous cell carcinoma (OSCC). There is a range of PMDs known but the most important recognised are erythroplakia (erythroplasia), leukoplakia, lichenoid lesions, actinic cheilitis and submucous fibrosis and many cancers are associated with such lesions (especially in South-East Asian people). Of course PMDs, although regarded as early lesions in possible progression to malignancy, may well, in molecular terms, be rather ‘late’ in that several genetic changes may be present with no clinical signs detectable. Oral cancer itself in the initial clinically detectable stage is often a red or red and white area without symptoms, so it can be very difficult to differentiate PMDs from early cancers and both are rarely painful. The initial PMD lesions are usually solitary and asymptomatic when they are small and thus, in the early stages, it is quite possible to make a misdiagnosis. Lesions of oral cancer can range from a few millimetres, to several centimetres diameter in the more advanced cases. In advanced cancers, there is often a red or red and white single lesion, ulcer or lump with irregular margins which are rigid to touch (indurated) and there may be pain, especially in the tongue and floor of the mouth lesions. These are easier to recognise: the RULE is to look out for a single lesion of three or more weeks’ duration, especially a: • • • •

Red and/or white lesion Ulcer Lump Especially when in a combination, or if indurated (firm on palpation).

Such lesions should be regarded with suspicion, and urgent biopsy arranged. If people notice any of these changes, they should seek help from their dentist, doctor, or another healthcare professional without delay. The risk of malignant transformation in the PMD varies enormously but, over a 5-10 year period, is approximately as follows:

• • • •

Erythroplasia: 85%+ malignant transformation Actinic cheilitis: 10% malignant transformation Leukoplakia: 5%+ malignant transformation – Non-homogeneous (highest - 30%) – Verrucous – Speckled – Sublingual – Homogeneous (lowest - 3%) Lichen planus/lichenoid lesions: 1-5% malignant transformation: – Lichenoid (highest) – Lichen planus (lowest).

Potentially malignant lesions are initially usually symptomless, so any symptoms should raise the index of suspicion of malignant change. What is the natural history of PMDs? The natural history of PMDs is not absolutely clear and, though the risk of malignant development is not reliably predictable, it is greatest in: • Older patients • Females • Never-users of tobacco. • PMDs that are: – non-homogeneous – on the lateral and ventral tongue, floor of the mouth and retromolar/soft palate complex – large lesions covering several intra-oral subsites or – of long duration. Factors predictive of future malignant transformation may also include factors discussed below, such as: • • • • •

Epithelial dysplasia Expressions of P53 tumour suppressor protein Changes involving chromosomes 3p or 9p termed ‘loss of heterozygosity,’ or LOH Chromosomal polysomy History of cancer in the upper aerodigestive tract.

Epithelial dysplasia (from Greek dys = poor and plasia = a moulding) is a term describing the combination of disorderly maturation and disturbed cell proliferation seen in OSCC and in some PMDs (and in some benign disorders) (Figure 1). Epithelial

dysplasia is usually graded as mild, moderate or severe, depending on the extent of the abnormality seen. This grading process is subjective, but it is still the single most useful tool for prediction of the behaviour of abnormal epithelium. A total of 148 male patients with oral PMDs in Taiwan were studied with a mean follow-up period of 38 months. The malignant transformation rate was highest in subjects diagnosed with oral epithelial dysplasia. In this group the transformation rate was 7.62 per 100 people per year. The anatomical site of PMDs was the only statistically significant variable associated with malignancy: higher for tongue lesions than with buccal lesions. A UK study of 1,357 patients with biopsy-confirmed oral PMDs showed the most common PMD to be lichen planus/lichenoid reactions. Among all PMDs, 15% had epithelial dysplasia. Thirty five patients developed OSCC over the follow-up period (2.6%). Patients with severe dysplasia had a higher risk of transformation to oral cancer compared to those with no dysplasia. A significant trend over dysplasia grades was evident. Transformation to oral cancer was also associated with increasing patient age. Dysplasia on biopsy examination is thus one of the main histological features that appears to precede the onset of malignancy and it appears to be the most predictive marker for malignant potential in current use. Cellular atypia is the main feature of dysplasia and the rate of malignant changes can be as high as 36% when moderate or severe dysplasia is present. Sadly, a number of studies have shown that the reliability of dysplasia grading and histopathological examination cannot be guaranteed; pathologists can differ in their diagnosis one from another and even the same pathologist can sometimes give a different opinion at different times (a phenomenon common with some other diagnostic procedures in healthcare). Furthermore, some potentially malignant lesions on initial biopsy have shown no serious pathology but have, on excision, been shown to contain cancers in up to 10%. Also, the clinically normal mucosa at lesional margins may actually harbour alterations at the molecular level, contributing to the persistence/recurrence of the lesion, or to subsequent OSCC. Because of such uncertainties, much effort has gone into identifying the genetic changes that underlie mouth cancer and to find biomarkers such as DNA ploidy (aneuploidy), and changes in the p53, and loss of heterozygosity (LOH) in chromosomes 3p, 9p, 4q or 17p that might better predict malignant change. Malignant transformation of the involved epithelium is a culmination of constant exposure to carcinogens and an accumulation of genetic alterations. Molecular aberrations have been identified in oral premalignant mucosal lesions, which increase in number as lesions progress toward malignancy. However, despite considerable progress in such molecular biology, there is still no single marker or set of markers that reliably predict malignant transformation in an individual patient, although the presence of dysplasia and of other changes, such as these genetic changes, are suggestive. The extent or grade of dysplasia is currently the accepted reference method by which the malignant potential is gauged to predict malignant transformation, but

many specialists now believe that seeing severe dysplasia is often tantamount to a diagnosis of early carcinoma, since the epithelial basement membrane may well be breached even when not detected in the biopsy specimen submitted for histopathological examination. Detection of dysplasia thus suggests early intervention hopefully to reduce future malignant transformation. Dysplasia grading is widely used to assess risk of transformation, despite limited data on predictive value. DNA ploidy analysis has been proposed as an alternative and in studies had equivalent predictive value and also detected additional risk lesions in the absence of histological evidence of dysplasia. Future directions are hopeful and are leading to increased reliability of prognostic factors, most of which rely on molecular studies under development. Newer markers suggestive of transformation potential in potentially malignant disorders include: • • • •

Cancer history positive Chromosomal polysomy [ploidy] Loss of chromosomal heterozygosity (LOH) – High risk - LOH for 9p, 17p and 4q – Intermediate risk - LOH for 9p alone or LOH 9p plus either LOH 17p or LOH 4q – Low risk - LOH for chromosome 9p only p53 protein expression.

What is the recommended management of patients with PMDs? Management of patients with PMD is a controversial issue because of the above observations and since there is no reliable evidence base. Certainly, a biopsy and a histologic examination are required because dysplasia may precede malignant changes, and a specialist opinion is advised. Sadly, the evidence base on which treatment is founded is also not ideal. Cessation of smoking habits appears to result in some lesions regressing or resolving, so possible aetiological factors should be removed, and an observation of 2-4 weeks seems acceptable to observe any possible regression. It is not possible yet to define the risk of malignant transformation of a PMD reliably, nor to predict the effects of any interventions reliably. Oral dysplasia shows a significant rate of transformation to cancer, related to grade, and may be decreased significantly but not eliminated by excision. This suggests the need for excision and continued surveillance. Lesions that are not excised demonstrate considerably higher transformation rate than those that are excised. Therefore, rather than so-called ‘watchful waiting’ of PMDs, it is probably best to remove all oral erythroplasias/leukoplakias, if feasible, especially if there is epithelial dysplasia on biopsy.

Surgery may have a beneficial effect, but there is little evidence that this will reliably reduce the risk of later recurrence, or malignant transformation of PMDs, at the same or another site. Thus, despite a lack of solid evidence, surgical resection still remains considered the best practice, regardless of histologic grade. The most commonly used modalities are surgical excision or CO2 laser excision so that the specimen can be sent for histopathological examination. Laser fulguration or ablation does not permit the examination of the whole lesion and, bearing in mind the above comments, would seem less desirable. For widespread lesions, photodynamic therapy (PDT) may sometimes be considered. The evidence from systematic reviews is that medical therapies are not reliably effective: topical anticancer agents, such as podophyllin or bleomycin or retinoids, have only temporary efficacy, and perhaps their best indication is when the location or extent of the lesion prevent adequate surgical removal. Medical measures that lessen the size, extent or histopathological features of dysplasia within PMD are also associated with a risk of adverse effects. Recurrence rates after any form of treatment may be up to 30%, probably mainly depending on the duration of follow-up. The efficacy of continuous follow-up of PMD patients is virtually unknown. There is also neither evidence base nor absolute consensus as to the optimum review interval or protocol for other PMDs. Fully informed consent is crucial, all the uncertainties being discussed with the patient. Management of PMDs is not informed by high level evidence but consensus supports targeted use of biopsy and histopathological assessment. The management of biopsy-proven dysplastic lesions thus favours: • Advice to avoid or reduce known carcinogens, eg tobacco, alcohol and betel • Surgical excision when the size of the lesions and the patient’s function allow • Long-term surveillance.

Conditions associated with PMDs Erythroplakia (erythroplasia) (Figure 2) Red oral lesions are usually far more dangerous than white lesions. Erythroplasia is a red and often velvety lesion which, unlike leukoplakias, does not form a plaque but is level with, or depressed below, the surrounding mucosa; 75–90% prove to be carcinoma or carcinoma in situ or show severe dysplasia. Histopathologically, erythroplasia typically shows at least moderate or severe dysplasia. Epithelial dysplasia is in general regarded as the most important indicator of the malignant potential. Erythroplasia mainly affects patients of either gender in their sixth and seventh decades, is usually related to tobacco and alcohol use, and typically involves the floor of the mouth, ventrum of the tongue, or the soft palate.

Leukoplakia (Figure 3) A workshop co-ordinated by the WHO Collaborating Centre for Oral Cancer and Precancer agreed that the term leukoplakia should be used to recognise â&#x20AC;&#x2DC;white plaques of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancerâ&#x20AC;&#x2122;. Currently, the term leukoplakia therefore implies a diagnosis by exclusion (eg of lichen planus, candidosis). By definition, the term excludes nonpremalignant entities, such as frictional keratosis or smokers keratosis. White oral lesions usually result from increased keratinization or candidosis and, in contrast to erythroplasia, are mostly neither malignant nor premalignant. Lichen planus/lichenoid lesions (Figure 4) Oral lichen planus (OLP) is regarded as a potentially malignant disorder with an annual malignant transformation rate usually <0.5%. The evidence is weak but transformation may occur in any clinical type and may be more common in lichenoid lesions and on the tongue. Unfortunately, there are no strategies known to prevent this malignant transformation and, although continuous follow-up of patients is advised, any evidence of benefit is questionable. NICE guidelines clearly state that patients with oral lichen planus/lichenoid lesions should be monitored for oral cancer as part of the routine dental examination. If there is any change causing concern, particularly the development of a lump, a specialist opinion should be obtained. Actinic cheilitis (Figure 5) Actinic cheilitis (actinic keratosis of lip, solar keratosis, solar cheilosis; from the Greek aktino = rays and cheili = lips) is common in sun-overexposed individuals, and is essentially a sunburn, but chronic actinic cheilitis is a PMD. Seen mainly in older men, chronic actinic cheilitis is most common in Caucasians from the tropics. Particularly at risk are people whose lifestyles include much time spent outdoors, especially farmers, sailors, fishermen, windsurfers, skiers, mountaineers, golfers, etc. Sun ultraviolet light UVB can damage particularly the lower lip vermilion. Submucous fibrosis (Figure 6) Oral submucous fibrosis (OSMF) is a chronic disorder seen only in people who chew betel products. The basic issue in OMSF appears to be an increase in submucosal collagen, for which there may be some genetic predisposition. OSMF can affect the oral and sometimes pharyngeal mucosa, and develops insidiously, usually diffusely, often initially presenting with oral burning sensations. It is most obvious when characterised by tightening of the buccal, and sometimes palatal and lingual mucosae, especially when causing trismus. Symmetrical fibrosis in the cheeks, lips, tongue or palate appears as vertical bands running through the mucosa, and restricted oral opening. 73

Figure 1. Epithelial dysplasia - a predictor of transformation.

Figure 2. Erythroplasia.

Figure 3. Leukoplakia (sublingual).

Figure 4. Lichenoid lesion.

Figure 5. Actinic cheilitis.

Figure 6. Submucous fibrosis.

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Chapter 8

Safeguarding children

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Tips for best practice

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Safeguarding children is not just about referring them when you have concerns but is about changing the environment to ensure that risks to their welfare are minimised. These tips for best practice will help a dental practice to not only fulfil the responsibilities of current legislation and ethical guidance but also to take an active role in safeguarding children: • • • • •

Identify a member of staff to take the lead on child protection Adopt a child protection policy Work out a step-by-step guide of what to do if you have concerns Follow best practice in record keeping Undertake regular team training.

Staff member to lead on child protection In a busy dental practice there are many important clinical governance issues competing for time and attention. Appointing an individual staff member to lead on child protection can be an effective way of ensuring that this issue is not overlooked. You will need to: • •

identify an appropriate person define their role.

The person The child protection lead should be someone who: • • • •

is a good listener has respect for confidential information is able to handle difficult or distressing issues sensitively thinks before taking action.

The child protection lead could be: •

a dentist or any other suitably trained member of the dental team.

Their role The role of the child protection lead might include the following duties: • • • • • •

keeping an up-to-date list of local contacts for child protection advice and referral making this information readily available to staff ensuring that Local Safeguarding Children Board /Area Child Protection Committee (LSCB/ACPC)* procedures are available and up-to-date organising staff training auditing practice keeping details of local sources of confidential emotional support for staff (this might be needed by staff who are involved in distressing child protection cases, or who have been abused themselves or observed abuse in their families).

Child protection policy A suitable child protection policy statement for a dental practice should affirm the practice’s commitment to protecting children from harm and should explain how this will be achieved. The date on which the policy is adopted should be stated, together with a date when it will be due for review. However, a policy alone is not enough. Safeguarding children is about changing the whole environment. You can do this by: • • • •

listening to children providing information for children providing a safe and child-friendly environment having other relevant policies and procedures in place.

Listening to children You should create an environment in which children know their concerns will be listened to and taken seriously. You can communicate this to children by: • • •

asking for their views when discussing dental treatment options, seeking their consent to dental treatment (as appropriate to their age and understanding) in addition to parental consent involving them when you ask patients for feedback about your practice e.g. by providing a suggestion box or by carrying out a patient satisfaction survey listening carefully and taking them seriously if they make a disclosure of abuse.

Information for children To support children and families, you can provide information about: • •

local services providing advice or activities e.g. Sure Start services, parenting courses, toddler groups and youth groups sources of help in times of crisis e.g. NSPCC Child Protection Helpline, NSPCC Kids Zone website, Childline, Samaritans, local support groups for children or parents.

A safe and child-friendly environment A safe and child-friendly environment can be provided by: • • • •

taking steps to ensure that areas where children are seen are welcoming and secure with facilities for play considering whether young people would wish to be seen alone or accompanied by their parents ensuring that staff never put themselves in vulnerable situations by seeing young people without a chaperone ensuring that your practice has safe recruitment procedures in place.

Other relevant policies and procedures Clinical governance policies that you already have in place will contribute to your practice being effective in safeguarding children. Some examples are: • • • • •

complaints procedures so that children or parents attending your practice can raise any concerns about the actions of your staff that may put children at risk of harm public interest disclosure policy (or ‘whistleblowing’ policy) so that staff can raise concerns if practice procedures or action of other staff members puts children at risk of harm code of conduct for staff clarifying the conduct necessary for ethical practice, particularly related to maintaining appropriate boundaries in relationships with children and young people (e.g. including a statement that staff members will be chaperoned when attending to unaccompanied children) guidelines on use of restraint (‘physical intervention’ or ‘clinical holding’) so that staff know how to intervene appropriately for children unable to comply with dental care consent policy and procedures as discussed above.

Step-by-step guide of what to do if you have concerns When you have concerns about a child it is essential to be able to access information and advice immediately so that you can take action promptly. As a minimum, every dental practice should have: • •

a copy of the LSCB/ACPC procedures folder or the website saved as a ‘favourite’ if available online an up-to-date list of telephone numbers of local contacts for advice or referral.

Teams working regularly with children will find it useful to work out their own stepby-step guide of what to do if they have concerns about a child. Written guidelines could be produced, perhaps by adapting a published example of good practice.

Best practice in record keeping A routinely high standard of record keeping is essential for a dental team who take safeguarding children seriously. Records must include accurate basic personal information about every child and comprehensive clinical records of their dental care. Basic personal information When a child attends any healthcare service for the first time, basic personal information must be recorded. Accurate records of these simple details contribute to safeguarding children. The information required is defined in government guidance and must be recorded for every child and checked for changes at every visit: • full name • address • gender • date of birth • school • name(s) of person(s) with parental responsibility • primary carer(s), if different.

Clinical records When treating children, in addition to details of examination, diagnosis and treatment provided, it is good practice to record:

• • •

who accompanied the child and, if not the parent, their relationship to the child observations of behaviour, not only physical signs a summary of any discussions with the child and parent.

These recommendations apply at any time, even when there are no concerns about the child. When there are child protection concerns, the following additional points are particularly pertinent: • •

record observations and reasons given for seemingly trivial injuries which may, over a period of time, show a repeating pattern of injury make diagrams in addition to written descriptions (drawings, either freehand or on a mouth, face or body map proforma or clinical photographs with consent) clearly labelled with the child’s name and date

• • • •

record observations in a way that will be understandable to colleagues so that, even if no single team member gets to know the child well, a written record builds up over time. This overcomes the problem that abusers sometimes avoid detection by taking a child to different practitioners on different occasions so that no-one picks up on ‘the big picture’ clearly state the difference between the facts and your opinion keep administrative notes such as attendance, non-attendance and cancelled appointments in addition to the clinical notes keep a list of questions to ask yourself when assessing a child, in paper based or electronic format (view example On next page).

Custom screen in electronic patient records (reproduced with permission of Software of Excellence)

The clinical records should be: • • •

accessible only to health professionals who ‘need to know’ readily accessible to health professionals who need to know, so should be stored in one place stored securely: paper-based records should be stored in locked filing cabinets in rooms accessible only to staff, and never left unattended when in use; electronic records should be password protected.

Regular team training All members of the dental team should receive appropriate training. When arranging this you will need to consider: • • • •

the frequency of training the content of training providers of training some special considerations

Child protection training should be mandatory for all staff at induction, with updates at regular intervals thereafter. However, until recent years it has been reported that many dentists have never received any child protection training. In 2006 the

Royal College of Paediatrics and Child Health, together with other contributing organisations, published the ‘Intercollegiate Document’ as guidance (revised in 2010 and 2014). This recommends that staff should receive child protection training every three years as a minimum. When arranging training, you should check that the aims and objectives of a course meet the learning needs of your team. Guidance on the recommended level of competence for staff with varying degrees of involvement with children is shown in the Table 1. It has been suggested that dentists who have done child protection training point to the following factors as being most valuable: • • •

the opportunity to discuss case scenarios of relevance to dentistry hearing other viewpoints and interacting with participants from other agencies meeting local professionals (in healthcare and social services) whom they might contact in the future for advice or to refer.

