CHURCHILL’S POCKETBOOKS

Clinical Dentistry
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CHURCHILL’S POCKETBOOKS

Clinical Dentistry
4th EDITION

Edited by
Professor Crispian Scully CBE
MD, PhD, MDS, MRCS, BSc, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE,
FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed (HC), Dr.hc

Co-Director, WHO Collaborating Centre for Oral Health-General Health;

Emeritus Professor, UCL (London) and Visiting Professor, Universities
of Athens, Edinburgh, Helsinki, Hertfordshire, Middlesex and Plymouth

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2016
© 2016 Elsevier Ltd. All rights reserved.

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copyright by the Publisher (other than as may be noted herein).

First edition 1998

Second edition 2002
Third edition 2007
Fourth edition 2016

ISBN 978-0-7020-5150-0
International ISBN 978-0-7020-5149-4

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they have
a professional responsibility.
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check the most current information provided (i) on procedures featured or (ii) by the
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formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their
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individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
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 Preface to the
Fourth Edition

As initiators of Clinical Dentistry, and editors of the first three edi-

tions, we are not only pleased to note the impressive success of the book
internationally but, in our increasingly busy senior academic roles, are also
delighted to pass the reins to our long-time colleague and friend, Professor
Crispian Scully CBE, and wish him and the contributors continued success
with the 4th edition.
Professor Ivor Chestnutt Cardiff
Professor John Gibson Glasgow

The primary objective of this Pocketbook was to provide a readily

accessible source of information when it is most needed, as an aide-
mémoire prior to carrying out clinical tasks or to enable students
(at undergraduate and postgraduate level) to apprise themselves
of important details prior to tutorials and seminars. Those aims
remain.
In a publication of this nature, information must be presented in
a concise and, at times, didactic fashion. The intent is to include
sufficient basic information to permit examinations to be passed.
However, the desire of an educationalist is always to promote deep
learning and the layout and content of the text are intended to moti-
vate and guide the reader to the appropriate parts of more substan-
tive texts, many of which have proven both inspirational and
motivational for the editors and contributors of this book throughout
their careers.
This textbook is widely used by more and more undergraduate
dental students, vocational dental practitioners, general professional
trainees, dental surgeons in primary care and in the hospital service,
as well as dental care professionals in-training and post-qualification.
I was requested to take on the editing of the 4th edition. For this
edition I have expanded the size and type of authorship. Although a
large proportion of current contributors were involved in earlier
editions, some previous authors were unavailable to help, so we have
also recruited a range of other top people in their fields. The current
authors are all experienced clinicians, teachers and/or managers
within their individual specialties and emphasis has been given to
information of practical clinical significance. Descriptions of rarely
encountered conditions and situations have been deliberately
minimized.
vi • Preface to the Fourth Edition

In updating this edition, each author has addressed significant

changes within his or her areas of expertise and I am grateful to them
for their enthusiasm and great industry and particularly for comply-
ing with deadlines.
Thus this new 4th edition has not only been invigorated and
enhanced but also the chapter order has been rearranged. We have
also expanded on practical aspects related to the regulator – the
General Dental Council; and on the dental team roles, and practice
management. The book has been written to be used in conjunction
with Scully’s Handbook of Medical Problems in Dentistry (Elsevier
2016) and now includes issues related to overseas dental staff, access
for disabled, advertising, aetiopathogenesis of dental disease, assaults
on staff, behaviour at work and outside (GDC standards), building
design, chaperoning, clothing, finance management, foundation and
vocational training, governance, health and safety, hiring and firing,
identifying staff, independent practice, infection control, information
technology, management skills, marketing, NHS regulations, over-
seas staff, professionalism, protected characteristics, significant event
analysis, time-keeping and things staff must do before starting work
and leaving a job. The aims and objectives remain the same – to
educate and inspire each member of the whole dental team, whether
in-training or post-qualification.
I am indebted for support from the authors, Professor Ivor Chest-
nutt, Professor John Gibson, Professor Justin Stebbing and at Elsevier,
Mrs Lynn Watt and Mrs Alison Taylor. Our thanks are also due to
former contributors, including Iain. B. Buchanan, Barbara. L. Chad-
wick, Ivor. G. Chestnutt, John Gibson, Jason Leitch, Joe McManners,
Jeremy Rees and Dave Stenhouse.
Crispian Scully
London, 2016
 Contributors

Stephen Barter
BDS MSurgDent RCS
Specialist Oral Surgeon
Perlan Specialist Dental Centre
Hartfield Road
Eastbourne, UK

Stephen Barter is Clinical Director of Perlan Specialist Dental Centre, East-

bourne; Specialist in Oral Surgery and Hon. Lecturer in the Department of
Periodontology, UCL Eastman Dental Institute, London; ITI Fellow and past
Chairman of the UK and Ireland ITI Section and has been involved in the teach-
ing and development of dental implantology for over 20 years.

