Oxford Handbook of Clinical Dentistry 6th Edition PDF

OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Clinical Dentistry Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Oxford Handbook of Genetics Programme 4e Oxford Handbook of Genitourinary Oxford Handbook of Acute Medicine...

OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Clinical Dentistry Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Oxford Handbook of Genetics Programme 4e Oxford Handbook of Genitourinary Oxford Handbook of Acute Medicine, HIV and AIDS 2e Medicine 3e Oxford Handbook of Geriatric Oxford Handbook of Anaesthesia 3e Medicine 2e Oxford Handbook of Applied Dental Oxford Handbook of Infectious Sciences Diseases and Microbiology Oxford Handbook of Cardiology 2e Oxford Handbook of Key Clinical Oxford Handbook of Clinical and Evidence Laboratory Investigation 3e Oxford Handbook of Medical Oxford Handbook of Clinical Dermatology Dentistry 6e Oxford Handbook of Medical Imaging Oxford Handbook of Clinical Oxford Handbook of Medical Diagnosis 3e Sciences 2e Oxford Handbook of Clinical Oxford Handbook of Medical Statistics Examination and Practical Skills 2e Oxford Handbook of Neonatology Oxford Handbook of Clinical Oxford Handbook of Nephrology and Haematology 3e Hypertension 2e Oxford Handbook of Clinical Oxford Handbook of Neurology 2e Immunology and Allergy 3e Oxford Handbook of Nutrition and Oxford Handbook of Clinical Dietetics 2e Medicine – Mini Edition 8e Oxford Handbook of Obstetrics and Oxford Handbook of Clinical Gynaecology 3e Medicine 9e Oxford Handbook of Occupational Oxford Handbook of Clinical Health 2e Pathology Oxford Handbook of Oncology 3e Oxford Handbook of Clinical Oxford Handbook of Pharmacy 2e Ophthalmology 3e Oxford Handbook of Clinical Oxford Handbook of Oral and Rehabilitation 2e Maxillofacial Surgery Oxford Handbook of Clinical Oxford Handbook of Orthopaedics Specialties 9e and Trauma Oxford Handbook of Clinical Oxford Handbook of Paediatrics 2e Surgery 4e Oxford Handbook of Pain Oxford Handbook of Complementary Management Medicine Oxford Handbook of Palliative Care 2e Oxford Handbook of Critical Care 3e Oxford Handbook of Practical Drug Oxford Handbook of Dental Therapy 2e Patient Care Oxford Handbook of Oxford Handbook of Dialysis 3e Pre-Hospital Care Oxford Handbook of Emergency Oxford Handbook of Psychiatry 3e Medicine 4e Oxford Handbook of Public Health Oxford Handbook of Endocrinology Practice 3e and Diabetes 3e Oxford Handbook of Reproductive Oxford Handbook of ENT and Head Medicine & Family Planning 2e and Neck Surgery 2e Oxford Handbook of Respiratory Oxford Handbook of Epidemiology for Medicine 3e Clinicians Oxford Handbook of Oxford Handbook of Expedition and Rheumatology 3e Wilderness Medicine Oxford Handbook of Sport and Oxford Handbook of Forensic Exercise Medicine 2e Medicine Handbook of Surgical Consent Oxford Handbook of Oxford Handbook of Tropical Gastroenterology & Hepatology 2e Medicine 4e Oxford Handbook of General Oxford Handbook of Urology 3e Practice 4e Oxford Handbook of Clinical Dentistry Sixth edition David A. Mitchell and Laura Mitchell with contributions from Lorna McCaul 1 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © David A. and Laura Mitchell, 99, 995, 999, 2005, 2009, 204 The moral rights of the authors‌have been asserted First published 99 Second edition published 995 Third edition published 999 Fourth edition published 2005 Fifth edition published 2009 Sixth edition published 204 Impression:  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 98 Madison Avenue, New York, NY 006, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 204930095 ISBN 978–0–9–967985–0 Printed in China by C&C Offset Printing Co. Ltd Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.  v Preface to the first edition Dental students are introduced to real live patients at an early stage of their undergraduate course in order to fulfil the requirements for clinical training, with the result that they are expected to absorb a large quantity of information in a relatively short time. This is often compounded by clinical allocations to different specialities on different days, or even the same day. Given the obvious success of the Oxford handbooks of clinical medicine and clinical specialities, evidenced by their position in the white coat pockets of the nation’s medical students, the extension of the same format to den- tistry seems logical. However, it is hoped that the usefulness of this idea will not cease on graduation, particularly with the introduction of Vocational Training. While providing a handy reference for the recently qualified gradu- ate, it is envisaged that trainers will also welcome an aide mémoire to help cope with the enthusiastic young trainee who may be more familiar with recent innovations and obscure facts. We also hope that there will be much of value for the hospital trainee struggling towards FDS. The Oxford Handbook of Clinical Dentistry contains those useful facts and practical tips that were stored in our white coat pockets as students and then postgraduates; initially on scraps of paper, but as the collection grew, transferred into notebooks to give a readily available reference source. The dental literature already contains a great number of erudite books which, for the most part deal exclusively, in some depth, with a particular branch or aspect of dentistry. The aim of this handbook is not to replace these specialist dental texts, but rather to complement them by distilling together theory and practical information into a more accessible format. In fact, reference is made to sources of further reading where necessary. Although the authors of this handbook are not the specialized authorities usually associated with dental textbooks, we are still near enough to the coal-face to provide, we hope, some useful practical tips based on sound theory. We were fortunate whilst compiling this handbook in being able to draw on the expertise of many colleagues; the contents, however, remain our sole responsibility. The format of a blank page opposite each page of text has been plagiarized from the other Oxford handbooks. This gives space for the reader to add his own comments and updates. Please let us know of any that should be made available to a wider audience. We hope that the reader will find this book to be a useful addition to their white coat pocket or a companion to the BNF in the surgery. vi Preface to the second edition It would appear that our ‘baby’ is now a toddler and rapidly outgrowing his previous milieu. Caring for such a precocious child is hard work and therefore we have again relied on the help of understanding friends and col- leagues who have contributed their knowledge and expertise. The pace of change in dentistry, both scientifically and politically, is so fast that although the first edition was only published in 99, this second edition has involved extensive revision of all chapters. Advances in dental materials and restorative techniques have necessitated major revision of these sections and we are indebted to Mr Andrew Hall, who has helped update the chapter on restorative dentistry. Since the first edition was published, political changes in the UK have resulted in a shift towards private dentistry. This changing emphasis is reflected in the practice management chapter, which now includes a new page on independent and private practice. In addition recent developments in cross-infection control and UK health and safety law have been included. That old favourite, temporomandibular pain dysfunction syndrome, has also been given the treatment and is now situated on a newly devised page in the chapter on oral medicine. Non-accidental injury, guided tissue regeneration, AIDS, ATLS, and numerous other topical issues have been expanded in this edition. One aspect of this developing infant remains, however, unchanged. The sole purpose of this book is to enable you, the reader, to gain easy access to the sometimes confusing conglomerate of facts, ideas, opinions, dogma, anecdote, and truth that constitutes clinical dentistry. To this framework you should add, on the blank pages provided, the additional information which will help you treat the next patient or pass the next exam, or more importantly the practical hints and tips which you will glean with experience. It is the potential for that interaction which makes this book distinctive in clinical dentistry. It is participating in that interaction which makes your book unique.  vii Preface to the third edition Like any proud parents we are surprised and delighted with the contin- ued development of our ‘baby’, and we are grateful to all those who have helped or provided positive feedback. We are also grateful to our col- leagues who have helped with the ‘baby-care’. Of course, now being of school age, peer group rivalry has arrived, but ours is a robust child and despite being the first kid on the block welcomes both competition and change. Some of this change is reflected by bringing in a new contributor who has overseen a complete overhaul of the restorative dentistry chapters and a large number of new contributions to reflect dentistry in the late 990s. Our own areas of (increasingly erudite) specialist expertise have grown apace but we think we have curbed the temptation to dwell on these in what is, after all, a generalist text for the earlier years; we trust the odd excursion will be forgiven. We hope that the new sections, which include: evidence-based medi- cine/dentistry; the new NHS complaints procedure, objective structured clinical examinations, the 997 Advanced Life Support Guidelines, and the completely revised restorative chapters will prove helpful and informative. We would, however, like to remind you that the blank pages are there for your additional notes—and it is this that makes your copy of this Handbook unique. Please do not hesitate to share these annotations with us, we would be happy to include the best we receive in the next edition and to acknowl- edge the contributor. As always while we are grateful for the contributions of our colleagues the contents and the brickbats remain our sole responsibility. viii Preface to the fourth edition A new millennium means new technology and new challenges. So the time has come to update the Oxford Handbook of Clinical Dentistry. In fact the pace of change is such that all chapters in this new edition have been completely revised. To continue the analogy of earlier prefaces: our teenager is keen on exploring new avenues, so