Advanced Operative Dentistry A Practical Approach
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Contributors
Professor David Bartlett Dr Andrew Hall
Professor of Prosthodontics/Honorary Consultant in Senior Lecturer/Honorary Consultant in Restorative Dentistry,
Restorative Dentistry, Dundee Dental School,
Head of Prosthodontics, Kings College London Dental Institute, Dundee, UK
Guy’s Hospital, London, UK
Dr John Radford
Professor David Ricketts Senior Lecturer/Honorary Consultant in Restorative Dentistry,
Professor of Cariology and Conservative Dentistry/Honorary Dundee Dental School,
Consultant in Restorative Dentistry, Dundee, UK
Section Leader,
Section of Operative Dentistry, Fixed Prosthodontics and Professor William Saunders
Professor of Endodontology/Honorary Consultant in
Endodontology,
Dundee Dental School, Restorative Dentistry,
Dundee, UK Dundee Dental School,
Dundee, UK
Dr Graham Chadwick Dr Brian Stevenson
Senior Lecturer/Honorary Consultant in Restorative Dentistry, Lecturer/Honorary Specialist Registrar in Restorative Dentistry,
Dundee Dental School, Dundee Dental School,
Dundee, UK Dundee, UK
Dr Angela Gilbert Dr Carol Tait
Senior Lecturer in Restorative Dentistry, Senior Clinical Teaching Fellow,
Dundee Dental School, Dundee Dental School,
Dundee, UK Dundee, UK
vii
Preface
Advanced operative procedures in dentistry encompass all dental subjects and disciplines such as oral surgery, the placement
and restoration of dental implants and endodontics to name a few; however, these subjects are comprehensively addressed in
other texts. This book therefore concentrates on fixed prosthodontics which involves the preparation of teeth for laboratory-
made indirect restorations such as crowns, bridges, veneers, inlays and onlays. Where alternative, more conservative treatments
are possible – for example the placement of direct composite to alter the shape of teeth – these are also described.
The necessity for advanced indirect restorations is the result of disease or conditions which have compromised the denti-
tion. It is important to appreciate that using restorations does not treat the diseases or conditions, and their identification
and prevention underpin successful treatment. The first five chapters of this book therefore focus on the main diseases and
conditions (dental caries, periodontal disease, endodontic problems, tooth wear and aesthetic problems) which can lead to
the need for advanced operative techniques and addresses how these techniques can impact on the remaining dentition
and oral health. In the ensuing chapters details of materials, techniques and tooth preparation are described which aim to
empower the reader to achieve a high standard of care for their patients.
Indirect restorations are made in a dental laboratory and clear communication between dentist and laboratory tech-
nician is essential. This takes the form of accurate impressions, occlusal registration and aspects of appearance such as
the shade and contour required, all of which are devoted an individual chapter. Clear prescription of restoration design
and material choice is also required and these are discussed in relation to the individual restorations. In many dental
schools little or no laboratory work is carried out by undergraduate dental students; however, an understanding of
how indirect restorations are made is important as certain aspects of tooth preparation have to be followed to facilitate
laboratory construction. Laboratory procedures can also impact upon how materials and restorations are handled at the
chairside. As such, these aspects of laboratory work are described throughout the book.
The provision of advanced indirect restorations is costly and can often have an impact on the remaining dentition and
dental health. The advantages and disadvantages associated with their provision have to be balanced for each individual
patient for them to be able to give informed consent. These principles underlie successful treatment planning, execution
and hence patient care, and are the principles behind this text.
ix
Acknowledgements
This textbook would not have been possible if it were not for the patients who allowed their clinical photographs to be
used for medical education; the authors, undergraduate students, postgraduate students and clinical trainees who
allowed their clinical work to be included; the dental technicians who made the indirect restorations used to illustrate
this book, in particular John McLeish, Kevin Linklater, Donald Aitkenhead, Stewart Fairlie and Dave McMahon; and
clinical photographer Simon Scott whose expertise in clinical and laboratory imaging has been invaluable. The authors
would like to sincerely thank all those who have been involved and given their time generously and unreservedly.