John A.D. Cameron

BDS DGDP LLB (Hons)
Senior Clinical/Dental Adviser
Practitioner Services
NHS National Services Scotland
Edinburgh;
University of Aberdeen Dental School
Aberdeen, UK

John Cameron is Senior Dental Adviser at NHS National Services Scotland,

Senior Clinical Lecturer at the University of Aberdeen Dental School, Lead for
Law, Ethics and Professionalism. He is also Chairman of the Dentists Health
Support Programme and Trust.
viii • Contributors

Iain Chapple
BDS FDSRCPS PhD FDSRCS CCST (Rest Dent)
Periodontal Research Group and MRC Centre for
Immune Regulation
School of Dentistry
College of Medical and Dental Sciences
University of Birmingham
Birmingham, UK

Professor Iain Chapple is Head of Periodontology at the University Birming-

ham’s School of Dentistry and Clinical Lead for an NHS service base of 6
million. He is Associate Editor of Journal of Clinical Periodontology and Period-
ontology 2000 and former Scientific Editor of the British Dental Journal and
former Associate Editor of Journal of Periodontal Research. President of The
British Society of Periodontology (2014–2015), President of The Periodontal
Research Group of the International Association of Dental Research (2007),
Treasurer and Executive Committee member of the European Federation of
Periodontology (EFP) (2007–2013), EFP Scientific Advisory Committee Chair-
man (2013–2015), Secretary General (2016–), EFP Workshop Co-Chairman
(2009–current). He has written and edited seven books and 16 book chapters
and published over 140 full papers on Medline. He was awarded the Tomes
Medal by the Royal College of Surgeons of England in 2012.

Fiona Cox
B.Ed MInstLM
Ferndale Dental Clinic Ltd
Devizes, UK

Fiona Cox is co-owner at Ferndale Dental Implant and Cosmetic Clinic. She has
a wide experience in management within the private health sector and the NHS
dental and medical health fields.
 Contributors • ix

Martyn Cox
BSc (Hons) BDS MFGDP RCS (Eng) FRSM, PhD
Clinical Director Ferndale Dental Implant Clinic
Implant mentor and tutor Dentale Advanced
Implant course, Honorary Specialist Oral Surgeon,
Solihull Hospital
Lecturer

Martyn Cox is the Clinical Director at Ferndale Dental Implant and Cosmetic
Clinic, Devizes. He is a clinical trainer/lecturer and mentor in Advanced
Implantology in Bristol and Shrewsbury, an Honorary Oral Surgeon at Solihull
Hospital, Birmingham and a lecturer on the FGDP Oral Surgery course. Martyn
has been awarded numerous research prizes in the UK and has published
widely in both UK and international peer-reviewed journals including several
oral cancer textbooks and has lectured on implantology, oral cancer and
human papilloma virus genetics in the UK, Europe and the USA.

Daljit Gill
BDS BSc MSc FDS RCS MOrth FDS (Orth) RCS (Eng)
UCLH Eastman Dental Hospital
London, UK

Dr Daljit Gill is a Consultant Orthodontist at Great Ormond Street NHS Founda-

tion Trust and UCLH Eastman Dental Hospital. He has written a number of
textbooks and is involved in training orthodontists, therapists and nurses.
x • Contributors

Nikos Donos
DDS MS FHEA FDSRCSEngl PhD
Head Centre for Oral Clinical Research
Professor and Chair Periodontology and Implant Dentistry
Honorary Professor, UCL Eastman Dental Institute, UK
Honorary Professor, University of Hong Kong
Honorary Professor, Griffith University, Australia
Centre for Clinical Oral Research
Institute of DentistryBarts and The London School of
Medicine and DentistryQueen Mary University of
London (QMUL)

Awarded the title of Honorary Professor at the Faculty of Dentistry in Hong

Kong (2009) and the title of Adjunct Professor at the Dental School, Griffith
University, Australia (2012), Professor Donos is involved as editorial board
member in a number of international and national peer-reviewed journals in
the field of Periodontology and Implant Dentistry and has published exten-
sively. In 2011, he was awarded the prestigious annual IADR-Periodontology
Group Award in Periodontal Regenerative Medicine. His clinical expertise is in
the field of Periodontics and Implant Dentistry and he has significant experi-
ence in periodontal/bone regeneration and implant related surgical procedures
as well as treatment of peri-implantitis, topics which he regularly lectures on
at a national and international level.

David H. Felix
BDS MB ChB FDS RCS (Eng) FDS RCPS (Glasg) FDS
RCS(Ed) FRCP(Ed)
Dean of Postgraduate Dental Education
NHS Education for Scotland
Edinburgh, UK

Dr David H. Felix is Postgraduate Dental Dean, NHS Education for Scotland and
Chair of the Joint Committee for Postgraduate Training in Dentistry. Previously
Consultant in Oral Medicine Glasgow Dental Hospital and School. He is a
former Dean of the Faculty of Dental Surgery of The Royal College of Surgeons
of Edinburgh and a former President of the British Society for Oral Medicine.

Mark Griffiths
MBBS FDS RCS BDS
Visiting Professor, UCL (Eastman Dental Institute);
Honorary Research Fellow, School of Physiology,
Pharmacology and Neuroscience
University of Bristol
Bristol, UK

Mark Griffiths is Visiting Professor, UCL (Eastman Dental Institute), London,

UK and Honorary Research Fellow, School of Physiology, Pharmacology and
Neuroscience at the University of Bristol. He is a retired NHS Consultant in
Special Care Dentistry at the Bristol Dental Hospital. Holder of Patent: Monitor-
ing electrical activity (Electroencephalograph) and Member of University of
Bristol Neuroscience Community.
 Contributors • xi

Athanasios Kalantzis
DipDS MFDSRCS MBChB MRCS FRCS (OMF)
Oral and Maxillofacial Surgery Consultant
Central Manchester Foundation Trust
Manchester, UK

After qualifying in Dentistry in Athens, Greece and in Medicine in Sheffield,

UK, Mr Kalantzis trained in Oral and Maxillofacial Surgery at the Oxford Uni-
versity Hospitals and served as Members Representative and Fellows in Train-
ing Representative of the British Association of Oral & Maxillofacial Surgeons
as well as Officer of the Junior Trainees Group. He is a member of the Royal
College of Surgeons of England and has taught oral and maxillofacial trainees
for several years. He has presented papers nationally and internationally and
has experience in organizing as well as chairing national and international
conferences.
Mr Kalantzis is co-author of the books Oxford Handbook of Dental Patient Care
2e and the Oxford Specialist Handbook of Medicine and Surgery for Dentists and is
on the Editorial Board of Medical Problems in Dentistry 6e, and is a regular
reviewer for journals such as Oral Oncology and British Journal of Oral & Maxil-
lofacial Surgery.

