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Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current information provided (i) on proce-
dures featured or (ii) by the manufacturer of each product to be administered, to verify the rec-
ommended dose or formula, the method and duration of administration, and contraindications. It
is the responsibility of the practitioner, relying on his or her own experience and knowledge of the
patient, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the
Publisher nor the Editor assumes any liability for any injury and/or damage to persons or property
arising out or related to any use of the material contained in this book.

The Publisher

ISBN-13: 978-0-323-02565-2

Publishing Director: Linda Duncan
Senior Editor: John Dolan
Developmental Editor: John Dedeke
Editorial Assistant: Marcia Bunda
Publication Services Manager: Julie Eddy

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Page 217

veys differ in their estimates of the prevalence of

gingivitis; the U.S. Employed Adults Survey

reports an average gingivitis prevalence of 44%

compared with the NHANES III estimated gingivi-

tis prevalence of 63%. These surveys also

reported that from one half to two thirds of U.S.

adults have subgingival calculus, affecting

between 22% and 34% of available sites per


b. Chronic periodontitis. Chronic periodontitis is the

most common form of periodontitis. Its preva-

lence, extent, and severity increase with age. The

U.S. Employed Adult Survey and NHANES III sug-

gest that the loss of some attachment is virtually

ubiquitous among U.S. adults. The prevalence

estimate for having at least one site with 1 mm or

more of attachment loss was between 92.5%

(NHANES III) and 99.7% (U.S. Employed Adult


3. Oral cancer. In the United States approximately

30,000 new cases of oral and pharyngeal cancer

are diagnosed annually. The great majority of

these are squamous cell carcinomas. Surveillance,

Epidemiology, and End Results (SEER) data (1973–

1997) indicate that the annual age-adjusted inci-

dence of oral and pharyngeal cancer in the United

States is 9.7 new cases per 100,000. These rates vary

substantially by gender, with males showing an

annual age-adjusted incidence rate of 14.5 per

100,000 compared with 5.6 per 100,000 for females.

In the United States, oral and pharyngeal cancer

accounts for 3% of new cancers among males and

1.6% of new cancers among females. The incidence

of oral and pharyngeal cancers increases with

age and alcohol/tobacco use and is relatively

uncommon before age 40.

Cancers of the lip and oral cavity account for

approximately two thirds of all new oral and pha-

ryngeal cancers, with the tongue being the most

common site of incident cancers of the oral cavity.

Although Caucasians have a markedly higher inci-

dence rate for lip cancer, overall, male African-

Americans show the highest oral and pharyngeal

cancer incidence rates, with these rates being

markedly higher for pharyngeal sites.

In the United States approximately 8000 deaths

occur each year as the result of oral and pharyngeal

cancer, representing 1.7% of all cancer deaths

among men and 1% of all cancer deaths among

women. Overall, the 5-year survival rate for oral and

pharyngeal cancers is approximately 50%. However,

survival rates for oral and pharyngeal cancer vary

considerably depending on cancer site, gender, and

race. For instance, whereas 5-year survival rates for

cancer of the lip are approximately 90%, the survival

rate for cancers of the tongue is approximately

half that when all persons are considered together

and is only approximately 20% among African-

American males, who have the overall poorest oral

cancer survival rates. Women tend to have higher

survival rates, with the exception of cancer of the lip.

Although pharyngeal cancers account for only

approximately one third of all incident oral and pha-

ryngeal cancers, they have a relatively poor survival

rate, accounting for nearly 50% of all deaths attrib-

uted to oral and pharyngeal cancer.


Prevention is classified into three different levels:

Primary prevention: prevents the disease before it

occurs. This level includes health education, disease pre-

vention, and health protection. Examples include commu-

nity water fluoridation and sealants. Preventing a disease

before it occurs is the most effective way to improve

health and control costs.

Secondary prevention: eliminates or reduces diseases

after they occur. Examples include amalgams and com-

posite restorations. This level requires more resources

than primary prevention. Therefore, it is more costly.