xi
Chapter |1|
Management of dental caries
David Ricketts, Graham Chadwick, Andrew Hall
CHAPTER CONTENTS covered in plaque do not develop clinically detectable car-
ies whereas other tooth surfaces covered with plaque in
Dental caries the disease 1 the same mouth do. Many other factors, such as dietary
The restorative cycle 2 habits, fluoride and saliva impact upon the disease pro-
Caries detection and diagnosis 3 cess which is complex and dynamic in nature. From the
earliest stage, continued demineralization is not inevitable
Caries risk assessment 5 and lesion arrest is possible by simply disrupting the
What is caries risk? 5 plaque biofilm on the surface of the tooth at regular inter-
Caries risk factors 7 vals. Very early lesions which are not detected clinically
Social deprivation 7 may therefore not progress to clinically detectable white
spot lesions and the carious process is better represented
Past caries experience 7
by Figure 1.2.
Oral hygiene 7 It is often said that if an early white spot lesion devel-
Diet 8 ops, remineralization can take place. While complete
Fluoride 8 remineralization and resolution of the lesion is unlikely,
the clinically apparent remineralization of a white spot
Saliva 9
lesion may also be due to its surface abrasion following
Summary and principles of treatment improved oral hygiene procedures. Remineralization or
planning for a high caries risk patient 13 regrowth of partially demineralized apatite crystals in the
surface zone of an enamel lesion (Figure 1.3) has been
reported. However, the relatively well-mineralized surface
DENTAL CARIES THE DISEASE zone acts also as a diffusion barrier to ions, making it less
likely that, in the underlying body of the lesion, supersat-
Dental caries is a disease that is common to all dentate uration with respect to apatite will occur with subsequent
individuals. At the hydroxyapatite crystal level it could mineral deposition. Prevention of the disease is therefore
be considered a ubiquitous phenomenon. For dental car- our primary aim. However, for many patients, this pri-
ies to occur a bacterial biofilm has to accumulate on a mary prevention fails and lesions develop. Caries risk
tooth surface. The bacteria within the biofilm metabolize assessment and early caries detection are important so
dietary sugar substrates producing acids which, over time, that further prevention can be targeted to those patients
lead to demineralization of the tooth tissue. Thus the and lesions that are in need. In this situation a method
requirements for the carious process may be depicted by of monitoring the lesion is also important to determine
the Venn diagram seen in Figure 1.1. However, this dia- the outcome of our preventive approach; that is, has the
gram is overly simplistic and implies that the disease pro- lesion arrested or progressed.
cess and its progression are inevitable. Clinically, this is Primary prevention can fail for a number of reasons.
not the case. Some tooth surfaces that are frequently It may be due to the fact that the patient has not visited
© 2011 Elsevier Ltd.
1
Advanced Operative Dentistry: A Practical Approach
Body of lesion Surface zone
Susceptible Bacterial
tooth surface biofilm
Dental
caries
Sugar
substrate Time
Figure 1.1 Venn diagram depicting the requirements for
caries to occur.
↑ Sugar intake
No fluoride
Poor OH Figure 1.3 High definition macroradiograph of a section of
a tooth showing two enamel lesions on the bilateral walls
Demineralization of a fissure. The relatively well-mineralized surface zone and
body of the lesion can clearly be seen.
