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3

Dental healthcare

Derrick Garwood

It is now reasonable to expect a set of permanent to prevention by the individual is of far greater teeth to last a lifetime. This contrasts starkly with benefit than treatment. the situation only a generation ago, when it was The link between dental caries and diet has widely accepted that teeth would have to be long been recognised. The incidence of dental extracted and replaced by dentures well before caries increased significantly after the seven- old age. teenth century with the greater consumption of Loss of teeth, other than by accident, is caused refined carbohydrates, particularly sugars. The by two different pathological processes: dental prevalence in developing countries has until caries and periodontal disease. Today, these are recently been low compared with western very rarely life-threatening, although dental nations, but is now increasing as western-style treatment may produce adverse effects in suscep- diets are adopted. Conversely, the high preva- tible individuals. Certain pre-existing medical lence in western nations reached a peak in the conditions dramatically increase the risks of 1960s, but is now declining as a result of treatment. For example, haemophiliacs are at risk improved dental health education and the use of of severe haemorrhage after dental procedures. fluoride, especially in fluoride-containing tooth- Subacute bacterial endocarditis may occur in pastes (see Anatomy and morphology below). individuals with a history of rheumatic fever or Surveys were conducted in the UK in 1973, valvular heart disease, as a result of a bacteraemia 1983 and 1993 to assess the dental health of chil- following extractions, calculus removal (scaling), dren. The results show that over 20 years, the or other invasive dental procedures. Dental total decay experience of children has fallen healthcare in susceptible individuals is, therefore, dramatically (Downer, 1994): extremely important. However, for most people, • by 55% at five years of age dental disease is more of a social embarrassment • by 82% at eight years of age and inconvenience than a serious health risk; at • by 75% at 12 years of age worst, it may reduce the quality of life if many • by 74% at 14 years of age. teeth are lost. In terms of the effects of dental disease on the In 1973, just 7% of children of 12 years of age community, its treatment is costly and results in had no experience of permanent tooth decay; loss of time from school or work. Unfortunately, by 1993 this figure had risen to 50%. However, most expenditure is on the treatment of estab- marked regional inequalities remain, with much lished disease rather than disease prevention. In higher caries rates in Northern Ireland and Scot- the UK, millions of teeth are extracted every year. land than in England. It also appears that the rate Some extractions are unavoidable (e.g. to reduce of decline has levelled out in children of five years overcrowding), but the overwhelming majority of age, so there is still room for improvement. are a direct result of dental disease. An even Periodontal disease is responsible for the loss greater number of teeth undergo some form of of more teeth than dental caries. Although gener- restorative treatment. A dedicated commitment ally considered a disease of adults, it also occurs

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in children. Surveys of the dental health of adults surrounding the oral cavity have important roles in the UK have shown that the majority of people in: aged over 35 with some natural teeth exhibit evi- • masticating food dence of periodontal disease. As the incidence of • initiating digestion by salivary enzymes caries decreases, and the number of teeth that are • swallowing food, fluid and saliva retained consequently increases, periodontal • respiration disease will assume even more importance as a • speech. cause of tooth loss. In the past, periodontal disease was thought to be a normal process of ageing, but this is not the case; it is totally pre- Gingivae ventable. Dental healthcare is not new; people have The gingivae (gums) cover the alveolar ridges: attempted to clean their teeth with various bony horseshoe-shaped projections of the maxil- abrasive substances throughout history. Ancient lae (upper jaw bone) and mandible (lower jaw Egyptians used mixtures of burnt egg shells, bone). The gingival epithelium is continuous with myrrh, ox hoof ashes and pumice; ancient Greeks the mucous membrane of the inner surface of the used granulated alabaster stone, coral powder, lips and cheeks, and with the epithelium of the emery, pumice, rust and talcum; and the Romans hard palate and the floor of the oral cavity. used bones, hooves, horns, shells and myrrh. Healthy gingivae are coral pink with a stippled Mouthwashes have also been used throughout surface, whereas the oral mucous membrane is history, and ancient Chinese writings advocate red. Folds of soft tissue (called fraena) run between the use of urine to treat periodontal disease. the alveolar ridges and the lips and cheeks. Gingi- Toothbrushes or toothpicks in a variety of forms val connective tissue forms a collar around each have been employed for thousands of years. tooth, and is attached to the tooth surface by Modern dental healthcare products have junctional epithelium. There is a shallow trough evolved as understanding of the mechanism and (the gingival crevice, Figure 3.1) between the crest prevention of dental disease has increased. These of gingival tissue and the tooth, which in health products have traditionally been sold through is between 0.5 and 1 mm in depth. community pharmacies, so the pharmacist can make a significant contribution to dental health education. However, a sound knowledge of the Teeth properties, actions and uses of the products is essential, together with a basic understanding of The teeth are supported on the upper and lower dental anatomy and the aetiology of dental alveolar ridges, and are important structures disease and its prevention. These subjects and the required for mastication. They also profoundly pharmacist’s role are discussed below. affect speech, and facial appearance and expres- This chapter is concerned only with diseases sion. that affect the teeth and gums. For diseases of other tissues in the oral cavity, the reader is referred to Disorders of the ear, nose, and Anatomy and morphology oropharynx in Harman (1990). Each tooth consists of the crown, which projects through the gingivae into the oral cavity, and one or more roots, which anchor the tooth in its Dental anatomy and physiology socket (see Figure 3.1). The different types of teeth (Figure 3.2) reflect their varied functions: The oral cavity is the area between the cheeks, • incisors are chisel-shaped and used for cutting lips, hard and soft palates, and the pharynx; the into food floor of the oral cavity is formed by the tongue • canines have a pointed surface (the cusp) for and its associated muscles. The structures tearing and shredding food

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Figure 3.1 Section through a molar to show the anatomy of a typical tooth.

• premolars (bicuspids) have two cusps for The surfaces facing adjacent teeth are also chewing food important because of their association with • molars have four cusps for crushing and grind- dental caries and early periodontal disease (see ing. Dental disease below). For effective mastication, each tooth should meet its opposing tooth in the The cusps of premolars and molars are separated other jaw; if one of the pair is missing, the by fissures, and the whole biting surface of these remaining tooth is less effective because it has teeth is called the occlusal surface. Other surfaces nothing to work against. include: Incisors, canines and premolars have only one • the palatal surface – the surface of upper teeth root, with the exception of the upper first pre- nearest the palate molar, which usually has two. Lower molars • the lingual surface – the surface of lower teeth usually have two roots and the upper molars facing the tongue three, except the third molars, which may have • the labial surface – the surface of incisors and one, two or three. canines facing the lips The principal component of a tooth is • the buccal surface – the surface of premolars dentine. In the crown, this is covered with and molars facing the cheeks. enamel; in the root, it is covered with cementum.

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Figure 3.2 Morphology of teeth: (a) Primary dentition (b) Permanent dentition (see Table 3.1 for key to identification of teeth).

Dentine surrounds a cavity containing pulp; in eventually wear them away. Enamel also insu- the crown, the cavity is termed the pulp chamber; lates teeth from heat, cold and other pain- in the root, it becomes the root canal. producing stimuli. However, it is brittle and requires the support of dentine; if this support is Dentine lost (e.g. as a result of caries) it readily fractures. Dentine is a hard yellowish substance consisting Enamel is thinnest where it approaches the root, of calcium hydroxyapatite, water and an organic but at the cusps (or edges of incisors) it may be up matrix of collagen and mucopolysaccharides. It is to 2.5 mm thick. Its colour is governed by its sensitive to touch and extremes of temperature, thickness, and it appears lightest and almost although the exact reason for this is not known. translucent at the tooth tip. Where the enamel Dentine is deposited continuously throughout layer is thin, the tooth appears yellow because life, gradually reducing the size of the pulp cavity. the dentine beneath shows through. Colour, This normal physiological process proceeds at a however, does not indicate the strength of teeth, relatively slow rate compared with the secondary which tend to darken with age. deposition of dentine following loss of tooth sub- stance (e.g. as a result of dental caries, excessive Cementum wear or cavity preparation). Cementum is softer than dentine. It is a bone-like substance consisting of calcium hydroxyapatite Enamel and an organic matrix of collagen and Enamel is the hardest substance in the animal mucopolysaccharides. It is laid down continu- kingdom, and consists mainly of calcium ously, and the thickness may treble throughout hydroxyapatite; the remainder is water and an life; some cementum is resorbed, but these areas organic matrix similar to keratin. The primary are repaired by further deposition. Cementum function of enamel is to protect teeth from the attaches the tooth to the socket by means of the forces of mastication, which would otherwise periodontal ligament (see below).

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Pulp Pulp is composed of loose areolar connective tissue richly supplied with blood vessels, lymphatic vessels and nerves, which reach it via the apical foramen. The nerve supply consists of sympathetic nerves and sensory nerves, but as the only sensory receptors are pain receptors, all stimuli are per- ceived as pain. Pulp becomes more fibrous and less vascular with age, and is reduced in overall size as dentine is laid down (see above). These changes reduce the sensitivity of teeth with age.

Periodontal ligament A tooth is suspended firmly in its socket by the periodontal ligament, which connects the cementum to the underlying bone. Its function is to support the tooth, and protect both tooth and bone from excessive pressures during chewing and biting. The periodontal ligament is com- posed of collagenous fibrous connective tissue, with a rich vascular supply to provide essential nutrients to the cementum. Its nerve supply includes both touch and pain receptors, which are important in controlling mastication. Cementoblasts and osteoblasts are also present, and are responsible for laying down new cemen- tum and bone, respectively, throughout life.

Dentition The term dentition refers to the natural teeth and their position in the alveolar ridges. In humans, there are two dentitions: the primary dentition (deciduous teeth, baby teeth or milk teeth) and Figure 3.3 Permanent dentition: (a) Upper jaw (b) Lower jaw (see Table 3.1 for key to identification of teeth). the permanent dentition. There are 20 primary and 32 permanent teeth (Table 3.1).