Tertiary prevention: limits a disability from a disease or

rehabilitates an individual in later stages to restore tissues

after the failure of secondary prevention. Examples

include dentures and crown and bridge.

A. Community and school based prevention

1. Community water fluoridation. The Centers for

Disease Control and Prevention (CDC) has recog-

nized community water fluoridation as “one of the

great public health achievements of the twentieth

century.” Community water fluoridation is defined

as the adjustment of the concentration of fluoride of

a community water supply for optimal oral health.

The recommended level of fluoride for a commu-

nity water supply in the United States ranges from

0.7 to 1.2 parts per million (ppm) of fluoride,

depending on the mean maximum daily air temper-

ature over a 5-year period. In the United States, most

communities are fluoridated at approximately

1 ppm, which is equivalent to 1.0 mg of fluoride per

liter of water. At this level, fluoridated water is odor-

less, colorless, and tasteless. Of all the measures

used to prevent dental caries in the United States,

water fluoridation is the most economical and cost-


The effectiveness of fluoridation is well-documented.

The early studies demonstrated that fluoridation

prevents 50% to 70% of caries in the permanent

teeth of children. However, due to the widespread

use of fluorides in the United States, the measurable

effectiveness of community water fluoridation

is currently 20% to 40%. This is explained by the fact

that many other fluoride-containing products

are now available, such as dietary fluoride

supplements, rinses, toothpastes, professionally

applied treatments, etc.

2. School water fluoridation. School water fluoridation

was developed and tested in the United States in the

1960s for use in rural schools with an independent

water supply. Fluoridation of water supplies of

individual schools is similar to community water

fluoridation in that no direct action is required of

Section 6 Patient Management ▼ 207

Page 218

beneficiaries other than direct consumption of or

use of the water in food preparation. The major dif-

ference is that the recommended concentration for

school water fluoridation is 4.5 times the concentra-

tion of fluoride recommended for community water

supplies in the respective geographic area. The

higher concentrations are recommended to com-

pensate for part-time exposure because children

spend only part of their time at school.

Studies conducted on school fluoridation have

shown that a 20% to 30% reduction in caries can be

expected when children have consumed school

water fluoridation for 12 years. The practicality of

school water fluoridation is good when a commu-

nity does not have a central water supply. All the

children benefit with no individual effort required on

the part of the recipient.

3. Topical fluoride. The application of topical fluoride

to the teeth increases tooth resistance to caries. The

fluoride can be delivered either brushed as a varnish

or in a tray as a gel. Fluoride gels will be discussed

in the office-based preventive methods section.

a. Fluoride varnishes. Fluoride varnishes were

accepted for use in the United States in 1994.

Fluoride varnish is not intended to be as perma-

nent as a fissure sealant but, rather, it is consid-

ered a vehicle for holding fluoride in close

contact with the tooth for a period of time. A the-

oretical advantage of varnishes over other meth-

ods of professional fluoride application is that

varnishes are adhesive and, hence, should maxi-

mize fluoride contact with the tooth surface.

Varnishes are a way of using high fluoride

concentrations in small amounts of material.

The efficacy of fluoride varnishes ranges

between 7% and 75%. Fluoride varnishes may be

especially useful to prevent root surface caries

among the growing number of older adults who

have gingival recession. In addition, fluoride var-

nishes may be especially attractive for use with

disabled children and bed-bound patients who

still have their own teeth.

Currently, fluoride varnishes are being used in

demonstration programs to help prevent infant or

early childhood caries among children in some

Women, Infants, and Children (WIC) and Head

Start programs.

4. Fluoride supplements. Fluoride supplements are

available only by prescription and are intended for

use by children living in non-fluoridated areas. For

optimum benefits, use of fluoride supplements

should begin when a child is 6 months old and be

continued daily until the child is 16 years old. The

need for taking fluoride supplements over an

extended period of time makes dietary fluoride sup-

plements less cost-effective than water fluoridation;

therefore, fluoride supplements are considerably

less practical as a widespread alternative to water

fluoridation as a public health measure.

