Section I the Patient BLUK133-Jacobsen December 7, 2007 16:38
Total Page：16
File Type：pdf, Size：1020Kb
BLUK133-Jacobsen December 7, 2007 16:38 Section I The Patient BLUK133-Jacobsen December 7, 2007 16:38 “I’m ready when you are.” 2 BLUK133-Jacobsen December 7, 2007 16:38 Chapter 1 The Patient – His Limitations and Expectations Section I The provision of high-quality restorative dentistry depends upon the dentist: Making an accurate diagnosis Devising a comprehensive and realistic treatment plan Executing the treatment plan to a high technical standard Providing subsequent continuing care There is a very strong tendency, particularly in the and here re-education is often necessary to bring him field of fixed prosthodontics, for the dentist to become down to the practical and feasible. over-interested in the technical execution of treat- It might be that the dentist has the skills and tech- ment. There is a vast range of materials and equip- nical facilities to perform advanced procedures, but ment to stimulate this interest and compete for his before he puts bur to tooth, he must stop and ask attention. It is perhaps inevitable that dentists can be- whether this is really what this patient needs and come obsessive about types of bur or root canal file, wants. If the answer is no, then to proceed is an act the pros and cons of various materials and the precise of pure selfishness that might also be regarded as techniques of restoration. negligent! This is not to decry such interest because a high Certainly the dentist may have certain treatment standard of technical execution is essential for the goals for all his patients – no pain or caries, healthy longevity of restorations. However, technical execu- periodontium, complete occlusion – but the way in tion must be seen in the context of the four-point se- which he prescribes and delivers his care has to be quence listed above. Without a sound diagnosis and tempered by the patient’s aspirations for his own treatment plan, even the best technical execution will mouth and his readiness to accept care. be doomed to failure. A prolonged treatment plan could be very incon- A major influence on the formulation of the treat- venient to a shift worker or to a mother with young ment plan is: children or those with no personal transport. It might create restorations that will be beyond the mainte- The Patient (Frontispiece) nance capacity of the lazy or disinterested, or those with inadequate washing facilities. It is usually by his own volition that he seeks restora- Perhaps the patient is a reluctant attender, ex- tive advice and treatment, and he usually brings with tremely apprehensive of dental care and its possible him certain problems and limitations that influence discomforts, and will require some form of therapeu- treatment planning and the delivery of care. tic help just to get the simple things done. The short, Each patient also attends with strong preconcep- unambitious treatment plan is more likely to succeed tions based on his previous experience of dentistry. here, and if the patient’s confidence can be obtained, This could be good or bad, with a single traumatic the more complex treatment could be provided episode being able to reverse many years of coopera- later. tion. The patient will have some idea of what dentistry Advanced restorations require skill and facilities, could or might do for him, and what he wants from and these have to be paid for, either by the state or his dentist. Some of his concepts could well be lim- by the patient. Both have limited resources and both ited or unambitious, and education has a major role to deserve value for money. Committing resources to play here. Conversely, sometimes his concepts could an ambitious treatment plan should involve judge- be over-ambitious, complex bridgework for instance, ment on the likely lifespan of the restorations in that BLUK133-Jacobsen December 7, 2007 16:38 4 I. The Patient Dentist Patient Ability Needs Training Aspirations Facilities Section I Treatment Plan Materials and Mouth techniques Caries rate Durability Periodontal index Simplicity Level of care Fig. 1.1 Influences on the formulation of a treatment plan. particular mouth and its conditions, and whether the There is considerably more awareness of the cos- expense is justifiable – cost benefit analysis. metic possibilities of modern dentistry and thus de- The intra-oral conditions bring as much influence mand for new materials and techniques. Much of this to bear. The caries rate, the number of missing teeth, is expensive and has not been fully evaluated over a the periodontal condition, the presence of dentures sufficient period for total confidence in its durability. and the quality of previous restorative work all act The patient deserves a proper explanation about the as limitations to the scope of the treatment plan. All reservations there are about particular lines of treat- of us like to provide our best work for those who ment. will appreciate it and look after it. Disinterest on the The provision of restorative treatment is a complex dentist’s part is created by the appearance of large arrangement wherein the patient, the dentist, the tech- plaque deposits and evidence of little care. nical support and the materials must be in harmony to The other side of the equation is what may be avail- produce a satisfactory result. The limitations of one able and this relates to the dentist’s skills and train- element will inevitably change the effects of the oth- ing, the materials and techniques at his disposal, and ers. It is important to remember that the treatment is the facilities available for providing care (Fig. 1.1). only as good as its weakest link – don’t let that be These, in turn, could well modify or even dictate the you! patient’s aspirations – a clean, well-equipped and ef- The key to success throughout is communication – ficient practice would indicate a good level of care listen and learn from what the patient says, explain to the average patient, whilst the reverse could well what can be done for him, and then decide jointly lower his expectations. on what should be done. If you are not sure, do not The dentist should offer only what is realistically commit yourself, but delay the decision and take ad- available and work within his own limitations. It is vice from your colleagues or even your local con- certainly no disgrace to say that certain options are sultant. beyond your capabilities and it is possible to consider This book begins by talking about how to find out referral to an appropriate specialist. It could also be what’s wrong with the patient and what does he want that the options the patient has aspirations towards done about it, coupled with the limitations the patient are those with a lower success rate, and it is sensible brings to formulating a treatment plan and then to to tell him this frankly. executing it. BLUK133-Jacobsen December 7, 2007 16:43 Section II The Restoration and Its Environment BLUK133-Jacobsen December 7, 2007 16:43 34 BLUK133-Jacobsen December 7, 2007 16:43 Chapter 5 Applied Biology of the Teeth The techniques for the restoration of tooth structure require a detailed knowledge of the tissues against which the material is to be placed. The purpose of this chapter is to describe the hard tissues of the human tooth and their relationship with their environment. The implications for restorative dentistry of enamel and dentine structure and pulp physiology are discussed. Introduction Prisms The crystals of enamel are not randomly arranged but Section II Caries is a microbially initiated disease causing lo- are grouped together to form rods or prisms of mate- calised destruction of mineralised tissues in the body, rial, extending from the enamel–dentine junction to including bone. For the purpose of this book only the surface of the tooth. In the original English litera- caries of the teeth will be considered and the signs ture the preferred term is that of ‘prisms’ whereas in of presence of the disease will be described as the more recent writings the term ‘rod’ is preferred and localised destruction of enamel, dentine and more in fact induces a clearer image of the structure in the briefly, of cementum. As is the case with other patho- mind of the reader.Because the remainder of this book logical conditions, a clear understanding depends will use the word ‘prism’, the old-fashioned term will upon a knowledge of the basic structure of the tis- be used here. sues involved. Each prism has a mean cross-sectional diameter of about 5 μm but because the surface area of the outer enamel is greater than that of the enamel–dentine junction the prisms tend to increase in diameter from Enamel Structure and Chemistry the junction to the outer surface. The cross-sectional shape of the prisms has been variously described as Enamel is the outer protective covering of the crown octagonal to fish scale or keyhole shaped but this de- of the tooth and is an extremely hard, brittle, white, pends to some extent on the angle of section through shiny substance. It is composed basically of billions the prisms. The keyhole concept is the classical con- of crystals of hydroxyapatite that are roughly octago- struction in human enamel and is shown diagram- nal in cross section with a diameter of about 360 nm. matically in Fig. 5.1. The broad part of the keyhole is The length of the crystals has proved difficult to de- often referred to as the head and the narrow part as termine but they are thought to be long and ribbon- the tail.