DentalUpdate

November 2018 . Volume 45 . Number 10

„ Social Media: The Dangers of Social Media and Young Dental Patients’ Body Image

„ Restorative Dentistry: Occlusal Splints for Bruxing and TMD – A Balanced Approach?

„ Periodontal Disease: Risk Assessment in Periodontal Disease

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 INSIDE THIS ISSUE

901 COMMENT orthodontic-periodontal interface and understand the CPD Aims, Objectives and Learning Outcomes:
Marginal gains in dentistry? clinical implications and management of patients with To identify and manage developmental defects of
FJ Trevor Burke periodontal disease. enamel in primary molars.
Enhanced CPD DO C Enhanced CPD DO C
902 SOCIAL MEDIA/RESTORATIVE DENTISTRY
The Dangers of Social Media and Young Dental 935 ORAL SURGERY 973 SAFEGUARDING
Patients’ Body Image Prevention and Optimal Management of Peri-Surgical Child Safeguarding in Dental Practice – What you
S Rana and M Kelleher Pain in Dentistry need to know
CPD Aims, Objectives and Learning Outcomes: T Renton D Auld
To understand the possible adverse effects that CPD Aims, Objectives and Learning Outcomes: CPD Aims, Objectives and Learning Outcomes:
new media, the internet and viral trends can have To understand the importance of managing patient To understand the various types of child abuse,
on young patients’ concerns and expectations expectations in managing their pain and be up-to- some of the ways in which these may present in
about their dental and/or facial appearance when date with current recommendations for optimal peri- the dental setting, when to act and where to seek
they are at a particularly vulnerable time in their surgical pain management. help and advice on how to make safeguarding
emotional and physical development. Enhanced CPD DO C referrals, when appropriate.
Enhanced CPD DO C & DO D Enhanced CPD DO C & DO B
947 ORTHODONTICS
912 RESTORATIVE DENTISTRY
How Orthodontic Therapists have Changed the 977 ORAL SURGERY/RADIOLOGY
Provision of Orthodontic Treatment Are Changes in Specific Landmark Anatomy on a
Occlusal Splints for Bruxing and TMD – A Balanced
S Ainscough, D Roberts-Harry, A Shelton, S Littlewood Panoramic Image Suggestive of Maxillary Sinus
Approach?
and T Hodge Disease?
R Jagger and E King
CPD Aims, Objectives and Learning Outcomes: To T Kerai and K Ganesan
CPD Aims, Objectives and Learning Outcomes:
explore how the introduction of OTs has impacted the CPD Aims, Objectives and Learning Outcomes:
To describe different types of occlusal splints orthodontic workforce and changed the provision of To identify changes on panoramic radiographs
and the ways that splints should be used in the orthodontic treatment in both primary and secondary that may indicate maxillary sinus disease of
management of bruxism and temporomandibular care, and address the issues of OT supervision. odontogenic origin and appreciate the limitations
disorders. Enhanced CPD DO C & DO B of panoramic radiography and the necessity for
Enhanced CPD DO C & DO D more advanced radiographic imaging.
952 ORAL MEDICINE
920 PERIODONTAL DISEASE Oral Manifestations of Secondary 985 O&M SURGERY/ RESTORATIVE DENTISTRY
Risk Assessment in Periodontal Disease Hyperparathyroidism: A Case Report and Literature Odontogenic Myxoma of the Maxilla: Diagnostic
L Chapple and I Chapple Review Considerations, Surgical Resection and Prosthetic
CPD Aims, Objectives and Learning Outcomes: J Cheng Rehabilitation
To explain the importance, purpose and impact CPD Aims, Objectives and Learning Outcomes: YEK Gamie, Z Gamie, D Seymour and PH Whitfield
of periodontal risk assessment in contemporary To appreciate the appearance and prevalence CPD Aims, Objectives and Learning Outcomes:
dental practice. of oral and radiographic manifestations and To review odontogenic myxoma and follow a case
Enhanced CPD DO C & DO A appropriate treatment guidelines of secondary from tumour resection to immediate restorative
hyperparathyroidism which may occur as a result of rehabilitation.
928 ORTHODONTICS/PERIODONTICS chronic kidney disease. Enhanced CPD DO C
The Orthodontic/Periodontal Interface Part 3 Enhanced CPD DO C
S Griffiths, S El-Kilani, D Waring, J Darcey and OH 991 TECHNIQUE TIPS
Malik 961 PAEDIATRIC DENTISTRY Prosthodontics: The Admix Impression
CPD Aims, Objectives and Learning Developmental Defects of Enamel in Primary Molars: K Butt and K Dewan
Outcomes: To demonstrate the importance A Review
of multidisciplinary management within the S Marshall and T Kandiah 994 CPD QUESTIONS

CPD in Dental Update in partnership with

EDITORIAL DIRECTOR Chris Deery Tif Qureshi

FJ Trevor Burke Professor of Paediatric Dentistry, School of Dental Elegance, 178 Blackfen Road
Professor of Dental Primary Care, University Clinical Dentistry, Sheffield S10 2TA Sidcup, Kent DA15 8PT
of Birmingham School of Dentistry Ken Hemmings Tara Renton
Consultant Professor of Oral Surgery, King's College London
EXECUTIVE EDITOR
Eastman Dental Hospital, London WC1X 8LD Dental Institute
Angela Stroud David Ricketts
Edwina Kidd
EDITORIAL BOARD Emerita Board Member Professor of Cariology and Conservative Dentistry,
Avijit Banerjee Dundee Dental Hospital
c/o George Warman Publications
Professor of Cariology and Operative Unit 2, Riverview Business Park, Jonathan Sandler
Dentistry Walnut Tree Close, Guildford GU1 4UX Professor and Consultant Orthodontist, Chesterfield
Hon Consultant/Clinical Lead Mike Lewis and North Derbyshire Royal Hospital
Restorative Dentistry (GKT Hospital Trust) Professor of Oral Medicine Damien Walmsley
Faculty of Dentistry, Oral & Craniofacial School of Dentistry, Cardiff University Professor of Restorative Dentistry, University of
Sciences, King’s College London Cardiff CF14 4XY Birmingham School of Dentistry
Steve Bonsor (c/o RCPSG) Louis Mackenzie
The Dental Practice GDP and Clinical Lecturer
21 Rubislaw Terrace University of Birmingham School of Dentistry
Aberdeen AB10 1XE and King's College London
Len D'Cruz Cover Picture: 'The apple bites back'
Philip Ower (Courtesy of Sandip Popat, Consultant in
GDP, Woodford Dental Care, Woodford Restorative Dentistry, John Radcliffe Hospital,
Green, Essex Hillbrow, Liss, Hants, GU33 7PZ
Oxford.)

November 2018 DentalUpdate

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 Comment

Authors' Information
Dental Update invites submission of articles Marginal gains in dentistry?
pertinent to general dental practice. Articles should
be well-written, authoritative and fully illustrated. Readers who have had contacts with big business will be aware of the
Manuscripts should be prepared following the concept of Six Sigma. This was invented at Motorola in 1986 and adopted
Guidelines for Authors published in the April by many companies, most famously by Jack Welsh at General Electric. The
2005 issue (additional copies are available from the concept aims to eliminate error in the manufacturing process. For example,
Editor on request). Authors are advised to submit Trevor Burke in a complex manufacturing process, such as in an aircraft engine, only one
part needs to be defective for the whole engine not to work. Unwanted
a synopsis before writing an article. The opinions
variation spells disaster, so statistical methodologies are used to eliminate this. A company that has
expressed in this publication are those of the
achieved Six Sigma has a 99.997% success rate, which means 3.4 errors per million opportunities to
authors and are not necessarily those of the editorial
make a mistake.1
staff or the members of the Editorial Board. The
Matthew Syed’s book Black Box Thinking2 should be prescribed reading for all dental
journal is listed in Index to Dental Literature, Current
students and practising clinicians, as it addresses, among other topics, ‘The Logic of Failure’, ‘The
Opinion in Dentistry, MEDLINE & other databases.
Blame Game’ and ‘Cognitive Dissonance’. However, it was the section on ‘Marginal Gains’ that
Subscription Information caught my eye. In this, Matthew describes a Six Sigma-like aim for improvement in the Team Sky
Full UK £144 | Europe £177 | Airmail £192 professional cycling team. Their manager developed an approach whereby, if one breaks a big goal
Retired GDP/Vocational Trainee/DCP £85 into small parts, and then improves on each of these (even if minimally), then this would facilitate a
Student (Undergraduate) £49 (Foundation Year) £95 massive increase when all are put together.
11 issues per year Might it be possible to apply the concepts of Six Sigma and marginal gains to dentistry?
Single copies £23 (Europe £27 | ROW £33) In restorative dentistry, indeed in all aspects of dentistry, clinical techniques generally involve a
Subscriptions cannot be refunded. number of stages. If clinicians can improve each stage marginally, might the end product be more
For all changes of address and subscription than marginally better? If I ensure that I have etched the enamel when using a so-called self-etch
enquiries please contact: or Universal bonding agent, the margins of the restoration that I placed will look better (ie will have
accumulated less stain) at five years3 and patients will not complain about suboptimal appearance.
Dental Update Subscriptions
If I ensure that the impression that I take for a lower denture extends just that little bit further, the
Mark Allen Group, Unit A 1–5, Dinton Business Park,
denture will have better support and patient comfort will be optimized.
Catherine Ford Road, Dinton, Salisbury SP3 5HZ
Regarding oral surgery, having recently listened to a great lecture by Tara Renton at
FREEPHONE: 0800 137201
the Dental Update Study Day, post-op pain after removing a wisdom tooth will be reduced by
Main telephone (inc. overseas): 01722 716997
small but significant steps including, pre-operative management of the patient’s expectations,
E: [email protected] consent outside the dental chair (where the patient can hear and retain what is said to them),
Managing Director: Stuart Thompson smart infiltration dentistry, which in the main provides optimal intra-operative pain control, careful
Creative Manager: Lisa Dunbar handling of the tissues and by prescribing NSAIDs pre-operatively. Add to that ‘homecheck’ for
Design Creative: Georgia Critoph-Evans patients in order to provide reassurance. For dental implants, may I suggest that such treatment is
prosthodontically driven, and the use of stents may provide that marginal gain in location of the
Dental Update is published by: George Warman implant.
Publications (UK) Ltd, which is part of the
Mark Allen Group. Of course, success also depends upon carrying out the correct treatment and not
having a premature failure of one aspect of treatment, as per Six Sigma. The use of materials with
research to back them up, rather than own label ones which don’t,4 should help minimize failure.
The first dentine-bonding agent that I used had five bottles, and they weren’t even numbered! If I
made a mistake with one, the complete process would be ruined. If we could achieve a marginal
improvement in our isolation, bonding (or base placement – if you still do that) and restoration
www.markallengroup.com
placement – in increments for example for a non-bulk-fill posterior composite and avoiding
GEORGE WARMAN PUBLICATIONS (UK) LTD overpreparation of the tooth – who knows how much longer the restoration might survive.
Unit 2, Riverview Business Park, Walnut Tree Close,
Extrapolate that to the NHS and fewer restorations would require premature replacement, with a
Guildford, Surrey GU1 4UX
Tel: 01483 304944, Fax: 01483 303191 significant saving to the exchequer. It’s all about doing the little things right. Saying ‘it’ll do’ won’t
email: [email protected] do!
website: www.dental-update.co.uk

References
1. Syed M. The Times: p20. Monday 8 October 2018.
2. Syed M. Black Box Thinking. London: John Murray Publishers, 2015.
The Dental Faculty of the Royal College of Physicians and
Surgeons of Glasgow offers its Fellows and Members 3. Peumans M, De Munck J, Van Landuyt KL, Poitevin A, Lambrechts P, Van Meerbeck B. Eight-year
Dental UpdateDVDQH[FOXVLYHPHPEHUVKLSEHQHÀW
clinical evaluation of a 2-step self-etch adhesive with and without selective enamel etching.
Dent Mater 2010; 26: 1176–1184.
4. Johnsen GF, Le thieu MK, Hussain B, Pamula E, Reseland JE, Lyngstadaas SP. Own brand label
DU ISSN 0305-5000 restorative materials – a false bargain? J Dent 2017; 56: 84–98.
November 2018 DentalUpdate 901
 SocialMedia/RestorativeDentistry Enhanced CPD DO C & DO D

Shivani Rana

Martin Kelleher

The Dangers of Social Media and

Young Dental Patients’ Body Image
Abstract: New media poses new dangers for many younger dental patients and, in particular, to their body image. There is now a
generation of younger dental patients that have grown up entirely in the digital era where social media is just part of their normal life.
Most of the images they are exposed to have some benefits, but others can pose significant risks for them. For instance, images are readily
available to them of the supposed ‘ideal’ dental or facial appearance and sometimes accompanied by some alleged ‘quick fix’ to achieve
dental or facial improvement. There are potential dangers of being exposed persistently to such highly idealized images in that many
adolescents perceive that their happiness is largely dependent on achieving these artificially enhanced versions of alleged dental or facial
beauty. There are dangers in some impressionable young people seeking elective interventions to improve their appearance in various
ways which can have longer term mental or physical health consequences. Dentists need to be aware of these important issues in order to
help younger people avoid various dangers and to help to safeguard their longer term dental and emotional health.
This article aims to provide professionals in various fields with recommendations on advising young patients about some of
the dangers of spurious claims about ‘do-it-yourself’ dentistry or facial aesthetics, as well as helping them avoid destructive or unstable
treatments, especially those of the ‘quick fix’ variety. Caution is advised in relation to dentists and young patients not believing unproven
claims for some treatments.
CPD/Clinical Relevance: It is important to challenge unrealistic aspirations of some adolescents about their appearance early on, in order
to help to manage those expectations more sensibly and thereby avoid later disappointment, complaints or litigation.
Dent Update 2018; 45: 902–910

Many younger people now regard their appearance. adolescents to look beautiful and/or to
smile as a fashion statement. To possess The influences driving such have a fashionable smile?’;
the currently fashionable very white, even desires are probably many and varied „ ‘How do these pressures affect their
smile, many young people have had, or but may be partly related to new self-confidence and mental health?’;
aspire to have, some ‘cosmetic’ dentistry media in its various manifestations. „ ‘Can failure to be ‘liked’ or not
done to achieve their preferred dental Teenagers are bombarded with images considered ‘beautiful’ lead to anxiety
in various media about supposed or depression, particularly in some
Shivani Rana, BDS(Hons), MJDF RCS(Eng), ‘beauty’ and how this can be achieved vulnerable young patients?’.
PgCert(DentEd), Dental Core Trainee 2−3 in different ways, including dentistry Interestingly, there is, as yet,
in Restorative Dentistry, Oral Surgery and various facial aesthetic procedures. little convincing research published
and Oral and Maxillofacial Surgery, Some of these images are carefully which has evaluated the wider or
Department of Restorative Dentistry and concealed, commercially driven longer term negative impacts of
Traumatology, King’s College Hospital advertorials for treatment promising social media on younger people. The
Dental Institute, Bessemer Road, London instant gratification, but they often aim of this article is to consider how
SE5 9RS and Martin Kelleher, MSc, fail to draw adequate attention to the social media influences body image
FDS RCPS, FDS RCS(Ed), FDS RCS(Eng), inherent dangers for someone’s longer concerns, with particular reference to
Consultant in Restorative Dentistry, term facial or dental health. paediatric dentistry. It will assess how
Department of Restorative Dentistry and Some questions that need social media might well have negative
Traumatology, King’s College Hospital to be addressed include: consequences for some vulnerable
Dental Institute, Bessemer Road, London „ ‘What are the likely effects of social individuals, as well as for the dental
SE5 9RS, UK. media in increasing pressure on profession and for society at large.
902 DentalUpdate November 2018
 SocialMedia/RestorativeDentistry

'Perfect Teeth' 'Perfect Lips'

How to get... How to get...
Veneers Lip augmentation

White Lip shape/size

Braces Lip colour
Table 1. Phrases and words linked to search terms ‘Perfect Teeth’ and ‘Perfect Lips’.

Figure 1. Catastrophic tooth surface loss caused

by bulimia in a patient trying to control his body Social media and body in the consequences of social media use
size. Note the ‘enamel ring of confidence’ around image problems and abuse might be effective in limiting the
the periphery of these eroded teeth. negative aspects of its usage.
Adolescence is a time of
increased vulnerability in relation
to anxiety, low self-esteem and Social media usage and dental
Social media statistics depression.3,4 Studies have shown that viral trends
Over the past couple of years, adolescents who spend more time When used responsibly, new
‘fourth-screen’ technology (meaning online and using social media sites media in various forms can lead to exciting
a small portable video screen such as tend to have increased levels of anxiety opportunities. In relation to dentistry, it has
on a mobile phone) has changed the and depression.5,6 Concerns about been suggested that social media could be
way young people communicate with their body image might be one related a key tool for enhancing the effectiveness of
each other. Photo and video-sharing factor amongst others, such as poor good dental health messages.9
applications such as Snapchat and sleep quality and low levels of physical There appear to be benefits in
Instagram exist almost entirely on activity. regards to other aspects of healthcare, from
mobile devices, most of which can fit Ferguson et al reported that, virtual consultations to employing virtual
easily in the palm of the hand and can although social media did not appear reality approaches to treat anxiety and post-
be accessed at any time of the day or to have direct effects on body image traumatic stress disorder, as well as other
night. related outcomes, the negative aspects mental health conditions.
Mobile-based social media has of social comparison were found to However, social media can also
allowed many people to use and be more focused on peers, rather than be dangerous and sometimes has disastrous
combine various services to build a being directly affected by television or personal and legal consequences. It is
comprehensive, digital identity. As of social media exposure.7 now so quick and easy for young people
mid-2016, the most actively used social One systematic review to access both good as well as dangerous
networking platforms, apart from text found that social networking sites content, that it can be difficult for parents/
(SMS) messaging applications, are are associated with increased body guardians to monitor the young person’s
Facebook, Tumblr and Instagram.1 dissatisfaction and disordered eating real usage, owing to its availability being
Data from Greenwood et al across genders.8 One way of controlling 24/7 in nature, and to control or to discuss
showed that 83% of women and 75% body shape is with vomiting/bulimia. everything that children or adolescents
of men use Facebook in the USA, while The consequence of young patients might see, or have seen.
38% of women and 26% of men use who are anxious to control their At some point, whether
Instagram.1 body shape and weight by bulimia consciously or subconsciously, many
It appears that 88% of 18−29 can be devastating for teeth because young people will compare themselves
year-olds use Facebook, whereas 59% hydrochloric acid from the stomach has to someone they may see somewhere
of the same age group use Instagram. a pH of 1 and teeth dissolve below a on social media − be that comparing
It seems that much younger audiences pH of 5.5 (Figure 1). physical appearance, financial status or
may have moved to private messaging Bearing in mind that sense of style. However, those comparisons
apps.1 These percentages slowly engagement in photo-based activities can be deceiving, with filters and photo
decrease in the higher age groups up to on Facebook is sometimes related to a editing applications being used to achieve
those aged 65 and over, where 62% use desire to control body shape, further the desired ‘perfect’ image. For most
Facebook but only 8% use Instagram.1 research should be undertaken into adolescents that comparison will be benign
In the UK, a similar pattern image-based social networking sites, and transient. However, for others it has
can be seen, with the gap for Facebook such as Instagram or Snapchat. the potential to be deeply upsetting and
users between the age ranges having It is recognized that it is to provoke an unhealthy desire to pursue
reduced to 4% between those users difficult to limit exposure to social some speculative treatment to correct
aged 55+ and those aged 15−24 years.2 networking sites, but greater education a perceived dental or facial problem,
November 2018 DentalUpdate 903
 SocialMedia/RestorativeDentistry

but the trend for plumper lips remains.

Over the last 5 years, non-
surgical cosmetic interventions have
gradually become normalized. As treatment
has become more readily available and
acceptable, it remains important to
remember the work of Napoleon, which
showed that there was a high degree of
recognizsable mental illness in patients
presenting for plastic surgery.10 About
25% were narcissistic but there were
also significant numbers with obsessive/
compulsive disorders, paranoia and other
types of recognizable mental illness. One
could envisage these facial augmentation
Figure 2. Results of Pinterest search for ‘Perfect Teeth’. treatments being undertaken in young
patients with under-diagnosed mental
health concerns, with significant longer
term health and/or legal consequences.
Currently, there is legislation in
place to attempt to regulate the provision
of non-surgical facial aesthetic procedures
and there have been steps taken to clamp
down on interventions. The Department of
Health’s Regulation of Cosmetic Interventions:
Research Among Teenage Girls (2013) found
that media is consumed by teenage girls in
a similar way to that of young adults. One
of the conclusions reached was to control
airtime allowed for cosmetic procedure
advertisements, both on television and
radio.11
However, the internet is
Figure 3. Results of Pinterest search for ‘Perfect Lips’. virtually unregulated and that is where
a lot of young people can be exposed
to uncontrolled and possibly dangerous
misinformation which can easily lead them
regardless of the feasibility, desirability, perfect smile have been posted online and in to trouble.
stability, or other consequences of these ‘gone viral’ (ie been widely re-circulated The Review of the Regulation on
elective interventions for their longer term and therefore seen by very many people) Cosmetic Interventions (2013) recommended
oral, physical or mental health. and these may well have significant oral a register for those performing cosmetic
health implications. For instance, in 2015 interventions, classifying dermal fillers as
fans of the then 17-year-old Kylie Jenner, prescription only medical advice, in order to
Search terms used in relation to try to ensure that any practitioners should
dental and facial appearance who had lip fillers placed, invented the
Kylie Jenner Lip Challenge. That challenge be properly qualified. It proposed a ban
If one enters the following terms on inducements to have treatment by, for
involved placing a shot glass over the lips to
into the Pinterest search engine, several example, special financial offers.12 In 2016,
create negative pressure by suctioning. This
phrases appear to be linked to them (Table the Royal College of Surgeons in England
causes vessel engorgement, initiating an
1). stated that only licensed doctors, registered
inflammatory reaction to achieve the end
It is clear from this simple search dentists and nurses should provide
result of lip swelling. Although temporary,
alone that the current perceived desires are cosmetic treatments.13
if done long enough and often enough,
most often for whiter teeth and fuller lips
it could lead to longer term soft tissue
(Figures 2 and 3). Orthodontics
damage − images and videos of which
can be found online on platforms such There have been various trends
Facial augmentation as Twitter and YouTube. Thankfully, the on the internet related to straightening
Strange ideas to achieve the popularity of this ‘challenge’ has reduced teeth including ‘Do It Yourself (DIY) Braces’.
904 DentalUpdate November 2018
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 SocialMedia/RestorativeDentistry

claims for the retention being ‘permanent’,

relapse can and does occur and, when this
happens, this can produce understandable
unhappiness in affected patients.16,17
In 2013, the Philippines Dental
Association gave notice to the general
public not to use DIY dental products owing
to the health hazards. The British Dental
Association might wish to consider taking
similar action too.

Dental bleaching
Kershaw et al found that
Figure 4. Periodontal disease caused by elastic bands.14 artificially whitened teeth elicited preferable
judgements about peoples’ personal
characteristics when they were compared
to those with average coloured teeth.18
and, if deemed suitable for that particular
Night guard vital bleaching is safe when
brand of alignment system, are then sent undertaken by trained dental professionals,
material to take their own impressions. These but there are age and concentration
are returned and are subsequently scanned. restrictions under European Law as the
A computer designs the aligners and bleaching products involved are currently
consumers then receive clear aligner trays to covered by the EC Cosmetics Directive.
Figure 5. Intra-oral view of DIY aligners not undergo this computer-generated treatment
fitting well on the mandibular arch.15
The lack of availability to these safe and
plan (Figure 5). However, patient expectations proven methods of bleaching for those
of the outcomes of treatment do not appear under 18 can influence young people,
to get analysed in any robust way before who believe that their teeth are not white
One ‘DIY Braces’ procedure was shown providing them with such treatment. There enough, to consider alternative routes to
in 2012 using elastic bands with a are no radiographs taken first of all, for the getting lighter coloured teeth. Kelleher
tutorial on how to do this by a Youtuber assessment of bone support, root length explored the ethical, safety and legal issues
(singerforeverlove) which appeared to or periapical status, nor is any clinical in bleaching discoloured teeth in younger
have closed her large midline diastema examination carried out to assess them patients.19 The EC Cosmetics Directive
over 44 days using an elastic band around for gingival biotype or health over already regulations on bleaching in the UK restrict
her front two teeth. The risks which were prominent crooked teeth. Some of these the concentration of bleaching products
not mentioned in that online supposed internet sites offering such treatments may to under 6% hydrogen peroxide and then
tutorial include instability of those very well be off-shore and they may not be only in those over 18. As a result, some
teeth, mobility of the teeth, as well as subject to consumer protection legislation or adolescents have taken to using other
periodontal disease (Figure 4). perhaps the regulations of the General Dental products, such as self-applied Whitestrips
Instead of elastic bands, Council (GDC). which are readily available on the internet.19
patients may buy into newer entrants One can speculate about the Other forms of DIY tooth
to the market including, direct-to-the- question of duty of care and where this whitening methods have gone viral,
consumer DIY orthodontics, ‘Straight might lie in these cases. Young ‘consumers’ including using concoctions made of
Teeth Direct’ and ‘Your Smile Direct’, of such internet advertised services may not baking soda and fresh lemon juice. Lemon
which suggest omitting even consulting be warned adequately of later complications is well known to be very erosive and is
or seeing any registered dentist, let but there may well be some sort of disclaimer dangerous for the structure of enamel.
alone having a detailed assessment by in the small print, which may or may not Interestingly, Colgate recommends a DIY
a GDC accredited orthodontist. As this have been understood by the young person tooth whitening regimen with either
advertising increases on the internet, in at that time. If something appears too good hydrogen peroxide and baking soda
particular, where do the responsibilities to be true, there is usually a good reason for (which is rather akin to micro-abrasion) or
of the Advertising Standards Authority or it. The risks of elective orthodontics include using apple cider vinegar and baking soda
Consumer Rights Act 2015, or the dental complications such as gingival recession, (essentially accelerated acid erosion).20
profession as a whole fit in with these root resorption and relapse.16 Risks seem Despite the casual warnings in the small
worrying developments? to be higher with more complex cases and print about the breakdown of enamel with
In one system, scarcely these may not always be identified initially prolonged use, when a usually reputable
informed patients, or ‘consumers’, are by less experienced clinicians, let alone by toothpaste manufacturer recommends
encouraged to upload their photographs young dental patients. In spite of spurious these unscientific methods, it is easy to see
906 DentalUpdate November 2018
 SocialMedia/RestorativeDentistry

a Another problem with DIY tooth in ‘cosmetic dentistry’. Those marketing

whitening is that there are dangers in young messages can then be heavily promoted on
patients attempting to self-diagnose the new media by search engine optimization.
causes of their possibly discoloured teeth. This blurring between the commercial self-
There are, of course, several causes for interest of some dentists and responsible
discoloured teeth, including caries which, if oral healthcare can, in theory at least, pose
not treated appropriately, can continue to a risk to the longer term health of some
progress to pulpal death with all the known younger patients, but also to the long-term
unfortunate consequences for patients. reputation of the dental profession.
The bleaching product is not In 2014, the Malcolm Pendlebury
b the only issue. In a recent article by Omran, lecture to the Faculty of General Dental
the dangers of DIY tooth whitening were Practice (UK) stated that the dental
highlighted when a 14-year-old female profession should now consider people as
patient needed to have her DIY whitening ‘customers, not clients, or indeed, patients’
tray removed under general anaesthetic as and, by implication, provide them with
it remained in situ once she had placed the whatever they requested.22 This has
‘boil and bite’ thermoplastic material over her serious implications in terms of providing
fixed appliances to create her own whitening whatever the adolescent customer might
tray.21 request, regardless of the unpredictable
Figure 6. (a) A patient presented with relapse of The EC Cosmetics Directive biologic or other consequences for
orthodontic treatment even when undertaken legislation does not appear to be universally young people in the longer term. Many
over a course of 3 years. (b) The spacing was accepted outside of the dental profession, experienced practitioners and indemnifying
camouflaged using composite bonding. with beauticians being seen regularly in organizations, who have had to deal with
shopping malls and advertising various the untoward consequences of aggressive
‘whitening’ products in their beauty ceramic veneers and crowns done in young
a
parlours, with most of these promising people, as well as unstable orthodontics,
rapid results. Most young patients remain would challenge this view.
unaware that these salons are providing According to one market
ineffective and illegal treatments but, owing research company (Mintel), 25% of the
to the advertising on the internet, some British population have received some
are attracted by the idea of a ‘quick fix’ at a form of cosmetic dentistry, with night
low cost. There is no scientific basis for this guard vital dental bleaching being one of
illegal activity, much of which involves using the most popular treatments, which is the
unproven or unregulated products of varying least invasive for young patients who want
b lighter coloured teeth.19
concentrations. Gingival burns can occur due
to the high concentration of the hydrogen Ceramic veneers were also
peroxide used to get short-term superficial recorded as being popular treatments in
colour changes, which usually relapse once these surveys. There has been a move to
the oxygen comes back out of the teeth after digital smile design and also to the use
a few days. of CAD CAM to try to satisfy ‘customer
demand’. Of course consumers have some
rights, but one might ask if it is genuine
The relationship between the healthcare to provide multiple ultra-white
Figure 7. (a) This young patient had been refused dentist and the patient or porcelain veneers just to change the colour
dental bleaching for her fluorosis as she was ‘consumer’ of teeth in someone who is under 18 just
below the age of 18 years. (b) This is the same Young patients may consult because they demand it, and they are
patient following prolonged night guard vital registered healthcare professionals for forbidden by EC and UK law from having
bleaching with 10% carbamide peroxide and
cosmetic dental treatment, possibly with the much safer and scientifically proven
non-destructive direct composite bonding to
the hope of safer and effective treatment. dental bleaching? Would doing multiple
close her anterior open bite.
Some dentists advertise their ‘cosmetic’ destructive ceramic veneers fail a ‘Daughter
skills with terms such as ‘the perfect smile’, Test’23 which states that ‘knowing what I
or advertise their perhaps self-nominated know about dentistry and its consequences in
why patients would then not wish to see a awards on the internet with terms such as the long term would I do this treatment on my
dentist for a proven, safer, more effective, ‘Best Cosmetic Dentist’. They might imply to own daughter?' Would I really leave my own
but more expensive approach using an ADA the public that the recipient has had GDC child with very discoloured teeth until the
approved technique with 10% carbamide approved specialist training or possesses, child is 18? The dental profession should be
peroxide within customized mouthguards.19 by virtue of that award, great expertise allowed and encouraged to look after the
November 2018 DentalUpdate 907
 SocialMedia/RestorativeDentistry