we are going to indulge this by expanding our horizons into new attitudes and technology with a section on Dentistry and the World Wide Web, and also a section on web-based learning. This new, twenty-first century edition has the added bonus of col- our plates and more diagrams to aid understanding. We are, as ever, indebted to contributors past and present. The new recruits bring both knowledge and enthusiasm to their areas of expertise as well as to the book as a whole, and build on the work of previous contribu- tors. To all we are greatly indebted. The ultimate responsibility for errors or oversights remains, as always, ours. Please keep sending us feedback—this is the best way for us to improve future editions. Let’s just hope the teenager doesn’t rebel!! Preface to the fifth edition The first draft of this book was started in 989, the year the Berlin wall came down and the first edition appeared in 99 making our ‘child’ legal by this, the fifth, edition. As an eighteenth birthday present this edition includes, as well as the usual extensive rewrite and update of the text, a substantial improvement in the quality of the illustrations, which are now in colour and integrated into the text. This will mean less space for making your own notes in the blank pages but we suspect you will be willing to make the trade-off. In keeping with previous practice new contributors have been included in order to ensure the material is as up to date as possible and we have tried to avoid overemphasizing our current areas of sub-specialization. As before, this book is the sum of its previous incarnations helped by feedback from readers from all parts of the world and the input of contributors. As always, responsibility for any errors or omissions lies with us.  ix Preface to the sixth edition By the time this, the sixth edition of the Oxford Handbook of Clinical Dentistry reaches the shelves or the app on your smartphone it will have celebrated its 2st birthday. Now a mature adult it has, for the moment, declined to leave home and despite its experience and worldly wise nature has certain hankerings towards younger, simpler days. For this reason along with the usual extensive updates and rewrites we want to re-emphasize the interactive nature of this book by encouraging you to personalize your copy using the blank ‘noteboxes’ where you create your version by augmenting or perhaps even correcting the content in light of your reading (and if you do, let us know the details for future editions, please don’t just make vague comments on an Internet review site) or more importantly your personal clinical experience. x Acknowledgements In addition to those readers whose comments and suggestions have been incorporated into the sixth edition, we would like to thank the following for their time and expertise in updating individual chapters: Mr S. Fayle, Mr A. Graham, Dr H. Gorton, Ms E. McDerra, Dr I. McHenry, Dr L. Middlefell, Mr L. Savarrio, Mr R. Singh KC, Ms J. Smith, Dr I. Suida, Ms Y. Shaw, Mr I. Varley. In addition, this book is the sum and distillate of its previous incarnations, which would not have been possible without; Mr K. Abdel-Ghalil, Mr B. S. Avery, Mr N. Barnard, Professor P. Brunton, Ms F. Carmichael, Mr N. E. Carter, Mr P. Chambers, Mr M. Chan, Dr A. Dalghous, Mrs J. J. Davison, Dr R. Dookun, Ms S. Dowsett, Dr C. Flynn, Dr H. Gorton, Dr I. D. Grime, Mr A. Hall, Mr H. Harvie, Ms V. Hind, Ms J. Hoole, Dr J. Hunton, Mr D. Jacobs, Mr W. Jones, Mr P. J. Knibbs, Ms K. Laidler, Mr C. Lloyd, Mr M. Manogue, Professor J. F. McCabe, Dr L. Middlefell, Dr B. Nattress, Mr R. A. Ord, Dr J. E. Paul, Mr J. Reid, Professor A. Rugg-Gunn, Professor R. A. Seymour, Professor J. V. Soames, Ms A. Tugnait, Dr D. Wood, and Professor R. Yemm. We acknowledge the hard work and expertise of Katherine Grice, the medical artist responsible for improving our amateur diagrams beyond recognition. We are grateful to the editor of the BMJ, the BDJ and Professor M. Harris, the Royal National Institute of the Deaf, Laerdal, and the Resuscitation Council UK for granting permission to use their diagrams, and VUMAN for allowing us to include the Index of Orthodontic Treatment Need. Once again the staff of OUP deserve thanks for their help and encouragement. Note Although this is an equal opportunity publication, the constraints of space have meant that in some places we have had to use ‘he’ or ‘their’ to indicate ‘he/she’, ‘his/hers’, etc.  xi Contents Symbols and abbreviations xii  History and examination  2 Preventive and community dentistry 23 3 Paediatric dentistry 55 4 Orthodontics 9 5 Restorative dentistry : periodontology 7 6 Restorative dentistry 2: repairing teeth 27 7 Restorative dentistry 3: replacing teeth 263 8 Restorative dentistry 4: endodontics 325 9 Oral surgery 35 0 Oral medicine 407  Maxillofacial surgery 463 2 Medicine relevant to dentistry 503 3 Therapeutics 575 4 Analgesia, anaesthesia, and sedation 603 5 Dental materials 627 6 Law and ethics 667 7 Professionalism and communication 689 8 Practice management 73 9 Syndromes of the head and neck 75 20 Useful information and addresses 76 Index 779 xii Symbols and abbreviations Some of these are included because they are in common usage, others because they are big words and we were trying to save space. 2 this is important E cross-reference ∆ diagnosis $ supernumerary –ve negative +ve positive &/or and/or i increased d decreased < less than > greater than 7 approximately # fracture µ micro (e.g. µm) ? question/ask about (when ? appears alone) ∴ therefore ° primary 2° secondary 3° tertiary 5; inc lower second premolar, lower incisor 2; inc upper lateral incisor, upper incisor 3-D three dimensional ACS American College of Surgeons ACTH adrenocorticotrophic hormone ADH antidiuretic hormone ADJ amelo-dentinal junction Ag antigen AIDS acquired immune deficiency syndrome ALS advanced life support AOB anterior open bite AP antero-posterior ARF acute renal failure ASAP as soon as possible ATLS advanced trauma life support  SYMBOLS AND ABBREVIATIONS xiii BCC basal cell carcinoma bd twice daily BDA British Dental Association BDJ British Dental Journal BIPP bismuth iodoform paraffin paste BLS basic life support b/w bitewing BMA British Medical Association BNF British National Formulary BP blood pressure BPE Basic Periodontal Examination BRON bisphosphonate related osteonecrosis BSS black silk suture Ca2+ calcium CAD/CAM computer-aided design/computer-aided manufacture C&S culture and sensitivity CDS Community Dental Service C/I Contraindication Class I Class I relationship Class II/ Class II division  relationship Class II/2 Class II division 2 relationship Class III Class III relationship CLP cleft lip and palate cm centimetre CMV cytomegalovirus CNS central nervous system C/O complaining of CPD Continuing Professional Development CPITN Community Periodontal Index of Treatment Needs CPR cardiopulmonary resuscitation CSF cerebrospinal fluid CSM Committee on Safety of Medicines CT computed tomography CVA cerebro-vascular accident CXR chest X-ray DCP Dental Care Professional dL decilitre DN dental nurse DOH/DH Department of Health DPF Dental Practitioner’s Formulary xiv SYMBOLS AND ABBREVIATIONS DPT dental panoramic tomogram (politically correct: OPT/OPG) DVT deep venous thrombosis EBA ethoxy benzoic acid EBM/D evidence-based medicine/dentistry EBV Epstein–Barr virus ECC early childhood caries ECG electrocardiograph EDTA ethylene diamine tetraacetic acid e.g. for example EMD enamel matrix derivative EMLA eutectic mix of lidocaine and prilocaine ENT ear, nose, and throat EO extra-oral ESR erythrocyte sedimentation rate EUA examination under anaesthesia F female F/- full upper denture (and -/F for lower) FA fixed appliance FABP flat anterior bite plane FB foreign body FBC full blood count FESS functional endoscopic sinus surgery fL femtolitre FNAC fine-needle aspiration cytology f/s fissure sealant FWS freeway space g gram GA general anaesthesia GAP generalized aggressive periodontitis GDC General Dental Council GDP general dental practitioner GDS General Dental Services GI glass ionomer GKI glucose, potassium, insulin GMP general medical practitioner GP gutta-percha GTR guided tissue regeneration h hour Hb haemoglobin HDU high dependency unit  SYMBOLS AND ABBREVIATIONS xv Hep B/C hepatitis B/C Hg mercury HIV human immunodeficiency virus HLA human leucocyte antigen HPV human papilloma virus HRT hormone replacement therapy HSV herpes simplex virus ICP intercuspal position ICU intensive care unit ID inferior dental IDB inferior dental block IDN inferior dental nerve i.e. that is IE infective endocarditis Ig immunoglobulin (e.g. IgA, IgG, etc.) IM intramuscular IMF intermaxillary fixation inc incisor INR international normalized ratio IO intra-oral IOTN Index of Orthodontic Treatment Need IRM Intermediate Restorative Material® ITP idiopathic thrombocytopenic purpura IU international units IV intravenous K+ potassium KCT kaolin–cephalin clotting time kg kilogram kV kilovolt L litre LA local anaesthesia LAP localized aggressive periodontitis LFH lower face height LFT liver function test LLS lower labial segment LMA laryngeal mask airway m metre M male mand mandible/mandibular MAOI monoamine oxidase inhibitor xvi SYMBOLS AND ABBREVIATIONS max maxilla/maxillary MCQ multiple choice question MCV mean corpuscular volume MEN multiple endocrine neoplasia mg milligram MHz megahertz MI myocardial infarction micromol micromoles min minute mL millilitre mm millimetre mmHg millimetres of mercury mmol millimole MMPA maxillary mandibular planes angle MRI magnetic resonance imaging MST slow release morphine MSU mid-stream urine MTA mineral trioxide aggregate NAD nothing abnormal detected NAI non-accidental injury NGT naso-gastric tube NHS National Health Service NiTi nickel titanium NLP neurolinguistic programming nm nanometre nocte at night NSAID non-steroidal anti-inflammatory drug NUG necrotizing ulcerative gingivitis NUP necrotizing ulcerative periodontitis O2 oxygen o/b overbite OCP oral contraceptive pill od once daily OD overdenture O/E on examination OH oral hygiene OHCM Oxford Handbook of Clinical Medicine OHI oral hygiene instruction OHP overhead projector/projection o/j overjet  SYMBOLS AND ABBREVIATIONS xvii OMF oral and maxillofacial OP out-patient ORIF open reduction and internal fixation OSCE objective structured clinical examination OTC over the counter OVD occlusal vertical dimension P/- partial upper denture (and -/P for lower) PA posteroanterior PCA patient-controlled analgesia PCR polymerase