Dental notation Table 3.1 The dentitions Two different systems are used to identify the (a) Primary dentition (b) Permanent dentition teeth in their positions in the alveolar ridges. In both systems, the two dental arches are divided A (1) central incisor 1 central incisor into four quadrants: the upper left and right, and B (2) lateral incisor 2 lateral incisor the lower left and right (Figure 3.3). C (3) canine 3 canine Traditionally, a tooth has been identified by D (4) first molar 4 first premolar specifying the quadrant in which it is situated and E (5) second molar 5 second premolar the number or letter of the tooth itself; for example, 6 first molar the upper right six or the lower left D. Note, 7 second molar however, that it is always assumed that the observer 8 third molar (wisdom tooth) is facing the patient, causing lateral inversion – as

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in a mirror. Thus the upper left six is written as QUADRANT 5 QUADRANT 6 6 and the upper right C as C (Figure 3.4). 55 54 53 52 51 61 62 63 64 65 Today, the International Tooth Numbering System is becoming accepted all over the world as 85 84 83 82 81 71 72 73 74 75 the standard system of tooth identification. In QUADRANT 8 QUADRANT 7

this system, each quadrant is assigned a number (a) Primary dentition (Table 3.2). A tooth is denoted by specifying its quadrant QUADRANT 1 QUADRANT 2 number and then its individual number. In this system, the deciduous teeth are given the 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 numbers 1 to 5, not the letters A to E. Thus, the 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 upper left six now becomes 26, and the upper QUADRANT 4 QUADRANT 3 right C becomes 53 (Figure 3.5). In speech, these are referred to as ‘two-six’ and ‘five-three’, not (b) Permanent dentition ‘twenty-six’ and ‘fifty-three’. Figure 3.5 The International Tooth Numbering System.

UPPER RIGHT UPPER LEFT Tooth development QUADRANT QUADRANT Teeth usually start erupting at about six months E D C B A A B C D E of age with the emergence of the central incisors,

E D C B A A B C D E followed at about eight months of age by the LOWER RIGHT LOWER LEFT lateral incisors. The first molars appear at about QUADRANT QUADRANT 12 months of age, the canines at about 18 months of age, and the second molars at about 24 (a) Primary dentition months of age, although there is wide individual variation. As a general rule, lower teeth tend to UPPER RIGHT UPPER LEFT erupt before the corresponding upper teeth. QUADRANT QUADRANT Contrary to popular belief, there is little 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 evidence to suggest that the eruption of teeth in children causes systemic illness. As teeth begin to 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 erupt, the shape of the jaw bone changes. Prema- LOWER RIGHT LOWER LEFT ture loss of primary teeth may adversely affect the QUADRANT QUADRANT subsequent spacing of the permanent teeth and the shape of the jaws. (b) Permanent dentition Teeth are mineralised before eruption, so they Figure 3.4 Traditional notation system. are hard enough to withstand the rigours of mastication immediately. Secondary maturation takes place after eruption; this is an important process in increasing their resistance to dental Table 3.2 Quadrants in the International Tooth caries (see Dental disease below). Fluoride is par- Numbering System ticularly important in this process (see Prevention 1 upper right quadrant, permanent dentition of dental disease below). 2 upper left quadrant, permanent dentition Teeth may become stained during develop- 3 lower left quadrant, permanent dentition ment as a result of: 4 lower right quadrant, permanent dentition • systemic administration of some drugs (e.g. 5 upper right quadrant, deciduous dentition tetracyclines) 6 upper left quadrant, deciduous dentition • ingestion of high levels of fluoride (see Pre- 7 lower left quadrant, deciduous dentition vention of dental disease below) 8 lower right quadrant, deciduous dentition • systemic illness (e.g. chickenpox or measles).

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These are intrinsic stains and cannot be removed • facilitating chewing and swallowing from the tooth substance. Pathological lesions • assisting speech. (e.g. dental caries or pulp necrosis, see Dental disease below) may cause intrinsic stains in devel- The inorganic component includes bicarbonate, oped teeth. calcium, chloride, magnesium, phosphate, pot- The entire set of primary teeth is lost between assium, sodium and sulphate. six and 12 years of age, and replaced by the per- The proportions of the different components manent dentition. This permanent set is not, vary with the source of the saliva and also with however, completed until adulthood. The first per- the flow rate. This has the effect of changing the manent teeth to erupt are the first molars at about pH of submandibular saliva from 6.47 (flow rate six years of age, followed by the central incisors at of 0.26 mL/minute) to 7.62 (flow rate of about seven years of age. The lateral incisors 3.0 mL/minute), and of parotid saliva from 5.8 appear at about eight years of age, and the canines, (flow rate of 0.1 mL/minute) to 7.8 (flow rate of first premolars and second premolars between 3.0 mL/minute). nine and 11 years of age. The second molars erupt Saliva helps maintain oral hygiene and at about 12 years of age, and the third molars prevent dental disease in several ways: (wisdom teeth) between about 17 and 21 years of • the bicarbonate and phosphate content acts as age. Human evolution has resulted in a jaw that a buffer in acidic environments may be too small to accommodate the full denti- • antibacterial enzymes (e.g. lysozyme and tion. In many cases, the third molars do not erupt lactoperoxidase) control oral bacteria fully but remain impacted; if they cause pain and • inorganic components help re-mineralise infection, they must be surgically removed. In tooth enamel and prevent dental caries some cases, third molars fail to develop at all. • water and mucin assist the tongue in clearing food debris and bacteria from the gingivae and teeth. Saliva Saliva is continuously secreted to keep the Approximately 0.5 to 1.5 litres of saliva is secreted mucous membranes moist, but the flow increases each day. There are three pairs of salivary glands: dramatically in response to stimulation by food. the sublingual and submandibular glands in the Heavy secretion of saliva continues after food has floor of the oral cavity, and the parotid glands (the been swallowed, to clean the mouth and buffer largest) below each external auditory meatus. Sali- any acidic components. vary flow is affected by various factors (e.g. age, Reduced secretion of saliva causes a dry mouth sex, nutritional and emotional state, time of day (xerostomia). This may result from certain and season of the year). Over 50% of unstimulated medical conditions (e.g. anaemia or diabetes mel- saliva (resting saliva) is secreted from the sub- litus) or as a side-effect of some drugs (e.g. adren- mandibular glands, whereas more than 50% of ergic neurone blocking drugs, antidepressants, stimulated saliva comes from the parotid glands. antihistamines, antimuscarinics, anxiolytics, Saliva is formed from serum and composed of diuretics, hypnotics or lithium). Sympathetic water (99.5%) containing dissolved proteins and stimulation in response to fear or anxiety causes inorganic ions. The proteins include glycopro- the glands to stop secreting, giving a character- teins (mucin), albumins, globulins and enzymes. istic lack of saliva. Radiotherapy to the head and One major protein component is the enzyme neck can also reduce salivary flow, although it amylase, which initiates digestion of starch in usually returns to normal after a period of the oral cavity. Antibacterial enzymes are also months. present. The watery and mucinous character of Dry mouth may be relieved by administering saliva is important in: Artificial Saliva DPF, an inert, slightly viscous, aqueous liquid containing sodium chloride, • lubricating the mucous membranes of the oral hypromellose ‘4500’, benzalkonium chloride, cavity saccharin sodium, thymol, peppermint oil,

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spearmint oil and amaranth solution. Alternative to form colonies on the salivary pellicle, after formulations may be used, and several commer- about three to eight hours. Streptococcus mutans cial preparations are available. Frequent sips of is of particular importance. Actinomyces spp. cool drinks and sucking pieces of ice or sugar-free may also be found at this stage. After 24 hours, pastilles may also be of value. other species, including Gram-negative anaer- obes, are attracted and start to multiply. The bacterial composition continues to become more complex, and the earlier species of Dental disease colonising microorganisms assume less import- ance. Plaque reaches its mature state after about Two distinct dental diseases may ultimately result seven days. Micro-organisms make up about in loss of teeth: dental caries and periodontal 70%, although the exact composition varies disease. Both diseases can occur at any age, but from one area of the oral cavity to another, dental caries is generally more prevalent in depending upon the micro-environment and children, and periodontal disease in adults. The accessibility for cleaning. Mature plaque has a aetiology of each disease is different, but the different role from new plaque in the aetiology common factor is the presence of bacteria in of dental disease. dental plaque. Food is not essential for plaque formation, but the presence of dietary sugars, especially sucrose, increases its rate of formation and thickness. Bac- Plaque teria utilise sugars as an energy substrate, produc- ing extracellular mucilaginous polysaccharides Plaque is a film of soft material that forms on the (glucans), which provide the plaque matrix and teeth, gingivae, restorations and orthodontic facilitate the firm adhesion of plaque to the tooth appliances. It is composed predominantly of surface. micro-organisms, but other constituents include: Plaque is highly tenacious and can only be removed from the teeth by mechanical means • dietary carbohydrates (see Prevention of dental disease below). It forms • organic acids formed by the bacterial metabol- rapidly over all tooth surfaces after cleaning, ism of carbohydrates and is virtually always present in areas that are • glucans (dextrans) resulting from the metabol- difficult to clean. Plaque can only be detected ism of dietary carbohydrates by streptococci during the initial stages of formation by using • proteins (including enzymes) from saliva disclosing agents (see Prevention of dental • leucocytes disease below). However, if deposits are allowed • toxins from Gram-negative bacteria. to build up, it becomes clearly visible. In the The first stage of plaque formation is the develop- early stages of development, plaque is thought ment of the salivary pellicle, a thin layer of muco- to be cariogenic; mature plaque, however, is proteins derived from the glycoproteins of saliva. more likely to influence the development of Mucoproteins are unstable in solution and periodontal disease. adsorb to hydroxyapatite in tooth enamel. Pelli- Staining of the salivary pellicle or plaque may cle formation begins immediately after cleaning occur. Such extrinsic stains can be removed and the teeth, and the whole of the crown, except should not be confused with permanent intrin- areas exposed to friction, becomes covered. The sic stains that are part of the tooth substance (see pellicle readily takes up extrinsic stains (see Anatomy and morphology above). The com- below). These are not necessarily harmful to the monest extrinsic stain is tar from tobacco, teeth, but are unattractive and generally con- usually found on the lingual surfaces of the sidered socially unacceptable. The pellicle is very lower teeth and ranging in colour from light quickly colonised by commensal bacteria to form brown to black. The degree of staining generally plaque. reflects the standard of oral hygiene rather than Streptococcus spp. are usually the first bacteria the amount of tobacco smoked. Brown-black

