Good dental practice is as much about behaviour as technical treatments and expertise. Most importantly, successful dental practice requires trivial compliance from the patients, but this is often obstructed in complex ways by patients themselves. In this article, we outline the classical approach to behaviour change and argue that interventions should be rooted in proper diagnoses of non-compliance, rather than in the rationality-based assumptions of this framework. We then argue by illustration for the relevancy of behavioural sciences in dental practice and identify three specific, experimental insights from the behavioural sciences that may easily be applied and tested. The three examples illustrate the habit of flossing regularly, how to reduce no-shows in patient treatments by introducing proper commitment devices, and how experiments on retrospective pain experience may relate to retention.
A tooth can be a threat to us in three different ways; in itself, via the pulp and the periodontal ligament, and when it is removed.
Using teeth as a biting tool may cause lethal bite wounds, but may also introduce bacteria into the tissues, and thereby infections.
The oral cavity is the entry to the gastrointestinal tract, to the airways, and to our immune system and has several defense mechanisms against infections. The local, oral bacteria are important in the defense against exogenous bacteria when in a hemostasis with the host, but may also act opportunistically and cause infections. Serious infections in teeth or jaws are rare after the introduction of antibiotics and improved oral care, but they can still be life threatening if not treated properly. Proper, clinical diagnosis and pus evacuation is of critical importance, and hospitalizing must be considered in serious cases.Complications when removing the tooth is best avoided and handled through a thorough medical history and clinical examination. The operators’ clinical skills and expertise are important.
Identification of unknown, odontogenic foci is a challenging task for a dentist. However, the task is important, as a number of patients with affected general health have a odontogenic focus. A clear example of this is indocarditis which appears to be caused by bacteremia – a life threatening condition. In many cases, oral bacteria are involved which underlines the importance of identifying the foci.
The problem must be solved in a systematic manner. The journal is the foundation, containing a complete anamnesis and a thorough, clinical examination. The findings are supported by an x-ray examination, and a cone-beam scanning is a valuable tool if a conventional x-ray examination is not sufficient. However, to interpret and understand the findings, knowledge of the anatomy in the region is important.This chapter contains three examples of identification of unknown foci.
Osteonecrosis of the jaws (ONJ), in layman’s terms “dead bone” or “dead jaw”, is a severe complication to anti-resorptive treatment with bisphosphonate, denosumab, and certain chemotherapeutic drugs. These drugs are used against osteoporosis and various malignant conditions (breast cancer, prostate cancer, multiple myeloma) with metastases in the skeleton. ONJ can cause pain, loss of teeth and parts of the jaws, and loss of masticatory function. Thus, ONJ is a severe cancer related complication, or ostoporosis treatment complication. ONJ was first reported in 2003, and during the last 10 year, a large number of cases have been reported worldwide.
Chitosan, a natural, carbohydrate polymer derived from the deacetylation of chitin, is the second most common polymer found in nature after cellulose. Chitosan is produced commercially from crab and shrimp shell wastes with different degrees of deacetylation and molecular masses. Because of chitosan’s promising biological activities, including non-toxicity and antimicrobial activity, it is used for a variety of purposes in food production, medicine, agriculture, cosmetics, and biotechnology. The mechanism behind chitosan’s antimicrobial activity is still somewhat uncertain. The main theory is that positively charged amino groups of chitosan participate in an electrostatic interaction with negatively charged groups in the cell surface of bacteria, resulting in damage to the cell wall, influencing the permeability or barrier properties.
Resin composites are now the most used dental restoration material in the Nordic countries. Annual failure rate for composite fillings seems to be 1-3 %, but individual studies have reported higher numbers. The main reason for the replacement of composite fillings is the development of secondary caries. To prevent such a development, experiments with antimicrobial agents incorporated in resin composites are carried out. Chitosan has shown an antimicrobial effect against oral bacteria and is tested for the use as an antimicrobial agent in composites and other dental materials and oral hygiene products.
Traumatic injuries to permanent teeth are common. Correct emergency treatment may be decisive for the prognosis of the injured teeth. Adequate clinical and radiographic examinations are necessary to make correct diagnosis, which is the basis for choice of immediate treatment and the next follow-up. In this article, a systematic examination of the dental trauma patient in general and the emergency treatments of three types of injury, complicated crown fracture (enamel-dentin-pulp fracture), root fracture, and avulsion, are described. In case of complicated crown fracture, partial pulpotomy should be the first choice of treatment. Root fracture has good prognosis, and root canal treatment should only be performed in the coronal segment when there are signs of pulp necrosis. Handling of the avulsed tooth at the site of the accident and immediately after the avulsion is of utmost importance for the long-term prognosis. All dentists should be able to provide immediate treatment to a dental trauma patient. The follow-up to dental injuries requires both knowledge and skills.
Many different materials and techniques are available for restoring posterior teeth. As a result, the clinical decision-making is challenging as the influence of several factors related to the tooth, material, patient and operator must be taken into consideration. There are great variations among dentists’ clinical decisions, but the overall philosophy should be minimally invasive and biological and the focus ideally should move from longevity of the restoration to longevity of the tooth. The first choice should be the least invasive: direct composite. Neither literature nor the user manuals from the manufacturers place any restrictions on the extension of composite restorations. However, if there are technical difficulties in using proper matrix technique or achieving acceptable anatomic contour, or if parafunctional activities are present, indirect restorative techniques should be considered.