Lesion arrest
Improved OH THE RESTORATIVE CYCLE
Fluoride
↓ Sugar intake
A significant proportion of a dentist’s work time is spent
replacing restorations and the most common reason given
Figure 1.2 Diagram depicting the dynamic nature of the to justify this clinical decision is the presence of secondary
carious process and how it can be influenced by some external caries. This is caries that develops under or adjacent to a
factors. restoration placed to repair a carious lesion. The term sec-
ondary caries is, however, misleading as it implies that the
a dentist to receive such advice or, worse still, they may restoration is somehow the cause. In certain situations
have attended a dentist or dental care professional and this is true when the restorative procedures have been
not been given preventive advice and treatment. However, carried out incorrectly. For example, ledges create plaque
for some patients, regardless of their attendance pattern, stagnation areas, poor contact points allow food packing
the preventive advice is ignored or they are unable to and poor adaptation with an inadequate bond of materi-
follow it through no fault of their own. For example, an als to tooth tissue leads to microleakage (Figure 1.4). Most
elderly patient may know that oral hygiene procedures ’secondary caries’ is actually new caries that has just
are important in caries prevention, but they may not have formed adjacent to the restoration and is better termed
the manual dexterity, due to a physical disability, to carry as such: caries adjacent to a restoration (CAR). The
them out efficiently. appearance of caries, following restoration of a tooth,
When primary prevention fails, demineralization illustrates the continued high caries risk of the patient
within the carious lesion can progress to a stage that it and also shows that restoration alone does not change
becomes heavily infected with bacteria and no longer this. In order to prevent recurrence it is fundamental that
manageable with preventive procedures alone. Indeed, the caries risk be managed. If successful, this might avoid
the surface of the lesion can break down and a microcav- the need for more advanced restorative work, and ensure
ity or frank cavity can result which can no longer be kept its predictability when carried out.
clean of plaque. In these situations caries removal and res- Unlike directly placed restorations, which are packed
toration with an appropriate dental material is required. and adapted to cavity walls and margins, indirect restora-
The patient has now entered the restorative cycle. tions are made on models from impressions taken of
2
Chapter |1| Management of dental caries
A B
Figure 1.4 Bitewing radiographs of a high caries risk patient. The amalgam restorations placed in the lower right second
premolar tooth distally, the upper right second molar mesially and the composite restoration upper left first premolar distally
have ledges and are poorly contoured, encouraging food packing and caries adjacent to the restorations.
tooth preparations. As such, discrepancies in the mar-
ginal fit, seating and hence the width of cement lute
exposed to the oral cavity can occur. Marginal discrepan-
cies in the order of 70 mm have been reported in well-fit-
ting restorations. When fitting an indirect restoration it is
important to assess its fit to ensure the marginal discre-
pancies are kept to a minimum. A dental probe is useful
for checking this and for ledges. Poor plaque control in
relation to ill-fitting and contoured restorations not only
increases the patient’s risk to new caries, but also to peri-
odontal disease if the margins are close to the gingival Figure 1.5 Disclosed biofilm on the buccal surface of the
tissues. lower left second premolar tooth has partially been removed
exposing the white spot lesion beneath. The biofilm on the
mesial surface of the first molar tooth completely obscures the
CARIES DETECTION AND DIAGNOSIS detection of the white spot lesion beneath.
It is important when examining a patient for primary car-
ies or caries adjacent to restorations that the teeth are refractive indices between enamel and air results in greater
examined clean. The carious process initially takes place light scattering, enabling easier recognition of the white
in the biofilm on the surface of the tooth and the product spot lesion. The occlusal lesion in Figure 1.7 clearly illus-
of that process is the initial lesion in the tooth. To see the trates this and it stands to reason that a lesion that needs
lesion and make a diagnosis the biofilm needs to be to be dried to enable its diagnosis is less severe than one
removed (Figure 1.5). It is also essential that the teeth that is seen even on a wet surface. The examination of
are examined both wet and dry. The importance of drying clean teeth under both wet and dry conditions forms the
is illustrated in Figure 1.6. When light illuminates a sound basis for a clinical visual classification system known as
tooth, the light can either be transmitted, or it can the International Caries Detection and Assessment System
undergo refraction or reflection. Refraction is the ability (ICDAS II). This system characterizes lesions of increasing
of a tooth to bend (scatter) light and will vary according severity by correlating the visual appearance of the lesions
to the refractive index of the material the light passes with their histological depth (Table 1.1). The ICDAS II cri-
through. The porosities created in enamel during the cari- teria can also be applied to caries adjacent to restorations.
ous process are normally filled with water (refractive For further information on the ICDAS, visit the website
index ¼ 1.33) which has a refractive index close to enamel http://www.icdas.org/index.htm.
(1.66). In this situation little light scattering occurs. If the A number of caries detection devices have been invented
lesion is dried and the water is replaced with air which has to aid detection and monitoring of early carious lesions;
a lower refractive index (1.0), the larger difference in however, their use has mainly focussed on primary caries.