a non-specialists. This is sometimes referred the case even if the patient offers serious
to as ‘anterior alignment orthodontics’ financial inducement for undertaking some
as opposed to ‘short-term orthodontics’. elective treatment which is likely, in the
A quick internet search revealed longer term, to lead to possible adverse
attractive sounding names such as ‘Six outcomes. Failure to disclose appropriate
Month Smiles’, ‘Quick Straight Teeth’ and balancing information in advance is likely
‘Fastbraces’. All of these terms emphasize to invalidate the patient’s consent for such
time and/or speed of delivery but many do elective procedures. Claiming ignorance of
not draw enough attention to the careful such adverse risks is not likely to be easy to
case selection requirements or long-term defend in cases of complaint or litigation.
b consequences, such as indefinite retention A study by Scott and Newton
being required in many cases. found that requests for aesthetic dental
The general public appears treatment and the availability of such
to be keen to explore these seductively treatment options are increasing as the
sounding options rather than having expectations of smile appearance change.
comprehensive longer-term fixed They noted that this has produced
appliances. However, the abilities and increasing concern about body dysmorphic
experience of dental professionals vary disorder in which patients appear to
greatly, and the ability to recognize be overly concerned about perceived
simpler, apparently straightforward cases, minor or non-existent problems in their
c which can indeed be delivered predictably appearance.25
over a short period of time, requires Patients with body dysmorphic
relevant orthodontic knowledge, analytic disorder, or patients with eating disorders,
skills, training and experience. There may potentially influenced by new social
well be a large group of young patients media, may present in dental practices.
currently having ‘short term orthodontics’ A dentist may be the first healthcare
which will have longer term consequences provider to notice these conditions and
of relapse and/or root resorption (Figure possibly be asked to intervene. If this
6). problem is suspected early on, then it is
often advisable to refer these patients, if
Figure 8. (a) Right lateral view; (b) left lateral appropriate, to specialist services.
views; and (c) occlusal view. The role of ethical healthcare However, at times it may well be
professionals appropriate for pragmatic non-destructive
Ethical healthcare professionals treatment to be undertaken, such as in the
need to be able firstly to ascertain whether case of bulimic patients, or those addicted
patients presenting for aesthetic facial to sipping multiple erosive drinks, such as
best long-term dental health interests of or dental care have obvious reasons for restoring significantly shortened eroded
young patients using scientifically proven their particular concerns. Having listened teeth with direct protective resin composite
products that do not damage young carefully to their concerns, it would then because, if treatment is unnecessarily
teeth. be appropriate to discuss the various risks delayed, these powerful acids can produce
Dental professionals should and benefits of different treatments, and irreversible significant tooth surface loss
not be encouraged to provide electively to advise them that, although articles of the upper anterior teeth in vulnerable
destructive ‘cosmetic’ treatment merely and images are available on websites, adolescents (Figure 1).
to satisfy some new media-informed in teenage magazines and in non-peer Another example would be
‘consumer’, which may open the dental reviewed journals, that many are not to young patients with fluorosis requiring
professional up to serious litigation. be recommended as being appropriate dental bleaching (Figure 7), or young
Some orthodontic companies in their particular case. The Montgomery patients with hypodontia who may
have taken advantage of the apparently vs. Lanarkshire Health Board decision be advised to bleach their canines to
increasing narcissism in young people, involved the UK Supreme Court to camouflage the restorative prosthesis better
possibly fuelled by pictures on the uphold patient autonomy in relation to (Figure 8). In these such cases, it would be
internet of very white and even teeth consent and the necessity for healthcare deemed clinically appropriate to provide
and who therefore want to have a professionals to disclose the material risks dental bleaching, despite the patient being
quick solution for mildly crooked teeth. of different treatments.24 An honest and under the age of 18.
This has resulted in the evolution and full discussion of possible problems and This patient was treated at
aggressive promotion of various types the alternatives is necessary and desirable another hospital for her hypodontia for
of short-term orthodontics with these before any irreversible elective dental over 4 years but, as she was under the
tooth movements being done mainly by treatment is undertaken. This remains age of 18 years, she was not provided
908 DentalUpdate November 2018
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 SocialMedia/RestorativeDentistry

with selective dental bleaching of her likely appearance or stability outcomes of personalities in plastic surgery. Ann Plast
canines prior to making the bridges. This any proposed ‘cosmetic’ treatment. Avoid Surg 1993; 31: 193−208.
resulted in multiple colour contrasts and using dangerous words like ‘perfect’ or 11. Creative Research. Regulation of Cosmetic
the disappointing end result after such ‘permanent’, which are absolute terms. A Interventions: Research among Teenage Girls.
prolonged treatment. cautious approach is more likely to result London: Department of Health, 2013.
Overall, patient education in a satisfied patient, particularly if the 12. Keogh B, Halpin T, Leonard R et al. Review
remains the key.8 If young patients request treatment outcomes eventually turn out to of the Regulation on Cosmetic Interventions,
some ‘cosmetic’ improvement to have a exceed the young patient’s now much more London: Department of Health, 2013.
‘Perfect Smile’, or make enquiries about realistic expectations. 13. Royal College of Surgeons. Professional
changing some aspect of their dental Standards for Cosmetic Surgery. The Royal
appearance, then gentle exploration College of Surgeons, 2016.
References
with them of their issues and explanation 14. Marino VA, Fry HR, Behrents RG. Severe
1. Greenwood S, Perrin A, Duggan M. Social
of what is probably the most sensible localised destruction of the periodontium
Media Update 2016. Pew Research Center:
management for them is an appropriate secondary to subgingival displacement of
Internet & Technology, 2016. Available at:
response. The balancing message to get an elastic band report of a case.
http://www.pewinternet.org/2016/11/11/
across is that speculative, destructive, or J Periodontol 1988; 59: 472−477.
social-media-update-2016/ (Accessed 11
unstable dental treatment will not be of 15. Behrents RG. Do-it-yourself impressions
February 2017).
long-term benefit to these vulnerable and clear retainers: a fairy tale. Am J Orthod
2. Clicky Media™. UK Social media stats | 2013
young patients. Dentofacial Orthop 2016; 150: 205−207.
vs 2018. Clicky™. Available at: https://www.
16. Alani A, Kelleher M. Restorative
clicky.co.uk/2016/07/social-media-stats-
Conclusions 2013-vs-2016/ (Accessed 11 February
complications of orthodontic treatment.
Br Dent J 2016; 221: 389−400.
Social media provides 2017).
17. Dental Protection. Capability: the dangers of
unsupervised access to images of 3. McLaughlin K, King K. Developmental
short courses. Annual Review 2014; 23.
current trends in beauty and fashion. trajectories of anxiety and depression in
18. Kershaw S, Newton J, Williams D. The
These images may lead patients to seek early adolescence. J Abnorm Child Psychol
influence of tooth colour on the perceptions
speculative treatments on social media 2015; 43: 311−323.
of personal characteristics among female
which can have longer term negative 4. Orth U, Maes J, Schmitt M. Self-esteem
dental patients: comparisons of unmodified,
consequences for their dental health and development across the life span:
decayed and ‘whitened’ teeth. Br Dent J
appearance. longitudinal study with a large sample from
There are commercially driven Germany. Devel Psychol 2015; 51; 248−259. 2008; E9: 1−7.
advertisements for dubious treatments 5. Banjanin N, Banjanin N, Dimitrijevic L, Pantic 19. Kelleher M. The law is an ass: ethical and
promoted on the internet which are not I. Relationship between internet use and legal issues surrounding the bleaching of
based on sound scientific evidence or depression: focus on physiological mood young patients’ discoloured teeth. Faculty
legal, therefore not safeguarding young oscillations, social networking and online Dent J 2014; 5: 56−67.
patients’ long term wellbeing. addictive behaviour. Comput Human Behav 20. Mool T. How to Make Your Own Teeth
Tech-savvy, often younger 2015; 43: 308−312. Whitening Paste. 2015. Colgate.com.
dentists need to be more active in 6. Pantic I, Damjanovic A, Todorovic J et Available at: http://www.colgate.com/en/
challenging many of these spurious al. Association between online social us/oc/oral-health/cosmetic-dentistry/
claims on the internet in order to networking and depression in high school teeth-whitening/article/how-to-make-
protect vulnerable young people from students: behavioural physiology viewpoint. your-own-teeth-whitening-paste-0315
being harmed by irreversibly damaging Psychiatr Danub 2012; 24: 90−93. (Accessed 11 February 2017).
procedures. One should put patients’ 7. Ferguson C, Munoz M, Garza A, Galindo M. 21. Omran A. DIY whitening. Br Dent J 2017;
interests first and take the time to explain Concurrent and prospective analyses of 223: 239.
honestly the balancing risks and benefits peer, television and social media influences 22. Moyes W. Pendlebury Lecture. London: Royal
of all the realistic treatment options on body dissatisfaction, eating disorder College of Surgeons of England/General
available. symptoms and life satisfaction in adolescent Dental Council, 2014.
As a healthcare professional, girls. J Youth Adolesc 2014; 43: 1−14. 23. Kelleher MG. The ‘daughter test’ in aesthetic
one ought not to carry out electively 8. Holland G, Tiggemann M. A systematic (‘esthetic’) or cosmetic dentistry.
destructive ‘cosmetic’ treatment if it is review of the impact of the use of social Dent Update 2010; 37: 5−11.
against one’s clinical judgement, even if networking sites on body image and 24. Farrell A, Brazier M. Not so new directions in
there are commercial or fashion pressures disordered eating outcomes. Body Image the law of consent? Examining Montgomery
being exerted by practice owners or by 2016; 17: 100−110. v Lanarkshire Health Board. J Med Ethics
patients to do so. 9. Bhola S, Hellyer P. The risks and benefits of 2016; 42: 85−88.
Never over-promise and social media in dental foundation training. 25. Scott S, Newton T. Body dysmorphic
then under-deliver. It seems sensible to Br Dent J 2016; 221: 609−613. disorder and aesthetic dentistry.
be modest in one’s promises about the 10. Napoleon A. The presentation of Dent Update 2011; 38: 112−118.

910 DentalUpdate November 2018

The soft art of Luxury
If your Patient can make an impression on your chair,
then you’ll have made an impression on your Patient.
 RestorativeDentistry Enhanced CPD DO C & DO D

Robert Jagger

Elizabeth King

Occlusal Splints for Bruxing and

TMD – A Balanced Approach?
Abstract: Occlusal splints are classified in this article into three groups according to the way that opposing teeth contact the splint:
1) partial occlusal contact; 2) full occlusal contact in retruded arc of closure; and 3) full occlusal contact in protrusion. Each type of splint
has relative advantages and disadvantages. Splints do not reliably or predictably reduce bruxism and there are differences between
individuals in their response to the wearing of splints. When treating temporomandibular disorders, splints should be provided as part
of a package of conservative physiotherapy type measures. There is no evidence that any one type of splint is most effective. Long-term
wearing of designs that may lead to permanent occlusal changes should be avoided or the patient should be carefully monitored for
occlusal changes.
CPD/Clinical Relevance: The article describes the effect of splints on bruxism. Advice is provided on best practice in respect of the use of
splints in the management of temporomandibular disorders.
Dent Update 2018; 45: 912–918

Occlusal splints and misleading. This, unsurprisingly, has and gives examples of each type. Examples
led to confusion about the value of dental in each group are discussed below.
Occlusal splints are inter-
occlusal splints.
occlusal appliances commonly used in
The purpose of this article is to Partial occlusal contact (relaxation) splints
dental practice to manage bruxism and
describe the different types of occlusal Partial occlusal contact splints
temporomandibular disorders (TMD).
There are many articles and studies on splints and to examine the evidence cover some or all teeth in one arch. When
the effectiveness of occlusal splints. Many relating to their effectiveness in managing the mouth closes, limited tooth contacts are
of the articles provide only opinions and bruxism and TMD. made in any mandibular position, including
many of the studies are not well designed retruded contact position. Prolonged use of
and include different types of patients Types of occlusal splints this type of splint can result in changes in
followed over different periods of time with Many types of occlusal splints the dental occlusion.1
different assessment and outcome criteria. have been described. They may be classified
There is also a large amount of web-based according to the material from which they Soft splint
information regarding treatment of TMD are made or by whether they cover some All teeth are covered by the
with splints, much of which is inaccurate or all the teeth in the dental arch. More splint, which can be made on the maxillary
usefully, they can be classified into three or mandibular arch (Figure 1). Soft splints
general groups according to the way that are made by thermoforming a blank
Robert Jagger, BDS, MScD, FDS RCS, opposing teeth contact the splint: polyvinylacetate-polyethylene sheet (3 mm
Consultant in Restorative Dentistry, Bristol 1. Partial occlusal contact (sometimes or 4 mm) onto a dental cast. No occlusal
Dental Hospital, Lower Maudlin Street, termed ‘relaxation’ splint); adjustment is made. As a result of the hinge
Bristol BS1 2LY and Elizabeth King, BDS, 2. Full occlusal contact in retruded arc of arc of closure of the mandible, initial tooth
MSc, MFDS RCS, Consultant in Restorative closure (often termed ‘stabilizing' splint); contact will be on the posterior part of the
Dentistry, Morriston Hospital, Morriston, 3. Anterior repositioning splint. splint.
Swansea, SA6 6NL, UK. Table 1 shows the three groups of splints Advantages of this type of
912 DentalUpdate November 2018
 RestorativeDentistry

SCi (Sleep Clench inhibitor)

Partial Occlusal Contact Full Occlusal Contact in Full Occlusal Contact in
This appliance was previously
(Relaxation Splints) Retruded Protrusion
called the Nociceptive Trigeminal Inhibition
(Stabilizing Splints) (Anterior Repositioning
Tension Suppression System (NTI-tss). This
Splints)
is a small commercially produced anterior
Soft splint Michigan splint Maxillary bite plane (modified by the dentist at the
chairside) that covers the incisor teeth
SCi Tanner appliance (usually in the maxilla) only (Figure 3). It is
said to stimulate the periodontal ligament
Anterior bite plane Hard thermoformed splint
to activate feedback in order to reduce
Gelb splint (posterior bite Laminate thermoformed Mandibular the contraction intensity of the muscles of
plane) splint mastication. Occlusal changes have been
noted.2 Due to the size, it is susceptible to
Table 1. Examples of types of splints.
being swallowed or inhaled.

Full occlusal contact (stabilizing) splints

a The stabilizing splint aims to
provide a stable occlusion where retruded
contact position is the same as intercuspal
contact position. It is constructed on an
articulated dental cast and adjusted so that
there are equal bilateral contacts in the
retruded contact position. The conventional
stabilizing splint has a flat occlusal surface
and has balanced contacts in lateral
excursions. The stabilizing splint is more
Figure 1. Soft splint. robust than the soft splint and will not
b
produce occlusal changes. It is, however,
more time-consuming and technique
sensitive and is therefore more expensive to
produce.

Michigan splint
This type of splint is constructed
from acrylic resin on the upper arch. It
Figure 4. Michigan splint: (a) in occlusion produces what may be considered an
retruded contact; (b) occlusal view. (Courtesy of ideal occlusion. Ramping is created on the
Dr Andrew Barber). splint to give canine protection in lateral
excursions and equal bilateral incisal
contacts, giving posterior disclusion in
Figure 2. Anterior bite plane.
protrusion. There are no non-working side
splint are that it has reasonable acceptance
occlusal contacts (Figure 4). Construction
and is relatively cheap and easy to make.
and use of this form of splint has been
Disadvantages are that it is relatively bulky,
described in detail by Moufti et al.3
it may need frequent replacement due to
deterioration, particularly in a patient with
sleep bruxism, and it has the potential for Tanner appliance
producing a posterior open bite.1 This has very similar features to
the Michigan splint but is constructed for
Anterior bite plane the mandibular arch.
An anterior bite plane is a soft
or hard splint covering anterior teeth only Thermoformed splint
(Figure 2). Contacts are made by at least This type of splint is less widely
four opposing incisor teeth to prevent used. It is made of a hard material (eg
overloading teeth. An anterior open bite Erkodur, EM Natt, London, UK) or from a
may develop due to over-eruption of hard and soft laminate disc (eg Erkoloc-Pro,
Figure 3. SCi type splint.
posterior teeth. EM Natt, London, UK). The thermoformed
November 2018 DentalUpdate 913
 RestorativeDentistry

a a the splint is to re-capture an anteriorly

displaced disc preventing further disc
displacement and pain and clicking of
the temporomandibular joint. It is usually
constructed on the upper arch with
ramping to slide the mandibular teeth to
the more anterior position. It must be worn
full time for an extended period. Anterior
repositioning splints have been described
by Davies and Gray.5 They have the potential
for occlusal change, particularly a posterior
b open bite.6 They are used specifically for
painful disc displacements. They are not
commonly used and will not be discussed in
b
more detail in this article.

The effects of splints on

bruxism
Bruxism is the repetitive,
sustained habitual clenching and/or
Figure 6. Anterior repositioning splint:
grinding of the teeth and/or bracing or
(a) intercuspal occlusion; (b) maximum thrusting the mandible.7 It is classified into
intercuspation in protrusion on the splint. primary and secondary bruxism.
(Courtesy of Mr Stephen Davies). Primary bruxism can occur as
c awake bruxism (AB) or sleep bruxism (SB).
AB is considered to be a concentration or
stress-related activity or parafunction. Sleep
and are liable to split posteriorly. bruxism is a sleep movement disorder.8
The construction of the laminate Some individuals may exhibit both AB
splint and its use in the management of tooth and SB. Secondary bruxism is associated
wear has been described by Longridge and with medical conditions including cerebral
Milosevic.4 The hard thermoformed splint is palsy and learning difficulties, or it can be a
made in a similar way. Thermoformed splints side-effect of various medications and illicit
are adjusted in the laboratory and/or in drugs.
the clinic to ensure that maximum bilateral Bruxism is associated with a
contacts are made in retruded contact (Figure wide range of detrimental effects such as
d 5). tooth wear, damage to restorations and
The occlusal surface of certain TMD. It can also cause tooth contact noises
thermoformed materials, eg Erkolok Pro, that can be unpleasant for partners of those
EM Natt, London, UK, can be modified by who have SB.
the technician in the laboratory or at the Available evidence is that
chairside by the clinician by adding auto- occlusal splints do not reliably or
polymerizing acrylic resin to provide features predictably prevent or reduce SB. A finding
of a Michigan splint, including anterior of a systematic review of the literature was
ramping that will provide canine guidance in that evidence-based recommendations on
lateral excursions and posterior disclusion in management of SB at the individual level
Figure 5. Thermoformed splint: (a) trimmed protrusion. are not available.9
on the cast; (b) occlusal adjustment on the Studies on SB have given
articulator; (c) in the mouth (occlusal view); (d) in
Anterior repositioning splints contradictory results. Two studies showed
the mouth.
This type of splint is sometimes a reduction in SB with stabilizing type
called a protrusion splint. As in the case splints.10,11 In both these studies, however,
of the stabilizing splint, even contact of a similar reduction was obtained with
splints are relatively easy to construct and fit. all opposing teeth can be made with the comparison appliances that covered only
A laminate splint may be more comfortable splint. The splint, however, holds the lower the palate.
for patients to wear than a hard splint. jaw forward to give maximum contact in In two other studies, neither
Laminate splints, however, are less durable a protrusive position (Figure 6). The aim of occlusal nor palatal splints were found to
914 DentalUpdate November 2018
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 RestorativeDentistry

influence the SB outcome variable.12,13 One after incorporation of the intra-oral appliance records are kept, including diagnosis,
of the studies,13 however, noted that variable is caused by a specific effect of the appliance, discussion of treatment options and
SB outcomes were found in individual cases. such as changes in occlusal contacts or informed consent.
Some patients had a decrease in masticatory occlusal vertical dimension. Records should be made of
muscle activity, while others showed no It is also important to note that follow-up appointments, including review
change or an increase. the effect of a splint on bruxism does not of symptoms and examination of the
A variable individual effect was necessarily correlate with reduction of TMD mouth, to ensure that there are no adverse
also shown by Okeson.14 He investigated associated pain. Nascimento et al found that, effects, and an assessment of the condition
the effects of both hard and soft occlusal although there was no significant decrease of the splint.
splints on night-time muscle activity in 10 in mean masticatory muscle activity of
subjects. Soft polyvinyl splints were found SB subjects using stabilizing type splints, Summary
to increase masseter and temporalis muscle a significant decrease in TMD signs and
This article has classified splints
activity in many subjects, reducing muscle symptoms was observed after 60 days of
into partial occlusal contact splints, full
activity in only one participant while causing use.12
occlusal contact splints in retruded position
a statistically significant increase in muscle Similarly, in the study of Baad-
and full occlusal contact in protrusion
activity in five of the ten participants. The Hansen et al15 reduction in masticatory
(anterior repositioning splint), according to
hard (full contact stabilizing type) occlusal muscle activity with the SCi splint compared
the way teeth in the opposing arch make
splint significantly reduced muscle activity in to the stabilizing splint was not directly
contact. Of these, the anterior repositioning
eight of the ten participants. related to pain reduction.
splints are not widely used.
There is little information about There is no evidence that any
The effects of splints on bruxism
the effect of anterior bite planes on bruxism. specific type of splint is most effective. A
are not well understood. There is no
One study, however, indicated a strong stabilization type splint does not appear
evidence that splints reliably prevent either
inhibitory effect on muscle activity in jaw to be more effective than a soft splint, an
awake or sleep bruxism.
closing muscles during sleep of the SCi anterior bite plane type splint, or even a
When used to manage TMD,
part-coverage type splint compared with a non-occluding palatal splint. As previously
splints should be used as part of a ‘package’
stabilizing type splint.15 It may be concluded mentioned, several studies have reported
of physiotherapy type measures. There is
therefore that splints do not reliably or occlusal changes associated with the use
little evidence that one type of splint is
predictably reduce SB and that there are of partial occlusal contact splints and with
more effective than another.
probably individual differences in response to the anterior repositioning splints. A clinical
Soft splints are widely used as
the wearing of a splint. observation by the authors is that soft splints
they are inexpensive and easy to make but
can exacerbate pain and locking in some
are also relatively susceptible to perforation
patients, but that it is very unusual for that
The effects of splints on to happen with stabilizing type splints. It
by bruxing. They may exacerbate TMD
temporomandibular disorders has been recommended that soft splints can
symptoms and, like other partial occlusal
(TMD) be useful for short-term treatment, whilst
contact splints and anterior repositioning
Temporomandibular disorders splints, they may produce occlusal changes.
stabilizing splints are more appropriate
(TMD) are a range of conditions that affect for long-term use because of their relative
the TMJ and/or the muscles of mastication. robustness and low risk for occlusal change.22 References
The commonly occurring TMD are myalgia, Contemporary guidelines 1. Harkins S, Marteney JL, Cueva O, Cueva L.
arthralgia and disc derangements.16 These for management of TMD state that local Application of soft occlusal splints in patients
presentations have been known by a wide conservative physiotherapy type measures suffering from clicking temporomandibular
variety of names including TMJ dysfunction are used as a first line of management, joints. Cranio 1988; 6: 71−76.
and myofascial pain. Whilst mild symptoms which includes resting the TMJ and muscles 2. Stapelmann H, Türp JC. The NTI-tss device for
are common, TMD is said to affect 5−12% of (by avoiding chewing hard foods, etc), jaw the therapy of bruxism, temporomandibular
the population.17 exercises and heat application.23-25 Splint disorders, and headache − Where do we stand?
There have been a number of therapy is recommended as a measure A qualitative systematic review of the literature.
scientific reviews of articles relating to splint that can be used to supplement these local BMC Oral Health 2008; 8: 22.
treatment for TMDs18-21 and the findings of measures. 3. Moufti MA, Lilico JT, Wassell RW. How to make a
these can be summarized as follows. Full-time wear or long-term wear well-fitting stabilisation splint. Dent Update 2007;
Splints are an effective treatment of specific designs that lead to permanent 34: 398−408.
method for TMDs. Splints have not been occlusal changes should be avoided. If partial 4. Longridge NN, Milosevic A. The bilaminar (dual-
shown to be more effective than other forms contact splints, such as soft splints, are worn laminate) protective night guard. Dent Update
of treatment including, for example, stress long-term, the dental occlusion should be 2017; 44: 648−654.
management, jaw exercises and acupuncture. carefully monitored. The worst case outcome 5. Davies SJ, Gray RJ. The pattern of splint
The mechanism(s) for the benefits with use of splints should be nothing more usage in the management of two common
that splints provide is not clear. It is not than a failure to relieve symptoms.22 temporomandibular disorders. Part I: The anterior
certain that improvement of pain symptoms Good practice dictates that clinical repositioning splint in the treatment of disc

November 2018 DentalUpdate 917

 RestorativeDentistry

displacement with reduction. Br Dent J 1997; 183: evaluation. Sleep Breath 2008; 12: 275−280. 20. Türp JC, Komine F, Hugger A. Efficacy of
199−203. 13. Van der Zaag J, Lobbezoo F, Wicks DJ, Visscher CM, stabilization splints for the management
6. Kai S, Kai H, Tabata O, Tashiro H. The significance Hamburger HL, Naeije M. Controlled assessment of of patients with masticatory muscle pain: a
of posterior open bite after anterior repositioning the efficacy of occlusal stabilization splints on sleep
qualitative systematic review. Clin Oral Investig
splint therapy for anteriorly displaced disk of the bruxism. J Orofac Pain 2005; 19: 151−158.
2004; 8: 179−195.
temporomandibular joint. Cranio 1993; 1: 146−152. 14. Okeson JP. The effects of hard and soft occlusal
21. Fricton J, Look JO, Wright E et al. Systematic
7. Lobbezoo F, Ahlberg J, Glaros AG et al. Bruxism splints on nocturnal bruxism. J Am Dent Assoc 1987;
defined and graded: an international consensus. 114: 788−791. review and meta-analysis of randomized
J Oral Rehabil 2013; 40: 2−4. 15. Baad-Hansen L, Jadidi F, Castrillon E, Thomsen controlled trials evaluating intraoral orthopaedic
8. American Academy of Sleep Medicine. International PB, Svensson P. Effect of a nociceptive trigeminal appliances for temporomandibular disorders.
Classification of Sleep Disorders 3rd edn. Darien, IL: inhibitory splint on electromyographic activity in J Orofac Pain 2010; 24: 237−254.
American Academy of Sleep Medicine, 2014. jaw closing muscles during sleep. J Oral Rehabil 22. Klasser GD, Greene CS. Oral appliances in the
9. Manfredini D, Ahlberg J, Winocur E, Lobbezoo 2007; 34: 105−111. management of temporomandibular disorders.
F. Management of sleep bruxism in adults: a 16. Peck CC, Goulet JP, Lobbezoo F et al. Expanding
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
qualitative systematic literature review. J Oral the taxonomy of the diagnostic criteria for
2009; 107: 212−223.
Rehabil 2015; 42: 862−874. temporomandibular disorders. J Oral Rehabil 2014;
10. Dubé C, Rompré PH, Manzini C, Guitard F, de 41: 2−23. 23. Durham J. Summary of Royal College of Surgeons
Grandmont P, Lavigne GJ. Quantitative polygraphic 17. National Institute of Dental and Craniofacial (England) clinical guidelines on management of
controlled study on efficacy and safety of oral Resarch. Prevalence of TMJD and its signs temporomandibular disorders in primary care.
splint devices in tooth-grinding subjects. J Dent Res and symptoms. https://www.nidcr.nih.gov/ Br Dent J 2015; 218: 355−356.
2004; 83: 398−403. DataStatistics/FindDataByTopic/FacialPain/ 24. Greene CS. Managing the care of patients with
11. Harada T, Ichiki R, Tsukiyama Y, Koyano K. The PrevalenceTMJD.htm. (Accessed 13.12.17). temporomandibular disorders: a new guideline
effect of oral splint devices on sleep bruxism: 18. Al-Ani MZ, Gray RJ, Davies SJ, Sloan P, Glenny AM.
for care. J Am Dent Assoc 2010; 141: 1086−1088.
A 6-week observation with an ambulatory Stabilization splint therapy for the treatment of
25. National Institute for Clinical and Health and Care
electromyographic recording device. temporomandibular myofascial pain: a systematic
Excellence (NICE). Temporomandibular disorders
J Oral Rehabil 2006; 33: 482−488. review. J Dent Educ 2005; 69: 1242−1250.
12. Nascimento LL, Amorim CF, Giannasi LC 19. Dao TT, Lavigne GJ. Oral splints: the crutches for (TMDs). Clinical Knowledge Summaries 2016.
et al. Occlusal splint for sleep bruxism: an temporomandibular disorders and bruxism? Crit https://cks.nice.org.uk/temporomandibular-
electromyographic associated to Helkimo Index Rev Oral Biol Med 1998; 9: 345−361. disorders-tmds (Accessed 15.8.17).

