Dentistry at a Glance

By Elizabeth Kay

A fully illustrated, concise and accessible introduction to the study of dentistry 

• Central title in the At a Glance series for dentistry students
• Covers the entire undergraduate clinical dentistry curriculum
• Topics presented as clear double-page spreads in the recognizable At a Glance style
• Contributions from leading figures across the field of dentistry
• Companion website with self-assessment MCQs and further reading

• Language: English
• Publisher: Wiley
• Release date: Feb 18, 2016
• ISBN: 9781118629499

Book preview

Contributors

Kamran Ali

Associate Professor / Clinical Lead in Oral Surgery, Peninsula Schools of Medicine and Dentistry, Plymouth University, Devon, UK

Finbarr Allen

Consultant in Prosthodontics and Oral Rehabilitation, Cork Dental School and Hospital, Cork, Ireland

Rupert Austin

Clinical Lecturer in Prosthodontics, King's College London Dental Institute, King's College London, London, UK

Toni Batty

Practice Manager, Torrington Dental Practice, Devon, UK

Igor R. Blum

Consultant and Hon. Senior Lecturer in Restorative Dentistry, The Dental Institute, King's College Hospital, King's College London, London, UK 

Tatiana M. Botero

Clinical Associate Professor, Cariology Restorative Sciences and Endodontics School of Dentistry, University of Michigan, Michigan, USA

Andrew Bridgman

Barrister, St Johns Buildings, St John Street, Manchester, UK

Malcolm Bruce

Year 2 Lead and Clinical Dentistry Module Lead, Peninsula Schools of Medicine and Dentistry, Plymouth University, Devon, UK

Martyn Cobourne

Professor of Orthodontics, King's College London Dental Institute, London, UK;

Hon Consultant in Orthodontics, Guy's and St Thomas' NHS Foundation Trust, London, UK

Jennifer Collins

General Dental Practitioner, UK

StJohn Crean

Dean, School of Medicine and Dentistry, University of Central Lancashire, Lancashire, UK

Martin Fulford

Professional Lead - Dentistry, Bristol, N. Somerset, Somerset and S. Gloucester Area Team, NHS England, Somerset, UK

Sue Greening

Consultant in Special Care Dentistry and Clinical Director of the Community Dental Service - Aneurin Bevan Health Board, Wales, UK

Nick Grey

Faculty Associate Dean for Teaching and Learning, The University of Manchester, Manchester, UK

Duncan Parker-Groves

Dental Officer, Defence Dental Service, RAFC Cranwell, Royal Air Force, Lincolnshire, UK

Stephen Hancocks OBE

Editor-in-Chief, British Dental Journal, London, UK

G. R. Holland

Professor, School of Dentistry, University of Michigan, Michigan, USA

Ian Holloway

Associate Dean Df1, NHS South West, UK

Matthew Jerreat

Consultant in Restorative Dentistry, Peninsula Schools of Medicine and Dentistry, Plymouth University,

Devon, UK

Elizabeth Kay

Foundation Dean, Peninsula Dental School; Faculty Associate Dean, Peninsula Schools of Medicine and Dentistry, Plymouth University, Devon, UK

Nigel M. King

Winthrop Professor of Paediatric Dentistry, University of Western Australia, Australia

Russ Ladwa

Private Practitioner, London, UK

Kevin Lewis

Dental Director, Dental Protection Limited, London, UK

Michael A. O. Lewis

Professor of Oral Medicine and Dean, School of Dentistry, Cardiff University, Cardiff, UK

Gerry Linden

Professor of Periodontology, School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, Belfast, UK

Fraser McCord

Emeritus Professor, University of Glasgow, Glasgow, UK

Colman McGrath

Clinical Professor, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China

James Mehta

General Dental Practitioner, Creffield Lodge Dental Practice, Colchester, UK

Alasdair G. Miller  

Dental Postgraduate Dean, NHS South West, UK

Ian Mills

Partner, Torrington Dental Practice, Torrington, Devon & Academic Clinical Fellow, Peninsula Schools of Medicine and Dentistry, Plymouth University, Devon, UK

David R. Moles

Director of Postgraduate Education and Research, Peninsula Schools of Medicine and Dentistry, Plymouth University, Devon, UK

Tim Newton

Professor of Psychology as Applied to Dentistry, King's College London Dental Institute, King's College London, London, UK

A. Robert Prashanth

School of Dentistry, University of Western Australia, Australia

Nigel D. Robb

Reader / Honorary Consultant in Restorative Dentistry, Specialist in Special Care Dentistry, School of Oral and Dental Sciences, University of Bristol, Bristol, UK

Anthony Roberts

Professor of Restorative Dentistry (Periodontology), Cork University Dental School and Hospital/University College Cork, Cork, Ireland