Tatiana Macfarlane
BSc PhD MICR FHEA
Senior Research Fellow
University of Aberdeen, Dental School
Aberdeen, UK

Dr Tatiana Macfarlane is a Senior Research Fellow at the University of Aber-

deen Dental School, UK. She previously worked at the University of Manchester
in England, European Institute of Oncology in Italy and International Agency
for Research of Cancer in France. Her main research interests are in epidemiol-
ogy of head and neck cancer and oral health epidemiology. She has been
involved in major international collaborations such as Alcohol-related Cancers
and Genetic Susceptibility in Europe (ARCAGE) and International Head and
Neck Cancer Epidemiology Consortium (INHANCE). She is a Fellow of the
Royal Statistical Society (RSS), Fellow of the Institute of Learning and Teaching
in Higher Education (ILTHE), member of the International Epidemiological
Association (IEA), member of the American Association for Cancer Research
(AACR) and professional member of the Institute of Clinical Research (ICR).
She has authored over 120 peer-reviewed papers.
xii • Contributors

Avril Macpherson
BDS (Edin) FDS RCSEd MFDS RCSEd MSND RCSEd
DipConSed (N’castle) PGCTLCP (Edgehill) FHEA
Clinical Director
Liverpool University, Dental Hospital
Liverpool, UK

Avril Macpherson was appointed Consultant/Honorary Senior Clinical Lec-

turer in Special Care Dentistry, Liverpool University Dental Hospital and School
of Dentistry, in 2010. She is a member of the British Society of Disability and
Oral Health Executive Committee, the Specialty Advisory Committee in Special
Care Dentistry (RCSEng), the Specialty Advisory Board in Oral Medicine and
Special Care Dentistry (RCSEd) and is a Regional Specialty Advisor in Special
Care Dentistry (RCSEng). Avril teaches widely in conscious sedation and special
care dentistry and is a member of teaching faculty of the Society for the
Advancement of Anaesthesia in Dentistry and a Resuscitation Council
Advanced Life Support instructor. She is a RCSEd examiner for MFDS and
MSCD examinations.

Jasmine Murphy
BDS (Hons) MSt (Camb) MFGDP UK MFDS RCS (Edin)
MFDS RCS (Eng) MRes (Manc) FDS RCS (Eng) FFPH
Consultant in Public Health (Children and Young
People, Sexual Health, Dental Public Health)
Leicester City Council
Leicester, UK

Jasmine Murphy is a Consultant in Public Health at Leicester City Council and

registered as a Specialist in Dental Public Health with the General Dental
Council. Children in Leicester have been reported to have the worst level of
dental health in England and therefore Jasmine established the Oral Health
Promotion Partnership Board and is driving forward the implementation and
mobilization of Leicester’s first Oral Health Promotion Strategy for pre-school
children. Leicester’s dental public health programme ‘Healthy Teeth, Happy
Smiles!’ is an early intervention programme that is modelled on Scotland’s
ChildSmile. Jasmine also contributed to Public Health England’s ‘Commission-
ing Better Oral Health’ guidance, is a core member of the National Institute
of Health and Care Excellence (NICE) Public Health Advisory Committee
and is also currently contributing to NHS England’s Commissioning Guide on
Paediatric Dentistry. Jasmine has also recently been invited to join the Editorial
Board of Oral Diseases journal.
 Contributors • xiii

Farhad B. Naini
BDS (Guy’s) MSc (Lond) PhD (KCL) FDSRCS (Eng)
MOrthRCS (Eng) FDSOrth.RCS (Eng) GCAP(KCL) FHEA
Consultant Orthodontist
Maxillofacial Unit
Kingston Hospital and St George’s Hospital
London, UK

Dr Naini is the Consultant Orthodontist in the Maxillofacial Units at Kingston

Hospital and St George’s Hospital, Chair of the multidisciplinary Cranio-Orbito-
Facial Surgery Group and Research Lead for Dentistry and Orthognathic
Surgery. He has over 80 peer-reviewed publications and is editor of major
textbooks on orthodontics and orthognathic surgery. He is also author of the
reference textbook Facial aesthetics: concepts and clinical diagnosis.

Tim Newton
BA PhD CPsychol AFBPsS CSci
Unit of Social and Behavioural Sciences
King’s College London, Dental Institute
Guy’s Hospital
London, UK

Professor of Psychology as Applied to Dentistry and Honorary Consultant

Health Psychologist at King’s College London Dental Institute, Tim has worked
in the behavioural sciences in relation to dentistry for over 20 years, and his
particular interests include the management of dental anxiety, interventions
to enhance oral health related behaviour and the working life of the dental
team. He has published over 250 peer-reviewed articles in scientific journals.