Prior to prescribing any fluoride supplement, an

accurate assessment of all potential sources of

fluoride intake should be explored. Fluoridated

water may be consumed from sources other than

the home water supply, such as the workplace,

school and/or day care, bottled water, filtered

water, and from processed beverages and foods

prepared with fluoridated water. If the daily intake

of fluoride is insufficient, parents should be

informed that small daily dosages are beneficial to

a child’s teeth. Fluoride supplementation can best

be accomplished initially by the use of fluoride

drops. Around the age of 3, the drops can be

replaced by fluoride tablets.

a. Tablets. Another method for administering sys-

temic fluoride in school settings is the daily use of

dietary fluoride supplements in the form of

tablets. Supervised, self-administered use of fluo-

ride tablets is a well-established regimen that has

been used in the United States and abroad for

more than 40 years. Studies conducted in this

country have shown that the daily use of fluoride

tablets on school days will provide up to a 30%

reduction in new carious lesions.

Because the compliance required for this regi-

men—daily for 16 years—may be more than

most parents can achieve, this procedure often is

used in schools. The daily consumption of fluo-

ride tablets in school settings is an excellent

method to use in areas where the water is


See the Pedodontics section for fluoride sup-

plementation chart.

b. Fluoride mouth rinse. Fluoride mouth rinse has

been used in schools in the United States for

approximately three decades and it is the most

popular school-based fluoride regimen in the

United States. Fluoride rinse solutions are used to

provide the tooth enamel surface with a constant

supply of fluoride ions, which help remineralize

initial carious lesions. This method is recom-

mended only for children 6 years of age or older

because younger children may swallow the solu-

tion. For this reason fluoride rinse solutions are

not appropriate for the treatment of infants with

Early Childhood Caries. The rinsing is generally

supervised in classrooms by teachers or adult

volunteers. This procedure is usually not used in

schools in communities that have been fluori-

dated for 3 or more years.