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Dental disease 71

stains may occur following use of chlorhexidine disease by virtue of the plaque deposits present mouthwashes, and plaque may become stained on its surface. a dull yellow by food dyes. Children sometimes have black or green stains; these are thought to be derived from chromogenic bacteria. Dental caries

Definition and aetiology Dental caries Calculus destroys the mineralised portion of the tooth, and is one of the most common diseases in Dental calculus (tartar or scale) is mineralised western society; prevalence in the UK is particu- plaque, which may occur in any area of the larly high. Once established, the disease process mouth. Prevalence is high in most populations is irreversible; unless treated, it leads inexorably and increases over 30 years of age. Calculus is to destruction of the tooth. composed of inorganic salts (70%) plus organic Dental caries is a disease of the modern world. material and micro-organisms (30%). Composi- Numerous studies have demonstrated that a high tion varies with location and the age of the cal- sugar diet is implicated in its aetiology, although culus. The organic constituents are similar to the exact mechanism remains unclear. However, those of plaque, and the micro-organisms com- it is known that sugars alone do not cause dental parable to those in mature plaque. caries; it is the combination of sugars in the oral Plaque acts as an organic matrix for calculus cavity and plaque on the teeth. Dietary sugars formation, although the exact mechanism is dissolved in saliva readily diffuse into plaque, unknown; it is possible that a plaque com- where bacteria (particularly streptococci in early ponent acts as a seeding agent. Calculus pro- plaque) ferment them to produce organic acids vides a hard, rough surface for the formation of (e.g. lactic acid). These acids demineralise tooth more plaque, which is difficult to remove and enamel and dentine. Bacteria then invade, may itself become calcified; in this way, incre- causing infection and inflammation. The infec- mental layers of calculus are built up. Calculus tion progressively destroys the dentine until the formation usually begins between two and 14 pulp is reached. If unchecked, this eventually days after the start of plaque development, but results in pulp death. Infection then spreads may be as early as four to eight hours in some through the apical foramen to the apical part of individuals, and does not appear to be depen- the periodontal ligament and an abscess may dent on diet. result. Calculus above the gingival margin (supragin- The frequency of sugar consumption has a gival calculus) is formed from the minerals in greater influence than the quantity consumed saliva. It is especially prevalent opposite the ducts (National Dairy Council, 1995). However, the of the principal salivary glands (i.e. on the lingual quantity consumed is important in increasing surface of lower front teeth and the buccal surface plaque thickness and the rate of formation (see of upper molars). Supragingival calculus is mod- Plaque above). The incidence of caries is higher in erately hard and usually white or pale yellow, children and adolescents than in adults because although it may become stained by tar from secondary maturation of dental enamel gradually tobacco or pigments from food. increases its resistance to acid attack. Fluoride Subgingival calculus occurs below the gingi- also increases the resistance of enamel. val crest. It contains fewer micro-organisms than Several host factors may influence the initial supragingival calculus, is difficult to remove, development of caries or the rate of decay. The very hard, and stained a dark colour by the structure of teeth varies between individuals, and breakdown products of blood. Previously the presence of deep fissures and pits predisposes thought to cause periodontal disease, subgingi- to caries formation. The chemical composition of val calculus is now considered to be merely an enamel also varies, and some people have teeth indicator of its presence. However, calculus that are more resistant to acid attack than others. does influence the development of periodontal Crowded or badly aligned teeth render good

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plaque control difficult; the resultant stagnation bottles produces the same effect. Such practices areas are more susceptible to caries. allow prolonged contact between the teeth and Although dental caries may attack any surface sugar, resulting in severe and extensive caries of the tooth, more than 50% of lesions affect the affecting several teeth, particularly the upper occlusal surfaces of back teeth, with marginally incisors. more occurring in the upper arch than the lower. The properties of saliva (e.g. mineral composi- First molars appear to be more susceptible than tion, viscosity and rate of production) vary other teeth, whilst the lowest prevalence is in between individuals, affecting their susceptibility lower incisors and canines. There are three types to caries. Saliva is the body’s natural means of of caries: cleaning and buffering the oral cavity. It is also involved in the re-mineralisation of enamel, • Pit and fissure caries which can reverse early dental caries (see below). Lesions that occur in pits and fissures are the Xerostomia, caused by a reduction in salivary most common type of caries. The initial break secretion (see Anatomy and morphology above), is in the enamel is seen as a small black pit, associated with an increased incidence of caries. which may extend into dentine. The under- lying dentine is destroyed more quickly than Symptoms The initial stages of dental caries enamel, and eventually a bluish-white area are asymptomatic. Pain is first felt when dentine appears around the initial pit. The enamel col- is exposed during the open-cavity stage, although lapses as more of the underlying dentine is there is wide variation in the degree of pain destroyed, and the later stages are marked by experienced. Short-term pain on exposure to an open cavity. heat, cold or sweet substances during the early • Smooth surface caries stages of decay indicates that prompt treatment Smooth surface caries is the least common. It may save the pulp from irreversible damage. can occur on any smooth surface, but particu- Inflammation of the pulp (pulpitis) produces larly on the proximal surfaces between teeth. swelling of the pulp tissue in an enclosed area. Lingual surfaces are affected less frequently This sometimes results in a throbbing pain that than buccal or labial surfaces. The lesion initi- is exacerbated by heat and relieved by cold. ally appears chalky-white, becoming gradually Pain lasting for some time (e.g. up to 20 rougher as the enamel starts to break down. minutes) indicates that damage to the pulp is The subsequent stages are the same as in pit irreversible. Severe pain that is unconnected and fissure caries. with any stimuli or disturbs sleep signifies • Cervical caries extensive decay. If untreated, the pain eventu- Cervical caries is more common in older ally subsides once pulp necrosis occurs, because people. It attacks exposed dentine at the neck of degeneration of the nerve supply. However, of the tooth, where the crown meets the root. the infection may spread through the apex and As there is no enamel at this point, an open cause inflammation of adjacent tissues. A peri- cavity is formed from the beginning. The sub- apical abscess may then occur, which can be sequent stages are as described above under pit extremely painful during the acute phase as and fissure caries. pressure builds up in the enclosed space around On average, it takes about two years for a cavity the apical foramen. The pain is exacerbated by to be clinically visible in permanent teeth, pressure on the tooth and subsides once the pus although there is wide individual variation. The has discharged. time span may be as short as three months in primary teeth. Treatment Early dental caries is reversible Rampant caries (‘dummy’ caries or ‘bottle’ because minerals present in saliva allow caries) occurs in infants allowed to suck com- re-mineralisation of the enamel to take place. The forters (dummies) coated with sugary substances organic matrix is still intact at this stage, which (e.g. honey, jam or undiluted fruit syrups). Drink- allows the deposition of further crystals. ing concentrated sweetened liquids from feeding Once the matrix collapses, this is impossible.

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Re-mineralisation is more likely to be successful if Prevention of chronic gingivitis therefore pre- further acid attack is kept to a minimum by strict vents chronic periodontitis. Gingivitis may also plaque and dietary sugar control. Fluoride is be an acute condition, but, unlike chronic gin- highly beneficial in re-mineralisation (see Preven- givitis, this is always painful. tion of dental disease below), as it converts the inorganic hydroxyapatite in enamel to the more Chronic gingivitis resistant fluorapatite. Irreversible caries may require a variety of Definition and aetiology Chronic gingivitis is treatments, including: the result of inflammatory changes produced in the gingivae by endotoxins and enzymes from • restorations (fillings) plaque bacteria. Undisturbed plaque deposits • root canal treatment (endodontics) may cause the initial inflammatory reaction • crowns or bridges within two to four days. • extraction. Some medical conditions (e.g. diabetes melli- tus, leukaemias and scurvy) may increase the risk Analgesics may be given for pain relief until of chronic gingivitis. The precise mechanism for dental treatment is available, but controlling the this is unknown, but it may be a result of altered pain does not in any way control the disease, and host response to bacterial products (e.g. toxins dental referral should not be delayed longer than and enzymes). Administration of some drugs (e.g. necessary. For measures to prevent dental caries, cyclosporin, nifedipine, oral contraceptives or see Prevention of dental disease below. phenytoin) may also predispose to gingivitis. In some cases, these may cause severe gingival Periodontal disease hyperplasia in which the gingivae cover most of Definition and aetiology Periodontal disease the crown of the tooth. Any disorder or drug encompasses several inflammatory disorders which reduces salivary secretion increases the which affect the supporting structures of the susceptibility to chronic gingivitis (see also Dental teeth. It is one of the most common conditions caries above). in the world, affecting the vast majority of people People who habitually keep their lips apart, at some stage in their lives. Chronic periodontal particularly when asleep, show a greater inci- disease is slow, insidious and usually painless, but dence of inflammation of the anterior gingivae, the eventual result may be destruction of the most likely as a result of excessive drying of the underlying bone. It causes the loss of more teeth tissues. Smokers are also more susceptible; it is than dental caries because the supporting struc- not certain whether this is caused by tobacco tures cannot be repaired as effectively as teeth can smoke or poor oral hygiene, which has been be restored. shown to be greater in smokers than non- Like dental caries, periodontal disease is smokers. caused by plaque bacteria. However, diet is not Pregnant women are more susceptible to thought to be an important factor in its develop- gingivitis (‘pregnancy gingivitis’) as a result of ment, and dental caries is not a cause; completely hormonal changes affecting connective tissues, undecayed teeth can be affected. Plaque deposits including those of the gingivae. Some pregnant around the gingival margin and within the gin- women may even complain of loose teeth. gival crevice are most important in the aetiology Scrupulous oral hygiene will prevent pregnancy of periodontal disease. gingivitis, and the tissues revert to normal after Where inflammation is confined to the gingi- parturition. Puberty is also commonly associated vae, the condition is called gingivitis. Spread of with an increased incidence of gingivitis; again it inflammation to the periodontal ligament and is not clear whether this is associated with hor- alveolar bone is termed periodontitis. Chronic monal changes or poor standards of oral hygiene. gingivitis precedes chronic periodontitis, but does not always lead to it. The reason why some Symptoms Inflammation results in oedema, cases progress and others do not is not known. causing the gingival crevice to deepen and