3
Advanced Operative Dentistry: A Practical Approach
Refractive index of enamel =1.66 Refractive index of enamel =1.66
Refractive index of water =1.33 Refractive index of air =1.00
Difference = 0.33 Difference = 0.66
A B C
Figure 1.6 When light illuminates sound enamel (A) it undergoes transmission, refraction and reflection, porosities created during
the carious process are normally filled with water (B) with a refractive index close to that of enamel. As a consequence, there is
little light scattering. When the lesion is dried and air fills the porosities (C) the difference in refractive index with enamel is greater
and greater light scattering occurs, making the white spot lesion easier to detect.
A B
Figure 1.7 White spot lesion at entrance to the fissure (A) is seen more clearly when dry (B).
When a restoration is placed their use is often complicated; examination, supplemented with an intraoral radiograph,
for example, the laser fluorescence devices, the DIAGNO- remains the examination of choice for the evaluation of
dent and the newer DIAGNOdent pen (Figure 1.8), which restoration margins and adjacent caries. A dental probe
detect fluorescence from bacterial porphyrins, cannot dif- can be used to remove plaque, assess the fit of a restoration
ferentiate between staining around a restoration margin and assess for any loss in tooth surface integrity (cavita-
and caries as they both fluoresce. Similarly, false-positive tion), but it must not be used with pressure to detect stick-
readings could occur if electrical conductance methods iness as this can lead to errors in diagnosis and more
were used around metallic restorations. The clinical visual importantly damage to early lesions.
4
Chapter |1| Management of dental caries
Table 1.1 International Caries Detection and Assessment System (ICDAS II)a
ICDAS CRITERIA COLLAPSED CRITERIA FOR CLINICAL USE CORRESPONDING
HISTOLOGY
0 No or slight change in enamel 0 No or slight change in enamel translucency 0 No enamel demineralization or
translucency after prolonged air drying after prolonged air drying (>5 s). a narrow surface zone of opacity
(>5 s). (edge phenomenon).
1 Opacity or discoloration hardly visible 1 Opacity or discoloration hardly visible on a 1 Enamel demineralization
on a wet surface, but distinctly visible wet surface, but distinctly visible after air limited to the outer 50% of the
after air drying. drying. enamel layer.
2 Opacity or discoloration distinctly 2 Opacity or discoloration distinctly visible 2 Demineralization involving
visible without air drying. without air drying. between 50% of the enamel
and the outer third of dentine.
3 Localized enamel breakdown in 3 Localized enamel breakdown in opaque or 3 Demineralization involving the
opaque or discoloured enamel. discoloured enamel and/or greyish middle third of dentine.
4 Greyish discoloration from the discoloration from the underlying dentine.
underlying dentine.
5 Cavity in opaque or discoloured
enamel exposing the dentine – involving
less than half of the tooth surface 4 Cavity in opaque or discoloured enamel 4 Demineralization involving the
6 Cavity in opaque or discoloured exposing the dentine. inner third of the dentine.
enamel exposing the dentine – involving
> half tooth surface.
a
The original codes and description of lesions are seen in the left column, a collapsed version more appropriate for clinical practice in the middle
and the corresponding lesion depth as would be seen histologically on the right.
The identification or detection of a carious lesion as What is caries risk?
outlined here is only one part of the diagnostic process.
Lesion characteristics, including severity (depth and min- Caries risk is a prediction as to whether a patient is likely
eral loss) and activity, as well as caries risk factors (see to develop new caries in the future. This is a complex pro-
later), are all taken into consideration. It is only when cess, which a dentist does on a day-to-day basis, by either
all this information is processed that a true diagnosis, consciously or subconsciously assessing the impact of fac-
prognosis and treatment plan can be made. tors which affect caries. It is important to note that caries
risk can change throughout a patient’s life and a dentist
can have a positive impact on reducing this risk. Events
in a patient’s life can also have a negative effect on caries
CARIES RISK ASSESSMENT risk; for example, an elderly patient may be placed on
medication which causes a dry mouth. In addition, this
The patient seen in Figures 1.4 and 1.9 is a young patient patient may require a removable partial prosthesis which
who has received multiple restorations, a number of will complicate oral hygiene procedures.
