Prof 42 69355/11/03

PROF 42 69355/11/03 30/1/04 11:12 am Page 14 Faculty of Dental SurgeryClinical guideline summaries - Fourth edition Professor Fraser McDonald is Chairman of the Faculty of Dental
Surgery Clinical Effectiveness Committee. Professor McDonald’s
undergraduate qualification was completed in 1980 at Birmingham
University. He has subsequently obtained qualifications in
specialisation in orthodontics and is currently the head of the
department at Guy’s, King’s and St. Thomas’. He has served on
the Board of Faculty of Dental Surgery since 1998.
by Professor Fraser McDonald
NHS Dentistry Options for Change
dentistry will enable treatment, driven by
emphasises as one of its key actions the
need and supported by evidence, to follow a
development of a quality service through
degree of standardisation across the
clinical pathways. This innovative approach
country. It is essential however that any
to improving the quality of care through
clinical pathway, protocol or guideline is
nationally agreed protocols of evidence-
regularly reviewed and updated to ensure
based best practice is being implemented in
that clinical practice continues to develop
medical practice. Such a development in
and innovation is encouraged.
systematically reviewed available evidence, will be welcomed by clinicians and encourage the develop clinical guidelines to improve the provision of the highest possible standards of effectiveness and efficiency of clinical practice care. The Clinical Effectiveness Committee would based upon systematically reviewed evidence.
wish to acknowledge the contribution of the The publication of the summaries in Dental members of its constituent working groups and Profile of the majority of the guidelines produced its many authors; without their sustained by the Faculty to date continues in this edition.
enthusiasm and commitment these guidelines This demonstrates an important collaboration with the Dental Practice Board and is intended to contribute to a sustained drive toward evidence- supported by categories of evidence, explanatory detail and references, is available on the The aim of the Clinical Effectiveness Committee has been to produce guidelines which deal with www.rcseng.ac.uk/dental/fds .Those looking for commonly encountered clinical situations. It is more information will find it there.
hoped these guidelines, based on regularly and PROF 42 69355/11/03 30/1/04 11:12 am Page 15 Faculty of Dental Surgery - Clinical guidelines .continued from page (i) Treatment of intrinsic discolouration in permanent anterior teeth in
children and adolescents: a guideline summary
Principal Authors: Alyson Wray and Richard Welbury
Paediatric Dentistry Working Party
Introduction
established, specifically whether both dentitions are Intrinsic discolouration can be defined as discolouration affected or not, whether all teeth in one dentition are which is incorporated into the structure of either enamel or equally affected, and whether or not there is a dentine and which cannot be removed by prophylaxis with symmetrical or chronological pattern.The features of toothpaste or pumice. Intrinsic tooth discolouration can be a discolouration may have been evident at tooth eruption, significant cosmetic, and in some instances, functional, or may have developed subsequently and become problem. Loss of vitality secondary to trauma or infection either more or less severe in the intervening time. If frequently results in tooth discolouration which is not possible, the extent of discolouration should be identified responsive to conventional endodontic therapy. Similarly with respect to the depth of affected enamel or dentine.
fluorosis, tetracycline staining, localised and chronological hypoplasia, and both amelogenesis and dentinogenesis imperfecta can all produce a cosmetically unsatisfactory Appropriate radiographs will show abnormalities of dentition and, in the latter two examples, a structurally ‘at enamel and dentine structure, abnormal tooth risk’ dentition as well. These Guidelines are designed to morphology and the adequacy of root canal fillings in outline the most appropriate options for treating the different non-vital teeth. Sensibility testing will suggest the aetiological categories of intrinsic discolouration of the presence or absence of a functioning nerve supply, anterior permanent dentition in child and adolescent implying an intact vasculature. Histological sectioning of exfoliated or extracted teeth may identify hereditary and 1 History
A careful, detailed history is essential for the accurate Management
diagnosis of intrinsic tooth discolouration, as the choice The treatment of choice is dependent on the diagnosis. In of treatment is greatly influenced by the aetiology.
many cases of discolouration there is a hierarchy of Specifically: details of the mother’s obstetric history treatment options. These should be pursued in a logical and the delivery; medical history including neo-natal or order until a satisfactory cosmetic outcome is achieved. Pre- early childhood illness and any drugs taken; dental treatment photographs, shade taking and sensibility tests history including infections relating to primary teeth; trauma to the primary and permanent teeth; family history of discoloured or abnormal teeth; fluoride history including supplementation, residence in natural 1 Microabrasion
water fluoridation areas, toothbrushing habits including Microabrasion involves the removal of a small amount the amount of paste used, the type of paste in of surface enamel and classically incorporates both childhood and any admitted swallowing of paste.