Providers of further training include: • • • • •

postgraduate medical and dental deaneries in-practice training by health trust child protection trainers LSCBs/ACPC multi-agency training distance learning specialist courses.

Providers of child protection training should be aware of: • • •

the stressful nature of child protection training the potential for disclosure of childhood abuse by course participants the need to provide support or referral for participants if necessary.

More than 1 in 10 adults in the UK remember being abused as children. Even in small dental practices, it is likely that training may bring back unpleasant memories for some members of staff. Team leaders would do well to be prepared with details of agencies able to offer support to staff who were abused as children. *Local Safeguarding Children Board; a multi-agency board responsible for developing local procedures and providing training; LSCBs replaced Area Child Protection Committees (ACPCs) in 2006; social services work with the police, health services, education and probation services, with input from other agencies such as the NSPCC, domestic violence forum, youth services or armed services, backed up by contributions from many other groups of professionals

Table 1.

Training level Level 1.

Appropriate for:

Summary of core competences:

All staff including non-clinical staff working in health care settings

Recognises potential indicators of child maltreatment

Whom in the dental team?

Understands the potential impact of a parent/carerâ&#x20AC;&#x2122;s physical and mental health on the well-being and development of a child or young person Takes appropriate action if concerned

Level 2.

Minimum level for non-clinical and clinical staff who have some degree of contact with children and young people and/or parents/ carers Whom in the dental team?

As for Level 1 Uses professional and clinical knowledge and understanding to identify any signs of child abuse or neglect Acts as an effective advocate for the child or young person Clear about own and colleaguesâ&#x20AC;&#x2122; roles, responsibilities and professional boundaries Able to refer as appropriate to social care if a safeguarding or child protection concern is identified Shares appropriate and relevant information with other teams Acts in accordance with key guidance and legislation

Level 3.

Clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns Whom in the dental team?

Levels 4-5.

As for Level 1 and 2 Draws on child and family-focussed clinical and professional knowledge Contributes to interagency assessments, the gathering and sharing of information and analysis of risk Undertakes regular documented reviews of own and team child protection practice

Named and designated professionals

Chapter 9

Complaints handling

Make this CPD Verifiable

The GDC’s policy in relation to first tier complaints resolution

Turn to page 167 to find out how

Here we look at the GDC’s document Shifting the balance which outlines the Council’s approach to handling complaints now and in the future. Even with an increased focus on prevention through upstream activity, it is inevitable that sometimes things will go wrong, and a patient will wish to make a complaint. In recent years, societal influences, coupled with changes to healthcare funding models, have led to changes in the relationship between dental professionals and patients and an increase in the number of people raising concerns with professional regulators. The fact that most patients now pay for, or make a financial contribution towards, their treatment means that the patient-professional relationship is arguably more complex than in some other areas of healthcare: it comes with a ‘consumer’ dimension, which has an impact on patient expectations. This means that dental professionals need to be equipped to manage those expectations, and to deal with patients appropriately and sensitively when they are not met. The Professional Standards Authority has set out the principles of good regulation and what this means in practice in its publication Right Touch Regulation. A key element of this is seeking solutions as close as possible to the problem for the benefit of both the patient and the professional. In the case of dentistry, this usually means within the practice or other care setting. We know that complaints can be difficult to manage, but it is important that everyone involved in patient care understands the importance and the principles of good complaints handling. We also know that most complaints received by dental professionals are resolved quickly and effectively, but good practice is not as widespread as it needs to be to enable the system of regulation to work well for everyone. The GDC receives a large number of complaints that do not raise issues that can or should be resolved through a fitness to practise investigation. While the GDC does not and should not investigate these matters, they do need to be addressed, and the best place for this to happen is very often in the practice or care setting. We want to work with the profession to ensure that resolution is sought and found in the most appropriate place. This involves ensuring patients know how, and feel confident, to raise their concerns by the most appropriate route. It also means working to maintain high standards in complaint handling across the profession.

In order to inform this work we are gathering and analysing the available intelligence – both our own and our partners’ - on complaint handling. Our initial findings indicate that most dental practices have complaints handling procedures, and are following them. For example, as part of a CQC inspection in England, a practice’s complaints handling procedure will be checked. The CQC’s 2015/16 inspections data show that 90% of inspections have the outcome ‘no action required’, meaning that they were not found to be in breach of any of the CQC’s regulations.

First tier complaints Data from the Dental Complaints Service (‘DCS’ - a service to facilitate the resolution of complaints about privately funded dental care) suggests that a significant proportion of complaints can be resolved satisfactorily when directed to the practice. When the DCS receives a complaint about private treatment, it is made clear to the patient that the DCS will not assist until the registrant has been provided with an opportunity to respond to the complaint first. After three weeks, patients are contacted to see whether their complaint has been resolved. More than 85% of cases are resolved at this stage. While there is evidence to show that almost all practices have complaints handling procedures in place, and in many cases these are effective in resolving complaints, the GDC still receives many complaints that could have generated better outcomes for both the patient and the professional had they been handled more effectively in the practice. Indeed 71% of cases received by the GDC in 2015 were closed at either the triage or assessment stage, meaning that the issue as identified by the complainant did not amount to an allegation of impaired fitness to practise. The fact that the GDC continues to receive a significant number of complaints which do not raise an allegation of impaired fitness to practise shows that there is still more that can be done to strengthen first tier resolution. The GDC wants to work with the profession and our partners to build on the good practice that already exists to maximise the potential of local resolution. Working together to support good complaint handling There are several ways in which the GDC, the profession and our partners can support early and positive complaint resolution, resulting in better outcomes for patients and professionals. Some of them are captured in our proposals for upstream engagement and activity, including the embedding of good practice in preregistration training, and encouragement of CPD on relevant topics. Management of feedback and complaints is one of the aspects of the Standards for the Dental Team on which we will gather data and intelligence and use it to inform the profession and our own upstream activity. Just as we encourage professionals

to develop and maintain their expertise in their clinical practice, so would we encourage development of ‘softer skills’ and business management skills where appropriate. We have identified some specific ways in which the current upstream activity in relation to complaints handling could be increased and improved, including provision of tailored material upon registration. The ‘welcome pack’ provided to dental professionals upon registration has been identified as an opportunity to provide context to the standards and supporting guidance documents in general, which could include information on the principles of effective complaints handling. In addition to this upstream activity there are other ways in which the GDC and the profession can jointly seek to both prevent complaints, and ensure that when they arise, they are swiftly, sensitively and thoroughly dealt with. We are currently working on a profession-wide complaints handling initiative to share good practice and bring about improvements. A working group drawn from a range of organisations across the profession is considering: • • • •

Examples of current good practice Barriers to effective complaints resolution in practice and how they can be overcome What we can all do to encourage patients to use local resolution when appropriate How to embed a culture in which complaints provide learning for service improvement.

Encouraging early resolution As noted above, one of the challenges in resolving complaints in the practice is influencing patient behaviour, encouraging them to seek resolution of problems at an early stage with the professional from whom they have received care. Patients therefore need to feel able to approach the practice or treatment provider with feedback. Our preliminary analysis of the available data and information on the willingness of patients to complain to care provider indicates that many are, but that there is clearly more to do. Whilst remaining sensitive to the concerns of patients who may not initially feel comfortable complaining to the practice, we believe that with the right assurances from effective complaints procedures, information on what to expect, and approachable and welcoming cultures in practices, patients can be encouraged to resolve less serious complaints locally. An unpublished report from the Patients Association on improving complaints handling in primary care suggests that patients (General Practice) can be unwilling to complain directly to the practice where they received their care, especially

directly to those staff who have provided their treatment. The GDC patient and public survey 2016, available at https://beta.gdc-uk.org/about/what-we-do/ research, shows that 40% of those who had complained or considered complaining about a dental professional had done so (or considered doing so) to the practice where the treatment was carried out. Qualitative information (unpublished) from the GDC’s corporate strategy event showed that whilst some patients will look to resolve issues locally in the practice they attend, there can be concerns about consequences for complaining – such as the impact on their treatment and being ‘struck off’ the surgery list. It is also vital that the information available to patients in the care setting, clearly sets out what they can expect from the process and what their options are so that patients feel informed and reassured in taking their complaint to the practice. This links closely to the initiatives we are exploring with our partners on how complaints can be handled by the most appropriate body. Any work carried out in this area must ensure that patients have their complaints and concerns listened to, acted upon and responded to by the organisation that can provide the most appropriate path to resolution. In cases where the GDC is not best placed to resolve the complaint, the benefits of local resolution must be clearly communicated, so that the patient feels confident that their voice will be heard. The Regulation of Dental Services Programme Board (NHS England, the NHS Business Services Authority, the Department of Health, the CQC, the GDC and Healthwatch England) have published a statement on dental complaints to ensure there is a shared understanding of the correct route for complaints among providers. The statement was produced in recognition of the fact that: • • • •

The dental complaints system is complex and confusing for patients, providers and regulators – especially given the mixed public/private provision of dental services Overlaps between organisations bring a lack of clarity, with multiple organisations potentially responsible for different aspects of the same complaint There is a lack of consistency: different organisations are subject to different timeframes for dealing with complaints, and cover different nations of the UK Patients who initially approach the ‘wrong’ body may then be lost to the system completely.

Supporting and encouraging good complaints handling While complaints handling is included in the Standards for the Dental Team the GDC clearly cannot ensure that good practice is followed in every case. Responsibility for quality management and improvement must rest with professionals, with

appropriate support from the GDC, system regulators, professional bodies and indemnity providers. This includes encouraging learning from complaints and feedback and using it to improve services and prevent future complaints. Training on customer service and effective complaint resolution is an important part of ongoing development for dental professionals, and should be incorporated into pre-registration training and CPD. Help and support in handling and responding to complaints is also widely available from organisations such as indemnity providers and professional associations. However, not all dental professionals are seeking help and advice when needed, refreshing their customer service skills, or using the feedback from complaints to improve services in the practice. CQC inspection reporting helps to shed light on common characteristics of both good and poor complaints handling procedures which showed: • • • • • • • • •

Patients not being made aware of the complaints process Policy does not include who to contact or timescale for a response Complaints not adequately logged Action taken in response to complaints not recorded No systems in place to respond to verbal comments or complaints Staff not recognising concerns as complaints Staff not having adequate training to deal with complaints Opportunities to learn from complaints and improve quality of service not taken No way to assess the quality of service through anonymous feedback, questionnaires, comments box or website.

Encourage patient feedback in the practice One of the key themes in all our proposals is better use of data, information and intelligence to inform not only our activity but that of our partners and the profession. Patient feedback is a very valuable form of intelligence, particularly when seeking to improve and develop services, determine CPD requirements or reflect on the effectiveness of CPD. We would encourage professionals, as part of a joint effort to improve outcomes for patients, to actively seek feedback from patients and use it to improve performance and identify where changes within the service are required. Acting on feedback reassures patients that they are being listened to and can prevent future complaints. Encouraging and using patient feedback to improve services is likely to be practice led – with practice management and administration taking a lead role. As such, this is something that will be considered as we revise our guidance for employers.

Notable practice in complaints handing A CQC inspection report published in July 2016 identified ‘notable practice’ with regards to handling complaints and using feedback to improve services. As a direct result of complaints received from patients, the practice manager introduced customer service training for reception staff. The practice manager followed this up by asking staff to complete a quiz about customer service, which included such things as the importance of making eye contact with patients. The practice also introduced training for all other staff. To address concerns or complaints about waiting times, as it had received complaints of this nature, the practice also provided a leaflet for patients to explain why the dentists may be running late. Any complaints were comprehensively discussed in staff meetings and the practice manager ensured that staff had learned from previous complaints. The whole process was well-documented and detailed. This is notable practice because of the commitment to learn from complaints.

Facilitated resolution: the current position Until 2006, no mechanism for resolving complaints about privately funded dentistry existed, prompting the GDC to establish the Dental Complaints Service (DCS). In its first ten years of operation, the DCS has become a well-respected and cost-effective resolution service, highly rated by the patients and professionals who use it. The DCS model is simple. It: • • •

Provides an advocacy service for patients, helping them understand the complaints process and set out their complaint clearly and constructively. In more than 85% of cases, this is the only intervention that is required to resolve the complaint Facilitates constructive discussions between the patient and the professional. Around 13% of complaints are resolved at this stage Provides non-adversarial independent panels to resolve the very small proportion of complaints that remain. The panels comprise volunteer clinicians and non-clinicians. As well as the high satisfaction ratings from its users, the DCS delivers significant cost savings by dealing with many cases that might otherwise have come to the GDC. The average cost of a complaint managed through the DCS is approximately £210, compared to an average of £61,000 for a full fitness to practise investigation and final hearing. Making more use of this form of resolution therefore makes sense from the point of view of benefits to patients, service to professionals and reducing cost.

We now intend to take forward work in four areas: • • • •

Developing new ways of promoting the benefits of this form of resolution, in conjunction with dental professionals. In order to be most effective, patients and professionals need to understand the benefits of quick and early resolution, and how they can access it. It is important to distinguish between promoting proportionate resolution and ensuring that patients know how to access services to assist with this, and encouraging them to complain where it is not justified. Part of this might involve ensuring that the name and how we explain the role of any future service clearly reflect its function. Exploring with the profession and its representatives the benefits of integrating a mediation service into practice complaints handling processes so that it is clear to patients that there is an alternative route to try before raising a complaint with the GDC. Extending the availability of the advocacy element of the service – supporting patients in finding the right home for their complaint and helping them express it clearly and constructively – to patients of NHS-funded treatment. Currently more than 40% of callers to the DCS wish to complain about NHS funded treatment. While we have no current plans to extend the facilitation or resolution elements of the service to such patients, the costs of limited additional support in the first stage are likely to be marginal and the benefits potentially very significant. As set out in our corporate strategy Patients, Professionals, Partners, Performance, we will proceed with plans to extend coverage of the service to those with pre-payment plans for private dental care. To support this work and other elements of our reform plans – for example, effective routing of fitness to practise cases – we will be reviewing the current operation of the DCS in 2017 with a view to informing the shape of any future service.

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Chapter 10

Minimal Intervention Dentistry for the management of dental caries By J E Frencken From the book The art and science of Minimal Intervention Dentistry and Atraumatic Restorative Treatment

Make this CPD Verifiable Turn to page 167 to find out how

This article describes the problems associated with the traditional treatment for managing dental caries and carious lesions, and discusses an alternative approach called Minimal Intervention Dentistry. The rationale is that current understanding of the caries process means that adopting this approach can ensure that individuals can keep their teeth healthy and functional throughout their lives.

Is the traditional treatment for managing dental caries and carious lesions still justified? The traditional treatment for managing dental caries and carious lesions can be defined as the implementation of the invasive operative â&#x20AC;&#x2DC;drilling and fillingâ&#x20AC;&#x2122; approach. This approach has been practised by the dental profession for more than two centuries. In many countries it is still being practised and it is taught in many dental schools around the world. Results from a recent systematic review and meta-analysis that covered 30 studies from 17 countries show that the traditional treatment is still very much integrated into the provision of oral healthcare. The metaanalysis found that a carious lesion confined to the enamel in an occlusal surface of a permanent tooth would be drilled away (enameloplasty) by 12% of the dentists interviewed and by 21% if the enamel carious lesion was present in the approximal surface. A carious lesion reaching the enamel-dentine junction (e-dj) was for 48% of dentists an indication that they should resort to operative intervention in approximal surfaces using the traditional class II cavity preparation (Table 1). A difference was seen in dentists who would intervene invasively across geographical regions with Scandinavian dentists intending to intervene less than their colleagues from North America and Eastern Europe. The difficulty and observed lack of knowledge transfer is also apparent in a 2016 USA study. In treating a carious lesion in the occlusal surface, 32% of dentists interviewed would include the total pits and fissures system in the cavity preparation, even if the carious lesion was small and no signs of carious lesion had been found in other parts of the pits and fissures system (Figures 1 and 2). Many of the operative techniques in the traditional treatment approach have been described by G.V. Black. He developed standard operative procedures

and instrumentation for restoring cavities with amalgam or gold foil. Amalgam is on its way out as a consequence of the Minamata Treaty on Mercury and gold foil is not considered a restorative material anymore. New treatment insights have emerged that are derived from cariological and restorative research, and from the development of adhesive materials. These developments have replaced the standard procedures in restorative treatment in many countries, but, apparently, not in all. Why are the G.V. Black principles for cavity design still practised by many dental practitioners and why are they still taught at many dental schools when superior, tissue-saving and tooth-prolonging, restorative treatments are available? Over the last five decades, research in all aspects of oral health has provided the dental profession with ample evidence-based results to justify moving away from the traditional towards a minimal intervention approach in managing dental caries and carious lesions. This shift has the potential to serve the public more appropriately.

How successful has the dental profession been in serving the public worldwide? The prevalence and severity of dental caries have decreased during the last four decades around the world. This was expected as dental caries, in essence, is a preventable disease. Many studies have been carried out to investigate which factors keep healthy teeth healthy and which cause tooth surfaces to demineralise. This great attention to oral health makes it difficult to accept that ‘untreated carious cavities in permanent teeth’ landed number one on the prevalence list of 291 medical diseases and conditions investigated over the period 1990-2010. ‘Untreated carious cavities in primary teeth’ landed as number ten on the list. How is this possible, particularly as the global economic impact of all dental diseases amounted to US$442 billion in 2010? This figure is huge considering that the two major dental diseases, dental caries and periodontal diseases, are largely preventable. Something has gone seriously wrong somewhere. It is safe to assume that the extensive and exclusive use of the traditional ‘drill and fill’ treatment concept worldwide is a factor that has greatly contributed to these terrible results. It is high time that the dental profession takes responsibility for improving these results. It should take action that will lead to a drastic reduction in the prevalence of ‘untreated carious cavities in teeth’ in world communities. The measures proposed will differ from country to country and from community to community. One of the evidence-based measures that can be implemented universally is the Minimal Intervention Dentistry (MID) approach.

What is understood by Minimal Intervention Dentistry? The aim of MID is to keep teeth healthy and functional for life. For keeping teeth free from carious lesions, the following important strategies should be implemented:

(i) early carious lesion detection and assessment of caries risk with validated instruments; (ii) remineralisation of demineralised enamel and dentine; (iii) optimal caries-preventive measures; (iv) minimally invasive operative interventions; and (v) repairing rather than replacing defective restorations. It is evident from these strategies that MID does not exclusively equate to cutting smaller cavities than before, as many dentists had initially thought. The first three strategies should be employed throughout a personâ&#x20AC;&#x2122;s life. A â&#x20AC;&#x2DC;minimally invasive operative interventionâ&#x20AC;&#x2122; is undertaken only if oral health maintenance has failed and an obvious cavity into dentine has developed. Re-treatment of restorations should aim at repairing through resealing, refurbishing or repolishing first before considering replacing the restoration. The success of the MID concept is dependent on good co-operation between the public/patient and the dental practitioner. A well-established and functioning health insurance system may facilitate this.