chain reaction PDH past dental history PDL periodontal ligament PEA pulseless electrical activity PEG percutaneous endoscopic gastrostomy PFM porcelain fused to metal (crown) PI Plaque Index PJC porcelain jacket crown PM premolar PMH past medical history PMMA polymethylmethacrylate PO per orum (by mouth) ppm parts per million PR per rectum PRR preventive resin restoration PU pass urine qds four times daily RA relative analgesia RAS recurrent aphthous stomatitis RBC red blood cell count RCCT randomized controlled clinical trial RCP retruded contact position RCT root canal treatment/therapy RIG radiologically inserted gastrostomy RMGIC resin-modified glass ionomer cement RRF retrograde root filling Rx treatment SC subcutaneous SCC squamous cell carcinoma sec second SF sugar free xviii SYMBOLS AND ABBREVIATIONS SLE systemic lupus erythematosus spp. species SS stainless steel STD sexually transmitted diseases TB tuberculosis TC tungsten carbide tds thrice daily TENS transcutaneous electrical nerve stimulation TIBC total iron binding capacity TMA titanium molybdenum alloy TMJ temporomandibular joint TMPDS temporomandibular pain dysfunction syndrome TNF tissue necrosis factor TTP tender to percussion ULS upper labial segment URA upper removable appliance URTI upper respiratory tract infection US (S) ultrasound (scan) UTI urinary tract infection U&Es urea and electrolytes VF ventricular fibrillation Xbite crossbite X-rays either X-ray beam or radiographs yr year ZOE zinc oxide eugenol  Chapter  1 History and examination Contents Listen, look, and learn 2 Presenting complaint 3 The dental history 4 The medical history 6 Medical examination 8 Examination of the head and neck 9 Examination of the mouth 0 Investigations—general 2 Investigations—specific 4 Radiology and radiography 6 Advanced imaging techniques 8 Differential diagnosis and treatment plan 20 Relevant pages in other chapters It could, of course, be said that all pages are relevant to this section, because history and examination are the first steps in the care of any patient. However, as that is hardly helpful, the reader is referred specifi- cally to the following: dental charting E Tooth notation, p. 762; medical conditions, Chapter ; the child with toothache E p. 62; pre-operative management of the dental patient E Pre- operation, p. 554; cranial nerves E p. 524; orthodontic assess- ment E p. 24; pulpal pain E p. 222. Principal sources Experience. 2 Chapter  History and examination Listen, look, and learn Much of what you need to know about any individual patient can be obtained by watching them enter the surgery and sit in the chair, their body language during the interview, and a few well-chosen questions (see Chapter 7). One of the great secrets of healthcare is to develop the ability to actually listen to what your patients tell you and to use that informa- tion. Doctors and dentists are often concerned that if they allow patients to speak rather than answer questions, history-taking will prove inefficient and prolonged. In fact, most patients will give the information necessary to make a provisional diagnosis, and further useful personal information, if allowed to speak uninterrupted. Most will lapse into silence after 2–3min of monologue. History-taking should be conducted with the patient sit- ting comfortably; this rarely equates with supine! In order to produce an all-round history it is, however, customary and frequently necessary to resort to directed questioning, here are a few hints: Always introduce yourself to the patient and any accompanying person, and explain, if it is not immediately obvious, what your role is in helping them. Remember that patients are (usually) neither medically nor dentally trained, so use plain speech without speaking down to them. Questions are a key part of history-taking and the manner in which they are asked can lead to a quick diagnosis and a trusting patient, or abject confusion with a potential litigant. Leading questions should, by and large, be avoided as they impose a preconceived idea upon the patient. This is also a problem when the question suggests the answer, e.g. ‘is the pain worse when you drink hot drinks?’. To avoid this, phrase questions so that a descriptive reply rather than a straight yes or no is required. However, with the more reticent patient it may be necessary to ask leading questions to elicit relevant information. Notwithstanding earlier paragraphs, you will sometimes find it necessary to interrupt patients in full flight during a detailed monologue on their grandmother’s sick parrot. Try to do this tactfully, e.g. ‘but to come more up to date’ or ‘this is rather difficult—please slow down and let me understand how this affects the problem you have come about today’. Specifics of a medical or dental history are described in E The dental his- tory, p. 4; E The medical history, p. 6. The object is to elicit sufficient information to make a provisional diagnosis for the patient whilst establish- ing a mutual rapport, thus facilitating further investigations &/or treatment.  Presenting complaint 3 Presenting complaint The aim of this part of the history is to have a provisional differential diag- nosis even before examining the patient. The following is a suggested out- line, which would require modifying according to the circumstances: C/O (complaining of ) in the patient’s own words. Use a general intro- ductory question, e.g. ‘Why did you come to see us today? What is the problem?’. Avoid ‘What brought you here today?’ unless you want to give them the chance to complain about transport or car parking. If symptoms are present Onset and pattern When did the problem start? Is it getting better, worse, or staying the same? Frequency How often, how long does it last? Does it occur at any particular time of day or night? Exacerbating and relieving factors What makes it better, what makes it worse? What started it? If pain is the main symptom Origin and radiation Where is the pain and does it spread? Character and intensity How would you describe the pain: sharp, shooting, dull, aching, etc. This can be difficult, but patients with specific ‘organic’ pain will often understand exactly what you mean whereas patients with symptoms with a high behavioural overlay will be vague and prevaricate. Associations Is there anything, in your own mind, which you associate with the problem? The majority of dental problems can quickly be narrowed down using a simple series of questions such as these to create a provisional diagnosis and judge the urgency of the problem. 4 Chapter  History and examination The dental history It is important to assess the patient’s dental awareness and the likelihood of raising it. A dental history may also provide invaluable clues as to the nature of the presenting complaint and should not be ignored. This can be achieved by some simple general questions: How often do you go to the dentist? (this gives information on motivation, likely attendance patterns, and may indicate patients who change their GDP frequently) When did you last see a dentist and what did he do? (this may give clues as to the diagnosis of the presenting complaint, e.g. a recent RCT) How often do you brush your teeth and how long for? (motivation and likely gingival condition) Have you ever had any pain or clicking from your jaw joints? (TMJ pathology) Do you grind your teeth or bite your nails? (TMPDS, personality) How do you feel about dental treatment? (dental anxiety) What do you think about the appearance of your teeth? (motivation, need for orthodontic treatment) What is your job? (socio-economic status, education) Where do you live? (fluoride intake, travelling time to surgery) What types of dental treatment have you had previously? (previous extractions, problems with LA or GA, orthodontics, peri- odontal treatment) What are your favourite drinks/foods? (caries rate, erosion, it is worth including specific questions as to whether or not they use tobacco, alcohol, or other recreational drugs)  The dental history 5 Notebox: Summary points of the dental history (you write here) 6 Chapter  History and examination The medical history There is much to be said for asking patients to complete a medical his- tory questionnaire, as this encourages more accurate responses to sensitive questions. However, it is important to use this as a starting point, and clarify the answers with the patient. Example of a medical questionnaire QUESTION YES/NO Are you fit and well? Have you ever been admitted to hospital? If yes, please give brief details: Have you ever had an operation? If so, were there any problems? Have you ever had any heart trouble or high blood pressure? Have you ever had any chest trouble? Have you ever had any problems with bleeding? Have you ever had asthma, eczema, hayfever? Are you allergic to penicillin? Are you allergic to any other drug or substance? Do you have or ever had: arthritis? diabetes? epilepsy? tuberculosis? jaundice? hepatitis especially B or C? other infectious disease, HIV in particular? Are you pregnant? Are you taking any drugs, medications, or pills? If yes, please give details: (see Chapter 3) Who is your General Medical Practitioner (GMP)? 2 Check the medical history at each recall. 2 If in any doubt contact the patient’s GMP, or the specialist they are attending, before proceeding. NB A complete medical history (as required when clerking in-patients) would include details of the patient’s family history (for familial disease) and social history (for factors associated with disease, e.g. smoking, drinking, and for home support on discharge). It would be completed by a systematic enquiry: Cardiovascular Chest pain, palpitations, breathlessness. Respiratory Breathlessness, wheeze, cough—productive or not.  