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 PeriodontalDisease Enhanced CPD DO C & DO A

Liz Chapple

Iain Chapple

Risk Assessment in Periodontal

Disease
Abstract: Risk assessment is vital for preventive dental care and validated technologies exist that enable the dental professional to assess
a patient’s risk of developing periodontal disease. Information personalized to individual patients can be presented in a simplified format,
which patients can understand, enabling them to make informed decisions on, and start taking responsibility for, their oral health.
CPD/Clinical Relevance: This paper aims to explain the importance, purpose and impact of periodontal risk assessment in contemporary
dental practice, where a focus on prevention and personalized biofeedback is an ethical and cost-effective way forward.
Dent Update 2018; 45: 920–926

Risk assessment in periodontal behaviours and home care strategies, if foundation for one’s natural dentition and
disease they wish to lower their risk of that disease for successful restorative dentistry, which
developing. is increasingly important given the ageing
Risk assessment is the
Within the field of oral health, population. Effects of periodontitis within
foundation stone for prevention, employing of the available risk assessment systems, the mouth include tooth loss, pain, halitosis,
the latest evidence base to identify those periodontal risk assessment holds pride of aesthetic compromise and reduced
patients who have a higher likelihood place. This is because: masticatory ability, all of which impact
of developing a specific disease, then „ Validated systems have been shown to negatively upon self-confidence and quality
providing them with enhanced preventive predict the likely risk of tooth loss through of life. Beyond the mouth, periodontitis
care pathways. A key aspect involves periodontal disease with a degree of is significantly and independently
persuading at risk people that they accuracy.1 associated with chronic inflammatory non-
differ from the rest of the population „ Assessment of periodontal risk is complex communicable diseases of ageing, including
and therefore have to work harder, both involving genetic, environmental and cardiovascular disease, diabetes mellitus,
with their clinician and in their personal lifestyle exposures, and individual clinician rheumatoid arthritis and chronic kidney
assessment of risk has been shown to be disease.6
highly variable.2 „ Periodontitis is preventable7 but it
Liz Chapple, BA(Hons), Director, Oral „ Susceptibility to periodontal disease is essential to identify it early before
Health Innovations Ltd (UK supplier of varies across a broad spectrum. Some irreversible damage occurs.
PreViserTM and DEPPA technology) and people are disease resistant and others „ Evidence is emerging for positive
Iain Chapple, PhD, BDS, FDS RCPS, exhibit high risk even prior to accounting outcomes on both psychological and
FDS RCS, CCST(Rest Dent), Professor for lifestyle and behavioural risk factors.3 clinical markers of health that can be
of Periodontology and Consultant in „ Periodontal disease matters. Periodontitis achieved through periodontal risk
Restorative Dentistry, Head of School affects 45−50% of the adult population and
of Dentistry and Periodontal Research assessment.8,9
severe periodontitis affects 10% of adults.4
Group, College of Medical and Dental Despite substantial efforts being made in
Sciences and Birmingham Community oral health education and associated oral Aims
Healthcare Foundation Trust, Birmingham health improvements, the prevalence of In 2002, the American
Dental School, 5 Mill Pool Way, severe disease is reported to be increasing.5 Academy of Periodontology stated that
Edgbaston, Birmingham, B5 7EG, UK. A healthy periodontium is an essential risk assessment ‘should be part of every
920 DentalUpdate November 2018
 PeriodontalDisease

comprehensive dental and periodontal which are influenced by genetic, baseline, who had poor plaque control
assessment’. A green paper calling for environmental and lifestyle factors. and generalized gingival inflammation
global action on periodontal disease In health, the commensal but received no dental care or treatment,
endorsed by professional periodontal oral flora exists in a state of symbiosis provides evidence for the spectrum of
organizations throughout the world with each other and with our immune periodontal risk. Over a 15-year period,
states ‘A critical element is that prevention system. When inflammation of the approximately 8% demonstrated rapid
needs to be tailored to the individual’s periodontal tissues occurs due to progression of periodontal disease (high
needs through diagnosis and risk biofilm accumulation, this balance in risk), 11% no progression (resistant) and
profiling’.10 The General Dental Council the microbiota is upset (dysbiosis) and 81% moderate progression (variable
(GDC) places periodontal risk assessment an overgrowth of pathogenic bacterial positive risk).
firmly in its training requirements for phylotypes results. Experimental Whilst bacteria are a necessary
undergraduates.11 Steele’s review of gingivitis studies by Löe et al in 196514 requirement to initiate and potentially
National Health Service (NHS) dental clearly demonstrated that plaque propagate periodontitis, the majority of
care services in 200912 stated that ‘For triggers gingival inflammation, and tissue damage is host-mediated,17 yet
new patients there should be a formal oral also that removal of that plaque biofilm existing management protocols do not
health assessment to evaluate the risks triggers resolution of the inflammatory address host susceptibility; rather they
of all major dental disease (decay, gum process. Subsequent research, however, focus almost entirely on plaque removal.
disease and oral cancer) and the need for demonstrated that the causal association An everyday analogy is that of driving a
treatment. Personalised prevention should between plaque and gingivitis was car: the bacteria are the key that turns the
be started’. not quite that simple. Hillam and Hull ignition, but it is the host response that
The aim of this paper is to demonstrated, in 1977, that gingival moves the car forward by forming the
discuss the logic behind this approach, tissues which were inflamed accumulated gearing and accelerator control system.
and why risk-driven prevention is critical more plaque than healthy non-inflamed Factors known to increase periodontitis risk
if NHS dental care for an increasingly sites in the same people.15 Therefore, are cigarette smoking, poorly controlled
ageing population, with multi-morbidity, plaque causes gingivitis but gingivitis diabetes mellitus, poor oral hygiene and
is to survive. also causes plaque accumulation because local plaque retention factors, which
The aims of this narrative of the additional nutrients supplied intensify the bacterial challenge. Genco
review are: within gingival crevicular fluid exudates and Borgnakke also review the evidence for
1. To review current understanding of from inflamed sites (eg iron from haem), obesity, osteoporosis, low dietary calcium
the roles of the dental plaque biofilm providing periodontal pathogens like and vitamin D and stress as systemic risk
and the host’s immune response in the P. gingivalis with essential nutrition. This factors in their 2013 paper.18
pathogenesis of periodontitis.13 circular process limits the effectiveness of
2. To revisit the evidence that professional mechanical plaque removal
(PMPR) if patients do not implement good
Assessing risk
demonstrates how risk-targeted
oral hygiene practices at home. Indeed, The risk factors for periodontitis
prevention can improve health and
the latest results from the European carry different weights and interactions.
wellbeing.
Federation of Periodontology (EFP) Assessing periodontal disease is not a
3. To introduce the key technologies
consensus review16 states that ‘in relation simple process. Persson et al2 demonstrated
available to assess periodontal disease
to gingival health, there is little benefit to that dentists who examined the same sets
risk and explain how they support
PMPR without oral hygiene instruction (OHI) of patient data came to widely differing
clinicians in decision-making.
and indeed that repeated thorough OHI can conclusions on the grading of risk. When
4. To consider the frequently ignored
achieve a similar benefit to repeated PMPR’. benchmarked against a standardized
intent of risk assessment and the
It is unequivocal that gingivitis risk scoring method (the PreViser™ risk
element we would deem the most
is the precursor to periodontitis and assessment algorithms), they consistently
important: providing patients with
that plaque accumulation is also a pre- under-estimated the level of risk for
simple, personalized information to
requisite: periodontitis will not develop high susceptibility patients.19 A further
empower them to make decisions about
in a pristine mouth or in someone who study by the same group20 demonstrated
their current and future health.
lacks the necessary risk factors. However, that, in their assessment of risk, dentist
it is apparent to any clinician that some scoring was mainly influenced by the
Aetiology and pathogenesis patients with abundant plaque do not presence of existing disease. Disease and
of periodontitis develop periodontal attachment or risk are, however, very different entities,
Periodontitis is a complex bone loss, whilst other patients with the former representing current status
disease. Once considered to be a simple apparently excellent oral hygiene may and the latter the likelihood of disease
bacterial infection, triggered by plaque, suffer from severe periodontitis. Löe et occurring or developing in the future. A
we now know that it requires a series of al's longitudinal study on the Sri Lankan patient with severe disease is logically at
complex interactions between the host’s tea workers,3 a seemingly homogeneous high risk of future disease, but a young
inflammatory and immune responses cohort, aged between 14 and 31 at patient, for example with a large number
November 2018 DentalUpdate 921
 PeriodontalDisease

of unmanaged risk factors, but limited

clinical or radiographic evidence of
disease, could also be at elevated risk.

Periodontal disease risk

assessment systems
In a recent consensus
meeting by the EFP, based upon
underpinning systematic reviews,1
two systems were reported as having
evidence of validity: PreViser™18 (also
provided through DEPPA, the Denplan
PreViser™ Patient Assessment in the UK)
and the Periodontal Risk Assessment
(PRA) tool.21 The predictive ability of
these tools has been demonstrated
in a number of studies.22,23 PreViser™
technology is widely used in general
dental practice in both the UK and
USA. It is an online assessment, which
evaluates 11 factors: patient age,
smoking, diabetes, history of perio
surgery, pocket depth, BOP, furcation
involvements, sub-gingival restorations,
root calculus, radiographic bone height
and the presence of vertical bone lesions.
A fundamental element of the tool is its
patient report, which is designed as a
patient biofeedback and communication
tool. The report (Figure 1) includes
numeric and traffic light coded
representations of periodontal disease
risk (on a scale of 1−5) and severity (on
a scale of 1−100). A graph is produced
which tracks change (improvement/
deterioration) since the previous
assessment. Suggested treatment
options, based on the clinical inputs, are
also provided to discuss with the patient.
The PRA is often referred
to as the spider diagram (Figure 2)
and is widely known from specialist
teaching programmes. Available online
it produces a functional graphical
representation of a patient’s risk
based on six clinical, systemic and
environmental factors being:
1. Percentage BOP;
2. Number of residual periodontal
pockets ≥5 mm;
3. Number of lost teeth;
4. Alveolar bone loss in relation to
patient age;
Please note: ALL types of screening can produce false negatives/positives and NO algorithms are 100% effective. 5. Systemic and/or genetic
predispositions;
Figure 1. Mocked up PreViser™ Periodontal Assessment.
6. Environmental factors such as tobacco
922 DentalUpdate November 2018
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 PeriodontalDisease

How is risk assessment received

by patients?
Evidence from the NHS pilots is
that, funding methodology aside, the oral
health assessment is welcomed by patients
and dentists for its preventive approach.
Patients now expect more information, and
thus control, of their own oral health. More
importantly, empowering patients to play
a stronger role in the maintenance of their
own health requires their understanding of
their specific risk factors for periodontitis,
eg oral hygiene, smoking, losing weight
or acceptance of treatment. Without such
knowledge of their own risk status, the
preventive care plan provided by their
clinician will not be effective in the longer
term. The information patients receive from
a dentist can be confusing. Risk assessment
systems aim to present this information in
a way that patients can understand, placing
knowledge and control in their hands, so
that they can make appropriate decisions.
Risk assessment can also highlight to
patients how they differ from the rest of the
population through numerical comparison.
Figure 2. Functional diagram to evaluate the patient’s risk for recurrence of periodontitis (http://www. In a questionnaire-based survey
perio-tools.com/pra/en/index.asp). published by Newton and Asimakopoulou
in 2016,26 participants expressed a high
level of acceptability of the DEPPA tool. In
particular, the tool was seen as enhancing
use. recall periods, reduction of risk factors, the relationship between the patient and
This tool is designed to be used after intensity of treatment and referral to
practitioner and providing information to
periodontal therapy has been completed. specialists more effectively. Conversely,
support behaviour change.
Other systems include a risk-based prevention also prevents
A further randomized controlled
simplified risk assessment proposed over treatment. As stated in the Steele
trial8 considered the psychological impact
by Trombelli et al,24 which has been report,12 ‘Longer recall intervals are a
of including PreViser™’s individualized
validated against PreViser™, and marker of success, not an abdication of
periodontal risk assessment in
DentoRisk®, developed by Lindskog duty, and the recall interval is integral to
consultations. The study demonstrated
et al,25 where patients’ risk is first a continuing care arrangement. A move
that, relative to those who just had a
determined for their whole dentition away from the six-month interval should
routine consultation, patients who had a
and is combined with a skin test be the prize of a preventively led service,
periodontal risk assessment saw periodontal
for inflammatory reactivity. Where releasing resources for other services’.
disease treatment as more effective, were
DentoRisk® identifies a patient as high Quantifying risk and
more confident in their ability to follow
risk, tooth-based risk assessments can disease by means of scores enables the
a periodontal treatment regimen, and
then be calculated. success of care plans to be objectively
reported higher intentions of adhering to
measured, which is valuable on an
periodontal disease instructions.8
individual, practice and population
How should/does risk level. The incorporation of periodontal
assessment change patient risk and disease markers into capitation Does risk-targeted prevention
care plans? banding calculations can ensure that improve clinical markers of
The aim of risk assessment is sufficient time is allowed for periodontal periodontal health?
to identify patients who are at risk before treatment. Periodontal disease risk levels Axelsson’s7 30-year study began
irreversible damage occurs. By assessing are employed by public and private in 1971 and demonstrated that, by using a
periodontal risk in addition to disease, health providers and insurers to focus risk-based approach to determine intensity
the clinician is able to determine the resources on those who need them of treatment, it is possible to maintain
high risk patient’s care plan in terms of most for prevention. a population with almost no loss of
November 2018 DentalUpdate 925
 PeriodontalDisease

periodontal support. Green D, Laverty D, Dietrich T. Global RC. Perceived risk of deteriorating
More recently, a randomized epidemiology of dental caries and periodontal conditions. J Clin
controlled trial (RCT) presented by severe periodontitis − a comprehensive Periodontol 2003; 30: 982−989.
Asimakopoulou at the IADR 2017, and review. J Clin Periodontol 2017; 21.
21. http://www.perio-tools.com/pra/en/
submitted for publication, showed 44(Suppl 18): S94−S105. index.asp
how, over a 12-month period, a simple 5. Adult Dental Health Survey 2009. 22. Page RC, Martin J, Mancl L, Garcia
behavioural intervention using PreViser™’s 6. Chapple IL. Time to take periodontitis R. Longitudinal validation of a risk
individualized periodontal disease risk seriously. Br Med J 2014; 348: g2645. calculator for periodontal disease.
communication significantly improved 7. Axelsson P. Periodontitis is preventable. J Clin Periodontol 2003; 30: 819−827.
clinical outcomes (bleeding and plaque) J Periodontol 2014; 85: 1303−1307. 23. Matuliene G, Studer R, Lang NP et
and self-reported interdental cleaning 8. Asimakopoulou K, Newton T, Daly B, al. Significance of periodontal risk
vs a routine periodontal assessment at 3 Kutzer Y, Ide M. The effects of providing assessment in the recurrence of
months.8 periodontal disease risk information on periodontitis and tooth loss.
psychological and clinical outcomes: J Clin Periodontol 2010; 37: 191−199.
Conclusion a randomized controlled trial. J Clin 24. Trombelli L, Farina R, Ferrari S, Pasetti
Periodontol 2015; 42: 350−355. P, Calura G. Comparison between
In spite of efforts by the dental
9. Asimakopoulou K, Nolan M, McCarthy two methods for periodontal risk
profession in oral hygiene instruction
C, Newton T. The effects of goal-setting, assessment. Minerva Stomatol 2009; 58:
and general overall improvements in
planning and self-monitoring (GPS) on 277−287.
oral hygiene levels in the population,
behavioural and periodontal outcomes: 25. Lindskog S, Blomlöf J, Persson I et
the prevalence of severe periodontitis is
a randomised controlled trial. IADR al. Validation of an algorithm for
increasing.
2017, abstract 0371. chronic periodontitis risk assessment
The focus of modern
10. Tonetti MS, Jepsen S, Jin L, Otomo- and prognostication: risk predictors,
healthcare systems must move towards
Corgel J. Impact of the global burden explanatory values, measures of quality
patients taking personal responsibility
of periodontal diseases on health, and clinical use. J Periodontol 2010; 81:
for their own wellbeing. Health messages
nutrition and wellbeing of mankind: a 584−593.
delivered to all people are an important
call for global action. J Clin Periodontol 26. Newton J, Asimakopoulou K. The
part of this process, but evidence is
2017; 44: 456−462. perceived acceptability of the
emerging that personalizing data to the
11. General Dental Council. Preparing for DEPPA patient assessment tool: a
patient and presenting it in a simple
practice: Dental team learning outcomes questionnaire survey of Denplan Excel
format so that patients can understand
for registration (2015 revised edition). patients. Br Dent J 2016; 221: 65−69.
their unique health and risk status, carries
12. Steele J. NHS dental services in England:
both psychological and clinical impact.
An independent review. June 2009.
Moreover, it sits well with the new era of
13. Meyle J, Chapple I. Molecular aspects
precision medicine, where patients are
of the pathogenesis of periodontitis.
treated as individuals and the ‘one size fits
Periodontology 2000 2015; 69: 7−17.
all’ philosophy is becoming an approach
14. Loe H, Theilade E, Jensen SB.
from a bygone era.
Experimental gingivitis in man.
J Periodontol 1965; 36: 177−187.
References 15. Hillam D, Hull P. The influence of
1. Lang N, Suvan J, Tonetti M. Risk factor experimental gingivitis on plaque
assessment tools for the prevention formation. J Clin Periodontol 1977; 4:
of periodontitis progression: a 56−61. CPD ANSWERS
systematic review. J Clin Periodontol 16. Needleman I, Nibali L, Di Iorio A. September 2018
2014; 42(Suppl 16): S59−S70. Professional mechanical plaque
2. Persson R, Mancl L, Martin J, Page RC. removal for prevention of periodontal
Assessing periodontal disease risk: a diseases in adults − systemic review 1. C 6. B
comparison of clinicians’ assessment update. J Clin Periodontol 2015;
versus a computerized tool. J Am 42(Suppl 16): S12−S35. 2. B 7. C
Dent Assoc 2003; 134: 575−582. 17. Meyle J, Chapple I. Molecular aspects
3. Löe H, Ånerud A, Boysen H, Morrison of the pathogenesis of periodontitis. 3. D 8. C
E. Natural history of periodontal Periodontology 2000 2015; 69: 7−9.
disease in man, rapid, moderate and 18. Genco RJ, Borgnakke W. Risk factors 4. B 9. D
no loss of attachment of Sri Lankan for periodontal disease. Periodontology
laborers 14−46 years of age. J Clin 2000 2013; 62: 59−94. 5. B 10. B
Periodontol 1986; 13: 431−440. 19.
19. www.previser.co.uk
4. Frencken JE, Sharma P, Stenhouse L, 20. Persson R, Attstrom R, Lang NP, Page
926 DentalUpdate November 2018
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 Orthodontics/Periodontics Enhanced CPD DO C

Sarah Griffiths

Sara El-Kilani, David Waring, James Darcey and Ovais H Malik

The Orthodontic/Periodontal
Interface Part 3
Abstract: Adult patients are increasingly seeking orthodontic treatment. It is essential to establish optimal periodontal health in
these patients before embarking on such treatment, which demands the interaction between the general dental practitioner (GDP)
and orthodontist for effective management. This article focuses on the management of periodontal disease in orthodontic patients,
orthodontic considerations, retention and complications that may arise. This is demonstrated throughout a series of clinical cases treated
within a multidisciplinary team. The management of patients with periodontal disease is often challenging; the clinical issues that require
consideration are discussed throughout this article.
CPD/Clinical Relevance: This article provides a summary of the orthodontic and periodontal implications of different treatment
techniques and management for the general practitioner.
Dent Update 2018; 45: 928–934

Adult patients are increasingly requesting undertaking orthodontic treatment response.5 It is this inflammatory response
orthodontic treatment. An epidemiological has increased significantly, especially that results in the collateral damage of
study at the Eastman Dental Hospital since 1985.1 This may be due to social tissue breakdown.6 Many risk factors
revealed that the number of adults acceptability of appliance therapy, with the have been identified that may influence
main motivation of adult patients being the periodontal disease progression which are
desire to improve their dental appearance.2 listed in Table 1.
Sarah Griffiths, BDS, MFDS RCS(Ed), Adults can be excellent The destruction of bone,
StR in Orthodontics, Sara El-Kilani, candidates for orthodontic treatment. periodontal ligament and connective
BDS, MOrth RCS(Ed), StR in Othodontics, They are motivated and co-operative, tissue fibres joining adjacent teeth has
David Waring, BChD, MDentSci, MFDS however, consideration must be given to a significant role in stabilization of the
RCS(Eng), MOrth RCS(Ed), FDS(Orth) the periodontal condition in this group tooth position within the soft tissue
RCS(Ed), Honorary Clinical Teaching of patients. Periodontitis is a common environment.7,8 Loss of this connective
Fellow/Consultant Orthodontist, James problem in adults. It has been found that tissue attachment can lead to drifting,
Darcey, BDS, MSc(OMFS), MDPH, 72% of adult patients have at least one tilting or rotation of teeth (Figure 1).
MFGDP RCS(Eng), MEndo RCS(Ed), site with clinical attachment loss (CAL) Periodontally compromised
FDS Rest Dent RCS(Ed), Consultant equal to or more than 3 mm.3 Furthermore, patients often present with:
in Restorative Dentistry, University of the cumulative impact of periodontal „ Mobile teeth;
Manchester Dental Hospital, Higher challenges over a lifetime may result in „ Proclined incisors;
Cambridge Street, Manchester, M15 6HF older patients having more CAL. „ Spacing due to drifting of teeth or early
and Ovais H Malik, BDS, MSc(Orth), Though plaque has a significant loss of teeth;
MFDS RCS(Ed), MOrth RCS(Eng), MOrth role in the aetiology of periodontal disease, „ Rotations;
RCS(Ed), FDS(Orth) RCS(Eng), Consultant the seminal work of Löe and colleagues4 „ Overeruption of teeth.
in Orthodontics, University of Manchester demonstrated that plaque alone is not the It is essential that referring
Dental Hospital, Higher Cambridge Street, critical factor in disease progression. There practitioners control periodontal disease
Manchester, M15 6FH, Salford Royal NHS is a complex interaction in the subgingival before referral. The signs of periodontal
Foundation Trust and Northenden House environment between disease-causing disease include:
Orthodontics, Sale Road, Manchester M23 bacteria, their numbers and virulence within „ Presence of plaque or calculus with
0DF, UK. the biofilm and the host inflammatory inadequate oral hygiene;
928 DentalUpdate November 2018
 Orthodontics/Periodontics

Systemic Local disease stability.12

Diabetes Poor oral hygiene

Corrective therapy
Decreased immunity, eg Leukaemia, HIV/ Poorly contoured dental restorations If, after initial therapy, the oral
AIDS hygiene has improved but there are some
isolated, residual active periodontal pockets,
Smoking Plaque
these may benefit from more targeted
Hormonal changes Calculus treatment. Further non-surgical treatment
could be undertaken using site-specific
Genetics Gingivitis
curettes but, when residual pockets exceed
Age 6 mm and show disease activity with
Table 1. Systemic and local risk factors for periodontal disease. bleeding on probing, it may be necessary to
consider surgical instrumentation.13 Surgery
allows the following:
„ Access for root surface instrumentation;
of Periodontology updated its guidelines „ Modification of gingival morphology to
in 2016 indicating that all BPE code 3 improve plaque control; and
and 4 sextants should have relevant „ Facilitation of pocket reduction via
radiographs.9 The Faculty of General Dental healing with long junctional epithelium or
Practice (FGDP) indicates that vertical simply by recession.
bitewings should be taken when a patient „ Surgery should not be considered in
has pocketing of more than 6 mm (BPE patients with poor oral hygiene, smokers or
score 4), which should be supplemented medically compromised patients.
with periodical radiographs at sites where
Figure 1. Patient presenting with proclined alveolar bone image is not included.10 Supportive periodontal therapy
incisors, spacing and drifting of teeth. Following active treatment,
Periodontal management prior maintenance therapy must be planned
to orthodontic treatment for the patient. This will involve targeted
instrumentation of residual pockets and
The sequence of disease
bleeding sites, reiteration of oral hygiene
„ Subgingival calculus; management includes three fundamental
and continued motivation. The intervals for
„ Recession; stages:
supportive periodontal therapy should be
„ Bleeding on probing (BOP); 1. Cause-related therapy (initial therapy);
based upon patient risk factors.11 The GDP
„ Mobility; 2. Corrective therapy;
should aim for pocket depths less than 5
„ Radiographic evidence of alveolar bone 3. Supportive periodontal therapy
mm without bleeding and bleeding and
loss; (maintenance).
plaque scores less than 15%; ideally BPE
„ Probing depths >4 mm (CAL). scores of 0. By definition, many patients
However, especially for those Cause-related therapy requiring orthodontic treatment will have
patients that self-refer into orthodontic This includes patient education, imbrications and crowding automatically
practices, it is important that orthodontists motivation, oral hygiene instruction and generating BPE scores of 2, as crowding
undertake a basic periodontal examination smoking cessation advice. This instruction automatically generates a plaque retention
(BPE) on new patients to screen for disease. phase underpins the success of any future factor.
Should a formal diagnosis of chronic care and cannot be underestimated. Periodontal screening for
periodontitis be made, any orthodontic From here, removal of subgingival plaque children and adolescents assesses six index
ambitions must be put on hold and the and calculus with targeted root surface teeth (UR6, UR1, UL6, LL6, LL1 and LR6)
disease investigated. It is imperative to instrumentation of all pockets >3 mm using a simplified BPE to avoid the problem
liaise with the patient’s GDP at this point. should be performed. This should be of false pockets.14 BPE codes 0−2 are used in
The GDP should pick up the referral with undertaken with local anaesthetic the 7- to 11-year-olds, while the full range
a thorough patient examination including over multiple visits. It also important to of codes 0, 1, 2, 3, 4 and * can be used in the
BPE, radiographs and, if necessary, a six identify and remove any plaque retentive 12- to17-year-olds.
point periodontal chart. The choice of restorations. Once completed, no further Once the GDP is satisfied
radiograph is dependent upon extent probing should be undertaken until a that the periodontal disease is under
of disease and the improved diagnostic review (for 6-point charting and bleeding control, consideration can then be given
yield of vertical bitewings and selected on probing) in 2−3 months, depending for orthodontic treatment, an example
periapicals over orthopantomograms upon risk factors.11 On review, an absence of which is shown in Figure 2. If the GDP
cannot be understated. The British Society of bleeding on probing is suggestive of feels that specialist support is necessary
November 2018 DentalUpdate 929
 Orthodontics/Periodontics

a a

b
Figure 2. Patient who has undergone periodontal
treatment and is now ready for orthodontic
treatment. Note the excellent oral hygiene and
healthy gingivae. b

Figure 5. (a, b) Gingival defect and mucogingival

surgery.

to control the periodontal disease, the

British Society of Periodontology has d
published useful guidance and levels of
complexity for when to refer a patient.
A referral should be made to a specialist
when there is severe horizontal alveolar
Figure 3. Case demonstrating molar tubes bone loss (>50%) with evidence of true
being used to avoid gingival overgrowth (a) in pocketing of 6 mm or more.15
comparison to (b) in which bands have been Alternatives to orthodontic
used, leading to overgrowth of gingivae. treatment should be explored with the
patient. This may include restorative
e
camouflage with directly bonded
restorations and/or extraction of more
severely displaced teeth.

Orthodontic considerations
In patients with stabilized
periodontal disease, it is critical to
maintain effective plaque control,
therefore it is ideal to keep appliances Figure 6. (a−e) Case 1: Pre-treatment intra-oral
and mechanics simple. Placement of a images of 58-year-old woman who presented
fixed orthodontic appliance can induce with periodontal disease.
plaque accumulation due to the difficulty
Figure 4. Diagram to illustrate the apically of cleaning adequately around bands
repositioning of the centre of resistance following and brackets. A study comparing the bacterial categories increased in number
periodontal disease which has led to reduced
microbial populations before and after after fixed appliance placement. It was
periodontal support.
orthodontic treatment showed that all also found that the greater the number
930 DentalUpdate November 2018
 Orthodontics/Periodontics

a a need to be adapted for patients with

previous periodontal disease. Where
there is a reduced periodontium, there
is a reduced periodontal ligament
(PDL) surface to receive orthodontic
forces. The centre of resistance of the
tooth is displaced more apically and
therefore there is an increase in the
extrusive component of the applied
force. This has been demonstrated in
b
Figure 4. Teeth tend to tip rather than
b move bodily due to the repositioning
of the centre of resistance. The use of a
light force and rigid working archwire
will reduce this tendency.
Reduced periodontal
support with the same force
against the crown produces greater
pressure in the PDL, therefore lighter
orthodontic force should be used to
c
move teeth with reduced periodontal
c support to reduce the risk of
undermining resorption.
Correcting an increased
overbite in adult patients can be
challenging. Since adults lack growth
potential, any attempt to correct the
overbite by extruding posterior teeth
will not be stable and will risk further
reduction of periodontal support
Figure 7 (a-c) Case 1: Molar tubes were used to of molar teeth. Overbite reduction
avoid gingival ovegrowth. A push coil was used
d
can be achieved either by surgical
in the lower right quadrant to create space for methods (segmental osteotomy) or
the lower right second premolar with a premolar
orthodontic methods alone (intruding
extraction in the lower left quadrant. The patient
anterior teeth).
maintained an excellent standard of oral hygiene
throughout.
Utility arches such as the
Burstone arch can reduce overbite
by relative intrusion of anterior
teeth. Care should be taken to avoid
of orthodontic auxiliaries, the greater the extrusion of molars. Temporary
increase in microbial populations.16 Anchorage Devices (TADs) inserted at
e
Considerations should be given the posterior region can be used to
to: prevent the extrusion of molars. TADs
„ Avoiding hooks, elastics and excessive can also be used directly to intrude
composite following bracket placement; anterior teeth. When TADs are inserted
„ Wire ligatures should be used where
between incisors they should have
possible instead of elastomeric modules;
a low profile so that the direction
„ Consider bonds/tubes on molar teeth
of traction is not labial to the crown
instead of molar bands (Figure 3a, b)
surface to prevent proclination of
Throughout treatment it is important for Figure 8. (a-e) Case 1: Post-treatment views. incisors during intrusion.
the patient to continue to see the GDP or Upper and lower bonded retainers placed to
hygienist for regular 3-monthly scaling avoid relapse.
and maintenance with a full periodontal Orthodontic consent
re-examination every 6-months. Close The consent process is
communication is essential between removed if oral hygiene and/or periodontal extremely important for patients with
orthodontist and GDP and patients disease deteriorates. previous periodontal disease. Risks
should be warned that appliances will be Orthodontic mechanics often discussed should include:
November 2018 DentalUpdate 931
 Orthodontics/Periodontics

c
Figure 10. Case 2: Pre-treatment OPG radiograph showing moderate horizontal bone loss.