What is the rationale for Minimal Intervention Dentistry? MID for managing dental caries was able to evolve because many studies were performed on a pallet of dental caries-related topics. Change-determining results are presented in Table 2. These results show that well-organised oral healthcare has led to major improvements. For example, the proportion of 70-year olds in Sweden who retained their natural teeth increased from 13 in 1973 to 21 in 2003. Among 50-year-old Swedish women, the mean number of teeth increased from 15 in 1968/69 to 27 in 2004/05. The percentage of edentulous women decreased from 18 to 0.3 over the same period. The same pattern is apparent in other European countries. At the same time, life expectancy in the Organisation for Economic Co-operation and Development (OECD) countries increased from 65 years in 1960 to 78 years in 2013. Currently, over 30% of the population in Japan is older than 65. If these older people wish to eat a good meal and enjoy various types of drinks, enjoy good appearance and engage in a social life with confidence as they used to, they need to keep their natural teeth functional in old age. This suggests that tooth-saving measures should become a way of life for them when they are young. For dental practitioners it implies that they should ask themselves when performing a dental procedure: how will my selected treatment affect the life of the tooth and, implicitly, the quality of life of that person when she or he reaches old age? This means that communication between patients and dental practitioners about which treatments and which oral care measures are most appropriate will grow in importance in the years to come.

Which proven outcomes of research were instrumental in the development of MID? A new sustainable dental caries management concept is not the product of an afternoonâ&#x20AC;&#x2122;s intellectual activity. Alternative (oral) healthcare concepts develop over time and are built on proven outcomes of research. The same is true of MID. Cornerstones that have been instrumental in the development and evolution of MID have been published by the World Dental Federation (FDI) Task Group and are summarised in Table 2. By early 1990, research had shown that managing dental carious lesions should depart from the traditional surgical / technical approach and move to a more â&#x20AC;&#x2DC;biologicalâ&#x20AC;&#x2122; approach. The research pointed to a completely new approach to managing dental caries and the carious lesion. The first publication on MID for managing dental caries appeared in 1991.

A traumatic Restorative Treatment: an example of an MID approach A great number of carious lesion preventive and minimally invasive operative intervention approaches are available. However, the only MID approach that combines preventive and restorative care in one concept is the atraumatic restorative treatment (ART) approach (Figure 3). ART application leads to a highviscosity glass-ionomer sealant and sealant-restoration. It uses hand instruments only to produce these treatments and this leads to low levels of dental anxiety and treatment pain among patients, and to a low level of stress among dental practitioners, particularly when a difficult patient requires service. As no electricity and running water are used, ART can be applied in the dental practice and in a field situation. It has been considered the most researched example of MID. With the many studies performed over the last two decades, it has become apparent that the quality of ART sealants and ART restorations matches that of similar treatments produced traditionally with rotating instrumentation. In addition, the studies showed that the ART treatments were provided to the satisfaction of patients and dental practitioners. There are sufficient reasons to share the positive results derived from using ART with dental practitioners.

Epilogue Preventing carious lesion development is possible and it is therefore an essential element in any sustainable oral health care system. I think that all dental professionals have the obligation to implement the evidence-based outcomes of research to improve the oral health of their patients. With this in mind, dental professionals should use contemporary knowledge of the dental caries process to arrive at the best way

of controlling carious lesion development and of halting the progression of enamel and dentine carious lesions with the ultimate objective of increasing the life of teeth and securing functioning of the dentition.

Concluding statements • • •

All dental professionals have the obligation to implement the results of research with a view to improving the oral health of their clientele. This is implied in the Minimal Intervention Dentistry approach. The aim of Minimal Intervention Dentistry is to keep healthy teeth healthy and functional for life. Atraumatic Restorative Treatment is an example of a combined caries preventive and restorative treatment within Minimal Intervention Dentistry.

a).

b).

Fig. 1 Enamel carious lesion in an occlusal surface that is arrested. This remineralised and healed carious lesion will likely be destroyed by five out of 10 dentists. Fig. 2 a,b a) Arrested enamel carious lesion; b) cross-section of the lesion under ‘a’ which cavitation is confined to the enamel.

Fig. 3 The position of ART sealant and ART restoration within the Minimal Intervention Dentistry approach for

managing dental caries

Table 1. The mean percentage and range (%) of dentists that would intervene invasively (restoratively) by type of surface and depth of carious lesion

Type of surface

Depth of carious lesion

Occlusal

confined to enamel only 12

Mean (%)

Range (%) 9-21

Occlusal

confined to enamel or in outer dentine

62-80

Approximal

confined to enamel, not reaching the e-dj

4-44

Approximal

confined to enamel or extending up to e-dj

21-70

Table 2. Summary of events and significant outcomes of research that were instrumental in the development and evolution of the Minimal Intervention Dentistry concept for managing dental caries by period of research

Period

Event

Significant outcome

1940-1970

Discovery of fluoride in water

Reduction in number of dentine cavities and retardation of enamel carious lesions

1950-1970

Discovery of free sugar as a driver of the caries process

Frequency and intake daily determines its cariogenity

1960-1980

Discovery of dental biofilm as the main aetiological factor

Removal or, at least, disturbance of it from tooth surfaces daily is necessary

1955-1980

Development of adhesive dental materials and systems

No need for ‘extension for prevention’ concept, leading to smaller-sized restorations

1970-1990

Survival studies on traditional restorative care

Should avoid the ‘repeat restoration cycle’

1960-1990

Clinical studies on removal of carious tissue in cavities

Only soft, decomposed tooth tissue needs to be removed, leaving partly demineralised dentine behind to remineralise

Chapter 11

What worries patients about dentistry? Professor Liz Kay Foundation Dean Peninsula Dental School

Make this CPD Verifiable Turn to page 167 to find out how

For the dental team, dentistry is a routine, relatively simple and ‘normal’ part of everyday life. It is vital, however, that they remember that the patient’s view is very different. A dental visit for many is a rare occurrence, less than once a year for most people. People who visit dental practices are going to put themselves in a situation in which they will: • • • • • • • • •

Feel out of control Risk being reprimanded Have to lie down in front of someone (sometimes of the opposite sex - a very bizarre thing to do) Not know what is going on because they cannot see Be undergoing an operation while awake Potentially be uncomfortable, if not in pain Expose a sensitive and sensual part of their body Not be able to speak clearly Have to pay money for the privilege!

On reflection, it perhaps seems more odd that some people do voluntarily attend for treatment, rather than surprising that they don’t! In this article we look at some of the potentially difficult moments in a dental visit that might cause anxiety, embarrassment, discomfort or worry for the patient. Anything that the dental team can do help the patient through these situations will increase the patient’s satisfaction and diminish their fear. Patients who are anxious and afraid are difficult and stressful for the dental team to deal with and to treat. Care at each of these points in the process of dental treatment will not, of course, ensure that every patient will be relaxed and happy, but the imaginative and empathetic team will find ways of dealing with these situations which will, at least, offer support to the patient when they most need it.

Getting there Being unable to find where you wish to go is anxiety provoking for anyone, especially if there is a specific time at which your presence is expected. Therefore,

as mentioned earlier, all new patients should be given instructions, preferably both verbal and written, as to how to find the practice, where the best (and second best) places to park are, and directions to the practice via public transport. Clear signposting of the practice will also help.

Being on time Patients do not know how a dental practice is organised. They therefore do not know exactly when to arrive. If they are told that their appointment is at 3 p.m., should they arrive at 2.50 pm to ‘check in’, or will they have to wait anyway, even if they are on time? Also, many patients worry about the consequences of being unavoidably late (and yet you do not really want them to arrive early, as waiting will increase their anxiety). Will the receptionist tell them off if they are late, or the dentist? Will their appointment be given to someone else and will they have to pay for being late? All of these questions may arise in the patient’s mind. Whether the patient is late or not, all of this uncertainty (especially if the patient is trapped in a traffic jam whilst worrying) increases their anxiety, which diminishes their ability to communicate. This in turn will result in a less than satisfactory relationship between them and members of the dental team. Patients, and particularly those who are new to the practice, should therefore be given precise details of what is expected of them in terms of time keeping and details of what they can expect from the dental practice.

How long will I have to wait? Sitting in a dental waiting room (anticipating the treatment you might or might not receive, hearing the noise of the drill being used on others, watching other patients looking less than happy) for some patients, is the worst part of a trip to the dentist. Thus, the dental team must make all possible efforts to ensure that the practice is running to time. Obviously, delays are sometimes unavoidable. Simply saying that you are sorry about them having to wait, explaining why the hold-up has occurred and letting them know approximately how long they are likely to wait will at least allow the patient a choice as to whether or not they wish to stay, even if doing so does not reduce their anxiety and nervous tension.

How the practice is organised? When the patient arrives at the practice, what could be more disconcerting than a notice on a hatch (and I’ve actually seen this) saying ‘Knock and Wait’. If nothing happens when the patient knocks, how long should they wait? If they knock again, will whoever is in there think that they are an impatient nuisance? If they don’t knock again, and instead wait...and wait…, perhaps their first knock wasn’t heard. What if

someone comes out by chance, perhaps they’ll think them stupid? How loudly should they knock? We all feel silly when negotiating unknown systems and we all feel intimidated by situations in which we feel helpless and under the control of someone else. Therefore, patients need, if at all possible, to be given instructions as to how the practice is organised, before they get there. However, if this is not possible, the first entrance to the surgery should indicate to the patient how to proceed and what to expect, for example: Welcome to the Burnside Dental Practice. Please enter and turn left, where you will see the reception desk. The receptionist will assist you.

Being reprimanded Almost every single patient worries about being ‘told off’. Perhaps the receptionist will be cross if they are too early/too late, perhaps the nurse won’t like it if they forget to leave their coat in the right place, the dentist will probably tell them that their mouth is unclean, and is bound to be displeased that their last visit was two years ago. Research has shown that fear of reprimand is a very powerful barrier to dental attendance. It is therefore important that the dental team remember that, at the end of the day, the patient is a client, and can choose to go elsewhere. None of us are perfect and as the dental team we have no right to judge patients. If we do so and find them wanting, we certainly have no right to tell them so. Reprimanding patients, even if ‘it’s for their own good’ will simply alienate them and is likely to make them less ‘compliant’ with our wishes, rather than more so.

Meeting the dentist The dentist has a powerful, stereotyped image to throw off before true communication can take place with a patient. Therefore, despite dentists’ best efforts, patients are likely to find the dental surgeon an intimidating individual. Not only is the dentist someone who will have almost total control over them, she or he is also someone who carries a sort of ‘professional mystique’ and belongs to a ‘high status’ profession. The dentist may appear to be very clever, but may be judged as a very ‘different’ type of person by the patient, and such judgements will affect the relationship between the dentist and patient.

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Anything the dentist can do to try to develop a sense of equality with the patient will be helpful. This might include ensuring normal social etiquette is observed, for example: • • • •

Introducing oneself Discarding the white coat (which is worn more to indicate status than for any other reason) Shaking hands on introduction Engaging the patient in everyday conversation.

A particular point that might be raised here is the issue of names. It is increasingly common for people to use first names to address other people whom they do not know. Many people, particularly those of the older generations, find this odd, if not discourteous. Others find it acceptable. However, it is probably not appropriate to call a patient by their first name unless either you have been invited to do so or you have introduced yourself by your first name. For the patient to have to call you by your title, but to be referred to by their first name implies that the dental team is more powerful and that the patient is subordinate. This is counterproductive to the ambience you wish to achieve.

The equipment The equipment in a surgery is so familiar to the dental team that they probably almost do not notice it, let alone recognise its intimidating potential. It is however very unusual for people to walk into a room full of electronic gadgetry such as exists in a dental surgery. Thus, even though there may be insufficient time to explain the nature and use of every piece of equipment, the nurse, hygienist, therapist or dentist should, at the very least, recognise the fact that it may seem threatening to the patient. “Does all this equipment bother you? I won’t be using most of it.” “Try not to worry about all this equipment Mrs. Smith, we’ll only be using the light and the chair today.”

The instruments As referred to earlier, it is hard to put oneself in a patient’s shoes and realise that the all too familiar rack of excavators and root planers may look like instruments of torture to a patient. Again, explanation of their uses is the simplest and most effective solution, although rather time consuming. Alternatively, trays of instruments should be kept out of sight until they are being used. At that point, it is sensible to explain what the instrument is, and what it does, so that the patient still retains some control.

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Obviously the words used should be carefully chosen (for example, handpieces ‘clean’ decay out of a tooth rather than ‘cut’ it out).

The drill The drill is one of the most commonly cited fear stimulus for patients. The noise seems to be particularly off-putting. Therefore, the drill should be run before using it in the mouth in order that the patient may become accustomed to the noise. They should also be warned that you are about to do this! Similarly, it is necessary to remember that the noise of the drill when it is being used to cut a cavity sounds different to the patient than it does to the person who is wielding it or to those nearby. It is helpful to express to the patient that you understand this, and know that it can be disconcerting. Many patients connect the noise of the drill with the experience of pain, and it is known that worries about discomfort might actually cause more problems than pain itself. Some patients are particularly worried by ‘drilling’. In such cases, giving some control to the patient can be very comforting. Telling the patient that you will stop what you are doing if they raise a hand, or finger, increases their feeling of control. Many clinicians find that although the patient will often use the signal in order to reassure themselves that they do indeed have control, once they know that you will stop if they really want you to, they will find the procedure acceptable.

What will be done? Much of patients’ anxiety and feelings of lack of control stem from uncertainty about the treatment they will receive. Given that the procedures they may undergo range from an extraction (which is, after all, out-patient surgery) to simple advice and reassurance, this is understandable. This anxiety can be counteracted at a first visit by giving patients choices in their treatment. On subsequent visits, as long as the dialogue between the patient and practitioner is maintained, and all treatment plans fully explained, the patients’ feeling of not knowing what to expect will be reduced.

Why is the dentist doing this? Unfortunately, tales of patients undergoing unnecessary dental treatment abound in the media. Although repeated reports and a Government Enquiry have demonstrated that such unscrupulousness is extremely rare, patients have no way of knowing what is ‘necessary’ and what is not. Explaining your diagnoses to the patient and then negotiating with them (rather than telling them) what is to be done, will go a long way towards reassuring the patient that any treatment being undertaken is in

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their best interests. Patient satisfaction with treatment, and their acceptance of the costs, is greatly assisted by offering patients choices at the outset.

Will it hurt? Pain, discomfort and dentistry are inextricably linked, at the very least in the patient’s mind. However, when people are asked to explain what is ‘worst’ about a dental visit, the response “not knowing exactly what is going to happen” is more often mentioned than pain. Therefore, pain or discomfort seem to be tolerated, so long as they are explained, and the patient is warned.

“This might sting a bit.” “You’ll feel a bit a little pinch.”

Clearly, as a patient’s experience of dental treatment grows, and their relationship with the nurse and practitioner develops, they will come to worry less about pain being inflicted. No practitioner can promise a certainty of completely painfree dentistry, and both experience and research findings suggest that it is not necessary to do so. If a patient understands what is to happen and why, their pain threshold can be remarkably heightened. The most important thing to remember is that anxiety and feelings of vulnerability lower pain thresholds. If a patient does experience pain, a supportive and empathetic dental team can do much to alleviate their reaction to it.

Will it hurt afterwards? The dental team’s entire day is spent dealing with oral disease. A patient usually only faces the practical clinical consequences of disease during a visit to a dental practice. Therefore, patients cannot be expected to know how long their anaesthetic will take to wear off, whether the pain will return, or whether the treatment will cause pain to occur later in the day. The dental team must therefore give the patient as much information as possible regarding the natural history of their complaint/disease, and, as far as possible should advise the patient what action to take if certain circumstances arise. “If it starts to ache when the anaesthetic wears off, take two paracetamol, then telephone if it is still painful tomorrow.” If this information is not given and explanations are not offered, untoward symptoms after treatment will engender distrust in the team, their competence and their honesty. Once again, knowing what to expect and knowing that the dental team can predict what will happen will make symptoms understandable and hence,

103

bearable. Pain which one is not expecting is much more worrying than pain from a known cause. Patients should also be advised as to how long their symptoms might last and whether or not they will be able to perform their usual daily activities.

Lying down Would you find it natural to lie supine in front of someone you did not know? If you were intimidated by them or did not trust them, how comfortable would you feel lying down? Is it natural to rest your head between the knees of someone with whom you are not intimately connected? Of course not. And yet, although it breaks almost every social taboo in the book, dental teams expect patients to accept the adoption of the supine position as if it were something normal. Of course, to the dental team it is normal, but most certainly it is not a day-to-day occurrence for most ordinary people. Women especially find that lying supine in front of someone makes them feel very ill at ease. Whilst placing patients in this position is almost inescapable in modern dental practice, this does not mean that the patient will necessarily feel comfortable with it. There are three things that might help to alleviate this problem. â&#x20AC;˘

Never tip the chair backwards without warning the patient, and asking their permission to do so

â&#x20AC;˘

Express to the patient that you recognise that to lie in front of someone is an abnormal, although, in the current circumstances, acceptable, thing to do

â&#x20AC;˘

Try not to leave the patient supine for any longer than is necessary, particularly when holding a conversation with them.

104

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Chapter 12

Abuse of vulnerable adults Adapted from The Management of Abuse: A Resource Manual for the Dental Team

Make this CPD Verifiable Turn to page 167 to find out how

By Elizabeth Bower et al.

In contrast to the attention given to child abuse, there has been little consideration of the abuse of vulnerable adults in the British dental literature. The abuse of older and disabled people does not have the same emotional resonance as child abuse and as a consequence, the drive and interest to bring about change has not shown the same momentum. Abuse of vulnerable adults is both under-recognised and under-reported. Vulnerable adults comprise a significant proportion of the UK population with the forecast that those aged 65 and over will rise to 21% by 2026. Approximately 18% of the UK population (9 million people) have a disability and of these, approximately 1.2 million people have some form of learning disability; 4% of men and 5% of women have a serious disability. The prevalence of disability increases rapidly with age. Seventy-three per cent of men and 75% of women aged 85 and over have a disability. Twenty per cent of those with a disability are under 45 years of age. There are social class differences in the prevalence of disability; people in Social Classes IIIM, IV and V have a markedly higher prevalence of disability than those in Social Classes I,II and IIINM. Although there is a long history of research into the abuse of people living in institutional settings interest in the abuse of vulnerable adults living in the community and in family settings only began in Britain in the 1980s, following on from research conducted in the United States. In recent years the extent of the abuse has become more apparent and the issue is now widely debated both in professional organisations and in the media. Successive governments have signified commitment to the identification and prevention of abuse of vulnerable adults and policy documents and legislation touch on this issue by addressing the status and welfare of vulnerable adults.

Who is a vunerable adult? A vulnerable adult is a person aged 18 or over â&#x20AC;&#x2DC;who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitationâ&#x20AC;&#x2122; (Department of Health).

106

Community care services include all care services provided in any setting or context. The weakness of this definition rests in its exclusion of a number of individuals who have mild or moderate learning disabilities and who manage their lives relatively independently but remain very vulnerable to exploitation within their local communities.