The medical history 7 Gastrointestinal Appetite and eating, pain, distension, and bowel habit. Genitourinary Pain, frequency (day and night), incontinence, straining, or dribbling. Central nervous system Fits, faints, and headaches. Screening for medical problems in dental practice Certain conditions are so commonplace and of such significance that screening (specifically looking for asymptomatic markers of disease) is justi- fiable. Whether or not it is appropriate to use the dental practice environ- ment to screen for hypertension, smoking, or drug and alcohol abuse is very much a cultural, personal, and pragmatic decision for the dentist. What is crucial is that if you choose to initiate say a screening policy for hypertension in practice (i.e. you measure every adult’s blood pressure) you must ensure you are adequately trained in the technique, are aware of and avoid the risk of inducing disease (people get anxious at the dentist and may have ‘white coat hypertension’ which is of no significance), and act on significant results in a meaningful way. Generating a cohort of ‘worried well’ who then overload their GMP is hardly helpful whereas detecting significant hypertension in an unsuspecting middle-aged man who then has this cor- rected, could be. 8 Chapter  History and examination Medical examination For the vast majority of dental patients attending as out-patients to a prac- tice, community centre, or hospital, simply recording a medical history should suffice to screen for any potential problems. The exceptions are patients who are to undergo general anaesthesia and anyone with a positive medical history undergoing extensive treatment under LA or sedation. The aim in these cases is to detect any gross abnormality so that it can be dealt with (by investigation, by getting a more experienced or specialist opinion, or by simple treatment if you are completely familiar with the problem). This is a summary, for more detail see Chapter 2. General Look at sclera in good light for jaundice & anaemia. Cyanosis, peripheral: blue extremities; central: blue tongue. Dehydration, lift skin between thumb and forefinger. Cardiovascular system Feel and time the pulse. Measure blood pres- sure. Listen to the heart sounds along the left sternal edge and the apex (normally 5th intercostal space mid-clavicular line on the left), murmurs are whooshing sounds between the ‘lup dub’ of the normal heart sounds. Palpate peripheral pulses and look at the neck for a prominent jugular venous pulse (this is difficult and takes much practice). Respiratory system Look at the respiratory rate (2–8/min), is expansion equal on both sides? Listen to the chest, is air entry equal on both sides, are there any crackles or wheezes indicating infection, fluid, or asthma? Percuss the back, comparing resonance. Gastrointestinal system With the patient lying supine and relaxed with hands by their sides, palpate with the edge of your hand for liver (upper right quadrant) and spleen (upper left quadrant). These should be just palpable on inspiration. Also palpate bimanually for both kidneys in the right and left flanks (healthy kidneys are not palpable) and note any masses, scars, or hernia. Listen for bowel sounds and palpate for a full bladder. Genitourinary system Mostly covered by abdominal examina- tion. Patients with genitourinary symptoms are more likely to go into post-operative urinary retention. Pelvic and rectal examinations are neither appropriate nor indicated and should not be conducted by the non-medically qualified. Central nervous system Is the patient alert and orientated in time, place, and person? Examination of the cranial nerves E Cranial nerves, p. 524. Ask the patient to move their limbs through a range of movements, then repeat passively and against resistance to assess tone, power, and mobility. Reflexes: brachioradialis, biceps, triceps, knee, ankle, and plantar are commonly elicited (stimulation of the sole normally causes plantar flex- ion of the great toe). Musculoskeletal system Note limitations in movement and arthritis, especially affecting the cervical spine, which may need to be hyperextended in order to intubate for anaesthesia.  Examination of the head and neck 9 Examination of the head and neck This is an aspect of examination that is undertaught and overlooked in both medical and dental training. In the former, the tendency is to approach the area in a rather cursory manner, partly because it is not well understood. In the latter it is often forgotten, despite otherwise extensive knowledge of the head and neck, to look beyond the mouth. For this reason the examina- tion described here is given in some detail, but so thorough an inspection is only necessary in selected cases, e.g. suspected oral cancer, facial pain of unknown origin, trauma, etc. Head and facial appearance Look for specific deformities (E Cleft lip and palate, p. 68), facial disharmony (E Orthodontics and orthognathic surgery, p. 66), syndromes (Chapter 9), traumatic defects (E Mandibular fractures, p. 470; E Mid-face fractures, p. 472; E Nasal and malar fractures, p. 474), and facial palsy (E Oral manifestations of neurological disease, p. 450). Assessment of the cranial nerves is covered in E Cranial nerves, p. 524. Skin lesions of the face should be examined for colour, scaling, bleeding, crusting, palpated for texture and consistency and whether or not they are fixed to, or arising from, surrounding tissues. Eyes Note obvious abnormalities such as proptosis and lid retraction (e.g. hyperthyroidism) and ptosis (drooping eyelid). Examine conjunctiva for che- mosis (swelling), pallor, e.g. anaemia or jaundice. Look at the iris and pupil. Ophthalmoscopy is the examination of the disc and retina via the pupil. It is a specialized skill requiring an adequate ophthalmoscope and is acquired by watching and practising with a skilled supervisor. However, direct and consen- sual (contralateral eye) light responses of the pupils are straightforward and should always be assessed in suspected head injury (E Pupils, p. 468). Ears Gross abnormalities of the external ear are usually obvious. Further examination requires an auroscope. The secret is to have a good auroscope and straighten the external auditory meatus by pulling upwards, backwards, and outwards using the largest applicable speculum. Look for the pearly grey tympanic membrane; a plug of wax often intervenes. Mouth See E Examination of the mouth, p. 0. Oropharynx and tonsils These can easily be seen by depressing the tongue with a spatula, the hypopharynx and larynx are seen by indirect laryn- goscopy, using a head-light and mirror, and the post-nasal space is similarly viewed. Skill with a flexible nasendoscope is essential for those (e.g. OMF trainees) who examine this area in detail regularly. The neck Inspect from in front and palpate from behind. Look for skin changes, scars, swellings, and arterial and venous pulsations. Palpate the neck systematically, starting at a fixed standard point, e.g. beneath the chin, working back to the angle of the mandible and then down the cervical chain, remembering the scalene and supraclavicular nodes. Swellings of the thy- roid move with swallowing. Auscultation may reveal bruits over the carotids (usually due to atheroma). TMJ Palpate both joints simultaneously. Have the patient open and close and move joint laterally whilst feeling for clicking, locking, and crepitus. Palpate the muscles of mastication for spasm and tenderness. Auscultation is not usually used. 10 Chapter  History and examination Examination of the mouth Most dental textbooks, quite rightly, include a very detailed and compre- hensive description of how to examine the mouth. These are based on the premise that the examining dentist has never before seen the patient, who has presented with some exotic disease. Given the constraints imposed by routine clinical practice, this approach needs to be modified to give a somewhat briefer format that is as equally applicable to the routine dental attendee who is symptomless as to the new patient attending with pain of unknown origin. The key to this is to develop a systematic approach, which becomes almost automatic, so that when you are under pressure there is less likeli- hood of missing any pathology. As any abnormal findings indicate that fur- ther investigation is required, the reader is referred to the page numbers in parenthesis, as necessary. EO examination (E Examination of the head and neck, p. 9.) For routine clinical practice this can usually be limited to a visual appraisal, e.g. swellings, asymmetry, patient’s colour, etc. More detailed examination can be carried out if indicated by the patient’s symptoms. IO examination Oral hygiene. Soft tissues. The entire oral mucosa should be carefully inspected. Any ulcer of >3 weeks’ duration requires further investigation (E An approach to oral ulcers, p. 456). Periodontal condition. This can be assessed rapidly, using a periodontal probe. Pockets >5mm indicate the need for a more thorough assessment (E Basic Periodontal Examination (BPE), p. 74). Chart the teeth present (E Tooth notation, p. 762). Examine each tooth in turn for caries (E Caries diagnosis, p. 26) and examine the integrity of any restorations present. Occlusion. This should involve not only getting the patient to close together and examining the relationship between the arches (E Definitions, p. 22), but also looking at the path of closure for any obvious prematurities and displacements (E Crossbites, p. 52). Check for evidence of tooth wear (E Tooth wear/tooth surface loss, p. 244). For those patients complaining of pain, a more thorough examination of the area related to their symptoms should then be carried out, followed by any special investigations (E Investigations—specific, p. 4).  Examination of the mouth 11 Notebox: Summary points for history and examination (you write here) 12 Chapter  History and examination Investigations—general 2 Do not perform or request an investigation you cannot interpret. 2 Similarly, always look at, interpret, and act on any investigations you have performed. Temperature, pulse, blood pressure, and respiratory rate These are the nurses’ stock-in-trade. You need to be able to interpret the results. Temperature (35.5–37.5°C or 95.9–99.5°F) i physiologically post-operatively for 24h, otherwise may indicate infection or a transfusion reaction. d in hypo- thermia or shock. Pulse Adult (60–80 beats/min; child is higher (up to 40 beats/min in infants). Should be regular. Blood pressure (20–40/60–90mmHg) i with age. Falling BP may indi- cate a faint, hypovolaemia, or other form of shock. High BP may place the patient at risk from a GA. An i BP + d pulse suggests i intracranial pressure (E Assessing head injury, p. 468). Respiratory rate (2–8 breaths/min) i in chest infections, pulmonary oedema, and shock. Urinalysis is routinely performed on all patients admitted to hospital. A positive result for: Glucose or ketones may indicate diabetes. Protein suggests renal disease especially infection. Blood suggests infection or tumour. Bilirubin indicates hepatocellular &/or obstructive jaundice. Urobilinogen indicates jaundice of any type. Blood tests (Sampling techniques E For sampling, p. 556.) Reference ranges vary. Full blood count (EDTA, pink tube) measures: Haemoglobin (M 3–8g/dL, F .5–6.5g/dL.) d in anaemia, i in poly- cythaemia and myeloproliferative disorders. Haematocrit (Packed cell volume.) (M 40–54%, F 37–47%.) d in anaemia, i in polycythaemia and dehydration. Mean cell volume (76–96fL.) i in size (macrocytosis) in vitamin B2 and folate deficiency, d (microcytosis) iron deficiency. White cell count (4– × 09/L.) i in infection, leukaemia, and trauma, d in certain infections, early leukaemia, and after cytotoxics. Platelets (50–400 × 09/L.) See also E Platelet disorders, p. 506.  