Paul P. Nixon
BDS FDSRCS (Eng) DDRRCR
Consultant in Maxillofacial Radiology
School of Dentistry
Liverpool University, Dental Hospital
Liverpool, UK

Paul Nixon is Consultant in Maxillofacial Radiology in Royal Liverpool Univer-

sity Hospital, clinical lead in the Dental Radiology Department and is also a
specialist in Oral Surgery. He is an honorary clinical lecturer of the University
of Liverpool and has an honorary contract at Alder Hey Children’s Hospital.
He has authored or coauthored 26 publications. He is on the council of the
British Society of Dental and Maxillofacial Radiology where he is audit lead and
is responsible for their website. He recently served as external examiner for the
MSc in Maxillofacial radiology at King’s College London for 6 years, is an
examiner for the MJDF examination of the Royal College of Surgeons of
England and is a member of the Royal College of Radiologists.
xiv • Contributors

Will Palin
BMedSc MPhil PhD FADM
Biomaterials Unit, The School of Dentistry
College of Medical and Dental Sciences
University of Birmingham
Birmingham, UK

Will Palin is a Reader in Biomaterials at the School of Dentistry, University of

Birmingham. With a background in materials science, his developmental
research for both dental and wider medical applications has attracted grant
funding from the EPSRC, BBSRC, NIHR, Ministry of Defence and various indus-
trial partners. He has authored over 70 publications and six book chapters. He
is Editor of the European Journal of Prosthodontics and Restorative Dentistry,
Subject Editor for Biomaterials Adhesion, International Journal of Adhesion and
Adhesives and Board Member for Journal of Biomaterials Applications, Dental
Materials and Journal of Dentistry.

Andrew Paterson
LLM BDS (Hons) FDSRCPS DRDRCS (Edin) MRDRCS (Edin)
Consultant in Restorative Dentistry, NHS Ayrshire and
Arran;
Honorary Clinical Senior Lecturer, University of
Glasgow;
Maxillofacial Unit
The University Hospital Crosshouse
Kilmarnock, UK

Andrew Paterson is a Consultant in Restorative Dentistry mainly involved in

the prosthodontic management of head and neck cancer, trauma and hypo-
dontia patients in a District General Hospital. Formerly an NHS Consultant at
Glasgow Dental Hospital with 20 years’ experience in a private specialist restor-
ative and prosthodontics referral practice dealing with all aspects of restorative
dentistry. Part-time associate dento-legal adviser with an indemnity insurer.
Contributor to all previous editions of this textbook.

Crispian Scully
CBE PhD MD MDS MRCS FDSRCPS FFDRCSI FDSRCS
FDSRCSE FRCPath FmedSci FHEA FUCL FSB DSc DChD
DMed (HC) Dr HC
Emeritus Professor
University College London
London, UK

Professor Crispian Scully is a Director of the WHO Collaborating Centre in

Oral Health-General Health; journal Founder and Editor of Oral Oncology and
Oral Diseases; and author or editor of 50 books, 200 book chapters and over
1000 papers on MEDLINE. He is UCL Professor Emeritus, has been Dean at UCL
and Bristol, and president of several international and UK societies and has
medals from Universities of Helsinki, Santiago de Compostela and Granada;
Fellowship of UCL; and Doctorates from Universities of Athens, Granada, Hel-
sinki and Pretoria.
 Contributors • xv

John C. Steele
MB ChB BDS MFDS RCSEd FDS (OM) RCSEd Dip Oral
Med PGCTLCP FHEA
Consultant and Specialist in Oral Medicine
The Leeds Teaching Hospitals NHS Trust;
Honorary Senior Lecturer in Oral Medicine
Faculty of Medicine & Health
University of Leeds
Leeds, UK

Dr John C. Steele is dual qualified in both medicine and dentistry and is cur-
rently Consultant, Honorary Senior Lecturer and Specialist in Oral Medicine
based in Leeds. He has previously worked in a number of medical and surgical
posts including emergency medicine. He has co-authored 14 articles published
in peer-reviewed journals and has reviewed manuscripts for five national and
international dental and medical journals. He is a current member of Council
of the British Society for Oral Medicine.

Damien Walmsley
PhD MSc BDS FDSRCPS
The School of Dentistry
College of Medical and Dental Sciences
University of Birmingham
Birmingham, UK

Professor Walmsley is a recognised both for his research and teaching. His
research is on the the use of ultrasonics in dentistry including its use in period-
ontology, endodontics and its healing effects in repairing teeth. His present
research funding includes imaging biofilm and observing its real time removal
via ultrasonic instruments. He is very active in Interdisciplinary doctoral train-
ing centres at the University of Birmingham and is Graduate Director for
Dentistry. He publishes his work in high impact scientific journals which has
resulted in research and advisory roles for all the major dental companies. He
is a well respected educator in Prosthodontics and also contributes to courses
on Information Technology and Law/ethics courses. Clinically his work evolves
around Prosthodontics and he is the leader of a busy NHS department. He is
Scientific Advisor to the British Dental Association and enjoys a high profile in
the media. He is a past President of the British Prosthodontic Society. Interna-
tional roles include Past President of the Association for Dental Education in
Europe and deputy chair of U21 Health Sciences. Editorial duties include past
Editor of the Journal of Dentistry and he is on the Editorial boards of the BDJ,
European Journal of Dental Education, Journal of Dental Education, Journal
of Endodontics. European Journal of Restorative Dentistry and Dental Update.
xvi • Contributors

Richard Welbury
Professor of Paediatric Dentistry
School of Dentistry
University of Central Lancashire
Preston, UK

Richard Welbury is Professor of Paediatric Dentistry at the University of

Glasgow Dental School and currently Dean of the Dental Faculty and Vice-
President of the Royal College of Physicians and Surgeons of Glasgow.

Paul H.R. Wilson

BSc BDS MSc FDSRCPS FDS(RestDent) DipDSed
Consultant in Restorative Dentistry
Oxford University Hospitals NHS
Foundation Trust, Headington, Oxford UK
The Circus Dental Practice
Bath, UK

Paul H.R. Wilson is Consultant in Restorative Dentistry at Oxford University

Hospitals NHS Foundation Trust and he works in private specialist dental prac-
tice in Bath. He is visiting Senior Clinical Lecturer at the Universities of Aber-
deen and Bristol. He completed postgraduate training at Guy’s & St Thomas’
Hospitals, London and King’s College London.