Defining abuse of vunerable adults Abuse is defined as ‘the violation of an individual’s human and civil rights by any other person or persons’. Like the abuse of children, it can take the form of a single or repeated harmful act, or a failure to prevent harm. Abuse can be physical, sexual, psychological, or financial, and/or take the form of neglect. The definition also encompasses discrimination, particularly in regards to the person’s age or disability, and institutional abuse, where the ethos, culture, management, and organisation of an institution lead to abusive practices at a corporate level. Examples of institutional abuse include poor care standards, inadequate staffing, a lack of responses to complex needs, rigid routines, a lack of training on antidiscriminatory practice, and an insufficient knowledge base within the service. Abuse can occur over a long period, such as in ongoing family problems where domestic violence between spouses or generations is a long term feature of family life. Alternatively, it may be situational, where abuse arises in a previously satisfactory relationship due to deterioration in the health or behaviour of the vulnerable adult or deterioration in the health and social situation of the carer. Difficulties due to debt, alcohol or mental health problems in the carer may contribute to the neglect of the vulnerable adult. Abuse may also be opportunistic, such as theft occurring because money has been left around. Serial abuse, in which the perpetrator seeks out and ‘grooms’ vulnerable adults, usually involves financial or sexual abuse. It is important to note that the definition does not include self-neglect, which usually occurs due to the inability of an independently living, mentally competent elderly or disabled person to meet the needs necessary for their own physical and mental well-being. Such an adult is able to refuse care unless they are at severe risk of harm. Examples of abuse of vulnerable adults are given in Table 1.

Who abuses vulnerable adults and in what circumstances? Vulnerable adults are usually abused by people with whom they are in regular contact rather than strangers. Such people can be relatives, professional staff, paid care workers, volunteers, other service users, neighbours, and friends. It is estimated that two-thirds of abused older people are harmed by family members who act as

107

carers. Sexual abuse by other service users accounts for up to half of the reported incidents of sexual abuse in adults with learning disabilities. Abuse can take place in any context, including places previously assumed to be safe. It may occur in a vulnerable adultâ&#x20AC;&#x2122;s home, whether the adult is living alone or with a relative. It can also occur within residential or day care settings, nursing homes, hospitals and in public places.

Incidence and prevalence There have been few UK studies on the incidence and prevalence of abuse of vulnerable adults. Many cases go unreported. Most studies look at the numbers and details of reported cases, and the figures often say more about how policies and procedures are being put into operation, and whether staff are trained to identify abuse and report it, than the actual incidence and prevalence of abuse. There have been no prevalence studies examining abuse in care settings in the UK but current estimates of the prevalence of abuse, based on surveys in the UK and overseas, indicate a rate of around 5% for all types of abuse for people over the age of 65 living in the community. There are few data on the prevalence of abuse for other groups of vulnerable adults and a lack of agreement on which type of abuse occurs most frequently although neglect is probably the most common. Others argue that material abuse occurs most often but also that sexual abuse occurs infrequently in older people. This contrasts with the abuse of adults with learning disabilities, where comparatively high levels of sexual abuse and low levels of financial abuse have been reported. However, this may reflect a research focus on sexual abuse and exploitation as, where monitoring of other forms of abuse in adults with learning disability takes place, physical abuse occurs just as often as sexual abuse.

Why are elderly and disabled adults more vulnerable to abuse? Factors increasing the likelihood of abuse in this group of people can be divided into three main categories; the attitudes and assumptions held by others, inadequacies in service provision and factors associated with impairment.

Assumptions and attitudes of others Many societies devalue and disempower disabled people. Elderly people are vulnerable to ageist attitudes in Western societies which characterise older people as physically frail and existing at the margins of society. Individuals whom society devalues are more vulnerable to abuse, and in such a climate, it is less likely that their experiences of abuse will be taken seriously at a local and/or political level.

108

There is a lack of awareness amongst the general public and health care professionals of the vulnerability of disabled and elderly adults, and many health care professionals are not adequately trained to recognise the signs of abuse. It is easier to assume that behaviour changes or physical injuries are caused by the impairment rather than considering the possibility of abuse.

Services for vulnerable adults Inadequacies in the provision of essential services limit the ability of disabled and elderly people to contribute towards, and access, community resources and services including dental services. Gaps in essential services leave vulnerable adults and their carers unsupported and isolated, both of which are risk factors for abuse. Problems in service provision can relate to a lack of staff training and professional development, the attitudes and personality of individual staff members, work related stress, the organisational structure and culture of a service provider, a lack of resources, poor management, and a lack of accountability. Dependency on an abusive carer can create difficulties in disclosing abuse, especially if the carer is the only person through which the vulnerable person communicates. Fear of losing other essential services may also inhibit complaints. A lack of coordination and collaboration between the various service providers for vulnerable adults can lead to a failure to promote the overall welfare of the adult, and a failure to identify early signs of abuse. There is often a failure to consult with vulnerable adults about their views, wishes and feelings, and they often have little choice and control over many aspects of their lives.

Impairment factors Vulnerable adults are often totally dependent on others for intimate personal care, and a number of carers may be involved in providing this care, both factors increasing the risk of exposure to abusive behaviour. If vulnerable adults have communication difficulties, they may be unable to tell someone that they are being abused. They are often physically unable to resist or avoid abuse. Moreover, they may have challenging behaviour which can frustrate or antagonise a poorly supported or trained carer. It may be tempting but wholly inappropriate to blame the abuse on the characteristics of the vulnerable adult. The focus of attention should always be on changing attitudes, improving services, expanding support, training carers etc. There is no justification for abusing a vulnerable adult in any circumstances.

109

Presentation The presentation of the abuse of vulnerable adults varies widely and depends on the type of abuse, the age, culture, extent and type of disability etc. of the abused adult, the context in which the abuse is occurring, and the environment in which the examination takes place. However, as with child abuse or domestic violence, it is in the combination of signs relating to the behaviour of the patient, the behaviour of the carer, and the history and examination, that suspicions of abuse arise. In contrast to treating children and families, many vulnerable adults will be examined by GDPs in their own homes or in care homes during domiciliary visits, and it is sometimes easier to notice signs of abuse or neglect when patients are situated in their domestic context than when they attend the surgery. The many physical, social and psychological barriers to the disclosure of abuse tend to ensure it remains carefully hidden by all concerned. Vulnerable adults do not often complain, and abuse is often only spotted by careful observation. The potential indicators of abuse are listed in Table 2. The list is not intended to be exhaustive and no individual sign is pathagnomic of abuse.

Management The management of the abuse of vulnerable adults revolves around early detection, appropriate referral, and provision of ongoing treatment and support. It is the responsibility of the GDP or other dental clinician who has examined the vulnerable adult to ensure that appropriate action is taken (Table 3). It is important to focus on the needs of the vulnerable adult, rather than the needs of the carer, related family problems and potential solutions to those problems. Whilst the other issues may have to be addressed by various agencies in the medium and long term, the GDPâ&#x20AC;&#x2122;s responsibility is always to the health and wellbeing of the vulnerable adult. Whilst it is important to be sensitive to the cultural background of the patient in managing the case, there are no circumstances in which the abuse of vulnerable adults is acceptable. Cultural factors cannot be used as justification for abuse, and that anxiety about being accused of racism should not prevent a GDP taking action to safeguard the welfare of a patient. â&#x20AC;&#x192;

110

Table 1 Examples of abuse of vulnerable adults • • • • • • • • • • • • • • • •

Failing to arrange for a dentist to examine an elderly person with broken or ill-fitting dentures Leaving a housebound person alone for days on end Hitting a vulnerable adult when she doesn’t do what you ask her to Opportunistic theft of an elderly person’s purse whilst providing care in the home Failing to ensure a vulnerable person is kept clean Swearing at an elderly relative when he/she asks for help to go to the toilet Preventing an elderly relative from seeing her friends Coercing an elderly person into changing his/her will Failing to help a physically disabled person to clean their teeth Forcing a vulnerable adult to have sex against their will Telling a young adult with learning disabilities that he is stupid and a waste of space Failing to provide a physically disabled person with assistance for eating and drinking Slapping a lady with dementia for wetting the bed Failing to ensure that an elderly person is kept warm Sedating the residents of a care home in order to give the staff an easy night Failing to provide adequate protection to stop a person with severe dementia falling out of bed

Table 2 Types of abuse: presenting indicators in general dental practice/domiciliary setting General • Appointments often missed • Difficulties in arranging appointments/frequent cancellations • Poor compliance with treatment regimens • Injuries are inconsistent with explanation given • Explanations of injuries are conflicting or vague • Delay in presentation for treatment of dental problems/injuries Behaviour of patient • Appears passive or afraid of carer • Remains quiet while carer responds to questions • Withdrawn/detached • Anxious • Poor eye contact • Closed body position/holding head down • Patient minimises injuries 111

Behaviour of carer • Attitudes of indifference or anger to the vulnerable adult • Caregiver ignoring vulnerable adult • Caregiver not allowing the vulnerable adult to speak for him/herself • Inappropriate displays of affection by caregiver • Caregiver blaming the vulnerable adult (eg for bad behaviour, incontinence, or forgetfulness) • Verbal intimidation, berating, or use of humiliating language by carer • Threats of punishment or deprivation Features of the domestic environment • Lack of amenities eg TV, personal grooming items • Dirty, smelly, unsanitary conditions • Soiled bed • Indications of unusual confinement eg patient is closed off in a particular room, tied to furniture • Obvious absence of assistance or attendance • Obvious absence of protection eg to prevent patient with severe dementia falling out of bed Physical abuse General signs • Cuts, lacerations, puncture wounds, open wounds, bruises, welts, discolouration, black eyes, burns, bone fractures, concussion • Recognisable shape or pattern to bruises such as slap mark, bite mark, rope mark • Signs of restraint (visible restraint or bruising eg rope marks) • Untreated injuries in various stages of healing or not properly treated • Broken glasses • Overdosing or under-dosing of medication • A vulnerable adult disclosing an experience of being hit, slapped, kicked or mistreated Oro-facial signs • Lip trauma, fractured, subluxated or avulsed teeth, missing teeth • Fractures of the mandible, maxilla or zygomaticomaxillary complex • Eye injuries, orbital fractures • Bruising of the edentulous ridges or the facial tissues • Unexplained alopecia (from pulling hair) • Evidence of prior trauma to dental or oro-facial structures

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Neglect General signs • Impaired skin integrity/ulcers, rashes, sores, lice, unkempt appearance, body odours • Soiled clothing or bed • Inappropriate clothing • Malnourishment, emaciation or dehydration without an illness related cause • Lack of appropriate physical aids such as glasses, hearing aids, assistance with eating and drinking • Failure to provide a safe environment • A vulnerable adult telling you he/she is left alone for long periods of time Oro-facial signs • Poor oral hygiene, halitosis • Rampant dental disease • Absence of dentures • Glossitis, angular chelitis, other oral infections • Xerostomia Psychological abuse • Helplessness • Hesitation to talk openly, fearfulness • Withdrawal, passive affect • Denial of a situation • Confusion or disorientation • Anger without apparent cause • Sudden change in behaviour • Emotionally upset or agitated • Depression • Unusual behaviour (sucking, biting, rocking) • A vulnerable adult telling you they are being verbally or emotionally abused, are isolated, or left alone for days on end Financial abuse • Lack of dental care • Caregiver questions dentist on necessity of dental work for older person ‘ at his age’ • The vulnerable adult suffers from substandard care in the home, despite adequate financial resources • Disappearance of a vulnerable adult’s possessions in an institutional setting • Vulnerable adult poorly dressed • Signatures on cheques, etc that do not resemble the vulnerable adult’s signature, or signed when the adult cannot write • The inclusion of additional names on an older person’s bank account

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• • •

Unpaid bills Confusion of a vulnerable adult regarding their financial situation A vulnerable adult telling you that someone has taken their money

Sexual abuse • A vulnerable adult telling you that they have been sexually assaulted or raped • Oral signs of sexually transmitted diseases eg syphilitic or herpetic ulceration • Signs of psychological abuse

Table 3 Role of the GDP or other dental clinician in the management of abuse of vulnerable adults • • • • • • • •

Recognise the signs of abuse Respect what the victim says and be sympathetic Provide treatment for oro-facial injuries and refer for treatment if necessary Assess risk to victim Make appropriate referrals Give helpful information not advice Keep comprehensive records Support and follow-up

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Chapter 13

Improving outcomes following dental trauma With acknowledgement to the Greater Manchester Local Dental Network

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The incidence of dental trauma is estimated at between 1% and 3% of the population/year and an estimate is that approximately 20-30% of the population are living with a dentition that may have suffered trauma. High risk groups can be broadly split into ages 2-4, 10-12 and adolescents onwards. The circumstances and causes of trauma vary according to these three age groups. In the age group 2-4 years it is associated with the developmental transition from crawling to walking: as one may expect this presents a high risk of trips and falls with consequential damage to soft tissues and the deciduous dentition. From ages 10-12 the risk largely comes from sports injuries and general accidents, while from adolescence through to early adulthood the risk largely comes in the form of alcohol related injury and road traffic accidents. These latter injuries usually occur at weekends when access to care may be restricted. Trauma is more common in males than females. The most commonly affected teeth are the upper central incisors, followed by lower centrals then the upper lateral incisors. While over 90% of such trauma is dentoalveolar alone, nearly a third will also incur a soft tissue injury component. Perhaps surprisingly, jaw fractures are comparatively rare, present in about 6% of cases. In most cases the trauma will have been minimal, meaning that no further treatment is required but for others the consequences can be more severe. Simple cases may include uncomplicated fractures of dentine and enamel while more severe case could involve discolouration of teeth, loss of vitality, resorption or loss of the tooth. Timely and appropriate management is critical if such negative outcomes are to be minimised.

Improving outcomes following dental trauma Examining the patient with trauma History A confused or disorientated patient could be suggestive of systemic problems, drugs, alcohol or underlying head injury. The safest option is such circumstances would be an acute referral to hospital care. If the patient has capacity, try to determine where the injury occurred since the location may sometimes indicate the possibility of contamination of the tooth and inform the decision to seek tetanus prophylaxis.

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How did the injury occur? This may lead to identification of the impact zones i.e. a chin injury is often combined with crown or crown-root fractures in premolar and molar regions and blunt impact trauma may result in tooth displacement. Sharp or blunt trauma and the velocity all add information on what the likely injury may be. When did the injury occur? In relation to a tooth avulsion injury the length of time and the extra-oral storage condition becomes very important when planning immediate care and assessing the risk of future complications. It is also important to assess whether there are signs of brain injury such as loss of consciousness, amnesia, nausea and vomiting which require medical attention. If there is a positive history of brain injury, refer to the local Accident and Emergency Department. If the patient attends alone it may be prudent to arrange a taxi and arrange a chaperone at this point. If teeth are broken or avulsed can all missing pieces be accounted for? This is essential information as not only can avulsed teeth be re-implanted but fractured portions can be reattached. Furthermore one must be vigilant to fragments being embedded in soft tissues and if fragments are unaccounted for this indicates the need for soft tissue radiographs. There is a need to ask if the patientâ&#x20AC;&#x2122;s bite feel right as this can alert the clinician to the possibility of a displacement injury or fracture or disruption of occlusion. This will be confirmed during the examination. Always essential of course but a medical history in these circumstances can be rapid but thorough. There are very few medical or systemic factors that may affect acute trauma management in primary care but questions should include the following factors that may contribute to underlying signs and symptoms: bleeding disorders or anticoagulant therapy (for increased risk of bruising), haematoma and intracranial bleed; tetanus status. Even patients with very complex medical histories should be offered standard acute trauma care including reimplantation as the challenges presented with prosthetic rehabilitation may be more complex than the risks posed by immediate first line treatment. A social history will include questions on smoking, alcohol habits, occupation and hobbies. Smokers should be counselled that continued smoking may have an impact upon healing times while an alcohol history may signpost the clinician to causation (did the injury occur whilst under the influence of alcohol?) It may also alert the clinician to the need to offer advice about reducing alcohol consumption and/or referral to their GP for support. In relation to occupation and hobbies, if the patient has a high risk of future trauma through occupation and/or pastimes they should be counselled on the importance of modifying behaviour until healing has occurred as well as taking future preventive measures. Implant based reconstructions should not be considered in patients continuing to play contact sports.

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Examination Where necessary clean the patient and administer local anaesthetic. Soft tissue examination will include assessment of all lacerations. If there are significant extra-oral lacerations that require suturing with risk of scarring at a later date the wound should be cleaned and the patient referred to a local acute facility such as a max-facs or plastics unit for appropriate treatment. As a follow-up to answers to the question about the patientâ&#x20AC;&#x2122;s bite examination must include assessment of any disturbance in the bite. This may indicate a luxation injury with displacement, an alveolar or jaw fracture or a fracture of the condylar region. Limited opening or deviation on opening may be consistent with condylar head fracture. Significant disturbances of occlusion or step deformities in the occlusal plane may be suggestive of mandibular fracture or dento-alveolar fracture. If suspected refer to Maxillofacial Services. Sensitivity testing of teeth can give false positives and negatives immediately after trauma as well as being very painful for the patient who is already distressed. When patients present with multiple or severe injury this can be saved for review stages of treatment. Periapical radiography with paralleling holders should be taken at baseline. If alveolar fracture or root fracture is suspected a second view is sensible. If available an occlusal film is best as this shows any fractures in different plane. Key features to assess on radiographs include: apical development, fracture lines of the root, fracture lines of the alveolus, periodontal ligament alterations. If there are missing teeth/fragments are they all accounted for? If not take a radiograph of the lip (Figure 1). Place the film in the labial sulcus and reduce the exposure time to 1/5 of that for an anterior exposure. If fragments cannot be accounted for consideration should be given to referral to an A&E department for a chest radiograph. Photographic examination should be considered as this offers an exact documentation of the extent of injury and can be used later in treatment planning, legal claims or clinical research. Note that patient consent is required. Soft tissue injuries can present in a variety of forms from lacerations that may be closed and heal by primary intention to crush, contusion and abrasion injuries. The correct management of such injuries can have a significant impact on healing and future cosmetics. If a patient presents in primary care with such injuries it can be hard to know what to do. Following administration of a local anaesthetic wounds should be gently cleaned with gauze and sterile water. If there is no positive history of allergy chlorhexidine or iodoform may be used but attention must be paid to any possible allergic response. Contaminants should be removed if possible. If wounds are very 118

deep, ‘through and through’, heavily contaminated, in close proximity to vital structures such as the parotid, facial nerve or salivary ducts or you feel there may be a high risk of poor outcomes if plastics or max-facs are not involved, refer to the local A&E department.

Suturing Suturing using -0, 5-0 or 6-0 with a reverse cutting needle is recommended using a non- braided, monofilament non-resorbing material such as nylon or polypropylene to facilitate healing but if follow-up may not be possible or likely a resorbing suture such as Vicryl is also good. There are many techniques described but simple interrupted sutures allow accurate wound approximation and spread the tension whilst minimising tissue inflammation. Pass the needle and suture into the dermis. The objective should be to slightly evert the wound margins for optimal healing. For deeper wounds placing a subdermal suture with a resorbable material can be used to approximate the edges and reduce tension on the finer sutures. This suture will be buried and left to resorb. For removable sutures these should be removed 5-7 days after placement.

