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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance (Dentistry)
- Sprache: Englisch
Prosthodontics at a Glance is a title in the popular At A Glance series and focuses on prosthodontics from diagnostics through treatment to post-operative maintenance. It is an ideal companion for all students of dentistry, clinicians and members of the dental team with an interest in prosthodontics.
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Seitenzahl: 270
Veröffentlichungsjahr: 2012
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Table of Contents
Cover
Titles in the dentistry At a Glance series
Title page
Copyright page
Dedication
Epigraph
Preface
Acknowledgements
Section 1: Overview of prosthodontics
1 Overview: rehabilitation of natural teeth
Indirect intracoronal prostheses
Indirect extracoronal prostheses
2 Overview: rehabilitation by artificial teeth
Removable full dentures (RFD)
Removable partial dentures (RPD)
Fixed partial dentures (FPD)
Dental implants
Section 2: Diagnostics
3 Diagnostics: history taking
Family medical history
Social history
Personal medical history
Medical complications
4 Diagnostics: initial consultation
Initial complaint
Dental history
Extra-oral examination
Intra-oral examination
Soft tissues
Dental charting
Periodontal charting
Occlusion
5 Diagnostic adjuncts 1
Illumination
Magnification
Oral precancer and cancer lesions
Vitality testing methods
Other diagnostic methods
6 Diagnostic adjuncts 2
Caries detection
Periodontal assessment
7 Radiography
X-ray tube
Radiation safety and precautions
Conventional dental radiography
Digital dental radiography
8 Computed tomography
Conventional CT
Cone beam CT
Clinical applications of CBCT
9 Dental photography
Principles of digital photography
Equipment
Camera settings
Dental photographic set-ups
10 Occlusal analysis
Occlusal data registration
Mechanical articulators
Virtual articulators
Occlusal analysis
11 Plaster casts and additive diagnostics
Dental casts
Diagnostic wax-ups
Uses of wax-ups
Digital study models and simulations
Section 3: Treatment planning
12 Treatment planning: evidence-based treatment
Scientific credence
Clinical erudition
Patients’ needs and wants
13 Treatment planning: decision-making
Review (monitor) caries
Shortened dental arch (SDA)
Reposition
Section 4: Occlusion
14 Occlusion: terminology and definitions
Curves of Spee, Wilson and Monson
Centric occlusion
Centric relation
Guidance
Interferences
15 Occlusion: clinical procedures
Centric occlusion
Centric relation
Visual and tactile inspection
Impressions
Occlusal records
Articulators
Facebow transfer
16 Occlusion: laboratory procedures
Pouring casts
Maxillary cast location
Mandibular cast location
Mandibular excursions
Adjusting contacts and OVD
Anterior diagnostic wax-up
Broadrick flag
Custom incisal guidance table
17 Occlusion: adjustment and splints
Occlusal adjustment
Occlusal stabilising splints
Bite raising appliance
The Dahl appliance
Section 5: Periodontal aspects
18 The dentogingival apparatus
Superficial anatomy
Dentogingival apparatus
Biologic width
BW variations
Methods for determining BW dimension
19 Prosthodontic considerations
Periodontal biotypes and bioforms
Contact points
Trauma from occlusion
Biologic width violation
Peri-implantitis
Periodontal plastic surgery
Regenerative therapy
Section 6: Endodontic aspects
20 The dental pulp
Aetiology
Pathogenesis
Clinical manifestations and diagnosis
Treatment modalities
Technological adjuncts
Endodontic controversies
21 Intraradicular support
Indication for posts
Guidelines for post placement
Ideal properties of a post
Choice of post
Canal preparation and post cementation
22 Coronal support: core build-up
Ideal properties of a core build-up material
Materials for core build-up
Core build-up for vital teeth
Core build-up for non-vital teeth
Section 7: Anterior dental aesthetics
23 Anterior dental aesthetics: basic principles
Facial perspective
Dentofacial perspective
Dental perspective
Gingival perspective
24 Anterior dental aesthetics: theories
Genesis of beauty
Geometric theories
Psychological theories
Perception theories
25 Anterior dental aesthetics: guidelines