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pockets to develop between the gingivae and the more common from the late teens onwards. It is teeth. At this stage, these are called ‘false pockets’; the most common cause of loss of teeth in they should not be confused with the true peri- patients over 30 years of age. odontal pockets of chronic periodontitis (see below). The epithelium of the crevice becomes Symptoms Inflammation spreads through the ulcerated. Subgingival plaque accumulates in gingival crevice and eventually destroys the peri- the deepened crevices, and bacterial products odontal ligament, with the junctional epithelium produce further inflammation. A vicious cycle is moving downwards onto the root. A true peri- set up, which causes the crevices to enlarge odontal pocket is formed and gingival recession further. may occur, exposing the coronal portion of the In the presence of gingivitis, gingival crevicular root. As periodontal pockets deepen, plaque and fluid exudes through the junctional epithelium debris can collect within them, exacerbating the into the gingival crevice. This cannot be detected inflammatory process. The depth of the pockets by the patient, but can be measured using crevicu- may be measured using a dental probe and lar strips (small filter paper strips), and is an indi- indicates the progression of the disease. Further cator of the extent of inflammation. Crevicular spread of inflammation to the supporting bone fluid contains immunoglobulins (IgA, IgG and causes resorption, which eventually loosens the IgM) and neutrophils (polymorphonuclear leuco- teeth. cytes), which may exert a protective effect. Many symptoms of chronic gingivitis are The outward symptoms of chronic gingivitis present. As the periodontal pockets deepen, are mild, so many sufferers do not realise they however, the swelling and reddening of the gin- have the condition. Established chronic gingivi- givae may subside, leading to the mistaken belief tis is marked by changes in appearance: the gin- by the patient that the gingivitis has resolved. In givae become reddened, glossy, soft and swollen. fact, inflammation is still present, but is now Halitosis may also be present. Pain is usually much deeper in the tissues. Chronic periodonti- absent, although abrasive food or vigorous tooth- tis eventually causes extensive damage that is brushing may produce discomfort. The main largely irreversible, and patients should seek symptom, bleeding gums, is all too often attrib- treatment at the earliest opportunity (Figure 3.6). uted to toothbrushing trauma and ignored. Treatment Treatment of chronic periodontitis Treatment Mild chronic gingivitis can be is similar to that of chronic gingivitis (see above). treated by good plaque control (see Prevention of It involves thorough scaling and polishing, dental disease below). The only dental treatment usually over several appointments. Root planing required may be oral hygiene instruction, but it is to clean the roots and remove infected cemen- wise to refer patients to their dentist. In many tum is usually necessary. In severe cases, where cases, scaling is necessary. This involves the periodontal pockets are very deep, surgery may removal of plaque and calculus from the crown and exposed root surfaces. The surfaces are then initial lesion polished to remove any rough areas that may attract plaque accumulations. For measures to gingivitis early lesion prevent chronic gingivitis, see Prevention of ͖ (reversible) dental disease below. established lesion

Chronic periodontitis years

Definition and aetiology Chronic periodonti- periodontitis advanced lesion tis, which is always preceded by chronic gingi- (irreversible) vitis, results in irreversible damage to the periodontal ligament and alveolar bone. It is rare Figure 3.6 The chronological progression of gingivitis to in children under 13 years of age, but becomes periodontitis.

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be required to reshape the gums and facilitate Juvenile periodontitis routine plaque removal by the patient. In the last few years, it has become possible to replace lost Definition and aetiology Juvenile periodonti- alveolar bone by sophisticated techniques (e.g. tis (periodontosis) is a chronic periodontal periodontal bone grafting and guided tissue disease occurring in adolescents and young regeneration), but these are highly specialised adults. Its development appears to be indepen- and not widely available. dent of the level of oral hygiene. The cause of this Chlorhexidine mouthwash or gel may be severe chronic periodontal disease is not known, useful to control plaque deposition, but is no sub- although it has been suggested that the bacterial stitute for toothbrushing. It is not recommended flora in the mouths of sufferers may be exces- for long-term use, may stain the teeth, and sively virulent. should be restricted to the treatment phase. Treatment of chronic periodontitis may be a Symptoms The features of juvenile periodonti- long process, and is heavily dependent on tis appear similar to chronic periodontitis, but its improved home dental care by the patient. Oral early onset and associated bone loss make it a hygiene measures alone will not arrest chronic more serious condition. Pain is usually absent periodontitis, but serve as a valuable adjunct to unless a lateral periodontal abscess develops. The periodontal treatment and are essential to most common presenting features are drifting of prevent further disease. Corrective measures (e.g. teeth and localised periodontal pockets. These are restorations or orthodontic procedures) in areas usually only apparent during dental examin- prone to plaque accumulation may also be ation; radiographs may also show severe bone beneficial. For measures to prevent chronic peri- loss. The disease often progresses relentlessly odontitis, see Prevention of dental disease below. despite dental intervention, and the prognosis for affected teeth is not good. Periodontal abscess Treatment Treatment is similar to that for Definition and aetiology A periodontal chronic periodontitis, but more follow-up abscess may develop from a periodontal pocket examinations are required to monitor progress of which becomes blocked with exudate or a foreign the disease. Periodontal surgery is not always body (a lateral periodontal abscess). Alterna- successful. Treatment may have to rely on strict tively, infection of the pulp may spread through plaque control measures plus frequent scaling, the apical foramen (periapical periodontal root planing and polishing. Chlorhexidine solu- abscess). tion is only of value if it can penetrate the peri- odontal pockets, which in juvenile periodontitis Symptoms Both types of periodontal abscess are very deep; use of a syringe with a suitable present with a throbbing pain, exacerbated by nozzle may be required. pressure on the tooth involved. Gingivae in the area of the abscess become red and swollen; this may spread to surrounding tissues (e.g. the Primary herpetic gingivostomatitis cheeks or lips). Once pus has discharged, the acute phase subsides and, if untreated, often leads Definition and aetiology Primary herpetic to a painless chronic abscess which may continue gingivostomatitis is an acute gingivitis occurring to exude pus. Abscesses cause further resorption mainly in children between six months and five of the surrounding bone. years of age. It is caused by a primary infection with herpes simplex virus type 1 (HSV 1). On Treatment Treatment of periodontal abscesses recovery, the virus lies dormant in the ganglia of may involve drainage, mouthwashes and the trigeminal nerve and produces latent herpes administration of antibiotics. Root canal therapy, labialis (cold sores) in response to various stimuli extraction or periodontal surgery may sub- (e.g. emotional disturbance, fever, menstruation, sequently be required. sunlight or local trauma).

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Symptoms Symptoms include fever, malaise, and infected tissue. Hydrogen peroxide mouth- gingivitis, pharyngitis and generalised adenopa- washes may be used between dental appoint- thy. Vesicles appear all over the oral cavity and on ments, and the patient should be fully instructed the lips, rupturing to form excessively painful in good oral hygiene procedures. All patients ulcers. Accompanying symptoms may include should be followed up regularly as tissue destruc- profuse salivation and halitosis. The child tion may make subsequent plaque removal diffi- appears unwell, irritable, unable to eat, and has a cult in some areas. high temperature.