„ Stopping treatment early if periodontal ensuring patient factors are addressed and
disease becomes active; monitored alongside careful orthodontics.
„ Enforced extractions;
„ Longer treatment time; Case 1
„ Relapse.
The following case shows pre-
d and post-treatment images of a 58-year-old
Orthodontic retention female who presented with periodontal
Orthodontic retention is a disease. The patient was keen to improve
crucial part of any orthodontic treatment, her smile with orthodontic treatment. She
but particularly important for teeth that presented with crowding in the upper and
have been periodontally involved, as the lower arches with rotation of the lower left
potential for relapse is high. A long-term canine and drifting of the upper left lateral
permanent (bonded) retainer prevents incisor (Figures 6 a−e).
relapse by maintaining alignment, but After a period of periodontal
allows some physiological movement. and restorative treatment from the patient’s
e
However, this bonded retainer should be GDP, orthodontic fixed appliances were
cleanable to prevent plaque accumulation commenced (Figures 7a−c). The final
and allow adequate oral hygiene. result is shown in Figures 8a−e, which was
a compromised finish with some areas
Orthodontic complications of gingival recession and black triangles
present between incisors and premolars.
Complications that can arise
However, the patient was extremely happy,
following orthodontic treatment in the
with the final result improving her self-
periodontally compromised patient
confidence.
Figure 9. (a−e) Case 2: Pre-treatment intra-oral can include gingival inflammation,
views. gingival recession, alveolar bone loss,
dehiscences, fenestrations, black triangles Case 2
forming between incisor teeth and root The following case shows pre-
„ Risk of disease progression and risk to shortening. Figure 5 shows gingival and post-treatment images of a 47-year-
dental health; defects and mucogingival surgery. old female who had a previous history of
„ Treatment outcomes may be limited; Complications can be minimized by periodontal disease (Figures 9 a−e). The
932 DentalUpdate November 2018
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 Orthodontics/Periodontics

a pre-treatment OPG radiograph in Figure 10 summary of developments, clinical

shows moderate horizontal alveolar bone implications and future directions.
loss, particularly in the lower incisor region. J Periodont 2000; 14: 216−248.
The patient maintained an excellent 7. Taylor C, Roudsari RV, Jawad S, Ashley
standard of oral hygiene so treatment MP, Darcey J. The aetiology and
involved extraction of the maxillary second management of labial and vertical
premolars and fixed appliances. migration of maxillary incisors: ‘Do you
Figures 11 a−e shows the final catch my drift?’. Br Dent J 2014; 216:
result, which is a compromise. However, 117−123.
the patient was extremely happy with 8. Johal A, Ide M. Orthodontics in the
b
the result. This case shows an example adult patient, with special reference
of the standard of oral hygiene expected
to the periodontally compromised
throughout treatment and how an
patient. Dent Update 1999; 26:
excellent result can still be achieved.
101−108.
9. British Society of Periodontology.
Summary Important News: Revised BPE Guidelines
This article has described are now available. BSP, March 2016.
the different orthodontic treatment Available from http://www.bsperio.
techniques and considerations when org.uk/news/important-news-
undertaking orthodontic treatment in revised-bpe-guidelines-ar
patients following appropriate periodontal 10. The Faculty of General Dental Practice.
c management. It is imperative to ensure 5.2 Recommendations. Available
that any patient with periodontal disease from http://www.fgdp.org.uk/
has had successful periodontal treatment publications/selection-criteria-for-
before embarking on a course of dental-radiography1/5-radiographs-
orthodontic treatment.
in-periodontal-assessment-/52-
recommendations.ashx
References: 11. Darcey J, Ashley M. See you in three
1. Khan RS, Horrocks EN. A study of months! The rationale for the three
adult orthodontic patients and their monthly periodontal recall interval: a
d treatment. Br J Orthod 1991; 18: risk based approach. Br Dent J 2011;
183−194. 211: 379−385.
2. McKiernan EX, McKiernan F, Jones ML. 12. Lang N, Joss A, Orsanic T, Gusberti
Psychological profiles and motives of F, Siegrist B. Bleeding on probing.
adults seeking orthodontic treatment. A predictor for the progression of
Int J Adult Orthod Orthognath Surg periodontal disease? J Clin Periodontol
1992; 7: 187−198. 1986; 6: 590−596.
3. Steele J, Treasure E, O’Sullivan I, 13. Lindhe J, Socransky SS, Nyman S,
Morris J, Murray J. Adult Dental Health
Haffajee A, Westfelt E. Critical probing
Survey 2009: transformations in British
depths in periodontal therapy.
oral health 1968−2009. Br Dent J 2012;
J Periodontol 1982; 9: 323−336.
213: 523−527.
14. Ainamo J, Nordblad A, Kallio P. Use
e 4. Löe H, Anerud A, Boysen H, Smith M.
of the CPITN in populations under
The natural history of periodontal
20 years of age. Int Dent J 1985; 34:
disease in man. The rate of
periodontal destruction before 40 285−291.
years of age. J Periodont 1978; 49: 15. British Society of Periodontology.
607−620. The Good Practitioner’s Guide to
5. Socransky SS, Haffajee AD. Microbial Periodontology 3rd edn. BSP, March
mechanisms in the pathogenesis of 2016. Available at http://www.
destructive periodontal diseases: a bsperio.org.uk/publications/good_
critical assessment. J Periodontal Res practitioners_guide_2016.pdf?v=3
1991; 26: 195−212. 16. Bloom RH, Brown LR. A study of the
Figure 11. (a−e) Case 2: Post-treatment views. 6. Page RC, Offenbacher S, Schroeder HE, effects of orthodontic appliances on
Upper and lower bonded retainers placed to the oral microbial flora. Oral Surg Oral
Seymour GJ, Kornman KS. Advances
avoid relapse.
in the pathogenesis of periodontitis: Med Oral Pathol 1964; 17: 658−667.
934 DentalUpdate November 2018
 Enhanced CPD DO C OralSurgery

Tara Renton

Prevention and Optimal

Management of Peri-Surgical Pain
in Dentistry
Abstract: It is every patient’s right to expect optimal pain management in relation to routine elective surgery. Dentistry is a profession
predicated upon causing and/or managing pain in patients. Poorly managed pain, or severe pain, peri-operatively, is the predominant
cause of complaints in NHS dentistry, often leading to legal or GDC scrutiny. Whether the unexpected or persistent pain initiates the
patient’s suspicions about possible sub-optimal treatment, which then precipitates a complaint, is a possible hypothesis. For now,
however, focusing on managing the patient holistically using up-to-date pain management should be a priority for all dental teams.
Recent evidence highlights the risks of opiate and opioid dependence and mortality. In addition, the minimal benefit these medications
provide for peri-operative pain management compared with other over-the-counter (OTC) analgesics is recognized. Competent patient
management, optimal local anaesthetic techniques and intelligent prescription of non-steroidal anti-inflammatories and paracetamol are
the mainstay for odontogenic and surgical pain management.
CPD/Clinical Relevance: It is imperative that dental teams are familiar with current optimal peri-surgical pain management to optimize
the patient’s experience and minimize complaint.
Dent Update 2018; 45: 935–946

The definition of pain is that it is ‘an without a brain you won’t feel pain! Your inflammatory pains are protective and
unpleasant sensory and emotional experience little finger or tooth doesn’t feel the pain, healthy pains. Persistent neuropathic or
associated with actual or potential tissue it’s the brain’s somatosensory cortex that centralized/dysfunctional pains are a result
damage, or described in terms of such overlays the pain experience on the digit or of disease of the pain neuromatrix due to
damage’ (International Association for tooth that is in danger, to effect appropriate multiple changes in the functioning of the
the Study of Pain, IASP).1 Please dwell on protective behaviours (including removing peripheral and central nervous system, with
this definition, it proposes that pain can your digit from harm or escaping the resultant psychological and behavioural
potentially occur with no physical damage dental chair!). The brain tells whatever part changes. The understanding of pain has
(for example, have any of you been dumped of your body that’s getting hurt to move progressed significantly over the last 10
by text?) or at the prospect of impending away from the cause. When this system is years with the identification of these four
pain (for example a forthcoming visit to the disconnected, that is when healthy healed types of pains (Figure 1).2
dentist). Your brain is the ‘boss’ of pain, as tissue continues to ‘feel‘ pain, which is due Acute pain is ‘the normal,
to the brain continuing to overlay the pain predicted physiologic response to trauma
to the healthy tissues. This is the cause of which can be chemical, thermal, or
Tara Renton, BDS, MDSc, PhD, FDS RCS, chronic or pathological (also suspected to mechanical stimulus ... associated with
FRACDS(OMS) FHEA, Professor of Oral be due to central sensitization) pain. surgery, trauma, or acute illness.’3
Surgery, King’s College London, King’s The mechanisms underlying Healthy acute protective pain
College London Dental Institute, King’s acute and chronic pain are different. includes the following. Nociceptive pain is
College Hospital, Bessemer Road, Thus pain management needs to reflect the conversion of tissue injury and release
London SE5 9RS, UK. these differences. Acute nociceptive and of algogenic factors (intracellular cellular
November 2018 DentalUpdate 935
 OralSurgery

Figure 1. Different types of pain. (Adapted from Woolf CJ. What is this thing called pain? J Clin Invest 2010; 120: 3742–3744.)

components released due to cell damage) persistence of infection. or poor pain diagnosis are leading causes
which act as ‘foreign bodies’, exciting pain Although pain in response to of complaints, often escalating to litigation.
receptors on nociceptive nerve fibres tissue damage is a normal phenomenon, Kalenderian et al6,7 have demonstrated
(C, A delta and A beta fibres), causing it may be associated with significant, that poorly managed perioperative pain
transduction from chemical inflammation unnecessary, physical, psychological is the leading adverse event in routine
into an action potential and transmission, and emotional distress.4,5 If a patient is dental care. In Finland, a national overview
to the progression of an action potential, phenotypically or genetically predisposed, assessing patient complaints about their
advancing up to the tertiary order neurones pathological pain may result in continued dental care also reported that poorly
to the somatosensory cortex; once reached overlay of pain in the digit or tooth by managed pain was the leading adverse
the ‘ouch’ is acknowledged, resulting in the brain. This may be neuropathic pain event.8,9 This makes sense; if patients have
reflex withdrawal of the digit from danger. caused by nerve lesions (physical damage an unpleasant experience at the dentist,
Inflammatory pain follows nociceptive pain or lesional damage by systemic disease) with either unexpected pain or severe
if tissue damage persists. The inflammatory or centralized ‘dysfunctional’ pain related pain during a dental procedure, this may
response aims to resolve the tissue damage, to multiple pain presentations likely due set the basis for patients to question the
whilst resulting in tissue tenderness and to central sensitization conditions, such as quality of other aspects of their care. Thus,
muscle spam. This reaction aims to protect TMD arthomyalgia, fibromyalgia, migraines, patient expectations must be managed,
the body and prevent further damage by irritable bowel syndrome, interstitial cystitis, not just in the short term for post-surgical
restricting activity (for example walking on vulvodynia and other persistent pain inflammatory pain, but in the context of
a broken leg). This process should usually conditions. chronic neuropathic pain if there is risk of
resolve in days or weeks, depending on The General Dental Council have nerve injury.7,9
the degree of tissue damage and the identified that poor management of pain Poor pain management in
936 DentalUpdate November 2018
 OralSurgery

surgical settings is known to be associated pain management in their patients. The others may be more susceptible to lack
with slower recovery, greater morbidity, correct diagnosis, underpinning successful of coping and catastrophizing (‘football
longer lengths of stay, lower patient management, and the treatment of player patients’), who need a lot more
satisfaction, and higher costs of care, trigeminal pain by dental teams involves attention and support.
suggesting that optimal pain care in several aspects including: Pain and its management
these settings is of utmost importance 1. Excluding sinister causes of pain (cancer); is complex as the individual’s pain
in promoting acute illness management, 2. Managing patients presenting with acute experience is unique and based upon
recovery and adaptation.10 The American dental pain related to underlying pathology his/her gender, beliefs, religion, ethnicity,
Veteran Clinical Practice Guidelines have (eg pulpitis, ulcer); prior pain experience, psychological
been developed for the management of 3. Preventing or minimizing peri-operative factors, nocebo and placebo effects,
acute post-operative pain, although the pain in patients undergoing surgery; etc.22 Holistic patient management is
basis for many of the recommendations 4. Managing patients presenting with fundamental in pain management, with
was by expert consensus rather than chronic orofacial pain conditions; increasing evidence supporting and
empirical evidence. Peri-operative pain is 5. Preventing chronic pain. educating patients in the expected pain
not managed well in dentistry. A population levels (managing their expectations),
study of 1086 individuals demonstrated Managing the dental patient being caring, empathetic, providing
that 42.5% reported pain during dental undergoing surgery appropriate anxiolysis, distraction and,
treatment and severe pain was reported by on occasions, providing alternative
25% of patients.2 In another study, of 1422 Pre-operative techniques (hypnosis and acupuncture).
subjects who completed questionnaires There are two significant The development of communication
at baseline and five-year follow-up, 96.4% challenges often overlooked in dentistry. skills, psychological interventions and
had visited a dentist over the observation First, dentists are the only surgeons who alternative therapies for anxiolysis
period, with 42.5% reporting having pain primarily operate on conscious patients. and pain management, and patient
during treatment and with 19.1% having The second overlooked screening for conditions predisposing
pain that was moderate to severe in challenge is that dentists operate in the them to increased risk of heightened pain
intensity.11 More alarmingly, 10−15% of most highly innervated region of the body experience or persistent pain, are the
patients felt poorly cared for undergoing with representation of the sensory cortex future of effective pain management.23–25
routine dental care.12 of over 50%. The trigeminal nerve is the
Barriers to optimal pain ‘great protector’ of the fundamental systems
Psychological factors driving pain
management may come from the that underpin our very existence (airway,
eyesight, brain, smell, taste and hearing). We all recognize that certain
healthcare provider in terms of inadequate
Thus, is it any wonder that the primordial patients in our practice are more
knowledge regarding pain management.13
reaction to threatened, perceived or ‘brittle’ and cope less well with dental
None of the current guidance to ‘surgical
actual pain in the trigeminal system causes procedures. Catastrophizing, fear of pain,
pain analgesia’ applies to dentistry,
significant limbic affective and emotional fear of surgery, introspection, increased
including the WHO acute pain ladder,14 NICE
responses, the main one being wanting to pre-operative anxiety, introverted
neuropathic pain guidelines,15 or IASP pain
‘run for the hills’ and NOT sit in the dental personality, poor coping skills and
recommendations.16 The current guidance
chair! hypervigilance states are all related
that may apply to dental procedures ONLY
The dental team have therefore to higher operative pain reports and
mentions medical management for pain.17,18
to overcome operating on awake patients persistent pain after routine surgery.25
The ageing population also
presents challenges in diagnosing and in the most sensitive region of the body by
managing trigeminal pain, with more using complex skills. Most of the success Genetic factors
complex medical comorbidity, complex of treatment will be predicated upon the Genetic factors can lead to
dentition needs due to retained heavily team’s ability to communicate, establish increased anxiety, catastrophizing and
restored dentition and an increased patient trust and good clinical skills and other psychological traits that predispose
h
propensity to develop chronic pain very little to do with actual analgesia alone the patient to chronic pain and increased
conditions and cancer.19 Chronic orofacial (even though pain-free treatment is the sensitivity to surgical pain.26 Prior
pain is comparable with other chronic objective but is rarely accomplished). abuse and neglect can also lead to the
pain conditions in the body, and accounts Local anaesthesia only blocks development of psychological factors
for between 20 and 25% of chronic pain nociceptive pain and analgesics reduce that predispose the patient to increased
conditions.20 In the study by Locker and inflammatory post-surgical pain successfully susceptibility to pain.27 Variations in the
Grushka,21 some pain or discomfort in but, due to pain’s multiple components, catecholamine metabolizing enzyme
the jaws, oral mucosa, or face had been these alone are not enough to manage genes (MAOA and COMT) show significant
experienced by less than 10% of patients in peri-operative pain in our patients. Some associations with the maximum post-
the previous 4 weeks. patients may be stoic types (‘rugby player’), operative pain rating, while the serotonin
The dental team has five more able to cope with the anticipated transporter gene (SLC6A4) shows
main responsibilities with regards to and actual surgical discomfort, whereas association with the onset time of post-
November 2018 DentalUpdate 937
OralSurgery

operative pain.28,29 A recent genetic study in expectations, satisfaction, and functional take some simple clear pre-operative steps
mice and humans revealed the modulatory outcomes in patients undergoing lumbar to ensure success of the planned treatment:
effect of MC1R (melanocortin-1 receptor) and cervical spine surgery and other „ Correct diagnosis and correct treatment
gene variants on k-opioid receptor- general surgical procedures.35 But beware, plan;
mediated analgesia whereby red heads showing videos to patients with previous „ Full medical history and recent
display additional opioid need and are less negative dental experience can result in prescription chart;
sensitive to local anaesthetics.30 significantly increased anxiety!36 „ Recognition of mental health factors
including anxiety;
Anxiety Information „ Patient relationship − empathy works;
There could be many reasons Optimal patient clinician „ Manage patients’ expectations;
for increased anxiety when patients need communication reduces post-surgical  – Education pre- and post-op
dental treatment. Increased anxiety will pain.37 Information received after surgery – Frank consent (includes surgical
result in lowering of the patients’ pain is essential for each patient in facilitating consent, financial consent and
threshold. Studies have illustrated that 71% the transition from hospital to home.38 future required maintenance
of patients undergoing dental treatment recognition).
are not anxious, 16% moderately anxious, Laser
9% highly anxious and 4% phobic.31 Anxiety Laser acupuncture is Pre-surgical
is determinant for pain during dental care demonstrated to reduce post-surgical Pre-surgical prevention of
and pain is related to local anaesthetic pain.39 surgical and post-surgical pain.
procedures.
In a study comparing UK and Pre-operative analgesia
Alternative and holistic management of
Dutch dental patients' MDAS scores, the Failure of inferior alveolar
pain
percentage of respondents with high nerve blocks to anaesthetize teeth with
Alternative methods for pain
dental anxiety (HDA) (total MDAS score management should not be dismissed. symptomatic irreversible pulpitis (‘hot
≥19) was 11.2%. Significant prevalence of „ Distraction: With most patients having pulps’) is partly due to inflammatory
HDA across several distressing experiences mobile phones, tablets and headphones sensitization of sodium channels resistant
was shown in both UK and Dutch samples at their disposal, few dentists take the to LA inducing peripheral nociceptor
notably: extreme helplessness during opportunity to exploit these devices for sensitization and central sensitization.45
dental treatment, lack of understanding of distraction during surgical procedures, There are limited studies in relation to
the dentist and extreme embarrassment which can significantly reduce operative dental surgery that demonstrate a pre-
during dental treatment. There were little pain.40 Music alone has also been shown emptive analgesic benefit.46 However,
or no effects of non-dental trauma, with to reduce post-surgical pain in non- ibuprofen has been reported to provide
the exception of sexual abuse in the UK dental procedures.41 Other alternative more intensive pain relief in adjunct to
sample.32 techniques may include using a placebo, dental blocks, and ibuprofen47 is superior to
or a difficult memory task. But when they paracetamol in facilitating analgesia related
Empathy put the two together, ‘the level of pain to LA for mandibular pulpitis.48
There is also evidence that the reduction that people experienced added A prospective randomized study
dentists’ attitudes are determinants for up, there was no interference between was conducted, on pre-emptive analgesia,
pain.33 Empathy likely facilitates patients’ them’.42 in which patients undergoing third molar
downward inhibitory processes by „ Hypnotism: The evidence for peri- surgery were randomly allocated to a
managing their expectations and reduces operative hypnotism is conflicting but protective analgesia (1.6 g modified release
peri-surgical pain experience.22 some prospective studies do show an ibuprofen) or conventional analgesia (400
analgesic effect.43 mg conventional ibuprofen) orally for 2 h
Education „ Acupuncture: Acupuncture can also pre-operatively. Post-operative outcomes of
Education and managing reduce operative pain and the need for interest were pain intensity at 30 min, 1, 6,
patients’ expectations can significantly LA and analgesics for dental surgical 24 and 48 h. The time to rescue analgesia,
reduce operative pain and the need pain.44 overall assessment of pain control, safety
for post-surgical analgesia. Providing and tolerability profiles were also recorded.
pre-operative education about post- The patient It was concluded that there was no
operative pain (POP) can improve patients’ Patients may be able to difference in the protective analgesia group
knowledge, as well as encouraging a maximize downward inhibition of pain compared with conventional analgesia
positive attitude towards it. It provides with good sleep habits, good diet and group in improving the post-operative pain
realistic expectations about POP and mindfulness or meditation techniques, experience. A different protective analgesia
its management, reduces anxiety and but evidence remains weak for this regimen may be necessary, which employs
increases patient satisfaction.34 There is a holistic approach. a more aggressive and multimodal strategy
positive relationship between pre-operative The clinician and team must for post-operative pain management.49,50
938 DentalUpdate November 2018
 OralSurgery

The minimal effect of pre-prandial analgesia There is evidence that dentists’ it has been demonstrated that palatal and
may be due to the average lidocaine inferior attitudes are also determinants for pain.56 incisal blocks are not required.29
dental block, which lasts for 3 hours 25 Advancement of psychological and „ Standard local anaesthetic technique
minutes, providing plenty of opportunity sedation techniques for anxiolysis have for mandibular dentistry is currently the
to take post-surgical analgesia during nearly eradicated the need for patients inferior dental block which is remarkably
this period. This provides more effective requiring general anaesthesia for routine inefficient as pulpal anaesthesia rates are
analgesia and reduces the effect of pre- dental care.57,58 low and onset is slow (15−30 minutes).
emptive analgesia. Dental phobia is extreme Malamed61 stated that the rate of
dental fear, which interferes with normal inadequate anaesthesia ranged from 31%
During surgery functioning. For any dental treatment, it is to 81%. When expressed as success rates,
The surgeon should use the an ethical, legal and professional duty of this indicates a range of 19% to 69%. These
following practices: dentists to obtain valid informed consent numbers are so wide ranging as to make
„ Allow some patient control; from their patients. Prevalence of dental selection of a standard for rate of success
„ Assess and manage anxiolysis; fear was 24.3% which is less common than for IANB seemingly impossible.61
„ Smart local anaesthesia;45 fear of snakes (34.8%), heights (30.8%) and „ There is increasing evidence that
„ Minimal access surgical technique (less physical injuries (27.2%). Dental phobia infiltration articaine 4% buccal infiltration
tissue damage = less pain); appeared most common (3.7%), followed plus lidocaine intra-ligamental or infiltration
„ Post-op advice. by height phobia (3.1%) and spider phobia is appropriate for all dental procedures
All forms of sedation and (2.7%). Fear of dental treatment was in the mandible with the exception of
anaesthesia should be administered associated with female gender, rated as posterior molar endo and restoration of
in an environment of trust, empathy, more severe than any other fear, and was pulpitic second molars.45
and competence. Such an integrated most strongly associated with intrusive „ The future is likely to be 2% articaine
approach will result in reduced drug re-experiencing (49.4%). The findings for all dental LA procedures, with 1:400K
dosages, decreased need for multiple drug suggest that dental fear is a remarkably epinephrine or no vasoconstrictor
techniques, improved patient safety, and severe and stable condition with a long for simple procedures or procedures
better control of anxiety.23 duration, only declining after the age of in children. With the development of
70 years.59 The question arises as to how combined topical anaesthetics, jet
dental phobia impacts on patients’ ability applicators and computerized delivery
Anxiolysis
to give valid informed consent. The impact systems, improved LA experience for
Dental anxiety is prevalent patients is ensured.
across a broad spectrum of the of dental phobia on patient consent must
population.51 The tools for measuring a not be under estimated and measures must
patient’s anxiety levels can provide a simple be incorporated to ensure that the patient Minimal access surgery
indication for his/her sedation need and is appropriately informed.60 Extreme fear There is a paucity of evidence
may impair patient ability to understand to support that minimally invasive surgery
include the indication for sedation need52,53
information about the procedure, their reduces post-surgical pain, however, there
and modified dental anxiety scale54 (MDAS
capacity to make balanced decisions, and to is increasing evidence that minimally
score of 13 or more indicates anxiety).
make these decisions voluntarily. The dental invasive surgery does reduce chronic post-
A study has illustrated that 71%
chair and syringe represent the most feared surgical pain.
of patients undergoing dental treatment
are not anxious, 16% moderately anxious, associative objects and, perhaps, consent
9% highly anxious and 4% phobic.55 and conversation with the patient should Post surgery
Anxiety is a determinant for pain during take place in a medical consultation setting, „ Post-op advice;
dental care and pain is related to local allowing the patient to be more relaxed, „ Accessibility for patient contact;
anaesthetic procedures. Dental anxiety is ideally restricting the use of the dental „ Post-op proactive analgesic regimen:
not associated with gender and frequency chair for examination and treatment only. - ibuprofen (600 mg) and paracetamol (1 g)
of dental visits, however, feeling of lack of A trusting rapport between dentist and orally on day of surgery;
control and pain anticipation were strong patient, supporting patient understanding - if pain next day continue analgesia 6
predictors of anxiety. These results highlight by providing useful information material, hourly as is routine. You MUST ensure
the important role that dental healthcare and keeping regular appointments, may your patients are not already consuming
providers could play in counselling anxious help overcome these obstacles. other paracetamol-containing analgesia
patients to reduce the impact of these and advise against taking more than 20
factors on seeking dental care. Successful Tailored local anaesthesia paracetamol tablets in 24 hours to prevent
management of anxiety positively impacts „ Local anaesthetics work by preventing permanent liver damage.
on the patient’s surgical experience, nociceptive pain by blocking the
however, the evidence is weak for direct transmission of the action potential. The Home check
anxiety management and reduced peri- standard lidocaine infiltration techniques A key factor in patient
operative pain experience. work effectively in the maxilla and recently satisfaction is a sense that the care-giver
November 2018 DentalUpdate 939
 OralSurgery

is doing his/her best and is genuinely

concerned that therapy is adequate. For this
reason, follow-up is crucial. Unfortunately,
despite a widespread focus on educating
healthcare providers to perform this follow-
up, such a re-assessment often does not
occur.62

Post-operative analgesia
Effective odontogenic pain
management and post-operative pain
management is fundamental to quality
dental care. Conventional analgesics act
by interrupting ascending nociceptive
information or depressing downward
inhibition. For dental or routine day case
surgery post-surgical pain control, oral
analgesia is usually prescribed as over-
the-counter (OTC) analgesic medications
including, NSAIDs, paracetamol, opiates
or combinations of these medications.
A meta-analysis of Cochrane reviews of
randomized controlled trials (RCTs) testing
the analgesic efficacy of individual oral
analgesics in acute post-operative pain
has helped facilitate indirect comparisons
between oral analgesics.63 The results from
this review and previous systematic reviews
of randomized post-surgical analgesic trials
helped to formulate the Oxford League
Table of Analgesic Efficacy which is used by
healthcare professions worldwide (Figure
2).64 Analgesic efficacy is expressed as
the number-needed-to-treat (NNT). This
estimates the number of patients who need
to receive the analgesic for one to achieve
at least 50% relief of pain compared with a
placebo over a six-hour treatment period.
The more effective the analgesic, the lower
the NNT. Oral NSAIDs perform well and
paracetamol in combination with an opioid
is also effective.65-68
A single dose paracetamol (1 g)
provided 50% post-operative pain relief for
4 hours in over 50% of patients.69
Codeine is not as effective as
NSAIDs or paracetamol for TMS pain.70
Aspirin may be better than paracetamol
for post TMS pain.71 Optimal analgesia is
reported to be combined paracetamol
with Ibuprofen as they work synergistically,
working extremely effectively for third
molar surgery and other moderate pain-
inducing dental procedures.72 Combined
Ibuprofen 400−600 mg + paracetamol 500
Figure 2. The Oxford League Table of Analgesic Efficacy.
mg−1 g has the lowest number needed
940 DentalUpdate November 2018
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 OralSurgery

• NSAIDs NSAIDs and paracetamol (Table 1).74

– Allergy to aspirin Optimal pain management for dental or

– History of asthma operative surgical pain
– Under 12 years – Reyes syndrome NSAIDs should be combined
– History peptic ulceration or GI bleeding with paracetamol, when possible,
• Duodenal ulcer (DU) 3–4% Peptic ulcer (PU) 4–7% (risk factors >75yr/history PU or reducing the effective dose and, hence,
heart disease/ + H pylori 27%) possible side-effects.63-73 This synergistic
effect is attributed to different sites of
– Bleeding disorders – reduced platelet adhesion action of the two analgesics.77 Oral non-
– Pregnancy/breast feeding steroidal drugs often supplement the
– Renal impairment initial prescription of paracetamol. Taking
– Decreases effectiveness of anti-hypertensives paracetamol with NSAIDs only when
• Paracetamol necessary can limit potential side-effects
of the NSAID.75
– No inflammatory action
• Side-effects are rare Codeine is ineffective for dental pain and
addictive
• Decreases liver function (CI AZT therapy) What is significant is that
Irreversible hepatic impairment 10–15g within 24 hours (ONLY 20–30 tablets) adding codeine to paracetamol and
•
NSAIDs provides minimal pain relief
• Renal impairment benefit (<1% additional analgesia) but
Table 1. Contra-indications to prescribing analgesics. significant side-effects such as nausea,
constipation and potential addiction.