‘abrasion’ with dental instruments and ‘erosion’ with an acid mixture. The term ‘abrasion‘ has been used by 2 Examination
some authors. There are two main techniques for microabrading discoloured or hypoplastic teeth. These A standard extra-oral examination and full mouth intra- are the hydrochloric acid/pumice technique which oral examination should be undertaken, with special requires very careful isolation of the affected teeth, and emphasis on the presence and/or absence of both the phosphoric acid/pumice technique. These primary and permanent teeth. The distribution of any techniques are simple to perform and the depth of discolouration or hypoplasia should be clearly enamel removed in 10 applications is approximately PROF 42 69355/11/03 30/1/04 11:12 am Page 16 100 µm. (0.1 mm.). Microabrasion is indicated for alternative and should be used in child and adolescent fluorosis, post-orthodontic demineralisation, localised patients. Resin can be used by either to camouflage/ hypoplasia due to infection or trauma, and idiopathic replace discrete localised areas of abnormal enamel hypoplasia where the discolouration is limited to the (localised composites) or to cover the entire enamel outer enamel layer. Analysis of the effectiveness of surface (veneer). Composite resin restorations are microabrasion should be delayed for approximately one indicated in cases of hypoplasia caused by moderate to month post-treatment, as the appearance of the teeth severe fluorosis, localised hypoplasia not responsive to will continue to improve during this time.
microabrasion, chronological hypoplasia, tetracycline staining, discolouration due to loss of vitality not 2 Non-vital bleaching
responsive to non-vital bleaching, amelogenesis and This technique is indicated for non-vital, endodontically dentinogenesis imperfecta, and idiopathic hypoplasia.
treated teeth which have become discoloured due to Composite veneers can be placed directly on to the the deposition of blood degradation products in the tooth surface or fabricated indirectly in the laboratory.
dentinal tubules.(19-39) A well-condensed root canal filling must be present prior to starting non-vital 5 Porcelain veneers
bleaching. Most techniques utilise hydrogen peroxide or Porcelain veneers are indicated for hypoplastic and sodium perborate (Bocasan) either together or discoloured teeth in patients aged 16 years and over, independently. Where a non-vital tooth has an when techniques such as microabrasion, non-vital unsatisfactory root canal filling this should be replaced bleaching and composite resins have failed to produce with a well-condensed gutta percha restoration prior to 3 Vital bleaching
Notes on claiming fees under
This technique involves the external application of the Statement of Dental
hydrogen peroxide to the surface of the tooth followed Remuneration
by its activation with a heat source. It is indicated for mild tetracycline staining without obvious banding, mild fluorosis, and single teeth with sclerosed pulp Treatment of intrinsic discolouration in permanent
chambers and root canals. The results have been teeth in children and adolescents
• Where treatment involving microabrasion or internal bleaching is proposed, the practitioner will need to apply for a discretionary fee under item 40 (code 4001).
This technique involves the daily placement of However, where such treatments are proposed for patients carbamide peroxide gel into a custom-fitted tray of treated under capitation arrangements attention is drawn either the upper or lower arch. It is carried out by the to the provisos to item 41 (capitation) in the SDR; patient at home and is initially done on a daily basis.
additional fees shall only be payable for treatment under The technique is indicated for mild fluorosis, and item 40, where a laboratory cost is involved (proviso 2), or moderate fluorosis as an adjunct to microabrasion.
where treatment is necessitated by trauma (proviso 3).
(Authors’ note regarding Vital Bleaching with products • At the present time, the DPB is unable to authorise which release more than 0.1% hydrogen peroxide - At discretionary fees for treatment involving external the time of preparation of this summary [Dec 2002] the legal status of this technique in the United Kingdom was under review by the Department of Trade and • Treatment under code 1601 is only appropriate for the provision of porcelain veneers at upper incisor and canine teeth. Where veneers are proposed in any other material, 4 Composite resin restorations
or at any other tooth notation, a discretionary fee should The large size of the immature pulp chamber and pulp horns, and the immature gingival contour of the It is important to note that treatment claimed for under code adolescent patient contra-indicates the use of porcelain veneers. Composite resin offers a satisfactory

Source: http://www.nhsbsa.nhs.uk/Documents/ArchivePDF/part_4_march_2004.pdf