General guidelines
Template
Patient input
Clinical feasibility
26 Anterior dental aesthetics: bleaching
Mechanism
Techniques
Precautions
Side-effects
Section 8: Intracoronal restorations
27 Choice of intracoronal restorations
Non-cavitated carious lesions
Cavitated carious lesions
Replacement restorations
28 Choice of materials for direct restorations
Palliative dressings
Silver mercury amalgam
Resin-based composites
Glass ionomers
Combination materials
Section 9: Extracoronal restorations
29 Choice of extracoronal restorations
Decision-making rationale
Decision making-guidelines
Survival rates
Section 10: Materials for indirect restorations
30 Cast metal alloys, titanium and resin-based composites
Strength of restorative materials
Cast metal alloys
Titanium
Resin-based composites
31 Ceramic materials
Overview
Classification
CAD/CAM blocks (ingots)
Section 11: Tooth preparation
32 Micro-invasive and minimally invasive techniques
Micro-invasive techniques
Microabrasion
Other methods
33 General guidelines for rotary tooth preparation
Instrumentation
Soft tissue integrity
Hard tissue integrity
34 Preparation for resin-bonded fixed partial dentures
Rochette and Maryland appliances
Fibre-reinforced composite
Tooth preparation
Prosthesis design
Cementation
35 Preparation for inlays and onlays
Definitions
Guidelines for inlay preparation
Guidelines for onlay preparation
CAD/CAM inlays and onlays
36 Preparation for porcelain laminate veneers
Rationale
Indications for porcelain laminate veneers
Preparation designs
Preparation guidelines
37 Preparation for full coverage crowns and fixed partial dentures
Margin location
Margin geometry
Preparation design
FPD considerations
Section 12: Temporary restorations
38 Provisionals
Function of provisionals
Choice of materials
Techniques for fabrication
Temporary cements
Section 13: Impressions
39 Impression materials
Dental compound
Zinc oxide eugenol paste
Irreversible hydrocolloids
Polyvinyl siloxane
Polyether
Digital impressions
40 Impression techniques and armamentarium
Tray selection
Tray adhesive
Material manipulation
Undercuts
Moisture control
Single and two stages
Recoil
41 Impressions: soft tissue management
Periodontal health
Chemical retraction
Physical retraction
Surgical retraction
Section 14: Dental laboratory
42 Computer-aided design and manufacture technology
Capture
Design
Fabrication
Pros and cons
Section 15: Cementation
43 Luting agents
Mechanism
Interfaces
Properties
Classification
44 Luting agents for definitive restorations
Resin-modified glass ionomers
Conventional resins
Adhesive resins
Choice of cements
45 Dentine bonding agents
Historical background
Bonding to tooth substrate
Dentine bonding mechanism
Contemporary DBAs
Efficacy
Clinical applications
46 Luting techniques
Clinical factors
Pre-treatment of intra-oral abutment
Pre-treatment of intaglio surface
Cementation procedure
Section 16: Removable prostheses
47 Removable prostheses
Indications
Edentulism
Removable full dentures (RFD)
Removable partial dentures (RPD)
Section 17: Dental implants
48 Osseointegration
Definitions
Processes
Clinical assessment
49 Implants: general considerations
Rationale and indications
Contraindications
50 Implants: treatment planning
Preoperative assessment
Prosthetically driven treatment planning
51 Augmentation and site preparation
Ridge defects
Principles of GTR and GBR
Bone grafting materials
Bone grafting techniques
Other methods
Soft tissue grafting
52 Implants: surgical techniques
Flap design
Flapless design
Two-stage – submerged
One-stage – non-submerged
Post-extraction placement
Immediate loading
53 Types and configuration of implants
Types of dental implants
Materials
Components
Geometry
Surface modifications
54 Implant abutments
Connections
Materials
Prefabricated abutments
Customised castable abutments
Customised CAD/CAM abutments
55 Restorative options
Transferring data
Fixed cement-retained
Fixed screw-retained
Implant-retained overdentures
Index
Titles in the dentistry At a Glance series
This edition first published 2012
© 2012 by Irfan Ahmad
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Library of Congress Cataloging-in-Publication Data
Ahmad, Irfan, BDS.
