Pickard’s Manual of Operative Dentistry, Eighth edition Edwina A. M. Kidd, et al OXFORD UNIVERSITY PRESS OXFORD MEDICAL PUBLICATIONS Pickard’s Manual of Operative Dentistry MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page i Professor HM Pickard 1909–2002 MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page ii Edwina A. M. Kidd Professor of Cariology Guy’s, King’s, and St Thomas’ Dental Institute King’s College London Bernard G. N. Smith Professor of Conservative Dentistry Guy’s, King’s, and St Thomas’ Dental Institute King’s College London Timothy F. Watson Professor of Microscopy in Relation to Restorative Dentistry Guy’s, King’s, and St Thomas’ Dental Institute King’s College London Based on the first five editions of A manual of operative dentistry H. M. Pickard Emeritus Professor in Conservative Dentistry University of London Formerly of the Royal Dental Hospital of London School of Dental Surgery Pickard’s Manual of Operative Dentistry Eighth edition 1 MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page iii 3 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Sao Paulo Shanghai Taipei Tokyo Toronto Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press, 2003 The moral rights of the author have been asserted Database right Oxford University Press (maker) First edition published 1961 Sixth edition published 1990 Seventh edition published 1996 (reprinted 1996, 1998 (twice), 2000) Eighth edition published 2003 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data ISBN 0 19 850928 6 10987654321 Typeset by EXPO Holdings, Malaysia Printed in China on acid-free paper by MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page iv It is 41 years since the first edition of this book was pub- lished. In that time there have been so many developments in our understanding of dental disease, in materials, and in techniques so that there is now very little of that first edition remaining except the basic philosophy for managing patients with dental disease. This philosophy has several parallel threads which weave together. • Dentists primarily look after people with dental prob- lems – not just mouths or teeth. • An understanding of the disease processes is funda- mental to their management. • The diseases should be managed – not just treated. • Prevention is the keystone of management. The effect- iveness of the prevention of dental caries in a selected group is shown by the fact that about three-quarters of undergraduate dental students at our dental institute now have no caries or restorations. Sadly, this is not yet the case with all people of that generation. • When treatment is needed, the development of excel- lent operative skills is still of paramount importance. This can only be achieved by extensive supervised clinical practice and chairside teaching which remain as important as ever in the crowded undergraduate curriculum. If students do not develop sufficient skill during their undergraduate course there is little opportunity for most dentists to develop basic skills in a supervised setting after qualification. • When active treatment is needed, the choice of mater- ials and techniques should be based on a thorough understanding of them and the advantages and dis- advantages of the alternatives. This choice is getting more difficult as the range of materials and techniques increases so that an even greater understanding of the properties of dental materials is now necessary. One of the major developments since the seventh edition has been the increased use of bonding techniques which in turn allow much less destructive tooth preparation. For example, in the seventh edition the use of amalgam for the management of smooth surface lesions was deleted, and we now feel that the evidence to support the use of composite materials for occlusal lesions is sufficient for us to recom- mend that amalgam should no longer be used for occlusal restorations. These developments justify a new chapter (Chapter 6) which brings together parts of other chapters from the last edition and adds substantial new material. The intention is that this book contains the material a student needs to know (except endodontic and periodontal treatment) up to the point that crowns become necessary. In other words, students can provide long-term stabilization, including permanent intracoronal restorations and cores for crowns, until they have learnt about crowns and then can continue treating the same patients if that is the policy of their undergraduate school. An increasing number of schools adopt policies of ‘whole patient care’ and ‘continuity of care’ so that students can manage their own patients and all their dental needs from an early introduction through to the end of the undergraduate course. In some schools this gives the students three or more years of contact with some patients at regular recalls after the initial course of treatment. During that time they can move on to other procedures, as necessary, with the same patient, for example crowns, bridges, and partial dentures. They also have an opportunity to see the short-term (one or two years) success or failure of their restorations. Previous editions have included a brief list of ‘further reading’ at the end of each chapter. This has been brought up to date and retained but we suggest that readers use the list of topics at the beginning of each chapter as ‘keywords’ to initiate their own computer search of the literature. There are two significant, current educational and clinical concepts which we believe we have developed further in this edition. The first is ‘problem solving’ and the emphasis on managing disease rather than treating it as an example of real problem solving. The second concept is ‘evidence-based prac- tice’. This is a manual of operative dentistry, not an authori- tative textbook, however many of the changes in this edition are based on recent research evidence. If evidence is consid- ered as not just research-based scientific evidence but includes the evidence of experience, then we believe that this edition reflects the current state of play in operative dentistry. We are considerably indebted to many colleagues who have allowed us to use their illustrations. They are acknow- ledged in the captions to the relevant figures together with a source of the original publication where applicable. E. A. M. K. B. G. N. S. T. F. W. March 2003 Preface to the eighth edition MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page v PART I DISEASES, DISORDERS, DIAGNOSIS, DECISIONS, AND DESIGN 1 Why restore teeth? 