Dental management of patients at risk of osteochemonecrosis of the jaws: a critical review

Osteonecrosis of the jaw bones is a complication of bisphosphonate (BP) drug usage characterised by trans-mucosal exposure of necrotic bone, often followed by infection and pain. Osteonecrosis is observed in cancer patients on high-potency intravenous BP more frequently than in osteoporotic individuals using low-potency oral BP. The management of osteonecrosis caused by BP is often unsatisfactory and control of risk factors is considered the most effective means of prevention. Surgical manipulation and dental infection of the jawbone are the major risk factors, hence it is suggested that careful management of oral health and relevant dental procedures may decrease the risk of osteonecrosis in individuals on BP. Recommendations for dentists and oral surgeons have been suggested by different groups of clinicians but they are often controversial and there is no clear evidence for their efficacy in reducing the likelihood of osteonecrosis development. This report critically reviews current dental recommendations for individuals using BP with the aim of helping the reader to transfer them into practice as part of pragmatic and non-detrimental clinical decisions making.

Access to special care dentistry, part 9. Special care dentistry services for older people

This article looks at three common neurological conditions associated with later years: stroke, Parkinson's disease and dementia. All of them impact on oral health, access to dental services and delivery of dental care, and treatment goals need to be adapted to take into account patients' changing needs, medical status, pattern of recovery or the stage of dementia that they have reached. The article concludes by considering the topic of elder abuse. The dental team may have a role both in identifying abuse and ensuring appropriate action is taken.

Special Care Dentistry: a professional challenge

As a profession we have a responsibility to ensure that the oral health needs of individuals and groups who have a physical, sensory, intellectual, medical, emotional or social impairment or disability are met. In the UK, over 200,000 adults have profound learning disabilities and/or complex medical conditions. Adults with a disability often have poorer oral health, poorer health outcomes and poorer access to services than the rest of the population. This paper examines the need for Special Care Dentistry based on a review of published literature, surveys and health policy, and suggests how services might be delivered in the future. Existing models of good practice reveal that established clinicians working in this field have a patient base of between 850 and 1,500 patients per year and work across primary care and hospital settings, liaising with colleagues in health, social services and the voluntary sector to ensure integrated health care planning. On this basis, a conservative estimate of 133 specialists is suggested for the future, working in networks with Dentists with Special Interests (DwSIs) and primary dental care practitioners. A skilled workforce that can address the wider needs of people requiring Special Care Dentistry should be formally recognised and developed within the UK to ensure that the needs of the most vulnerable sections of the community are addressed in future.

Verifiable CPD paper: oral health of remand prisoners in HMP Brixton, London

OVERVIEW

This study investigated the general and oral health status and behaviours and the dental treatment requirements of remand prisoners. It makes recommendations on how their oral health care needs may be met.

METHOD

A convenience sample of 78 remand prisoners participated in the study within HMP Brixton. The study involved a structured interview, to establish health status and behaviours as well as perceived oral health needs, combined with an oral examination to establish normative treatment need.

RESULTS

Prisoners' general health was compromised. In particular, there were high levels of mental illness and infectious disease. Unhealthy behaviours such as tobacco smoking, alcohol use, drug dependency, and high sugar diets were commonplace. This affected the remand prisoners' oral health, which presented with high levels of decay and relatively low levels of both missing and filled teeth. Whilst prisoners made high use of prison dental services, they made little use of dental services outside of prison. The high turnover of remand prisoners and high demand for emergency care made the delivery of preventive and routine care difficult.

CONCLUSION

Remand prisoners have compromised general and oral health compared with the general population. They exhibit poor oral health, which is contributed to by their lifestyles and health behaviours.

The use of acupuncture in controlling the gag reflex in patients requiring an upper alginate impression: an audit

BACKGROUND

A pronounced gag reflex (GR) can be a problem to both the acceptance and delivery of dental treatment. Despite a range of management strategies, some patients cannot accept even simple dental treatment. The aim of this study was to evaluate the use of acupuncture point CV-24 in controlling a profound gag reflex during dental treatment requiring an upper alginate impression.

METHOD

Members of the British Dental Acupuncture Society were invited to take part in an audit of the role of acupuncture point CV-24 in controlling the gag reflex. They were issued with patient inclusion criteria, a standardised procedure instruction sheet and a recording form. All patients fulfilling the inclusion criteria had an upper dental alginate impression taken (or an attempt made at it) before acupuncture, and a second upper alginate impression taken immediately after acupuncture of point CV-24. The GR assessment was undertaken prior to insertion of the acupuncture needle using the Gagging Severity Index (GSI); and after the acupuncture and impression taking using the Gagging Prevention Index (GPI). Both the GSI and GPI were recorded at three stages of the dental impression taking procedure, ie, when the empty impression tray was tried in the mouth, when the loaded tray was inserted into the mouth, and on completion of the impression taking.