The avulsed tooth It is advisable to have in-practice training on correct telephone advice for callers ringing to report a traumatic dental injury especially when a tooth has been avulsed. This should include: • • • • • • •

Making sure the tooth is a permanent tooth (do not replant primary teeth) Keeping the patient calm Picking up the tooth by the crown (describe this as the ‘shiny’ part) and avoid touching the root If the tooth is dirty, wash it under cold running tap water (10 seconds maximum) Reposition tooth – hold tooth by the crown and push it gently back into the socket until it is level with the other teeth Encourage patient to bite on a handkerchief to keep tooth in position If replantation is not possible or the caller is unsure whether the tooth is a primary or secondary tooth, place the tooth in milk and bring it with the patient to the practice or dental clinic immediately. Any type of milk may be used. If milk is not available the tooth may be stored in the buccal sulcus though care must be taken to avoid ingestion and the tooth transferred to milk as soon as possible thereafter. 119

When should a tooth not be replanted? • • • • • •

In most cases, replantation of an avulsed tooth is the best treatment. However, there are some cases where replantation is not appropriate: When tooth is a primary tooth When other injuries are severe and warrant preferential emergency medical treatment such as a head/eye/limb injury When medical history indicates that replantation would put the patient at risk i.e. a patient undergoing chemotherapy or with a cardiac defect (in this case risks/benefits of replantation will need to be carefully discussed with the patient/carer and medical team – for children immediate referral to a specialist in Paediatric Dentistry is indicated) When the tooth is extensively periodontally involved When the tooth is extensively carious and unrestorable.

How should an avulsed tooth be replanted? Administer local analgesia to both buccal and palatal/lingual tissues although replantation without local analgesia is possible when there is minimal disruption to the socket and this will also allow quicker replantation. Gently irrigate the socket with a syringe filled with saline to remove the clot and pick up the tooth by the crown without scrubbing or scraping the surface. If the tooth is contaminated wash it in saline and if necessary, dab with gauze soaked in saline to remove debris. If the tooth will not replant fully then stop as alveolar bone fragments can prevent replantation. In this case withdraw the tooth and place it back in saline/ milk. Use a blunt instrument (such as a flat plastic) in the socket to reposition bony fragments and once again attempt replantation. A check radiograph should be taken to ensure the root is placed correctly in the socket an the occlusion should be checked. This is an instance in which antibiotics should be prescribed. If under the age of 12 prescribe amoxicillin or penicillin V 250mg, 4x/day for 7 days (28) and if over the age of 12 prescribe Doxycycline 100mg twice/day for 7 days. A tetanus booster may be required if contamination of the tooth has occurred – if in doubt refer to a medical practitioner within 48 hours.

Splinting Splint the replanted tooth to one uninjured tooth either side using a physiological splint for two weeks. Acid etch wire and composite splint or titanium trauma splint are recommended (Figure 2). Advise the patient to eat a soft diet and maintain as good

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oral hygiene as possible, rinsing with chlorhexidine mouthwash (unless allergic to chlorhexidine then use hot salty mouthwashes instead). Appropriate analgesia is also to be recommended.

Extirpation For mature teeth, extirpate, clean and shape prior to splint removal at 2 weeks, dress with calcium hydroxide and obturate within 1 month. For immature teeth, do not extirpate but monitor closely as for revascularisation. If pulpal regeneration fails (signs of sinus, pain or periapical inflammation) extirpate and dress with non-setting calcium hydroxide. Refer if not confident managing open apices.

Figure 1 Radiograph showing fractured hard tissue fragment in lip soft tissue

Figure 2 Application of wire and composite splint following anterior trauma

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Chapter 14

Appraisals, staff training and development policy Glenys Bridges Adapted from Dental practice management

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Appraisals Although surveys reveal that few employers are ‘satisfied’ with their performance review or appraisals systems they are a well-established personnel management technique. Managers should invest time and energy to ensure performance reviews provide opportunities to enhance work performance and relationships. The purpose of appraisals is to: • • • • •

Enable staff and managers to be more effective Recognise the achievements of staff and managers Conduct a performance related overview of the practice Identify developmental opportunities Identify further goals.

At their best appraisals can be very motivating and rewarding for both parties but first you must recognise that an appraisal is not a substitute for daily supervision nor is it part of a disciplinary process. An appraisal is ongoing professional development for individuals and for the team and works best when practice policy defines, when, where and who is involved in the appraisal process. A suggested process is as follows: Inform

- Send the appraisee a letter of notification setting the time and place and purpose of the meeting.

Venue

- Ensure the meeting is planned to take place somewhere private and free from interruptions.

Layout - Layout has a huge influence on atmosphere and mood. Create a relaxed situation, preferably at a meeting table, or in easy chairs, ideally sit at a 90 degree angle to each other to avoid face to face confrontation.

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Introduction Relax the appraisee by opening with a positive statement, smile, be warm and friendly, it is your responsibility to create a calm and non- threatening atmosphere. Explain what will happen - encourage a discussion and as much input as possible from the appraisee - tell them it is their meeting not yours. Open with some general discussion about how things have been going. Ask if there are any additional points to cover and note them down so as to include them when appropriate. Review and Measure Review the activities, tasks, objectives and achievements one by one, keeping to distinct, separate items one by one and avoid going off on tangents or vague unspecific views. If you have done your preparation correctly you will have an order to follow. If something off-subject comes up then note it down and say you’ll return to it later (and ensure you do). Concentrate on hard facts and figures and solid evidence and avoid conjecture, anecdotal or non-specific opinions, especially about the appraisee. Being objective is one of the greatest challenges for the appraiser - as with interviewing, resist judging the appraisee in your own image, according to your own style and approach - facts and figures are the acid test and provide a good neutral basis for the discussion, free of bias and personal views. For each item agree a measure of competence or achievement as relevant, and according to whatever measure or scoring system is built into the appraisal system. This might be simply a yes or no, or it might be a percentage or a mark out of ten, or an A, B, C. Reliable review and measurement requires reliable data and if you don’t have the reliable data you can’t review and you might as well re-arrange the appraisal meeting. If a point of dispute arises, you must get the facts straightened out before making an important decision or judgement, and if necessary defer to a later date. Agree and action plan - An overall plan should be agreed with the appraisee, which should take account of the job responsibilities, the appraisee’s career aspirations and the practice’s priorities. The plan can be staged if necessary with short, medium and long term aspects, but importantly it must be agreed and realistic. Agree specific objectives - These are the specific actions and targets that together form the action plan. As with any delegated task or agreed objective these must adhere to the SMART rules - Specific, Measurable, Agreed, Realistic, and Time-bound. Agree necessary support - This is the support required for the appraisee to achieve the objectives, and can include training of various sorts (external courses and seminars, 123

internal courses, coaching, mentoring, secondment, shadowing, distance- learning, reading, watching videos, attending meetings and workshops, workbooks, manuals and guides); anything relevant and helpful that will help the person develop towards the standard and agreed task.

Record main points, agreed actions and follow-up- Swiftly follow-up the meeting with all necessary copies and confirmations, and ensure a copy of the final agreement goes to the appraisee and a further copy goes into the appraisee’s personnel file

Giving feedback Performance feedback can be given as praise or criticism, both of which are judgments about performance, effort or an outcome. Always ensure that feedback is constructive and based on evidence, rather than opinions or feelings. Constructive feedback is: • Information-specific • Issue-focused • Based on evidence. It comes in two varieties: Recognition- of good work and achievements Remedies- this should be thought of as remedial support. Recognition feedback should: • •

Firstly identify the topic or issue that the feedback is about Then provide the details, without details feedback is vague and unfocused.

The way in which you say something carries more weight than what you say. Be direct when delivering your message and: Avoid: ‘Should’ phrases because they only imply remedies. For example, ‘Jane, you should check patients’ medical histories and contact details every visit’. This is not really performance feedback. It implies that Jane did not do something well, but it doesn’t provide directive feedback. Avoid: ‘Yes, but’ messages. For example, ‘Sarah, you have worked hard on this project, but...’. What follows is the real point of the message. Words like ‘but,’ ‘however’ and ‘although,’ create contradictions. In fact, putting ‘but’ in the middle tells the other person, ‘Now here is the real message’.

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Appreciation expressed on its own is simple praise. When strengthened by the specifics of constructive feedback, the appraisee can recognise the message is more powerful.

Remedial feedback: When feedback is negative it pays to take time to get your thoughts in order. This may mean delaying the feedback to give you thinking time to ensure your feedback comes across as constructive. Always keep clear notes on the feedback given so that you can the review details of your feedback in future, rather than relying on your memory.

Interview techniques To focus attention on the appraisee ask open-ended questions, with a focus on the issues being addressed and concentrate on one issue at a time to maintain clarity. An appraisal should never introduce criticism that has not already been addressed through the daily supervising and feedback systems. If there is need to revisit problem areas do not make this the opening topic. Make sure that the criticism is valid and focused on actions, rather than on the person, and recognise any improvements since the previous discussion of the problem. If you have a staff member who is clearly unhappy or going through a difficult time the appraisal should be postponed and the underlying problems addressed. Never think to yourself, we can deal with that in appraisal. If it is praise, say it or do it immediately and keep appraisals as a shared review process.

Trouble shooting If there is a failure to agree when the feedback given is refuted by the employee, a second interview should be set within two or three days to re-visit the areas of disagreement. If this interview fails to provide a solution a third party should be introduced as an arbiter and their decision is final. Arbitration arrangements must be built into appraisals policy. The arbiter should be a named person to be called upon if there is an initial failure to agree.

Trust and confidence Without a basis of trust, appraisals will create apathy and disrespect. For an individual to truly participate in the appraisal process they must believe in the capabilities and

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integrity of the appraiser. To create trust the manage must: • • •

Follow practice policies Observe ethical codes Have delivered on previous promises.

Research shows that a failure in trust may be forgiven more easily if it is interpreted as a failure of competence rather than a lack of benevolence or honesty. The degree to which one party trusts another is a measure of belief in their honesty, fairness, or benevolence. Confidence is based upon a belief in the competence of another person and so for team members to have trust and confidence in the appraisals process requires a fair, consistent and structured process to be followed for each team member and that all actions agreed are honoured and followed through.

Staff training and development policy When practices applied for Care Quality Commission (CQC) registration, many needed to dust off a series of random polices, previously collated and long forgotten. In many professional practices ethical intentions and high principles serve well in place of meaningful policy and procedures.

Policy and procedure Once headline policy has been set in the business plan the role of the manager is to determine practical procedures for its implementation. These practical steps are the follow through between good intentions and practical results. In respect of a training and development policy, firstly you need to specify the aim or purpose of the policy and define the results that you expect to achieve through this policy. Then go on to make a clear statement in an opening to a policy statement, such as; ‘Through our staff training and development activities we aim to safeguard the welfare of our patients and staff. Every member of the team will receive induction training and regular training updates to ensure full observation of legal and ethical guidelines’. With this in place the next decision to be made is in respect of the scope of the policy, here you specify to which team members the policy is applicable. A staff development policy will apply universally to the entire team. The next step is to identify the person accountable for the enforcement of the policy. This will ultimately be the employer, who may rely on the practice manager for the day-to-day implementation of the procedures; the practical measures selected to secure the policy’s aims. The final section will be an outline of the review and monitoring processes, for example, this policy will be reviewed at least annually, or immediately if required. A policy might include these elements: 126

New staff induction programme All new staff members are required to participate in our induction programme, ‘Welcome to our Practice’. The greatest care is taken during staff selection to allow them to continue their professional development throughout their career at the practice. During the three month induction programme new team members are given thorough training in health and safety requirements, the use of all materials, equipment, systems, policies and procedures. On completion of the induction programme a decision will be made whether to confirm the appointment with a permanent contract. This decision will be based upon a performance review at the end of the probationary period

Annual Performance Reviews (APR) When a permanent contract has been accepted the first APR will take place, during which training and performance targets will be agreed up until the end of the current calendar year at which point they will join the practice APR system and the individual will be required to start building a CPD portfolio to be reviewed as part of their APR. This must contain:

• • • •

A current job description A Personal Development Plan CPD records Evaluations of activities carried out.

Job descriptions All staff will be given a detailed job description upon recruitment. The aim of the job description is to outline work and team roles for each team member. Updates will be negotiated during APRs, in response to the development needs of the business and the team.

Personal Development Plans All CPD activities endorsed by this practice must be consistent with GDC regulations and the overall aims of the practice. Training needs will be identified with reference to the following criteria:

• • •

Legal requirements Ethical requirement Business development.

Agreed CPD activities aim to improve compliance/performance in at least one of the above areas. A learning contract, defining aims and objectives for the activity, will be established before any activity is ‘signed off’ by the practice manager.

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5 Mentoring This practice runs a mentoring system but this is not intended to replace direct contact with the practice manager or directors. The purpose of the system is to offer training opportunities and a first point of contact with the closest team member in terms of experience and background. Each member of the team will be appointed a mentor who will be able to offer guidance and support in respect of workplace issues. Confidentiality within this relationship will be respected within the scope of the practice code of conduct for mentoring. Any blatant breech of this code will be regarded as gross misconduct and could result in disciplinary action. 6

In- house training sessions Monthly staff meetings will be held to a standard agenda. The meeting will include a training session on a topic relevant to the needs of the practice. Topics will include updates on Health and Safety issues and core CPD practical updates. Some of these sessions will be lead by team members and others will be led by guest facilitators invited into the practice for their specialist knowledge. One monthâ&#x20AC;&#x2122;s notice of each session will be given to team members. Attendance at these sessions is required.

Postgraduate training Where postgraduate training is required it is the responsibility of team members to fulfil their responsibilities. The practice will allocate time and in certain cases funding for travel and course fees, when at least four weeksâ&#x20AC;&#x2122; notice of attendance is given.

Peer review In addition to monthly staff meetings, peer group meetings will be arranged within the practice. The purpose of these meetings is to audit performance and identify quality developments.

Membership of professionals associations Employees are encouraged to join and actively participate in their professional associations. In certain cases, membership fees will be met from the CPD budget. Updates and development within groups of the profession should be discussed at staff meetings.

This policy will be reviewed at least annually, in conjunction with practice needs and professional requirements.

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Chapter 15

Conditions causing dental pain

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As a general guide, pain of pulpal origin is often poorly localised in the region of the mouth supplied by a specific branch of the trigeminal nerve. In some instances the pain may be referred to the opposing jaw quadrant. The acutely inflamed pulp will usually respond vigorously to the application of cold. An electric pulp tester simply confirms pulp sensibility and is not a very useful additional test in these circumstances. However, pain from low-grade chronic pulpitis, and variable degrees of pulp sensibility in multi-rooted teeth, often complicate diagnosis of the pulpal status. In these circumstances, several pulp testing methods are advised. The affected tooth will not usually be particularly tender to percussion. Pain of periapical origin involves the apical periodontal ligament and/or the surrounding bone. When the pain is caused by inflammatory exudate or pus under pressure, it is usually the result of a non-vital pulp. The tooth will usually not respond positively to sensitivity tests, but will be tender to percussion and readily identifiable by the patient.

Dentine hypersensitivity or reversible pulpitis (vital pulp) Dentine hypersensitivity is caused by the movement of fluids within exposed dentinal tubules, with consequent agitation of the odontoblasts, their processes and associated sensory nerves. Such fluid movements may be caused by cold, heat, dehydration, pressure and osmotic solutions. Patients often complain of pain from hot, cold or sweet foods and drinks. The pain is usually sharp, moderately severe and of short duration (transient) lasting only a few seconds after the stimulus is removed. Examination will usually reveal exposed dentine. This can be due to a variety of causes; in a carious cavity, adjacent to a fractured or leaking restoration (that also may be associated with a cracked cusp), at the neck or cervical region of a tooth where there has been gingival recession (cervical sensitivity), and where a tooth has been fractured. Active acid erosion may also cause the dentine tubules to be exposed and make the teeth very sensitive. Pain can usually be elicited at the time of examination by gently blowing the suspect tooth with air from the triple syringe or by applying cold or heat to the exposed dentine surface. Cold applied to an area that does not contain exposed dentinal tubules usually provides a normal pulpal response. Hypersensitivity may also occur following the insertion of restorations,

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especially large resin composites in molar teeth, and resin-bonded crowns in young patients. This pain usually resolves after a few weeks, but the affected tooth may require endodontic treatment in some instances. Treatment is directed at removing the cause and protecting the exposed tubules. The pain should then cease and any pulpitis present should resolve. Cavities should be restored and fractured or leaking restorations should be replaced. Any heavy occlusal contacts or high spots present should be removed. In some instances during the inadvertent removal of deep caries-affected tissue (not caries-infected tissue) a small pulp exposure with slight bleeding may occur, which then may be covered with usually a calcium hydroxide paste, provided that there have been either no or only brief minimal pain symptoms. For externally exposed dentine surfaces, common forms of treatment are to apply either a fluoride varnish such as VarnishAmerica Original/White (Medical Products Labs), or a casein-derived paste such as Tooth Mousse Plus (GC International), supplemented by desensitising toothpastes such as Sensodyne or Sensodyne Pronamel (GlaxoSmithKline).

Cracked tooth syndrome In cracked tooth syndrome the pulpal effects present are caused by deep cracks that begin in the crowns of posterior teeth. In heavily restored teeth the cracks tend to run transversely beneath the undermined cusps, while in non-restored teeth having heavy wear facets the cracks usually run vertically across the marginal ridges and ultimately progress to involve the pulp and periodontal tissues. Old restorations should be removed for closer examination of the extent of the cracks and the remaining dentine. When the pulpal hypersensitivity is due to a cracked tooth, if there are no loose coronal tooth fragments, and transient pain occurs only on biting, and during the wedge test, the crack can often be prevented from progressing by means of a cusp-coverage restoration or an artificial crown. Alternatively, if sufficient enamel walls remain, then the enamel can be etched and an intra-coronal resin composite restoration placed. However, long-term failures are likely to be higher than when extra-coronal resin composite or other cusp coverage restorative materials are placed. Initially, stabilisation of the cracked tooth can be achieved using a glass-ionomer cemented orthodontic band. Occlusal contacts should be minimal. If the symptoms persist, then either endodontic treatment or tooth extraction will be necessary. Extraction is required when vertical crack progression involves the periodontal attachment apparatus, and the tooth is considered to be non-restorable. The teeth most likely to fracture are maxillary premolars and molars, and mandibular first molars. The cusps most likely to fracture are the buccal cusps of maxillary premolars, and the lingual cusps of mandibular molars. The presence of an enamel fracture line and a large restoration increases the risk for tooth fracture.

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Irreversible pulpitis (vital pulp) The symptoms are usually a severe throbbing spontaneous pain, which often radiates to adjacent structures, and is made worse by lying down because of raised intrapulpal pressure. The pain may be constant, or last for longer than 10 minutes after a stimulus such as heat or cold has been applied. In such cases the pulp is usually irreversibly damaged and conditions can only deteriorate further. Thus, the severe pain may last for several days and then stop quite suddenly when the pulp becomes non-vital. Sometime later, the previous pulpal pain may be replaced by a more localised pain from an acute apical periodontitis caused by necrotic pulp tissue and bacteria and their toxins present within the confined root canal. The diagnosis of irreversible pulpitis is based on the dental pain history and examination, which may reveal a large carious cavity, previous restorative treatment such as the placement of a deep restoration close to the pulp (that may be exposed), a discoloured tooth crown, or a fractured tooth. Periapical radiographs may not show any periapical changes, apart from a widened periodontal ligament space, which may be related to tooth extrusion caused by inflammatory exudate. Consequently, the tooth will be tender to bite on or when percussed. Retention of the tooth requires a pulpectomy and subsequent root canal obturation. Otherwise, extraction of the tooth is indicated. The options and implications of endodontic and subsequent restorative treatments should be discussed with the patient, as should the functional and aesthetic usefulness of the tooth in relation to a sensible, albeit quickly assessed, overall treatment plan.

