DentalUpdate

March 2018 . Volume 45 . Number 3

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„
Restorative Dentistry: The Options for a Tooth that Requires Root Canal Treatment

„ Oral Health: The Dentist’s Role in Smoking Cessation Management – A Literature Review
and Recommendations: Part 1

„ Restorative Dentistry: Post-operative Sensitivity and Posterior Composite Resin

Restorations: A Review
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References: 1. Khan S et al. J Dent Res 96 (Spec Iss A): 2122, 2017. 2. Seong J et al. j Dent Res 96(Spec Iss A): 0215, 2017. 3. GSK Data on File 205072. July 2016. 4. GSK Data on File 207212. April 2017. 5. Parkinson C et al. Am
J Dent 2015;28(4): 190–196. 6. Baker S et al. Longitudinal validation of the Dentine Hypersensitivity Experience Questionnaire (DHEQ). Poster presented at: IADR/AADR/CADR General Session & Exhibition; 2013 March 20-23,
Seattle, Washington. 7. GSK Data on File. MMR Research, 2016. Survey of 204 Dentists and 200 Hygienists.

Trade marks are owned by or licensed to the GSK group of companies. CHGBI/CHSENO/0026/18.
 INSIDE THIS ISSUE

181 COMMENT 215 ORTHODONTICS S Gupta, AI Narayan, A Vijay and D Balakrishnan

An urgent message for the four UK Chief Dental
Officers
FJ Trevor Burke
182 RESTORATIVE DENTISTRY
The Options for a Tooth that Requires Root Canal
Treatment
S Eliyas, P Briggs and JE Gallagher
CPD Aims, Objectives and Learning Outcomes:
To understand options available for a tooth that
requires root canal treatment and the long-term
clinical implications of the decision made.
Enhanced CPD DO C
197 ORAL HEALTH
The Dentist’s Role in Smoking Cessation
Management – A Literature Review and
Recommendations: Part 1
RM Keat, J-C Fricain, S Catros, L Monteiro, LM da
Silva, MD Freitas et al
CPD Aims, Objectives and Learning Outcomes:
To offer gold-standard cessation advice to the
dental team.
Enhanced CPD DO C & DO A
207 RESTORATIVE DENTISTRY
Post-operative Sensitivity and Posterior
Composite Resin Restorations: A Review
J Sabbagh, JC Fahd and RJ McConnell
CPD Aims, Objectives and Learning Outcomes:
To identify the possible causes of post-operative
sensitivity and explore how it can be avoided
and treated.
Enhanced CPD DO C
An Alternative Approach to Replacement of an CPD Aims, Objectives and Learning Outcomes:
Avulsed Central Incisor To understand the integration of various biological
AA Lakhani and AMC Flett
elements in the field of implantology.
CPD Aims, Objectives and Learning Outcomes:
To describe a cost-effective and aesthetic Enhanced CPD DO C
orthodontic result following avulsion of a central
incisor.
255 BOOK REVIEW
Enhanced CPD DO C
227 PAEDIATRIC DENTISTRY/ ORAL MEDICINE 256 PERIODONTICS
Lichen Planus in Children The Impact of Medication on the Periodontium: A
M Agel, M Al-Chihabi, H Zaitoun, MH Thornhill and Review of the Literature
AM Hegarty
S Khalid, D Chatzistavrianou and F Blair
CPD Aims, Objectives and Learning Outcomes:
To understand the various clinical presentations, CPD Aims, Objectives and Learning Outcomes:
aetiology and modes of management of oral To provide an overview of the medications
lichen planus in the paediatric patient. affecting the periodontium and the management
Enhanced CPD DO C of drug-influenced gingival diseases.
Enhanced CPD DO C
236 PRACTICE MANAGEMENT
Understanding Our Patient Base: An Introduction
to Data Analytics in Dental Practice 266 UPDATES FROM AMERICA
R Pritchett, S Coleman, J Campbell and S Pabary Gloving and Hand Hygiene – Mutually Inclusive
CPD Aims, Objectives and Learning Outcomes: Activities
To describe simple techniques to use data from
practice management software and provide a CJ Palenik
step-by-step guide to basic statistical analysis
using Microsoft Excel.
271 TECHNIQUE TIPS
Enhanced CPD DO C & DO A Patient Information Leaflet
FJ Trevor Burke
247 IMPLANT DENTISTRY
Soft Tissue Profile around Dental Implants Placed
in the Aesthetic Zone – A Biological Update 274 CPD QUESTIONS

CPD in Dental Update in partnership with

Chris Deery Tara Renton

EDITORIAL DIRECTOR
Professor of Paediatric Dentistry, School of Clinical Professor of Oral Surgery, King's College London
FJ Trevor Burke
Dentistry, Sheffield S10 2TA Dental Institute
Professor of Dental Primary Care, University of
Birmingham School of Dentistry Ken Hemmings David Ricketts
Consultant Professor of Cariology and Conservative
EXECUTIVE EDITOR Eastman Dental Hospital, London WC1X 8LD Dentistry, Dundee Dental Hospital
Angela Stroud Edwina Kidd Jonathan Sandler
EDITORIAL BOARD Emerita Board Member Professor and Consultant Orthodontist,
c/o George Warman Publications Chesterfield and North Derbyshire Royal Hospital
Avijit Banerjee Unit 2, Riverview Business Park, Damien Walmsley
Professor of Cariology and Operative Dentistry Walnut Tree Close, Guildford GU1 4UX
Hon. Consultant Restorative Dentistry Professor of Restorative Dentistry, University of
Louis Mackenzie Birmingham School of Dentistry
Deputy Director of Education (Clinical Skills)
King’s College London Dental Institute GDP and Clinical Lecturer
University of Birmingham School of Dentistry
Steve Bonsor (c/o RCPSG) and King's College London
The Dental Practice Tif Qureshi
21 Rubislaw Terrace
Dental Elegance, 178 Blackfen Road
Aberdeen AB10 1XE
Sidcup, Kent DA15 8PT
Len D'Cruz Cover Picture: Time to upgrade your surgery?
(Courtesy of Alex Lee, Design Creative)
GDP, Woodford Dental Care,
Woodford Green, Essex

March 2018 DentalUpdate

 More effective
caries prevention
than a regular
fluoride toothpaste
Colgate® Duraphat® Toothpaste is clinically proven
to deliver a 76% reversal in root carious lesions1,†
Name of the medicinal product: Duraphat® 5000 ppm Fluoride Toothpaste. Active ingredient: Sodium Fluoride 1.1%w/w (5000 ppm F-). Indications: For the prevention of dental caries in adolescents and adults, particularly
amongst patients at risk from multiple caries (coronal and/or root caries). Dosage and administration: Brush carefully on a daily basis applying a 2cm ribbon onto the toothbrush for each brushing. 3 times daily, after each
meal. Contraindications: This medicinal product must not be used in cases of hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: An increased number of
potential fluoride sources may lead to fluorosis. Before using fluoride medicines such as Duraphat®, an assessment of overall fluoride intake (i.e. drinking water, fluoridated salt, other fluoride medicines - tablets, drops,
gum or toothpaste) should be done. Fluoride tablets, drops, chewing gum, gels or varnishes and fluoridated water or salt should be avoided during use of Duraphat® Toothpaste. When carrying out overall calculations
of the recommended fluoride ion intake, which is 0.05mg/kg per day from all sources, not exceeding 1mg per day, allowance must be made for possible ingestion of toothpaste (each tube of Duraphat® 500mg/100g
Toothpaste contains 255mg of fluoride ions). This product contains Sodium Benzoate. Sodium Benzoate is a mild irritant to the skin, eyes and mucous membrane. Undesirable effects: Gastrointestinal disorders:
Frequency not known (cannot be estimated from the available data): burning oral sensation. Immune system disorders: Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions. Legal classification: POM. Marketing
authorisation number: PL00049/0050. Marketing authorisation holder: Colgate-Palmolive (U.K.) Ltd. Guildford Business Park, Midleton Road, Guildford, Surrey, GU2 8JZ. Recommended retail price: £7.99 (51g tube). Date of
revision of text: February 2015.

References: 1. Baysan A et al. Reversal of Primary Root Caries Using Dentifrices Containing 5,000 and 1,100 ppm Fluoride. Caries Res 2001;35:41-46. † After 6 months use. *YouGov Omnibus for Colgate UK, June 2015. Claim applies
to the Colgate® brand.

www.colgateprofessional.co.uk www.colgatetalks.com

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March 2018
Comment
An urgent message for
the four UK Chief Dental
Trevor Burke
Officers
I have recently reminded readers that The Minamata Convention on Mercury is a global treaty,
signed by the UK and over 100 countries from all over the world in October 2013 with the intention of protecting human
health and the environment from the adverse effects of mercury. It contains clauses which limit the use of mercury from
all sources, with dentistry being the only area which ‘escaped’ with a ‘phase down’ in mercury use, as opposed to a total
ban. The Convention has now been ratified by 55 countries and signed by 128 countries, with the arrangements sealed
within the Convention being that the Convention would enter into force on 15th August 2017 in the ratifying countries,
that being 90 days after the fiftieth ratification was received. The implication of this being that, from 1st July 2018,
amalgam use will be banned in the UK for children under the age of 15 years and for pregnant or nursing women.
The need to find an amalgam ‘replacement’ is therefore now extremely urgent but, for the CDOs, this material has to fulfil,
not only a list of ideal requirements, but also that any replacement material should not cost more than amalgam to place,
given that we are all aware that the NHS in the UK is strapped for cash. Therein lies the problem: it has been known since
the early days of composite restorations in posterior teeth that such restorations take longer to place than amalgam.1
And, given that dentists’ time is the most expensive part of any restoration, where is the money going to come from?
I am sure that this may be a reason for the collective silence from the Departments of Health and I do not blame the
CDOs for this. We are in chastened times financially. However, some help may be at hand. Resin composite materials
have excellent physical properties (when compared with the ‘gold standard’ amalgam2). While it would be superb if a
material which possessed all the ideal ‘amalgam substitute’ properties was available (and in this I include self-adhesion
to tooth substance), this dream material is not yet with us. In this regard, early bulk fill materials (such as Dentsply’s SDR®)
required the placement of a layer of conventional composite to cap their surface because their wear resistance was not
good enough, but there are now materials which do not appear to need a capping (such as Filtek™ One [3M] and Tetric
Ceram Bulk Fill (Ivoclar). Also, not needing to place a capping layer also seems to reduce stress in a restored MOD cavity.3
In addition, glass ionomer materials have been with us for many years, and reinforced versions are now available, such as
Ketac™ Universal (3M) and Equia® Forte (GC). However, while they may perform adequately in smaller/occlusal cavities,
they may not yet be indicated for larger cavities in posterior teeth.4
Given the terms of the Minamata agreement, and the now very tight timescale, additional training may urgently be
needed for some dentists, since not all will have been trained in how to avoid the problems of shrinkage stress and
achieving a tight contact with posterior composite restorations. The stated aim, by two authorities in the field, is that
all dental students, by no later than 2020, ‘should have the knowledge skills, competencies and confidence to restore
damaged and diseased posterior teeth effectively with state-of-the-art resin composite systems’.5 Perhaps this statement
should be applied to all dentists in clinical practice?
So, we now have resin-based materials which may be cured to 4 mm or 5 mm and may therefore be faster to place than
conventional resin composite materials: perhaps, therefore, bulk fills are our alternative in the short to medium term?
And, apart from the mercury argument, the ‘black or white’ debate ignores the benefits of using an adhesive material −
less invasive cavities which save tooth structure.
The urgent message to Drs Hurley, Bridgman, Taylor and Reid therefore is: I know that you have a difficult decision to
make because the alternatives to amalgam are more costly to place (notwithstanding UDAs in England and Wales), but
our NHS dental workforce awaits your advice on what to do in July for under 15s. Why not bite the bullet and take this
opportunity to introduce bulk fill restorative materials into the NHS armamentarium for this age group and collect data
on the survival of such restorations, as has been done in Denmark for a similar age group.6 That would then provide a
potential evidence base for the adoption of resin-based dentistry across all age groups.
References
1. Burke FJT. Attitudes to posterior composite filling materials: a survey of 80 patients. Dent Update 1989; 16: 114−120.
2. Combe EC, Burke FJT, Douglas WH. Clinical Dental Materials. Dordrecht, The Netherlands: Kluwer Academic Publishers,
1999.
3. Tomaszewska IM, Kearns JO, Ilie N, Fleming GJP. Bulk fill restoratives: to cap or not to cap − that is the question?
J Dent 2015; 43: 309−314.
4. Burke FJT. Dental materials: what goes where? The current status of glass ionomer as a material for loadbearing
restorations in posterior teeth. Dent Update 2013; 40: 840−844.
5. Wilson NHF, Lynch CD. The teaching of posterior resin composites: planning for the future based upon 26 years of
research. J Dent 2014; 42: 503−516.
6. Pallesen U, van Dijken JWV, Halken J, Hallonsten A-L, Hoigaard R. Longevity of posterior resin composites in permanent
teeth in Public Dental Health Service. A prospective 8 years follow up. J Dent 2013; 41: 297−306.
DentalUpdate 181
 RestorativeDentistry
Shiyana Eliyas
Peter Briggs and Jennifer E Gallagher
The Options for a Tooth that
Requires Root Canal Treatment
Abstract: There have been many advances in the replacement of teeth, especially using dental implants. There are a number of other
options for when a tooth is lost; however, there is also value in maintaining a tooth with the provision of root canal treatment and a good
coronal seal. This article summarizes the advantages and disadvantages of each option with supporting evidence from the literature.
CPD/Clinical Relevance: This review article provides an updated practical perspective to decision-making when it comes to teeth
requiring root canal treatment.
Dent Update 2018; 45: 182–195
In this age of increasing emphasis on body
image and youthful appearance, the perfect
white smile is fast becoming a norm by which
people are judged.1-3 This may influence the
retention of natural teeth, however, there is
a possibility that the natural tooth is being
replaced when complex restorative dental
treatment is required, possibly in order to
achieve the ideal appearance more easily.
When the public and some of the profession
consider implants a panacea, what are the
Shiyana Eliyas, BDS, MFDS, MRD,
FDS(Rest Dent), PhD, Consultant in
Restorative Dentistry, Department
of Maxillofacial Surgery, St George’s
University Hospitals NHS Foundation
Trust, Blackshaw Road, London SW17
0QT, Peter Briggs, BDS, MSc, MRD, FDS
(Rest Dent), Interim Postgraduate Dental
Dean, London; Health Education England,
Stewart House, 32 Russell Square, London
WC1B 5DN and Jennifer E Gallagher,
PhD, MSC, BDS, DCDP, FDS, DDPH, FHEA,
King’s College London Dental Institute
at Guy’s, King’s College and St Thomas’
Hospitals, Division of Population and
Patient Health, Denmark Hill Campus,
Bessemer Road, London SE5 9RS, UK.
182 DentalUpdate
options for a tooth that requires root canal
treatment? Is there a place for providing
dentistry to retain a natural tooth?
The effect of tooth loss on a
person’s quality of life has been investigated
in several studies,4-9 with a general consensus
that tooth loss had a negative impact on
quality of life, and patients citing reduction in
chewing ability following the loss of teeth as
a cause. However, the prospect of tooth loss
is less dramatic in recent times because of
the variety of options available for filling the
space or spaces. With the reported success
rates of implants, there is a possible departure
towards replacing teeth with implants if
complex restorative work is required to
maintain the tooth in situ. A number of articles
have described the virtues of maintaining a
natural tooth in relation to accepting a space
or providing a prosthetic replacement.10-16
This article summarizes the
available evidence for root canal treatment
and maintenance of teeth, and potential
options for restoring a space when a tooth is
lost. The virtues of maintaining teeth where
possible, even with complex restorative
treatment, especially root canal treatment, is
discussed. The options for spaces resulting
from tooth loss include accepting the space,
removable and fixed prosthodontics (both
tooth- and implant-supported), and range
Enhanced CPD DO C
from the least invasive (root canal treatment
and maintenance of a tooth) to potentially the
most invasive (extraction and replacement
with conventional fixed prosthodontics or
implants). This article should inform decision-
making discussion with patients, especially
with regard to maintenance/failure of teeth
and restorations in the long term.
Root canal treatment and
maintenance of the natural tooth
Root canal treatment and
maintenance of the natural tooth has high
success rates17-19 and high survival rates.14,
20-26
The natural tooth will maintain alveolar
bone and soft tissue contours,27-29 enabling
future restoration of the space using dental
implants. The main advantage of root canal
treatment was reported as the ability to
manage non-healing, resulting in tooth
retention with fewer interventions than with
implant-supported prostheses.30 Root canal
treatment can avoid extractions in medically
compromised patients, such as those who
have undergone radiotherapy to the head
and neck, those taking bisphosphonates, or
who have blood dyscrasias where special
precautions or avoiding extraction may be
favoured.31
However, root canal treatment
March 2018
 RestorativeDentistry

Study Country Years data No of teeth Survival rates treatment. The absence of further treatment
and type collected included of the tooth alone was deemed success. When
of service success was assessed in the UK, outcome of
evaluated root canal treatment performed in the Royal
Air Force had a significantly higher success
Lazarski et al, USA 1993−1998 109,542 94.4% at 3.5 years rate of 85%, using radiographic and clinical
200120 Private signs to define success and failure, with the
practice of review period grouped into <3 years and >3
generalists & years since root treatment.37
specialists A retrospective cohort study of
Salehrabi USA 1995−2002 1,462,936 97% at 8 years patients (n = 174) treated in NHS general
& Rotstein Private practice (n = 12) in the UK, on the survival of
2004,21 practice of mandibular first permanent molars that were
generalists & root canal-treated within the state-funded
endodontists National Health Service, also assessed the
quality of the root fillings by the radiographic
Chen et al Taiwan 1998 1,557,547 91.1%−95.4% at 5 years appearance of the root filling.24 Root canal
2007,22 Private treatments were assessed radiographically
practice by an endodontist and deemed ‘optimal’
Lumley et al, UK (NHS) 1991−2001 30,843 74% at 10 years or ‘sub-optimal’ (in accordance with the
200823 General Consensus report of the European Society
dental of Endodontology on quality guidelines for
practice root canal treatment38), or the radiograph
was classed as missing/unreadable. Training,
Tickle et al, UK (NHS) 1998−2003 174 90.8% at 5 years calibration and reliability of this examiner was
200824 General not reported. Healing as seen radiographically
dental was not assessed. Failure was defined as
practice extraction, replacement of the root filling or
Ng et al, Mix of (Meta-analysis 86% (95%CI, 75%−98%) periradicular surgery performed on the tooth.
201025 countries of 14 studies) at 2−3 years The review period varied up to 7.7 years with
and settings 93% (95%CI, 92%−94%) <10% failure rate. Similar failure rates were
(Review at 4−5 years seen in ‘optimally filled’, ‘sub-optimally filled’
− pooled 87% (95%CI,82%−92%) and ‘unreadable/missing radiographs’ groups.
success) at 8−10 years The majority of the failures were within the
Table 1. Survival rates in for root canal treated teeth. first year following treatment. Root canal
treated teeth restored with crowns had a
lower risk of failure than those restored with
intra-coronal restorations. It was assumed
is a lengthy and complex procedure, which present only the retention or survival of the that these ‘successful’ teeth were free of
is only possible when there is enough tooth following root canal treatment.20-25,36 signs and symptoms of infection and that is
remaining tooth structure for restoration These studies do not address the quality of why they were not extracted, re-treated or
after root canal treatment.32 A minimum treatment or the clinical signs and symptoms, surgically treated. This paper was considered
number of radiographs are required33 and but only assess the presence or absence of controversial as it implied an acceptance of
can take more than one appointment to further treatment or extraction of the tooth as ‘sub-optimal’ root fillings, as survival rates
complete, depending on complexity. The cost the end point. They do not give any indication were still high as long as prompt definitive
implications to the dentist, such as time and of the clinical or radiographic status of the restoration of the tooth is carried out.39-40
the cost of single use root canal instruments,34 tooth (Table 1). Recent detailed and
are often reflected in the fee presented to the The reported survival of root canal comprehensive systematic reviews by Ng
patient. The cost to the patient also includes treated teeth include 8-year survival of 97% in et al17-18,41 attempted to collate the various
the purchasing of a definitive restoration for the United States,21 5-year retention rates of outcome findings. Ng et al examined the
the tooth after root canal treatment. Long- 91.1%−95.4% in Taiwan,22 and 3.5-year survival effects of study characteristics on probability
term review is usually a minimal intervention, of 94.44% in the United States.20 In the UK, of success of primary root canal treatment.41
unless symptoms arise and patient-related there have been similar studies, with 10-year They used the presence or absence of clinical
outcomes are similar with root canal treated survival rates of 74% in NHS General Dental signs and symptoms as well as ‘strict’ (absence
teeth and implant-supported single crowns.35 Practice.23 These studies have not examined of apical radiolucency at recall) and ‘loose’
Insurance companies and the quality of treatment provided, or the state (reduction in size of apical radiolucency at
dental public health bodies are inclined to of the treated tooth in the mouth following recall) criteria for radiographic interpretation
March 2018 DentalUpdate 183
 RestorativeDentistry
in describing success. Clinically, root canal
treated teeth should be compared with what
is described to be normal, ie the lack of pain,
swelling, sinus tracts, tenderness to palpation
and percussion, tenderness in function and
mobility.11,42
Root canal treatment is described
as ‘primary root canal treatment’ if it is the
first time root canal treatment is provided for
a tooth. If the root canal treatment is redone
or revised, it is termed ‘secondary root canal
treatment’. Ng et al investigated the influence
of clinical factors on the probability of success
of primary root canal treatment.17 The review
set out to examine the influence of numerous
patient and operator factors. Four conditions
were found to improve the outcome of
primary root canal treatment significantly:
pre-operative absence of periapical
radiolucency, root filling with no voids, root
fillings extending to two millimetres from the
radiographic apex and remaining within the
root canal system, and satisfactory coronal
seal. In this meta-analysis,17 which used both
‘strict’ and ‘loose’ criteria, estimated pooled
success rates of primary root canal treatment
was 74.7% (95% CI, 69.8%−79.5%) under ‘strict’
criteria and 85.2% (95%CI, 82.2%−88.3%)
under ‘loose’ criteria, during a review period
of six months to 30 years. The idea that, since
technology and materials have improved over
time, the success rates should also improve,
was explored, but no supportive evidence was
seen. It is thought that this lack of increase in
success rate is as a result of ‘more adventurous
case selection fuelled by confidence in better
skills and outcomes’.41
Ng et al also carried out a
similar systematic review on the outcome
of secondary root canal treatment with a
pooled weighted success rate based on ‘strict’
criteria of 76.7% (95% CI, 73.6%−89.6%)
and that based on ‘loose’ criteria of 77.2%
(95% CI, 61.1%−88.1%).18 The conditions for
success were similar to those for primary
root canal treatment. The success rates from
studies carried out in the 2000s were the
lowest whether ‘strict’ or ‘loose’ criteria were
used. Treatment carried out by specialists
surprisingly had the lowest estimates of
success regardless of the use of ‘strict’ or
‘loose’ criteria, which is thought to be as a
result of specialists possibly managing more
complex cases. The qualifications of the
operator had no significant influence on the
outcome of secondary root canal treatment.
The weighted pooled success rate for teeth
184 DentalUpdate
Success rate of primary root canal
treatment, ie root canal treatment
done for the first time in a tooth (Ng
et al, 2008a)17
Using ‘strict’ 74.7%
criteria (95% CI, 69.8%−79.5%)
Using ‘loose’ 85.2%
criteria (95% CI, 82.2%−88.3%)
Table 2. Summary results from two systematic reviews.
without periapical lesions pre-operatively was
28% higher than for those with pre-operative
periapical lesions. The systematic reviews
on outcomes of primary and secondary root
canal treatment17-18 both suggest that the size
of pre-operative periapical lesions are not
relevant as long as enough time is given for
healing. The weighted pooled success rate
for teeth without pre-operative perforation
was 32% higher than that for teeth with pre-
operative perforation. Root fillings extended
beyond the apex had the lowest success rate
regardless of the presence or absence of a
periapical lesion. Due to lack of adequate
data,17-18 a meta-analysis relating to many
related aspects of root canal treatment was
not performed. These aspects included
the effect of canal obturation, the use of
rubber dam, apical instrumentation, size of
apical preparation, canal taper, separation
of instrument during root canal treatment,
medicament used, root-filling techniques and
materials, quality of root-filling and number
of treatment visits on the outcome of root
canal treatment. The summary of success rates
from the two systematic reviews is shown in
Table 2.
Cheung and Chan43 investigated
the survival of primary root canal treatment
carried out by undergraduates and
postgraduates in a dental hospital in Hong
Kong using a retrospective longitudinal
design. They found a 50% success rate at 9.2
years, with the survival of root-filled teeth
being significantly influenced by the tooth
type (maxillary and mandibular molar teeth
faired worse than anterior and premolar
teeth), pre-operative periapical status (better
if there was no evidence of periradicular
pathology prior to treatment) and the type
of coronal restoration (teeth with crowns
Success rate of secondary root
canal treatment, ie revision
root canal treatment (Ng et al,
2008b)18
76.7%
(95% CI, 73.6%−89.6%)
77.2%
(95% CI, 61.1%−88.1%)
survived significantly longer than those with
intra-coronal plastic restorations only.43,44
Ng et al carried out a systematic
review on tooth survival following non-
surgical root canal treatment.25 Although
14 studies were included (10 retrospective
and 4 prospective), a direct comparison was
hindered by the heterogeneity of the studies.
The pooled percentage of reported tooth
survival over 2−3 years was 86% (95% CI,
75%−98%), over 4−5 years was 93% (95%
CI, 92%−94%) and over 8−10 years was 87%
(95% CI, 82%−92%). In descending order of
influence, the factors seen to be effecting
survival were: a crown restoration after root
canal treatment, the tooth having both the
mesial and distal proximal contacts, tooth not
functioning as an abutment for removable
or fixed prostheses and tooth type (non-
molar teeth). Similar findings have been
supported by other publications.36,45-46 The
most recent publications from Ng et al relate
to the findings from a prospective study of
the factors affecting outcomes of non-surgical
root canal treatment19,26 (Table 3).
In terms of root canal outcome
in primary care versus secondary in the
UK, the success rate of primary root canal
treatment in one secondary care unit in the
UK was 83% (95% CI, 81%−85%) and that for
secondary root canal treatment was 80% (95%
CI, 78%−82%).19 The 4-year cumulative tooth
survival rates for primary root canal treatment
was 95.4%(95% CI, 93.6%−96.8%) and that for
secondary root canal treatment was 95.3%
(95% CI, 93.6%−96.5%).26 For comparison, no
outcome data are available for the success of
root canal treatments performed in primary
dental care in the UK. The survival of root
canal treated teeth has been estimated at
90.8% at five years24 and 74% at 10 years.23
March 2018
in NEW Ultrasoft Pro – ink and denim resistant, antimicrobial, soft-to-touch (33 colours)
 RestorativeDentistry
Study Conditions found to improve periapical healing
1. The pre-operative absence of periapical lesion
2. Presence of periapical lesion, the smaller its size
Success rate of primary 3. The absence of a pre-operative sinus tract
root canal treatment 83% 4. Achievement of patency at the canal terminus
(95% CI, 81%−85%) 5. Extension of canal cleaning as close as possible to its
(Ng et al, 2011a)19 apical terminus
6. The use of EDTA solution as a penultimate wash followed
by a final rinse of NaOCl in secondary root treatment
cases
7. Abstaining from using 2%CHX as an adjunct irrigant to
Success rate of secondary NaOCl solution
root canal treatment 80% 8. Absence of tooth/root perforation
(95% CI, 78%−82%) 9. Absence of inter-appointment flare-up (pain/swelling)
(Ng et al., 2011b)26 10. Absence of root-filling extrusion
11. Presence of satisfactory coronal restoration
Table 3. Summary of factors affecting outcome of non-surgical root canal treatment.
Since the introduction of UDAs in April procedure is performed’.41
2006,47 it is no longer possible to calculate The assumption is that a well-
the numbers of root canal treatments carried condensed and well-extended root-filling,
out in the NHS as this banding system groups as seen radiographically, may mean a job
together types of treatment rather than well done by a conscientious clinician, with
recording individual items of treatment. appropriate isolation, access and irrigation.
Root canal treatment carried out However, it is not appropriate always to make
by postgraduate students and specialists this assumption. Published data suggest
had the highest weighted pooled success that a large percentage of general dental
rate irrespective of strict or loose criteria practitioners use endodontic techniques
being used to measure success.41 It has been with no evidence of clinical effectiveness. The
said that educational background of the survival rate of root-filled teeth if rubber dam
operator may have an impact on dentists’ is used during treatment has been shown
decision-making or case selection.48-49 Other to be statistically significantly higher than if
studies have suggested that the background rubber dam was not used,53 and yet rubber
or experience of the operator can have dam was used by between 0.9% and 47% of
an influence on the technical outcome dentists surveyed using questionnaires.54-66
of endodontic procedures.50-51 A clinical Electronic Apex Locators were being used
study by Alley et al showed endodontic by between 2.7% and 70% of dentists
treatments by specialists were significantly surveyed.56-57,60-63,67-69 Reported rates of sodium
more successful than those carried out by hypochlorite use for irrigation is between 33%
GDPs.52 The difference in outcome between and 95% of responding dentists.54-55,57-59,60-63,70-71
generalists and root canal specialists is less A longitudinal study by Dugas
clear in some studies. For example, of 29,895 et al reported on the Quality of Life (QoL)
non-surgical root canal treatments performed and satisfaction outcomes of root canal
by non-endodontists, 1,390 (4.65%) required treatment on two Canadian populations aged
subsequent retreatment or periradicular 25−40 years in two different dental schools.72
surgery. In comparison, of 14,718 non- Seventeen questions chosen from Oral Health
surgical endodontic treatments carried out Impact Profile (OHIP) 49 were used with a five-
by endodontists, 597 (4.06%) cases required point Likert scale. The subjects acted as their
subsequent retreatment or periradicular own controls by reporting how the disease
surgery.20 Ng et al highlight the lack of tools or pre- and post- root canal treatment affected
methodology to objectively quantify operator the quality of life. In this study population,
skills, the need to balance between technical almost all of the subjects reported pain prior
skill and ‘understanding of the problem and to root canal treatment, but less than 50%
the motivation and integrity with which the reported a form of functional limitation.
186 DentalUpdate
Subjects who had experienced ‘painful aching’
prior to root canal treatment reported the
highest rate of improvement and those
who had difficulty with ‘pronouncing words’
reported the lowest rate of improvement.
The logistic regression model for ‘predicting
improvement in the ability to perform
usual jobs’ in this study predicted that the
subjects are five times more likely to perceive
improvement if the subjects had a high school
education.
Improvement in ‘physical pain’
and ‘social disability’ were significantly
higher if treated by an endodontist than a
generalist. The logistic regression model for
‘predicting improvement in the ability to
perform 'usual jobs’ in this study predicted
that the subjects are seven times as likely
to perceive improvement in the ability to
perform 'usual jobs' when the treatment was
provided by an endodontist than a generalist.
The logistic regression model for ‘predicting
improvement in temperature sensitivity’
showed that patients were 2.7 times more
likely to perceive an improvement if the
treatment was completed by an endodontist.72
Hamasha and Hatiwsh73 used the same
questionnaire used by Dugas et al72 and found
no significant differences in the improvement
of oral health between patients treated by
undergraduates, postgraduates and specialists
in some domains and improvements in favour
of specialists in other domains. For example,
satisfaction was higher when treated by a
specialist in relation to ‘time involved, intra-
operative pain, pleasantness and general
satisfaction’ when compared to treatment
by undergraduate students. However, there
was least satisfaction with the treatment cost
when compared to treatment by postgraduate
or undergraduate students.73
As long as there is sufficient
tooth structure to restore the tooth, it is
possible to revise the root canal treatment if
there is a flare up years later, as it is accepted
that no material provides a perfect seal for
indefinite periods of time. The long-term
maintenance of the tooth will be no different
to maintenance of the rest of the dentition,
with emphasis on prevention of caries and
periodontal disease. Subjects who had an
anterior tooth root canal treated rather than
extracted reported the peak satisfaction of
100%.72 Gatten et al35 compared QoL relating
to patients with endodontically-treated teeth
with implant treatment. Both cohorts reported
similar QoL and satisfaction; however,
March 2018