Treatment The condition is self-limiting, and Tooth wear untreated ulcers heal without scarring within 14 to 21 days. Treatment is not generally given for Definition and aetiology Recent evidence sug- primary HSV 1 infection, but measures that may gests that tooth wear is now a significant problem be taken to relieve the discomfort include para- in both children and adults (Smith, Bartlett and cetamol for pain, bland mouthwashes and soft Robb, 1997). It is rarely possible to differentiate food. Chlorhexidine mouthwash or gel may be of between the different aetiological factors, but the value as an alternative to toothbrushing until the dental profession is particularly concerned about pain subsides. Where secondary infection occurs, dental erosion. This may be defined as the pro- systemic antibiotics may be necessary. gressive loss of hard dental tissues caused by the action of acids on the teeth, without the involve- ment of bacteria. Acute ulcerative gingivitis Erosion may result from occupational exposure Definition and aetiology Acute ulcerative gin- to acid fumes or chronic contact with gastric acid givitis (acute necrotising ulcerative gingivitis, as a result of frequent vomiting or oesophageal trench mouth or Vincent’s disease) is an acute, reflux. However, the frequent ingestion of dietary destructive, ulcerative condition affecting the acids, in the form of carbonated drinks and fruit gingivae. It occurs most commonly between 14 juices, is now considered to be of major import- and 30 years of age. The micro-organisms most ance, particularly in children. The extent of the often present are fusiform bacilli and spiro- problem was measured by the 1993 Child Dental chaetes, but the evidence suggests that these are Health Survey. 52% of children of five and six not the causative agents. Predisposing factors are years of age had erosion of the deciduous incisors, stress, worry, and fatigue. After an initial attack and the permanent teeth of more than 30% of there is a strong tendency for recurrence. those of 14 years of age were affected (Office of Population Censuses and Surveys, 1994). Symptoms Acute ulcerative gingivitis is of sudden onset, usually begins in the gingival papil- Prevention and treatment Prevention consists lae, and may extend throughout the gingivae. It is of reducing the frequency of contact with the characterised by general malaise, marked gingival causative agent, where this can be identified. bleeding, inflammation and swelling. Fever is Teeth that are severely worn may require exten- generally absent, but the pain may be so severe as sive restoration work. to render eating and talking impossible. Halitosis and excessive salivation are also common. Characteristic ‘punched-out’ grey ulcers, which Gingival recession bleed readily, often develop at the crest of the gin- gival papillae. These ulcers develop a pseudomem- Definition and aetiology Gingival recession brane composed of a necrotic grey slough. may occur in healthy mouths, even in the young. Recession can take place around teeth Treatment Treatment comprises the adminis- that have a thin bone covering, teeth that tration of metronidazole or nimorazole in are subject to excessive biting forces or where conjunction with local debridement of necrotic there are bony defects. Trauma produced by

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over-zealous toothbrushing may exacerbate this dental disease below) will also improve breath process. odour. Mouthwashes (see Prevention of dental disease Symptoms The gingivae are pushed back and below) are often used to freshen the breath, the underlying cementum is worn away to although their value in treating halitosis is ques- expose dentine. This may cause increased sensi- tionable. tivity and pain, particularly on exposure to heat, cold or sweet substances. Gingival recession can increase the risk of developing root caries. Prevention of dental disease Treatment The primary cause of recession should be eliminated where possible. For Dental disease may not be life-threatening, but it example, selective grinding by the dentist is an can severely affect the quality of life. Loss of effective way of equalising biting forces and many or all the permanent teeth necessitates the reducing excessive loading on an individual use of dentures, which can create a different set tooth. Desensitising toothpastes (see Prevention of problems. For the young, the social stigma of of dental disease below) may be used to reduce the wearing dentures is now much greater than in sensitivity of the dentine. Topical application of the past, when the wholesale loss of teeth was such a toothpaste directly to the sensitive area common. may also be beneficial. Fluoride varnishes may be Lost teeth which are not replaced by dentures applied by the dental surgeon to promote re- create problems for the remaining teeth, and may mineralisation of the exposed dentine. The even alter the shape of the jaw. Adjacent teeth tend patient should be encouraged to adopt a less to tilt or drift into the gaps, which may alter the vigorous toothbrushing technique to prevent biting pattern. Loss of one tooth from a comple- further recession. mentary pair may limit chewing movements because the remaining tooth has nothing to bite against, and it often over-erupts. There is also the Halitosis psychological aspect of altered appearance, because gaps in the permanent dentition are not Definition and aetiology Halitosis (bad generally considered attractive. Premature loss of breath) is characterised by an offensive breath primary teeth may affect the spacing of the sub- odour. It is highly prevalent and is a source of sequent permanent teeth and influence jaw social embarrassment to many. development. Halitosis is often a symptom of periodontal Decayed teeth may be restored if treated in disease. However, abnormal breath odours are time, but scrupulous dental healthcare is essen- produced by elimination of certain substances via tial to save them from further damage. Secondary the lungs, and may be a symptom of systemic caries may form around the margins or under- disease (e.g. ketones in uncontrolled diabetes neath a filling if bacteria and sugar can gain mellitus or ammoniacal compounds in uraemia). access. Should this occur, the tooth must However, in the majority of cases, halitosis results be refilled. Subsequent fillings are larger, and from anaerobic bacterial putrefaction in the oral eventually the tooth may need to be crowned or cavity and is not caused by systemic disease. Mal- even extracted. odorous breath may also arise following smoking, It is absolutely essential that the gingivae are alcohol consumption or ingestion of certain in peak condition before advanced dentistry is foods (e.g. garlic). carried out, because the position of the gingival margins is used as a reference point. Inflamed Treatment Halitosis may be controlled by gingivae may be swollen and cover more of the minimising the oral bacterial population. All crowns of the teeth than normal. If the measures advocated to reduce the level of gum inflammation subsequently subsides following disease and hence bleeding (see Prevention of improvements in dental healthcare, the margins

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may recede to a more normal position and, Disclosing agents for example, expose the edges of crowns and bridges. Plaque cannot readily be seen on teeth, making it Almost all dental disease is completely pre- difficult to convince an unwilling or sceptical ventable, but this requires a high degree of moti- person of its presence. A disclosing agent that vation on the part of the individual. The only stains plaque should be recommended. Various passive measure available is water fluoridation, proprietary disclosing tablets and fluids are avail- which reduces the incidence of dental caries but able. Some can distinguish between new and not periodontal disease. Both caries and chronic mature plaque, staining each a different colour. periodontal disease are painless conditions until Re-application after brushing serves to illustrate the later stages, by which time irreversible the effectiveness of brushing technique and high- damage has already occurred. Many people are light areas where improvements may be required. unable to appreciate that a problem exists if there Patients should be advised to smear white soft are no outward signs and symptoms. Conse- paraffin on their lips, to prevent discoloration by quently, they cannot easily be convinced of the the dye contained in the disclosing agent. need to take preventive measures. This represents one of the greatest barriers to be overcome in Toothbrushing dental health education. Toothbrush design Selecting a toothbrush can be daunting when Plaque control faced with the vast array of designs available, backed up by impressive claims from manu- Plaque control is the basis of prevention of dental facturers. In reality, there is no general consensus disease. Plaque bacteria, particularly those of of opinion on the best design for a toothbrush, mature plaque, are responsible for the vast major- and the ultimate selection is based on personal ity of periodontal disease; therefore, prevention preference. However, certain factors may help is aimed at keeping the level of plaque to an when making a choice. absolute minimum. The role of plaque in dental Nylon bristles are preferable to natural bristles caries is more complex because it is the combi- because they do not absorb fluids or harbour nation of sugar and plaque that results in tooth micro-organisms as readily, and the control of decay (see Dental disease above). Theoretically, if bristle quality during manufacture is easier. plaque were removed from the teeth immediately Natural bristle toothbrushes also have the dis- before consuming sugar, dental caries would not advantage that they become soft (and therefore develop. However, for most people this is totally less effective) when wet. Multi-tufted, small impractical. It is also unlikely that the teeth are bristles are better than fewer, larger bristles. ever completely plaque-free, because plaque Rounded ends to the filaments generally offer no forms extremely rapidly after cleaning, and some major advantage over cut ends, although they areas are inaccessible. Prevention of caries must, may prevent soft tissue injury by over-enthusi- therefore, combine both good plaque control and astic toothbrushers. sugar control. Soft-texture brushes are less efficient in remov- The most effective means of removing plaque ing plaque than medium brushes, but may be of from teeth is with a toothbrush; invariably, value for those with sensitive teeth, painful gum toothpaste is used as well. Regular toothbrushing dis-orders or gingival recession. Hard brushes is begun by many people when young and should be avoided because they may cause gingi- continued throughout life. However, in many val trauma or recession. The brush-head should be cases, the brushing regimen is inadequate for small enough to reach awkward areas, but not so complete plaque control. Some areas of the den- small that effective plaque removal requires pro- tition cannot be reached by a toothbrush, and longed brushing. A medium-sized brush-head additional methods (e.g. dental floss or inter- with multi-tufted nylon bristles of medium proximal brushes) must also be employed. texture is probably the best choice for most adults.

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Interproximal brushes or brushes shaped like miniature bottle brushes may be required for extremely awkward areas (e.g. badly aligned teeth or bridges) or large interdental spaces. Electric brushes can be particularly valuable for people with mental or physical disabilities. ° When used by the able-bodied, there is no 45 evidence that they are intrinsically superior to manual toothbrushes, but they can achieve effec- tive plaque removal much more quickly. Many Figure 3.7 The Bass method. people, especially children, find them pleasant to use, and are therefore more likely to maintain a satisfactory oral hygiene regime. Rechargeable electric toothbrushes are considered preferable to battery-operated brushes, which lose torque quickly. Toothbrushes should be renewed relatively frequently. A worn toothbrush cannot effectively remove plaque, but there is no simple means of 45° detecting when a toothbrush is past its prime. It has been estimated that the lifespan of a tooth- brush being used correctly is probably only a few Figure 3.8 The Charters method. weeks.