RESULTS

Twenty-one dentists submitted 64 case reports of which 37 fulfilled the inclusion criteria. Prior to acupuncture all 37 patients (20 females and 17 males with a mean age of 46.8 years) were unable to accept the impression taking. After acupuncture of point CV-24, an improvement of between 51-55% (mean 53%) for the three stages of impression taking was noticed. Thirty patients (81%) were able to accept the impression taking, whereas seven (19%) remained unable to tolerate the procedure. Assessed by the GSI and GPI, there was a significant decrease in GR scores at all three stages of the impression taking procedure (median 3 vs 1; 4 vs 2; 4 vs 2; p < 0.0001). Thus before acupuncture, the patients had moderate to severe GR and after acupuncture the GR had reduced to a level which only complicated dental treatment slightly.

CONCLUSION

Our results indicate that acupuncture of point CV-24 is an effective method of controlling severe GR during dental treatment including impression taking. However, the results of the current audit need to be tested in a randomised controlled study in order to substantiate the effectiveness of this method.

A review of gagging problems in dentistry: 2. Clinical assessment and management

A pronounced gag reflex can be a severe limitation to a patient's ability to accept dental care and for a clinician's ability to provide it. It can compromise all aspects of dentistry from diagnostic procedures to active treatment and can be distressing for all concerned. Many 'management' techniques have been described. This paper describes the different categories of treatment used to manage people with pronounced gag reflexes.

A review of gagging problems in dentistry: aetiology and classification

Some people have a pronounced gag reflex that can be a severe limitation to their ability to accept dental care and the clinician's ability to provide it. It can compromise all aspects of dentistry, from diagnostic procedures to active treatment and can be distressing for all concerned. Many techniques have been described that attempt to overcome the problem. Dentists will undoubtedly see patients with gagging problems and knowledge of a variety of management strategies is necessary to aid the delivery of dental care. This first paper looks at the background to gagging problems and their classification and categorization prior to clinical treatment. The second article will look at the clinical assessment of the patient presenting for dental treatment with a history of gagging problems. It will also review methods used to manage patients with gagging reflexes during dental treatment.

Views and experiences of parents and siblings of adults with Down Syndrome regarding oral healthcare: a qualitative and quantitative study

AIMS

To investigate experiences and expectations of parents/siblings of adults with Down Syndrome (DS) regarding oral healthcare, and explore factors impacting on access and experience of dental care for this group.

DESIGN

A two phase qualitative and quantitative study using in-depth interviews with a convenience sample of six parents/siblings, and a postal questionnaire of 200 parents/siblings of adults with DS who are members of the Down Syndrome Association.

RESULTS

The main themes elicited from the qualitative interviews related to concern, experiences, parents'/siblings' attitudes, preferences and information. The response rate from the postal questionnaire was 63.5%. Adults with DS attended the dentist regularly but received little restorative treatment. Experience of oral healthcare was influenced by the attitudes and skills of dental health professionals; stigma; and relatives' expectations of dentists, their oral health beliefs, information and support received, knowledge and priorities. Parents/siblings wanted dentists to be proactive in providing more information on oral health issues in collaboration with other health and social care professionals.

CONCLUSIONS

Whilst most adults with DS visited the dentist regularly, relatively little treatment had been provided. Parents highlighted a need for appropriate and timely oral health information early in their child's life, and access to dentists who were sympathetic, good communicators and well-informed about DS.

A review of gagging problems in dentistry: 2. Clinical assessment and management

A pronounced gag reflex can be a severe limitation to a patient's ability to accept dental care and for a clinician's ability to provide it. It can compromise all aspects of dentistry from diagnostic procedures to active treatment and can be distressing for all concerned. Many 'management' techniques have been described. This paper describes the different categories of treatment used to manage people with pronounced gag reflexes.

A review of gagging problems in dentistry: I. Aetiology and classification

Some people have a pronounced gag reflex that can be a severe limitation to their ability to accept dental care and the clinician's ability to provide it. It can compromise all aspects of dentistry, from diagnostic procedures to active treatment and can be distressing for all concerned. Many techniques have been described that attempt to overcome the problem. Dentists will undoubtedly see patients with gagging problems and knowledge of a variety of management strategies is necessary to aid the delivery of dental care. This first paper looks at the background to gagging problems and their classification and categorization prior to clinical treatment. The second article will look at the clinical assessment of the patient presenting for dental treatment with a history of gagging problems. It will also review methods used to manage patients with gagging reflexes during dental treatment.