patients recommended preserving the natural
dentition wherever possible.35 Where it is not
possible to restore a tooth, extraction and
one of the following options may be more
appropriate.
Accepting a space
The simplest option is to accept
the space left by the extraction of a tooth,
as no further treatment is required. This is
somewhat reversible, as the options for filling
the space are still potentially available. When
posterior teeth are lost, function has been
said to be adequate as long as there are four
opposing posterior units (one molar tooth
being equivalent to two premolar units) and
this has been termed a shortened dental
arch.74 Although dated, this is considered
a seminal study, which assessed the oral
function of 118 patients attending a dental
school in Nijmegen (Netherlands), grouped
into six classes according to the degree and
distribution of contacting posterior units.
Twenty four percent of subjects possessed a
complete dentition and 82% of patients were
functioning with a shortened dental arch
for more than 5 years. The largest number of
subjects was in the fully dentate group, with
an even distribution in the other five groups.
Oral function was measured using a ‘chewing
test’, where light-absorbing materials were
released from raw carrots during chewing.
The number of chewing strokes and patient
complaints with oral function were recorded.
A shortened dental arch was not shown to
lead to craniomandibular dysfunction or oral
discomfort.75-77 However, with decreasing
number of occluding units, the chewing
strokes needed for swallowing increased.74,78
The drifting of adjacent teeth
and overeruption of opposing teeth leading
to loss of inter-occlusal or restorative space
is a possibility, although the movement is
largely clinically insignificant in periodontally
healthy adult patients, and long-term stability
is possible.79-85 Some studies have found that
the movement of unopposed teeth was more
than 2 mm in only 24% of subjects81 and more
than 3 mm in only 6% of subjects.82 Occlusal
collapse was not seen in those with shortened
dental arches.83 While not randomized
controlled trials, these studies compare
groups with shortened dental arches with
control groups to measure clinically important
parameters.
Accepting a space may not
March 2018
be preferred to saving a tooth of strategic
importance.86 Additionally, the loss of a tooth
may lead to further alveolar bone loss.87-88
In the upper jaw, a shortened dental arch
was viewed negatively due to aesthetics,
therefore accepting a space is unlikely to be
possible in the anterior zone.74,89 The long-
term maintenance of a space may be the
easiest option from a dental point of view,
however, the psychological impact of having
a space in the mouth has been recognized
for quite some time, with some reports of
patients likening the distress of a space left by
a missing tooth being as severe as the distress
to one’s wellbeing when having ‘trouble
with relatives’.90 If maintaining a space is
unacceptable, there are options for removable
prostheses (dentures) and fixed prostheses
(bridges or implants).
Removable partial dentures
The partial denture is, in most
cases, the next least destructive alternative
to accepting a space. The advantages
of partial dentures include restoring of
appearance, mastication and function, and
the disadvantages include potential damage
to hard and soft tissues.91-92 This, however,
may not be ideal in patients with periodontal
disease or recurrent carious lesions as poor
oral hygiene and plaque trapping around the
removable prosthesis may lead to adverse
consequences for the remaining dentition.93-94
Removable prostheses are a largely reversible
method of restoring spaces, although there
is potential for damage to abutment teeth if
excellent oral health is not adhered to. Long-
term review and maintenance is needed for
prevention of further dental disease of the
remaining dentition, with replacement of the
prosthesis with changing anatomy as required.
With the ageing population, dentures have
the advantage of being removed and no
longer used, should abutment teeth start
to deteriorate or if it becomes difficult to
maintain optimal oral hygiene.
Denture construction is time
consuming and may take four to six visits
to deliver with associated laboratory costs.
Long-term maintenance is likely to include
caries prevention and maintenance of
periodontal stability, as well as replacement of
the prosthesis. Patients may encounter social
issues with wearing a removable appliance,
and fail to internalize (psychologically accept)
a removable appliance, therefore choosing
RestorativeDentistry
not to wear removable appliances, especially if
only posterior teeth are missing.95-99 It should
be noted that, while healing after extraction
occurs, there is possible need for temporary
wear of an immediate denture, even if the
definitive restoration is likely to be a bridge or
implant-retained prosthesis.
No significant differences have
been found in patient-related outcomes
with provision of a removable denture and
acceptance of a shortened dental arch in a
pilot multi-centre, randomized controlled trial
in 14 dental schools in Germany including
only 34 patients.100
Conventional and adhesive fixed
partial dentures
Full preparation and adhesive
fixed prostheses include cantilevered and
fixed-fixed designs of bridges using natural
teeth as abutments to restore spaces, with full
or minimal preparation of abutment teeth.
Bridges are well tolerated by patients.101-104
These studies utilized self-completed patient
questionnaires prior to and after providing
prostheses of conventional and resin-retained
designs, mainly in dental hospital settings.
Sample sizes varied between 33 and 192
patients. These were usually cross-sectional
studies and not randomized controlled
trials. Some used an OHIP questionnaire101-102
and some used other non-validated
questionnaires.103-104
For conventional bridgework,
there is a requirement for tooth preparation,
potential for de-cementation of restorations,
and the need for replacement of
restorations.105 Results of a cross-sectional
study of 77 teeth, that were vital before bridge
placement, showed the long-term damage
to abutment teeth has been approximated at
30% losing vitality at 10 years and 35% at 15
years after placement of various fixed-fixed
conventional bridge designs between 1981
and 1989 in a dental school in Hong Kong,
reviewed at 187 +/- 23 months.106 It was not
clear who carried out the clinical examination,
but the radiographic examination was carried
out by two pre-calibrated independent
examiners with inter-examiner Kappa scores
of 0.79. The study was not ideal as there was
reliance on accurate record-keeping prior to
treatment. Some patients who failed to attend
a review were questioned by telephone
rather than clinically examined, with the
limitations of assessing pulp vitality clinically
DentalUpdate 187
 RestorativeDentistry
and radiographically while restored with
bridges. However, there are no better studies,
especially from the UK.
A minimum of two appointments
is needed for construction of the definitive
prosthesis, with an interim temporary
restoration. Again, laboratory costs with long-
term maintenance and replacement costs
need consideration. A meta-analysis of data
from a systematic review of the literature
(19 studies of prospective and retrospective
designs, with clinical examination at least at
5-year follow-up) revealed that conventional
fixed-fixed bridges have a 10-year probability
of survival of 89% and 10-year probability
of success of 71%.107 A meta-analysis of a
systematic review of cantilevered bridges
(13 studies with a minimum follow-up time
of 5 years and with clinical examination at
follow-up) had a reported survival of 82% and
success rate of 63% at 10 years, with the most
common cause of complications being loss of
pulp vitality of the abutment tooth.108 In these
studies, various bridge designs have been
combined, however, details of each study
were available within the systematic reviews.
For adhesive bridgework, in
which the tooth preparation is minimal
or not needed,109-110 there is potential for
de-cementation. The reported median survival
for cantilever designs is 9.8 years, for fixed-
fixed designs is 7.8 years.109 In no-preparation
cantilever designs the abutment tooth is left
unharmed even if the bridge fails. Djemal et
al, in a cross-sectional study, assessed 832
restorations in 593 patients in a postgraduate
dental institute setting.109 The technique,
operator, materials and bridge designs were
not controlled for. Where patients did not
attend follow-up, the patient or general
dental practitioner caring for the patient was
contacted to ascertain if the restoration was
still in service. The restorations were assessed
by three of the authors with no mention of
calibration, training or inter/intra- examiner
reliability. A third of restorations were
placed in patients with hypodontia (missing
teeth), who usually also have small potential
abutment teeth. Despite the heterogeneity of
the sample, details for each design of bridge
can be extracted from the publication. Other
studies have reported a 65% survival at 10
years, where all designs of resin-retained
bridges were pooled in a systematic review of
retrospective and prospective cohort studies
with a minimal follow-up time of 5 years.111
Seventeen studies reporting 16 different
188 DentalUpdate
cohorts were included for meta-analysis,
the oldest of which was carried out in 1991.
The studies were heterogeneous, with a
variety of bridge designs, operators, settings
(mostly universities or specialist clinics) and
materials being included. Many studies were
excluded due to not meeting the minimum
requirement of 5-year follow-up. The most
recent publication still reports on patients
treated between 1994 and 2001, where
the outcome of 771 resin-retained bridges
performed at a dental school were reported
to have 80% survival rate at 10 years.110 Bridge
design and materials were standardized,
operators were various and the follow-up
examinations were carried out by one of the
authors without mention of training or intra-
examiner reliability.
Patient perceptions of resin-
retained bridgework are limited, with
published studies comparing patients
who have undergone restoration of spaces
with those who have not yet completed
treatment.112
Implant-supported prostheses
The alternative fixed option is
implant-supported prostheses to restore
spaces. There is a need for a surgical phase,
with possible grafting procedures if there is a
lack of bone or appropriate soft tissue,113 with
good survival rates reported in a systematic
review of the literature involving 39 studies
including three randomized controlled
trials.114 Complication rates and failure of
implant have been reported as higher in
smokers and those prone to periodontal
disease, without professional maintenance,115
as well as those suffering from diabetes,
those having undergone radiation therapy
to the head and neck and postmenopausal
oestrogen therapy.116 There may be difficulty
with achieving ideal aesthetics in the anterior
region, and there may be potential risk of
damage to other structures (roots of adjacent
teeth, antrum and inferior dental, lingual and
mental nerves), such that implant therapy may
not always be possible.117 There is a need for
long-term maintenance of implant-supported
prostheses, as biological and technical
complications may occur.105,115,118-22 Some
studies have reported similar failure rates for
both root canal treated teeth and implant-
retained prosthesis, however, intervention
is required more often for implant-related
prosthesis to achieve survival when compared
to root canal treated teeth.13,30,123
The reported survival rate at 10
years for implant-supported fixed partial
dentures is 87%; that for implant-supported
single crowns in 98%.124 The economic costs
are higher than that of root canal treatment
and removable prostheses; however
comparable or lower than that for tooth-
supported conventional prostheses in the
long term.14 Therefore, it may be prudent to
consider the retention of natural teeth for as
long as possible, to ensure that the lifetime
of restorations to replace missing teeth start
later, reducing the number of times these
restorations need to be serviced or replaced in
a patient’s lifetime.
It is also noteworthy that
specialists often provide implants and general
dental practitioners most often provide root
canal treatment.125 Survival rates of implants
provided by inexperienced practitioners have
been reported as 20% lower when compared
to that provided by implant specialists.126-8 In
comparison, root canal treatment provided by
specialists has a higher success rate than that
provided by generalists (98.1% and 89.7%,
respectively) at five years after treatment.129
Studies have reported no
significant difference in the survival
rates of root-filled teeth and of implant-
supported single crowns.13,30,123,130-1 Therefore,
conventional root canal treatment or
retreatment is the clinical procedure of choice
whenever a tooth is restorable but suffers
endodontic pathology. Morris et al stated
that the difficulty in making this comparison
between implants and natural teeth is that
implants are measured often in terms of
survival (implant is still present despite
associated problems), whereas root-filled
teeth are measured in terms of success (the
tooth is present with signs of clinical and
radiographic healing).131
Patient perception of quality of
life improves with dental implant provision.35
The quality of life of patients treated with
implant-retained dentures (measured by
OHIP) have shown satisfaction with their
prostheses.112,132-133 Other studies assessed
quality of life before and one month after
restoration of implants and reported some
improvements in aesthetic and functional
aspects when anterior teeth were replaced
using dental implants.134 Research in primary
dental care within the UK also supports the
view that quality of life is improved with
dental implants, as measured by OHIP 49 in
March 2018
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 RestorativeDentistry
Years of Implant-supported single crown
follow-up
Success Survival
2−4 years 99% 96%
4−6 years 98% 97%
6+ years 95% 97%
Table 4. Weighted success and survival rates of a systematic review comparing implant-supported single crowns, tooth borne fixed-partial dentures (bridges)
and root-filled teeth
107 patients.135
Discussion
There are no randomized
controlled studies comparing the outcomes of
accepting a space, conventional and implant-
based removable and fixed partial dentures
and the outcome of root canal treatment. A
systematic review revealed weighted success
and survival rates of implant-supported
single crowns; fixed-partial dentures (bridges)
and root-filled teeth, as shown in Table 4.14
Although, carried out in accordance with
guidance for systematic reviews, the included
studies were not randomized controlled
trials, were heterogeneous, and limited
to publications in English. This was still a
thorough summary of the available literature.
The success rates of root-filled teeth are
comparable to the success of fixed-partial
dentures at more than 6 years follow-up, and
the survival of root-filled teeth is comparable
to that of implant-supported single crowns at
more than 6 years follow-up.14
Whether success or survival rates
are taken into consideration, it is clear that
it is worth providing endodontic treatment,
as success and survival rates are comparable
to extraction and replacement of the space
with a denture, bridge or implant. These
alternatives have other disadvantages and
a more significant maintenance cost than
with endodontic treatment, as summarized
in Figure 1. Maintenance of the tooth has
been shown to be the most cost-effective
first line treatment option, following the
failure of which, replacement with a single
implant-retained restoration is the most cost-
effective.136
A systematic review of the
literature explored patient perceived benefit
(oral health-related quality of life and patient
satisfaction) of reconstructive dentistry.137
190 DentalUpdate
Fixed-partial dentures (tooth-borne
bridges)
Success Survival
78% 94%
76% 93%
80% 82%
Although the available evidence was of
variable quality, there were general trends
showing patient perceived benefit when
complete dentures and implant-retained
overdentures were provided, with more
significant improvements with implant-
retained prostheses. Studies included
revealed general satisfaction with resin-
bonded bridgework. There was little reported
difference in quality of life when patients
with shortened dental arches were compared
to those with removable partial dentures.
Concluding remarks suggested the lack
of suitable evidence to assess changes in
quality of life in relation to restorative dental
procedures, with the exception of edentulous
mandibles treated with conventional and
implant-retained prostheses.137
Where complex fixed partial
dentures are provided, requiring significant
manual dexterity to be able to maintain
good oral hygiene, it must be borne in mind
that the potential difficulties of maintaining
oral health in an ageing population, where
deteriorating motor skills, visual impairment
and osteoarthritis may hinder manual
cleaning of the oral cavity and dementia,
may prevent patients adhering to changing
oral healthcare regimens.138-40 Access to
care for these patients may change and
motivation to maintain oral health may
deteriorate.141-2 Carers may not always be
able to provide the level of oral care required,
even when the method is demonstrated to
them. Patients may not be able to tolerate
lengthy dental treatment with increasing
age and accumulation of medical ailments.
Being rendered edentulous later in life may
mean reduced ability to adapt to or tolerate
dentures. Often, dental failures occur in
older people due to caries, therefore having
complex fixed restorations maintained by
natural teeth can lead to fast deterioration
Root-filled teeth
Success Survival
89% 94%
94% 94%
84% 97%
when dietary changes occur and oral hygiene
becomes less than optimal.143 Extractions
may be contra-indicated due to previous
or current medical treatment or disease.
Implant treatment in older people is at risk of
failure due to peri-implant disease resulting
from deterioration of oral hygiene.144 These
complications related to implants may be
more difficult and costly to resolve than those
associated with tooth-borne restorations. It
may be most appropriate to maintain the
natural dentition for as long as possible to
reduce long-term, maintenance-related
complications and costs.14 Patients should be
involved in informed decision-making that
affects their future dentition and maintenance.
Conclusion
When outcomes of alternatives to
maintaining a natural tooth are considered,
including the biological, financial, and
psychological concerns of patients, it is better
to spend available resources to maintain a
natural tooth for as long as possible, in order
to ensure that the commencement of the
lifetime of the alternative to maintaining a
space is delayed.
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March 2018

Tooth-retained: aesthetics and function maintained
May require intervention/revision in future
Root canal Will maintain space and bone for future implant treatment
treatment Options left open for replacing tooth if lost in the future
Maintenance burden no different to other natural teeth
Accept space Minimal maintenance burden
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education/sgh/Documents/Access%20to%20
dental%20care%20for%20frail%20elderly%20
people%20V2.pdf Accessed 13 May 2017.
140. Jablonski RY, Barber MW. Restorative dentistry for the
older patient cohort. Br Dent J 2015; 218: 337−342.
141. Borreani E, Jones K, Scambler S, Gallagher E. Informing
the debate on oral health care for older people; a
qualitative study of older people’s views on oral health
and oral health care. Gerodontology 2010; 27: 11−18.
142. Niesten D, Van Mourik K, Van Der Sanden W. The impact
of having natural teeth on the QoL of frail dentulous
older people. A qualitative study. BMC Public Health 2012;
12: 839.
143. De Marchi RJ, dos Santos CM, Martins AB, Hugo
FN, Hilgert JB, Padilha DM. Four-year incidence and
predictors of coronal caries in south Brazilian elderly.
Community Dent Oral Epidemiol 2015; 43: 452−460.
144. Dudley J. Implants for the ageing population. Aust Dent J
2015; 60(Suppl 1): 28−43.
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DentalUpdate 195
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 Enhanced CPD DO C & DO A OralHealth

Ross M Keat
Jean-Christophe Fricain, Sylvain Catros, Luis Monteiro, Luis Martins da Silva, Marcio Diniz Freitas, Angel Brandariz, Giovanni Lodi, Alberto Pispero,
Saman Warnakulasuriya, Zahid Khan and Rui Albuquerque

The Dentist’s Role in Smoking

Cessation Management −
A Literature Review and
Recommendations: Part 1
Abstract: In Europe, 29% of individuals identify as smokers, with tobacco use directly related to 650,000 mortalities each year across the continent;
roughly 14% of all deaths. From a dental perspective, smoking is directly implicated in numerous chronic, and potentially life-threatening,
sequelae which exclusively affect the oral cavity. By familiarizing the dental team with gold-standard cessation advice, it can be ensured that
smokers are assisted at every available opportunity. Dentists should aim to give cessation advice to smokers based on how willing they are to
change their smoking habit. The authors are developing an online resource to assist with smoking cessation advice. It is available at http://www.
smokingcessationtraining.com/
CPD/Clinical Relevance: Dentists will see many smokers regularly, and advice should be given routinely to this cohort of patients. By improving
understanding of potential oral sequelae and identifying individuals who may wish to quit, targeted advice can be offered to increase cessation
success. Brief patient-centred advice ensures the highest chance of delivering successful smoking cessation, alongside safeguarding time for the
dentist to examine and treat the individual.
Dent Update 2018; 45: 197–206

Ross M Keat, BDS, MFDS, PgCert, Birmingham
Dental Hospital/School of Dentistry, Jean-
Christophe Fricain, DDS, PhD, Université de
Bordeaux, Sylvain Catros, DDS, PhD, Université
de Bordeaux, 33000 Bordeaux Cedex, France, Luis
Monteiro, DDS, PhD, Instituto Universitário de
Ciências da Saúde (IUCS), Luis Martins da Silva,
DDS, PhD, Instituto Universitário de Ciências da
Saúde (IUCS), 4585-116 Gandra PRD, Portugal,
Marcio Diniz Freitas, DDS, PhD, School of
Medicine and Dentistry, University of Santiago
de Compostela, Angel Brandariz, DDS, PhD,
School of Medicine and Dentistry, University of
Santiago de Compostela, Spain, Giovanni Lodi,
DDS, PhD, Dipartimento di Scienze Biomediche
Chirurgiche e Odontoiatriche, Alberto Pispero,
DDS, Dipartimento di Scienze Biomediche
Chirurgiche e Odontoiatriche, Milan 20142, Italy,
Saman Warnakulasuriya, OBE, BDS, PhD, FDS
RCS, DSc, King’s College London Dental Institute,
Department of Oral Medicine and Pathology,
London SE5 9RW, Zahid Khan, BDS, MFDS, PgCert,
Birmingham Dental Hospital/School of Dentistry
and Rui Albuquerque, DDS, PhD, Birmingham
Dental Hospital/School of Dentistry, University of
Birmingham, 5 Pebble Mill Road, Birmingham B5
7EG, UK.
March 2018
Dentists find themselves in a privileged
position. They can access a part of the body
actively affected by smoking, even when the
individual is healthy. They should therefore
be proactive in delivering smoking cessation
advice to prevent the deterioration of
oral and indeed general health in these
individuals.
This article presents a review
of current strategies regarding the need
for, and provision of, adequate smoking
cessation advice by the dental profession
and is split into two parts. This part focuses
on the oral implications of smoking,
alongside the role of the dentist in eliciting
a change toward cessation. This means that
there must be a basic understanding of
how to implement brief cessation advice.
The dentist can then impart knowledge
appropriately to the smoker of potential
oral sequelae. For example, a smoker
noticing that his/her teeth are becoming
loose may be a crucial motivating factor in
encouraging cessation.
Part 2 focuses on the 'stages
of change' approach to encourage
smoking cessation, continuing a ‘patient-
centred’ approach. Knowledge of the
'stages of change' model ensures that the
dentist offers advice that is appropriate
based on the patient’s willingness to
quit, safeguarding the dentist-patient
relationship. It is important that the dentist
understands nicotine replacement therapies
(NRT), pharmacotherapy and electronic
cigarettes to answer any questions which
may be fielded by the patient. We have
therefore provided simple, yet thorough and
appropriate, information within the second
article.
Background
For over 200 years, there has
been an ever-increasing body of evidence
regarding the risks of tobacco use.1 Links
DentalUpdate 197
 OralHealth
between clay pipe smoking and malignancy
of the lip and mouth were made as early
as 1795 by Sömmering,2 with later studies
linking smoking with lung cancer and
vascular disease.3 Smoking was initially an
accepted ‘social norm’ in society, viewed
simply as a glamorous habit, with little
attention paid to tobacco’s addictive
nature. The concept of physical, and more
so psychological, addiction in relation to
cigarette smoking is a relatively new one
and it is only comparatively recently that
the role of nicotine in sustaining smoking
behaviour has become widely accepted.4
Smoking is the largest cause of
preventable disease and an important cause
of premature death worldwide.5 Almost
90% of lung cancer diagnoses and 25−30%
of all cancer-related deaths are in smokers.6
Eighty percent of chronic obstructive
pulmonary disease diagnoses are made in
individuals who have a history of smoking.7
Further damning indictments are made by
the US Surgeon General in the report ‘The
Health Consequences of Smoking − 50 Years
of Progress.’8 In this report, it is claimed
that ‘cigarettes are a defective product −
unreasonably dangerous, killing half its
long-term users and addictive by design.’
It is now understood that
cigarette smoking is a manifestation of
nicotine dependence in both physical and
psychological forms.9 Nicotine addicts will
engage in smoking to relieve boredom
and as a habitual act, manifestations of
the psychological addiction, alongside
regulating the draw and inhalation that they
take of a cigarette, titrating their nicotine
dose to their perceived physical need.10
What risks of smoking should
dentists be aware of?
Oral cancer
There is a great deal of evidence
citing smoking as the main causative agent
in oral cancer.11 Indeed, smokers have a
three times greater chance of developing
oral cancer, as shown by a meta-analysis of
254 publications reporting a relative risk
3.43 for oral cancer among current tobacco
smokers compared with non-smokers.11
Conditions commonly defined
as cancer of the oral cavity comprise
those classified in the ‘International
Classification of Diseases’ (IDC) as cancers
198 DentalUpdate
of the lip, tongue, mouth and oropharynx
(ICD10 codes: C00-08). The most common
sites affected by cancer are the tongue,
gingivae, floor of mouth and lip.12 It has
been identified that smokers often drink
higher quantities of alcohol and the synergy
of alcohol and smoking in causing oral
and pharyngeal cancer should not be
overlooked. Whilst alcohol consumption
has been linked with oral and pharyngeal
cancer, it is the synergistic effect of alcohol Figure 1. Oral squamous cell carcinoma in the
with smoking that significantly increases the floor of the mouth in a 53-year-old male smoker
of 20 cigarettes/day.
risks of such neoplasms.13
In Europe, oral cancer accounts
for 0.7% of all deaths from cancer. It is the
15th most common cancer, with 61,400
diagnoses and 23,600 deaths across Europe
in 2012.14 Of these diagnoses and deaths
42,600 and 17,600, respectively, were
reported in male patients.14 There was a 11%
increase in 5-year survival following an oral
cancer diagnosis from 2003 to 2013 when
compared to 1993 to 2003. In the 2003–
2013 group, patients typically presented at Figure 2. Oral leukoplakia in the floor of the
an older age, with more advanced disease mouth in a 45-year-old-male smoker of 30 ciga-
and more distant metastases. The reasons rettes/day, reported as having ‘mildly dysplastic’
for increased survival therefore remain histopathological changes.
unclear, though likely involves improvement
in surgical and medical therapies.15
Four years after stopping
smoking, the risk of oral cancer is 35% leukoplakia is shown in Figure 2.
lower than for a ‘current smoker.’ It can take Erythroplakia is defined as ‘A
another 15 years for this to reach the level fiery red patch that cannot be characterized
of someone who has never smoked.16 In clinically or pathologically as any other
addition a meta-analysis, based on nine definable disease.’18 These present as
studies, reported a non-significant risk carcinoma in 51% of cases, severe dysplasia
among former smokers when compared or CIS in 40% of cases, and mild to moderate
with non-smokers.11 dysplasia in 9% of cases. When a single
An example of a squamous cell lesion contains both red and white patches,
carcinoma in the floor of mouth can be seen it is referred to as ‘erythroleukoplakia’.18
in Figure 1. These typically show the highest rates of
more severe dysplasia on biopsy.
Assessing the presence of
Erythroplakia/Leukoplakia
dysplasia and providing smoking cessation
Both erythroplakia and advice is therefore extremely important
leukoplakia can present with atypical in individuals presenting with these
histopathological changes and are more conditions.19
commonly seen in smokers than non-
smokers. Microscopical changes observed
are described as ‘dysplasia.’ Oral mucosal conditions
Leukoplakia is defined as a ‘white Nicotinic stomatitis
plaque of questionable risk having excluded This typically presents as a
known diseases or disorders that carry no greyish-white appearance of the palate,
increased risk of cancer.’17 They are benign with a reddened, nodular appearance of
in 80%, dysplastic in 12%, carcinoma in situ inflamed minor salivary ducts throughout.
(CIS) in 3%, and invasive carcinomas in 5% The condition resolves following
of cases. An example of a mildly dysplastic smoking cessation and has no long-term
March 2018

