Decision-Making in Operative Dentistry E-Book

Paul A. Brunton

• Herausgeber: Quintessence Publishing Co. Ltd.
• Kategorie: Fachliteratur
• Serie: QuintEssentials of Dental Practice
• Sprache: Englisch

Seitenzahl: 116

Veröffentlichungsjahr: 2002

Beschreibung

Operative Dentistry is a rapidly changing field of restorative dentistry. Advances in caries diagnosis and management strategies, pulp protection philosophies, tooth preparation techniques and dental materials have left practitioners somewhat unsure as to what is best practice. This book answers many of the questions frequently posed by practitioners, encourages a less interventive philosophy and is an easy-to-use resource for clinical decision-making.

Leseprobe

Quintessentials of Dental Practice – 3Operative Dentistry – 1

Decision-Making in Operative Dentistry

Author:

Paul A Brunton

Editors:

Nairn H F Wilson

Paul A Brunton

Quintessence Publishing Co. Ltd.

London, Berlin, Chicago, Copenhagen, Paris, Milan, Barcelona, Istanbul, São Paulo, Tokyo, New Dehli, Moscow, Prague, Warsaw

British Library Cataloguing in Publication Data

Brunton, Paul A. Decision-making in operative dentistry. - (The quintessentials of dental practice) 1. Dentistry, Operative - Decision making I. Title II. Wilson, Nairn H. F. 617.6'05

ISBN 1850973032

Copyright © 2002 Quintessence Publishing Co. Ltd., London

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.

ISBN 1-85097-303-2

Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Chapter 1 Clinical Diagnosis of Dental Caries. Is it Caries?

Aim

Outcome

Introduction

Diagnostic Tests

True positive

False positive

True negative

False negative

Sensitivity and Specificity

Visual Examination

Transillumination

Radiography

Lasers

Electrical Conduction Methods

Recommended Reading

Chapter 2 Caries Risk Assessment and Criteria for Intervention. When Should You Intervene?

Aim

Outcome

Introduction

When Should You Intervene?

Caries Risk Status

Determining Risk

Occlusal Caries

Sound fissure

Stained fissure

Stained and decalcified fissure

Cavitation

Proximal caries

Cervical caries

Recommended Reading

Chapter 3 Preservative Operative Intervention. How to Intervene?

Aim

Outcome

Tooth Preparation

Occlusal preparation

Proximal preparations in posterior teeth

Proximal preparations in anterior teeth

Cervical or smooth surface preparations

Managing Deep Caries

Direct pulp capping

Indirect pulp capping

Stepwise excavation

Sealing caries in

General Points

Material selection

Isolation

Caries removal

Internal preparation features

Occlusal considerations

Use of magnification

Newer Preparation Techniques

Micropreparation techniques

Chemomechanical methods of caries removal

Clinical procedures

Sonic preparation

Air abrasion

Lasers

Recommended Reading

Chapter 4 Material Considerations. Which Material Today Doctor?

Aim

Outcome

Introduction

Amalgam

Introduction

Advantages

Disadvantages

Indications

Contraindications

Resin Composite

Introduction

Curing strategies for resin composites

Advantages

Disadvantages

Indications

Contraindications

Flowable resin composites

Tips for using resin composites

Dentine-bonding agents

Wet bonding

Tips for using bonding agents

Compomers

Introduction

Advantages

Disadvantages

Indications

Contraindications

Resin-modified and Traditional Glass Ionomer Cements

Introduction

Advantages

Disadvantages

Indications

Contraindications

Ormocers

Giomers

General Points

Fluoride release

Antimicrobial release

Conclusions

Recommended Reading

Chapter 5 Pulp Protection Regimes. Sealers, Liners and Bases

Aim

Outcome

Introduction

Sealers

Liners

Bases

Bonded bases

Indications for Sealers, Liners and Bases

Amalgam restorations

Resin-composite restorations

Recommended Reading

Chapter 6 Minimising the Effects of Further Operative Intervention. Replace, Repair or Refurbish Failing Restorations?

Aim

Outcome

Introduction

Criteria for Repair and/or Refurbishment

Patient-centred Criteria

Tooth-specific Criteria

Secondary caries

Marginal defects

Bulk fracture

Fracture of adjacent tooth tissue

Marginal staining or restoration discolouration

Marginal excesses or overhangs

Wear

Clinical Procedures

Repair

Refurbishment

Recommended Reading

Chapter 7 Notes on the Aetiology and Operative Management of Non-carious Tooth Tissue Loss. Erosion, Attrition or Abrasion?

Aim

Outcome

Introduction

Abrasion

Attrition

Erosion

Clinical Consequences

Management of NCTTL

Prevention of Further NCTTL

Monitoring of NCTTL

Treatment of NCTTL

Desensitisation treatments

Simple restorations

Canine risers

Recommended Reading

Foreword

It is widely accepted that more that 60 per cent of a general dental practitioner’s time is spent practising operative dentistry, predominantly the replacement of restorations. Central to success in this major element of everyday practice is effective decision-making. Realising that goal is difficult given limitations in many of the existing diagnostic systems and techniques – and the lack of consensus in respect of criteria for certain forms of operative intervention. Moreover, the existing literature gives mixed messages – for example, in relation to the use of liners, bases and sealers.