Toothbrushing technique forth in a circular motion. It is particularly useful The aim of toothbrushing is to remove plaque if the interdental papillae have receded, leaving and food debris; it can also deliver the topical flu- the proximal surfaces of the teeth accessible to oride in toothpastes to the teeth. Toothbrushing the toothbrush. technique has been the subject of much argu- Whichever technique is used, the most ment and many suggestions have been put important factor in toothbrushing is that every forward. However, different dentitions may accessible surface of every tooth should be require different techniques; any technique that thoroughly cleaned during each session. Many results in good plaque control without causing people concentrate on the buccal and labial sur- damage to the teeth or soft tissues can be faces, but forget the lingual and occlusal surfaces. regarded as satisfactory. It is helpful to divide the dentition into sections Two of the most frequently recommended and concentrate on one section at a time. techniques are the Bass and Charters methods. In Patients who are concerned about their tooth- the Bass method, the head of the brush is applied brushing technique should be referred to their at an angle of 45º to the long axis of the teeth and dental surgeon for evaluation. pressed in an apical direction against the gingival margin (Figure 3.7). It is then moved antero- Toothbrushing frequency posteriorly with short vibratory strokes. In order The most widely accepted routine is once in the to gain adequate access to the lingual surfaces of morning and once at bedtime. Some authorities the anterior teeth, the brush must be turned into also advocate brushing the teeth after lunch, but a vertical position. This method effectively this is probably not practical for many people. removes soft deposits located above and below The thoroughness of plaque removal is more the gingival margin. important than the frequency; nothing is gained In the Charters method, the head of the brush by several cursory attempts at toothbrushing is applied to the teeth at an angle of 45º to the throughout the day. occlusal plane (Figure 3.8), and jiggled back and Toothbrushing before bed is important to

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prevent the reduced salivary flow during sleep Toothpastes may act as vehicles for active ingredi- allowing the build-up of thick plaque deposits. ents. About 95% of all toothpastes sold in the UK Therefore, removing as much plaque and debris contain fluoride (see below) in the form of sodium as possible before sleeping considerably reduces fluoride or sodium monofluorophosphate (MFP). overnight plaque levels. Theoretically, the best The fluoride content of toothpaste is usually time to brush teeth would be before eating, about 0.1%. Fluoride-containing toothpastes because sugar is only cariogenic in the presence deliver fluoride to the enamel surface, which is of plaque. In practice, plaque is unlikely to be extremely important in preventing dental decay. completely removed, so it is probably best to rec- Desensitising toothpastes contain various com- ommend toothbrushing after meals, to remove pounds to block the perception of painful stimuli plaque and sugars together. by dentine. Chlorhexidine (see below) inhibits However, toothbrushing should be avoided plaque formation on the teeth and is included in immediately after consuming acidic foods or toothpaste indicated for the control of gingivitis. drinks, and after vomiting. This is because at this Most people cover the entire brush head with point the enamel is particularly delicate, being in toothpaste, which is far in excess of the quantity the first stages of acid attack. After approximately needed. All that is required is an amount the size 30 minutes, the enamel is stabilised as a result of of a pea. Too much toothpaste generates a lot of re-mineralisation. foam and induces a premature desire to spit and rinse. For many people, this signals the end of toothbrushing. Ingestion of too much fluoride Toothpaste toothpaste by children, who swallow much more A toothpaste (dentifrice) is applied with a tooth- than adults, could possibly result in fluorosis, par- brush to clean the teeth, but the action of the ticularly if fluoride supplements are also being toothbrush is far more important than the tooth- administered. paste. It has even been suggested that toothpaste is not necessary for plaque removal. However, Dental floss and interdental woodsticks toothbrushing with water alone is of little benefit in stain removal. Toothpastes also polish the Dental floss and interdental woodsticks are used tooth surfaces, and plaque forms less readily on to remove plaque from the areas between the smooth surfaces than rough surfaces. Many teeth (embrasures) where a toothbrush cannot people like the freshening effect toothpaste has in reach. These areas should be cleaned regularly, the mouth, particularly first thing in the morning. but not every time the teeth are brushed; once a Toothpastes are composed of the following day should be sufficient. ingredients: Dental floss • humectants, which prevent the toothpaste Dental floss is available in waxed or unwaxed drying out, control microbial growth and forms; the choice is one of personal preference. provide a vehicle for the other ingredients Unwaxed floss splays out in contact with the • abrasives, which polish the tooth surface and tooth surface and may be more efficient at remove debris, plaque and stains removing plaque. It may also be easier to pass • surface-active agents, which loosen debris and through tight interdental spaces. However, the facilitate its removal loose threads may tear against the margins of fill- • binders and thickeners, which prevent separ- ings, in which case waxed floss may be preferable. ation of the aqueous and non-aqueous con- Dental tape, which is wider than dental floss, is stituents and thicken the formulation also available, and special types of floss are manu- • flavourings, which improve consumer accept- factured for cleaning bridges. Correct use of floss ability, thereby increasing the likelihood of may remove some subgingival plaque. patients maintaining good plaque control A long piece of floss (approximately 30 cm) • colourings, used to improve appearance and should be wound around the first two fingers of consumer acceptability. each hand, leaving approximately 10 cm in

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between. The floss is held taut and carefully inserted into the space between two teeth. It is then held firmly against one of the teeth and carefully moved vertically up and down to remove the plaque. This is repeated for the tooth on the other side of the space. On no account should the floss be moved horizontally between the teeth; this can severely damage the gingivae. The procedure is repeated until all the teeth have been thoroughly cleaned. An alternative method of using dental floss involves tying a length of floss (approximately 15 cm) into a loop. The lower teeth are cleaned by holding the floss between both index fingers. The left thumb and right index finger are used to clean the upper left quadrant, and the right thumb and left index finger to clean the upper right quadrant.

Interdental woodsticks Figure 3.9 The woodstick should follow the gingival Interdental woodsticks should not be used contour. without proper instruction from a dentist as they can cause tissue damage. They are less effective than floss and do not remove subgingival plaque; Mouthwashes they should not be used where teeth are closely positioned. Mouthwashes are liquid preparations containing Interdental spaces can be cleaned by inserting many of the same constituents as toothpastes (see and manipulating the woodstick, taking care to above). Essential differences are the exclusion of follow the normal contour of the interdental abrasives and thickening agents. They may, in papillae (Figure 3.9). The mouth must be clean addition, contain antibacterial agents, astringents, and the gingivae healthy; rubbing inflamed gin- demulcents or ethanol. Antibacterial mouth- givae over subgingival calculus will exacerbate washes may help control gingivitis, but not peri- periodontal disease. Regular use of woodsticks odontitis; however, the evidence is not conclusive, can improve the shape of the interdental papillae except for chlorhexidine. Mouthwashes do assist and reduce food stagnation. in the removal of debris, tenacious mucus and purulent secretions, and in the cleansing of trau- matised areas (e.g. aphthous ulcers). Water irrigation Patients using mouthwashes to treat oral Water irrigation units direct jets of water at and lesions should be referred to their doctor or dental between the teeth, and are promoted for plaque surgeon if the condition persists for more than removal. However, plaque is an extremely sticky, seven days; severe cases should be referred tenacious substance and is unlikely to be immediately. Anti-plaque mouthwashes intended removed by water alone. Water irrigation units to loosen plaque before toothbrushing have been are ineffective in removing stains from tooth sur- developed, although the evidence for their effec- faces. It is also possible that the water jet could tiveness is inconclusive. force bacteria into the crevicular epithelium and the underlying connective tissue. Any resultant Chlorhexidine bacteraemia would pose a serious risk for patients Chlorhexidine is a cationic antibacterial agent susceptible to bacterial endocarditis (e.g. those available in a mouthwash or dental gel. Chlorhex- with a history of rheumatic fever). idine gluconate has proven activity against plaque

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bacteria and prevents the build up of plaque compromise must be made so that the health of deposits. However, it is not an effective substitute the body as a whole is considered. Thus, it is rec- for toothbrushing, except for short-term use in ommended that the frequency of carbohydrate painful oral conditions (see Dental disease above). consumption, rather than the amount, should be In some cases, chlorhexidine stains the teeth a reduced. If snacks are eaten between meals, they blackish colour along the gingival margins. should consist of non-sticky savoury rather than sticky sweet foods, but it must be borne in mind Hydrogen peroxide that sugar is also present in many processed The antimicrobial action of hydrogen peroxide is savoury foods. negligible. Non-cariogenic sugar substitutes may be used, although it is probably wiser to attempt to do Sodium chloride without sweet foods and drinks. Sugar alcohols A sodium chloride mouthwash can be prepared (e.g. sorbitol, mannitol and xylitol) are available; by dissolving half a teaspoon of salt in a tumbler- they are not as cariogenic as sugars because ful of warm water, or by diluting Compound plaque bacteria are less able to utilise them as sub- Sodium Chloride Mouthwash BP in an equal strates to produce energy. However, large quanti- volume of warm water. It is particularly useful in ties cause osmotic diarrhoea, and the daily intake promoting healing (e.g. of extraction sockets and should not exceed 50 to 80 g. Hydrogenated aphthous ulcers) and establishing the drainage of glucose syrups are licensed for use in the UK, and pus. available evidence suggests that they are less cariogenic than sucrose. Sodium bicarbonate Sodium bicarbonate may be used as a 2% solution Fluoride to rinse the mouth. Its alkalinity makes it an effective mucolytic agent, but it does not have In the early 1900s, it was noted that the inhabi- any antibacterial action. tants of certain areas of America had mottled teeth. This was eventually found to be caused by increased levels of fluoride in the local drinking Prevention of dental caries water; the condition was therefore called fluoro- sis. These people had a lower prevalence of dental Dietary management caries than the population as a whole. Similar Dental caries is unlikely to be prevented by observations were made in the UK and elsewhere; plaque control alone; a reduction in sugar children living in areas supplied with water con- consumption is also important. Soft, sticky foods taining a high level of natural fluoride had release sugars over a long period of time by cling- healthier teeth than those in areas whose water ing to tooth surfaces. Also, different sugars affect had a low fluoride content. The role of fluoride in pH to varying degrees: lactose and galactose cause the prevention of dental caries was investigated; a smaller fall in pH than glucose, maltose, sucrose worldwide epidemiological studies confirmed or fructose. There is no difference in cariogenic that caries is reduced in areas where the water potential between refined and unrefined sugars, supply contains at least 1 mg/L (1 ppm) of fluo- or some ‘natural’ (e.g. honey) and processed ride. However, concentrations of fluoride above products. All should be avoided as far as possible. 1 mg/L may cause fluorosis. Fluoride is also Fruits and vegetables are a preferred alternative to present in many foodstuffs, but significant cakes, biscuits, puddings, confectionery and any amounts are found only in tea and the bones of other foods with a high sugar content. sea-fish. Animal studies suggest that complex carbo- There is a strong anti-fluoridation lobby in the hydrates may be cariogenic, although to what UK, which objects to fluoridation of water sup- extent is not known. However, suggesting that plies on the grounds that it is dangerous, unnec- these should also be avoided would contradict essary, uneconomic and of negligible benefit. the advice given to prevent other disorders. A Careful and controlled studies have refuted all