Figure 3. Nicotinic stomatitis in a 52-year-old
male smoker of 20 cigarettes/day.
consequences. An example of nicotinic
stomatitis can be seen in Figure 3.
Smoker’s melanosis
Twenty-two percent of
smokers develop tobacco-associated oral
melanin deposits, with severity being
dose dependent.20 It affects women more
commonly than men.20 The condition can
(but doesn’t always) resolve following
smoking cessation and has no long-term
health consequences. An example of
smoker’s melanosis can be seen in Figure 4.
Oral candidosis
Smokers have an increased risk
of oral candidosis, but the mechanism is not
fully understood.21 This could potentially be
due to cigarette smoke, which is nutritional
for C. albicans (the causative agent of
candidal infection), or because the smoking
results in localized epithelial alterations,
resulting in candida colonization.22 Smoking
may also have a role in suppressing the oral
immune response and disrupting normal
bacterial flora.23 The condition can be
treated with anti-fungal medications and
usually causes no long-term consequences
except when candidal hyphae enter
the surface epithelium causing chronic
candidosis. A classic appearance of oral
candidosis can be seen in Figure 5.
Periodontal disease
There are clear, well documented
links between smoking and periodontal
disease. Smokers have a 2- to 3-fold
increased risk of clinically identifiable
periodontitis. They also have fewer teeth
and are more likely to be edentulous than
non-smokers. The risk of alveolar bone loss
is seven times greater amongst smokers
March 2018
OralHealth
Figure 4. Smoker’s melanosis in a 30-year-old
female smoker of at least 20 cigarettes/day.
Figure 5. Oral pseudomembranous candidosis in
a 47-year-old male smoker of 20 cigarettes/day.
than non-smokers, and the severity of
periodontal disease in smokers appears
to be dose dependent.24 There is evidence
that smoking cessation reduces the risk of
periodontal disease.24 Successful treatment
of periodontal disease in smokers is lower
than that in non-smokers.24 Increased
prevalence of periodontal disease is linked
to smoking dampening the body’s immune
Figure 6. Periodontitis in a 32-year-old male
response, meaning that the smoker has a
smoker of 20 cigarettes/day.
reduced ability to clear pathogens.24
Smoking also increases the
prevalence of acute necrotizing ulcerative
gingivitis and acts as a co-destructive in oxidative metabolism and oxygen
factor for periodontal tissue damage transport. There is also the introduction of
alongside other predisposing factors (for contaminants into the wound from tobacco
example diabetes).24 An example of chronic smoke, further inhibiting healing; an
periodontal disease can be seen in Figure 6. example of this would be that it takes longer
for a socket to heal following extraction in a
smoker than a non-smoker.
Dry mouth, halitosis and caries
The use of any tobacco product
Smoking has been shown to
is associated with increasing risk of alveolar
reduce salivary flow rate.25 A drier mouth
osteitis, or ‘dry socket.’ This has, in part, been
results in numerous oral sequelae, with
related to the vasoconstrictive effects of
one of these being increased halitosis. Less
nicotine on small blood vessels.27 Abstaining
saliva leads to reduced ‘cleansing’ of the oral
from smoking following oral surgery/trauma
mucosa and smokers typically have worse
has therefore been shown to reduce the risk
oral hygiene than non-smokers. A drier
of a ‘dry socket’ occurring.27
mouth with poorer oral hygiene will also
result in an increased incidence of dental
caries.26 There is evidence to suggest that Implants
smoking causes irreversible damage to Smoking is implicated in the
minor salivary glands, meaning that salivary failure of dental implants in all areas of the
flow may not increase to original levels even mouth.28 Although there is a risk of dental
after successfully stopping, making timely implant failure in all patients, smoking can
cessation paramount. be considered a ‘significant risk factor’ in
dental implant placement.28
Wound healing
Smoking is implicated in poor Aesthetics
wound healing.27 This is because smoking All forms of smoking and
reduces blood flow to oral tissues alongside chewing tobacco can discolour teeth,
inhibiting the enzyme systems necessary and smokers are more likely to perceive
DentalUpdate 199
 OralHealth
their teeth as discoloured compared to
non-smokers.29 Smoking can also lead to
increased incidence of tooth loss and has
also been linked to increased skin ageing.30
Smoking also leads to an
increased amount of calculus formation
which can look unsightly, requiring a dentist
or hygienist to remove it.
Recurrent Apthous Stomatitis
Recurrent Apthous Stomatitis
(RAS), is one of the most common
conditions to manifest within the oral cavity.
It affects up to 20% of the population at
some point in their lives and about 2%
chronically. Most patients present with
occasional ulceration which resolves
rapidly without complications. Others
have severe ulcers that interfere with diet
and function. Such ulcers are a common
result of stopping smoking, affecting two
in five quitters.31 Reassurance regarding
oral aphtous ulcers should be given from
primary care practitioners. In more severe or
complex cases, referral to an oral medicine
department may be indicated.
The role of dentists
As dentists, we are central in
dispensing advice regarding smoking
cessation. Fifty-seven percent of the EU
population regularly visit a dentist,32 giving
dental professionals the opportunity to
offer information and support to those
who smoke. A Cochrane review shows that
brief intervention by health professionals
is effective in helping tobacco users to
quit.33 This ‘brief’ advice has been shown
to increase smoking cessation by 2%.
Whilst this number seems small, it could
equate to between 63,000 and 190,000
people quitting each year in Britain alone.34
By referring to stop smoking services,
successful cessation increases to 15%.35
The effects of smoking on the
body are numerous, but often smokers do
not believe anything bad will happen to
them. This reduces the incentive to stop,
and is also linked with relapse in those who
have quit.36 As dentists, we have access to
an area of the body that is actively affected.
A healthy, unrestored smile is perceived to
be an important social asset.37 The prospect
of losing this may be an important factor in
successful smoking cessation.
200 DentalUpdate
Dentists often cite issues such
as lack of time or education as a reason
why they do not offer smoking cessation.38
By understanding how behavioural
management and medical therapies are
used in smoking cessation, the dental
team can offer suitable advice to patients,
helping to increase successful cessation.
Members of the dental team can then
remain empathetic and supportive during
the patient’s cessation journey, offering
positive feedback and advice regarding his/
her chosen cessation modality.
Despite being well positioned
to offer cessation advice, individuals
working within dentistry do not always
discuss their patient’s tobacco use. A study
by Smith et al39 showed that motivated
dentists were particularly good at offering
smoking cessation to patients. However,
less than 50% of dental practices involved
in the study offered referrals to stop
smoking services. Further studies confirm
that dentists are often poor at referring
to stop smoking services, or offering brief
interventions ‘in-house’.40 There is substantial
evidence to suggest that such ‘in-house’
interventions are useful for helping smokers
quit.41 When it is considered that patients
expect their oral health professionals to
assist in cessation attempts, this gives
further reason for dental professionals
to understand and implement cessation
techniques.42
Brief cessation advice; the use
of the 5 and 3 ‘A’s protocol of
smoking cessation
The 5 ‘A’s approach to smoking
cessation is the internationally accepted
approach to brief intervention in nicotine
users, with this ‘brief’ advice in primary
care settings shown to increase smoking
cessation by 1−3%.43 The 3 ‘A’s contains a
similar message, but in a condensed format.
Before the stages of the 5’A’s and 3’A’s are
discussed, it is important to understand that
different countries have different protocols
to implement smoking cessation, and these
are based on WHO Article 14 guidance in the
Framework Convention on Tobacco Control.44
This article encourages the creation of
a sustainable infrastructure to promote
and deliver increased levels of smoking
cessation based on best available scientific
evidence, encouraging implementation of
reproducible and successful methods of
smoking cessation.
The 5 ‘A’s protocol
These guidelines can be
summarized by the 5 ‘A’s:
Ask about and record smoking status.
Advise smokers of the benefit of stopping
in a personalized and appropriate way.
Assess motivation to quit (using stages of
change model).
Assist smokers in their quit attempt.
Arrange follow up with stop smoking
services.
Advice from the healthcare
practitioner does not have to be focused on
the minutiae of cessation and needs only to
last three minutes.45 Whilst knowledge of the
treatment modalities to result in cessation
are useful, ultimately the specialized stop
smoking services will be able to discuss
any potential issues adequately with the
individual.
The 3 ‘A’s protocol
For practitioners who genuinely
do not have time, a 3'A’s approach may be
acceptable. As dentists seem to be content
with the first two ‘A’s in either scenario, it is
the addition of ‘action’ on responses which
increases success rates in quitting. This can
be summarized as follows:
Ask and record smoking status.
Advise patient of personal health benefits.
Act on patient’s response.
This very brief advice can be delivered
in less than one minute and there is an
absence of conclusive evidence to indicate
that the 5’A’s approach is more successful
than the 3’A’s.46
The authors are aware of the
need to be pragmatic in the approach to
smoking cessation in the dental setting,
therefore advise that the 3’A’s intervention is
the best brief intervention to be undertaken
by dentists. It is easier to complete than the
5’A’s and, if done properly, both approaches
result in similar rates of smoking cessation.
A flow chart to show a potential patient
interaction is shown in Figure 7.
Patient-centred cessation
It is important to maintain
the patient at the centre of any cessation
attempt. It must therefore be ensured that
March 2018
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 OralHealth

ASK:
Recently quit/ All patients their
trying to quit current smoking Non-
status Smoker
Congratulate.
Congratulate. Continue with
Reaffirm choice and Smoker check-up
offer support

‘Are you interested

in quitting?’

Yes
No ADVISE:
‘What would you
‘I’d recommend stopping; there like to know?’
are huge health benefits. If
you’d like any further information
Answer questions with a
about quitting I’d be happy to talk to
patient-centred approach
you, or you can collect a leaflet
from reception.’ Does patient seem
interested in further
support?

Remain non-judgemental. Yes

Decision to pursue smoking No
cessation is now patient-
centred
ACT:
Provide details
Continue with of local stop
check-up. Answer smoking service
any further
Smoking Cessation Advice
Healthcare professional training questions

Figure 7. A recommended flow chart for brief smoking cessation intervention based on the 3 ‘A’s approach.

practitioners focus their approach on the
responses of patients. For example, if the
patient smokes, and does not wish to stop
now, the dental professional must remain
non-judgemental. The dental professional
could say, for example, ‘I can understand you
don’t want to quit right now. I’m sure you
are aware smoking is bad for you, so if at any
point you want to discuss quitting with me I
would be happy to talk about it.’ This allows
March 2018
patients to plan their actions. If patients
are positive in their response, the authors
recommend that the 3 ’A’s approach can be
continued. The authors appreciate that the 5
‘A’s is a more thorough approach to smoking
cessation, however, the 3 ‘A’s is easier and
more likely to be implemented in the fast-
paced dental environment. This intervention
should be viewed as a flow chart,
dependent on the patient’s response, not
something that is simply undertaken with
no regard for the patient’s interaction.
Solberg et al showed that a healthcare
professional’s approach to smoking
cessation is central to its success.47
Dental professionals should therefore act
appropriately when discussing quitting
with an addicted individual. Ultimately,
the decision to contact stop smoking
services can be made by the individual.
DentalUpdate 203
 OralHealth
Self-referral has been shown to be linked
to increased success in cessation, and the
dentist can empower the individual to make
this decision.48
Conclusions
A misperception made by
many is that willpower alone is enough to
fuel a quit attempt, something which is
refuted by nicotine addicts and academics
in equal measure.49 One third of successful
cessation attempts necessitate either
medical or psychological therapy to result
in a successful outcome and these will be
discussed in part 2.50
It is important to remember that,
even after dispensing advice in the correct
way, some smokers will choose to reject
the conventional smoking cessation model
despite being aware that they may have an
increased chance of successful cessation.51
The reasons for this are often difficult to
quantify and are more complex than simple
misconceptions or correctable barriers
to treatment.52 With these individuals,
practitioners must simply be supportive and
understanding of the patient’s wishes and
understand that brief cessation advice can
offer some, albeit limited, benefit.
Acknowledgments
This project is co-funded by the
European Union´s Erasmus+ programme
‘Smoking Cession Advice: Healthcare
Professional Training’ under grant agreement
Nº 2016-1-UK01-KA202-024266.
The European Commission
support for the production of this
publication does not constitute an
endorsement of the contents which reflects
the views only of the authors, and the
Commission cannot be held responsible
for any use which may be made of the
information contained therein.
We would like to acknowledge
the excellent contribution of Dr Senathirajah
Ariyaratnam, Clinical Senior Lecturer in
Oral Medicine, University of Manchester
for this work as an External Reviewer of
the European Union − Erasmus+ project
‘Smoking Cessation Training: Healthcare
Professional Training’.
References
1. Doll R. Uncovering the effects of smoking:
204 DentalUpdate
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1998; 7: 87−117.
2. Sömmering ST. De Morbis Vasorum
Absorbentium Corporis Humani. Frankfurt:
Varrentrapp & Wenner, 1795.
3. Doyle JT, Dawber TR, Kannel WB, Heslin AS,
Kahn HA. Cigarette smoking and coronary
heart disease: combined experience of the
Albany and Framingham studies. N Engl J
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4. Cosci F, Pistelli F, Lazzarini N, Carrozzi L.
Nicotine dependence and psychological
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5. Samet JM. Tobacco smoking: the leading
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Vallyathan V, Green FH. Contributions of
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8. US Department of Health and Human
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Smoking: 50 Years of Progress: A Report
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Department of Health and Human Services,
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion, Office
on Smoking and Health, 2014: 17.
9. Ho R. Why do people smoke? Motives for
the maintenance of smoking behaviour
and its possible cessation. Aust Psychol
1989; 24: 385−400.
10. Ross KC, Dempsey DA, Helen GS, Delucchi
K, Benowitz NL. The influence of puff
characteristics, nicotine dependence,
and rate of nicotine metabolism on daily
nicotine exposure in African American
smokers. Cancer Epidemiol Biomarkers Prev
2016; 25: 936−943.
11. Gandini S, Botteri E, Iodice S, Boniol M,
Lowenfels AB, Maisonneuve P, Boyle P.
Tobacco smoking and cancer: a meta‐
analysis. Int J Cancer 2008; 122: 155−164.
12. Mecklenburg RE. National Cancer Institute
& Institute of Dental Research Guide for
Health Professionals. Tobacco Effects in the
Mouth. Darby PA, USA: Diane Publishing,
2004.
13. Bagnardi V, Blangiardo M, La Vecchia
C, Corrao G. A meta-analysis of alcohol
drinking and cancer risk. Br J Cancer 2001;
85: 1700.
14. Ferlay J, Soerjomataram I, Dikshit R, Eser S,
Mathers C, Rebelo M et al. Cancer incidence
and mortality worldwide: sources, methods
and major patterns in GLOBOCAN 2012. Int
J Cancer 2015; 136: E359−386.
15. Amit M, Yen TC, Liao CT, Chaturvedi P,
Agarwal JP, Kowalski LP et al. Improvement
in survival of patients with oral cavity
squamous cell carcinoma: an international
collaborative study. Cancer 2013; 119(24):
4242−4248.
16. Marron M, Boffetta P, Zhang ZF, Zaridze D,
Wünsch-Filho V, Winn DM et al. Cessation of
alcohol drinking, tobacco smoking and the
reversal of head and neck cancer risk. Int J
Epidemiol 2010; 39: 182−196.
17. Warnakulasuriya S, Johnson N, Van der
Waal I. Nomenclature and classification
of potentially malignant disorders of the
oral mucosa. J Oral Pathol Med 2007; 36:
575−580.
18. Yardimci G, Kutlubay Z, Engin B, Tuzun Y.
Precancerous lesions of oral mucosa. World
J Clin Cases (WJCC) 2014; 2: 866.
19. Poate TW, Warnakulasuriya S. Effective
management of smoking in an oral
dysplasia clinic in London. Oral Dis 2006;
12: 22−26.
20. Axell T, Hedin CA. Epidemiologic study
of excessive oral melanin pigmentation
with special reference to the influence of
tobacco habits. Scand J Dent Res 1982; 90:
434−442.
21. Soysa N, Ellepola A. The impact of
cigarette/tobacco smoking on oral
candidosis: an overview. Oral Dis 2005; 11:
268−273.
22. Arendorf TM, Walker DM. The prevalence
and intra-oral distribution of Candida
albicans in man. Archiv Oral Biol 1980; 25:
1−10.
23. Samaranayake LP, MacFarlane TW (eds).
Host Factors and Oral Candidosis. London:
Wright, 1990: pp66−103.
24. Kinane DF, Chestnutt IG. Smoking and
periodontal disease. Crit Revs Oral Biol Med
2000; 11: 356−365.
25. Rad M, Kakoie S, Brojeni FN, Pourdamghan
N. Effect of long-term smoking on whole-
mouth salivary flow rate and oral health.
J Dent Res Dent Clin Dent Prospects 2010; 4:
110−114.
26. Campus G, Cagetti MG, Senna A, Blasi G,
Mascolo A, Demarchi P, Strohmenger L.
Does smoking increase risk for caries? A
cross-sectional study in an Italian military
academy. Caries Res 2011; 45: 40−46.
27. Cardoso CL, Rodrigues MT, Júnior OF, Garlet
GP, de Carvalho PS. Clinical concepts of
dry socket. J Oral Maxillofac Surg 2010; 68:
1922−1932.
28. Strietzel FP, Reichart PA, Kale A, Kulkarni
M, Wegner B, Küchler I. Smoking interferes
with the prognosis of dental implant
treatment: a systematic review and meta‐
analysis. J Clin Periodont 2007; 34: 523−544.
29. Alkhatib MN, Holt RD, Bedi R. Smoking
and tooth discolouration: findings from a
national cross-sectional study. BMC Public
Health 2005; 5: 27.
30. Rexbye H, Petersen I, Johansens M, Klitkou
L, Jeune B, Christensen K. Influence of
environmental factors on facial ageing. Age
Ageing 2006; 35: 110−115.
31. McRobbie H, Hajek P, Gillison F. The
relationship between smoking cessation
and mouth ulcers. Nicotine Tob Res 2004; 6:
655−659.
32. Nihtila A, West N, Lussi A, Bouchard
P, Ottolenghi L, Senekola E et al. Oral
health behavior and lifestyle factors
among overweight and non-overweight
young adults in Europe: a cross-sectional
questionnaire study. Healthcare (Basel)
2016; 4: E21.
33. Stead LF, Bergson G, Lancaster T. Physician
advice for smoking cessation. Cochrane
Database Syst Rev 2008 Apr 16; (2):
CD000165.
34. Watt RG, Johnson NW, Warnakulasuriya
March 2018
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206 DentalUpdate
Smoking cessation: Action on smoking opportunities for the dental
team. Br Dent J 2000; 189: 357−360.
35. West R, McNeill A, Raw M. Smoking cessation guidelines for health
36.
professionals: an update. Thorax 2000; 55: 987−999.
Curry SJ, Grothaus L, McBride C. Reasons for quitting: intrinsic and
extrinsic motivation for smoking cessation in a population-based
sample of smokers. Addict Behav 1997; 22: 727−739.
37. Dunn WJ, Murchison DF, Broome JC. Esthetics: patients’ perceptions of
38.
dental attractiveness. J Prosthodont 1996; 5: 166−171.
Richmond R, Zwar N, Borland R, Stillman S, Cunningham M, Litt J et al.
Smoking cessation for Australian general practice − evaluation of best
practice guidelines. Aust Fam Physician 2005; 34: 505−507.
39. Smith SE, Warnakulasuriya KA, Feyerabend C, Belcher M, Cooper DJ,
Johnson NW. A smoking cessation programme conducted through
dental practices in the UK. Br Dent J 1998; 185: 299−303.
40. Needleman IG, Binnie VI, Ainamo A, Carr AB, Fundak A, Koeber A et al.
Improving the effectiveness of tobacco use cessation (TUC). Int Dent J
2010; 60: 50−59.
41. Carr A, Ebbert J. Interventions for tobacco cessation in the dental
setting. Cochrane Database Syst Rev 2012 Jun 13; (6): CD005084.
42. Rikard-Bell G, Donnelly N, Ward J. Preventive dentistry: what do
Australian patients endorse and recall of smoking cessation advice by
their dentists? Br Dent J 2003; 194: 159−164.
43. Stead LF, Bergson G, Lancaster T. Physician advice for smoking
cessation. Cochrane Database Syst Rev 2008 Apr 16; (2): CD000165.
44. Geneva: WHO, 2003. WHO Framework Convention on Tobacco Control.
Available at: http://www.who.int/tobacco/framework/WHO_FCTC_
english.pdf. Accessed on Feb 14 2017.
45. Al-Doghether MH. The behavioural interventions for smoking cessation.
Asia Pacif Fam Med 2004 Jan 1; 3: 19−28.
46. Dawson GM, Noller JM, Skinner JC. Models of smoking cessation brief
interventions in oral health. N S W Public Health Bull 2013; 24: 131−134.
47. Solberg LI, Kottke TE, Majeskie MR, Fiore MC, Baker TB. Patient
perceptions: an important contributor to how physicians approach
tobacco cessation. Tob Control 1998; 7: 421−423.
48. Borland R, Partos TR, Yong HH, Cummings KM, Hyland A. How much
unsuccessful quitting activity is going on among adult smokers? Data
from the International Tobacco Control Four Country cohort survey.
Addiction 2012; 107: 673−682.
49. Hughes JR. Four beliefs that may impede progress in the treatment of
smoking. Tob Control 1999; 8: 323−326.
50. Hughes JR, Burns DM. Impact of medications on smoking cessation.
In: Population Based Smoking Cessation: pp155–164. Proceedings of
a Conference on What Works to Influence Cessation in the General
Population. Smoking and Tobacco Control Monograph No 12. Bethesda,
MD: National Cancer Institute, 2001.
51. Morphett K, Partridge B, Gartner C, Carter A, Hall W. Why don’t smokers
want help to quit? A qualitative study of smokers’ attitudes towards
assisted vs. unassisted quitting. Int J Environ Res Public Health 2015; 12:
6591−6607.
52. Smith AL, Carter SM, Chapman S, Dunlop SM, Freeman B. Why do
smokers try to quit without medication or counselling? A qualitative
study with ex-smokers. BMJ Open 2015; 5: e007301.
March 2018
 Enhanced CPD DO C
Joseph Sabbagh
Jean Claude Fahd and Robert J McConnell
Post-operative Sensitivity and
Posterior Composite Resin
Restorations: A Review
Abstract: With an increasing use of posterior composite resin restorations, the incidence of post-operative sensitivity has become an
everyday clinical problem. The aim of this paper is to identify the possible causes of post-operative sensitivity and explore how it can be
avoided and treated.
CPD/Clinical Relevance: This paper addresses the different causes responsible for post-operative sensitivity following composite
placement. Also the management of this situation is discussed.
Dent Update 2018; 45: 207–213
In many countries the use of amalgam to
restore posterior teeth is declining, with
composite resin replacing it as the material of
choice.1 As composite resin replaces amalgam
as the material of choice for restoring posterior
teeth, the incidence of post-operative
sensitivity has increased, with the highest
incidence in posterior composite restorations.2
The more complex the restorative procedure
required for the placement of a composite
resin restoration, including etching of enamel
and dentine and the application of acidic
adhesive monomers, may be related to the
Joseph Sabbagh, DDS, MSc, PhD, FICD,
Professor, Restorative and Aesthetic
Dentistry Department, Lebanese
University, Beirut, Lebanon, Jean Claude
Fahd, DDS, DESS, Former Chairperson,
Restorative and Aesthetic Dentistry
Department, Lebanese University, Beirut,
Lebanon and Robert J McConnell, BDS,
FFD, PhD, Emeritus Professor, Restorative
Dentistry, University Dental School and
Hospital, Wilton, Cork, Ireland.
March 2018
higher incidence of pain.
Post-operative sensitivity can be
difficult to manage. Patients often complain
of sensitivity at different levels and intensities,
often with no evidence of failure of the
restoration.3
Brännström first explained the
physiology of pulpal pain in 1962,4 and in 1963
he described in his thesis the hydrodynamic
fluid movement theory.5 Pain results from
indirect innervations caused by dentinal
fluid movement in the tubules, which then
stimulates mechanoreceptors near the
odontoblast processes. The response of the
pulpal nerves is proportional to the fluid
flow generated. The A-delta fibres respond to
stimulation of dentinal tubules (eg airblast),
whereas pulpal C-fibres respond to bradykinin
or capsaicin. This study has implicated pulpal
A-delta fibres in mediating dentinal sensitivity
and pulpal C-afferent fibres in mediating
pulpal inflammation.
Factors which may be responsible
for sensitivity following the placement of
composite restorations include:
„ The remaining dentine thickness;
„ The tubule diameter and the sealing of the
tubules following etching; and
RestorativeDentistry
„ The overall pulp status of the tooth.
Other factors relate to the operator
and the restorative procedure.
Langeland concluded that dentine
exposed during the preparation of cavities or
crowns should be covered immediately with a
non-irritating material to seal the tubules and
thus prevent microleakage.6
This paper will address the
possible aetiological factors and outline
prevention and management modalities to
decrease the occurrence of hypersensitivity.
Types and causes of tooth
sensitivity
There are three types of tooth
sensitivity:
1. Physiological;
2. Pathological; and
3. Iatrogenic.
A sound tooth shows normal or
physiological sensitivity when exposed to cold
or hot stimuli.7
Pathology, such as caries, cracks,
erosion or gingival recession may cause an
exaggerated response to thermal, chemical or
mechanical stimuli.
DentalUpdate 207
 RestorativeDentistry
Iatrogenic sensitivity is caused
by procedures carried out by the dentist or
dental healthcare worker. Examples include
periodontal procedures and removal and
replacement of tooth structure during intra-
coronal and extra-coronal restorations.
Iatrogenic factors
Cavity preparation
Several studies have demonstrated
that a temperature increase during cavity
preparation can lead to irreversible damage
of dental tissues. An increase of over 5 °C may
cause pulp necrosis.8 While using cutting burs
during cavity preparation, abundant water
irrigation should be used in order to decrease
pulpal heating. It is preferable to use a turbine
with four water holes for irrigation instead of
a single hole directed towards the bur. This
will ensure thorough and abundant irrigation.
During preparation, regular changing of burs
and the use of light pressure will reduce heat
and pressure.
During caries excavation, all
efforts must be made to minimize pulp
overheating and vibrations, by using manual
caries excavation with a sharp excavator or
using a slow running round steel bur with light
pressure.
Post-operative sensitivity related to the adhesive
system
According to the manufacturers,
self-etch adhesives (known also as 6th, 7th
and 8th generation) cause less sensitivity than
total-etch systems. Many studies have been
conducted and contradictory results have
been reported. Some studies did not observe
any difference in post-operative sensitivity
and marginal discoloration when using self-
etch or total-etch adhesives systems.9 Others
concluded that, in deep cavities, the use of
self-etching bonding systems was effective in
reducing post-operative sensitivity compared
to total-etch adhesive systems.10,11
A further study12 used randomized
clinical trials that compared the clinical
effectiveness of the self-etch technique with
the etch and rinse technique used for direct
resin composite restorations in permanent
teeth of adult patients. The risk/intensity of
post-operative sensitivity was the primary
outcome measure. They concluded that the
type of adhesive or the technique used for
208 DentalUpdate
posterior resin composite restorations did
not influence the risk and intensity of post-
operative sensitivity.
Swift et al compared the incidence
of post-operative sensitivity to the type of
adhesive system, total-etch versus self-etch.13
They reported that, during the first week after
placement of Class I posterior composite
restorations, 23% of the patients experienced
post-operative sensitivity following the
use of either total-etch (Optibond Solo Plus,
Kerr, Orange, USA) or self-etch (Xenon III,
Dentsply, Konstanz, Germany) adhesive. But
sensitivity decreased greatly with time, and
the differences between the two groups was
not statistically significant. Thus, the incidence
of post-operative sensitivity may not be
influenced by the bonding system.9 10 11
Post-operative sensitivity and the use of
desensitizers
The role of the adhesive layer
is to seal the dentine tubules exposed by
the etchant and to bond and retain resin
composite to the walls of the cavity. Multiple
layers of bonding agents do not prevent or
decrease sensitivity. The shear bond strength
of some adhesives may be negatively
influenced by multiple layers of bonding
agent, although with the one-step self-etching
system, the application of consecutive coats
can improve bond strength.10 11
Studies have been carried out to
investigate the effectiveness of desensitizing
agent on post-operative sensitivity.14
Many have found that the application of a
desensitizing agent to the dentine surface can
have an influence on the bond strengths of the
systems.
One study evaluated the efficiency
of Gluma (glutaraldehyde Heraeus Kulzer,
Mitsui Chemical Group, Japan), and Hyposen
(strontium chloride) (Pharma GmbH + Co,
Aachen, Germany) with the bonding systems
Xeno III (Dentsply, Konstanz, Germany), AdheSE
(Ivoclar Vivadent, Liechtenstein) and Clearfil
New Bond (Kuraray, Japan).15 While Gluma had
no significant influence on bond strength
of the three adhesive systems, Hyposen
significantly decreased the bond strength
values of Clearfil New Bond.
Another desensitizing agent, MS
Coat ONE (SunMedical, Japan), is a water-
based, resin-containing oxalate desensitizing
agent. The oxalic acid from the agent reacts
chemically with calcium ions from the tooth
structure to form the insoluble calcium oxalate
crystals which block dentinal tubules. Based
on this phenomenon, outward fluid flow in
the acid-etched dentine can be reduced by
applying the oxalate desensitizer prior to
adhesive application. As a result, the post-
operative dentine hypersensitivity is reduced.
However, it has been found that the use of MS
Coat ONE prior to the application of Prime &
Bond NT reduces the shear bond strength.
Therefore, the use of a desensitizer
agent may be helpful in reducing the
incidence of post-operative sensitivity,
however, its use may compromise the bond
strength of the composite to the cavity
wall.16−19
Post-operative sensitivity and the type of light
source
There are four basic types of
dental curing lights:
1. Tungsten halogen;
2. Light-emitting diode (LED);
3. Plasma arc curing (PAC); and
4. Laser.
The two main dental curing lights
are the halogen and LED. All curing lights will
cure resins, providing that the wavelength
delivered by the bulb matches the absorption
picture of the photo initiator. The two main
categories of light-curing devices use either
broader-light-spectrum, quartz-tungsten-
halogen bulbs (QTH) with photo-spectrum
emissions in the range of 400 nm to 500 nm,
or light-emitting diodes (LED) that provide
light in the blue-visible spectrum with a range
of 450 nm to 490 nm. A light source with low
intensity will only cure the top surface of the
composite. Incomplete polymerization may be
a cause of post-operative pain.
The pulsedelay mode of the
LED curing light reduces the incidence and
severity of post-operative sensitivity following
placement of a posterior composite restoration
compared to the fast mode of the same
curing light by reducing the amount of cuspal
movement.20 Other studies did not find any
significant difference in post-op sensitivity
when restoring Class I and II restorations using
a soft start polymerization.21,22
During composite placement,
the light source should be held close to
the uncured composite material and an
incremental technique used ensuring
that the opposing walls are not bonded
together. Resin composite should be placed
March 2018