5 Dental caries 5 The carious process and the carious lesion 6 Plaque retention and susceptible sites 6 Severity or rapidity of attack 7 The carious process in enamel 7 The carious process in dentine 9 Root caries 11 Secondary or recurrent caries 11 Residual caries 12 Diagnosis of dental caries 12 The diagnostic procedure 12 Assessment of caries risk 16 Symptoms of caries 18 The relevance of the diagnostic information to the management of caries 18 Preventive, non-operative treatment 18 Patient involvement 19 Why is the patient a caries risk? 19 Mechanical plaque control 19 Use of fluoride 20 Dietary advice 20 Salivary flow 20 Operative treatment 20 Caries in pits and fissures 20 Approximal lesions 20 Smooth surfaces and root caries 20 Tooth wear 20 Erosion 22 Attrition 23 Abrasion 24 Summary of the causes of tooth wear 24 Acceptable and pathological levels of tooth wear 24 Consequences of pathological tooth wear 24 Diagnosing and monitoring tooth wear 24 Preventing tooth wear 27 The management of tooth wear 27 Contents MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page vii viii Contents Trauma 27 Aetiology of trauma 27 Examination and diagnosis of dental injury 28 Management of trauma to the teeth 28 Developmental defects 28 Acquired developmental conditions 28 Treatment of developmental defects 30 Hereditary conditions 30 Further reading 31 2 Making clinical decisions 35 Who makes the decisions? 35 Professionalism 35 Large and small decisions 36 The four main decisions 36 Diagnosis 36 Prognosis 36 Treatment options 36 Further preventive measures 34 The information needed to make decisions and how it is collected and recorded 36 History 37 Examination 40 Examination of specific areas of the mouth 41 Detailed charts 42 Special tests 43 The history and examination process 45 Planning the treatment 46 Some common decisions which have to be made 47 Diagnosing toothache 47 Whether to restore or attempt to arrest a moderate-size carious lesion and whether to restore or monitor an erosive lesion 50 Whether to extract or root treat a tooth 52 Which restorative material to use 52 Further reading 52 3 Principles of cavity design and preparation 55 G. V. Black 55 Why restore teeth? 55 What determines cavity design? 55 The dental tissues 55 The diseases 56 The properties of restorative materials 56 Resin composites 57 Composition of composites 58 Polymerization of composites 58 Glass ionomer cements 58 Conventional, autocuring, glass ionomer cements 59 Resin-modified glass ionomer cements (RMGIC) 59 Polyacid-modified resin composites (PAMRC) 59 Fluoride-releasing materials 59 Dental amalgam 60 Composition of amalgam alloys and their relevance to clinical practice 60 MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page viii The safety aspects of amalgam 61 Cast gold and other alloys 61 Principles of cavity design 62 When is a restoration needed? 62 Gaining access to the caries 62 Removing the caries 63 How should soft, infected dentine be removed? 63 Stepwise excavation 64 Put the instruments down: look, think, and design 64 The final choice of restorative material 64 Making the restoration retentive 64 Design features to protect the remaining tooth tissue 65 Design features to optimize the strength of the restoration 65 ‘Resistance form’ 66 The shape and position of the cavity margin 66 Possible future developments in cavity design 66 The control of pain and trauma in operative dentistry 66 Pre-operative precautions 67 Pain and trauma control during tooth preparation 67 Avoiding postoperative pain 68 Cavity lining and chemical preparation 68 Objectives and materials 68 Further reading 69 PART II TREATMENT TECHNIQUES 4 The operator and the environment 75 The dental team 75 The dental school and practice environment 75 The surgery 76 Positioning the patient, the dentist, and the dental nurse 76 Lighting 77 Siting of work-surfaces and instruments 77 Aspirating equipment; cavity washing and drying 78 Hand and instrument cleaning 78 Close-support dentistry 78 Maintaining a clear working field for the dentist 78 Instrument transfer 79 Moisture control 80 Reasons for moisture control 80 Techniques for moisture control 80 Magnification 86 Protection, safety, and management of minor emergencies 88 Eye protection 88 Airway protection 88 Soft tissue protection 89 Avoiding surgical emphysema 89 Dealing with accidents and accident reporting 90 Protection from infection 90 Further reading 90 5 Instruments and handpieces 93 Hand instruments 93 Instruments used for examining the mouth and teeth 93 ix Contents MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page ix x Contents Instruments used for removing caries and cutting teeth 94 Instruments used for placing and condensing restorative materials 94 Hand instrument design 95 Using hand instruments 96 Maintaining hand instruments 96 Sharpening hand instruments 96 Decontaminating and sterilizing hand instruments 97 Rotary instruments 97 The air turbine 97 Low-speed handpieces 97 Maintaining and sterilizing handpieces 98 Burs and stones 98 Finishing instruments 99 Maintaining and sterilizing burs and stones 101 Tooth preparation with rotary instruments 101 Speed, torque, and ‘feel’ 101 Heat generation and dissipation 101 Effects on the patient 101 Choosing the bur for the job 102 Surface finish 102 Finishing and polishing restorations 102 Air abrasion 103 Auxiliary instruments and equipment 103 6 Bonding to tooth structure 107 Why bond to tooth tissue? 