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these claims, and fluoridated water has been • Fluoride level above 700 µg/L (0.7 ppm) shown to be safe and effective. However, most of no supplementation required. the UK population does not benefit from fluori- dated water supplies. This contrasts starkly with These doses take into account the small amount other nations (e.g. Russia and the USA) where of fluoride ingested during toothbrushing. Two fluoridation is widespread; it is mandatory in the divided doses should be administered each day to Republic of Ireland. avoid the plasma concentration peaking at a Fluoride is effective both topically and sys- value that could cause fluorosis. However, this temically (Duckworth, 1993). The topical effect is requires a high degree of motivation, and once now considered more important as the greatest daily administration (preferably in the evening) concentrations of fluoride are found at the tooth is an effective compromise; forgotten doses surface. There are several theories to explain the should not be doubled the following day. Fluo- mode of action of fluoride. The most popular is ride tablets should be sucked or dissolved in the that the calcium hydroxyapatite in enamel is mouth rather than swallowed whole, to allow a replaced by calcium fluorapatite. This has a lower topical as well as a systemic effect. In the UK, critical pH and therefore increases the resistance fluoride supplementation is now considered of enamel to acid attack. Fluoride is also import- unnecessary for infants under six months of age, ant in re-mineralisation and the reversal of early irrespective of local water concentrations. caries, especially smooth surface caries. Fluoride Additional protection may be provided for can block the enzymes of plaque bacteria and those at increased risk of caries by the use of may inhibit the metabolic conversion of sugars to fluoride rinses or the application of fluoride gels. acids. Application of topical fluoride can re- Rinses may be used daily or weekly. A concen- mineralise enamel and completely reverse the tration of 0.05% sodium fluoride may be used for development of early carious lesions; it may also daily rinsing, and of 0.2% for weekly or fort- arrest, or slow down, the progress of later lesions. nightly rinsing. The mouth should be rinsed for There is some evidence that the presence of sys- one minute; the rinse should not be swallowed, temic fluoride during tooth development results and eating and drinking should be avoided for in a smoother, less fissured morphology that is 15 minutes after use. Gels must be applied by a less susceptible to caries. dental surgeon, usually twice a year; extreme Oral fluoride supplements containing sodium caution is necessary to prevent any excess from fluoride may be given to children living in areas being swallowed. Less concentrated gels have where the level of fluoride in the water is less than recently become available for home use. Fluoride 1 ppm. Pharmacists should check the level with varnishes may also be applied by the dental the water authority, and issue the following surgeon; they are particularly valuable for young guidelines when selling fluoride supplements. or disabled children as the varnish adheres to the Doses are expressed as the amount of fluoride ion teeth and sets in the presence of moisture. to be taken daily. These guidelines are for tem- It should be borne in mind that fluoride does perate climates; the dose may be less in tropical not confer complete protection, and minimal climates where more water is consumed. sugar consumption, together with good plaque control, is still essential to prevent dental decay. • Fluoride level less than 300 µg/L (0.3 ppm) six months to two years of age – 250 µg two to four years of age – 500 µg Dental intervention more than four years of age – 1000 µg • Fluoride level of 300 to 700 µg/L (0.3 to It cannot be emphasised too strongly that the 0.7 ppm) most important preventive measures are those less than two years of age – no supplementa- routinely undertaken by the individual at home. tion required However, regular visits to the dental surgeon are two to four years of age – 250 µg necessary to identify early caries, some of which more than four years of age – 500 µg may be reversed. For lesions that cannot be

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reversed, restorative treatment limits the amount measures should be directed towards reducing of tooth tissue lost. X-ray examination is essential tooth decay. However, the practices and habits to detect some cavities, especially those between adopted during childhood will also combat peri- teeth, and will also show early periodontal bone odontal disease if continued into adulthood. destruction. Instilling good dietary habits (see above) is Some individuals are more susceptible to absolutely essential in the early years, together caries than others. Some of the factors respons- with fluoride supplementation (see above), if ible may be outside their control (e.g. those that necessary. Parents should not add sugar to are genetically inherited or occur during tooth feeding bottles or coat dummies with sweet sub- development, see Dental disease above). The risks stances. Children should be discouraged from may be minimised by strict attention to oral adding sugar to foods or drinks (e.g. cereals, fruit, hygiene and use of fluoride products. However, tea or coffee). A taste for savoury foods should dental intervention may be necessary to ensure be encouraged because, once attained, a ‘sweet effective plaque control (e.g. orthodontic pro- tooth’ is very difficult to eliminate. cedures, which involve moving teeth into more Toothbrushing should be started as soon as the favourable positions under mild pressure, or first tooth erupts, and the child encouraged to extractions to reduce overcrowding). Orthodon- take an active part as soon as possible. Reasons for tic appliances provide a surface for plaque build- cleaning the teeth should be explained, and the up and can irritate the gingivae. They may presence of plaque demonstrated using a disclos- increase susceptibility to dental disease, and must ing agent. Children’s toothbrushes with small be kept scrupulously clean. heads and short handles should be employed. Fissures on the occlusal surfaces of molars and Use of dental floss is not usually necessary in chil- premolars are most prone to dental caries. Here, dren, and would be difficult because of lack of fluoride is less effective in preventing caries than manual dexterity. However, flossing should be in other areas of the tooth (see above). Deep fis- started as soon as possible in adolescence. sures may be treated with proprietary sealants. Thumbsucking should be actively discouraged, This involves filling the fissures and pits with a because it may alter the alignment and spacing of plastic substance. If applied properly, no decay the front teeth. should occur as long as the sealant remains in Children should be introduced to the dental place. Sealants should be applied as soon as poss- surgeon at an early age, certainly by the time all ible after eruption. The method is painless but the primary teeth have erupted. Good oral time-consuming, and may be difficult if a child is hygiene practices reduce the necessity for treat- unco-operative. ment and ensure that a child builds a good Regular dental check-ups are also important relationship with the dental surgeon right from for adults. The dental surgeon is able to offer the start. advice and training in good plaque control tech- niques. It is generally recommended that routine check-ups should take place every six months, Care of dentures although some young children may benefit from visits every four months. Adults with good Anyone who wears a complete set of dentures plaque control may only need an annual check- may assume that it is too late to worry about up. It must be stressed that regular dental check- dental healthcare. However, plaque accumulates ups are not a substitute for good oral hygiene. on dentures in exactly the same way as on natural teeth, and must be removed regularly to avoid mucosal inflammation. Removal of Prevention of dental disease in children plaque and food debris also reduces the likeli- hood of bacterial putrefaction and the resultant In children, caries is more of a problem than offensive mouth odours. Plaque on dentures is periodontal disease, so dental healthcare subject to the same risks of staining (e.g. from

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coffee, tea, tobacco or red wine) as natural teeth. dentures should be taken to a dental surgeon or Regular cleaning will maintain an attractive dental technician for professional repair as soon appearance. Partial dentures must be kept as possible. scrupulously clean in order to preserve the Once a tooth has been lost, the surrounding remaining natural teeth. Dentures should alveolar bone gradually resorbs, the rate varying always be cleaned out of the mouth, once or dramatically between individuals. Dentures rest twice a day. They are not usually worn at night, on the alveolar ridge and extensive bone loss when they should be placed in water to prevent results in a poor fit. Loose dentures affect eating them drying out and distorting. and speaking; the effects may be severe enough to Dentures are generally made of acrylic materi- make the wearer withdraw socially. Eating may als that are softer than enamel, so equipment and also be painful, because uneven contact means products designed for natural teeth should never that the soft gingivae are excessively loaded in be used. Some partial dentures are metal: chrome- some areas. The hard palate provides a wide cobalt alloy is most commonly used. Denture surface over which biting forces are distributed, brushes resemble nail brushes on long handles. whereas lower dentures can only cover the alveo- There is very often a thick tuft of bristles on the lar ridge, because the floor of the oral cavity is opposite side of the head, which can be used to taken up by the tongue and its associated clean awkward areas. Toothpastes specifically muscles. Consequently, lower dentures tend to designed for dentures should be used and highly be more difficult to wear than upper dentures. abrasive cleansers avoided, because of the risks of Denture fixatives, usually containing karaya gum scratching; household bleach, disinfectants or or tragacanth, are used by many people to antiseptics should never be used. Alternatively, increase retention. However, anyone having brushing with soap and water can be just as effec- problems should be referred to their dental tive. Disclosing solutions may be used to detect surgeon. plaque on dentures and assess the thoroughness The risk of developing oral lesions is increased of cleansing routines in exactly the same way as in some systemic disorders. Pharmacists should for natural teeth. always enquire about any underlying condition Tablets or powders that release oxygen when when a patient presents with denture problems dissolved in water may be used to soak the den- (e.g. there is an increased incidence of oral can- tures to remove plaque; a stronger acidic cleanser didiasis in diabetics). A dry mouth may also make may be required for stubborn stains. Soaking, wearing dentures difficult and uncomfortable, so however, is no substitute for brushing and can pharmacists should be aware of the conditions lead to ‘crazing’ of the acrylic surface; minute and drugs that reduce salivary secretion (see cracks develop which make the denture appear Dental diseases above). Patients may need to be dull and render it much more susceptible to stain- referred to their doctor as well as their dental ing. Metal components may corrode in certain surgeon. solutions, and the manufacturer’s instructions New dentures may take getting used to, especi- should always be consulted before soaking. Some ally if the patient has not worn dentures before. dentures have soft linings; the dental surgeon They may produce gum discomfort and even should be consulted about the safest way to clean sores or ulcers. Unless the symptoms are these. extremely mild, patients should be referred to Dentures must be handled with great care; their dental surgeon as the dentures may require they should be cleaned over a bowl of water or a adjustment. In the meantime, an oral prep- soft surface in case they are dropped. Denture aration containing a local anaesthetic may be repair kits are available to carry out emergency applied to the affected area. repairs, but should only be used as a very last The fit of dentures is rarely satisfactory for resort; the slightest misalignment or excess of more than five years, and they must be renewed repair material can make a denture unwearable. periodically. Denture wearers should visit their Household adhesives should never be used; the dental surgeon every one to three years (every six