Graeme Wright
BDS FDS(Paed Dent) RCPSG MPaed Dent RCSEd
PGCLTHE FHEA
Consultant in Paediatric Dentistry
Royal Hospital for Sick Children
Edinburgh, UK

Graeme Wright is Consultant in Paediatric Dentistry at Edinburgh Royal

Hospital for Sick Children. He is an Executive Board member of BSPD, organizer
of the IAPD 2015 International Congress and editorial board member of
‘Dental Traumatology’. His sub-specialty interests are Dental Traumatology
and Oncology/Haematology related to dentistry.
 Contents

Preface to the Fourth Edition v

Contributors vii

1. Dental public health, epidemiology and prevention 1

Tatiana Macfarlane, Jasmine Murphy

2. Social and psychological aspects of dental care 27

Tim Newton

3. Dental disease 39
Crispian Scully

4. The dental team 71

Crispian Scully, John Cameron

5. Law, ethics and quality dental care 93

John Cameron

6. Practice management 121

Fiona Cox, Martyn Cox

7. History and examination 167

Mark Griffiths

8. Dental and maxillofacial radiology 175

Paul Nixon

9. Pain and anxiety management 201

Avril Macpherson

10. Drug prescribing and therapeutics 223

Mark Griffiths

11. Dental materials 237

William Palin, Damien Walmsley
xviii • Contents

12. Implantology 269

Stephen Barter, Nikos Donos

13. Oral medicine 289

David H. Felix

14. Oral and maxillofacial surgery 337

Athanasios Kalantzis

15. Orthodontics 391

Daljit Gill, Farhad Naini

16. Paediatric dentistry 429

Graeme Wright, Richard Welbury

17. Periodontology 461

Iain Chapple

18. Removable prosthodontics 475

Andrew Paterson

19. Operative dentistry 513

Paul H.R. Wilson

20. Special care dentistry 577

Avril Macpherson

21. Emergencies 621

John Steele

Appendices 637
Appendix A: Average dates of mineralization and eruption
of the primary dentition 638
Appendix B: Tooth notation 640
Appendix C: Tooth eruption 640

Index 643

Dental public health,
epidemiology
and prevention
Dental public health 1
Oral health epidemiology 3
The prevention of oral diseases 4
The wider determinants of
health 5
Oral health promotion 6
Common risk factors 6
Barriers to healthy behaviours 7
Changing disease levels 8
Caries risk 9
Diet and dental caries 10
Fluoride 12
Modes of action 12
Smoking and oral health 16
Smokeless tobacco and oral
health 17
Electronic cigarettes and oral
health 18
1
Hookah (shisha) and oral health 19
Alcohol consumption and oral
health 19
Other substance abuse and oral
health 21
HIV infection and oral health 21
Prevention of dental neglect 22
Sport trauma 23
Temporomandibular disorders 23
Frequency of dental attendance 23
Routine scale and polish 23
Prevention in older patients 24
Pregnancy and oral health 25
Oral health in special population
groups 25
Conclusion 26

Dental public health

Definition
This is a non-clinical specialty involving the science and art of preventing oral
diseases, promoting oral health to the population rather than the individual.
It involves the assessment of dental health needs, developing policy and
strategy and ensuring appropriate dental health services to meet the needs
of the population.

Dental Public Health (DPH) is concerned with the oral health of a

population rather than individuals and has been defined as the
science and art of preventing oral diseases, promoting oral health
and improving the quality of life through the organized efforts of
society. Dental public health practice requires an understanding of
the challenges in the delivery, planning and management of health
services in order to ensure that the provision of health services meets
the needs of the population. This dental specialty requires specific
skills in undertaking oral health needs assessments and developing
specific oral health policies and strategies that protect and promote
2 • C L I N I C A L D E N T I S T RY

population level oral health. It also involves a comprehensive under-

standing and appreciation of the principles and methods that under-
pin oral health promotion, oral health inequalities, the wider
determinants of health and health behaviour.
Oral health has improved in the UK over the last 30 years, but there
is evidence that inequalities have widened. With limited funding and
the ever-growing evidence base for interventions, dental public
health specialists must make decisions, develop policies and imple-
ment strategies that are based on the best available scientific evidence
in order to meet oral health goals, reduce oral health inequalities and
sustain necessary resources. Such activities also involve the system-
atic use of data and information systems, application of programme
planning frameworks, engagement with the communities in the
decision-making process, conducting sound evaluation and dissemi-
nating lessons that have been learnt.
The evidence-based decision-making process which is applied
in dental public health integrates best available research evidence,
practitioner expertise and other available resources including the
characteristics, needs, values and preferences of those who will
be affected by the intervention. Once health needs are identified
through a community assessment, the scientific literature can iden-
tify programmes and policies that have been effective in addressing
those needs. However, the amount of available evidence can be
overwhelming.
There are many types of evidence (e.g. randomized controlled
trials, cohort studies, qualitative research) and the best type of evi-
dence depends on the question being asked. Not all types of evidence
(e.g. qualitative research) are equally represented in reviews and
guidelines. The concept of a ‘hierarchy of evidence’ can be problem-
atic when appraising the evidence for public health interventions
as not all populations, settings and health issues are necessarily
represented in evidence-based guidelines and/or systematic reviews.
An important objective for those engaged in evidence-based dental
public health is to improve the quality, availability and use of evi-
dence in public health decision-making. The wide-scale implementa-
tion of evidence-based dental public health requires not only a
workforce that understands and can implement the evidence base for
dental public health efficiently but also sustained support from health
department leaders, practitioners and policy makers.
Evidence-based practice guidelines are based on systematic reviews
and/or meta-analyses of research-tested interventions and can help
practitioners select interventions for implementation.