Douglas Robertson

Clinical Lecturer/Honorary Specialist Registrar in Restorative Dentistry, Glasgow Dental School, University of Glasgow, Glasgow, UK

Helen Rogers

Clinical Lecturer/Honorary SpR in Oral Medicine, School of Dentistry, Cardiff University, Cardiff, UK

Reza Vahid Roudsari

Clinical Lecturer and Honorary StR in Restorative Dentistry, School of Dentistry, The University of Manchester, Manchester, UK

Fleur R. Stoops

LDFT in Glasgow, NHS Education Scotland, UK

Carly L. Taylor

Clinical Lecturer / Honorary StR in Restorative Dentistry, Manchester Dental School, University of Manchester, Manchester, UK

S. R. Tinsley

Freelance photographer and illustrator, Cornwall, UK

Angus Walls

Director Edinburgh Dental Institute, University of Edinburgh, Edinburgh, UK

Robert Witton

Director of Social Engagement & Community-Based Dentistry, Peninsula Schools of Medicine and Dentistry, Plymouth University, Devon, UK

Hai Ming Wong

Clinical Assistant Professor in Paediatric Dentistry, The University of Hong Kong, Hong Kong, China

Graeme Wright

Specialist and Honorary Clinical Teacher in Paediatric Dentistry, Glasgow Dental Hospital and School, Glasgow, UK

Natasha Wright

Consultant in Orthodontics, Guy's and St Thomas' NHS Foundation Trust, London, UK

Cynthia Yiu

The University of Hong Kong, Hong Kong, China

Preface

I was immensely honoured and flattered when, based on the reputation of Peninsula Dental School, of which I am Foundation Dean, John Wiley and Sons Publishers approached me to ask me to lead the production of a comprehensive dental textbook. They asked me if I felt that everything a dental undergraduate student needed to know about could be put into one book, and whether I could produce such a tome.

I agreed to the project because, in today's world, where information can be sourced so easily, what is important to students is that someone provides, not so much the detail of the information, but the signposts to show them what they need to look at, and think about, and what is important. A single text containing all that there is to know about dentistry would be a never ending task. However a book which has the intention of simply indicating and highlighting the essentials, whilst stimulating interest and a desire to learn, was a task I was delighted to take on.

I, and the colleagues who wrote this book, hope that this is how it will be seen – as a launchpad for the wonderful experience of a life of learning in dentistry. Every person who has contributed to this book has passion for their subject, and more importantly, and wonderfully, a will to spend their time giving a future generation of dentists the benefit of their knowledge and experience.

The authors are drawn from experts and enthusiasts all over the world and I am deeply grateful to all of my colleagues who have given of their expertise so willingly and so assiduously. Whilst everyone involved has done a fantastic job, I would like to thank a few people particularly. My profound gratitude goes to Dr Kamran Ali who contributed all of the oral pathology and oral surgery chapters. His substantial presence in this book is testament to his huge commitment to teaching and learning and perhaps explains the very high regard in which all of his students and staff hold him.

I also need to particularly mention Professor Mike Lewis, who not only contributed chapters, but also gave cheery moral support and was unfailingly and unremittingly generous with images for the book. Likewise Dr Ian Mills, whose expert general practitioner view is an essential component of this text. He also did a fantastic job with the provision of images to illustrate his, and other people's, texts.

My most grateful thanks and eternal gratitude go to Jane Newman. Without her this book would unquestionably never have seen the light of day! This book owes its very existence to her patient persistence, her unbelievable organisational skills and her charm and determination. Organising over forty busy academics to deliver pieces of work to set deadlines is no mean feat! Jane has contributed in many ways to the book, and co-ordinated and provided administrative support to the whole of this enormous project. And she remained calm, and buoyed my confidence that we would succeed and did so throughout the entire process. So, I hope everyone who uses the book, or answers the MCQs, or benefits in any way from this publication will remember that Jane made it all happen.

Finally, both Jane and I would like to thank our publishers, John Wiley and Sons, and their Associate Commissioning Editor, Sara Crowley-Vigneau and Editorial Assistant Jessica Evans. Their encouragement and support were invaluable and we hope that they are pleased with the end result.

I so hope you enjoy, as well as benefit from, this book. We would value any feedback you can give us. Good luck with your studies, and look forward to your lives. Dentistry is a wonderful profession. This book holds the foundations on which you will build the rest of your careers.

Professor Liz Kay

Foundation Dean Peninsula Dental School

Acknowledgements

With very grateful thanks to the following people and organisations:

Dentsply

Pensilva Village Stores

Tepe Oral Hygiene Products Ltd

Carestream Dental Ltd

Journal of the Canadian Dental Association

The General Dental Council

The Dental Trauma Guide

Dr Nikolaos Silikas

Mrs Margaret Newman

Sue Greening

iADH

Department of Health

RCSEng Photo Archives with permission from Royal College of Surgeons of England

Royal Society of Medicine

British Dental Association

Torrington Dental Practice

A-dec Dental UK Ltd

UK Interprofessional Group

David Moles thanks Jenny Collins for help with producing ­figures.