Prosthodontics at a glance / Irfan Ahmad.
p. ; cm. – (At a glance)
Includes bibliographical references and index.
ISBN 978-1-4051-7691-0 (pbk. : alk. paper)
I. Title. II. Series: At a glance series (Oxford, England).
[DNLM: 1. Prosthodontics–methods. 2. Oral Surgical Procedures, Preprosthetic. WU 500]
617.6'9–dc23
2012007472
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: courtesy of Irfan Ahmad
Cover design by Meaden Creative
For my caring wife, Samar, my shining children Zayan and Zaina, and my loving father Mansur Ahmad
What good’s a disease that won’t hurt you?
Lou Reed
Preface
In a Utopian context, a tooth should survive throughout life, unscathed by disease or trauma. However, in the real world, a tooth endures vicissitudes, often necessitating clinical intervention for ensuring its viability. Assuming a pessimistic stance, from nascence to its final demise, a tooth may undergo the following pathological sequelae: incipient fissure or proximal caries, intracoronal decay, pronounced multi-surface caries, endodontic involvement, extracoronal restoration, intra- and periradicular compromises with or without periodontal involvement leading to extraction, and eventual replacement by either a denture (removable or fixed) or dental implants. On an optimistic note, it is not a fait accompli that these events are inevitable; clinical intervention at any stage can prevent progression to the next, more destructive, eventuality. All these aforementioned stages require some form of clinical intervention for salvaging or replacing lost teeth. This is the basic premise of prosthodontics.
Prosthodontics is defined as restoring and/or replacing missing teeth. At times, the line dividing restorative dentistry and prosthodontics can be vague. As a generality, restorative dentistry is concerned with restoring teeth directly, involving a single visit, while prosthodontics is restoring or replacing teeth indirectly, invariably involving multiple visits, usually with impression and employing a dental laboratory. Furthermore, prosthodontics is a multidisciplinary subject, involving specialties such as periodontics, endodontics, orthodontics, implantology and oral surgery.
Besides resolving pathology, another factor requiring consideration is vanity. In an ever-increasing appearance-conscious society, elective cosmetic dental treatment is burgeoning. Although, at times, this type of treatment may be questionable, the communication revolution has created immense patient awareness leading to an escalating demand for patient-driven treatment planning. Hence, cosmetic or aesthetic treatment is now a major part of prosthodontics.
The purpose of this book is to describe the main concepts of prosthodontics. Its aim is to act as a platform for further reading on a chosen aspect of prosthodontics. The ordered format of the ‘At a Glance’ series accelerates learning, ensures relevance to daily clinical practice, and avoids the tedium and frustration of a verbose text.
Irfan Ahmad
Acknowledgements
There are innumerable friends and colleagues who have, directly or indirectly, helped with the fruition of this project, and at the outset my apologies if I do not mention each person by name. Instead, I offer ‘a big thank you’ to all those who have supported and inspired me during the four years it has taken to write this book.