In addressing questions frequently posed by practitioners, Decision-Making in Operative Dentistry – Volume 3 of the Quintessentials for General Practitioners Series – is highly relevant to the modern practice of dentistry. For practitioners not yet introduced to the concepts of minimal intervention, the repair and refurbishment of restorations, and conservative techniques for the management of tooth wear, this book will be a revelation. For colleagues familiar with such concepts, Decision-Making in Operative Dentistry will be an invaluable guide to the “when, where and how” of the modern patient-centred approach to the conservation of teeth. Written in the succinct, easy-to-read style that characterises the Quintessentials for General Dental Practitioners Series, this book will not fail to give the busy practitioner new knowledge and insight that can be immediately applied to the benefit of patients. For practitioners who think that operative dentistry has not really changed since they were a student, this book is indispensable reading.

Nairn Wilson Editor-in-Chief

Preface

This book does not seek to provide the reader with comprehensive coverage of the subject of operative dentistry. There are already several excellent textbooks available that have addressed the subject in depth, particularly from the undergraduate’s perspective.

This book is about the practice of contemporary operative dentistry in primary dental care. Its principal aim is to assist clinical decision-making in the dental surgery and provide answers to the questions practitioners frequently ask. As such, the approach to the subject is very different and somewhat novel.

Preservative operative dentistry is the philosophy on which this book is based. The continued use of amalgam, particularly for initial lesion management, does not sit well with this philosophy. Amalgam has, however, been included in this edition to ensure comprehensive coverage. I suspect that future editions will not cover or support the continued use of amalgam.

The classification of lesions of caries has changed in recent years. Accordingly, I have not used Black’s classification, preferring to classify lesions as occlusal, proximal and cervical. Similarly, the FDI system of tooth notation has been used. On a final note, this book considers the restoration of the adult dentition with direct restorative materials and techniques. Readers will be aware that operative dentistry includes the provision of single-unit indirect restorations, which is outside the remit of this publication.

On reading this book the reader will be able to:

diagnose caries more effectively, especially in its early stages

intervene appropriately and only when absolutely necessary

prepare teeth minimally and effectively

select the correct restorative material

understand modern pulp protection regimes

select restorations suitable for repair and refurbishment procedures

identify and treat non-carious tooth tissue loss.

Paul A Brunton

Acknowledgements

The author would like to thank Drs Andrew Bristow, Paul McCabe, Leean Morrow, David Simpkins, Chris Sweet, Ian Wood and Professor David Watts for reviewing the entire manuscript and providing valuable feedback.

The author is also indebted to the following individuals and publishers who have generously provided illustrations which have made the publication of this book possible. Figs 1-6–1-9: Dr Denise Cortes, Gama Filho University, Brazil; Figs 1-5 and 1-16: Dr Roger Ellwood; Figs 1-11 and 1-12: Dr Viv Rushton; Fig 1-15: KaVo (UK) Ltd.; Fig 4-5: Professor NairnWilson; Figs 4-6–4-13: reproduced with kind permission of Independent Dentistry; Figs 6-2–6-6, 6-9–6-12, 6-13–6-18: reproduced with kind permission of Quintessenz Verlag, Berlin; Figs 7-2–7-4: Ms Leean Morrow; and Figs 7-6, 7-8 and 7-9: reproduced with kind permission of FDI World Press Ltd.

Chapter 1

Clinical Diagnosis of Dental Caries. Is it Caries?

Aim

With changing patterns of disease experience the diagnosis of caries, particularly in its early stages, continues to be difficult for clinicians. The aim of this chapter is to improve understanding of modern methods of caries diagnosis.

Outcome

Practitioners will be familiar with modern methods of detecting dental caries and their relevance to contemporary dental practice.

Introduction

The pattern of dental caries has changed in recent years, with smooth surface lesions becoming less common and new lesions more likely to develop in pits and fissures. It is arguably easier to diagnose early caries on smooth surfaces (with the exception of proximal surfaces) than in pits and fissures, particularly when occult occlusal caries is present. In this condition the tooth can appear sound when examined visually but on radiographic examination there is extensive caries affecting the dentine (Fig 1-1).

Fig 1-1 Radiograph showing caries as follows: mesial 16, distal and mesial 15, distal 45, mesial and distal 46 and mesial 47.

Diagnostic Tests

With all diagnostic tests there is potential for operator error. For example, four outcomes are possible when a diagnostic test is applied to detect caries. These are as follows:

True positive

This occurs when caries is present and the test correctly identifies this. A good diagnostic test will have a high percentage of true positive outcomes.