endodontic treatments and several extractions as a For the patient in Figures 1.4 and 1.9, extensive and
result of caries. There is new primary caries and caries advanced restorative procedures are likely to be necessary.
adjacent to existing restorations which has led to But before they can be considered his caries risk has to be
loss of restorations and tooth fracture. This patient has modified. Even though it is obvious that he is currently at
a high risk of developing caries unless a treatment a high caries risk, an assessment should be made to estab-
plan dominated by a preventive approach is adopted. lish the main risk factors and a treatment plan formulated
Simply re-restoring the teeth is not addressing the caries to address them. Once this preventive approach has been
problem. instituted, stabilization of active caries is required and
5
B
A C
Figure 1.8 The DIAGNOdent pen laser fluorescence device (A) with display on the back of the handle (B) and the approximal
sapphire tip (C).
A B
C D
Figure 1.9 Clinical images of a high caries risk patient with multiple restorations and new carious lesions. The patient’s bitewing
radiographs are seen in Figure 1.4.
6
Chapter |1| Management of dental caries
elimination of plaque-retentive factors such as poorly 6
contoured restorations should take place. Reassessment
of caries risk is then required over a period of time before 5
advanced operative techniques are considered.
4
d3mft
Caries risk factors 3
Social deprivation 2
Caries prevalence, and hence risk, has been shown to be
1
closely associated with social deprivation in many coun-
tries. For example, in Scotland, DEPprivation CATegories
0
(DEPCAT) have been derived from censuses in small post 1 2 3 4 5 6 7
code areas. Variables taken into consideration in deriving DEPCAT score
DEPCAT scores are:
Figure 1.11 The relationship between social deprivation
• Overcrowding
categories (DEPCAT score) and the percentage of the
• Male unemployment
population who have dentine caries, missing or filled teeth
• Low social class
(d3mft), the least affluent (score 7) having the highest d3mft
• No car. for 5-year-old children.
DEPCAT score 1 is the most affluent and DEPCAT score 7 (From Sweeney PC, Nugent Z, Pitts NB. Deprivation and dental caries
the least affluent. Figures 1.10 and 1.11 clearly demonstrate status of 5-year-old children in Scotland. Community Dent Oral
the relationship between caries prevalence and social depri- Epidemiol 1999;27:152–159.)
vation, with the least affluent areas having fewer caries-free
individuals and the highest average decayed (at the dentine Past caries experience
level), missing and filled teeth (d3mft). Whilst these figures A strong predictor of future caries is previous caries experi-
are derived on a population basis, dentists need to be ence. A dental history and chart are important to assess den-
aware of this association, and careful assessment of caries tal attendance, how often restorations and re-restoration
risk on an individual patient basis needs to be carried out have been required, and whether teeth have been lost due
prior to advanced operative procedures. to caries. The clinical and radiographic examination will
reveal any new carious lesions. Following preventive advice,
preventive treatment and stabilization of caries, assessment
of the patient’s compliance with attendance and treatment
70
will be required. This will be followed by reassessment
of caries risk over a period of 6–12 months before embark-
60
ing on a more advanced phase of the treatment plan.
50
Caries free (%)
40 Oral hygiene
The level of oral hygiene can be assessed in a number of
30 ways. At its simplest, the Silness and Löe index can be
used to measure the amount and distribution of plaque
20 accumulation around teeth. Commonly this is done on
buccal and labial surfaces of undisclosed key teeth such
10 as first molar, incisor and premolar teeth (e.g. UR6,
UR1, UL4, LL6, LR1, LR6).
0
1 2 3 4 5 6 7
DEPCAT score Silness and Löe plaque index:
• 0 ¼ No plaque visible
Figure 1.10 The relationship between social deprivation • 1 ¼ Plaque visible on a probe
categories (DEPCAT score) and the percentage of the
population who are caries free, the least affluent (score 7)
• 2 ¼ Plaque visible with the naked eye
having the fewest caries-free teeth for 5-year-old children. • 3 ¼ Plaque visible all around tooth.