Numerous studies have demonstrated that

dental caries can be reduced by approximately

25% to 28% by rinsing daily or weekly in school

with dilute solutions of fluoride. Rinsing weekly

with a 0.2% neutral sodium fluoride (NaF) solu-

tion requires fewer supplies and less time than

daily rinsing with a 0.05% NaF solution

5. Sealants. A fissure sealant is a plastic, professionally

applied material used to occlude the pits and fis-

sures of teeth. The objective is to provide a physical

barrier to the impaction of substrate for cariogenic

bacteria in those crevices and thus to prevent caries

from developing. Sealants also can halt the carious

208 ▼ Section 6 Patient Management

Page 434

Receptors, for autonomic pharmacology,

275–276, 276f, 276t

Reconstruction, cysts and tumors

relating to, 98

Reconstructive dentoalveolar surgery,

80–81, 80t

Recurrent aphthous ulcer. See RAU

Recurrent dislocation, chronic, 90

Regeneration. See GTR; Periodontal


Regional odontodysplasia, 124

Removable dental prosthesis. See RDP

Removable partial prosthodontics, 318,


Reparative dentin, 24

Replacement root resorption,

inflammatory root resorption v., 24

Replantation, intentional, 13

Respiratory pharmacology, 300, 300f

Restorations. See also Amalgam

restorations; Composite


all-ceramic, 336–337

cast, 38, 337–339, 338t

dental bonding, 61–64

dental caries relating to, 34

diagnosis of, 36

of endodontically treated teeth, 27

gold inlay/onlay, 53, 68–73, 69f, 71f,

72f, 73f

indirect esthetic inlay-onlay, 53

liners and bases, 52–53

metal-ceramic, 335–336, 336t

provisional, 337, 337t

of teeth, operative dentistry relating

to, 53–73

teeth preparation for, 54–58, 55f, 56f,

57f, 58f

treatment planning for, 40–41

types of, 47–48, 48t

Restorative clinical techniques, for

amalgams, 57–60, 59f, 60f

Restorative considerations, of periodon-

tal therapy, 267, 267f

Restorative dentistry, for children,

184–185, 185f

Restorative implantology, 319–321, 320f,

320t, 321f

Retainers, 172

Retention form, secondary resistance

and, 51, 57

Retention, orthodontics relating to,


Reversible pulpitis, 2

Rheumatoid arthritis. See RA

Risk management/risk avoidance, 230

Root canal system, components of, 16f

Root fractures, 20–21, 21f, 196

vertical, 10, 19, 19f

Root planing and scaling, 255–256

Root resection, 13

Root resorption, 188, 188f

external v. internal, 25t

inflammatory v. replacement, 24

Root sensitivity, 266

Root-end resection, 12

Root-surface sensitivity, 40, 40f

Rubber dam, 51–52, 51f, 52f

Sagittal split osteotomy, 87f

Saliva, 34

Salivary glands

diseases of, 115t

benign neoplasms, 115

malignant tumors, 115

reactive lesions, 113–114, 114f

major, metabolic enlargement of,

114, 114b

Sarcoidosis, 114

Scaling and root planing, 255–256

Scammon’s growth curves, 148, 148f

Scarlet fever, 107

School water fluoridation, 207–208

Scleroderma, 109–110

Sealants, 34, 208–209

pit and fissure, 200–201, 201f

Secondary resistance and retention

form, 51, 57

Sedative hypnotics, 282–284, 283f, 284t

Selective anesthesia test, 7

Self-etching primer systems. See SEP

SEP (self-etching primer systems), 63

Sex hormones, 304–305, 305t

Simplified Oral Hygiene Index. See OHI-S

Sjögren’s syndrome, 114

Skeletal movements, treatment relating

to, 174

Skeletal neuromuscular blockers,

280–281, 281t

Skeletal problems, in preadolescents,


Skeletal relationships-cephalometrics,

152–154, 153f, 154f

Smokeless tobacco-associated white

lesion, 111

Smoking, 249, 249t, 262

Soft tissue

cysts of, 104

dentoalveolar surgery of, 80

diseases of. See Oral diagnosis, oral

pathology and

orofacial, 35

Sonic instruments, 256

Space management, in developing


basic rules of, 188

factors relating to, 191–193, 191f, 192f

incisor loss relating to, 188–189, 189f

primary cuspid loss relating to,

189–190, 190f

primary first molar loss relating to,

190, 190f

primary second molar loss relating

to, 190–191, 190f, 191f

Spherical or admixed amalgam, 61

Splinting, 196

occlusal correction and, 264–265

Squamous cell carcinoma, 111–112,

111b, 111f

Stafne bone cyst, 104, 104f

Stainless steel archwire materials, 162

Static equilibrium, 159–160, 160f


asepsis and, 14–15

disinfection and, 217–218

Stomatosis, nicotine, 105, 105f

Stress, dental anxiety, and pain,


Subluxation, 195

Sucrose, 34

Suction biopsies, 95

Suppurative periradicular periodontitis, 4

Surgery. See also Specific entries

for odontogenic infections, 92–94

orthodontic treatment combined

with, 175f

for anteroposterior corrections,


for genioplasty, 174

indications for, 172, 173f

orthognathic surgical procedures

relating to, 174

skeletal movements relating to, 174

timing/sequencing of, 174

for transverse corrections, 174

for vertical corrections, 174

Surgical extractions and impactions, 78

Syphilis, 107

Systemic arthritic conditions, 90

Systemic factors, periodontal disease

influenced by, 249–251, 249t


bacterial, 95

of drug action, 271

Teeth. See also Pediatric dentistry;


crowded and irregular, early

treatment for, 165–166

development and developmental

disturbances of. See

Development and developmental

disturbances, of teeth

discolored, bleaching of, 26–27

impacted, classifications of, 78, 79b

missing, early treatment for, 166

Teething, 198

Temporal arteritis, 89, 89t

Temporomandibular disorders. See TMD

Temporomandibular joint disfunction.