About the companion website

Part 1 Introduction

Chapters

Chapter 1: Principles of dental practice

Chapter 2: Patient confidentiality

Chapter 3: Record keeping

Chapter 4: Consent

Chapter 5: Communication with patients

Chapter 6: History taking

Chapter 7: Past medical history

Chapter 8: Equipment and operating positions

Chapter 9: Cross-infection control

Chapter 10: Examination of the mouth

Chapter 11: Special tests

Chapter 12: Reading and reporting radiographs

Chapter 13: Diagnostic ‘surgical sieve’

Chapter 14: Charting the oral cavity

Chapter 15 Charting the oral cavity

Chapter 16: Treatment planning

1 Principles of dental practice

Dental practice has been carried out for over 7000 years, and there is evidence of dentistry being practised around the River Indus at that time. From 2600 BC, there are records of the Egyptians practising dentistry, making prostheses and carrying out oral surgery. The purpose of dental practice has, since its inception, been very similar. What has changed over time is the equipment, techniques and materials available to practitioners, and patients’ desires and expectations.

The key principles

The key GDC principles are given in Box 1.1.

Box 1.1 The principles of practice in dentistry

As a dental professional, you are responsible for doing the following.

Put patients’ interests first

Communicate effectively with patients

Obtain valid consent

Maintain and protect patients’ information

Have a clear and effective complaints procedure

Work with colleagues in a way that is in patients’ best interests

Maintain, develop and work within your professional knowledge and skills

Raise concerns if patients are at risk

Make sure your personal behaviour maintains patients’ confidence in you and the dental profession

Source: General Dental Council (2015). Available at: http://standards.gdc-uk.org/. Information correct at the time of going to press. Please visit the General Dental Council website to check for any changes since publication. Reproduced with the permission of the General Dental Council.

The ethics of a profession is a complex area as it encompasses the views of the profession and those of the society which it serves. These may change over time. Some professional ethics are very obvious, for example the relief of a patient’s dental pain should be the first objective for dentists treating patients. However, other issues, which have an ethical dimension, may change based on society’s views. For example, there is a dilemma over the ethics of the provision of treatments simply to improve the appearance of teeth. Another major challenge to general practitioners is how to earn a living by providing care to patients whilst maintaining ethical professional standards. Dentists could provide treatments because the patient requests it, so long as it is feasible. The dentist could charge a higher fee, rather than offer a patient a simpler lower-cost procedure. Such decisions are not a simple matter of right or wrong. Ethics and professional standards are important as they provide a ‘litmus test’ to assist a practitioner decide what they should do. Asking the question ‘can the proposed treatment be supported?’, if reviewed against the GDC’s key standards, is critical to providing appropriate care.

The purpose of dental practice in more detail

Relief of pain to patients – types of pain in the mouth in order of prevalence is:

Sensitivity to cold and sweet, which is often due to loss of dentine around the cervical margin of teeth

Pain from within a tooth – inflamed dental pulp tissues – which is reversible or irreversible

Pain from the bone around and under a tooth with an abscess

Pain from unhealthy gums or infection of the gums, gingivitis, periodontitis, e.g. acute ulcerative gingivitis

Pain from ulcers of the soft tissues of the mouth

Pain arising within the nervous system of the mouth, e.g. trigeminal neuralgia, psychogenic pain

Pain from oral cancer

Pain referred to the jaws, e.g. angina.

Restore function of the oral tissues so that patients can eat, drink and socialise as they require. Options are:

Remove the painful or mobile tooth – extraction

Restore the tooth with fillings or crowns, with or without root fillings

Replace missing teeth with removable prostheses (e.g. dentures) or fixed prosthesis (e.g. bridges and dental implant retained crowns)

Provision of orthodontics to straighten teeth to improve the function and appearance

Provision of tooth whitening and other procedures to improve the aesthetics of the teeth.

Provide advice and treatments to prevent further dental disease:

Advice on diet and frequency of consumption of sugar and acid drinks

Advice on tooth pastes, mouth washes and cleaning of teeth, including interdentally, gum margins and the tongue

Advice on lifestyle issues – smoking, alcohol consumption

Procedures to reduce the chance of dental decay, e.g. the application of high-concentration fluoride varnishes, gels and fissure sealants

The object of these interventions is the promotion and maintenance of dental and oral health.

Promotion of the oral health of the community – dentists may be involved in dental health promotion in their community. This might be talks to schools and other groups, encouragement of local authorities to add fluoride to water, education of staff who care for patients (e.g. in residential and nursing homes), oral cancer awareness months, etc.