(From Sweeney PC, Nugent Z, Pitts NB. Deprivation and dental caries This is useful as a screening tool, but to assess the level of
status of 5-year-old children in Scotland. Community Dent Oral oral hygiene throughout the mouth of a patient and to
Epidemiol 1999;27:152–159.) establish whether there has been a change in oral hygiene
7
Advanced Operative Dentistry: A Practical Approach
with time, full mouth plaque scores should be recorded. In a caries risk assessment the diet needs to be evaluated.
For this, the tooth is divided into four surfaces: mesial, This can either be by patient recollection and appropriate
buccal, distal and lingual. The teeth are disclosed and questioning or a diet diary can be kept, in which all that
the presence of plaque is recorded on a chart. The propor- is eaten and drunk for at least three consecutive days is
tion of surfaces covered in plaque can then be calculated recorded. This should include two working (or school) days
to give an objective figure at baseline with which compar- and one non-work day because a patient’s diet may be
ison is made when reassessing caries risk. Figure 1.12 completely different on the different days. The diet diary
shows a typical plaque chart. can then be used to highlight the dietary sugar content,
Many patients with poor oral hygiene may not have including any hidden sugars as well as the frequency of sugar
received any guidance on oral hygiene instruction and consumption. This enables the practitioner to provide realis-
its implementation. Such guidance and implementation tic and achievable diet advice. Figure 1.13 shows the diet
is a core feature in an effective preventive program. Dis- diary of the patient seen in Figures 1.4 and 1.9. It is clear that
closing plaque is an important first step for patients to there is frequent intake of sugar in coffee and tea, and
see where the plaque builds up, where they are missing mint sweets between meals. Either eliminating the sugar
with their current oral hygiene procedures and to note completely or using an artificial sugar substitute that is not
the relationship between plaque accumulation and dental cariogenic can be advised. At reassessment the diet diary
caries. The choice of toothbrush and appropriate tooth can be repeated to assess compliance with this advice.
brushing technique must be discussed and demonstrated Diet diaries are frequently criticized as patients often do
to the patient. Use of interdental aids, such as dental floss not fill them in correctly and can deliberately avoid record-
and interdental brushes, needs to be gradually introduced, ing what they know is likely to be the cause of the caries. It
so as not to overwhelm the patient. can be argued that if they know what not to include, they
It also is important when providing patients with fixed have the knowledge necessary to prevent their caries and
and removable prostheses that they are designed in such a may already be in the process of amending their diet.
way as to facilitate these oral hygiene procedures. Special
additional hygiene procedures may need to be advised
and then demonstrated; for example, the use of super Fluoride
floss, also known as three-in-one floss, beneath bridge Topical fluoride is important in a caries preventive program
pontics and connectors. and information on its use needs to be gathered in a caries
risk assessment. Although most European-marketed adult
Diet toothpastes contain fluoride at about 1400 ppm, some
toothpastes do not contain fluoride, such as some obtained
An association between dietary sugars and caries has long
from health food shops and websites; if in doubt, check the
been established. Once sugar is consumed, the bacteria
list of ingredients. Frequent brushing with a fluoride tooth-
within the biofilm are able to produce acid, resulting in
paste is adequate for lower caries risk individuals, but for
a rapid fall in plaque pH. When this falls below a critical
those who are higher risk supplemental fluoride should
pH, often considered to be in the region of pH 5.5, the
be considered. These can be applied professionally in the
plaque fluid becomes undersaturated with respect to
surgery/office or by the patient at home. In the surgery/
tooth mineral, and demineralization of the tooth occurs.
office, a fluoride varnish can be applied to early lesions
It may take some time for the pH and plaque fluid min-
and susceptible restoration margins. Duraphat varnish
eral saturation to return to resting levels. In terms of
(Colgate-Palmolive (UK) Ltd, Guildford, Surrey) contains
plaque and salivary pH this is characterized by the Ste-
a 50 mg/ml suspension, which equates to 2.26% (22 600
phan curve. A subsequent sugar snack may cause another
ppm) of sodium fluoride. This should be avoided in
dip in pH. Frequent sugar intakes may keep the biofilm
patients who are hypersensitive to colophony, one of its
undersaturated with respect to tooth mineral and below
constituents, and for patients with severe asthma who have
the critical pH for several hours each day. Sticky, sugary
been admitted to hospital for the condition. Application of
foods may also remain around the teeth for prolonged
fluoride in high doses leads to the formation of calcium fluo-
periods of time and have a similar effect.