With equipment for computer-aided design and manufacturing (CAD/CAM) in the dental office, the dentist again becomes his own dental technician. While the equipment itself is not subject to health-related regulation, the European Medical Devices Directive imposes requirements on the prosthodontic devices it produces. As a manufacturer of custom-made, medical devices, the dental office is required to document its ability to ensure that the produced prostheses function satisfactorily, and that any failure to meet the defined quality criteria is followed up systematically.
The capability to analyse the cause of failure is essential to the systematic improvement of quality. In the face of market forces favouring interoperable components rather than a vertically integrated CAD/CAM system, this requirement places an increased responsibility on the dental office to use the comprehensive data generated by the CAD system to understand the reasons for a clinical failure or the need for rework of a prosthetic device, and to prevent recurrence of the problem. Frequently, knowledge of the behaviour of materials both during production and in the finished prosthesis is needed in order to attain the necessary understanding of sub-optimal, clinical performance.
A radiographic examination is meant to support the clinical examination of mandibular third molars aiding the surgeon to establish a treatment plan. When deciding on which radiographic method to use, the ALARA-principle should always be kept in mind, and for most general dental practitioners a periapical examination is the only available method in the clinic. Studies have shown however that in around 25 % of the cases, it is impossible to obtain a sufficient periapical image; therefore panoramic imaging is the state-of-the-art method where this unit is available. In cases of over-projection between the third molar and the mandibular canal in the panoramic image and specific signs that a close contact exists between the molar and the mandibular canal, an additional 3D radiographic examination (CBCT) may be indicated to explore if there is direct contact between the third molar and the mandibular canal indicated by no bony separation between these structures. A direct contact as seen in CBCT-sections has been shown to be the most important factor with an impact on deciding on performing a coronectomy instead of removing the whole tooth. Studies, where the full tooth was removed seem to indicate, that the use of CBCT does not change the outcome for the patient with regard to sensory disturbances to the inferior alveolar nerve and moreover, the costs and the radiation burden to the patient are higher for CBCT than for conventional 2D methods.
In conclusion, periapical or panoramic imaging is sufficient in most cases before removal of mandibular third molars, but CBCT may be suggested when one or more signs for a close contact between the tooth and the canal are present in the 2D conventional image – if it is believed that CBCT will change the treatment or the treatment outcome for the patient.
The occurrence of peri-implantitis has been assessed in several studies. Huge variations in the prevalence of peri-implantitis have been reported, mainly due to variations in the patients included in the studies as well as in the definition of peri-implantitis. Peri-implantitis seems to be a significant clinical problem due to the increasing use of implants, especially in patients with various known risk factors. In addition, treatment of peri-implantitis is still complex and unpredictable, especially when advanced peri-implantitis lesions have developed. Moreover, the peri-implantitis lesion may be so advanced that implant removal is the only treatment modality available. Due to the advanced peri-implantitis-induced alveolar bone loss, complex bone regenerative procedures are frequently required before new implants can be inserted. Therefore, early diagnosis and adequate treatment of peri-implantitis are extremely important to minimize the risk of advanced disease development. Moreover, focus on known risk factors is also important, including meticulous infection control before implant treatment in patients with tooth loss due to periodontitis, optimal implant treatment, optimal oral hygiene, and a systematic maintenance care program.
The practice of evidence-based dentistry means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Individual clinical expertise means the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. It follows that a systematic review can help the clinician to gain knowledge about the evidence of a certain intervention or a certain diagnostic method. This article focuses on the rationale behind the systematic review and how it is conducted. The process starts by formulating one or more relevant questions. Inclusion and exclusion criteria are decided regarding study design, population, intervention, control, outcome, and outcome measures. The process then involves literature search and data extraction of relevant, full text articles. Quality assessment of relevant studies, conducted by at least two independent readers, is performed using quality assessment forms. Based on the quality of the included studies, the results are summarized, and the quality of evidence is formulated. If the effects are uncertain, or if the question cannot be answered from existing research, a knowledge gap is present. The identification of such gaps is important because they indicate the necessity of new research. Ethical and health economic aspects should also be integrated in a comprehensive, systematic review.
Dental fear (DF) is one of the most common specific phobias, and the estimated prevalence in Scandinavia is reported to be 5 % among adults (1) and up to 9 % among children (2). Depending on the severity of DF, the patients are often impaired in the regularity of contact with the dental care, and patients suffering with DF more often experience an inferior oral health compared to other patients (3). The ways of treating DF mainly involves adequate psychological care, and a successful and well-used treatment is cognitive behavior therapy (CBT). A meta-analysis which examined DF patients treated with CBT showed a significant reduction of fear, and that approximately 80 % of the treated patients continuously and independently received dental care (4). Various methods for measuring DF have been used over the years. Dental Anxiety Scale (DAS) is the most common and well-known measuring tool and it is based on self-perceived grading of DF (5). Other measuring tools have been developed to include a more diverse assessment, for example Index of Dental Anxiety (IDAF) where cognitive, behavioral, emotional, and psychological aspects are taken into account (6). Research is ongoing to measure dental fear in more objective ways, for example through stress hormone levels in the saliva (7).
It is unknown how many people have the status as undocumented immigrants, but in Sweden, the number is estimated to be 35.000 people. This group of people is reported to have more oral health problems than others. However, providing dental care to these immigrants is not always regulated by society or by the social security system. Meeting with and treating these patients may pose ethical dilemmas for the dental health care professionals. Ethical guidelines state that the dentist should act in the best interest of the patient. From an ethical point of view, undocumented immigrants have the right to receive health care, including dental treatment, on equal terms with others. But in order to fully achieve this, society needs to organize and clarify how this should be carried out.