Investigations—general 13 Biochemistry Urea and electrolytes are the most important: Sodium (35–45mmol/L) Large fall causes fits. Potassium (3.5–5mmol/L) Must be kept within this narrow range to avoid serious cardiac disturbance. Watch carefully in diabetics, those in IV ther- apy, and the shocked or dehydrated patient. Suxamethonium (muscle relax- ant) i potassium. Urea (2.5–7mmol/L) Rising urea suggests dehydration, renal failure, or blood in the gut. Creatinine (70–50micromol/L) Rises in renal failure. Various other bio- chemical tests are available to aid specific diagnoses, e.g. bone, liver func- tion, thyroid function, cardiac enzymes, folic acid, vitamin B2, etc. Glucose (fasting 4–6mmol/L) i suspect diabetes, d hypoglycaemic drugs, exercise. Competently interpreted proprietary tests, e.g. ‘BMs’ equate well to blood glucose (E Hypoglycaemia, p. 547). Virology Viral serology is costly and rarely necessary. If you must, use 0mL clotted blood in a plain tube. Immunology Similar to virology but more frequently indicated in com- plex oral medicine patients; 0mL in a plain tube. Bacteriology Sputum and pus swabs are often helpful in dealing with hospital infections. Ensure they are taken with sterile swabs and transported immediately or put in an incubator. Nasal and axillary swabs are used to screen for MRSA in all in patients undergoing hospital-based procedures. Stool samples are still generally used to detect Clostridium difficile although toxin can be detected in blood. Blood cultures are also useful if the patient has septicaemia. Taken when there is sudden pyrexia and incubated with results available 24–48h later. Take two samples from separate sites and put in paired bottles for aerobic and anaerobic culture (i.e. four bottles, unless your lab indicates otherwise). Biopsy See E Biopsy, p. 386. Cytology With the exception of smears for candida and fine-needle aspi- ration, cytology is little used and not widely applicable in the dental special- ties. The diagnosis of premalignant or malignant lesions using cytology only is not widely accepted. 14 Chapter  History and examination Investigations—specific Sensibility testing It must be borne in mind when vitality testing that it is the integrity of the nerve supply that is being investigated. However, it is the blood supply which is of more relevance to the continued vitality of a pulp. Test the suspect tooth and its neighbours. Application of cold This is most practically carried out using ethyl chlo- ride on a pledget of cotton wool. Application of heat Vaseline should be applied first to the tooth being tested to prevent the heated GP sticking. No response suggests that the tooth is non-vital, but an i response indicates that the pulp is hyperaemic. Electric pulp tester The tooth to be tested should be dry, and pro- phy paste or a proprietary lubricant used as a conductive medium. Most machines ascribe numbers to the patient’s reaction, but these should be interpreted with caution as the response can also vary with battery strength or the position of the electrode on the tooth. For the described methods misleading results may occur (Table .). Table . Misleading results False-positive False-negative Multi-rooted tooth with vital + Nerve supply damaged, blood non-vital pulp supply intact Canal full of pus Secondary dentine Apprehensive patient Large insulating restoration Test cavity Drilling into dentine without LA is an accurate diagnostic test, but as tooth tissue is destroyed it should only be used as a last resort. Can be helpful for crowned teeth. Percussion is carried out by gently tapping adjacent and suspect teeth with the end of a mirror handle. A positive response indicates that a tooth is extruded due to exudate in apical or lateral periodontal tissues. Mobility of teeth is i by d in the bony support (e.g. due to peridontal disease or an apical abscess) and also by # of root or supporting bone. Palpation of the buccal sulcus next to a painful tooth can help to deter- mine if there is an associated apical abscess. Biting on to gauze or rubber can be used to try and elicit pain due to a cracked tooth. Local anaesthesia can help localize organic pain. Radiographs (E Radiology and radiography, p. 6; E Advanced imaging techniques, p. 8; E X-rays—practical tips and helpful hints, p. 748.) (See Table .2.)  Investigations—specific 15 Table .2 Radiographic choice for different areas Area under investigation Radiographic view General scan of teeth and jaws (retained roots, DPT unerupted teeth) Localization of unerupted teeth Parallax periapicals Crown of tooth and interdental bone (caries, Bitewing restorations) Root and periapical area Periapical Submandibular gland Lower occlusal view Sinuses Occipito-mental, DPT TMJ DPT, MRI Skull and facial bones Occipito-mental PA and lateral skull Submento-vertex 16 Chapter  History and examination Radiology and radiography Radiography is the taking of radiographs, radiology is their interpretation. Referring to a radiologist as a radiographer ensures upset. Radiographic images are produced by the differential attenuation of X-rays by tissues. Radiographic quality depends on the density of the tis- sues, the intensity of the beam, sensitivity of the emulsion, processing tech- niques, and viewing conditions. Intra-oral views Use a stationary anode (tungsten), direct current d dose of self-rectifying machines. Direct action film ( i detail) using D or E speed. E speed is double the speed of D hence d dose to patient. Rectangular collimation d unneces- sary irradiation of tissues. Periapical shows all of tooth, root, and surrounding periapical tissues. Performed by: Paralleling technique Film is held in a film holder parallel to the tooth and the beam is directed (using a beam-aligning device) at right angles to the tooth and film. Focus-to-film distance is increased to minimize magnification; the optimum distance is 30cm. The most accurate and reproducible technique. Bisecting angle technique Older technique which can be carried out without film holders. Film placed close to the tooth and the beam is directed at right angles to the plane bisecting the angle between the tooth and film. Normally held in place by patient’s finger. Not as geometrically accurate a technique as more coning off occurs and needlessly irradiates the patient’s finger. Bitewing shows crowns and crestal bone levels, used to diagnose caries, overhangs, calculus, and bone loss 2/3 of which come from sweets, table sugar, and soft drinks.3 65% of all soft drink sales are to tone of the voice > what is said. Don’t deny patient’s fear. Explain—why, how, when. Reward good behaviour, ignore bad. Get child involved in Rx, e.g. holding saliva ejector. Giving the child some control over the situation will also help them to relax, e.g. raising their hand if they want you to stop for any reason (‘enhancing control’). Tell, show, do Self-explanatory, but use language the child will understand. Behaviour shaping Aim to guide and modify the child’s responses, selectively reinforcing appropriate behaviour, whilst discouraging/ignoring inappropri- ate behaviour. Reinforcement This is the strengthening of patterns of behaviour, usually by rewarding good behaviour with approval and praise. If a child protests and is uncooperative during Rx, do not immediately abandon session and return them to the consolation of their parent, as this could inadvertently reinforce the undesirable behaviour. Try to ensure that something is completed, (e.g. placing a dressing or even an examination) and focus on the successful com- pletion of this, rather than the failure to complete what might have been originally planned. Modelling Useful for children with little previous dental experience who are apprehensive. Encourage child to watch other children of similar age or siblings receiving dental Rx happily. Desensitization Used for child with pre-existing fears or phobias. Involves helping patient to relax in dental environment, then constructing a hierarchy of fearful stimuli for that patient. These are introduced to the child gradu- ally, with progression on to the next stimulus only when the child is able to cope with previous situation. Should parent accompany child into surgery? Essential on first visit, thereafter depends upon child’s age and clinician’s preference. If in doubt ask child’s preference. However, if parent is dental phobic, their anxiety in the dental environment can be detrimental, so in these cases it is worth considering leaving the parent in the waiting room. Younger children are more likely to suffer ‘separation anxiety’, and many parents nowadays wish to be involved in, and informed about, their child’s Rx. In the event of anxiety-related behaviour being encountered, parental presence in the surgery does enable consent for any adjustment in treatment to be easily maintained. Ideally parents should be motivated positively and instructed implicitly to act in the role of the ‘silent helper’.  