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months if they have partial dentures) to have to see if alternative diluents to syrup may be used their dentures checked and the fit re-evaluated. when dispensing reduced-strength preparations. Whenever the opportunity arises, pharmacists should stress: The role of the pharmacist • the insidious and painless nature of dental disease • prevention is better than cure Pharmacists have traditionally been involved in • complete prevention is totally feasible selling dental products to the public, and are • regular dental check-ups are essential at any therefore ideally positioned to reinforce health age. education messages from the dental profession and other dental healthcare authorities. In It should also be emphasised that periodontal addition, pharmacists can recognise disorders disease is not a normal ageing process, but a patho- of the oral cavity and refer patients to general logical disease that can be prevented by good oral practitioners or dental surgeons as appropriate. hygiene. Children should be encouraged to adopt Dental healthcare is essential for a healthy life- good habits from as early an age as possible. style, and should be placed equally among other Pharmacists should be familiar with diseases forms of lifestyle modification. Pharmacists and drugs that may increase the susceptibility to should not take over the role of dental health dental caries or periodontal disease (see Dental education from dental surgeons, but rather diseases above), and offer counselling on preven- augment it. Much can be achieved by dental sur- tive measures where appropriate. It is imperative, geons and pharmacists liaising. This also ensures however, that pharmacists do not compromise that pharmacists endorse the dental healthcare patients’ confidence in prescribed medicines, or advice given by the dental profession. increase their anxiety over a disease state. The dis- In most cases, the sale of dental healthcare cussion needs to be handled with tact and sensi- products is a passive process. It would not be tivity, maintaining a positive attitude throughout practical to become actively involved in every and emphasising there is nothing difficult about sale, but pharmacists may perceive that a good dental heathcare. Sometimes, there is no problem exists (e.g. by noticing repeat purchases alternative to a prescribed medicine, and the of mouthwashes or a customer’s difficulty in patient’s medical health may seem more import- selecting a toothbrush or toothpaste). Dental ant than their dental health. Neither should be healthcare products should be positioned so that compromised at the expense of the other and, in pharmacists can observe customers, and there- most cases, dental health can be maintained with fore offer help when necessary. In large pharma- good plaque and sugar control. If a patient is cies, locating the dental healthcare section close over-anxious, pharmacists should discuss the to the dispensary serves to raise the status of matter with the patient’s doctor and dental dental products in the eyes of the public from surgeon in an attempt to resolve the difficulty. mere toiletries to essential healthcare items. Pregnant women are prone to gingivitis and Pharmacists should be aware of the importance should be counselled that good plaque control of sugar control in the prevention of dental caries, will minimise problems. It is also essential that and therefore only counter-prescribe non- pregnant women and children do not take tetra- cariogenic liquid medicines, particularly for chil- cyclines, as these may cause intrinsic discol- dren. Mouth and throat lozenges may contain oration of children’s permanent teeth during the cariogenic sugars, and this should be pointed out developmental stages. to patients. Pharmacists have little control over There may be occasions when patients consult medicines supplied on prescription unless generic pharmacists about dental problems. Anyone with items are requested. However, a discussion with dental pain should always be referred to a dentist, local doctors to make them aware of any sugar- because it may be difficult to establish the cause, free alternatives may be valuable. Pharmacists and usually only a dentist will be able to carry out should also check the manufacturer’s information the treatment necessary to alleviate the patient’s

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discomfort. If patients are unable to obtain emer- measure, but often require a high degree of gency treatment from their own dental surgeon, manual dexterity on the part of the patient. At all pharmacists should supply the address and tele- costs, patients should be dissuaded from using phone number of the nearest emergency dental household glues to re-cement a crown. The result service. Analgesics may be administered in the can be painful and cause difficult and expensive meantime, but it must be stressed that the dental problems. problem does not disappear with the pain, and Teeth which have been knocked out in an acci- dental treatment must be sought at the earliest dent may be successfully re-implanted; however, available opportunity. The belief that placing an they may not survive a lifetime, or may discolour aspirin tablet against the offending tooth will and require crowning. Such teeth should be relieve toothache should be firmly discouraged, placed in a clean container of milk and immedi- because of the risk of extensive mucosal ulcera- ately taken by the patient to the dental surgeon. tion; aspirin is of greater benefit in pain relief if On no account should the teeth be washed, taken systemically. rinsed or cleaned in any way. It is vital that there Some patients may have been given the all- is the minimum delay possible in seeking treat- clear by their dentist, or told that their problem ment. If the tooth has fallen onto a dirty surface, is due to gingival recession and exposure of the the patient may require immunisation against root surface. In this case, pharmacists can recom- tetanus. mend one of the proprietary brands of desensi- People who visit a dental surgeon have been tising toothpaste, preferably one containing sufficiently motivated to make an appointment. fluoride. It should be explained that two or three However, many people never see a dental weeks’ conscientious brushing is required before surgeon, but buy dental healthcare products. these toothpastes exert their maximum effect. Others may not follow any sort of oral hygiene Most people have mouth ulcers occasionally. regimen, but still visit a pharmacy for other Aphthous ulcers are the ordinary mouth ulcers reasons. Pharmacists, therefore, can interact with that appear singly or in small numbers, often at significantly more people than dental surgeons, times of stress. Various proprietary remedies are and should take advantage of this situation when- on the market, some of which contain a local ever possible. The impact of any educational anaesthetic to render the ulcers less painful. material (e.g. books, leaflets or posters) in a phar- Pharmacists should recommend an appropriate macy is potentially greater than in a dental product, as well frequent hot salty mouthwashes, surgery, and pharmacists would do well to include which often have a beneficial effect. dental health information among their displays. A patient with mouth ulcers need only be referred to a dental surgeon if the ulcers are: • particularly large References • last more than ten days or so • repeatedly occur in the same place, which Downer M C (1994). The 1993 national survey of chil- implies that they could be traumatic in origin dren’s dental health: a commentary on the prelimi- (e.g. caused by a sharp tooth or rough filling) nary report. Br Dent J 176: 209–214. • widespread or in large clusters, especially in young children, which could indicate infec- Duckworth R M (1993). The science behind caries pre- vention. Int Dent J 43: 529–539. tion with herpes simplex virus • associated with an objectionable taste or Harman R J, ed. (1990). Disorders of the ear, nose, and halitosis oropharynx. In: Handbook of Pharmacy Health-care: • caused by dentures. Diseases and Patient Advice. London: Pharmaceutical Press, 239–248. A number of emergency kits are available for patients to insert their own temporary fillings National Dairy Council (1995). Diet and Dental Health. London: NDC. and temporarily cement crowns that have become detached. These are a good interim Office of Population Censuses and Surveys (1994).

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Dental disease among children in the United Levine R, ed. (1996). The Scientific Basis of Dental Health Kingdom. OPCS Monitor. London: OPCS. Education. London: Health Education Authority.

Smith B G N, Bartlett D W, Robb N D (1997). The preva- Löe H, Kleinman D V, eds (1986). Dental Plaque Control lence, aetiology and management of tooth wear in Measures and Oral Hygiene Practices. Oxford: IRL the United Kingdom. J Prosthet Dent 78: 367–372. Press.

Mehta D, ed. (1998). Dental Practitioner’s Formulary 1998–2000. London: British Medical Association Further reading and Royal Pharmaceutical Society of Great Britain. O’Brien M (1993). Children’s Dental Health in the United Kingdom. London: HMSO. Centre for Pharmacy Postgraduate Education (1995). A distance learning course for community pharma- Rugg-Gunn A J (1993). Nutrition and Dental Health. cists. Oral Health, Volumes I & II. London: HMSO. Oxford: Oxford University Press.

Ekstrand J, Fejerskov O, Silverstone L M, eds (1988). Flu- Tay W M, ed. (1990). General Dental Treatment. Edin- oride in Dentistry. Copenhagen: Munksgaard. burgh: Churchill Livingstone.

Embery G, Rolla G, eds (1992). Clinical and Biological WHO (1985). Prevention methods and programmes for Aspects of Dentifrices. Oxford: Oxford University oral diseases: report of a WHO expert committee. Press. WHO Tech Rep Ser 713.

Useful addresses

British Dental Association (BDA) General Dental Council 64 Wimpole Street 37 Wimpole Street London W1M 8AL London W1M 8DQ Tel: 020 7935 0875 Tel: 020 7887 3800

British Fluoridation Society The Oral and Dental Research Trust Sandlebrook Keats’ House Mill Lane 36 St. Thomas Street Alderley Edge London SE1 9RN Cheshire SK9 7TY Tel: 020 7955 4699 Tel: 01565 873936 FDI World Dental Federation British Society for Disability and Oral Health 7 Carlisle Street Department of Sedation and Special Care Dentistry London W1V 5RG Floor 26, Guy’s Tower Tel: 020 7935 7852 London SE1 9RT Tel: 020 7955 5000 Ext. 3047

Sample chapter from Handbook of Pharmacy Health Education, 2nd edition