Effectiveness in controlling haemorrhage after dental scaling in people with haemophilia by using tranexamic acid mouthwash

AIMS

To compare the effectiveness of tranexamic acid mouthwash (TAMW) in controlling gingival haemorrhage after dental scaling with that of using factor replacement therapy (FRT) prior to dental scaling in people with haemophilia.

DESIGN

Double-blind cross-over randomised control trial.

SETTING

Dedicated hospital dental practice for patients with inherited bleeding disorders.

METHOD

Sixteen patients with haemophilia who required dental scaling participated in this pilot study. The experimental treatment regime (ETR) involved transfusing each patient with saline before scaling both quadrants on one side of the mouth followed by oral rinsing with TAMW four times daily for up to eight days. The control regime (CR) involved giving each patient FRT before scaling the opposite side of the mouth followed by use of a placebo TAMW. Each patient underwent both treatments in a random-ised sequence. Both the operator and the patients were unaware of which were the ETR and CR episodes. On both occasions the patient kept a log book of the rinsing regime and any post-operative bleeding. Additionally, a structured post-treatment telephone interview was conducted to assess the effectiveness and the patient acceptability of the ETR.

RESULTS

Thirteen patients completed the study. No statistically significant difference was found in gingival bleeding and mouthwashing frequencies between the ETR and the CR (p > 0.05). Five patients reported no gingival bleeding with either the ETR or the CR. No patient, using either regime, required extra FRT due to gingival haemorrhage. All subjects found the ETR acceptable and easy and reported feeling safe in using TAMW alone to control gingival bleeding after dental scaling.

CONCLUSION

TAMW use after dental scaling was as effective as using FRT beforehand in controlling gingival haemorrhage for people with haemophilia.

Clinical trial of an air-abrasion/chemomechanical operative procedure for the restorative treatment of dental patients

The aim of this study was to investigate whether caries removal with air-abrasion/Carisolv gel is an acceptable and viable alternative in the treatment of dental patients. Twenty-two patients were treated with conventional methods (local anaesthetic injection/drill) followed by alternative treatment (air-abrasion and Carisolv gel) in a general practice setting, by the same operator. The participants' pre-operative anxiety levels were measured using the Modified Dental Anxiety Scale. Their postoperative levels of anxiety/dislike for aspects of both conventional and alternative treatments were assessed using a visual analogue scale. Levels of anxiety/dislike for both treatments were compared and statistically analysed. Results showed 100% of subjects were concerned about several aspects of conventional treatment including pain/discomfort on injection, taste of anaesthetic, length of time tissues remained numb, noise of the drill, its sensory vibrations and water coolant. However, 75% of the study population were happy with all aspects of the air-abrasion technique including dust, pain/discomfort and vibrations produced. Overall, the study population found Carisolv gel to be an acceptable alternative method of caries removal in terms of time taken, pain/discomfort and taste. There were statistically significant differences between patients' perceptions of various aspects of the two treatment methods. All participants found the alternative treatment to be pain-free, quicker and overall more acceptable compared with conventional treatment. The conclusion drawn from the study was that air-abrasion/Carisolv gel treatment was a well-accepted and viable alternative to conventional local anaesthetic injection and drill for dental patients.

The effects of the combination of chlorhexidine/thymol- and fluoride-containing varnishes on the severity of root caries lesions in frail institutionalised elderly people

OBJECTIVES

To compare the clinical effects of a fluoride-containing varnish (Fluor-Protector) in combination with a chlorhexidine-containing varnish (Cervitec) on existing root caries lesions in a group of frail elderly subjects.

METHODS

A randomised double blind longitudinal study was utilised. Subjects (n = 102) were randomly allocated to a Test or Placebo group. All leathery and soft root caries lesions in all subjects were coated with Fluor-Protector while the lesions in the Test group were also coated with Cervitec and the lesions in the Placebo group were coated with a Placebo varnish. Treatments were repeated five times in a 12-month period. Clinical parameters associated with root caries, measurements of individual lesions and salivary levels of caries associated bacteria were made at intervals.