Acute periapical abscess (non-vital pulp) A periapical abscess may occur shortly after an earlier history of acute pulpitis, but often occurs spontaneously many years later. The associated continuous pain varies in severity depending upon whether an acute infection is confined within relatively dense cortical bone or whether, subsequently, the infection has tracked through the alveolar bone subperiosteally to involve the overlying soft tissues. In the latter instance, the pain is much reduced, and especially if a draining sinus is present. The toothâ&#x20AC;&#x2122;s pulp will usually be non-vital. Occasionally, a multi-rooted tooth may have one or more vital root canals, the other(s) being non-vital. The affected tooth is usually mobile and, because of the inflammation and pus present at the apical region(s), will be elevated in its socket. Thus, the tooth will be painful to bite on. The alveolar mucosa overlying the apex of the affected tooth may be slightly red, swollen and tender to palpation. As the infection spreads to the adjacent soft tissues there is greatly increased swelling with oedema from the inflammation. The periapical abscess formed usually points intraorally beneath the alveolar mucosa, and only rarely does an abscess point extraorally beneath the skin. Occasionally,

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the drainage of inflammatory exudate and pus occurs into an adjacent periodontal pocket, and even into the maxillary sinus and floor of the nose. The patient will have enlarged submandibular lymph nodes and may also have a fever from toxaemia. In most instances a periapical radiograph will reveal an apical radiolucency associated with the affected tooth, in particular when there has been an acute exacerbation of a previous chronic low-grade apical infection. The periapical radiographic appearance is very variable, and not necessarily definitive of the histological diagnosis of the original lesion present. Treatment requires drainage of the inflammatory exudate and pus. This can be achieved either by providing an access opening into the pulp chamber of the tooth and ensuring adequate drainage through the apical foramen of the root canal, or by tooth extraction where the pus is drained via the resultant socket. Particularly when a soft tissue swelling is fluctuant (submucosal abscess or â&#x20AC;&#x2DC;gumboilâ&#x20AC;&#x2122;), additional drainage of pus and inflammatory exudate may be required by an incision into the centre of the soft tissue swelling. Antibiotics may be prescribed if the patient has a fever or is feeling unwell but are otherwise not indicated. Heavy occlusal contacts present should be adjusted to reduce apical tissue trauma and to provide relief from pain on biting.

Acute periodontal abscess (vital pulp usually) This condition is of lateral periodontal rather than of pulpal origin, and arises from within a periodontal pocket. Pain is usually not as severe as for a periapical abscess. The abscess presents as a localised soft tissue swelling adjacent to the tooth, which is usually vital except in cases where the tooth has previously been root filled or if there is a periodontal-endodontic lesion. There is usually pre-existing periodontal disease and the tooth will be mobile and tender to percussion. Periodontal probing will usually reveal a deep and wide pocket with pus and bloody exudate from the abscess. Periapical radiographs will often show an angular loss of alveolar bone adjacent to the roots of affected teeth, in particular when the interproximal and furcation surfaces of the roots are involved. Treatment comprises either extraction of the tooth, or instrumentation of the root surface and soft tissue walls of the pocket. The latter treatment removes the pus and bacterial plaque.

Acute pericoronitis This condition arises around erupting molars, almost exclusively the mandibular third molars. Pericoronitis is common during late adolescence when these teeth start to erupt. It presents as acute pain, swelling in the region of the angle of the mandible, and trismus (inability to open fully the mouth). Cervical lymphadenitis is usual and the operculum (gum flap) partially covering the erupting molar is usually very

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painful, swollen and ulcerated because of trauma from the opposing molar tooth. Radiographs will show an erupting molar, which may be impacted. Several treatments are available including either extraction or selected cusp reduction of the opposing tooth, hot salt mouth washes, and irrigation beneath the operculum of the impacted tooth using 0.2% chlorhexidine. In some instances, antibiotics may be required. If the erupting molar is impacted then it should be scheduled for extraction after the acute stages of the infection have resolved.

Localised (alveolar) osteitis –dry socket Symptoms of this condition usually occur 2-4 days after a tooth has been extracted. The blood clot breaks down to form a dry socket. The risk is increased by smoking, oral contraceptives, extraction of mandibular molars, surgical trauma, pericoronitis and pre-existing infections. Pain may be moderate to severe, throbbing and constant, and radiating from the jaw to the ear and neck. There is a foul smell and taste, and enlarged submandibular lymph nodes. The exposed bone in the socket is extremely sensitive. Treatment involves analgesics, gentle rinsing of the socket to remove debris, then careful drying and placement of a long-acting topical analgesic paste. Metronidazole antibiotic mixed with Orabase Paste with Benzocaine (Colgate Oral Pharmaceuticals) may be applied from a syringe. An alternative is the application of Alvogyl Dry Socket Alveolar Dressing (Septodont). This is repeated after a few days, if required. Systemic antibiotics are not required. Reduction of plaque before and after extractions by good oral hygiene and gentle rinsing with 0.12% chlorhexidine solution reduces the occurrence of dry socket.

Acute Necrotising Ulcerative Gingivitis (ANUG) Acute necrotising ulcerative gingivitis (ANUG) or ‘trench mouth/ Vincent’s angina’ is a variably painful infection of the gingival tissues caused by spirochete and fusiform microorganisms. It usually occurs in patients with poor oral hygiene and a reduced resistance to opportunistic infections. The gingival tissues are inflamed with ‘punchedout’ interdental papillae and pseudomembranous ulceration. There is usually a fetid odour, and the patient may have a fever with enlarged submandibular lymph nodes. Treatment requires gross scaling, rinsing with warm saline mouthrinses, brushing with a soft toothbrush, and improved general health. In some instances, particularly in patients with compromised immune systems, antibiotics such as metronidazole should be prescribed.

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Other causes of dental and orofacial pain Acute maxillary sinusitis This often causes periodontitis in the adjacent maxillary posterior teeth, and can follow an upper respiratory tract infection or less often seasonal allergic rhinitis. In some instances, the maxillary sinusitis is caused by periapical infections of adjacent teeth, and also may follow tooth extractions either when root fragments are displaced into the sinus or an oro-antral fistula is created. The infected sinus pain is a continuous, often severe, ache that usually takes 5-7 days to begin to resolve. Bending down and the impact of walking down stairs may increase the pain. There is the sensation of pressure and local tenderness over the affected sinus, usually accompanied by slight puffiness under the eye on the affected side, nasal congestion and a mucus discharge. There is often an associated loss or decreased sense of taste and smell, a headache, sore throat, earache and swollen cervical lymph nodes. An occipito-mental radiograph (Waters sinus view) may show an increased opacity of the affected sinus or a fluid level. Treatment involves analgesics, and re-establishing sinus drainage with nasal decongestants, and allergen suppressants if hayfever is also present as shown by sneezing, itchy red or watery eyes, and itchy ears, nose and throat. Antibiotics may be required when acute infection is present as shown by a mucopurulent discharge and fever.

Craniomandibular disorder (CMD) This is commonly the result of cyclic stress overloads affecting the masticatory system. Less commonly it may arise from acute trauma and inflammation of the TMJs. CMD may principally affect the masticatory muscles (for example, myofascial pain dysfunction) as well as other muscles of the shoulder girdle, and/or the TMJs (for example, disc displacements, arthritis) to varying extents. The condition is usually unilateral, and mainly affects females. Approximately 50% of patients may be clinically depressed and have other physical symptoms. The risk of depression increases significantly with chronic painful conditions. Pain and stiffness on mandibular movements may be worse on wakening, following nocturnal tooth grinding or clenching. The masticatory muscle attachments are tender to bimanual palpation, there is pain with limited jaw opening from muscle spasm (trismus), and the TMJs may be tender to palpation with clicking or crepitus sounds occurring during jaw movements. Auscultation may be enhanced by using a stethoscope. Painful masticatory muscles may mimic the constant dull pain of acute maxillary and frontal sinusitis. The associated stress-related tooth grinding and clenching also can lead to pulpitis and periodontitis in multiple opposing teeth. However, the dental pulps are usually vital. Tension headaches and tender neck and shoulder girdle muscles often accompany these dental symptoms and signs.

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Short-term nonsteroidal anti-inflammatory drug (NSAID) analgesics, heat or cold applications, a soft diet, muscle relaxants, reassurance and counselling for psychological stresses and habits are usually adequate to control acute episodes. For recurrent and persistent conditions, correctly-fabricated and adjusted/ re-adjusted heat-cure clear acrylic resin Michigan splints may be prescribed. Alternatively, occlusal splints may be constructed using dual laminate thermoplastic materials, to which self-cure acrylic resin is added to the harder occlusal surface layer of the thermoplastic material. Such splints are thicker, and the softer inner surface layer cannot be relined. In some instances, recent restorative treatment may precipitate CMD due to sudden occlusal changes and prolonged opening of the mouth. A careful examination of recent restorations or prostheses should be made, and the occlusion adjusted as required. Often, a shiny â&#x20AC;&#x2DC;high spotâ&#x20AC;&#x2122; on a metallic restoration is detected, and the restored tooth is often sensitive to percussion. Ischaemia, and lung cancer may mimic CMD pain. Lower jaw pain also may be caused by cervical spinal nerve injuries, such as whiplash, osteoarthritis, spondylitis and degenerative disc disease. Occasionally, pain may be referred from pulpallyinvolved teeth in one jaw to sound teeth in the opposing jaw, without crossing the midline. Local anaesthetic injections can be used to locate the tooth responsible.

Somatic pain Most pain complaints seen by dentists are related to somatic pain caused by local inflammation of the hard and soft oral tissues. Soft tissue lesions include mucosal vesicles and ulcers caused by physical trauma (cheek/tongue biting, removable prostheses, foreign bodies, sialoliths, iatrogenic), chemicals (aspirin, trichloracetic acid), infections (herpes simplex, infectious mononucleosis, angular cheilitis and denture stomatitis), and malignant neoplasms (squamous cell carcinoma).

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Chapter 16

Impairment in childhood – oral health implications

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This article examines oral and dental problems which may be experienced by people with a range of impairments that commenced at birth or during childhood. Apart from a few conditions, people with this range of impairments will encounter the same oral and dental diseases as the rest of the population. There are additional factors such as access to dental care and support in carrying out activities of daily living, which can result in higher levels of tooth loss and untreated disease.

Cerebral palsy Cerebral palsy (CP) is one of the major causes of physical impairment. It has been described as ‘a disorder of movement and posture due to a defect or lesion of the immature brain’. Other impairments associated with CP include visual, hearing and speech impairment, epilepsy and learning difficulties. The condition affects 1:500 children by school age in industrialised countries but the level and type of impairment depends on the areas and degree of brain damage. Cerebral palsy results in a wide spectrum of disability ranging from virtually unnoticeable physical impairment involving one limb (monoplegia) through to all four limbs (quadriplegia). Movement may also be affected in the following groups: • • •

Spastic; increased muscle tone contractions and difficulty with head control Athetoid; involuntary movements and difficulty with balance Ataxia; difficulties with balance and co-ordination.

Children may also have mixtures of the above groups. Oral factors in cerebral palsy A range of factors include • Malocclusion • Bruxism • Attrition • Swallowing, gag and cough reflex • Acid regurgitation

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• • •

Feeding and dietary factors Jaw dislocation Effects of medications.

Oral developmental abnormalities may affect oral health. Malocclusion, caused by irregular teeth or overcrowding, is common with delayed eruption of the teeth as a contributory cause. Factors associated with difficulties with the process of eating and digestion can result in a diet of soft and minced food. The use of dietary supplements and laxatives with very high sugar content can produce extensive levels of caries very rapidly in the absence of effective oral hygiene procedures. Without the normal oral processes of chewing and swallowing food can be retained in the mouth. The increasing use of PEG (Percutaneous Endoscopic Gastronomy) feeding has helped with improving nutritional status but the need for regular oral hygiene can be overlooked. The effects of some anticonvulsant drugs can produce gingival hyperplasia. Xerostomia is a side effect of some antispasmodic medications and anticholinergic drugs given to reduce drooling. Oral and dental disease in cerebral palsy Children with CP appear to experience higher levels of dental caries and plaque as compared to the rest of the population. Feeding problems, clearing residual food and malocclusions combined with mouth breathing appear to contribute to the higher levels of dental and oral disease. They also experience more extractions and untreated disease.

Learning disability Learning disability is a collective term to describe a greater difficulty in learning than others of the same age. Another definition commonly used is: ‘a significant impairment of intelligence and social functioning acquired before adulthood’. It can cover learning in a specific area as seen in dyslexia, dyspraxia and attention deficit and hyperactivity disorder (ADHD), or a more global learning difficulty seen in Down syndrome, autism, cerebral palsy and other congenital or genetic disorders. The process of identification of a learning disability in a child has improved over recent years. Approximately 5% have some degree of learning disability, mild, moderate or severe with the majority being males. Oral and dental disease in people with learning disability There does not appear to be much difference in the prevalence of dental caries between children with and without impairments. However children with a disability are more likely to have untreated disease and have teeth extracted more frequently. There is also a higher prevalence of dental caries in children with

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a mild learning disability compared to those in special schools and institutions. This is attributed to lower access to cariogenic foods and a more comprehensive approach to dental care. There are many studies demonstrating a poor standard of oral hygiene and plaque control in children with learning disabilities. Again, the poorest levels are seen in those with a mild learning disability not receiving regular dental treatment. Adults with a mild learning disability are often not in regular contact with dental services and studies of those attending day centres and institutions show higher levels of untreated decay and periodontal disease than the general population.

Oral health care for people with learning disabilities The key to improving oral health for people with learning disabilities is via effective prevention and adequate access to dental services. Children and their families are in contact with a wide range of health and education professions and an integrated approach involving the dental team will ensure more comprehensive care. Clinical guidelines and integrated care pathways for the oral health care of people with learning disabilities have been published by the British Society for Disability and Oral Health and the Faculty of Dental Surgery, Royal College of Surgeons of England. These provide detailed guidance for everyone involved in the care of people with learning disabilities. The guidelines focus on integrated care for: • • • •

Pre-school children School age children Transition from adolescence to adulthood Adults and older people.

At each stage, evidence based guidelines are provided for: • • • •

Prevention and promotion of oral health Oral assessment and care planning Management of specific conditions Training and education for parents and carers.

Down syndrome Down syndrome is the most common genetic cause of learning disability and is caused by a chromosomal abnormality with an incidence of 1:6-800 live births. The incidence increases with maternal age, rising as high as 1:37 at 44 years. Down syndrome can be diagnosed in pregnancy with maternal and foetal blood testing. Apart from the characteristic physical appearance of a short stature and facial

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characteristics, there are medical and physical aspects that can affect oral health and dental management. Some of the medical aspects of Down syndrome include: • Congenital heart disease • Leukaemia • Respiratory disease • Atlanto-axial (cervical spine) instability • Immunodeficiency • General anaesthetic risk • Early onset Alzheimer’s disease. These factors can have implications for oral and dental care. Some of the oral factors of Down syndrome include: • Abnormal jaw relationships • Cleft lip and palate • Malocclusions • Reduced masticatory ability • Poor lip posture • Mouth breathing • Large tongue and tongue thrusting • High arched palate • Abnormal shaped crowns of teeth • Missing teeth • Gingival hyperplasia from anticonvulsant medication.

Oral and dental disease in Down syndrome There is an increased susceptibility to periodontal disease in this group, compounded by difficulties in maintaining a good standard of oral hygiene due to anatomical factors. Lower levels of dental caries have been reported which may be due to a higher pH of saliva and the small, more spaced teeth.

Autism and Asperger’s syndrome Autism is a collective term for a range of disorders and is now more often known as Autistic Spectrum Disorder (ASD). In the UK the prevalence rate is 9:1,000 people. Although there are four times as many boys affected, girls tend to be more severely affected. The condition is usually diagnosed by the age of three years. There are difficulties with verbal and non-verbal communication, with forming relationships and

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often other signs, such as repeated body movements. There are associations with learning difficulties, epilepsy and Down syndrome. There are no obvious causes of autism aside from a possible genetic link and although there has been considerable publicity regarding a possible link with the MMR vaccine, there does not appear any conclusive evidence one way or another. A feature of people with ASD is that they like routine. They may also have a very short attention span and a need for continuity. An exaggerated sensitivity to smells and lights may also be present. Asperger’s syndrome is part of the ADS, however, language and communication skills are not as affected. People with Asperger’s are likely to have good intellectual ability but may have a short attention span. Children with this syndrome can have poor co-ordination and delayed development of motor skills. Oral and dental disease in Autistic Disorder Spectrum There is little general difference in childhood levels of dental disease. Some children may have higher levels of caries from receiving sweets to reward behaviour. Conversely, some children may be on restricted diets due to either their own wishes or due to parents finding that sugars and food colourings adversely affect their behaviour. The short attention span and need for continuity can affect the way that dental care is provided, as extra planning is needed. People with more severe aspects of the disorder may have difficulties tolerating dental care. Muscular Dystrophy Although diseases affecting the musculature are relatively uncommon, muscular dystrophy is the most common of these in childhood. Of these, Duchenne muscular dystrophy is the most common, the most severe form and is progressive from early childhood, affecting 1:4,000 male births. Becker type, which is less disabling, progresses more slowly and mobility is less likely to be affected. There are several other rarer forms, which are classified by the groups of muscles affected. In myotonic dystrophy, which occurs mainly in adults, facial weakness, speech and swallowing difficulties may occur. Children with muscular dystrophy may also have scoliosis and learning difficulties, one form is associated with epilepsy. Oral and dental disease in muscular dystrophy There are no specific oral features, although malocclusions due to widening of the jaw arches may occur. This is caused by the greater pressure of the tongue in relation to the weakness of lip and cheek muscles. Delayed eruption of teeth is also sometimes seen. The ‘open mouth’ posture due to weakness in the facial muscles

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is a risk factor for oral health. The resultant dryness of the mouth and difficulties in maintaining self-care due to upper limb weakness increases the risk factors for dental caries and periodontal disease. Swallowing difficulties may complicate oral care. The respiratory and cardiac problems are a risk factor for general anaesthesia. It is important to provide training and education for parents and carers as support for oral self-care is required. Rickets and osteomalacia Rickets is mainly caused by a deficiency of vitamin D. This can lead to a failure in bone formation. Rickets occurs in children, the disease in adults, osteomalacia, presents mainly during pregnancy and lactation. The deficiency is mainly due to a dietary deficiency of meat, oily fish and a lack of exposure to sunlight and had largely disappeared in the UK. It is now seen more often amongst recent immigrants who have suffered malnutrition and ethnic minorities, related to cultural food and dress practices. In children the bones are weak and prone to fracture and deformity. In adults it affects the weight-bearing bones. Oral and dental disease in rickets There may be delays in the eruption of teeth, although tooth structure is rarely affected except in severe cases. Rheumatoid arthritis and juvenile arthritis Rheumatoid arthritis is an acutely disabling disease, which affects all ages, with females more frequently affected than males. It has a variable course, but is generally progressive with severe inflammation. Swelling with acute pain and joint deformity usually affects hands and feet and later knees, ankles, wrists and elbows. In the active phase anaemia is common. Approximately 15% of people with rheumatoid arthritis develop SjĂśgrenâ&#x20AC;&#x2122;s syndrome, the symptoms of which are dry mouth and eyes. When the temporomandibular joint is affected, mouth opening may be limited.