• Systematic reviews use explicit methods that focus on a particular

research question which locates and critically appraises all high
quality research evidence relevant to that question. They result
 Dental public health, epidemiology and prevention • 3

in reports and recommendations that summarize the effectiveness

of particular interventions, treatments or services and often
include information about their applicability, costs and implemen-
tation barriers.
• Meta-analysis is a statistical technique to combine pertinent data
from several studies to develop a single conclusion that has
greater statistical power. The benefits of meta-analysis include a
consolidated and quantitative review of the large, complex and
sometimes conflicting body of literature.

The Cochrane Library (http://www.cochranelibrary.com) is an

online collection of databases that contain different types of high-
quality, independent evidence to inform healthcare decision-making.
The Centre for Evidence-based Dentistry (CEBD; http://www.cebd.org)
sets out an approach to systematizing the evidence for different
research questions, with the highest level of evidence being system-
atic reviews and randomized clinical trials, with case series and
expert opinion as the lowest level of evidence.
To find evidence tailored to their own context, practitioners may
need to search resources that contain original data and analysis.
Peer-reviewed research articles, conference proceedings and techni-
cal reports can be found for example in PubMed (http://www.ncbi
.nlm.nih.gov/pubmed). Maintained by the US National Library of
Medicine, PubMed is the largest and most widely available biblio-
graphic database of biomedical literature.

Oral health epidemiology

Epidemiology, which is defined as the study of disease distribution
and its determinants in specified populations, is the basic science of
public health because it studies the patterns, causes and effects of
health and disease conditions in human populations. It is the corner-
stone of public health and informs policy decisions and evidence-
based practice by identifying risk factors for disease and targets for
preventive health care. Furthermore, epidemiology has been used to
generate much of the information required by public health profes-
sionals to develop, implement and evaluate effective intervention
programmes for the prevention of disease and promotion of health,
such as the eradication of smallpox, the anticipated eradication of
poliomyelitis, and prevention of diphtheria, tetanus, measles, menin-
gitis and mumps, heart disease and cancer. The ‘art’ of epidemiology
is knowing when and how to apply the various epidemiological strat-
egies to answer specific health questions. Such designs include
descriptive epidemiological studies (such as cross-sectional or
surveys) and analytical (such as cohort studies, case-control studies
and randomized clinical trials).
4 • C L I N I C A L D E N T I S T RY

Dental caries is a public health concern and collecting data on its

prevalence, incidence and trends is an important field in oral health
epidemiology. Definitions used include:
• Prevalence: the proportion of individuals with disease (cases) in
a population at a specific point in time.
• Incidence: the number or proportion of individuals in a popula-
tion who experience new disease during a specific time period.
• Trend: the changes or differences in the prevalence or incidence
of disease with respect to time.

The prevention of oral diseases

The major oral diseases – dental caries, periodontal disease and
mouth cancer (see Chapter 3) – are not inevitable, but are to a large
extent influenced by the wider determinants of health, i.e. psychoso-
cial, economic, political, environmental, social and lifestyle factors.
The aetiology of these conditions is increasingly well understood and
prevention is largely possible if appropriate policies and strategies are
in place which influence or assist people in adopting appropriate
changes in behaviour.
Prevention is defined in three stages:

• Primary prevention – steps taken to ensure disease does not occur

• Secondary prevention – promoting early intervention in those already
affected to halt progression at incipient stage of disease
• Tertiary prevention – treatment of well-established disease to restore
function and avoid further episodes

The prevention of oral diseases can also be regarded as measures

applied either on a population basis, or at an individual level. Examples
of measures applied on a population basis include water fluoridation
and health promotion campaigns. Preventive measures on an indi-
vidual basis can be applied either by a dental professional (e.g. fluo-
ride varnish, fissure sealants, diet counselling, smoking cessation) or
by the individual, e.g. tooth-brushing.
In the developed world, dentistry has traditionally taken a
‘treatment-oriented’ approach, with the view that individuals were
reliant on dental professionals for maintenance of oral health, but
recent decades have seen a change to a more ‘preventive-oriented’
approach. Factors influencing this transition include:
• increased understanding of the nature of dental caries, periodon-
tal disease and other oral diseases
• increased appreciation of the shortcomings of traditional restora-
tive dentistry
 Dental public health, epidemiology and prevention • 5

• increased evidence based on preventative approaches

• changing aspirations of patients (perhaps of greatest
importance).

The wider determinants of health

Oral health and general health are determined by a complex interac-
tion between individual characteristics, lifestyle and the physical,
social and economic environment. People living in poorer areas tend
to have worse oral and general health when compared to those living
in more affluent areas. Given the close links between oral health and
other indicators such as family income, there is increasing pressure
to tackle the wider social determinants of health through the imple-
mentation of appropriate interventions. The wider social determi-
nants of health (Figure 1.1) are the circumstances in which people
are born, grow up, live, work, and age. These circumstances are in
turn shaped by a wider set of forces: economics, social policies and
politics.
Oral health inequalities are the ‘differences in oral health status
between different population groups’. Inequalities in oral health exist
between social classes, countries within the United Kingdom and
among certain minority ethnic and population groups. Oral health
inequalities can only be reduced through the implementation of
effective and appropriate oral health promotion policies and strate-
gies which tackle the wider social determinants of health. The

General socioeconomic,
cultural and environmental conditions
Living and working
conditions
Social and
community networks
Individual
lifestyle factors

• Work environment Individuals • Housing

• Unemployment (age, gender and • Water and sanitation
• Education genetic factors) • Agriculture and food
• Healthcare services production

Figure 1.1 Determinants of health (based on Dahlgren G & Whitehead M 1991

Policies and strategies to promote social equity in health. Institute for Future
Studies, Stockholm (Mimeo).
6 • C L I N I C A L D E N T I S T RY

improvements in oral health over the last 30 years have been largely
a result of fluoride toothpaste and social, economic and environmen-
tal factors.