in successive increments of no more than
2mm and cured. This will result in complete
curing, a reduction in polymerization stresses,
improved marginal adaptation and decreased
cuspal flexure. Both the vertical and oblique
incremental techniques have been outlined in
the literature.23,24 The exception to the above
technique are the bulk fill resin materials and
these will be discussed later in this paper.
Regular assessment of the light-
curing device using a radiometer will decrease
the risks of post-operative hypersensitivity.
Post-operative sensitivity and the type of
composite materials and placement technique
Many factors may be responsible
for post-operative sensitivity when placing
composite into the cavity:
„ Contraction resulting from polymerization
shrinkage will cause cusp deflection;25,26
„ Incomplete coating of the dentine surface
with adhesives following acid etching;
„ Bulk filling placement using non-bulk fill
composite materials;
„ Poor adaptation of composite material to
internal walls and floors, especially on the
cervical floor in an interproximal restoration;
„ Occlusal discrepancies. As for all
restorations, the occlusion of the new
restoration should be checked before
discharging the patient. Any discrepancy in
lateral or protrusive function may initiate
tooth sensitivity.
The incidence of post-operative
sensitivity is more frequently reported for Class
I and Class V composite restorations due to the
configuration factor or C-Factor responsible
for the stresses seen in certain designs.27
This design factor is the ratio between the
numbers of bonded walls versus unbonded
walls in a prepared cavity. The higher the
C-Factor, the higher is the stress resulting from
polymerization shrinkage. In Class V and I
cavities, the C-Factor is the highest (5/1), since
five walls of the cavity are bonded, and only
one (the occlusal surface) is unbonded. In a
Class IV cavity, the C-Factor is the lowest (1/5),
since only one surface of the cavity is bonded
and the five others are free. Polymerization
shrinkage of between 1.7 and 5.7% of the total
volume of the restoration causes the resin to
pull away from the cavity wall, leaving a small
gap. This gap permits the ingression of oral
fluids and bacteria and is termed microleakage
with resultant post-operative sensitivity.
Contrary to the widely held
March 2018
opinion of the influence of the C-Factor on
the success of composite resin restorations,
Ferracane and Hilton outlined, in a recent
paper, that there is no direct evidence
between contraction stresses in dental
composite restorations and reduced clinical
longevity.28 Clinically, it is important that
attention be given to the correct placement of
posterior composite restorations, especially in
Class I and Class V lesions.
The remaining dentine thickness
is also correlated to the incidence of post-
operative sensitivity. Restorations made in
shallow and medium depth cavities showed
significantly lower post-operative sensitivity
compared with those made in deep cavities.29
During cavity preparation, only the highly
infected, irreversibly demineralized caries
should be removed and all remaining dentine
is retained and protected.30
During the placement of the
restoration, the operator should endeavour
to achieve, as far as possible, a void-free
restoration with close adaptation of the
composite to the walls of the cavity.
Post-operative sensitivity with
resin restorations is not related to the absence
of a protective layer or liner, but rather to the
depth of the cavity.31 The use of glass-ionomer
cement liner in occlusal cavities restored
with resin composite does not reduce post-
operative sensitivity,32 as the intensity of the
pulpal response depends on the remaining
dentine thickness.33
Flowable composite may result
in a better adaptation of the first layer of
composite. Flowable resin should be applied
in a very thin layer following the application
of a bonding agent. The application of a
flowable resin to the proximal boxes of Class II
composite restorations improve post-operative
sensitivity.34−37
Two types of matrices are
available: metallic and clear or translucent. If a
metal matrix is used, then all increments must
be cured from the occlusal direction. Similar
clinical outcomes were observed after 4 years
of placement of Class II restorations using both
metallic or translucent matrices.38
The layering technique is a
concept allowing the dentist to achieve high
aesthetic restorations using new systems
of resin composites by combining different
opacities, but it remains a time consuming
procedure. Today, new bulk filling resin
systems from different companies are
available, relying on different technologies,
RestorativeDentistry
such as flowable resin composite, sonic energy
or fibre-based resin composite.39 These systems
allow optimal composite packing in one or two
layers and good adaptation to cavity walls and
adequate time for material sculpturing.40,41
Bulk filled composites are resins
with a modified chemical composition. The
practicality of the new material is that it can be
light-cured in up to 4−5 mm thickness at once,
which will minimize the clinical application
time compared to regular composite
restorations.42
A randomized controlled clinical
trial43 compared the incremental and bulk
filling techniques and materials for restoring
posterior teeth. At day 7, there was no
significant difference between the two groups
in terms of post-operative sensitivity or
tenderness on biting.
Treatment options for the
management of post-operative
sensitivity44,45
Prevention of post-operative
sensitivity is the best line of treatment. A
thorough clinical examination of the tooth
involved and an investigation of any preclinical
symptoms is vital.
Post-operative sensitivity
occurring following a composite restoration
may continue for a number of days, and it
may decrease with time. It is more common in
Class I and Class V cavities and, in these cases,
it is most likely due to inappropriate filling
techniques. If pain persists for longer than
10 days, then the authors would suggest the
following protocol:
1. Check the occlusion, especially for non-
working interferences;
2. Examine the intensity of the light-curing
device;
3. If pain persists, remove the composite
and replace with a temporary restoration,
glass-ionomer or zinc oxide eugenol
cement;46
4. If this results in relief of the pain, place a
new composite, paying special attention to
recommended filling technique;
5. If pain persists, then root canal treatment
may be the required treatment.
Conclusion
Achieving a successful composite
restoration is technically more difficult than
a successful amalgam restoration. Post-
DentalUpdate 209
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 RestorativeDentistry
operative sensitivity may become a clinical
complication with the placement of a posterior
resin system. Furthermore, composite resin
placement takes more time than an amalgam
placement. The appropriate use of correct
materials and techniques will reduce post-
operative sensitivity. When preparing the
cavity, the appropriate use of burs, and
avoiding dehydration of the dentine during
the adhesive process, are vital.
Whereas any resultant post-
operative sensitivity can be troublesome,
the literature would suggest that it tends to
decrease over time.47
References
1. Opdam NJM, Bronkhorst EM, Loomans
BAC, Huysmans NJM. 12-year survival of
composite vs. amalgam restorations.
J Dent Res 2010; 89: 1063−1067.
2. Porto I. Post-operative sensitivity on direct
resin composite restorations: clinical
practice guidelines. Int J Res Develop (IJRD)
2012; 1:1−11.
3. Akpata ES, Sadiq W. Post-operative
sensitivity in glass-ionomer versus
adhesive resin lined posterior composites.
Am J Dent 2001; 14: 34−38.
4. Brännström M. The elicitation of pain in
the human dentine and pulp by chemical
stimuli. Arch Oral Biol 1962; 7: 59−62.
5. Brännström M. A hydrodynamic
mechanism in the transmission of pain
producing stimuli through the dentine. In:
Sensory Mechanisms in Dentine. Anderson
DJ (ed). Oxford: Pergamon Press, 1963:
pp73−79.
6. Langeland K. Tissue Changes in the Dental
Pulp. An Experimental Histological Study.
Oslo: Oslo University Press, 1957.
7. Canadian Advisory Board on Dentine
Hypersensitivity. Consensus-based
recommendations for the diagnosis and
management of dentine hypersensitivity.
J Can Dent Assoc 2003; 69: 221−226.
8. Zach L, Cohen G. Pulp response to
externally applied heat. Oral Surg Oral Med
Oral Pathol 1965; 19: 515−530.
9. Perdigao J, Geraldeli S, Hodges J. Total-
etch versus self-etch adhesive: effect on
postoperative sensitivity. J Am Dent Assoc
2003; 134: 1621−1629.
10. Ito S, Tay FR, Hashimoto M, Yoshiyama
M, Saito T, Brackett WW et al. Effects
of multiple coatings of two all-in-one
adhesives on dentin bonding. J Adhes
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Dent 2005; 7: 133−141.
11. Arisu HD, Eligüzeloğlu E, Uçtaşli MB,
Omürlü H. Effect of multiple consecutive
applications of one-step self-etch
adhesive on microtensile bond strength.
J Contemp Dental Practice 2009; 10: 67−74.
12. Reisa A, Loguercioa AD, Schroederb M,
Luque-Martineza I, Mastersonc D, Maiad
LC. Does the adhesive strategy influence
the post-operative sensitivity in adult
patients with posterior resin composite
restorations?: A systematic review and
meta-analysis. Dent Mater 2015; 31:
1052−1067.
13. Swift EJ Jr, Ritter AV, Heymann HO,
Sturdevant JR, Wilder AD Jr. 36-month
clinical evaluation of two adhesives and
microhybrid resin composites in Class I
restorations. Am J Dent 2008; 21: 148−152.
14. Gupta N, Reddy UN, Vasundhar PL,
Ramarao KS, Varma KP, Vinod V.
Effectiveness of desensitizing agents in
relieving the pre- and postcementation
sensitivity for full coverage restorations: a
clinical evaluation. J Contemp Dent Pract
2013; 14: 858−865.
15. Kobler A, Schaller HG, Gernhardt CR.
Effects of the desensitizing agents
Gluma and Hyposen on the tensile bond
strength of dentin adhesives. Am J Dent
2008; 21; 388−392.
16. Gillam DG, Mordan NJ, Sinodinou AD,
Tang JY, Knowles JC, Gibson IR. The
effects of oxalate-containing products
on the exposed dentine surface: an SEM
investigation. J Oral Rehabil 2001; 28:
1037−1044.
17. Kerns DG, Scheidt MJ, Pashley DH,
Horner JA, Strong SL, Van Dyke TE.
Dentinal tubule occlusion and root
hypersensitivity. J Periodontol 1991; 62:
421−428.
18. Pashley EL, Tao L, Pashley DH. Effects of
oxalates on dentin bonding. Am J Dent
1993; 6: 116−118.
19. Awang RAR, Masudi SM, MohdNor WZW.
Effect of desensitizing agent on shear
bond strength of an adhesive system.
Archiv Orofac Sci (AOS) 2007; 2: 32−35.
20. Piccioni MA, Baratto-Filho F, Kuga MC,
Morais EC, Campos EA. Cuspal movement
related to different polymerization
protocols. J Contemp Dent Pract 2014; 15:
26−28.
21. Alomari Q, Omar R, Akpata E. Effect of LED
curing modes on postoperative sensitivity
after Class II resin composite restorations.
J Adhes Dent 2007; 9: 477−481.
22. Chan DC, Browning WD, Frazier KB,
Brackett MG. Clinical evaluation of the
soft-start (pulse-delay) polymerization
technique in Class I and II composite
restorations. Oper Dent 2008; 33: 265−271.
23. Deliperi S, Bardwell D. An alternative
method to reduce polymerisation
shrinkage in direct posterior composite
restorations. J Am Dent Assoc 2002; 133:
1387−1398.
24. Dauvillier B, Aarnts M, Feilzer A.
Developments in shrinkage control of
adhesive restorations. J Esthet Dent 2000;
12: 291−299.
25. Fleming GJ, Hall DP, Shortall AC, Burke FJ.
Cuspal movement and microleakage in
premolar teeth restored with posterior
filling materials of varying reported
volumetric shrinkage values. J Dent 2005;
33: 139−146.
26. Fleming GJ, Khan S, Afzal O, Palin WM,
Burke FJ. Investigation of polymerisation
shrinkage strain, associated cuspal
movement and microleakage of MOD
cavities restored incrementally with
resin-based composite using an LED light
curing unit. J Dent 2007; 35: 97−103.
27. Feilzer AJ, de Gee AJ, Davidson CL. Setting
stress in composite resin in relation to
configuration of the restoration. J Dent Res
1987; 66: 1636−1639.
28. Ferracane JL, Hilton TJ. Polymerization
stress − is it clinically meaningful? Dent
Mater 2016; 32: 1−10.
29. Unemori M, Matsuya Y, Akashi A, Goto Y,
Akamine A. Composite resin restoration
and postoperative sensitivity: clinical
follow-up in an undergraduate program.
J Dent 2001; 29: 7−13.
30. Banerjee A, Watson TF, Kidd EA. Dentine
caries: take it or leave it? Dent Update
2000; 27: 272−276.
31. Kaurani M, Bhagwat SV. Clinical evaluation
of postoperative sensitivity in composite
resin restorations using various liners. N Y
State Dent J 2007; 73: 23−29.
32. Burrow MF, Banomyong D, Harnirattisai
C, Messer HH. Effect of glass-ionomer
cement lining on postoperative sensitivity
in occlusal cavities restored with resin
composite. A randomized clinical trial.
Oper Dent 2009; 34: 648−655.
33. Auschill TM, Koch CA, Wolkewitz M,
Hellwig E, Arweiler NB. Occurrence
and causing stimuli of postoperative
sensitivity in composite restorations. Oper
March 2018

Dent 2009; 34: 3−10.
34. Lindberg A, van Dijken JW, Horstedt P. In
vivo interfacial adaptation of class II resin 39.
composite restorations with and without
a flowable resin composite liner. Clin Oral
Invest 2005; 9: 77−83.
35. Efes BG, Dörter C, Gömec Y, Koray F. Two- 40.
year clinical evaluation of an ormocer,
a nanofill composite with and without
a flowable liner. J Adhes Dent 2006; 8:
119−126. 41.
36. Reis A, Loguercio AD. A 24-month follow-
up of flowable resin composite as an
intermediate layer in non-carious cervical
lesions. Oper Dent 2006; 31: 523−529. 42.
37. Ziskind D, Adell I, Teperovich E, Peretz
B. The effect of an intermediate layer of
flowable composite resin on microleakage
in packable composite restorations. Int J 43.
Paed Dent 2005; 15: 349−354.
38. Demarco FF, Pereira-Cenci T, de Almeida
André D, de Sousa Barbosa RP, Piva
E, Cenci MS. Effects of metallic or
translucent matrices for class II composite 44.
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restorations: 4-year clinical follow-up
findings. Clin Oral Invest 2011; 15: 39–47.
Sabbagh J, McConnell RJ, McConnell
MC. Posterior composites: update on
cavities and filling techniques. J Dent
2017; 57: 86−90.
Ajaj RA. Relative microhardness and
flexural strength of different bulk fill
resin composite restorative materials.
J Am Sci 2015; 11: 155–159.
Czasch P, Ilie N. In vitro comparison of
mechanical properties and degree of
cure of bulk fill composites. Clin Oral
Investig 2013; 17: 227−235.
Sabbagh J, McConnell RJ, McConnell
MC; Posterior composites: update on
cavities and filling techniques. J Dent
2017; 57: 86−90.
Hickey D, Sharif O, Janjua F, Brunton
PA. Bulk dentine replacement versus
incrementally placed resin composite:
a randomised controlled clinical trial.
J Dent 2016; 46: 18−22.
Sobral MA, Garone-Netto N, Luz MA,
RestorativeDentistry
Santos AP. Prevention of postoperative
tooth sensitivity: a preliminary clinical
trial. J Oral Rehabil 2005; 32: 661−668.
45. Dababneh RH, Khouri AT, Addy M.
Dentine hypersensitivity − an enigma?
A review of terminology, epidemiology,
mechanisms aetiology and management.
Br Dent J 1999; 187: 606−611.
46. He LH, Purton DG, Swain MV. A suitable
base material for composite resin
restorations: zinc oxide eugenol. J Dent
2010; 38: 290−295.
47. Briso ALF, Mestrener SR, Delicio G,
Sundfeld RH, Bedran-Russo AK, de
Alexandre RS, Ambrosano GMB. Clinical
assessment of postoperative sensitivity
in posterior composite restorations. Oper
Dent 2007; 32: 421−426.
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 Enhanced CPD DO C
Amar A Lakhani
Andrew M C Flett
An Alternative Approach to
Replacement of an Avulsed Central
Incisor
Abstract: This report describes the case of a young girl who underwent orthodontic and restorative treatment following the ankylosis of
an UR1. The case sets out an alternative treatment to prosthetic replacement following the loss of an incisor tooth.
CPD/Clinical Relevance: This case report gives an insight into an alternative treatment using orthodontics to provide a cost-effective and
aesthetic result following avulsion of a central incisor.
Dent Update 2018; 45: 215–225
When an avulsion injury occurs in a
permanent maxillary incisor, ankylosis
often occurs. In order to restore aesthetics
and function, dental treatment is required.
Avulsion is classed as complete
displacement of a tooth from its socket.1
Ankylosis is frequently a sequela following
avulsion injury. The determining factor
in whether a tooth becomes ankylosed
after avulsion is the health and status
of the periodontal ligament (PDL) after
injury. Minimal damage and disruption to
the PDL reduce the chances of ankylosis.
There are three main factors that have the
strongest impact on PDL:
1. Healing;
2. Stage of root development, storage
medium (dry or wet); and
3. Total time outside the socket prior to
Amar A Lakhani, BChD(Leeds), MFDS
RCS(Ed), Dental Core Trainee, Chesterfield
Royal Hospital and Andrew M C Flett,
Consultant Orthodontist, Queen’s Medical
Centre, Derby Road, Nottingham, NG7
2UH, UK.
March 2018
re-implantation.2
Optimal conditions are
considered to occur when the tooth is
re-implanted immediately following
injury and has an open root apex. The
risk of ankyloses injury in this case
is approximately 12% after 5 years.3
Suboptimal conditions are considered to
occur when the tooth has been out of the
socket for over 5 minutes, not stored in a
physiologic medium, such as saliva, and
has complete root development.
Following avulsion, the
approximate risk of ankylosis is 74%
after 10 years.3 If ankylosis does occur,
the clinician will then need to manage
the rehabilitation of the tooth through
prosthetic or restorative means. The
clinical signs of ankylosis, particularly in
a growing patient, are infraocclusion and
a high pitched sound upon percussion of
the tooth. Radiographically, replacement
resorption is often seen. If this situation
is not detected early, complications from
ankylosis include loss of vertical alveolar
bone height, tipping of teeth and acute
periapical periodontitis.4,5
When faced with the loss
of a central incisor, due to avulsion/
Orthodontics
anklylosis, the principles of management
are immediate replantation, application of
a flexible splint for up to two weeks and
initiation of root canal treatment 7−10 days
after replantation and before splint removal.
The factors to consider when
treatment planning a patient with an
ankylosed tooth are:
„ Cost-benefit analysis;
„ Patient co-operation and motivation; and
„ Long-term prognosis.
This clinical case report
examines these factors and considers
an alternative approach to replacing an
avulsed central incisor.
Case report
Patient HG first attended in
October 2012. Her presenting complaints
were that she was missing her UR1, use
of an upper partial denture, and that she
felt that her upper canine tooth 'stuck out'.
Patient HG was wearing a partial acrylic
denture (spoon denture) at the time,
with which she was unhappy due to lack
of retention, poor aesthetics and social
embarrassment. The UR1 had suffered an
avulsion injury 3 years previously and the
DentalUpdate 215
 Orthodontics

a e h

i
f

g j

Figure 1. (a–j) 6/6/13. Initial intra-oral and extra-oral views, including partial denture.

tooth was re-implanted by her dentist
after an extended extra-oral time of one
hour. Unfortunately, this tooth became
ankylosed and had to be extracted in
August 2012 to prevent further loss
of alveolar bone height and recurrent
infection.
Orthodontic examination
showed that the patient had a mild Class
216 DentalUpdate
II skeletal base with a Class II division
1 incisal relationship. The overjet was
measured at 5 mm with an average
overbite. The upper arch showed
moderate crowding with the UL3 having
contact point displacement of 6 mm.
There was average inclination of the upper
incisors. The lower teeth presented mild
crowding of 3 mm, retroclination of the
lower incisors, a moderate curve of spee
and a lower centreline shift to the right
by 3 mm. The lips were competent at rest,
with full incisor show on smiling. Buccal
segments were ½ Class II on the left-hand
side and ¾ Class II molar on the right-
hand side. The IOTN was 4d, due to the
displaced canine (Figures 1 and 2).
As this was a complex case
March 2018

Figure 2. OPT taken 16/10/12.
with many treatment options, following
the orthodontic examination, the
patient was subsequently seen at a
joint orthodontic and restorative clinic.
This allowed for a full discussion of all
treatment options to allow the patient
and parents to make an informed choice
with the help of a multidisciplinary
team.
It was concluded that the
UR1 had experienced replacement
resorption, hence its subsequent
extraction. Irregular gingival contours
and a significant palatal concavity with
a rather unusual midline palatal fissure
indicated that implant placement would
be difficult without careful planning
and bone grafting.6 The defect in the
alveolar ridge would have also made
replacement using a resin-bonded
bridge aesthetically challenging.
The various treatment options were
discussed and a final treatment plan was
decided upon.
Options
1. Extraction of UL3 and no further
treatment
Although this was an option
it was not appropriate as this plan would
not address the patient’s concerns, and
would leave her with an unsatisfactory
partial denture.
March 2018
2. Extraction of UL3, fixed appliances
upper and lower arches to maintain space
for prosthesis
Prosthetic replacement
could involve the use of a resin-bonded
bridge or partial denture before
implant placement. When the patient
is 18, a dental implant placement
could be considered. Alternatively, a
resin-bonded bridge as a definitive
restoration of the UR1 space could be
used. In regard to the resin-bonded
bridge, there are several factors that
need to be considered for the bridge
to be successful, including careful case
selection, bridge design and clinical
technique.7 Due to the patient’s vertical
ridge defects, replacing the soft tissue
using a bridge becomes difficult. Pink
porcelain or composite can be used
to replace soft tissue. However, the
restoration often becomes bulky and
can compromise oral hygiene.7 The
provision of either a bridge or implant in
the space would be technically difficult
with limited survival and success rates in
a suboptimal site, as highlighted in the
joint clinic discussion.
3. Autotransplantation of the UL3 or UL5
into the UR1 space, fixed appliances upper
and lower arches
Autotransplantation is
defined as the movement of one tooth
from one position to another, within
Orthodontics
the same person.8 When implant
placement is not a viable option, for
example in a patient under the age of
18, autotransplantation of an immature
tooth can be considered an option. It
has been previously reported in the
literature that autotransplantation with
space closure may represent a viable
aesthetic result.9
Ideally, transplanting the
UL5 into the UR1 space would preserve
upper arch symmetry, and allow
alignment of the UL3, utilizing space
created by extraction distally to the
canine. If the UL5 was lost in the future,
bone would have been preserved for
implant placement once growth had
ceased. Transplanting the UL3 would
reduce orthodontic treatment time.
However, this would also leave a small
compromise in aesthetics due to
asymmetry.
There are several criteria that
have to be met for autotransplantation
to be a viable option. These include
donor tooth criteria, recipient site
criteria and careful patient selection.
Ideally, the donor tooth chosen for
transplantation should have two thirds
of its root developed with an open
apex. This provides the tooth with the
potential for pulp regeneration in the
transplant site (apex opening >1 mm
radiographically).8 Unfortunately, in
this case, all the patient’s premolars
were fully formed with practically
closed apices (Figure 2), and so this
treatment modality was deemed to
have a low chance of success. The lack
of bone, labially in the UR1 region,
was a further reason that the success
of autotransplation was doubted.
The success of autotransplantation is
largely down to the technical skill and
experience of the surgical team. Whilst
our surgical team have experience in
this treatment modality, they felt that to
attempt autotransplantation in this case
was too complex to guarantee success.
4. Extraction of UL3, fixed appliances in
the upper and lower arches to close space
and camouflage the UR2 as an UR1
This plan also incorporated
camouflage of the UR3 in the UR2 site
and both first premolars as canines with
DentalUpdate 217
 Orthodontics
composite build-ups, if required. The
aim would be to put the first premolars
in a Class I canine position and to finish
with the molars in a full unit, Class
II relationship. This option removed
the need for placing the prosthesis in
a suboptimal site and would reduce
the short- and long-term costs for the
patient and the National Health Service.
It also allowed re-establishment of the
alveolar ridge by means of migration
of the UR2 through orthodontic tooth
movement. Extraction of the UL3 would
also shorten treatment time.
a Rectangular 18/25 nickel
b d
c e
Figure 3. (a–e) 28/11/13. Bonding of the Lower 7s, 0.016” NiTi RP and invert UR3.
218 DentalUpdate
Option 4: Treatment a
Option 4 was chosen and the
finalized treatment plan was carried out
as follows:
1. Oral hygiene to an exemplary standard;
2. Extraction of the UL3, lower arch
treated none extraction;
3. Fixed appliances upper and lower
arches (MBT™) to close space in the upper
arch as detailed above.
4. Finish and retain.
b
Treatment progression
Treatment started in June
2013 and began with initial alignment
with 0.016” nickel titanium archwires. The
UR3 was inverted to change the torque
from -7 to +7, to reduce the prominence
of the canine root labially (Figure 3).
titanium archwires were used to continue
to level and align the teeth until working c
stainless steel 19/25 archwires could be
placed (Figure 4).
The next stage of treatment
was to place nickel titanium push coil
between the UR3 and UR2 to migrate
the UR2 towards the midline. When
d
e
Figure 4. (a–e) 19/6/14. 18/25 NiTi archwire with
push coil between the UR3 and UR2.
March 2018
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a a
b e
c
Figure 5. (a–c) 8/10/14. Impression and plaster
models of upper arch with and without wax-up
space had been created mesially and
distally around the tooth, an alginate
impression was taken of the upper arch
with the archwires removed. The wire
was replaced and the position of the
UR2 was held exactly by placing stainless
steel tubing, either side of the tooth, on
the archwire. This impression was used
to provide a kesling set-up and build the
UR2 to a relative size to the UL1. Once
the clinician was happy with the mock
up, a medium-bodied silicone impression
material (vinyl polysiloxane) was used to
create a stent, which could be used intra-
orally to build the tooth up in composite
(Figure 5).
Space has been created
mesially and distally between the UR2
due to the push coil. The UR2 was built-
up palatally, incisally, mesially and distally
March 2018
Orthodontics
d
f
but not labially due to the attachment
of the bracket to enamel. The tooth was
prepared in the usual way and Herculite
XRV™ (Kerr, Orange, CA, USA) enamel and
dentine composite was used to build the Figure 6. (a–g) 8/10/14. Composite build-ups
tooth up. The build-up was finished with focusing on the UR2.
green and white stones and Sof-flex discs
(Figure 6).
Now that the UR2 was a
size relative to the UL1, the remaining
was instructed to wear Class III elastics 24
orthodontic treatment involved upper
hours a day. Final detailing and finishing
centreline correction and complete
space closure in the upper arch. This was was completed on round stainless steel
achieved by the use of a power chain on archwires (Figure 7).
an upper 19/25 stainless steel archwire. The patient was debonded
To allow mesial movement of the upper after 2 years of orthodontic treatment
buccal segments and prevent reduction with the occlusion and facial appearance
of the overjet and overbite, the patient as in Figure 8.
DentalUpdate 221
 Orthodontics

a a f

b b

c
c

d d

i
e
e

Figure 7. (a–e) 2/4/15. Class III elastics, power-

chain on upper 19/25 stainless steel archwire. Figure 8. (a–i) 24/9/15. Debond and review.

222 DentalUpdate March 2018

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Discussion
This case is a good example
of an effective method to treat a patient
who has suffered ankylosis with bone loss
following an avulsion injury in childhood.
Avulsion injuries are more common in
patients with a large maxillary overjet,
according to the literature.10 There are
many advantages of using orthodontics
and direct composite bonding to restore
a patient’s dentition. A primary advantage
is that it is a cost-effective option in the
short- and long-term. There are no initial
implant/bridge costs for placement and
no costs associated with implant/bridge
management and future replacement.
The cost of a bridge on the NHS is
currently priced at £244.30.11 Dental
implants are often not provided on the
NHS and the average cost of an implant
in the UK is currently between £1500 and
£4000.12
This treatment has been
minimally invasive, utilizing the patient’s
remaining dentition to provide a good
aesthetic result and restore alveolar bone
in the UR1 position.
From a critical perspective,
the upper centreline is to the right
by approximately 1.5 mm. This may
have occurred due to the asymmetric
arrangement and size of teeth in the
upper left and right labial segments.
Considering the overall result, it was felt
that this was acceptable and unlikely to
be noticed by members of the public.13
The authors note that
symmetry was not preserved in this case,
however, they feel that this has been
adequately camouflaged. In hindsight, a
superior aesthetic result may have been
achieved by extraction of the UL2 instead
of the UL3. This would have left the
patient with both maxillary canines in the
lateral incisor positions, creating a more
symmetrical finish. Relapse potential
of aligning a high buccally positioned
canine would have to have been
considered during the consent process.
Ideally, the UR3 would benefit
from bleaching and build-up in the future
to achieve a more aesthetic result. The
patient’s low smile line masks the higher
gingival margin of the UR3 compared to
the UL2. Careful monitoring of the UL2
build-up by the GDP is essential to ensure
March 2018
that good gingival health is maintained.
Using composite build-ups to
alter tooth morphology to resemble the 8.
UL1 counterpart has enabled a minimally
invasive treatment plan where there was
little need for tooth preparation. The
patient has the option to have further
restorative dentistry performed, if desired. 9.
Conclusion
In this case, the orthodontic
team have been able to work closely with 10.
their restorative colleagues to provide the
optimal treatment for the patient, which
has been both cost-effective and has
provided an aesthetic end result. 11.
Avulsion injuries can be
very traumatic for children and it is
important to re-implant the tooth as
soon as possible. If ankylosis does occur,
classically, there are several options to
replace the tooth via prosthesis. This case 12.
has provided an alternative treatment
plan to restore the space created due to a
lost tooth.
References
13.
1. Duggal M, Cameron A, Toumba
J. Paediatric Dentistry at a Glance.
Oxford: Wiley-Blackwell, 2013.
2. Andreasen JO, Borum MK, Jacobsen
HL, Andreasen FM. Replantation of
400 avulsed permanent incisors.
Endod Dent Traumatol 1995; 11:
51−58.
3. Dental Trauma Guide − Avulsion
Prognosis [online]. Accessed
December 2015. Available from
http://www.dentaltraumaguide.
org/Permanent_Avulsion_
Prognosis.aspx
4. Andersson L, Andreasen J, Day P.
International Association of Dental 1. C
Traumatolgy Guidelines of Traumatic
Dental Injuries: 2. Avulsion of 2. A
Permanent Teeth. Dent Traumatol
2012; 28: 88−96.
5. Emerich K, Wyszkowski J. Clinical 3. D
practice: dental trauma. Eur J Pediatr
2010; 169: 1045−1050.
6. Meredith N. Assessment of implant 4. C
stability as a prognostic determinant.
Int J Prosthodont 1998; 11: 491−501.
5. D
7. Durey KA, Nixon PJ, Robinson S,
Chan MF. Resin bonded bridges:
Orthodontics
techniques for success. Br Dent J 2011;
211: 113−118.
Nimčenko T, Omerca G, Varinauskas
V et al. Tooth auto-transplantation
as an alternative treatment option: a
literature review. Dent Res J (Isfahan)
2013; 10: 1−6.
Zachrisson B. Planning esthetic
treatment after avulsion of maxillary
incisors. J Am Dent Assoc 2008; 139:
1484−1490.
Bastone E, Freer T, McNamara J.
Epidemiology of dental trauma: a
review of the literature. Aust Dent J
2000; 45: 2−9.
NHS Dental Services Explained
[online]. Accessed December 2015.
Available from http://www.nhs.uk/
NHSEngland/AboutNHSservices/
dentists/Pages/nhs-dental-charges.
aspx
Dental implants information
hub. Dental Implants Prices UK
[online]. Accessed December
2015. Available from http://www.
dentalimplantscosthq.co.uk/dental-
implants-cost-uk/
Johnstone CD, Burden D, Stevenson.
The influence of dental to facial midline
discrepancies on dental attractiveness
ratings. Eur J Orthod 1999; 21: 517−522.
CPD ANSWERS
January 2018
6. C
7. C
8. D
9. C
10. C
DentalUpdate 225
 !
 