RESULTS

The clinical severity of the lesions in the Test group did not change significantly during the 12-month study period. In the Placebo group the mean lesion width and lesion height and length of exposed root increased significantly and the lesions were significantly closer to the gingival margin. There were no significant changes in the salivary levels of caries-associated microorganisms after 12 months although, in both groups, there was initially a significant reduction in the salivary levels of mutans streptococci.

CONCLUSIONS

The combination of Fluor-Protector and Cervitec is a useful, simple, quick and non-invasive method for the control and management of existing root caries lesions. The procedure could be performed by a dental hygienist and may be usefully applied in other high-risk groups including persons with Parkinson's disease, debilitating neuromuscular conditions and dry mouth from whatever cause.

The emotional effects of tooth loss in partially dentate people attending prosthodontic clinics in dental schools in England, Scotland and Hong Kong: a preliminary investigation

AIM

To compare the emotional effects of tooth loss in three partially dentate populations.

DESIGN

A questionnaire survey.

MATERIALS AND METHODS

A questionnaire was completed by 150 partially dentate subjects undergoing routine prosthodontic care at Guy's, King's and St Thomas's Dental Institute, London; the Dental School, Dundee, Scotland; and the Faculty of Dentistry, University of Hong Kong. Data were analysed using the Chi-square test.

RESULTS

Forty nine per cent of all participants reported difficulties in accepting the loss of some of their teeth. People from Dundee were less likely to have difficulties accepting tooth loss (P = 0.001). People from London took longer to come to terms with their tooth loss and were more likely to feel less confident (P < 0.001). Fifty five per cent of all participants restricted their choice of foods and 54 per cent had not enjoyed their food as much as before. Fewer people in Dundee restricted their choice of food (P < 0.001) and were more likely to enjoy their food (P = 0.009). People in Hong Kong were most likely to restrict their choice of food (P = 0.006). Thirty five percent of all subjects felt unprepared for the effects that tooth loss had upon them. People in Hong Kong were more prepared for tooth loss than those in Dundee and London (P = 0.003). In addition, they were less concerned about leaving their dentures out overnight (P = 0.024).

CONCLUSIONS

The emotional effects of tooth loss were significant in all groups. People from London took longer to come to terms with their tooth loss.

The implications of visual impairment in an elderly population in recognizing oral disease and maintaining oral health

The incidence of impairment and disability increases in the elderly population. Disability can affect elderly people's ability to maintain oral health, maintain access to dental care, and accept dental treatment. The oral health of visually impaired people can be disadvantaged, since they are not in a position to detect and recognize early oral disease and may be unable to take immediate action unless informed of the situation. The aim of this pilot study was to identify the problems experienced by a visually impaired elderly population regarding the maintenance of oral health and the need to seek treatment. Sixty-two legally blind people underwent a structured interview and a clinical dental examination. Data are presented descriptively. All the participants would be potentially able to maintain their own adequate oral health level if given the appropriate stimulus. At the time of the study, 53% brushed their own teeth, 39% of whom brushed daily. Of the denture wearers, 58% cleaned them at least once a week. Most of the participants were independent. Eighty-two percent believed that they did not need help to brush their teeth or dentures, even though 85% had never been shown how to brush their teeth. Eighty percent of people did not realize that regular oral reviews were necessary. Other barriers to regular care included poor health, mobility problems, cost, and fear. Twenty-one percent of the sample had toothache or a denture problem. The professionally assessed treatment need was high in the dentate group, and 32% of denture wearers had denture-related pathology. The professionally assessed treatment need was greater than the visually impaired people's perceived need for care. The majority of visually impaired elderly were capable of maintaining a reasonable level of oral hygiene by themselves and were aware of their own dental needs but either had no reason to seek care or were unable to access oral health care services. It is important for visually impaired persons to realize that they need supervision to maintain good oral hygiene standards and to ensure the early identification of oral pathology. Also, the barriers to access to oral health services need to be reduced.

A transcultural perspective on the emotional effect of tooth loss in complete denture wearers

PURPOSE

The purpose of this study was to compare the emotional effects of tooth loss in three edentulous populations.

MATERIALS AND METHODS

A questionnaire study involved 142 edentulous subjects undergoing routine prosthodontic care at Guy's, King's and St Thomas's Dental Institute, London; the Dental School, Dundee, Scotland; and the Faculty of Dentistry, University of Hong Kong. Data were analyzed using the chi-squared test.