Oral health promotion

Health promotion is the process of enabling people to increase control
over, and to improve their health (World Health Organization
[WHO]). It moves beyond a focus on individual behaviour towards a
wide range of social and environmental interventions. Health pro-
motion describes activities and actions designed to enhance positive
health and prevent ill-health by a combination of prevention, health
education and health protection. There are a number of approaches
that can be chosen when planning an oral health promotion initia-
tive including: settings (e.g. nurseries, schools, care homes), popula-
tion group (e.g. children, pregnant women, adults, vulnerable
groups) and topic based (e.g. dental caries, periodontal disease, oral
cancer).
Prevention. Described above.
Health education. Any combination of learning experiences
designed to help individuals and communities improve their health
by increasing their knowledge or influencing their attitudes (WHO).
It involves the provision of information aimed at influencing beliefs,
attitudes and behaviour relating to oral and dental health. In its
widest sense, it also includes provision of information about access
to and appropriate use of health services.
The key messages for oral health (see Chapter 3) are: reduce the
intake of sugar-containing food and drink, particularly the frequency
of sugar consumption and avoid between-meal sugar snacks; brush
teeth twice daily with a toothpaste containing fluoride; attend the
dentist regularly; do not use tobacco; reduce alcohol consumption.
Health protection. The practice of a nation to protect, improve and
restore health of individuals in a community or entire populations.
It functions through collective societal activities, programmes, serv-
ices and institutions aimed at improving health of people. It com-
prises laws, regulations, policies and voluntary codes of practice
aimed at preventing disease and enhancing health, e.g. legislation
making use of car seat-belts compulsory, thereby reducing the preva-
lence of maxillofacial injuries due to road traffic accidents.

Common risk factors

Traditionally, there has been an emphasis on dental health educa-
tion, either with individuals or groups, which has focused on impart-
ing knowledge. It has been shown that conventional oral health
 Dental public health, epidemiology and prevention • 7

Risk conditions

Risk factors Diseases Risk factors

Diet Obesity Tobacco
Cancers
Stress Heart disease Alcohol
School Workplace
Respiratory disease
Control Dental caries Exercise
Periodontal disease
Policy Hygiene Trauma Injuries Housing

Political Physical Social

environment environment environment
Figure 1.2 Common risk approach. Reproduced from Watt RG, Sheiham S 2000
The common risk factor approach: a rational basis for promoting oral health.
Community Dentistry and Oral Epidemiology 28(6):399–406 with permission
from John Wiley.

education is neither effective nor efficient (Kay and Locker, 1996),

especially if these oral health programmes only concentrate on indi-
vidual behaviour change and do not take into account the influence
of socio-political factors as the key determinants of health.
The common risk factor approach (Figure 1.2) takes a broader
perspective and targets risk factors common to many chronic condi-
tions and their underlying social determinants. The key concept of this
approach is that concerted action against common health risks and
their underlying social determinants will achieve improvements in a
range of chronic health conditions more effectively and efficiently
than isolated, disease-specific approaches. This approach acknowl-
edges that many diseases have common predisposing risk factors to
oral health. A poor diet that is high in sugars, and smoking are
examples of behaviours which impact adversely upon oral as well as
general health. As these causes are common to a number of other
chronic diseases, adopting a collaborative approach is more rational
than one that is disease specific. It also recognizes that engendering
lasting changes in individual ‘lifestyle’ behaviours requires support-
ive social, economic and political environments.

Barriers to healthy behaviours

The principle of health education is that by provision of appropriate
information and circumstances, beliefs and attitudes of individuals
8 • C L I N I C A L D E N T I S T RY

Upstream
Stop! Do not
‘Causes of the
jump in
causes’

General
politics Midstream
Help Help
Social policy

Public health policy + strategy

Health promotion Health care and services

Downstream

Lifestyle
Economy Life chances Health Quality of life
and environment

Figure 1.3 Upstream and downstream approaches.

will be affected sufficiently to result in the adoption of behaviour

likely to enhance health and diminish the chance of disease. However,
dental disease is heavily influenced by socioeconomic and other con-
straints that may restrict the choices available. Whilst parents may
realize that fresh fruit is preferable to chocolate bars, non-availability
or price may preclude its provision. Similarly, sugar-containing food-
stuffs are often given to children not only when they are hungry but
also as a reward or a pacifier.
The dominant preventive approach in dentistry, i.e. narrowly
focusing on changing the behaviours of high-risk individuals, has
failed to effectively reduce oral health inequalities, and indeed may
have increased the oral health equity gap. A conceptual shift is
needed away from this biomedical/behavioural ‘downstream’
approach, to one addressing the ‘upstream’ underlying social deter-
minants of population oral health (Figure 1.3).
Failure to change our preventive approach is a dereliction of
ethical and scientific integrity (Public Health England, 2014).