However, the protagonists that come to mind are my family, relatives and close friends; Karl-Wilhelm Theis for his rock-solid unflagging moral support, Horst-Wolfgang and Christian Haase for creating an aura for global belonging, aesthetic dentistry icon Claude Rufenacht et Madame for showing me a world of art that I never knew existed, Nairn Wilson for pointing me in the right direction regarding topics in this book, Stephen Hancocks for his charismatic persona, Alan Sidi for his continuing help, Federico Ferraris, Angelo Putignano, Francesco Mangani, Antonio Cerutti, Carlo Zappala, Lauro Dusetti, Dinos and Mary Kontouras, Dimitrios Kapagiomnidis and Alex Grous for being wonderful company at conferences where we have lectured, Mauro Fradeani for his comprehensive teaching methods, direct composite artists Didier Dietschi, Roberto Spreafico and Newton Fahl, Serhiy and Vera Radlinsky for their entrepreneurial skills, Meshari Al-Otaibi for organising exceptional dental symposia, Petar Duchev, Yaroslav Zablotskyy and Joso Skara for creating unique teaching environments for their fellow dental colleagues, Nitzan Bichacho and Bernard Toutai for their everlasting guidance, my friends at the European Academy of Esthetic Dentistry, Ireneusz Czyzewski, Ivona and Wydawnictwo for their compassion, Harald Kubiak-Essmann and his team for supplying images of the latest advances in CAD/CAM technology, Ilan Gilboa, Ami Smidt, Yuval Eilat, Rafi Romano, Nitzan Fuhrer and Avishai Sadan for their continuing encouragement, Giulio Rasperini for his vivacious gregariousness, Ann-Louise Holding for her warm friendship, forward-looking clinician Egle Kunciuviene, Douglas Terry for his unrivalled enthusiasm, Rich Groves for his comradeship, critical thinking Graeme Beresford, Stephen Chu for his ongoing advancements in cutting-edge clinical research, living dental legend Denis Tarnow for being an exceptional role model, and Hina Robinson for ‘being there’.
Image acknowledgements:
Ami Smidt (Figs. 11.6, 32.7–32.9, 39.18, 39.20 and 39.21)
Ilan Gilboa (Figs. 26.4 to 26.6)
Giulio Rasperini (Figs. 52.10 to 52.12)
Alan Sidi (Figs. 19.3, 19.4, 19.11, 19.12, and 51.11)
Patrick Holmes (Figs. 19.9a to 19.10, 52.1 to 52.6, 55.11 to 55.13. 55.18 to 55.20 and 55.22)
Dorina van der Merwe (Figs. 10.2, 10.3, 39.1 to 39.3, 47.3 and 47.4)
I would like to extend a special and warm thanks to Manuela Brusoni for her friendship, kindness, and belief in my work. Ciao Manuela!
Finally, my gratitude goes to Sophia Joyce and her team at Wiley-Blackwell for their patience in enduring the lapsed deadlines for this book. Thanks for waiting!
Irfan Ahmad
1
Overview: Rehabilitation of Natural Teeth
An indirect restoration requires taking an impression and employing a dental laboratory to fabricate the prosthesis. Conversely, a direct restoration is carried out chair-side, usually in a single visit, without using a dental laboratory. Dental prostheses can either be intra- or extracoronal.
Indirect Intracoronal Prostheses
Intracoronal prostheses are defined as those surrounded by one or more natural tooth surface(s). This categorisation is broadly based on Black’s cavity classification:
Class I
: lesions of pits and fissures of all teeth, predominantly in premolars and molars;
Class II
: lesions on the proximal surfaces of posterior teeth, referred to as MO (mesial-occlusal), DO (disto-occlusal), and MOD (mesial-occlusal-distal);
Class III
: lesion in the anterior teeth, similar to a class II lesion, the class III lesion typically appears at the contact point;
Class IV
: the class IV lesion is a class III lesion including the incisal corner of an anterior tooth;
Class V
: typically occurs at the cervical margins on the buccal, rather than the lingual, aspect of any tooth;
Class VI
: not originally in Black’s classification, but has become accepted as an additional lesion that occurs on the tips and cusps of posterior teeth, or along the biting surfaces of the incisors.
Three developments have made Black’s cavity classification redundant. First, research has elucidated biological mechanisms such as demineralisation/remineralisation and the role of fluoride ion, and removal of infected and affected dentine is no longer a prerequisite. Second, new restorative materials such as resin (plastic)-based adhesives and filling materials, and therapeutic filling materials, which are both bacteriostatic and bactericidal, avoid removing vast amounts of tooth. Third, improved and sophisticated techniques such as adhesive protocols allow restorations of small lesions, preventing progression to larger cavities. All these advances preserve more of the natural tooth, and Black’s classification is therefore used today as a notation, rather than as a basis for restoring decay. Whereas, in the past, cavity design was geometric (dictated by the restorative material), it is now amorphous (dictated by the extent of disease).