RESULTS

Difficulty in accepting tooth loss was a relatively common experience (44%) in all groups, with almost half feeling that their confidence had been affected. The majority (66%) felt that their choice of food was restricted and that the overall eating experience was less enjoyable, particularly the Hong Kong group. A significant proportion of the participants were concerned about their appearance without dentures, although the trend was less marked in Hong Kong. Forty-three percent felt that they were not adequately prepared for tooth loss, although the Hong Kong group was least concerned.

CONCLUSION

In general, the emotional effect of tooth loss was significant in all groups. The restrictions on daily activities were generally greater in the Hong Kong group. However, this group was much less inhibited by denture wearing. The differences observed in the Hong Kong Chinese are most likely due to different cultural values and expectations associated with these aspects of daily living.

The role of acupuncture in controlling the gagging reflex using a review of ten cases

The gagging reflex is a physiological reaction which safeguards the airway from foreign bodies. In some people this response is exaggerated to the extent that the acceptance/provision of dental treatment is not possible. The aim of this paper is to review the role of acupuncture in controlling gagging as a safe, cheap, quick and relatively non-invasive technique.

METHOD

Ten people agreed to try ear acupuncture to control gagging during dental treatment. Prior to treatment the severity of gagging was assessed. Acupuncture needles were inserted into a specific anti-gagging point on each ear, manipulated briefly and left in situ. Dental treatment was then carried out and the effectiveness of the acupuncture in preventing gagging was assessed. After treatment, the needles were removed and the patient discharged. All acupuncture was carried out by a dentist trained in its use.

RESULTS

Four people had a severe gag reflex which made treatment impossible and six had a very severe reflex which made treatment impossible and affected their dental attendance. Ear acupuncture completely controlled the gag reflex in eight cases (23 treatment episodes) and partially controlled the reflex in two cases (two treatment episodes). Dental treatment could be carried out in all cases and at all visits. The cost of materials was 0.2 pounds per person per visit. Additional clinical time was in the order of 2-3 minutes. There were no adverse reactions to the technique and, on all occasions, patients were fit to leave the surgery and travel home unaccompanied.

CONCLUSIONS

Ear acupuncture was successful in controlling the gag reflex. It is a safe, quick, inexpensive and relatively noninvasive technique. A controlled clinical trial is required to investigate any placebo effect.

The emotional effects of tooth loss in a group of partially dentate people: a quantitative study

This study investigated the reactions to tooth loss in a partially dentate group of 100 people using a questionnaire-based method. Partially dentate people who experienced difficulties in accepting their tooth loss were more likely to feel less confident, restrict food choice, enjoy food less, avoid laughing in public and avoid forming close relationships than those people who had no difficulties accepting tooth loss. Also, they were more likely to feel that they had not been adequately prepared for the effects that tooth loss had on their confidence, daily living activities and appearance.

The delivery of oral care services to elderly people living in a noninstitutionalized setting

Advances in medical science are enabling people to survive more illness and disability. As people live longer, their mobility and/or ability for self-care often are reduced by physical or mental disability and other chronic diseases. It may become unreasonable or impractical for them to access mainstream dental services. Increasing numbers of dentate elderly people with expectations of oral health higher than earlier cohorts of elderly people are likely to bring increasing demands to the dental profession for their continuing care. Thus, the oral care for disabled elderly people in noninstitutionalized settings may pose a challenge. The oral care options available to this group of people include the dental surgery/operatory, a mobile dental service, home-based or domiciliary dental care, a mix-and-match combination of surgery-based and domiciliary care, and cyberspace. Noninstitutionalized, disabled elderly people may have to rely on domiciliary care services for their oral health care. This paper explores the training implications, the necessary knowledge and skills base, the benefits and limitations to both the service provider and user, the equipment available, and the cost/funding of domiciliary dentistry. Domiciliary dental care services need to be developed by improving pre- and postdoctoral training programs and by establishing realistic remuneration for dental teams providing this care so that noninstitutionalized, disabled elderly people can access oral health care.

Down's syndrome and oral care

Down's syndrome is caused by a chromosomal abnormality and is characterized by certain physical, mental and medical features. A number of these features, such as learning disability, cardiac anomalies and an altered immune system, can have a profound effect on oral health and the delivery of oral care. In turn, this can affect social acceptability and quality of life. The optimum potential of the person with Down's syndrome is achieved via a multidisciplinary approach that involves the members of the dental team from an early stage.