Osteogenesis imperfecta (brittle bone disease) As lay terminology for this rare condition implies, brittle bone disease is a disorder in which bone is extremely fragile and prone to multiple fractures, particularly in childhood. This arises from a defect in the collagen fibres forming the infrastructure for bone formation. Although the fractures heal rapidly, permanent physical deformity may result from repeated fractures. This condition is usually inherited, although in 25% of cases children are born into families with no history of the disorder. There are four types of the disorder with symptoms ranging from mild to severe.

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The range of problems associated with the condition include: • Early hearing loss • Bruising • Respiratory problems • Dentinogenesis imperfecta (underdeveloped dentine in teeth). Treatment of the condition involves managing the fractures and encouraging mobility by splinting or the insertion of metal rods in the long bones. Oral and dental disease in osteogenesis imperfecta Approximately half the people with osteogenesis imperfecta also have dentinogenesis imperfecta, often referred to as opalescent teeth. The teeth are bluish and prone to wear. Malocclusions and delayed eruption are often seen. Extensive restorative dental care is often required. Spina bifida and hydrocephalus Spina bifida and hydrocephalus may occur together or independently. Spina bifida is a congenital defect caused by incomplete development of the spinal neural tube. It is a collective term that covers three conditions of varying severity: • • •

Spina bifida occulta Spina bifida cystica menigocele Spina bifida cystica myelomenigocele.

Spina bifida occulta does not cause any physical or neurological abnormality. The two forms of spina bifida cystica are a major cause of paraplegia in children and usually require surgical correction. Other complications can include: • Hydrocephalus • Congenital hip dislocation • Epilepsy • Learning difficulties. Spina bifida occulta is present in 5-10% of the population, but is usually not noticeable. Spina bifida cystica is present in approx. 1:1,000 pregnancies. There is a gender variation of 3:2 women to men and an increased incidence among some ethnic groups. The condition appears to be caused by environmental and genetic factors. Folic acid taken during pregnancy can significantly reduce the incidence. History of a sibling with spina bifida is an increased risk as is an adult having a child with spina bifida.

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Hydrocephalus Hydrocephalus is caused by obstruction to the circulation of cerebrospinal fluid. It may be secondary to congenital conditions, infections, haemorrhage or tumours and can cause brain damage due to pressure or atrophy. Unless treated, hydrocephalus leads to enlargement of the skull, brain damage or death. Epilepsy, visual impairments, spasticity and learning difficulties or dementia may present as complications. The condition is treated by the insertion of a valve to divert cerebrospinal fluid away from the area and to reduce pressure. The valves may become dislodged or blocked and require regular monitoring. Oral and dental disease in spina bifida There are no specific oral or dental factors associated with spina bifida except how paraplegia and complications may affect access to services. There is a high incidence of latex allergy among people with spina bifida and antibiotic cover may be required to protect potential infections of the valve. Sensory impairments The major sensory impairments are loss, or reduction of sight, hearing or both. Total deafness in childhood is rare and the commonest cause of conductive deafness is often due to chronic secretory otitis media following recurrent middle ear infections. Some groups are at higher risk including people with; cleft lip and palate and Down syndrome. Conductive deafness is often intermittent and can resolve with no treatment. Sensorineural hearing loss occurs in 1:1,000 births. It is usually present from birth and results from damage to the cochlea, auditory nerve or other abnormality. It is more profound and may be progressive. It may follow infections such as measles or meningitis and is a feature of many syndromes. Visual abnormalities occur in 1:3,000 births. There are genetic causes for 50% of severe visual impairments. Other causes include infections, trauma and retinopathy related to premature birth. Children can also have a combination of hearing and visual impairment. Oral and dental disease and sensory impairments There are no specific factors in oral and dental disease associated with sensory impairments. However there may be problems accessing appropriate dental care and maintaining oral health due to difficulties with communication. This can result in higher levels of untreated dental caries and periodontal disease, and complications receiving dental care.

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Chapter 17

The role of saliva in mineral equilibria – caries, erosion and calculus formation

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Bob ten Cate The importance of saliva in the prevention of dental caries is dramatically shown in patients with impaired salivary function. When, as a result of medication or radiation in the oro-facial region, salivary flow is reduced the dentition may be completely destroyed within a short period of time. Unlike ‘general’ caries, that which results from xerostomia is often seen at the incisal or occlusal edges of the teeth and in the cervical region. This can sometimes lead to entire layers of enamel being chipped off even on the smooth surfaces. Caries due to impaired saliva quantity has an appearance and location different from ‘general’ caries (Figure 1). The same is true for the loss of tooth mineral due to ‘dental erosion’ which develops as a result of frequent acid intake.

Saliva-pellicle-plaque Saliva is never in direct contact with the dentition. Even at sites where the plaque is removed by the mechanical cleansing effect of the mucosa or the antagonistic teeth, a thin layer of proteins and lipids of salivary origin (the acquired enamel pellicle) covers the enamel (Figure 2). This layer forms immediately after a surface has been completely cleaned, and it has been shown that the pellicle adheres so strongly to the enamel that it is not totally removed during toothbrushing or prophylaxis. The pellicle protects the enamel to some extent from severe mechanical and chemical damage, the latter for instance imposed by acids in the oral environment. The acquired pellicle has been shown to contain 130 different proteins derived from cellular (68%), plasma (18%), and salivary (14%) sources. Laboratory experiments have shown that the pellicle delays the initiation of caries and the dissolution of enamel when teeth are placed in low pH soft drinks. At retention sites dental plaque forms the second layer separating the tooth surface from saliva. Plaque is mainly composed of bacteria in a polysaccharide matrix. Much attention has recently been given to the liquid phase of plaque (the ‘plaque fluid’), as this is the solution often in closest contact with the tooth surface. Mineral dissolution and (re)precipitation processes, as they occur during caries and calculus

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formation, are directed by the composition of the plaque fluid more than by the composition of saliva, although the two are related. Recently, much attention has been given to the biofilm properties of dental plaque, which explain the resilience of bacteria in plaque to antimicrobial treatments and antibiotics.

Enamel composition The calcified tissues in the body are composed of a calcium phosphate mineral phase and an organic matrix. The latter has different roles, such as forming the â&#x20AC;&#x2DC;cementâ&#x20AC;&#x2122; which holds the mineral crystals together, and regulating their formation and regeneration. In enamel, the tissue-forming cells (ameloblasts) secrete an organic matrix onto which crystallites are laid down. This is a process which takes place prior to the eruption of the tooth into the oral cavity. Once erupted, the ameloblasts (being on the outside of the tooth) are worn off and the fate of the enamel is no longer determined by cellularly driven mechanisms but by the interactions between the oral fluids (saliva and plaque fluid) and the enamel. In dentine, on the other hand, the odontoblasts, being on the pulpal side, remain active and deposit secondary dentine after eruption, or tertiary dentine as a result of a chemical or mechanical insult to the teeth. This can be seen as a natural defence mechanism of the body against caries and mechanical trauma. For enamel the body has to rely on saliva as a protective substance. Saliva contains a number of components which have a specific role in this respect. The above-mentioned organic constituents, proteins and lipids, form the enamel pellicle which is a diffusion barrier to acids formed in the dental plaque, and in general regulates dissolution and precipitation processes. Of similar importance are the inorganic components, especially calcium and phosphate ions. In its composition saliva possesses features similar to those of the other body fluids, although the degree of saturation with respect to minerals is different. The mineral phase of enamel consists of an impure hydroxyapatite, HAP. This mineral is the least soluble in a range of calcium phosphates which are found in nature, and more specifically in the body. Two characteristics of this substance need to be discussed in relation to their importance in the oral environment. Firstly, hydroxyapatite is very permissive in incorporating foreign ions in the crystalline lattice. These may be either positively charged (sodium, potassium, zinc or strontium ions) or negatively charged (fluoride or carbonate ions). The concentrations of these impurities in the tissue are influenced by their presence during its formation. These mineral modifications have either a positive or a negative effect on the solubility: carbonate incorporation makes the apatite more soluble, while fluoride incorporation makes it less soluble.

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Secondly, the solubility of the apatite mineral depends highly on the pH of the environment which is therefore the driving force for dissolution and precipitation of hydroxyapatite. Apart from such physico-chemical considerations, other regulatory mechanisms exist, also in saliva. One example of this is ‘nucleators’ for precipitation: solutions which are supersaturated with respect to a given mineral do not necessarily precipitate unless this precipitate can form onto a surface. For calculus formation these nucleators are the plaque bacteria, which facilitate mineralisation of the plaque. In enamel in contact with saliva fluid or plaque fluid, mineral deposition may occur onto the hydroxyapatite crystallites.

Saliva and the Stephan curve The mineral composition of saliva and plaque fluid is given in Table 1 which shows that differences in composition exist between them even though they are presumed to be in equilibrium. At this stage one can only speculate about the causes of this observation. Possibly the ‘solid’ phase of the plaque exchanges ions with the plaque fluid very slowly, which, due to its capillary nature, is never in true equilibrium with the saliva. The calcium and phosphate content and in particular the pH of these liquids determine whether enamel will dissolve (leading to caries) and whether mineral may be precipitated (which would result in calculus formation). At physiological pH, saliva and plaque fluid are supersaturated with respect to the hydroxyapatite phase of enamel. This implies that HAP will precipitate if a suitable precipitation nucleus is available. However, after eating foods or drinks containing fermentable carbohydrates, acids are formed in the plaque leading to a fall and subsequent rise in pH called a ‘Stephan curve’ (Figure 3). When the pH is lowered, the concentration of ions needed for saturation increases and in the pH range around 5.6 (the ‘critical’ pH) the tissues will start to dissolve to maintain saturation. The lower the pH, the faster this demineralisation. As a result, the phosphate and hydroxyl ions released will take up protons (H+) thus slowing down or reversing the fall in pH. Consumption of foods or drinks containing fermentable carbohydrates also increases salivary flow; the increased buffering power of saliva, and the washing out of remaining sugars and acids from plaque, contribute to the pH-rising phase of the Stephan curve. During the recovery phase the plaque gradually becomes saturated and later supersaturated with HAP, and after the critical pH value is exceeded mineral may reprecipitate. Ideally, this occurs at the sites ‘damaged’ during the demineralisation. As mentioned before, the exact composition of the apatite formed depends on the composition of the solution from which it is precipitated, in this case the plaque fluid. If, for instance, fluoride is present, this will ‘co-precipitate’ to form a fluoridated hydroxyapatite. In short, this periodic cycling of pH results in a step-bystep modification of the chemical composition of the outer layers of enamel which

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become somewhat less soluble with time. This process is known as the post-eruptive maturation of the enamel. It has been argued that some demineralisation is beneficial because it will remove the more soluble components of enamel, rich in carbonate, which may be replaced with a fluoride rich component, making the enamel more resistant to subsequent demineralisation.

Caries and remineralisation If frequency of carbohydrate consumption is too high, the redeposition of mineral (during the recovery phase of the Stephan curve) is far from complete and there is a cumulative loss of enamel substance. Then a caries lesion will be formed, which is often the ‘forerunner’ of the caries cavity. A caries lesion is characterised by subsurface loss of mineral while the surface, due its lower solubility, remains apparently intact. Only small pores are ‘etched’ in the surface layer at sites corresponding with the interprismatic regions. These enable the transport of acids into the deeper layers of the tissue and of dissolved ions out of the tissue. Even when a lesion has been formed, saliva can play an important role in preventing excessive decay. With improved oral hygiene or other preventive measures (e.g. fluoride), deposition of mineral from saliva or plaque fluid may take place instead of further tissue loss. In a laboratory model, remineralisation can be illustrated when early enamel lesions are immersed in saliva. From radiographs the disappearance of the radiopacities is evident. Clinically, remineralisation was documented in a longitudinal study of drinking water fluoridation and more recently in various toothpaste clinical trials. In the Dutch Tiel Culemborg study the investigators noted that 50% of the lesions seen at the first molar buccal surfaces of 8-year-old children disappeared during the next seven years. A factor put forward to explain this finding was the further eruption of the teeth which brought the lesions out of the area at risk and in direct contact with saliva from which the remineralisation took place. A closer look at the data revealed that the lesions were seen at rather different stages. In some cases the surfaces appeared chalky and dull, while others were yellowish and shiny. It was concluded that the first type (found more often in the non-fluoridated town) indicated active caries lesions. The dull appearance was due to recently exposed (non light reflecting), acid ‘treated’ enamel, a phenomenon also seen after the deliberate acid etching of enamel prior to placing sealants or composites. The shiny appearance of ‘arrested’ lesions (found more often in the fluoridated town) was due to the deposition of mineral and organic components from saliva in the porous carious enamel. With time such lesions will also accumulate dyes from food and, unless completely remineralised, eventually develop into ‘brown spots’.

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Erosion Acids formed in dental plaque are the cause of dental caries. Recently, attention has also been given to a different group of acids, those which are present in foods and drinks and which have a direct eroding effect on the dentition. Various reviews report that around 30% of adolescents show signs of erosion in their dentition and that erosion is also often seen in very young patients. In erosion, tissue loss does not occur by subsurface demineralisation but by a layer-wise removal of enamel or dentine. The pH in such cases is substantially lower than in dental plaque, with values between pH 2 and 3 not being uncommon in beverages. Apart from being caused by so-called extrinsic sources, erosion may result from gastric fluids (at pH values just above 1) when patients suffer from eating disorders resulting in frequent vomiting or gastroesophageal reflux. Not only is erosion different from caries at the microscopic level, also the distribution around the oral cavity is typical and indicates where acids first come in contact with the dentition and where protective factors are present. The most common site for erosion in some patients is the lingual aspect of mandibular molars. This points to the role of serous saliva and salivary pellicle in protecting the dentition against erosion. Studies to correlate saliva properties with susceptibility to erosion have shown that a low buffer capacity will make individuals more prone to erosion. Salivary flow rates have not been shown to be related to erosion at the individual level. Also in laboratory studies saliva, probably in particular salivary mucins and pellicle, has been shown to slow down the rate of tissue loss. As dental erosion is caused by fluids with very low pH it is easy to explain why fluoride, calcium and phosphate additions have little or no effect in its aetiology. It would require massive amounts of one of these ions to come near to saturation for either HAP or FAP. Recent studies to increase both pH and ion composition have resulted in a beverage with reduced risk for erosion. Obviously such changes to the gastric fluids which cause erosion are not possible.

Calculus Plaque fluid is supersaturated with respect to many calcium phosphate minerals. Mineralisation inhibitors present in plaque prevent these minerals from precipitating unless the inhibitors are degraded by enzymes or nucleators for precipitation are present. It has been shown that dead or â&#x20AC;&#x2DC;dyingâ&#x20AC;&#x2122; bacteria (or components from bacterial cell walls) serve as nuclei for precipitation. Unlike in enamel, where the calcium phosphate mineral is present as HAP, in calculus four different calcium phosphates may be found, with the distribution of minerals being determined by the age of the deposit.

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Because salivary secretions are the main sources of calcium and phosphate in the oral cavity, calculus forms most abundantly on the tooth surfaces opposite the orifices of the main salivary glands. Saliva secretion from the parotid glands may lead to calculus formation on the buccal surfaces of the maxillary molars, while submandibular saliva may contribute to calculus deposition on the lingual surfaces of the mandibular anterior teeth. In addition to the difference between calculus at various sites around the mouth, the variation in calculus from supraand subgingival parts of the tooth should be mentioned. Both are formed as a result of the mineralisation of dental plaque, but for subgingival calculus, crevicular fluid and exudate from infected periodontal tissue substitute for saliva in providing the materials from which calculus is formed. Subgingival calculus develops from subgingival plaque, a process that is not necessarily related to a prior formation of supragingival calculus. Chemical analyses have shown that the mineral density of subgingival calculus is higher, which makes it even harder to remove by a dentist or hygienist. The rate at which calculus forms is variable among individuals. In general, supragingival calculus forms first on the lingual aspects of the lower anterior teeth.

Clinical Highlights The arrest and/or reversal of early caries lesions is a natural and very important means of caries prevention which can be enhanced by intervention. Saliva contains calcium and phosphate at concentrations such that it is supersaturated with respect to hydroxyapatite. As a result, saliva reduces the dissolution of tooth mineral in caries, and replaces mineral (that is, remineralises the crystals) in early lesions. Salivary hypofunction will eliminate both these functions. Salivary stimulation increases its potential for remineralisation. Fluoride in the mouth inhibits demineralisation if it is present in the aqueous phase between the enamel crystals at the time of an acid challenge. Fluoride enhances remineralisation of early lesions by helping calcium and phosphate, derived primarily from saliva, to regrow the surfaces of partially dissolved crystals. This will produce a fluorapatite-like surface which is more resistant to subsequent acid attack. Hence strategies which maintain the ambient level of fluoride in saliva can help control caries. From a clinical viewpoint, a continual supply of elevated levels of fluoride in the mouth is a very effective preventive measure against caries. Methods which deliver fluoride to the mouth (water, toothpaste, mouth rinses or professionally applied topicals) are very effective in caries prevention, even in patients with severely reduced salivary flow. In fact, fluoride is essential in these patients. 151

Because of the supersaturation of saliva, calculus formation would occur much more generally were there no inhibitors of calcification present in saliva and plaque. Teeth in direct contact with strong acids (food or gastric) will be eroded. This process is somewhat delayed by saliva-derived pellicle or salivary mucins. â&#x20AC;&#x192; Table 1 Calcium, phosphate and fluoride levels in human stimulated whole saliva and plaque fluid Saliva: Approximate concentration ranges mmol/l ppm --------------------------------------------------------------------------------------Calcium 0.75 l.75 30-70 Phosphate 2.0 5.0 60 155 Fluoride 0.0005 0.005 0.01-0.10 Plaque fluid: Mean (SD) values mmol/l ppm --------------------------------------------------------------------------------------Calcium ion 0.85 (0.52) 34 (21) Phosphate 11.5 (3.3) 356 (102) Fluoride 0.0049 (0.0027) 0.09 (0.05)

Figure 1

Figure 2

Figure 3

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Chapter 18

Helping the dentally anxious patient

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Many people are anxious about visiting the dentist and undergoing treatment, for a variety of reasons. These include previous bad experiences, perceived fears and sometimes anxiety provoked by family members or friends. The degree apprehension or anxiety is very variable and it is estimated that about 10% of the UK population are at the extreme end of this spectrum and are graded as dentally phobic. Whatever the level of anxiety there are techniques that can be used to help reduce and manage anxiety in the dental setting with the aim of allowing the patient to accept examination and treatment hopefully with the need for anxiolytic drugs or forms of sedation or a general anaesthetic. The broad principles are borrowed from main stream psychology in dealing with a range of anxiety states and phobias of many different kinds. More recently Cognitive Behaviour Therapy (CBT) has been applied to dentistry and in this article we look at two of the main techniques used in this approach, relaxation and distraction skills, and systematic desensitisation.