ride which is relatively soluble and acts as a fluoride reser-
voir, protecting against further carious attack by inhibition
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 of tooth mineral dissolution when the local pH falls. High
91% dose fluoride toothpastes (Duraphat 2800 ppm F (not
recommended for <10 year olds) and Duraphat 5000 ppm
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 F (not recommended for <16 year olds); Colgate-Palmolive
89% (UK) Ltd) are available by prescription and are useful
for high-risk patients. Fluoride mouthwashes can be used
Figure 1.12 Typical plaque chart of a high caries risk patient on a daily (usually around 0.05% sodium fluoride, 227
before oral hygiene instruction and stabilization of caries. ppm F) or weekly basis (usually around 0.2% sodium
8
Chapter |1| Management of dental caries
Sunday Monday Tuesday
Time Items Time Items Time Items
9.30 Mug of tea/1 sugar 6.45 Mug of tea/1 sugar
Before breakfast
10.30 Bacon roll 7.15 Bowl of porridge with 7.15 Jam doughnut
Breakfast Mug of tea/1 sugar syrup Mug tea/1 sugar
Mug of tea/1 sugar
11.30 Mug of coffee/ 2 sugars, 10.30 Mug of coffee/ 2 sugars, 10.45 Mug of coffee/2 sugars
chocolate bar biscuit
Morning 12.00 Mug of coffee/2 sugars
12.15 Half a packet of mints 3 mints in morning
through morning
2.15 Bowl of soup 1.00 Egg sandwich, bag crisps, 1.30 Banana, crisps,
Mid-day meal Can of cola drink chocolate bar chocolate bar
Mug of coffee/2 sugars Mug of coffee/2 sugars
4.00 Mug of coffee/2 sugars 3.30 Mug coffee/2 sugars Mints
Crisps 3.30 Can of cola drink
Afternoon
Mints
Half packet mints 6.30 Mug tea/1 sugar
6.00 Roast chicken, veg, 8.30 Spaghetti bolognaise 8.00 Prawns, salad, potatoes,
Evening meal 2 glasses wine Can of cola drink water
8.00 Mug coffee/2 sugars 9.30 Mug coffee/2 sugars
Evening
10.00 Hot chocolate
Figure 1.13 Diet diary of patient seen in Figures 1.4 and 1.9 at initial assessment.
fluoride, 909 ppm F) depending upon patient choice and
Table 1.2 Unstimulated and paraffin-wax-stimulated
what suits their lifestyle best. Note that formulations and
whole saliva for a normal patient and one with
fluoride content of mouthwashes may differ between
hyposalivation
countries.
SALIVA FLOW UNSTIMULATED STIMULATED
Saliva ml/min ml/min
Saliva is extremely important for oral health and function. Normal 0.3 1.5
In its absence, there can be devastating effects, which
include difficulty with mastication, swallowing and speech, Dry mouth 0.1 0.5♀ : 0.7♂
loss of taste, oral soreness, a feeling of thirst and wide-
spread rampant caries. The feeling of a dry mouth, or xeros-
tomia, is usually a result of hyposalivation or oral dryness.
It is a side effect of commonly prescribed drugs such as patients with advanced operative dentistry it is important
antihypertensives, diuretics, antidepressants, antipsychotics, to bear in mind that these restorations have to be main-
antispasmodics and some antihistamines. Other causes of tained throughout life and changes in a patient’s medical
dry mouth include autoimmune diseases such as Sjögren’s history (e.g. medication causing a dry mouth) may increase
syndrome, diabetes, radiotherapy to the head and neck, their caries risk and hence the level of maintenance
and the use of recreational drugs such as caffeine, alcohol required in the future.
and amfetamines. A patient with a dry mouth will want to take frequent
Clinically, a dry mouth can be obvious and an exami- sips of liquid. It is obviously important for this liquid
nation difficult as the dental mirror sticks to the oral not to contain sugar due to the reduced oral clearance.