 






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 Enhanced CPD DO C PaediatricDentistry/OralMedicine

Mona Agel

Mamdouh Al-Chihabi, Halla Zaitoun, Martin H Thornhill and Anne M Hegarty

Lichen Planus in Children

Abstract: Lichen Planus (LP) is a chronic, inflammatory disease of the skin and mucous membranes. It is more frequently seen in the
middle-aged and elderly population but can be present in children, although this is relatively rare. This paper describes the presentation
and management of lichen planus in children, illustrated by seven cases seen within the Paediatric Dentistry Unit. Dentists should be aware
of the condition and understand when referral to a specialist centre is required and the need for multidisciplinary management of complex
cases.
CPD/Clinical Relevance: Although oral lichen planus is rare in children, it is important that dentists are able to identify its clinical
presentation and abnormal changes to the oral mucosa, as well as being aware of possible local and systemic causes of the condition so
that reassurance and correct management pathways can be implemented in primary care practice.
Dent Update 2018; 45: 227–234

Lichen planus is a chronic inflammatory
disease associated with a cell-mediated
immune reaction affecting the skin and
mucous membranes.1 Wickham, in 1895,
described the characteristic appearance of skin
lesions as, ‘white striae that develop atop the
flat surfaced papules’.2
Up to six clinical appearances of
oral lichen planus (OLP) have been described
in the literature.3 The characteristic sites
involved are the buccal mucosa, lateral borders
of the tongue and, less frequently, the gingival
Mona Agel, BDS, MJDF RCS(Eng), MDPH,
Specialty Dentist in Paediatric Dentistry,
Charles Clifford Dental Hospital,
Mamdouh Al-Chihabi, BDS, MFDS,
MClinDent, Specialty Trainee in Paediatric
Dentistry, Charles Clifford Dental Services,
Halla Zaitoun, BDS, MFDS, MDentSci,
FRCS(Paed), Consultant in Paediatric
Dentistry, Charles Clifford Dental Services,
Martin H Thornhill, MBBS, BDS, PhD,
MSc, FDS RCS(Edin), FDS RCSI, FDS
RCS(Eng), Professor of Translational
Research in Dentistry, School of Clinical
Dentistry, University of Sheffield and
Anne M Hegarty, MSc(OM), MBBS, MFD
RCSI, FDS(OM) RCS, Consultant in Oral
Medicine, Charles Clifford Dental Services,
Sheffield, UK.
March 2018
tissues. Table 1 describes the different types of
oral lichen planus seen.4
Oral lichen planus is relatively
rare in children, so few reports on this subject
are present in the literature.5,6 This paper
reports seven different cases of oral lichenoid
disease in children with the aim of supporting
clinicians in recognizing the presentation of
OLP and its subsequent management.
We present a series of cases seen
on the joint Oral Medicine and Paediatric
dentistry clinic of the Charles Clifford Dental
Hospital. This demonstrates the ages and
gender of the patients seen, along with a
brief description of the presenting complaint,
clinical presentation and the management
plan.
Demographic factors
Lichen planus is a chronic
inflammatory mucocutaneous disease. It
commonly involves the oral mucosa but other
extra-oral sites may be affected including the
skin, scalp, genital area and the nails. Oral
lichen planus (OLP) affects between 0.1%
and 2.2% of the adult population.7 It is seen
most frequently in the middle-aged and
elderly population,8 with females accounting
for approximately 60−65% of patients.9 The
incidence rates for children are limited to case
reports and case series, owing to the small
number of cases that present clinically. There is
no apparent gender predilection in children.10
OLP affects all races, although reports
suggest that childhood lichen planus is more
common in the tropics, especially in Indian
populations.11 OLP has been reported in six
boys aged 6 to 14 years over a 20-year period
in 200112 and, in another case series, reported
in three girls.6
Aetiology
The exact aetiopathogenesis of
lichen planus is not completely understood,
but a T-lymphocyte infiltrate suggests cell-
mediated immunological damage to the
epithelium.13,14
Lichen planus has been associated
with genetic predisposition, diabetes,
hypertension, infections including hepatitis
C, autoimmune liver disease and dental
restorations.9,13,15
Childhood lichen planus has been
documented as a complication of Hepatitis
B vaccinations (HBV) where the recombinant
proteins of the HBV vaccine, especially the viral
S-epitope, may trigger a cell-mediated auto-
immune response targeted at keratinocytes
giving rise to a lichenoid reaction.16,17 It is
also found in association with predisposing
conditions such as Graft versus host disease
(GvHD) and chronic active Hepatitis C.18
Genetic factors and lifestyle have also been
cited as aetiological factors. More recent
studies suggest that at least 50% of cases
reported had a familial history of lichen
DentalUpdate 227
 PaediatricDentistry/OralMedicine

Lichen Planus Clinical Presentation

Reticular Most common type of LP

Characteristic interlacing white keratotic lines
Papular Small lesions (0.5−1.0 mm diameter) − often overlooked during
clinical examination
Raised papules may be seen with another type of LP
Plaque-like Plaques can be smooth, flat areas or irregular, elevated area
Figure 1. Erosive oral lichen planus.
Erythematous/ Second most common type of oral LP
Atrophic Presents as areas of erythema and may be surrounded by fine
keratotic striae Patients will need to be
Ulcerative Variant of the erosive type (Figure 1) encouraged to maintain excellent oral hygiene
as this is believed to be contributory in
Bullous Variant of the erosive type reducing symptoms.3 However, this is likely to
Bullae form and rupture very soon after appearing, resulting in the be difficult during periods of disease activity.
classic appearance of erosive LP Since LP is relatively uncommon
Table 1. Clinical presentations of oral lichen planus.3,4 in children, there is very little information
in the literature relating specifically to the
treatment of the condition in this age group.
The concepts of treatment of LP are the same
planus.19 In the seven cases presented in Table however, its occurrence with Turner’s
as those for adults, with attention to the
2, there was no family history of lichen planus, syndrome is yet unrecognized.
recommended age-specific dosages for topical
which is consistent with an earlier case series.20
or systemic medication used for children.
Reports in the literature describing
Diagnosis Treatment is based around
children with cutaneous lichen planus have
removal or avoidance of aggravating factors
highlighted additional oral involvement in The clinical presentations of oral
and management of symptoms. Symptoms
4−39% of cases.21-24 Interestingly, two of our lichen planus are diverse, ranging from the
may include burning sensation or discomfort
seven cases had cutaneous and oral mucosal classical white symmetrical reticular network
eating certain foods and so avoidance of those
lesions and in both these cases the referral had found characteristically bilaterally on the
foods/flavours should be encouraged. Any
come from medical colleagues based on the buccal mucosa, to widespread and debilitating
amalgam restoration in close proximity to a
initial cutaneous lesions. ulcerative lesions. LP may be diagnosed readily
lesion may need to be replaced. Patch testing
It is unusual for children by its clinical presentation alone, particularly if may help to diagnose a lichenoid reaction.
to develop an oral lichenoid reaction the classic reticular form is noted.15 However, Topical analgesia such as
in association with dental amalgam.25 in most cases histological evaluation of tissue Benzydamine hydrochloride (Difflam®, 3M
Hypersensitivity to dental amalgam is rare and, from a biopsy is required for a definitive Health Care Limited, UK) mouthrinse or
according to Holmstrup,26 is due to corrosion diagnosis to be made.3 spray is an anti-inflammatory agent that can
products of amalgam restorations. In almost The differential diagnosis of lichen provide symptomatic relief in cases where
all cases it seems to be related to mercury, planus includes chronic candidosis, chronic pain is experienced during speech and eating.
with only a few cases implicating silver, cheek chewing, lichenoid reaction to dental Antiseptic mouthrinses, such as chlorhexidine
copper, or tin.26,27 These oral lichenoid lesions amalgam or drugs, Graft versus host disease gluconate (Corsodyl®, GlaxoSmithKline, UK)
(OLL) represent a contact allergy to dental and possible vesiculobullous conditions in may also be used13 and is available in gel form
amalgam which may develop after sustained children presenting with bullae or ulcers.3 (1.1% w/w) or as a spray. Topical preparations,
contact for several years.28,29 Resolution of oral such as Gengigel® (Ricerfarma SRL, Milano) are
lesions after removal of amalgam restorations also used. The active ingredient in Gengigel® is
in such patients has been reported.29 This Management hyaluronic acid, which promotes tissue healing
improvement was found within one week Children affected with LP are often and provides pain relief. It is available as a gel
to three months of replacing amalgam asymptomatic or minimally symptomatic or mouthrinse.
restorations, with greatest improvement when but it is important that parents or carers are Topical corticosteroids, such as
the lesion is in close contact with OLLs.25 aware that there is currently no cure for the betamethasone sodium phosphate (Betnesol®
There are three case reports condition. Asymptomatic LP (generally the UCB Pharma) are indicated in the treatment
in the literature stating lichen planus in reticular and plaque forms) does not usually of LP. Betnesol® is available as a 0.5 mg
association with Turner’s syndrome.30-32 require treatment or intervention. Diagnosis tablet to be dissolved in water and used as a
Previous associations of lichen planus with and providing the patient with information mouthrinse. Similarly, fluticasone propionate
other medical disorders have been described, about the condition will provide reassurance. preparations (Flixonase®, Allen & Hanburys
228 DentalUpdate March 2018
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Ltd, UK) and Beclometasone spray (Clenil
Modulite®, Chiesi Ltd UK − 50 micrograms)
may be used to help alleviate symptoms.13
Fluticasone propionate drops (Flixonase®
Nasule® Drops 400 micrograms (1mg/ml)) are
mixed with water and used as a mouthrinse.
No single successful treatment regimen has
been identified, although betamethasone
sodium phosphate mouthrinse and fluticasone
propionate preparations are widely used.33
The risk of topical and systemic steroid use in
children is an important consideration.
Tacrolimus or ciclosporin are
topical immunomodulators that may be
used as second-line treatment in persistent
OLP.33 In very severe cases of OLP, systemic
corticosteroids are considered, particularly
if the OLP is widespread and involving other
body sites that are non-responsive to the first-
line topical therapies.7
Because of the paucity of
randomized controlled clinical trials to
evaluate therapies for children, there is
a lack of strong evidence supporting the
effectiveness of any palliative therapy for OLP
in this age group. Recent systematic reviews
of therapies for symptomatic OLP concluded
that topical corticosteroids are considered
to be first-line treatment33 and evaluated
interventions for treating erosive LP, which
failed to show superior effectiveness of any
specific treatment.34
Clinical cases (Table 2)
Case one
Presenting complaint
A 15-year-old Caucasian girl was
referred by her dentist to the joint Paediatric
Oral Medicine clinic at Charles Clifford Dental
Hospital, with a 6-month history of a burning
sensation affecting the oral mucosa when
consuming spicy foods. Her medical and family
histories were unremarkable.
Clinical findings
Extra-orally, no abnormalities were
detected. Intra-oral examination revealed
white striae bilaterally in the left buccal sulcus
and on the right dorsum of the tongue. No
other mucosal or skin surface lesions were
noted.
Diagnosis
An incisional biopsy of the left
buccal mucosa was carried out and the
histopathology revealed hyper-parakeratinized
March 2018
PaediatricDentistry/OralMedicine
stratified squamous epithelium overlying a
fibrous connective tissue with adipose tissue
at the deep aspect and thickening of the
basement membrane. A definitive diagnosis of
oral lichen planus was made.
Management
The management consisted of
avoidance of irritating foods and Difflam®
spray to be used when symptomatic. Periodic
review showed an improvement in both b
symptoms and severity of the lichen planus.
The lesions are currently present but quiescent
and no topical therapy is needed.
Case two
Presenting complaint
A 13-year-old Caucasian girl Figure 2. (a, b) Oral lichenoid reaction on lateral
was referred regarding a 6-month history of border of the tongue associated with large
pain in the mouth which was aggravated on amalgam restoration (Case 2).
food intake. The past medical history was
unremarkable.
Clinical findings
the Paediatric Physician as lichen planus.
Oral examination revealed a white,
Clinical findings
translucent lesion with exaggerated fissuring
Extra-oral examination revealed
on the left lateral border of the tongue,
measuring approximately 20 mm long x 8 mm dry skin on the face, neck and hands with
wide. Large amalgam restorations in UL6 and small and dry nails. Oral examination showed
LL6 were present (Figure 2). a depapillated red patch on the right side of
the dorsum of the tongue with three ulcers
Diagnosis
on the ventral surface of the tongue. It was
Routine haematology and
also noted that there were white striae and
biochemistry were unremarkable. An incisional
plaque-like patches in the lower right and left
biopsy revealed features consistent with a
lichenoid tissue reaction. As a result patch
lingual sulci.
testing to the dental series was requested and Diagnosis
showed a positive reaction for both amalgam A diagnosis of mucocutaneous
alloy and mercury. lichen planus, with lesions affecting the oral
mucosa and the genital area, was made
Management
The management included based on the patient’s history and clinical
examination.
replacement of the amalgam fillings in both
UL6 and LL6 with glass ionomer cement. The Management
lesion subsequently resolved and was not The oral lichen planus lesions
discernible six months later. were successfully controlled using Gengigel®
and betamethasone sodium phosphate
mouthrinse. The patient is currently under
Case three
regular review.
Presenting complaint
A 13-year-old Caucasian girl was
Case four
referred by her Consultant Paediatrician with
a chief complaint of red and painful gums Presenting complaint
with small blisters. Medically the patient had A 14-year-old Caucasian girl was
been diagnosed with Turner’s syndrome at referred from the Oral & Maxillofacial Surgery
birth and she also suffered from eczema. The department regarding a white patch on the
patient was originally referred to Sheffield buccal mucosa. Medical history revealed the
Children’s Hospital regarding rashes on the patient to have Irritable Bowel Syndrome and
genital area, which had been diagnosed by an allergy to penicillin.
DentalUpdate 231
 PaediatricDentistry/OralMedicine

Case Gender Age Presenting Complaint Clinical Presentation Medical History Diagnosis Treatment
1 F 15 Burning sensation on White striae in buccal Nil Lichen Planus Difflam®
consuming spicy food sulcus and dorsum of mouthwash
tongue
2 F 13 Pain on eating White translucent Nil Lichenoid Replace
lesion with fissuring on tissue reaction amalgam with
lateral border of tongue associated glass ionomer
adjacent to a large with amalgam cement
amalgam restoration restoration
3 F 13 Painful gums and Intra-oral depapillated Turner’s Lichen Planus in Gengigel®
blisters red patch on right side syndrome association with Betnesol®
of dorsum of tongue Eczema Turner’s syn- mouthwash
with 3 ulcers on ventral drome
surface of tongue
White striae and plaque-
like patches in lingual
sulcus
4 F 14 Nil Bilateral white striae on Irritable Bowel Lichen Planus Nil
buccal mucosa Syndrome
Penicillin allergy
5 M 8 Nil Bilateral white striae VACTERL Lichen Planus Gengigel®
on gingivae, buccal association associated with
and palatal mucosa T-cell T-cell immune
and lateral and ventral lymphopenia deficiency
surfaces of the tongue Developmental
with erythema delay
6 F 12 Nil Small, reticular, white Nil Lichenoid tissue Nil
patches on buccal reaction
mucosa and retromolar
area
7 M 14 Nil Unilateral white striae Growth and Lichenoid tissue Replace
on buccal mucosa and muscular reaction amalgam with
lateral border of tongue problems related glass ionomer
to meningococcal cement
Septicaemia in
infancy
Table 2. Case series of patients with oral lichen planus seen within the unit of Paediatric Dentistry in Charles Clifford Dental Hospital.

Clinical findings was performed under local anaesthesia Management

Intra-oral examination revealed
white striae on the buccal mucosa bilaterally.
No other mucosal or skin lesions were present.
Diagnosis
Investigations included a full
blood count, haematinics and biochemistry
screen. The results were uniformly normal. An
incisional biopsy of the right buccal mucosa
232 DentalUpdate
and the histopathology revealed
a hyperplastic stratified squamous
epithelium overlying a fibrovascular
connective tissue with adipose tissue
at the deep aspect. Thickening of the
basement membrane was also seen. A
definitive histopathological diagnosis of
oral lichen planus was made.
As the patient was asymptomatic
no active treatment was provided and the
patient is under periodic review.
Case five
Presenting complaint
An 8-year-old boy of South Asian
ethnicity was referred by his Consultant
March 2018

Paediatrician to the joint Paediatric Oral
Medicine clinic regarding asymptomatic white
lesions on the oral mucosa. The patient’s
medical history included; VACTERL association
which consists of anomalies affecting
Vertebral, Anal, Cardiovascular, Tracheo-
Esophageal, Renal/Radial systems and the
Limbs. Additionally, he had T-cell lymphopenia
and developmental delay. The patient was
taking Co-trimoxazole prophylaxis. He was
under the care of Dermatology, Paediatric
surgery, Infectious diseases and Immunology
specialists at Sheffield Children’s Hospital.
Clinical findings
Extra-oral examination showed
papular lesions affecting the neck, trunk and
legs. Intra-oral examination revealed bilateral
white striations on the gingivae, buccal and
palatal mucosa and the lateral and ventral
surfaces of the tongue with a background of
erythema (Figure 3).
Diagnosis
A skin biopsy taken of lesions
on patient’s back under general anaesthetic
by paediatric dermatology confirmed the
diagnosis of lichen planus, negating the need
for oral biopsy.
Management
No treatment was required as
the lesions were asymptomatic. The patient
remains under regular review.
Case six
Presenting complaint
A 12-year-old Caucasian girl was
referred by her dentist to the Oral Medicine
Clinic at Charles Clifford Dental Hospital, with
a 3-month history of an asymptomatic, white
lesion on the left buccal mucosa and right
retromolar region. Her medical and family
histories were unremarkable.
Clinical findings
Extra-oral examination showed
no skin lesions. However, the patient gave a
3-month history of previous red, itchy and dry
rashes on her hands and feet. The lesions had
been treated with steroid cream and were
completely resolved. Intra-oral examination
showed small, reticular, white patches on the
left buccal mucosa and the right retromolar
area.
Diagnosis
An incisional biopsy of the
left buccal mucosa was undertaken and
histopathology showed hyperplastic and
March 2018
PaediatricDentistry/OralMedicine
a
b Figure 4. Plaque-like oral lichen planus of the
Figure 3. (a, b) Reticular oral lichen planus (Case 5).
atrophic parakeratinized stratified squamous
epithelium overlying fibrous connective tissue,
confirming a diagnosis of a lichenoid tissue
reaction.
Management
No active treatment was provided
and the patient is under 6-month review.
Case seven
Presenting complaint
A 14-year-old Caucasian boy was
referred by his dentist to the joint Paediatric
Oral Medicine Clinic at Charles Clifford
Dental Hospital regarding an asymptomatic
white patch on the buccal mucosa. The
medical history revealed that the patient
had growth and muscular problems relating
to meningococcal septicaemia in infancy.
The patient’s regular medications included
Naproxen and Codeine pain-killers. He had no
known allergies.
Clinical findings
Extra-orally no abnormalities were
detected. Intra-oral examination revealed
unilateral white striae affecting the buccal
mucosa and lateral border of the tongue.
Amalgam restorations were present on UR6
and UL6. The patient recently completed
a course of orthodontic treatment with
removable appliances (Figure 4).
Diagnosis
An incisional biopsy was carried
out and revealed features consistent with a
tongue (Case 7).
lichenoid tissue reaction. Patch testing for the
constituents of amalgam filling material and
stainless steel wire were requested. The results
revealed the patient had an allergic contact
reaction to mercury and vanadium.
Management
The amalgam restorations were
replaced with glass ionomer cement.
Conclusion
Lichen planus is rare in children
and oral mucosal involvement is rarer still. The
cases described in this paper demonstrate
the aetiopathogenesis and presentation
of oral LP, highlighting that this should be
considered in the differential diagnosis of
oral mucosal lesions in children. The general
dental practitioner may be the first healthcare
professional to identify such lesions in
paediatric patients and should know when to
refer to a specialist for appropriate assessment
and management.
References
1. Thornhill MH. Immune mechanisms in oral
lichen planus. Acta Odontol Scand 2001; 59:
174−177.
2. Khandelwal V, Nayak PA, Nayak UA, Gupta A.
Oral lichen planus in a young Indian child. BMJ
Case Rep 2013; bcr2013010516. doi:10.1136/
bcr-2013-010516.
3. Edwards PC, Kelsch R. Oral lichen planus:
clinical presentation and management.
J Can Dent Assoc 2002; 68: 494−499.
4. Ismail SB, Kumar SK, Zain RB. Oral lichen planus
and lichenoid reactions: etiopathogenesis,
diagnosis, management and malignant
transformation J Oral Sci 2007; 49: 89−106.
5. Kanwar AJ, De D. Lichen planus in childhood:
report of 100 cases. Clin Exp Dermatol 2010; 35:
257−262.
6. Scully C, Almedia OPD, Welbury R. Oral lichen
planus in childhood. Br J Dermatol 1994; 131:
131−133.
7. Al-Hashimi I, Schifter M, Lockhart PB et al.
Oral lichen planus and oral lichenoid lesions:
diagnostic and therapeutic considerations. Oral
DentalUpdate 233
 PaediatricDentistry/OralMedicine
Surg Oral Med Oral Pathol Oral Radiol Endod
2007; 103(Suppl): 525. e1−12. Epub 2007 Jan
29.
8. Silverman S Jr, Griffith M. Studies on oral lichen
planus II. Follow up on 200 patients, clinical
characteristics, and associated malignancy. Oral
Surg Oral Med Oral Pathol 1974; 37: 705−710.
9. Scully C, El-kom M. Lichen planus: review and
update on pathogenesis. J Oral Pathol 1985; 14:
431−458.
10. Luis-Montoya P, Dominguez-Soto P, Vega
Memije E. Lichen planus in 24 children with
review of the literature. Pediatr Dermatol 2005;
22: 295−298.
11. Clover GB, Dawber RP. Is childhood idiopathic
atrophy of the nails due to lichen planus? Br J
Dermatol 1987; 116: 709−712.
12. Alam F, Hamburger J. Oral mucosal lichen
planus in children. Int J Paediatr Dent 2001; 11:
209−214.
13. Hegarty AM. Oral lichen planus: aetiology,
diagnosis and treatment. Dent Nurs 2012; 8:
141−146.
14. Walton LJ, Macey MG, Thornhill MH, Farthing
PM. Intra-epithelial subpopulations of T
lymphocytes and langerhans cells in oral lichen
planus. J Oral Pathol Med 1998; 27: 116−123.
15. Eisen D, Carrozzo M, Bagan Sebastian JV et al.
Number V. Oral lichen planus: clinical features
and management. Oral Dis 2005; 11: 338−349.
16. Limas C, Limas CJ. Lichen planus in children: a
possible complication of Hepatitis B vaccines.
Pediatr Dermatol 2002; 19: 204−209.
17. Agarwal S, Garg VK, Joshi A, Agarwalla A, Sah
M
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234 DentalUpdate
SP. Lichen planus after vaccination in a child:
a case report from Nepal. J Dermatol 2000; 27:
618−620.
18. Cottoni F, Ena P, Tedde G, Montesu MA. Lichen
planus in children: a case report. Pediatr
Dermatol 1993; 10: 132−135.
19. Anuradha Ch, Chandra Sekar P, Sridhar Reddy
G, Arvind babu RS, Kiran Kumar K, Reddy BVR.
Oral mucosal lichen planus in children − report
of three cases. J Orofac Sci 2011; 3: 20−23.
20. Patel S, Yeoman CM, Murphy R. Oral lichen
planus in childhood: a report of three cases. Int
J Paediatr Dent 2005; 15: 118−122.
21. Kumar V, Garg BR, Baruah MC, Vasireddi SS.
Childhood lichen planus. J Dermatol 1993; 20:
175−177.
22. Kanwar AJ, Handa S, Gosh S, Kaur S. Lichen
planus in childhood: a report of 17 patients.
Pediatr Dermatol 1991; 8: 288−291.
23. Nanda A, Al-Ajmi HS, Al-Sabah H, Al-Hasawi F,
Alsaleh QA. Childhood lichen planus: a report
of 23 cases. Pediatr Dermatol 2001; 18: 1−4.
24. Sharma R, Maheshwari V. Childhood lichen
planus: a report of fifty cases. Pediatr Dermatol
1999; 16: 345−348.
25. Issa Y, Duxbury AJ, Macfarlane TV, Brunton
PA. Oral lichenoid lesions related to dental
restorative materials. Br Dent J 2005; 198:
361−366.
26. Holmstrup P. Oral mucosa and skin reactions
related to amalgam. Adv Dent Res 1992; 6:
120−124.
27. Banoczy J, Roed-Petersen B, Pindborg JJ,
Inovay J. Clinical and histologic studies on
0845 340 2293
electrogalvanically induced oral white lesions.
Oral Surg Oral Med Oral Pathol 1979; 48:
319−323.
28. McParland H, Warnakulasuriya S. Oral lichenoid
contact lesions to mercury and dental
amalgam − a review. J Biomed Biotech 2012.
Online information available at http://dx.doi.
org/10.1155/2012/589569
29. Thornhill MH, Pemberton MN, Simmons RK,
Theaker ED. Amalgam-contact hypersensitivity
lesions and oral lichen planus. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2003; 95:
291−299.
30. Kurgansky D, Burnett JW. Widespread lichen
planus in association with Turner’s syndrome
and multiple endocrinopathies. Cutis 1994; 54:
108−110.
31. Knoth W, Meyhöfer W. On skin diseases
associated with the Ullrich-Turner syndrome.
Hautarzt 1965; 16: 392−400.
32. Cornbleet T, Webster JR, Musgrave DP. Turner’s
syndrome associated with lichen planus. AMA
Arch Derm Syphilol 1950; 62: 564−568.
33. Thongprasom K, Carrozzo M, Furness S, Lodi
G. Interventions for treating oral lichen planus.
Cochrane Database Syst Rev 2011 Jul 6; (7):
CD001168. doi: 10.1002/14651858.CD001168.
pub2.
34. Cheng S, Kirtschig G, Cooper S et al.
Interventions for erosive lichen planus affecting
mucosal sites. Cochrane Database Syst Rev 2012
Feb 15; (2): CD008092. doi: 10.1002/14651858.
CD008092.pub2.
March 2018
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 PracticeManagement Enhanced CPD DO C & DO A

Rosie Pritchett

Shirley Coleman, James Campbell and Shiv Pabary

Understanding Our Patient Base:

An Introduction to Data Analytics
in Dental Practice
Abstract: Dental practices are continually collecting patient data but it is often an underutilized resource. There is a growing trend
towards use of data analytics within companies to guide business decisions. For dental practices which use digital systems, a large reserve
of patient information is readily available. Simple data analytic techniques are presented which can be used to extract substantial insight
into patient demographics, DNA (did not attend) rates and many other areas of practical relevance to clinical service delivery and business
management.
CPD/Clinical Relevance: Data analytics is well established in many industries and has the potential for encouraging colleagues to look at
their data and understand their patient base and changes over time; practice owners can gain insight into patient demographics to guide
business decisions and improve patient care.
Dent Update 2018; 45: 236–246

Data analytics means taking an inquisitive
look at raw data, such as patient addresses,
and extracting meaningful information by
summarizing, illustrating and analysing the
data. Assessing the information in context
Rosie Pritchett, BDS(Hons), BSc(Hons),
General Professional Trainee within
Newcastle Dental Hospital, NE2 4AZ;
InDental Practice Ltd, Newcastle,
Shirley Coleman, PhD, CStat, Principal
Statistician, ISRU, School of Maths and
Stats, Newcastle University, NE1 7RU
and James Campbell, BDS(Hons),
MA(Cantab), General Professional Trainee
within Newcastle Dental Hospital, NE2
4AZ; InDental Practice Ltd, Newcastle and
Shiv Pabary, MBE, BDS(Hons), MFGDP
(UK), DipConsSed, Practice Owner,
InDental Practice Ltd, Fewster Square,
NE10 8XQ, UK.
236 DentalUpdate
leads to knowledge and the opportunity
to use this knowledge to make decisions
based on evidence. Dental practices collect
vast quantities of data everyday but usually
it is only interpreted as clinical records
or for auditing purposes. More broadly
across the healthcare sector, data supports
clinical decisions, disease surveillance and
population health management.1 Barriers
to further analysis in dental practice
include poor quality data, lack of analytics
experience, lack of time and resistance to
change.2
An example of data analytics
within a small business is the analysis of
a year’s worth of daily sales in a clothing
shop.3 Plotting a graph of typical sales
takings per day of the week demonstrates
that, though Saturday takings per hour are
the highest overall, sales per customer are
higher mid-week (Figure 1).
This suggests that
proportionately more customers browse at
weekends, while more come to purchase
on weekdays. This simple analysis helps to
guide the choice of appropriate opening
hours to reflect the change in sales across
weekends and weekdays.
Let us consider how we might
analyse the kinds of data available in
dentistry and apply it to the decisions
practices must make.
There are many different types
of practice, for example: a private squat
in a rented surgery; a mini-corporate
expanding; several independent dentists
forming a rebranded group practice. These
practices all face different types of clinical
and business challenges and these will
determine which analyses will be most
helpful.
For example, practices
might focus on: acquiring new patients;
minimizing the risk of an expansion
plan; revitalizing the patient base or
re-orientating the practice focus. Others
March 2018

Step
1 Describe the business and the
people it affects
2 Prioritize strategic questions
3 Review data resources, staff
skills and software
4 Identify relevant data
5 Describe and improve the
data
Table 1. Step-by-step guide to analysing data.
Analysis of mean daily sales
£120.00
£100.00
£80.00
£60.00
£40.00
£20.00
£0.00
Mon Tue Wed
Sales per hour
Figure 1. Data analytics of sales in a clothing shop.
might wish to identify: patients with unmet
needs; those willing to invest significantly
in dental treatment; true value underlying a
practice sales pitch; operational inefficiency.
Each practice faces a distinct set
of concerns and it is important to address
which areas are of most urgency to their
situation. A range of guidance exists on
selecting appropriate research questions.4
What analysis is possible will be
constrained by staff knowledge and training
in data analytic techniques, as well as the
data sources available.5 The following need
to be considered:
„ What software systems and databases
exist?;
„ Who handles data collection and
storage?;
March 2018
6 Consider access and
confidentiality issues
7 Summarize data, eg tables,
graphs
8 Enrich data using open sources
9 Analyse data
10 Report and recommend next
steps
Thu Fri Sat Sun
Sales per customer
„ What analytic software is available in the
practice (eg Microsoft Excel)?;
„ What skill set exists in-practice and what
training is required?
Dental practices affect a wide
range of people who are all stakeholders in
the practice and in the data analytics about
to be carried out. For example, principal(s),
associate(s), employed staff, existing
and new patients, local community and
competing practices.
The data collected and held by
the practice has many dimensions, any of
which can be the focus of the data analytics:
dates and times of appointments, types of
treatment, age and gender of patients.
Combining patient information
with open data, from sources such as the
PracticeManagement
Office for National Statistics (ONS) or the
NHS Business Services Authority (BSA),
provides a wealth of potential insight.6
Methodology
Stepwise guidelines for
analysing data in a dental practice
constitute a structured approach for any
practice wishing to use its data to enhance
its clinical and business performance.
These steps should not just
form a one-off lengthy project, but provide
a framework for ongoing assessment and
continuous improvement (Table 1). The
impact of small, measurable business
decisions based on data analytics can be
demonstrated by the changing trends in
outcomes (Table 2).
Preparing data for analysis can
take up a considerable proportion of the
project time. Errors and omissions in data
should be recorded and form part of a
continuous improvement cycle for data
quality. Once the benefits of data analytics
are demonstrated, then all staff should buy
in to providing data that is fit for purpose.
We have applied this framework
in a detailed service evaluation of a test
dental practice to illustrate how its own
data enriched with freely available open
data can be analysed to reveal valuable
insights.
Describing the business and
prioritizing
The test dental practice provides
mainly NHS care within North East England.
The practice opened in 1981 and moved to
purpose-built premises in 2009 comprising
ten surgeries. As well as general dentistry,
the practice also holds sedation and
orthodontic contracts, and accepts private
endodontic referrals.
This practice has a stable base
of patients and is not necessarily looking to
expand. The focus of interest is analysis of
the existing patient base in order to:
„ Enhance access to meet regulatory
requirements;
„ Optimize activity to improve operational
efficiency; and
„ Improve compliance with recall
guidelines to ensure continuity of care.
These are some specific
questions:
DentalUpdate 237
 PracticeManagement

Data Analysis Application

Office for National Statistics (ONS) data can be used to view
demographics of a catchment area
Practice software data on appointments can be extracted,
revealing patient longevity of attendance, turnover rate, typical
fees or costs of treatment per patient
Use of focus groups to collect information to inform
development of an online or paper questionnaire that will
canvass patient and local community opinion of the practice
Quantitative analysis of forward order book and financial
turnover; qualitative analysis of data on staff training and skills
Providing evidence of the characteristics of the local population
as justification to the BSA for deviating from regional or national
norms in NHS claims; market research for presentation to prospective
lenders when financing practice acquisition
Establishing operational performance of the practice: evidencing
and documenting efforts at improving access; justifying goodwill
valuations; targeting under-served or high-value groups
Enhance reputation of practice and build word-of-mouth;
demonstrate commitment to constant improvement and patient-
centred care
Informing decision to acquire a practice; due diligence on claims
about operating efficiency and ultimate valuation

Table 2. Applications of data available within a dental practice.