Relaxation and distraction skills The aim for an introductory session is to introduce the patient to two forms of relaxation techniques and the use of distraction that they can develop for use during future sessions, as well as generally when feeling anxious. Introduce this task by explaining to the patient that typically when they are anxious they create a sense of physiological tension in their body, and that they need to learn the skills to relax their muscles and decrease the tension they are feeling.

Building and maintaining rapport It is important throughout the session, and the therapy in general to continue to address the rapport the clinician has with the patient. At this early stage, it may be worth asking the patient how they feel about this session and to note any feelings of optimism or pessimism. In subsequent appointments or sessions you can ask if they are feeling more or less anxious than attending the previous one. Look for signs of change in the thoughts and level of fear the individual is reporting. Also any changes

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in health status, toothache or other problems (such as work demands) which may have an impact on their ability to work on the tasks set and to attend appointments. There is evidence that both distraction and relaxation are effective techniques in reducing dental anxiety. Relaxation techniques generally aim to address the physiological components of dental anxiety such as increased heart rate, breathlessness, muscle tension and perspiration. Distraction focuses attention away from the distressing procedure or situation. Examples include: • Controlled breathing • Progressive muscle relaxation • Ideas for distraction. Controlled breathing Controlled breathing is a relaxation technique whereby patients are asked to breathe slowly and deeply in a steady rhythm and by using their diaphragm. This can regulate breathing and in turn reduce anxiety. It can be very relaxing in the short term but the patient should avoid overusing this technique otherwise they may hyperventilate and feel giddy.

Progressive muscle relaxation This involves the gradual, deliberate tensing of the muscles of the body and then releasing them, perhaps starting with the feet and working up the body. Each muscle group is first tensed for a few seconds, and then relaxed, before moving to the next muscle group until the whole body is relaxed and the patient feels at ease. Ask the patient to focus on the feelings of tension when they tighten their muscles and their relaxation when they let go. Point out to them that when they are anxious they are using a lot of energy being tense.

Ideas for distraction Distraction techniques can include listening to music, playing video games or watching a TV screen, or carrying out a mental exercise. Distraction is a useful technique for short procedures. A common technique for distraction involves the patient imagining themselves in a safe and pleasant environment or performing mental tasks which take their mind off the physiological changes, for example making mental shopping lists or planning a pleasurable activity.

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Setting homework Relaxation and distraction are skills like any other that needs to be learned and it helps if patients practise relaxation and distraction skills at home and identify which techniques are most useful to them. Homework for the patient is to read information about relaxation and distraction and to practice these skills over the time until the next appointment, ideally recording their attempts in diary form. It might be useful to work with the patient to identify when would be a good time to undertake this homework, and what they should do if they fail to do it on any given day. Typically barriers to performing this type of homework are, lack of opportunity during the day, and patients giving up when it does not seem to work. Point out to them that it may take some time to perfect these skills, and if they put in a lot of hard work it should yield better benefits.

Summary and feedback Summarise what has been achieved in the session including; â&#x20AC;˘ An introduction to relaxation and distraction techniques â&#x20AC;˘ Homework setting Practice relaxation and distraction skills daily Keep a diary of relaxation and distraction practice â&#x20AC;&#x201C; noting which techniques they find most effective. Obtain feedback using the standard two questions;

1. What was most useful in the session today? 2. Was there anything the patient would like us to change in future sessions, because they found it less helpful?

The session ends with confirmation of the next appointment and any questions from the patient. Subsequent sessions will continue to monitor patient success, or otherwise, with the techniques, building on positive progress and revising any elements that the patient is having difficulty with. The objective is to have the patient build an ability to be able to cope with stressful situations and manage them according to use of these skills.

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Systematic desensitisation Systematic desensitisation involves training patients in deep muscle relaxation, constructing a hierarchy of situations that elicit varying and increasing degrees of anxiety or fear and then progressing through the hierarchy in a relaxed, non-anxious state. It is important that the hierarchy is negotiated with the patient. Exposure to actual objects may create too much fear to begin with so the first step of the hierarchy may involve imagining the object or looking at a picture of the feared object. Systematic desensitisation has been shown to be effective in reducing dental anxiety and the effects are long-lasting. Dental situation sort cards can be used to generate a hierarchy of anxiety provoking situations. These cards can be text only or text and images of various situations with the practice and within the surgery environment. Patients can initially identify which of the situations named on the cards provoke anxiety. This is a useful exercise in itself as, although some people are anxious about everything to do with dentistry, it is more often the case that only specific aspects of dentistry are troublesome. Once the situations that do not invoke anxiety have been removed, the remaining cards can then be ordered in a hierarchy from those that are least to most feared. An alternative to the sort cards is simply asking patients what they feel they can and cannot achieve, the list in Table 1 provides a starting point and gives some idea of where to start with the systematic desensitisation. The patient will require several sessions of systematic desensitisation; the idea of these sessions is to work with the patient to gradually build up to perform behaviours that they have been avoiding. After the patient has identified which behaviours provoke anxiety these are broken down into smaller steps and the patient gradually performs each step repeatedly until they can perform them without anxiety, and then gradually building up through the successive step to achieving the goal behaviour. All sessions of systematic desensitisation should have roughly the same structure:

1. Set the agenda for that session â&#x20AC;&#x201C; note which behaviour you are going to be tackling and which step in that behaviour.

2. Review homework and goals from the previous session. The format for this component is largely similar to that included in the description of the relaxation and distraction session.

3. Discuss with the patient which level of the hierarchy you will be undertaking in this session.

4. Summary and feedback. Again the format of this is described in previous sessions. One additional useful tool is to provide feedback to the patient

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describing the achievements they have made – for example completed behavioural tasks.

Following the patient’s training in relaxation, a list of the steps of the systematic desensitisation is drawn up. The patient then tries to achieve the first step. During the step they rate their anxiety on a scale of 0 to 10, where 10 is the highest level of anxiety. If the patient’s anxiety is too high (above 5) then either the step can be broken down further into smaller elements or repeated until their anxiety decreases. Once their anxiety has habituated to that step, the next step is attempted. Patients will vary in the extent the behavioural elements that they need to learn. Below are four examples of common targets for systematic desensitisation with suggested steps and homework to achieve each one. Note that not every step need take one session – some may take longer and some will take less time all depending on the individual. An example is that the injection module is usually completed with two sessions. • Module 1: Entering the surgery and sitting in the chair • Module 2: Oral examination • Module 3: Injections • Module 4: Drilling

Module 1: Entering the surgery and sitting in the chair Going to a local dental surgery each day, walking in, spending time if possible Walking up to the door of the dental surgery and standing at the door for increasing periods of time Waiting in the waiting room for increasing periods of time Look at pictures of dental surgery Note questions about any equipment in the room Going into surgery and sitting in dental chair for increasing period of time (from 1 second building up gradually to five minute periods) Imagine sitting in a dental chair View images of dental chairs Imagine reclining in dental chair Sitting on dental chair and gradually put chair back, at increasing angles Note thoughts when thinking about going back in the dental chair Sitting on dental chair with chair back and the light on. Start with light on shining away from mouth (for example on stomach) Gradually move light further up the body until it is in the position for observing the teeth Imagine sitting in the dental chair with the light on. Note any thoughts. Practise relaxation skills and distraction.

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Module 2: Oral examination Teach the patient the ‘STOP’ signal while sitting in the chair – emphasise that the dentist will stop when the signal is used Sitting in the dental chair and opening mouth for increasing periods of time Imagine sitting in a dental chair with mouth open. Note any thoughts that occur concerning the examination Practise relaxation skills and distraction Patient ‘examines’ them self using a disposable mirror around their mouth Practise daily putting the dental mirror in the mouth Look in a mirror at home to see the dental mirror in the mouth Practise touching teeth with mirror Dentist and patient hold mirror and examine together Dentist performs examination Patient practices use of ‘STOP’ signal

Module 3: Injections Teach the patient the ‘STOP’ signal while sitting in the chair – emphasise that the dentist will stop when the signal is used Looking at the dental equipment Clinician looks and touches the equipment first and explains the purpose of each element Look at a photograph of the injection equipment Show length of needle Looking at the dental equipment: patient looks at and touches some dental equipment Dentist explains the purpose of each element Demonstrates how much liquid is in the cartridge Watch video of a patient having a dental injection Topical anaesthetic: explain role of topical anaesthetic Taste topical anaesthetic and practise having topical on for length of time required Watch video of steps in dental injection Patient has topical anaesthetic applied Capped needle held in mouth for 30 seconds – similar time to that taken for an injection Topical anaesthetic applied: patient has uncapped needle held in mouth for 30 seconds Brief injection - 5 to 10 seconds (<half cartridge) given Full injection

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Module 4: Drilling Teach the patient the ‘STOP’ signal while sitting in the chair – emphasise that the dentist will stop when the signal is used’ Explain difference between feeling the sensation of pressure, and pain: local anaesthetic blocks pain but not vibration Patient advised to buy an electric toothbrush to simulate sensation of having vibrating handpiece in mouth and to use daily Show dental equipment, including handpiece, burs, polishing cups Look at a photograph of the drilling equipment Patient handles dental equipment themselves Listen to sound of drill for increasing periods of time Handpiece (without any attachments) held near mouth and put on Increase period of time that the handpiece runs up to maximum of 1 minute Patient practises use of ‘STOP’ signal Scale and polish Appointment for filling if required As can be appreciated from these lists of suggested activities the desensitising approach is one of gradual, tiny steps taken at the patient’s pace and backed up by the development of trust with the clinician and supported by the relaxation and distraction skills developed in the first part of the therapy. All patients will develop at different rates but the important element is to maintain the gradual progress, reflect, praise and move on to the next small step. Table 1: Assessing the steps patients can manage in undertaking dental treatment Making an appointment Entering the room Walking into the dental surgery Sitting in the chair Sitting back in the chair Light shining on mouth Tolerating things in your mouth Examination X-rays Local anaesthesia Scaling Polishing Drilling Filling Extraction

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Chapter 19

Antimicrobials and periodontal surgery Adapted from the BPS Good Practitioner’s Guide with acknowledgment

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Antimicrobials Antimicrobials have very little place in routine periodontal therapy. It is important to be aware that antibiotic resistance has been increasing in the population over the last few decades. As prescribing clinicians it is essential that we limit the use of antibiotics to situations where a clear evidence base exists, so that patients with specific conditions will benefit. Apart from the risk of microbial resistance, there may be a small but serious risk of anaphylaxis. Wherever possible the old principles of ‘drainage of infection’ and ‘removal of cause’ are still pertinent, and if this can be achieved then the use of antibiotics can be avoided in the management of patients that are systemically well. In terms of periodontal disease there are relatively few indications for using systemic or locally delivery antibiotics. However, there are certain limited circumstances where their use is appropriate and will assist in periodontal disease management.

Systemic antibiotics Chronic periodontitis There is no indication for the use of systemic antibiotics when managing chronic periodontitis.

Aggressive periodontitis Where a diagnosis of aggressive periodontitis has been made systemic antibiotics may be indicated. However, the research remains unclear whether the benefits outweigh the risks. One approach that can be considered is to provide initial nonsurgical treatment without antibiotics and only to consider using them if the results are poor despite excellent oral hygiene and effective root surface debridement. However, it is referral is recommended for a patient diagnosed with suspected aggressive periodontitis for specialist care if available. Antibiotics should be prescribed at the end of a thorough course of conventional

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subgingival debridement carried out in as short a time-frame as possible, usually 7-10 days. A number of antibiotic regimes have been proposed for treatment of aggressive periodontitis however the combination of choice according to current research is amoxicillin 250 mg t.d.s with metronidazole 200 mg t.d.s for 7 days starting on the day of the final debridement. In the UK, changes in the recommended dosages of amoxicillin means that the dose of amoxicillin is 500 mg t.d.s for 7 days. For patients allergic to penicillin, doxycycline 100 mg OD for 21 days (with a 200 mg â&#x20AC;&#x153;loading doseâ&#x20AC;? on the first day) is recommended. It should also be appreciated that a longer course of antibiotics is likely to be met with greater non-compliance than a shorter course. Systemic antibiotics should only ever be used as an adjunct to professionallyadministered mechanical therapy, and not in isolation. â&#x20AC;&#x192; Necrotising periodontal diseases These conditions are relatively rare, but when diagnosed part of the management regime should include the use of metronidazole 200 mg t.d.s for 3 days. Metronidazole is used for its spectrum of action against the fuso-spirochaetal anaerobes associated with this disease. In addition, addressing risk factors associated with the disease (smoking, stress, poor oral hygiene and poor diet) is key to treatment success.

Periodontal abscess A single periodontal abscess should be managed by drainage of the abscess, either by instrumentation during subgingival debridement or incision, and not by use of antibiotics. However, if there is systemic involvement (sign of fever/ malaise) and facial swelling, antibiotics may be helpful in initial management but only when combined with debridement. In cases of multiple lateral periodontal abscesses, involvement of an underlying systemic condition such as undiagnosed diabetes should be considered, and the patient referred for relevant tests.

Local delivery antibiotics There are a range of local delivery antibiotic systems available. However, their indications for use are limited. Use of these systems should only be considered after a course of non-surgical treatment, and certainly not as a first-line periodontal treatment. Local delivery antimicrobials are an adjunct to conventional subgingival debridement and not a substitute for it. Their use can be considered in cases where isolated periodontal pockets have failed to respond to conventional nonsurgical

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treatment on a number of occasions, where there is no detectable calculus at the site, and where the patient is maintaining good levels of plaque control. However, the benefit resulting from their use appears modest. If isolated site(s) are not responding despite good plaque control, referral should be considered.

Periodontal surgery The principles of management of chronic periodontitis revolve around the control of bacterial plaque. The two key aspects of this are effective supragingival plaque removal undertaken by the patient and thorough subgingival debridement performed by the dental professional. Periodontal surgery is another tool in the armamentarium of the clinician in achieving such aims. Periodontal flap surgery is almost invariably performed after a course of thorough non-surgical treatment. It should only be considered in highly motivated patients and the presence of optimal plaque and risk factor control. Following a course of non-surgical treatment in cases of moderate to advanced disease, and despite good plaque control, there may still be residual increased pockets and bleeding on probing. Most patients requiring periodontal surgery should be referred for specialist care unless you have the relevant expertise and experience. The principle aims of periodontal flap surgery are: 1

Access for debridement Removal of subgingival root surface deposits may be difficult where the pockets are deep or where access is poor, in particular molar teeth with complex root anatomy or furcation involvement. With a periodontal flap raised, the root surface can be visualised and cleaned until free of deposits. There may also be scope for pocket reduction or elimination by means of reshaping the bone and soft tissues during surgery. The aim is to achieve both shallow pockets and gingival tissues that are easier to access and clean, both by the patient and professional during maintenance.

Regenerative surgery Conventional periodontal flap surgery heals primarily with the formation of a long junctional epithelium. It is thought that this occurs as a result of epithelial cells being first to grow into the void left around the root surface following surgery. Regenerative surgical procedures, in contrast, aim to promote the regeneration of the periodontal tissues that have been lost through the disease process. The aim is thus to promote re-growth of cementum, periodontal ligament (PDL) and alveolar bone. Such treatment can be more effective in achieving shallow pockets than conventional periodontal surgery in certain situations, such as deep narrow vertical bone defects. 164

Several regenerative approaches are currently in use and are termed Guided Periodontal Tissue Regeneration (GPTR). The aim is to prevent the rapid down growth of epithelial cells into the void after periodontal surgery by introducing a membrane (resorbable or non-resorbable) and hence allowing a protected area for the slower turnover tissues, such as bone and PDL, to form. The use of enamel matrix protein based regenerative materials, such as EmdogainÂŽ, may also be advantageous in terms of attachment gain and probing depth reduction. When applied to a defect, after open flap debridement and surface treatment, enamel matrix proteins aggregate to form a scaffold which promotes bone formation in the defect. Alternatively, the defect can also be directly filled with filler materials to â&#x20AC;&#x2DC;graftâ&#x20AC;&#x2122; the defect. These fillers may either be bone grafts from the patient or from human, animal or artificial sources.

Crown lengthening Crown lengthening surgery involves the removal of the periodontal tissues to increase the clinical crown height for aesthetic reasons or to provide adequate sound tooth tissue for restoration. Crown lengthening surgery may be limited to the soft tissue when the thickness of the tissues are excessive In such cases this can be performed using a scalpel, electrosurgery or soft tissue lasers. However, the dento-gingival anatomy and the position of the soft tissue are, to a large degree, dictated by the position of the underlying bone. In these cases, following removal of soft tissue alone, the gingival margin will rebound during healing to re-establish the soft tissue height above the bone crest, with loss of the amount of crown that was surgically exposed. In such cases a stable position can only be achieved by shifting the entire dento-gingival complex apically. This requires bone removal, and to access the bone a periodontal flap must be raised.

Crown lengthening can be performed to facilitate restorative dentistry and allow access to subgingival restoration margins. Subgingival margins may result from oblique vertical fracture of a cusp or from the removal of extensive caries. In some cases, such as severe toothwear, there may not be adequate coronal tissue for mechanical retention of extracoronal restorations. Crown lengthening is a way to increase this.

Aesthetic crown lengthening uses the same techniques but applied to a different situation. In patients with a high smile line and where the anatomical crown is still partially hidden by an excess of soft tissues (as in cases with delayed passive eruption) a simple gingivectomy may be enough to achieve the desired result. In patients where there is an excess of both soft and hard tissue (as in cases of tooth wear with compensatory over eruption) careful planning with diagnostic wax ups and a periodontal flap procedure with appropriate bone removal may be required to achieve correct tooth and

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gingival dimensions. If crowns or veneers are required as part of this treatment you will need to wait four to six months for the new gingival contour to stabilise before placement.

Management of recession (Mucogingival surgery) There are a number of reliable periodontal surgical techniques available to manage mucogingival problems such as gingival recession. The key indication for such surgery is aesthetics. Whilst other complications of recession can include temperature sensitivity and root caries, these would normally be managed conservatively by appropriate care including dietary analysis, tailored oral hygiene instruction and use of high concentration fluoride preparations.

This type of surgery is technically demanding but can improve aesthetics and long-term stability. The likely extent of coverage can be assessed using the Miller’s classification of the initial recession defect. As a rule surgical root coverage procedures should only be considered for Miller class I and II defects (i.e. periodontally healthy patients).

Class I • Recession not extending to the mucogingival junction • No loss of interdental bone or soft tissue Class II • Recession extending to or beyond the mucogingival junction • No loss of interdental bone or soft tissue Class III • Recession extending to or beyond the mucogingival junction • Loss of interdental bone or soft tissue coronal to the apical extent of the marginal tissue recession Class IV • Recession extending to or beyond the mucogingival junction • Loss of interdental bone or soft tissue level with or apical to the extent of the marginal tissue recession

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