The anxious child 61 Sedation Sometimes indicated for the genuinely anxious child who wishes to coop- erate and also may help children with over-active gag reflexes and those where analgesia additional to LA may be needed (e.g. for difficult extrac- tions such as 6s). Oral Drugs such as midazolam and chloral hydrate have been advocated, although specialized knowledge and skills are required. Intramuscular Rarely used in children. Intravenous Rarely used in children >2yrs of age. Per rectum Popular in some Scandinavian countries. Inhalation Uses nitrous oxide/oxygen mixture to produce RA and is most popular technique for use with children. Effective for d anxiety and i toler- ance of invasive procedures in children who wish to cooperate but are too anxious to do so without help. It is a good idea not to carry out any Rx during the visit when the child is introduced to ‘happy air’. Let child position nose-piece themselves. See also Chapter 4. Hypnosis Produces a state of altered consciousness and relaxation, though it can- not be used to make subjects do anything that they do not wish to do. Appropriate training is necessary for those wishing to practise hypnosis. It can be described as either a way of helping the child to relax, or as a special kind of sleep. General anaesthesia Allows dental rehabilitation &/or dental extractions to be achieved at one visit. GA should only be used for dental Rx when absolutely necessary (i.e. when other methods of management, e.g. LA or sedation, are deemed unsuitable). Alternative strategies and the risks of GA must be discussed to enable parents to make an informed decision. The risk of unexpected death of a healthy person: under GA has been estimated to be about 3 or 4 in  million. under sedation has been estimated to be about  in 2 million. Other behaviour problems and their management Some children attempt to delay Rx by a barrage of questions. This is usually a sign of anxiety, and firm but gentle handling is needed. Tell the patient that you understand their anxieties and that you will explain as you go along. The temper tantrum—try to establish communication. Praise good and ignore bad behaviour. Set an easily achievable goal, e.g. brushing teeth and make sure it is achieved—comment on the positive outcome, rather than what was not achieved.  J. Hartland 200 Medical and Dental Hypnosis, Churchill Livingstone. 62 Chapter 3 Paediatric dentistry The child with toothache When faced with a child with toothache, pulpal or periodontal pathology are the commonest causes. The dentist has to use clinical acumen to try and determine the state of the affected tooth/teeth, as this will decide the Rx required (Table 3.). To that end the following investigations may be employed: History Take a pain history (see E Dental pain, p. 222) from the child and parent. Beware of variations in accuracy; anxious children may deny being in pain when faced with an eager dentist, whereas parents who feel guilty for delaying seeking dental Rx may exaggerate pain. Remember some pathology is painless, e.g. chronic periradicular periodontitis. Examination Swelling, temperature, lymphadenopathy? Intraorally look for caries, abscesses, chronic buccal sinuses, mobile teeth (? due to exfolia- tion or apical infection), and erupting teeth. Percussion Can be unreliable in children. Gentle finger pressure first. Care needed to establish a consistent response and compare with unaf- fected ‘control’ teeth. Sensibility testing Using thermal (e.g. ethyl chloride on cotton wool) or electrical stimulation. Again, establish a consistent, reliable response on a ‘control’ tooth before testing the tooth/teeth in question. Check for false-positives, by altering the intensity of stimulus (e.g. cotton ball with ethyl chloride, followed by a dry cotton ball). Less reliable in primary teeth. Radiographs Bitewing X-rays may be useful. Not only are they less uncomfortable for small mouths than periapicals, but they also often show the bifurcation area where radiolucency secondary to periodontitis is often first apparent. Diagnosis Fleeting pain on hot/cold/sweet stimuli = reversible pulpitis. Longer-lasting pain on hot/cold/sweet stimuli &/or spontaneous pain with no initiating factor (? child kept awake) but no mobility, not TTP = irrevers- ible pulpitis. Pain on biting and pressure &/or swelling and tenderness of adjacent tissues, mobility = acute periradicular periodontitis. Remember, the only 00% accurate diagnostic method is histological! With a fractious child keep examination and operative intervention to a minimum, doing only what is necessary to alleviate pain and win child’s trust. If extractions under a GA are required consider carefully the long-term prognosis of remaining teeth to try and avoid a repeat of the anaesthetic in the foreseeable future. Other common potential causes of toothache: Dentoalveolar trauma (E Dental trauma, p. 94). Mucosal ulceration (E Recurrent aphthous stomatitis (ulcers), p. 46). Teething (E Abnormalities of tooth eruption and exfoliation, p. 64). Table 3. Management of child with toothache Diagnosis Emergency management Definitive management Reversible pulpitis LA Pulpotomy or extraction Excavate soft caries Restore temporarily with a zinc oxide/eugenol cement. If exposed and vital—dress polyantibiotic paste (e.g. Ledermix®) Irreversible pulpitis LA Pulpotomy/pulpectomy Excavate soft caries or extraction Dress polyantibiotic paste. Restore temporarily with a zinc oxide/eugenol or GI cement Acute periradicular periodontitis LA (may not be necessary if loss of vitality is certain) Excavate soft caries until pulp chamber accessed—dress pulp chamber with polyantibiotic paste on cotton wool. The child with toothache Seal with temporary dressing Acute periodontitis with facial swelling Antibiotics and analgesics Extraction of tooth (or If: Ensure adequate fluid intake pulpectomy in selected No or mild pyrexia (38°C Immediate referral to specialist centre or intra-/extra-oral Poorly localized, spreading infection drainage Systemically unwell: dehydration, lethargy, nausea, and vomiting Swelling involving a ‘danger area’, i.e. floor of mouth 63 64 Chapter 3 Paediatric dentistry Abnormalities of tooth eruption and exfoliation Natal teeth are usually members of the ° dentition, not supernumer- ary teeth, and so should be retained if possible. Most frequently occur in lower incisor region and because of limited root development at that age, are often mobile. If in danger of being inhaled or causing problems with breast-feeding, they can be removed under LA. Teething As eruption of the ° dentition coincides with a diminution in circulating maternal antibodies, teething is often blamed for systemic symp- toms. However, local discomfort, and so disturbed sleep, may accompany the actual process of eruption. A number of proprietary ‘teething’ prepara- tions are available, which usually contain a combination of an analgesic, an antiseptic, and anti-inflammatory agents for topical use. Having something hard to chew may help, e.g. teething ring. Some are designed to be cooled in the fridge, which can enhance their soothing ability. Eruption cyst is caused by an accumulation of fluid or blood in the fol- licular space overlying an erupting tooth. The presence of blood gives a blu- ish hue. Most rupture spontaneously, allowing eruption to proceed. Rarely, it may be necessary to marsupialize the cyst. Failure of/delayed eruption 2 Disruption of normal eruption sequence (see Fig. 3.) and asymme- try in eruption times of contralateral teeth >6 months warrants further investigation. It must be remembered that there is a wide range of individual variation in eruption times. Developmental age is of more importance in assessing delayed eruption than chronological age. General causes Hereditary gingival fibromatosis, Down syndrome, Gardner syndrome, hypothyroidism, cleidocranial dysostosis, rickets. Local causes Congenital absence. Is the most likely cause for failure of appearance of 2 (E Hypodontia (oligodontia), p. 66). Crowding. Rx: extractions. Retention of primary tooth. Rx: extraction of ° tooth. Supernumerary tooth. Is the most likely reason for failure of eruption of  (E Hyperdontia, p. 66). Dilaceration (E Dilaceration, p. 72). Dentigerous cyst. Trauma to ° tooth leading to apical displacement of 2° incisor. Abnormal position of crypt. Rx: extraction or orthodontic alignment. See options for palatally displaced 3 (E Palatally displaced maxillary canines, p. 42). Primary failure of eruption usually affects molar teeth. The aetiology is not understood. Although bone resorption proceeds above the unerupted tooth, they appear to lack any eruptive potential. Refer for advice, usually extraction only option.  Abnormalities of tooth eruption and exfoliation 65 Infraoccluded (ankylosed) primary molarsâ ‡Occur where the ° molar has failed to maintain its position relevant to the adjacent teeth in the develop- ing dentition and is therefore below the occlusal level of adjacent teeth. Often due to ankylosis secondary to disruption in normal resorptive/repair cycle of exfoliation. This is usually self-correcting (if the permanent succes- sor is present and not ectopic) and the affected tooth is exfoliated at the normal time. However, where the premolar is missing or where the infraoc- cluded molar appears in danger of disappearing below the gingival level, extraction may be indicated (monitor carefully—if in doubt get a specialist opinion). Impaction of the upper first permanent molarsâ ‡ against the E occurs in 2–5% of children. It is an indication of crowding. In younger patients ( M and is often associated with smaller than average tooth size in remainder of dentition. Peg-shaped 2 often occurs in conjunction with absence of contralateral 2 NB 3 migrates down guided by the distal aspect of 2. When 2 is absent, peg-shaped, or small-rooted, it is important to monitor the maxillary canine for signs of ectopic eruption. Aetiology Often familial—polygenic inheritance. Also associated with ecto- dermal dysplasia and Down syndrome. Rx: ° dentition—none. 2° dentition—depends on crowding and malocclusion. 8—none. 2—see E Management of missing incisors, p. 2. 5—(NB 5 sometimes develop late). If patient crowded, extraction of E, either at around 8yrs for spontaneous space closure or later if space is to be closed as a part of orthodontic Rx. If lower arch well-aligned or spaced, consider preservation of E, and bridgework later. Hyperdontia Better known as supernumerary teeth. Prevalence ° dentition 0.8%, 2° dentition 2%. Occurs most frequently in premaxillary region. Affects M > F. Associated with cleidocranial dysostosis and CLP. If $ in ° dentition is followed in about 50% cases by $ in 2° denti- tion, so warn mum! Aetiology Theories include: offshoot of dental lamina, third dentition. Classification either by shape or position (Table 3.2) and orientation (e.g. ‘upright, ‘inverted’, etc.). 2 A. H. Brooks 974 J Int Assoc Dent Child 5 32.  Abnormalities of tooth number 67 Table 3.2 Classification of abnormalities by shape and position Shape or Position Conical (peg-shaped) Mesiodens Tuberculate (barrel-shaped) Distomolar Supplemental Paramolar Odontome Effects on dentition and treatment No effect. If unerupted keep watch (X-ray occasionally to exclude cystic change/damage to adjacent teeth—both relatively rare). If erupts—extract. Crowding. Rx: extract; if supplemental, extract tooth with most displaced apex. Displacement. Can cause rotation &/or displacement. Rx: extraction of $ and fixed appliance, but tendency to relapse. Failure of eruption. Most likely cause of  to fail to erupt. Rx: extract $ and ensure sufficient space for unerupted tooth to erupt. May require extraction of primary teeth &/or permanent teeth and orthodontic appliance. Then wait. Average time to eruption in these cases is 8 months.3 If after 2yrs unerupted tooth fails to erupt despite sufficient space, may require conservative exposure and orthodontic traction. 