The key points

Dentistry can – relieve pain, restore function, improve appearance, give individual and societal advice on promoting oral and general health

The delivery of care is defined by professional clinical standards and professional standards which are in turn based on professional ethics and the wishes of the society it serves. These are determined by society in consultation with the profession.

2 Patient confidentiality

Any information that a patient has entrusted to you in your professional capacity remains the property of the patient. Failing to keep that information safe and secure, or passing it on to others without the patient’s knowledge and agreement, is a breach of the professional trust that the patient has vested in you. Not only would this violate a fundamental ethical principle, but many forms of inappropriate disclosure would also be a criminal offence, under Data Protection legislation.

Patients disclose many different kinds of information to us in the course of our professional relationship with them – some of it being of a sensitive personal nature. Additionally, they will often allow us to capture less obvious forms of information about them, such as study models, X-rays and clinical photographs. In all these cases, they do so in the trust and expectation that we will keep this information safe, and only hold and use it in association with their own dental care and treatment unless they specifically agree otherwise.

Some of the information we hold regarding a patient may already be in the public domain, for example their name, address and phone number may appear in a public directory. But if we have been given this information by the patient within the confidentiality of our professional relationship with them, the fact that it may also be in the public domain for other reasons does not diminish our own ethical obligations in relation to that same information. The underlying principle is that it will always remain the patient’s information, not ours (Figure 2.1).

Figure 2.1 Diagram illustrating the flow of information and the escalating level of controls required (green>amber>red). The patient must agree to the onward sharing of information at each point represented by the three coloured arrows. Specific consents may be required in certain situations (refer to text and Tables 2.1 and 2.2)

Secondary information

We hold other forms of information, such as the fact that the patient attended (or is due to attend) the practice at a particular date and time. We may know what job the patient does or which company they work for. We may know the names of other people in the patient’s family. Even the simple fact that the patient is under your care is information that you have no right to pass on without the patient’s agreement.

Permission

The patient may give us permission (consent) to pass on to a third party some or all of the information that they have disclosed to us, for a purpose directly related to their dental care, for example when being referred to a hygienist or a professional colleague elsewhere. They may also allow us to use some of this information for a purpose unrelated to, or secondary to, their own dental care (Table 2.1). In all these cases the patient must be fully aware of the purpose for which the information will be used, the context in which it will appear, who will have access to it, for how long/ how often, etc.

Table 2.1 Secondary uses of confidential patient information, unrelated to their own care and treatment

The specific agreement of the patient is needed for any of the above, for each occasion when the information is used. If the intention is to use the information on more than the one occasion for which their permission was originally sought, the patient must have agreed to this at the outset.

If the patient consents to (for example) an image of their mouth and teeth being used in a professional/ academic setting for the specific purposes of one or more lectures to be given by a specific dentist, it is not then acceptable for that dentist to use the same image for an entirely different purpose such as ‘before’ and ‘after’ images placed on a practice website. It is even less acceptable for the image to be passed on to anyone else, and used for any other purpose, if the patient did not give their agreement in the expectation that this would happen.

Exceptions

Most of the time, the principles and duties of confidentiality will be clear and obvious. There are, however, some other instances where it is not possible, or perhaps not always necessary, for the specific agreement of the patient to be obtained before passing on confidential information about them. A common example arises when disclosing information about a minor (child) to their parent or someone else with a legal right to be provided with the information. Some other rare exceptions are listed in Table 2.2.

Table 2.2 Examples of situations where disclosure of confidential information about a patient to third parties may be acceptable in specific circumstances (advice should be sought from your indemnity provider regarding particular situations)

Privacy and security

In any healthcare environment, there needs to be a shared understanding on the part of the entire team that the information that patients have given to us is precious, important and needs to be protected. The fact that the patient trusts us enough to have given us this information about them, and believes that we will keep it safe, is one of the many privileges of being a healthcare professional.

For as long as we hold this information, and whether held in paper form or electronically, we need to take appropriate measures to ensure that the information is only ever accessible to people who need to have it. The same principle extends to any situation where we might be discussing some aspect of the care of one patient within the hearing of another.

There should be adequate safeguards for the secure protection of patient information within the practice/ healthcare environment, and also if any information is ever taken off the premises where it is usually kept. The security of the patient’s private information needs to be seamless.

In the case of any document or image from which the identity of the patient could be discovered, one should ask whether the information could be redacted in some way to de-identify the patient. Where information is held electronically, screensaver defaults, password protection and encryption are all examples of how one can prevent information becoming accessible to others unintentionally.

To manage the risks of holding, using and storing confidential information, any disclosure should always be limited to the minimum necessary to serve the required purpose. Similarly, information should be retained no longer than is absolutely necessary to serve the purpose for which it was collected. When, eventually, the information about a patient is no longer required, it is necessary to destroy that information in a safe and secure