A B C D E F G H I J
1 Number patient.titl patient.firs patient.lastname patient.coc patient.h patient.wo patient.dob patient.altr patient.typ
32 31 Miss K. EXAMPLE K ########## 12607
33 32 Miss A. Example EXAMPLE A ########## 17958
34 33 Mr T. Example EXAMPLE T 1.9E+09 ########## 12407
35 34 Mr A. Example EXAMPLE A 1.9E+09 ########## 17618 Excel has 140 columns with 25,176 rows of
36 35 Miss A. Example EXAMPLE A 1.9E+09 ########## 17614 patient data. (Figure 2). Many of the 140
37 36 Mrs S.M. Example EXAMPLE S 1.9E+09 ########## 17617 columns are empty and information, such
38 37 Mr M. Example EXAMPLE M 1.9E+09 ########## 17616
39 38 Mr S. Example EXAMPLE S 1.9E+09 ########## 17615 as the address, may be repeated. The data
40 39 Miss H. Example EXAMPLE H 1.9E+09 ########## 18307 are in patient number order. Notice some
Figure 2. Screen shot of anonymized Excel data. of the peculiarities typical of raw data, for
example the telephone numbers in column
F have been written in ‘scientific form’ so all
1. Are we treating a representative provide an extensive data source, our the detail is hidden.
demographic of patients (all ages and test practice uses EXACT (Software of As this is a practical guide, we
genders)?; Excellence). Each software provider has consider some ways to get started. The
2. Is access socially equitable?; and advisors on hand who can assist with FILTER option in Excel is useful for gathering
3. What are the patterns of attendance? downloading the appropriate information. an initial overview of the data. Hover
Within EXACT ‘Contact Lists’ of patients the cursor over the ‘patient.sex’ column
can be downloaded who fit certain criteria (column T in our dataset) and left click to
Reviewing data resources within a desired date range. highlight the column. Then click on DATA,
Collection and storage of For this example, the EXACT then FILTER. Selecting ‘female’ will show
data involves the whole team, including dataset downloaded into Microsoft Excel the number of female patients. We have
receptionists, the practice manager, included 25,176 entries, from 2005 to 2016. 13,441 of the total 25,176. So overall 53% of
nurses and associates. Within this practice, Very large datasets may require an extra patients are female. The dataset has a lot of
the practice manager is responsible step for downloading, to avoid this the missing values in other columns but there
for reporting and has a comprehensive date range can be narrowed. You may want are no missing values for gender. A more
knowledge of tools within the software. For to start with looking at the most recent 5 elegant way of counting the females is to
example, identifying patients who have not years. use an Excel function =COUNTIF(T2:T25177,
attended within a certain time period, and The following information can ‘female’) which returns the number 13,441
sending out reminder letters. With most be used to address the questions posed as the number of females. There are 11,735
practice software systems, any employee in the introduction: name, address and males, so the ratio of women to men is 1.15.
with access can obtain an overview of postcode, date of birth, gender, date of We can explore the ‘patient.
the data. There may be scope for further last visit, dentist seen, date of last missed balance’ (column X in our dataset) in
development of data analytic skills within appointment, patient first visit. a similar way and find out how many
the team. patients have zero or a negative balance of
payments.
Describing and improving the There are usually errors in any
Identifying relevant data data dataset.7 These include: multiple versions
Practice software systems The raw data exported into of postcodes, some with spaces and some
238 DentalUpdate March 2018
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References
1. Araujo MW, et al. J Am Dent Assoc 2015;146:610–622.
2. Johnson & Johnson. Data on file.
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 PracticeManagement

next available column (in our dataset this

Age distribution is column EN) type =datedif(h2,cq2,’y’)
10 and the AGE at last birthday will appear in
9 cell EN2. Cascade the command down the
8 column by double clicking in the lower right
7 hand corner of cell EN2. Patients with a
6 missing date of birth have age 116 as Excel
5 interprets blanks as 1st January 1900.
4 The data can be summarized
within Excel using pivot tables. To obtain a
3
pivot table, place the cursor on any entry
2
within the spreadsheet and click on INSERT
1
and PIVOT TABLE.
0
For example, to summarize the
4 9
0- 5-

+
4
9

4
9

4
9

9
4

9
4
9
age range of patients in the pivot table:
4

90
-1
-1

-2

-3

-4
-4

-5
-5

-6

-6
-7

-7
-8
-8
-2

-3
10
15

25

30

40
45

50
55

60

65
70

75
80
85
20

35

1. Drag ‘AGE’ to the ROWS and the patient

NE%
Figure 3. Age distribution of North East region and the practice.
without; addresses in a mix of upper and
lower case; dates of birth wrongly entered
and data items missing. A note should be
kept of all the corrections made and these
notes should be used to help improve the
data collection process.
The dataset is large (nearly 20
MB) so it is important not to make new
copies every time changes are made to
correct errors and omissions. It is always
important to keep an unchanged copy and
subsequent copies should be clearly named
to avoid confusion.
The EXACT dataset includes the
necessary data to analyse the numbers of
new patients, drop-out rate, net number
of new patients each year, gender mix,
number of missed appointments and their
cost in terms of time lost. Using basic data
manipulation techniques, we can extract
data that is relevant to these questions of
interest.
Access and confidentiality
The data should be handled
as per the Data Protection Act.8 Methods
must be imposed to ensure safe handling,
for example only using practice computers
for analysis, using a separate password
protected USB drive to store data and
keeping records confidential. To ensure
anonymity and that no data can be traced
back to individual patients, the names can
be erased from the data list or replaced with
March 2018
Practice %
unique ID codes.9
Care with patient data is
paramount and it is worth noting that, not
only names need to be considered, but
also dates of birth and postcodes. It is well
known that individuals can often be traced
by triangulation (combining different pieces
of information), particularly if they are
unusual in any way, for example if they are
the oldest person in a postcode with few
residences.
There is an important distinction
between using data for service evaluation
and carrying out research. The Medical
Research Council has a helpful tool to
decide if a project is a service evaluation or
research (http://www.hra-decisiontools.
org.uk/research/index.html). The data
analytics discussed in this article is a
service evaluation rather than research
and consequently it does not need ethical
approval.
Summarizing the data
Many different formulas are
available in Excel to extract information
from dates. For example, patient age can
be calculated from the difference between
the date of birth (in column H in Figure 2)
and the date the spreadsheet was created,
referred to as ‘general.date’ (in column CQ in
our dataset). Make sure that both columns
are in date format and use the ‘datedif’
formula to find age at last birthday. In the
number to the VALUES;
2. Click on ‘pivot chart’ to get a bar chart.
The bar chart shows the current age
distribution of patients in the practice.
Excel has reasonable help
facilities, accessed by clicking on ‘?’ at the
top right of the screen.
We can now produce some
insight from the data. For simplicity, all
analyses within this article were carried
out using Excel, however, other statistical
programs can be used.
Enriching the data
At this point we now have a
large, well-organized dataset, in our case,
regarding patient demographics and
appointments. National demographics are
useful to the practice as a comparison to
help understand unmet need, effectively
targeting marketing. Demographic data
are available from numerous open sources,
UK-wide and for local areas. In example 1,
we integrate public data on age distribution
with our established dataset.
Analysing the data
Example 1: Patient demographics and access
We have used ONS data to
compare the age range of the practice
patients with the North East population
(Figure 3). We can see that the practice
appears to be capturing a representative
sample of the general population overall.
The practice age distribution is similar to
the NE demographic except that there are
fewer very young children and older adults
DentalUpdate 241
 PracticeManagement
Year of first visit
2000
1800
1600
1400
1200
1000
800
600
400
200
0 of contracted NHS activity and assessing
2006 2007 2008 2009
Figure 4. Patient numbers by year of first visit.
and more people in middle age. A practice
which appeared to be low in the 25−45
age group may consider initiatives such as
late opening for those who have difficulty
attending during work hours.
Comparing the practice and
regional age distributions helps determine
whether clinical activity in the practice is
meeting the needs of the population.10
As the minutiae of NHS practice and
individual dentist performance is compared
numerically to regional and national
averages by the BSA, it will increasingly be
necessary to develop a good understanding
of how local demographics can deviate
from regional norms.
The patient postcodes
are included in the EXACT dataset.
The postcodes can be matched up to
geographical locations using other open
data, and mapping programs can be used
to visualize the location density of the
practice patient population. The postcodes
can also be allocated to ONS local area
census codes (called LA11), as shown in
analyses elsewhere.11 There are about 300
households in each local area and a full
range of demographic information can
be accessed, including unemployment
rates, deprivation levels, numbers of
children under 16 and numbers of adults
over 65. This information can be used
to explore possible correlation between
levels of deprivation and high dental
need11 or patient behaviour such as missed
242 DentalUpdate
2010 2011 2012 2013 2014 2015
appointments.
More advanced statistical
analyses can be used to predict areas of
growth and drop-out and lead to targeted
advertising to attract new patients or take
up of new treatments. Specialist statistical
software, such as the commercial package
SPSS or the freeware ‘R’, is needed for these
analyses.
Example 2: Patient recall and attendance
Our test practice is interested
in maintaining long-term patient contact,
to prevent deterioration in patient health
and comply with guidelines on appropriate
recall intervals.12 The data were used to
analyse which patients attend regularly, and
which patients are due for reassessment but
have not been in contact.
The number of patients
returning for treatment can be visualized
by plotting a bar chart of the year of last
appointment; this potentially gives an
estimate of how many patients have left the
practice.
In our example, 10,602 patients
(42% of the dataset but 50% of patients
with a recorded date of last visit) were seen
in the last 24 months.
The maximum recall suggested
by NICE guidance is 24 months for adult
patients;12 patients who have not attended
for over 2 years are likely to be due a
dental appointment. This analysis provided
evidence for the practice manager to use
EXACT to contact patients for a recall who
had not attended between 2 and 3 years
ago; it was assumed that those patients
who last attended more than three years
ago have moved out of the area or changed
dental practice.
Example 3: Patient turnover
Any practice depends on a
steady inflow of new patients that at least
equals the rate of attrition. Our practice is
interested in the rate of turnover and trends
in new patient attendance over the past ten
years. This is of relevance in managing levels
the impact of market conditions on the
business.
The number of new patients to
the practice was quantified for each year
since 2006. There appears to be a steady
influx of patients, with peaks in 2011 and
2012 (Figure 4).
The practice gained an
orthodontic contract in 2012, hence the
peak may relate to this giving wider appeal
to new patients. Monitoring the number
of new patients is informative, for example
before and after an advertising campaign
or introduction of a new product or service
to the practice. Further statistical analysis
can be carried out with specialist software
to see if there is a significant difference
between the observed number of new
patients and the expected number of new
patients.
To ascertain the turnover of
patients in the practice, the number of new
patients needs to be compared with the
number leaving the practice. Patients who
have not attended for a specified number of
years can be identified from the dataset. We
can find the number of days since the last
visit and set a cut-off point, in this case we
looked at patients who had not attended
for 5 years or more.
In our dataset, 4,186 patients
had a missing last visit date; 5,792 patients
out of 20,990 had a last visit 5 or more years
ago, therefore 28% of patients had not
attended for 5 years or more. These patients
merit further characterization to see if there
is a pattern developing.
We now need to match the
numbers in each year who have not
attended for 5 years or more with the
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 PracticeManagement

Net new patients accessing other primary care health services.14

Medical primary care has a well-established
900 higher female attendance rate across a broad
800 age range, but the differential is closing;
in our data it appears to be widening. This
700
did not cause concern, however, as our
600 differential was lower than for GP visits,
and is comparable with the gender gap
500
in attendance found when focusing on
400 those undergoing treatment for specific
conditions,15 as is typically the case for dental
300
attendees. There are slightly more women
200 than men in the North East region. According
to 2015 ONS census data, the ratio of women
100
to men is 1.04,16 however, the ratio of women
0 to men whose last visit was in 2016 is 1.26, as
2006 2007 2008 2009 2010 2011 2012 2013 shown in the graph.
Figure 5. Net number of new patients per year. If the gender mix is found to be
significantly different from expectation, then
3500
it would be worth exploring how access could
be improved and how the practice could be
3000
made more appealing to both sexes.
2500
Example 5: Missed appointments
2000 The practice wishes to minimize
female
the rate of missed appointments, as these
1500 male are a burden on operational efficiency. ‘Date
of Last Missed Appointment’ was extracted
1000 from the Contact List data. This does not
show how many appointments a patient has
500 missed, just that they have missed one at
some point in time. There were 7,949 patients
0 who had missed at least one appointment.
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
The number of patients missing appointments
Figure 6. Numbers of female and male patients by year of last visit.
has increased more recently, probably
because the number of patients has increased.
Further analysis could be carried out on the
7,949 patients by selecting a sample of those
numbers of new patients in order to find Looking at the gender of the who have missed appointments recently
the net number of new patients every year patients, the overall proportion of female and carrying out an in depth review of their
(Figure 5). patients is 53% (ie 13,441 females out of demographics and dental treatments.
The net number of patients 25,178). The gender mix is interesting as it Looking at missed appointments
increased in recent years and demonstrates a appears to be changing over time, with more before and after introducing a text reminder
steady growth. This is useful information when females seen recently (Figure 6). service would provide evidence to justify the
considering hiring associates and tendering The proportion of female patients expense of implementing such a process.
for new NHS contracts. A negative trajectory appears to be rising. This could imply that The dataset contains the length
could be a warning sign that changes need to attendance patterns are changing. Patient of the last missed appointment so the time
be implemented. behaviour varies considerably from time to lost due to missed appointments can be
time and it is important not to read too much calculated, for example the number of hours
Example 4: Gender mix into a single analysis. If the practice considers of missed appointments in the test practice
A straightforward analysis of gender balance to be important then this can over the last 5 years is 1,450 or approximately
gender mix gives considerable insight. This be further explored by statistical analysis and 60 days.
example is aimed at understanding the monitored by a control chart.13 Most missed appointments were
patient community and enhancing access. The proportional increase in found to be 5, 10 or 15 minutes in length.
We explore the data to see if it reflects the favour of female patients contrasts with a This may suggest double booking for short
experience of other healthcare settings. trend towards reduced gender disparity in examination slots would be beneficial. The
March 2018 DentalUpdate 245
 PracticeManagement
time of day and the age range of patients
with missed appointments is also interesting.
If they are mostly in the 25−35 age range, this
could be due to work or childcare constraints
and the practice could be advised to offer later
appointment times to improve access for this
group; or provide a nursery area.
The name of the dental
practitioner who the patient failed to attend
can also be revealing but this highlights
the importance of not using data analytics
to single out individuals. Work practice was
extensively studied in the manufacturing
industry where it was found beneficial to
involve and empower the work force for
quality improvement.13 However, it could be
useful to highlight any behavioural concerns
and training opportunities amongst associates
which could be discussed at appraisal.
Comparison with a second
snapshot of data taken a few months later
could be useful to investigate a specific
query. A new dataset can be downloaded
after implementing a change in the practice,
for example, offering adult orthodontics. An
overview of the data could reveal an increase
or decrease in specific demographics or
improved attendance within a selected age
range.
Reporting and recommendations
The findings from these examples
of applying data analytics to the test dental
practice were shared with the practice staff
and recommendations were made. Some
actions and changes under consideration as a
result of the analysis include:
„ The practice manager now sends out
reminder letters to those who have not
attended in the last 24 months because this
was highlighted as a concern;
„ Introduction of longer opening hours to
increase flexibility of appointments;
„ Ensure patients at either end of the age
spectrum are aware that they can attend for
check-ups, for example oral cancer screening
for edentulous patients;
„ Steady growth and population mix are
satisfactory so no change needed at present.
Discussion
Digital record keeping systems
provide a ‘big data’ resource that can be
utilized to provide meaningful insight into the
patient demographics of a dental practice.
246 DentalUpdate
Numerous web-based applications and
consultants are available to carry out this
analysis, however, this article aims to provide
the initial steps into practical data analysis.
Open data sources can add a further layer of
information to practice data by comparing
with local or national populations.
Data analytics can be used to
evaluate the effect of changes in skill mix
activity within the practice by looking at
net patient numbers and patient mix. The
changes in numbers of missed appointments,
DNAs and financial income can be monitored
in successive time periods. There are many
further applications of data analytics which
are relevant for dental practice data but which
have not been illustrated in this introductory
article. Previous research has shown that
treatment needs can be predicted for specific
demographic groups leading to opportunities
to monitor practice performance, tailor
services offered and prepare promotional
material.17 Data analytics can be used to
address queries arising from the DAF (Dental
Assurance Framework) benchmarks. The
techniques can also be extended to exploring
the coverage of the catchment area and
comparing several practices or geographical
locations (https://fingertips.phe.org.uk/).
Conclusion
This article aims to show what
insight can be gained from basic data
analytics. Further insight can be gained from
either studying the techniques yourself or
hiring someone to do it for you.
References
1. Raghupathi W, Raghupathi V. Big data
analytics in healthcare: promise and
potential. Health Inf Sci Syst 2014; 2: 1−10.
2. Vijay Sikka http://www.healthtechzone.
com/topics/healthcare/
articles/2015/09/21/410192-business-
intelligence-transforms-dental-
industry.htm
3. Ahlemeyer-Stubbe A, Coleman SY. A
Practical Guide to Data Mining in Business
and Industry. London: Wiley, 2014.
4. Newton JT, Bower EJ, Williams AC.
Research in primary dental care. Part 1:
setting the scene. Br Dent J 2004; 196:
523−526.
5. Coleman SY, Gob R, Manco G, Pievatolo
A, Tort-Martorell X, Reis M. How can SMEs
benefit from big data? Challenges and a
path forward. J Qual Reliab Engineer Int
2016; 32: 2151−2164.
6. Coleman S. Data mining opportunities for
small to medium enterprises from official
statistics. J Off Stat 2016; 32: 849−865.
7. Rahm E, Do HH. Data cleaning: problems
and current approaches. IEEE Data
Engineer Bull 2000; 23: 3−13.
8. Her Majesty’s Stationery Office. Data
Protection Act 1998. London: HMSO,
1998. Accessed at http://www.
legislation.gov.uk/ukpga/1998/29/
contents
9. Williams AC, Bower EJ, Newton JT.
Research in primary dental care. Part 3:
designing your study. Br Dent J 2004; 196:
669−674.
10. Bain R. Analysis of patient attendance
pattern. Dental Profile magazine 2002,
NHSBSA Dental Service publications.
Available at: http://www.nhsbsa.nhs.uk/
DentalServices/2873.aspx
11. Adult Dental Health Survey 2009
http://www.hscic.gov.uk/pubs/
dentalsurveyfullreport09
12.
12. Dental Checks: Intervals Between Oral
Health Reviews. National Institute for
Health and Clinical Excellence, 2004.
13. Wheeler D. Understanding Variation − the
Key to Managing Chaos. Knoxville: SPC
Press Inc, 1999.
14. Qresearch Report on Trends in
Consultation Rates in General Practices
– UK, 1995–2008. Publication date: 09:30
September 30, 2008. Available at: https://
digital.nhs.uk/catalogue/PUB02399
15. Wang Y, Hunt K, Nazareth I, Freemantle
N, Petersen I. Do men consult less
than women? An analysis of routinely
collected UK general practice data. BMJ
Open 2013; 3: e003320.doi:10.1136/
bmjopen-2013-003320.
16. Office for National Statistics. Census,
2015. Available at: https://www.ons.
gov.uk/lepopulationandcommunity/
populationandmigration/
populationestimates
17. Wanyonyi KL, Radford DR, Gallagher
JE. Dental treatment in a state-funded
primary dental care facility: contextual
and individual predictors of treatment
need? PLOS one 2017; 12: e0169004.
March 2018
 Enhanced CPD DO C ImplantDentistry

Sonam Gupta

Aparna Ichalangod Narayan, Ashita Vijay and Dhanasekar Balakrishnan

Soft Tissue Profile around Dental

Implants Placed in the Aesthetic
Zone − A Biological Update
Abstract: The success attained with endosseous implants is well documented in the literature but complications are inevitable due to high
risk factors associated with bacterial related breakdown of osseointegration and peri-implant mucosa. It is now apparent that maintenance
of a complete seal of the gingival cuff around implants is paramount for achieving predictable outcomes, as there is no room for error
when multiple implants are being placed in the maxillary anterior region. However, the restorative dentist not only faces a challenge in
restoring missing teeth but also the missing volume of three-dimensional gingival envelope encompassing them.
CPD/Clinical Relevance: This article has focused on the comprehensive understanding and integration of various biological elements that
are imperative in the rapidly advancing field of implantology.
Dent Update 2018; 45: 247–252

Rehabilitation of missing natural teeth by
osseointegrated implants has signified a
new advent in restorative dentistry. In the
past decade, much of the focus was on
achieving good bone to implant contact
for the survival and success of implants.
Recently, implant dentistry has seen a
paradigm shift from focusing on functional
restoration to aesthetic integration of
tissues.
Regardless of high success rates
attained with osseointegrated implants, the
Sonam Gupta, BDS, Postgraduate
student, Aparna Ichalangod Narayan,
MDS, Professor and Associate Dean,
Ashita Vijay, BDS, Postgraduate Student
and Dhanasekar Balakrishnan, MDS,
Professor and Head, Department of
Prosthodontics and Crown and Bridge,
Manipal College of Dental Sciences,
Manipal University, Manipal, Karnataka,
India.
March 2018
peri-implant mucosal response is still not
stated clearly.1 For a clinician, restoration in
the aesthetic zone has become a complex
and challenging task, particularly in sites
with deficiencies of soft tissue or bone and,
at the same time, maintenance of it has
become equally demanding. Simultaneous
removal of multiple teeth may often
result in flattening of the interproximal
osseous scallop and subsequent collapse of
interproximal papillae. Hence, management
of soft tissues in cases of multiple implant
placement becomes more critical. Therefore,
for a clinician it is a prerequisite to have
a clear vision and understanding of the
three-dimensional envelope of soft tissue
and bone surrounding the implant to aid in
selection of a proper treatment approach.
To date there are neither clearly
stated aesthetic parameters in the literature
nor does a consensus exist on the most
suitable method to use in any particular
case. The purpose of this article is to look at
various biological factors accountable for
the maintenance of adequate soft tissue
profile around implants placed in aesthetic
zones, that need to be evaluated for a
predictable outcome. The final aesthetic
outcome is dependent on many variables,
including but not limited to, the following:
1. Bony framework;
2. Biologic width;
3. Keratinized tissue;
4. Biotype of periodontium;
5. Existing tooth position;
6. Form of periodontium;
7. Tooth shape;
8. Smile line.
1. Bony framework
It is well documented in the
literature that soft tissues follow hard
tissues. Holmes noticed the collapse of
interdental papillae following the loss
of its osseous support.2 Clinicians may
overlook the minimum amount of bone
support needed around implant-supported
restorations for adequate soft tissue profile.
Tarnow et al in his study established the
significance of a vertical distance from the
base of the contact area to the crest of
DentalUpdate 247
 ImplantDentistry
the bone.3 It was observed that, when the
distance was 5 mm, the papilla was present
98% of the time. However, as the distance
increased to 6 mm, in 56% of cases the
papilla existed and, at 7 mm, the papilla was
seen only 27% of the time. A similar study
performed by Gastaldo et al correlated the
vertical and horizontal parameters between
adjacent implants and between a tooth
and an implant.4 It was reported that, at
a vertical distance of 3 mm, in 100% of
cases the papilla was present and, when
the distance increased to 8−10 mm, the
papilla was absent 60−75% of the time. The
author recommended the maintenance of a
minimum amount of 3−4 mm of horizontal
distance between two adjacent implants
(Figure 1a). Thus, it can be concluded that,
as there is an increase in distance from
the base of the contact area to the crest
of the bone, there is a reduced amount of
papillary fill, leading to the formation of
black triangles and creating an aesthetically
compromised result. Studies have reported
an average crestal bone loss of 1.04 mm
when the inter-implant distance is 3 mm or
less, as compared to 0.45 mm crestal bone
loss when the distance is greater than 3
mm.5,6 Hence, a minimum of 1.5 to 2 mm
of distance is recommended between a
natural tooth and dental implant for the
stability of peri-implant soft tissues (Figure
1).
2. Biologic width
One of the biological factors
that should not be neglected is the biologic
width. It is important to understand that
soft tissues around an implant behave
differently from those around a natural
7,8
tooth. Multiple animal and human studies
have demonstrated that biologic width
around implants is 1 mm longer than for
natural teeth. 9-12
The basic difference between
natural teeth and implants is the orientation to the increased risk of inflammation
of periodontal fibres. In addition, biologic
width around natural tooth is supracrestal
as compared to subcrestal formation in an
implant. It has been postulated that the
formation of the biologic width around
dental implants serves as a defence
mechanism against bacterial invasion.
Tarnow et al have demonstrated that
biologic width has both horizontal and
vertical components that affect both
248 DentalUpdate
a b
Figure 1. (a) Adequate interimplant distance. (b) Final aesthetic result.
interproximal bone and facial bone.13
Berglundh and Lindhe have demonstrated
that surgically reducing the thickness of
a gingival flap prior to suturing would
allow for a corresponding remodelling to
occur, permitting re-establishment of the
biologic width of peri-implant soft tissue Figure 2. Thin gingival biotype exhibiting poor
to its original dimension at the expense of aesthetic result.
reduced crestal bone height.14 Henceforth,
it is important to maintain the crest in
order to support overlying soft tissues.
The establishment of a stable biological characteristics and clinical experience.20,21
dimension around implant-supported Thus, 2−3 mm of keratinized mucosa
restorations may contribute to papillary fill width has been considered as desirable for
and encroachment of this space may lead to adequate soft tissue seal around implants.22
bone loss.
4. Biotype of periodontium
3. Keratinized mucosa
Different gingival biotypes
It has always been a debatable
respond differently to clinical situations. The
issue whether the presence of a sufficient
periodontal biotype could be categorized
band of keratinized mucosa around an oral
into flat-thick and scalloped-thin based
implant is imperative to maintain long-
1,15
on buccolingual thickness.23 Claffey and
term tissue health. Lang and Loe have
Shanley defined gingival thickness of 2
advocated the presence of a minimum of
mm or more as thick biotype and gingival
2 mm of keratinized gingiva and 1 mm of
thickness of not more than 1.5 mm as thin
attached gingiva to sustain healthy gingiva
16 biotype.24
around a natural tooth. Some authors
believe that the keratinized tissues are The thick periodontium
more resistant to abrasion and incur less comprises a thick band of keratinized
recession, therefore reducing the likelihood mucosa, more resistant to inflammation
25
for implant failure. In addition, mobile and trauma, though it is more prone to
mucosa can result in disruption of the pocket formation, but better at concealing
26
implant epithelial attachment, contributing metal implant margins. In addition,
the vascularity is maintained even after
subsequent to plaque accumulation. 17,18 surgery and prognosis becomes more
In contrast, Wennstrom et al validated predictable as primary closure can be
that the paucity of attached masticatory achieved easily. In contrast, thin biotype
mucosa did not jeopardize the long-term tissue exhibits compromised soft tissue
health of soft tissues, assuming that good healing following surgical and restorative
oral hygiene is maintained.19 However, treatment and higher susceptibility to
from the available literature, an adequate resorption of underlying bone.27 Several
amount of keratinized mucosal band has authors have reported increased incidence
been recommended for the maintenance of bony dehiscences and fenestrations with
of soft tissue health based on anatomic thin biotype tissue (Figure 2).28 In some
March 2018
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instances, the greyish hue of the implant
fixture or overlying superstructure
is visible through the mucosa. When
confronted with thin biotype, the
clinician should consider converting it
into thick biotype with gingival grafting
prior to implant placement for a more
favourable outcome.
5. Existing tooth position
The present gingival
silhouette is significantly influenced
by the existing tooth position, which
should be evaluated in the three planes
listed below to ensure predictability and
definitive outcome.
1. Vertical or apico-coronal plane
There are studies showing
between 1−2 mm of gingival recession
in the mid facial aspect subsequent
to extraction and immediate implant
placement.29,30 If a tooth is already
positioned apically compared to its
counterpart, extraction of the same
would result in long clinical crowns or
visible metal margins, resulting in an
aesthetic compromise (Figure 4). In
such cases, the hopeless teeth with free
gingival margin positioned 1−2 mm
more coronal to their existing position
would be in a more favourable situation
for an aesthetically pleasing outcome.
Therefore, orthodontic forced eruption
before extraction to attain a harmonious
gingival level should be delineated.31,32
2. Faciopalatal plane
One study has established a
minimum requirement of 1 mm of bone
to be remaining on the buccal and palatal
aspects following implant placement to
reduce the risk of failure.33 Nevertheless,
the potential for bone loss decreases
when 1.8 mm of bone thickness is
maintained on the facial aspect.34 A tooth
positioned too far facially will often result
in thin or non-existent bone labially.
Moreover, extraction in such
instances could result in vertical bone
loss with collapse of soft and hard tissues
(Figure 2). Since such cases hold a poor
prognosis for orthodontic extrusion, bone
augmentation and socket preservation
procedures would be a better treatment
March 2018
option prior to the implant placement.
3. Mesio-distal plane
The proximity of the adjacent
teeth essential for optimal proximal
support and volume of the interdental
papilla should be assessed by the
clinician prior to the commencement
of treatment. The mesiodistal width
should be equal to its contralateral tooth.
Excessive or deficient space should be
corrected with the use of orthodontics,
enameloplasty or restorations.
In addition to proximity of
the crown structure, the root proximity
is also influencing papilla volume.
Roots positioned in close proximity
possess thin interproximal bone, which
increases the risk of lateral resorption
resulting in reduced vertical height of the
papilla following extraction or implant
placement. Nevertheless, maintenance
of 1.5 mm of interproximal bone width
at the crest can prevent the violation of
biologic width.35
6. Form of periodontium
The gingival scallop could
be categorized into high, normal and
flat forms.36 In health, the underlying
bone crest remains 2 mm apical to the
cemento-enamel junction and trails
the scallop of the gingival margin.37 The
higher the scallop of the gingival margin,
the gingival loss is likely to be greater
following tooth extraction. In instances
where the scallop is flat, post extraction
changes in contour are reduced.37
7. Tooth shape
Tooth shape is another factor
Figure 3. High smile line presents greater
aesthetic challenge.
ImplantDentistry
influencing peri-implant aesthetics.
Square, ovoid and triangular forms are
the three basic tooth shapes. It must be
emphasized that tooth form affects soft
tissue profile, both coronal and apical
to the free gingival margin. The volume
and height of the gingival embrasure will
affect the coronal aspect. The proximity
of the roots and support of gingival
tissues, both facially and intrproximally,
would be influenced by the apical
aspect.35
It is interesting to note that
a square form would present the most
favourable clinical situation as the
proximal contacts are longer, therefore
the tooth portion would occupy the
majority of the interdental area, leaving
little room for the papillary fill, thus
reducing the probability of a black
triangle appearance. In contrast, the
triangular form presents the highest
risk for an aesthetic compromise since
the proximal contact point is positioned
more incisally and would necessitate
a greater volume of tissue to fill the
interdental area. Therefore, even the
slightest deficiency would produce a
compromise.
In addition, triangular
tooth shapes allow roots to be
positioned further apart, providing
thicker interproximal bone, and aid in
minimizing vertical bone loss. In contrast,
square and ovoid tooth forms are at
greater risk of bone loss as the osseous
crest is thinner. In summary, square tooth
forms pose less aesthetic risk compared
to triangular tooth forms.
8. Smile line
The fabrication of implant-
supported restorations for cases with a
Figure 4. Long clinical crowns with compromised
aesthetic results.
DentalUpdate 251
 ImplantDentistry
high smile line in the maxillary anterior
region is a formidable task, since
the gingival tissues are completely
exposed (Figure 3). In such situations,
maintenance of peri-implant soft tissues
during the surgical, provisional and
restorative phases is demanding. In
contrast, the patients exhibiting low smile
lines is less of a concern for the clinician
since the upper lip would hide the
interface present between the restoration
and soft tissues. Some patients with high
aesthetic demands will lift their lip up to
inspect the work.
Summary
An unaesthetic yet
functionally acceptable result is not
desirable but may be acceptable for
some patients. Even the slightest lack of
planning can result in severe cosmetic
deficiency. The final aesthetic outcome
depends on multiple variables that
include biological, surgical, implant
design and surfaces and prosthetic
factors. However, compared to other
variables influencing soft tissue profile,
biological factors that are closely
interrelated to each other are the most
difficult to manipulate. Attention to
detail in the assessment and provision
of implant treatment is important
to avoid an aesthetic compromise.
Some biological factors are not under
the control of the clinician. Any likely
compromise should be explained to
the patient in advance of treatment.
Commendable research has been
carried out in this field. Therefore, it is
a prerequisite for a clinician to keep
updated for the delivery of the best
possible patient care.
References
1. Goodacre CJ, Kan JY, Rungcharasaenq K.
Clinical complications of oseointegrated
implants. J Prosthet Dent 1999; 81: 537−552.
2. Holmes CH. Morphology of the interdental
papillae. J Periodontol 1965; 36: 455−460.
3. Tarnow DP, Magner AW, Fletcher P. The effect
of the distance from the contact point to the
crest of bone on the presence or absence of
the interproximal dental papilla.
J Periodontol 1992; 63: 995−956.
4. Gastaldo JF, Cury PR, Sendyk WR. Effect
of the vertical and horizontal distances
between adjacent implants and between a
tooth and an implant on the incidence of
252 DentalUpdate
interproximal papilla. J Periodontol 2004; 75:
1242−1246.
5. Garber DA, Salama MS, Salama H. Immediate
total tooth replacement. Compend Contin Educ
Dent 2001; 3: 21−60.
6. Traini T, Novaes AB Jr, Piatelli A, Papalexiou
V, Muglis VA. The relationship between
interimplant distances and vascularization of
the interimplant bone. Clin Oral Implants Res
2010; 21: 822−829.
7. Gargiulo A, Wentz FM, Orban B. Dimensions
and relations of the dentogingival junction in
humans. J Periodontol 1961; 32: 261−267.
8. Zetu L, Wang HL. Management of inter-dental/
inter-implant papilla.J Clin Periodontol 2005; 32:
831−839.
9. Vacek JS, Gher ME, Assad DA, Richardson AC,
Giambarresi LI. The dimensions of the human
dentogingival junction. Int J Periodont Rest Dent
1994; 14: 154−165.
10. Berglundh T, Lindhe. Dimension of the
periimplant mucosa. Biological width revisited.
J Clin Periodontol 1996; 23: 971−973.
11. Cochran DL, Hermann JS, Schenk RK,
Higginbottom FL, Buser D. Biologic width
around titanium implants. A histometric
analysis of the implanto-gingival junction
around unloaded and loaded nonsubmerged
implants in the canine mandible. J Periodontol
1997; 68: 186−198.
12. Etter TH, Håkanson I, Lang NP, Trejo PM,
Caffesse RG. Healing after standardized clinical
probing of the periimplant soft tissue seal: a
histomorphometric study in dogs. Clin Oral
Implants Res 2002; 13: 571−580.
13. Tarnow DP, Cho SC, Wallace SS. The effect of
inter-implant distance on the height of inter-
implant bone crest. J Periodontol 2000; 71:
546−549.
14. Berglundh T, Lindhe J. Dimensions of the peri-
implant mucosa. Biologic width revisited.
J Clin Periodontol 1961; 32: 261−267.
15. Carmichael RP, Apse P, Zarb GA, McCulloch
CAG. Biological, microbiological and clinical
aspects of the peri-implant mucosa. In: The
Brånemark Osseointegrated Implant. Albrektsson
T, Zarb GA (eds). Chicago: Quintessence Publ
Co, 1989: pp39−78.
16. Lang NP, Loe H. The relationship between
the width of keratinized gingiva and gingival
health. J Periodontol 1972; 43; 623−627.
17. Cairo F, Pagliaro U, Nieri M. Soft tissue
management at implant sites. J Clin Periodontol
2008; 35(8 Suppl): 163−167.
18. Warrer K, Buser D, Lang NP, Karring T. Plaque-
induced peri-implantitis in the presence
or absence of keratinized mucosa. An
experimental study in monkeys. Clin Oral
Implants Res 1995; 6: 131−138.
19. Wennstrom JL, Bengazi F, Lekholm U. The
influence of the masticatory mucosa on the
peri implant soft tissue condition. Clin Oral
Implants Res 1994; 5: 1−8.
20. Brånemark PI, Adell R, Breine U, Hansson
BO, Lindstrom J, Ohsson A. Intra-osseous
anchorage of dental prosthesis. Scand J Plastic
Reconstr Surg 1969; 3: 81−100.
21. Kenndy JE, Bird WC, Palcanis KG, Dorfman HS.
A longitudinal evaluation of varying widths of
attached gingiva. J Clin Periodontol 1985; 12:
667−675.
22. Bianchi AE, Sanfilippo F. Single tooth
replacement by immediate implant and
connective tissue grafts: a 1−9-year clinical
evaluation. Clin Oral Implants Res 2004; 15:
269−277.
23. Seibert J, Lindhe J. Esthetics and
periodontal therapy. In: Textbook of
Clinical Periodontology 2nd edn. Lindhe
J (ed). Copenhagen: Munksgaard, 1989:
pp477−514.
24. Claffey N, Shanley D. Relationship of gingival
thickness and bleeding to loss of probing
attachment in shallow sites following
nonsurgical periodontal therapy. J Clin
Periodontol 1986; 13: 654−657.
25. Kao RT, Fagan MC, Conte GJ. Thick vs thin
gingival biotypes: a key determinant in
treatment planning for dental implants.
J Calif Dent Assoc 2008; 36: 193−198.
26. Jung RE, Sailer I, Hammerle CH, Attin T,
Schmidin P. In vitro color changes of soft
tissues. Int J Periodont Rest Dent 2007; 27:
251−257.
27. Wilderman MN, Pennel BM, King K, Barron
JM. Histogenesis of repair following osseous
surgery. J Periodontol 1970; 41: 551−565.
28. Kao RT, Fagan MC, Conte GJ. Thick vs. thin
gingival biotypes: a key determinant in
treatment planning for dental implants.
J Calif Dent Assoc 2008; 36: 193−198.
29. Cosyn J, Eghbali A, De Bruyn H, Collys K,
Cleymaet R, De Rouck T. Immediate single-
tooth implants in the anterior maxilla:
3-year results of a case series on hard and
soft tissue response and aesthetics. J Clin
Periodontol 2011; 38: 746−753.
30. Cosyn J, Eghbali A, Hermans A, Vervaeke
S, De Bruyn H, Cleymaet R. A 5-year
prospective study on single immediate
implants in the aesthetic zone. J Clin
Periodontol 2016; 43: 702−709.
31. Salama H, Salama M. The role of orthodontic
extrusive remodeling in the enhancement
of soft and hard tissues profiles prior to
implant placement: a systemic approach to
the managaement of extraction site defects.
Int J Periodont Rest Dent 1993; 13: 312−333.
32. Salama H, Salama M, Garber D, Adar P.
Developing optimal peri implant papillae
within the esthetic zone: guided soft
tissue augmentation. J Esthet Dent 1995; 7:
125−129.
33. Morris HF, Ochi S, Orenstein IH, Petrazzuolo
V. AICRG, Part V: Factors influencing implant
stability at placement and their influence on
survival of Ankylos implants. J Oral Implantol
2004; 30: 162−170.
34. Spray JR, Black CG, Morris HF, Ochi S.
The influence of bone thickness on facial
marginal bone response: stage 1 placement
through stage 2 uncovering. Ann Periodontol
2000; 5: 119−128.
35. Philips K, Kois JC. Aesthetic peri-implant site
development. The restorative connection.
Dent Clin North Am 1998; 42: 57−70.
26. Kois JC. Altering gingival levels: the
restorative connection part I: biologic
variables. J Esthet Dent 1998; 10: 157−163.
37. Kois JC. Predictable single-tooth peri-
implant esthetics: five diagnostic keys.
Compend Contin Educ Dent 2004; 25:
895−896.
March 2018
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 OralMedicine