Systemic Signs Local Signs Antibiotics are ineffective in reducing post-

surgical pain
Over 50 years Recent onset
It is recognized that dentists
Previous history of carcinoma Rapid growth over prescribe antibiotics rather than
extract or extirpate the dental cause.
Smoking/alcohol/betel nut/pan Neuropathy – sensory or motor Over the last decade, GMP prescription
Night fevers Resorption of adjacent structures of antibiotics has significantly reduced,
whereas GDPs prescribe antibiotics
Weight loss Localized mobility of teeth even more https://www.fgdp.org.uk/
antimicrobial-prescribing
Blood loss/anaemia Progressive trismus
Antibiotics are ONLY
Persistent painless ulcer indicated with spreading infection which
cannot be drained. There are guidelines
Lymphadenopathy painless persistent
for prescribing antibiotics in dentistry:
Lack of response to conventional „ Scottish Dental Clinical Effectiveness
treatments: Programme (2011) Drug Prescribing
– Antibiotics For Dentistry: Dental Clinical Guidance.
– Endodontic surgery 2nd edn http://www.sdcep.org.uk/
wp-content/uploads/2016/03/SDCEP-
Table 2. Red flags for cancer. (Regulatory NICE recommend immediate referral to relevant specialist
Drug-Prescribing-for-Dentistry-3rd-
and maximum 2 week wait for consultation).
edition.pdf
„ National Formulary prescribing for
dentists file:///C:/Users/tarar/Desktop/
to treat (NNT) compared with other over dose per year in the UK as there dental%20update%20pain%20VJ/
commonly used analgesics, providing are related to cocaine use. Some of this pg860–872%20Prevention%20
evidence of the effectivity of this may be intentional but, on this basis, and%20Optimal%20Management%20
combination.73 many countries prohibit the availability of%20Peri-surgical%20Pain%20in%20
However, although these of paracetamol from pharmacies without Dentistry.pdf76
drugs are seemingly ‘benign’ over the prescription. If the pain is not responding
counter analgesics, there are reported The clinician must be aware to routine dentistry OR inflammatory
to be as many deaths from paracetamol of contra-indications to prescribing analgesics …….think again! Red Flags for
November 2018 DentalUpdate 943
OralSurgery

cancer are listed in Table 2. radical overview is needed in regard 2016; 147: 803−811. doi: 10.1016/j.
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Management of peri-
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skills. a patient complaint and healthcare
be improved.77 Pre-operative pain can
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be best managed by holistic strategies
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42: 583−587. 42. Jason T, Buhle JT, Bradford L, Lew 50. Leong SL, Coulthard P. Pain after
31. Fotedar S, Bhardwaj V, Fotedar V. MW, Kravits K, Garberoglio C, surgery: can protective analgesia
Dental anxiety levels and factors Williams AC. Use of preoperative reduce pain? A clinical randomised
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attending a dental teaching institute in pain and anesthesia-related side 51. Hawamdeh S, Awad M. Dental
Himachal Pradesh. SRM J Res Dent Sci effects. Int J Clin Exp Hypn 2011; 59: anxiety: prevalence and associated
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32. Humphris GM, King K. The prevalence 43. Friedman JJ, Wager TD. Distraction 270−273.
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 OralSurgery

L, Longman L, Pretty IA, Jenner extraction? Evid Based Dent 2005; 6: 66. dental pain model. Anesth Analg 2003;
T. Estimating the need for dental 64. Bandolier. Oxford League Table of 97: 163−167.
sedation. 1. The Indicator of Sedation Analgesia, 2007 75. Bailey E, Worthington HV, van Wijk
Need (IOSN) − a novel assessment tool. 65. Moore PA, Hersh EV. Combining A, Yates JM, Coulthard P, Afzal Z.
Br Dent J 2011; 211: E10. ibuprofen and acetaminophen for Ibuprofen and/or paracetamol
53. Pretty IA, Goodwin M, Coulthard P, acute pain management after third- (acetaminophen) for pain relief after
Bridgman CM, Gough L, Jenner T, Sharif molar extractions: translating clinical surgical removal of lower wisdom
MO. Estimating the need for dental research to dental practice. J Am Dent teeth. Cochrane Database Syst Rev 2013;
sedation. 2. Using IOSN as a health Assoc 2013; 144: 898−908. (12): CD004624.
needs assessment tool. Br Dent J 2011; 66. Simpson M et al. Effect of combination 76. FGDP Guidance Antimicrobial
211: E11. of preoperative ibuprofen/ prescription in dentistry 2006
54. Humphris G, Crawford JR, Hill K, Gilbert acetaminophen on the success of the
http://www.fgdp.org.uk/content/
A, Freeman R. UK population norms inferior alveolar nerve block in patients
publications/antimicrobial-
for the modified dental anxiety scale with symptomatic irreversible pulpitis.
prescribing-for-general-dental-
with percentile calculator: adult dental J Endod 2011; 37: 593−597.
pract.ashx
health survey 2009 results. BMC Oral 67. Ong CK et al. Combining paracetamol
77. Crawford FI, Armstrong D, Boardman
Health 2013; 13: 29. (acetaminophen) with nonsteroidal
55. Vassend O. Anxiety, pain and C, Coulthard P. Reducing postoperative
anti-inflammatory drugs: a qualitative
discomfort associated with dental systematic review of analgesic efficacy pain by changing the process. Br J Oral
treatment. Behav Res Ther 1993; 31: for acute postoperative pain. Anesth Maxillofac Surg 2011; 49: 459−463.
659−666. Analg 2010; 110: 1170−1179. 78. Gordon DB, de Leon-Casasola OA,
56. Naik PN, Kiran RA, Yalamanchal 68. Hargreaves KM, Goodis HE, Tay FR. Wu CL, Sluka KA, Brennan TJ, Chou R.
S, Kumar VA, Goli S, Vashist N. Seltzer and Bender’s Dental Pulp 2nd Research gaps in practice guidelines for
Acupuncture: an alternative therapy in edn. London: Quintessence Books, acute postoperative pain management
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Med Acupunct 2014; 26: 308–314. 69. Toms L, McQuay HJ, Derry S, Moore evidence for an American Pain Society
doi:10.1089/acu.2014.1028. RA. Single dose oral paracetamol Clinical Practice Guideline. J Pain 2016;
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659−666. 71. Seymour RA, Hawkesford JE, Sykes J, 80. Watt-Watson J et al. An integrated
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946 DentalUpdate November 2018
 Enhanced CPD DO C & DO B Orthodontics

Sarah Ainscough

Dai Roberts-Harry, Andrew Shelton, Simon Littlewood and Trevor Hodge

How Orthodontic Therapists

have Changed the Provision of
Orthodontic Treatment
Abstract: The last decade has seen the orthodontic workforce transformed by the introduction of orthodontic therapists. This article
aims to highlight how they have changed the provision of orthodontic treatment and how the orthodontic profession has caught up with
general dentistry where task delegation to dental therapists and hygienists has been commonplace for many years.
CPD/Clinical Relevance: This article will enable readers to see just what roles OTs undertake, increase their awareness of who may be
undertaking the treatment on the patients they refer on and highlight the guidelines on appropriate supervision that their referring
orthodontists should be following.
Dent Update 2018; 45: 947–951

By 2007, changes to the Dentist Act meant Dental Care Professional (DCP). registration are one year in length and
that the General Dental Council (GDC) The introduction of OTs was comprise two parts − an initial 4–week
permitted the training of Orthodontic in response to a high level of orthodontic core course with additional study days
Therapists (OTs). Therefore, at this time, the treatment need within the UK (estimated at throughout the year based at the training
first courses began training this grade of 50% of 11-year-olds requiring orthodontic centre, and workplace training in an
treatment1) but a poor orthodontist to approved orthodontic practice or hospital
patient ratio. Discussions about the role of orthodontic practice. After completion
Sarah Ainscough, BDS, MJDF, Dental OTs, initially known as orthodontic auxiliaries, of the course, including satisfactory
Core Trainee 2 in Paediatric and Special began as early as 1973. A pilot study was workplace reports, success in formative
Care Dentistry, Leeds Dental Institute, conducted at Bristol Dental School in the assessments, etc, the student can apply
Clarendon Way, Leeds LS2 9LU, Dai mid-nineties where dental nurses undertook to sit the Diploma in Orthodontic Therapy
Roberts-Harry, BDS, FDS, DOrth, MSc, a four-week training programme, which examination. The minimum requirements
MOrth, FDS(Orth), Specialist Orthodontist, taught a range of appropriate orthodontic stated by the General Dental Council are
The Roberts-Harry Dental Clinic, East skills. At the end of this pilot, it was found that the student can be a dental nurse
Parade, Harrogate HG1 5LB, Andrew that the students not only had a high level with a recognized qualification, a qualified
Shelton, BDS, MFDS, MOrth, MDentSci, of clinical and theoretical knowledge, but dental hygienist or dental therapist, or a
FDS(Orth), Consultant Orthodontist, that they also had practical abilities that dental technician with appropriate clinical
Montagu Hospital, Doncaster S64 OAZ, were closer to orthodontic postgraduate experience. The local trainer must be on
Simon Littlewood, BDS, FDS, MOrth, students and thus far surpassed the course
MDentSci, FDS(Orth), Consultant the orthodontic specialist list.
organisers’ expectations.2 The foundations
Orthodontist, St Luke’s Hospital, Little of the training programme for OTs were
Horton Lane, Bradford BD5 0NA and based on this pilot study and, in 2017, 10 The impact of orthodontic
Trevor Hodge, BDS, MFDS, MPhil(Orth), years after the first orthodontic therapist therapists on the orthodontic
FDS(Orth), FHEA, FDTFEd, Consultant courses started, there were more than 500 workforce
Orthodontist, Leeds Dental Institute, orthodontic therapists registered with the The composition of the
Clarendon Way, Leeds LS2 9LU, UK. GDC in the UK. Typically, courses leading to UK workforce delivering orthodontic
November 2018 DentalUpdate 947
 Orthodontics

Orthodontic Therapists Can Orthodontic Therapists Cannot

Clean and prepare tooth surfaces ready for orthodontic treatment Remove sub-gingival deposits
Identify, select, use and maintain appropriate instruments Give local analgesia
Insert passive removable orthodontic appliances Re-cement crowns
Insert removable appliances activated or adjusted by a dentist
Remove fixed appliances, orthodontic adhesives and cement Place temporary dressings
Identify, select, prepare and place auxiliaries Place active medicaments
Take impressions They do not carry out laboratory work other than previously listed
Pour, cast and trim study models as that which is reserved for dental technicians and clinical dental
technicians
Make a patient’s orthodontic appliance safe in the absence of a Diagnose disease, treatment plan or
dentist activate orthodontic wires – only dentists can do this
Fit orthodontic headgear Additional skills which orthodontic
Fit orthodontic facebows which have been adjusted by a dentist therapists could develop during their career include:
Take occlusal records including orthognathic facebow readings
Take intra- and extra-oral photographs
Place brackets and bands, prepare, insert, adjust and remove Applying fluoride varnish to the prescription of a dentist
archwires previously prescribed or, where necessary, activated by a
dentist
Give advice on appliance care and oral health instruction Repairing the acrylic component part of orthodontic appliances

Fit tooth separators Measuring and recording plaque indices and gingival indices
Fit bonded retainers Removing sutures after the wound has been checked by a dentist
Carry out Index of Orthodontic Treatment Need (IOTN) screening
either under the direction of a dentist or direct to patients
Make appropriate referrals to other healthcare professionals
Keep full, accurate and contemporaneous patient records
Give appropriate patient advice
Table 1. Scope of practice of the orthodontic therapist.

treatment has changed greatly over personal experience in East Yorkshire, the
efficiency in primary care orthodontics.
the past decade since the introduction introduction of OTs has led to an increase
of OTs.3 This change in skill mix is in access to specialist-led orthodontic
Increase in accessibility to specialist led
significant due to the scope of practice treatment. As local GDPs with
care and a decrease in geographical orthodontic experience have retired,
of OTs4 (Table 1). This has meant that
inequality the employment of OTs has allowed
orthodontists are now able to delegate
Historically, a significant commissioners to redistribute funding
many more clinical tasks to orthodontic
proportion of orthodontic treatment amongst the small pool of existing local
therapists, enabling each member of the
has been carried out by GDPs in the UK. specialists cost-effectively.
orthodontic team to use his/her time
efficiently. In places it has led to the In 2005, the workforce report5 (Figure
following: 1) revealed that 17% of orthodontic Facilitating the full role of the secondary
„ An increase in access to specialist-led providers had no orthodontic care service to be undertaken
care and a decrease in geographical qualification and, in six areas (Shropshire, The role of the orthodontic
inequality; Staffordshire, Trent, North and East consultant in secondary care has
„ Has facilitated the full role of the Yorkshire and Lincolnshire), the majority traditionally centred on five domains:
secondary care service; and of orthodontic provision was carried out 1. Clinical, management;
„ Has had a significant impact on by non-specialists. From the author’s (TH) 2. Clinical advice;
948 DentalUpdate November 2018
 Orthodontics

roles of the post, OTs can help utilization of this group of DCPs within
allow consultants to meet current the hospital setting. It is estimated that
challenges of the increasing clinical only 10−15% of the current OTs in the
and management demands, while still UK work in secondary care.
fulfilling the other key roles. OTs allow
for a better use of skills mix through Impact in primary care
task delegation: as permanent members Working with OTs has
of the team they provide continuity of the potential to offer similar levels of
care; under the supervision of a clear increased efficiency in primary care as
prescription they can provide some those described in secondary care. While
clinical cover in the absence of the there is no published evidence on the
consultant; and they improve efficiency ideal model of working with orthodontic
and clinical throughput once trained. An therapists in the UK, anecdotally, most
example of the improved efficiency can practitioners report either supervising
be found by looking at a hypothetical 3 OTs and having no personal list of
model of two consultants working patients or, alternatively, working
without OTs, each having a job plan alongside 2 OTs whilst also treating
based around one new patient clinic some patients.6 As well as a sensible
and seven treatment sessions. Based ratio of orthodontist:OT, efficiency is
on a consultant seeing 10 patients likely to be affected by the nature of
per treatment session, and working the clinical tasks being undertaken, as
Figure 1. Orthodontic workforce report from on clinics on average 44 weeks per well as the competency and experience
2005.
year, 6160 follow-up appointments of the OT. Most providers choose not
will be provided. Now compare this to involve OTs in the management of
to a scenario where there are the two new patients as they are specifically not
consultants on the same job plan, but taught about diagnosis, and treatment
working alongside three OTs, with the planning is not within their scope of
consultants working alone for 50% of practice. However, in the delivery of
the time and supervising OTs 50% of certain treatment modalities, OTs offer
the time. If the OTs work nine sessions significant opportunities in the delivery
with 10 patients a clinic for 46 weeks in of care. An aligner type treatment
the year, the net number of follow-up such as Invisalign™ is an example of
slots increases to 15,500. This represents a treatment where task delegation is
a 250% increase in output, but is still a exceedingly beneficial. These treatments
consultant-led service. This is based on are generally designed to move teeth
the experience of one of the authors (SL) using incremental, clear, custom-fitted
in a busy district general hospital in the aligners, which are changed periodically
north of England. (1−2 weeks on average) as an alternative
At the Consultant to fixed appliances. Aligner treatment
Orthodontist Group Symposium in often differs from fixed appliance
Liverpool 2016, a survey was conducted treatment, where the treatment plan
examining the use of OTs within is constantly reassessed, and new
secondary care. The main reasons cited mechanics prescribed and altered
for not employing OTs included lack of throughout treatment. According to
finances, lack of management interest one of the authors (DRH), he has shown
and lack of capacity to accommodate from his own practice that 75% of
Figure 2. Guidelines on Supervision of them. In addition, while many of the Invisalign™ treatment can be managed
Orthodontic Therapists.
delegates said that they would like by the OT, saving the orthodontist, on
to train an OT, many stated that they average, more than 4 hours of clinical
had no time to do so. However, a large time per case through the delegation
proportion of the delegates also said of patient education roles, initial record
3. Public health advice; that waiting list and financial targets collection, aligner delivery, attachment
4. Teaching; and were not being met at their hospitals. placement, some mid-treatment review
5. Research. Given then the potential to increase and refinement preparation and record
With resources in the NHS productivity of the orthodontic gathering.
stretched and pre-eminence being given workforce with the inclusion of an OT in Nevertheless, the
to achieving the clinical and management the team, there is likely to be an under- introduction of OTs has had negative
November 2018 DentalUpdate 949
 Orthodontics

implications for some members of can continue with the OT under the
the orthodontic workforce. In certain prescription of the orthodontist. If there
geographical locations, there is now less is any uncertainty as to what treatment
need for the employment of orthodontic is required, then no treatment should
specialists as either assistants or associates, be undertaken and an appointment
and dentists with a specialist interest in should be booked for the patient
orthodontics. An audit was carried out to see the supervising dentist. In
of the trainers of students of the first circumstances where a patient presents
four intakes of the Yorkshire Orthodontic as an orthodontic emergency, the OT
Therapy Course, where it was found can provide limited treatment to make
that 50% in specialist practice had not a patient’s orthodontic appliance safe;
Figure 3. The orthodontist gives instructions
employed new specialist orthodontists however, the patient should subsequently
to the orthodontic therapist at the start of the
since the introduction of orthodontic be booked an appointment with the treatment episode.
therapists, and a further 20% had replaced supervising dentist to ensure that
some orthodontist hours with therapist treatment continues to progress safely.
hours. It may be then that, in the future, These guidelines have recently been
there needs to be a reassessment of the updated and can be found on the British Orthodontic Society guidelines state
UK’s orthodontic workforce, although at Orthodontic Society website. that an orthodontist should supervise
the present time there are still areas with orthodontic therapists at every other visit,
a shortage of specialist providers. There is Impact of orthodontic in this study, the OTs were supervised
also some anecdotal evidence that some therapists on the quality of at every visit. The results also reflect the
GDPs who worked as clinical assistants treatment provided expertise of the individual clinicians who
alongside specialist orthodontists have also made and revised the treatment plans;
One of the main concerns it is possible that not every clinician will
reduced in number, which perhaps can
when OTs were introduced was whether be able to achieve these results with or
largely be attributed to financial reasons,
the quality of the treatment delivered without an OT.9
as the cost to employ an OT is significantly
would be affected. A recent cross-
less than employing a dentist.7 While this study is
sectional, retrospective observational
encouraging for the use of OTs, it is
study was conducted at two specialist
Supervision of orthodontic important also to recognize that, apart
orthodontic practices in Yorkshire.9
therapists from the PAR index, there are other
The aim was to compare patients
measurements to assess orthodontic
Since OTs have been introduced treated by an orthodontist alone, with
activity and the quality of patient care,
concerns have surfaced regarding isolated patients treated by therapists under the
such as patient reported outcome
cases of problems with their supervision supervision of an orthodontist. Factors
measures (PROMs) and patient reported
and, consequently, the British Orthodontic measured were the length of treatment,
experience measures (PREMs). PROMs
Society has produced guidelines for the the number of appointments and the
intend to capture patients’ perceptions of
supervision of qualified OTs8 (Figure 2). Peer Assessment Rating (PAR) index
their health status, functional status and
It is important that both the supervising change.
their health-related quality of life, whilst
dentist and the OT understand each other’s The PAR index was developed
PREMs capture patients’ perceptions
roles and competencies to ensure safe as a way of objectively measuring the
about their experiences in the healthcare
supervision. The guidelines advise that, outcomes of orthodontic treatment.
setting. There are currently no agreed
wherever practicable, the patient should It compares pre-treatment and post-
PROMs and PREMs for orthodontic care,
be seen with the supervising dentist but, treatment study models to assess the
but when they become available it is
where this is not possible, the patient change in malocclusion with orthodontic
hoped that future prospective research
should be seen by the supervising dentist treatment. The higher the malocclusion
could also look at PREMs and PROMs and
at least at every other visit (Figure 3). score, the more severe the malocclusion.
the effect OTs may have on them.
The supervising clinician needs to be a The greater the percentage reduction
specialist orthodontist, or a dentist who post-treatment, the greater the change in
is competent in orthodontics (this differs malocclusion and the more successful the Training future orthodontists
from training where the supervisor needs orthodontic treatment. to work with orthodontic
to be on the specialist list). In addition, In this study, measurements therapists
an OT can only see a patient when there were taken before the introduction of OTs Given that OTs have
is a clear, comprehensive prescription and afterwards, with the results showing significantly changed the provision
from the supervising dentist written in that there was no change in orthodontic of orthodontic treatment and now
the patient notes and it should not be treatment outcomes once therapists constitute a large part of a growing
changed. This therefore means that, when had been introduced. It is important to orthodontic workforce, it is important
the orthodontist is absent, patient care note, however, that, while the British that future orthodontists are educated
950 DentalUpdate November 2018
 Orthodontics

on working with, and supervising, dental team has the potential to provide a Hall AC. Report of the Orthodontic
therapists. It is hoped that future better service for patients. Workforce Survey of the United Kingdom
orthodontic specialist trainees will February 2005. Sheffield: University of
be trained to understand the role of References Sheffield, 2005.
orthodontic therapists, understand 6. Hodge T, Scott P, Thickett E.
1. Stephens CD, Harradine NWT. Changes
ethical and safe supervision and gain Orthodontic therapists and their
in the complexity of orthodontic
practical experience of supervision integration into the orthodontic team.
treatment for patients referred to a
during their training. Orthodontic Ortho Update 2015; 8: 14−17.
teaching hospital.
postgraduate students now need to 7. Hodge T, Parkin N. The twenty-first
Br J Orthod 1988; 15: 27−32.
understand and develop supervision century orthodontic workforce.
2. Bain S, Lee W, Day CJ, Ireland AJ, Sandy
skills during their training and be aware BDJ Team 2015; 1: 15031.
JR. Orthodontic therapists − the first
of supervisory guidelines to ensure 8. British Orthodontic Society and
Bristol cohort. Br Dent J 2009; 207:
the effective and safe use of these Orthodontic National Group. Guidelines
227−230.
invaluable DCPs in the workforce. on Supervision of Orthodontic
3. Hodge T, Parkin N. ‘Who does what’ in
the orthodontic workforce. Br Dent J Therapists. 2012. Available at: http://
Conclusion 2015; 218: 191−195. www.bos.org.uk/Portals/0/Public/
In conclusion, the 4. General Dental Council. Scope docs/General%20Guidance/
introduction of OTs offers the potential of Practice. 2013. Available GuidelinesonSupervisionof
for a more cost-effective, cost-efficient, at: http://www. gdc-uk. org/ OrthodonticTherapistsApril2017.pdf
accessible service in both primary and Newsandpublications/Publications/ (Accessed April 2017).
secondary care without impacting on Publications/Scope%20of%20 9. Rooney C, Dhaliwal H, Hodge T.
the quality of the treatment provided. Practice%20 September%202013. Orthodontic therapists − has their
Further research is required in this area, pdf (Accessed February 2017). introduction affected outcomes?
but the incorporation of OTs within the 5. Robinson PG, Willmot DR, Parkin NA, Br Dent J 2016; 221: 421−424.

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November 2018 DentalUpdate 951

 OralMedicine Enhanced CPD DO C

Jordan Cheng

Oral Manifestations of Secondary

Hyperparathyroidism: A Case
Report and Literature Review
Abstract: A 52-year-old male with secondary hyperparathyroidism resulting from polycystic kidney disease, undergoing dialysis
for 18 years, is documented. The case showed radiographic mandibular bilateral osteolytic lesions with ground glass appearance,
diminished lamina dura, maxillary horizontal bone loss, but no maxillofacial expansion. Additionally, cases of hyperparathyroidism are
reviewed to associate oral radiographic features with disease severity. The review suggests that in secondary hyperparathyroidism: 1)
jaw demineralization, lamina dura loss, and osteolytic lesions occur with varying consistency depending on disease stage; 2) there is
no gender predilection of oral manifestation occurrence; and 3) with advancing age, lamina dura changes may occur with increasing
frequency.
CPD/Clinical Relevance: This article discusses the oral radiographic signs and symptoms that present in patients with secondary
hyperparathyroidism.
Dent Update 2018; 45: 952–960

Clinical and radiographic examination of „ Chronic kidney disease (CKD); of calcium from the bones.7 If skeletal
the oral cavity can reveal many findings „ Sunlight deprivation; complications result from the secondary
indicative of systemic diseases. One „ Anti-convulsant or bisphosphonate hyperparathyroidism-derived calcium
such systemic condition is elevated treatment; dysregulation, this is described as renal
parathyroid hormone (PTH) in which its „ Malabsorption (through chronic osteodystrophy (ROD).8
oral manifestations have been described in When CKD progresses to its
pancreatitis, small bowl disease, gastric
both early and recent oral pathology and end stage, the treatment is either kidney
bypass surgery);
radiology textbooks.1−4 transplantation or long-term dialysis.9
„ Lithium and thiazide diuretics; or
Parathyroid hormone, a Since the availability of donors is limited,
„ Familial hypocalciuric hypercalcemia.5
hormone released by the parathyroid gland, by default, patients begin long-term
In primary hyperparathyroidism,
holds a vital role in calcium homeostasis. hemodialysis.9 Dialysis, however, will
an adenoma or ectopic parathyroid gland
PTH is secreted during low blood calcium not replace all the functions of a kidney.
secretes excess PTH into the blood. In Hence, complications from secondary
levels and encourages calcium release from secondary hyperparathyroidism, abnormal
the bones. Despite tight calcium control, hyperparathyroidism may emerge.10
calcium regulation (from chronic kidney The osteolytic impact of
homeostatic irregularities leading to an diseases such as a polycystic kidney or secondary hyperparathyroidism affects
increase in PTH level can occur in a variety vitamin D deficiency) stimulates greater every bone in the body, including the
of circumstances, such as: production and release of PTH. Tertiary ribs, clavicle, pelvic girdle, and the jaw
„ Hyperparathyroidism; hyperparathyroidism is also possible, where bones.11 Clinically, in the oral cavity,
excessive PTH is released as a result of the most obvious clinical manifestation
persistent secondary hyperparathyroidism.5 of both primary and secondary
Jordan Cheng, DMD, Faculty of Dentistry, In all instances, serum calcium is hyperparathyroidism are brown tumour
University of British Columbia, 2199 invariably deregulated.6 To compensate, lesions, which may be associated with pain
Wesbrook Mall, Vancouver, BC, Canada parathyroid gland hyperplasia increases PTH as well as maxilla or mandible swelling.7
V6T 1Z3. secretion, extracting extensive amounts Other clinical manifestations may include
952 DentalUpdate November 2018
 OralMedicine

a b Case report
A 52-year-old male reported to
the University of British Columbia Nobel
Biocare Oral Health Center (Vancouver,
BC, Canada) for general dental care and
maintenance. Medical history indicated
that, at age 17, he was diagnosed with
polycystic kidney disease and suffered from
chronic renal insufficiency. At age 35, he
received a cadaverous kidney transplant
that failed to integrate, and within a year,
both the transplanted and natural kidneys
were removed. He has been receiving
dialysis for the past 18 years.
Subsequent to nephrectomy, in
Figure 1. Periapical radiographs of (a) anterior and (b) posterior mandible. There is diminished lamina order to manage high PTH levels, at age 42,
dura in the anterior region but trabeculation pattern is still apparent. In the posterior region, osteolytic
he underwent partial parathyroidectomy.
radiolucent lesions (arrows) are present with a complete loss of lamina dura.
The patient indicated that, in discussion
with his surgeon, he was informed that
approximately 1% of original gland size was
left behind.
Currently, the patient utilizes
a home dialysis system five days a week.
He does not consume alcohol or tobacco
products. He has been placed on a low
potassium diet and takes supplemental
erythropoietin, vitamin D, and iron dextrin.
An intra-oral examination did
not reveal any evidence of maxillary or
mandibular expansion in the soft tissue.
Teeth UR8, UL8, LL5, LL6, LL7, LL8, LR2, LR6
and LR8 were found to be missing. There
was generalized Grade I mobility in the
dentition except the lower premolars, which
exhibited Grade II mobility. There were no
complaints of halitosis, reduction of saliva,
Figure 2. Panoramic radiograph of the skull shows well-circumscribed bilateral radiolucency (arrows). unspecific jaw pain, or teeth sensitivity on
There is maxillary bone loss and diminished lamina dura. Loss of trabeculation and generalized and mastication.
ground glass appearance in the mandible is evident. The mandibular canal (M) and cortical borders (C) Intra-oral and panoramic
are identifiable. radiographs showed marked evidence of
altered bone density (Figures 1 and 2).
Bilaterally, well-circumscribed multilocular
radiolucent lesions suggest potential brown
mobility and drifting of teeth, halitosis, or localized spotty calcification of soft
tumour7 in the mandible (Figures 1b and 2).
reduction in saliva, unspecific jaw pain, and tissues or salivary glands.8,15,19,20
Diminished or complete absence of lamina
tooth sensitivity during mastication and This paper reports a severe
dura was observed both in the anterior and
percussion.12−17 case of radiographic osseous changes
posterior mandibular regions. There was
Oral radiographic findings in in a 52-year-old male with secondary evidence of trabeculation in the anterior
hyperparathyroidism include generalized hyperparathyroidism resulting from mandible, but not in the posterior region
rarefaction of the jaws, with a loss of the polycystic kidney disease that has that exhibited a ground glass appearance.
medullar trabecular pattern and a ground been treated with long-term dialysis. The cortical border of the mandible and
glass appearance.14,18,19 There may be a Also, a literature review of the oral the mandibular canal were clear in the
generalized loss of lamina dura, loss of manifestations of hyperparathyroidism radiograph (Figure 2). There was, however,
cortical bone thickness, osteolytic bone is presented with an emphasis on profound horizontal bone loss in the
cysts seen in jaws, widening of periodontal connecting radiographic features with maxilla.
ligament space, narrowing of pulp chamber disease severity. The biochemical profile of
November 2018 DentalUpdate 953
OralMedicine

Year of Type of Duration Country Total Age or Male Female Ground Glass Radiolucent Presence of Loss of Thinning
Study HPT of No of Mean Appearance Osteolytic Maxillo- Lamina of Cortical
Dialysis Subjects Age Lesions facial Brown Dura Boundaries
or Mean (Range) Tumour of
(Years) Mandibular
Border

193421 Primary – USA 17 43 5 12 − − − 3 –

(13−62)

194135 Primary – USA 45 – * * 45 45 22 45 −

194536 Primary – USA 14 – * * − − − 2 −

194823 Secondary – USA 1 49 – 1 1 1 − − −

37
1956 Primary – USA 16 – – − − − − − −
16
1962 Primary – USA 42 46 21 21 – – 3 3 −
(20−70)

196238 Primary – USA 116 – * * – – – 47 –

196238 Secondary – USA 1 22 1 − − − 1 − −

196639 Secondary – South Africa 1 44 – 1 – – – – –

17
1968 Primary – USA 13 44 (15− 6 7 1 – 1 1 –
65)

196940 Secondary 16 USA 1 35 1 – 1 1 – 1 1

Primary – USA 1 44 1 – 1 1 – 1 1

197441 Primary – USA 1 48 1 – – – 1 – –

197442 Secondary 3 USA 1 21 – 1 – – 1 – –

43
1977 Secondary 10 USA 1 42 1 – 1 1 – 1 –

197844 Primary – USA 1 35 − 1 − − 1 1 −

197845 Secondary − USA 1 85 − 1 − − 1 − −

198026 Secondary 0.6 USA 38 48 36 2 14 2 − 17 −
(26−77)
198246 Secondary – Netherlands 12 35 (19− 7 5 – – – – 9
56)

198447 Secondary 8 Italy 1 19 1 − − − 1 − −

48
1985 Secondary 10 USA 1 20 1 − − − − − −
49
1985 Secondary - Israel 1 10 − 1 1 − − 1 −

198550 Secondary 0.5 USA 30 53 30 − 5 21 3 9 2

(39−66)

198651 Secondary – Hungary 44 36 22 22 – – – – –

(18–61)
198852 Primary − USA 1 43 − 1 − − 1 − −

199153 Secondary 0.25 Korea 31 44 * * 17 – – 11 8

(Range:
Not
stated)

199154 Secondary – Israel 24 40 (18− 12 12 – – – – –

65)

954 DentalUpdate November 2018

 OralMedicine

Year of Type of Duration Country Total Age or Male Female Ground Glass Radiolucent Presence of Loss of Thinning
Study HPT of No of Mean Appearance Osteolytic Maxillo- Lamina of Cortical
Dialysis Subjects Age Lesions facial Brown Dura Boundaries
or Mean (Range) Tumour of
(Years) Mandibular
Border
55
1993 Secondary – Denmark 5 40 3 2 – – – – –
(24−63)

199356 Secondary – Spain 1 3 – 1 – – 1 – –

199657 Secondary – Japan 1 42 1 – 1 – 1 – –

27
1997 Secondary 8.0 USA 9 30 4 5 5 – 9 5 5
(19−58)
200325 Secondary 9 USA 1 52 – 1 1 1 1 1 1
58
2006 Primary – Greece 2 73 (71− 1 1 – – 2 – –
76)
Secondary – Greece 3 53 (21− – 3 – – 3 – –
70)
200659 Secondary 8 Japan 1 52 – 1 1 – 1 1 –

200615 Primary – USA 39 54 11 28 – – – 39 39

(29−79)
200729 Secondary 5 USA 1 37 1 – 1 – – 1 1

200760 Secondary 4 Brazil 1 39 – 1 – – 1 – –

200861 Secondary - Brazil 1 38 − 1 1 − 1 1 1

201118 Secondary 8.75 Japan 2 40 2 – 2 – 2 2 2

(33−47)
201162 Secondary - India 1 50 − 1 1 1 1 − 1

201463 Secondary 0.5 India 1 11 1 − 1 1 1 − 1

20158 Secondary 4 India 1 40 − 1 1 − 1 1 1

201519 Secondary 3.25 Turkey 15 32 (15− 7 8 – – – 15 –

48)
201564 Secondary - USA 1 43 1 − − − 1 − −

201665 Secondary 6 Brazil 1 53 − 1 − 1 1 − −

66
2017 Secondary 7 China 1 39 − 1 1 − 1 1 1

Table 1. Summary of cases of oral manifestations of primary and secondary hyperparathyroidism in literature (1934−2017). * undefined.

