WHAT IS ACCEPTABLE DENTAL TREATMENT?

(Presented to an audience of Lawyers by ROGER GOULDEN on 12 June 1997, during a Law Society accredited conference).

THE DIAGNOSTIC PROCEDURES

1) THE CLINICAL EXAMINATION

In the past the examination of the teeth was centred around a check for cavities and decay. This was partly brought about by the logistics of working within the National Health Service in general dental practice where dentists' incomes are on a fee per item basis, with the more profitable items being fillings. It was also brought about by the underlying philosophy of dentistry which was predominantly a reparative exercise.

In more recent times prevention of dental disease has become as, or more important, than repair, so the examination has become more broad based. Not only are the teeth examined, but also the soft tissues are checked so that gum disease can be diagnosed, together with the occlusion, that is, how the upper and lower teeth meet and function together, and the jaw joint apparatus. Diet and oral hygiene standards are also examined.

2) THE RADIOGRAPHIC EXAMINATION

Not only are teeth hard tissue structures but they also have approximately half of their mass buried within the jaws. Visual examination is therefore limited so radiographs are an invaluable aid to examining the teeth and reaching a diagnosis. The different views commonly used by dental practitioners will be demonstrated.

Unfortunately radiographs require the exposure of the patient to X-rays which are known to be harmful. The levels of exposure that are acceptable are constantly being re-evaluated and have been the subject of numerous EC directives.

The contemporary guideline when planning whether further exposure is acceptable is covered by the acronym ALARA - `As Low As is Reasonably Achievable', with the condition that radiographs should only be taken when clinically necessary. And that definitely does not include the taking of radiographs for the purposes of preparing a medico-legal report.

THE TREATMENT PROCEDURES

An overview, with brief technical descriptions, of the major dental procedures carried out in general dental practice will be demonstrated. Some particular aspects will be discussed as follows:

1) PERIODONTICS (gum treatment)

Research carried out in recent years has brought about a fundamental change in the understanding of gum disease, and it is now believed that this progresses in bursts of activity, and is site specific, that is, it will not affect all teeth equally.

From this new understanding there is now a different approach to the diagnosis and monitoring of the disease based on examination of the soft tissues specifically to identify sites of disease activity. These are measured and recorded as periodontal indices and allow the disease progress to be monitored and treated accordingly.

2) FILLINGS

The locations on the teeth where cavities occur will be shown together with the contemporary concept of when interventive treatment is acceptable.

The traditional material used to restore cavities in back teeth, silver amalgam, has recently been questioned because of possible toxicity from its metal content. Although extensive research is continuing, the contemporary conclusion is that there is no evidence that it has any side effects.

However it is recognised that many patients might prefer non metallic materials, so the alternative filling materials, and an indication where these might be acceptable, will be considered.

Preventative measures including diet analysis and counselling, oral hygiene and fluoride applications, must be used in the treatment of individuals with dental decay and must be run parallel with the reparative aspects for the treatment to be acceptable.

3) ROOT CANAL TREATMENT

These treatments usually are performed to treat specific conditions where the nerve within a tooth has become exposed or infected. There will however be some clinical cases where elective root canal treatment might be planned and it is therefore appropriate to consider some of the risks inherent in these treatments to determine whether such treatment is acceptable.

4) CROWNS

Crowns fall into two definite categories. There are those which are used to restore damaged teeth where no alternative treatment exists, other than perhaps extraction, and there are those where a cosmetic improvement is sought.

The destructive nature inherent in the preparation of teeth for crowns will be illustrated since this must be part of the overall assessment when determining whether such restorations are acceptable.

5) BRIDGES

In a similar manner to crowns, these restorations which are used to replace missing teeth by means of an appliance permanently fixed to adjacent teeth, have both essential and elective indications.

The inherently destructive nature of the tooth preparations used for conventional bridges, and the often less than ideal outcomes, will be considered.

The conventional bridges will be compared with the less destructive, but possibly more unreliable, adhesive bridges.

6) VENEERS

The nature and uses of these restorations will be illustrated. Whereas these restorations were once held to be reversible procedures they are now usually irreversible in that some tooth structure must be removed. It is now therefore obligatory to make a careful assessment of their need to determine whether they are acceptable in any clinical situation.

7) DENTURES

These appliances answer a specific need in that they are only provided for patients with missing teeth. A determination of whether any particular design or construction is acceptable is more applicable to the partially edentulous than where all the natural teeth are missing. The alternatives are very limited for the totally edentulous.

8) IMPLANTS

These devices have become popular over the last decade and offer an elegant alternative to dentures and bridges in the replacement of missing teeth. They have moved from the experimental to a realistic treatment option.

However, quite apart from their considerable expense, they require several invasive surgical procedures so careful scrutiny of each clinical situation must be made when considering whether they are acceptable. The clinician is aided in the case selection and treatment planning by specific operating protocols which have developed alongside the clinical developments.

9) ORTHODONTICS

The discipline of orthodontics has developed towards a speciality within dentistry and many practitioner will have undergone additional training and qualification and limit their practices to this speciality.

However all registered dental surgeons are qualified to undertake orthodontic cases and the determination of what is acceptable in general practice must be for the individual practitioner. Recognising when to refer a patient for specialist assistance is the hallmark of the first class general practitioner.

Much of orthodontics, by definition, involves tooth movements and will thus be relatively non- invasive. However there is commonly a requirement to extract healthy, but superfluous, teeth in cases of over crowding so careful consideration of what is acceptable treatment is essential.

10) ORAL SURGERY

In the same manner as orthodontics, all registered dental practitioner are qualified to carry out oral surgery. But since dedicated oral surgeons invariably have a medical qualification in addition to one or more fellowships from the surgical Royal Colleges, there must clearly be a level of treatment beyond which the general practitioner should not venture.

The level of what is acceptable in the general practice environment will be explored.

11) SEDATION AND ANAESTHESIA

Anaesthetic and sedation techniques have matured from the frighteningly crude to the highly sophisticated, and this development has been accompanied by a correspondingly steep rise in the standard of training, personnel and equipment requirement for any practitioner wishing to provide this service. Nevertheless, the risks inherent in any anaesthetic procedure insist that a full case assessment be made before deciding that such techniques are acceptable. These must include evaluation of the individual patient and the nature of the planned treatment.