107 The substrate; enamel and dentine 107 Enamel 107 Dentine 108 Enamel–dentine junction 108 Cutting 109 Choice of materials for bonding techniques 109 Spectrum of bonding materials 109 Overall requirements for adhesion 109 Composites 110 Bonding to enamel 110 Bonding to dentine 110 Bonding to wet dentine (and enamel) 112 Important considerations on the use of bonding agents 113 Number of stages and film thickness 113 Speed of application 113 Good clear instructions 114 Ease of dispensing and handling 114 Sensitization 114 Shelf-life 114 Glass ionomer cements 114 Adhesion mechanisms: conventional glass ionomer cements 114 Conditioning the dentine 115 Bonding glass ionomer cements to enamel 115 Bonding glass ionomer cements to dentine 116 The resin-modified glass ionomer cements 116 The polyacid-modified resin composites 117 MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page x [...]... susceptible sites • Severity or rapidity of attack • The carious process in enamel • The carious process in dentine • Root caries • Secondary or recurrent caries • Residual caries Diagnosis of dental caries • The diagnostic procedure • Assessment of caries risk • Symptoms of caries • The relevance of the diagnostic information to the management of caries Preventive, non -operative treatment • Patient involvement... lesions (a) (b) Fig 1.16 (a) A molar tooth with a white spot lesion formed in an area of plaque stagnation at the fissure entrance (b) A hemisection of this tooth showing a larger lesion than would be expected from examination of the outer enamel surface This is purely a function of the direction of the enamel prisms in this region (By courtesy of Dental Update.) Histologically, the carious process may... disorganized or even non-existent Regular removal of the biofilm from the surface of any lesion encourages lesion arrest and these defense reactions then predominate This retreat of the pulp from injury has important implications in the operative management of caries (see p 64) Inflammation is the fundamental response of all vascular connective tissues to injury Inflammation of the pulp (pulpitis) may, as in any... to the offending tooth, and the patient may only be able to indicate which quadrant, or even which side, of the mouth is involved (See Chapter 2 for further details on the diagnosis and management of toothache.) The relevance of the diagnostic information to the management of caries There are three approaches to the management of active caries: • attempt to arrest the disease by preventive, nonoperative... tissues (operative dentistry) and prevent recurrence by preventive, nonoperative treatment • extract the tooth Preventive, non -operative treatment The management of active caries always requires preventive treatment and in cases where cavities preclude plaque control, MOD8E_01(1-32) 11/11/03 11:49 AM Page 19 Preventive, non -operative treatment operative treatment is also needed Notice the use of the... • Mechanical plaque control • Use of fluoride • Dietary advice • Salivary flow MOD8E_01(1-32) 11/11/03 11:49 AM Page 4 Operative treatment • Caries in pits and fissures • Approximal lesions • Smooth surfaces and root caries Tooth wear • Erosion • Attrition • Abrasion • Summary of the causes of tooth wear • Acceptable and pathological levels of tooth wear • Consequences of pathological tooth wear • Diagnosing... there are often areas of tubular sclerosis and reactionary dentine Bacteria seem to penetrate the tissues at an earlier stage in root caries than in coronal caries, although lesions are often rather superficial Despite the presence of these bacteria, active, soft root carious lesions can be converted into arrested lesions by regular tooth brushing with a fluoride-containing dentifrice The soft surface... place Operative dentistry also enables the patient to resume effective plaque control by filling the hole where plaque may stagnate Residual caries When preparing a carious tooth to receive a restoration the dentist removes soft, infected dentine This is part of the carious lesion, but not all of it Demineralization of dentine precedes bacterial infection and beyond the demineralized area is the region of. .. immediately after the patient has seen the hygienist The three-in-one syringe is invaluable in the diagnosis of the depth of penetration of the white spot lesion A white spot lesion that is visible only once the enamel has been throughly dried has penetrated about halfway through the enamel A white or brown spot lesion that is visible on a wet tooth surface has penetrated all the way through the enamel and... would be cavitated (a) (b) (c) (d) Fig 1.28 The radiographs record the progress of approximal caries on the distal aspect of a mandibular first premolar over a period of 18 months in a patient aged 15–16 years This picture has some historical interest It appears in the first edition of this book, published in 1961 Speed of progression is rapid There was no fluoride in toothpaste at this time (a) Early . Pickard’s Manual of Operative Dentistry, Eighth edition Edwina A. M. Kidd, et al OXFORD UNIVERSITY PRESS OXFORD MEDICAL PUBLICATIONS Pickard’s Manual of Operative Dentistry MOD8E-PRE(i-xiv). first five editions of A manual of operative dentistry H. M. Pickard Emeritus Professor in Conservative Dentistry University of London Formerly of the Royal Dental Hospital of London School of Dental. Surgery Pickard’s Manual of Operative Dentistry Eighth edition 1 MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page iii 3 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the