the patient revealed: calcium 2.41 mmol suggest secondary hyperparathyroidism.7 of primary hyperparathyroidism was
(Normal: 2.10−2.60 mmol), phosphate 0.8 Additionally, the patient’s medical history identified in a 7000-year-old cadaver from
mmol (Normal: 0.1−1.5 mmol), alkaline of nephrectomy, as a result of renal failure an early Neolithic cemetery, the first clinical
phosphate 57 U/L (Normal: 40−145 U/L), from polycystic kidney disease, and case of primary hyperparathyroidism was
and PTH 40.1 pmol/L (Normal: <7.0 pmol/L). continuation of long-term dialysis further diagnosed by Felix Mandl in 1925. Later,
These data indicate elevated levels of corroborated the diagnosis of secondary the oral manifestations were described by
parathyroid hormone, establishing the hyperparathyroidism with ROD. Albright et al in 1934.21,22 Subsequently, in
diagnosis of hyperparathyroidism. Further 1948, osteolytic lesions were recognized
observations of the normal blood calcium, Discussion in the mandible of a patient thought to
phosphate, and alkaline phosphatize levels Although the earliest evidence have hyperparathyroidism secondary to
November 2018 DentalUpdate 955
 OralMedicine

kidney failure,23 but it was not until 1963 cases, respectively), while ground glass The patient recorded in the
that the first confirmed case of maxillofacial appears more frequently in secondary present study continues to demonstrate
brown tumour was reported in a secondary hyperparathyroidism (15% and 25% an elevated serum level of PTH, despite
hyperparathyroidism patient.24 of cases, respectively). Radiolucent having the majority of its parathyroid
It was well recognized that osteolytic lesions, brown tumour, and hormone removed. One hypothesis is
dialysis may prolong the life of a CKD thinning of mandibular border seem to that there may have been an inadequate
patient but an elongated period of high have similar prevalence in both types of resection of PTH gland, a missed fifth PTH
levels of PTH exacerbates secondary hyperparathyroidism. gland, or presence of an ectopic gland.33
hyperparathyroidism. Subsequently, Loss of lamina dura has been Alternatively, a study where the parathyroid
associated brown tumours may progress heavily debated as a pathognomonic glands were genetically ablated from mice
to localized bone pain or pathological feature of hyperparathyroidism. Earlier demonstrated that experimental mice had
fractures.25 Ideally, clinicians could studies by Silverman et al indicated detected PTH levels equivalent to wildtype
use radiographic oral manifestations that only 4 patients out of 55 primary control mice.34 The auxiliary source of PTH
to evaluate an associated severity of hyperparathyroidism patients demonstrated was attributed to the thymus, suggesting an
secondary hyperparathyroidism in a long- changes in lamina dura.16,17 In contrast, ectopic source of PTH release may become
term dialysis patient. This is, however, not three separate studies of secondary available despite parathyroid gland removal.
always straightforward because the oral hyperparathyroidism noted lamina dura Regardless, re-occurrence risk of secondary
manifestations of hyperparathyroidism vary loss in 17 of 38 (45%),26 5 of 9 (55%),27 and hyperparathyroidism increases with time in
considerably in different patients. 15 of 15 (100%).19 It is plausible that the post-parathyroidectomy patients.33
A review of English language stronger relationship between lamina dura The patient described in the
literature of published cases of the loss and secondary hyperparathyroidism present study continues to attend the
previous 80 years (1934−2017), from 15 patients might be related to the duration dental clinic at the University of British
different countries, showed 544 cases of dialysis, reflecting changes in extensive Columbia on a regular basis. During a
of varying oral manifestations related to osseous calcium-leeching from prolonged one-year follow-up with the patient, there
primary or secondary hyperparathyroidism PTH exposure.28 The average duration of have not been any changes or concerns
(Table 1). Although initial studies were dialysis reported in the aforementioned regarding oral manifestations, including
reported from USA, subsequent reports studies were 0.6,26 8.0527 and 3.519 years, focal bone pain or intra-oral enlargements
from 14 other countries indicate that respectively, and are associated with the in the maxilla or mandible.
hyperparathyroidism can occur across all high frequency of lamina dura loss.
ethnic groups (Table 1). Of 544 cases, 210 Additionally, more recent Conclusion
showed a loss or absence of lamina dura single case reports with long-term dialysis
This report presents a patient
(male: 36, female: 49, unspecified: 125), 103 patients (>5 years) appear to have a high
who exhibits oral manifestations commonly
demonstrated a ground glass mandible frequency of lamina dura loss, ground glass
attributed to prolonged secondary
(male: 15, female: 12, unspecified: 76), 76 appearance, presence of brown tumours,
hyperparathyroidism resulting from long
showed the appearance of osteolytic lesions and thinning of the cortical boundaries of
duration dialysis. Findings showed lamina
(male: 25, female: 4, unspecified: 47), 73 the mandibular border.18,25,29 In the present
dura loss, ground glass mandible, and
reported thinning of the cortical boundary case, the patient has undergone dialysis for
the presence of osteolytic lesions, but no
of the mandible (male: 25, female: 40, 18 years and exhibits all radiographic traits,
evidence of clinical intra-oral maxillofacial
unspecified: 8), and 64 documented a except for maxillofacial swelling of a brown
enlargement. Further, although there was
clinical brown tumour (male: 16, female: tumour and thinning of the mandibular
no concrete observed gender predilection,
23, unspecified: 25). The analysis suggests border. In spite of this, he still presents
lamina dura loss may occur with increasing
that, with increasing age, there appears to with clearly demarcated radiographic
frequency in cases of prolonged dialysis and
be a trend towards a higher frequency of osteolytic lesions (Figures 1b and 2). These
subsequent secondary hyperparathyroidism.
oral manifestations in hyperparathyroidism observations strengthen the notion that
cases. Females may be less prone to some oral manifestations may appear after
presenting with a ground glass mandible long-standing disease.17 Ethical approval
but more prone to presenting with a An invasive biopsy to verify All procedures followed were
thinning of cortical boundary. Since the the presence of brown tumour7 was not in accordance with the ethical standards
unspecified count, however, is substantial, undertaken in the present case because of the responsible committee on human
any relationship between specific gender there was no evidence of intra-oral swelling experimentation (institutional and national)
and oral manifestation, if any, remains or other symptomatic complaints. Both and with the Helsinki Declaration of 1964
unclear. classical oral surgery textbooks and current and later versions. Informed consent
There was a total of 308 primary guidelines of putative brown tumour was obtained from the patient for being
and 236 secondary hyperparathyroidism management emphasize directly addressing included in the study.
cases and, in both circumstances, the the hyperparathyroidism treatment
lamina dura loss appears to be the rather than immediate brown tumour Acknowledgements
most common finding (46% and 32% of excision.7,30−32 I would like to acknowledge Dr
956 DentalUpdate November 2018
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 OralMedicine

Ravindra Shah for his guidance towards the 17. Silverman S, Ware WH, Gillooly C. Dental aspects 3rd edn. Missouri, USA: Mosby, 1944: p341.
publication of this manuscript. There is no of hyperparathyroidism. Oral Surg Oral Med Oral 32. Padgett E. Surgical Disease of the Mouth and
conflict of interest to state. Pathol 1968; 26: 184−189. Jaws 1st edn. Philadelphia, USA: WB Saunders
18. Asaumi J, Aiga H, Hisatomi M, Shigehara H, Kishi Company, 1938.
K. Advanced imaging in renal osteodystrophy of 33. Pitt SC, Sippel RS, Chen H. Secondary and
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47. Catizone L, Casolino D, Santoro A, Casanova S, Cerasoli P, Zucchelli P. An

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F. Brown tumors of the jaws associated with primary or secondary
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osteodystrophy manifesting as localized enlargement of the jaw. Nephrol
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secondary hyperparathyroidism requiring extensive resection: a forgotten
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65. Queiroz IV, Queiroz SP, Medeiros R, Ribeiro RB, Crusoé-Rebello IM, Leão JC.
Brown tumor of secondary hyperparathyroidism: surgical approach and
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www.shofu.co.uk
Oral Radiol 2017; 1−5.

960 DentalUpdate November 2018

 Enhanced CPD DO C PaediatricDentistry

Sophie Marshall

Thayalan Kandiah

Developmental Defects of Enamel

in Primary Molars: A Review
Abstract: Developmental defects of enamel (DDE) are not uncommon in both the primary and permanent dentition. This article presents
a review of the current literature and describes the definition, prevalence, aetiology, diagnosis and management of primary molars
affected by DDE.
CPD/Clinical Relevance: This article describes the diagnosis and management of DDE in practice to aid treatment planning in children
with primary molars affected by DDE.
Dent Update 2018; 45: 961–972

Definition, prevalence and crystals grow in length creating the enamel of enamel hypoplasia and severe early
aetiology thickness.2 Hypoplasia presents clinically as childhood as hypoplasia-associated severe
pitting, grooving or absence of enamel. early childhood caries (HAS-ECC).7
Historically, a collection of Hypomineralization, by contrast, DDE also includes fluorosis and
terms and definitions have been used to is a qualitative defect of enamel and occurs amelogenesis imperfecta. Fluorosis can
describe various developmental defects due to disturbances in the maturation present in mild forms as diffuse opacities or
of the enamel (DDEs). DDEs are classified phase of amelogenesis. Enamel maturation
mottling of the enamel and, in more severe
as demarcated opacities, diffuse opacities is a slow developmental process, with
cases, as marked opacities, discoloration,
and hypoplasia.1 Clinicians have intermixed two-thirds of the time needed for crown
formation being used for this phase.3 During pitting and enamel hypoplasia.8 It presents
these terms in attempting to describe the in a chronological manner in accordance
this phase, proteases remove the organic
clinical findings. material as mineralization continues.4 with increased fluoride ingestion.
Hypoplasia is a quantitative Hypomineralization presents as enamel Amelogenesis imperfecta (AI) is a genetic
defect of enamel caused by disturbances with a soft, chalky or cheesy appearance condition resulting in hypomature,
in the secretory phase of amelogenesis. and can vary in colour from white to yellow hypocalcified or hypoplastic enamel. AI
During the secretory phase, enamel or brown. A clear demarcation can usually should be suspected if the entire primary
be seen between the affected and non- and permanent dentition is affected and
affected enamel.5 often the permanent dentition is more
Sophie Marshall, BSc(Hons), BDS(Hons), It is important to severely affected. Parents of children
M(Paed Dent) RCPS(Glasg), Specialty differentiate between hypoplasia and with AI may also report a positive family
Registrar in Paediatric Dentistry, hypomineralization in order to provide history. This article does not discuss the
Department of Paediatric Dentistry and tailored care for patients affected by either
Thayalan Kandiah, BSc, BDS(Wales), management of fluorosis and amelogenesis
condition. Molar incisor hypomineralization imperfecta. Information on the
MFDS RCS(Ed), MClinDent, Paediatric (MIH) describes enamel hypomineralization
Dentistry (QMUL), MPaed Dent RCS(Eng), management of these specific conditions
affecting one or more permanent molars,
FDS RCS(Glas) Cert, Dental Sedation and can be obtained in previous Dental Update
which is frequently associated with
Pain Management (UCL), Consultant articles.9,10
affected incisors.6 Hypomineralized second The prevalence of DDE affecting
in Paediatric Dentistry, Department of primary molars (HSPM) refers only to the primary molar teeth has been
Paediatric Dentistry, East Surrey Hospital, second primary molars which are affected reported from between 6−49% in studied
Canada Avenue, Redhill, Surrey RH1 5RH, by hypomineralization. In 2012, Caufield populations with the second primary
UK. classified the concomitant presence molars most often affected.11,12,13 There
November 2018 DentalUpdate 961
 PaediatricDentistry

are several aetiological factors associated a

with DDE which can be acquired, systemic,
local or hereditary. Hypoplasia and
hypomineralization in the primary dentition
has been linked with maternal vitamin
D deficiency,14 low birth weight15,16 and
asthma or bronchitis in the first four years
of life.17 Hypoplasia and hypomineralization
in the permanent dentition has been
linked with; difficulties during pregnancy
b
or labour, exposure to cigarette smoking,
Figure 1. MIH affecting the UR1, UR6, UL1, UL6
ear infections, urinary tract infections,
in a child who also has hypomineralization of the
chicken pox and respiratory infections in ULE.
infancy.18,19 Recent studies have shown a
relationship between MIH and DDE of the
primary molars suggestive of a common
aetiology. Ghanim et al found that 40% of Screening of a child’s teeth
patients with HSPMs had at least one first should start by the age of 12 months
permanent molar which was affected by to allow for early detection of DDE on
hypomineralization.20 Casanova-Rosado et eruption of the teeth and to assess dental
disease risk.25 In order to assess the teeth, c
al also found that, for each primary tooth
with DDE, the odds of a permanent tooth they should be cleaned to remove debris
also having a DDE increased 1.38 times.21 and plaque and examination should be
More recently, Mittal and Sharma observed under standard clinical operatory lights.4
concomitant presence of MIH in 32.7% of Ghanim et al suggested a method for
children affected by HSPM. Furthermore, the recording of DDE in the permanent
the authors found that children affected and primary dentition for application in
by HSPM always had a higher odds ratio of epidemiological and clinical studies.23
MIH regardless of the severity of the HSPM Their recommendations included: not
(ie whether post-eruptive breakdown was scoring any tooth where less than a third
present or absent).22 This link between DDE of the crown had erupted and any DDE d
in primary teeth and DDE in the permanent less than 1 mm in diameter was not
dentition is thought to be due to the considered. Regarding primary molars, the
temporal proximity of development of the authors recommended that the clinical
primary molars and the first permanent status of the tooth is recorded. The details
molars and permanent incisors.23 Figure 1 of which should include:
shows an example of a child in the mixed „ The presence of any DDE;
dentition with DDE of the ULE and MIH „ The type of DDE (ie diffuse opacities,
affecting the maxillary permanent incisors demarcated opacities or hypoplasia);
and first permanent molars. „ The colour of the DDE;
„ The presence of any post-eruptive
Figure 2. (a) A grade I, white, demarcated opacity
Diagnosis breakdown (PEB) or atypical restorations; on the mesiopalatal cusp of the URE. (b) A grade
A comprehensive medical, „ An atypical pattern of caries; II, yellow, demarcated opacity on the occlusal
dental and family history should be taken „ If a primary molar has been lost due to and buccal surface of the LLE with minimal PEB
to identify the specific type of DDE and DDE (this may be difficult to confirm from buccally. (c) A grade III, yellow-white demarcated
exclude other dental diagnoses, including the dental history); opacity on the occlusal-buccal-lingual surface of
white spot lesions. White spot lesions „ If breakdown of the tooth is so the LRE with an atypical restoration present. (d)
can be differentiated from DDE as they extensive it is impossible to identify the A grade III, yellow-white, demarcated opacity of
cause of breakdown. the ULE with atypical caries and extensive PEB
generally appear at contact points or
resulting in gingival overgrowth. All four images
gingival margins, and are commonly Primary molars identified as
were taken from the same patient demonstrating
associated with plaque deposits.4 Children being affected by DDE should then be
the variation of presentation of DDE in one
with vitamin D deficiency rickets present further graded according to the amount of patient.
with enamel hypoplasia (ie grooving/pitting the tooth affected (Figure 2):
or loss of enamel as defined earlier), which 1. Less than 1/3 of the tooth affected;
appears to affect teeth in a chronological 2. At least 1/3 but less than 2/3 of the
manner.24 DDE in primary molars may be tooth affected; relative white appearance of the primary
under-reported due to breakdown of these 3. Greater than 2/3 of the tooth affected. teeth compared to permanent teeth. Tooth
teeth, resulting in only a diagnosis of caries DDE in the primary dentition surface loss may also cause difficulty in
being given. may be less apparent owing to the diagnosing enamel defects.4 However, the
962 DentalUpdate November 2018
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•
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 PaediatricDentistry

a caries risk and guide treatment planning interpapillary infiltration to anaesthetize the
of restorations and counselling of parents lingual/palatal mucosa, if this is required.
regarding the risk of DDE affecting the A description of this technique with
permanent dentition. A recent meta- accompanying images is available from
analysis has also shown a positive the Scottish Dental Clinical Effectiveness
association between enamel defects and Programme document Prevention and
dental caries in the permanent dentition.26 management of dental caries in children.28
When extrapolating this relationship to New computer-controlled delivery devices
the primary dentition, parents should be can be used to deliver local anaesthetic
informed of the increased risk of caries slowly and reduce pain associated with
in primary molars affected by DDE and this procedure. Clinicians must be aware of
given caries prevention advice suitable dose limits for local anaesthetic agents in
for children of high caries risk. This should children.
include oral hygiene instruction with the
use of toothpaste with an appropriate
Sensitivity
amount of fluoride for the patient’s age Children may present to their
and caries risk, diet advice, professional general dental practitioner (GDP) initially
fluoride application and fluoride toothpaste complaining of sensitivity from a primary
prescription, where necessary. This is in molar affected by DDE. Initial management
b accordance with the Public Health England should aim to relieve any discomfort. The
document Delivering better oral health: an following methods have been suggested
evidence-based toolkit for prevention.27 Risk for relief of sensitivity in hypomineralized
of dental disease for all children should be permanent teeth and should be considered
documented and reviewed at subsequent in the management of the same concerns in
appointments to guide management. primary teeth. These include:
Given the link between DDE in „ Placement of topical fluoride;5,29,30,31
primary teeth and increased risk of DDE „ Use of sensitive toothpaste or
in the permanent dentition, it would be toothpastes containing 0.4% stannous
prudent to warn parents that DDE in the fluoride;31 and
primary dentition may be an indicator „ The daily use of casein phosphopeptide-
that the permanent dentition may also be amorphous calcium phosphate (ie GC Tooth
affected. Mousse®).29,30
The clinician should consider the During toothbrushing, the use
patient experience throughout treatment, of warm water can minimize sensitivity.11
taking care to avoid negative experiences Where topical treatment of sensitivity
which may lead to anxieties regarding is unsuccessful, or where there is post-
treatment when the child is older. In order eruptive breakdown of teeth, with
Figure 3. (a, b) The LLE affected by DDE and or without caries present, sealants or
to increase patient comfort, adequate local
sealed with GIC. restorations are required.
anaesthesia should be provided, where
possible, when carrying out procedures
which may elicit sensitivity or discomfort Sealants
if local anaesthetic were not used. As hypomineralized primary
clinician should endeavour to record as Avoidance of air drying teeth which are not molars are at increased risk of developing
much of the information listed previously anaesthetized is advised to reduce the risk dental caries, fissure sealants should be
as possible as this can lead to appropriate of causing sensitivity during examination. considered for the management of affected
management for these teeth. Bitewing As an alternative, teeth can be dried with primary molars with intact enamel.32
radiographs should be attempted to cotton wool or gauze. When an affected primary
assess for dental caries and are valuable in When administering local molar is erupting, it can be provided with
treatment planning of the affected teeth. anaesthetic in children, clinicians should a glass ionomer cement (GIC) sealant until
take care to deliver pain-free anaesthetic. eruption. The GIC sealant will promote
This can be achieved by application of remineralization, prevent caries formation,
Management topical anaesthetic onto clean, dry mucosa. and provide relief of any symptoms that the
Early diagnosis and caries This must be left in situ for at least one patient may be experiencing.
prevention is essential in children with DDE minute before delivery of the anaesthetic Primary molars affected by
in their primary molars as they have an solution. The anaesthetic solution should DDE which are fully erupted, with no post-
increased risk of developing dental caries.7,11 be delivered slowly using a short needle, eruptive breakdown, can be managed
Correct diagnosis will aid assessment of first with buccal infiltration, followed by conservatively with resin-based sealant
November 2018 DentalUpdate 965
 PaediatricDentistry

a in view of the lack of available evidence

in this area.
Amalgam restorations should
be avoided in the management of DDE
in primary molars. This material is a
poor insulator, non-adhesive, requires
less conservative preservation of tooth
tissue, and has a higher failure rate
compared to composite restorations or
Figure 5. Post-operative view following preformed metal crowns.33 Furthermore,
placement of preformed metal crowns on the recent EU legislation has prohibited the
LLE, LLD, LRE and LRD to manage DDE using the general use of amalgam in primary teeth
Hall Technique. and in children under the age of 15 after
July 2018.34
Glass ionomer cement (GIC)
bonds to dentine and is a good insulator.
sealants regularly fail, or if moisture It does, however, have poor wear
control is suboptimal, GIC sealants are resistance31 and is susceptible to acid
preferable.29 If the patient continues to dissolution. GIC does have the added
experience sensitivity, preformed metal benefit of releasing fluoride, and being
crowns should be considered. Figure 3 less technique sensitive than composite.
b shows a primary molar affected by DDE It can be considered for temporization
and sealed occlusally with GIC. of primary molars with DDE given
When comparing MIH- its ease of use, particularly where
affected permanent molars to unaffected moisture control is compromised.29
permanent molars, a greater failure rate Temporization with GIC can allow time
of fissure sealants is seen in teeth affected for acclimatization of the patient until
by MIH.33 This is due to the reduced bond cooperation improves to allow for
strength resulting from the poorer quality composite or preformed metal crown
enamel in cases of hypomineralization. restoration.
For this reason, fissure sealants should Composite restorations in
be reviewed regularly and maintained. the primary dentition can be considered
Strategies to improve the bond strength for small one and two surface cavities
of resin-based restorations are discussed and placement should ideally be carried
in the next section. out using local anaesthetic and rubber
dam.31,35 Lygidakis et al showed full
Restorations retention of all composite restorations
Where there is breakdown in hypomineralized permanent molars
of primary molars affected by DDE or (with no more than two surfaces
cavitated carious lesions associated affected) after 4-year follow-up when
with these teeth, restoration is required. composite was placed under ideal
Figure 4. (a) Placement of an orthodontic Clinicians will need to make a decision clinical conditions.36 Enamel pre-
separator mesial to the LRE in a 4-year-old with regarding the most appropriate treatment with sodium hypochlorite has
DDE or the LRE one week prior to the placement restorative material to use. This will been suggested to improve the bond of
of a PMC using the Hall Technique. (b) The same depend on several factors, including: composite to permanent teeth affected
tooth following placement of the PMC. patient cooperation level; patient and by DDE.29,37 In a single case study, a 5%
guardian preferences for the type of sodium hypochlorite pre-treatment
restorative material; and the skill and of enamel affected by amelogenesis
experience of the clinician providing the imperfecta (AI) showed improved
restorations. Optimal conditions for fissure treatment. There is limited published bonding to enamel. This is thought to
sealant placement will increase longevity. evidence regarding outcomes of be due to deproteinating and exposing
Fissure sealants require adequate moisture restorations placed in primary molars the enamel mineral, which is encased
control and ideally would be placed under with DDE. Much of the evidence used in in acid-insoluble proteins. The method
rubber dam conditions. This would require this section refers to the management used was as follows: teeth were cleaned
the use of local anaesthetic for patient of permanent molars with MIH and with pumice and rinsed with water, 5%
comfort and to minimize tooth sensitivity has been extrapolated to apply to the sodium hypochlorite was applied to
during the procedure. If resin-based management of primary molars with DDE the tooth with a brush for one minute.
966 DentalUpdate November 2018
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 PaediatricDentistry

The tooth was then rinsed and air dried prior after pulp therapy, extraction is indicated.46 with previous dental concerns or
to placement of the composite restoration Those children in whom a primary molar is increased disease risk.
using separate etch and bond stages.37 This removed in an otherwise healthy arch, with
method has not been reported for use in good oral hygiene, could benefit from space Conclusion
primary molars affected by DDE. If this was to maintenance in the following scenarios:
Children with DDE in primary
be considered, use of rubber dam isolation 1. Loss of a primary first molar where
molars should be provided with a tailored
would be essential to protect the soft tissues. crowding is severe, ie more than 3.5 mm
treatment plan, to include disease
Preformed metal crowns (PMCs) (half a unit) per quadrant.
prevention and management of the
are the restoration of choice for primary 2. Loss of a primary second molar, except in
spaced arches. affected primary molars, as detailed in
molars affected by DDE with multi surface this article. For cooperative children, this
cavitation or post-eruptive breakdown. They The details of space maintenance
design which can be used are described in treatment can be provided in general
provide a complete seal over the primary dental practice. Those children who
the Royal College of Surgeons of England
molar, protecting it from further breakdown.12 guideline, from which this advice is taken.47 are pre- or potentially cooperative may
PMCs are indicated in primary molars affected require treatment within a specialist
by localized or generalized developmental setting, where inhalation sedation can be
problems, as stated in Royal College of considered to aid treatment delivery. In
Surgeons of England guidance.38 This
Review
some cases, general anaesthetic may have
guidance describes in detail the procedural Children should be reviewed
to be considered and should be treatment
steps for placement of conventional PMCs on every 3 months if they have high dental
planned by a specialist in paediatric
primary molars. The authors of this guidance disease risk with a maximum recall interval
dentistry.
stress the importance of good adaptation of of no greater than 6 months. Individual
Given the limited evidence
the distal margin of second primary molars factors related to disease risk should tailor
available on the topic of DDE in primary
to avoid impaction of the first permanent recall interval.48 Radiographic review of
molars, particularly regarding outcomes
molars if they are not erupted at the time of primary molars with DDE should be carried
of treatment, this would be an interesting
PMC placement. Readers are also directed to out according to caries risk in line with
area for the development of research
a Dental Update article which describes, with the Faculty of General Dental Practitioners
studies.
images, conventional PMC placement.39 (FGDP) guidelines.49
PMCs can also be provided References
using the Hall Technique. This is a minimally Summary
invasive technique for PMC placement which 1. Jalevik B. Prevalence and diagnosis
In order to manage DDE in
of molar-incisor-hypomineralisation
requires no tooth preparation or anaesthetic. primary molars, a practitioner must first
(MIH): a systematic review. Eur Archiv
Hall technique PMCs are indicated for correctly diagnose the type of condition
Paed Dent 2010; 11: 59−64.
occlusal lesions if the patient is unable to based on a comprehensive medical, family
2. Bartlett JD. Dental enamel
accept a sealant or composite restoration, or and dental history. An assessment of
development: proteinases and their
to restore proximal or multisurface cavities disease risk should be made, the same as
enamel matrix substrates. Int Sch Res
where conventional PMC placement may be for any patient, in order to tailor disease
Notices Dent 2013; 1−24. (Article ID
difficult due to limited patient cooperation.40 prevention advice.
684607).
Readers are directed to previous Dental When treatment planning, the
3. Smith CE. Cellular and chemical
Update articles related to the use of the clinician will need to consider the dental
events during enamel maturation. Crit
Hall Technique for procedural tips, with diagnosis, disease risk, cooperation level
Rev Oral Biol Med 1998; 9: 128−161.
images, when using this technique.41,42 A of the patient, and acceptability of dental
4. Seow WK. Clinical diagnosis of
2015 Cochrane review found that PMCs materials, as discussed with patients and
enamel defects: pitfalls and practical
placed on primary molar teeth are likely to their guardians. A period of temporization
guidelines. Int Dent J 1997; 47:
reduce the risk of major failure in the long and acclimatization may be required in
173−182.
term, compared to plastic restorations.43 order to provide young children with the
5. Weerheijm KL. Molar incisor
Both conventional and Hall Technique PMCs best possible treatment.
hypomineralization (MIH): clinical
have excellent long-term success rates of Consideration should be given to
the long-term prognosis and restorability presentation, aetiology and
94%44 and 95%,45 respectively. Figures 4 management. Dent Update 2004; 31:
and 5 demonstrate the use of PMCs in the of the tooth, along with the child’s ability
to cope with treatment. Where there is a 9−12.
management of DDE in primary molars. 6. Weerheijm KL, Jalevik B, Alaluusua
hopeless prognosis or lengthy treatment
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Extraction teeth in a pre-cooperative child, clinicians Caries Res 2001; 35: 390−391.
In cases where a primary molar is should consider if extraction would be 7. Caufield PW, Li Y, Bromage TG.
affected by DDE with associated periapical more appropriate than restoration. Hypoplasia-associated severe early
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 PaediatricDentistry

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40: 836−839. Morgan M, Bailey D. Prevalence of uk/wp-content/uploads/2013/03/
10. Visram S, McKaig S. Amelogenesis demarcated hypomineralisation SDCEP_PM_Dental_Caries_Full_
imperfecta − clinical presentation defects in second primary molars in Guidance1.pdf (Accessed September
and management: a case report. Dent Iraqi children. Int J Paediatr Dent 2013; 2017).
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11. Salanitri S, Seow WK. Developmental 21. Casanova-Rosado AJ, Medina-Solis CE, incisor hypomineralization: review
enamel defects in the primary Casanova-Rosado JF et al. Association and recommendations for clinical
dentition: aetiology and clinical between developmental enamel management. Pediatr Dent 2006; 28:
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133−140. dentition. Eur J Paediatr Dent 2011; 12: 30. Sapir S, Shapira J. Clinical solutions
12. Slayton RL, Warren JJ, Kanellis MJ, 155−158. for developmental defects of enamel
Levy SM, Islam M. Prevalence of 22. Mittal N, Sharma BB. Hypomineralised and dentin in children. Pediatr Dent
enamel hypoplasia and isolated second primary molars: prevalence, 2007; 29: 330−336.
opacities in the primary dentition. defect characteristics and possible 31. Fayle SA. Molar incisor
Pediatr Dent 2001; 23: 32−36. association with Molar Incisal hypomineralisation: restorative
13. Montero MJ, Douglass JM, Mathieu Hypomineralisation in Indian children. management. Eur J Paediatr Dent
GM. Prevalence of dental caries and Eur Archiv Paediatr Dent 2015; 16: 2003; 4: 121−126.
enamel defects in Connecticut head 441−447. 32. Feigal RJ. The use of pit and fissure
start children. Pediatr Dent 2003; 25: 23. Ghanim A, Elfrink M, Weerheijm K, sealants. Pediatr Dent 2002; 24:
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al. Enamel hypoplasia of the teeth studies on enamel hypomineralisation. Arapostathis K. Treatment
associated with neonatal tetany: a Eur Archiv Paediatr Dent 2015; 16: management of first permanent
manifestation of maternal vitamin 235−246. molars in children with Molar-Incisor
D deficiency. The Lancet 1973; 2: 24. Davit-Beal T, Gabay J, Antoniolli P, Hypomineralisation. Eur J Paediatr
811−814. Masle-Farquhar, Wolikow M. Dental Dent 2005; 6: 179−184.
15. Lai PY, Seow WK, Tudehope DI, complications of rickets in early 34. The European Parliament EU
Rogers Y. Enamel hypoplasia and childhood: case report on 2 young Legislation in Progress. Mercury.
dental caries in very-low birthweight girls. Pediatrics 2014; 133: e1077− Aligning EU legislation with
children: a case-controlled, e1081. Minamata. http://www.europarl.
longitudinal study. Pediatr Dent 1997; 25. American Academy of Pediatric europa.eu/RegData/etudes/
19: 42−49. Dentistry. Policy on Early Childhood BRIE/2017/595887/EPRS_
16. Correa-Faria P, Martins-Junior PA, Caries (ECC): Classifications, BRI(2017)595887_EN.pdf (Accessed
Vieira-Andrade RG, Oliveira-Ferreira Consequences and Preventive August 2017).
F, Marques LS, Ramos-Jorge ML. Strategies 2011. http://www.aapd. 35. Kandiah T, Johnson J, Fayle S. British
Developmental defects of enamel org/media/policies_guidelines/p_ Society of Paediatric Dentistry: a
in primary teeth: prevalence and eccclassifications.pdf (Accessed April policy document on management of
associated factors. Int J Paediatr Dent 2016). caries in the primary dentition. Int J
2013; 23: 173−179. 26. Vargas-Ferreira F, Salas MMS, Paediatr Dent 2010; 20(Suppl 1): 5.
17. Tourino LFPG, Correa-Faria P, Ferreira Nascimento GG et al. Association 36. Lygidakis NA, Chaliasou A, Siounas G.
RC et al. Association between between developmental defects of Evaluation of composite restorations
molar incisor hypomineralisation in enamel and dental caries: a systematic in hypomineralised permanent
schoolchildren and both prenatal and review and meta-analysis. J Dent 2015; molars: a four year clinical study. Eur J
postnatal factors: a population based 43: 619−628. Paediatr Dent 2003; 4: 143−148.
study. PLoS 2016; 11: e0156332. 27. Public Health England. Delivering 37. Venezie RD, Vadiakas G, Christensen
18. Ford D, Seow WK, Kazoullis S, Better Oral Health: an Evidence Based JR, Wright JT. Enamel pretreatment
Holcombe T, Newman B. A controlled Toolkit for Prevention 3rd edn. 2014. with sodium hypochlorite to
study of risk factors for enamel https://www.gov.uk/government/ enhance bonding in hypocalcified
hypoplasia in the permanent uploads/system/uploads/ amelogenesis imperfecta: case report
dentition. Pediatr Dent 2009; 31: attachment_data/file/367563/ and SEM analysis. Pediatr Dent 1994;
382−388. DBOHv32014OCTMainDocument_3. 16: 433−436.
970 DentalUpdate November 2018
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38. Kindelan SA, Day P, Nichol R, 939−944. 18.