Book Review
Grey Areas in Restorative Dentistry
- don’t believe everything you think.
Robert L Caplin. J and R Publishing, 2015.
(178pp. £34.99). ISBN 9780993109300.
Published online: 10 July 2015 doi:10.1038/
sj.bdj.2015.538.
Embarking on a career in dentistry is an
immensely exciting and rewarding experience
but the transition from dental school to
clinical practice can be a daunting process. As
clinicians we are faced with difficult clinical
scenarios, which require the integration of
knowledge, experience and practical skill to
manage them successfully.
Grey Areas in Restorative Dentistry- don’t believe
everything you think! is an inspiring book,
which enriches the reader with a background
of knowledge to solve everyday clinical
problems which can be treated with an array
of different strategies.
The chapters are arranged in a logical order
which cover a range of topics, including what
the aims of treatment are, what radiographs and free pages to construct notes and
should be taken at a new patient exam and consolidate thoughts, much like a workbook.
restoring teeth which have an inadequate root This book is an excellent addition to any
canal treatments. Each chapter is structured foundation dentist’s reference text and for
with a solid foundation of teaching by the dentists who wish to compare their thought
author and well-selected references to processes to other experiences clinicians. The
evidence-based practice, where possible. book could easily be used to supplement and
The chapters are illustrated with images and support tutorials in dental foundation trainees
radiographs, which are of a generally of a high where scenarios are relevant to everyday
standard throughout the book. This helps to practice.
enhance and enrich the text. At first glance, David Green
the algorithms seemed rather simplistic but, Birmingham Dental Hospital and School
on reflection, this was required in order for
the reader to be effectively guided through a
complex clinical problem.
The passion and dedication of the author as an
experienced educator is reflected throughout
the book and cases are selected in a way
to challenge the reader and channel the
thought processes. The book covers a good
range of dental cases, synoptically covering
restorative dentistry and oral surgery, which
are all relevant to managing intricate clinical
situations. Each chapter ends with scenarios

The UK’s leading peer-reviewed clinical journal

DentalUpdate
July/August 2017 . Volume 44 . Number 7

„ Im
Imp
Implant
pla
p la
ant
n De
Dentistry:
ntisst
stryy:: Dental
Dent Implants: An Overview
„ P
Pe
e
errrio
riiio
odonti
d cs: Diagnosis
Periodontics: Diagagnosi and Management of Chronic and
Ag
A gg
g g
grreessive
s
Aggressive Pe
eriod
odontit Part 3: Two Clinical Reports
Periodontitis
„
„Res
Restorative
Resto
Rest
e
esto
essto r e Dentistry:
torativ De Complications of an Ageing Dentition Part 3: Overview and
enttisstry: C
Reportt
Ca e Repor
Case R

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March 2018 DentalUpdate 255

 Periodontics Enhanced CPD DO C

Sehrish Khalid

Despoina Chatzistavrianou and Fiona Blair

The Impact of Medication on the

Periodontium: A Review of the
Literature
Abstract: Periodontal disease is a plaque-related disease. Although systemic medications cannot initiate periodontal disease, they
can, however, adversely affect the periodontal tissues and exacerbate existing disease. Medications can have an effect on oral health,
periodontal disease diagnosis, gingival and oral mucosal tissues or the alveolar bone. Side-effects of systemic medications require
various levels of management. Ultimately, a strict oral hygiene regimen is essential to prevent and reduce the effect of medications on
the periodontal tissues. The aim of this paper is to present the effects of various medications on the periodontium, educate and increase
awareness for dental professionals of these effects and discuss management protocols.
CPD/Clinical Relevance: This paper aims to provide an overview of the medications affecting the periodontium and the management of
drug-influenced gingival diseases.
Dent Update 2018; 45: 256–265

Periodontal disease is a complex bacteria, with the clinical determinants of diagnosis;

inflammatory disease that affects the soft
and hard periodontal structures; including
the gingivae, cementum, periodontal
ligament and alveolar bone.1 Periodontal
disease is plaque-related2 and initiated by
Sehrish Khalid, BDS, MFDS RCS(Ed),
Dental Core Trainee in Restorative
Dentistry, Despoina Chatzistavrianou,
DDS, MFDS RCS(Ed), MClinDent(Pros),
MPros RCS(Ed), Specialist in
Prosthodontics, Specialty Registrar in
Restorative Dentistry, Fiona Blair, BDS,
LDS, FDS(Rest) RCPS, MSc, DRD, MRD,
Consultant and Senior Clinical Lecturer in
Restorative Dentistry, Birmingham Dental
Hospital and University of Birmingham
School of Dentistry, Birmingham
Community Healthcare NHS Trust, 5 Mill
Pool Way, Edgbaston, Birmingham B5 7EG
UK.
256 DentalUpdate
host response and genetic environmental risk
factors influencing the severity and extent of
disease.3,4,5,6
Although the main aetiology
of periodontal disease is poor oral hygiene
and the presence of dental plaque,
certain medications can exacerbate
existing periodontal disease. Phenytoin,
cyclosporine and calcium-channel blocking
antihypertensive drugs are the most
commonly quoted drugs related to gingival
disease; however, other medications can
have an adverse effect on the periodontium,
especially in the presence of suboptimal oral
hygiene (Table 1).7,8,9,10
Medications
Medications affecting the
periodontium, summarized in Table 2, can be
classified into four categories and are:
1. Medications affecting oral health;
2. Medications affecting periodontal disease
3. Medications affecting gingival and oral
mucosal tissues;
4. Medications affecting alveolar bone.11
Medications affecting oral health
Xerostomia is a common side-
effect of certain medications and is related
to increased plaque accumulation, which in
turn increases the risk of periodontal disease
and caries.12 The most common medications
causing xerostomia are antihypertensives
(including diuretics, angiotensin converting
enzyme inhibitors and calcium channel
blockers), antidepressants, sedatives, centrally
acting analgesics, anti-parkinson medication
and anti-allergy medication.13
Medications affecting periodontal disease
diagnosis
Bleeding on probing is a
sign of active periodontal disease. Anti-
thrombotic agents, including anti-coagulants
March 2018
 Periodontics

(eg Warfarin), anti-platelet agents (eg and certain calcium channel blockers not entirely clear, however, owing to its
clopidogrel), and non-steroidal anti- (eg Nifedipine, Amlodipine, Verapamil, lipophilic nature, minocycline has extensive
inflammatory drugs (NSAIDs) (eg Aspirin) can Diltiazem, Isradipine) are related to gingival tissue penetration and ability to bind
predispose patients to gingival bleeding.11 enlargement,7,8,9 with prevalence of 50%, to collagen. Subsequent degradation/
Additionally, herbal remedies with ginger or 30% and 10%, respectively.9,15,16 In addition oxidation results in the grey/blue deposit
garlic may be associated with false positive to these, oral contraceptives and hormone which discolours the bone.23 Pigmentation
bleeding on probing.11 On the other hand, replacement therapies have been associated is more likely to occur with doses
corticosteroids and antibiotics have the with increased expression of periodontal exceeding 100 mg and when used for over
potential to reduce bleeding on probing and disease.17,18 Prednisolone and Azathioprine a year.
underestimate existing periodontal disease.14 may possibly offer protection against gingival Systemic corticosteroid use
enlargement in organ transplant patients, but is associated with reduced alveolar bone
good oral hygiene is still a prerequisite.19 A density24 and increased susceptibility
Medications affecting gingival and oral mucosal
strict oral hygiene regimen will aid prevention to bone loss in pre-existing periodontal
tissues
of gingival enlargement and is the most disease. Antibiotics and NSAIDs prevent
Phenytoin, Cyclosporine
important element of gingival health.20,21 bone loss but the evidence for their use in
treatment is inconclusive.25
Drug-influenced gingival diseases Anti-resorptive medications
Medications affecting alveolar bone including bisphosphonates (Alendronate,
- Drug-influenced gingival enlargements
Minocycline, a semi-synthetic Zoledronate) and RANK ligand inhibitors,
- Drug-influenced gingivitis
type of tetracycline used to treat acne, such as the mono-clonal antibody
a) Oral contraceptive-associated gingivitis
rosacea and rheumatoid arthritis, can cause Denosumab (Xgeva®, Prolia®) are used in
b) Other
black pigmentation of the gingival tissues, management of patients with osteoporosis,
Table 1. Classification of gingival diseases
teeth and the underlying alveolar bone.22 Paget’s disease of bone and bone
modified by medications.10
The mechanism of bone pigmentation is metastases.26 The mode of action is mainly
through direct inhibition of osteoclastic
Effect on Periodontium Medications
function, thus preventing bone resorption
Xerostomia Antihypertensives and remodelling. The systemic effect
Diuretics of generalized increased skeletal bone
Angiotensin Converting Enzyme (ACE) inhibitors density of such medications also benefits
Calcium channel blockers the alveolar bone but increases the risk
Antidepressants of Medication Related OsteoNecrosis of
Sedatives the Jaw (MRONJ),27,28 with increased risk
Centrally acting analgesics through intravenous administration.26
Anti-Parkinson medication MRONJ is characterized by exposed
Anti-allergy medication alveolar bone, tooth mobility, non-healing
ulcers and idiopathic soft tissue infections.
Predisposition to gingival Anti-coagulants (Warfarin)
Animal and human studies undertaken
bleeding Anti-thrombotic agents
to establish the effect of anti-resorptive
Non-steroidal anti-inflammatory drugs (NSAIDs)(Aspirin)
medications on the periodontal tissues
Herbal remedies with ginger or garlic
have shown varied outcomes. Prevention
Possible reduction of bleeding Corticosteroids or reduction in bone resorption in plaque-
on probing Antibiotics induced periodontitis has been observed,
however, other studies show an increase in
Drug-induced gingival Anti-convulsants
periodontal tissue destruction. Therefore,
overgrowth Immunosuppressants
due to the low level of evidence, the use of
Calcium channel blockers
such medications in the foreseeable future
Increased expression of Oral contraceptives as an adjunct to non-surgical periodontal
periodontal disease Hormone replacement therapy therapy is unlikely and a more robust
evidence base is needed.29
Discoloration of gingival Tetracyclines
Prescribers of bone anti-
tissues
resorptive medication need to ensure
Reduced alveolar bone density Corticosteroids that the patient undergoes a thorough
dental examination to identify and treat
Medication Related Bisphosphonates
any pre-existing oral disease prior to
OsteoNecrosis of the Jaw Denosumab
commencement of taking the medication.
(MRONJ)
Teeth of poor prognosis should be removed
Table 2. Summary of effects on the periodontium by common classification of medications.
and patients educated on the importance
March 2018 DentalUpdate 257
 Periodontics
of good plaque control and regular dental
examinations. Prevention of dental disease
is important for these patients, as future
extractions or surgery may carry a risk of
MRONJ.
Drug-induced gingival
overgrowth
Irrespective of the causative
medication, the clinical appearance of
drug-induced gingival overgrowth remains
the same, with the onset usually occurring
1−3 months following commencement
of the medication.30,31 The dosage of
medication, combined with the amount
of dental plaque and periodontal
inflammation, is linked to the prevalence
and severity of the overgrowth seen.30
The anterior gingiva is one
of the most commonly affected sites.
The overgrowth begins normally in the
interdental papilla region and spreads to
cover the buccal and palatal surfaces of the
teeth.31
Although largely a cosmetic
concern, due to the overgrowth causing
a reduction in clinical crown height and,
in some cases, completely obscuring the
teeth;30 the enlargement can also cause
speech and masticatory difficulties,30,32
especially in young children.32 Fibrosis
can occur in chronic overgrowth cases,
leading to tooth migration and possible
secondary malocclusions in the presence of
altered masticatory habits.32 Enlargement
of the interdental papillae can also lead
to displacement of teeth and resulting
diastemas.30
Although the gingival
enlargement is not directly harmful,
inflammatory changes become apparent
due to the difficulties in plaque control;
leading to oedema, erythema and
bleeding. This appearance is commonly
encountered in the presence of pre-
existing periodontal disease.30
Patients with gingival
overgrowth may be at an increased risk
of periodontal disease, as well as tooth
decay. Gingival overgrowth creates pseudo-
pocketing coronal to the cement-enamel
junction, which may hinder effective
plaque control. In periodontally susceptible
patients, this may progress to loss of
periodontal attachment.32
258 DentalUpdate
Management
Non-surgical management
Due to the presence of false
pocketing in cases of gingival overgrowth,
it is important to ascertain if there has
been any periodontal bone loss through
appropriate radiographic examination, thus
determining the presence of underlying
chronic periodontal disease, which will
require appropriate treatment.30
Preventive measures are by
far the mainstay of treatment for gingival
overgrowth and high standards of plaque
control need to be achieved in order to
control the level of any superimposed
inflammation.30,32 Intensive tailored
oral hygiene instruction33 should be
demonstrated, with special attention
to subgingival and interdental plaque
removal. Adjunctive use of chemical plaque
controlling agents, such as essential oil,32,34
cetylpyridinium chloride and chlorhexidine
mouthwashes may be beneficial. There
is evidence that chlorhexidine used at
concentrations of 0.1% or 0.2% can reduce
the severity of drug-induced gingival
overgrowth when used adjunctively to
mechanical oral hygiene measures.34
However, there should be caution in long-
term use of chlorhexidine rinses as unwanted
side-effects may occur, including brown
discoloration of tooth surfaces and mucosa,
taste disturbance and, more seriously,
mucosal erosion, desquamative gingivitis and
parotid swelling.35 Thorough deposit removal
with scaling and root surface debridement
should be undertaken alongside removal
of plaque retentive factors, as necessary.
Surgical intervention may need to be
considered if primary local measures alone
do not aid resolution.30,32
Substitution of the causative medication
Potential for overgrowth is
something that the patient’s medical
practitioner should consider prior to
prescribing; whilst effective management of
established overgrowth lies mainly with the
patient’s dental professional.33
Gingival enlargement is a
significant side-effect for some patients,
using medication including phenytoin,
vigabatrin and primidone for epileptic
control.36 Valproic acid has a lower incidence
of gingival enlargement and may be an
alternative to phenytoin,37 although patients
may be reluctant to consider changing
medication where their condition has been
under long-term control.
Immunosuppressant medication
is used to protect against organ transplant
rejection and is also used for management
of conditions, including multiple sclerosis,
rheumatoid arthritis, and dermatological
disorders, including psoriasis and vesiculo-
bullous disorders. Hypertension is a known
side-effect of cyclosporin therapy38 and
studies have confirmed increased risk
and severity of gingival enlargement
when immunosuppressant medication is
taken alongside calcium channel blocker
antihypertensive medication.37
Changing medications to those
that do not cause gingival enlargement
may be beneficial, with evidence of a 40%
recurrence rate after surgery, if medication
is not altered.39 Any suggested change
should be communicated with the patient’s
medical practitioner, who will consider any
adverse risks to the patient’s general health;32
in which case the local risk of gingival
overgrowth may not be as significant.30
In most cases, medication can be safely
changed.
Tacrolimus is increasingly used
as an alternative immunosuppressant to
cyclosporine, which does not carry the
same risk for gingival overgrowth,40,41
with additional advantages of improved
cardiovascular risk profile, superior renal
function and reduced hypertensive side-
effects.42,43 Finally, Angiotensin Converting
Enzyme (ACE) inhibitors have been
suggested as an alternative to nifedipine,
whilst maintaining a similar efficacy and less
risk of gingival overgrowth.34
Pre-operative post-operative
views of drug-induced gingival overgrowth
cases are given in Figures 1 and 2.
Surgical management
Where gingival overgrowth
is significant, a surgical approach may be
required to restore function and aesthetics,
however, recurrence post-operatively is
possible.39
Various surgical methods exist,
including reduction and removal of the
enlarged gingival tissues by gingivectomy,
periodontal flap surgery, laser excision or
March 2018
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a a
b b
c c
Figure 1. (a−c) Pre-operative views of calcium
channel blocker (Nifedipine) drug-induced
gingival overgrowth case.
electrosurgery.44 When histopathological
examination of excised tissue is required,
with confirmation of complete edge
excision, this may best be achieved with
conventional blade surgery. Conventional
gingivectomy procedures may be carried
out using an external bevel technique,
however, total or partial internal bevel
gingivectomies reduce post-operative
complications but require greater technical
skill.
The most widely recognized
complications of gingivectomies are post-
operative pain and bleeding, which may be
reduced with laser or electrosurgery excision
techniques. However, tissue necrosis can
be a side-effect of electrosurgery, and may
adversely affect the aesthetic outcome.45
Laser excision provides a superior incision
margin and improved wound healing due
to a coagulated layer along the incision,
March 2018
Figure 2. (a−c) Post-operative views showing
resolution of the drug-induced gingival
overgrowth after changing the medication to
a non-calcium channel blocker drug alongside
non-surgical treatment of the underlying
periodontal condition.
as well as a reduced incidence of scarring,
and may be beneficial in less co-operative
patients and for patients with medical
contra-indications to conventional surgery,
such as those with bleeding/coagulation
disorders.45,46
The use of systemic medications to treat
gingival enlargement
Systemic use of the macrolide
antibiotic azithromycin has been reported to
show improvement in gingival overgrowth,47
however, metronidazole31 and clarithromycin,
from the same family of antibiotics, do
not produce the same marked effect. A
3−5 day course of azithromycin has been
shown to be efficacious in helping to
Periodontics
manage cyclosporine-induced gingival
overgrowth and does not affect the
control level markers of serum ALT,48
creatinine or cyclosporine.40,41 The mode
of action is unknown but is thought to
reduce inflammation associated with the
overgrowth,49 and through preventing
collagen synthesis by blocking fibroblast
cell proliferation.50,51 An alternative
mode of action may be through an
increase in gingival fibroblast phagocytic
activity, which reverses the ability of
cyclosporin-induced inhibition of collagen
degradation, however, this phenomenon
has not been reproduced in humans and
is limited to animal studies.44 Evidence at
present is weak and unproven,43 therefore
further studies are required to determine
the exact role of azithromycin in reducing
gingival enlargement before it could be
considered for mainstream use.47-50
The use of corticosteroid anti-
inflammatory therapy in the treatment of
gingivitis and other gingival conditions
is equivocal and there appears to be no
beneficial effect of systemic corticosteroid
use on gingival inflammation, probing
depths and recession.52
Conclusions
Patients are increasingly
taking systemic medications that affect
the health of periodontal tissues. Medical
colleagues are becoming more aware
of the importance of screening for, and
treating dental disease, before prescribing
medications or carrying out medical
procedures, such as organ transplantation;
requiring follow-up medication that
may be long-term, or life-long, with a
significant effect on the periodontal and
other oral tissues. Dental professionals
need an understanding of the effects of
medication on the tissues and various
modes of management of conditions that
may develop as a result.
The foundations for good
management are preventive advice with
ongoing good oral hygiene and plaque
control. This is essential for patients taking
bone anti-resorptive medication where
management of new dental disease may
be problematical and carry the risk of
MRONJ.
Gingival overgrowth can be
managed with a non-surgical approach in
DentalUpdate 261
 Periodontics
the first instance, but may require surgery.
However, in a large number of cases, liaising
with the medical profession to substitute
the causative medication, along with
excellent plaque control, is key to preventing
recurrence and repeated surgical procedures.
References
1. Bannister S, Dixon D, Barnes J, Bisch F,
Campbell C, Hill M, Faiella R, Villar C,
Zackin S. Glossary of Periodontal Terms.
Chicago IL, USA: American Academy of
Periodontology, 2018. http://members.
perio.org/libraries/glossary?ssopc=1
2. Socransky SS. Relationship of bacteria to
the etiology of periodontal disease.
J Dent Res 1970; 49: 203−222.
3. Socransky SS, Haffajee AD. The bacterial
etiology of destructive periodontal
disease: current concepts. J Periodontol
1992; 63: 322−331.
4. Grossi SG, Genco RJ, Machtet EE, Ho AW,
Koch G, Dunford R, Zambo JJ, Hausmann
E. Assessment of risk for periodontal
disease. II. Risk indicators for alveolar
bone loss. J Periodont 1995; 66: 23−29.
5. Clarke NG, Hirsch RS. Personal risk
factors for generalized periodontitis.
J Clin Periodontol 1995; 22: 136−145.
6. Page RC, Sims TJ, Geissler F, Altman
LC, Baab DA. Defective neutrophil and
monocyte motility in patients with early
onset periodontitis. Infect Immun 1985;
47: 169−175.
7. Angelopoulos AP, Goaz PW. Incidence of
diphenylhydantoin gingival hyperplasia.
Oral Surg Oral Med Oral Pathol 1972; 34:
898−906.
8. Seymour RA, Thomason JM, Ellis JS. The
pathogenesis of drug-induced gingival
overgrowth. J Clin Periodontol 1996; 23:
165−175.
9. Ellis JS, Seymour RA, Steele JG,
Robertson P, Butler TJ, Thomason JM.
Prevalence of gingival overgrowth
induced by calcium channel blockers: a
community-based study. J Periodontol
1999; 70: 63−67.
10. Armitage GC, Cullinan MP. Comparison
of the clinical features of chronic and
aggressive periodontitis. Periodontol
2000 2010; 53: 12−27.
11. Ciancio SG. Medications: a risk factor
for periodontal disease diagnosis and
treatment. J Periodontol 2005; 76:
2061−2065.
262 DentalUpdate
12. Butt GM. Drug-induced xerostomia.
J Can Dent Assoc 1991; 57: 391−393.
13. Guggenheimer J, Moore PA. Xerostomia:
etiology, recognition and treatment.
J Am Dent Assoc 2003; 134: 61−69.
14. Ciancio SG. Medications’ impact on
oral health. J Am Dent Assoc 2004; 135:
1440−1448; quiz 1468−1469.
15. Barclay S, Thomason JM, Idle JR,
Seymour RA. The incidence and
severity of nifedipine-induced gingival
overgrowth. J Clin Periodontol 1992; 19:
311−314.
16. Seymour RA, Smith DG, Rogers SR. The
comparative effects of azathioprine and
cyclosporin on some gingival health
parameters of renal transplant patients.
A longitudinal study. J Clin Periodontol
1987; 14: 610−613.
17. Loe H, Silness J. Periodontal disease in
pregnancy. I. Prevalence and severity.
Acta Odontol Scand 1963; 21: 533−551.
18. Paganini-Hill A. The risks and benefits of
estrogen replacement therapy: Leisure
World. Int J Fertil Menopausal Stud 1995;
40: 54−62.
19. Wilson RF, Morel A, Smith D, Koffman
CG, Ogg CS, Rigden SP, Ashley FP.
Contribution of individual drugs to
gingival overgrowth in adult and
juvenile renal transplant patients treated
with multiple therapy. J Clin Periodontol
1998; 25: 457−464.
20. Ciancio SG, Yaffe SJ, Catz CC. Gingival
hyperplasia and diphenylhydantoin.
J Periodontol 1972; 43: 411−414.
21. Hall WB. Dilantin hyperplasia: a
preventable lesion. J Periodontal Res
1969; 4: 36−37.
22. Poliak SC, DiGiovanna JJ, Gross
EG, Gantt G, Peck GL. Minocycline-
associated tooth discoloration in young
adults. J Am Med Assoc 1985; 254(20):
2930−2932.
23. Cockings JM, Savage NW. Minocycline
and oral pigmentation. Aust Dent J 1998;
43: 14−16.
24. Kribbs PJ. Comparison of mandibular
bone in normal and osteoporotic
women. J Prosthet Dent 1990; 63:
218−222.
25. Caton J, Ryan ME. Clinical studies
on the management of periodontal
diseases utilizing subantimicrobial dose
doxycycline (SDD). Pharmacol Res 2011;
63: 114−120.
26. Ruggiero SL, Dodson TB, Fantasia J,
Goodday R, Aghaloo T, Mehrotra B,
O’Ryan F; American Association of Oral
and Maxillofacial Surgeons. American
Association of Oral and Maxillofacial
Surgeons position paper on medication-
related osteonecrosis of the Jaw − 2014
Update. J Oral Maxillofac Surg 2014; 72:
1938−1956.
27. Geurs NC, Lewis CE, Jeffcoat MK.
Osteoporosis and periodontal disease
progression. Periodontol 2000 2003; 32:
105−110.
28. Ruggiero SL, Mehrotra B, Rosenberg
TJ, Engroff SL. Osteonecrosis of the
jaws associated with the use of
bisphosphonates: a review of 63 cases.
J Oral Maxillofac Surg 2004; 62: 527−534.
29. Badran Z, Kraehenmann MA, Guicheux
J, Soueidan A. Bisphosphonates in
periodontal treatment: a review. Oral
Health Prev Dent 2009; 7: 3−12.
30. Heasman PA, Hughes FJ. Drugs,
medications and periodontal disease.
Br Dent J 2014; 217: 411−419.
31. Nakib N, Ashrafi SS. Drug-induced
gingival overgrowth. Dis Mon 2011: 57;
225−230.
32. Moffitt M. Bencivenni D, Cohen R.
Treatment modalities for drug–induced
gingival enlargement. J Dent Hyg 2012;
86: 272−277.
33. Meraw SJ, Sheridan PJ. Medically
induced gingival hyperplasia. Mayo Clin
Proc 1998; 73: 1196−1199.
34. Mohamed NS, El-Zehery RR, Mourad
MI, Grawish Mel-A. Impact of three
different mouthwashes on the incidence
of gingival overgrowth induced by
cyclosporine-A: a randomized controlled
experimental animal study. Oral Surg
Oral Med Oral Pathol Oral Radiol 2015;
120: 346−356.
35. Calderini A, Pantaleo G, Rossi A,
Gazzolo D, Polizzi E. Adjunctive effect of
chlorhexidine antiseptics in mechanical
periodontal treatment: first results of a
preliminary case series. Int J Dent Hygiene
2013; 11: 180−185.
36. Bharti V, Bansal C. Drug-induced gingival
overgrowth: the nemesis of gingiva
unravelled. J Ind Soc Periodont 2013; 17:
182−187.
37. Kohnle M, Lütkes P, Witzke O, Philipp T,
Heemann U. Conversion to tacrolimus in
cyclosporin A treated patients with gum
hyperplasia. Transplant Proc 1998; 30:
2122−2123.
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38. Kutkuhn B, Hollenbeck M, Heering P, Koch M, Voiculescu A,