3 D. D. DiBiase 97 Dent Pract Dent Rec 22 95. 68 Chapter 3 Paediatric dentistry Abnormalities of tooth structure Disturbances in structure of enamel Enamel usually develops in two phases, first an organic matrix and second mineralization. Disruption of enamel formation can therefore manifest as: Hypoplasia Caused by disturbance in matrix formation and is characterized by pitted, grooved, or thinned enamel. Hypomineralization Hypocalcification is a disturbance of calcification. Affected enamel appears white, yellow, or brown and opaque. May become more discoloured post-eruptively. Affected enamel may be weak and prone to breakdown. Most disturbances of enamel formation will produce both hypoplasia and hypomineralization, but clinically one type usually predominates. Aetiological factors (not an exhaustive list) Localized causes Infection (‘Turner tooth’), trauma, irradiation, idiopathic (see E Enamel opacities, p. 74). Generalized causes Environmental (chronological hypoplasia): Pre-natal, e.g. rubella, syphilis. Neo-natal, e.g. prolonged labour, premature birth. Post-natal, e.g. measles, congenital heart disease, fluoride, nutritional. Hereditary: Affecting teeth only—amelogenesis imperfecta. Accompanied by systemic disorder, e.g. Down syndrome, tuberous sclerosis. Chronological hypoplasia So called because the hypoplastic enamel occurs in a distribution related to the extent of tooth formation at the time of the insult. Characteristically, due to its later formation, 2 is affected nearer to the incisal edge than  or 3. Fluorosis See E Fluoride, p. 28. Treatment of hypomineralization/hypoplasia depends on extent and severity Posterior teeth Small areas of hypoplasia can be fissure-sealed or restored conventionally, but more severely affected teeth will require crowning. SS crowns (E Stainless steel crowns, p. 86) can be used in children as a semi-permanent measure. Anterior teeth Small areas of hypoplasia can be restored using composites, but larger areas may require veneers (E Veneers, p. 250) or crowns. Molar incisor hypomineralization (MIH) (Fig. 3.2) Aetiology unknown. Prevalence i over the past two decades in developed countries. Primarily affects 6s, but ~50% also have defects on permanent incisors.  Abnormalities of tooth structure 69 Affected 6s have hypomineralized defects of enamel, varying from discoloration to severe enamel dysplasia with post-eruptive breakdown. Sensitivity i, 2° caries i. Defects may affect anything from one to all 6s. Yellow/white opacities on buccal surface of affected incisors. Distribution often asymmetrical. No clear chronological pattern. Inc less prone to enamel breakdown than 6. Rx options include intracoronal restoration, SS crowns, or extraction (E Extraction of poor quality first permanent molars, p. 38). Consider partial composite veneering for incisors. Amelogenesis imperfecta Many classifications exist, but generally these are classified by the type of enamel defect &/or the mode of inheritance. There are now known to be >25 mutations in four different genes (AMELX, ENAM, KLK4, MMP20) that are associated with AI).4 Main types Hypoplastic—enamel may be thin (smooth or rough) or pitted. Most commonly autosomal dominant inheritance. Hypocalcified—enamel is dull, lustreless, opaque white, honey, or brown coloured. Enamel may breakdown rapidly in severe cases. Sensitivity i, calculus i common. May be autosomal dominant or recessive. Hypomaturation—mottled or frosty looking white, opacities, sometimes confined to incisal third of crown (‘snow-capped teeth’). Usually both ° and 2° dentitions and all the teeth are affected. The differ- ent subgroups give rise to a wide variation in clinical presentation, ranging from discoloration to soft &/or deficient enamel. It is therefore difficult to make general recommendations, but it is wise to seek specialist advice for all but the mildest forms. Rx: in more severe cases, SS crowns and composite resin can be used to maintain molars and 2° inc, prior to more permanent restorations when child is older. Disturbances in the structure of dentine Include dentinogenesis imperfecta, dentinal dysplasias (types I and II), regional odontodysplasia, vitamin D-resistant rickets, and Ehlers–Danlos syndrome—all of which are rare. Dentinogenesis imperfecta (hereditary opalescent dentine) Is more common affecting  in 8000. Both ° and 2° dentitions are involved, although later-formed teeth may be less so. Main types: I—associated with osteogenesis imperfecta. II—teeth only. Affected teeth have an opalescent brown or blue hue, bulbous crowns, short roots, and narrow flame-shaped pulps. The ADJ is abnormal, which results in the enamel flaking off, leading to rapid wear of the soft dentine. Rx: along similar lines as for severe amelogenesis. 4 J. T. Wright Developmental defects of the teeth (M http://www.dentistry.unc.edu/research/ defects/pages/ai.htm). 70 Chapter 3 â ‡ Paediatric dentistry 2 Early recognition and Rx of amelogenesis and dentinogenesis imperfecta important to prevent rapid tooth wear. Disturbances in the structure of cementum Hypoplasia and aplasia of cementum are uncommon. The latter occurs in hypophosphatasia and results in premature exfoliation. Hypercementosis is relatively common and may occur in response to inflammation, mechanical stimulation, or Paget’s disease, or be idiopathic. Concrescence is the uniting of the roots of two teeth by cementum. Fig. 3.2â ‡ Upper first permanent molar in a patient with molar incisor hypomineralization, prior to restoration.  Abnormalities of tooth structure 71 Notebox: Summary points on abnormalities of tooth eruption, number, and structure (you write here) 72 Chapter 3 Paediatric dentistry Abnormalities of tooth form Prevalence.5 Normal width  = 8.5mm, 2 = 6.5mm. Double teeth Gemination ccurs by partial splitting of a tooth germ. Fusion occurs as a result of the fusion of two tooth germs. As fusion can take place between either two teeth of the normal series or, less com- monly, with a $ tooth, then counting the number of teeth will not always give the correct aetiology. As the distinction is really only of academic interest, the term ‘double teeth’ is to be preferred. Both ° and 2° teeth may be affected and a wide variation in presentation is seen. The prevalence in the 2° dentition is 0.–0.2%. Rx for aesthetics should be delayed to allow pulpal recession. If the tooth has separate pulp chambers and root canals, separation can be considered. If due to fusion with a $ tooth, the $ portion can be extracted. Where a sin- gle pulp chamber exists sometimes the tooth can be contoured to resemble two separate teeth or the bulk of the crown reduced. Macrodontia/megadontia Generalized macrodontia is rare, but is unilaterally associated with hemifa- cial hypertrophy. Isolated megadont teeth are seen in % of 2° dentitions. Microdontia Prevalence ° dentition M *D. J. Stewart 978 Br Dent J 45 229. The traumatically induced type is caused by intrusion of the ° incisor, resulting in displacement of the developing 2° incisor tooth germ. The effects depend upon the developmental stage at the time of injury. Rx: depends upon severity and patient cooperation. If mild it may be possible to expose crown and align orthodontically provided the apex will not be positioned against the labial plate of bone at the end of the Rx, otherwise extraction indicated. Turner tooth Term used to describe the effect of a disturbance of enamel and dentine formation by infection from an overlying ° tooth therefore usually affects premolar teeth. Rx: as for hypoplasia E Hypoplasia, p. 68. Taurodontism Of academic interest only, but seems to crop up on X-rays in exams much more frequently than in clinical practice. Means bull-like, and radiographi- cally an elongation of the pulp chamber is seen. Rx: none required. 74 Chapter 3 Paediatric dentistry Abnormalities of tooth colour Extrinsic staining By definition this is caused by extrinsic agents and can be removed by proph- ylaxis. Green, black, orange, or brown stains are seen, and may be formed by chromogenic bacteria or be dietary in origin. Chlorhexidine mouthwash causes a brown stain by combining with dietary tannin. Where the staining is associated with poor oral hygiene, demineralization and roughening of the underlying enamel may make removal difficult. Rx: a mixture of pumice powder and toothpaste or an abrasive prophylaxis paste together with a bristle brush should remove the stain. Give OHI to prevent recurrence. Intrinsic staining This can be caused by: Changes in the structure or thickness of the dental hard tissues, e.g. enamel opacities. Incorporation of pigments during tooth formation, e.g. tetracycline staining (blue/brown), porphyria (red). Diffusion of pigment into hard tissues after formation, e.g. pulp necrosis products (grey), root canal medicaments (grey). Enamel opacities Are localized areas of hypomineralized (or hypoplastic) enamel. Fluoride (E Fluoride, p. 28) is only one of a considerable number of possible aetio- logical agents. Treatment Four possible approaches: Approach  Acid pumice abrasion technique is effective for some types of diffuse (surface) enamel defects. Two methods (take pre-op photos to monitor improvement): Hydrochloric acid technique (quicker, but great care needed) A mixture of 8% hydrochloric acid and pumice is applied to the affected area using a wooden stick. Careful isolation with rubber dam, use of a neu- tralizing agent (e.g. sodium bicarbonate) and protection of the soft tissues/ patient is essential. The mixture is rubbed into the surface for 5sec and then rinsed away. These two steps are repeated (max. 0 times—removing /2 intercuspal distance. Bulbous crown (5) ° molars have a more bulbous crown form than 2°, molars, making matrix placement more difficult. Inclination of the enamel prisms (6) In the cervical /3 of ° molars the enamel prisms are inclined in an occlusal direction so there is no need to bevel the gingival floor of a proximal box. Cervical constriction (7) is more marked in ° molars, therefore if the base of the proximal box is extended too far gingivally it will be difficult to cut an adequate floor without encroaching on the pulp. Alveolar bone permeability This is i in younger children, thus it is usually possible to achieve local anaesthesia of ° mandibular molars by infiltration alone, up to 6yrs of age. Thin pulpal floor and accessory canals (8) may explain the greater incidence of inter-radicular involvement following pulp death. Root form (9) ° molars have proportionately longer roots than their permanent counterparts. They are also more flared to straddle the devel- oping premolar tooth. The roots are flattened mesio-distally, as are canals within.  