False positive

A false positive result occurs when a diagnostic test incorrectly identifies caries when caries is not present.

True negative

This outcome is the opposite of a true positive result. It occurs when the test correctly identifies an individual as caries free and they are, in fact, free of the condition.

False negative

If a patient has caries and the test incorrectly deems them to be caries free then the outcome is defined as false negative.

These four possible outcomes of a diagnostic test are summarised in Fig 1-2.

Fig 1-2 Diagrammatic representation of diagnostic test outcomes.

Sensitivity and Specificity

The numbers of true positives and false negatives are related numerically; hence the proportion of true positive results for a diagnostic test (sensitivity) is 1 minus the false negative rate.

Specificity is the proportion of correctly identified true negative results and this is 1 minus the false positive rate. It is calculated as follows:

A good diagnostic test would have both high specificity and high sensitivity, which means the number of times the test is likely to give an incorrect result is low. In practice, as the level of either sensitivity or specificity rises, the other falls, so a balance must be struck.

The sensitivity and specificity of diagnostic tests commonly used to detect dental caries are shown in Table 1-1.

Table 1-1

The sensitivity and specificity of diagnostic tests commonly used to detect dental caries.

Test

Sensitivity

Specificity

Visual examination

0.38

0.99

Transillumination

0.67

0.97

Radiographs

0.59

0.96

Laser

0.76-0.87

0.72-0.87

Electrical conductance

0.80-0.97

0.56-0.89

Visual Examination

Visual examination of a tooth is the most widely used method of diagnosing dental caries. This method is, however, incredibly inaccurate. The use of a probe, blunt or otherwise, is contraindicated as it is a poor test of the presence of caries and likely to cause cavitation of an early demineralised lesion. Probes should therefore be used to remove soft depo-sits only during a clinical examination.

Whilst cavitation is quite easy to diagnose, looking for discolouration, which is suggestive of caries, is more difficult (Fig 1-3). The operator’s ability to see discolouration depends on the nature and direction of the illumination and whether magnification is used or not. Radiographs are useful aids in confirming a clinical suspicion of caries, especially proximal caries (Fig 1-4). When radiographs are used to confirm the presence of occlusal caries, however, superimposition of the cuspal pattern can be a problem, which makes their use for detecting early occlusal caries somewhat limited.

Fig 1-3 Frank occlusal caries with cavitation in 36.

Fig 1-4 Radiographs of a new patient, which emphasize the benefit of baseline bitewing radiography.

Transillumination

This technique uses an intense beam of white light to transilluminate the tooth (Fig 1-5). The tip of the light is placed on the buccal or lingual surface of the tooth and as caries has a lower index of transmitted light it shows as darkening of the tooth (Figs 1-6–1-7). This technique can be used to detect proximal caries in anterior teeth and selected posterior teeth and may be useful in the diagnosis of cracked tooth syndrome (Figs 1-8 –1-9).

The light units used for transillumination typically have an output of 2,000 lux generated from a 150 watt lamp with a tip diameter of 0.5 mm. The units are relatively inexpensive and, given the increasing number of fibre optic handpieces, it would be feasible to have a fibre optic tip attached to dental units. Special equipment is not required for the transillumination of anterior teeth. The beam of light from the operating light can be redirected with a hand mirror to transilluminate anterior teeth. The high sensitivity seen with this technique, arguably greater than when radiographs are used, offers practitioners a promising non-interventive technique for caries diagnosis.

Fig 1-5 Light for transillumination of teeth.

Fig 1-6 Transillumination of distal aspect of 35 showing distal caries.

Fig 1-7 Radiograph confirming presence of caries distally in 35.

Fig 1-8 Transillumination of 21 and 22 showing caries distally in 21 and mesially in 22.

Fig 1-9 Radiograph confirming presence of caries distally in 21 and mesially in 22 detected by transillumination.

Radiography

Radiographs are useful for the following:

To confirm a clinical suspicion of proximal caries.

To detect early non-cavitated proximal lesions, which are amenable to preventive care.

For serial monitoring of lesions to look for evidence of disease activity.

To provide an indication of the size and extent of the lesion, remembering that clinically the lesion will always be more extensive.

The aim when using radiographs is really to separate lesions, if present, into those which require restorative therapy as distinct from those which will respond to preventive regimes (Fig 1-10).

Fig 1-10 Radiograph showing lesions to be monitored in distal of 24 and mesial 25 and one which requires restorative therapy in distal of 35.

For the detection of caries, intraoral radiographs, specifically bitewing radiographs for posterior teeth and periapical radiographs for anterior teeth, are the only radiographs that should be used. Extraoral radiographs (for example, panoramic radiographs) have no place in the diagnosis of caries, as they can be misleading and wildly inaccurate (Figs 1-11–1-12).

Fig 1-11 Part of a DPT suggesting caries is present in mesial of 44.

Fig 1-12 Intra-oral radiograph, which confirms that 44 is sound.