Lip-biting in patients with profound neuro-disability

Profound neuro-disability due to severe brain damage affects approximately 1200 people per year in the UK. Approximately half of these patients exhibit exaggerated or abnormal oral reflexes. Biting, bruxism and ruminating movements may result in dental or soft tissue trauma, with severe lip or tongue lacerations. This paper describes 10 patients referred to the dental department at the Royal Hospital for Neuro-disability with lip bites and/or severe bruxism, during a 12-month period. Management options include: monitoring the lesion; smoothing teeth; providing a bite raising appliance; or extracting teeth. This paper discusses the difficulty in management of lip trauma in this group of patients and emphasizes the importance of an interdisciplinary approach.

Value of routine evaluation of the voiding phase when performing urodynamic testing in women with lower urinary tract symptoms

PURPOSE

Lower urinary tract symptoms in women are often evaluated by cystometrography. We only assessed the bladder response to filling and not the impact of abnormal voiding, which is known to cause lower urinary tract symptoms. We determined the prevalence of voiding abnormalities in women with lower urinary tract symptoms and compared cystometrography to cystometrography plus voiding pressure flow study for evaluating this condition. We also determined whether storage or voiding symptoms predicted abnormal voiding.

MATERIALS AND METHODS

We reviewed the records of 134 women who underwent video urodynamics with cystometrography and voiding pressure flow study to evaluate lower urinary tract symptoms. Patients with a history of neurological disease, grade 4 pelvic prolapse or a primary complaint of stress incontinence were excluded from study. All participants completed an American Urological Association symptom index and scores were subclassified as total, storage and voiding. A diagnosis was made in each case based on cystometrography findings, while any additional diagnoses when applicable were based on the voiding pressure flow study. Symptom scores were compared in women in whom the voiding study did and did not add information.

RESULTS

Mean patient age was 53.1 years (range 19 to 90). Voiding studies added information in 44 cases (33%), including dysfunctional voiding in 16, obstruction due to a moderate cystocele in 6, primary bladder neck obstruction in 6, external-detrusor sphincter dyssynergia as the initial presentation of neurological disease in 5, obstruction after incontinence surgery in 3, urethral stricture in 3, post-void contraction mimicking symptoms in 2, impaired contractility in 2 and an obstructing urethral diverticulum in 1. A total of 32 patients (24%) did not void during the study. Those with voiding abnormalities had higher total and voiding but similar storage symptom scores (23.1 versus 18.5, 12.3 versus 8.0 and 10.8 versus 10.5 points, p = 0.0008, 0.0001 and 0.58, respectively).

CONCLUSIONS

Women with lower urinary tract symptoms may have voiding abnormalities that are missed by cystometrography only. Voiding studies are useful for properly diagnosing and treating such cases. Women with abnormal voiding seem to have more severe voiding symptoms than those without such abnormalities. Occult neurological disease may also be identified in patients with lower urinary tract symptoms and voiding abnormalities.

The impact of dental anxiety on daily living

AIM

To explore the impact of dental anxiety on daily living.

METHOD

Twenty people attending a dental sedation clinic completed the Modified Dental Anxiety Scale, and were interviewed privately using a reflexive, in-depth technique. All interviews were audio-tape recorded and transcribed. The transcripts were analysed to identify the impact of dental anxiety upon the participants' daily lives. Twenty-five per cent of the qualitative data was reviewed by an independent researcher to ensure the reliability of the analysis.

RESULTS

The mean age of participants was 41 years (range 23 to 60). The mean MDAS score was 21.5 (range 14 to 25). Five main impacts of dental anxiety were identified: physiological; cognitive; behavioural; health; and social. Subsumed under these broad categories were: the fright response; a vast array of negative thoughts, feelings and fears; avoidance behaviour and behaviours related to eating, oral hygiene, and self-medication; and other manifestations of anxiety in the dental environment including muscular tension, crying and aggression were all identified. Dental anxiety was also found to disturb sleep and to have a profound affect socially, interfering with work and personal relationships.

CONCLUSION

The impact that dental anxiety can have on people's lives is wide-ranging and dynamic.

Oral management of patients following oncology treatment: literature review

Many tumours of the head and neck are treated by clinical oncologists using radiotherapy. This treatment modality is particularly effective in destroying rapidly dividing cells, hence its value in cancer treatment. The tissues of the oral mucosa, the salivary glands and blood vessels can be damaged as the result of radiotherapy treatment. As a result, patients experience unwanted oral effects that have both short and long-term implications. The outlook following treatment for head and neck cancer continues to improve and, as people keep their teeth into later life, dentists will increasingly be expected to address the oral problems that patients experience after radiotherapy. The aim of this article is to review the current literature concerning the implications and management of these oral implications of cancer treatment.