Smaller lesions are restored by a direct approach, while larger Class II or Class IV are restored indirectly with inlays or onlays (extracoronal), when a direct approach is mechanically or aesthetically inferior. Inlays and onlays are fabricated in a dental laboratory using a variety of materials including composite resins, ceramics and cast gold alloys.
Indirect Extracoronal Prostheses
Extracoronal prostheses are defined as those surrounding one or more natural tooth surface(s). The indications for extracoronal restorations are:
Restoring structurally compromised teeth;
Improving function (e.g. altering occlusal vertical dimension – OVD);
Improving aesthetics (e.g. anterior maxillary and mandibular sextant);
Abutments for a fixed partial denture (FPD).
Extracoronal prostheses are categorised as:
Inlays and onlays
– the difference between an inlay and an onlay is the extent of tooth loss requiring replacement. Broadly speaking, an inlay ‘fits into’, while an onlay incorporates cuspal coverage and ‘fits onto’ the tooth;
Porcelain laminate veneers (PLV)
– the principal use of PLVs is improving anterior aesthetics by altering tooth morphology and colour. PLVs are the least invasive of extracoronal restorations, usually involving the buccal surfaces of anterior teeth. If the underlying tooth colour is acceptable, only minimal tooth reduction is necessary (0.3–0.8 mm) for improving shape and colour with a thin porcelain laminate fabricated in a dental laboratory. PLVs are the most prescribed type of restoration for purely cosmetic reasons. However, it should be remembered that preparing vital healthy teeth for PLVs with little aesthetic improvement is contentious, especially if similar results are achievable with less invasive protocols such as
bleaching
or composite resin fillings;
Partial coverage crowns
– partial coverage crowns are an extension of PLVs. They occupy a midpoint between full coverage and the minimally invasive PLV. Many configurations are possible, e.g.
1
/
2
,
3
/
4
,
7
/
8
, etc. The rationale for partial coverage is retaining as much natural tooth substrate as possible, and hence preserving pulpal and structural integrity;
Full coverage crowns and fixed partial dentures (FPD) or bridges
– a full coverage, 360° crown is indicated for severely broken-down teeth, abutments for FPDs, or rarely for elective aesthetic treatment. Various materials are used for fabricating crowns depending on the clinical scenario, e.g. cast metal, metal-ceramic, all-ceramic, composite and acrylic. For vital teeth, a crown can be supported either by coronal dentine or a core build-up. For endodontically treated teeth a post-and-core complex may be necessary. Intraradicular posts are available in many materials, designs, configurations and sizes. A core can be fabricated directly in the mouth using amalgam or composite, or indirectly in a dental laboratory using cast metals or ceramics. The sole purpose of a post-and-core complex is supporting the eventual extracoronal crown. Posts and cores do not reinforce or strengthen teeth, but weaken an already compromised root and the remaining coronal dentine. A
ferrule effect
is highly desirable for cores (with or without posts);
Combination prostheses
– depending on the extent of the clinical requirements, any intra- and extracoronal restoration can be combined into a single entity, e.g. inlay + onlay or PLV + inlay (veneerlay).
2
Overview: Rehabilitation by Artificial Teeth
Oral rehabilitation of missing teeth is achieved with removable or fixed prostheses. The distinction between the two is that removable prostheses are supported by both soft tissues and teeth and/or implants, whereas fixed prostheses are exclusively supported by teeth and/or implants. Before deciding to replace missing teeth, the shortened arch concept should be considered.
Removable Full Dentures (RFD)
Edentulous rehabilitation is either with full/full dentures, totally supported by the alveolar ridges, or with overdentures supported by strategically placed implants and/or retained natural tooth roots for additional stability.