mucosa. The amount of saliva production can also be Plain water should be advised. Some patients also suck
measured under either unstimulated or stimulated condi- on sweets, especially those with a bitter taste, to stimulate
tions. The normal unstimulated and paraffin-wax-stimu- some salivary flow. Again this should be avoided and
lated flow rates are given in Table 1.2, together with sugar-free sweets or sugar-free chewing gum can be sug-
those for patients diagnosed as having hyposalivation. gested as a good alternative. Even then care must be taken
Saliva and its constituents have many important proper- as some artificial sugars such as sorbitol can be metabo-
ties which are illustrated in Figure 1.14. When providing lized by plaque in some subjects and this could be of
9
Advanced Operative Dentistry: A Practical Approach
Dilution of acid
in biofilm
Maintains
Lubrication supersaturation of Ca
(salivary mucins and PO4 with respect
which hold water) to hydroxyapatite
Buffer systems
neutralise acid Saliva Oral clearance
in biofilm
Salivary α-amylase Food clearance
aids food (starch) physically washing
clearance away
Antimicrobial proteins
and glycoproteins
e.g. Secretory IgA, lysozyme,
lactoferin
Figure 1.14 Important constituents and properties of saliva.
Figure 1.15 Commercially available kit to measure the counts
concern for some xerostomic patients. For some patients,
of organisms within saliva (CRT Bacteria, Ivoclar Vivadent,
artificial saliva may give relief from the symptoms of dry Schaan, Liechtenstein).
mouth, but it is important to ensure that the pH is not
acidic which could cause erosion in the dentate patient.
Referral to an oral medicine specialist should also be
considered for a patient with a dry mouth as a result of chairside, to selective culture plates. Following incubation
radiotherapy or Sjögren’s syndrome. If there is sufficient at 37 C for 48 hours, the numbers of colony forming
functional glandular tissue remaining, prescription of units (CFUs) are estimated by comparing the cultures to
pilocarpine can be considered to stimulate salivary flow. a chart (Figure 1.16). Figures 1.17 and 1.18 illustrate this
for a high caries risk patient and one of low risk.
Saliva microbiology The various caries risk factors described are subjectively
Salivary tests for mutans streptococci and lactobacilli have drawn together for each patient, with the outcome influ-
been used for many years and commercially available kits encing the patient’s treatment plan. A more formal and
have been produced to measure the counts of both organ- objective way of assessing this is by using a computer-
isms within saliva. It is assumed that if the levels of these based caries risk model. The Cariogram is such a system
cariogenic organisms are high in the dental biofilm on the which was developed in Malmö Dental School by Dou-
surface of the tooth or within active carious lesions, the glass Bratthall and co-workers. Information is gathered
levels will also be high in the saliva. Indeed, a number from the patient about caries risk, clinical and radio-
of studies have found associations with these two organ- graphic findings, and the results from various salivary
isms in saliva and the caries experience of individuals. tests. This information is given a score of 0–3 (or in some
More recent evidence suggests that these salivary counts cases 0–2). These scores are then entered into the Cario-
are not good in predicting future caries; however, they gram program, from where information is weighted
may be useful in assessing patients’ compliance with die- according to its impact on caries risk. The program evalu-
tary advice, for as the level and frequency of sugar in the ates the data and then presents it as a pie chart with a clear
diet reduces, the ensuing modification in the local oral indication of future caries risk expressed as a ’Chance to
environment is reflected in a reduced count of both spe- avoid caries’. The various risk factors described above and
cies. This can serve as a tangible reward to a compliant those evaluated in the Cariogram and the corresponding
patient and spur on their efforts in changing their dietary scores given are detailed in Table 1.3. Table 1.3 also sum-
lifestyle. marizes actions that can be taken to address each factor
Figure 1.15 illustrates one such kit (CRT Bacteria, Ivo- positively, with an aim to change the patient’s caries risk.
clar Vivadent, Schaan, Liechtenstein). In this a sample of Figures 1.19 and 1.20 show what the Cariogram would
stimulated mixed saliva is collected and applied, at the look like for a low- and a high-risk patient, respectively.
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