See TMJ disfunction

Test cavity, 7

Thermal tests, 6–7

Third-party reimbursement, 220

Thyroid congenital abnormalities, 103

Thyroid pharmacology, 300–301, 301f

Tissue management, 332–334

Tissues and organs, autonomic

pharmacology relating to, 277, 277t

Titanium-tissue interaction, 260

TMD (temporomandibular disorders)

counseling for, 90

medical therapy for, 90

occlusion for, 90–91

overview of, 89

physical therapy for, 90

surgery for, 91

types of, 89–90

424 � Index

Page 435

TMJ (temporomandibular joint)

disfunction, 90

TN (trigeminal neuralgia), 88–89

Tooth fractures, 81, 81b

Tooth movement

biology of, 155–157

mechanical principles in, 157–160

types of, 159

Tooth reaction, in children, dental

trauma relating to, 194

Tooth sectioning, 79

Topical fluoride, 208

Tori removal, 80

Total joint replacement, for TMD, 91

Total-etch, 62–63

Toxicology, 308–310, 312t

Toxins, 310, 312t

Transverse corrections, 174

Trauma, dental, in children, 194–196

Trauma surgery

facial fractures, 81

mandible fractures, 81, 81f, 82f

midface fractures, 81–82

tooth fractures, 81, 81b

Traumatic injuries, endodontics relating


avulsion, 22–23, 22f, 196

biologic consequences of

apical neurovascular supply

damage, 24

attachment damage: external

resorption, 23

complicated fractures, 20

displacement injuries, 21–22

examinations of, 19–20

inflammatory root resorption,

replacement root resorption v.,


root fractures, 20–21, 21f

uncomplicated fractures, 20

Treatment overview, for dental caries

agents, 34

fluoride rinses, 34

recall, 34

Treatment overview, for (Continued)

restorations, 34

sealants, 34

xylitol products, 34

Treatment planning

for operative dentistry, 38–42

indications for, 39–40, 39t

restorations relating to, 40–41

root-surface sensitivity relating to,

40, 40f

for orthodontics, 154–155

Treatment principles, of odontogenic


antibiotics, 94, 94b, 95

bacterial targets relating to, 95

dentist, specialist v., 92, 94b

host defense mechanism, evaluation

of, 92, 94b

medical support, 94

microbiology relating to, 95

osteomyelitis relating to, 95

severity, determination of, 92

surgery as, 92–94

Trigeminal neuralgia. See TN

True combined lesions, 10

Tuberculosis, 107

Tumors. See also Connective tissue


cysts and

reconstruction relating to, 98

surgical management of, 96–98

of jaw, surgical management of

malignant, 97–98

overview of, 96

reconstruction relating to, 98

treatment modalities of, 97t

malignant, of salivary gland, 115

mixed, 115, 115f

odontogenic, 118–119, 118t

Warthin’s, 115

UCR (usual, customary, and reason-

able), 220

Ultrasonic instruments, 256

Uncomplicated fractures, 20

U.S. Employed Adults Survey, 206–207

U.S. Public Health Service. See USPHS

USPHS (U.S. Public Health Service), 61

Usual, customary, and reasonable. See


Varicella (chicken pox), 106

Vasoconstrictors, 287, 288t

Verrucous carcinoma, 111

Vertical corrections, 174

Vertical dimension, appliances for

control of, 165

Vertical ramus osteotomy, intraoral,


Vertical root fracture, 10, 19, 19f

Viral infections, 105–107, 106f, 106t

Vital pulp therapy

apexification, 26

apexogenesis, 26

direct pulp capping, 24–26

indirect pulp capping, 24

materials for, 24

partial pulpotomy, 26

pulpectomy, 26, 187

pulpotomy, 26

Warthin’s tumor, 115

Wegener’s granulomatosis, 109

White sponge nevus, 122

WHO (World Health Organization),


World Health Organization. See WHO


healing, repair, regeneration of, 264

irrigation of, 79, 79b

management of, biopsies relating to,


X-ray film

intensifying screens, grids, and,


processing of, 130–131, 131t, 132b

Xylitol products, 34

Index � 425

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