Changing disease levels

Dental disease levels in the UK population have reduced significantly
in the last three decades.
 Dental public health, epidemiology and prevention • 9

The 2009 Adult Dental Health Survey demonstrated that the pro-
portion of edentulous adults fell dramatically from 30% in 1978 to
6% in 2009. However, the survey also showed that stark inequalities
exist. For example, people from managerial and professional occupa-
tion households had better oral health (91%) compared with people
from routine and manual occupation households (79%) (The Health
and Social Care Information Centre, 2011).
The 2013 National Children’s Dental Health Survey (Office for
National Statistics, 2015) showed that there were reductions in the
extent and severity of tooth decay present in the permanent teeth of
12 and 15 year olds overall in England, Wales and Northern Ireland
between 2003 and 2013.
Large proportions of children, however, continue to be affected by
disease, and the burden of disease is substantial in those children that
have it. In 2013, nearly a half (46 per cent) of 15 year olds and a
third (34 per cent) of 12 year olds had “obvious decay experience” in
their permanent teeth. This was a reduction from 2003, when the
comparable figures were 56 per cent and 43 per cent respectively.
Furthermore, nearly a third (31 per cent) of 5 year olds and nearly
a half (46 per cent) of 8 year olds had obvious decay experience in
their primary teeth. Untreated decay into dentine in primary teeth
was found in 28 per cent of 5 year olds and 39 per cent of 8 year
olds. Overall, 58 per cent of 12 year olds and 45 per cent of 15 year
olds reported that their daily life had been affected by problems with
their teeth and mouth in the past three months.
Caries still affects a large number of children in lower socioeco-
nomic groups and within some ethnic minorities, as do its sequelae
(odontogenic infections; Chapter 3). There is a threefold difference in
levels of caries between the least and most deprived communities.
Upstream action addressing risks, beliefs, behaviours and the living
environment by ensuring appropriate policies and strategies are in
place are probably as important as affordable access to professional
treatment. This follows the sentiment of the Marmot Review ‘Fair
Society, Healthy Lives’, which dominates the wider public health
agenda of tackling avoidable differences in health using an ‘upstream’
approach. An upstream approach is when trying to change people’s
individual behaviours (such as encouraging the use of fluoride tooth-
paste with tooth brushing or adding fluoride to the water supply),
leads to beneficial effects flowing ‘downstream’ in the reduction in
dental treatment required due to a reduction in caries prevalence in
the population.

Caries risk
The ability to determine susceptibility to dental caries on either a
population or individual patient basis would offer a number of
advantages.
10 • C L I N I C A L D E N T I S T RY

Population basis. Permits developing appropriate policies and strat-

egies which seek to target resources, the location of clinics and the
implementation of preventive programmes.
Individual basis. Determines the need for caries control measures
such as socioeconomic factors, existing caries status, clinical judge-
ment of dental professional, the timing of dental recall appointments,
decisions as to suitability for advanced restorations, suitability for
orthodontic treatment.
Various tests have been devised for determining caries risk such as:
• counts of salivary lactobacilli (Dentocult LB), mutans streptococci
(Dentocult SM)
• tests of salivary buffering capacity (Dentobuff).
These tests have met with limited success as, due to the multifactorial
aetiology of dental caries, variation precludes accuracy and consist-
ent estimation of the caries susceptibility of an individual patient at
the chairside. The clinical judgement of the dental clinician, current
caries experience and socioeconomic factors of the patients have
proven the most reliable indicators of caries risk assessment. Deter-
mination of disease risk is an important factor in determining how
frequently patients should attend for preventive dental care such as
fluoride varnish applications, fissure sealants, etc.

Diet and dental caries (see also Chapter 3)

Evidence that sugar causes caries
There is clear and extensive evidence of the relationship between the
frequency and amount of sugar consumption and the prevalence and
severity of dental caries:
• epidemiological data show a correlation between sugar consump-
tion and caries on a national basis
• caries prevalence is higher in communities with high sugar
intake, e.g. sugar cane and confectionery industry workers
• caries prevalence increases following introduction of a sugar-
containing diet in isolated communities, e.g. the Inuit, island
communities such as Tristan da Cunha
• experimental clinical studies (such as Vipeholm Study) investigat-
ing the relationship between sugar intake and dental caries show
positive correlation between consumption of sugar (between
meals and at meals) and caries increment
• caries decreases following restriction of sugar, e.g. wartime diets.
Recently a number of research papers have argued that the increased
availability of fluoride has lessened the impact of sugar in the aetiol-
ogy of dental caries. However, there can be little doubt that a diet rich
 Dental public health, epidemiology and prevention • 11

pH
Plaque pH
Critical pH 5.5
Safe Net loss of calcium and phosphate ions below critical pH
zone

Danger
zone

6 7 8 9 10 11 12
Bottle Breakfast Snack Sippy cup Sippy cup Lunch
Figure 1.4 The effect of repeated sugar consumption.

in sugar, particularly if consumed at frequent intervals, will result in

caries development.

Factors influencing cariogenicity of foods

Cariogenic potential is related to consistency: sticky retentive foods
are more cariogenic than liquid non-retentive forms, e.g. toffee is
more cariogenic than chocolate.
The frequency of consumption is crucial. Snacking or ‘grazing’ results
in plaque pH being below the point where net outflow of calcium and
phosphate ions from the tooth surface occurs for prolonged periods
(Figure 1.4).

Dietary advice
The factors related to changing behaviour are particularly important
in encouraging patients to adopt a less cariogenic diet. Effective
dietary counselling requires knowledge of a patient’s habits relating
to non-milk extrinsic sugar consumption.

Diet diary
• Useful for those with high caries experience
• Must encourage patient to complete accurately
• Should cover a 3-day period including either Saturday or Sunday
• When completed, analyse with patient; highlight cariogenic food-
stuffs, particularly hidden sugars
• Allows formulation of personal advice for each individual
• Where possible, advise patient (and parent) in both written and
verbal form.

The ultimate message is ‘eat less sugar and eat sugar

less often’.