BLUK133-Jacobsen January 5, 2008 21:39 Restorative Dentistry

BLUK133-Jacobsen x January 5, 2008 21:39 Preface Modern educational theory reveals the difficulty that all learners have in making links between ‘boxes’ of information that are actually connected but are taught in ‘modules’. This problem is compounded by the modular style of education now provided in most schools in the United Kingdom. Dentistry, of course, has a multitude of these boxes and it seems to be taking longer for students to establish the links between the boxes – to ‘integrate’ the information. Students seem to finish one year of study and pass on to the next, consigning the first to the filing cabinet, without realising the importance of the ‘continuum of dental education’. The ‘Integrated Approach’ attempts to develop the links that make for success in restorative dentistry. This new edition of the book tries to balance the old tried and tested with the new kids on the block. It tries to hit the moving target of developments in materials without losing the basic techniques that have served our patients well and will continue so to do. The days of molar endodontics and conventional bridgework may be numbered but until many more dentists are trained in the use of implants, messing about up root canals and trying to cut parallel-sided preparations will still be required. P.H.J. Cardiff 2007.

BLUK133-Jacobsen January 5, 2008 21:39 Acknowledgements Many people, friends and colleagues have helped in the gestation, writing and production of this book and its predecessors. My sincere thanks are due to all the specialist contributors. To Alan Harrison and David Whittaker for the chapters they wrote for the first edition which have stood the test of time and needed little change. Thanks to John Moran for revising Martin Addy’s chapters. I welcomed our implantologist Robert Adams to the team and thank him for suffering the indignities of being ‘integrated’. Lastly, to my dear friend Gavin Pearson, who has been a stalwart supporter, adviser and co-conspirator for more years than we both want to remember, my sincere thanks not only for updating the biomaterials text but also for his personal support and advice. Mr Frank Hartles and the staff of the Audiovisual Aids Unit at Cardiff have contributed greatly through the clinical photographs and the new artwork – in particular Mr Sam Evans and Miss Ruth Bowen deserve a personal mention and thanks. Artwork from the first edition was done by Mr Peter Cox, freelance Medical Artist, and by Mrs Jo Griffiths and I thank them again for their efforts. Within the clinical chapters, many of the cases illustrated are from my own clinical practice within the University Dental Hospital, Cardiff, and here I would like to emphasise the need for such cases to be planned and treated by the efforts of an integrated team. Without the skills and support of Mr Jeff Lock, Chief Dental Technologist, who has worked with me for over 20 years and seems to be able to see my crown margins when I cannot, together with a very large number of dental nurses, the quality of care that these patients received would have been considerably reduced. The staff of Blackwell Publishing, particularly Miss Katrina Chandler and Miss Amy Brown, have assisted in the development and publication of the book. Finally, all my undergraduates and postgraduates provided the inspiration to put this thing together (again) – I hope they like it. P.H.J.

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BLUK133-Jacobsen December 7, 2007 16:38 Section I The Patient

BLUK133-Jacobsen December 7, 2007 16:38 “I’m ready when you are.” 2

December 7, 2007 16:38 Chapter 1 The Patient – His Limitations and Expectations The provision of high-quality restorative dentistry depends upon the dentist: Making an accurate diagnosis Devising a comprehensive and realistic treatment plan Executing the treatment plan to a high technical standard Providing subsequent continuing care There is a very strong tendency, particularly in the field of fixed prosthodontics, for the dentist to become over-interested in the technical execution of treatment. There is a vast range of materials and equipment to stimulate this interest and compete for his attention. It is perhaps inevitable that dentists can become obsessive about types of bur or root canal file, the pros and cons of various materials and the precise techniques of restoration. This is not to decry such interest because a high standard of technical execution is essential for the longevity of restorations. However, technical execution must be seen in the context of the four-point sequence listed above. Without a sound diagnosis and treatment plan, even the best technical execution will be doomed to failure. A major influence on the formulation of the treatment plan is: The Patient (Frontispiece) It is usually by his own volition that he seeks restorative advice and treatment, and he usually brings with him certain problems and limitations that influence treatment planning and the delivery of care. Each patient also attends with strong preconceptions based on his previous experience of dentistry. This could be good or bad, with a single traumatic episode being able to reverse many years of cooperation. The patient will have some idea of what dentistry could or might do for him, and what he wants from his dentist. Some of his concepts could well be limited or unambitious, and education has a major role to play here. Conversely, sometimes his concepts could be over-ambitious, complex bridgework for instance, and here re-education is often necessary to bring him down to the practical and feasible. It might be that the dentist has the skills and technical facilities to perform advanced procedures, but before he puts bur to tooth, he must stop and ask whether this is really what this patient needs and wants. If the answer is no, then to proceed is an act of pure selfishness that might also be regarded as negligent! Certainly the dentist may have certain treatment goals for all his patients – no pain or caries, healthy periodontium, complete occlusion – but the way in which he prescribes and delivers his care has to be tempered by the patient’s aspirations for his own mouth and his readiness to accept care. A prolonged treatment plan could be very inconvenient to a shift worker or to a mother with young children or those with no personal transport. It might create restorations that will be beyond the maintenance capacity of the lazy or disinterested, or those with inadequate washing facilities. Perhaps the patient is a reluctant attender, extremely apprehensive of dental care and its possible discomforts, and will require some form of therapeutic help just to get the simple things done. The short, unambitious treatment plan is more likely to succeed here, and if the patient’s confidence can be obtained, the more complex treatment could be provided later. Advanced restorations require skill and facilities, and these have to be paid for, either by the state or by the patient. Both have limited resources and both deserve value for money. Committing resources to an ambitious treatment plan should involve judgement on the likely lifespan of the restorations in that Section I BLUK133-Jacobsen