Guidelines for oral health care for long-stay patients and residents

People in residential or continuing care have an equal right to good oral health as people residing in the community. Entry to residential or continuing care provides an opportunity to assess need, identify problems, improve oral and dental health thereby contributing to improved general health and quality of life. This document provides guidance to establish standards for oral health care which are appropriate to the needs, demands and choices of individuals whether they live in continuing or residential care (Appendix 5).

The emotional effects of tooth loss: a preliminary quantitative study

AIM

To establish how widespread the emotional effects of tooth loss are.

METHOD

A questionnaire, distributed to 100 edentulous people undergoing routine prosthetic care in the Department of Prosthetic Dentistry at Guy's, King's and St Thomas' Dental Institute (GKT), was used to explore the emotional effects of tooth loss.

RESULTS

Ninety four people completed the questionnaire of whom 42 stated that they had experienced difficulties in accepting the loss of their teeth. In comparison with people who had no difficulties in accepting the situation, these people were: more likely to feel less confident about themselves; more likely to feel inhibited in carrying out everyday activities; and less able to accept the inevitable change in facial shape which occurs following the loss of teeth. Additionally, they took longer to come to terms with their tooth loss (All these differences were statistically significant). Just over three-quarters of the people who were unprepared for the loss of their teeth, felt that an explanation from the dentist prior to dental extractions would have helped.

CONCLUSION

The impact that tooth loss can have on people and their lives should not be underestimated. In this study it affected 45% of the participants.

Parkinson's disease and oral care

Parkinson's disease is a relatively common, progressive, neurological disorder. Its key features of resting tremor, bradykinesia, akinesia, restricted mobility and postural instability militate against independence for daily living, mobility, good nutrition and oral health. The successful management of the disease requires a multi-disciplinary approach in which the dietician, speech therapist, nurse and dental staff are pivotal members of the care team.

Preliminary study of the impact of loss of part of the face and its prosthetic restoration

STATEMENT OF PROBLEM

Loss of a part of the face or having a congenitally missing ear, nose, or eye is likely to have both a social and a psychologic impact on those affected. The nature and extent of this impact has not been explored previously. The provision of facial prostheses is an increasingly viable and beneficial treatment option, but the psychologic and social adjustment to the prosthesis has not been described.

PURPOSE

This study performed a preliminary investigation of patients' responses to loss of part of the face, and their perceptions of the prosthetic restoration of their missing facial part.

METHODS

Nine individuals who had experienced prosthetic replacement of an ear, nose, or eye were interviewed. Interviews were semistructured, each respondent was interviewed individually and the interviewer followed a predetermined interview schedule. Themes emerging in the interviews were identified.

RESULTS

The main themes relating to the loss of the facial part were the importance of the story of the loss, coping through bargaining, and the impact of the loss on relationships. The important themes identified in regard to the prosthesis were issues in the maintenance of the prosthesis and the reactions of other people to the prosthesis.

CONCLUSION

Loss of part of the face requires great adjustment. The reactions of other people were marked. Provision of a facial prosthesis can assist in the process of adjustment.

Domiciliary dental care

Domiciliary dental care is an important and growing area of treatment provision. However, adequate training is required in order to develop the knowledge and skills necessary to perform such care. This article draws attention to the likely increase in demand for domiciliary dental care services and the reasons for it; and highlights the issues and skills involved for dentists, hygienists and their teams in providing domiciliary dental care in order to facilitate quality of care and safe practice.

Breaking bad news: a guide for dental healthcare professionals

During their professional career most dental practitioners will be faced with a situation in which they have to break 'bad news'. This article examines the communication skills involved in breaking bad news to patients. The process is broken down into three broad stages: preparation; discussing the information; and reviewing the situation. Within each of these stages specific and practical recommendations are given. The importance of recognising the impact which such interactions have upon the dental practitioner is emphasised.

The emotional effects of tooth loss in edentulous people

AIM

To explore the range of reactions to, and feelings about, tooth loss.

METHOD

In this qualitative study, 50 edentulous people undergoing routine prosthetic dental care were interviewed privately using a reflexive, in-depth technique. All the interviews were tape-recorded and transcribed. The transcripts were scrutinised to identify the common themes related to tooth loss. Interpreter bias was minimised by two researchers scrutinising the transcripts independently.

RESULTS

The participants had a mean age of 69.9 years (range 51 to 86) and had been edentulous for a mean of 18.4 years (range 0.25 to 57 years). The main themes identified in reaction to tooth loss were: bereavement, lowered self-confidence, altered self-image, dislike of appearance, an inability to discuss this taboo subject, a concern about prosthodontic privacy, behaving in a way that keeps the tooth loss secret, altered behaviour in socialising and forming close relationships, premature ageing, and lack of preparation.