Removable Partial Dentures (RPD)
An RPD relies on support from both soft tissues and adjacent or surrounding natural teeth or implants. These dentures can be fabricated entirely from acrylic resins, or in combination with cast metal frameworks. Clasp, rests and precision attachments are often incorporated into the denture design for additional retention and stability. A variation of RPDs are overdentures, retained by tooth roots or mini implants.
Fixed Partial Dentures (FPD)
Before dental implants, fixed partial dentures were the state-of-the-art prostheses for replacing missing teeth, but involve gross tooth preparation of supporting abutments. More conservative FPDs, with minimal or no preparation, include Maryland, Rochette or fibre-reinforced bridges. While the advantages of minimal preparation are obvious, these types of bridge are less retentive, requiring frequent recementing and are often used as transitional protheses, e.g. during the surgical healing phase following bone grafting or implant placement. Other uses include splinting periodontally compromised mobile teeth, or as an interim restoration while awaiting a more permanent restoration.
Conventional FPDs require preparation of abutment teeth for supporting the final prosthesis incorporating pontic(s) for replacing missing tooth or teeth. Numerous FPD configurations are possible, e.g. fixed-fixed, cantilever, telescopic, with or without precision attachments for stress relief for long spans. FPDs have a cast metal substructure, which is subsequently veneered with porcelain. Newer all-ceramic FPDs use dense ceramic frameworks, e.g. of zirconia or alumina, for supporting the veneering porcelain. Although conventional FPDs using natural teeth as abutments are destructive, they still have a place in prosthodontics where local anatomy contraindicates surgery or implant placement. Besides natural tooth abutments, implants can also act as abutments for FPDs.
Dental Implants
Dental implants are titanium root forms placed into alveolar bone. Following osseointegration, the implants are prosthetically restored with a variety of artificial prostheses including RFD, RPD and FPD. Implants are extremely versatile and used for replacing a single missing tooth, or as abutments for FPDs for replacing several missing units. In addition, implants offer many advantages compared to conventional prostheses including:
Improved stability
for implant supported RFDs and RPDs;
Preventing mechanical, periodontal and endodontic insult
of supporting teeth associated with RPDs (e.g. by clasps or occlusal rests);
Occlusal rehabilitation
of edentulous areas;
Greater bite force
compared to exclusively tissue-borne prostheses, improving masticatory performance and therefore allowing a wider choice of foods;
Avoiding tooth preparation of natural teeth
bounding missing spaces, e.g. for conventional FPDs, reducing possibilities of endodontic and periodontal complications;
Preventing further bone loss
(due to bone stimulation by the implants in edentulous areas);
Immunity from secondary caries
of natural tooth abutments used for conventional FPD.
Although implants offer numerous advantages compared to conventional treatment modalities, detailed planning, clinical training, experience and meticulous execution are mandatory for avoiding complications and failures. Before deciding whether the patient is a suitable candidate for dental implants, an initial MAP (medical, anatomy, prognosis) assessment is necessary:
Medical
considerations – age, race, gender, compromised immune system, diabetes, osteoporosis, bisphosphonate therapy, radiotherapy, psychological stress, pregnancy;
Anatomy
– soft tissue volume, dental biotype, bone quality and quantity, aesthetics (site: anterior or posterior regions of mouth), reduced vascularity from previous surgical traumas (e.g. apicectomies), proximity to vital structures (nerves, blood vessels, sinuses), occlusal clearance, parafunctional habits (e.g. bruxism);
Prognosis
– not only for an implant, but also for conventional treatment options depending on prevailing clinical situation such as:
A risk assessment is essential before deciding whether to pursue conventional treatment options, or consider implants at the outset. The cost implications of conventional vs implant treatment are also worth consideration. If the prognosis for conventional treatment is poor, it is futile spending time and money which could be better allocated for treatment that has greater long-term predictability.
3
Diagnostics: History Taking
History taking is the first stage before embarking on dental treatment. Recent medical advances have prolonged life expectancy, and age-related and chronic illness treated with long-term medication influences an individual’s medical status. Furthermore, the ever increasing elderly population retain more of their natural teeth, requiring regular dental maintenance. Collating a patient’s history is not confined to medical anamnesis, but also takes account of familial medical traits and social habits. All these factors can, and may, affect dental procedures.