BLUK133-Jacobsen Section I 4 December 7, 2007 16:38 I. The Patient Dentist Patient Ability Training Facilities Needs Aspirations Treatment Plan Materials and techniques Durability Simplicity Fig. 1.1 Mouth Caries rate Periodontal index Level of care Influences on the formulation of a treatment plan. particular mouth and its conditions, and whether the expense is justifiable – cost benefit analysis. The intra-oral conditions bring as much influence to bear. The caries rate, the number of missing teeth, the periodontal condition, the presence of dentures and the quality of previous restorative work all act as limitations to the scope of the treatment plan. All of us like to provide our best work for those who will appreciate it and look after it. Disinterest on the dentist’s part is created by the appearance of large plaque deposits and evidence of little care. The other side of the equation is what may be available and this relates to the dentist’s skills and training, the materials and techniques at his disposal, and the facilities available for providing care (Fig. 1.1). These, in turn, could well modify or even dictate the patient’s aspirations – a clean, well-equipped and efficient practice would indicate a good level of care to the average patient, whilst the reverse could well lower his expectations. The dentist should offer only what is realistically available and work within his own limitations. It is certainly no disgrace to say that certain options are beyond your capabilities and it is possible to consider referral to an appropriate specialist. It could also be that the options the patient has aspirations towards are those with a lower success rate, and it is sensible to tell him this frankly. There is considerably more awareness of the cosmetic possibilities of modern dentistry and thus demand for new materials and techniques. Much of this is expensive and has not been fully evaluated over a sufficient period for total confidence in its durability. The patient deserves a proper explanation about the reservations there are about particular lines of treatment. The provision of restorative treatment is a complex arrangement wherein the patient, the dentist, the technical support and the materials must be in harmony to produce a satisfactory result. The limitations of one element will inevitably change the effects of the others. It is important to remember that the treatment is only as good as its weakest link – don’t let that be you! The key to success throughout is communication – listen and learn from what the patient says, explain what can be done for him, and then decide jointly on what should be done. If you are not sure, do not commit yourself, but delay the decision and take advice from your colleagues or even your local consultant. This book begins by talking about how to find out what’s wrong with the patient and what does he want done about it, coupled with the limitations the patient brings to formulating a treatment plan and then to executing it.

BLUK133-Jacobsen December 19, 2007 15:45 Section I Chapter 2 History and Examination It is very important to listen to what the patient has to say about his problems. This aspect of care can be neglected in an obsession to ‘get inside the mouth’. The history is the basis for diagnosis and treatment planning – there is potential for harm to the patient if it is neglected. The history should provide a clear account of the patient’s experience of health care prior to the current attendance. It should establish an organised body of knowledge about the patient’s dental past and his fitness to receive future treatment – it forms part of the rationale for his management. The history, though, is very subjective and prone to differences in the perceptions and aspirations of the patient and the dentist. These differences may be reduced or exaggerated by the level of communication between the two, and the dentist must bear this problem in mind. Clearly, it is the dentist’s responsibility to create the right atmosphere for the patient to tell his story. The patient must be sitting comfortably in quiet surroundings and be confident in the dentist’s sympathetic attention. He should be sitting upright, not supine and vulnerable, and facing the questioner with his eyes at the same level. This avoids the ‘operating’ position, with its overtones of discomfort and interrogation. The dentist should sit in front of the patient facing him, and not out of sight behind him. The most limiting aspect of the history is that to a certain extent it is not strictly factual. It is the patient’s perception of events or circumstances. Even items of medical history can be incorrectly remembered and misunderstood, and in difficult cases the patient’s medical practitioner must be contacted for information. The dental aspects are often muddled, particularly in the identification of a troublesome tooth in amongst 30 or so others. The dentist has to sift this information and organise it, give it the weight it deserves, and then record it and draw conclusions from it. He has to pick up inconsistencies in the story and use a systematic approach so as not to miss anything. However, he must beware of the too precise patient with an obsessively detailed history, which can be just as misleading or unhelpful as that provided by someone who is vague. Patient’s memories or understanding of previous treatment are often confused or just blank. Some may not remember having root treatment; the dentist just spent a long time fiddling with the tooth! The history should be taken slowly, with pauses for writing in the notes; this helps the patient relax and lets further information come to his mind. Evaluation of Dental Pain Of all the aspects of history taking, this is the one where a systematic approach is essential. The patient in pain can often be rambling and disjointed. The dentist must have a clear plan in mind and must bring the patient back to it by firm questioning. The following questions are important: Where is the pain, e.g. tooth, gum, face, ear? Does it change position, i.e. radiate elsewhere? Describe the pain, e.g. throbbing, sharp, dull. How long has the pain been there? How strong is it? How long does it last? What brings it on? What takes it away? Does it come at any particular time day or night? How often does it occur? Is it getting worse or getting better? Are there any associated symptoms, e.g. swelling, bad taste?