CONCLUSION

Tooth loss can be disabling and handicapping. It has a profound impact on the lives of some people, even those who are apparently coping well with dentures. The profession needs to consider how it can prepare people for the effects of tooth loss.

Use of CHROMagar Candida medium for isolation of yeasts from dental samples

A new differential medium, CHROMagar Candida, for the isolation of clinically important yeasts was investigated to determine its usefulness in facilitating the study of oral yeasts. The recovery of yeasts on the medium was not significantly different from the recovery on Sabouraud dextrose agar. The identities of 450 green colonies on CHROMagar Candida, presumptively identified as Candida albicans on the basis of the manufacturer's instructions, were confirmed by testing for beta-N-acetylgalactosaminidase. Candida tropicalis also formed distinctive colonies, and other yeasts including Candida (Torulopsis) glabrata, Candida Parapsilosis, Candida Magnoliae, Candida lusitaniae, Candida Famata, Candida kefir, and Saccharomyces cerevisiae were readily distinguished from C. albicans and C. tropicalis isolates. CHROMagar Candida is a very useful medium, and its use will facilitate the study of yeasts associated with dental diseases.

A self-help group for complete denture wearers

Denture provision is a frequent source of frustration and misunderstanding for both patients and dentists. This study investigates the role of a self-help group in helping denture wearers with long standing problems to come to terms with their difficulties and to reduce their demands on the dentist. Eleven people with clinically satisfactory dentures and long standing perceived problems were invited to join the programme. Evaluation at 2 and 12 months afterwards indicated everyone had benefited in some way. Benefits included eating foods previously avoided, the opportunity for social intercourse and reducing the visits to the dentist.

Dental needs of pre-retirement and retired people in an inner-city area

Perceived and normative dental needs were assessed for people of pre-retirement (55-64 years) and retirement age (65-74 years) in Camberwell, London, using a postal questionnaire and dental examination. Of the pre-retirement group, 77% were dentate compared with 65% in the older cohort. The younger age-group were more likely to believe teeth were more important and to perceive a need for dental care. People who attended for the examination were more likely to perceive a need for (64% and 15% respectively) and want treatment (39% and 17%) than non-examinees. Also, they were more likely to be unhappy with their appearance (43% and 20%) and to be in pain (42% and 21%). Treatment need was similar for both groups with regard to restorative and extraction needs. However, the retirement group were more likely to have deep periodontal pockets (33% and 8%) and a greater normative need for denture care.

Oral care of people with disability: a qualitative exploration of the views of nursing staff

This study aimed to identify influences, attitudes and actions of nursing staff in relation to oral care for people with disabilities. Individual in-depth interviews of twenty two nursing staff were conducted. Enabling and inhibiting factors in the reported attitudes, approaches and practices were identified. The main enabling factors were that nursing staff saw mouth care as part of their role and took an empathic and caring approach to its delivery. They aimed to make the residents socially acceptable, improve their self-esteem and make their mouths clean and breath fresher. Inhibiting factors were: a lack of training, time constraints associated with workload, and poor understanding of the processes causing dental disease. The study concludes that improvements in oral care by nursing staff can be encouraged by working with nurses' attitudes, values and beliefs. Once the desired behaviour change has occurred then the lack of knowledge can be addressed.

Death from cancer at home: the carers' perspective

OBJECTIVES

To collect information from principal carers of people who had died at home with cancer; to identify areas of support which need improvement.

DESIGN

Semistructured interviews with carers two to four months after the death.

SETTING

38 general practices in the Exeter, Torbay, and Plymouth health districts.

SUBJECTS

207 carers.

MAIN OUTCOME MEASURES

Services received by carers and quality of support.

RESULTS

161 of 207 patients were aged 60 or over. 88 carers were aged under 60, 110 were 60-80, and 9 were > 80. Carers had difficulty in getting urgent professional help in only 15 out of 177 cases. 124 carers were not given advice on financial help and 174 were not told of support available from local charities. Although pain was well controlled, 25% of patients had no relief of other symptoms. Overall, 150 carers considered the support excellent, 45 good, 8 moderate, 2 poor, and 2 had no comment.

CONCLUSIONS

Although care has improved in recent years, health professionals need to give carers more advice about help available outside health services. Domestic help was often needed earlier. Better appreciation of carers' problems is needed.