Reinhard T, Grabensee B. Development of insulin resistance and
Blu-Mousse® elevated blood pressure during therapy with cyclosporine A.
follows you into the digital world. Blood Press.1997; 6: 13−17.
Bite registrations have never 39. Ilgenli T, Atilla G, Baylas H. Effectiveness of periodontal therapy
been more accurate. in patients with drug-induced gingival overgrowth. Long-term
results. J Periodontol 1999; 70: 967−972.
40. Hernández Vallejo G, Arriba L, Frías MC et al. A preliminary
case series. J Periodontol 2003; 74: 1816−1823. doi: 10.1902/
jop.2003.74.12.1816.
41. Ching-Wen Chang CW, Yang CJ, Lai YL. Phenytoin- and
amlodipine-induced gingival overgrowth. J Dent Sci 2012; 7:
85−88.
42. Jurewicz WA. Tacrolimus versus ciclosporin
immunosuppression: long-term outcome in renal
transplantation. Nephrol Dial Transplant 2003; 18: i7−i11.
43. Pham SM, Kormos RL, Hattler BG, Kawai A, Tsamandas AC,
Demetris AJ et al. A prospective trial of tacrolimus in clinical
heart transplantation: intermediate-term results. J Thorac
Cardiovasc Surg 1996; 111: 764−772.
44. Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA. The
management of drug induced gingival overgrowth. J Clin
Periodontol 2006; 33: 434−439.
45. Marshall RI, Bartold MP. A clinical review of drug-induced
gingival overgrowths. Aust Dent J 1999; 44: 219−232.
46. Fornaini C, Rocca JP. CO2 laser treatment of drug-induced
gingival overgrowth − case report. Laser Ther 2012; 21: 39−42.
47. Clementini M, Vittorini G, Crea A, Gualano MR, Macri LA, Deli
G, La Torre G. Efficacy of AZM therapy in patients with gingival
overgrowth induced by Cyclosporine A: a systematic review.
BMC Oral Health 2008; 8: 34.
48. Tokgöz B, Sarı HI, Yıldız O, Aslan S, Sipahioğlu M, Okten T,
Oymak O, Utaş C. Effects of azithromycin on cyclosporine-
induced gingival hyperplasia in renal transplant patients.
Transplant Proc 2004; 36: 2699−2702.
49. Kwun WH, Suh BY, Kwun KB. Effect of azithromycin in the
treatment of cyclosporine-induced gingival hyperplasia in renal
Blu-Mousse® by Parkell. transplant recipients. Transplant Proc 2003; 35; 311−312.
Precision bite registration is only the beginning.
50. Kim J-Y, Park S-H, Cho K-S, Kim H-J, Lee C-K, Park K-K et al.
Mechanism of Azithromycin treatment on gingival overgrowth.
J Dent Res 2008; 87: 1075−1079.
51. Wirnsberger GH, Pfragner R, Mauric A, Zach R, Bogiatzis A,
Holzer H. Effect of antibiotic treatment with azithromycin on
cyclosporine A-induced gingival hyperplasia among renal
transplant recipients 1998; 30: 2117−2119.
52. Safkan B, Knuuttila M. Corticosteroid therapy and periodontal
disease. J Clin Periodontol 1984; 11: 515−522.
March 2018 DentalUpdate 265
 UpdatesfromAmerica
Charles John Palenik
Gloving and Hand Hygiene −
Mutually Inclusive Activities
Wearing gloves and proper
hand hygiene (HH) are two major
tenets of today’s dental office infection
control programme. In fact, the two
activities are mutually inclusive. Their
protective success depends on the correct
application of the other.
Wearing gloves does not
eliminate the need for HH. Rather,
frequency of HH must increase. HH
should be performed immediately before
donning gloves. Lowering microbial
contamination decreases the chances
of soiling the non-sterile glove supply
when reaching for new gloves and
decreases transient skin flora. Gloves can
have small, unapparent defects or be
torn during use. Also, hands can become
contaminated during glove removal.
These circumstances increase the risk
of operative wound contamination
and exposure of dental healthcare
professionals’ (DHCPs’) hands to patient
micro-organisms. In addition, bacteria can
multiply rapidly in the moist environments
present underneath gloves. Hands should
be dried thoroughly before donning
gloves and washed again immediately
after glove removal.1
Personal protective equipment
(PPE) refers to wearable equipment that
Charles John Palenik, GC Infection
Prevention and Control Consultants
and Infection Control Writing Support,
Indianapolis, Indiana, USA.
266 DentalUpdate
is designed to protect DHCPs’ personal
clothing and skin from exposure/contact
with infectious agents. Dental PPE
includes gloves, face masks, protective
eyewear (goggles and face shields)
and protective clothing (eg reusable
or disposable gowns, jackets and
laboratory coats). Gloves are used in
situations involving possible contact with
patient blood or body fluids, mucous
membranes, non-intact practitioner
skin (eg exposed skin that is chapped,
abraded or has dermatitis) or other
potentially infectious materials (OPIMs).1,2
Gloves protect the wearer,
the patient currently being treated,
other DHCPs, subsequent patients, the
immediate environment and even family
members. Gloves are universally used in
healthcare, involving many direct patient
care procedures including surgery,
laboratory activities and environmental
cleaning. Gloves enhance patient and
practitioner safety. It is important to keep
the environment as clean as possible
so that it does not become a source of
microbial transmission.3
Because gloves are task-
specific, their selection should be
based on the type of procedure to
be performed (eg surgery or patient
examination). Sterile surgeon gloves are
FDA (US Food and Drug Administration)
cleared medical devices and are less
likely than patient examination gloves
to harbour pathogens or have defects
that could contaminate an operative
wound or practitioner skin. Sterile gloves
are reserved for invasive procedures.
Enhanced CPD DO C
Non-sterile patient examination gloves
are also FDA regulated and are used in
patient care, examinations, other non-
surgical procedures involving contact
with mucous membranes and laboratory
procedures.1,2,3
There is no evidence that
differences exist concerning safety or
clinical effectiveness among differing
types of gloves. Also, there are no
differences between latex and nitrile
gloves concerning touch sensitivity
or psychomotor performance. It is
always best to know how to use gloves
correctly.3
There are several practical
admonitions. These include:
1. Wearing a new pair of gloves for each
patient;
2. Removing gloves promptly after use;
3. Washing hands immediately to avoid
transfer of micro-organisms to other
patients or the environment;
4. Removing gloves that are torn, cut
or punctured as soon as feasible and
washing hands before regloving;
5. Not washing surgeon or patient
examination gloves before use or
washing, disinfecting or sterilizing gloves
for reuse;
6. Ensuring that appropriate gloves in the
correct size are readily accessible;
7. Using appropriate gloves (eg
puncture- and chemical-resistant utility
gloves) when cleaning instruments and
performing housekeeping tasks involving
contact with blood or OPIM; and
8. Interacting with glove manufacturers
regarding chemical compatibility of their
March 2018

Figure 1. Demonstrating how hands are inserted
into the gloves and pulled up and over the
gown’s cuff, covering all skin surfaces. (Modified
from References 3 and 5).
glove material and dental materials being
used.1,2,3
Personal protective
equipment is donned in a specific
sequence − gown, mask, protective
eyewear and, finally, gloves. Hands are
inserted into the gloves and pulled up
and over the gown’s cuff, covering all skin
surfaces.3
PPE must also be removed in
a prescribed sequence. After treatment,
most of the patient’s body fluids have
been deposited on outer PPE surfaces.
Care must be taken not to contaminate
skin, mucus membranes, underlying
clothes and the local environment.
Removal should be by level of
contamination, with the most soiled
coming off first. The removal order is
gloves, followed by protective eyewear,
gowns and masks.1,3,4,5
To remove gloves correctly,
grasp the outside edge, near the wrist,
peel away from the hand, turning the
glove inside out. Hold the removed
glove in the gloved hand. Then, slide an
ungloved finger under the wrist of the
remaining glove and peel off from the
inside, creating a bag containing both
gloves. Discard and perform HH.3,4,5
Hand hygiene is the most
important measure to prevent spread of
infections among patients and DHCPs.
Education and training programmes
should thoroughly address indications
and techniques for HH practices before
performing routine and oral surgical
procedures.1,2
HH should be performed
March 2018
UpdatesfromAmerica
b
when:
1. Hands are visibly soiled;
2. After bare-handed touching of
instruments, equipment, materials and
other objects likely to be contaminated
by blood, saliva or respiratory secretions;
3. Before and after treating each patient;
and
4. Before putting on gloves and again
immediately after glove removal.
For routine dental
examinations and non-surgical
procedures, use water and plain soap
(hand-washing) or antimicrobial soap Figure 2. (a, b) Demonstrating how to remove
(hand antisepsis) specific for healthcare gloves correctly. (Modified from References 3
and 5).
settings or use an alcohol-based hand
rub (ABHR).2
Soap and water hand-washing
generally is not affected by organic
4. Lower incidences of skin irritation;
materials and should be used when
5. Are simply made with few components;
hands are visibly soiled (eg blood, body
and
fluids). Soap and water are effective when
6. Do not promote microbial resistance.2,3
properly performed, are familiar to DHCP
or produce few allergies. Use can dry the For surgical procedures,
skin and cause irritations, though these perform a surgical hand scrub before
can be prevented or treated well with putting on sterile surgeon’s gloves. For
hand lotions. The learning process takes all types of hand hygiene products,
some time and usually requires a sink and follow the product manufacturer user
running water.2 instructions.1,2,3,5
ABHRs are now broadly Traditionally, HH compliance
available and widely used and have the among all healthcare professionals has
following qualities: been suboptimal. Things have improved
1. Very good activity; over the last ten years because of
2. Are more effective than soap and increased awareness, in-service training
water; and increased electronic and visual
3. Are a faster process; monitoring. This is essential because
DentalUpdate 267
 UpdatesfromAmerica

there is a direct relationship between References at: http://www.medscape.org/

proper HH and the rate of healthcare-
associated infections among patients
and practitioners.1,2,3
When assessing
performance, it is important to review
possible behavioural aspects that
might be affecting compliance. New
tools and innovative technologies are
constantly emerging; however, whistles
and bells cannot replace proper basic
HH practices. Stressing the importance
of HH and encouraging personal
responsibility and collaboration should
help improve compliance. Many
mistakes are small, but often they add
up to become a large problem. Gloves
can help reduce the risk but, if used
inappropriately, may contribute to the
problem.3
1. Centers for Disease Control and
Prevention. Guidelines for Infection
Control in Dental Health-Care Settings
— 2003. MMWR 2003; 52(RR-17):
14−66. Also available at: https://www.
cdc.gov/mmwr/PDF/rr/rr5217.pdf
2. Centers for Disease Control and
Prevention. Summary of Infection
Prevention Practices in Dental Settings:
Basic Expectations for Safe Care. Atlanta,
GA: Centers for Disease Control and
Prevention, US Department of Health
and Human Services, October 2016.
Also available at: https://www.cdc.
gov/oralhealth/infectioncontrol/pdf/
safe-care2.pdf
3. Medscape Education Family Medicine.
Infection Transmission Risks Associated
with Nonsterile Glove Use. Available
viewarticle/880896?src=par_cdc_
stm_mscpedt&faf=1 Accessed
October 2017.
4. Bingham J, Abell G, Kienast L, Lerner
L, Matuschek B, Mullins W et al. Health
care worker hand contamination at
critical moments in outpatient care
settings. Am J Infect Control 2016; 44:
1198−1202.
5. Centers for Disease Control and
Prevention. Guidance for the Selection
and Use of Personal Protective Equipment
(PPE) in Healthcare Settings. Available
at: https://www.cdc.gov/HAI/pdfs/
ppe/PPEslides6-29-04.pdf. Accessed
October 2017.

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 DentalUpdate

DentalUpdate
October 2017 . Volume 10 . Number 4
October 2017 . Volume 44 . Number 9

The Aberrant Canine Part 1: Aetiology and Diagnosis

Managing the Adenomatous Odontogenic Tumour (AOT): A Case
Series
Reflections on Twelve Years of Breakages – Lessons to be Learnt
„ Restorative Dentistry: Immediate Management of the Single-Unit Extracted Tooth in the
Anterior Aesthetic Zone − Temporizing/Stabilizing Tissues
„ Restorative Dentistry: Tooth Anatomy: A Practical Guide Part 2. Drawing Anterior Teeth
„Restorative Dentistry: Tooth Wear and Occlusal Ageing

DentalUpdate
October 2017 . Volume 44 . Number 9

„ Restorative Dentistry: Immediate Management of the Single-Unit Extracted Tooth in the

DentalUpdate
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Anterior Aesthetic Zone − Temporizing/Stabilizing Tissues
„ Restorative Dentistry: Tooth Anatomy: A Practical Guide Part 2. Drawing Anterior Teeth
„Restorative Dentistry: Tooth Wear and Occlusal Ageing

„ Restorative Dentistry: Immediate Management of the Single-Unit Extracted Tooth in the

or Aesthetic Zone − Temporizing/Stabil
Anterior izing
in Tissues
Temporizing/Stabilizing
„ Restorative
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 TechniqueTips

Technique Tips: Patient Information Leaflet

Information for Patients for whom Deep Caries has been Sealed
into a Vital Asymptomatic Tooth
The concept of sealing deep caries
into a vital asymptomatic tooth, rather
than removing all caries and risking a
pulpal exposure with all the inevitable
sequelae (ranging from pulp-capping to
root canal-filling), has gained increasing
acceptance from the time when Mertz-
Fairhurst and colleagues published their
ten-year randomized controlled trial
in 1998.1. In this work, in a split mouth
research design study, all patients
received an amalgam restoration (50%
of which were sealed after restoration
placement) and a resin composite
restoration, with all the caries being Figure 1. Occlusal cavity in an asymptomatic, vital lower first and second molar tooth. Remaining caries
removed from the amalgam cavities, could have been removed using a large, sharp spoon excavator.
but only the ‘soft strands of decay’ being
removed from the composite cavities.
Results of subsequent work by Kidd et al
indicated that, when caries was sealed
into a cavity and the cavity re-opened
after five months, the residual caries had
become harder, darker and dryer, and
that the number of bacteria associated
with the lesion had substantially
decreased.2 In clinical research on
primary teeth from Brazil,3 there were
two treatment groups, with incomplete
caries removal in 4 to 7-year-old children,
cavities treated with Ca(OH)2 or gutta-
percha (gutta-percha to indicate an
inert base), the cavities sealed with Figure 2. Cavities in Figure 1 filled with resin composite, margins etched and sealed with Biscover™
resin composite for 4 to 7 months, (Bisco).
and then re-opened and examined.
The soft caries changed to hard or
leathery and the number of bacteria
reduced in both treatment groups. The
authors concluded that ‘the resin-based
composite sealing of caries lesion, with supported the concept of sealing caries fewer pulps will be exposed’;5
or without a calcium hydroxide liner over into vital asymptomatic teeth,5,6,7,8 providing ‘One can state that there is
the infected remaining tissue, may help statements such as: substantial evidence that the removal of all
preserve dental tissue as well as pulp ‘There is no clear evidence that infected dentine in deep carious lesions is
vitality’. A related study4 concluded that it is deleterious to leave infected dentine, not required for successful caries treatment,
‘resin-based composite may arrest the even if it is soft and wet, prior to sealing the provided that the restoration can seal the
progress of underlying caries’. Review cavity, and this cautious approach may be lesion from the oral environment effectively’ 6
articles and Cochrane reviews have also preferable to vigorous excavation because (present author’s italics);

FJ Trevor Burke, DDS, MSc, MDS, MGDS, FDS RCS(Edin), FDS RCS(Eng), FFGDP(UK), FADM, University of Birmingham Dental School of
Dentistry, 5 Mill Pool Way, Pebble Mill, Birmingham B5 7EG, UK.
March 2018 DentalUpdate 271
 TechniqueTips

As a patient, what you need to know is:

„ Dental decay (caries), one of the commonest diseases on earth, has caused a deep hole in your tooth. The decay is close to the nerve
but the tooth is still alive and not causing pain. One way of treating deep decay is to drill or scrape out all the decay and risk exposing
the nerve of the tooth. Your dentist will then need to carry out extensive treatment on the affected tooth: this may involve placement of
a root filling and a crown or other restoration to protect the cusps of the root-filled tooth.
„ The methods of treatment for deep decay in teeth which are alive and not causing symptoms have changed! With your permission, I
propose to avoid scraping out all the decay because this could expose the nerve and then a root filling or extraction would be needed.
Having removed part of the decay, I will fill the tooth and this will stop the progress of the decay. I will review the tooth in 6 to 12
months and take an X-ray then (or earlier should you have any discomfort). Provided the tooth remains alive, no further treatment should
be needed. Please note that, on the follow-up X-ray, the decay that I left will show as a black area.
„ You should be aware that this technique has gained credibility for vital teeth as the research base for this has expanded and become
positive.
As a patient, what you also need to know is:
„ If you change dentists and you have a subsequent X-ray on the tooth with deep decay, your new dentist could say that the previous
dentist has left decay in a tooth when, in fact, (s)he has done this based on good clinical research. That’s why you need to know what
your dentist has been trying to achieve.
„ Placing a well-sealed filling over the decay will ensure that the decay doesn’t come back. There is, however, always a small chance that
your tooth will die and a root filling will be needed, but this is much less than if the nerve of the tooth is exposed by drilling away all the
decay.
„ You have had deep decay in your tooth. That therefore means that you have a problem with your diet and/or with your oral hygiene/
toothbrushing. You will therefore need to address this − your dentist and/or his/her hygienist will give you advice on this.

Table 1. Patient Information Leaflet for patients for whom deep decay has been sealed into a tooth.

‘Partial caries removal is
preferable to complete caries removal’;7
‘These techniques (sealing
caries) show clinical advantage over
complete caries removal’.8
The recent Dental Update
review by Kidd et al9 is particularly clear,
indeed forthright, in its conclusions,
namely, that ‘when restoring deep caries
lesions in vital, asymptomatic teeth,
vigorous excavation is likely to expose
the pulp. This complete excavation is not
needed and should be avoided’. These
authors stress that it is the seal which
is important. The message therefore
is clear, that sealing caries into a vital
asymptomatic tooth has become an
accepted technique. In that regard,
however, the author has encountered
comments from UK-based general dental
practitioners who have suggested that
a variety of authorities do not accept
this concept and have criticized dentists
for leaving caries under restorations.
Moreover, dentists who are not aware
of the concepts described above may
criticize colleagues, should a patient for
whom caries has intentionally been sealed
into a deep cavity attend such a dentist.
It may therefore be considered that there
272 DentalUpdate
is a need to provide patients with an
Information Leaflet explaining the concept
of sealing caries into vital asymptomatic
teeth: this is presented in Table 1. It is also
to be hoped that ‘non-believers’ in the
sealing-caries concept also become more
aware by reading reviews such as that
mentioned above, by Kidd and colleagues.9
An example of the concept is
presented in Figures 1 and 2.
References
1. Mertz-Fairhurst EJ, Curtis JW, Ergle JW,
Rueggeberg FA, Adair SW.
Ultraconservative and cariostatic
sealed restorations: results at year 10.
J Am Dent Assoc 1998; 129: 55−65.
2. Paddick JS, Brailsford SR, Kidd EAM,
Beighton D. Phenotypic and genotypic
selection of microbiota surviving
under dental restorations. Appl Environ
Microbiol 2005; 71: 2467−2472.
3. Pinto AS, deAraujo FB, Franzon R,
Figueirido FC, Henz S, Garcia-Godoy F,
Maltz M. Clinical and microbiological
effect of calcium hydroxide protection
in indirect pulp capping in primary
teeth. Am J Dent 2006; 19: 382−387.
4. Franzon R, Casagrande L, Pinto AS,
Garcia-Godoy F, Maltz M, deAraujo FB.
Clinical and radiographic evaluation
of indirect pulp treatment in primary
molars: 36 months follow up. Am J
Dent 2007; 20: 189−192.
5. Kidd EAM. How “clean” must a cavity
be before restoration? Caries Res 2004;
38: 305−313.
6. Thompson V, Craig RC, Curro FA, Green
WS, Ship JA. Treatment of deep caries
lesions by complete excavation or
partial removal. A review. J Am Dent
Assoc 2008; 139: 705−712.
7. Ricketts DNJ, Kidd EAM, Innes
N, Clarkson J. Complete or
ultraconservative removal of decayed
tissue in unfilled teeth. Cochrane
Database Syst Rev 2006 Issue 4.
8. Ricketts DNJ, Lamont T, Innes N, Kidd
EAM, Clarkson J. Operative caries
management in adults and children
(Review). Cochrane Database Syst Rev
2013 Issue 3.
9. Kidd EAM, Fejerskov O, Nyvad B.
Infected dentine revisited. Dent
Update 2015; 42: 805−809.
March 2018
BDA Theatre NEW FOR 2018!
The BDA Theatre features sessions from dentistry’s top innovators and
thinkers. The programme is designed by dentists for dentists, giving you
the knowledge and insights you need to stay up to date.
BDA Members will receive priority access into the Theatre.
Friday 18th May
09:30 - 10:30 Bio-aesthetic smile rehabilitations: restorative trends and realities
Dr Didier Dietschi, Senior Lecturer, University of Geneva and Private
Practitioner, Geneva, Switzerland
Free-hand bonding has evolved from a mere filling material to a versatile aesthetic
solution for a broad range of moderate to complex clinical situations such as
post-orthodontic smile enhancements, the aesthetic and functional rehabilitation of
tooth wear or even the veneering of eroded, and discoloured, anterior teeth. This talk
will give an overview of the most recent clinical advancements in direct composite
application, with multiple case presentations and relevant clinical knowledge.
10:50 - 11:50 “Congratulations, you have just inherited someone else's dental
implants - now what?”
Dr Koray Feran, BDS MSc FDSRCS, Principal Dental Surgeon and Clinical
Director, The London Centre for Implant and Aesthetic Dentistry (LCIAD)
Even though a clinician may not be placing or restoring dental implants, they are
likely to become responsible for patients with existing implant work. The objectives
are for the general dental surgeon and indeed their hygiene/therapist team to
understand the basic current types of dental implants and dental prosthetics and
how these require attention and remedial work over time in general dental practice.
12:15 - 13:15 What is good practice? Delivering dentistry for the child patient
Dr Siobhan Barry, Senior Lecturer and Consultant in Paediatric Dentistry,
University of Manchester
This presentation will highlight appropriate behaviour management techniques to
facilitate the examination and treatment of the child patient. Preventive regimens
and recall intervals will be recommended. Treatment planning for the child patient
under various sedation modalities will be highlighted.
13:35 - 14:35 The interceptive treatment of tooth wear using no-prep or minimally
invasive techniques
Dr Didier Dietschi, Senior Lecturer, University of Geneva and Private
Practitioner, Geneva, Switzerland
Novel treatment approaches for tooth wear involve the use of ‘no-prep’ or ultra-
conservative direct and indirect restorations as an interceptive approach to restore
a pleasing smile line, a new Vertical Dimension of Occlusion (VDO) and occlusal
scheme. This lecture will review current thinking and present highly selective
concepts which can restrict ongoing tissue destruction and restore worn teeth
according to the various forms and extent of tooth wear pathology.
14:55 - 15:55 Continuous care planning and future-proofing your dentistry
Dr Claire Field, Consultant and Specialist in Restorative Dentistry,
University of Sheffield
16:15 - 17:15 Ethical restorative strategies which empathise and manage the
psychological and emotional motivations of the patient
Dr Richard Porter, Private Practitioner and Consultant in Restorative and
Implant Dentistry, St. George’s Hospital, London
This lecture will explore the fine line dentists walk every day when planning and
treating patients, between their motivation for ‘perfection’ and providing ethical
health care. You will see and understand a variety of cases which describe the
patient’s psychological wishes, what ‘the right thing to do’ is and how fiscal
motivation can blur ethical treatment planning. The power of appearance will be
explained in full.
REGISTER FOR FREE:
WWW.THEDENTISTRYSHOW.CO.UK/DU
Saturday 19th May
09:30 - 10:30 Direct composite resin restorations, are there limitations?
Dr Niek Opdam, Private Practitioner and Associate Professor,
Radboud University, Nijmegen, Netherlands
Composite resin nowadays is used in restorative dentistry for more complex
dentistry such as the rehabilitation of severe tooth wear, treating cracked teeth
or extending the lifetime of teeth which have poor prognosis. But what about
the limitations of its use? What are the factors that determine the survival of our
restorative work? Is it the materials and clinical excellence of the dentist or are
patient and other dental factors more important? Several complex direct cases will
be shown which address the limitations of direct work.
10:50 - 11:50 Contemporary management of complex aesthetic and restorative
dilemmas using an interdisciplinary approach
Dr Tidu Mankoo, Private Practitioner, Windsor
The aesthetic rehabilitation of the periodontally and structurally compromised
dentition and inadequate or failing implant treatment in the aesthetic zone remains
a challenge despite the numerous advances in the treatment of periodontitis,
regenerative and dental implant therapies. This presentation will review the
contemporary interdisciplinary concepts in management of the aesthetic zone with
a view to achieving optimum long-term aesthetics and stability. With this in mind,
novel approaches for aesthetic rehabilitation of complex aesthetic and restorative
dilemmas will be presented. The outcomes depend on the clinical management
and an understanding and application of the biological factors that influence our
treatment outcomes. The optimal management of the interplay between bone, soft
tissues and prosthetics determines the aesthetic outcome and the long-term stability
of soft tissue aesthetics. An interdisciplinary approach is often the key to success.
12:10 - 13:10 Effective dental management of patients in later life
Dr Charlotte Stilwell, Specialist in Prosthodontic Dentistry, London
As life expectancy increases, dentists are faced with managing their patients into
more advanced age. Both the younger and older elderly patients present a host
of new challenges to delivery of effective care. This lecture will examine these
challenges and discuss effective oral and dental management from both the
patient’s and the dentist’s perspective.
13:30 - 14:30 Your role in patient management after treatment for oral cancer
Dr Mark Singh, BDS (Lon) MFDS RCS (Eng) MBBS (UWI) MRCS (Eng)
FRCS (OMFS), Consultant Oral and Maxillofacial Surgeon,
Mid Essex Hospital Trust
The talk aims to explore how you can help to improve local care provision for
cancer patients who have undergone treatments for oral cancer. It will highlight the
issues and suggest ways in which primary care can offer such services. Tertiary
care has traditionally provided specialist services. However, within the NHS, there
are opportunities for dental practices to provide some of these services, thereby
complementing what is on offer. This in turn would help improve oral care in the region,
increase dental attendances as well as reduce the need for interventions in hospitals.
14:50 - 15:50 Caries management in practice
Dr Bhupinder Dawett, GDP, Derbyshire and National Institute for Health
Research, Doctoral Research Fellow (University of Sheffield)
The talk will describe the need for a MI vision in dental practice and will discuss
incorporating new innovations and technologies. There will also be a focus on how to
involve patients in a new MI approach to their dental care with some further detail on
current practice-based research and Minimum Intervention dentistry.
16:10 - 17:00 Replacement of missing teeth - where are we now?
Dr Arshad Ali, Clinical Director, Scottish Centre for Excellence in Dentistry,
Glasgow
This lecture will discuss the different ways of replacing missing teeth, including
advantages and disadvantages for all types of restorations. Topics covered will
include removable partial dentures, adhesive bridge work, conventional bridge
work and implant restorations. The emphasis will be on clinical aspects of these
treatments, with practical hints and tips which practitioners will be able to introduce
into their clinical practice immediately.
CPD
continuing education

Test your knowledge on the content of the articles published.

The following 10 questions relate to some of the articles carried this month. Only one answer is correct.

To receive CPD credit answer the questions online at www.dental-update.co.uk or alternatively complete the enclosed answer sheet.

Q1 ELIYAS, BRIGGS AND GALLAGHER 45: 182–195 Q6 AGEL ET AL 45: 227–234

Regarding dental implants:
A. The economic costs are less than RCT.
B. Patient perception of quality of life improves after provision of
implants.
C. Survival of root-filled teeth is much less than survival of implant-
supported single crowns.
D. The failure rate is lower in patients who are smokers.
Regarding oral lichen planus:
A. This is seen most frequently in the middle-aged and elderly
population.
B. This is an acute inflammatory disease.
C. In adults, this is seen more often in males.
D. The pathogenesis is well understood.

Q2 KEAT ET AL 45: 197–206 Q7 PRITCHETT, COLEMAN, CAMPBELL AND PABARY 45: 236–246
Links between clay pipe smoking and malignancy of the lip were Regarding data analytics in dental practice:
first made in: A. This is of no value in reducing failed patient attendances.
A. 1995. B. This may not provide ‘evidence’ of areas in which the practice
B. 1895. could be growing.
C. 1795. C. There is no need to handle the data in accordance with the
D. 1695. Data Protection Act.
D. This means taking an inquisitive look at raw data.
Q3 KEAT ET AL 45: 197–206
Regarding oral cancer: Q8 GUPTA, NARAYAN, VIJAY AND BALAKRISHNAN 45: 247–252
A. There is no link between erythroplakia and oral cancer. Following the work of Tarnow et al, to achieve a papilla in
B. Four years after stopping smoking, the risk of oral cancer is the almost all cases, the vertical distance from the base of the
same as for a current smoker. contact area to the crest of the bone should be:
C. Smoking is not a main causative agent. A. 1 mm.
D. In Europe, oral cancer accounts for 0.7% of all deaths from cancer. B. 3 mm.
C. 4 mm.
D. 5 mm.
Q4 SABBAGH, FAHD AND MCCONNELL 45: 207–213
Regarding post-op sensitivity with resin restorations: Q9 KHALID, CHATZISTAVRIANOU AND BLAIR 45: 256–265
A. This is related to the absence of a liner.
B. A glass-ionomer cement liner in occlusal cavities has been shown The following medications are related to gingival
to reduce post-op sensitivity. enlargement:
C. Discrepancy in occlusion is never related to this. A. Aspirin.
D. Remaining dentine thickness is correlated to this. B. Denosumab.
C. Prednisolone
D. Cyclosporine

Q5 LAKHANI AND FLETT 45: 215–225

Q10 KHALID, CHATZISTAVRIANOU AND BLAIR 45: 256–265

Regarding ankylosis:
A. This is never related to an avulsion injury.
B. A determining factor re whether this occurs after avulsion is the
health of the periodontal ligament after injury.
C. Teeth with this sound normal on percussion.
D. Radiographically, replacement resorption is rarely seen.
Regarding minocycline:
A. This never causes black pigmentation of gingival tissues.
B. This is a semi-synthetic tetracycline used to treat acne.
C. This cannot bind to collagen.
D. Pigmentation of gingival tissues may occur with doses
exceeding 0.5 mg after one year.

CPD in Dental Update in partnership with

DEADLINE FOR SUBMISSION: 15 May 2018
10 QUESTIONS REPRESENT 4 HOURS OF CPD
ANSWERS FOR JANUARY CPD ON PAGE 225

March 2018
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