BLUK133-Jacobsen 6 December 19, 2007 15:45 I. The Patient Frequency of attack 10 Relieving factor Pain intensity (analogue) Section I 9 8 7 6 5 Intensity of attack 4 3 2 1 Duration of attack Stimulation and timing Fig. 2.1 Schematic characterisation of pain. The diagram shows the initiation of the pain, the frequency of the pain, its intensity, its duration and the effect of any relieving factors. It can be useful to have the patient scale the intensity of the pain from 1 to 10 and give some pictorial representation of the intensity, duration and frequency of each attack (Fig. 2.1). Do not lead the patient; questions should be phrased so that a positive reply, rather than a plain ‘yes’ or ‘no’, is required. The description of the pain will lead to certain provisional diagnoses and also allow the exclusion of others. Pulpal disorders The correlation of symptoms with actual pulp state is very poor. It is possible for several grades of pathology to be present within the same pulp. For instance, a single pulp could have an area of necrosis, an area of chronic pulpitis and an area of acute pulpitis (Chapter 6), but it would almost certainly be the acute pulpitis that provoked the painful symptoms. So bearing in mind the pitfalls of the precise diagnosis, the following generalisations about symptoms can be made. Physiological response The pulp will respond to extremes of temperature through a sound crown, but the pain will be transient and stop as soon as the stimulus is removed. When dentine is exposed by caries, trauma or simply gingival recession, then saliva and acid or alkali ions will reach the odontoblastic processes. The disturbance of the neutral pH will cause symptoms, usually of a transient and mild nature. Temperature changes may stimulate pain, either when larger areas of cervical dentine are exposed or when caries has spread well into the tooth. However, the pain stops when the stimulus is removed, though in dentine hypersensitivity, the pain can be quite unpleasant. Once toxins or bacteria reach the pulp, the symptoms become more severe. Acute pulpitis The symptoms are classically an intense throbbing pain, initiated by heat, sometimes relieved by cold, well localised to one tooth, though sometimes radiating to the ear from the lower molar region. The patient is kept awake at night, and standard analgesics are not very effective. It is usually episodic, with increasing frequency and intensity of each episode, until it becomes continuous. It stops when the pulp dies or is removed. Chronic pulpitis/slow dying (moribund) pulp This condition often produces no symptoms, but may give rise to vague, dull and diffuse pain along a

December 19, 2007 15:45 2. History and Examination quadrant; i.e. it is poorly localised. Examination will often reveal several teeth with deep restorations, any one of which could be the cause. Apical infection Chronic apical infection is usually symptomless – hence the need for continued radiographic review of root-treated teeth. Acute apical periodontitis usually creates an intense throbbing pain, not affected by temperature, fairly continuous, worse at night and initiated or made worse by biting or knocking the tooth. It is usually well localised, and percussing the teeth for diagnostic purposes is unnecessary (and cruel!). Routine analgesics are not very successful and the pain goes immediately the pressure within the bone is relieved, usually when the infection has caused perforation of the cortical plate followed by a soft tissue abscess, or sinus formation. If pressure builds again in the soft tissues, then a throbbing pain is again likely, but not as intense as that produced by the rigidly confined infection. In the latter case, swelling will be an accompanying complaint. Periodontal disease 7 The more common symptoms arise from the muscles of mastication and give rise to facial pain and headaches. The pain is usually in the area of the affected muscles, though occasionally retro-orbital pain is described. The character of the pain is typical of all acute muscular problems – soreness, tenderness, difficulty with movement, and sometimes a clear starting point is remembered, such as a wide yawn, removal of wisdom teeth, etc. Pain described outside the muscle areas may not be from temporomandibular dysfunction; for instance, the maxillary antrum sometimes produces overlapping anterior pain. The most classic pain picture is that of trigeminal neuralgia, with its trigger zone and paroxysms of intense pain. However, this character can be modified into atypical facial pain that may be trigeminal in origin, psychotic or due to central nervous system lesions. Pain that crosses the midline is often psychotic in origin. However, in all these cases, the purely dental causes must be eliminated first. Diagnosis of pain – summary General acute conditions

Restorative Dentistry, United Bristol HealthCare NHS Trust, Bristol, U.K. Removable Prosthodontics Gavin J Pearson, PhD, BDS (Lond), LDSRCS (Eng) Professor of Biomaterials in relation to Dentistry, Queen Mary Westfield College, London, U.K. Dental Biomaterials David K Whittaker, PhD (Wales), BDS (Manc), FDSRCS (Eng) Emeritus Professor of Oral