Family Medical History
There is widespread consensus among physicians that many diseases have a genetic origin, and a sibling may harbour genes which may or may not manifest as an eventual ailment. Also, many diseases are multi-factorial, and even if a given gene for a specific disease is possessed, it is not a foregone conclusion that disease will follow. For example, having a gene for cardiac problems does not mean that a myocardial infarction is inevitable. If diet, smoking and lassitude are controlled, an individual with a cardiac family history may never suffer a heart attack. The same is applicable with a family history of chronic periodontitis.
However, knowing the family medical background helps risk assessment and tailoring treatment plans unique for each patient. For example, an individual with a family history of diabetes and periodontitis will require more frequent periodontal maintenance to prevent activation of the offending gene(s) leading to periodontal destruction.
Social History
Many patients are reticent to divulge social practices since they do not perceive that this will influence their dental care. A caring and sympathetic approach is necessary, combined with detailed explanations, to obtain this information. For example, smoking, drug addiction or alcohol abuse affect many dental procedures and their prognosis. Another increasingly prevalent dental ‘disease’ is tooth wear, which is non-infectious loss of tooth substrate (erosion, attrition and abrasion) due to lifestyle choices such as drinking effervescent acidic beverages or stress-related occlusal grinding.
Gauging the persona of a patient is more difficult and takes time, especially when treatment is protracted. A patient’s personality, expectations and wishes may be irrelevant for simple procedures or for alleviating pain, but are decisive for certain aesthetic or cosmetic treatment outcomes.
Personal Medical History
Medical history taking involves completing a questionnaire, a medico-legal document, which is regularly updated, reflecting the patient’s changing health status. Diligent questioning is necessary to establish all medical history and medication, especially if the patient does not realise the relevance of divulging this information for dental care. The choice of medical questionnaire lies between a form bespoke for a given practice, a proprietary form purchased from dental stationers, the Medical Risk Related History (MRRH) or the European Medical Risk Related History (EMRRH) form. The bespoke and proprietary are both non-standardised questionnaires and the risk assessment is piecemeal, depending on the prevailing medical conditions. The MRRH and EMRRH forms are an attempt to standardise risk assessment, using the American Society of Anesthesiologists (ASA) scale for rating the severity of medical complications for easier assessment of the state of the patient’s health.
Medical Complications
A significant proportion of the population have medical histories or medication that affects numerous dental procedures. Furthermore, some diseases can place the dental team at risk of contracting illness or exposure to pathogenic organisms. The most significant systemic diseases affecting dentistry are summarised below.
Cardiovascular diseases
include hypertension, ischaemic cardiovascular disease (angina), myocardial infarction, congestive cardiac insufficiency, valvopathy and cardiac arrhythmias (with or without a pacemaker). A practical knowledge of cardiopulmonary resuscitation
(CPR)
is essential.
Allergies
can either be constitutional, e.g. asthma, or drug induced. The most common
anaphylactic
reaction is due to penicillin, but can also be precipitated by many other drugs. The symptoms are usually apparent within 15 minutes of taking the offending drug. Other allergies that may complicate dental treatment are
latex gloves
,
local anaesthesia
or dental materials, especially alloys containing
nickel
.
Diabetes mellitus
is not only a debilitating systemic disease, but may also increase the severity of periodontal destruction and complicate surgical or implant procedures.
Type I
diabetes is insulin dependent, while
type II
diabetes is controlled by diet. Many patients are oblivious to their condition until symptoms appear, and if detailed questioning arouses suspicion, referral to a medical practitioner for further tests is advisable.
Infectious diseases,
e.g.
hepatitis A, B, C
,
HIV
and
tuberculosis
, do not contraindicate dental care, but stringent cross-infection control is mandatory.
Epileptic
convulsions are controllable by medication in the majority of cases, but the dental surgery environment may cause stress and trigger an epileptic attack.
Tendency to bleed