Willmott N, Fayle SA, BSPD. UK 42. Patel A, Ray-Chaudhuri E, Sood S. 46. Rodd HD, Waterhouse PJ, Fuks AB,
National Clinical Guidelines in Technique Tips − Fitting Hall crowns. Fayle SA, Moffat MA. UK National
Paediatric Dentistry: stainless steel Dent Update 2016; 43: 296−297. Guidelines in Paediatric Dentistry.
preformed crowns for primary 43. Innes NPT, Ricketts D, Chong LY, Pulp therapy for primary molars. Int
molars. Int J Paediatr Dent 2008; Keightley AJ, Lamont T, Santamaria J Paediatr Dent 2006; 16(Suppl 1):
18(Suppl 1): 20−28. RM. Preformed crowns for decayed 15−23.
39. Rogers HJ, Batley HA, Deery C. primary molar teeth (review). 47. The Clinical Effectiveness Committee
An overview of preformed metal Cochrane Database Syst Revs 2015; of The Faculty of Dental Surgery
crowns Part 1: conventional Issue 12. of The Royal College of Surgeons
techniques. Dent Update 2015; 42: 44. Ludwig KH, Fontana M, Vinson LA, of England. Extraction of primary
933−938. Platt JA, Dean JA. The success of teeth − balance and compensation.
40. University of Dundee. The Hall stainless steel crowns placed with September 2001, updated
Technique. A minimal intervention, the Hall Technique. A retrospective November 2006.
child centred approach to study. J Am Dent Assoc 2014; 145: 48. National Institute for Clinical
managing the carious primary 1248−1253. Excellence. Dental checks: intervals
molar. https://dentistry.dundee. 45. Innes N, Evans DJ, Stirrups DR. between oral health reviews.
ac.uk/files/3M_93C%20 The Hall Technique; a randomized 2004. https://www.nice.org.uk/
HallTechGuide2191110.pdf controlled clinical trial of a novel guidance/cg19 (Accessed May
(Accessed July 2017). method of managing carious 2016).
41. Hyde AC, Rogers HJ, Batley HA, primary molars in general dental 49. https://www.rcseng.ac.uk/
Deery C. An overview of preformed practice: acceptability of the dental-faculties/fds/publications-
metal crowns Part 2: the Hall technique and outcomes at 23 guidelines/clinical-guidelines/
technique. Dent Update 2015; 42: months. BMC Oral Health 2007; 7: (Accessed November 2017).

972 DentalUpdate November 2018

 Enhanced CPD DO C & DO B Safeguarding

David Auld

Child Safeguarding in Dental

Practice − What you need to know
Abstract: This paper aims to define the types of child abuse and how this may present to the dental team. It briefly outlines actions which
should be taken if and when safeguarding concerns may arise.
CPD/Clinical Relevance: The dental practice is an environment where signs of child abuse commonly present. It is both an ethical and legal
duty for the dental practitioner to act appropriately in the protection of children attending the practice. Child safeguarding is one of the
GDC’s recommended topics for Continuing Professional Development.
Dent Update 2018; 45: 973–976

In the UK in 2016, over 58,000 children inspections.4 form of child abuse, accounting for 49%
were placed on Child Protection Plans Dentists, and the dental team as of children on child protection plans in
(CPPs) because they were considered by a whole, can be instrumental in the wider the UK.2
local authorities either to be suffering safeguarding team in preventing harm to Neglect may present in a child
from abuse or to be at risk of abuse.1 vulnerable children and adults. Our role as having consistently poor hygiene or
Over the past 10 years, the numbers as dentists is often not to diagnose abuse clothing, persistent scabies or persistent
of children on CPPs and number of per se, but there are a number of ways in headlice, inadequate access to food,
children in Local Authority Care (those which the dental team can contribute to faltering growth/failure to thrive,
removed from the family home) have safeguarding the safety and wellbeing of abandonment, inadequate supervision
increased.2 This is thought to be at least children. or failure to access appropriate
in part due to increased reporting by Dentists tend to see patients medical treatment. It can be difficult
both professionals and members of the more frequently than other health to distinguish some of the above from
public. There have also been increases in professionals in most cases, and they are poverty, and it can be very difficult to
numbers of police-recorded child sexual likely also to see siblings or other family judge the threshold for neglect.5 As such,
offences and indecent image offences members in the practice, and so they are it is almost always necessary for dentists
over the past few years.2 Safeguarding well placed to be able to detect forms of to discuss their findings with experienced
children is one of the General Dental abuse and act accordingly. Dentists may colleagues and/or other professionals
Council’s recommended topics for also witness concerning behaviours or before taking any further action.
CPD,3 whilst keeping people safe and injuries, or disclosures may be made in
safeguarding them from abuse forms an the dental setting.
Dental neglect
important strand of one of the key lines Dental neglect (Figures 1
of enquiry for Care Quality Commission Types of abuse and 2) has been defined by Harris et
Neglect al in the British Society of Paediatric
Neglect can be defined as Dentistry’s guidance on the subject, as
David Auld, BDS, MFDS RCPS, MDentSci, the persistent failure to meet a child’s ‘the persistent failure to meet a child’s
MPaedDent, Specialist in Paediatric basic physical needs, likely to result in the basic oral health needs, likely to result in
Dentistry, Clarendon Dental Spa, Leeds, serious impairment of the child’s health the serious impairment of a child’s oral or
UK. or development.5 It is the commonest general health or development’.6 As with
November 2018 DentalUpdate 973
 Safeguarding

a generalized neglect and other forms safeguarding lead and, if appropriate,

of abuse, it may present in isolation or with a social worker. If unsure about
alongside other forms of abuse. A recent whether to make a referral and looking
clear case of dental neglect seen by the for general advice, then it may not
author was a child who presented with be necessary or appropriate to share
acute pain and odontogenic infection, personal information regarding the child.7
with evidence of extensive untreated However, best practice in
dental disease, a poor attendance record information governance should be
and poor oral hygiene, with clinical observed when sharing information.8 As
records showing that previous dentists such, where possible, and where doing
b had explained the presence of disease, so is not thought to endanger the child,
given appropriate advice on oral hygiene then consent to make a referral and share
and attendance for appointments, information should be sought where a
and had made plans to carry out the referral is deemed necessary. That said, if
necessary treatment. With the family consent is not given to share information
being aware of existing disease and in a safeguarding situation, the duty of
having failed both to ensure access to care to the child over-rides this and the
professional care and to ensure adequate appropriate information will need to be
home care, this was a clear case of dental disclosed to the appropriate authorities.7,8
neglect. In addition, the boy was noted Serious Case Reviews examining
to be grubby in appearance (not an numerous high-profile fatalities caused
especially alarming feature on its own) by abuse have highlighted the failure
Figure 1. (a, b) A 3-year-old child with rampant, and smelled strongly of stale urine. It was of agencies to share information as
active, early childhood caries and poor oral also noted that he had been excluded contributing to the failure to recognize
hygiene. from school due to behavioural problems, the extent of the abuse and failure to take
appeared of particularly short stature, appropriate preventive action.
and other family members had previously
raised concerns with social services. When
Physical abuse
concerns were raised with his mother, she
became abusive towards staff. With all Physical abuse, as defined
these features present, a child protection by the UK government, is ‘a form of
(section 47) referral was made to the local abuse which may involve hitting, shaking,
children’s social services department. throwing, poisoning, burning or scalding,
However, as Harris et al point drowning, suffocating or otherwise causing
out,6 cases are not always so clear-cut. physical harm to a child. Physical harm
Dental neglect does not always warrant may also be caused when a parent or carer
a child protection referral; indeed, a fabricates the symptoms of, or deliberately
preventive single-agency approach, induces, illness in a child’.9 Over half of
Figure 2. A 15-year-old boy with a poor
with the dental team supporting the injuries sustained in child physical abuse
attendance record, who had not brushed his
teeth for some months, attending with acute family to ensure that dental needs are are seen in the orofacial region,10,11 and
periapical periodontitis of the UR3. being met, monitoring attendance and are thus recognizable by the dental team.
compliance, would be appropriate in a However, injuries at other sites may also
case of extensive caries where the family be noted on other areas of exposed skin.
have found it difficult to access care, but Injuries seen may be bruises (particularly
where no other child protection concerns in the shape of implements, slap marks
are present. If attendance does not or grip marks), abrasions and lacerations,
improve or conditions deteriorate, then it burns (such as the well-defined, round
may be appropriate to take a preventive, wound seen in cigarette burns), bite
multi-agency approach, involving school marks, eye injuries and/or fractures.
nurses/health visitors and/or GPs or social Features to be particularly suspicious of
workers, if one is assigned, in order to are injuries presenting late or untreated,
ensure compliance.6,7 those with histories not compatible
If unsure as to the most with the clinical appearance or age
appropriate course of action, or if and stage of development of the child,
Figure 3. Left arm of 7-year-old boy showing uncertain of the diagnosis of neglect, injuries noted bilaterally − therefore less
bruising on the forearm where he had been
then the practitioner should discuss likely to be caused during one episode
grabbed.
the case with the practice/service of accidental trauma − and bruising or
974 DentalUpdate November 2018
 Safeguarding

injuries to children who are too young to the same day. either contact abuse, where a perpetrator,
be mobile or are non-ambulatory. Whilst With some exceptions, it is best who may be an adult or child, engages
accidental injuries will tend to occur on practice to explain your concerns to parents in physical sexual activity with a child,
bony prominences such as elbows, knees, and seek consent for referral.13 However, or non-contact abuse, where the
shins, forehead, nose and chin, injuries when parents/carers are being abusive abuser involves the child in looking at
at other sites are less likely to be caused or violent, putting you or colleagues at or producing pornographic material,
accidentally. Extra-oral sites of injury risk, if the child may be placed at greater encouraging sexual behaviours or
to be wary of are ears, side of face and risk, if referral may interfere with a police grooming them in preparation for abuse.
neck/top of shoulders, soft tissues of the investigation or social work enquiry, in cases Victims do not always see themselves
cheeks, periorbital haematoma (especially of sexual or organized abuse, or where as victims. Dentists are most likely
bilaterally), chest, abdomen, back (except fabricated or induced illness is suspected, to pick up on sexual abuse through
over bony spine), the inner aspect of then referral should proceed without behavioural or emotional signs, unless
the arms (Figure 3), forearms, (where discussion with parents/carers.7 disclosures are made or lesions are
the victim may raise arms in defence), or present in the orofacial region, such as
ligature marks on the wrists or ankles, Emotional abuse features of sexually-transmitted diseases
bruising to the soles of feet, inner thigh Emotional abuse, also known or petechiae in the palate, which may
or certainly any injury to the groin area as psychological abuse, is usually found indicate oral sex.7,8 Inappropriate,
or genitals.7,8 That said, non-accidental alongside other forms of abuse and/or sexualized behaviours, pregnancy or
injuries do not occur exclusively at these neglect, but may occur alone, and may other emotional signs of abuse may be
sites; the author recently attended a child be difficult to identify. It is defined as seen. As with physical abuse, suspected
who sustained a large haematoma on the the persistent emotional maltreatment cases of sexual abuse or emotional abuse
forehead following his head being forced of a child and may have far-reaching need to be discussed with safeguarding
into a table by his father. implications for the child’s emotional and leads and referred using local procedures
Intra-orally, whilst a torn labial mental wellbeing. This may involve parents as per LSCBs, usually by telephone and
frenum can be caused in falls while or carers telling the children that they are followed up in writing within 48 hours.
learning to walk or accidental trauma worthless, unloved or inadequate. It may
in older children, in non-ambulatory include not giving children opportunities to Other behaviours suggestive of abuse
patients, it is usually a sign of force- express their views, deliberately silencing Maltreatment should be
feeding or a blow to the mouth. Other them or making fun of what they say or considered when behaviours such
penetrating or blunt trauma may also be how they communicate. It also may involve as self-harming, runaway behaviour,
seen in the mouth and, when taking a unexplained secondary day- or night-
bullying, including online bullying by
history and examining a child presenting time wetting or soiling or smearing of
peers.7,8
with orofacial trauma, one must always faeces are seen. It should be suspected
Possible indicators of emotional
carefully consider the compatibility of the
abuse which may be noted in the dental where there is repeated stealing, hiding
history with the clinical findings and age
surgery are poor growth, developmental/ or hoarding of food where not explained
of presentation of the child.
educational delay, low self-esteem, marked by conditions such as Prader-Willi
There are some conditions
changes in behaviour or emotional state Syndrome.8
which can present and look similar to
not fully explained by non-maltreatment
physical abuse: vesiculobullous diseases
and impetigo can mimic burns, and
stressful events (such as bereavement Conclusions
or parental separation), including Increased vigilance, awareness
children who present frequently with
becoming highly anxious, distressed or and improved safeguarding training over
bruising or who are reported to bruise
withdrawn, being emotionally immature, recent years have helped identify many
very easily may benefit from referral
having attachment disorders, displaying children in need or at risk of abuse and
to exclude bleeding disorders. Some
aggressive/oppositional/challenging helped them and their families receive
birthmarks can be mistaken for bruising
behaviour or excessively good behaviour/ the necessary support. Safeguarding
and conjunctivitis may be confused with
orbital trauma. Recurrent fractures may desire to please.7,8 There also may be a is a complex and delicate area where
present in osteogenesis imperfecta. history of running away. Parents/caregivers dentists may feel out of their depth and
However, if suspicious of non- may ignore the child or use abusive or it can undoubtedly be a stressful part
accidental injury, then the first step is to threatening language, or have unrealistic of a clinician's work. Meticulous record-
discuss with a trusted colleague, such expectations of the child’s ability to cope keeping, good communication skills
as a practice/department safeguarding with dental treatment. and sensitive handling are imperative.
lead, named nurse or doctor.7,12 If still However, there are always colleagues,
concerned, an urgent referral needs to Sexual abuse both within and outwith the profession,
be made via the pathways set out by the Sexual abuse is legally defined who can be looked to for support and
Local Safeguarding Children Board (LSCB), slightly differently across the four nations advice, such that safeguarding issues
with a paediatrician seeing the child on of the UK,12,14-16 but essentially involves never have to be dealt with alone.12,14-16
November 2018 DentalUpdate 975
Safeguarding

It is the duty and privilege of clinicians to provide care and support

New, fossil free to children at risk of abuse, and their families, in a child-centred
aspirator tubes manner, in order to prevent harm to vulnerable children and young
manufactured people.

from renewable
resources. References
1. Department for Education. Characteristics of Children in Need in
England, 2015−16. London: Department for Education, 2016.
Manufacturers of 2. NSPCC. How safe are our children? The most comprehensive
products can make a overview of child protection in the UK. London: NSPCC, 2017
difference regarding 3. https://www.gdc-uk.org/professionals/cpd/cpd-topics.
global warming caused (Accessed 11 November 2017).
by greenhouse gases. 4. https://www.cqc.org.uk/sites/default/files/20150611_
By using bio-based dental_care_provider_handbook.pdf. (Accessed 11
polyethylene, we November 2017).
reduce the level of 5. National Institute for Health and Care Excellence. Child Abuse
carbon dioxide in the and Neglect. London: NICE, 2017.
atmosphere. We can 6. Harris JC, Balmer RC, Sidebotham PD. British Society of
help save our planet Paediatric Dentistry: a policy document on dental neglect.
for future generations. Int J Paediatr Dent 2009; May 14. [Epub ahead of print]
7. Harris J, Sidebotham P, Welbury R, Townsend R, Green M,
Goodwin J, Franklin C. Child Protection and the Dental Team:
An Introduction to Safeguarding Children in Dental Practice.
Sheffield: Committee of Postgraduate Dental Deans and
Directors (COPDEND) UK, 2006.
8. National Institute for Health and Care Excellence. Child
Maltreatment: When to Suspect Child Maltreatment in Under 18s.
London: NICE, 2017.
9. National Institute for Health and Care Excellence. Child Abuse
and Neglect. London: NICE, 2017.
10. Cairns AM, Mok JYQ, Welbury RR. Injuries to the head, face,
mouth and neck in physically abused children in a community
setting. Int J Paediatr Dent 2005; 15: 310−318.
Hygovac Bio®
11. Jessee SA. Physical manifestations of child abuse to the head,
face and mouth: a hospital survey. ASDC J Dent Child 1995; 62:
245−249.
12. HM Government. Working Together to Safeguard Children – A
Guide to Inter-agency Working to Safeguard and Promote the
Welfare of Children. London: The Stationery Office, 2015.
13. HM Government. Information Sharing − Advice for Practitioners
Providing Safeguarding Services to Children, Young People,
Parents and Carers. London: The Stationery Office, 2015.
14. Department of Health. Co-operating to Safeguard Children and
Young People in Northern Ireland. Belfast: DoH, 2017.
15. The Scottish Government. The National Guidance for Child
Protection in Scotland. Edinburgh: The Scottish Executive, 2010.
16. The Welsh Government. All Wales Child Protection Procedures.
Cardiff: The Welsh Gorvernment, 2008.
976 DentalUpdate November 2018
 Enhanced CPD DO C OralSurgery/Radiology

Thamesh Kerai

Kandasamy Ganesan

Are Changes in Specific Landmark

Anatomy on a Panoramic Image
Suggestive of Maxillary Sinus
Disease?
Abstract: Dental panoramic radiography is a commonly employed investigation in dentistry, however, its use in the primary indication
of maxillary sinus disease is often underestimated. Being able to identify anomalies or abnormalities involving the maxillary sinus on
radiographs will facilitate early intervention and appropriate referral to the relevant specialties.
CPD/Clinical Relevance: Dentists should have a good understanding of radiographic anatomy of the maxillary sinus. Recognizing
radiographic changes allows appropriate referral and improved patient care.
Dent Update 2018; 45: 977–984

Due to their anatomical location, the maxillary 2.7 million panoramic radiographs per year in consider developmental and anatomical
sinuses should be assessed when establishing the UK, and they will often be the first to identify variations, which may present as false-positive
a diagnosis for orofacial pain and any diseases coincidental findings of maxillary sinus disease.2 radiographic change of disease.
relating to upper teeth.1 Dentists should be Being able to distinguish between
able to interpret conventional panoramic dental and maxillary sinus symptoms enables Landmarks in the maxillary sinus
radiography, including having good the dentist to determine when dental treatment area on a panoramic image
knowledge of normal anatomy and its variants. is appropriate and when referral to a different
specialty is more apt. Similarly, being able to Radiological assessment of
For general dental practitioners (GDPs),
interpret dental radiographs systematically will the maxillary sinuses requires a thorough
panoramic radiography is widely accessible
enable the dentist to identify both dental and examination, including the degree of
and is a common radiographic technique
sinus pathology competently. aeration and alteration of the bony outlines
used in assessing pathosis, particularly of
Extensive lesions occupying the of the maxillary sinuses. There are three
larger lesions not fully imaged by intra-oral
maxillary sinus can often produce surprisingly key anatomical radio-opaque lines visible
radiography. Dentists are thought to prescribe
few clinical features. Therefore, panoramic on a panoramic radiograph, which should
radiographs can frequently be used to indicate be carefully traced when detecting disease
the presence of maxillary sinus disease.3 associated with the maxillary sinus. Two
Thamesh Kerai, BDS(Hons) MFDS There is a wide variety of further lines should also be acknowledged,
RCSEd, Dental Core Trainee in Oral and pathological conditions that affects the maxillary that is those of the hard palate and the floor
Maxillofacial Surgery and Kandasamy sinuses (Table 1). These can be categorized into of the maxillary antrum. However, these would
Ganesan, BDS, MDS(OMFS), MFDS those that originate from the sinus epithelium, only be distorted in extensive lesions which
RCS(Eng), FFD RCSI (Oral Surg Oral the adjacent paranasal sinuses, nasal cavity, perforate these walls and, therefore, they
Med), Consultant in Oral Surgery, Oral dental tissues, or in the adjacent bony structures would be clinically palpable.
and Maxillofacial Surgery Department, with expansion into maxillary antrum.2 The three lines are:
Southend University Hospital, Essex SS0 Specifically, extrinsic cysts of odontogenic origin 1. The anteromedial wall of the maxillary
0RY, UK. will be the focus of this article. One should also antrum;
November 2018 DentalUpdate 977
 OralSurgery/Radiology

Pathological and developmental conditions affecting the maxillary sinuses which present with radiographic changes
Examples
Inflammatory Acute and chronic sinusitis
Trauma Haematoma
Neoplasms Adenocarcinoma

Ameloblastoma
Calcification Anthrolith
Developmental conditions Fibrous dysplasia
Other bone abnormalities Paget's disease of bone
Intrinsic Mucous (or mucosal) retention cyst
Odontogenic
Developmental Keratocyst
Dentigerous cyst
Cysts Odontogenic

Extrinsic Inflammatory Radicular cyst

Non-odontogenic Nasopalatine cyst

Table 1. Examples of pathological and developmental conditions that affect the maxillary sinuses. The list of examples is by no means exhaustive but the
effects of odontogenic cysts are demonstrated in this article.

over the maxillary sinuses (Figure 2).

The anteromedial wall of the
maxillary antrum is composed of the lateral
wall of the nasal cavity and the facial surface of
the superior maxilla (Figure 2).

Interpreting maxillary sinus

disease on two-dimensional
(2-D) images versus visualizing
maxillary sinus disease on three-
dimensional (3-D) images
The absence of any of the real hard
tissue shadows shown in Figure 1 may indicate
Figure 1. A standard panoramic radiograph with the key hard tissue shadows associated with the right
the presence and extent of sinus disease
maxillary sinus outlined. A line diagram represents these landmarks more clearly. 1) Pterygomaxillary
fissure; 2) zygomatic buttress; 3) anteromedial wall of the maxillary antrum. The hard palate (red arrow)
(Figures 3−8). This article presents a series of
and floor of the maxillary antrum (yellow arrow) should also be considered. clinical cases in which a dento-alveolar lesion
was suspected on a panoramic radiograph
and a referral to an oral surgery specialist was
made for further investigation.
2. The pterygomaxillary fissure; (superiorly), pterygoid plate of the sphenoid By considering these changes on
3. The zygomatic buttress. bone (inferiorly) and the posterior wall of the panoramic radiography (Figure 1), along with
These anatomical hard tissue shadows maxillary sinus (anteriorly). This landmark a clinical history and examination, further
can be illustrated on a standard panoramic appears as a teardrop-shaped shadow (Figure 2). radiographic investigation, such as computed
radiograph (Figure 1). The zygomatic processes of the tomography (CT) or cone-beam computed
The pterygomaxillary fissure is maxilla are thick buttresses of bone, which tomography (CBCT), was performed if it was
medial to the temporal fossa and is bounded extend laterally from the maxilla and appear as deemed appropriate. In the majority of cases,
by the pterygoid process of the sphenoid bone J-shaped or hockey stick shadows superimposed 2-D imaging does not allow visualization of
978 DentalUpdate November 2018
 OralSurgery/Radiology

the size of the disease process, its effects on

surrounding structures and its composition.
Therefore, 3-D imaging is often required to
complement the primary investigations.4

Discussion
Although there are clear
radiographic changes visible on panoramic
radiography, there is no indication as to the
extent of the disease. Despite the obvious
advantages of low radiation dose and a large
visualization of the facial bones, their use is
limited for a number of reasons.4 Panoramic
radiographs are unreliable in comprehensively
confirming the absence or presence of disease
Figure 2. These three lines can be represented on the lateral and frontal views of the skull. The frontal owing to the superimposition of soft tissue, air
process of the maxilla (green surface) and lateral nasal wall compose the anteromedial wall of the and artefactual shadows which can overlie the
maxillary sinus (red line). The zygomatic buttress (white line) is located in the region of the zygomatic
required hard tissue structures. Furthermore,
process of the maxilla. The relative position of the pterygomaxillary fissure is marked as the blue line.
panoramic images are prone to distortion,
particularly due to positioning errors.1 In
a addition, if a panoramic radiograph appears
normal, then it does not necessarily indicate
that there is no disease present (false-negative
findings). However, the clinician should be able
to appreciate that both clinical symptoms and
radiographic changes may signify that further
investigations are required, usually in the form
of 3-D radiographic imaging.
Appropriate referral for advanced
imaging in a secondary or tertiary care
setting should comply with Ionizing Radiation
(Medical Exposure) Regulations
(IR(ME)R) 2000.5 If an abnormality is identified
on a panoramic radiograph, either by a GDP
or another specialty, then a referral to an
appropriate specialist should be made. At this
stage, the specialist may consider advanced
imaging, such as a CBCT or conventional CT
b scan, to assist with patient management or
treatment.
There have been various studies
that have compared the use of 2-D and
3-D radiographic imaging in evaluating the
maxillary sinuses. Tadinada et al showed that,
although both panoramic radiographs and
Figure 3. (a, b) A 41-year-old female presented
with a one-year history of recurrent left-sided
CBCT showed high sensitivity for identifying
facial pain. A CT scan revealed a large cyst maxillary sinus pathology, CBCT showed
associated with an ectopic left maxillary third considerably higher specificity.6 In addition,
molar. The cyst occupied almost the entire their findings indicate that there is merely a 1
maxillary sinus and extended into the left lateral in 2 success rate in the detection of pathology
nasal fossa. Note the loss of the hard tissue by panoramic radiographs. Similarly, Vallo et al
shadows of the lateral nasal wall, zygomatic highlighted a statistically significant difference
buttress and pterygomaxillary fissure on the in the identification of apical periodontitis
panoramic radiograph. Histopathology results in the posterior maxilla between panoramic
following enucleation confirm the lesion as a
radiography and CBCT, with the latter being
dentigerous cyst.
more favourable.7
November 2018 DentalUpdate 979
 OralSurgery/Radiology

a b

Figure 4. (a, b) A 32-year-old female presented with recurrent intra-oral and nasal pus drainage. The upper left third molar was extracted three years earlier
and the panoramic radiograph highlights the loss of the hard tissue shadow of the left pterygomaxillary fissure. The axial section of the CT scan shows a
well-defined corticated ovoid lesion containing irregular soft tissue. She was diagnosed with a 4 cm thick-walled, odontogenic keratocyst occupying the left
maxillary sinus.

a b

Figure 5. (a−c) A 28-year-old male presented with an asymptomatic, slow-growing, left-sided, extra-
oral swelling of the maxilla. The CT scan indicated that there is a large and expansive presumed cystic
bony mass in the anterolateral aspect of the maxilla. The cystic mass encroaches the anterior half of
the left maxillary antrum and measures 5.5 x 3.9 x 4 cm. The shadow of the left anteromedial wall on
the panoramic radiograph is completely lost. The 3-D reconstruction illustrated the extent of the lesion
perforating through the anterolateral wall of the maxilla, hence the ability to palpate the lesion on
presentation. Histopathological findings indicated that this was likely to be a large residual cyst.

A recent study by Dau et al that panoramic radiography alone was expertise. Similar findings were reported by
examined the diagnostic accuracy of panoramic insufficient in evaluating sinus disease, Malina-Altzinger et al, with advanced imaging
radiography versus CBCT in symptomatic however, it still remains a useful diagnostic providing a more consistent and precise
maxillary sinus pathologies.8 It was concluded tool, depending on the clinician’s training and evaluation of specific maxillary sinus conditions.9
980 DentalUpdate November 2018
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 OralSurgery/Radiology

a b

Figure 6. (a, b) A 49-year-old male presented with a left-sided nasal obstruction and a foul taste in his mouth. The left anteromedial wall appeared partially
absent on the panoramic radiograph. A CT scan showed expansion of the anterior and lateral wall of the left maxilla. The upper left third molar is embedded
in the posterior wall of the maxillary sinus. A dentigerous cyst associated with the unerupted upper left third molar completely occupies the left maxillary
sinus.

a b

Figure 7. (a, b) A 68-year-old female directly referred from a GDP for a left-sided, slow-growing swelling of the face. On examination, there was an obvious
swelling on the left maxillary prominence and zygomatic area. The panoramic radiograph confirms its cystic nature with the loss of the left zygomatic
buttress and periodontal ligament space of the upper left second and third molars. The CT scan illustrated a homogeneous cystic lesion that expands
superiorly in the left maxillary antrum and protrudes medially into the middle and inferior turbinates, causing partial blockage of the nasal air spaces.
Enucleation of the entire cyst and histopathological findings confirmed the lesion as an odontogenic keratocyst.

a b

Figure 8. (a, b) A 26-year-old male presented to our ear, nose and throat (ENT) colleagues complaining of a left-sided nasal obstruction and epiphora.
He had a 4-month history of an increasing, non-painful bony swelling in the left maxilla, specifically in the region of the upper left first premolar, second
premolar and first molar. The left anteromedial wall of the maxillary antrum is absent on the panoramic radiograph. One should note the large periapical
radiolucent lesions associated with the roots of the upper right and left first molars. The CT scan identified a large expansile 3 x 4.4 x 4 cm bony cystic
lesion occupying the entire left maxillary sinus and completely blocking its drainage. The size of this lesion has caused obliteration of the left nasal cavity
and deviation of the nasal septum. There is a smaller bony cystic lesion in the right maxillary antrum. Enucleation of the bilateral cysts was performed and
confirmed as radicular cysts associated with the upper right and left first molars.