Anatomy of primary teeth (& relevance to cavity design) 77 Radicular pulpâ ‡ (0) follows a tortuous and branching path, making com- plete cleansing and preparation of the root canal system almost impossible, although instrumenting canals is often easier than suggested in some texts. In addition, as the roots resorb, a different approach to RCT is needed for the ° dentition, pure zinc oxide and eugenol being the obturation material of choice. Copyright © David A. 1 and Laura Mitchell, 2014 2 3 4 5 6 7 8 9 10 B L M D Fig. 3.3â ‡Cross-sections of second deciduous molar showing features of anatomy of primary molars. 78 Chapter 3 Paediatric dentistry Extraction versus restoration of primary teeth Despite a welcome reduction in the prevalence of dental decay, the dilemma of whether to restore or extract a ° tooth is still all too familiar. In making a decision a number of factors should be considered: Age This will influence the likely cooperation for restorative procedures, the expected remaining length of service of the affected tooth, and the severity of sequelae following early tooth loss (as the earlier the tooth is lost, the greater the potential for space loss). Medical history For patients where recurrent bacteraemia carries i risks (e.g. immunocompromised, risk of endocarditis) it is generally consid- ered that ° tooth pulp therapy should be avoided, with extraction (taking appropriate precautions where necessary) often being more appropri- ate. Conversely, in haemophiliacs, extractions should be avoided and ° teeth preserved, if possible, until their exfoliation. Prevention is particularly important in all such patients. Motivation and cooperation of parents As it is the parents that bring the child to the surgery, we must explain to them the benefits of main- taining the ° dentition. Unfortunately, a small proportion of the population may regard a dentist that fills ° teeth with suspicion—after all, everyone knows that baby teeth fall out! Extent of caries In a child with an otherwise caries-free mouth every attempt should be made to preserve an intact dentition. Where there is extensive caries, restoration of Es and loss of Ds can be an acceptable compromise. Pain If a child is suffering pain from one or more teeth, this needs to be alleviated as soon as possible. If symptom-free, then the dentist will have more time to explore the extent of the lesion(s) and the child’s cooperation. Extent of lesion(s) In ° molars destruction of the marginal ridge indi- cates a high probability of pulpal involvement.7 If several ° molars require pulp therapy, and cooperation/motivation is poor, serious thought should be given to extraction rather than restoration. Position of tooth Although early loss of ° incisors will have little effect, extraction of C, D, or E will, in a crowded patient, lead to localization of the crowding. Extraction of Es, particularly in the upper arch, should be deferred, if possible, until the 6 has erupted. 7 M. S. Duggal 2002 Eur J Paed Dent 3 2.  Extraction versus restoration of primary teeth 79 Presence/absence of permanent successor Bear in mind the amount of crowding present and the likelihood of spontaneous space closure. Malocclusion If still undecided, it is worth considering the occlusion. In a particularly crowded case, restoration of a decayed tooth may be indicated if further space loss would mean that extraction of more than one premolar per quadrant would be required. Much has been written about compen- sating (same tooth in opposing arch) and balancing (contralateral tooth) extractions, although this is still an area of some controversy.8 The rationale is that a symmetrical problem is easier to deal with later but if taken to its logical conclusion, gross caries of D| and ⎡E will result in a clearance! In general, loss of Cs in a crowded patient should be balanced to prevent a centre-line shift. Balancing Ds in a child with i risk of caries also has the advantage of removing very caries prone contacts (i.e. E–D and D–C). So much for the theory; in practice, it should be remembered that a happy and cooperative patient is more important long term. When treating a child under local analgesia leaving extractions unbalanced and monitor- ing for centreline shift may be preferable to prolonging intervention in the dental chair. 8 W. P. Rock & British Society of Paediatric Dentistry 2002 Int J Paed Dent 2 5. 80 Chapter 3 Paediatric dentistry Local analgesia for children Although there is no scientific evidence to suggest that ° teeth are less sensitive than 2° teeth, clinically it is sometimes possible to complete cavity preparation of minimal cavities without LA, especially on ° anterior teeth. However, Walls et al. found that restorations placed without LA did not survive as long as those where LA was used.9 Adequate management of approximal caries in ° molars usually requires LA. General principles Explain to patient in terms they will understand what you are trying to do and why. Use flavoured topical anaesthesia (e.g. 20% benzocaine). Warm anaesthetic solution to room temperature only. Use fine-gauge (e.g. 30-gauge) disposable needle. Always have dental nurse to assist. Hold mucosa taut. Verbal distraction can help at the moment of needle penetration. Use slow rate of injection. Warn about post-op numbness and avoidance of self-inflicted trauma (e.g. lip chewing/sucking). Choice of anaesthetic agent st choice Lidocaine 2% with :80 000 adrenaline. Maximum dose = 4.4mg/ kg. 2nd choice Prilocaine 3% with felypressin (0.03IU/mL)—may give slightly less profound anaesthesia. Maximum dose = 6.6mg/kg. In both lidocaine and articaine maximum dosage equates to (i) 2.2mL for a healthy 0kg .5yr-old child and (ii) 4.4mL for a healthy 20kg 5yr-old (i.e.  × 2.2mL cartridge per 0kg). This may need to be reduced for children with certain medical conditions. Articaine 4% with adrenaline may be used (maximum dose 7mg/kg) and there is some evidence that ° molar teeth can be more reliably anaesthe- tized by infiltration alone. However, articaine is not licensed for children yr old suckle frequently during the night, possibly due to the lactose in breast milk.2 Characteristically, starts with the maxillary ° incisors, but in more severe cases the first ° molars are also involved. The mandibular incisors are relatively protected by the tongue and saliva. Severe ECC may also be associated with the prolonged and frequent intake of sugar-based medications; however, both pharmaceutical compa- nies and doctors are more aware of the problem and the number of alter- native sugar-free preparations is increasing. See Table 3.6 for list. Rampant caries A term with no specific definition, but often used to describe extensive, rapidly progressing caries affecting many teeth in the primary &/or permanent dentition. Radiation caries Radiation for head and neck cancer may result in fibrosis of salivary glands and salivary flow. Patients often resort to suck- ing sweets to alleviate their dry mouth, which exacerbates the problem. Management of radiation caries requires specialist referral. 2 G. J. Roberts 982 J Dent 0 346.  Primary molar pulp therapy 91 Primary molar pulp therapy NB Primary molar roots resorb. Where the carious process has jeopardized pulpal sensibility there are two alternatives: (i) extraction; (ii) pulp therapy. Indication and contraindications See E Extraction versus restoration of primary teeth, p. 78. Any medical condition where a focus of infection is potentially dangerous is a contraindication to pulp therapy. Pulp therapy may be preferable to extraction in children with bleeding disorders. Tooth must be restorable following pulp therapy. Diagnosis of state of the pulp can be difficult, as not only is a child’s percep- tion of pain less precise than an adult’s, but the clinical picture may also be complicated by death of one root canal whilst the other(s) remain vital. Indicators of possible pulp involvement Breakdown of marginal ridge. Symptoms. Tenderness to percussion, i mobility, buccal swelling/sinus. Inter-radicular radiolucency seen radiographically (usually on bitewings). Definitions Indirect pulp treatment: treatment without exposure of the pulp. Direct pulp capping: management of exposure by direct capping—not usually advocated in primary molars due to poor outcomes. Pulpotomy: removal of coronal pulp and Rx of radicular pulp. Pulpectomy: removal of entire coronal and radicular pulp. 92 Chapter 3 Paediatric dentistry Pulp therapy techniques Indirect pulp treatment Indicated for asymptomatic, vital ° molars with no pulp exposure after removal of all soft caries. Technique Removal of all soft caries. Leaving carious, but firm, affected dentine in vital, asymptomatic ° molars has been shown to be reasonably success- ful. Margins of cavities should be rendered caries free to ensure an adequate coronal seal. Works best in occlusal cavities: less likely to be successful in approximal caries due to early pulpal involvement. Setting calcium hydroxide can be used in the deepest portion, with GIC, composite or SS crown (see E Stainless steel crowns, p. 86). If pulp exposure occurs, pulpotomy/pulpectomy are usually more appropriate restorative techniques. Pulpotomy (for the vital primary molar pulp) In ° molars the relatively larger pulps result in earlier pulpal involvement, therefore amputation of the coronal pulp leaving healthy radicular pulp in situ (pulpotomy) gives more consistent results than techniques that attempt to retain vitality of the whole pulp, e.g. indirect pulp capping. Materials The most commonly used medicaments are: Ferric sulfate—the technique currently recommended by most authorities.3 Formocreosol—still used by some, however, recent concerns about the toxicity and potential mutagenicity of formalin-containing compounds has led many authorities to advise against its use where suitable alternatives exist. Calcium hydroxide—time consuming to use and success not as good as ferric sulfate. MTA (mineral trioxide aggregate)—initial trials show promise. Ve