November 2018 DentalUpdate 983

OralSurgery/Radiology

Conclusion
Dryz® Whilst caution is advised for the use of panoramic
creates a dry working radiography in eliminating the presence of disease, it can be a reliable
environment every time. indicator of extension of the disease process through the walls of the
maxillary sinus. It should be appreciated that the floor and medial and
posterior walls of the antrum are well shown on panoramic radiographs.
Consequently, it is a useful adjunct for indicating large disease processes
that have perforated the sinus walls. This is critical as lesions will often fill
the sinus space before patient symptoms are displayed. The use of such
2-D radiographic imaging should not be underestimated, but it is clear
that it should be supplemented with far superior imaging techniques
prior to any intervention to aid in diagnosis and surgical planning.
This case series has outlined the value in detecting a
distortion or absence of three anatomical landmarks on panoramic
radiographs. This initial incidental finding has led to a change of
approach at a consultant and junior level. Clinicians would benefit by
having an increased awareness of certain radiographic features, which
indicate the need for further imaging, and the aim is for this level of
understanding to be translated to the primary care setting.
It is the authors’ recommendation that clinicians should
identify such changes in panoramic radiographs and correlate this
information with the clinical findings to make an appropriate referral to
a specialist in a secondary or tertiary care setting. At this stage, based
on the history and clinical examination, the need for more reliable and
advanced imaging, such as CT or CBCT, should be considered.

Conflicts of interest:
None.

References
1. Whaites E, Drage N. Essentials of Dental Radiography and Radiology 5th edn. Edinburgh:
Churchill Livingstone/Elsevier, 2013.
2. Bell GW, Joshi BB, Macleod RI. Maxillary sinus disease: diagnosis and treatment. Br Dent J
2011; 210: 113−118.
3. Farman AG, Nortjé CJ. Pathologic conditions of the maxillary sinus. Panoramic Imaging News
2002; 2: 1−6.
4. Shahbazian M, Vandewoude C, Wyatt J, Jacobs R. Comparative assessment of panoramic
radiography and CBCT imaging for radiodiagnostics in the posterior maxilla. Clin Oral Invest
2014; 18: 293−300.

Dryz® Gingival Hemostatic Retraction Paste 5. British Institute of Radiology, Society and College of Radiographers. A Guide to
stops gingival bleeding and seepage that may Understanding the Implications of the Ionising Radiation (Medical Exposure) Regulations in
interfere with impression taking. Diagnostic and Interventional Radiology. London: The Royal College of Radiologists, 2015.
6. Tadinada A, Fung K, Thacker S, Mahdian M, Jadhav A, Schincaglia GP. Radiographic
evaluation of the maxillary sinus prior to dental implant therapy: a comparison between
two-dimensional and three-dimensional radiographic imaging. Imaging Sci Dent 2015; 54:
169−174.
7. Vallo J, Suominen-Taipale L, Huumonen S, Soikkonen K, Norblad A. Prevalence of mucosal
abnormalities of the maxillary sinus and their relationship to dental disease in panoramic
radiography: results from the Health 2000 Health Examination Survey. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2010; 109: 80−87.
8. Dau M, Marciak P, Al-Nawas B et al. Evaluation of symptomatic maxillary sinus pathologies
using panoramic radiography and cone beam computed tomography − influence of
professional training. Int J Implant Dent 2017; 3: 13.
9. Malina-Altzinger J, Damerau G, Grätz KW, Bernd Stadlinger PD. Evaluation of the maxillary
sinus in panoramic radiography − a comparative study. Int J Implant Dent 2015; 1: 17.

984 DentalUpdate November 2018

 Enhanced CPD DO C O&MSurgery/RestorativeDentistry

Yehya EK Gamie

Zakareya Gamie, David Seymour and Paul H Whitfield

Odontogenic Myxoma of the

Maxilla: Diagnostic Considerations,
Surgical Resection and Prosthetic
Rehabilitation
Abstract: A 15-year-old female with a history of orthodontic treatment was referred by her general dental practitioner (GDP) to the Oral
and Maxillofacial Surgery (OMFS) department after noticing a right buccal maxillary swelling during a routine check-up. Examination and
radiographic investigations revealed a lesion extending from UR3 to UR6 causing bony expansion with no evidence of root resorption.
Following biopsy and histopathological analysis, a diagnosis of Odontogenic Myxoma (OM) was made. Treatment involved a segmental
resection and fitting an immediate partial denture. Options for long-term rehabilitation include removable and implant-supported
prostheses.
CPD/Clinical Relevance: This case highlights the importance of thorough clinical and radiographic examination, and joint treatment
planning between the Restorative and OMFS departments.
Dent Update 2018; 45: 985–990

Odontogenic Myxoma (OM) was first of mesenchymal origin.2-4 It is rare and her GDP for a routine examination. The GDP
described in 19471 and is a benign, locally accounts for between 1% and 17.7% of noticed an asymptomatic firm expansion
invasive, non-metastasizing neoplasm odontogenic tumours.5 Occurring at any of bone in the upper right quadrant along
age, it is most common in the second and with a slightly displaced UR4. There was no
third decades of life, with a higher incidence evidence of erythema, ulceration or pus
in females and in the mandible.2-6 Many discharge (Figure 1).
Yehya EK Gamie, BDS, MFDS RCS(Ed), cases are detected during routine dental
Oral and Maxillofacial Surgery Trainee/ examinations.5,7 Features include slow and
Dental Surgeon, York Hospital/Aintree
Investigations
asymptomatic growth, tooth displacement
University Hospital, Liverpool, Zakareya A panoramic radiograph taken
and root resorption, delayed eruption, pain,
Gamie, BSc(Hons), MBChB, MRCS, PGCert in April 2016 (Figure 2) revealed a mixed
facial asymmetry, cortical bone perforation
(Genomic Medicine), PhD Student and radiolucent/radio-opaque area in the
and soft tissue invasion.2-8 Radiographically,
Honorary Clinical Research Associate right maxilla extending from the distal
OM may appear as unilocular or multilocular
in Trauma and Orthopaedic Surgery, aspect of the UR3 to the mesial aspect of
radiolucencies and are described as having
Newcastle University, David Seymour, the UR6, causing displacement of teeth. A
a soap bubble, honeycomb or tennis racket
BChD, MFDS RCS(Ed), MSc ClinDen(Rest cone beam computed tomography (CBCT)
appearance.3-8
Dent) FDS RCS(Ed), Consultant in scan taken in July 2016 was more useful
Restorative Dentistry, Paul H Whitfield, in exposing the dimensions of this lesion,
MBBS, BDS, FDS, FRCS, Consultant Oral Initial presentation along with a sparse and course trabecular
and Maxillofacial Surgeon, York Hospital, A fit and well 15-year-old female pattern and patchy calcifications (Figure
Wigginton Road, York, North Yorkshire, was referred to the OMFS department at 3). Expansion of the buccal plate and right
YO31 8HE, UK. York Hospital in April 2016 after attending maxillary sinus encroachment could also be
November 2018 DentalUpdate 985
 O&MSurgery/RestorativeDentistry

Figure 1. Pre-operative intra-oral view showing

bony expansion adjacent to the UR3 and a
displaced UR4 and UR5.

Figure 2. Panoramic radiograph showing a radiolucent area in the right maxilla which extends from
seen but no root resorption was evident. the distal aspect of the UR3 to the mesial aspect of the UR6. Root displacement can also be seen.
Further examination under
general anaesthesia (GA) in August 2016
revealed a soft tissue mass extending
around the upper right premolars and
a thick white jelly-like material invading
into bone. A biopsy and histopathological
analysis showed spindle-shaped cells with
an eosinophilic cytoplasm embedded
in loose myxoid matrix (Figure 4). A
diagnosis of OM was reported in October
2016.

Surgical treatment and

restorative rehabilitation
Surgical resection was
performed under GA in January 2017. A
buccal and palatal full mucoperiosteal
flap was raised and UR3 and UR6 were
extracted. A block resection with a Figure 3. Pre-operative CBCT scan of the right midface showing the lesion. A sparse and course
safe margin was carried out using trabecular pattern and patchy calcifications are visible
a piezoelectric saw along with an
osteotome. This extended to a level
below the infra-orbital foramen (Figure
5 a, b). The right buccal fat pad was used a clear vacuuform material. The immediate
for immediate reconstruction and was denture was of reasonable fit and required
sutured over the defect. The resection minimum adjustment (Figure 7).
involved the antrum but oral mucosa
closure was achieved and hence an
obturator was not required.
Discussion
An upper partial immediate Features of OM vary and it
denture was designed in collaboration should be considered in the differential
between the restorative dentist and diagnosis of both radiolucent and mixed
surgeon (Figure 6). This was constructed radiolucent/radio-opaque lesions in both
via impressions taken prior to the jaws for all age groups. Table 1 shows
planned surgery. differential diagnoses in adults and
An immediate Essix retainer children and it includes a wide variety Figure 4. Histopathological analysis revealing
was also constructed as a reserve of benign but also malignant tumours.2 the typical spindle cells of myxoma immersed
in abundant myxomatous intercellular matrix
option if necessary (Figure 6). This was Clinical, radiographic and microscopic
(Hematoxylin-eosin stain, magnification 10X).
constructed by bonding acrylic teeth to features are important in the diagnosis
986 DentalUpdate November 2018
LOUPE LIGHT COMBO
2.5X MICRO & ENDEAVOUR HEAD LIGHT

EMAIL: [email protected]
Call: 01733 315203
 O&MSurgery/RestorativeDentistry

Figure 8. Panoramic radiograph following orthodontic treatment approximately nine months prior to
the GDP referral.

Figure 5. Surgical resection of the tumour. (a)

Intra-operative view showing the patient post
resection. (b) The gross pathological specimen.

Figure 9. Post-operative follow-up panoramic radiograph after the surgical resection of the OM.

of head and neck lesions. Histology with Surgical management varies

immunohistochemical analysis is most depending on the location, size of
Figure 6. Immediate prosthetic
reliable in distinguishing myxoma from tumour, age of patient and individual
rehabilitation using an Essix retainer (left) or
immediate partial denture (right). malignant tumours.2 experience.2 This ranges from enucleation
Early diagnosis is vital and it and the application of Carnoy’s solution to
is imperative that, during routine follow- surgical resection with a 0.5−2 cm margin
up, extra- and intra-oral examinations are and immediate microvascular free flap
thorough and systematic. Prior to the GDP reconstruction.2-4,7,8
referral, the patient received orthodontic Carnoy’s solution penetrates
treatment in secondary care. A panoramic cancellous spaces in bone and thus
radiograph was taken in July 2015 (Figure 8) devitalizes and fixes remaining tumour cells.
and this lesion was missed. This highlights It is preferably not to be used in the vicinity
the importance of carefully examining and of neural structures or the maxillary sinus
reporting radiographs along with continued to prevent neuropathy or necrosis of the
education and training in line with Ionizing sinus wall.10 Other complications include
Figure 7. Immediate partial denture in situ intra- Radiation (Medical Exposure) Regulations infection, dehiscence and bone sequestrum
operative.
2000 (IRMER).9 formation.11 Carnoy’s solution has also been
November 2018 DentalUpdate 989
 O&MSurgery/RestorativeDentistry

Bregni R, de Almeida OP, Contreras-Vidaurre

Children Adults
E, Vargas PA et al. Odontogenic myxoma:
Benign Eosinophilic granuloma Ameloblastoma clinico-pathological, immunohistochemical
and ultrastructural findings of a multicentric
Histiocytosis Odontoma
series. Oral Oncol 2008; 44: 601−607.
Intraosseous haemangioma Odontogenic keratocyst 6. Noffke CE, Raubenheimer EJ, Chabikuli
NJ, Bouckaert MM. Odontogenic myxoma:
Cherubism Aneurysmal bone cyst
review of the literature and report of 30 cases
Cranial fasciitis Central giant cell granuloma from South Africa. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2007; 104: 101−109.
Malignant Rhabdomyosarcoma Rhabdomyosarcoma
7. Leiser Y, Abu-El-Naaj I, Peled M. Odontogenic
Eosinphilic granuloma Carcinoma myxoma − a case series and review of the
surgical management.
Metastasis
J Craniomaxillofac Surg 2009; 37: 206−209.
Ameloblastoma 8. Subramaniam SS, Heggie AA, Kumar R, Shand
Table 1. Differential diagnosis of odontogenic myxoma. 2 JM. Odontogenic myxoma in the paediatric
patient: a review of eight cases. Int J Oral
Maxillofac Surg 2016; 45: 1614−1617.
9. Department of Health and Social Care.
reformulated without chloroform because of A minimum of 5 year follow-up Ionising Radiation (Medical Exposure)
its association with cancer and reproductive is advised prior to moving onto the final Regulations 2017: guidance. Available
toxicity.12 reconstructive phase,7 with the first 2 years from https://www.gov.uk/government/
Unlike most neoplasms, being the period when the neoplasm is publications/ionising-radiation-medical-
the myxoma is not encapsulated and most likely to recur.4 Annual panoramic exposure-regulations-2017-guidance
myxomatous tissue infiltrates adjacent bone radiographs for all lesions are advocated (Accessed 29 October 2018).
without immediate destruction. This could (Figure 9). CBCT imaging is more reliable for 10. Kaczmarzyk T, Mojsa I, Stypulkowska J. A
explain why conservative approaches, such maxillary lesions.8 systematic review of the recurrence rate for
as curettage or simple local excision, have a keratocystic odontogenic tumour in relation
reported recurrence of approximately 10% Acknowledgements to treatment modalities. Int J Oral Maxillofac
to 33%.4,7 Despite aggressive local growth, I would like to thank Emane Surg 2012; 41: 756−767.
OMs are not believed to undergo malignant Gamie for her assistance and the Oral 11. Ribeiro Junior O, Borba AM, Alves CA, de
transformation or metastasize.13 and Maxillofacial Surgical team, Dental Gouveia MM, Coracin FL, Guimaraes Junior
This patient was initially seen in Laboratory and Radiology Department at J. Keratocystic odontogenic tumors and
the department within two weeks after the York Hospital for their support. Carnoy’s solution: results and complications
GDP referral, which is in line with National assessment. Oral Dis 2012; 18: 548−557.
Institute for Health and Care Excellence 12. Fabrizi L, Taylor GW, Canas B, Boobis AR,
(NICE) suspected cancer guidelines.14 The References Edwards RJ. Adduction of the chloroform
benign tumour was resected approximately 1. Thoma KH, Goldman HM. Central myxoma of metabolite phosgene to lysine residues of
nine months afterwards. This needs to be the jaw. Oral Surg Oral Med Oral Pathol 1947; human histone H2B. Chem Res Toxicol 2003;
reviewed as the Department of Health states 33: B532−540. 16: 266−275
that patients have a right to start consultant- 2. Kansy K, Juergens P, Krol Z, Paulussen M, 13. Barros RE, Dominguez FV, Cabrini RL.
led treatment within a maximum of 18 Baumhoer D, Bruder E et al. Odontogenic Myxoma of the jaws. Oral Surg Oral Med Oral
weeks.15 myxoma: diagnostic and therapeutic Pathol 1969; 27: 225−236.
Patients facing loss of their teeth challenges in paediatric and adult patients − a 14. National Institute for Health and Care
and associated structures may experience case series and review of the literature. Excellence (NICE). Suspected cancer:
apprehension towards losing their social J Craniomaxillofac Surg 2012; 40: 271−276. recognition and referral (NG12). Available
image or daily function.16 The restorative 3. Simon EN, Merkx MA, Vuhahula E, Ngassapa from https://www.nice.org.uk/guidance/
dentist’s role is to provide functional D, Stoelinga PJ. Odontogenic myxoma: a ng12 (Accessed 29 October 2018).
and aesthetic restorations for a smooth clinicopathological study of 33 cases. 15. Department of Health. Referral to treatment
transition. A cobalt chrome partial denture Int J Oral Maxillofac Surg 2004; 33: 333−337. consultant-led waiting times rules suite.
can be provided once healing is complete, 4. Lo Muzio L, Nocini P, Favia G, Procaccini Available from https://www.gov.uk/
for increased comfort and retention whilst M, Mignogna MD. Odontogenic myxoma government/publications/right-to-start-
monitoring for any recurrence. In the case of the jaws: a clinical, radiologic, consultant-led-treatment-within-18-weeks
of a paediatric patient, several appliances immunohistochemical, and ultrastructural (Accessed 29 October 2018).
could be provided until growth is complete study. Oral Surg Oral Med Oral Pathol Oral 16. Santosa RE. Provisional restoration options
prior to bone augmentation and implant Radiol Endod 1996; 82: 426−433. in implant dentistry. Aust Dent J 2007; 52:
rehabilitation. 5. Martinez-Mata G, Mosqueda-Taylor A, Carlos- 234−242; quiz 54.

990 DentalUpdate November 2018

 TechniqueTips

Technique Tips
Prosthodontics: The Admix Impression

The ‘admix impression’ is practitioner in the construction of a

a definitive secondary impression conventional mandibular complete
technique used in the management denture in patients with a severely
of severely resorbed mandibular resorbed atrophic mandibular ridge.
ridges covered with atrophic
mucosa.1 First described by McCord
The admix impression technique
and Tyson, it involves the use of
a viscous admix of impression 1. A primary impression
cake compound and greenstick should be taken of the edentulous Figure 1. A severely resorbed mandibular
tracing compound.2 Mandibular mandibular ridge for the construction ridge equating to Cawood and Howell ridge
ridges equating to Cawood and of an accurate close-fitting custom- classification V. Note the presence of folds of thin
Howell ridge classification V and tray. The British Society for the Study atrophic mucosa.
VI often pose clinical challenges of Prosthetic Dentistry (BSSPD)
when constructing a satisfactory states that primary impressions
conventional complete denture.3 should accurately record clinically
As the mandibular alveolar ridge relevant anatomical landmarks of the
resorbs there is a reduced area of edentulous mouth without excessive
support available for a mandibular tissue distortion.8 Rigid stock trays
complete denture.4 The ridge may may need to be modified to achieve
be complicated further with folds this.9 Clinical landmarks that should
of thin atrophic (non-keratinized) be recorded when making a primary
mucosa, which may cause pain and impression of an edentulous
discomfort upon contact with a mandible are highlighted in Table 1 Figure 2. An edentulous mandible illustrating
denture base.1 and Figure 2. the following anatomical landmarks relevant
2. Following a primary to mandibular complete denture construction:
The McGill Consensus
impression, it is critical that a detailed 1 − Retromolar pad; 2 − Residual alveolar ridge;
in 20025 and the York Consensus
design for a custom-tray is outlined to 3 − Mylohyoid ridge; 4 − Buccal shelf; 5 −
in 20096 concluded that a two
the technician. A close-fitting, non- Retromylohyoid fossa.
implant-supported mandibular
overdenture is the first choice perforated, light-cured, acrylic
standard of care, as opposed to a custom-tray, which covers all the
conventional mandibular denture clinically relevant landmarks and is
for edentulous patients. However, 2 mm short of the functional depth of Prosthetic Dentistry (BSSPD)
this option may not always be the sulcus, is required. To avoid guidelines state that definitive
feasible in some cases owing to distortion of the lower lip during secondary impressions ‘should record
financial constraints, patient choice impression taking, and to allow the entire functional denture-bearing
or systemic medical conditions. accurate functional movements to area to ensure maximum support,
A randomized control trial found take place, a stub handle design retention, and stability for the denture
that patients with a mandibular should be incorporated.11 In addition, during use’.8 The custom-tray is tried in
ridge equating to Cawood and finger rests in the premolar region the mouth and extensions are
Howell ridge classification V (Figure allow the tray to be stabilized during checked. The tray should be covering
1) and VI preferred mandibular the impression without restricting the clinical landmarks highlighted
dentures constructed with definitive border-moulding movements.11 An above in Figure 2 and also be 2 mm
impressions made using the admix example of a mandibular custom-tray short of the depth of the sulcus to
impression technique.7 The aim of with a stub handle and finger rest allow border moulding to take place in
this paper is to re-visit the ‘admix design is shown in Figure 3. order to record the functional depth
impression’ technique to aid the 3. The British Society of and width of the sulcus.

Kasim Butt, BDS, MJDF RCSEng, PgCert(Dent Ed), Dental Core Trainee in Restorative Dentistry and Karun Dewan, BDS, MFDS RCSEng,
LDS RCSEng, MSc(Prosth Dent), FDS RCS(Rest Dent), Consultant in Restorative Dentistry, Birmingham Community Healthcare NHS
Foundation Trust, Priestley Wharf, Holt Street, Birmingham B7 4BN, UK.

November 2018 DentalUpdate 991

 TechniqueTips

Anatomical Landmark Clinical Relevance to Prosthesis

Retromolar Pads Retention/Peripheral seal – The posterior border of the mandibular complete denture
should extend up to between half to two-thirds of the retromolar pads, displacing them and
providing a peripheral seal.
Buccal Shelves Located between the alveolar ridge crest and the external oblique ridge. Provides primary
support for a mandibular complete denture.
Residual Alveolar Ridge Provides stability and secondary support if the ridge is well formed with good height and
width.
Retromylohyoid Fossa Located distal to the attachment of the mylohyoid muscle. Provides stability when engaged
bilaterally by the disto-lingual aspect of the denture flange.
Mylohyoid Ridge The mylohyoid muscle attaches the mylohyoid ridge. When the inferior border of the
denture flange contacts the contracted mylohyoid muscle a border seal may be achieved,
contributing to retention.
Buccal and Lingual Sulci The denture flange needs to fill the width and depth of the sulci to achieve a peripheral
border seal, contributing to retention.
Fraenum Attachments The denture needs to be notched around these to prevent trauma and displacement during
function.
Table 1. Anatomical landmarks that should be recorded in a primary impression of an edentulous mandible and their clinical relevance to a mandibular
complete denture prosthesis.10

is quickly loaded into the tray (with a

well-fitting special tray a layer of 3−4
mm is usually sufficient). Once the tray
is loaded, it should be soaked back in
the water bath for 30 seconds. Once
removed, it is promptly transferred to the
patient’s mouth.
7. Using a standard impression
technique, the tray is stabilized with
pressure on the finger rests and border
Figure 3. Mandibular custom-tray with a stub Figure 5. A completed admix impression of a moulding is undertaken. Patients are
handle and finger rest design. severely resorbed edentulous mandibular ridge. instructed to carry out functional
movements such as licking their upper
lip, swallowing and raising their tongue
seven parts by weight of greenstick to the roof of the mouth. The working
are required.2 These impression time for this admix material is 1−2
materials are coated in Vaseline, minutes and therefore it is important
and placed in a water bath set to that these movements are rehearsed
a temperature of 68−70 degrees prior to definitive impression-taking and
Celsius.2 Figure 4 shows the conducted in a prompt manner.
materials needed for an admix 8. On removal, the impression
impression. is chilled in water, and then re-inserted.
5. Once the separate Clinicians should press on the finger rests
constituents are warmed evenly, in the premolar region and reciprocate
Figure 4. The materials needed for an admix the admix is created by kneading this pressure with their thumbs on
impression. the inferior body of the mandible. Any
the materials together with gloved
fingers coated in Vaseline. The final discomfort in the denture-bearing area
colour is a browner green than the which patients feel at this point can
4. Three parts by weight of original greenstick (Figure 5). either be highlighted to technicians for
(red) impression cake compound to 6. The impression material the application of relief on the master

992 DentalUpdate November 2018

 TechniqueTips

cast, or the impression surface can References 6. Thomason JM, Feine J, Exley C, Moynihan
be adjusted with a hot wax knife.2 1. McCord JF, Grant AA. Prosthetics: P, Müller F, Naert I et al. Mandibular
This provides an objective test as the impression making. Br Dent J 2000; 188: two implant-supported overdentures
pressure placed using this technique 484. as the first choice standard of care
on the chilled impression simulates the 2. McCord JF, Tyson KW. A conservative for edentulous patients − the York
pressure on the completed denture prosthodontic option for the treatment Consensus Statement. Br Dent J 2009;
in function. This affords credibility to of edentulous patients with atrophic 207: 185−186.
patients that they should be able to bite (flat) mandibular ridges. 7. McCord JF, McNally LM, Smith PW, Grey
without discomfort. Br Dent J 1997; 182: 469−472. NJ. Does the nature of the definitive
3. Cawood JI, Howell RA. A classification of impression material influence the
Conclusion the edentulous jaws. Int J Oral Maxillofac outcome of (mandibular) complete
The admix impression is a Surg 1988; 17: 232−236. dentures? Eur J Prosthodont Rest Dent
useful alternative prosthetic technique 4. Scott BJ, Hunter RV. Creating complete 2005; 13: 105−108.
in the management of severely dentures that are stable in function. Dent 8. BSSPD. Guidelines in Prosthetic and
resorbed mandibular ridges when Update 2008; 35: 259−267. Implant Dentistry. Ogden A, ed. London:
finances, patient choice or systemic 5. Feine JS, Carlsson GE, Awad MA, Chehade Quintessence, 1996.
medical conditions prevent dental A, Duncan WJ, Gizani S, Head T, Lund JP, 9. Field J. First impressions count: how to
implant treatment. It provides an MacEntee M, Mericske-Stern R, Mojon take a primary impression. Dent Nursing
accurate impression of the severely P. The McGill consensus statement on 2016; 12: 72−79.
resorbed atrophic mandibular ridge. It overdentures. Mandibular two-implant 10. Turner JW, Moazzez R, Banerjee A. First
also allows thin folds of non-keratinized overdentures as first choice standard of impressions count. Dent Update 2012; 39:
mucosa, which may be painful upon care for edentulous patients. Montreal, 455−471.
contact with the denture base, to be Quebec, May 24−25, 2002. 11. Basker R. Prosthetic Treatment of the
identified and relieved prior to denture Int J Oral Maxillofac Implants 2002; 17: Edentulous Patient 5th edn. Oxford: Wiley
base construction. 601. Blackwell, 2011.

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October 2018 . Volume 45 . Number 9

October 2018
„
Paediatric Dentistry: Speech and the Dental Interface

„ General Practice: Just Ask ‘Could this be Sepsis?’

„ Dental Trauma/Orthodontics/Paediatric Dentistry: Sports Mouthguards and Orthodontic Treatment

September 2018 July/August 2018 June 2018

DentalUpdate DentalUpdate DentalUpdate

September 2018 . Volume 45 . Number 8 July/August 2018 . Volume 45 . Number 7 June 2018 . Volume 45 . Number 6

„
Paediatric Dentistry: Speech and the Dental Interface

„ General Practice: Just Ask ‘Could this be Sepsis?’

„ Dental Trauma/Orthodontics/Paediatric Dentistry: Sports Mouthguards and Orthodontic Treatment

„
Restorative Dentistry: Tooth Wear Guidelines for the BSRD Part 3: Removable Management of „
Restorative Dentistry: Tooth Wear Guidelines for the BSRD Part 2: Fixed Management of Tooth
Tooth Wear Wear „
Restorative Dentistry: Tooth Wear Guidelines for the BSRD Part 1: Aetiology, Diagnosis
and Prevention
„ Restorative Dentistry: An Update on Discoloured Teeth and Bleaching Part 2: Mechanism of „ Restorative Dentistry: An Update on Discoloured Teeth and Bleaching Part 1: The Aetiology
Action of Bleaching Agents and Management of Discoloured Teeth and Diagnosis of Discoloured Teeth „ Periodontics: Prognostication in Periodontics – Science or Art?

„ Removable Prosthodontics: Immediate Dentures Part 2: Denture Construction „ Removable Prosthodontics: Immediate Dentures Part 1: Assessment and Treatment Planning „ Restorative Dentistry: Endodontics or Implants?

„
Paediatric
Paeddiaatrric Dentistry:
D Speech and the Dental Interface

„ General
Generaal Practice:
Prac Just Ask ‘Could this be Sepsis?’

„ Dental
Dentall Trauma/Orthodontics/Paediatric
Traum
Tr Dentistry: Sports
ts Mouthguards and Orthodontic
onticc Treatment
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Regarding social media: Regarding Orthodontic Therapists (OTs):
A. A smile is NOT regarded as a fashion statement. A. Their training was first permitted in 1947 in the UK.
B. A systematic review has shown that social networking sites B. All work in secondary care in the UK.
are associated with increased body dissatisfaction. C. In 2017, there were more than 500 OTs working in the UK.
C. This is never dangerous. D. Courses leading to their registration in the UK take 10 years.
D. 2% of 18−29 year-olds use Instagram.

Q2 JAGGER AND KING 45: 912–918 Q7 CHENG 45: 952–960

Regarding splints: Regarding hyperparathyroidism:
A. The Tanner appliance is the most effective. A. The first case was diagnosed in 1925.
B. Soft splints never exacerbate pain. B. Loss of lamina dura is never a feature of this.
C. Evidence indicates that occlusal splints do not reliably or C. Long-term dialysis is never implicated in this.
predictably prevent or reduce sleep bruxism. D. There is reduced secretion of parathyroid hormone in this.
D. The Michigan splint is placed on the lower posterior teeth.

Q3 CHAPPLE AND CHAPPLE 45: 920–926 Q8 MARSHALL AND KANDIAH 45: 961–972
Regarding periodontal disease: Regarding developmental defects of enamel (DDE) in primary
A. This is a simple bacterial infection. molars:
B. Periodontitis will not develop in someone who lacks the necessary A. This does not include fluorosis.
risk factors. B. Patients with this do not require the taking of a family history.
C. All patients with abundant plaque develop periodontal disease. C. This is over-reported.
D. Periodontitis affects 4.5% of the adult population. D. There is an increased risk of developing caries.

Q4 GRIFFITHS ET AL 45: 928–934 Q9 AULD 45: 973–976

Regarding correction of an increased overbite in adult patients: In 2016, the number of children placed on Child Protection Plans
A. This is simple. was:
B. This is always achieved by surgical methods. A. Zero.
C. Any attempt to correct this by extruding posterior teeth will not B. 18,000.
be stable. C. 38,000.
D. Adults have great growth potential. D. >58,000.

Q5 RENTON 45: 935–946 Q10 GAMIE, GAMIE, SEYMOUR AND WHITFIELD 45: 985–990
The proportion of patients reporting pain during dental Regarding odontogenic myxoma:
treatment in two studies conducted was: A. Cases of this are never detected during routine dental
A. Zero. examinations.
B. 22.5%. B. It is not possible to ‘miss’ this on a radiograph.
C. 42.5%. C. Higher incidence is in males.
D. 52.5%. D. This shows slow, asymptomatic growth.

CPD in Dental Update in partnership with DEADLINE FOR SUBMISSION: 16 January 2019

10 QUESTIONS REPRESENT 4 HOURS OF CPD

ANSWERS FOR SEPTEMBER CPD ON PAGE 926

994 DentalUpdate November 2018

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